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Based on observation, interview and record review, the Governing Body failed to:

A. produce a complete copy of Medical Staff Bylaws, Rules and Regulations for review. The available partial Medical Staff Bylaws were missing the credentialing, grievance regulations for the facility from January through July 8, 2019.

Refer to Tag A 0048


B. to provide clear delineation of privileges for 3 of 3 medical staff members from June of 2018 through July of 2019.

Refer to Tag 0051


C. ensure defibrillator pads used with a defibrillator to give lifesaving treatment for cardiac dysrhythmias were not expired and immediately available in two crash carts in the radiology department.

D. ensure emergency supplies on the crash cart were not expired and immediately available. There were expired endotracheal tubes in two crash carts in the radiology department. There was an expired Co 2 monitoring device in one crash cart in the radiology department.

E. ensure the Radiology technician was trained on the process of calling for immediate assistance during a patient emergency in the Cat Scan Room.

F. Ensure the Radiology Cat Scan contrast was stored per the manufacturer's guidelines. Contrast was stored in a warmer that did not have a thermometer and no way to monitor the temperature of the contrast. The facility could not ensure the contrast stability of the contrast that was given intravenously for patients having a Cat Scan. Also, the facility could not ensure that that Cat Scan contrast stored in a warmer did not have an elevated temperature that would place all patients having a Cat Scan with intravenous contrast at risk of a burn injury.

Refer to Tag A 144


G. ensure that all entries in the patient medical record were legible, complete, dated, timed, and authenticated in 16 (Patient #'s 1,2,3,4,5,6,7,14,15, 18, 19, 20, 21, 22, 23 &24) of 16 records reviewed.


Refer to Tag A 450

H. ensure that orders were authenticated promptly by the ordering practitioner. This deficient practice was found in 4 (Pt's #2,3,6, &7) of 7 patients reviewed.

Refer to Tag A 454


I. ensure the facility dispensed patient home medications safely.

J. ensure the medication room at the nurses' station was secure.

K. failed to reduce afterhours access to the primary pharmacy for the facility from January through June 9, 2019.

Refer to Tag A 489


L. ensure that the Radiology department had a process to ensure that the radiation workers maintained a safe radiation exposure. The hospital did not have personnel who monitored staff exposure on a regular basis.

Refer to Tag A 538


M. ensure there was a supervising radiologist designated to supervise the ionizing radiology services at the facility. Also, the facility failed to establish criteria in the Medical Staff Bylaws for designation of a Supervising radiologist.

Based on observation, interview and record review, the Governing Body failed to:

A. produce a complete copy of Medical Staff Bylaws, Rules and Regulations for review. The available partial Medical Staff Bylaws were missing the credentialing, grievance regulations for the facility from January through July 8, 2019.

Refer to Tag A0048


B. to provide clear delineation of privileges for 3 of 3 medical staff members from June 2018 through July 2019.

Refer to Tag 0051


C. ensure defibrillator pads used with a defibrillator to give lifesaving treatment for cardiac dysrhythmias were not expired and immediately available in two crash carts in the radiology department.

D. ensure emergency supplies on the crash cart were not expired and immediately available. There were expired endotracheal tubes in two crash carts in the radiology department. There was an expired Co 2 monitoring device in one crash cart in the radiology department.

E. ensure the Radiology technician was trained on the process of calling for immediate assistance during a patient emergency in the Cat Scan Room.

F. Ensure the Radiology Cat Scan contrast was stored per the manufacturer's guidelines. Contrast was stored in a warmer that did not have a thermometer and no way to monitor the temperature of the contrast. The facility could not ensure the contrast stability of the contrast that was given intravenously for patients having a Cat Scan. Also, the facility could not ensure that that Cat Scan contrast stored in a warmer did not have an elevated temperature that would place all patients having a Cat Scan with intravenous contrast at risk of a burn injury.

Refer to Tag A144

G.ensure that all entries in the patient medical record were legible, complete, dated, timed, and authenticated in 16 (Patient #'s 1,2,3,4,5,6,7,14,15, 18, 19, 20, 21, 22, 23 &24) of 16 records reviewed.

Refer to Tag A450


H. ensure that orders were authenticated promptly by the ordering practitioner. This deficient practice was found in 4 (Pt's #2,3,6, &7) of 7 patients reviewed.

Refer to Tag A454


I. ensure the facility dispensed patient home medications safely.

J. ensure the medication room at the nurses' station was secure.

K. reduce afterhours access to the primary pharmacy for the facility from January through June 9, 2019.

Refer to Tag A489


L. ensure that the Radiology department had a process to ensure that the radiation workers maintained a safe radiation exposure. The hospital did not have personnel who monitored staff exposure on a regular basis.

Refer to Tag A 538


M. ensure there was a supervising radiologist designated to supervise the ionizing radiology services at the facility. Also, the facility failed to establish criteria in the Medical Staff Bylaws for designation of a Supervising radiologist.

Refer to Tag A546

N. establish a Utilization Review Committee to carry out the Utilization Review functions of the hospital.

Refer to Tag A0654


O. develop and implement a Utilization Review plan that identified the frequency that cases would be reviewed or monitored by a Utilization Review Committee or the method used to review the medical necessity of admissions to the institution, the duration of stays, and professional services provided.

Refer to Tag A0655


P. ensure the infection control officer developed a system that maintained a clean and sanitary environment for 27 (ER triage, ER entrance, ER Hallways, ER housekeeping closet, Isolation, ER Ambulance entrance, ER nurses station, ER Room 2, ER Room 6, ER patient supply room, ER biohazard/decontamination room, Pediatric Broselow cart in ER, Sterile Processing Room, Respiratory department, Materials Management, Radiology room 1, Radiology room 2, Radiology teleradiology room, Radiology patient bathroom, Cat Scan room, main radiology crash cart, kitchen, CT room transvaginal ultrasound room, West wing room 126, West wing room 136, West wing clean utility room, West wing medication room.) of 27 areas observed.

Refer to Tag A 749

Based on interview and record review the facility failed to produce a complete copy of Medical Staff Bylaws, Rules and Regulations for review. The available partial Medical Staff Bylaws were missing the credentialing, grievance regulations for the facility from January through July 8, 2019.



This deficient practice had the likelihood to effect all patients of the facility.


Findings included.


On 7/10/2019 in the conference room the credentialing files for staff #5,#9 and #28 were reviewed. All three medical staff files were missing peer references. A request was made for a copy of the Medical Staff Bylaws, Rules and Regulations for the purpose of determining how many peer letters were required.

A partial copy of the Rules and Regulations was provided. The present Chief Executive Officer (CEO), Staff #1, confirmed the previous CEO, prior to leaving, had destroyed all or most of the facility's legal documentation and there was not a complete set of the rules and regulation in the facility.

The documentation destruction became known after the start of the New Year but it was not determined until the request was made that the Medical Staff Bylaws, Rules and Regulations were missing.

The CEO confirmed there was not a complete Document for Medical Staff Bylaws, Rules and Regulations.

Based on document review and interview the facility failed to provide clear delineation of privileges for 3 of 3 medical staff members from June of 2018 through July of 2019.


This deficient practice has the likelihood to effect all patients of the facility.


Findings included.


On 7/10, 20109 in the conference room the credentialing files for staff #5, #9 and #28 were reviewed.

Staff physician #5 requested full privileges on June 2018, The Board signed off on the request for privileges, without exception, at the end of the final page. A lack of documentation was seen on the candidates request of privileges form, indicating the Governing Board had not reviewed the details of the requested privileges.

A review of the requested privileges included, delivery, diagnosis and evaluate, high risk pregnancy, renal dialysis complications. Surgical services included, abdominal paracentesis, cardiac pacing transvenous or transcutanious, nonconscious sedation.

Interview with the Chief Executive Officer confirmed the facility no longer provided surgical services or delivered babies or other obstetrical services.

Staff physician #9 requested full privileges on June 2018, The Board signed off on the request for privileges, without exception, at the end of the final page. A lack of documentation was seen on the candidates request of privileges form, indicating the Governing Board had not reviewed the details of the requested privileges.

A review of the requested privileges included, delivery, diagnosis and evaluate, high risk pregnancy, renal dialysis complications. Surgical services included, abdominal paracentesis, cardiac pacing transvenous or transcutanious, nonconscious sedation.

Interview with the Chief Executive Officer confirmed the facility no longer provided surgical services, dialysis or delivered babies or other obstetrical services.

