HospitalInspections.org

Based on observation and interview the facility failed to maintain proper maintenance of equipment resulting in the potential for spread of infectious disease amongst the patients receiving treatment at the facility. The finding includes:

On January 25, 2017 at approximately 1130 during the tour of the facility in the kitchen, it was revealed the pressure gauge on the dishwasher machine was not functioning properly. To avoid an atomizing effect on the dish surface which reduces the contact temperature, the pressure range of the dishwasher machine must measure between 15-25 psi.
The finding was confirmed with staff EE and FF at the time of discovery.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on January 23, 2018, the facility failed to comply with the applicable provisions of the 2012 Edition of the Life Safety Code, resulting in the potential for patient harm. Findings include:

See the following K-tags on the CMS-2567 dated 1/23/18 for Life Safety Code citations.
K-0351
K-0372
K-0511

Based on observation, interview and record review the facility failed to ensure that expired medications and IV (intravenous) solutions were removed from available stock and not available for patient use on two of four crash carts and in the automated medication dispensing system resulting in the potential for less than optimal patient outcomes. Findings include:

On 1/23/18 at approximately 1118 during a tour of the emergency department with the nurse manager, Staff D, it was observed that the crash cart in the trauma bay had two 2% Lidocaine pre-filled syringes in the medication drawer that were dated with a manufacturers expiration date of 1/1/2018 and were available for patient use. Further observation with Staff D at 1140 of the facilities automated medication dispensing system in the emergency department revealed two IV bags of Lactated Ringers/5% Dextrose (fluid and electrolytes) that were dated with manufacturer expiration dates of 9/2017, and three IV bags of 5% Dextrose that were dated with a manufacturer expiration dates of 12/2017 and were available for patient use. Staff D confirmed the above observations and removed the expired items.

On 1/23/18 at 1150 Staff D stated that, "Pharmacy is responsible for monthly checks of all medications and IV solutions. Pharmacy is available everyday from 0600 to 1300 and replaces any used stock. I don't know how any expired medications or IV solutions could be in the Omnicell (automated dispensing system) because when new stock is added it must be scanned in".

On 1/24/18 at approximately 1050 during observations of the surgical area with the OR (operating room) supervisor, Staff S, it was observed that the crash cart in the PACU (surgical recovery room) had one 2% Lidocaine pre-filled syringes in the medication drawer that was dated with a manufacturer expiration date of 12/1/2016 and was available for patient use. Staff S confirmed that the Lidocaine was expired and should have been removed from the crash cart. Staff S removed it from the crash cart and stated she would have pharmacy replace it.

On 1/25/18 at 1100 the facilities pharmacy manager, Staff Y was interviewed regarding the above observations. Staff Y stated, "I was informed of the expired items. I know one of the syringes expired 1/1/2018, but the other one expired in 2016 which means it was overlooked multiple times. The crash carts are restocked daily as needed and monthly by our pharmacy technicians, and also checked by the pharmacist, who is out of town today. Responsibility ultimately falls on the pharmacist. The Omnicell scan does not track expiration dates. The pharmacy technician is prompted to enter the date when new stock is added to the system. I can only assume that staff is not rotating stock properly. Staff should enter the date of the oldest stock (stock that will expire first). Staff must be entering the date of the new stock instead. They print a daily list of all medications in the system with expiration dates, which should show the date of the item that will expire next if they are entering the dates properly. When restocking they should be verify the dates on the stock currently in the system for the expiration date. We will be reeducating all staff.

On 1/24/18 at 1400 the facility policy titled "Medication Procurement and Storage Policy" dated reviewed 8/1/17 documented the following: Purpose-To provide a safe accurate process for the procurement and storage of medications for use with patients at (name of hospital). Policy- The pharmacy department is responsible to uphold the proper procedures for obtaining all medications within the scope of the formulary and to assure those medications are stored under proper conditions to ensure medication integrity and personnel safety."

Based on interview and record review, the facility failed to ensure missed medication (holds) were communicated and documented to the medical doctor for 1 of 10 patients (#6) in accordance with accepted standards of practice out of a total of 20 sampled patients, resulting in the potential for less than optimal outcomes. Findings include:

On 1/24/2018 at approximately 0940 a review of the electronic closed medical record was conducted for patient #6 with the Nurse Manager for the Emergency Department and the Medical Surgical unit Staff D and the following was documented:

According to the medical record patient #6 was admitted to the facility on 11/7/17 with diagnoses that included congestive heart failure, diabetes mellitus, dementia, and chronic venous ulcers. Further record review revealed the patient was discharged on 11/12/17.

A review of physician orders dated 11/7/17 documented the patient was on Humalog insulin 10 units before every meal.

A review of the patient's medication administration record (MAR) dated 11/8/17 documented the patient's Humalog insulin was "held" (not given) because the patient was not eating well. The nurse documented the patient's blood glucose result was 147 at 1730. However, there was no further evidence in the medical record that documented the nurse notified the physician that she held the patient's insulin on 11/8/17 at 1730. At that time Staff D explained the nurse should have notified the physician and documented accordingly.

A review of the facility's policy titled "Medication Administration Workflow and Safety Policy", dated 8/14/2018, documented:
"VI. Holding medication in EPIC
In the MAR...The primary nurse is responsible to notify the provider (medical doctor)."

Based on interview and record review, the facility failed to ensure nursing staff developed a comprehensive care plan that addressed anticoagulation therapy for 1 of 10 patients (#6) out of a total of 20 sampled patients, resulting in the potential for less than optimal outcomes. Findings include:

On 1/24/2018 at approximately 0940 a review of the electronic closed medical record was conducted for patient #6 with the Nurse Manager for the Emergency Department and the Medical Surgical unit Staff D and the following was documented:

According to the medical record patient #6 was admitted to the facility on 11/7/17 with diagnoses that included congestive heart failure, diabetes mellitus, dementia, and chronic venous ulcers. Further record review revealed the patient was discharged on 11/12/17.

A review of physician orders documented the patient was on coumadin therapy (a medication used to prevent blood clots) 2.5 milligrams (mg) 6 days per week and 3.0 mg 1 day per week (Monday's).

A review of the patient's nursing care plans revealed there was no care plan for anticoagulation therapy. At that time Staff D confirmed there was no care plan for anticoagulation therapy. She said "there should have been one".

A review of the facility's policy titled, "Care plan preparation" per Lippincott procedures date stamped 1/24/2018 documented: A nursing care plan should be written for each patient, preferably within 24 hours of admission.