HospitalInspections.org

Based on a review of 6 Medical Records (#9, #10, #11, #36, #37, #38), it was determined that the facility failed to ensure that all patients were provided informed consent before receiving medical treatment.

Findings include:

Two ( 2) of eight (8) Medical Records reviewed (#9 and #38) had no evidence of a signed informed consent for treatment.

Based on observation during a tour of the Psychiatric Unit on June 13, 2012, in the presence of Staff #33 and #36, it was determined that the facility failed to ensure that all patients receive care in a safe setting.

Findings include:

1. The Psychiatric Units (Voluntary and Involuntary) failed to comply with suicide prevention based on the following:

a. The sink faucets in all patient room bathrooms were not of the suicide proof type and could support a patient's weight in a suicide attempt.

b. In Room #101, the toilet supply pipe cover was detached from the wall.

c. In the four (4) shower rooms, the shower handles were not of the suicide proof type and could support a patient's weight in a suicide attempt.

d. Throughout the unit, there were four (4) hospital beds in use, that could support a patient's weight in a suicide attempt.

Based on review of eight (8) medical records (#10, #34, #36) and review of facility policy and procedure, it was determined that the facility failed to ensure that all patients were kept free from restraints, unless authorized by a physician.

Findings include:

Reference #1: Facility's Policy titled, "Restraints and Seclusion" states, "X. Restraint Orders: Acute Med-Surg Needs--Physician Order--The physician/LIP must perform a face-to-face evaluation of the patient and evaluate the need for restraints within 1 hour of restraint application and provide a written order. The order must include the date, time, usage type (med-surg), reason, type of restraint to be used, duration and a signature..."

Reference #2: Facility's Policy titled, "Restraints and Seclusion" states, "X. Restraint Orders: Behavioral Management Needs--Physician Order--The order must include the date, time, usage type (behavioral), reason, type of restraint/seclusion to be used, duration and a signature...Discontinuation of Restraint (the same standards apply to both areas)--As early as feasible in the restraint process, the patient is made aware of the rationale for restraint and the criteria for discontinuation. This can be accomplished by RN's, LIP's, PA's, and NP's. Reason for early release is documented..."

1. Review of Medical Record #34 revealed the following:

a. The patient's restraint flowsheet indicated that the patient was in medical restraints for 24 hours on 6/7/12 and for 24 hours on 6/8/12.

i. The physician restraint orders dated 6/7/12 and 6/8/12 lacked evidence of time limits for the patient to be in restraints, as required in Reference #1.

b. On 6/4/12 the patient's restraint flowsheet indicated that the patient was kept in two point restraints for medical reasons for 24 hours without a valid physician order.

c. The above was confirmed with Staff #1.


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2. Review of Medical Record #10 revealed the following:

a. The patient was placed in 4 point restraints at 2045 on 5/2/12. An order for 4 point restraints was completed by an RN with no date or time documented on the order.

i. A physician countersigned the RN's signature, but there is no date or time of entry.

ii. No "Indications for Termination" [of restraints] were documented on the restraint order.

3. Review of Medical Record #36 revealed the following:

a. The patient was placed in 4 point restraints at 1145 on 6/3/12. An order for 4 point restraints was completed by a physician with no date or time documented on the order.

i. No "Indications for Termination" [of restraints] were documented on the restraint order.

A. Based on observation and staff interview conducted on 6/13/12, it was determined that the facility failed to ensure that prefilled syringes were discarded within one hour of preparation, in accordance with United States Pharmacopoeia (USP) guidelines.

Findings include:

Reference: United States Pharmacopeia, Chapter 797 when addressing immediate-use CSPs (Compounded Sterile Products) states that they are
"exempt from the requirements described for Low-Risk Level CSPs only when all of the following criteria are met ...4. Administration begins not later than 1 hour following the start of the preparation of the CSP."

1. A 3 ml [milliliter] syringe containing a clear fluid, labeled "Atropine mg[milligram]/ml," was found in the medication refrigerator in the anesthesia workroom located in the Operating Room Suite. The time and date of preparation was not indicated.

2. A 5 ml syringe containing a clear fluid, labeled "Succinylcholine," was was found in the medication refrigerator in the anesthesia workroom located in the Operating Room Suite. The time and date of preparation was not indicated.

