HospitalInspections.org

Based on observations and maintenance staff interview on 4/10/13, the facility failed to maintain minimum Standards of the 2000 Edition of the National Fire Protection Association's (NFPA) 101 Life Safety Code for 1 of 1 roll down fire door. A two hour fire wall separating the health care occupancy (clinic) lacked a functioning roll down fire door to complete the separation of the two occupancy types.

Based on observation and staff interviews, the hospital failed to properly discard expired supplies in the emergency room. Supplies in excess of 2 years past their expiration date were located and available for patient use. Findings include:

On 4/9/13 at 9:05 a.m., during the review of the emergency department the following expired supplies were observed by the surveyor:
-1 bottle of hydrogen peroxide with the manufacturer's expiration date of 11/11;
-1 package of gloves, size 8, with the manufacturer's expiration date of 2/13;
-1 package of gloves, size 6 1/2, with the manufacturer's expiration date of 5/12;
-3 packages of Pediatric Quik combo RTS for pacing, defibrillation, and ECG electrodes with the manufacturer's expiration date of 1/28/13; and
-1 bottle of E-Z lubricating jelly with the manufacturer's expiration date of 2/13.

On 4/9/13 at 9:10 a.m., the surveyor observed 2 vials of sodium chloride 0.9% with the manufacture's expiration date of 12/12, in the ER nose tray.

On 4/9/13 at 9:15 a.m., staff member J, a CNA stated the staff checked the ER for outdated supplies every 3 to 6 months.

On 4/9/13 at 9:25 a.m., the surveyor observed 2 packets of Sani hand wipes for kids with the manufacturer's expiration date of 6/10, on the nurse's station counter.

Based on observations and maintenance staff interviews on 4/10/13, the facility failed to maintain minimum Standards of the 2000 Edition of the National Fire Protection Association's (NFPA) 101 Life Safety Code.
Findings include:
1) K011 maintenance of a two hour barrier from an non-health care occupancy type,
2) K052 lack of certification of installation documentation for an upgraded Fire Alarm Control Panel,
3) K054 lack of sensitivity testing for smoke detectors since 2004, and
4) K062 lack of sprinkler system maintenance affecting all of facility. Please see the life safety code State of Deficiencies for further information.

Based on document review, policy review, and staff interviews, the facility failed to develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases for all patients and personnel. In addition, the facility failed to follow professional standards of practice for 6 (#s 3, 4, 12, 14, 17, and 18) of 18 observed patients when facility personell were required to complete handwashing. Findings include:

1. Infection Control Program:

The infection control nurse (staff member C) reported during an interview on 4/10/13 at 10:15 a.m., that she that she received infection control reports by two methods.

a. The infection control report from the lab quarterly. Once she received the culture reports, she matched them up with the patients in the facility. Staff member C stated she reviewed the patient's chart to identify what signs and symptoms the patient had which necessitated the run of a culture. However, the signs and symptoms precipitating a culture and/or antibiotic use were not clearly and consistently documented in the medical record.

b. Antibiotic use by patients was reported to her by telephone on occassion. On 4/11/13 at 9:30 a.m., during an interview Staff member C, she stated it was hard to decide if the infections were hospital acquired or community acquired as nursing staff did not write notes about the signs and symptoms of the illness.

The infection control program was not effective to identify and investigate infections within the facility.

2. Handwashing and medication handling:

The Hand Washing policy of the facility required:
"....3. If hands are NOT visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following conditions:
a. Before & after direct contact with residents/patients
b. Before donning sterile gloves
c. Before performing any non-surgical invasive procedures
d. Before preparing or handling medications
e. Before handling clean or soiled dressings, gauze pads, etc.
f. Before moving from a contaminated body site to a clean body site during resident/patient care
g. After contact with resident's/patients intact skin
h. After handling used dressing, contaminated equipment
i. After contact with objects) e.g. medical equipment) in the immediate vicinity of the resident/patient
j. After coughing, sneezing, smoking, or blowing the nose
k. After removing gloves

Note the use of gloves does not replace hand washing/hand hygiene..."

