HospitalInspections.org

Based on observation and interview, the facility failed to assure patient care equipment was clean and free of contaminants related to dust, walls in disrepair and residue on patient nutrition equipment. The failed practice did not prevent the spread of contaminants to patients and had the potential to affect all patients admitted to the facility. Findings follow:

A. Tour of the facility was conducted on 06/27/12 from 1430-1515 and 06/28/12 from 0830-0855 with the Chief Nursing Officer (CNO) and revealed:
1) In the patient nourishment room shared by the Medical/Surgical Unit and Emergency Department, the microwave had brown crusty residue on the glass plate located inside which did not assure it was free from contaminants.
2) The ice machine had a brown and white residue in the drain pan which did not assure it was free from contaminants.
3) At the nurse's station for the Medical/Surgical Unit, the patient scales had a thick layer of dust on the base and two mobile vital signs monitors had thick layers of dust on the bases of both which did not assure they were free from contaminants.
4) In Exam Room #1 in the Emergency Department (ED), there was dust on the patient monitor and on the base of the mobile light which did not assure they were free from contaminants.
5) In Trauma Room #1 in the ED, there were chips and gouges in the wall at the head of the stretcher which was a porous surface and did not assure it could be cleaned or disinfected.
6) Outside Trauma Rooms #1 and #2 on either side of the scrub sink in the ED, the window sills had thick layers of dust which did not assure they were free from contaminants.
7) On the wall guards along the hallways in the ED and Medical/Surgical Unit, there were layers of dust which did not assure they were free from contaminants.
B. Findings were verified with the CNO during the tour.

Based on observation and interview, the facility failed to assure outdated sterile supplies were not available for patient use. The failed practice did not assure the sterile integrity of supplies and had the potential to affect all patients admitted to the facility. Findings follow:

A. Tour of the facility was conducted on 06/27/12 from 1430-1515 and 06/28/12 from 0830-0855 with the Chief Nursing Officer (CNO) and revealed:
1) In the Clean Utility room shared by the Medical/Surgical Unit and Emergency Department, the following supplies were expired:
a) Granufoam dressing, size medium, x (times) 7 with expirations of 03/25/11.
b) Granufoam dressing, size small, x 1 with an expiration of 04/21/11.
c) Pneumothorax kit, x 1 with an expiration of 01/2010.
d) Thoracentesis kit, x 2 with expirations of 09/2011 and 12/2010.
e) Lumbar Puncture kit, x 1 with an expiration of 03/2010.
f) Multi-lumen Central Venous kit, x 1 with an expiration of 04/2009.
2) In Trauma Room #1 in the ED, the following supplies were expired:
a) Suture, Maxon size 0, x 5 with expirations of 01/2012.
b) Suture, Plain Gut size 4-0, x 53 with expirations of 03/2012.
3) In the Central Sterile processing room, the following supplies were expired:
a) Surgislip (instrument cleaner) x 2 with expirations of 01/2010.
b) BIP (brand) Code (instrument cleaner) x 1 with an expiration of 12/1998.
B. Findings were verified with the CNO at the time of the tour.

Based on interview, it was determined the facility did not have policies and procedures for the determination of the volume of water needed for potable and non-potable use for patients, staff, and visitors and did not have arrangements with local utilities and other water suppliers for the provision of emergency sources of water in the event of normal water supply disruption. The failed practice had the potential to affect the health and safety of patients due to the risk of dehydration in the event of a loss of the normal water supply. The failed practice had the potential to affect all patients admitted to the facility, staff, and visitors, and two of two patients on the first day (06/27/12) of the survey. The findings follow:

In an interview on 06/28/12 at 1340 the Foodservice Director verified the facility did not have a written policy for estimating the volume of water required to meet patient, staff and visitor needs in the event of normal water supply disruption or agreements with local providers for emergency water supply.