3. Upon interview, Staff #40 stated that facility policy was to discard predrawn syringes if not used within one hour of preparation and that the syringes should have been discarded.

B. Based on observation and staff interview conducted on 6/13/12, it was determined that the facility failed to ensure that drugs were maintained in accordance with manufacturer's recommendations.

Findings include:

1. During a tour of the Intravenous Preparation Room in the Pharmacy, several parenteral preparations were found stored out of the overwrap provided by the manufacturer. These medications were all given a 30 day beyond use date.

a. Upon request, Staff #3 was unable to provide a policy and procedure addressing the beyond use date for medications removed from the overwrap. The beyond use date varies by drug, size of the bag, and manufacturer and is not 30 days for all medications.

C. Based on document review and staff interview conducted on 6/13/12, it was determined that the facility failed to ensure implementation of policies and procedures addressing the inspection by pharmacy personnel of drug storage areas.

Findings include:

Reference: Facility policy titled "Drug Storage Areas - Monthly Inspections" states, "Procedure:...3. The Pharmacy Department shall inspect at least once every two months all patient care areas in the Medical Center and at least once every three months all other areas of the Medial Center where drugs intended for administration to patients are stored..."

1. Review of pharmacy inspection records for 2012 revealed the following:

a. There was no evidence of a pharmacy inspection of the Operating Rooms, Anesthesia Workroom, or the Post Anesthesia Care Unit for January through June 13,2012.

b. The Same Day Stay, a patient care area, was inspected once on March 14th, from January through June 13, 2012.

c. There was no evidence of pharmacy inspections in the Pharmacy for 2012 with the exception of the IV Room, IV Room refrigerator and freezer and the RX Room, which were inspected in January 2012.

2. These finding were confirmed by Staff #3.

Based on observation and staff interview conducted on 6/12/12, it was determined that the facility failed to ensure that patient medication cassette drawers contained medications for the patient whose name appeared on the drawer and that the cassette drawers for discharged patients were removed.

Findings include:

1. At 10:30 AM, the contents of medication cassette drawers on Unit E4 were compared with the patient census and medication orders. The following discrepancies were found:

a. Spiriva, Advair 250/50 and Deep Sea Saline Nasal Spray, labeled with the name of Patient #47 were found in a medication cassette drawer labeled with the name of Patient #46. Patient #47 had been discharged on 5/30/12. Patient #46 had been admitted on 6/10/12. Upon interview, Staff #3 confirmed that pharmacy staff had failed to properly remove Patient #47's medication upon discharge.

b. Two (2) Risperidone 0.5mg tablets were found in the medication cassette drawer labeled for Patient #21. The patient had been discharged on 6/11/12. Additionally, Risperidone is dispensed from the drug dispensing device and should not be in the patient's medication cassette drawer. These findings were confirmed by Staff #3.

c. A tube of Nystatin Cream was found in a drawer bearing the name of Patient #16. The patient had been discharged on 6/1/12. Upon interview, Staff #3 confirmed that the label on the drawer as well as the medication in the drawer should have been removed upon the patient's discharge.

d. Advair 250/50 was found in a drawer bearing the name of Patient #17. The patient had been discharged on 6/11/12. Upon interview, Staff #3 stated that, although the cassettes are "updated" between 5:00AM-6:00AM, information regarding patients discharged may not have been processed by the pharmacy prior to the updating.

e. A Lidoderm patch, dispensed for Patient #20 on 6/7/12, was found in the medication cassette drawer bearing the name of Patient #48. Upon interview, Staff #3 confirmed that the medication should have been removed from the drawer.

Based on observation and staff interview conducted on 6/12/12, it was determined that the facility failed to ensure all medications were kept in locked storage areas.

Findings include:

Reference: Facility Policy, "Security of Medication Storage Areas" states under Procedure, "... 2. All medication carts and cabinets shall remain locked at all times when not in use. If a medication cart or cabinet must be left unattended at any time, it shall be locked during the time in which it is unattended."

1. During a tour of the ICU/CCU unit at 2:20 PM, two medication carts were not locked.

a. These findings were confirmed by Staff #7 and Staff #10.

