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Based on observation and interview, it was determined the facility failed to maintain patient care equipment in that a Bair Hugger machine used in the Operating Room (OR) had rust on the exterior of the machine; three of three (Room #1, #2 and #3) bedside tables in the Pre-Operative area had rust on the casters of the tables. The failed practice did not ensure the equipment was maintained to prevent the spread of infection. The failed practice had the potential to affect all patients on which the Bair Hugger was used and all patients admitted to the Pre-Operative area. The findings follow:

A. Observation on 02/09/16 at 1020 revealed the Bair Hugger machine in OR #1 had rust on the exterior surfaces. The findings were confirmed in an interview with the OR Manager on 02/09/16 at 1020.
B. Observation on 02/09/16 at 1045 revealed three bedside tables in the Pre-Operative area had rust on the casters of the tables. The findings were confirmed in an interview with the OR Manager on 02/09/16 at 1045.

Based on observation, review of manufacturer's recommendations and interview, it was determined the facility failed to maintain one of one blood glucose monitor in that the Level 1 and Level 3 control solutions were not dated when opened. The failed practice did not ensure the blood glucose monitor was maintained to provide accurate blood glucose testing. The failed practice had the potential to affect all patients on which the blood glucose monitor was used. The findings follow:

A. Observation of the on 02/09/16 at 1120 revealed the Level 1 and Level 3 Stat Strip glucometer control solutions were not dated as to when they were opened.
B. Review of the Nova Stat Strip Glucose Control Solution manufacturer's recommendations on 02/09/16 revealed, "The expiration date is printed on the control vials. Once opened, solutions stored as indicated will be stable for up to 3 months or until the expiration date, whichever comes first."
C. The findings of A and B were confirmed in interview with Licensed Practical Nurse #1 on 02/09/16 at 1105.

Based on interview, it was determined the facility failed to inspect 80 of 80 fire/smoke dampers in the facility every four years (or every six years under CMS Waiver per S&C Letter 10-04-LSC dated October 30, 2009). The failed practice had the potential to affect all patients, staff, and visitors because the facility failed to ensure the reliability of the dampers to close in the event of a fire or smoke event. The facility had a census of three patients on 02/08/16. See K-104.

Based on policy review and interview, it was determine the facility failed to provide evidence policies were reviewed on an annual basis for 14 (Medical Records, Maintenance, Anesthesia, Post Anesthesia Care Unit, Central Supply, Surgery, Emergency Department, Case Management, Swing Bed, Dietary, Cardiopulmonary, GI Lab, Rural Therapy Services, and Therapy Services) of 17 (Infection Control, Radiology, Pharmacy, Medical Records, Maintenance, Anesthesia, Post Anesthesia Care Unit, Central Supply, Surgery, Emergency Department, Case Management, Swing Bed, Dietary, Cardiopulmonary, GI Lab, Rural Therapy Services, and Therapy Services) policy manuals reviewed. The failed practice did not ensure the facility was operating under current policies and had the potential to affect any patient in the facility. Findings follow.

A. Review of policy manuals revealed the following.
1) The Medical Records, Maintenance, Rural Therapy Services, and Therapy Services manuals did not have evidence of any review date.
2) Anesthesia, Post Anesthesia Care Unit, Central Supply, Surgery, Case Management, and GI Lab had a review date of 08/13/14
3) Emergency Department and Swing Bed had a review date of 08/08/13
4) Dietary had a review date of 01/28/14
5) Cardiopulmonary had a review date of 09/06/13
B. During an interview on 02/10/16 at 0900, the Assistant Administrator confirmed the policies were not reviewed annually.

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:

During an interview with the Director of Pharmacy on 02/09/16, the Director verified they do not have policies and procedures in place to ensure annual re-certification of IV Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood.