Based on Fire Alarm System and Generator inspection documentation review, and Fire Plan policy and procedure review, and interview, it was determined the facility did not meet Life Safety Code requirements as follows:

A. The facility failed to ensure the fire alarm system was inspected annually as required. The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the fire alarm system devices to alert building occupants and the fire department of a fire emergency was not assured. See K52.
B. The facility failed to conduct weekly inspections of the emergency generator which had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the generator to provide emergency power to the facility in the event of the loss of normal power was not evaluated and could not be assured. See K144.
C. The written facility fire plan did not provide for the rescue of patients, isolation of fire and smoke, evacuation of smoke compartments, or the extinguishment of fire by fire extinguishers. The failed practice had the potential to affect all patients, staff, and visitors because proper response to fire could not be assured without a detailed written plan. See K48.

Based on interview it was determined the facility did not ensure regular inspections by the local fire department due to a lack of documentation available for review. The failed practice had the potential to affect the health and safety of all patients, staff and visitors because the fire department familiarity of the potential hazards and physical layout of the facility was not assured. The facility had a census of two patients on the first day (06/27/12) of the survey. The findings follow:

In an interview on 06/28/12 at 0940, the Maintenance Director verified there was no documentation of fire department inspection available for review.

Based on review of PYXIS Activity Logs and interview, the facility failed to ensure two nurses provided signatures at the change of shifts to reflect discrepancies of controlled substances for one of one Nursing Station PYXIS. The potential exists for discrepancies to be present without resolution. Findings follow:

A. A tour of the hospital pharmacy was conducted on 06/27/12 between 1205 and 1400 in which PYXIS Activity Logs were reviewed and found 89 of 98 shifts (7am-7pm and 7pm-7am) were unsigned by two nurses from 05/09/12 and 06/26/12.
B. These finding were verified through interview with Registered Nurse #1 on 06/26/12 at 1332.

Based on observation, review of policy and interview, the facility failed to ensure Intravenous (IV) solutions were locked in one (Clean Utility) of five (Clean Utility, Pharmacy, Patient Halls, Emergency Department (ED) and Nursing Station) areas toured. The failed practice did not ensure IV solutions were only available to licensed personnel and could not assure the integrity of the IV solutions were maintained. The failed practice had the potential to affect all patients who received IV fluids. Findings follow:

A. During a tour on 06/27/12 between 1205 and 1400, the Clean Utility room was unlocked and had multiple cases and single bags of IV fluids stored. Examples follow:
1) Twenty six bags of Lactated Ringers and 5% Dextrose 1000 milliliter (ml) for injection;
2) Eight bags of Sodium Chloride 0.9% 1000 ml for injection;
3) Four bags of Sodium Chloride 0.9% 500 ml for injection;
4) One case of Sodium Chloride 0.45% 1000 ml for injection;
5) One case of Potassium Chloride 20 milliequivalent (meq) and Sodium Chloride 0.45% 1000 ml for injection; and
6) One Case Lactated Ringers and Dextrose 5% 1000 ml for injection.
B. Review of policy titled "Drug Storage, Drug Preparation Areas" stated "Drugs shall be stored in well-secured areas. If necessary, to prevent accessibility to unauthorized personnel, drug storage areas shall be locked".
C. Findings were verified through interview with Pharmacist #1 on 06/27/12 at 1325.

Based on Controlled Substance Records review, policy review and interview, the facility failed to maintain controlled II (two) substance records in a manner that all data was readily retrievable in that 10 (07/15/10, 08/05/10, 08/12/10, 08/26/10, 10/18/10, 10/26/10, 12/06/10, 01/06/11, 02/02/11 and 02/24/11) of 20 Controlled II Substance orders from 07/01/10 to 06/29/2012 did not contain a DEA(Drug Enforcement Agency) order form along with the Distributors invoice. The failed practice could not assure adequate control and accountability of all Controlled II Substances. Findings follow:

A. A tour of the pharmacy on 06/27/12 between 1205 and 1400 revealed 9 Controlled II Substance invoices with no DEA order form associated with them. Pharmacist #1 could not produce the order forms when asked for them.
B. Review of policy titled "Records/Forms" stated "All records shall be maintained according to State and Federal Laws". Policy also stated "Unless a longer period is required by law, the following documents shall be retained for at least (3) years: C-II (Controlled II) records, DEA order forms ...."
C. Findings were verified through interview on 06/28/12 at 1105 by the Pharmacist #1.

