HospitalInspections.org

Based on staff interviews, observations, and document review, it was determined that the facility failed to inform each patient or the patient's representative, of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.

Findings include:

1. On 1/20/11 at 10:25 AM, Staff #20 was asked to provide for review, a copy of the hospital policy and procedure in which the Medicare beneficiary, who is an inpatient, be provided a standardized notice, "An Important Message from Medicare" (IM) within two days of admission and that a copy of the IM is presented in advance of the patient's discharge, but not more than two calendar days before the patient's discharge.

a. On 1/20/11 at 10:25 AM, Staff #20 stated that the hospital does not have a hospital policy and procedure regarding "An Important Message from Medicare" (IM) notice.

2. On 1/20/11 at 10:45 AM, in the presence of Staff #20, three of four Medical Records (#31, #32, and #33), of four Medicare Beneficiaries reviewed did not contain the required signed and dated "An Important Message from Medicare" (IM) notice.

3. All the above was confirmed by Staff #20 on 1/20/11 at 11:45 AM.

Based on review of the facilities Plan of Correction dated November 10, 2010, a tour of the facility, and an interview with facility staff, it was determined that the facility failed to implement the Plan of Correction.

Findings include:

Repeat deficiencies:
1. No signage was present instructing visitors to report to the receptionist's desk prior to proceeding to another location within the facility.

2. The above was confirmed by Staff #1.

Based on document review and staff interview, it was determined that the facility failed to measure, analyze, and track quality issues effectively, to improve outcomes within all departments.

1. A review of the 2010 Performance Improvement data from the Food and Nutrition Department revealed that the "Calorie Count Completion" was reported as being below the goal of 100% for all four quarters.

a. The "Reason for not meeting goal," was, "Unable to retrieve patient data for all meals."

2. A review of the Performance Improvement Committee minutes dated October 14, 2010 stated, "Calorie Count Completion up to 80% from 77.8 It was requested that NPO status should be excluded from calorie count. Would like it stated that patient went NPO."

3. A review of the PI Indicator Worksheet from the Food and Nutrition Department failed to provide any evidence of analysis or tracking of any quality indicators to assess the process of data review.

4. There was no evidence in the Performance Improvement for 2010 of an analysis or actions identified, for the Calorie Count Completion, to improve the process of data collection in order to establish a goal of 100%.

Based on medical record review and staff interview conducted on 1/19/11, it was determined that the facility failed to ensure that medications were administered in accordance with physician's orders.

Findings include:

1. A Post Anesthesia Care Unit order was written in Medical Record #10 on 1/18/11 for "Morphine Sulfate 5mg IV q 5 min PRN for total dose of 20 mg [5 milligrams intravenously every 5 minutes as needed for total dose of 20 milligrams]." The administration of Morphine 2.5 mg at 18:30, 18:35, 18:40 and 18:45 is recorded on the Post-Anesthesia Record.

A. Based on medical record review conducted on 1/19/11, it was determined that the facility failed to ensure that all medication orders are signed, dated and timed by the prescriber.

Findings include:

1. The "Additional Orders" section of the Post Anesthesia Care Unit Admission Orders in Medical Record #10 include an order for "Hydralazine 10mg IV [intravenously] now" and "Regular Insulin 10 units SQ [subcutaneously] now then BS [blood sugar] check in 1 hr." The order sheet was signed by the physician, dated 1/18/10, and timed at 18:05. Upon review of the Post Anesthesia Care Record it was noted that the patient arrived to the unit at 17:47. Hydralazine was given at 19:10 and Regular Insulin 10 units SQ was administered at 19:45. The nurse's note at 1900 states, "Patient resting and arousable...BP 200/88 Dr.--- aware. The nurse's note at 19:10 states, "Given Hydralazine 10 mg IV for [arrow up] BP. The nurse recorded a blood sugar of 303 at 19:45. Based on the timing of the notes and the physician's orders, it appears that the orders for Hydralazine and Insulin were not ordered on 1/18/10 at 18:05, the time the order sheet was signed. It appears that these orders were written by the physician at a later time and were not signed, dated and timed by the physician when written.


