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Based on review of facility polices and procedures, review of facility documents, observations, and interview with staff (EMP), it was determined that the facility failed to maintain direct patient-care supplies, equipment, and medications/biologicals, according to facility policy, to ensure that a safe setting was provided for all patients.

Findings include:

Review on December 5, 2017, of the facility policy, "Patient Rights", dated "03/2016", revealed "Policy ... s. every patient has the right to receive care in a safe environment without hazardous objects."
Review on December 5, 2017, of the facility policy, "Dating of Multiple Dose Containers", dated, "11/2016", revealed "... Policy: All unopened medication will not be used beyond the earliest occurrence of: (1) manufacturers expiration date or (2) when the medication is potentially or actually compromised by compromised, including contamination, precipitate, temperature abnormalities, etc. All medications in opened containers will be labeled appropriately with expiration date, will be inspected prior to each use for signs of contamination or deterioration, and will be promptly discarded when indicated ... Procedure ... B. Sterile Products 1. Ampule: After a single use, the ampule will be discarded ... 4. Irrigation Fluids a. Sterile water or saline for irrigation will receive a 24-hour expiration date. If there is evidence of contamination or deterioration before 24 hours elapses, the product will be discarded. b. Proper labeling will include: Open Date and Time, Expiration Date and Time, Initials ... 6. Improperly Stored Products All opened medication containers will be discarded if they have not been labeled properly with regards to expiration date."
Review on December 6, 2017, of the facility policy, "Medical Equipment Management Plan", dated, "05/2017", revealed "Purpose ... The objective of the Medical Equipment Management Plan is to develop a system that addresses the identification, selection, handling, inspection, storage, use and disposal of medical equipment ... goals ... Assure that all medical equipment is working properly and repairs are made in a timely manner ... Monitor all service and preventative maintenance inspections to assure that medical equipment is maintained and serviced so equipment continues to function properly ... Provide service and maintenance for selected equipment in the Medical Equipment Management inventory ..."
Review on December 6, 2017, of the facility document, "[Company Name] Limited Clinical Engineering Service Agreement", dated "07/01/16", revealed "... Initial Agreement Term (in years) Three (3) ... Equipment Inspection and Preventative Maintenance Inspection and preventative maintenance services (IPM) will be provided for the equipment listed in Exhibit A ... Exhibit A: List of Equipment ... Monitor [Manufacturer Name] ... Nebulizer [Manufacturer Name] ..."
Review on December 6, 2017, of the facility document, "Job Description Director of Nursing", revealed "... Essential Job Functions ... Manage the daily operations of nursing services ... Ensure nursing services are provided in compliance with the laws and regulations of federal, state and local governmental agencies and with the standards, rules and regulations of various accrediting and approval agencies, including Joint Commission and CMS ..."
Observations on December 5, 2017, between approximately 8:30 A.M. and 10:30 A.M., of the facilities Main Nurses Station, revealed one (1) multi-drawer emergency code cart. Further observations of the code cart revealed one (1) of one (1) "Adult Manual Resuscitator Bag Valve Mask" (Respiratory resuscitation equipment), expired on "2015-12", hanging on a pole attached to the code cart. Further observations of the code cart drawers revealed one (1) of one (1) bottle of "Hydrogen Peroxide 3%, 473 ml, 16 FL. Oz.", expired on "11/17" and one (1) of one (1) bottle of "Sterile Normal Saline Solution, 250 ml", expired on "01/2017". Further observations of the Nurses Station revealed multiple storage cabinets by the code cart. Further observations of the upper storage cabinets revealed five (5) of five (5) bottles of "Hydrogen Peroxide 3%, 473 ml, 16 FL. Oz.", expired on "11/17". Further observations of the main Nurses Station revealed one segregated, card-swipe access Medication Room. Further observations of the Medication Room revealed multiple upper and lower storage cabinets. Further observations of the bottom storage cabinets revealed one (1) of one (1) "Sterile Urethral Catheterization Tray", expired on "2016-02", one (1) of one (1) "Hydrogel Coated Latex 16 French Foley Catheter" (Urinary catheter), expired on "2017-02", two (2) of two (2) "Single Use Disposable 14 French Catheter" (Urinary catheter) expired on "2015-09", and one (1) of one (1) "12 French 2-Way Foley Catheter" (Urinary catheter) expired on "2016-12". Further observations of the Medication Room upper cabinets revealed two (2) of two (2) "Adult Manual Resuscitator Bag Valve Mask" (Respiratory resuscitation equipment), expired on "2015-12". Further observations of the Nursing Unit revealed one main patient supply storage area. Further observations of the storage area revealed multiple storage shelves. Further observations of one of the storage shelves revealed one (1) box, quantity of fifty (50) units, containing thirty-three (33) of thirty-three (33) remaining "Single Use Disposable 14 French Catheter" (Urinary catheter), all expired on "2015-09".