Physician #28 refused to request privileges and asked if her spouse could complete the form on her behalf. She was not permitted to have her spouse complete the credentialing request on her behalf, she had not been removed from the active physician list.

Based on observation and interview the facility failed to ensure that patients received care in a safe setting in 2 (Main radiology department & Cat Scan Room) of 2 areas.


The facility failed to ensure:

A. defibrillator pads used with a defibrillator to give lifesaving treatment for cardiac dysrhythmias were not expired and immediately available in two crash carts in the radiology department.

B. emergency supplies on the crash cart were not expired and immediately available. There were expired endotracheal tubes in two crash carts in the radiology department. There was an expired Co 2 monitoring device in one crash cart in the radiology department.

C. the Radiology technician was trained on the process of calling for immediate assistance during a patient emergency in the Cat Scan Room.

D. Radiology Cat Scan contrast was stored per the manufacturer's guidelines. Contrast was stored in a warmer that did not have a thermometer and no way to monitor the temperature of the contrast. The facility could not ensure the contrast stability of the that was given intravenously patients having a Cat Scan. Also, the facility could not ensure that that Cat Scan contrast stored in a warmer did not have an elevated temperature that would place all patients having a Cat Scan with intravenous contrast at risk of a burn injury.


It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients having a cat scan in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death.

Refer to Tag A144

Based on observation and interview, the facility failed to ensure that patients received care in a safe setting in 2 (Main radiology department & Cat Scan Room) of 2 areas.

The facility failed to ensure:

A. defibrillator pads used with a defibrillator to give lifesaving treatment for cardiac dysrhythmias were not expired and immediately available in two crash carts in the radiology department.

B. emergency supplies on the crash cart were not expired and immediately available. There were expired endotracheal tubes in two crash carts in the radiology department. There was an expired Co 2 monitoring device in one crash cart in the radiology department.

C. the Radiology technician was trained on the process of calling for immediate assistance during a patient emergency in the Cat Scan Room.

D. Radiology Cat Scan contrast was stored per the manufacturer's guidelines. Contrast was stored in a warmer that did not have a thermometer and no way to monitor the temperature of the contrast. The facility could not ensure the contrast stability of the that was given intravenously patients having a Cat Scan. Also, the facility could not ensure that that Cat Scan contrast stored in a warmer did not have an elevated temperature that would place all patients having a Cat Scan with intravenous contrast at risk of a burn injury.


It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients having Cat Scan (CT) procedure with contrast in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death.



Findings Include:


During an observation tour on 7-10-2019 after 10:00 AM the following was observed:

CRASH CARTS

CT Room:

The Defibrillator pads (used with a defibrillator to give lifesaving treatment for cardiac dysrhythmias) expired in 2018; over 1 year ago. The suction catheter expired in 2018; over 1 year ago.

The laryngoscope blade and handle that were stored in the emergency intubation kit were uncovered. The blades had not been through the high-level disinfection process and the handle was not labeled clean or dirty. There was a tongue blade stored in the kit with a gauze sponge taped to the end of it.

KY Jelly packets expired 6-30-2018; over 1 year ago.

There were three endotracheal tubes that expired ranging from 4-2018 to 3-2019, over 1 year ago.

The portable suction had not been checked. Staff #21 stated he was not aware it had to be checked.



Main Radiology Department:

The Defibrillator pads (used with a defibrillator to give lifesaving treatment for cardiac dysrhythmias) - one packed expired 1-2018, over 1 ½ years ago. The other package expired
12-2018; almost 1 year ago.

The emergency intubation kit had laryngoscope blades and a handle that were stored in the emergency intubation kit open and uncovered. The blades had not been through the high-level disinfection process and the handle was not labeled clean or dirty. There were patient oral airways stored uncovered exposing them to a buildup of dirt, dust, and contamination.

KY Jelly packets expired 6-30-2018, over 1 year ago.

There were three endotracheal tubes that expired ranging from 3-2018 to 12-2018, over 1 year ago.

The portable suction had not been checked. Staff #21 said he was not aware it had to be checked.

There was a CO 2 Monitoring device that expired 9-2016, almost 3 years ago.


EMERGENCY CALL SYSTEM IN THE CT ROOM

During a tour on 7-10-2019 after 10:00 A.M., Staff #21 was asked to demonstrate how the CT Staff would call for assistance during an emergency. Staff #21 stated there was no emergency call system. Staff #21 stated he would have to get to the phone and make an overhead page for help. Staff #21 was asked how emergency care such as CPR (Cardio-Pulmonary Resuscitation) would be rendered if the staff had to go across the room and get the phone to call for help. Staff #21 stated he didn't know, but it had always been that way.

After 11:30 A.M., it was discovered that a Code Blue Button was available for use in the CT room. The system was tested and found to be working.



CAT SCAN (CT) CONTRAST


There was Contrast for Cat Scans stored in a warmer that did not read the temperature. The temperature was not monitored by the CT staff. The manufacturer temperature storage recommendations were 59-86 degrees F. The temperature in the warmer was checked by facility maintenance staff. The temperature ranged from 99.6 to 100.4 degrees F, almost 15 degrees above the manufacturer recommendations.

The facility did not have a thermometer in the Cat Scan to monitor the temperature of the contrast. The facility could not ensure the contrast stability of the contrast that was given intravenously to patients having a Cat Scan. Also, the facility could not ensure that that Cat Scan contrast stored in a warmer did not have an elevated temperature that would place all patients having a Cat Scan with intravenous contrast at risk of a burn injury.


Review of the Cat Scan patients totals for January 2019 to present revealed the following:

There was a total of 185 patients who had a Cat Scan with contrast since January 2019.


Staff # 21 & #2 confirmed the above findings.


Review of facility policy/procedure titled, "Crash Cart, Defibrillator, & Cardio scope checks" with no date of review revealed the following:

"Purpose:
To Assure the availability of supplies and functioning of emergency equipment, the following must be done.

1. Crash carts must be checked every eight hours in all areas to assure lock is intact and expiration dates are current...
7. Date will be checked for expiration ...
9. Remove and clean monitor/defibrillator from crash cart after each use ..."

Based on observation and interview the facility failed to:

A. ensure that all entries in the patient medical record were legible, complete, dated, timed, and authenticated in 16 (Patient #'s 1,2,3,4,5,6,7,14,15, 18, 19, 20, 21, 22, 23 &24) of 16 records reviewed.


Refer to Tag A450

B. ensure that orders were authenticated promptly by the ordering practitioner. This deficient practice was found in 4 (Pt's #2,3,6, &7) of 7 patients reviewed.
Refer to Tag A454

Based on record review and interview, the facility failed to ensure that all entries in the patient medical record were legible, complete, dated, timed, and authenticated in 16 (Patient #'s 1,2,3,4,5,6,7,14,15,18, 19, 20, 21, 22, 23 &24) of 16 records reviewed.

This deficient practice had the likelihood to cause harm to all patients treated in the emergency room.


During review of patient emergency room medical records on July 8, 2019 after 12:00 PM the following observations were made:


PATIENT #1

Patient #1 was a 74-year-old male who presented to the emergency room (ER) on 7-8-2019 for the complaint of, "Yellow jacket stings". The patient arrived at 1003. There was not a time listed for triage. The ESI (Emergency severity level index) level assigned was 4. The nurse signature was illegible and was not dated or timed. The physician signature was not dated or timed. The emergency room physician record was not dated or timed.

The facility documents, "Participating Provider Notice, Conditions of Admission, Consent Form, Patient Consent and Acknowledgment of receipt of privacy notice, and Notice of Medicare Non-Covered Outpatient Drugs" were dated but not timed.


PATIENT 2

Patient #2 was a 17-year-old female who presented to the ER on 7-8-2019 for a complaint of "Sore throat since Friday". The patient arrived at 845 AM. There was not a time listed for triage. The ESI level assigned was 4. The nurse signature was not dated or timed. The physician signature was not dated or timed. The emergency room physician record was not dated or timed.

The facility documents, "Participating Provider Notice, Conditions of Admission, Consent Form, Patient Consent and Acknowledgment of receipt of privacy notice, and Notice of Medicare Non-Covered Outpatient Drugs" were dated but not timed.

The Consent to Treat form noted, "Pt's mom Crystal Cozine gave verbal consent by phone to treat and sign" The consent had two signatures of ER staff. The date was listed. There was no time noted. There was no way to determine if consent for treatment was obtained from the parent prior to treating a minor.

