HospitalInspections.org

Based on observation, interview and policy review, the facility failed to meet the requirement because expired supplies were available for patient use in the malignant hyperthermia cart.

Findings Include:

During a tour of the post anesthesia care unit on 02/12/19 at 10:10 a.m. accompanied by S#4, observation and inspection of the malignant hyperthermia cart revealed 19 Mini Spike Dispensing Pins that expired "2018-11."

In an interview at the time of the observations, S#4 confirmed the findings.

The hospital's policy entitled, "Outdated Supplies/Expired Supplies," reviewed "6/18," was reviewed on 02/12/19 at 4:40 p.m. in a conference room and stated the following in part:

RESPONSIBILITY: It is the responsibility of the Central Supply Tech and all employees to verify the use by date on all products in their departments.

POLICY:
II. If a date has expired, the supplies are pulled from the shelves and from the patient areas.

Based on observation, interview, and policy review, the facility failed to meet the requirement to provide a clean and sanitary environment because dusty debris was found on a shelf in a Pyxis; dirty and peeling tape were found on a counter in a medication room and a cart such that they could not be properly cleaned; dusty dried debris was found on bins used to store patient supplies; degraded and dirty caulk with rust colored areas were found at a sink backsplash area at a nurses station such that it could not be properly cleaned; unpackaged oral airways, laryngoscope blades, yankauer suction tips and Magill forceps were available for patient use; a stained 4x4 and debris were found in a pyxis bin; and spatter was found on labels of bins used to store supplies.

Findings Include:

1. A. During a tour of the emergency department on 02/11/19 at 2:17 p.m. accompanied by S#1, observation revealed the following in the medication room:

Dusty debris on the bottom shelf of the Pyxis used to store intravenous fluids.

Dirty and peeling tape that attached a piece of paper with directions for charging insulin to the counter used to store bins of extension sets and saline flushes such that the counter could not be properly cleaned.

Dusty and dried dirty debris on the ledges of a blue bin used to store intravenous extension sets and a blue bin used to store normal saline flush syringes.

1. B. In an interview at the time of the observations, S#1 confirmed the findings.

2. A. During a tour of the emergency department on 02/11/19 at 2:35 p.m. accompanied by S#1, observation and inspection of the pediatric crash cart revealed an emergency airway roll that contained three unpackaged oral airways.

2. B. In an interview at the time of the observations, S#1 confirmed the findings.

3. A. During a tour of the emergency department on 02/11/19 at 2:49 p.m. accompanied by S#1, observation of the handwashing sink at the nurse station revealed the following:

Degraded and dirty caulk to the backsplash area with rust colored areas to the back left counter behind the faucet such that the area could not be properly cleaned.

A water stained yellow paper with culture tubes attached to it labeled as Collection Protocol for Microbiology against the backsplash area.

3. B. In an interview at the time of the observations, S#1 confirmed the findings.

4. A. During a tour of the post-anesthesia care unit on 02/12/19 at 10:14 a.m. accompanied by S#4, observation and inspection revealed the following:

Peeling tape with debris around the edges of a paper malignant hyperthermia poster taped to the top of the malignant hyperthermia cart such that it could not be properly cleaned.

An unpackaged Magill forceps in an airway bag on top of the crash cart.

4. B. In an interview at the time of the observations, S#4 confirmed the findings.

5. A. During a tour of operating room #3 on 02/12/19 at 11:02 a.m. accompanied by S#4 and S#6, observation and inspection of drawer #5 of the anesthesia cart revealed 13 unpackaged airways.

5. B. In an interview at the time of the observations, S#4 confirmed the findings.

6. A. During a tour of operating room #1 on 02/12/19 at 11:05 a.m. accompanied by S#4 and S#6, observation and inspection revealed the following:

A 4x4 with brownish stain and amber bits of debris in the 4th bin of drawer one of the anesthesia pyxis.

2 unpackaged Magill forceps and 5 unpackaged Yankauer suction tips in drawer 1 of the anesthesia cart.

9 unpackaged oral airways in drawer 5 of the anesthesia cart.

6. B. In an interview at the time of the observations, S#4 confirmed the findings.

7. A. During a tour of the newborn nursery on 02/12/19 at 2:20 p.m. accompanied by S#9, observation revealed reddish brown spatter on labels of 6 pull out bins used to store patient supplies.

7. B. In an interview at the time of the observations, S#9 confirmed the findings.

8. A. During a tour of the intensive care unit on 02/12/19 at 3:24 p.m. accompanied by S#8, observation and inspection of the pediatric crash cart revealed 10 unpackaged laryngoscope blades and 2 unpackaged Magill forceps in the Broslow Bag.

