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Based on observation, interview and record review the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effect of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients in 6 of the 6 smoke compartments. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey. This deficient practice had the potential to affect all 18 patients.

Findings Include:
K-18: Corridor openings were not smoke tight.
K-29: Hazardous areas were not enclosed with hourly rated fire barriers.
K-51: Fire Alarm system missing visible appliances.
K-67: Pressure relationships and air flows not met.
K-147: Open junction box for electrical system.

Please refer to the specific K-tags for additional details.

Based on observation, record review and interview the facility failed to monitor temperature in 6 of 6 areas (Pharmacy, Vaccine, ED, OR, OB, Medical/Surgical). This deficient practice had the potential to affect all 18 patients.

Findings:

Review of the facility policy "Medication Inspections & Outdates" dated 4/24/2014 revealed that "Refrigerators containing medications must be checked to ensure that they have a working thermometer with the alarm switch set to the 'ON' position. The refrigerator temperature should be between 2-8 [degrees Celsius]."

During an interview on 9/21/2015 at 2:40 PM, Pharmacy Tech F stated all refrigerator temperatures are checked "daily." Review of the temperature monitoring graph for September 2015 reveals the temperatures are monitored primarily Monday through Friday; 8 of 21 days in September did not have temperature readings. The log states refrigerator temperatures should be maintained at 36-46 degrees Fahrenheit (the equivalent to 2-8 degrees Celsius).

Per the temperature log, the ED medication refrigerator was maintained at temperatures of 29 to 35 degrees Fahrenheit, below the threshold of 34 degrees. Tech F stated the ED refrigerator "was alarmed and should go off" if the temperatures were out of range, but could not confirm what limits the alarm range was set.

The OB medication refrigerator had temperatures above the maximum threshold of 46 degrees, with readings at 47 and 48 degrees.

There was no monitoring of the OR medication refrigerator.

Per interview on 09/21/15 at 3:00 PM COO A stated the facility had had a recent transition to automated dispensing machines which monitored the temperatures of the refrigerators. COO A confirmed the facility did not have a policy in place to reflect the process change.

Facility policy "Warming Cabinet" dated 10/2014 states: "1. The warming cabinet will be monitored by all nursing staff to provide a ready supply of warm bath blankets. 2. The temperature will be set to maintain a range between 110 degrees and 130 degrees F. 3. There will be a log documenting the weekday internal cabinet temperature..."

Per interview with ED RN P on 9/22/2015 at 7:50 AM ED staff checks the temperature of the blanket warmer daily but per observation at the time of the interview there was no log in which these checks are documented.

Based on observation, interview and record review the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effect of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients in 6 of the 6 smoke compartments. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey. This deficient practice had the potential to affect all 18 patients.


Findings Include:
K-18: Corridor openings were not smoke tight.
K-29: Hazardous areas were not enclosed with hourly rated fire barriers.
K-51: Fire Alarm system missing visible appliances.
K-67: Pressure relationships and air flows not met.
K-147: Open junction box for electrical system.

Please refer to the specific K-tags for additional details.

Based on observation, interview and record review this hospital failed to ensure 10 of 12 services were provided in a safe and effective manner

Findings include:

Based on observation, record review and interview the hospital failed to ensure medications, biologicals and perishable supplies were monitored in 6 of 12 (ED, Radiology, Lab, Rehab, Diagnostic Care, Surgical suites) areas observed. (See C-276)

Based on observation, record review and interview, the facility failed to maintain a clean environment and adhere to accepted standards of practice in 6 of 12 departments observed (Surgical Suite, Maternity, Rehab, Lab, Dietary, EVS), and during 1 of 3 observations of patient care (Patient #13). (See C-278)

Based on record review and interview the hospital failed to ensure pain was reassessed in 3 of 6 (#9,10 & 20) patients complaining of pain out of a total sample of 22. (See C-296)

Based on record review and interview the hospital failed to ensure nursing care plans included interventions for 7 of 17 records (pt.s #9,10,11,12,19,20 and 22) with care plans out of 22 records reviewed. (See C-298)

The cumulative effect of these systematic failures has the potential to affect all patients who receive care at this facility including the 18 patients in the hospital at the time of this survey.

Based on observation, record review and interview the hospital failed to ensure medications, biologicals and perishable supplies were monitored in 6 of 12 (ED, Radiology, Lab, Rehab, Diagnostic Care, Surgical suites) areas observed. This deficient practice had the potential to affect all 18 patients.

