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Based on observation and interview, the facility failed to ensure that expired supplies were not available for use on patients in the Emergency Department (ED). This failure could potentially affect all patients treated in the ED resulting in adverse or delayed treatment. The facility census was nine. The ED treats about 17 patients per day.

Findings included:

1. Observation on 03/18/14 at 8:30 AM in the ED Trauma Room #1 showed:
- Three bags of Lactated Ringers and 5% Dextrose solution (fluid with added minerals and sugar used to treat patients with low blood volume), 1000 mL (milliliters- a unit of measurement), expired 02/14.
- One Hemoccult Developer solution 15 mL (used to determine if stool contained blood), expired 07/13.
- Four commercially prepared sterile vials that contained a solution that insured survival of organisms in stool while specimens are being transported to be tested for bacteria, expired 12/13.
- Three "Evacuated Container" sterile bottles used for collecting body fluid specimens to be tested, expired 10/13.

2. Observation on 03/18/14 at 9:00 AM in the ED storage room showed 16 anaerobic (used to test for organisms that do not require oxygen to grow) blood culture bottles and ten aerobic (used to test for organisms that require oxygen to grow) blood culture bottles (used to collect blood samples to determine if bacteria is present), all expired on 02/28/14.

3. During an interview on 03/18/14 at 9:20 AM, Staff X, Licensed Practical Nurse (LPN), stated that all the nurses check for expired supplies, usually towards the end of the month. She stated that there was no check off sheet or process, "It's just something we do." She stated that these expired supplies should have been removed from this area.

4. During an interview on 03/19/14 at 12:50 PM, Staff A, Director of Nursing, stated that there was not an ED specific policy or procedure on how expiration dates on supplies in the ED were supposed to be checked. Staff A stated that the nurses were supposed to check expiration dates on supplies monthly, usually around the end of the month. She stated the expired supplies should be removed from the area.

The ED Manager was not available for interview during this survey.

Based on observation, interview and policy review, the facility failed to ensure medications were secured in a manner to avoid tampering and potential harmful use and to secure medication designated for emergency treatment. The pharmacy failed to have a process in place to control and track the red breakaway tags used to secure/lock medication drawers in the crash carts (a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate a patient) in the Emergency Room and Acute Care Patient areas. The facility census was nine.

Findings included:

1. The facility could not provide a Policy or Procedure to direct staff for the use, storage or replacement of the red breakaway locks used to secure the crash carts.

2. Observation on 03/17/14 at 3:20 PM showed a crash cart in Acute Care Patient area with a numbered, red, breakaway tag used to secure the drawer containing medications to be used in case of an emergency.

3. During an interview on 03/17/14 at 3:20 PM, Staff A, Director of Nursing, stated she didn't know what the procedure was to replace the red breakaway tag when the cart needed to be used in an emergency. After discussion with the staff nurses, Staff A stated that the red breakaway tags were locked in the Respiratory Therapy cabinet in the medication room. She had no explanation as to why the Respiratory Therapists had access to these tags but stated that all the staff nurses had access to the tags.

4. During an interview on 03/18/14 at 1:40 PM, Staff Q, Registered Pharmacist (RPH)/Director of Pharmacy, stated that she didn't know what the procedure was for storing the red breakaway tags for the crash carts. She stated that she never knew what to do with them. Staff Q stated that there was no policy or procedure for tracking the tags but understood that they probably shouldn't be available to Respiratory Therapists and that the replacement tags should be tracked by total number of replacement tags available and numeric order by the Pharmacy Department to ensure control and avoid potential tampering.

Based on observation and interview, the facility failed to ensure fresh water supply resources serving a medical-surgical nutrition room remain free of potential cross-contamination by sewage containing human waste or infectious wastes. This deficient practice of potentially contaminated freshwater resources affects all staff, visitors, and patients the patient census was nine.

Findings included:

1. Observation on 03/18/19 at 8:45 AM of the Medical-Surgical nutrition room showed a length of one inch plastic pipe from the ice machine drain plumbed directly into a three inch diameter pipe attached to a floor drain. The plastic drain pipe completely penetrated the larger three inch pipe and did not leave an air gap. Without an air gap or open space between the collar of the sewer pipe and the ice machine drain, waste water could potentially be siphoned back through freshwater plumbing and spread contamination to other areas of the building.

