HospitalInspections.org

Based on findings from observation and interview, many of the items in the pharmacy were stored in outer corrugated cardboard shipping containers used in their transport. Corrugated cardboard shipping containers can harbor dust and bacteria and are a source of fungal contamination and bacterial spores.

Findings include:

--Per observations on 11/14/11 at 2:30 pm, items considered to be clean and maintained in inventory by the pharmacy were being stored in the corrugated cardboard boxes used to ship them. The Director of Facilities was present at the time the observation was made and confirmed this finding.

Based on findings from observation and interview, the walls in the ultrasound room were not smooth and easily cleanable.

Findings include:

--Per observations on 11/14/11 at 1:10 pm, the wallboards in the ultrasound room were in disrepair and the paint was peeling. The Director of Facilities was present at the time the observation was made and verified this finding.

Based on findings from observations and interview, portions of walls and the floor of the dry food storage area and portions of the walls, floor, and windows of the kitchen were either not clean or not cleanable. Additionally, the handwashing sink in the cafeteria serving area was not maintained in good repair.

Findings include:

--Per observations on 11/14/11 at 2:45 pm, the paint on the wall behind the compresser in the dry food storage area was peeling; the floors in the dry food storage area and kitchen were not clean; the walls and windows in the kitchen were not clean; the ceramic wall tiles in the sink area of the kitchen were not intact and cleanable; and the basin in the handwashing sink in the cafeteria serving area was not smooth and easily cleanable. The Director of Facilities was present at the time these observations were made and acknowledged these findings.

Based on findings from observations, document reviews and interviews, the hospital did not follow generally accepted infection control (IC) practices. Specifically, 4 of 9 personnel files reviewed lacked documented evidence of rubeola immunity, and 2 of 4 physician's credentials files lacked documented evidence of rubella immunity. Also, in 1 of 1 observations of care provided to a patient on droplet isolation precautions, an RN (RN # 2) did not don a mask when entering the room or wash his/her hands upon exiting the room.

Findings include:

-Per review of hospital's policy and procedure (P & P) entitled "Assessment of Employee's Health Infection Control Guidelines," last revised 6/06, it indicates that staff pre-employment requirements include proof of rubeola (measles) immunity per the "Measles Immunity Policy" and rubella antibody test for all employees.

Per review of hospital's P & P entitled "Measles Immunity Policy," last revised 6/06, it states "Documentation of proof of immunity to measles from all personnel...Proof of immunity is defined as acceptable documentation of...History of physician-diagnosed measles disease in the past, or ... Laboratory (serologic) evidence of measles immunity, or ...Two doses of live measles vaccine administered on or after 12 months of age given at least one month apart..."

--Per review of LPN # 1's, the CT Technician's, the Pharmacy Technician's, and RN # 1's personnel files, they all lacked evidence of immunity to rubeola.

--Per review of Physician #1's and Physician #2's credentials files, both lacked evidence of immunity to rubella.

--During interview of the Infection Control Nurse on 11/16/11, the above findings were verified.

--Additionally, per observations on 11/17/11 at 10:35 am, RN # 2 entered a droplet isolation room and did not don a mask as required by generally accepted standards of infection control. He /she provided care to the patient. He/she then removed gloves, did not wash hands and exited the room. He/she went to the medication room and removed medication from the pyxis, then documented in the medication administration record on the medication cart. RN # 2 reentered the droplet isolation room, again without donning a mask, and provided care to the patient.

--During interview with the 3E Nurse Manager on 11/17/11 at 11:05 am, this finding was verified.

Based on findings from document reviews and interviews, nutritional services were not being provided in accordance with hospital policy and procedure (P & P). Specifically, a dietician was not part of the Skin and Wound Assessment Team (SWAT) meetings as required by the hospital's P & P. Also, in 1 of 3 medical records (MR) reviewed, although a dietary consult was ordered it was not provided prior to discharge.

Findings include:

--Per review of the hospital's P & P entitled "Pressure Ulcer Prevention and Management," last reviewed 7/14/11, it states that the SWAT team meets at least weekly and includes the Dietician/Designee.

--Per review of the SWAT meeting minutes dated 10/27/11 and 11/1/11, the Dietician was not in attendance.

--Per review of Patient A's MR, on 11/3/11 a dietary consult regarding "prediabetes per protocol" was ordered; however, Patient A was discharged on 11/7/11 without the consult.

--Per interview of the Dietician on 11/15/11 at 10:30 am, he/she verified that Patient A did not have a dietary consult prior to discharge. In addition he/she does not attend team meetings for patients.

Based on findings from document review and interview, 3 of 3 policy and procedure (P & P) manuals reviewed during the survey lacked evidence of review within the past year as required by this regulation. Specifically, the Infection Control P & P Manual, the Central Sterile P & P Manual and the Nursing P & P Manual were not reviewed annually.