Findings include:

Observations in the laboratory;

During a tour of the lab with lab manager C on 09/21/15 at 2:45 PM, 6 outdated vaccutubes (for the drawing of blood) were observed in a tote on the lab counter. The tubes had expiration dates of 07/2015. Per interview with C at the time of the observation, these tubes could be inadvertently used by staff.

Facility policy "Drug Storage & Handling" dated 08-13-02 states: "Multi-dose vials will have a 28 day expiration date, unless otherwise specified by the manufacturer once use."

Observations in the Rehabilitation gym:

During a tour of the rehab gym on 09/21/15 at 2:15 PM with Rehab Director D, an opened multi-dose vial (30 ml.) of dexamethasone was observed undated in the medication cabinet. Per interview with D at the time of the observation, multi-dose vials should be dated when opened.


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Observation in Diagnostic Care area:

A tour of the sleep study room was conducted on 9/21/2015 at 2:34 PM. A bottle of Isopropyl Alcohol used by the sleep study technician was found in a cabinet opened and undated.
This finding was discussed with and confirmed per interview by Director of Nursing A on 9/21/2015 at 3:40 PM.


Observations in the Surgical Suite:

At 8:40 AM on 9/22/2015, in the Anesthesia workroom, the logs for the medication refrigerator were reviewed. The logs had no temperatures recorded on the weekends. In an interview with Surgery Manager B at the time of the tour, B stated that the temperatures are recorded on the days they are in the department and doing surgery.

In the same Anesthesia workroom the following intravenous (IV) fluids were found to be expired in the Malignant Hyperthermia cart: three 100 cubic centimeter (cc) bags of D5 (dextrose 5%), two 100 cc bags of .9 NS (normal saline), four 500 cc bags of Mannitol 20% (medicated IV solution used to pull fluid from the organs). Surgery Manager B confirmed these findings and in an interview at the time of the discovery stated that the cart is checked every month for outdates, however there is no documentation that this is done.


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Facility policy "Medication Inspections & Outdates" dated 4/24/2014 states "Inspections are intended to ensure that all medication storage areas are safe, clean, well-organized and free of all expired or otherwise unusable medications...A staff member will perform and document the area inspection...no less than once per month."

ED

During observation of the ED on 9/22/2015 at 7:50 AM, the pediatric crash cart contained the following expired medications: Atropine (expired 8/31/2015); Dobutamine (expired 7/2015); Dopamine (expired 8/2015). The cart contained 4 pediatric intubation kits expired 6/2015. A notation on the medication cart documents a medication check for expired medications was performed on 4/29/2015.

RN P stated at the time of the observations that expired medications should not be available for patient use. P went on to state that pharmacy staff checks the carts monthly for expired medications and ED staff is responsible for monitoring expired supplies.

Radiology

Per observations on 9/21/2015 at 1:55 PM, the radiology department contained the following expired items: open, undated bottle of alcohol; opened, undated bottle of provodone iodine with a manufacturer's expiration date of 10/2013; open, undated bottle of vinegar with a manufacturer's expiration date of 2010; open bottle of Caviwipes for equipment disinfection expired 10/2011. Radiology Director E stated at the time of the observations that expired supplies should be removed.

Based on observation, record review and interview, the facility failed to maintain a clean environment and adhere to accepted standards of practice in 6 of 12 departments observed (Surgical Suite, Maternity, Rehab, Lab, Dietary, EVS), and during 1 of 3 observations of patient care (Patient #13). This deficiency had the potential to affect all 18 patients served by the hospital at the time of the survey.

Findings include:


Rehab Gym:

During a tour of the Rehab Gym with Director D on 09/21/15 at 2:15 PM it was observed that hand towels and hand cleaning gels was kept in a cabinet under the sink. Per interview with D at the time of the observation these items should be stored in a clean area not subject to plumbing leaks.

Laboratory:

During a tour of the lab with Manager C on 09/21/15 at 2:45 PM it was observed that cleaning towels were kept in a cabinet under the sink. Per interview with C at the time of the observation C was not aware of limitations of storing items under the sink.


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Per interview with Infection Preventionist L on 9/22/2015 from 1:17 PM-1:40 PM regarding the facility's standards of practice for infection control include; Centers for Disease Control, The Association for Professionals in Infection Control, The Association of peri-Operative Registered Nurses, and The Association for Advancement in Medical Instrumentation. Infection Preventionist L also stated that items for patient care should not be stored under the sinks and environmental rounds are completed routinely to check for this.


