HospitalInspections.org

Based on record review and interviews the facility failed to ensure nursing staff developed a nursing care plan for 2 of 20 sampled patients (#15 and 20).

The findings are:

Record review for sampled patient #15 revealed she was admitted to the hospital on 5/7/13. Record review revealed no documentation of care plans. Interview and record review with sampled staff E on 8/6/13 at approximately 1:55PM confirmed the facility did not develop any care plans for this patient while in the hospital from 5/7-5/9/13.

Record review for sampled patient #20 revealed she was admitted to the hospital on 7/17/13. Record review revealed no documentation of care plans. Interview and record review with sampled staff E, on 08/6/13 at approximately 2:00PM confirmed no care plans were developed for this patient for the hospitalization of 7/17-7/19/13.

Record review of the facility's policies and procedures for "Nursing Care Plan" Policy #NADM-95, page 1,revealed the statement the policy is patients admitted as in-patients will have an individualized, written plan of care based on the patient's needs, problems and strengths. The nursing care plan is initiated at the time of the patient's admission to a nursing unit.

Based on record review and interview the facility failed to ensure 4 of 20 sampled patients' records (#5, 6, 11 and 12) documented a completed medical history and physical examination no more than 30 days before or 24 hours after admission.

The findings are:

1. Record review, done on 8/5/13, of the open record for sampled patient #11 revealed she was admitted to the hospital on 8/1/13. The record review failed to reveal documentation of a patient history and physical completed by the physician. Interview and electronic record review with sampled staff B on 8/5/13 at approximately 2:00PM confirmed the record did not contain the patient's history and physical.

2. Record review, done on 08/5/13, of the open record for sampled patient #12 revealed she was admitted to the hospital on 8/3/13. The record review failed to reveal documentation of a patient history and physical completed by the physician. Interview and electronic record review with sampled staff B on 8/5/13 at approximately 2:10PM confirmed no history and physical present on the patient. Sampled staff B called the director of nurses (DON) and requested the history and physical.


Interview with the DON on 08/6/13 at approximately 10:50AM revealed she is unable to find the patients' history and physical. On 08/6/13 at approximately 11:15AM the Director of Quality and Risk, sampled staff A was asked for the policy and procedure for the completion of the patients' history and physical. At approximately 12:30PM she provided the surveyor with a copy of the facility's policy and procedure entitled Health Information (Medical Records) which states " 6. Physician examination report to be performed no more than seven days prior to admission or within forty eight hours after admission and the History and Physical is to be on the medical record within 48 hours."




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Record review for sampled patient #5 indicated he was admitted 7/29/13 with a diagnosis of Congestive Heart Failure. The record lacked documentation of a patient history and physical completed by the physician.

Record review (completed 8/5/13) for sampled patient #6 indicated he was admitted 8/2/13 with a diagnosis of Chronic Obstructive Pulmonary Disease. The record lacked documentation of a patient history and physical completed by the physician. Interview with the director of nursing on 8/6/13 at 10:00 am confirmed the findings. She stated hospital policy is for history and physicals to be in the record within 48 hours of admission.

Based on observations and interviews the facility failed to ensure outdated drugs were not available for patient use in 2 of 6 hospital medical departments, emergency department and the medical/surgical department.

The findings are:

Inspection of the medical/surgical drug room located behind the nurses' station was conducted on 8/5/13 at 11:11AM with sampled staff F. The inspection revealed one 100 ml (milliliter) bag of 5% Dextrose IV solution with expiration date of 5/1/13 and one 100 ml bag of 5% Dextrose with 0.3% Sodium Chloride with the expiration date of 04/1/13. Sampled staff F confirmed these medications were expired and removed them from the area.


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Inspection of the treatment room located in the emergency department was conducted on 8/5/13 at 10:00 am with sampled staff D. The inspection revealed five bottles of Iodoform dressing used for packing wounds with an expiration date of 11/2012. Interview with staff D confirmed these dressings were expired.

Based on observation, staff interview and record review the hospital failed to monitor Operating Room temperatures and humidity levels according to facility policy for 1 of 2 operating rooms. (#2)
The findings are:

A tour of operating rooms (OR) #1 and #2 on 8/6/13 at 2:48 pm with the OR director was conducted. While in OR #2 a loud noise was heard from the corner of the room. There was a large white machine standing in the corner. The director said it is a dehumidifier and it is broken and we are working on it. Next to it was a portable dehumidifier in use and one across the room. The room registered 68% humidity. He said OR #2 is used for most all surgeries and we schedule surgeries weekly on Tuesdays, Wednesdays and Thursdays.

Interview with the director on 8/8/13 at 10:30 am indicated he did not know the status of the large dehumidifier. He indicated he has been here about a year and the two small portable dehumidifiers have been in use since then. He said he put in a request, no date given, to the maintenance department for it to be fixed. He also said when the humidity in the OR are too high he will call the maintenance department and they do something on the roof and usually the temperature will come down making the room less humid. When asked, if the humidity level is too high prior to surgery do they postpone surgery or delay it he said "No"..

Interview with the maintenance director on 8/8/13 at 10:10 am stated he doesn't do anything with equipment in the surgery department and he has not received any work order to fix the dehumidifier. He said he doesn't do anything on the roof for humidity.
Interview with the OR director on 8/8/13 at 10:30 am indicated surgical staff log daily the temperature and humidity levels of the two OR's.
Review of humidity log for the month of June for OR #2 indicated levels from 70% to 89% including the days surgery is scheduled. The log for July indicated levels from 80% to 89% and the month of August indicated levels from 74% to 79%.
Interview with OR director on 8/8/13 at 11:00 am stated the temperature in OR #2 was 65 degrees with humidity level of 68% today. Surgery was in progress at that time. The log that morning prior to surgery showed humidity level of 75%. The OR director was asked if he adjusted the temperature to adjust the humidity levels prior to surgery. He stated "No".

Interview with maintenance director on 8/8/13 at 12:00 noon said he did not receive a work order or a call to correct the humidity levels in the OR. He could not say when the large dehumidifier stopped working. He said he has been working at the hospital for 3 years and new nothing about it. He also did not know when the 2 portable dehumidifiers were brought for use.
He stated he just got a work order for the large dehumidifier and he will be working on this after speaking to the Chief Executive Officer (CEO).

Interview with the Director of Nursing on 8/8/13 at 12:20 pm indicated she did not know the large dehumidifier was not working and that they were using 2 small portable dehumidifiers. She stated surgery is scheduled weekly on Tuesdays, Wednesdays and Thursdays using OR #2.

Review of hospital policy " Operating Rooms Temperature and Humidity Controls " dated 04/04/07 indicates it is imperative that the Peri Operative area temperature and humidity are kept within the State and Federal mandated guidelines. The Peri Operative Nursing Staff is responsible for ensuring the temperature and humidity are checked and recorded daily. Any variation from required rules and regulations or from the Facility policy must be reported immediately to the OR Supervisor. Note: Do not use portable dehumidifier unless instructed to do so by administrative authority. The policy indicates for both OR's to have temperatures of 65 degrees and humidity setting of 50%. The policy gives instructions for different temperature and humidity levels and how to adjust and if after 30 minutes no change then call the OR supervisor. If this doesn't change the levels then call the HVAC Company.
Review of Center for Disease Control (CDC) guidelines for temperature and humidity in operating rooms recommends humidity levels between 35% - 60%.

The infection control log for tracking hospital infections was reviewed from June 2013 to August 8, 2013. There were no hospital acquired respiratory or wound infections.