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Based on facility tours and staff interviews, the facility failed to maintain a safe environment to protect the health and safety of patients.

This failure contributed to the potential for patient injury due to improperly stored supplies and the use of expired supplies and medications during patient procedures.

FINDINGS:

1. The facility failed to ensure that supplies and medications used during patient procedures were not expired.

a) On 07/15/13 at 11:30 a.m., a tour of the facility's inpatient unit and ultrasound room was conducted with the facility's Chief Nursing Officer (CNO).

The crash cart in the ultrasound room, which also served as the crash cart for the inpatient unit, was viewed and contained an Intravenous (IV) start kit with a manufacturer's expiration date of 04/2013, 2 capnography monitors with manufacturer's expiration dates of 04/2013, 3 vials of Verapamil with manufacturer's expiration dates of 07/2013, and 2 vials of Inderal with manufacturer's expiration dates of 06/2013. The facility's CNO verified the manufacturer's expiration dates and immediately removed the items.

b) On 07/15/13 at 12:00 p.m., a tour of the facility's laboratory was conducted with the facility's CNO and the area where patient care was conducted was viewed. Shelving in the patient care area contained 6 lavender laboratory specimen tubes with manufacturer's expiration dates of 04/2013 and 6 gold laboratory specimen tubes with manufacturer's expiration dates of 01/13. The facility's CNO verified the manufacturer's expiration dates and immediately discarded the items.

c) On 07/15/13 at 12:30 p.m., a tour of the facility's Emergency Department (ED) was conducted with the facility's Chief Nursing Officer (CNO). A warming cabinet in the ED contained 6 bags of Normal Saline intravenous (IV) fluid, with 2 that were labeled with a handwritten date of 07/14/13 and 4 that were labeled with a handwritten date of 08/06/13. There were also 6 bags of Lactated Ringers IV fluid that were labeled with a handwritten date of 05/14/13. Additionally, there were 6 containers of Sterile Water that contained no date. The CNO stated that staff were expected to label the solutions and to keep the solutions in the warming cabinet for no more than 4 weeks, as per manufacturer's instructions.

b) While viewing the fluid warmer, an ED staff nurse was interviewed. The ED staff nurse was unable to state whether the handwritten dates on the bags of IV fluid represented the date the IV fluid was put in the warmer or whether it was the date the IV fluid was to be removed from the fluid warmer.

d) On 07/15/13 at 12:50 p.m., an interview was conducted with the facility's CNO. S/he stated it was her expectation that expired equipment and medications would not be stored or available in patient care areas and that all items placed in the warmer would be consistently labeled.

Based on observations and staff interviews, the facility failed to ensure that radiological procedures were performed in a manner that protected both staff.

This failure contributed to staff being exposed to harmful radiation.

FINDINGS:

1. The facility failed to ensure that radiology staff wore dosimetry badges while working in areas that exposed them to radiation.

a) On 07/15/13 at 12:15 p.m., the facility's radiology department was toured with the facility's Chief Nursing Officer (CNO) and Radiology Technician (RT) #1. RT#1 was observed not wearing his/her dosimetry badge during the tour.

b) An interview was conducted with RT#1 during the tour of the Radiology Department. RT#1 stated s/he knew the dosimetry badges were to be worn at all times but that s/he had sent in his/her dosimetry badge for a routine radiation exposure reading. S/he stated that s/he had not received another dosimetry badge prior to sending in his/her old dosimetry badge. RT#1 stated s/he had worked two shifts without wearing a dosimetry badge.

2. The facility failed to ensure that staff members properly stored their dosimetry badges.

a) On 07/15/13 at 12:15 p.m., the facility's radiology department was toured with the facility's Chief Nursing Officer (CNO) and Radiology Technician (RT) #1. RT#1 stated that all staff members in the radiology department worked at both this facility and at the facility's other location in another town. RT#1 stated that all staff members had only one dosimetry badge and brought it with them between the sites. RT#1 could not state how the staff members stored their dosimetry badges while transporting them between facilities or after leaving a facility. RT#1 stated that s/he was aware that dosimetry badges were not to be stored in cars because of the risk of creating a false radiation reading.

b) During the same tour of the Radiology Department, the CNO was interviewed. The CNO stated that each radiology technician had only one dosimetry and that it was his/her expectation that dosimetry badges would be stored properly when not in use.

c) On 07/15/13 at 12:55 p.m., an interview was conducted with Radiology Technician (RT) #2. RT#2 stated that all of the radiology staff worked at both this facility and the other facility in another town. RT#2 stated that radiology staff often transported their dosimetry badges in their private vehicles and left them there for several days between shifts.