Interview with EMP2, on December 5, 2017, between approximately 9:30 A.M. and 10:30 A.M., confirmed that all expired supplies found at the Nurses Station, in the code cart, in the medication room, and in the main supply storage area "were" expired. Further interview with EMP2 confirmed that all Adult Manual Resuscitator Bag Valve Masks (Respiratory resuscitation equipment), "were" expired, and that the facility "did not" have any other non-expired Bag Valve Masks within the facility. Further interview with EMP2 confirmed that the expired Bag Valve Masks "would" have to be still used until new masks could be ordered and obtained.
Interview with EMP1, on December 5, 2017, at 1:57 P.M., confirmed the facility "does not" have a current policy, procedure, or protocol for maintaining sterile patient care supplies, and checking expiration dates, on a routine basis.
Observations on December 5, 2017, between approximately 8:30 A.M. and 10:30 A.M., of the facilities Nursing Unit revealed one segregated, card-swipe access Medication Room. Further observations of the Medication room revealed multiple upper and lower storage cabinets. Further observations of the upper storage cabinets revealed one (1) of five (5) bottles of "Sterile Water Solution, 100 ml", opened, with a hand-written date on the bottle top "opened 11-1-17". Further observations of the bottle revealed the manufacturer statement that once the bottle is "open" the contents are "no longer sterile". Further observations of additional upper cabinets revealed three (3) of eight (8) vials/bottles of "Sterile Water for Injection, 10 ml, single dose". Further observations of the three (3) vials/bottles revealed their plastic tops were removed, exposing the rubber injection port, and liquid contents were removed (the vials/bottles had a distinct, lesser amount of liquid contents when compared to the vials/bottles with an intact top).
Interview with EMP2, on December 5, 2017, between approximately 9:30 A.M. and 10:30 A.M., confirmed that the bottle of Sterile Water and vials/bottles of sterile water for injection "were not" multi-dose in nature and "should not" have been stored in the medication room once they were opened/utilized.
Observations on December 5, 2017, between approximately 8:30 A.M. and 10:30 A.M., of the facilities Nursing Unit revealed revealed one, segregated, card-swipe access Medication room within the main Nurses station. Further observations of the Medication room revealed multiple upper and lower storage cabinets. Further observations of the upper storage cabinets revealed one (1) of two (2) [Manufacturer Name] Nebulizer (breathing treatment machine). Further observations of the nebulizer revealed the last inspection date was on "7/2016" and the next inspection due date was "7/2017". Further observations of the monitor revealed no other updated inspection sticker(s) as well as no tag to indicate the monitor was broken and out-of-service. Further observations of the Nursing Unit revealed one Equipment Storage room, located near the unit Dining Area. Further observations of the Equipment Storage room revealed one (1) of two (2) [Manufacturer Name] vital sign monitor. Further observations of the monitor revealed the last inspection date was on "7/2016" and the next inspection due date was "7/2017". Further observations of the monitor revealed no other updated inspection sticker(s) as well as no tag to indicate the monitor was broken and out-of-service.
Interview with EMP2, on December 5, 2017, between approximately 9:30 A.M. and 10:30 A.M., confirmed that the vital sign monitor and nebulizer "did not" have updated preventative maintenance inspection stickers on them and "did not" have tags to indicate the monitor or nebulizer, were broken and out-of-service.

Based on review of facility policies and procedures, facility documents, and interview with staff (EMP), it was determined the facility failed to adopt policies and procedures that support a non-punitive approach to staff reporting adverse patient events, medical errors, near misses/close calls, and situations in which staff consider unsafe.