Observations in the Surgical Suite area:

The following observations were made on 9/22/2015 between 7:20 AM and 10:30 AM in the operating room, surgical corridor, decontamination and sterilization, and post anesthesia care unit.


At 8:58 AM in the post-anesthesia care unit two boxes of gloves and a large roll of paper toweling for use in the paper towel dispenser for staff to use after washing hands, was found under the sink. Manager B stated that the items should not be under the sink.

At 9:25 AM and 9:40 AM Surgical Technician H was observed carrying soiled surgical equipment in containers across the hall from the operating room into the decontamination area, removed gloves after depositing the gloves in decontamination, but did not perform hand hygiene upon glove removal.

The facility's policy titled, "Handwashing," dated 7/2011, states in part under Policy, "Hospital personnel shall wash their hands or use waterless hand cleanser to prevent the spread of infections: ...before applying and after removing gloves."

At 10:15 AM an observation of clean endoscope storage was made accompanied by Surgical Manager A,B and Surgical Technicians H and I. The clean scopes were hung on hooks in a corner of the clean equipment wrapping room where items are brought in clean to wrap for sterilizing.

AORN Recommended Practice: Cleaning and Processing Endoscopes Recommendation IX: Flexible endoscopes should be stored in a manner that protects the device from damage and minimizes microbial contamination. IX.a: Flexible endoscopes should be stored in a closed cabinet with venting that allows air circulation around the flexible endoscope ... " AORN perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings, 2014 Edition.


The above findings were reviewed and confirmed by Surgery Manager B in an interview on 9/22/2015 at 12:10 PM.


Observations in Maternity:

During a tour of the Maternity floor on 9/22/2015 at 11:30 AM, accompanied by Clinical Coordinator Q, a bag of soiled laundry was observed on the floor in the soiled utility room.


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Dietary

Facility policy "Date Marking" dated 12/2014 states: "When to date mark: ...B. The food requires refrigeration...C. A commercially-prepared item that is opened...When to discard: ...C. The expiration date with which the manufacturer guarantee the food will no longer meet quality standards."

On 9/21/2015 at 1:30 PM the medical/surgical diet station refrigerator contained 2 jello containers expired 8/1/2015; 8 pudding containers expired 8/17/2015; 4 pudding containers expired 6/8/2015; an opened, undated and partially used loaf of bread; an opened, undated and partially used jar of applesauce; an opened, undated and partially used container of peanut butter. The refrigerator door signage stated: "All Staff--No personal food items are allowed in this refrigerator..." The refrigerator contained 2 unlabeled, undated Styrofoam containers. Dietary Aide O stated at the time of the observations that the Styrofoam containers were "leftovers" from the nursing staff and "shouldn't be in there."

Observation of the kitchen on 9/22/2015 at 11:30 AM revealed the following items: Open, undated dry pudding mix; open bag of marshmallows expired 8/20/2015; closed bag of marshmallows expired 8/20/2015; open, undated container of brown rice; open, undated bag of white rice; open, undated bag of dry cereal; open container of baking powder expired 9/2014. The above findings were confirmed at the time of the observations with Dietary Director N. Director N stated staff is responsible for labeling open items and disposing of expired food.


EVS

During observations on 9/22/2015 at 1:00 PM, the medical/surgical housekeeping supply closet contained an automated dilution control system for disinfectant solution. Maintenance Director G stated at the time of the observation that the solution was used for disinfecting a variety of surfaces in patient care areas. G stated staff were not performing any type of quality assurance monitoring on the product to ensure optimal and appropriate microbicidal concentration.

Based on record review and interview the hospital failed to ensure pain was reassessed in 3 of 6 (#9,10 & 20) patients complaining of pain out of a total sample of 22. This deficiency had the potential to affect all 18 patients being served by the hospital at the time of the survey.

Findings include:

Hospital policy: "Pain management program" revised 11/2014 states: "The patient will undergo re-assessment of pain at least once per shift and within 1 hour after control measure employed by hospital staff."

1. Per review of the MR, pt. #20 was receiving pain medications for pain ratings of 5-8 on a scale of 10. Pt. #20 received pain med's at the following times that were not re-assessed.

According to the pain flowsheet in the MR pt. #20 rated pain at 7 on 09/15/15 at 10:00 PM and received pain medication, there was no re-assessment of pain documented for 9 hours.

