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Based on clinical record review and interview, it was determined the facility failed to ensure a Registered Nurse supervised and evaluated the care of two of two (#29 and #30) Geriatric Psychiatric Unit patients in that weights were not obtained as ordered by the physician. Failure to obtain and document weights as ordered did not allow the physician to have information necessary to make informed decisions regarding care of the patients. The failed practice affected Patient #29 and #30 on 02/01/18. Findings follow:

A. Review of the clinical record of Patient #29 showed physician's orders dated 01/24/18 for weights to be obtained every Monday. Review of the clinical record of Patient #29 showed a weight of 199.6 recorded on 01/25/18. There was no weight recorded for Monday, 01/19/18. During an interview with the Geriatric Psychiatric Unit Director at 10:30 AM on 02/01/18 she verified the findings.

B. Review of the clinical record of Patient #30 showed physician's orders dated 01/26/18 for weights to be obtained every Monday and Thursday. Review of the clinical record of Patient #30 showed a weight of 111 recorded on 01/26/18. There was no weight recorded for Monday, 01/29/18. During an interview with the Geriatric Psychiatric Unit Director at 9:50 AM on 02/01/18.

Based on review of Occurrence Report Forms, review of policy, review of clinical records and interview, it was determined the facility failed to maintain accurate records in that one (#1) of two (#1 and #2) incidents of a medication given to a wrong patient were not documented in the chart of the patient that received the medication in error. By not documenting the medications the patients received, the facility was not keeping an accurate record of the patient's course of treatment and care. The failed practice had the potential to affect all patients that are treated at the facility. Findings follow:

A. Record review of the policy titled, "Medication Administering and Monitoring Policy," dated 01/2002, showed that all medical records must contain documentation of every medication administered to include: patient name, medication, actual time of medication administration, dose, route, and response to medication.
B. Review of Occurrence Report Form for Incident #1 showed Patient #32 received Clindamycin 600 mg (milligram) intravenously on 07/26/17 at 5:30 AM that was not ordered for him.
C. Review of clinical record for Patient #32 showed no evidence of the medication error.
D. During an interview on 01/30/18 at 1:39 PM, the Director of Quality verified there was no evidence in Patient #32's clinical record indicating they received the medication that was not prescribed for them.

Based on policy and procedure review, clinical record review and interview, it was determined the facility failed to ensure verbal orders were authenticated within 48 hours per facility policy and procedure for one (#30) of two (#29 and #30) Geriatric Psychiatric Unit patients. Failure to ensure verbal orders were authenticated did not allow the facility to be in compliance with their policy. The failed practice affected Patient #30 on 02/01/18. Findings follow:

A. Review of the policy and procedure titled, "Verbal/Telephone Orders," received from the Director of Health Information Management on 01/30/18 showed verbal orders were to be authenticated by the prescriber with 48 hours.
B. Review of Patient #30's clinical record showed three of three (01/26/18 at 12:30 PM, 01/27/18 at 9:50 AM, and 01/28/18 at 10:30) verbal orders not signed within the 48 hour time frame.
C. During an interview at 9:55 AM on 02/01/18 the Geriatric Psychiatric Unit Director verified the findings in A and B.

Based on clinical record review, policy and procedure review and interview, it was determined the facility failed to ensure the discharge summary for two (#15 and #16) of five surgical records were authenticated and dated by the responsible Physician to verify its content. The failed practice did not allow the responsible physician to verify the outcome of the patient's hospitalization, disposition of the case or provisions for follow up care. The failed practice affected patient # 15 and #16. Findings follow:

A. Review of policy and procedure titled, "Discharge Summary," showed it did not state who was to complete or authenticate the discharge summary.
B. Review of Patient #15 and #16 discharge summaries showed no authenticating Physician signature or date.
C. Interview on 02/01/18 at 10:00 AM, the Chief Nursing Officer (CNO) stated that the Surgeons were not signing the discharge summaries.

Based on review of United States Pharmacopeia Chapter 797 (2008), review of Pharmacist's annual compounding skills and interview, it was determined the facility failed to ensure gloved fingertip sampling and media fill testing was completed as part of the annual re-certification of Intravenous (IV) Admixture technique for three of three (#1-#3) Pharmacists trained to compound medications in the Compounding Aseptic Isolator. By not performing gloved fingertip testing on the personnel, the facility could not assure the sterility of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the Compounding Aseptic Isolator. Findings follow:

A. Review of United States Pharmacopeia Chapter 797, 2008 showed that gloved fingertip testing and media fill testing was to be completed as part of the annual re-certification of Intravenous (IV) Admixture technique.
B. Review of annual IV skills checklists performed by Pharmacists #1-#3 showed gloved fingertip testing and media fill testing was not evaluated as part of the annual re-certification of Intravenous (IV) Admixture technique.
C. During an interview on 01/30/18 at 1:30 PM, the Director of Pharmacy verified gloved fingertip testing and media fill testing was not evaluated as part of the annual re-certification of Intravenous (IV) Admixture technique.