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B. Based on staff interview and medical record review of discharged patients, it was determined that the facility failed to ensure that verbal orders were dated, timed and signed by the authorizing prescriber.

1. In 7 out of 10 medical records of discharged patients, there was no evidence that the verbal orders were signed within 30 days after discharge.

2. Staff #21 stated during interview on 1/20/11, that the Medical Records Department receives all printed physician's orders from the Pharmaceutical Department prior to the mandated 48 hour time frame for authentication.

3. There is no mechanism in place to ensure that all verbal orders are signed and authenticated by the prescriber before they are sent to the Medical Records Department for storage.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that verbal or telephone orders were authenticated within 48 hours.

Findings include:

1. Medical Record #29 revealed the following:

a. Telephone orders dated 11/8/10 at 12PM, 1400, and 1500 did not include a physician's signature authenticating the orders.

2. Medical Record #26 revealed the following:

a. Telephone orders dated 9/10/10 at 10:00 AM and 2:00 PM did not include a physician's signature authenticating the orders.

3. Medical Record #27 revealed the following:

a. Telephone orders dated 11/13/10 at 12:15 AM, 4:40 PM, and 7:50 PM did not include a physician's signature authenticating the orders.

4. Medical Record #31 revealed the following:

a. A telephone order dated 12/6/10 (no time on order) did not include a physician's signature authenticating the order.

b. A telephone order dated 12/7/10 at 21:45 did not include a physician's signature authenticating the order.

5. Medical Record #33 revealed the following:

a. A telephone order dated 12/15/10 at 0505 did not include a physician's signature authenticating the order.

The above was confirmed by Staff #1.

A. Based on observation and staff interview conducted on 1/19/11, it was determined that the facility failed to ensure that pharmacy controlled the distribution of medications.

Findings include:

1. During a tour of Unit E4 at approximately 10:30 AM, the following unit dose medications were found stored in the bottom drawer of the medication carts.

a. One tablet/capsule/injectable each of Plavix 75mg, Toprol XL 50mg, Verapamil 120mg, Losartan 50mg, Aspirin 325mg, Sensipar 30mg, Sertraline 50mg, Lisinopril 5mg, Metoprolol 50mg, Hydralazine 10mg, Labetalol 200mg and Ecotrin 325mg.

b. Two tablets/capsules each of Gabapentin 300mg, Pravastatin 20mg, Glyburide 5mg and Prednisone 10mg.

c. Two open bottles of Nitroglycerin 0.4mg tablets

d. Four 1 gm tubes of Nitrobid Ointment

2. Upon review of the pharmacy unit inspections for Unit E4, it was noted that extra medications in the medication carts was not identified as noncompliant during any inspections in 2010. Upon interview, Staff #5 confirmed that there was a possibility that pharmacy staff was "cleaning out" the medication carts during inspections but not identifying the problem on the inspection forms.

3. Upon review of the contents of Drawer 12, Pocket 19 of the Pyxis drug dispensing device located on Unit E4 it was noted that the pocket contained 3 unit dose containers of Phenytoin 100mg/4ml and 2 unit dose containers of Phenytoin 125mg/5ml. Upon interview Staff #5 confirmed that the pocket was suppose to contain just Phenytoin 100mg/4ml. Since the nurse is prompted to remove a requested drug and dosage strength from a particular pocket when using the Pyxis drug dispensing device, placing more than one dosage strength into a pocket greatly increases the risk of a medication error.

4. Famotidine 20mg in Normal Saline Solution, dated to be administered on 1/15/11 was found in Patient #8's medication cassette drawer. The medication had been discontinued and therefore not administered but had not been returned to pharmacy.