Based on observation, review of policy, review of manufacturer's package insert and interview, it was determined the facility failed to control medications in that repackaged Lorazepam was dated beyond manufacturer's recommendation of 90 days; Lorazepam was not refrigerated at 36-46 degrees Fahrenheit per manufacturer package insert in one (Medical/ Surgical) of three (Medical/ Surgical, Emergency Services and Surgical Services) medication areas toured. By not controlling medications, the facility could not assure the safety or efficacy of them. The failed practice had the likelihood to affect all patients receiving medication. Findings follow:

A. A tour of the facility was conducted on 02/09/16 from 1000 to 1100. During the tour, observation revealed the following in the Medical/Surgical unit: 23 individually drawn up oral syringes of Lorazepam 1 mg (milligram)/.5 ml (milliliter) was stored at room temperature. The Pharmacist was asked what expiration date she was applying to the syringes and she stated "6 months."
B. A review of policy titled "Medication Storage" stated "To maintain quality and assure security, medications will be stored in the manner prescribed by the Arkansas State Health Department, United States Pharmacopeia, National Formulary, Nuclear Regulatory Commission and the manufacturer."
C. Review of Lorazepam's manufacturer's package insert revealed "Store at Cold Temperature-Refrigerate 2-8 degrees Celsius (36-46 degrees Fahrenheit)." "Discard opened bottle after 90 days."
D. During an interview on 02/09/16 at 1100, the Pharmacist verified the Lorazepam syringes were dated six months from repackaging date, not the 90 days as recommended by the manufacturer. The Pharmacist also verified manufacturer package insert stated to Store at Cold Temperature-Refrigerate 2-8 degrees Celsius (36-46 degrees Fahrenheit).


Based on observation, review of manufacturer information on Rocuronium Bromide and Succinylcholine and interview, it was determined the facility failed to ensure a method was instituted to reflect how long Rocuronium Bromide and Succinylcholine had been stored at room temperature on one of one Anesthesia cart observed. The potential existed for the medications to be stored at room temperature in excess of manufacturer guidelines leading to a decrease in potency of the medications upon administration to patients. The practice had the likelihood to affect all patients who received the medications during surgery. Findings follow:

A. A tour of Surgical Services was conducted on 02/09/16 from 1000 to 1050. The following observations were made on the Anesthesia Cart:
1. #4 Succinylcholine 200 mg (milligram)/10 ml (milliliter) were not dated when removed from refrigerated storage;
2. #1 Rocuronium Bromide 100 mg/10 ml was not dated when removed from refrigerated storage; and
3. #1 Rocuronium Bromide 50 mg/5 ml was not dated when removed from refrigerated storage.
B. Review of package insert for Succinylcholine stated "The multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency."
C. Review of packaging for the Rocuronium Bromide stated "Upon removing from refrigerator to room temperature, use within 60 days."
D. During an interview on 02/09/16 at 1015, the Operating Room Manager verified the vials were not dated to reflect how long they had been stored at room temperature.


Based on observation, review of policy and interview, the facility failed to ensure medications were properly controlled in one (Operating Room (OR) #1) of two (OR #1 and #2) OR toured in that medications were found unlocked and available to unlicensed personnel. By not assuring only licensed personnel had access to the medications, the facility could not assure the medications' safety and efficacy. The failed practice had the likelihood to affect all patients who receive medications from the facility. Findings follow:

A. During a tour of the facility on 02/09/16 from 1000 to 1100, observation revealed the following medications in a cabinet in Operating Room #1, unlocked:
1) #42 Dantrolene 20 mg (milligram)/vial;
2) #2 8.4% Sodium Chloride 50 ml (milliliter) syringe;
3) #2 Dextrose 50% 50 ml syringe; and
4) #5 Sterile Water for injection 100 ml.
B. Review of policy titled Medication Storage stated "Medications should be inaccessible to non-licensed co-workers."
C. During an interview on 02/09/16 at 1020, the Operating Room Manager verified the drugs were left in the cart unlocked and available to non-licensed personnel at night during cleaning.

Based on observation, policy review, review of Monthly Record of Medication Area Reviews and interview, it was determined one of one emergency crash cart in Surgical Services did not contain emergency drugs to include standard emergency pharmaceuticals, antivenins, common poison antidotes, parenteral fluids and plasma substitutes as required by policy " Emergency Drugs " , effective October 2014. There was no evidence the Pharmacy Department had inspected the Surgical crash cart monthly for 13 of 13 (January 2015 to January 2016) months reviewed. The potential existed for the Surgical crash cart not to have medications present for patient emergencies. The failed practice had the likelihood to affect all patients that needed emergency care. Findings follow:

A. During a tour of the facility on 02/09/16 from 1000 to 1100, observation revealed the crash cart in Surgical Services had only one drug on it, #4 Adenocards (antiarrhythmic).
B. Review of policy titled Emergency Drugs effective October 2014 stated "The director of pharmacy shall maintain and keep available the medical staff approved stock of antidotes and other emergency drugs, both in pharmacy and in patient care areas ...Emergency drugs shall be inspected by the pharmacy at least monthly ...Expired drugs shall be removed and replaced." "Emergency drugs available for immediate use shall include but will not be limited to: standard emergency pharmaceuticals, antivenins, common poison antidotes, parenteral fluids and plasma substitutes."
C. Review of Monthly Record of Medication Area Reviews for January 2015 to January 2016 revealed pharmacy was not inspecting the crash cart in Surgical Services from January 2015 to January 2016.