2. The medication carts on Unit E4 were found unlocked at 10:30 AM.

b. This finding was confirmed by Staff #3.

A. Based on observation and staff interview, it was determined that the facility failed to ensure that expired medications were not available for patient use.

Findings include:

1. On 6/12/12 at approximately 11:30 AM, one intravenous (IV) bag of Piperacillin-Tazobactam 3.375gm (gram) in Dextrose 5% Water, labeled "exp 4/14/12", was noted in the medication refrigerator on Unit E4.

a. These findings were confirmed by Staff #2 and Staff #3.

2. On 6/13/12 at approximately 11:00 AM, expired medications were noted in the following areas of the Operating Room (OR) Suite:

a. Anesthesia Work Room Medication Refrigerator:

(i) Three vials of Succinylcholine 200mg (milligram)/10ml (milliliter), expired 6/1/12

(ii) Six "iStat" Glucose, expired 4/14/12

(iii) One vial of Methergine 0.2mg/ml, expired 3/31/12

(iv) One opened multiple dose vial of Novolin R Insulin 10ml, labeled "expires 5/15/12"

b. Malignant Hyperthermia Cart:

(i) Two bottles of Rubbing Alcohol, expired 7/31/11

(ii) Sixteen Benzoin Tincture 10% Swabsticks, expired 2/28/12

(iii) One bottle of Hibiclens Antiseptic Skin Cleanser, expired 7/31/11

(iv) Two IV bags of Sodium Chloride 0.9% Irrigation 3,000ml, expired 5/1/12

c. OR #6 Pyxis (medication dispensing machine) and storage cabinets:

(i) Six vials of Droperidol 5mg/2ml, expired 11/1/11

(ii) Eight vials of Ketorolac 30mg/ml, expired 6/1/12

(iii) One Epinephrine 1mg/10ml Abboject, expired 4/1/12

(iv) Four vials of 0.5% Bupivacaine 1:200,000 30ml, expired 2/1/12

(v) One vial of Labetalol 100mg/20ml, expired 4/1/12

(vi) One opened multiple dose vial of Atropine 8mg/20ml, labeled "expires 4/28/12"

(vii) Three cans of Hurricaine Topical Anesthesia Spray, expired 1/31/12

(viii) Thirty Benzoin Tincture 10% Swabsticks, expired 3/31/11

d. Cysto Room Pyxis:

(i) Two ampules of Epinephrine 1mg/ml, expired 5/31/11

e. These findings were confirmed by Staff #15, Staff #23 and Staff #24.

3. On 6/13/12 at 2:00 PM, the following expired medications were noted in the Pharmacy:

a. Sixteen vials of Ampicillin 250mg, expired 1/31/12

b. Twenty-five vials of Ceftriaxone 2gm, expired 3/31/12

c. Three vials of Pfizerpen 5 (Penicillin G Potassium), expired 1/31/12

d. These findings were confirmed by Staff #3 and Staff #29.

B. Based on observation and staff interview, it was determined that the facility failed to ensure implementation of policies and procedures addressing the expiration of multiple dose vials.

Findings include:

Reference: Facility Policy titled, "Multi-Dose Medication Vials/Single Dose Vials" states "1. ...When a multiple dose vial is opened, the nurse will place the calculated expiration date on the vial (28 days from the date the vial was opened, or the manufacturer's expiration date, whichever occurs sooner). After the 28 days expiration the vials should be discarded."

1. On 6/13/12 at approximately 11:00 AM, the following opened multiple dose vials were noted without the calculated expiration date (beyond use date) written on the vial in the following areas of the Operating Room (OR) Suite:

a. OR #6 Pyxis:

(i) Labetalol 100mg/20ml

(ii) Neostigmine Methylsulfate 10mg/10ml

(iii) Flumazenil 0.5mg/5ml

(iv) Glycopyrrolate 1mg/5ml

(v) Succinylcholine 200mg/10ml

(vi) Atropine 8mg/20ml

b. Cysto Room Pyxis:

(i) Neostigmine Methylsulfate 10mg/10ml

c. These findings were confirmed by Staff #15, Staff #23 and Staff #24.