PATIENT #3

Patient #3 was a 38-year-old female who presented to the ER on 7-7-2019 for a complaint of "Chills, can't move, Abd pain, back flank pain". The patient arrived at 5:55 AM. There was no time listed for triage. The ESI level assigned was 3. The nurse signature was not dated or timed. The physician signature was not dated or timed. The emergency room physician record was not dated or timed.

The facility documents, "Participating Provider Notice, Conditions of Admission, Consent Form, Patient Consent and Acknowledgment of receipt of privacy notice, and Notice of Medicare Non-Covered Outpatient Drugs" were dated but not timed.


PATIENT #4

Patient #4 was a 1-year old male who was brought to the ER on 7-8-2019 by the mom for complaint of, "Mom states he woke up at 1:30 am with a croupy cough". The patient arrived at 3:45 am. The ESI level assigned was 4. There was no time listed for triage. There was an illegible signature for the nurse. The nurse signature was not dated or timed. The physician signature was illegible and there was not dated or timed. The emergency room physician record was not dated or timed. The physician signature was illegible.

The facility documents, "Participating Provider Notice, Conditions of Admission, Consent Form, Patient Consent and Acknowledgment of receipt of privacy notice, and Notice of Medicare Non-Covered Outpatient Drugs" were dated but not timed.


PATIENT #5

Patient #5 was a 1-year old male who was brought to the ER on 7-8-2019 by the mom for complaint of, "Fever/ Pulling at ears." The patient arrived at 0950 am. The ESI level assigned was 4. There was no triage time listed. The nurse signature was not dated or timed. The physician signature was not dated or timed. The emergency room physician record was not dated or timed.

The facility documents, "Participating Provider Notice, Conditions of Admission, Consent Form, Patient Consent and Acknowledgment of receipt of privacy notice, and Notice of Medicare Non-Covered Outpatient Drugs" were dated but not timed.



PATIENT #6

Patient #6 was a 31-year-old female was presented to the ER on 1-9-2019 for complaint of, "Medical Clearance." The patient arrived at 8:32 p.m. The ESI level assigned was 3. There was no triage time listed. The nurse signature was not dated or timed. The physician signature was illegible and was not dated or timed. The emergency room physician record was not dated or timed.

The medical exclusionary form was signed by the physician and dated. There was no time.
The facility documents, "Participating Provider Notice, Conditions of Admission, Consent Form, Patient Consent and Acknowledgment of receipt of privacy notice, and Notice of Medicare Non-Covered Outpatient Drugs" were dated but not timed.


PATIENT #7

Patient #7 was a 13-year-old female who presented to the ER on 1-23-2019 for a complaint of, "c/o having suicidal thoughts." The patient arrived at 4:00 p.m. The ESI level assigned was 3. There was no triage time listed. The nurse signature was illegible and was not dated or timed. The physician signature was not dated or timed. The emergency room physician record was not dated or timed.


The facility documents, "Participating Provider Notice, Conditions of Admission, Consent Form, Patient Consent and Acknowledgment of receipt of privacy notice, and Notice of Medicare Non-Covered Outpatient Drugs" were dated but not timed.


An interview with Staff # 4 on July 8 after 2:00 P.M revealed the following:

Staff #4 was asked if the facility required records to be dated and timed. Staff #4 stated they should have a date on them but are not always timed. Staff #4 was asked if there was a policy on the requirements for dating and timing medical records. Staff #4 stated she was not aware of one.

Staff #3 & #4 confirmed the above findings.


28659

On 7/10/2019 the medical record (MR) for patient (Pt/pt)) #14, #15, #22, #23, and #24 were reviewed.

All pt MR's were found to have consent for admission and treatment without a time the patient signed the document.

On 7/10/2019 an interview with the Chief Nursing Officer (CNO) confirmed the staff were not aware time was required when admission paper work was completed.

All pt MR's were found to have physician's verbal orders without a date and time the physician authenticated their order.

The above findings were confirmed by staff #1, the CNO.

Pt #15 had physician's orders not authenticated by the prescribing physician.









41831

Review of medical records on 7-10-2019 revealed the following:



PATIENT #18
The facility document titled, "Consent Form" was signed by the patient and dated but was not timed.
The nursing shift assessments (all) form had check marks in the treatment box, indicating the assessment was performed, but they were not timed.


PATIENT #19
The facility document titled, "Consent Form" was signed by the patient and dated but was not timed.
The nursing shift assessment form had check marks in the treatment box, indicating the assessment was performed, but they were not timed.


PATIENT #20
The facility document titled, "Consent Form" was signed by the patient and dated but was not timed.
The nursing shift assessment form had check marks in the treatment box, indicating the assessment was performed, but they were not timed.


PATIENT #21
The facility document titled, "Consent Form" was signed by the patient and dated but was not timed.
The nursing shift assessment form had check marks in the treatment box, indicating the assessment was performed, but they were not timed.


In an interview on 7/10/2019 at 1:00 p.m., Staff #1 stated the admission staff were not aware a time was required when patient consent to treat forms were signed. Staff # 1 also stated she was unaware that nursing assessments were not completed.

Staff #1 confirmed the above findings.

Based on interview and record review, the facility failed to ensure that orders were authenticated promptly by the ordering practitioner. This deficient practice was found in 4 (Pt's #2,3,6, &7) of 7 patients reviewed.

This deficient practice had the likelihood to cause harm to all patients.

PATIENT #2
There was an entry listed under the tests tab that read, "Strep Swab". Staff #2 was asked if that entry was the physician's order. Staff #2 confirmed it was. There was no physician signature and no date or time on the order.

PATIENT #3
There was a verbal order that read, "V/O Physician #5 - UA (Urinalysis), UHCG (Urine Pregnancy test)." There was no indication of what nurse took the order. There was no date or time on the order. The physician did not authenticate the order.
There was a verbal order that read, "V/O Physician #5 - Ibuprofen (A non-steroidal anti-inflammatory drug) 600 mg." There was no indication of what nurse took the order. There was no date or time on the order. The physician did not authenticate the order.

PATIENT #6
There was a verbal order that read, "V/O Physician #5 - CBC (Complete Blood Count), CMP (Complete Metabolic Panel), CPK (Creatine Phosphokinase), Salicylate, Acet (Acetaminophen), ETOH (ethyl alcohol), UA (Urinalysis), UDS (Urine Drug Screen), and EKG (Electrocardiogram)." There was no indication of what nurse took the order. There was no date or time on the order. The physician did not authenticate the order.

PATIENT #7
There was an entry on the test tabs that read, "CBC (Complete Blood Count), CMP (Complete Metabolic Panel), CPK (Creatine Phosphokinase), UA (Urinalysis), UDS (Urine Drug Screen), UHCG (Urine Pregnancy test) Salicylate, Tylenol, ETOH (ethyl alcohol)." There was no indication of what nurse took the order. There was no date or time on the order. The physician did not authenticate the order.
An interview with Staff #3 on July 8th after 12:00 P.M. revealed the following:
Staff #3 was asked if the nursing staff routinely wrote verbal orders in the Emergency department. Staff #3 confirmed they did.

Staff #3 confirmed the above findings.

Based on observation, interview, and document review the facility failed to 1) dispense safe patient medication, 2) failed to secure the nurses medication administration room and 3) failed to reduce after hours access to the primary pharmacy for the facility from January through June 9, 2019.

This deficient practice had the likelihood to effect all patients of the facility.


Findings included.

1.
On the afternoon of 7/8/2019 the nurses medication room (Med Room) was observed with two bags hanging from hooks inside the Med Room. Upon opening the bags it was determined that each bag held patient medications brought from home for the purpose of being dispensed while the patient (pt) was in the hospital at observation status. Between the two bags of medication, the following was found.

Clonazepam 0.5 mg (milligram) #6
Gabapentin 300 mg #86
Gabapentin 300 mg #45
Gabapentin 300 mg #9
Bupropion XL 150 mg #5
Bupropion XL 150 mg empty bottle
Hydroxizine 50 mg #20
Tropiramate 50 mg #6
Topiramate 50 mg #27
Topiramate 50 mg #14
Benzotropine 0.5 mg empty bottle with
Haloperidol 5 mg #1 inside the empty bottle
Bupropion XL 150 mg #2
Hydroxizine 50 mg #12
Gabapentin 300 mg #3

On 7/9/2019 RN #17 confirmed the medications were patient medications, brought from home to be administered by the nurse for the patient who brought them. She further confirmed the home medications were not approved or verified by the facility's house pharmacy prior to being administered.