Based on review of policy, review of Safety Event Summary and Follow-up History Reports and interview, it was determined the facility failed to notify the practitioner who ordered the medication of the medication error for 10 (#1-3 and 5-11) of 11 (#1-11) incidents in 2015 and the Director of Pharmacy failed to review all medication errors per policy. 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. By not reviewing the medication related errors, the Director of Pharmacy was not reviewing, tracking and trending errors in order to put policies and procedures in place to minimize medication related errors. The failed practice had the potential to affect all patients. Findings follow:

A. Review of policy titled Medication Errors stated "The medication error shall be reported to the practitioner who ordered the drug and the attending physician." "The Director of the Pharmacy should review all of the medication related error reports."
B. Review of review of Safety Event Summary and Follow-up History Reports revealed 10 (#1-3 and 5-11) of 11 (#1-11) medication related errors in 2015 were not reported to the prescribing physician.
C. During an interview on 02/09/16 at 1138, the Director of Pharmacy verified there was no evidence the above listed medication related errors were reported to the prescribing physician and also, verified they did not review the medication related errors.

Based on observation, policy and procedure review and interview, it was determined the facility failed to control the spread of infection in that an endotracheal tube package was open and sitting on top of the anesthesia cart in Operating Room (OR) #1 and one of three endoscopes was touching a towel on the bottom of the endoscope storage cabinet. The failed practice promoted the spread of infection. The failed practice had the potential to affect all patients who were intubated during an operative procedure and all patients on which the endoscope was used. The findings follow:

A. Observation on 02/09/16 at 1030 revealed an endotracheal tube sitting on top of the anesthesia cart in OR #1. The endotracheal tube package was opened. In an interview with the OR Manager on 02/09/16 at 1030, she confirmed the endotracheal tube packaging should not be opened until ready for use.
B. Observation on 02/09/16 at 1120 revealed three endoscopes were hanging in the endoscope storage cabinet. One of the endoscopes was touching a towel on the bottom of the storage cabinet. In an interview with the OR Manager on 02/09/16 at 1120, she confirmed the endoscope should not be touching the towel on the bottom of the cabinet.
C. Review of the policy "Disinfection of Endoscopes" on 02/09/16 revealed "Do not store the endoscope coiled. Store endoscopes hanging in a manner which will protect the scope." In an interview with the OR Manager on 02/09/16 at 1130, she confirmed the policy and procedure did not direct the staff to hang the endoscope to not come in contact with anything.


Based on personnel file review, policy and procedure review and interview, it was determined the facility failed to provide annual N-95 Respirator fit testing for 10 of 10 (Registered Nurse (RN) #1, #2, #3, #4 and #5, Licensed Practical Nurse (LPN) #2 and #3, Licensed Respiratory Care Practitioner #1 and Aide #1 and #2) personnel files reviewed. The failed practice did not ensure the personnel were protected from potential exposure to tuberculosis. The failed practice had the potential to affect all personnel in the facility. The findings follow:

A. Review of RN #1, #2, #3, #4 and #5, LPN #2 and #3, Licensed Respiratory Care Practitioner #1 and Aide #1 and #2's personnel files revealed there was no evidence of N-95 Respirator fit testing. A request was made to the Assistant Administrator on 02/10/16 at 1435 for evidence of N-95 Respirator test fitting. He confirmed at that time there was no evidence of N-95 Respirator test fitting.
B. Review of the policy "Fit Testing of N95 Respirator" on 02/10/16 revealed, "As of Sept. 30, 2007, The Occupational Safety and Health Administration (OSHA) require annual respirator fit testing for health care workers who treat Tuberculosis (Tb) patients. 1. Health care workers who care for/treat Tb patients must be fit tested annually."
C. The findings of B were confirmed in an interview with the Assistant Administrator on 02/10/16 at 1435.