Findings include:

Review on December 6, 2017, of the facility's "Safety Management Plan", dated December 2016, revealed there was no provision to prohibit any retaliatory action against a health care worker for reporting adverse patient events, medical errors, near misses/close calls, and situations in which staff consider unsafe.

A request was made to EMP1, on December 6, 2017, for any policies that the facility adopted to support a non-punitive approach to staff reporting adverse patient events, medical errors, near misses/close calls, and situations in which staff consider unsafe. None was provided.

Interview with EMP1, on December 6, 2017, at 10:23 AM, confirmed there was no provision to prohibit any retaliatory action against a health care worker for reporting adverse patient events, medical errors, near misses/close calls, and situations in which staff consider unsafe in the facility's patient safety plan. EMP1 further confirmed that the facility did not adopt any specific policies and procedures that supported a non-punitive approach to staff reporting adverse patient events, medical errors, near misses/close calls, and situations in which staff consider unsafe.

Based on review of facility policy and procedures, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure preventative care guidelines and interventions were established regarding the Braden Scale Skin Assessment for one (1) of one (1) medical records reviewed (MR1).
Findings include:
Review on December 5, 2017, of MR1 nursing documentation "Nursing Assessment - Braden Skin Assessment" dated August 9, 2017, revealed "... Score ... Sensory Perception 1. Completely limited 2. Very Limited 3. Slightly Limited 4. No Impairment ... Moisture 1. Constantly Moist 2. Very Moist ... Activity ... 1. Bedfast 2. Chairbound 3. Walks Occasionally ... Mobility 1. Immobile 2. Very Limited 3. Slightly Limited ... Nutrition ... 1. Very Poor 2. Inadequate 3. Adequate ... Friction/Sheer ... 1. Problem 2. Potential Problem ... Low Risk: 15-23 ... Moderate Risk:13-14 ... High Risk:10-12 ... Very High Risk: 9 or less ..." Further review of MR1 revealed "Braden Skin Assessment Score of 16 ..." Further review of MR1 "Braden Skin Assessment" revealed no documented evidence of preventative care guidelines or interventions to follow based on the Braden Skin Assessment Score.
A request was made to EMP2 at 8:51AM on December 5, 2017, for the facility policy and procedures regarding the Braden Scale Skin Assessment. None was provided.
A request was made to EMP2 at 8:51AM on December 5, 2017, for the facility policy and procedures regarding Skin Assessment. None was provided.
Interview on December 5, 2017, at 8:51AM with EMP2, confirmed there is no policy and procedures regarding the Braden Scale Skin Assessment. Further interview confirmed "... there is no turning schedule, offloading of heels ... or interventions in place based on the Braden Skin Assessment Score ... for all medical records ..." Interview with EMP2 also confirmed there is no Skin Assessment Policy.

Based on review of facility polices and procedures, review of facility documents, observations, and interview with staff (EMP), it was determined that the facility failed to ensure that medications/biologicals were maintained in accordance with approved medical staff policies and procedures.

Findings include:

Review on December 5, 2017, of the facility policy, "Dating of Multiple Dose Containers", dated, "11/2016", revealed "... Policy: All unopened medication will not be used beyond the earliest occurrence of: (1) manufacturers expiration date or (2) when the medication is potentially or actually compromised by compromised, including contamination, precipitate, temperature abnormalities, etc. All medications in opened containers will be labeled appropriately with expiration date, will be inspected prior to each use for signs of contamination or deterioration, and will be promptly discarded when indicated ... Procedure ... B. Sterile Products 1. Ampule: After a single use, the ampule will be discarded ... 4. Irrigation Fluids a. Sterile water or saline for irrigation will receive a 24-hour expiration date. If there is evidence of contamination or deterioration before 24 hours elapses, the product will be discarded. b. Proper labeling will include: Open Date and Time, Expiration Date and Time, Initials ... 6. Improperly Stored Products All opened medication containers will be discarded if they have not been labeled properly with regards to expiration date."
Review on December 6, 2017, of the facility document, "Job Description Director of Nursing", revealed "... Essential Job Functions ... Manage the daily operations of nursing services ... Ensure nursing services are provided in compliance with the laws and regulations of federal, state and local governmental agencies and with the standards, rules and regulations of various accrediting and approval agencies, including Joint Commission and CMS ..."
Observations on December 5, 2017, between approximately 8:30 A.M. and 10:30 A.M., of the facilities Nursing Unit revealed one segregated, card-swipe access Medication Room. Further observations of the Medication room revealed multiple upper and lower storage cabinets. Further observations of the upper storage cabinets revealed one (1) of five (5) bottles of "Sterile Water Solution, 100 ml", opened, with a hand-written date on the bottle top "opened 11-1-17". Further observations of the bottle revealed the manufacturer statement that once the bottle is "open" the contents are "no longer sterile". Further observations of additional upper cabinets revealed three (3) of eight (8) vials/bottles of "Sterile Water for Injection, 10 ml, single dose". Further observations of the three (3) vials/bottles revealed their plastic tops were removed, exposing the rubber injection port, and liquid contents were removed (the vials/bottles had a distinct, lesser amount of liquid contents when compared to the vials/bottles with an intact top).
Interview with EMP2, on December 5, 2017, between approximately 9:30 A.M. and 10:30 A.M., confirmed that the bottle of Sterile Water and vials/bottles of sterile water for injection "were not" multi-dose in nature and "should not" have been stored in the medication room once they were opened/utilized.

Based on review of facility policy and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure laboratory reports were obtained to monitor the patient's condition for one (1) of one (1) medical records reviewed (MR1).
Findings include:
Review on December 6, 2017, of facility policy, "Orders, Noting" dated February 2017, revealed "Policy ... Practitioners orders shall be noted by the nurse or trained unit support staff as soon as possible for timely implementation ... Orders for lab work, X-rays, ... written on the appropriate log and entered onto the nursing communication tool ... When all orders from entry have been appropriately handled or "taken off " signify that the orders have been noted by drawing a line at the bottom of the order with your signature, date and time below the line ..."
Review on December 6, 2017, of MR1 physician documentation "Practitioner Order" dated September 3, 2017, revealed "Date/Time... 9/3/17... 5:30PM ... UA/C&S, CBC, BMP, TSH ..." Further review of physician orders revealed documented evidence of notation of the order on September 3, 2017, with signature, date "September 3, 2017" and time "1945" by a registered nurse.
Review on December 6, 2017, of facility document, "Laboratory Log" revealed "... Date/Time of Order ... Time Lab Called ... Patient Name ... Test Ordered (S if Stat) ... Date/Time Results Received ... C if Critical ... Practitioner Notified Name/Date/Time ... Comments ... Additional Orders ..."
Review on December 6, 2017, of facility document, "Laboratory Log" for the month of September 2017, revealed no documented evidence of laboratory work ordered or obtained for MR1.
Review on December 6, 2017, of facility document, "Atlantic Diagnostic Laboratories, LLC Lab Form" for the month of September 2017, revealed no documented evidence of laboratory work ordered or obtained for MR1.
Interview on December 6, 2017, with EMP ... at 9:55AM, confirmed documented evidence of physician orders for lab work on September 3, 2017, and confirmed appropriate notation of the physician order by a registered nurse for MR1. Further interview confirmed no documented evidence of laboratory work ordered or obtained for MR1.

Based on review of facility policy and procedures, review of facility documents, observation, and interview with staff (EMP), it was determined the facility failed to ensure medications were stored in a secure manner.

Findings include:

Review on December 5, 2017, of the facility policy, "Expired, Damaged or Contaminated Drugs", dated, "09/2016", revealed "... Policy: All expired, damaged, and/or contaminated medications are segregated until they are removed from the facility ... Procedure 1. ... Pharmacy will completely segregate expired, damaged, and/or contaminated medication in a separate and secure area ... 4. ... Segregated medications will be removed on a routine basis and either destroyed or turned over to the control of an authorized pharmaceutical credit corporation ..."
Review on December 6, 2017, of the facility document, "Job Description Director of Nursing", revealed "... Essential Job Functions ... Manage the daily operations of nursing services ... Ensure nursing services are provided in compliance with the laws and regulations of federal, state and local governmental agencies and with the standards, rules and regulations of various accrediting and approval agencies, including Joint Commission and CMS ..."
Observations on December 5, 2017, between approximately 8:30 A.M. and 10:30 A.M., of the facilities Nursing Unit revealed one segregated, card-swipe access Medication Room. Further observations of the Medication room revealed one (1) of two (2) clear, plastic, locked-boxes hanging on the wall by the entrance door. Further observations of one locked box revealed greater than fifty (50) loose, unidentifiable, intact pills and capsules lying in the box. Further observations of the box revealed a non-secure opening, on the top of the box, that was approximately two (2) inches long and one (1) inch wide, allowing for items to be dropped into the box, but also allowing for items to be easily retrievable/removed from the box (i.e. utilizing long forceps, tweezers, or grasping tool).
Interview with EMP3, on December 5, 2017, between 8:30 A.M. and 9:00 A.M., confirmed that the clear, plastic box was utilized for "wasted" medications. Further interview with EMP3 confirmed that all wasted medications could go into the box including "narcotics". Further interview with EMP3 confirmed that they "were not" aware of how often Pharmacy comes to empty the wasted medications box.
Interview with EMP2, on December 5, 2017, between approximately 9:30 A.M. and 10:30 A.M., confirmed that the clear, plastic box was utilized for "wasted" medications. Further interview with EMP2 confirmed that the top opening of the box "was not" secure and that medication could be retrieved from the inside of the box.

Based on review of facility polices and procedures, review of facility documents, observations, and interview with staff (EMP), it was determined that the facility failed to ensure that direct, patient-care supplies and equipment, were maintained in an acceptable and safe manner.

Findings include:

