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Based on interview, it was determined temperature (68-73 degrees Fahrenheit) and humidity (30-60%) levels in 2 of 2 surgical rooms (Operating Room and Outpatient Treatment Room #1) were not monitored to ensure the levels were within range as specified in the Arkansas Department of Health, Rules and Regulations for Hospitals and Related Institutions (Section 46.E-Table3). Failure to monitor temperature and humidity levels can result in an unacceptable environment due to ineffective sanitizing from cleaning solutions and and unacceptable moisture on surfaces in the rooms. The failed practice had the potential to affect the health and safety of all patients receiving surgical or diagnostic services in the rooms with an average of 4 surgical cases per month in the Operating Room and an average of 30 endoscopic procedures in the Outpatient Treatment Room #1 (OP-1). The findings follow:

In an interview on 09//28/10 at 1400, the Maintenance Director stated there was no historical data for temperature and humidity levels in the Operating Room or Outpatient Treatment Room #1) available for review.

Based on generator log review, observation, and interview, it was determined the facility did not meet Life Safety Code requirements related to monthly 30 minute load exercising of the generator and portable heating devices. Load exercising of the generator provides a method of testing the generator for reliability to ensure continuation of life support and fire safety equipment. Portable heating devices are a fire hazard and have the potential to affect all occupants of the facility as a result of fire caused by improper portable heater failure or improper usage. The failed practice had the potential to affect all patients admitted to the facility with an average daily census of 4.3 patients and 8 of 8 patients on 09/27/10. See K-70 and K-144 for further details.

Based on observation and interview, the facility failed to ensure outdated medications were not available for patient use in six (Pharmacy, Emergency Room, Surgery, Nursing Station, Intensive Care Unit, Outpatient Surgery/Procedure Area) of six medication areas. The potential existed for the average daily census of 4.3 inpatients and the average daily census of 17 Emergency Room patients to receive outdated medications which could affect patient safety. Findings follow:

A. A tour of the critical access hospital was conducted on 09/28/10 between 1025 and 1450 in which the following outdated medications were observed:

Emergency Room
1) Two Dextrose 5% 500 milliliters (ml) intravenous (IV) solutions expired 07/01/10;
2) One Dextrose 5% 500 ml IV solution expired 01/01/09;
3) One Lactated Ringers 1000 ml IV solution expired 09/01/10;
4) Two Prochlorperazine 10 milligrams (mg)/2 ml expired 07/10;
5) Ten Prochlorperazine Maleate 10 mg tablets expired 05/10;
6) Seven Epinephrine 1 mg/ml injectable expired 08/10;
7) One Diltiazem 50 mg/10 ml expired 08/10;
8) One Dextrose 5% 250 mg IV solution expired 05/01/10;
9) One Bacteriostatic Sterile Water 30 ml expired 09/01/10;
10) One Children Fleet Enema expired 07/09; and
11) Forty-seven Sodium Chloride 0.9% Inhalation Therapy expired 03/10.
Surgery
1) Sojourn 250 ml expired 03/10; and
2) Two Heparin 10,000 units (u)/ml expired 08/10.
Outpatient Surgery/Procedure Area
1) One Fleet Phospho-Soda expired 12/09;
2) Fifty-two Sodium Chloride 0.9% for Inhalation Therapy expired 11/09.
Nursing Station
1) One bottle of Nitroglycerin 1/150 tablets expired 08/10;
2) Two Furosemide 40 mg/4 ml expired 08/01/10;
3) Two Digoxin 0.5 mg/2 ml expired 07/10;
4) One Dopamine 400 mg/5 ml expired 02/10;
5) One Epinephrine Intracardiac expired 07/01/10;
6) One Lidocaine 100 mg/5 ml expired 01/01/10;
7) Four Lidocaine 100 mg/5 ml expired 07/01/10;
8) Two Atropine Sulfate 0.5 mg/5 ml expired 08/01/10;
9) One Dopamine 800 mg/250 ml IV solution
10) Two Heparin 10,000 u/ml expired 08/10;
11) One Dextrose 5% 500 ml IV solution expired 07/01/10;
12) One Sodium Chloride 0.45% 500 ml IV solution expired 07/01/10;
13) One Verapamil 2 ml Injectable expired 03/01/10;
14) One Childrens Tylenol Elixir 120 ml expired 03/10;
15) One Guaifenesin 100 mg/5 ml 120 ml expired 03/10; and
16) One Prochlorperazine 10 mg/2 ml expired 07/10.
Intensive Care Unit
1) One Dopamine 800 mg/250 ml expired 08/01/10;
2) Two Epinephrine Intracardiac expired 07/01/10;
3) Two Heparin 10,000 u/ml expired 08/10;
4) Three Phenytoin 100 mg/2 ml expired 06/10;
5) One Protonix 40 mg Intravenous expired 07/09;
6) Two Lidocaine 100 mg/2 ml expired 07/01/10; and
7) One Dextrose 5% 500 ml IV solution expired 07/01/10.
Pharmacy
1) Ninety-seven Diltiazem 60 mg tablets expired 08/10;
2) Twenty Spectracef 400 mg tablets expired 07/10;
3) Fifteen Probenecid 500 mg tablets expired 03/08;
4) Eighty-four Labetalol 200 mg tablets expired 04/10;
5) One hundred Doxycycline 100 mg tablets expired 12/09;
6) Fifteen Zonisamide 100 mg capsules expired 08/09; and
7) Five Terbinafine 250 tablets expired 07/09.
B. Interviews were conducted on 09/28/10 in which nursing personnel verified the medications were outdated as follows: the Director of Nursing verified the medications were outdated in the Emergency Room at 1100 and verified the outdated medications observed in the Intensive Care Unit and Nursing Station at 1430. RN (Registered Nurse) #1 verified the medications were out of date in Surgery and Outpatient Surgery/Procedure Area at 1115 and 1130 respectively. RN #2 verified the medications observed in the Pharmacy were outdated.