On 7/10/2019 in the afternoon, an interview with the staff consultant pharmacist confirmed the home medications were not verified through the pharmacy. They were not counted or signed for to verify what the patient brought and the amount of medication brought was documented for security purposes.

On 7/10/2019 a review of the current policy for use of patient home meds read,
A. Patient's drugs shall not be administered unless specifically authorized by the responsible prescribing practitioner. (Not the admitting physician or hospitalist)
B. Identification of a patient's personal drugs must be by the attending physician, another responsible prescribing practitioner, or a pharmacist. (Not the nurse)
C. Drugs brought into the facility shall not be administered unless the drugs have been absolutely identified, their quality and integrity is not questionable, and there is a written order from the responsible prescribing practitioner to administer the drugs.
D. The pharmacy should affix a supplemental label to the container to verify that a physician has authorized the administration of the drugs contained therein.

2.
On the morning of 7/8/2019 during a tour of the west wing medical surgical unit the nurses medication room (where all medications are stored for safety on the nursing unit) was observed with the keys in the entry door lock. The medication room was behind the nurses station. Registered Nurses (RN/RN's) were observed moving in and out of the station.

On 7/9/2019 again the west wing medication room was observed with keys in the lock to the medication room. Staff RN #17 was interviewed and confirmed the keys were kept in the door.

With the keys in the outside door lock available at all times medications were not secure when nurses were away form the station.


3. On 7/10/2019 an interview with consultant pharmacist #16 confirmed the pharmacy was closed after 5:30 Monday through Friday and was closed at 3:30 on weekends.

She further explained the staff nurses were granted permission to enter the pharmacy after hours to secure medication for patients when needed.

A request was made to review the list of who had access after pharmacy hours. The list held the name of 38 Registered Nurses and Licensed Vocational Nurses who had after hours access to the house pharmacy. The Consulting pharmacist confirmed all hospital nursing staff had access. Only the agency nursing staff were denied access.

The pharmacy staff explained each nurse got an orientation to where the medications were stored and a sign in and out sheet was kept in the pharmacy.

The consultant pharmacist stated to her knowledge no medication errors had ever occurred.

The access of non-pharmacy staff into the pharmacy was not tracked in the quality program, nor was medication removed from the pharmacy.

The consultant pharmacist confirmed she came one time a week for about an hour each time.

Based on observation and interview the facility failed to:

A. ensure that the Radiology department had a process to ensure that the radiation workers maintained a safe radiation exposure. The hospital did not have personnel who monitored staff exposure on a regular basis.

Refer to Tag A 538


B. ensure there was a supervising radiologist designated to supervise the ionizing radiology services at the facility. Also, the facility failed to establish criteria in the Medical Staff Bylaws for designation of a Supervising radiologist.

Refer to Tag A546

Based on record review and interview, the facility failed to ensure that the Radiology department had a process to ensure that the radiation workers maintained a safe radiation exposure. The hospital did not have personnel who monitored staff exposure on a regular basis.

This deficient practice had the likelihood to harm all staff performing radiological procedures at the facility.


During record review of the "Radiation Dosimeter Reports" 7-10-2019, Staff #21 was asked how he would report abnormal levels of radiation at the facility. Staff #21 stated the facility had not identified any abnormal readings. Staff #21 was asked how that was determined. Staff #21 provided dosimeter reports from 1-19-2019 to 5-30-2019. Staff #21 was noted to initial his readings on the report. Staff #21 was asked how the other radiology employees were reviewed. Staff #21 stated he hung the reports up for them to look at. Staff #21 was asked who was responsible for reviewing the reports at the facility. Staff #21 confirmed he was responsible for monthly checks and Staff #25 reviewed the reports every six months. Staff #21 was asked to explain how to identify an abnormal reading on the dosimeter report. Staff #21 stated, "I don't remember the levels. I will have to look them up." Staff #25 was identified as the facility radiation safety officer. Staff #25 had not signed any dosimeter reports as reviewed since the 1-19-2019 report. Staff #21 confirmed there was no Radiation safety officer at the facility full time, nor did Staff #25 review the reports monthly. Staff #21 confirmed that Staff #25 only looked at the dosimeter reports every 6 months.

Review of the contract for the Radiation safety officer between Staff #25 and the facility revealed the following:

"IV. The Physicist shall provide the following services:
...Oversee the Personnel Dosimetry Monitoring program...
...Adhere to all state and federal radiation protection regulations and JCAHO standards as they pertain to radiology ..."

The contract was dated 12-21-01. The facility could not provide any review of the contract since that time.


Review of the facility policy titled, "Film Monitoring Badges" with a review date of March 2019 revealed the following:

" ...Procedure:
C. Information obtained from film badge reports is reviewed by the Radiation Safety Officer (Physicist), who will investigate and make recommendations to correct that causes of unusual exposures."


Staff #1 confirmed the above findings.

Based on observation and interview, the facility failed to have a radiologist designated to supervise the ionizing radiology services at the facility. Also, the facility failed to establish criteria in the Medical Staff Bylaws for designation of a Supervising radiologist.

This deficient practice had the likelihood to harm all staff performing radiological procedures at the facility.


Findings include:

During a tour of the radiology department on July 10, 2019 after 8:30 A.M., Staff #21 stated said the Radiology director was Physician #30.

During an interview on 7-10-2019 after 1:00 p.m., Staff #1 stated Physician #30 was the supervising radiologist for the facility. Staff #1 was asked if Physician #30 was a contracted radiologist or a facility employee. Staff #1 stated she would check. Staff #1 later confirmed that the facility did not have a contract with Physician #30. Staff #1 stated the facility used Physician #30 as a telemedicine radiologist, but he also came once a year to look at the facilities and review radiology reports.

During record review of the "Radiation Dosimeter Reports" 7-10-2019, Staff #21 was asked how he would report abnormal levels of radiation at the facility. Staff #21 stated the facility had not identified any abnormal readings. Staff #21 was asked how that was determined. Staff #21 provided dosimeter reports from 1-19-2019 to 5-30-2019. Staff #21 was noted to initial his readings on the report. Staff #21 was asked how the other radiology employees were reviewed. Staff #21 stated he hung the reports up for them to look at. Staff #21 was asked who was responsible for reviewing the reports at the facility. Staff #21 confirmed he was responsible for reviewing the reports monthly and Staff #25 reviewed them every six months. Staff #21 was asked to explain how to identify an abnormal reading on the dosimeter report. Staff #21 stated, "I don't remember the levels. I will have to look them up." Staff #25 was identified as the facility radiation safety officer. Staff #25 had not signed any dosimeter reports as reviewed since the 1-19-2019 report. Staff #21 confirmed there was no Radiation safety officer at the facility full time, nor did Staff #25 review the reports monthly. Staff #21 confirmed that Staff #25 only looked at the dosimeter reports every 6 months.

Staff #1 and Staff #2 confirmed the facility did not have any supervision over radiology services by a radiologist.

Review of the Medical Staff Rules and Regulations, approved by the Medical Staff on 1-15-2019 and the Board of Managers on 1-28-2019, did not reveal any criteria in the Medical Staff Bylaws for designation of a Supervising radiologist.

Based on review of records and interview, the facility failed to develop and implement an effective Utilization Review Plan. The facility failed to:

A. establish a Utilization Review Committee to carry out the Utilization Review functions of the hospital.

Refer to Tag A0654


B. develop and implement a Utilization Review plan that identified the frequency that cases would be reviewed or monitored by a Utilization Review Committee or the method used to review the medical necessity of admissions to the institution, the duration of stays, and professional services provided.

Refer to Tag A0655

Based on record review and interview, the facility failed to establish a Utilization Review Committee to carry out the Utilization Review functions of the hospital.

This deficient practice had the likelihood to cause harm to all patients.


Findings:

A request was made on 7-9-2019 after 2:00 PM for the Utilization Review Plan and the meeting minutes of the Utilization Review Committee. Staff #24 was unable to provide minutes. Staff #24 confirmed that there was an informal Utilization Review Committee. All reviews were done verbally and there was no documentation.

The Utilization Review Plan, Reference was provided and reviewed. The effective date was 6/28/2019. The plan did not designate a Utilization Review Committee.

Staff #1 and #24 confirmed the above findings.

Based upon record review and interview, the facility failed to have an active Utilization Review (UR) Plan that reviewed the medical necessity of admissions to the institution, the duration of stays, and professional services provided.