On 4/10/13 starting at 7:30 a.m., the surveyor observed staff member F deliver medications to patient #s 12 and 14. The staff member set up patient #12's medications. The staff member took the medication cup, closed the medication room door, went down the hallway and entered patient #12's room. The staff member did not wash or sanitize his hands upon entering the room. Staff member F gave the patient her eye drops and oral medications. While assisting the patient with her eye drops the staff member touched the patient's skin. Staff member F left the patient's room, went down the hallway to the medication room door, got his keys out of his pocket, and opened the medication room door. The staff member did not wash or sanitize his hands after giving the patient the eye drops or when leaving the patient's room.

Staff member F then started to set up patient #14's medications. The staff member took the medication cup, closed the medication room door, went down the hallway and entered patient #14's rooms. Staff member F gave the patient her medications, left the room, went down the hallway to the medication room door, got his keys out of his pocket, and opened the medication room door. The staff member did not wash or sanitize his hands after leaving the patient's room.

b. On 4/11/2013 starting at 7:30 a.m., staff member G sanitized his hands, took the keys out of his uniform pocket, opened the medication room door, and propped the door open. The staff member opened the cupboard door, pulled out patient #12's basket of medications, and set up the morning medications. The staff member put patient #12's basket away with the patient's set up medication. Staff member G did not wash or sanitize his hands before starting to set up patient #17's medications.

The staff member then took out patient #17's basket of medication out of the cupboard. The medications were in individual plastic envelopes. Staff member G used his fingers to take out medications out of the envelope for 2 of 4 oral medications. The staff member put patient #17's basket of medication away with the patient's set up medications.

Staff member G then took out patient #14's basket of medication. The staff member used his finger to take out the patient's metformin. The staff member needed a medication not in the patient's basket, so he shut the medication room door, walked down the hallway to the pharmacy, took the keys out of his pocket, and opened the door. The staff member got the medication packet he needed, closed the pharmacy door, went back down the hallway, took the keys out of his pocket, opened the medication room door, and propped the door open. Staff member G did not wash or sanitize his hands. The staff member went back to setting up the medications for patient #14. The staff member touched 4 of 9 oral medications for patient #14.

c. On 4/11/13 starting at 7:40 a.m., the surveyor observed staff member G deliver medication to patient #s 12, 14, 17, and 18. The staff member took the keys out of his pocket, opened the medication door, opened the cupboard door and got patient #12's medication cup. The staff member shut the medication door and entered patient #12's room without washing or sanitizing hands. The staff member gave the patient her eye drops, oral medications, and started the patient's nebulizer treatment. The staff member left the room went to the medication room door, sanitized his hands, took his keys out of his pocket, and opened the medication room door to get patient #17's medications.

Staff member G got patient #17's medications, shut the medication room door, went down the hallway, and entered patient #17's room. The staff member did not sanitize his hands upon entering the residents room. The staff member gave patient #17 a shot in his abdomen, then gave the patient his oral medications. The staff member put the needle in the sharps box and left the patient's room. The staff member did not wash or sanitize his hands after leaving the patient's room.

Staff member G went back to the medication room, took his keys out, opened the medication door and got out patient #14's medications. The staff member shut the medication room door, went down the hallway and entered patient #14's room. The staff member did not wash or sanitize his hands upon entering the patient's room. Staff member G gave the patient her oral medications. The staff member left the patient's room, went back to the medication room, took his keys out, opened the medication room door and got patient #18's medications. Staff member G did not wash or sanitize his hands after leaving patient #14's room.

Staff member G shut the medication room door, went down the hallway, and entered patient #18's room. The staff member got gloves from the box, put the gloves on, and gave the patient a suppository. Staff member G removed his gloves, tossed the gloves in the garbage, and went to give the patient his oral medications. The patient did not have juice so the staff member went out of the room to get the juice. The staff member did not wash or sanitize his hands after removing his gloves.