Based on observation, policy review, job description review, consultant dietitian review, clinical record review and interviews, it was determined the facility failed to ensure the nutritional needs of patients were met in that there was no designated Dietary Department Director; failed to enforce kitchen sanitation procedures; failed to ensure the competency of support staff; failed to provide nutrition screening for three of three (#12, #13 and #14) patients when trained staff was off; and failed to provide nutrition assessment for two (#7 and #8) of four (#7-#9 and #11) current clinical records selected for nutrition review. The failed practice had the potential to affect all patients admitted to the facility. Evidence follows:

A. Review of Job Descriptions revealed there was no Job Description for a Department Director. Interview at 1405 on 09/29/10 with the Chief Nursing Officer (CNO), who was currently acting as Interim Administrator, revealed the Medical Staff had not designated a qualified individual as Dietary Director with authority over the day to day activities of the department.
B. Review of Infection Control Dietary Policies and Procedures revealed the following failures:
1) The After Hours Food Policy stated registered nurses (RNs) would assemble a cold, substantial meal for patients after hours, but lacked any reference to infection control practices while preparing patient food in the kitchen.
2) The Admittance to Galley Policy allowed entry by dietary employees, nursing employees, housekeeping employees and the Chief Executive Officer. The policy did not limit staff entry into the kitchen for patient meal related practices.
C. Observation and interview revealed kitchen sanitation failures related to separation of patient and staff food and entrance of personnel into the patient kitchen for non-patient related reasons:
1) Observation at 0900 on 09/28/10 revealed a refrigerator containing staff lunches and personal food items located in the patient kitchen. Galley Technician #1 stated at 0910 on 09/28/10 that nursing came in the kitchen whenever they wanted to get food from the refrigerator.
2) At 1015 on 09/28/10 Business Office Employee #1 was observed to enter the patient kitchen and obtain ice from the ice machine to fill her personal drink cup. She failed to restrain her waist length hair while in the kitchen.
3) Galley Technician #1 confirmed the observation at 1015 on 09/28/10 and confirmed the employee was not permitted to enter the kitchen by policy. She stated it was common practice for employees to enter the patient kitchen for ice and lunches, but she had no authority to enforce the policy.
D. Review of Clinical Dietary Policies and Procedures, dietary employee credentials and Consultant Reports revealed the facility failed to follow it's policies related to nutrition screening and diet counseling:
1) The Screening Assessment and Follow-up Procedure documented a Certified Dietary Manager (CDM) would screen all patients for nutritional risk within 24 hours of admission. Patients at risk would be assessed within 72 hours of admission and the Registered Dietitian (RD) and Physician must be notified. The policy contained a mechanism for notifying the Physician, but not for notifying the RD. The Initial Nutrition Screen Form documented each patient who received a nutrition screen score of 3 points or above required referral to the RD.
2) The Diet Instructions Policy stated diet instructions would be done upon physician order by the RD, CDM or authorized Galley Technician.
3) The facility failed to provide evidence of certification as a dietary manager (CDM) or documented competency related to diet instructions or nutrition screening for Galley Technician #2.