An interview with Staff #24 on 7-9-2019 after 2:00 PM revealed the following:


Staff #24 stated that she reviewed all the admissions. Staff #24 stated she made sure all the charts had a diagnosis code that matched the admission status. Staff #24 stated she coordinated with the payer source frequently to ensure admissions were appropriate. Staff #24 was asked to provide documentation of those reviews. Staff #24 stated she did not have any documentation. Staff #24 stated she made notes in chart as necessary but did not have any formal review process or documentation for those reviews.

Staff #24 was asked if the facility had an UR Review Committee. Staff #24 stated the committee consisted of two ER RN's, ER Director, and two physicians. Staff #24 was asked how she brought reviews up to the committee if there was a question of the medical necessity of the hospitalization. Staff #24 stated she would call one of the doctors. Staff #24 was asked to provide the documentation of those reviews. Staff #24 stated she did not have any documentation. All reviews were done verbally.

Staff #24 was asked to provide UR committee meeting minutes. Staff #24 stated there was no UR meetings. All questions/review were done verbally.


Staff #1 & 24 confirmed the above findings.



Review of the facility Utilization Review Plan with and effective date of 6/28/2019 revealed the following information:

"Outcome Standard:
The Utilization Review (UR) plan is designed to ensure patients are admitted and discharged in a manner consistent with the Medicare Condition of Participation.

...2). All patient must meet established criteria for admission; requiring a treatment that could not be delivered more appropriately in an alternate setting - (e.g. home health, nursing home, clinic, outpatient).

...5) When admitted to OBS (Observation) there is a maximum time frame of 24/48 hour before the physician must determine if the patient is to have a full admit or order to be discharged. The time lines commence from the date/timing that patient is transferred to OBS.

...8) The UR coordinator maintains on a regular basis, an evaluation of the length of stay for each patient according to the diagnosis.

9) The UR coordinator dialogues with the physician on a regular basis in regard to the approved length of stays and keeps them apprised should the patient exceed medical necessity.

10) The Medical Staff and Board of managers delegate the UR Committee the authority and responsibility to carry out the UR function."

Review of the Utilization Review plan did not include provisions for the frequency that cases would be reviewed or monitored by a Utilization Review Committee or the method to identify those cases "reasonably assumed to be outlier cases" that would require a review by a committee. The Utilization Plan did not address the facility UR Committee nor who the committee would be comprised of. The UR Plan did not outline the responsibilities of the UR Committee. The UR Plan did not outline the process when determining that an extended stay was medically unnecessary.

Based on observation and interview the facility failed to:

A. ensure a clean and sanitary environment in the triage room. The triage room had patient monitoring cords labeled clean or dirty. There was rust and chips of paint missing from equipment. There was chipped/missing laminate on cabinets. Tongue blades were stored in a basin in an open fashion uncovered. The blades were exposed to build up of dust, dirt, and contamination. The base of the drawer was covered in dust, dirt, and debris. There was an Ophthalmoscope stored in drawer covered in dust. Gauze sponges were in a bin inside a drawer of the cabinet. The sponges were stored in an open fashion uncovered. The sponges were exposed to build up of dust, dirt, and contamination. The door frame had chips of paint missing.

B. ensure a clean and sanitary environment in the Emergency Room (ER) entrance. At the Emergency room entrance wheelchairs were stored next to outside entrance of the ER. There was no way to tell if the wheelchairs were clean or dirty.

C. ensure a clean and sanitary environment in the ER hallway. In the Emergency hallway there was an Armstrong baby incubator in use that the filter had not been changed since 2015. Over 4 years ago. There was a cardboard box that had sterile Obstetrical supplies inside of the box. The metal frame on the baby warmer cabinet was covered in rust. The wheel casters on the baby warmer cabinet were coated in rust. There were ventilators in the hallway that had the ventilator circuit attached to the machine out of the manufacture package.

D. ensure a clean and sanitary environment in the ER housekeeping closet. In the Emergency Room housekeeping closet there were Traction splints and equipment stored on a wire rack that had a buildup of dust, dirt, and debris. The was no splash guard on the bottom rack exposing the splint and equipment to splashes and contamination when the floor was mopped. There was rust on the wheel casters of the wire racks. The hopper was covered in dust, dirt, and debris. The traction weights were covered in rust. Sitting next to a wire rack that stored cleaning supplies, there was a refrigerator and cabinet that stored food and drinks for the staff.

E. ensure a clean and sanitary environment in ER room 6. In Emergency room 6 there were glass jars that stored tongue blades, cotton balls, and Q-Tips. The tongue blades, Q-Tips, and cotton balls were stored in bulk and uncovered. The Intravenous supply bin had gauze sponges stored open and out of the package. The top of the crash cart was covered in dust, dirt, and debris. The blood pressure cord was laying on top of the crash cart. There was no way to tell if the cord was clean or dirty. The pulse oximeter cord was draped over the X-Ray view box. There was a suction canister on the wall. The frame for the suction canister frame was wrapped in a purple colored coban wrap. The wrap was not changed between patients and there was no way to clean it.

F. ensure a clean and sanitary environment in the ER isolation room. In the ER Isolation room, the door frame had missing chips of paint. In the isolation ante room there was a baby warmer that contained sterile obstetrical supplies stored with saran wrap. There were biohazard bins stored on the floor. The top of the bin was covered in dust. There was a cardboard box that contained Specimen cups stored on top of the biohazard bin. There was rust on the wheel casters of the bedside table. In the isolation room, the base of the wall that connected to the linoleum had chips of paint missing. The metal trim that connected the linoleum had separated in multiple places. There was a build-up of dust, dirt, and debris in the crevices. There was a trash can in the room that contained trash (IV Bag and betadine bottle) from the previous patient. The trash can did not have a lid on it. The linoleum floor had separated from the base of the door frame. The Intravenous supply bin had gauze sponges stored open and out of the package.

G. ensure a clean and sanitary environment in the ambulance entrance. In the ambulance entrance there was a gurney used to transport patients to and from the helipad. The gurney was covered in dust, dirt, and debris.

H. ensure a clean and sanitary environment in the ER nurse's station. In the ER Nurses station, the wall above the sink had a strip of the paint missing that exposed the wall. There were holes in the wall. The wall was covered in yellow stains/splashes. The refrigerator stored patient medications. The grate on the bottom of the refrigerator was covered in dust, dirt, and debris. The temperature log on the refrigerator for patient medications. The temperature was not being continuously monitored. Next to the sink on a counter were cups that were being used for patients; they were sitting on a counter next to a spray bottle of bleach. The nursing desk had missing/scraped pieces of laminate.

I. ensure a clean and sanitary environment in ER room 2. In ER Room 2 there were holes/scrapes in the wall. There were chips of paint missing. The cabinet had missing laminate on the trim. There were glass jars that stored tongue blades. The tongue blades were stored in bulk and uncovered. The glass jar of tongue blades was sitting next to a bottle of a cleaning agent Vesphene.

J. ensure a clean and sanitary environment in the ER Patient supply room. In the ER Patient Supply room there were patient supplies, patient blanket warmer, sterile surgical instruments, patient refreshments (Tea, coffee), and staff food (Cake) all stored in the same room. The sterile surgical instruments were stored in the cabinet above the coffee pot and food items.

K. ensure a clean and sanitary environment in the ER Decontamination/Biohazard room. In the ER Decontamination/Biohazard room there was a white plastic bowl sitting on the counter full of surgical instruments that had been washed. The container was not labeled clean or dirty. There was no lid on the container. The instruments were sitting on the counter next to biohazard containers that had biohazard material in them. There was a fan on the counter next to the bowl of instruments. There were ambulance patient transfer boards and cleaned bedside commodes stored in the biohazard room.

L. Ensure a clean and sanitary environment in the Pediatric Broselow cart. In the Pediatric Broselow Cart there were emergency pediatric disposable packs stored in the drawers that had expired in 2018; over 1 year ago. The facility had opened all the packs and removed the expired supply and re-taped the packs. This practice was done on all the color-coded emergency packs.

M. Ensure a clean and sanitary environment in the respiratory department. The refrigerator in the respiratory department used to store controls for blood gas machine was not being continuously monitored. There was no way to determine if the temperature went out of range. There was a package of electrode pads that had been opened and stored in a bin to use later. The manufacturer package stated, "do not open until immediately prior to use." There was skin prep gel in a bin that expired in 2011; over 8 years ago. There was a package of gauze sponges stored in a bin uncovered and in an open package. The sponges were exposed to a buildup of dust, dirt, and contamination.

