HospitalInspections.org

Based on clinical record review, interviews and review of Medical Staff Rules and Regulations, it was determined the facility failed to ensure physicians' telephone orders were authenticated, dated and timed for 8 (#6, #8, and #12-17) of 12 (#6-#17) patients. Failure to ensure physician's orders were dated and timed did not ensure orders would be followed and carried out in the time frame intended by the physician. The failed practice affected Patients #6, #8, #12, #13, #15-17. Findings follow:

A. Review of Patient #6's telephone orders from 01/25/14 through 01/26/14 revealed 3 (01/26/14 at 1445, 01/26/14 at 0130 and 01/26/14 at 0015) of 6 were not authenticated and 2 (01/26/14 at 0750 and 01/26/14 at 1020) were undated and untimed.
B. Review of Patient #8's telephone orders from 01/22/14 through 01/26/14 revealed 5 of 5 (01/25/14 at 1953, 01/26/14 at 0700, 01/23/14 at 1950, 01/23/14 at 2150 and 01/22/14 at 1750) were undated and untimed.
C. Review of Patient #12's telephone orders from 01/23/14 through 01/26/14 revealed 1 (01/25/14 at 1545) of 5 was not authenticated and 4 (01/24/14 at 1015, 01/24/14, 01/24/14 at 0115 and 01/24/14 at 0530) of 5 were undated and untimed.
D. Review of Patient #13's telephone orders from 01/24/14 through 01/26/14 revealed 4 of 4 (01/25/14 at 0840, 01/25/14 untimed, 01/25/14 untimed, 01/25/14 at 1142) were undated and untimed.
E. Review of Patient #14's telephone orders from 01/25/14 through 01/26/14 revealed 3 of 3 (01/25/14 1650, 01/26/14 at 1430, and 01/26/14 untimed) were not authenticated.
F. Review of Patient #15's telephone orders from 01/19/14 through 01/26/14 revealed 10 of 10 (01/24/14 at 0643, 01/21/14 at 1625, 01/21/14 untimed, 01/21/14 untimed, 01/22/14 at 0600, 01/22/14 at 2300, 01/23/14 at 1600, 01/19/14 at 1730, 01/19/14 at 1330, and 01/20/14 at 1540) were not authenticated.
G. Review of Patient #16's telephone orders from 01/25/14 through 01/26/14 revealed 1 (01/25/14 at 0932) of four was not authenticated and 3 (01/25/14 at 1430, 01/25/14 at 1800 and 01/26/14 at 0415) of four were undated and untimed.
H. Review of Patient #17's telephone orders from 01/24/14 through 01/26/14 revealed 2 (01/26/14 at 1900 and 01/24/14 at 1800) of 5 were not authenticated and 3 (01/24/14 at 2100, 01/24/14 at 2215 and 01/25/14 at 0900) of 3 were undated and untimed.
I. The above findings were verified by the Assistant Administrator of Patient Care at 1000 on 01/31/14.

Based on the review of Omnicell Controlled Substance Audit Records and interview, the facility failed to ensure audits of the controlled substances on the Omnicell Units were conducted at the change of shifts on four (Medical/Surgical Unit, Intensive Care Unit, Rehabilitation Unit, Geropsychiatric Unit) of four nursing units. The potential existed for discrepancies to occur without resolution. Findings follow:

A. Omnicell Controlled Substance Audit Records for four nursing units-Medical/Surgical, Intensive Care, Rehabilitation, Geropsychiatric) were reviewed on 01/29/14 at 0930 for 01/28/14. The records for each unit reflected controlled substance audits were being conducted daily and not at the change of shifts.
B. The Director of Pharmacy was interviewed on 01/29/14 at 0940 and verified the findings.

Based on observation and interview, the facility failed to ensure the accountability of a limited amount of scheduled drugs maintained in one of one "Night Locker", located in the Pharmacy, in that daily record audits were not conducted. The scheduled drugs were available to Nursing Service when the Pharmacy Department was closed. The potential existed for the lack of accountability for scheduled drugs. Findings follow:

A. On 01/29/14 at 1015, the following scheduled drugs were observed in the Pharmacy Night Locker:
1) Ninety 5 milliliter (ml) single dose containers of Guafenesin and Codeine Phosphate;
2) Sixty-one 5 ml single dose containers of Hydrocodone Bitartrate and Acetamiophen Solution;
3) One pint of Hydrocode Polistirex and Chlorpheniramine Polistirex Extended Realease Solution; and
4) One Diazepam 10 milligram Delivery System.
B. In interview on 01/29/14 at 1020, the Director of Pharmacy verified daily audits of the scheduled drugs were not being conducted and accountability could not be ensured.

Based on interview, it was determined the facility did not ensure regular inspections by the local fire department. 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 failed practice had the potential to affect 35 of 35 patients on census on 01/27/14 and all staff and visitors. The findings follow:

In an interview on 01/28/14 at 1040, the Engineering/Maintenance Manager verified there was no documentation of fire department inspection available for review.

Based operating room Temperature and Humidity Readings log review and interview, it was determined humidity levels above 60% relative humidity were maintained in four of four Operating Rooms in violation of the range specified (30%-60%) in the Arkansas Department of Health, Rules and Regulations for Hospitals and Related Institutions (Section 26.B.1; Section 74.D.1-Table 3) and failed to take corrective action when the levels were outside the required range. Failure to take corrective actions when outside the required ranges had the potential to affect the health and safety of surgical patients due to the potential of bacterial growth and compromising of wrapped sterile instruments. The failed practice had the potential to affect all patients admitted for surgery. The findings follow:

A. Review of the Temperature and Humidity Readings log on 01/27/14 at 1240 revealed relative humidity above 60% was documented for the year 2013 and through 01/27/14:
1. In Operating Room #1, relative humidity above 60% was documented on 17 of 56 days of surgery.
2. In Operating Room #2, relative humidity above 60% was documented on 14 of 56 days of surgery.
3. In Operating Room #3, relative humidity above 60% was documented on 25 of 56 days of surgery.
4. In Operating Room #4, relative humidity above 60% was documented on 20 of 56 days of surgery.
B. In an interview on 01/28/14 at 0910, the Engineering/Maintenance Manager verified there was no documentation of corrective action for the relative humidity readings above 60% available for review.

Based on review of the Surgical Services Policy and Procedure Manual and interviews, it was determined the facility failed to develop and implement a policy and procedure addressing the Do Not Resuscitate status of operative patients. Failure to develop and implement a policy and procedure addressing the Do Not Resuscitate status of operative patients did not allow the surgeon, the surgical services staff, patients and family members to be knowledgeable, accepting and approving of what steps would be undertaken in the event of the cardiac or respiratory arrest of a patient having surgery. Findings follow:

A. Review of the Surgical Services Policy and Procedure Manual revealed it did not contain policies and procedures addressing the actions the surgeons and surgical staff should take in the event an operative patient experienced a cardiac or respiratory arrest.
B. In an interview at 1245 on 01/29/14 with the Assistant Administrator of Patient Care, she stated she and the Surgical Services Director had looked through the policy and procedure manual; there was not a policy and procedure addressing the Do Not Resuscitate status of operative patients.

Based on clinical record review and interview, it was determined seven of seven (#1-#6, and #8)) patients operative reports did not include the time of surgery. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow:

A. Review of operative reports revealed the time of operation was not documented for Patients #1-#6 and #8.
B. Findings of Patient #1-#5 were confirmed by the Director of Nursing on 01/30/14 at 1110.
C. Findings of Patient #6 and #8 were confirmed by the Director of Nursing on 01/31/14 at 1050.