HospitalInspections.org

34603

Based on observation, interview and record review, the facility failed to ensure medications used in treating emergency cases were readily available and not expired. Findings include:

During an observation on 12/28/16 at 7:59 a.m., opened/used multiple-dose bottles of local anesthetics were on a shelf in the emergency department and included:
- one 10 ml multiple-dose bottle of injectable Lidocaine 1% with an open date of 11/26/16;
- one 30 ml multiple-dose bottle of injectable Bacteriostatic 0.9 % was not dated when opened;
- one 10 ml multiple-dose bottle of injectable Lidocaine 1% and Epinephrine 1:100,000 had an open date of 4/17/16;
- one 50 ml multiple-dose bottle of injectable Marcaine 0.5% was not dated when opened;
- one 20 ml multiple-dose bottle of injectable Xylocaine 1% had an open date of 10/29/16.

During an interview on 12/28/16 at 8:25 a.m., staff member A stated nurses working in the emergency department were required to check medication expiration dates monthly. She stated staff members had not checked the crash cart for expired medications in September 2016 and December 2016.

During an observation on 12/28/16 at 8:30 a.m., medications kept in the crash cart in the emergency department included the following:
- four 1 ml vials of injectable Dexamethasone 4mg/ml, expired 11/2016;
- twenty-five 5 ml vials of injectable Dopamine HCL 200mg/ml (40 mg/ml) injection, expired 10/1/16;
- one 1 ml vial of injectable Enalaprilat 1.25 mg/ml, expired 10/1/16;
- seven bottles of injectable Adenosine 6mg/2ml, expired 11/16;
- ten bottles of injectable Enalaprilat 1.25 mg/ml, expired 9/2016;
- five ampules of injectable Vitamin K1 10mg/ml injection, expired 12/1/16;
- three 50 ml abboject syringes of 8.4% Sodium bicarbonate 1 mEq/ml injection, expired 10/16;
- one injectable GlucaGen 1 mg vial, expired 6/2016;
- ten ampules of injectable Physostigmine Salicylate 1ml/ml injection, expired 10/16;
- one pre-packaged tablet of Metoprolol tartrate 25 mg, expired 7/23/16;
- ten pre-packaged tablets of Prednisone 20 mg, expired 5/13/16.

During an observation on 12/28/16 at 8:50 a.m., medications kept in the "Drug room" included:
- four vials of injectable Dexamethasone 4mg/ml, expired 11/2016;
- ten vials of injectable levetiracetam 500 mg/5ml, expired 7/16;
- fifteen vials of haloperidol 5mg/ml, expired 12/1/16;
- eight ampules of injectable Vitamin K1 10mg/ml, expired 12/1/16.

During an interview on 12/28/16 at 8:59 a.m., staff member D stated nurses were required to check medications used in the emergency department and hospital monthly. She stated all expired medications were to be removed from the crash cart or drug room and disposed.

A review of the facility's Emergency Crash Cart medication check list showed staff had not checked for expired medications in September 2016 and December 2016.

A review of the facility's Preparation and General Guidelines policy, revised 11/2014, read, "...B. EXPIRATION DATES...At a minimum, that date opened must be recorded...D...If the dispensing date cannot be determined, the product should not be used and should be discarded...F. Medication in multi-dose vials may be used until the manufacture's expiration date/for the length of time allowed by state law/for thirty days if inspection reveals no problems during that time. USP guidelines recommend discarding multi-dose vials at 28 days after opened."

A review of the facility's Pharmacy policy read, "Removal/Destruction of Drugs. 1. Outdated medication are removed from stock. Pharmacist removes, destroys or returns all expired drugs. E.R. Drugs and Stock Drugs. 1. Checked on a monthly basis. 2. Drugs are ordered before they expire. 3. Expired drugs are removed by pharmacist. 4. Nursing/and or pharmacy may check for expiration dates."

On 12/28/16 at 10:15 a.m., an unsuccessful attempt was made to contact the facility pharmacist by phone.