Based on observation, it was determined the facility failed to maintain the building physical structure, environment and equipment in a state of good repair for 3 (the Surgical Corridor, the Senior Care Unit, and the Labor and Delivery Unit) of 13 areas observed in that there was chipped tile, rusted metal support for a toilet and cracks and chips in the walls. The failed practice had the potential to affect all patients, staff, and visitors due to the potential for injury and infection control issues. Findings follow:

A. While on tour on 01/29/18 at 2:07 PM, it was observed a chipped tile on the wall outside of Operating Room (OR) #1 in the surgical corridor.
B. While on tour on 01/29/18 at 2:30 PM, it was observed a rusted metal support for the toilet in Room LDR (Labor and Delivery Room) 1 in the Labor and Delivery Unit.
C. While on tour on 01/29/18 at 3:05 PM, it was observed a cracks and chips in the walls near the toilets in Room 3015 in the Senior Care Unit.
D. During the tour, the Director of Plant Operations verified the failed practices.


29485

Based on observations and interviews, it was determined the facility failed to ensure equipment was free from rust, rips and tears and opened packages were not available for patient use in seven (Emergency Department (ED), Intensive Care Unit (ICU), Operating Room (OR), Pre-Operative Area, Post Anesthesia Care Unit (PACU), Labor and Delivery Recovery Post Partum (LDRP) Senior Care) of eight (ED, ICU, OR, Pre-Operative Area, PACU, LDRP, Medical Surgical, and Geriatric Psychiatric Unit) units. Failure to ensure equipment was free of rust, chipped paint, rips and tears did not allow the equipment to be cleaned; failure to ensure opened packages were not available for patient use had the potential to allow used items to be re-used on another patient. The failed practice likely affected any patient whose care involved the equipment located in those seven areas. Findings follow:

Observation on 01/29/18 from 1:17 PM to 3:10 PM showed:
1) ER Exam Room #4-Yankuer suction out of package and connected to tubing. Verified by the Infection Control Nurse at 1:17 PM on 01/29/18.
2) Hallway by ER Exam Room #4-Stretcher mattress with multiple rips in the top of the mattress, tape on metal frame and side rails. Verifies by the Infection Control Nurse at 1:25 PM on 01/29/18.
3) ICU #5-Nasal Cannula tubing opened, connected to oxygen tree. Verified by The Chief Nursing Officer (CNO) at 1:30 PM on 01/29/18.
4) OR #2-C-MAC Videolargnoscope one of four packages opened; transfer board with multiple rip and tears in covering; Berkley suction machine with multiple areas of rust on all four sides; side table, bowl stands, Intravenous (IV) Poles all with rusted areas on bases and around all castors; Verified by the Director of Surgical Services at 2:01 on 01/29/18.
5) Pre-Operative Area-five of five IV poles with bases which were rusted and paint chipped off. Verified by the Director of Surgical Services at 2:15 PM on 01/29/18.
6) PACU-IV pole base rusted and paint chipped; Yankuer Suctions in Bays #1 and #2 were opened. Verified by the Director of Surgical Services at 2:20 PM on 01/29/18.
7) LDRP #1-white toilet support extremely rusted. Verified by the Director of Plant Operations at 2:40 PM on 01/2918.
8) Geriatric Psychiatric Unit-mirrors in Room 3012, 3013, 3014, and 3015 had multiple areas of white spots on each of them; in Room 3015 a geri-chair was covered with linens that were dirty and used. During an interview with the Geriatric Psychiatric Unit Director at 3:10 PM on 01/29/18, she stated the above rooms were supposed to be clean and ready for patient occupancy.

Based on interview, it was determined the facility failed to report the failure of the fire alarm system for more than 4 hours in a 24-hour period. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that the appropriate action would be taken in the event of a fire for one of one buildings. The facility had a census of 27 on 01/29/18. Findings follow:

A. During an interview on 01/29/18 at 12:50 PM, the Director of Plant Operations stated that the Fire Alarm Control Panel (FACP), which controls the facility's fire alarm system, was disabled as the result of a power surge the facility experienced on 01/17/18. However, the incident was not reported to the Arkansas Department of Health, Health Facility Services Section until the time of the interview.
B. See K346.