N. ensure a clean and sanitary environment in the material management department. In the materials management department there was a wooden platform under a shelf that stored patient supplies. The platform had missing chips of paint and the wood was exposed. Sterile supplies were stored under the air conditioning vent. The floor had missing chips and scrapes of paint exposing the cement floor. The supply bins that stored patient supplies were covered with spills, dust, dirt, and debris. Metal racks storing patient supplies were covered in tape residue and rust. Non-sterile supplies were being stored above sterile supplies. There was a wooden pallet stored in room with sterile patient supplies. The wood had splinters and pieces of wood missing. A heater and patient bedside commodes were stored on the floor next to a metal file cabinet. The equipment was covered in dust and dirt. An electrical panel in the materials management department was stored on a wooden platform. The platform was covered in dust, dirt, debris, and a black substance that appeared to be oil stains. The wood platform had missing and chipped wood. The walls surrounding the electric panel had missing chips of paint.

O. ensure a clean and sanitary environment in Radiology room 1. In Radiology Room 1 the linen was stored on an open shelf uncovered. The walls had missing/chipped of paint. A foam positioner covered with a Chux pad (A disposable patient under pad) was used from patient to patient without changing the pad or cleaning the positioner. The floor next to the X-Ray equipment was covered in dust and dirt. The base of the X-Ray table was covered in dust and dirt. The base had missing chips of paint. The walls had scrapes and missing chips of paint.

P. ensure a clean and sanitary environment in the teleradiology room. In the room being used to store the computer for teleradiology, the floor going into the room was missing the linoleum and the subfloor was exposed. The floor in the room was not sealed and the concrete was exposed. There was a dead bug that appeared to be a roach. There was a metal step stool in the room that was covered in rust.

Q. ensure a clean and sanitary environment in the radiology patient bathroom. In the Patient Bathroom of the Radiology department there was a hole in the wall exposing the sheetrock. There was a switch box labeled emergency. The emergency call system did not work. The switch box was covered in rust.

R. Ensure a clean and sanitary environment in the radiology room 2. In the Radiology Room 2 the vinyl baseboard was separating from the wall. The crevices and floor were covered in dust, dirt and debris. The linoleum floor file had cracks in the seams of the floor and exposed the subfloor. There was dead bug on the floor that appeared to be a roach. The floor in the room had missing linoleum tiles that exposed the subfloor. There was a space between the X-Ray processor and the floor that had floor covered in dust, dirt, and debris. The floor was stained with a black substance. There was a broom base in the corner of the space that was covered with dirt. There was a metal equipment frame on the wall that was covered in rust.

S. ensure a clean and sanitary environment in the CT main room. In the CT Room the plastic covering for the CT table had shiny spots throughout the top of the covering that appeared to be contrast. Under the sink, there was a pipe coming up from the floor. The pipe was uncapped. There was a basin under the pipes and a towel next to the basin, that appeared to be a leak. Staff #21 stated maintenance had been working under sink. There was a patient urinal next to the basin. The portable Suction on the crash cart had a metal base that was covered in rust. There was a spider web in the corner behind the crash cart in the room. The blood pressure cuff was laying on the floor behind the crash cart.

T. ensure a clean and sanitary environment in the main radiology crash cart. In the Main radiology crash cart, the base of the portable suction was covered in rust. The defibrillator screen was covered in dust and dirt. The patient backboard used in emergencies was wood and had splinters and chips of the wood missing.

U. ensure a clean and sanitary environment in the food preparation area. In the food preparation room surfaces that included the shelving below were covered in rust. Two wooded surfaces, one dispensing plastic wrap and one on the counter was observed with the pain worn off to bare wood.

V. ensure a clean and sanitary environment in the kitchen. A small oven was observed with a buildup of oils and debris between the two pane windows of the oven door. The leaking seal around the glass allowed oils and backing debris to collect between the pane of glass making it unable to be sanitized. The large mixer was observed covered with a plastic cover but beneath the cover the gray metallic paint was worn and scratched revealing bare metal.

W. ensure a clean and sanitary environment in the kitchen walk in freezer. The walk-in freezer contained boxes of frozen meat. One (1) box of frozen meat was observed with inner plastic bag, which held the frozen meat open, exposing the frozen meat to freezer burn and cross contamination. The kitchen also used a small chest type freezer. The freezer did not have a manufacturer's thermometer and the staff had not kept a removable thermometer in the unit. Inside the chest freezer was three (3) large sacks of frozen rolls/biscuits open to be cross contaminated or freezer burned.

X. ensure temperatures for the dish washer were maintained and a log was keep up to date with parameters for the staff to follow.

Y. ensure a clean and sanitary environment in the clean dish room. The clean dish room was observed with clean pots and pans stored on open racks for air drying. The ceiling of the room held a large air vent with a wire covering. Both the vent and the wire covering were visibly soiled appearing to be grease/oil and heavy lint immediately above the open rack of pots and pans.

Z. ensure a clean and sanitary environment in the CT ultrasound room. An empty canister with layers of tape residue was labeled "Rapicide OPA", the test strips were labeled from the manufacturer to be used for "Rapicide OPA". The test strips had a hand-written expiration date of 6/2019. The manufacturer had provided a line space for writing the date opened. There was no date written on the bottle. General sanitation of the building was observed with visible dirt in corners and base boards, cobwebs from the ceiling, and Lint in the air ducts. Dead insects were observed in corners and shelving. A badly rusted rolling IV standard was stored in the corner of the ultra sound room.

AA. ensure a clean and sanitary environment in west wing room 136. There was a shower chair in the shower. On the underside of the shower chair there was dirt and there was rust noted on the legs.

BB. ensure a clean and sanitary environment in west wing room 127. There was a large hole noted in the wall behind the patient bed. The hole had a plastic circular cover surrounding the open space. There was a telephone cord hanging from the hole. In the patient's bathroom there were several tiles missing from the floor of the shower. There were tiles stacked in the corner that appeared to be the tiles missing from the shower. There were black stains in the grout on the wall and floor of the shower. There was paint peeling from the wall beside and behind the toilet. The wall was soft with holes and discolored areas were noted. There was no seal around the opening in the wall around the plumbing pipe. There was corrosion green oxidation noted to the plumbing pipe. There was rust noted on the soap dish in the shower. The toilet paper holder was rusted. The emergency call light in the bathroom had a sharp piece of rusted metal protruding from it which had the potential to cause injury. There were bugs noted in the light fixture in the bathroom.

CC. ensure a clean and sanitary environment in the clean utility room on the west wing. There were clean sharps containers and other patient supplies were stored on the floor.

DD. ensure a clean and sanitary environment in the West Unit Medication Room. There was a cloth bag stored on a wire rolling shelf under the counter next to the patient medication refrigerator. The bag had a patient sticker on the bag and contained patient's home medication in it. The bag was stored in an area where medications were prepared for other patients.


Refer to Tag A749

Based on observation, interview, and record review, the facility failed to ensure the infection control officer developed a system that maintained a clean and sanitary environment for 27 (ER triage, ER entrance, ER Hallways, ER housekeeping closet, Isolation, ER Ambulance entrance, ER nurses station, ER Room 2, ER Room 6, ER patient supply room, ER biohazard/decontamination room, Pediatric Broselow cart in ER, Sterile Processing Room, Respiratory department, Materials Management, Radiology room 1, Radiology room 2, Radiology teleradiology room, Radiology patient bathroom, Cat Scan room, main radiology crash cart, kitchen, CT room transvaginal ultrasound room, West wing room 126, West wing room 136, West wing clean utility room, West wing medication room.) of 27 areas observed.

This deficient practice had the likelihood to cause harm in all patients.


Findings Include:

During a tour on July 8, 2019 after 12:00 PM, the following observations were made:

TRIAGE ROOM

The Dyna-map blood pressure cuff, EKG, and pulse oximeter cords were not labeled clean/dirty. There was rust and missing chips of paint on the IV pole base. There was chipped/missing laminate on the side of the cabinet drawer. There was an Isolation protocol taped to a bedside table. The edges of the tape were frayed and coated in dust and debris. Tongue blades were stored in a basin in an open fashion uncovered. The blades were exposed to build up of dust, dirt, and contamination. The base of the drawer was covered in dust, dirt, and debris. There was an Ophthalmoscope stored in drawer covered in dust. Gauze sponges were in a bin inside a drawer of the cabinet. The sponges were stored in an open fashion uncovered. The sponges were exposed to build up of dust, dirt, and contamination. The door frame had chips of paint missing.


