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Based on interview and record review the facility failed to maintain equipment, readily available for treating emergency cases by accepted standards of practice when; the sterilizer was not being cleaned according to the manufacturer's instructions.

Findings Include:

Review of the facility provided Autoclave Sterilizer Operator's Maintenance Manual reflected;
"Daily ...3. Clean door gasket sealing lip and mating surface with a damp cloth ..., Weekly ...1. Clean Chamber and Trays ... Monthly ...1. Clean Chamber and Plumbing ...Perform Pressure Relief Valve Check ...."

During an interview in the afternoon, on 3/28/16 in the facility's clean room and on 3/29/16 in the conference room, Staff #7, Pharmacy Tech stated, "I sterilize all the equipment." ..."I don ' t do the Pressure Valve check." ... When asked about her training on the use of the Sterilizer, Staff #7 stated, "I didn ' t get any special training, I was shown by the last person how to use it." "I've been doing the sterilizing for years ...."

Review of Staff#7's personnel file, on 3/29/16, did not reflect training or a demonstrated competency check on the use of the facility's sterilizer.

During an interview in the afternoon, on 3/28/16 in the facility's conference room Staff #9, DON confirmed the finding.

Based on observation and interview, it was determined the facility failed to ensure equipment and supplies commonly used in life saving procedures were readily available for treating emergency cases.

Findings included:

On a tour of the facility on 3/28/16, the following were observed:
Medication room:
· BD [Becton Dickinson brand] Saf-T-Intima IV [intravenous] catheter 18 G [gauge] 1.00 inch expiration date: 2015/04
· Nine BD Insyte Autoguard 18 G 1.16 inch IV catheters expiration date: 2015/02
· Three 24 G 0.75 inch IV catheters expiration date: 2015/10
· Four 22 G 1 inch IV catheters expiration date: 2016/02
· 20 G 1 inch IV catheter expiration date: 2016/01
Laboratory:
· 33 red-top vacutainer tubes expiration 02/2016
Trauma room:
· Adult Colorimetric CO2 [carbon dioxide] detector expiration date 02/2016
Crash Cart #1:
· Laryngeal mask size 1 expiration date: 1/28/2015
· Laryngeal mask size 2 expiration date: 12/28/2014
· Laryngeal mask size 5 expiration date: 1/28/2016
· Flexiset cuffed endotracheal tube and stylet set expiration date: 1/2016
Crash Cart #2:
· Laryngeal mask size 1 expiration date: 1/28/2015
· Laryngeal mask size 1.5 expiration date: 12/28/2014
· Laryngeal mask size 2.5 expiration date: 1/28/2015
· Laryngeal mask size 4 expiration date: 1/28/2015
· Flexiset cuffed endotracheal tube and stylet set expiration date: 10/2015
· Two vials of Amiodarone hydrochlorothiazide injection 150 mg/3 mL [milliliter] expiration date: 11/2015
· Two vials of Adenosine injection 6 mg per 2 mL expiration date: 12/2015
· Two boxes of atropine sulfate 0.5 mg expiration date: 12/10/15
· One vial lidocaine 2% hydrogen chloride expiration date: 3/1/16
· Two packages Pediatric Medtronic electrodes expiration date 8/2015
· One package defibrillator pads expiration date: 11/2013

The above was confirmed with the director of nursing.

Based on observation during a tour of the facility it was determined that the facility failed to follow Health and Safety Code of Infectious Waste by not securing the area containing biohazardous waste.


Findings were:


Review of the facility's "Handling of Biohazardous Waste", stated in part, "Containers used for biohazardous waste shall be so secured as to deny access to unauthorized persons."

During a tour of the facility on 3/28/16 at 3:25 pm, in the east hallway across from the patient rooms, five (5) boxes containing biohazard waste was observed in a unlocked/unsecured room. This could be a potential contamination risk to unauthorized persons.