Based on observation, review of policy and interview, the facility failed to ensure outdated medications were not available for patent use in four (Patient Bed Areas, Emergency Department(ED), Clean Utility, Nursing Station) of five ( Patient Bed Areas, ED, Clean Utility, Nursing Station and Pharmacy) areas toured. By not disposing of expired medications, the facility could not assure the safety and efficacy of the product past the expiration date. The failed practice had the potential to affect the average daily census of four patients. Findings follow:

A. A tour of the facility on 06/27/12 between 1205 and 1400 revealed outdated medications in the following areas as follows:
1) Patient Bed Area 100 Hall Crash Cart
a) Two Atropine Sulfate 0.25 mg(milligram) for injection expired 10/01/11;
b) Two Furosemide 40 mg/4 milliliter(ml) vial expired 04/01/12;
c) Three Atropine Sulfate 1 mg/10 ml unit use syringe expired 06/01/12; and
d) One Dextrose 5% for injection 250 ml expired 03/01/12.
2) Patient Bed Area 200 Hall Crash Cart
a) Two Furosemide 40 mg/4 ml vials expired 04/01/12;
b) Two Atropine Sulfate 0.25 mg for injection expired 10/01/11; and
c) One Dextrose 5% 250 bottle expired 01/01/12.
3) ED Trauma #1 Crash Cart
a) Two Atropine Sulfate 0.25 mg for injection expired 10/01/11; and
b) One Amidate 40 mg/20 ml vial expired 04/01/12.
4) ED Trauma #2 Crash Cart
a) One Amidate 40 mg/20 ml vial expired 04/01/12;
b) Two Furosemide 100 mg/10 ml vial expired 06/01/12;
C) Two Sodium Chloride 0.9% 50 ml bags expired 03/01/12; and
d) One Sodium Chloride 0.9% 1000 ml bag expired 04/01/12.
5) Clean Utility
a) One Furosemide 100 mg/10 ml vial expired 06/01/12; and
b) Two Naloxone 0.4 mg/ml vial expired 06/01/12.
6) Nursing Station PYXIS
a) One Viscous Lidocaine 2% 20 ml expired 01/31/12; and
b) Nine Aspiring Tablets 325 mg expired 04/30/10.
B. A review of policy titled "Unusable Drugs and Devices, Discontinued Drugs" stated "Outdated or otherwise unusable drugs and devises shall be identified and their distribution and administration prevented. Discontinued and outdated drugs, and containers with worn, illegible, or missing labels shall be returned to the pharmacy for proper disposition."
C. Findings were verified through interview on 06/27/12 at 1331 by Pharmacist #1.

Based on review of Monthly Record of Medication Area Review logs, review of policy and interview, the facility failed to ensure monthly inspections of all medication areas were conducted for one (May 2012) of six (December 2011, January 2012, February 2012, March 2012 , April 2012, and May 2012) months as required by policy. By not inspecting medication areas monthly, the facility could not ensure medications were properly stored to maintain their integrity, stability and effectiveness. Findings follow:

A. A review of Monthly Record of Medication Area Review logs on 06/27/12 revealed no inspection of any medication area occurred for the month of May 2012.
B. A review of facility policy titled "Medication Area Inspections" stated "The director of pharmacy must conduct at least monthly inspections of all nursing care units or other areas of the hospital where medications are dispensed, administered or stored" .
C. During an interview with Pharmacist #1 on 06/28/12 at 0940, it was verified that The Director of Pharmacy had not inspected medication areas for May 2012.

