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Based on observation and interview, it was determined the facility did not meet Life Safety Code requirements related fire and smoke damper testing, maintenance of penetrations of fire and smoke barriers to resist the passage of fire and smoke, securing medical gas cylinders, posting of sigange to prohibit smoking near medical gas storage rooms, and fire separation of hazardous areas (medical records storage). The failed practice had the potential to affect all patients, staff, and visitors. The facility had a census of 12 patients on 10/21/14. See K-25, K-29, K-77, K-104 and K-141.

Based on interview, it was determined that the facility did not ensure regular inspections were done 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 facility had a census of 12 patients on 10/21/14.

In an interview on 10/21/14 at 1515, the Plant Operations Director verified there was no documentation of fire department inspection available for review.

Based on observation, review of Crash Cart daily check logs, review of policy and interview, it was determined the facility failed to ensure the contents of emergency supply kits/carts were checked each shift (per policy) in two (Malignant Hyperthermia (MH) Emergency Cart and Recovery Room Emergency Drug Stock Kit) of three kits/carts (MH Emergency Cart, Recovery Room Emergency Cart and Crash Cart) surveyed in Surgical Services. The potential existed for the crash carts not to have medications/supplies present for patient emergencies. The failed practice had the likelihood to affect all patients who needed medications in an emergency. Findings follow:

A. A tour of Surgical Services and Emergency Department on10/21/14 from 1230-1430 and two (Malignant Hyperthermia (MH) Emergency Cart and Recovery Room Emergency Drug Stock Kit) of three kits/carts (MH Emergency Cart, Recovery Room Emergency Cart and Crash Cart) surveyed were not being checked each shift (not documented on the crash cart daily check logs) to ensure the lock was intact and ready for a patient emergency.
B. A review of policy titled Daily Check of Crash Cart and Defibrillator stated "Each crash cart will be checked each shift to ensure that the lock is intact and that the number on the lock shall match the number on the orange sticker on top of the crash cart."
C. During interview on 10/21/14 at 1310, the Director of Surgical Services verified emergency carts/kits were not checked on each shift.

Based on interview, the facility failed to have policies and procedures in place to ensure annual re-certification of Intravenous (IV) Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood (per United States Pharmacopeia Chapter 797, 2008). By not evaluating the competencies of the personnel, the facility could not assure the sterility or accuracy of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the Laminar Flow Hood. Findings follow:

A. IV Admixture competencies were requested at the entrance conference on 10/21/14 at 1035 Surveyor #1 did not receive any.
B. During an interview with the Director of Pharmacy on 10/23/14 at 1035, the Director stated they did not have competencies, policies or procedures for annual competencies (ie: media fill tests or take samples of finished products and have them tested for sterility) of the personnel trained to compound medications in the Laminar Flow Hood.

Based on observation, review of policy and interview, it was determined the facility failed to ensure outdated medications were not available for patient use in one (Surgical Services) of two (Surgical Services and Emergency Department) patient care areas toured on 10/21/14. By not disposing of expired medication, the facility could not assure the safety and efficacy of the medication past the expiration date. The failed practice had the potential to affect any patient who was to receive these medications. Findings follow:

A. A tour of the facility on 10/21/14 between 1230 and 1430 revealed the following outdated medication in Surgical Services:
1) One-Dextrose 5% 1000 ml (milliliter) solution for injection expired 07/14;
2) Fourteen- Hydrocodone 5 mg (milligram)/ Acetaminophen 325 mg-10 expired 06/14 and 4 expired 05/14;
3) One-Vitamin K 10mg/1 ml vial for injection expired 10/1/14;
4) One-Heparin lock flush 10 units/5 ml syringe for injection expired 08/01/14;
5) One-Epinephrine 0.1 mg/ml 10 ml vial for injection expired 08/14;
6) One-Labetalol 100 mg/ 25 ml opened 07/26/14 expired 28 days after opening;
7) One-Oxymetazoline 0.05% 30 ml expired 03/14; and
8) One-Naloxone 0.4 mg/ml 1ml vial for injection expired 08/01/14.
B. A review of policy titled Outdated and Unusable Drugs and Devices stated "Outdated (expired), mislabeled or otherwise unusable drugs and devices shall not be available for patient use."
C. During an interview on 10/21/14 at 1345, the Director of Surgical Services verified the presence of expired medications.

