HospitalInspections.org

Based on observation and interview, the hospital failed to ensure patients at risk for harm to self or others were provided care in a safe setting as evidenced by failing to ensure rooms were free of tamper proof screws.

Findings:

A tour of the hospital on 09/27/2022 between 8:15 a.m. and 9:10 a.m. revealed the hospital failed to use tamper resistant screws in the following areas: 16 of 16 patient rooms, including entry door hinges, bathroom door handles for rooms a and b, room c door latch; group dayroom; male and female bathrooms door handles; dayroom light switch covers; quiet room windows and switch plates; seclusion room door latch.

In an interview on 09/27/2022 at 9:10 a.m., S3RN verified the non-tamperproof screws.

Based on observation and interview, the hospital failed to properly file and store patient records in a manner to protect them from fire or water damage as evidenced by storing paper medical records on open shelving.

Findings:

On 09/28/2022 at 9:25 a.m., a tour of the medical records stored in the garage area and storage shed revealed the medical records from 2012 through 2021 were stored on open shelves and in boxes not protected from fire and or water.

In an interview on 09/28/2022 at 9:25 a.m., S2DON and F6FacMgr verified the records were not protected from fire and water as noted above.

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use as evidenced by having expired and/or unusable medications available for patient use.

Findings:

Review of the Medication Storage policy presented by S2DON revealed: Vials that are opened are labeled per nursing to include date, time and initial of the nurse who opened the vial; Medications are checked for expiration dates on a regular basis by nursing staff. S2DON confirmed there was no written policy for the expiration and disposal of opened multidose vials.
An inspection report was presented by S2DON that indicated the medication cart was to be checked for expired medications by the nursing staff on the last shift of the month.

On 09/27/2022 at 9:20 a.m., a tour of the medication room revealed the following:
Novolog 100 units/ml, 10 ml vial opened and not dated;
Novolin 70/30, 10 ml vial with open date 10/18/2021;
Lantus 100 units/ml, 10 ml vial with open date 4/11/2022;
Levemir 100 units/ml, 10 ml vial with open date 4/2/2022;
Humalog 100 units/ml, 10 ml vial with open date 04/02/2022.

In an interview on 09/27/2022 at 9:25 a.m, S4LPN verified the expired medications and confirmed that they should have been discarded 28 days after opening.

Based on observation and interview, the hospital failed to maintain a system for controlling infections and communicable diseases by failing to maintain a sanitary environment.

Findings:

On 09/27/22 between 8:15 a.m. and 9:30 a.m., observations during the tour of the hospital revealed:
The clean linen located in the storage room was not covered;
The metal handles on the restraint bed in the seclusion room were rusty and dirty;
The kitchen contained a portable fan covered in dust blowing towards the three compartment sink;
The oven door handles were dirty and greasy and the inside of the oven was dirty;
Air condition vents in the kitchen were covered with dust;
Air condition vents in the day room were covered with dust;
An open, partially used bag of dry mashed potatoes was sitting on a shelf in the pantry;
An open, partially used bag of Ranch Dressing was sitting on a shelf in the pantry;
A pitcher of tea in the refrigerator not dated.

In an interview on 09/27/2022 at 9:10 a.m., S3RN verified the uncovered linen and rusty, dirty restraint bed handles.

In an interview on 09/27/2022 at 9:20 a.m,. S4DietMgr verified the dirty fan, air conditioning vents, dirty ovens, open mashed potatoes and Ranch Dressing, and undated tea.

Based on record review and interview, the physician failed to complete a neurological examination at the time of the admission physical examination for 8 of 8 (Patient #1-#8) patients reviewed for neurological exams in a total sample of 8 patients.

Findings:

A review of Patient #1-#8's medical record failed to give a methodology or detailed description used for gross testing of Cranial Nerves II-XII.

In an interview on 09/28/2022 at 10:30a.m., S2DON verified the hospital failed to ensure a complete neurological examination was completed as part of the admission physical examination for Patients #1-#8.