According to the pain flowsheet in the MR pt. #20 rated pain at 6 on 09/19/15 at 6:32 PM and received pain medication there was no re-assessment of pain documented until 6:16 AM on 09/20/15 when pt. #20 rated pain at 6.

According to the pain flowsheet in the MR pt. #20 rated pain at 7 on 09/20/15 at 2:10 PM and received pain medication there was no re-assessment of pain documented until 9:37 PM when pt. #20 rated pain at 5.

Per interview with RN M on 09/22/15 at 2:00 PM pain re-assessment should be documented within 1 hour of providing pain medications.


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2. Patient #9's closed maternal health record revealed that Patient #9 had a cesarean section on 8/5/2015. Patient #9 received the following pain medications post-operatively:

Morphine 2 milligrams (mg) intravenously (IV) on 8/5/2015 at 7:20 PM.

Morphine 4 mg IV on 8/5/2015 at 9:30 PM, on 8/6/2015 at 3:01 AM, 6:30 AM, 2:22 PM, and 8:45 PM.

Toradol 30 mg IV on 85/2015 at 11:30 PM, on 8/6/2015 at 5:12 AM, 2:22 PM, 7:51 PM, and on 8/7/2015 at 1:48 AM and 8:00 AM.

Hydrocodone with Tylenol (Vicodin) 5 mg/325 mg on 8/6/2015 at 1:06 PM and on 8/7/2015 at 2:19 AM, 6:21 AM, 10:30 AM, and 2:33 AM.
Ibuprofen 600 mg on 8/7/2015 at 2:33 PM.

There are no pain re-assessments documented for any of the above pain medication administrations. These findings were reviewed with, and confirmed per interview with Nurse Educator M on 9/22/2015 at 2:20 PM. M agreed that there were no documented pain re-assessments.

3. Patient #10's closed maternal health record revealed that Patient #10 had a vaginal delivery on 7/27/2015. Patient #10 received the following pain medications in the post-partum period:

Ibuprofen 600 mg on 7/27/2015 at 8:04 PM, on 7/28/2015 at 2:05 AM, 8:20 AM, 2:22 PM, 8:23 PM, and 7/29/2015 at 2:20 AM and 8:27 AM.

There are no documented pain re-assessments after 8:20 AM on 7/28/2015.

These findings were reviewed with, and confirmed per interview with Nurse Educator M on 9/22/2015 at 2:20 PM. Nurse Educator M agreed that there were no documented pain re-assessments.

Based on record review and interview the hospital failed to ensure nursing care plans included interventions for 7 of 17 records (pt.s #9,10,11,12,19,20 and 22) with care plans out of 22 records reviewed. This deficiency had the potential to affect all 18 patients being served by the hospital at the time of the survey.

Findings include:

Hospital policy "Nursing Care Plans" revised 11/14 states: "Process criteria are nursing interventions including the areas of assessment, nursing orders and teaching/discharge planning. The process criteria are to be accurate, state of the art nursing practices individualized to each patient by reflecting their preferences whenever possible."


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1. Patient #9's closed maternal record revealed that Patient #9 had a cesarean section on 8/5/2015. Patient #9's care plan consists of one problem: Potential for Post-Op [operative] Complications: Invasive Procedures. There are 3 goals: Patient will remain infection free during hospital admission; Patient will tolerate a regular diet by discharge; Patient will have pain controlled with po [by mouth] pain medication by discharge. There are no interventions on the care plan to identify how these goals will be met.

2. Patient #10's closed maternal record revealed that Patient #10 had a vaginal delivery with a slight tear that was sutured after being induced for labor due to pre-eclampsia (pregnancy complication with high blood pressure and other internal problems).

Patient #10's care plan consists of one problem: Pain Acute RT [related to] inflamation [sic]. There are 3 goals: Pt [patient] will state that pain is relieved or decreased by: discharge; Pt will demonstrate no signs of pain (grimace, guarding) by: discharge; Patient's usage of pain medication decreases to ___ by: [no date is entered].
There are no interventions on the care plan to identify how these goals will be met.

3. Pt. #11's closed newborn record revealed that Patient #11 was born on 8/5/2015 following a cesarean birth. Patient #11's care plan consists of one problem: Potential for Positive Growth and Development R/T [related to] Newborn Status. There are 3 goals: Infant will maintain effective breathing pattern starting at birth; Infant will remain infection free; Infant will maintain weight within 10% of birth weight. There are no interventions on the care plan to identify how these goals will be met.