4) Review of the RD Consultant Reports from 02/09/2010 revealed Galley Technician #1 was on Maternity Leave from 03/08 - 05/03/2010. The RD documented on 03/01/10 the facility would need to have someone complete the nutrition screens and fax assessments for patients who screened at nutritional risk while Galley Technician #1 was out. The RD documented on 04/16/10 Galley Technician #2 was not completing the nutrition screen forms and needed to be trained on nutrition screening.
E. Review of clinical records revealed the facility failed to follow its nutrition care policies for five (#7, #8, #12, #13 and #14) of seven patients reviewed for nutrition documentation (#7, #8, #9, #11, #12, #13 and #14) as follows:
1) Review of the clinical record for Patient #7 revealed she was an 87 year old female admitted weighing 94 pounds on 08/05/09 with dehydration, decreased appetite, weight loss and chronic renal disease. The patient was discharged on 08/08/10 and the clinical record lacked evidence of a nutrition screen or nutrition assessment.
2) Patient #8 was a 5 year old male admitted through the Emergency Room with nausea and vomiting x 2 days. The patient was admitted to the hospital on 09/25/09 and discharged on 09/27/09. Review of the nutrition screen revealed the patient was screened as a level 3 nutrition risk, due to dehydration rather than a level 6 nutrition risk for dehydration and pediatric nausea and vomiting times two days. Although the patient screened at nutrition risk, the clinical record lacked evidence the RD was notified.
3) Patient #12, #13 and #14 were all admitted during maternity leave for Galley Technician #1 as follows:
a) Patient #12 was a 54 year old female admitted on 04/01/10 with acute gastritis and dehydration and discharged on 04/05/10 without evidence of nutrition screening or assessment in the clinical record.
b) Patient #13 was an 87 year old male admitted at 30 pounds below his ideal weight on 04/12 with nausea and vomiting and an upper gastrointestinal bleed. The patient was discharged on 04/17/10 without evidence of nutrition screening or assessment in the clinical record.
c) Patient #14 was a 57 year old male admitted on 04/16/10 with dehydration, acute renal insufficiency, chronic constipation, diabetes, gastro-esophageal reflux disease and a fecal impaction. The patient was discharged on 04/23/10 without evidence of nutrition screening or assessment in the clinical record.
4) The above was confirmed by the CNO at 1320 on 09/29/10.
F. Interview with the Consultant RD at 1345 on 09/29/10 she confirmed she did not complete a competency form for Galley Technician #2, because she could not say she was competent to screen patients for nutritional risk; to assess patients at nutritional risk; to perform discharge planning or diet instructions.
G. Interview with the CNO at 1405 on 09/28/10 revealed Galley Technician #1 worked Monday through Thursday and every other weekend. They had no current process for back-up by a qualified individual for Fridays and for weekends Galley Technician #1 did not work. She stated the Consultant RD worked for one to two hours once a month.

Based on review of clinical record #1 and interview, the facility failed to have a qualified person responsibile for providing activities based on the needs and interests of patients admitted to the Swingbed Program. The outcome existed for activities to improve mental function and social interests of swingbed patients not be available due to the lack of a qualified person to assess the patients needs and plan activities. The failed practice had the potential to affect one patient in Swingbed on the first day of survey 09/27/10 and all patients admitted to the Swingbed Program. Findings follow:

A. Interview with the Chief Nursing Officer at 1045 on 09/29/10 confirmed there was not a qualified person directing the Activity Program.
B. Review of clinical record #1 revealed there were no evidence of the needs and interests of the swingbed patient being assessed.