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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 two ( #1 and #2) of two 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. Review of policy titled, "The Medical Record" stated all medical records must contain documentation of every medication ordered and every dose administered.
B. Review of Occurrence Report Forms showed the following:
1) On 03/05/17, Patient #16 received an updraft treatment that was prescribed for another patient.
2) On 07/18/17, Patient #17 received an Intravenous Antibiotic that was prescribed for another patient.
C. Review of clinical records for Patient #16 and #17 showed no evidence of the medication they received in error.
D. During an interview on 09/13/17 at 1:20 PM, the Nurse Executive and Director of Pharmacy verified there was no evidence in Patient #16 and #17's clinical record indicating they received the medication that was not prescribed for them.

Based on review of policies, review of current and discharged in-patient clinicl records and interview, it was determined the facility failed to ensure patients' responses to PRN (as needed) medications were documented in 4 (#4, #9, #14 and #15) of 8 (#1-#4,#6, #9, #14 and #15) in-patient records. By not documenting a patient's response to PRN medications, physicians and other health care providers were not fully informed of the patient's condition in order to help them make decisions on the provision of care to the patients. The failed practice had the likelihood to affect all patients who receive PRN medications. Findings follow:

A. Review of the policy titled, "Procedure: Pain Management," dated 11/03, showed that staff were to reassess pain 5-10 minutes after IV (Intra-venous) push administration and one hour after oral administration.
B. Examples of PRN medication not being reassessed follow:
1) Patient #4: Open clinical record reviewed from 09/10/17 through 09/13/17 showed three of four doses of PRN medication administrations lacked evidence of the patient's response.
2) Patient #9: Closed clinical record reviewed from 09/12/17 showed three of four doses of PRN medication administrations lacked evidence of the patient's response;
3) Patient #14: Closed clinical record reviewed from 07/26/17 through 07/28/17 showed nine of eleven doses of PRN medication administrations lacked evidence of the patient's response; and
4) Patient #15: Open clinical record reviewed from09/10/17 through 09/13/17 showed one of one doses of PRN medication administered lacked evidence of the patient's response.
C. During an interview on 09/13/17 at 10:55 AM, Patient #4's findings were verified by the Nurse Executive and Patients #9, #14 and #15 were verified by the Assistant Director of Nursing.

Based on review of medications dispensed prior to a pharmacist review and interview, it was determined the facility failed to have a process that assured 180 of 180 medication orders were reviewed for appropriateness by a pharmacist before the first dose was dispensed, while the pharmacy was closed. By not allowing the pharmacist to do a review of the medication orders prior to the first dose, the facility could not assure patient safety. The failed practice had the likelihood to affect all of the patients in the facility that received new orders after the pharmacy has closed. Findings follow:

A. Review, with the Director of Pharmacy, of the number of orders dispensed prior to a pharmacist reviewing the order showed that 180 medications were dispensed between 8/12/17 and 09/15/17 prior to being reviewed by a pharmacist while the pharmacy was closed.
B. During an interview on 09/14/17 at 09:00 AM, the Director of Pharmacy verified 180 doses of medication were dispensed prior to the pharmacist reviewing the order for appropriateness, while the pharmacy was closed.

Based on review of United States Pharmacopeia Chapter 797 (2008), review of annual compounding skills checklist and interview, it was determined the facility failed to ensure Gloved Fingertip Sampling was completed as part of the annual re-certification of Intravenous (IV) Admixture technique for four of four (#1-#4) pharmacists trained to compound medications in the Laminar Flow Hood. By not preforming 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 Laminar Flow Hood. Findings follow:

A. Review of United States Pharmacopeia Chapter 797, 2008 showed that Gloved Fingertip 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-#4 showed Gloved Fingertip Testing was not evaluated.
C. During an interview on 09/13/17 at 12:30 PM, the Director of Pharmacy verified Gloved Fingertip Testing was not done as part of the annual re-certification of Intravenous (IV) Admixture technique.