During an interview on 12/29/16 at 8:35 a.m., staff member A stated the expired medications removed from the crash cart on 12/28/16 were not available. She stated she would contact the pharmacy to inquire the order status.

During an interview on 12/29/16 at 4:25 p.m., staff member A stated medications ordered from the pharmacy had not be delivered to the hospital. She stated she anticipated the pharmacy would deliver the medications before 5:00 p.m.

During an interview on 12/29/16 at 4:50 p.m., staff member F stated all staff members working in the emergency department should be checking for medication expiration dates. She stated all emergency medications should be available to treat emergency cases.

34603

Based on observation, interview and record review, the facility failed ensure medications commonly used in life-saving procedures, including anticonvulsants, antidotes, and antiarrhythmic were disposed of before the manufacture's expiration date; failed to document the open date on multiple-dose bottles of local anesthetics; and failed to use multiple-dose bottles prior to 28 days after opening. These medications have the potential to affect all patients seeking treatment from the hospital and swing-beds. Findings include:

During an observation on 12/28/16 at 7:59 a.m., opened/used multiple-dose bottles of local anesthetics were on a shelf in the emergency department and included:
- one 10 ml multiple-dose bottle of injectable Lidocaine 1% had an open date of 11/26/16;
- one 30 ml multiple-dose bottle of injectable Bacteriostatic 0.9 % was not dated when opened;
- one 10 ml multiple-dose bottle of injectable Lidocaine 1% and Epinephrine 1:100,000 had an open date of 4/17/16;
- one 50 ml multiple-dose bottle of injectable Marcaine 0.5% was not dated when opened;
- one 20 ml multiple-dose bottle of injectable Xylocaine 1% had an open date of 10/29/16.

During an interview on 12/28/16 at 8:25 a.m., staff member A stated nurses working in the emergency department were required to check medication expiration dates monthly. She stated staff members had not checked the crash cart for expired medications in September 2016 and December 2016.

During an observation on 12/28/16 at 8:30 a.m., medications kept in the crash cart in the emergency department included:
- four 1 ml vials of injectable Dexamethasone 4mg/ml, expired 11/2016;
- twenty-five 5 ml vials of injectable Dopamine HCL 200mg/ml (40 mg/ml) injection, expired 10/1/16;
- one 1 ml vial of injectable Enalaprilat 1.25 mg/ml, expired 10/1/16;
- seven bottles of injectable Adenosine 6mg/2ml, expired 11/16;
- ten bottles of injectable Enalaprilat 1.25 mg/ml, expired 9/2016;
- five ampules of injectable Vitamin K1 10mg/ml injection, expired 12/1/16;
- three 50 ml abboject syringes of 8.4% Sodium bicarbonate 1 mEq/ml injection, expired 10/16;
- one injectable GlucaGen 1 mg vial, expired 6/2016;
- ten ampules of injectable Physostigmine Salicylate 1ml/ml injection, expired 10/16;
- one pre-packaged tablet of Metoprolol tartrate 25 mg, expired 7/23/16;
- ten pre-packaged tablets of Prednisone 20 mg, expired 5/13/16.

During an observation on 12/28/16 at 8:50 a.m., medications kept in the "Drug room" included:
- four vials of injectable Dexamethasone 4mg/ml, expired 11/2016;
- ten vials of injectable levetiracetam 500 mg/5ml, expired 7/16;
- fifteen vials of haloperidol 5mg/ml, expired 12/1/16;
- eight ampules of injectable Vitamin K1 10mg/ml injection, expired 12/1/16.

During an interview on 12/28/16 at 8:59 a.m., staff member D stated nurses were required to check medications used in the emergency department and hospital monthly. She stated all expired medications were to be removed from the crash cart or drug room and disposed.

A review of the facility's Emergency Crash Cart medication check list showed staff had not checked for expired medications in September 2016 and December 2016.