Based on observation, review of policy, review of United States Pharmacopeia (USP), and interview, it was determined the facility could not ensure medications from Multiple Dose Vials (MDV's) were not made available for patient use beyond 28 days once opened. This practice was observed in two (Emergency Department(ED), Nursing Station) of the five (Pharmacy, Patient Bed Units, ED, Clean Utility, Nursing Station) areas toured. The practice had the potential to affect any patient receiving these medications from a MDV. Findings follow:

A. A tour of the facility was conducted on 06/27/12 between 1205 and 1400. Mislabeled MDV's were observed as follows:
1) ED Trauma #1 Crash Cart
a) Labetalol 100 milligram/20 milliliter(mg/ml) vial, opened, not dated; and
b) Flumazenil 1.0 mg/ 10 ml vial, opened, not dated.
2) ED Trauma #1 Refrigerator
a) Humulin R U-100 vial, opened, not dated.
3) ED Trauma #2 Crash Cart
a) Labetalol 100 mg/20 ml vial, opened, not dated
4) Nursing Station Refrigerator
a) Lantus 100 Units/ml vial, opened, not dated;
b) Humulin R U-100 vial, opened, not dated;
c) Humulin N U-100 vial, opened, not dated;
d) Humalog vial, opened, not dated; and
e) Humulin 70/30 vial, opened, not dated.
B. A review of policy titled "Contamination Control of Multiple Dose Containers (Vials)" stated "Vials should be dated when opened."
C. A review of the United States Pharmacopeia, Second Edition, 06/01/08 revealed Multiple Dose Containers should not be used beyond 28 days, unless specified otherwise by manufacturer, or sooner if sterility was questioned or compromised.
D. Findings were confirmed through interview on 06/27/12 at 1345 by Pharmacist #1.

Based on observation, review of Evaluation paperwork of the Intravenous Hood (IV) hood, and interview, the facility failed to ensure the IV was able to maintain a sterile environment since the previous inspection in that the certification expired 01/31/12. The potential existed for any IV medications prepared in the hood after 01/31/12, not to be sterile. Findings follow:

A. During a tour of the facility on 06/27/12 between 1205 and 1400, a Performance Evaluation Label on the IV Hood, placed there from (named) was observed to have an expiration date of 01/31/12.
B. Review of the "Performance Evaluation for Biological Cabinet/ Horizontal & Vertical Air Devices" revealed (named) recommended the next inspection was due 01/31/12.
C. Findings were verified through interview with Pharmacist #1 and Pharmacy Technician # 1 on 06/27/12 at 0940.

Based on review of Medi-Dose Repackage Log, review of policy and interview, the facility failed to provide evidence the pharmacist was certifying the Unit Dose Repackaging of medications in the pharmacy. The failed practice could not ensure the pharmacist inspected the medication to ensure it had been repackaged in accordance to the policies by the facility. Findings follow:

A. A review of the Medi-Dose Repackage Log dated 04/20/12 through 06/13/12 revealed only Pharmacy Technician #1's signature for all 18 medications repackaged.
B. A review of policy titled "Unit Dose Packaging/Repackaging" stated "A pharmacist shall initial the register to certify that the drug has been properly packaged."
C. Findings were verified by Pharmacist #1 and Pharmacy Technician #1 through interview on 06/27/12 at 1300.

Based on clinical record review, it was determined the facility failed to ensure verbal orders were timed, dated, and authenticated by the ordering physician for seven (Patient#1-#5, #7, and #8) of eight (Patient #1-#8) closed records and one (Patient #20) of two (Patient #19 and #20) inpatient records. The failed practice did not indicate the Physician had reviewed the chart and had the potential to affect any patient under the care of those Physicians. Findings follow.