2. On 6/13/12 at approximately 2:00 PM while touring the Pharmacy, a multiple dose vial of Clindamycin 9gm/60ml labeled "opened 5/16" was noted in the IV Room. The manufacturer's label on the vial states: "...Discard vial within 4 hours after initial entry." Since the manufacturer's beyond use date was sooner than 28 days, the manufacturer's beyond use date of "4 hours after initial entry" must be followed.

a. This finding was confirmed by Staff #3 and Staff #29.

Based on observation and staff interview conducted in the presence of Staff #12, it was determined that the Food and Nutrition Services Director failed to ensure daily supervision of the Food and Nutrition Services Department.

Findings include:

Reference #1: The Refrigerator Cleanliness and Monitoring of Temperatures Policy and Procedure states, "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...Food and Nutrition associates will maintain the cleanliness of the patient pantry refrigerators and cabinets on all nursing units with exception of the MH units."

Reference #2: The Mental Health "Kitchen Duty" list states: "Clean spills in refrigerator...Check cabinets for crumbs....Wipe cabinets clean."

1. On 6/12/12, the following facility unit pantry cabinets and refrigerators were observed to be dirty:

a. Unit E2 pantry refrigerator contained purple stains on the door shelves and crumbs on the interior shelves.

b. Unit E5 pantry refrigerator contained dark stains and crumbs on the interior shelves. The cabinets and drawers contained unprotected single serve utensils stored with artificial sweetener and lemon juice packets.

c. Unit E4 pantry refrigerator contained dark stains and crumbs on the interior shelves. The cabinets and drawers contained bins with crackers and crumbs on the bottom.

d. The ICU/CCU pantry drawers contained Enteral-Patrol Pump sets stored with forks, napkins and condiments. The Enteral-Patrol Pump sets were not protected from contamination. In addition, the pantry refrigerator contained dark stains and crumbs on the interior shelves.

e. The STCF Dining area refrigerator contained a black stained gasket on the door which was in disrepair. The refrigerator produce drawer contained fruit stored with crumbs and wrappers.

f. The Mental Health Unit Noisy Room refrigerator contained a black stained gasket on the door that was in disrepair. The interior shelves and drawers contained stains, crumbs and wrappers.

2. On 6/12/12 at 12:30 PM, Staff #12 confirmed that all facility unit pantry cabinets and refrigerators were not maintained clean as required in the above referenced policy (Reference #1).

3. On 6/12/12 at 11:30 AM, Staff #12 and Staff #13 could not provide for review, the requested policy and procedure for maintaining the cleanliness of the patient pantry refrigerators and cabinets in the mental health units. Staff #13 stated that staff of the mental health units are responsible for maintaining the cleanliness of the patient pantry refrigerators and cabinets as stated in the posted "Kitchen Duty" list (Reference #2).

a. Staff #12 and Staff #13 confirmed that the mental health units, STCF Dining area and Mental Health Unit Noisy room pantry cabinets and refrigerators, were not maintained clean as stated on the "Kitchen Duty" list (Reference #2).
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A. Based on tours of the facility and staff interviews, it was determined that the facility failed to ensure that the condition of the physical plant and overall hospital environment was maintained.

Findings include:

1. A tour of the Psychiatric Unit on the morning of 6/13/12 in the presence of Staff #33 and #36 revealed the following:

a. Throughout the Voluntary and Involuntary units, the door frames had chipped paint.

b. Throughout the Voluntary and Involuntary units, the heating covers and vent covers were rusty and dusty.

c. In Room #106, the floor tiles around the toilet base were missing and the floor around the bed contained dirt build up.

d. Throughout the Voluntary and Involuntary units, the showers had mildew residue on the walls and around the base of the stalls.

e. Throughout the Voluntary and Involuntary units, the floors had dirt build up along floor edges.

f. In the shower room across from Room #106, the shower curtain had black residue and the shower rod was rusty.

g. In the Voluntary Unit, the wall near the public phone had chipped paint and black marks.

h. In Room #109, Room #113, Room #114, Room #116, and Room #117, the walls had patches of exposed white plaster.


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B. Based on observation, it was determined that the facility failed to maintain the physical plant for the safety and well being of patients.

Findings include:

1. On 3/13/12 at 10:35 AM, in the presence of Staff #5, the sink trap in the Observation Unit Soiled Utility Room was dried out allowing the escape of sewer gas.