Referenced code: NFPA 101; 2012 edition, Section 9.6.1.6

Based on interviews, Center for Disease Control (CDC) guidelines and policy and procedure review, it was determined the Infection Control Nurse failed to identify that breast milk was being improperly stored in that there was no mechanism to monitor, track and trend the individual patient room temperature in which the breast milk was kept; there was no refrigerator to store the breast milk at 77 degrees per CDC guidelines; there was no evidence the facility policy and procedure titled "Breast Milk Storage" was compared to CDC guidelines for uniformity; and there was no mechanism to follow the facility's policy and procedure to immediately refrigerate or freeze breast milk. Failure to ensure breast milk was stored at 77 degrees per CDC guidelines had the potential to allow bacterial growth in the breast milk and illness with prolonged hospitalization of infants. The failed practice had the potential to affect any breast-fed newborn from July, 2017 through February 1, 2018. Findings follow:

A. During the nursery tour at 2:45 PM on 01/29/18 the Interim Director of Women's Services was asked where the infant formula and breast milk were stored. The Interim Director of Women's Services stated the breast milk refrigerator had not worked since sometime in July of 2017.
B. During an interview with the Chief Nursing Officer at 3:20 PM on 01/29/18 she stated the refrigerator to store breast milk in was requested 08/31/17.
C. During an interview with the Infection Control Nurse at 9:15 AM on 01/31/18 she stated the facility adhered to CDC guidelines.
D. During an interview at 2:40 PM on 01/31/18, with the Interim Director of Women's Services, she was asked how breast milk was stored since July. The Interim Director of Women's Services stated staff were putting the breast milk in the patient nourishment refrigerator. The Interim Director of Women's Services stated during the Joint Commission survey in December of 2017 they learned they could not store breast milk in the patient nourishment refrigerator. The Interim Director of Women's Services was asked what they were doing with the breast milk since December and she stated they were leaving it in the mother's room for 2-3 hours. If the breast milk was not used at the next feeding it was thrown away and some mothers were sending it home with family. The Interim Director of Women's Services stated that now anything over four hours was discarded. The Interim Director of Women's Services was asked how they monitored the temperature of the room and she stated they checked the wall thermostat when they were in the room; if it was too hot, they turned the room temperature down, if it was too cold, they turned the room temperature up; and the breast milk was thrown away if either of the above occurred.
E. Review of the CDC guidelines titled "Proper Handling and Storage of Human Milk" showed fresh human milk could be at room temperature for 6-8 hours up to 77 degrees F and should be covered and kept as cool as possible; covering the container with a cool towel may keep the milk cooler.
F. Review of the facility policy and procedure titled, "Breast Milk Storage," received from the Director of Quality on 01/30/18 showed breast milk was to be refrigerated or frozen immediately after the pumping episode. Attached to the above policy and procedure was "Table 3" which stated freshly expressed human milk could be stored < (less than) four hours at 79 degrees F.


Based on observations and interview, it was determined the Infection Control Officer failed to monitor and ensure medication vials were cleaned prior to the removal of the medication in one of one Operating Room (#2). Failure to clean the top of the medication vial prior to removing the medication did not ensure the cleanliness of the top. The failed practice affected Patient #34 on 01/30/18. Findings follow:

During observation of Patient #34's surgical procedure at 1:30 PM on 01/30/18, the Director of Surgical Services was observed to remove the cap from a medication vial containing Bupivacaine and hold it while the Surgical Technician inserted a needle into the vial twice to remove its contents. The rubber septum of the vial was not cleaned prior to the removal of the medication. The findings were verified by the Director of Surgical Services at 1:35 PM on 01/30/18.


Based on policy and procedure review, observations and interview, it was determined the Infection Control Officer failed to ensure the surgical staff adhered to policy and procedure in that head hair was not completely covered in one (Infection Control Nurse) of six (Infection Control Nurse, Director of Surgical Services, Registered Nurse #2 and #3, Certified Registered Nurse Anesthetist, and Physician #5) OR personnel. Failure to ensure all hair was covered had the potential to allow dispersal of microorganisms from staff hair. The failed practice affected Patient #34 on 01/30/18. Findings follow:

A. During observation of the preparation and beginning of Patient #34's surgical procedure at 1:00 PM on 01/30/18, the Infection Control Nurse was observed to have forehead hair uncovered from 1:12 PM to 2:43 PM. The findings were verified by the Director of Surgical Services at 3:15 PM on 01/30/18.
B. Review of the policy and procedure titled "Surgical Attire" received from the Director of Surgical Services on 01/30/18 showed that all head and facial hair should be covered in the restricted areas of the surgical suite.