Based on review of policy, review of Medication Variance Forms and interview, it was determined the facility failed to notify the practitioner who ordered the medication of the medication variance (error) in 26 of 42 variances reviewed from 01/01/14 through 06/30/14. By not reporting medication errors to the prescribing physician responsible for the patient's care, the patients' physicians were not being kept abreast of the patient's condition and were not involved in the decisions of what to do after the error occurred. The failed practice had the potential to affect all patients. Findings follow:

A. Review of policy titled Medication Errors stated "Medication Errors (hereafter referred to as Medication Variances) shall be reported immediately to the practitioner who ordered the medication (or to the ER physician on call, or the attending practitioner or another responsible practitioner) if prescribing practitioner is not available."
B. Review of Medication Variance Forms from 01/01/14 through 06/30/14 revealed 26 variances were not reported to the prescribing physician.
C. During an interview on 10/24/14 at 0849, the Chief Nursing Officer verified medication variances were not reported to the prescribing physician.

Based on observation and interview, it was determined the facility failed to ensure one gallon of ProLystica used to clean dirty surgical instruments had not expired. The failed practice did not ensure the surgical instruments were clean and free of surgical debris. The failed practice affected all patients whose surgical procedure required the use of those instruments cleaned with the expired cleanser. Findings followed:

A. During the tour of Surgical Services at 1245 on 10/21/14, a gallon of ProLystica, not dated when opened, was noted to have an expiration date of 03/11/14. The Director of Surgical Services was asked what the ProLystica was being used for and she stated all dirty surgical instruments were cleaned with it prior to sterilization.
B. In an interview with the Director of Surgical Services at 1250 on 10/21/14 the findings in A.

Based on observation, review of policy and interview, it was determined the Medical Records Rooms and Secondary Medical Records Room used to store paper medical records were not protected from fire due to a lack of fire rated doors with automatic closing devices and compromised fire rated construction due to a missing section of the fire rated wall. The failed practice had the likelihood to affect all patients' records stored in the two medical record rooms. The findings follow:

A. On a tour of the Medical Records Department on 10/22/14 at 1230 with the Director of Medical Records, the following observations were made:
1) The doors to the Medical Records Room were not fire-rated and did not have automatic closing devices.
2) The door to the Secondary Medical Records Room was not fire rated and did not have an automatic closing device. A section of the wall to the room had been removed, leaving only a single layer of gypsum board and the metal wall studs exposed. Two layers of gypsum board, one on each side of the metal wall stud, were required for a 1 hour fire resistance rating. Therefore, the fire resistance of section of the wall with the missing gypsum board was compromised.
B. Review of policy titled Maintenance and Retention of Medical Information stated "Storage space is used that is designated to protect the computerized and paper records from unauthorized access, loss, tampering or defacement and inadvertent destruction ...Particular emphasis will be given to protection from damage by fire or water."
C. During an interview on 10/22/14 at the time of observation, the Director of Medical Records verified the findings at A1-2 and B.

Based on clinical record review and interview, it was determined the facility failed to ensure physician signatures were dated for five (#1, #2, #4, #5, and #7) of seven (#1-#7) Emergency Department (ED) records. The failed practice did not allow the date of the visit to be determined in the event of multiple ED visits and could affect any patient presenting to the ED. Findings follow.

A. Review of ED clinical records revealed physicians did not date their signatures for Patient #1, #2, #4, #5, and #7 patients.
B. During interview on 10/22/14 from 0930 through 1005, Registered Nurse #1 confirmed there was no date with the physician's signature.