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C. Based on observation, review of facility policy and procedure and staff interview, it was determined that the facility failed to ensure that all equipment is inspected at least annually in accordance with facility policy.

Findings include:

Reference: Facility policy, "Equipment Management Program" states on page 5 of 8, "All equipment will be inspected at least annually or more frequently if indicated by monitoring of service calls or recommended by the manufacturers in order to comply with PM schedules."

1. On 6/12/12 at approximately 2:00 PM, a tour of the ICU/CCU unit was done in the presence of Staff #7 and Staff #10. The following was observed:

a. The Lifepack-12 monitor (#90485) located on the crash cart outside of ICU #8 contained a Biomedical Engineering sticker with a re-inspection due date of 5/12.

b. A Medtronic Temporary single-chamber Pacemaker (#90762) located in the Pacemaker Cart contained a Biomedical Engineering sticker with a re-inspection due date of 5/11.

c. A Medtronic A-V sequential Pacemaker (#3984) located in the Pacemaker Cart contained a Biomedical Engineering sticker with a re-inspection due date of 5/10.

Based on observation, review of facility policy and procedure and staff interview, it was determined that the facility failed to ensure implementation of its policy and procedure for contact precautions.

Findings include:

Reference: Facility policy "Guidelines for Isolation Precautions" states on pages 8 and 9 of 15, "Contact Isolation Precautions Require: 1. Perform Hand Hygiene before donning gloves. 2. Gloves must be worn to enter the patient's room. 3. Gowns and/or masks, in additions to gloves, are indicated when potential exposure to contaminated environmental articles or body fluids is anticipated... 6. When leaving a Contact Precaution room, all healthcare workers and visitors must remove gloves and wash hands..." The policy continues to state on page 15, "Visitors desiring to see patients in isolation will be requested to adhere to isolation protocol as listed and observe the following procedures prior to entering the patient's room:
- Follow precautions per the isolation sign and report to the nurses' station with further questions...
- Visitors leaving an isolation room must:
- Remove and discard any PPE in the appropriate waste container.
- Handwash thoroughly."

1. On 6/12/12 between 1:45 PM and 2:30 PM, a tour of the ICU/CCU in the presence of Staff #7 and Staff #10 was completed and the following observations were made:

a. Patient #12, who was in ICU Room #8, was observed to be on Contact Isolation Precautions as indicated by the Contact Precautions sign posted on the door. The patient was placed on Contact Isolation because of positive Klebsiella pneumoniae in the urine. At 1:55 PM, a visitor observed without any PPE (personal protective equipment), was leaning on the patient's bed side rail. The female visitor failed to adhere to the facility policy and had substantial contact with environmental surfaces in the patient's room.

b. Patient #13, who was in ICU Room #4, was observed to be on Contact Isolation Precautions as indicated by the Contact Precautions sign posted on the door. The patient was placed on Contact Isolation because of + MRSA. At 2:00 PM, a visitor observed without any PPE (personal protective equipment), was sitting in a chair beside the patient's bed, holding his/her hand. The visitor failed to adhere to the facility's policy and had substantial contact with the patient and environmental surfaces in the patient's room.

c. Patient #14, who was in CCU Room #8, was observed to be on Contact Isolation Precautions as indicated by the Contact Precautions sign posted on the door. The patient was placed on Contact Isolation due to having a history of MRSA. At 2:10 PM, two visitors were observed not wearing any PPE (personal protective equipment). One visitor was observed sitting on the edge of the patient's bed and the other was observed standing near the patient while he/she (the patient) was sitting in a chair. The visitors failed to adhere to the facility's policy and they had substantial contact with the patient and environmental surfaces in the patient's room.

A. Based on review of three (3) medical records for the administration of respiratory treatments, review of facility policy and procedure and staff interview, it was determined that the facility failed to ensure that respiratory orders were implemented according to policy and physician order for 1 of 3 patients.