Based on observation, review of policy, review of manufacturer's information on Succinylcholine and interview, it was determined the facility failed to ensure Succinylcholine had been dated with the manufacturer's recommended expiration date (14 days once removed from refrigeration) in three of three (Cart #1, #2 and #6) Anesthesia Carts observed. The potential existed for the medications to be used beyond 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 medication during surgery. Findings follow:

A. Review of policy titled, "Dating of Medications Removed from Manufacturer Packaging" stated that when a medication is removed from its original manufacturer packaging (eg. refrigerator), the product will be marked with the appropriate expiration date based on manufacturer guidelines.
B. Review of package insert for Succinylcholine stated that the multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency.
C. During a tour of the facility on 09/11/17 from 12:54 PM until 2:45 PM, observation showed the following:
1) Anesthesia Cart #1 had 3 unopened vials of Succinylcholine that were not dated to indicate when they were removed from refrigeration or when they would expire;
2) Anesthesia Cart #2 had 1 unopened vial of Succinylcholine that was not dated to indicate when it was removed from refrigeration or when they would expire; and
3) Anesthesia Cart #6 had 1 unopened vial of Succinylcholine that was not dated to indicate when it was removed from refrigeration or when they would expire.
D. During an interview on 09/11/17 at 1:55 PM, the Assistant Director of Nursing verified the facility failed to ensure Succinylcholine had been dated with the manufacturers recommended expiration date.

Based on observation, it was determined the facility failed to maintain the building physical structure, environment and equipment in a state of good repair in that six (Operating Rooms (OR) #3, #4, and #6) of eight of the OR doors in the surgical suite were chipped and scraped. The failed practice had the potential to affect all patients staff and visitors due to the potential for injury presented by the damaged door as well as potential for infection control issues. The facility had a census of 17 patients on 08/11/17. Findings follow:

A. While on tour of the facility on 09/12/17 at 1:30 PM, observation showed large chips in the right side doors entering ORs #3, #4, and #6.
B. While on tour of the facility on 09/12/17 at 1:30 PM, observation showed scrapes from side to side across the right and left sides of the doors entering ORs #3, #4, and #6.
C. While on the tour, the Manager of OR (operating room) verified the doors were damaged.

Based on observation and interview, it was determined the facility failed to maintain the fire and smoke rated barrier in two (the electrical room which supplies the new emergency room and above the fire-rated doors outside the laboratory entrance) of seventeen areas observed by protecting penetrations in the barrier with a system or material capable of restricting the transfer of smoke. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:

A. While touring the facility on 09/12/17 at 1:20 PM, observation showed seven electrical conduits penetrating the smoke and fire barrier wall adjacent to the door to the electrical room which supplied the Emergency Room were not sealed with a material capable of limiting the transfer of smoke from one side of the barrier to the other.
B. While touring the facility on 09/12/17 at 2:00 PM, observation showed a large opening in the fire and smoke barrier above the fire-rated doors near the entrance to the laboratory.
C. During the tour, the Director of Plant Services verified the penetrations were not sealed with a material capable of restricting the transfer of smoke from one side of the barriers to the other.
D. See K300.

Referenced code: NFPA 101; 2012 edition, Section 8.4.4.1

Based on observations, review of manufacturer's guidelines, and interview, it was determined the infection control officer failed to identify and control infections as follows:
1. Follow manufacturer's guidelines in that there was no mechanism to ensure strips used to check the minimum effective concentration (MEC) of high level disinfection were stored at a temperature between 43 and 86 degrees Fahrenheit. Failure to ensure the strips were stored at the proper temperature had the potential to allow cross contamination of patients from scopes cleaned with weak or ineffective solution.
2. Label the contents of a bottle containing a yellow colored fluid. Failure to label the contents of the bottle did not ensure the correct usage of the contents.
3. Ensure only currently dated milk was available for patient consumption. Failure to ensure only currently dated milk was available for patient consumption had the potential to allow patient consumption of expired milk.
4. Ensure only currently dated supplies were available for patient use. Failure to ensure only currently dated supplies were available for patient use had the potential for infection.

The failed practices had the likelihood to affect all patients who received care and services at the facility. Findings follow:

A. Observation at 1:50 PM on 09/11/17 in the GI (gastrointestinal) work room revealed a bottle of opened Aldechek strips. Review of the manufacturer's guidelines printed on the bottle revealed the strips were to be stored at a temperature between 43 and 86 degrees Fahrenheit. Observation of the OR Dirty workroom revealed a bottle of opened Aldechek strips. During an interview with the Manager of OR at 1:50 PM on 09/11/17 she stated the temperature of the GI workroom and the OR dirty workroom was not checked.
B. Observation at 1:55 PM on 09/11/17 of the OR Dirty workroom revealed a 750 ml (milliliter) bottle containing 500 mls of a yellow colored fluid. The bottle did not contain a label identifying the contents of the bottle or what the contents were used for. During an interview at 1:55 PM on 09/11/17 the Nurse Executive there was no label on the bottle.
C. Observation of the patient nourishment refrigerator in the Emergency Room at 2:00 PM on 09/11/17 revealed five of five cartons of whole milk with expiration dates of 09/05/17. During an interview at 2:00 PM on 09/11/17 the Nurse Executive confirmed the milk was expired.
D. Observation of Trauma 1 supplies at 2:05 PM on 09/11/17 revealed one of one Introducer Adult Malleable expired 08/17. During an interview at 2:05 PM on 09/11/17 the Nurse Executive confirmed the expired Introducer Adult Malleable.

