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Based on observations and staff interviews, the facility failed to ensure that patient care supplies were maintained to ensure an acceptable level of safety and quality, and that patient care equipment was appropriately maintained for all physical therapy patients utilizing services at the Thompson Falls Clinic. Findings include:

1. During the survey of the operating room area on 3/30/10, beginning at 2:30 p.m., the surveyor noted the following;
- 2 three packs of Povidone Iodine swabsticks with manufacturer's expiration dates of 5/2007 and 1/2008.
- 2 Insyte Autoguard 16 gauge by 1.7 inch intravenous catheters with the manufacturer's expiration dates of 11/2008 and 4/2009.
- 1 Insyte Autoguard 14 gauge by 2.1 inch intravenous catheter with the manufacturer's expiration date of 3/2009.
- 2 Protect IV Plus 18 gauge by 1 1/4 inch intravenous catheters with the manufacturer's expiration dates of 6/2008 and 2/2010.- 3 Protect IV Plus 22 gauge by 1 inch intravenous catheters with the manufacturer's expiration date of 11/2009.

In an interview with the director of nursing on 3/30/10 at 2:40 p.m., the director stated that staff was responsible for checking supplies for outdates, but these had been missed.


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2. During the tour of the physical therapy area at the Thompson Falls Clinic on 3/30/10 at 10:15 a.m., a large therapy table, overlaid with a vinyl covered pad, was observed. The vinyl pad had several areas covered with tape. One area in the middle of the table pad appeared to have tape residue. The middle of this area had a small tear.

During the interview with the physical therapist on 3/30/10 at 10:30 a.m., the therapist stated the table was used for patients. The table was cleaned after every patient. He further indicated the tape covered numerous small holes on the table.

Based on observation and staff interview, the facility failed to ensure outdated medications were not available for patient use in the operating room. Findings include:

During the survey of the operating room area on 3/30/10, beginning at 2:45 p.m., the surveyor discovered the following outdated medications in the anesthesia cart;

- one 2 milliliter (ml) glass ampule of Bupivacaine 0.75% spinal with the manufacturer's expiration date of 1/1/10.
- one 10 ml vial of Vercuronium (paralytic) with the manufacturer's expiration date of Jan. 2010.
- one 2 ml vial of Sodium Nitroprusside 50 milligrams (mg) per 2 ml with the manufacturer's expiration date of 1/8/2009.
- one 1 ml ampule of 1.5% Lidocaine with Epinephrine 1:100,000 concentration with the manufacturer's expiration date of 1/9/09.
- one 5 ml ampule of Metoprolol 5mg/5ml with the manufacturer's expiration date of 2/1/10.
- one Albuterol inhaler with the manufacturer's expiration date of 2/08.
The cart also contained an open multi-dose vial of Bupivacaine 0.5% solution that was not labeled with the date that the vial had first been accessed.

In an interview with the director of nursing on 3/30/10, at approximately 3:00 p.m., the director stated that the anesthesia staff were responsible for checking the contents of the anesthesia carts for outdates. She stated that according to facility policy, staff are to date all multi-dose vials when they are opened or accessed.

Based on record review and staff interview, the facility failed to ensure that the records were legible, complete, and accurately documented for 5 (#s 3, 9, 10, 11, and 12 ) of 15 reviewed emergency department records. Findings include:

1. Patient #3. The facility form labeled "Interfacility Transfer Authorization" did not document the name of the accepting physician at the facility where the patient was being sent.

2. Patient #9. The facility form labeled "Chest Pain Standing Orders" was not timed as to when the order was received, did not include how the order was received (verbal, telephone, written.), and was not authenticated by the ordering physician with initials or a signature.

3. Patient #10. The facility form labeled "Emergency Department Record" did not document when the emergency room provider was notified of the patient arriving in the emergency department, or when the provider arrived in the emergency department to assess or care for the patient.

4. Patient #11. The facility form labeled "Emergency Department Record" did not document when the emergency room provider was notified of the patient arriving in the emergency department, or when the provider arrived in the emergency department to assess or care for the patient.

5. Patient #12. The facility form labeled "Emergency Department Record" did not document when the emergency room provider was notified of the patient arriving in the emergency department, or when the provider arrived in the emergency department to assess or care for the patient.

In an interview with the acute care manager on 3/30/10 at 11:30 a.m., the manager stated that the emergency department record had been changed in the last few months and the compliance on completion of the form had dropped.

Based on record review and staff interview, the facility failed to ensure that properly executed consent forms were obtained for 12 (#s 3, 4, 7, 8, 10, 11, 12, 13, 14, 15, 16 and 17) of 15 emergency room records. Findings include:

During the review of the selected emergency room records on 3/30/10, beginning at 10:00 a.m., the surveyor noted that the facility form labeled "Emergency Room Consent to Treatment and Emergency Screening" did not contain a space for documentation of the time when the patient or responsible party gave permission for treatment. The following patient records did not have patient specific documentation:

1. The facility form labeled "Emergency Department Record" did not have the time entered when the emergency room provider was notified of the patient arriving in the emergency department, or when the provider arrived in the emergency department to assess or care for the patient. These patients included: #s 3, 4, 7, 8, 10, 11, 12, 13, 14, 15, 16, and 17.

2. In an interview with the acute care manager on 3/30/10 at approximately 11:30 a.m., the manager stated that the facility form did not include a space to document when the consent for treatment was obtained.

Based on record review and staff interview, the facility failed to ensure that physician orders for 1 (#9 ) of 15 reviewed patient records were properly authenticated. Findings include:

During review of clinical records from the emergency department on 3/30/10, beginning at 10:00 a.m., the surveyor noted that the facility order sheet labeled "Chest Pain Standing Orders" for patient #9, dated 11/16/09, were not authenticated by the ordering physician. The sheet did not contain a time that the orders were given, a method of receiving the order (verbal, telephone, etc.) or a valid signature by the physician.

In an interview with the nursing management team on 3/30/10, beginning at 4:30 p.m., the director of nursing stated that all orders should include a physician signature, date, and time.

Based on document review and staff interview, the facility failed to ensure that the current list of governing body approved, individuals with surgical privileges, was maintained in the operating room area. Findings include:

During the survey of the surgery area on 3/20/10, beginning at approximately 2:30 p.m., the surveyor requested to see the surgical privileges book for the operating room. The nurse on duty obtained the binder containing surgical privileges from the office. During the review of the contents of the manual, the surveyor noted that dates of approval of surgical privileges contained in the manual were 2007 for all providers.

In an interview with the director of nursing on 3/30/10 at 2:50 p.m., the director stated that all of the providers had current privileges, but the updated lists had not been forwarded to the operating room for inclusion in the book.