A review of the facility's Preparation and General Guidelines policy, revised 11/2014, read, "...B. EXPIRATION DATES...At a minimum, that date opened must be recorded...D...If the dispensing date cannot be determined, the product should not be used and should be discarded...F. Medication in multi-dose vials may be used until the manufacture's expiration date/for the length of time allowed by state law/for thirty days if inspection reveals no problems during that time. USP guidelines recommend discarding multi-dose vials at 28 days after opened."

A review of the facility's Open Vial policy, revised 2/1995, read, "All medication vials (including sodium chloride, potassium, etc.) must be dated and initialed when opened. All stock vials must be discarded one month after opening..."

A review of the facility's Pharmacy policy read, "Removal/Destruction of Drugs. 1. Outdated medication are removed from stock. Pharmacist removes, destroys or returns all expired drugs. E.R. Drugs and Stock Drugs. 1. Checked on a monthly basis. 2. Drugs are ordered before they expire. 3. Expired drugs are removed by pharmacist. 4. Nursing/and or pharmacy may check for expiration dates."

A review of the facility's Pharmaceutical Services policy, revised 2/2008, read, "BSMC has pharmaceutical services that meet the needs of the patients and comply with the following standards:...b. Outdated, mislabeled, or otherwise unusable drugs and biologicals are removed from the facility and destroyed...2. When a pharmacist is not available, drugs and biologicals may by removed from the drug storage area by the licensed nurse on duty."

On 12/28/16 at 10:15 a.m., an unsuccessful attempt was made to contact the facility pharmacist by phone.

During an interview on 12/29/16 at 4:50 p.m., staff member F stated all staff members working in the emergency department should have been checking for medication expiration dates.

Based on interview and record review, the facility failed to perform annual staff performance evaluations for 4 of its nursing staff. Findings include:


1. Staff member D was hired in December of 2010.

A review of the employee's personnel file failed to show a yearly Employee Job Performance Evaluation had been conducted.

2. Staff member I was hired in June of 2015.

A review of the employee's personnel file failed to show a yearly Employee Job Performance Evaluation had been conducted.

3. Staff member J was hired in October of 1999

A review of the employee's personnel file failed to show a yearly Employee Job Performance Evaluation had been conducted.

4. Staff member L was hired in August of 2008.

A review of the employee's personnel file failed to show a yearly Employee Job Performance Evaluation had been conducted.

A request was made for employee annual performance evaluations for staff members D, I, J, and L. Yearly Employee Job Performance Evaluations were not received.

During an interview on 12/29/16 at 1:10 p.m., staff member M stated each department supervisor was responsible for completing the annual job performance evaluation.

During an interview on 12/29/16 at 1:45 p.m., staff member A stated she was responsible for conducting yearly Employee Job Performance Evaluations for the nursing staff. She stated she had not done any evaluations "for a while."

A review of the facility's Job Description for the Director of Nursing Services, revised 2/2008, read, "FUNCTIONS:...6. Analyzes and evaluates performance of personnel annually."

Based on record review and interview, the facility failed to ensure the patients had a working care plan upon admission to include all aspects of care as well as discharge for two patients (#s 13 and 16) of 20 sampled patients. Findings include:

1. Patient #13 was admitted to the facility on 1/3/15 as an in-patient.

Review of Patient #13's medical record lacked the Care Plan for the patient during her stay.

During an interview on 12/28/16 at 4:00 p.m., staff member D stated several times the computer program the facility was using was not the best program and many staff had a problem with using it.

2. Patient #16 was admitted to the facility on 11/26/15 as an in-patient.

Review of Patient #16's medical record lacked the Care Plan for the patient during her stay.

During the exit conference on 12/29/16 at 4:40 p.m., staff member A stated the facility had not care planned for in-patients because the patients are only there for in-patient status for 96 hours. She also stated the computer program the facility uses, sometimes deleted the care plan when the patient was discharged.

Review of the facility's policy and procedure titled Nursing Service Patient Records and Charting showed care plans are to be done.