A. Patient #1-eight of eight verbal orders were not signed, dated, or timed.
B. Patient #2-four of four verbal orders were not signed, dated, or timed.
C. Patient #3-one of one verbal order were not signed, dated, or timed.
D. Patient #4-five of five verbal orders were not signed, dated, or timed.
E. Patient #5-three of three verbal orders were not dated or timed, two of three verbal orders were not signed.
F. Patient #7-four of four verbal orders were not signed, dated, or timed.
G. Patient #8-six of six verbal orders were not signed, dated, or timed
H. Patient #20-four of four verbal orders were not signed, dated, or timed.
I. Findings were confirmed by the Director of Nursing at 0945 on 06/29/12.

Based on review of the Organizational Quality Assurance/Performance Improvement Plan, Governing Body Committee Meeting Minutes and interview, it was determined the Quality Assurance/Performance Improvement Plan was not reviewed and evaluated for its effectiveness by the Governing Body yearly. The failed practice had the potential to affect all patients. Findings follow:

A. Review of the Governing Body Committee Meeting Minutes for July 2011 through June 2012 revealed there was no evidence the Quality Assurance/Performance Improvement Plan was reviewed and evaluated for its effectiveness.
B. Interview with the Administrative Coordinator on 06/28/12 at 1423 confirmed the Quality Assurance/ Performance Improvement Plan was not presented to the Governing Body.

Based on review of Swing Bed Unit Policies and Procedures and interview, the facility failed to assure there were policies and procedures addressing patient's rights to refuse to perform services for the facility, the right to perform services for the facility, documentation in the patient's plan of care to include the need or desire for work, the nature of the services performed whether voluntary or paid, compensation for the paid services and the patient's agreement to the work arrangement. The failed practice did not assure patients with a need for therapeutic work rehabilitation were allowed to work or were allowed to refuse to work while admitted to the facility and had the potential to affect all patients needing work rehabilitation admitted to the facility. Findings follow:

A. Review of the Swing Bed Unit Policies and Procedures did not have evidence of policies addressing patients working or refusing to work in the facility.
B. Findings were verified with the Chief Nursing Officer on 06/28/12 at 1330.

Based on review of Swing Bed Unit Policies and Procedures and interview, it was determined the facility failed to ensure the results of investigations of abuse were reported to the State Agency. The failed practice did not assure the State Agency was capable of tracking data and had the potential to affect any patient with an abuse allegation. Findings follow.

A. Review of policy, "Professional Conduct and Relations" did not have evidence that the results of the investigation would be reported to the State Agency.
B. Findings were verified by the Chief Nursing Officer on 06/28/12 at 1245.

Based on review of Swing Bed Unit Policies and Procedures and interview, the facility failed to have a system or process addressing actions to take when an alleged violation of abuse occurred by staff, visitor, or another patient during the investigation of suspected/alleged abuse. The failed practice did not assure patients were free from abuse by staff or other patients/visitors suspected of abuse by not removing them from the area while an investigation was undertaken and had the potential to affect all patients admitted to the Swing Bed Unit. Findings follow:

A. Review of policy, "Professional Conduct and Relations" did not have evidence that anyone suspected of abuse of a patient would be removed from patient contact or reassigned to other duties while an investigation was undertaken.
B. Findings were verified with the Chief Nursing Officer on 06/28/12 at 1330.

Based on Swing Bed clinical record review and interview, the facility failed to assure a care plan was developed and implemented for one (#2) of two (#1-#2) patients. The failed practice did not assure each patient's plan of care identified their individual needs, interventions, progress and goals or that the plan of care was communicated between multiple shifts of nursing staff and had the potential to affect all patients admitted to a Swing Bed at the facility. Findings follow:

A. Review of the clinical record for Patient #2 revealed it did not have evidence of an interdisciplinary plan of care.
B. Findings were verified by the Chief Nursing Officer on 06/28/12 at 1450.