EMERGENCY ROOM (ER) ENTRANCE

Wheelchairs were stored next to outside entrance of the ER. There was no way to tell if the wheelchairs were clean or dirty.


EMERGENCY ROOM HALLWAY

There was an Armstrong baby incubator stored in the hallway. The filter on the side of the warmer had a metal sign that stated, "replace filter every four months." There was a label on the metal sign that noted the filter was replaced 6/2015, over 4 years ago. There was a cardboard box that had sterile Obstetrical supplies inside of the box. The cardboard box was in the cabinet under the warmer. The metal frame on the baby warmer cabinet was covered in rust.
The wheel casters on the baby warmer cabinet were coated in rust. There were ventilators in the hallway that had the ventilator circuit attached to the machine out of the manufacture package. The circuits were exposed to a buildup of dust, dirt, and contamination.


Review of ANSI/AAMI ST79:2017 revealed the following:
"11.1 Sterile Storage

Sterile items should be stored under environmentally controlled condition that reduces the potential for contamination ...

Supplies should be removed from external and web-edged shipping container before transport to any restricted area ...


EMERGENCY ROOM HOUSEKEEPING CLOSET

There were Traction splints and equipment stored on a wire rack in the closet. The splints and equipment had a buildup of dust, dirt, and debris. The was no splash guard on the bottom rack exposing the splint and equipment to splashes and contamination when the floor was mopped. There was rust on the wheel casters of the wire racks. The hopper was covered in dust, dirt, and debris. The hopper had a broom, dust pan, and portable Patient wheelchair stored in it. Sitting next to the hopper were weights for the traction equipment. The weights were covered in rust. Sitting next to a wire rack that stored cleaning supplies, there was a refrigerator and cabinet that stored food and drinks for the staff.

EMERGENCY ROOM 6

There were glass jars that stored tongue blades, cotton balls, and Q-Tips. The tongue blades, Q-Tips, and cotton balls were stored in bulk and uncovered. There was no way to ensure the supplies were not contaminated when getting one out of the container. The Intravenous supply bin had gauze sponges stored open and out of the package. The sponges were exposed to a buildup of dust, dirt, and debris. The top of the crash cart was covered in dust, dirt, and debris. The blood pressure cord was laying on top of the crash cart. There was no way to tell if the cord was clean or dirty. The pulse oximeter cord was draped over the X-Ray view box. There was no way to tell if the cord was clean or dirty. There was a suction canister on the wall. The frame for the suction canister frame was wrapped in a purple colored coban wrap. The wrap was not changed between patients and there was no way to clean it.


ISOLATION ROOM

The door frame had missing chips of paint. In the isolation ante room there was a baby warmer that contained sterile obstetrical supplies stored with saran wrap. There were biohazard bins stored on the floor. The top of the bin was covered in dust. There was a cardboard box that contained Specimen cups stored on top of the biohazard bin. There was rust on the wheel casters of the bedside table. In the isolation room, the base of the wall that connected to the linoleum had chips of paint missing. The metal trim that connected the linoleum had separated in multiple places. There was a build-up of dust, dirt, and debris in the crevices. There was a trash can in the room that contained trash (IV Bag and betadine bottle) from the previous patient. The trash can did not have a lid on it. The linoleum floor had separated from the base of the door frame. The metal door frame had missing chips of paint and rust on it. The Intravenous supply bin had gauze sponges stored open and out of the package. The sponges were exposed to a buildup of dust, dirt, and debris.


AMBULANCE ENTRANCE

There was a gurney used to transport patients to and from the helipad. The gurney was covered in dust, dirt, and debris.


ER NURSES STATION

The wall above the sink had a strip of the paint missing that exposed the wall. There were holes in the wall. The wall was covered in yellow stains/splashes. The refrigerator stored patient medications. The grate on the bottom of the refrigerator was covered in dust, dirt, and debris. The temperature log on the refrigerator for patient medications. The temperature was not being continuously monitored. There was no way to determine if the temperature of the medications went out of range. Next to the sink on a counter were cups that were being used for patients; they were sitting on a counter next to a spray bottle of bleach. The nursing desk had missing/scraped pieces of laminate.

ER ROOM 2

There were holes/scrapes in the wall. There were chips of paint missing. The cabinet had missing laminate on the trim. There were glass jars that stored tongue blades. The tongue blades were stored in bulk and uncovered. There was no way to ensure the supplies were not contaminated when getting one out. The glass jar of tongue blades was sitting next to a bottle of a cleaning agent Vesphene.


ER PATIENT SUPPLY ROOM
The room had patient supplies, patient blanket warmer, sterile surgical instruments, patient refreshments (Tea, coffee), and staff food (Cake) all stored in the same room. The sterile surgical instruments were stored in the cabinet above the coffee pot and food items.


ER DECONTAMINATION/BIOHAZARD ROOM

There was a white plastic bowl sitting on the counter full of surgical instruments that had been washed. The container was not labeled clean or dirty. There was no lid on the container. The instruments were sitting on the counter next to biohazard containers that had biohazard material in them. There was a fan on the counter next to the bowl of instruments. There were ambulance patient transfer boards and cleaned bedside commodes stored in the biohazard room.


STERILE PROCESSING ROOM

There were three boxes of surgical peel packs (pouch used to sterilize surgical instruments) that were expired. One expired 7-2014; over 5 years ago, one expired 6-2009; over 10 years ago, the third pouch expired 3-2007; over 12 years ago. Staff #3 stated the facility did not use those pouches. Staff #3 stated the facility now used Medical Action Sterilization Pouches. Staff #3 stated they were event related for expiration dates. The box had an expiration listed on it. Staff #3 stated the facility uses event related expiration dates. Staff #3 was asked if the facility had an IFU (Instructions for use) that list the guarantee of sterility for the product. Staff #3 stated they did not.

Review of an IFU provided by Medical Action on request revealed the following:

"Storage
1. Store in cool, dry and clean place.
2. Keep away from direct sun light and heat.
3. Expiration date is printed on all product packers.
This is three years from manufacture date. Product integrity has only been validated for
this stated shelf life."



PEDIATRIC BROSELOW CART

In the Pediatric Broselow Cart there were emergency pediatric disposable packs stored in the drawers that had expired in 2018; over 1 year ago. The facility had opened all the packs and removed the expired supply and re-taped the packs. This practice was done on all the color-coded emergency packs. Staff #3 stated the facility had to order this item in bulk and they were very expensive. Staff #3 stated the only thing in the pack that expired was the alcohol pad. Staff #3 was asked if the company had approved this process. Staff #3 confirmed they had not.

Staff #3 confirmed the above findings.



During a tour on July 9, 2019 after 12:40 P.M., the following observations were made:

RESPIRATORY DEPARTMENT

The refrigerator used to store controls for blood gas machine was not being continuously monitored. There was no way to determine if the temperature went out of range. There was a package of electrode pads that had been opened and stored in a bin to use later. The manufacturer package stated, "do not open until immediately prior to use." There was skin prep gel in a bin that expired in 2011; over 8 years ago. There was a package of gauze sponges stored in a bin uncovered and in an open package. The sponges were exposed to a buildup of dust, dirt, and contamination.

Staff #2 confirmed the above findings.


MATERIALS MANAGEMENT

There was a wooden platform under a shelf that stored patient supplies. The platform had missing chips of paint and the wood was exposed. Sterile supplies were stored under the air conditioning vent. The floor had missing chips and scrapes of paint exposing the cement floor. The supply bins that stored patient supplies were covered with spills, dust, dirt, and debris. Metal racks storing patient supplies were covered in tape residue and rust. Non-sterile supplies were being stored above sterile supplies. There was a wooden pallet stored in room with sterile patient supplies. There was no way to clean pallet. The wood had splinters and pieces of wood missing. A heater and patient bedside commodes were stored on the floor next to a metal file cabinet. The equipment was covered in dust and dirt. An electrical panel in the materials management department was stored on a wooden platform. The platform was covered in dust, dirt, debris, and a black substance that appeared to be oil stains. The wood platform had missing and chipped wood. The walls surrounding the electric panel had missing chips of paint.

Staff #27 confirmed the above findings.