Based on medical record review and staff interviews, the facility failed to ensure that a nursing care plan was developed and kept current for each inpatient.

This failure resulted in patient care not being directed by a plan that addressed the patient's ongoing needs.

Findings:

1. On 07/16/13, a review of 7 inpatient records revealed that 7 of the 7 inpatient records did not contain an adequate nursing care plan.

a) A review of 5 inpatient records (Sample Patients #10, 11, 16, 17, and 18) and 2 swing-bed patient records (Sample Patients #12 and 15) revealed that the care plans did not include measurable objectives or time tables to meet the patient's medical, nursing, mental, and psychosocial needs.

b) On 07/16/13, a review of Sample Patient #10's medical record was conducted. The patient was admitted to the hospital's inpatient unit for a non-healing wound. The patient's care plan listed multiple areas of patient care including wound healing, nutrition, and pain status. The patient's discharge note and nursing notes addressed each individual goal, but the care plan itself did not address if the goals for these areas had been met. An interview with the facility's Inpatient Nurse Manager during the record review confirmed that the nursing care plan did not adequately address whether the patient's goals were met.

c) On 07/16/13, a review of Sample Patient #11's medical record was conducted. The patient was admitted to the hospital's inpatient unit for pancreatic pain. The patient's care plan listed multiple areas of patient care including pain control. The patient's discharge note and nursing notes addressed each individual goal, but the care plan itself did not address if the goals for these areas had been met. An interview with the facility's Inpatient Nurse Manager during the record review confirmed that the nursing care plan did not adequately address whether the patient's goals were met.

d) On 07/16/13, a review of Sample Patient #12's medical record was conducted. The patient was admitted to the hospital's Swing-Bed program. The patient's care plan listed multiple areas of patient care including fluid status and weakness. The patient's discharge note addressed each individual goal, but the care plan did not address if the goals for these areas had been met. An interview with the facility's Inpatient Nurse Manager during the record review confirmed that the nursing care plan did not adequately address whether the patient's goals were met.

e) On 07/16/13, a review of Sample Patient #15's medical record was conducted. The patient was admitted to the hospital's Swing-Bed program. The patient's care plan listed multiple areas of patient care including mobility and the patient being a possible fall risk. The patient's discharge note addressed each individual goal, but the care plan did not address if the goals for these areas had been met. An interview with the facility's Inpatient Nurse Manager during the record review confirmed that the nursing care plan did not adequately address whether the patient's goals were met.

f) On 07/16/13, a review of Sample Patient #16's medical record was conducted. The patient was admitted to the hospital's inpatient unit for back pain. The patient's care plan listed multiple areas of patient care including pain status. The patient's nursing notes addressed each individual goal, but the care plan itself did not address if the goals for these areas had been met. An interview with the facility's Inpatient Nurse Manager during the record review confirmed that the nursing care plan did not adequately address whether the patient's goals were met.

g) On 07/16/13, a review of Sample Patient #17's medical record was conducted. The patient was admitted to the hospital's inpatient unit for hospice care. The patient's care plan listed multiple areas of patient care. The patient's nursing notes by both the facility's nurses and hospice nurses addressed each individual goal, but the care plan itself did not address if the goals for these areas had been met. An interview with the facility's Inpatient Nurse Manager during the record review confirmed that the nursing care plan did not adequately address whether the patient's goals were met.

h) On 07/16/13, a review of Sample Patient #16's medical record was conducted. The patient was admitted to the hospital's inpatient unit for a headache. The patient's care plan listed multiple areas of patient care including pain status. The patient's discharge note and nursing notes addressed each individual goal, but the care plan itself did not address if the goals for these areas had been met. An interview with the facility's Inpatient Nurse Manager during the record review confirmed that the nursing care plan did not adequately address whether the patient's goals were met.

i) On 07/16/13 at 11:55 a.m., an interview was conducted with the facility's Inpatient Nurse Manager. S/he stated that every patient, except observation status patients, was expected to have a nursing care plan in their record. S/he viewed the care plans contained in the medical records of the 7 inpatient records, but was unable determine by looking at the care plans if the 7 patients had met their goals. The Inpatient Nursing Manager stated that nursing staff often did not document if goals had been met in the care plan, but instead often documented it in the nursing notes.