29778


d. On 4/9/13 at 10:30 a.m., during the pre-pouring of the medications staff member A, sanitized hands, removed keys from pocket and opened medication cart, touched hair, opened drawers and then touched the medications when removing them from the blister packs and placing the medications into souffle cups. Staff member A then opened a probiotic bottle for patient #4 and removed a pill from the bottle with her fingers, opened a stock bottle of colace for patient #3 and poured 4 pills in the cover and with her finger, covered 2 pills, poured 2 pills into the souffle cup, returned the other 2 pills from the cover to the stock bottle, and put back in the medication cart.

e. On 4/10/12 at 10:30 a.m., staff member C stated the nursing staff discussed hand hygiene and infection control issues during monthly staff meetings.

f. On 4/10/13 at 4:30 p.m., during the evening meeting with the facility, staff member E stated the nursing staff should not be handling the medications with bare hands.

Based on clinical record review and staff interviews, the facility failed to ensure that orders by the physician were followed for 1 (#11) of 40 sampled patients. In addition, the facility failed to follow professional standards during the medication pass for 6 (#s 6, 12, 14, 17, 18 and #37) of 18 patients observed. Findings include:

1. Patient #11 was admitted to the facility on 11/16/12 with a diagnoses which included: CVA, dysphagia, left sided hemiparesis and hypertension.

Included in the medical record of patient #11 on 4/9/10 at 8:35 a.m., was a Physician Order dated 3/22/2013 at 11:30 a.m. for Hydrofoam Drsg [dressing] on L [left] buttox [sic] wound chg [change] daily and cleanse wound.

Documentation for the dressing change on 3/23/13 and 3/24/13 was absent from the March 2013 MAR.

During interview at 8:50 a.m. on 4/10/2013 with staff member B, the LPN reported that they were "not doing a dressing change any longer it is now open to air."

The physician orders in the medical record did not reflect a change to the original order.? Nursing staff failed to follow the physician order of 3/22/13.

2. Patient #37 was admitted on 12/12/2009 with a diagnoses to include; hypothyroidism, anemia and senile dementia.

The March 2013 MAR on 4/10/2013 at 10:45 a.m. contained a physician order for Zyprexa 5 mg PO q hs.

The MAR lacked evidence of the medication being given patient #37 for March 2, 8, 9, 15, 22, 23 and 29.? During interview with staff member D, an RN, she stated "If the medication is not signed out it was not given."

3. During observation of the medication pass on 4/9/2013 at 10:30 a.m., staff member A pre-poured the medications for the noon med pass. Staff member A did not initial or make any identifying mark on the MAR to indicate the medication had been pre-poured.?

During the noon meal on 4/9/2013, surveyors observed staff member A who administered the pre-poured medications to the patients. Staff member A neither checked the MAR prior to giving the medication nor initialed the MAR that the medications had been administered.

Surveyors confirmed their observations during Interview with staff member A on 4/9/2013 at 2:35 p.m. "In the morning I set up my medications then sign them out. At noon I set up the medications, give the medications in the dining room, then come back to the desk to sign the medications out. I do not make marks or sign the MAR to identify the meds were set up."

4. During observation of the medication pass on 4/11/2013 at 6:55 a.m., staff member B, walked into patient #6's room and set up her nebulizer treatment. Staff member B handed the mask for the nebulizer machine to patient #6, then turned the machine on. Staff member B then told the patient someone would be in when she was done with the breathing treatment to bring her to the dining room. Staff member B then left the room and pushed her medication cart to the dining room without ensuring that the medication was received properly.?


23085


5. On 4/11/2013 starting at 7:30 a.m., staff member G sanitized his hands, took the keys out of his uniform pocket, opened the medication room door, and propped the door open. The staff member opened the cupboard door, pulled out patient #12's basket of medications, and set up the morning medications. The staff member put patient #12's basket away with the patient's set up medication.