During a tour on July 10, 2019 after 8:30 A.M., the following observations were made:


RADIOLOGY DEPARTMENT - ROOM 1

The linen was stored on an open shelf uncovered. The walls had missing/chipped of paint. A foam positioner covered with a Chux pad (A disposable patient under pad) was used from patient to patient without changing the pad or cleaning the positioner. The floor next to the X-Ray equipment was covered in dust and dirt. The base of the X-Ray table was covered in dust and dirt. The base had missing chips of paint. The walls had scrapes and missing chips of paint.



TELERADIOLOGY ROOM

In the room being used to store the computer for teleradiology, the floor going into the room was missing the linoleum and the subfloor was exposed. The floor in the room was not sealed and the concrete was exposed. There was a dead bug that appeared to be a roach. There was a metal step stool in the room that was covered in rust.


PATIENT BATHROOM IN THE RADIOLOGY DEPARTMENT

There was a hole in the wall exposing the sheetrock. There was a switch box labeled emergency. The emergency call system did not work. The switch box was covered in rust.


RADIOLOGY DEPARTMENT - ROOM 2

The vinyl baseboard was separating from the wall. The crevices and floor were covered in dust, dirt and debris. The linoleum floor file had cracks in the seams of the floor and exposed the subfloor. There was dead big on the floor that appeared to be a roach. The floor in the room had missing linoleum tiles that exposed the subfloor. There was a space between the X-Ray processor and the floor that had floor covered in dust, dirt, and debris. The floor was stained with a black substance. There was a broom base in the corner of the space that was covered with dirt. There was a metal equipment frame on the wall that was covered in rust.


CT ROOM

The plastic covering for the CT table had shiny spots throughout the top of the covering that appeared to be contrast. Under the sink, there was a pipe coming up from the floor. The pipe was uncapped. There was a basin under the pipes and a towel next to the basin, that appeared to be a leak. Staff #21 stated maintenance had been working under sink. There was a patient urinal next to the basin. The portable Suction on the crash cart had a metal base that was covered in rust. There was a spider web in the corner behind the crash cart in the room. The blood pressure cuff was laying on the floor behind the crash cart.


MAIN RADIOLOGY CRASH CART

The base of the portable suction was covered in rust. The defibrillator screen was covered in dust and dirt. The patient backboard used in emergencies was wood and had splinters and chips of the wood missing.

Staff #2 & #21 confirmed the above findings.


28659

The following departments were identified with infection control issues.


Kitchen:

On the afternoon of 7/8/2019 a tour of the dietary department to include the food preparation, food dry storage, cold storage, clean dish room were observed. The tour was provided by the Director of the dietary department. Observations included the following.

Food preparation room

Surfaces that included the the shelving below the serving line, and shelving of cabinets behind the serving line revealed metal surfaces worn bare with rust visible.

Two (2) wooded surfaces, one dispensing plastic rap and one on the counter was observed with the pain worn off to bare wood.

Surfaces that are worn through the protective paint are unable to be safely sanitized. The broken paint has edges where bacteria may reside and bare wood will absorb odors, as well as detergent and sanitizing agents and are not safe to use afterward.

Equipment

A small oven was observed with a build up of oils and debris between the two (2)pane windows of the oven door. The leaking seal around the glass allowed oils and backing debris to collect between the pane of glass making it unable to be sanitized.

The large mixer was observed covered with a plastic cover but beneath the cover the gray metallic paint was worn and scratched revealing bare metal.

Kitchen Freezers

The walk in freezer contained boxes of frozen meat. One (1) box of frozen meat was observed with inner plastic bag, which held the frozen meat open, exposing the frozen meat to freezer burn and cross contamination.

The kitchen also used a small chest type freezer. The freezer did not have a manufacturer's thermometer and the staff had not kept a removable thermometer in the unit. Inside the chest freezer was three (3) large sacks of frozen rolls/biscuits open to be cross contaminated or freezer burned.

Temperatures for Dish washer.

A review of the log, maintained for the dish washing machine temperatures, revealed a log with no instructions or goal temperature parameters. The hand written log began 6/21/2019 and was current to July 8, 2019. The log indicated temperatures were recorded AM, Noon, and PM.

Twelve (12) recorded temperatures, between the above dates, were found to be outside the accepted parameters for temperature to meet sanitation requirements.

An interview with the Dietary Director confirmed she was not sure what the temperature parameters were without referring to the policy.

A review of the Policy for the dish machine temperatures indicated the temperature should be above 140 degrees and below 180 degrees.

The Dietary Director confirmed there were no instructions for rechecking the temperatures or reporting the temperatures should they not reach or return to the accepted parameters.


Clean Dish room

The clean dish room was observed with clean pots and pans stored on open racks for air drying. The ceiling of the room held a large air vent with a wire covering. Both the vent and the wire covering was visibly soiled appearing to be grease/oil and heavy lint immediately above the open rack of pots and pans.



Computed Tomography (CT) Building:

Observation an exam room of the CT building was the sanitation chemicals for sanitizing the probes used in transvaginal ultra sound testing. Observation are found below.

An empty canister with layers of tape residue was labeled "Rapicide OPA", the test strips were labeled from the manufacturer to be used for "Rapicide OPA". The test strips had a hand written expiration date of 6/2019. The manufacturer had provided a line space for writing the date opened. There was no date written on the bottle.

Upon review of three (3) unopened gallon bottles of sanitizing solution, it was discovered the solution was not Rapicide OPA, but Cidex OPA. Although both solutions are used for high level disinfection of instruments they are not chemically made the same. Rapicide OPA is ortho-Phthalaldehyde while Cidex OPA is compatible to Glutaraldehyde.

A review of the calibration log sheets for the use of the High Level Disinfectant revealed, the log was for the use of "Rapicide OPA" and not Cidex OPA. According to the log sheet, no sanitizer had been mixed since 3/2019

An interview with, staff #21, the Manager for the Radiology/CT department was interviewed and asked about the different procducts indicated for use in the high level disinfectant. He replied, "I don't know. I don't do that".

Interview with the Chief Executive Officer, staff #1, confirmed she had the correct log sheet in her files and did not realize the wrong log sheet was being used.

General sanitation of the building was observed with visible dirt in corners and base boards, cobwebs from the ceiling, and Lint in the air ducts. Dead insects were observed in corners and shelving.

A badly rusted rolling IV standard was stored in the corner of the ultra sound room.

The above findings were confirmed by staff #2, the Chief Operating Officer.


41831

On July 8, 2019 between 1:30 pm and 3:00 pm the following infection control issues were found on the West Wing Patient area.

Room 136 - A clean, unoccupied patient room.

There was a shower chair in the shower. On the underside of the shower chair there was dirt and there was rust noted on the legs. Rust cannot be sanitized.

Room 127 - A clean unoccupied patient room.

There was a large hole noted in the wall behind the patient bed. The hole had a plastic circular cover surrounding the open space. There was a telephone cord hanging from the hole. In the patient's bathroom there were several tiles missing from the floor of the shower. There were tiles stacked in the corner that appeared to be the tiles missing from the shower. There were black stains in the grout on the wall and floor of the shower. There was paint peeling from the wall beside and behind the toilet. The wall was soft with holes and discolored areas were noted. There was no seal around the opening in the wall around the plumbing pipe. There was corrosion green oxidation noted to the plumbing pipe. There was rust noted on the soap dish in the shower. The toilet paper holder was rusted. There was no way to properly sanitize them. The emergency call light in the bathroom had a sharp piece of rusted metal protruding from it which had the potential to cause injury. There were bugs noted in the light fixture in the bathroom.

Clean Utility room - Clean sharps containers and other patient supplies were stored on the floor

On July 9, 2019 between 9:30 am and 11:00 am the following infection control issues were observed on the West Wing.

West Unit Medication Room - There was a cloth bag stored on a wire rolling shelf under the counter next to the patient medication refrigerator. The bag had a patient sticker on the bag and contained patient's home medication in it. The bag was stored in an area where medications were prepared for other patients. There is no way to clean the bag.

An interview conducted on July 9, 2019 at 9:45 a.m. with staff # 17 revealed the following:

Staff # 17 said they routinely store patient's home medications in whatever bag is brought directly from the patient's home. Staff # 17 also said they do not place these bags in a separate bag before storing them into the medication room. An interview on July 9, 2019 at 10:40 a.m. with Staff # 1, CEO/Infection Control, stated, "the facility routinely stores patient's home medications in the medication room on the West Wing."

Review of facility policy "Administration of 'Home' Medications," dated 6/27/2019 revealed the following:

"All medication are returned to patient should they become a full admission, discharged home or transferred to another facility."