4. Pt. #12's closed newborn record revealed that Patient #12 was born on 7/27/2015 following induced labor due to pre-eclampsia. Patient #12 was identified as being small for gestational age. Patient #12 weighed 4 pounds 6 ounces at birth and gestational age was 36 and a half weeks.

Patient #12's care plan consists of one problem: Potential for Positive Growth and Development R/T [related to] Newborn Status. There are 3 goals: Infant will maintain effective breathing pattern starting at birth; Infant will remain infection free; Infant will maintain weight within 10% of birth weight. There are no interventions on the care plan to identify how these goals will be met.

5. Pt. #19 had a care plan which included the problem "Ineffective individual coping related to chemical misuse & abuse". Specific interventions were not listed to achieve this goal.

6. Pt. #20 had a care plan which included the problem "Ineffective airway clearance". Specific interventions were not listed to achieve this goal.

7. Pt. #22 had a care plan consisting of problems including; Potential for injury related to falls and patient will verbalized feelings regarding terminal disease. Neither problem specified what interventions would be implemented to achieve goals.

These findings were confirmed per interview with Nurse Educator M on 9/22/2015 between 2:40 PM and 4:00 PM. Per interview with M on 09/22/2015 at 2:30 PM, interventions should be listed as part of the initial plan of care.

Based on record review and interview the hospital failed to ensure medical records were complete and appropriately authenticated in 4 of 22 medical records reviewed (Patient # 7, 8,10, 12). This deficiency had the potential to affect all 18 patients being served by the hospital at the time of the survey.

Findings include:

1. Patient #7's medical record revealed that the immediate post-operative note does not have a time the physician completed and signed the form. The update to the history and physical, which is to be completed prior to surgery, was signed by the physician at 11:50 AM on 9/11/2015. Patient #7's surgery started at 11:15 AM. Per interview with Director of Nursing A on 9/22/2015 at 1:50 PM the update to the history and physical should not be completed after surgery.

2. Patient #8's medical record revealed that the post-anesthesia evaluation section of the Pre and Post Anesthesia evaluation form does not include a date and time for the physician's signature.

3. Patient #10's closed maternity record revealed that the general consent for treatment and the consent for receiving an epidural do not include a time Patient #10 signed these consents.

4. Patient #12's closed newborn medical record revealed that information on the Newborn Record form was incomplete. There is no documentation for when the Vitamin K was given, where it was given, or by whom. Other missing information from this form includes: information on initial respirations, measurements of head, chest, and length, and eye prophylaxis (erythromycin to the eyes after birth).

These findings were confirmed by interview with Director of Nursing A on 9/22/2015 at 4:20 PM who agreed this information was missing.

Based on record review and interview, facility staff failed to obtain signed consent upon inpatient admission for 4 of 18 inpatients reviewed (#1, #2, #16, #17) in a sample of 22. This deficiency had the potential to affect all 18 patients served by the hospital at the time of the survey.

Findings:

Facility policy "Admission/Medical-Surgical" dated 11/2014 states in part: "5. The admitting/business office obtains all pertinent identifying and insurance information from the patient or family prior to or as soon as possible after admission to the nursing unit. a.) When admitting/business office is closed, the information may be obtained by the nursing staff... e.) The authorization signatures required on the reverse of the admission sheet are obtained, witnessed, dated, and timed."

1. Pt. #1 was admitted to the facility on 9/17/2015. Pt. #1's MR, reviewed on 9/21/2015 at 1:00 PM, did not include a signed consent for admission.

2. Pt. #2 was admitted to the facility on 9/21/2015. Pt. #2's MR, reviewed on 9/22/2015 at 8:55 AM, did not include a signed consent for admission.

3. Pt. #16 was admitted to the facility on 9/8/2015. Pt. #16's MR, reviewed on 9/22/2015 at 2:30 PM, did not include a signed consent for admission.

4. Pt. #17 was admitted to the facility on 9/18/2015. Pt. #16's MR, reviewed on 9/22/2015 at 3:00 PM, did not include a signed consent for admission.

During an interview on 9/22/2015 at 5:00 PM, HIM Director R stated that admission consent forms are "to be signed when the patient comes in at registration or by nursing if it's off hours or overnight." Director R stated consents can be obtained either electronically or on paper and confirmed there were no admission consent forms available in either format for the above records.