2. During an interview on 03/18/14 at 9:00 AM, Staff S, Director of Maintenance acknowledged the observation and stated that would correct the problem.

Based on interviews, record reviews and policy reviews, the facility failed to ensure that a mid-level practitioner (A health care provider-eg, nurse practitioner, physician assistant, etc, whose activities are directed and/or dictated by a supervising physician) that was currently on the facility staff and at least one professional that was not on the facility staff were part of a group of professionals to develop and/or review facility policies and procedures. This had the potential to adversely affect the quality and consistency of all patient care in the facility. The facility census was nine.

Findings included:

1. Record review of the facility's documents titled, "Patient Care Policies Committee Meeting" dated 12/13/13, showed no mid-level practitioner or outside professional as part of the group that met for this meeting. The document did not name any policies or procedures that were reviewed or approved during the meeting. The document showed that the meeting began at 12:34 PM and adjourned at 12:34 PM.

Record review of the facility's documents titled, "Patient Care Policies Committee Meeting" dated 01/10/14, showed no outside professional as part of the group that met for this meeting. The document did not name any policies or procedures that were reviewed or approved during the meeting. The document showed that the meeting began at 12:28 PM and adjourned at 12:28 PM.

Record review of the facility's documents titled, "Patient Care Policies Committee Meeting" dated 03/14/14, showed no mid-level practitioner or outside professional as part of the group that met for this meeting. The document did not name any policies or procedures that were reviewed or approved during the meeting. The document showed that the meeting began at 12:25 PM and adjourned at 12:25 PM.
Staff Y, Chief Financial Officer (CFO), signed all three documents.

2. Record review of the policy and procedure manuals for Acute Care Nursing, Respiratory Therapy and Social Services showed that most of the policies and procedures were undated but had a cover sheet in the front of the manual with the statement, "ALL POLICIES AND PROCEDURES HAVE BEEN IMPLEMENTED AND APPROVED" on the dates of 02/25/13 and 02/18/14. All the cover sheets contained the same dates and were signed by: Staff R, Chief of Staff/Medical Director; Staff A, Director of Nursing (DON) and Staff Z, Administrator.

3. During an interview on 03/18/14 at 10:35 AM, Staff A, stated that she usually reviews and revises the Acute Care Nursing policies and procedures before they go to the committee for approval. She stated that a mid-level practitioner was not on the policy and procedure committee and that they did not have a professional on the committee that was not on the facility staff. Staff A also stated that the facility did not have a policy or procedure to direct them in the policy review/approval processes.

Based on observation, interview, record review, and policy review, the facility failed to follow contact isolation protocol for one patient (#8) of one patient with isolation precautions ordered and failed to ensure hand hygiene was used when staff provided care to three patients (#7, #8, and #9) of three patients observed. The facility also failed to repair or remove from service a damaged roller board in the surgical suite that could harbor bacteria. These failed practices increased the risk of infection and cross contamination and placed all patients, visitors and personnel at risk for hospital acquired infections (HAI) and contracting communicable diseases. The facility census was nine.

Findings included:

1. Record review of the facility's policy titled, "Infection Control Plan 2013-2014" revised on 10/13, showed that staff will implement the CDC (Centers for Disease Control and Prevention) Standard precautions to prevent infection and transmission of infections.

Record review of the facility's undated policy titled, "Placing and Maintaining a Patient on Significant Organism Associated Precautions (S.O.A.P.) Isolation," showed the following:
- Significant Organism Associated Precautions (S.O.A.P.) will be instituted in a case-by-case basis for organisms identified through surveillance as epidemiologically (the branch of medicine dealing with the incidence and prevalence of disease in large populations) significant. Clostridium difficile (C. diff is a spore bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) is an example of such an organism.
- Epidemiology (a branch of medical science that deals with the incidence, distribution, and control of disease) personnel, physicians and nursing personnel have the authority and responsibility to implement S.O.A.P. isolation.
- Place infected or colonized (occurs when a microorganism is found on or in a person without causing a disease or experiencing symptoms of the disease) patient in a single room or in the same room as other patient with the identical organism. Place S.O.A.P. sign on patient's door.
- Wear gloves for all contact with the patient, the patient's bedside equipment and the patient's immediate environment.
- Wear a gown for direct contact with the patient or with potentially contaminated equipment.