The staff member took patient #17's basket of medication out of the cupboard. The medications were in individual plastic envelopes. Staff member G used his un-washed/sanitized fingers to remove 2 of 4 of the oral medications from the envelope. The staff member put patient #17's basket of medication away with the patient's set up medications. 4

Staff member G took out patient #14's basket of medication. The staff member used his un-washed/sanitized fingers to remove the metformin from it's envelope. Lacking necessary medication, he shut the medication room door, walked down the hallway to the pharmacy, took the keys out of his pocket, and opened the door. The staff member retrieved the medication packet he needed, closed the pharmacy door, went back down the hallway, took the keys out of his pocket, opened the medication room door, and propped the door open. Staff member G did not wash or sanitize his hands before he set up the remaining medications for patient #14. The staff member touched 4 of 9 oral medications for patient #14.

Staff member G pre-poured the medications for patient #s 12, 14, 17, and 18, for the morning medication pass.?

Staff member G did not initial or make any identifying marks on the MAR to indicate the medication had been pre-poured.

6. On 4/11/13 at 8:03 a.m., staff member G stated he signed the medications out when all done passing the patients medications and had a minute.

?Nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm. DeLaune, S. & Ladner, P. (1998). Fundamentals of Nursing, Standards and Practice (p.237). Albany, N.Y.

?"Medications should be prepared for the resident immediately before administration. Medications should never be prepared in advanced and left in medicine cups for later use."
Clark, Thomas; Medication Guide for the Long-Term Care Nurse. 6th Edition, ASCP, Alexandria, VA. 2003. pp 67-68.

?"6. Coach patient to breathe slowly through the mouth at normal tidal volume.
7. Tap the nebulizer periodically to minimize residual volume.
8. Continue treatment until no aerosol is produced.
9. Rinse the nebulizer with sterile water and run dry.
10. Monitor patient for adverse response."
Egan's Fundamentals of Respiratory Care, eighth edition, Wilkins, RL, Stoller, JK, Scanlan, CL. Mosby, Missouri, 2003. p. 781.

According to Bermin, et al, "To prepare tablets or capsules from a floor-stock bottle, pour required number into bottle cap and transfer medication to a medication cup. Do not touch medication with fingers."

Based on clinical record review and staff interview, the facility failed to develop a care plan for 1 (#18) of 4 acute patients reviewed. Findings included:

On 4/11/13, patient #18's medical record was reviewed by surveyors. The midlevel provider had written an admission order for acute care for this patient on 4/10/13 at 11:30 p.m. However, per nursing documentation, the same day 30 minutes earlier, the patient was admitted into an outpatient observation room on 4/10/13 at 11:00 p.m. The medical record contained erroneous information and lacked a care plan for patient #18.

Staff member G stated during report with the midlevel providers and the physicians on 4/11/13 around 8:00 a.m., that the patient was admitted to acute care; however, during interview with surveyors on 4/11/13 at 10:00 a.m., staff member G, a nurse stated the night shift nurse told him that patient #18 was admitted into an outpatient observation room. Staff member G started a care plan for resident #18 on 4/11/13 at 10:00 a.m.

Based on record review and staff interview, the facility failed to ensure that date and time of entry accompanied signatures when providers and/or patients signed medical documentation and receipt of information forms for 25 (#s 1, 2, 3, 4, 6, 7, 8, 9, 12, 13, 14, 15, 19, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 39 and 40) of 40 patient medical records reviewed. Findings include:

1. During medical record review, surveyors noted 14 (#s 12, 13, 14, 15, 28, 29, 30, 31, 32, 33, 34, 35, 36, and 37) of 40 patients medical records lacked the time signatures were written on the Conditions of Registration documents.


29778


2. During the review of patient medical records, surveyors noted 23 (#s 1, 2, 3, 4, 6, 7, 8, 9, 12, 13, 14, 19, 28, 29, 30, 31, 33, 34, 35, 36, 37, 39 and 40) of 40 the medical records lacked the time signatures were written for The Patients Rights and Responsibilities.