Findings include:

--Per review of the Infection Control P & P Manual, the Central Sterile P & P Manual, and the Nursing P & P Manual, many P & Ps had not been reviewed annually. For example, a P & P entitled "Patient Care Procedures" in the Infection Control P & P Manual (which includes procedures for dressing changes, medication administration, obtaining vital signs, care of linen, and intravenous infusions) was last reviewed/revised on 5/01. A P & P entitled "Instrument Disinfection" in the Central Sterile P & P Manual was last revised/reviewed in 10/01. A P & P entitled "Pain Management Policy" in the Nursing P & P Manual was last reviewed/revised 8/30/07.

--During interview with the Director of Quality Resource Risk Management on 7/14/11 at 2:30 pm, these findings were acknowledged.

Based on findings from document review and interview, the hospital has not evaluated the care provided by a contracted service. Specifically, a contracted nurse who inserts Peripherally Inserted Central Catheters (PICC) in patients has not been evaluated for proficiency by the hospital. Also the registered nurse (RN #3) who provides the contracted service was not oriented to the hospital prior to beginning her service.

Findings include:

--Per review of the document entitled "Vascular Access Management Agreement," dated 12/1/09, it states "Hospital shall monitor the performance of the Vascular Access Services by Upstate, to ensure that all services provided to patients comply with all applicable provisions of Federal, State, and local statutes, rules and regulations and with standards set by the Hospital...The registered nurses assigned by Upstate to perform the Vascular Access Services shall successfully complete all of the mandatory education and training requirement reasonably established by the Hospital for its employed registered nurses..."

--Per review of MRs of Patients I, J, and K, all had PICC lines inserted prior to October 2011.

--However, per review of the Little Falls Hospital Education Orientation form completed by RN #3, who inserts PICC lines at the hospital, the date the orientation was completed was 11/2011 (months after RN #3 began inserting PICC lines at this hospital).

--Also, during interview of the Director of Quality Resources Risk Management on 11/17/11 at 10:00 am, he/she indicated that the services provided by the PICC line RN are not evaluated by the hospital.

Based on findings from document review and interview, care provided to patients ( Patient O and Patient Q) did not meet generally accepted standards of nursing practice or hospital policy. Specifically, in 1 of 1 medical record (MR) reviewed for a patient with neurological checks ordered, Patient O did not receive neurological checks as ordered by a physician. In 1 of 2 MRs reviewed for patients receiving pain medication prior to wound care, Patient Q did not receive pain medication per his/her established nursing care plan.

Findings include:

--Per review of the hospital's policy and procedure (P & P) entitled "Documentation of Nursing Care, " not dated, it states "As interventions and physician orders are completed these will be documented on appropriate forms in the patient's record."

--Per review of Patient O's medical record, a physician order dated 11/8/11 at 3:15 pm states "Neuro checks Q4hrs x 24 hrs."

Per review of form entitled "Neuro Assessment," dated 11/8/11, a neurological check was done at 4:45 pm, which included assessment of mental status, pupil reactions, hand grasp, and peripheral sensation. Another neurological check was not documented until the next day, 11/9/11, at 8:00 am (16 hours later). Although there was a nursing note written at 8:00 pm on 11/8/11 which indicated neuros were stable, it did not describe pupillary reactions or peripheral sensations.

--Per review of Patient Q's MR, a form entitled "Initial Wound Assessment Record," dated 11/8/11, contains the statement "pain medication prior to dressing change."

However, additional statements in the MR, for example, on 11/9/11, include "no complaints of discomfort prior to wound (dressing) change. Pain 5/10 on 1-10 scale after wound care, medicated."

--During interview with the Director of Quality Resource Risk Management on 11/17/11 at 2:00 pm., these findings were acknowledged.

Based on findings from document review and interview, nursing documentation did not meet generally accepted standards of nursing practice. Specifically, nursing staff did not document the site of administration of subcutaneous injections. Additionally, hospital staff did not document medication reconciliation activities per the hospital policy and procedure (P & P), in 3 of 6 inpatient medical records (MR) reviewed and in 2 of 5 ambulatory surgery unit (ASU) MRs reviewed regarding this issue.

Findings include:

--Per review of Patient B's MR, the Medication Administration Record (MAR) indicates that heparin 5,000 units subcutaneous (SQ) every 12 hours was ordered on 11/10/11. On 11/10/11, 11/11/11, 11/12/11, and 11/13/11 the nurse initialed the injection as being given but did not document the injection site.

--Per interview of 3 East Charge Nurse #1 on 11/16/11 at 11:15 am, he/she stated that documentation of subcutaneous injection sites are not required.