The about issue was confirmed by Staff # 9 and Staff # 16 during the facility tour.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals were properly locked in all storage areas when;

A.) the facility's main medication room door and the nursing station door were left propped open and; an unauthorized staff member was observed in the medication room unsupervised.
Additionally, the medication room has a large opening, approximately 3 feet by 3 feet wide, at counter height that cannot be shut and locked;

B.) (2) Vials of Mannitol and six (6) bags of Intravenous (IV) fluids were stored unsecured in a warmer accessible to the public;

Findings include:

A.) An observation during a tour of the facility, on 3/28/16 in the afternoon, revealed the facility's main medication room door and the nursing station door propped open.

An observation on 3/29/16 at 9:00 a.m. revealed the facility's main medication room door and the nursing station door propped open and no nurses in the station.

An observation on 3/29/16 at 2:00 p.m. revealed a facility nurse's aide sitting in the medication room; there were no nurses in the station.

During an interview on 3/29/16 in the afternoon, in the facility's medication room, Staff #12, RN stated, "We don't lock the door. I don't think it can even be locked."

During an interview on the afternoon of 3/29/16, in the conference room, Staff # 9, DON confirmed the findings.

B.) An observation during a tour of the facility's emergency room on 3/28/16, in the afternoon, revealed a large warmer in a patient exam room. The warmer contained (2) Vials of Mannitol and six (6) bags of IV fluids.

During an interview on 3/29/16, in the afternoon, in the conference room, Staff # 17, Pharmacist stated, "We should secure the medications."

Review of the facility provided FLOOR STOCK DRUGS and STORAGE OF DRUGS policy (undated) did not reflect how the drugs should be secured.

During an interview on 3/28/16, in the afternoon in the emergency room, Staff # 9, DON confirmed the findings.

Based on review of facility based policy, observation and interview, it was determined that the facility failed to ensure the premises are clean and orderly.

Findings included:

Facility based policy titled, "Infection Prevention and Control" reference number 301-46 stated in part, "Environmental Services: Floors and other horizontal surfaces shall be cleaned daily with an approved antimicrobial cleaning agent."

On a tour of the facility on 3/28/16, the following were observed:
· In patient room 335, layer of dust on over-bed light
· 5 chipped wall tiles throughout the North Hallway
· Small room with door marked "employee only" in the North Hallway had lighting detached and wires exposed
· 5 water-stained ceiling tiles in climate-controlled laboratory room
· Climate-controlled lab room with exposed areas around 2 pipes
· 2 water-stained ceiling tiles in laboratory hallway
· 4 water-stained ceiling tiles in main laboratory
· 2 water-stained ceiling tiles in laboratory office
· Throughout the facility, several under-sink areas used as storage

The above was verified with the director of nursing.

Based on observation, interview and record review the facility failed to develop and implement a policy for the storage drugs and biologicals in all storage areas when; (2) Vials of Mannitol and six (6) bags of Intravenous (IV) fluids were stored in an unmonitored warmer without a temperature parameter guide.

Findings include:

An observation during a tour of the facility's emergency room on 3/28/16, in the afternoon, revealed a large warmer in a patient exam room. The warmer contained (2) Vials of Mannitol and six (6) bags of IV fluids.
Further observation revealed the lack of a temperature log or an internal thermometer.

Review of the facility provided policy STORAGE OF DRUGS (undated) on 3/29/16 reflected;
" ...3. All drugs shall be stored at the proper temperature, as defined by the following terms .... (I) room temperature- Temperature maintained between 15 degrees Celsius (C) (59 degrees (F) Fahrenheit) and 30 degrees C (86 degrees F) (II) Cool ... (III) Refrigerate ... (IV) Freeze ..."

The policy did not reflect the proper storage temperature parameters for the warmed Mannitol and IV fluids; and if the temperatures are being maintained.

During an interview on 3/28/16, in the afternoon in the emergency room, Staff #9, DON confirmed the findings and stated, "We do not have a termperature log."