Findings include:

Reference: The facility's Respiratory Policy titled "Three Day Stop Orders" states;
Respiratory Therapy treatments will be re-evaluated every three days to determine the need for continued therapy. On the third day of therapy, a respiratory re-order sticker will be placed in the patient's chart on the physician's order sheet. This sticker will inform the physician that the therapy will be discontinued if a new order is not written for therapy to be continued.
If a specific number of days...The above policy does not pertain to COPD [chronic obstructive pulmonary disease] patients. Therapy will continue until the physician can be notified and a reorder of therapy is obtained."

1. On 6/12/12, review of Medical Record #32 revealed the following:

a. The patient was admitted on 6/5/12 for exacerbation of asthma. The physician order dated 6/7/12 at 1:30 PM states, "[change] Albuterol 5.0 mg. Neb (nebulizer) q4 [every 4 hours]." The next physician order was written on 6/11/12 at 12:35 PM for Albuterol Nebulizer treatments every four hours around the clock.

i. The respiratory administration record revealed that the patient received respiratory treatments on 6/10/12 at 16:48, 20:30, 22:52 and 6/11/12 at 01:29, 7:34 (AM), and 11:30 (AM), without a valid physician order.

ii. There was no evidence that an order was obtained to continue treatments. The above referenced policy was not implemented.

b. A physician order dated 6/6/12 at 4:00 PM states, "Daily Peak flow measures and document in progress notes."

i. There was no evidence of the daily peak flow measures in the progress notes.

2. The above findings were confirmed by Staff #41.

B. Based on review of three (3) medical records for respiratory assessment, review of facility policy and procedure and staff interview, it was determined that the facility failed to ensure that the respiratory assessments policy was implemented for 3 of 3 patients (Medical Records #32, #33, #34).

Findings include:

Reference: The facility's "Respiratory Assessments" policy states, "Procedure: After receiving a "new start" order for aerosolized medication treatment, the Respiratory Care Practitioner (RCP) will: ... 4. Auscultate patient's breath sounds. 5. Administer aerosol treatment. Monitor patient's heart rate and response to therapy. 6. After treatment is completed, the RCP will evaluate patient response, including, but not limited to: breath sounds before and after treatment, patient's heart rate, pre and post....."

1. Medical Record #32 -- The patient began respiratory nebulizer treatments on 6/6/12 until 6/12/12, every four hours, as ordered. The respiratory assessment for each treatment lacked evidence that the respiratory therapist consistently auscultated pre and post treatment breath sounds. In most treatments, there was only one documentation of lung assessment. Therefore, it was difficult to determine if lung assessments were completed pre and post treatment. In some instances such as on 6/9/12 at 7:38 AM, 6/10/12 at 0100, 0500, there was no evidence of pre or post breath sounds.

a. There was no evidence of a documented heart rate on 6/7/12 at 9:00 AM, 11:57 AM, 1600 and 2050; on 6/912 at 7:38 AM, 11:24 AM, 1615 and 2100; on 6/10/12 at 0100, 0500, 7:24 AM, 11:11 AM, 1648; on 6/11/12 at 7:34 AM, 1744; and on 6/12/12 at 7:41 AM. In some instances the heart rate was documented as being "normal."

2. Medical Record #33 -- The patient began respiratory nebulizer treatments on 6/10/12, every 6 hours. The respiratory assessment for each given treatment lacked evidence that the respiratory therapist consistently auscultated pre and post breath sounds. In most treatments, there was only one documentation of lung assessment. Therefore, it was difficult to determine if the lung assessment was done pre or post treatment. There was no evidence of a documented heart rate on 6/10/12 at 11:52 AM, 1652; on 6/11/12 at midnight, 5:00 AM, 11:00 AM, 1750; on 6/12/12 at 10:40 AM.

3. Medical Record #34 -- The patient began respiratory nebulizer treatments on 6/9/12, every 4 hours. The respiratory assessment for each given treatment lacked evidence that the respiratory therapist consistently auscultated pre and post breath sounds. In most treatments, there was only one lung assessment documented. Therefore, it was difficult to determine if the lung assessment was done pre or post treatment. There was no evidence of any heart rate on 6/9/12 at 11:11 AM, 1500; 6/10/12 at 4:43 AM, 7:15 AM, 11:08 AM, 1512, 1932; on 6/11/12 at 0058 AM, 5:28 AM, 7:33 AM, and 10:46 AM.

4. The above findings were confirmed by Staff #41.