Record review of the facility's undated policy titled, "Handwashing," showed the following direction to staff:
- Handwashing is the single most important procedure to reduce the risks of transmitting microorganisms (an organism that is so small that it is invisible to the naked eye) from one person to another or from one site to another and all health-care workers must comply with the handwashing policy.
Personnel should always decontaminate their hands:
- Before having direct contact with patients;
- After situations during which unanticipated microbial contamination of hands might have occurred especially those involving contact with mucous-membranes, blood or other body fluids, secretions, or excretions;
- If moving from a contaminated body site to a clean-body site during patient care; and
- After touching inanimate sources that might have been contaminated with virulent (dangerous) or epidemiological important microorganisms.

2. During an interview on 03/17/14 at 3:40 PM, Staff A, Director of Nursing (DON), stated that Patient #8 had C. diff and was on contact isolation.

3. Observation on 03/17/14 at 3:50 PM showed Staff C, Registered Nurse (RN), in Patient #8's room giving direct patient care. There was no sign on the patient's door warning staff, visitors or health care personnel that the patient was on contact isolation and Personal Protective Equipment (PPE, specialized clothing such as a gown, mask, gloves and shoe coverings or equipment worn for protection against infectious material) was required. The RN did not have on a protective gown and was not wearing gloves.

4. During an interview on 03/17/14 at 3:50 PM, Staff A, stated that she expected the RN to follow contact isolation protocol. She stated that she conducts inservices specific to the care of a patient with C. diff and didn't understand why there wasn't a sign on the patient's door. Staff A stated that maybe the patient's doctor had removed the contact isolation protocol.

5. Record review of the medical chart for Patient #8 showed that the physician's order for contact isolation protocol for C. diff remained in effect.

6. During an interview on 03/17/14 at 3:55 PM, Staff C, RN, stated that Patient #8 was not her patient and that she was trying to help out another nurse. She stated that she was aware that the Patient had C. diff and was on contact isolation and stated, "I'm going to go change my clothes." Patient #8's room was the last room on the hall and the furthest from the nurses' station. The RN had already exited the patient's room and was going to walk down the hall past all of the other patients' rooms to change her clothes.

7. Observation on 03/18/14 at approximately 8:30 AM showed Staff K, RN, entered the medication room to prepare medications for Patient #9. She failed to wash her hands:
- Upon entering the medication room;
- After using the computer to access the electronic medication administration record; and
- Before removing the medications from storage cart drawers.

8. During an interview on 03/18/14 at 4:00 PM, Staff K stated she should have washed her hands before handling the medications for Patient #9.

9. Observation on 03/18/14 at 9:00 AM showed Staff B, RN, in Patient #7's room for medication administration. The RN was waiting for the patient to finish taking her oral medication and began assessing the patient working her way down to the patient's feet. Staff B held both feet in her bare hands checking for pulses and edema (fluid buildup or swelling). Without performing hand hygiene the RN took the patient's medications in her bare hands and the patient's drinking glass and then handed them back to the patient to continue.

10. During an interview on 03/18/14 at 9:35 AM, Staff B, RN, stated, "Oh, I should have washed my hands before I picked up the medications after I checked her feet."

11. Observation in the surgical suite on 03/18/14 at 1:30 PM showed a roller board (equipment used to transfer patients) with signs of excessive wear which caused small parts of the surface material to chip off and expose the fuzzy white cloth liner, rendering the board uncleanable.
12. During an interview on 03/19/14 at 3:00 PM, Staff A, DON stated that they no longer used the roller board but they had failed to remove it from the area.