Based on observation and interview, it was determined the Infection Control Nurse failed to ensure items were cleaned between 2 (Patient #35 and #37) of 2 patients. Failure to ensure items were cleaned between patients had the likelihood to allow cross contamination between patients. The failed practice had the potential to affect Patient #35 on 01/31/18. Findings follow:

A. Observation at 12:00 PM on 01/31/18 showed Phlebotomist #1 set the lab draw tray on the floor while donning gown and gloves. After donning the gown and gloves, Phlebotomist #1 picked the lab draw tray up, went into Patient #37's room (#2056) and sat the lab draw tray down on the over-bed table. The lab draw tray was then picked up by Phlebotomist #2 and moved to the bedside table without being cleaned. After drawing the patient's blood, Phlebotomist #1 and #2 removed their gowns and gloves, disposed of them, and washed their hands. Phlebotomist #1 picked the lab draw tray up and carried it into Patient #35's room (#2060) where she set it on the bedside table without cleaning it.
B. During an interview with the Director of Quality at 12:10 PM on 01/31/18 she verified the findings in A.


Based on observation and interview, it was determined the Infection Control Nurse failed to ensure one of one (#1) Registered Nurse (RN) separated clean supplies from dirty supplies in that a package containing a pre-filled syringe was picked up off the floor and placed on top of a clipboard on which packages containing medications were also placed. Failure to separate clean from dirty had the potential to allow cross contamination of equipment, medication and workspace. The failed practice had the potential to affect Patient #36. Findings follow:

During observation of preparation for a capillary blood glucose check, RN #1 was observed to drop to the floor a packaged, pre-filled syringe containing 150 mg (milligrams) of Lovenox. RN #1 retrieved the syringe and placed it on her clipboard which was lying on top of the Computer on Wheels. Once in the patient's room, RN #1 poured the packages containing oral medications out of a cup onto the clipboard the Lovenox package was lying on, then opened each package and emptied the medications into a plastic cup. The above was verified by RN #1 at 12:25 PM on 01/31/18.


31039

Based on review of Arkansas Department of Health Rules and Regulations Pertaining to TB (Tuberculosis) (2013), review of physician's TB records, and interview, the Infection Control Officer failed to mitigate risks of TB transmission to patients and staff by not annually screening two (#1 and #4) of five (#1-#5) physicians for TB. By not assuring the Healthcare workers were screened annually, the facility couldn't assure they were controlling infections and communicable diseases of patients and personnel. The failed practice had the likelihood to affect all of the employees and patients in the facility. Findings follow:

A. Review of Arkansas Department of Health Rules and Regulations Pertaining to TB (2013) showed each hospital employee, health worker or medical staff who has contact with hospital patients shall receive annual TB screening.
B. Review of the physician's TB records showed the following:
1) Physician #1-no evidence of a screening in the past 12 months; and
2) Physician #4-no evidence of a screening in the past 12 months.
C. During an interview on 01/30/18 at 3:50 PM, the Infection Control Nurse verified Physician #1 and #4 did not have evidence of TB screening in the past 12 months.


Based on observation, policy review, Food Refrigerator Temperature Graph for January 2018 and interview, it was determined the facility failed to monitor the temperature for one of one (Post-Partum) food refrigerator observed. The failed practice created the potential for patients to experience a foodborne illness due to receiving food not stored below 40 degrees Fahrenheit. The failed practice had the likelihood to affect all patients who received food from that refrigerator. Findings follow:

A. Record review of the policy titled, "Food and Medication Refrigeration," dated 08/2006, showed that staff were to document the temperature of the food refrigerator daily on the Food Refrigerator Temperature Graph.
B. During a tour of the Post-Partum Unit on 01/29/18 at 1:13 PM, observation showed the following was being stored in the refrigerator for patient consumption:
1) #3 sandwiches;
2) #2 milks;
3) #30 cartons of assorted juices; and
4) #6 applesauces.
C. Review of the Food Refrigerator Temperature Graph for January 2018 showed the refrigerator's thermometer was not working 01/17/18 through 01/28/18.
D. During an interview on 01/29/18 at 2:48 PM, the Interim Director of Women's Services verified the Food Refrigerator Temperature Graph for January 2018 showed the refrigerator's thermometer was not working 01/17/18 through 01/28/18 and food and drinks were still being stored in it for patient consumption.

Based on policy and procedure review, clinical record review and interview, it was determined that one of one (# 31) Swing-Bed patient did not receive their Important Message from Medicare. Failure to ensure Medicare patients receive the Important Message from Medicare did not assure patients were informed of their rights under Medicare. The failed practice affected Patient #31. Findings follow:

A. Review of policy and procedure titled, "Important Message from Medicare Policy," received on 02/02/18 at 12:45 PM from the Swing Bed Director, stated all Medicare beneficiaries must receive the IM (Important Message from Medicare) and detailed notice.
B. Review of the clinical record for Swing-Bed Patient #31 showed no evidence the patient received the Important Message from Medicare.
C. The above findings in A and B were verified with the Swing Bed Director on 02/02/18 at 1:30 PM.