HospitalInspections.org

Based on document review, medical record review, and interview, nursing staff do not re-assess patient pain levels after the administration of pain medication per facility policy for 3 of 14 patients (Patient # 34, 35, and 38).

Findings include:

Review of facility document entitled "Pain Assessment and Re-assessment Safety Plan" (no date) revealed patients are to be reassessed and pain level is to be documented one hour after administration of pain medication.

Medical record review on 05/10/19 revealed on 05/09/19 at 06:05 PM, Patient # 34 received 500 mg acetaminophen. A pain re-assessment was not performed until 08:15 PM. On 05/09/19 at 08:42 AM Patient # 35 received 1 mg of Dilaudid. A pain re-assessment was not performed until 11:35 AM. On 05/07/19 at 10:04 PM, Patient # 38 received 1 tablet of Norco. A pain re-assessment was not performed until 05/08/19 at 00:19 AM.

Interview on 05/10/19 at 01:30 PM with Staff (A), Chief Nursing Officer verified the above findings.

Based on policy review, document review, observation, and interview the facility does not ensure current standards of practice related to the use of multi-dose vials in patient care areas.

Findings include:

Review on 05/09/19 of facility policy and procedure entitled "Medication Storage and Security" last revised 06/16 revealed all multi-dose vials should be labeled with date opened and given expiration date of 30 days after opening unless otherwise specified by the manufacturer. Open multi-dose vials of insulin are given expiration date of 28 days after opening.

Observation in Interventional Radiology procedure room on 05/07/19 at 11:50 AM revealed one (1) opened multi-dose vial of 2% Lidocaine, 20 ml, without date opened or expiration/beyond-use-date documented on vial.

Observation in the Emergency Department medication storage area on 05/07/19 at 11:00 AM revealed two (2) opened multi-dose vials of insulin dated 04/20/19 without expiration date/beyond-use-date documented on vial.

Observation on (S2) Medical Surgical unit medication room on 05/07/19 at 03:40 PM revealed two (2) opened multi-dose Humalog/insulin vials without expiration date/beyond-use-date documented on either vial.

Observation in the 3rd floor medication room on 05/08/19 at 10:00 AM revealed one (1) opened multi-dose vial of insulin dated 04/15/19 without an expiration date/beyond-use-date documented on vial.

Interview on 05/07/19 at 11:00 AM with Staff (D), Director of Emergency Services and ICU verifiedthe above findings in Emergency Department storage area.

Interview on 05/07/19 at 11:55 AM with Staff (FF) and Staff (GG), RN's Interventional Radiology verified the above findings in Interventional Radiology procedure room.

Interview on 05/07/19 at 03:40 PM with Staff (KKK), RN verified the above findings on S2 (Medical surgical).

Interview on 05/08/19 at 10:05 AM with Staff (U), Clinical Coordinator verified the above findings in the 3rd floor medication room.

Based on observation and interview, the facility failed to ensure egress pathways were appropriately marked and accessible in the event of an emergency situation. Specifically, the use of magnetic door holds that do not release with activation of the fire alarm or sprinkler system and exit signage directing individuals towards the magnetically held doors located in the main building lobby, the 2nd floor Hodge building maternity unit waiting area and the 3rd floor Hodge building Obstetrics/Gynecology outpatient clinic.

See findings under Tag # A710 and K222.

Based on observation and interview the facility failed to ensure egress pathways were appropriately marked and accessible in the event of an emergency situation. Specifically, the use of magnetic door holds that do not release with activation of the fire alarm or sprinkler system and exit signage directing individuals towards the magnetically held doors located in the main building lobby, the 2nd floor Hodge building maternity unit waiting area and the 3rd floor Hodge building Obstetrics/Gynecology outpatient clinic. This has the potential to prevent patients, staff and visitors from exiting the areas in the event of a fire.

Findings include:

Observation on 05/07/19 at 03:15 PM in the 3rd floor Obstetrics/Gynecology (OB/GYN) outpatient clinic revealed a door in the corridor with an exit sign above it, that was secured with a magnetic hold. Interview with Staff (VV), Facilities indicated the door separated the OB/GYN clinic from a private practice and the clinic was not sprinklered. There is no clinical need to secure these doors.

Observation on 05/07/19 at 03:30 PM in the 2nd floor Hodge building maternity waiting area revealed an exit sign located above the doors entering the maternity unit, that directed persons in the maternity waiting area to exit through the maternity unit. Interview with Staff (VV), Facilities indicated that the magnetic lock did not drop out with the fire alarm system. Interview at 05:30 PM with Staff (LLL), Director of Facilities indicated revealed a fire alarm report that indicated that the magnetic hold on the maternity unit doors drop out with activation of the fire alarm system could not be located.

Observation on 05/07/19 at 04:00 PM in the main building lobby revealed a set of double doors with magnetic holds. Interview with Staff (A), Vice President and CNO indicated that the doors are secured with the magnetic holds between 08:00 PM - 06:00 AM. The doors have an exit sign directing people from the lobby to the stairwell. The magnetic holds prevent people from utilizing this path of egress. The area is not fully sprinklered and there is no clinical need to secure these doors.

Interview on 05/07/19 at 04:45 PM with Staff (T), Chief Operating Officer verified these findings.

Based on medical record review, document review, and interview the facility did not develop a policy and procedure specifically related to fire prevention in the operating room.

Findings include:

Review of medical records of Patient #'s 46, 47, 50, 52, 53, and 54 revealed documentation of an intraoperative surgical site fire risk assessment with questions to determine risk scoring. However, the fire risk tool does not list what protective measures, prior to operative procedures, are actually implemented based on the risk scoring.

Review on 05/09/19 of facility policies related to Anesthesia and Surgical Services revealed no evidence of a policy related to fire prevention in the operating room.

Interview on 05/10/19 at 02:50 PM with Staff (A), Chief Nursing Officer and Staff (Z), Quality Coordinator, verified the above findings.