Review on December 5, 2017, of the facility policy, "Patient Rights", dated "03/2016", revealed "Policy ... s. every patient has the right to receive care in a safe environment without hazardous objects."
Review on December 6, 2017, of the facility policy, "Medical Equipment Management Plan", dated, "05/2017", revealed "Purpose ... The objective of the Medical Equipment Management Plan is to develop a system that addresses the identification, selection, handling, inspection, storage, use and disposal of medical equipment ... goals ... Assure that all medical equipment is working properly and repairs are made in a timely manner ... Monitor all service and preventative maintenance inspections to assure that medical equipment is maintained and serviced so equipment continues to function properly ... Provide service and maintenance for selected equipment in the Medical Equipment Management inventory ..."
Review on December 6, 2017, of the facility document, "[Company Name] Limited Clinical Engineering Service Agreement", dated "07/01/16", revealed "... Initial Agreement Term (in years) Three (3) ... Equipment Inspection and Preventative Maintenance Inspection and preventative maintenance services (IPM) will be provided for the equipment listed in Exhibit A ... Exhibit A: List of Equipment ... Monitor [Manufacturer Name] ... Nebulizer [Manufacturer Name] ..."
Review on December 6, 2017, of the facility document, "Job Description Director of Nursing", revealed "... Essential Job Functions ... Manage the daily operations of nursing services ... Ensure nursing services are provided in compliance with the laws and regulations of federal, state and local governmental agencies and with the standards, rules and regulations of various accrediting and approval agencies, including Joint Commission and CMS ..."
Observations on December 5, 2017, between approximately 8:30 A.M. and 10:30 A.M., of the facilities Main Nurses Station, revealed one (1) multi-drawer emergency code cart. Further observations of the code cart revealed one (1) of one (1) "Adult Manual Resuscitator Bag Valve Mask" (Respiratory resuscitation equipment), expired on "2015-12", hanging on a pole attached to the code cart. Further observations of the code cart drawers revealed one (1) of one (1) bottle of "Hydrogen Peroxide 3%, 473 ml, 16 FL. Oz.", expired on "11/17" and one (1) of one (1) bottle of "Sterile Normal Saline Solution, 250 ml", expired on "01/2017". Further observations of the Nurses Station revealed multiple storage cabinets by the code cart. Further observations of the upper storage cabinets revealed five (5) of five (5) bottles of "Hydrogen Peroxide 3%, 473 ml, 16 FL. Oz.", expired on "11/17". Further observations of the main Nurses Station revealed one segregated, card-swipe access Medication Room. Further observations of the Medication Room revealed multiple upper and lower storage cabinets. Further observations of the bottom storage cabinets revealed one (1) of one (1) "Sterile Urethral Catheterization Tray", expired on "2016-02", one (1) of one (1) "Hydrogel Coated Latex 16 French Foley Catheter" (Urinary catheter), expired on "2017-02", two (2) of two (2) "Single Use Disposable 14 French Catheter" (Urinary catheter) expired on "2015-09", and one (1) of one (1) "12 French 2-Way Foley Catheter" (Urinary catheter) expired on "2016-12". Further observations of the Medication Room upper cabinets revealed two (2) of two (2) "Adult Manual Resuscitator Bag Valve Mask" (Respiratory resuscitation equipment), expired on "2015-12". Further observations of the Nursing Unit revealed one main patient supply storage area. Further observations of the storage area revealed multiple storage shelves. Further observations of one of the storage shelves revealed one (1) box, quantity of fifty (50) units, containing thirty-three (33) of thirty-three (33) remaining "Single Use Disposable 14 French Catheter" (Urinary catheter), all expired on "2015-09".
Interview with EMP2, on December 5, 2017, between approximately 9:30 A.M. and 10:30 A.M., confirmed that all expired supplies found at the Nurses Station, in the code cart, in the medication room, and in the main supply storage area "were" expired. Further interview with EMP2 confirmed that all Adult Manual Resuscitator Bag Valve Masks (Respiratory resuscitation equipment), "were" expired, and that the facility "did not" have any other non-expired Bag Valve Masks within the facility. Further interview with EMP2 confirmed that the expired Bag Valve Masks "would" have to be still used until new masks could be ordered and obtained.
Interview with EMP1, on December 5, 2017, at 1:57 P.M., confirmed the facility "does not" have a current policy, procedure, or protocol for maintaining sterile patient care supplies, and checking expiration dates, on a routine basis.
Observations on December 5, 2017, between approximately 8:30 A.M. and 10:30 A.M., of the facilities Nursing Unit revealed revealed one, segregated, card-swipe access Medication room within the main Nurses station. Further observations of the Medication room revealed multiple upper and lower storage cabinets. Further observations of the upper storage cabinets revealed one (1) of two (2) [Manufacturer Name] Nebulizer (breathing treatment machine). Further observations of the nebulizer revealed the last inspection date was on "7/2016" and the next inspection due date was "7/2017". Further observations of the monitor revealed no other updated inspection sticker(s) as well as no tag to indicate the monitor was broken and out-of-service. Further observations of the Nursing Unit revealed one Equipment Storage room, located near the unit Dining Area. Further observations of the Equipment Storage room revealed one (1) of two (2) [Manufacturer Name] vital sign monitor. Further observations of the monitor revealed the last inspection date was on "7/2016" and the next inspection due date was "7/2017". Further observations of the monitor revealed no other updated inspection sticker(s) as well as no tag to indicate the monitor was broken and out-of-service.
Interview with EMP2, on December 5, 2017, between approximately 9:30 A.M. and 10:30 A.M., confirmed that the vital sign monitor and nebulizer "did not" have updated preventative maintenance inspection stickers on them and "did not" have tags to indicate the monitor or nebulizer, were broken and out-of-service.

Based on review of facility document, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that the necessary medical information accompanied the patient transferred to an acute care hospital for one (1) of one (1) medical records reviewed (MR1).
Findings include:
Review on December 6, 2017, of facility document, "Documents To Send With A Patient Going To The Hospital" date [unknown], revealed "... Facesheet, MAR, Last Labs(s) ... Dr. Transfer Order ... Psych Note ... Medical Note ... H&P ... Progress Note ..."
Review on December 6, 2017, of MR1 revealed the patient was transferred to an acute care hospital for emergency services on September 6, 2017. Further review revealed no documented evidence that the necessary medical information accompanied the patient transfer to the receiving hospital.
Interview on December 6, 2017, with EMP2 at 11:25AM, confirmed no documented evidence that the necessary medical information accompanied the patient transfer to the receiving hospital for MR1.