HospitalInspections.org

On the days of the recertification survey based on random observations and interview, the hospital failed to ensure all equipment was monitored for correct temperature to ensure the safety and well-being of patients.

The findings include:

On 2/25/2014 at 4:00 p.m., observations in the Laboratory (lab) log for refrigeration for the purpose of control solutions showed the lab logs had no documented temperatures since 2/23/2014. On 2/25/2014 at 4:00 p.m., Staff Member 13 verified the finding.

On the days of the recertification survey based on observations and interview, the hospital failed to ensure the premises was clean and orderly for light fixtures and sinks located in patient room 20, nurse supply closet, nurse station, telemetry room, and nurse supply area.

The findings include:

On 02/28/2014 at 1:00 p.m., observations with the maintenance supervisor revealed the overhead light fixtures located in patient room 20, nurse station, and the nurse supply closet had dead insects in the light fixture cover. Observations of the sinks located in the nursing supply storage area room, the nurse station, and the nurse supply closet had corrosion and a heavy white film around the faucets and in the sinks. On 02/27/2014 at 2:00 p.m., the findings were verified with the Maintenance Supervisor.





31672

On 2/25/14 at 1:25 p.m., observation in the main board room for telemetry revealed five (5) large random filled boxes, a Christmas tree, multiple board games and other various games cluttered in the floor blocking the electrical board. The findings were verified with Staff Member 3 at 3:00 p.m. on 2/25/14.

On the days of the recertification survey based on interview and review of Physician credentials and Medical Staff By-Laws, the governing body failed to re-appoint 9 of 11 credentialed staff physicians within the required 2 year period.


The findings are:

On 2/26/2014 at 12:45 P.M., a review of Medical Staff By-Laws, titled, ".... Section 3. Reappointment Process" reads, "- a. at least ten days prior to the final scheduled governing body meeting in the medical staff year, the medical staff shall review all pertinent information available on each practitioner scheduled for periodic appraisal, for the purpose of determining its recommendations for reappointment to the medical staff and for the granting of clinical privileges for the ensuring period, and shall transmit its recommendations, in writing, to the governing body. Where non-reappointment or a change in clinical privileges is recommended, the reason for such recommendation shall be stated and documented.... b. is amended to read: Reappointment shall be for a period of not more than two medical staff years....".

On 2/26/14 at 2:45 p.m., review of the Medical Executive Committee Meeting Minutes, dated January 8, 2014 at 7:30 a.m., revealed the following ".... X. Medical Staff Elections for 2014 are as follows:
A. The following were appointed unanimously by the medical staff:
the Chief of Staff, Chief of Emergency Services, Chief of Laboratory Services, and Chief of Radiology Services.
XIV. Credentialing Committee:
A. .....(CEO)stated he had no medical staff appointments or reappointment for review....".

On 2/26/14 at 1:00 p.m., review of Physician 1's credential file revealed the recommended appointment was dated and signed on 3/16/11 by the Chief of Medical Staff and the Secretary for the Board of Trustees. No current reappointment was in the record.

On 2/26/14 at 1:10 p.m., review of Physician 2's credential file revealed the recommended appointment was dated and signed on 1/20/10 by the Chief of Medical Staff and the Secretary for the Board of Trustees. No current reappointment was in the record.

On 2/26/14 at 1:20 p.m., review of Physician 3's credential file revealed the recommended appointment was dated and signed on 2/24/11 by the Chief of Medical Staff and the Secretary for the Board of Trustees. No current reappointment was in the record.

On 2/26/14 at 1:30 p.m., review of Physician 4's credential file revealed the recommended appointment was dated and signed on 1/21/10 by the Chief of Medical Staff and the Secretary for the Board of Trustees. No current reappointment was in the record.

On 2/26/14 at 1:40 p.m., review of Physician 5's credential file revealed the recommended appointment was dated and signed on 3/16/11 by the Chief of Medical Staff and the Secretary for the Board of Trustees. No current reappointment was in the record.

On 2/26/14 at 1:50 p.m., review of Physician 6's credential file revealed the recommended appointment was dated and signed on 8/21/07 by the Chief of Medical Staff and the Secretary for the Board of Trustees. No current reappointment was in the record.

On 2/26/14 at 2:00 p.m., review of Physician 7's credential file revealed the recommended appointment was dated and signed on 8/19/09 by the Chief of Medical Staff and the Secretary for the Board of Trustees. No current reappointment was in the record.