31039

Based on observation, review of policy and interview, it was determined the facility failed to maintain sterile dressing materials for wound care in that a Single Use bottle of 0.9% Sodium Chloride 1000 ml (milliliter) for irrigation was being used after it was opened, on a daily basis. Single Use Bottles do not contain any agents to prevent contamination, therefore should be discarded after the initial use. The failed practice had the likelihood to affect all patients that received wound care. Findings follow:

A. During a tour of Rehabilitation Services on 02/10/16 at 1330, observation revealed a Single Use bottle of 0.9% Sodium Chloride 1000 ml, open with approximately 400 ml's left in it.
B. Review of policy titled Therapy Services-Infection Control stated "Dressing of Wounds Following Treatment-Only sterile dressing materials are used and strict sterile technique is followed."
C. During an interview on 02/10/16 at 1355, The Physical Therapy Assistant explained she provided wound care to a patient and opened the bottle of 0.9% Sodium Chloride 1000 ml for this patient and used the same bottle on the same patient each day.

Based on observation, review of Medical Staff Application for Privileges and interview, it was determined the Operating Room (OR) and Surgical Scheduling did not maintain a list of current operating privileges for one of one (#1) physician. The failed practice did not ensure the physician was only performing procedures for which he was approved. The failed practice had the potential to affect all patients on which the physician performed a surgical procedure. The findings follow:

A. In an interview with the OR Manager on 02/09/16 at 1430, when asked for a list of surgical privileges for Physician #1, the OR Manager provided a list of privileges that expired 12/31/13. When the OR Manager as asked if she had a more current list of privileges, she stated she did not.
B. In an interview with the Scheduler (the person responsible for scheduling Physician #1's surgical cases) on 02/09/16 at 1430, when asked for a list of surgical privileges for Physician #1, the Scheduler stated she did not have a list of privileges available for Physician #1.

Based on Hospital Department Quality Assurance Report review and interview, it was determined the Cardiopulmonary Department failed to evaluate implemented corrective action plans for ongoing improvement for patients placed on oxygen with chest pain/arrythmias per the American Heart Association for three of three (First, Second and Third) Quarters reviewed for 2015. The failed practice did not ensure the Cardiopulmonary Department implemented corrective action plans to improve patient outcomes. The failed practice had the potential to affect all patients presenting to the facility with chest pain or arrythmias. The findings follow:

A. Review of the Hospital Department Quality Assurance Report for the First, Second and Third Quarters of 2015 revealed the Cardiopulmonary Department was monitoring "O2 (oxygen) on patients with CP (chest pain)/arrythmias per AHA (American Heart Association) Guidelines." The Report indicated the threshold for the First Quarter was 75% out of 100%. The Report indicated the threshold for the Second Quarter was 75% out of 100%. The Report indicated the threshold for the Third Quarter was 60% out of 100%. The corrective actions for the First, Second and Third Quarters was "Cardiopulmonary will again in-service ER (Emergency Room) nursing staff on importance of O2." The Improvement for the First, Second and Third Quarters was "Cardiopulmonary department will continue to monitor this." There was no evidence the corrective actions were evaluated to determine if a change in corrective actions was required.
B. The findings were confirmed in an interview with Licensed Respiratory Care Practitioner #1 on 02/08/16 at 1455.


Based on review of the Performance Improvement Sub-Committee Reports for 2015 and interview, it was determined the facility failed to perform Quality Assessment/Performance Improvement for the Infection Control and Emergency Departments for 2015. The failed practice did not ensure the Infection Control and Emergency Departments were monitoring areas where improvements to patient outcomes could be performed. The failed practice had the potential to affect all patients admitted to the facility. The findings follow:

A. Review of the Performance Improvement Sub-Committee Reports for 2015 revealed there was no evidence the Infection Control Department was reporting performance improvement activities. A request was made to the Laboratory Supervisor on 02/09/16 at 1400 for evidence of performance activities performed in 2015. In an interview with the Laboratory Supervisor on 02/09/16 at 1400, she stated the Infection Control Department had not performed any performance improvement activities for 2015.
B. Review of the Performance Improvement Sub-Committee Reports for 2015 revealed there was no evidence the Emergency Department was reporting performance improvement activities. A request was made to the Health Information Management Manager on 02/10/16 at 1230. In an interview with the Health Information Management Manager on 02/10/16 at 1230, she stated there was no evidence the Emergency Department reported any performance improvement activities for 2015.