8. B. In an interview at the time of the observations, S#8 confirmed the findings.

The hospital's Department of Pharmacy policy entitled, "Sanitation," reviewed "8/2018," was reviewed on 02/12/19 at 4:45 p.m. in a conference room and stated the following in part:

Pharmacy department and medication storage areas:
1. Work surfaces and equipment shall be cleaned and, if necessary, disinfected.
3. Pharmacy shall monitor the cleanliness of drug "cars"...

Based on observation, interview, and policy review, the hospital failed to meet the requirement because expired syringes of saline flush and multi-dose vials that were not properly labeled were available for patient use.

Findings Include:

1. A. During a tour of the emergency department on 02/11/19 at 2:35 p.m. accompanied by S#1, observation and inspection of the pediatric crash cart revealed and a medication drawer contained four 10 ml syringes of normal saline IV flush solution with an expiration date of "2019-01."

1. B. In an interview at the time of the observations, S#1 confirmed the findings.

2. A. During a tour of the pre-operative area on 02/12/19 at 9:53 a.m. accompanied by S#4, observation and inspection of the refrigerator revealed an opened vial of Novolin R Insulin labeled "02/11/19" with no beyond use date or the initials of the staff member that opened it.

2. B. In an interview at the time of the observations, S#4 confirmed the findings.

3. A. During a tour of operating room #1 on 02/12/19 at 11:05 a.m. accompanied by S#4 and S#6, observation and inspection of the anesthesia pyxis medication cart revealed an opened 100mg/20 ml multi-dose vial of Labetalol Hydrochloride that was not labeled with the date it was opened, the beyond use date and/or initials of the staff member that opened it.

3. B. In an interview at the time of the observations, S#4 and S#6 confirmed the findings.

C. The hospital's policy entitled, "Unusable and Outdated Drugs" reviewed "8/18," was reviewed on 02/12/19 at 4:30 p.m. in a conference room and stated the following in part:

PROCEDURE
1. A. All drug storage areas for the hospital will be inspected. Surgery and other patient care unit stock areas will be checked for outdated drugs, ... The pharmacy staff member conducting the inspection will remove all of these types of drugs from the area.

a. Nursing or other staff approved by license to administer medications, noting outdated drugs ...will contact the Pharmacy Department notifying the department of the drug's existence on his or her unit. A pharmacy staff member will then pick up the medication and take care of it accordingly.

2. Open multi-dose vials (does not include vaccines) will be discarded within 28 days of being opened (unless otherwise specified by the manufacturer), or when the manufacturer's labled expiration date is reached, whichever is sooner. All undated multi-dose vials and any vials marked as single dose hall be discarded immediately.

The hospital's policy entitled, "General Medication Administration Guidelines" reviewed "7/2018," was reviewed on 02/12/19 at 4:35 p.m. in a conference room and stated the following in part:

Label all multi-dose vials with the date and time when opened, your initials ...

Based on observation, review of available documentation and interview, the facility failed to ensure an effective quality assurance program to evaluate all patient care services and other services affecting patient health and safety; that involved all hospital departments and services.

Specifically, the facility's Quality Assurance/Performance Improvement (QAPI) program failed to include and evaluate the quality of the following services provided at this facility: Physical and Occupational Rehabilitation Services, Respiratory Services, Speech Pathology Services, Wound Care Services, Housekeeping Services, and the Outpatient Psychiatric Services.

Findings included:

Observations conducted throughout the facility during this recertification survey from 2/11/19 at 01:15PM through 2/13/19 revealed the facility provided services which included, in part;
Physical Therapy (PT) Rehabilitation Services,
Occupational Therapy (OT) Rehabilitation Services,
Speech Pathology Services,
Respiratory Services,
Outpatient Psychiatric Services,
Wound Care Services, and
Housekeeping Services.

Review of the Hospital/CAH (Critical Access Hospital) Database Worksheet dated 2/11/19 revealed the facility provided services which included, in part; Physical and Occupational Rehabilitation Services provided by facility staffing; Respiratory Services and Speech Pathology Services provided by arrangement of a contracted agreement. In addition, the facility also provided outpatient Psychiatric Services through a combination of facility staff and through agreement.

Review of the facility's Quality Council Minutes (QAPI) dated 1/31/19, 10/25/18, and 5/9/18; for the evaluation of the effectiveness of the specified service department's actions revealed the facility failed to ensure the following services provided were evaluated: Physical and Occupational Rehabilitation Services, Respiratory Services, Speech Pathology Services, Wound Care Services, Housekeeping Services, and outpatient Psychiatric Services.

Interview with the facility's Chief Nursing Officer (CNO) on 2/13/19 at 09:20 AM confirmed the above findings that the Quality Council reviews did not include the Psychiatric Outpatient Services as part of quality or PT/OT/Speech Rehabilitation services, and Respiratory services. The CNO also stated that Wound care services provided were a contracted service and not reviewed in the facility's QAPI; as well as Housekeeping was not evaluated as well.