Based on observations, interviews and clinical record reviews, it was determined the facility failed to:
1. Assure the scope of services was current to the facilitys capability to provide and perform surgeries. Failure to ensure the scope of surgical services was current did not allow the surgical services personnel to be knowledgeable regarding what services were approved and appropriate to be safely performed in the facility;
2. Assure surgeon's privileges were current. The failed practices did not allow the surgical services staff to be knowledgeable regarding what procedures each surgeon was credentialed to perform and did not ensure the surgical services staff had access to those privileges. See C0321;
3. Assure there was a tracheostomy kit available in the event of an emergency. Failure to ensure a tracheotomy kit was available for use in the operating rooms did not ensure the facility was prepared to meet the patient's surgical needs in the event of an emergency;
4. Develop protocols for all surgical procedures performed. Failure to develop protocols for surgical procedures did not allow surgical services staff to be knowledgeable regarding equipment, materials, supplies and other information the facility deemed as need to know information for surgical services staff preparing for a surgical procedure;
5. Assure the cleaning agent for dirty surgical instruments had not expired. The failed practice did not ensure the surgical instruments were clean and free of surgical debris. See C0278;
6. Assure a policy was developed regarding DNR (Do Not Resuscitate) status for patients undergoing a surgical procedure. Failure to develop and implement a policy and procedure addressing the DNR 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 during surgery; and
7. Assure operative reports included the time of surgery for six (#13, #15, #17, #20, #21) of six (#13, #15, #17, #20, #21) patients who underwent surgical procedures. Review of the policy and procedure titled Policies Related to Records of Surgical Patients revealed the policy and procedure did not contain any elements requiring time of surgery to be placed in the operative report. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event a patient underwent multiple surgeries in one day.

The cummulative effects of 1, 2, 3, 4, 5, 6 and 7 affected all patients who underwent surgical procedures in the facility in the last two years. Findings follow:

Scope of Services
Review of the scope of surgical services received from the Director of Surgical Services at 1530 on 10/22/14 revealed a list of surgical procedures performed in the facility. During an interview with the Director of Surgical Services at 1530 on 10/22/14, she was asked if the facility performed all of the procedures on the list. The Director of Surgical Services stated no; the facility did not have the necessary equipment to perform an Abdominal Aortic Aneurysm repair, a Cataract Removal, an ERCP (endoscopic retrograde cholangiopancreatogramendoscopic ), a Hallux Valgus, Lid Reconstruction, Release of Carpal Tunnel, etc. as examples and did not have an orthopedic surgeon to perform any orthopedic procedures.

Surgeons Privileges
It was determined the facility failed to ensure surgical privileges were updated every two years, failed to identify surgical procedures each surgeon could perform and be available to all surgical staff. The failed practices did not allow the surgical services staff to be knowledgeable regarding what procedures each surgeon was credentialed to perform and did not ensure the surgical services staff had access to those privileges. See C0321.

Tracheostomy Kit
During the tour of Surgical Services at 1245 on 10/21/14, the Director of Surgical Services was asked if a tracheotomy kit was available in the operating rooms. The Director of Surgical Services stated the only item they had for a tracheotomy kit was in the Crash Cart in the Post Anesthesia Care Unit. The Director of Surgical Services opened the crash cart in PACU and showed registered nurse surveyor a cricothyroidotomy needle.

Surgical Protocols
Surgical Protocols were requested on 10/21/4 at 1300. During an interview with the Director of Surgical Services at 1530 on 10/22/14, she stated she did not have Surgical Protocols.

Cleaning Agent Surgical Instruments
It was determined the facility failed to ensure one of one gallon of ProLystica used to clean dirty surgical instruments had not expired. See C0278.

DNR Status
A. Review of the Surgical Services Policy and Procedure Manual revealed there was no policy or procedure that addressed a surgical patient's DNR status.
B. During an interview with the Chief Nursing Officer at 1520 on 10/22/14, she stated the facility did not have a policy and procedure which addressed the DNR status of the operative patient.

Operative Reports
A. Review of the operative reports for Patient #13, #14, #15, #17, #20 and #21 revealed the operative reports did not contain the time of surgery.
B. The finding for Patient #17 was verified by the Chief Nursing Officer (CNO) at 1430 on 10/23/14.
C. The findings for #20 and #21 were confirmed by the Chief Nursing Officer at 1020 on 10/24/14.
D. The findings for Patients #13 and #15 were confirmed by the Obstetrics/Nursery Supervisor at 1030 on 10/24/14.