--During interview of the Director of Quality Resources Risk Management on 11/14/11 at 4:00 pm, he/she verified that hospital policy does not require documentation of injection sites for medications requiring repeated subcutaneous administrations.

--Per review of hospital P&P entitled "Medication Reconciliation," effective September 2008, it states "upon admission the medication reconciliation form will be initiated. Boxes will be checked to indicate if the medication was ordered, held or discontinued. Upon discharge the provider will check either resume or stop box for each medication."

--Per review of the MRs of Patients C, D, and E, the medication reconciliation forms lacked evidence that medication reconciliation had occurred at admission or discharge.

During interview of the 3 East Nurse Manager on 11/14/11 at 3:00 pm, these findings were verified.

--Per review of the MRs of Patients M and P, the medication reconciliation forms both list the patient's medications; however, the forms lack indication of whether the patient was to continue or discontinue the medications upon discharge and were not signed by the provider.

During interview with the ASU Nurse Manger on 11/17/11 at 10:00 am, these findings were verified.

Based on findings from document review and interview, physician telephone orders were not verified and countersigned by the prescribing practitioner within the time period specified by the Medical Staff Rules and Regulations, in 5 out of 9 medical records (MR) reviewed regarding this matter.

Findings include:

--Per review of the hospital's policy and procedure (P & P ) entitled "Verbal Orders and Telephone Orders," last revised 11/10/10, it states " ...Orders that are not written by a prescriber shall be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within the time period specified by medical staff rules and regulations..."

--Per review of the hospital document entitled "Medical Staff Rules and Regulations," not dated, it states "telephone verbal orders must be signed and dated by the end of the next calendar day by the ordering or attending practitioner."

--Per review of Patient Q's MR, a telephone order dated 11/7/11 stated "Benadryl 50 mg po qhs sleep prn." As of 11/15/11, eight days later, the order had not been signed by the prescribing practitioner. Another telephone order dated 11/8/11 stated "Ativan 1 mg po for anxiety now." As of 11/15/11, seven days later, the order had not been signed by the prescribing practitioner.

--Per review of Patient B's MR, a telephone order dated 11/10/11 stated "Change nitro 1/2 TD paste to every 8 hours." As of 11/14/11, four days later, the order had not been signed by the prescribing practitioner.

--Per review of Patient F's MR, a telephone order dated 11/10/11 stated "Oxygen nasal cannula to maintain sat equal to or greater than 90%." As of 11/14/11 the order had not been signed by the prescribing practitioner.

--Per review of Patient G's MR, a telephone order dated 11/13/11 stated "Tylenol 650mg PO Q 4 hours prn pain." As of 11/15/11, two days later, the order had not been signed by the prescribing practitioner.

--Per review of Patient H's MR, a telephone order dated 11/13/11 stated "Omeprazole 40 mg PO daily." As of 11/15/11 the order had not been signed by the prescribing practitioner.

--During interview of the Director of Quality Resource Risk Management on 11/17/11 at 2:00 pm, the above findings were acknowledged.

Based on findings from document review and interview, the hospital did not ensure that the Quality Assurance Performance Improvement (QAPI) program evaluated all patient care services and other services affecting patient health and safety. Specifically, the QAPI program did not document mortality reviews that were reported to have been done for unexpected deaths. Also the QAPI program did not include the hospital's 2 primary care outpatient clinics. Additionally, evidence of annual evaluations and/or peer reviews was lacking in the personnel files reviewed for 2 providers, i.e., a contracted dietician and an occupational therapist.

Findings include:

--Per review of the hospital's document entitled "Facility Inpatient Discharge Detail," dated 11/14/11, it indicated that 13 patients expired between 5/1/11 and 10/31/11.

However, per interview of the Director of Quality Resources and Risk Management on 11/17/11 at 10:00 am, he/she indicated that although physicians do meet and review unexpected mortalities, these reviews are not documented.

--Per review of the hospital 's QAPI program and QAPI meeting minutes for 2011, there is no documentation of any quality review and performance improvement activities for the 2 primary care outpatient clinics of the hospital.

During interview of the Director of Quality Resources Risk Management on 11/17/11 at 2:00 pm, the above finding was acknowledged.

--Per review of the personnel file for the contracted Dietician, it lacked performance evaluations and evidence of any peer reviews.

During interview of the Director of Quality Resources Risk Management on 11/17/11 at 1:00 pm, he/she verified that the Dietician's performance has not been evaluated.

--Per review of the personnel file for the Director of OT, who does provide OT services, his/her last 2 annual performance evaluations (dated 6/20/10 and 4/20/11) both lacked evidence of any peer reviews. The Director of OT is annually evaluated by the hospital's Chief Executive Officer only.

During interview with the Director of Quality Resources Risk Management on 1/17/11 at 2:30 pm, this finding was verified.