On 2/26/14 at 2:10 p.m., review of Physician 8's credential file revealed the recommended appointment was dated and signed on 2/24/11 by the Chief of Medical Staff and the Secretary for the Board of Trustees. No current reappointment was in the record.

On 2/26/14 at 2:20 p.m., review of Physician 9's credential file revealed the recommended appointment was dated and signed on 11/15/11 by the Chief of Medical Staff and the Secretary for the Board of Trustees. No current reappointment was in the record.

On 2/26/14 at 2:55 p.m., Staff Member 7 revealed, "I knew the reappointment had not been done, but the positions had to be appointed at this meeting for 2014. I'm sure if the doctors were appointed for these positions, then they would have had to have been re appointed and current." On 2/26/14 at 3:00 p.m., Staff Member 7 revealed, "besides being the administrator of this hospital, I am also the board chairman. My secretary takes the meeting minutes, and the Chief of Medical Staff signs the appointment letters. I have no Medical Staff Coordinator and me and my assistant just cannot keep up with all of the reappointment every two years. Besides, I have many other issues aside of these that I have to deal with. The eleven doctors all know they are to turn in credentialing information every two years, but if they don't do it, what do you want me to do? Fire them? I have known most of them for fifteen to twenty years, and I know they are very well credentialed to be here."

On the days of the recertification survey based on random observations, interviews, and review of hospital policy and procedure, the hospital failed to ensure 1 of 2 medication carts was locked in the medical surgical nursing unit, failed to label opened medication bottles, and discard expired medications.

The findings are:

On 2/25/14 at 2:30 p.m., randoms observations in the Medical-Surgical nurse station revealed 1 of 2 medication carts was not locked. The findings verified with Staff Members 1 and 2. Staff member 2 reported the medication cart is to be locked at all times.

On 2/26/14 at 10:20 a.m., a random observation in the radiology control room cabinet revealed an opened bottle of Gastrografin contrast that had no label with the date or time when opened. The findings were verified with Staff Member 15.

Hospital policy and procedures, titled, Medications, reads, "....drugs shall be kept in locked storage when unattended and shall be inaccessible to unauthorized individuals....".

Hospital policy, titled, Oral Contrast for Computerized Tomography, reads, "....if a full bottle of Gastrografin is not used at time of procedure, the remaining Gastrografin must be recapped properly, dated, and used within a three day period or the remaining bottle will be discarded and replaced with a new bottle....".






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On 02/26/2014 at 9:05 a.m., observations of Staff Member 2 administering medications to Patient 12 whose medications included Zantac 150 mg(milligrams) 1 tablet two times a day. Observation showed Staff Member 2 prepared the Zantac to give to the patient. Observation of the Zantac packet revealed the Zantac tablets that Staff Member 2 was going to administer to the patient had an expiration date of June 2013. Observation also showed another Zantac tablet packet on the medication cart with an expiration date of June 2013. On 02/26/2014 at 9:10 a.m., the findings were verified with Staff Member 2.

On the days of the recertification survey based on observations, interview, and hospital policy and procedure, the hospital failed to ensure infection control procedures were followed for 1 of 1 Staff Member administering medications to 2 of 6 patients. (Patient 11 and 12)


The findings include:


On 02/26/2014 at 8:45 a.m., observations of Staff Member 2 administering medications to Patient 11 showed Staff Member 2 performed hand hygiene for less than 3 seconds after completing the medication administration and before leaving the patient's room. Observations on 02/26/2014 at 9:05 a.m. of Staff Member 2 showed Staff Member 2 performed hand hygiene for less than 6 seconds before leaving the patient's room after administering medications to Patient 12. On 02/26/2014 at 9:15 a.m., the findings were verified with Staff Member 2.

Guidelines and standard nursing practice in the health care setting set forth in the Recommendation and Reports for the Centers for Disease Control, reads, "Morbidity and Mortality Weekly Report Recommendations and Reports October 25, 2002/Vol 51/No. RR-16 Guideline for Hand Hygiene in Health-Care Settings...2. Hand-Hygiene technique...B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacture to hands and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (lB) (90-92,94,411)...". Guidelines and standard nursing practice in the health care setting set forth by the Centers for Disease Control, reads, "...Hand Hygiene Guidelines Fact Sheet...When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry...".

On the days of the recertification survey based on observations and interview, the hospital failed to ensure a clean and sanitary kitchen that included ceilings, stove, oven, deep fryer, ice maker, and the screen door in the dock area.