Based on observation, review of presented documents and interviews, it was determined the facility failed to ensure surgical privileges were updated every two years, failed to identify surgical procedures each surgeon could perform and be available to all surgical staff. The failed practices did not allow the surgical services staff to be knowledgeable regarding what procedures each surgeon was credentialed to perform and did not ensure the surgical services staff had access to those privileges. The failed practice affected all patients undergoing surgical procedures in the facility. Findings follow:

A. During an interview with the Director of Surgical Services at 1355 on 10/21/14 she stated the surgical privileges for the surgeons were locked in her office.
B. During an interview with Registered Nurse #2 at 1400 on 10/21/14 she was asked how she knew what surgical procedures each surgeon was approved to perform. RN #2 stated she would call the Director of Surgical Services.
C. Review of the current surgical privileges received from the Director of Surgical Services at 1405 on 10/21/14 revealed three (#1, #3 and #4) of four (#1-4) surgical privilege forms greater than two years old (08/15/07 for Physician #1, 01/11/13 for Physician #2, 08/17/10 for Physician #3, and 11/18/08 for Physician #4), and none of the surgical privilege forms listed procedures the physicians were credentialed to perform.

Based on interview and review of the facility transfer/discharge notice it was determined the facility failed to include in its transfer/discharge notice to the patient the following information: the reason for transfer or discharge, the location to which the patient is transferred or discharged, the name, address and telephone number of the State long term care ombudsman and the mailing addresses and telephone numbers of the agencies responsible for the protection and advocacy of the developmentally disabled and the mentally ill. Failure to include the above information on the transfer/discharge form did not allow the patient and/or his family to be knowledgeable regarding the reason and location of transfer/discharge as well as the contact information of the organizations who could assist the patient/family in appealing the transfer/discharge. Findings follow:

A. Based on interview and review of the facility transfer/discharge notice received from the Case Manager/Quality Assurance Director at 1405 on 10/22/14 revealed it did not contain the name, address and telephone number of the State long term care ombudsman and the mailing addresses and telephone numbers of the agencies responsible for the protection and advocacy of the developmentally disabled and the mentally ill.
B. During an interview at 1405 on 10/22/14, the Case Manager/Quality Assurance Director verified the transfer/discharge notice did not include the findings in " A. "

Based on review of employee files and interview, it was determined the facility failed to obtain Criminal Background Checks (CBC) on five of five (Physical Therapists #1 and #2, Occupational Therapist #1, and Speech and Language Pathologists #1 and #2) contracted therapists. By not obtaining CBC, the facility could not assure they were contracting someone without a history of abusive behavior. The failed practice had the potential to affect all Swing Bed patients who receive Therapy. Findings follow:

A. Review of contracted therapists credentialing files revealed Physical Therapists #1 and #2, Occupational Therapist #1, and Speech and Language Pathologists #1 and #2 did not have a CBC in their files.
B. During an interview with the Chief Nursing Officer (CNO) on 10/23/14 at 1035, the CNO stated she thought the CBC was done by the contracted therapy company and verified they did not have CBC on the therapists.

Based on interview, policy and procedure review and clinical record review, it was determined the activities calendar for swing bed patients had not been developed and placed on the unit or in patient rooms. Failure to develop an activities calendar did not allow the swing bed patient and/or family to be knowledgeable of available activities and choose which activities they would like to participate in. The failed practice affected the one (#1) swing bed patient on 10/22/14. Findings follow:

A. An activities calendar was requested from the Case Manager/Quality Assurance Director at 1400 on 10/22/14. The calendar received from the Licensed Social Worker was blank except for handwritten entries on 10/16/14 which stated Admitted to SBed (swing bed), 10/19/14 Family visited and 10/21/14 which stated Activity Assessment.
B. Review of the policy and procedure titled Activities Program received from the Assistant Chief Nursing Officer at 1300 on 10/23/14 revealed the following: ...Activity Calendar: A documented monthly activities calendar will be maintained for each patient.
C. During an interview with the Case Manager/Quality Assurance Director and Licensed Social Worker at 1430 on 10/22/14 they both stated they did not prepare an activity calendar for the swing bed patients as they felt most of their swing bed patients could not participate in activities therefore the activities were written in as they occurred.