Based on observation, interview and record review the Governing Body failed to determine, implement, and monitor policies and to ensure that current policies provide quality health care in a safe environment when;

A.) There was no policy and procedure for the skills required and the cleaning instructions for the facility's autoclave sterilizer,

B.) The policy and procedure for the secure storing of Patient's medical records, did not include all medical records,

C.) The policy and procedure for pharmaceuticals did not include the secure storing and monitoring of the pharmaceuticals,

Findings include:

A.) Review of the facility provided Autoclave Sterilizer Operator's Maintenance Manual reflected; "Daily ...3. Clean door gasket sealing lip and mating surface with a damp cloth ..., Weekly ...1. Clean Chamber and Trays ... Monthly ...1. Clean Chamber and Plumbing ...Perform Pressure Relief Valve Check ...."

During an interview in the afternoon, on 3/28/16 in the facility's clean room and on 3/29/16 in the conference room, Staff #7, Pharmacy Tech stated, "I sterilize all the equipment." ..."I don't do the Pressure Valve check." ... When asked about her training on the use of the Sterilizer, Staff #7 stated, "I didn't get any special training, I was shown by the last person how to use it." "I've been doing the sterilizing for years ...."

Review of Staff#7's personnel file, on 3/29/16, did not reflect training or a demonstrated competency check on the use of the facility's sterilizer.

B.) An observation on the afternoon of 3/28/16, during a tour of the facility's West wing in-patient unit revealed over ten (10) boxes of patient records in an unlocked, unlabeled closet; the closet was accessible to unauthorized personnel, patients, and visitors.

During an interview on 3/29/16, in the medical records office, Staff #18, Medical Records Director stated, "The records in the closet were from a clinic that used to be a part of the hospital." "They are not stored in the main Medical Records department." ..."That room is supposed to remain locked."

Review of the facility provided Security Policy - 1000, SECURITY POLICY FOR MEDICAL RECORDS ROOM (dated 11/21/11) did not reflect security measures for the closet containing the clinic medical records.

C.) Observations during a tour of the facility, on 3/28/16 in the afternoon, revealed: the facility's main medication room door and the nursing station door were left propped open and; and an unauthorized staff member was observed in the medication room unsupervised; and (2) Vials of Mannitol and six (6) bags of Intravenous (IV) fluids were stored unsecured in a warmer accessible to the public, the warmer temperature was not being recorded.

Review of the facility provided FLOOR STOCK DRUGS and STORAGE OF DRUGS policy (undated) did not reflect how the drugs should be secured.

During an interview in the afternoon on 3/29/16, in the facility conference room, Staff #9, DON confirmed the findings.





36594

Based on facility document review, observation and interview, the facility failed to ensure all call lights/cords were within reach for patient safety.

Findings included:

Bylaws of the Concho County Hospital District stated in part,
"Section 2: The Powers and Duties of the Directors:
a. The Board of Directors has full power to manage and control the District. Any provision of the Act which provides a specific power or duty does not limit the general authority of the District to carry out the purposes of the Act creating the District.
b. The Board of Directors assumes full legal responsibility for determining, implementing, and monitoring policies and procedures governing the total operation of the facility as a Critical Access Hospital."

The National Fire Protection Association 99, Health Care Facility Code, Information Technology and Communications Systems, Chapter 7 clause 7.3.3.1.2.4 stated, "Bath stations shall be provided at each inpatient toilet, bath, shower, or sitz bath and shall be accessible to a patient lying on the floor."

The following were observed on a tour of the facility on 3/28/16:
· In the bathroom of room 31, the emergency cord was at least a foot off the ground
· In the bathroom of room 32, the emergency cord was tied to the railing
· In the bathroom of room 34, both emergency cords by the toilet and shower were tied up
· In the bathroom of room 35, the emergency cord by the toilet was wrapped around the railing while the emergency cord by the shower was tied up
· In the shared bathrooms of room 21 and 22, the emergency cord was at least a foot off the ground
· In the East hallway bathroom, available for patient use, there was no emergency call light accessible
In an interview with the director of nursing, they acknowledged the safety issues found above.