5. Levothyroxine 50mcg syrup, to be administered 1/12/11, was found in Patient #9's medication cassette drawer. According to the medication administration record, the patient received a dose on 1/12/11. The extra unused dose had not been removed from the patient's medication cassette drawer.

6. One 1000 ml bag of Potassium Chloride 10% in Dextrose 5% Normal Saline 0.45%, that did not have a pharmacy label, was found in the Medication Cart on Unit E4. Upon interview Staff #5 stated that this was not floor stock and he/she did not know how the medication got into the medication cart.

B. Based on observation and staff interview conducted on 1/19/11, it was determined that the facility failed to ensure that the patient's own medications are checked by the pharmacy prior to administration.

Findings include:

Reference: Facility policy titled "Patient's Own Medication" states, "...4. Before the medication can be administered to the patient, it must be brought to the pharmacy. The pharmacist will identify and verify the content for use in the medical center, and initial and date the medication..."

1. "Lubiprostone 24 mcg. by mouth daily, Patient's own med." was ordered in Medical Record #7 on 1/16/11. The administration of Lubiprostone 24mcg on 1/16/11, 1/17/11, 1/18/11, and 1/19/11 was recorded on the Medication Administration Record. Upon review of the prescription vial of Lubiprostone 24mcg from a retail pharmacy , it was noted that there were no markings on the vial to indicate that the medication had been checked by the pharmacy. Upon interview, Staff #5 confirmed that facility policy was for the pharmacy to check the patient's own medication prior to administration, in conformance with the policy referenced above. He/she confirmed that this had not been done.

Based on observation and staff interview conducted on 1/19/11, it was determined that the facility failed to ensure that medications were kept in locked storage areas.

Findings include:

1. During a tour of Unit E4 at approximately 10:30 AM, it was noted that 2 of the 3 medication carts were not locked.

2. One Ranexa 500mg tablet was found on top of the Pyxis drug dispensing device on Unit E4 at 11:00 AM.

These findings were confirmed by Staff #5

Based on observation on 11/19/11, it was determined that the facility failed to ensure that expired or otherwise unusable medications were not available for patient use.

Findings include:

1. A discharged patient's own supply of one Fluconazole 150mg, dispensed by a retail pharmacy on 7/30/10, was found in the medication refrigerator on Unit E4.

2. An opened vial of Humalog Mix 75/25 with the date "12/27" and an opened vial of Novolin N with the date "12/30" were found in the medication refrigerator on Unit E4. Upon interview, Staff #5 stated that opened vials were dated with the expiration date, therefore these vials were expired.

3. Two 1000ml bags of Potassium Chloride 20meq in Dextrose 5% Normal Saline 0.45% were found in the medication cart on Unit E4. The bags were labeled by the pharmacy for a patient to be used on 9/28/10 and 9/29/10.

4. Two 100 ml bags of Normal Saline solution that were out of the overwrap were found in the medication cart on Unit E4. The date the bag had been removed from the overwrap was not indicated. The manufacturer's recommendation is to discard 30 days after removing from the overwrap.

Based on document review and a tour of the kitchen in the presence of Staff #4, it was determined that the Food Service Director failed to provide daily supervision of the Food Services Department.

Findings include:

Reference 1: The Director of Food and Nutrition Position Specification states that the Director: "Plans, directs, coordinates and oversees all activities of the food and nutrition department." "Fosters a clean and clutter free environment." The Director of Food and Nutrition "Ensures all aspects of departmental operations including but not limited to patient services, production, catering and
retail operations function in a manner that ensures patient and customer satisfaction as well as optional efficiency and regulatory compliance." "Proactively leads direct reports in a manner that clearly promotes goals objectives, and accountability for responsible area(s)."

Reference 2: The Supervisor ' s of Food and Nutrition Position Specification states that the Supervisor reports to the Director, Food and Nutrition. The Supervisor's position summary states that "The Food & Nutrition Supervisor is responsible for assisting the manager in providing administrative direction in the management and coordination of the department." The Supervisor "Fosters a clean and clutter free environment and understands it is every associate's/employee's responsibility to maintain the appearance of all areas," and "Complies with organizational and departmental policies, procedures and standards."