Based on observation and interview, it was determined the infection control officer failed to ensure prevent and control infections in that a discharged room was not cleaned per policy and procedure to prevent cross contamination between patients. The policy and procedure titled, "Patient Room Cleaning" did not show any reference to cleaning the toilet seat. Failure to clean from the most clean area to the least clean area allowed cross contamination of patient care surfaces. The failed practice affected any patient who was admitted to Room 310. Findings follow:

A. Review of the policy and procedure titled, "Patient Room Cleaning" received from the Director of Environmental Services at 2:15 PM on 09/12/17 showed staff were to clean top, sides and drawer of nightstand, clean all surfaces of the over bed table, and clean the bowl with bowl cleaner. Review of the above policy and procedure did not show any reference to cleaning the toilet seat. During an interview at 1420 on 09/12/17 the Director of Environmental Services verified the policy and procedure received from him was the policy and procedure staff were to follow.
B. During observation at 1:10 PM on 09/12/17 of Housekeeper #2 cleaning room 310 after discharge of a patient, Housekeeper #2 cleaned the top, side and bottom of the nightstand, then moved to the over bed cabinetry and cleaned the bottom bed rack all with the same blue cleaning cloth. Housekeeper #2 pulled the trash from the trash can using the original cleaning cloth as a support to catch any leakage from the trash bag and carried it to her cart located in the hallway of the nursing unit. Housekeeper #2 then returned to the room and used the same original cloth to clean the metal rack of the patient bed and then cleaned the top and leg of the over bed table all with the same original cloth. At 1:30 PM Housekeeper #2 was stopped at this point and asked if she had received training on how many times she was supposed to change cleaning cloths as well as cleaning from top to bottom and not returning to the top. Housekeeper #2 stated "yes" she had received training and was supposed to change cleaning cloths 3 to 4 times during the cleaning of a room. Housekeeper #2 then switched to a white cleaning cloth. Housekeeper #2 moved to the bathroom cleaning the floor of the shower, then the shower chair/bench with the white cloth. Housekeeper #2 cleaned the toilet bowl with a brush, then raised the seat and cleaned underneath the seat, then closed the seat and cleaned the top of the toilet seat with the same brush she used to clean the toilet bowl. During an interview with the Nurse Executive at 1:50 PM she verified the observations in A.


Based on observation and interview, it was determined the infection control officer failed to identify and prevent infection in that one of one (#1) OR (operating room) housekeeper failed to clean from the most clean to the least clean area in the Eye Room. Failure to clean from the most clean area to the least clean area had the potential to contaminate clean equipment utilized in patient care. The failed practice had the potential to affect Patient #8 on 09/12/17. Findings follow:

A. Observation of the terminal clean of the Eye Room at 10:55 AM on 09/12/17 revealed the OR Housekeeper #1 cleaned one yellow trash can (least clean) and one black trash (least clean) can and then with the same cloth cleaned the Mayo Stand (most clean) which attached to the OR stretcher and held the sterile surgical drape.
B. During an interview at 11:00 AM on 09/12/17, the Nurse Executive stated the OR Housekeeper should have used a separate cloth or cleaned the Mayo Stand first.


31039

Based on review of policy, review of Arkansas Department of Health Rules and Regulations Pertaining to TB (Tuberculosis) (2013), review of Healthcare Worker's Tuberculosis records and interview, the Infection Control Officer failed to mitigate risks of TB transmision to patients and staff by not annually screening eight (#1-#8) of ten (#1-#10) Physicians; two (#2 and #3) of three (#1-#3) CRNAs (Certified Registered Nurse Anesthetists); two (#1 and #2) of two Physical Therapists: Two (#1 and #2) of two Physical Therapy Assistants; one (#1) of two (#1 and #2) OTs (Occupational Therapist) 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 policy titled, "Tuberculosis Control Plan" showed that the facility will follow the Arkansas Department of Health guidelines.
B. 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.
C. Review of the Healthcare Worker's Tuberculosis records showed the following:
1) Physicians #1-#8 had no evidence of a screening in the past 12 months;
2) CRNAs #2 and #3 had no evidence of a screening in the past 12 months;
3) Physical Therapists #1 and #2 had no evidence of a screening in the past 12 months;
4) Physical Therapy Assistants #1 and #2 had no evidence of a screening in the past 12 months; and
5) OT #1 had no evidence of a screening in the past 12 months.
D. During an interview on 09/12/17 at 2:40 PM, the Director of Infection Control and Employee Health verified the findings in A and B.