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Based on interview, record review and policy review, the facility failed to ensure that the Pharmacy Department policies and procedures were updated and reviewed with input from a professional group annually. Approximately 50 percent of the Department's policies and procedures had not been reviewed/revised or approved since 02/13. This failed process increased the risk of improper patient care and placed all patients at risk for receiving inadequate care throughout the facility. The facility census was nine.

Findings included:

1. The facility could not provide a policy and procedure directing the Registered Pharmacist (RPH)/Director of Pharmacy, in processes or procedures to maintain updated and revised policies and procedures to reflect current pharmacological best practices.

2. Record review of the Meeting Minutes titled, "Pharmacy and Therapeutics" dated 03/13, 06/13, 09/13 and 12/13 showed only three people present - Staff R, Chief of Staff, Staff A, DON, and Staff Q, Registered Pharmacist (RPH)/Director of Pharmacy. All four documents read the same: "Continual revisions to policy and procedure to reflect updated best practices". No policies or procedures were specifically named as being reviewed, revised or approved for the previous 12 months.

3. Observation on 03/18/14 at 1:40 PM showed Staff Q's office inside the Pharmacy Department covered with loose papers containing policies and procedures in the process of revision. She stated that she did not have all of the policies and procedures written but had been working on them and did not have them in a binder. Staff Q estimated that approximately 50 percent of the Pharmacy's policies and procedures had not yet been updated.

4. Observation on 03/18/14 at 4:30 PM showed Staff A presented a black binder (manual) and stated that it contained the policies and procedures for the Pharmacy Department. The cover sheet in the front of the manual titled, "Pharmacy Department Policy and Procedure Manual" dated 02/14/13, showed the documents contained in the manual had been Reviewed and Revised by Staff Q, RPH, Staff R, Chief of Staff/Medical Director and Staff Z, Administrator. The signature line for the Pharmacy Therapeutic Physician Advisor was blank.

5. During an interview on 03/19/14 at 12:30 PM, Staff Q stated that the policies and procedures placed in the manual had not been reviewed or approved by the policy and procedure committee or Medical Staff and should not have been placed in the manual under the cover sheet.

6. Record review of some of the policies and procedures in the manual had the following notations:
- Scheduled Time Policy "update";
- Home Medications "Reviewed 06/93";
- Floor Stock Procedure "Revised 01/20/95";
- Intravenous Fluid Treatment Administration "Reviewed 06/93";
- IV [intravenous, within the vein] "Push" Drugs reviewed 06/93;
- Standards for Intravenous Therapy "Reviewed 06/93";
- IV Policy "Reviewed 06/93";
- Total Parenteral Nutrition (feeding a person intravenously, bypassing the usual process of eating and digestion) "Reviewed 06/93"; and
- Policy and Procedure for PCA (Patient Controlled Analgesia, for pain) "Reviewed 07/93".

Based on observation, interview and policy review the facility failed to protect paper patient medical records stored in Medical Record storage room #5 from loss and destruction by fire. This deficient practice had the potential to adversely affect anyone who required historical information contained in those stored records. The facility census was nine.

Findings included:

1. Record review of the facility's undated policy titled, "Medical Records Department," showed direction to staff that the Director of the Medical Records Department shall be responsible for maintaining security and confidentiality of the medical records.

2. Observation of Medical Records storage room #5 on 03/18/14 at 2:00 PM with Staff N, Health Information Management (HIM) Manager, showed:
- Four large cardboard file boxes of paper patient medical records stored on a pallet on the floor (about 100 records);
- Boxes of holiday decorations, old appearing furniture, pieces of air condition/heater vent ducts, a variety of non medical record storage boxes;
- About 50% of the ceiling paint peeling and hanging down from ceiling surface; and
- No fire suppression equipment, no sprinklers, no smoke detectors, no fire alarms or connection with the main building fire alarm system (if there were a fire in the room #5, no staff in the main building would be alerted to the problem).

3. During an interview on 03/18/14 at 2:15 PM, Staff N stated that they had just started utilizing this room for additional medical record storage. Staff N stated that she was not aware of any specific hospital policy that required smoke detectors or fire alarms. She stated that she did not know what the other items were that were stored in this room.