The findings include:


On 2/25/2014 from 1:20 p.m. - 2:00 p.m., observations of the dietary department revealed stained ceilings with a brownish residue throughout the dietary department. The hood over the stove area had brownish residue and a dull brownish color. The cook stove had only 4 burners that were working. The stovetop was covered with a brownish residue. The oven had a brownish residue. The deep fryer had a black liquid. The kitchen ice maker had a broken latch on the right side of the hinge. The dock area screen door that opened to the cemented area had peeling paint and a brownish black residue on the door frame. On 2/25/2014 at 2:00 p.m., the Staff Member 14 verified the findings.

On the days of the recertification survey based on interview, chart review, and review of hospital policy and procedure, the hospital failed to ensure its own staff documented the patient's pain assessment and reassessment for effectiveness for 2 of 10 open patient charts reviewed (Patient 5 and 6), and failed to have a physician order for a procedure for 1 of 10 opened patient charts reviewed. (Patient 7)


The findings are:


On 2/25/14 at 1:48 p.m., review of Patient 5's open medical record revealed on 2/24/14 that the patient received Norco 5 milligrams (mg) per 325 at 1:50 p.m. There was no documentation of a pain assessment prior to the administration of the Norco and no documentation of a pain reassessment after the Norco was administered. The patient received Norco 5/325 mg on 2/24/14 at 8:00 p.m., but there was no documentation of a pain assessment prior to the administration of the Norco and no documentation of a pain reassessment after the Norco was administered. The patient received Norco 5/325 mg on 2/25/14 at 5:16 a.m., but there was no documentation of a pain assessment prior to the administration of the Norco and no documentation of a pain reassessment after the Norco was administered.

On 2/25/14 at 2:02 p.m., review of Patient 6's opened medical record revealed on 2/25/14 that the patient received Percocet 1 tab at 12:18 p.m., but there was no documentation of a pain assessment prior to the administration of the Percocet. The findings were verified with Staff Member 1.

On 2/25/14 at 2:30 p.m., review of Patient 7's opened medical record revealed at 4:47 p.m. on 2/24/14, a catheter (cath) urinalysis (ua) was performed on the patient. Further review of the physician's orders revealed there was no physician order for the cath ua. The findings were verified with Staff Member 2 who confirmed a physician order must be written for a cath ua.

Hospital policy and procedure, titled, Pain, reads, ".... A. assess the patient's onset, duration, character and location of pain by completing Pain Assessment Tool. B. Use the following numerical pain scale to rate the intensity of pain in older children and adults: 1-10.....I. Reassess patient pain 30-60 minutes after medication administration....Documentation- A. Onset...., B. Pain scale rating...., AC. Administration of pain medication or comfort measures utilized...., D. Pain scale rating following administration of pain medication....".

On the days of the recertification survey based on observations and interview, 1 of 2 Staff Members failed to ensure that the medication to be administered to the patient had not expired. (Staff Member 2)

The findings are:

On 02/26/2014 at 9:05 a.m., observations of Staff Member 2 administering medications to Patient 12 whose medications included Zantac 150 mg(milligrams) 1 tablet two times a day. Observation showed Staff Member 2 prepared the Zantac to give to the patient. Observation of the Zantac packet revealed the Zantac tablets that Staff Member 2 was going to administer to the patient had an expiration date of June 2013. Observation also showed another Zantac tablet packet on the medication cart with an expiration date of June 2013. On 02/26/2014 at 9:10 a.m., the findings were verified with Staff Member 2.

On the days of the recertification survey based on interview, personnel record review, and review of the hospital's policy and procedure, the hospital failed to provide training to 1 of 1 Registered Nurses for Organ Procurement Organization(OPO) Designated Requestor. (Staff Member 6)

The findings are:

On 02/26/27 at 10:45 a.m., review of Patient 1's closed chart revealed that Staff Member 6 signed as a "Designated Requestor" for OPO services provided to the patient's next-of-kin. On 02/26/14 at 12:20 p.m., review of Staff Member 6's personnel record revealed there was no documentation or evidence of training as a "Designated Requestor". On 02/26/14 at 12:18 p.m., Staff Member 4 revealed that none of the nursing staff had training to become a "Designated Requestor".

Review of the "South Carolina Donor Referral Network Designated Requestor Program" reads, "....Designated Requestor: an individual who has completed a course offered or approved by the OPO and designed in conjunction with the tissue and eye bank community....".