Reference 3: The Storage of Dishes and Utensils policy and procedure states that the "Dishes and utensils are stored in clean racks."

Reference 4: The Food Handling for Infection Control policy and procedure states that "All associates will receive annual in-service training on infection control."

Reference 5: The Refrigerator Cleanliness and Monitoring of Temperatures policy and procedure states that "All refrigerators/freezers in the Food & Nutrition Department as well as patient pantry refrigerator/freezers will be maintained in a clean state and at the proper temperature for its' contents."

1. On 1/19/11 at 10:45 AM in the presence of Staff #4, the main kitchen storage areas and cafeteria were observed to have dust and litter on the floors under all shelving, tables, carts, and sinks.

2. On 1/19/11 at 10:45 AM in the presence of Staff #4, two fire extinguishers hanging on the walls of the main kitchen production area were observed with a heavy layer of dust.

3. On 1/19/11 at 10:45 AM in the presence of Staff #4, approximately 20 or more gnats were observed on the walls and ceiling, and in the main kitchen, at the cafeteria-to-kitchen pass thru.

4. On 1/19/11 at 10:45 AM in the presence of Staff #4, five patient meal tray carts were observed with dirt and spatter on the interior surfaces, including the walls, ceiling and floor of the carts.

5. On 1/19/11 at 10:45 AM in the presence of Staff #4, an air vent on the wall in the main kitchen was observed with an accumulation dust.

6. On 1/19/11 at 10:45 AM in the presence of Staff #4, one cook's box and four Traulsen cold boxes/refrigerators were observed with dirt and spatter on the interior surfaces, including the walls, ceiling and floors.

7. On 1/19/11 at 10:45 AM in the presence of Staff #4, two plate lid holder racks with clean lids stored in them, were observed with dirt, food particles and litter on the bottom of the rack.

8. On 1/19/11 at 10:45 AM in the presence of Staff #4, brown stains and spots were observed on the walls and ceilings of the main kitchen and all storage areas throughout the nutrition services department.

9. On 1/19/11 at 11:15 AM Staff #4, was asked for a schedule and syllabus of all the Food and Nutrition Department training, including the annual in-service training on infection control, completed during the last year. Staff #4 stated that specific Food and Nutrition Department training/in-services were not completed last year. The annual in-service training on infection control was not completed as required per the Food Handling for Infection Control policy and procedure; Reference #4.

10. On 1/19/11 at 11:15 AM, Staff #4 confirmed that the Food and Nutrition Department was not maintained clean as stated and required in Reference 1, Reference 2, Reference 3, Reference 4, and Reference 5.

11. All the above was confirmed by Staff #4 on 1/19/11 at 11:15 AM.

Based on observations and a review of Emergency Department (ED) policies and procedures, it was determined that the facility failed to ensure that all ED policies are implemented.

Findings include:

Reference 1: The facility's Emergency Department policy titled, "Code Blue (Adult) White (Pediatric) Emergency Resuscitation" states, "PROCEDURE:...Integrity of Cart a) An RN is assigned daily to check the integrity of the code cart, and the presence of equipment as noted on the "Code Cart Daily Checklist... The RN checking the cart must sign the checklist and initial under the appropriate day/date, indicating the presence and working order of all equipment..."

1. It was observed during a tour of the ED on 1/19/11 at approximately 11:00 AM, that the "Code Cart Daily Check List Pediatric Cart" was not checked for the integrity of the equipment for 4 out of 7 days during the week of 12/26/10 through 1/1/11.

a. The Pediatric Code Cart was not checked daily for 3 out of 7 days for the week of 1/2/11 through 1/8/11.

b. There was no evidence that the Pediatric Code Cart was checked daily as stated in the ED policy referenced above.