Review of the facility's policy and procedure titled Charting showed nursing care plans would have patients' problems and nursing interventions identified.

Based on record review and interview, the facility failed to ensure the policies and procedures were reviewed annually. Findings include:

1. A review of the facility's radiology department policies and procedures lacked documentation of an annual review and revised dates. The last documented date was 5/1/12.


34603

2. A review of the facility's Open Vial policy lacked documentation of an annual review and revised date. The last revised date was 2/1995.

3. A review of the facility's Pharmaceutical Services policy lacked documentation of an annual review and revised date. The last revised date was 2/2006.

4. A review of the facility's Nursing Services policy lacked documentation of an annual review and revised date. The last revised date was 2/2008.

5. A review of the facility's Admissions policy lacked documentation of an annual review and revised date. The last revised date was 2/1995.

6. A review of the facility's Patient Records and Charting policy lacked documentation of an annual review and revised date. The last revised date was 8/1995.

7. A review of the facility's Discharge Planning policy lacked documentation of an annual review and revised date. The last revised date was 8/1995.

During an interview on 12/28/16 at 9:30 a.m., staff member E stated she was unaware of how often the policies and procedures should be reviewed or who had done them.

During an interview on 12/29/16 at 1:20 p.m., staff member H stated staff member G thought the review sheet for the radiology policies and procedures would be in front of the blue book or in the QA book. If it was not in either book, it was not done.

34603

Based on interview and record review, the facility failed to ensure an effective quality assurance program to evaluate quality which included ongoing monitoring, data collection, implementation, and evaluations of corrective actions to improve quality on a continuous basis. Findings include:

During an interview on 12/29/16 at 9:00 a.m., staff member A stated the emergency department did not have an ongoing quality assurance project. She stated she would begin a project as soon as possible. She stated the next project would include monitoring the crash cart medications for expired medications.

During an interview on 12/28/16 at 3:50 p.m., staff member D stated she was not aware of the current/ongoing quality assurance project was for the emergency department.

A review of Q[AP]I meeting notes, dated 10/28/2015 and 4/19/16, read, "Emergency Room- Nursing staff (along with ambulance volunteers) need further education and practice on the newly purchased LifePak heart monitor. Pharmacy- Supplies and pharmacy items in the ER cart must be checked monthly with outdated items properly disposed of."

A review of QAPI meeting notes, dated 7/27/16, read, "Emergency Room- Nursing staff (along with ambulance volunteers) need further education and practice on the newly purchased LifePak heart monitor. However, despite numerous efforts by the DON, a piece of equipment is missing that is needed for the transmission of data to the receiving facility..." No pharmacy notes were included.

A review of QAPI meeting notes, dated 10/26/16, read, "Emergency Room- No new QI's added. Ongoing QA's located in QAPI book. Pharmacy- No new QI's added. Ongoing QA's located in QAPI book."

34603

Based on record review and interview, the facility failed to ensure a background check had been conducted on all direct care staff before their date of hire. This practice has the potential to affect all patients and swing-bed patients. Findings include:

1. Staff member A was hired in June of 1976.

A review of the staff member's personnel file failed to show a background check had been conducted.

2. Staff member D was hired in December of 2010.

A review of the staff member's personnel file failed to show a background check had been conducted.

3. Staff member J was hired in October of 1999.

A review of the staff member's personnel file failed to show a background check had been conducted.

4. Staff member L was hired in August of 2008.

A review of the staff member's personnel file failed to show a background check had been conducted.

5. Staff member N was hired in December of 2007.

A review of the staff member's personnel file failed to show a background check had been conducted.

6. Staff member O was hired in January of 2015.

A review of the staff member's personnel file failed to show a background check had been conducted.

During an interview on 12/29/16 at 11:40 a.m., staff member M stated a background check was not conducted on all of the hospital staff members. She stated a background check should have been completed prior to the staff member providing direct patient care.