38994

Based on observation it was determined the facility failed to ensure a sanitary environment in that unwrapped open surgical instruments were found in OR #3 (Operating Room) of five (#1-5). The Infection Control Officer failed to ensure there was a system for identifying and controlling infections and communicable diseases in that the OR Manager was unable to determine the sterility of the unwrapped instruments found in OR #3. The failed practice had the potential to affect all patients admitted to the facility for surgical services.
Findings follow:

A. On 09/11/17 at 1:33 PM, Surveyor # 2 found a tray of eye instruments unpackaged in OR # 3. The OR Manager was unable to determine why or how long the instruments had been left in OR #3.

B. At 1:33 PM on 09/11/17 the OR Manager confirmed the unwrapped instruments.

Based on interview and review of the surgeon's privileges received from the Manager of the Operating Room (OR) on 09/11/17, it was determined the facility failed to keep current privileges for 10 (#2-11) of 56 credentialed surgeons listed in the OR Privilege Manual. Failure to ensure current surgeon's privileges were available to OR staff did not allow the OR staff to be knowledgeable regarding which surgical procedures the individual surgeons were credentialed to perform. The failed practice affected any patient whose surgical procedure was performed by Surgeon #2-11. Findings follow:

A. Review of the OR Privilege Manual received from the Manager of OR on 09/11/17 revealed:
1) Surgeon #2's last privilege sheet dated 02/24/15.
2) Surgeon #3's last privilege sheet dated 07/28/15.
3) Surgeon #4's last privilege sheet dated 05/21/15.
4) Surgeon #5's last privilege sheet dated 06/24/14.
5) Surgeon #6's last privilege sheet dated 07/28/15.
6) Surgeon #7's last privilege sheet dated 07/28/15.
7) Surgeon #8's last privilege sheet dated 07/22/15.
8) Surgeon #9's last privilege sheet dated 03/24/15.
9) Surgeon #10's last privilege sheet dated 05/26/15.
10) Surgeon #11's last privilege sheet dated 07/28/15.
B. During an interview at 2:50 PM on 09/13/17, the Nurse Executive verified the findings in A1-10.

Based on observations and interviews, it was determined the facility failed to develop a mechanism to ensure it followed its selected national practice standards, AORN (Association of Operating Room Nurses) Guidelines for Perioperative Practice, to ensure one of one (#1) Surgeon changed his surgical mask between surgical patients. Failure to develop and institute a mechanism to ensure surgical masks were changed between patients had the potential to allow cross contamination between patients. The failed practice affected Patient #7 and Patient #8 on 09/12/17. Findings follow:

A. Review of the AORN Guidelines for Perioperative Practice, dated 2015, revealed on page 106, Section I.h.3.: "A fresh surgical mask should be donned before the health care worker performs or assists with each new procedure. The mask should be replaced or discarded whenever it becomes wet or soiled or has been taken down."
B. Observation of Surgeon #1 from 10:30 to 11:21 AM on 09/12/17 showed he did not change his surgical mask before performing a surgical procedure on Patient #7 and did not change his surgical mask before performing a surgical procedure on Patient #8.
C. During an interview with the Manager of OR (operating room) and the Nurse Executive at 11:55 AM on 09/12/17, both stated the facility followed AORN Guidelines for Perioperative Practice national guidelines.

Based on clinical record review and interview, it was determined one of one Swing-Bed patient (#1) was not informed of their right to receive Medicare covered services in that no Important Message from Medicare was provided. The failed practice did not assure that each patient knows his or her rights and responsibilities under Medicare. The failed practice had the potential to affect all patients admitted to the Swing-Bed Unit. Finding follow:

A. Review of Swing-Bed Patient #1's clinical record showed no Important Message from Medicare had been provided to the patient.
B. The above finding were verified with the Nursing Administrator at 12:15 PM on 09/13/17.