Based on review of facility documents, observations and interviews, it was determined that the facility failed to ensure outdated, mislabeled, or otherwise unusable drugs were not available for patient use.

Findings included:

Review of the facility provided policy STORAGE OF DRUGS (undated) on 3/29/16 reflected;
..."4. Any drug bearing an expiration date may not be dispensed or distributed beyond the expiration date of the drug.
5. Outdated drugs shall be removed from dispensing stock and shall be quarantined together until such drugs are disposed of."

Facility based policy titled, "Medication Storage in the Emergency Department" reference number 300-11 stated in part, "All medications shall be stocked in the Emergency Department per par levels established between the Emergency Department and Pharmacy Services:
· Medication cabinets shall be stocked by Pharmacy Services:
o Pharmacy Services and nursing personnel shall check for outdates, per regulations."

Facility based policy titled, "Obtaining Stock Meds from Retail Pharmacy" revised 3/28/16 stated in part, "Meds in prescription vials should have name of drug, lot number, and expiration date. Expiration date should not be more than 1 year from procurement."

The following were observed on the tour of the facility on 3/28/16:
· Nine bottles of Azithromycin 500 mg [milligram]/vial expiration date: 09/2015
· In crash cart #2:
o Two vials of Amiodarone hydrochlorothiazide injection 150 mg/3 mL [milliliter] expiration date: 11/2015
o Two vials of Adenosine injection 6 mg per 2 mL expiration date: 12/2015
o Two boxes of atropine sulfate 0.5 mg expiration date: 12/10/15
o One vial lidocaine 2% hydrogen chloride expiration date: 3/1/16

The above was confirmed with the director of nursing.

Based on personnel document review and interview, it was determined the facility failed to ensure the nursing staff performed ongoing competencies.

Findings included:

No facility based policy existed addressing orientation and competencies to perform nursing services.

In review of six out of six nursing staff personnel files, no annual competencies were found.

In an interview with the director of nursing and staff member number 12 on the afternoon of 3/29/16, it was verified the nursing staff did not have annual competency requirements.

Based on observation, interview and record review the facility failed to ensure all locations where medical records are stored are maintained to provide for the integrity, security and protection of the records.

Findings include:

An observation on the afternoon of 3/28/16, during a tour of the facility's West wing in-patient unit revealed over ten (10) boxes of patient records in an unlocked, unlabeled closet; and accessible to unauthorized personnel, patients, and visitors.

During an interview on 3/29/16, in the medical records office, Staff #18, Medical Records Director stated, "The records in the closet were from a clinic that used to be a part of the hospital." "They are not stored in the main Medical Records department." ..."That room is supposed to remain locked."

Review of the facility provided Security Policy - 1000, SECURITY POLICY FOR MEDICAL RECORDS ROOM (dated 11/21/11) did not reflect security measures for the closet containing the clinic medical records.

Based on interview and record review the facility failed to provide an ongoing program of activities that is designed to appeal to a resident's interests and to enhance the resident's highest practicable level of physical, mental, and psychosocial well-being; and failed to ensure the activities program is directed by a qualified professional when three (3) of three (3) Swing Bed patients did not have activities assessments completed and were not offered activities during their stays. (Patients #11, 12, and 13)
Findings Include:
Review of Patient #11's medical record reflected, a 72 year old female was admitted to the swing bed unit on 1/13/16. The record did not include an activities assessment and the care plan did not reflect any activities were offered.
Review of Patient #12's medical record reflected a 78 year old female admitted to the swing bed unit on 1/27/16. The record did not include an activities assessment and the care plan did not reflect any activities were offered.
Review of Patient #13's medical record reflected, an 82 year old female was admitted to the swing bed unit on 3/01/16. The record did not include an activities assessment and the care plan did not reflect any activities were offered.
During an interview in the afternoon of 3/29/16, in the conference room, Staff #9, DON stated, "We are trying to find an Activity Director." When asked if the facility had a list of activities available Staff #9 stated, "No."
During an interview in the afternoon of 3/29/16, in the conference room, Staff #16, CEO, confirmed the finding.