Based on review of policies, death patient records and interview, it was determined the facility failed to have consistent policies and procedures to follow in the event of a patient death and failed to provide evidence that ARORA (Arkansas Regional Organ Recovery Agency) was notified for 5 (# 1, 6, 13, 17 & 20) of 20 (#1-20) deaths in the previous 12 months (02/01/15 through 01/31/16). By not providing evidence that ARORA was contacted on each death, the facility could not assure they were following their policy and fulfilling their Organ Procurement responsibilities. The failed practice had the likelihood to affect all persons who pass away at the Facility. Findings follow:

A. Review of Emergency Department policy D1.2 titled Death Record Form Reviewed October 2014 stated "Report every death (or imminent death) to ARORA at [numbers] ...Complete Certificate of Organ Donation Review section of form. Document reference number given to deceased by ARORA on form."
B. Review of Nursing Department Policy (not numbered) titled Death of a Patient effective 6/2014 stated "ALL deaths are referred to ARORA. ALL deaths are documented in the Expiration Discharge Flow sheet in EPIC".
C. Review of 12 months of death patient records (02/01/15 through 01/31/16) revealed death records for Patients # 1, #6, #13, #17 and #20 had no evidence ARORA was contacted.
D. During an interview on 02/10/16 at 1100, the Director of Nursing verified there was no evidence ARORA was contacted on 5 patients and the conflicting policies.

Based on review of Swing-Bed policies and procedures and interview, it was determined the facility failed to assure there were policies and procedures addressing patient ' s rights to work in the facility during their hospitalization. The failed practice did not assure patients with a need for therapeutic work rehabilitation were allowed to work or were allowed to refuse to work during their hospitalization. The failed practice was likely to affect all patients needing work rehabilitation in the facility. Findings follow:

A. Review of Swing-Bed policies and procedures revealed no evidence of policies addressing patients working or refusing to work while admitted to the facility.
B. During an interview on 02/09/16 at 1515, the Care Manager confirmed there was no policy regarding patient's right to work.

Based on review of Swing Bed policies and procedures and interview, it was determined the facility failed to assure there were policies and procedures addressing when married couples admitted to the facility could room together. The failed practice did not assure married couples' had a choice to room together were honored and was likely to affect all married couples admitted to the facility. Findings follow:

A. Review of Swing-Bed policies and procedures revealed no evidence of policies addressing married couples rooming together while admitted to the facility.
B. During an interview on 02/09/16 at 1515, the Care Manager confirmed there was no policy regarding married couples.

Based on interview, policy and procedure review and clinical record review, it was determined the facility failed to have a Swing-Bed activities director, an activities calendar, and an activity assessment in two of two (Patient #1 and #2) Swing Bed clinical records. Failure to have an activities director did not ensure someone was responsible for conducting therapeutic activities for patients. 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. Failure to have an activity assessment in the clinical record did not ensure staff was knowledgeable of patient likes and interests. The failed practice created the potential to affect all Swing Bed patients. Findings follow.

A. Review of policy titled "Social Services-Activities Program" stated, "Mercy Hospital Booneville will develop an activities program under the direction of the contracted LSW (licensed social worker). A written record will be maintained indicating the patient's daily activity participation and the patient's response to such activities. The major purpose of this activity record is to improve the services given to each patient. The hospital nursing staff, auxiliary members, and family members will be utilized to encourage patient participation in activity."
B. Review of clinical records revealed no evidence of an activity assessment, or any patient activities for two of two (Patient #1 and #2) Swing-Bed patients.
C. During an interview on 02/09/16 at 1515, the Care Manager confirmed there was no activities director, or activities calendar.
D. During an interview on 02/10/16 at 1300, the Director of Nursing confirmed there was no activities assessment on two of two clinical records.

Based on policy review and interview, it was determined the facility failed to have evidence of a contractual agreement with a dentist. The failed practice did not ensure a dentist would be available to provide emergency dental needs for patients. The failed practice had the potential to affect any patient admitted to a Swing-bed. The findings follow:

A. Review of policy titled "Dental Services" stated, "A qualified dentist, who is a member of the hospital staff and licensed by the State of Arkansas, will provide dental services when necessary and routine dental care when requested by the physician or his/her responsible party."
B. No evidence of a Dentist being on staff, or having a contractual agreement with the facility was provided.
C. During an interview on 02/10/16 at 0900, the Assistant Administrator confirmed there was no agreement with a dentist and the facility.