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Based on observation, interview, and policy review, the provider failed to implement policies and procedures to ensure:
*Hand sanitizers randomly found throughout the hospital were removed before they expired.
*The automated dispensing system used to add sanitizer to the laundry was working correctly for the sanitizing of colored linen.
*Thermometers had been maintained and were graphing the correct temperatures for two of two sampled medication refrigerators (nursing medication room and outpatient area).
Findings include:

1. Random observation on 1/21/15 from 8:00 a.m. to 11:00 a.m. throughout the hospital revealed:
*Multiple bottles of the Ecolab Quick-care waterless antimicrobial foaming hand sanitizer had expired.
*The bottles were located at the front entrance, rehabilitation (rehab) entrance, by the two treatment tables in rehab, the entrance of room 119, room 124, the family room, staff break room, the laboratory, the nursing home, the patient care services office, inside each of the two blood draw rooms, and in the hall by the blood draw rooms.
*The expired dates ranged from January 2013 to August 2014.

Interview on 1/21/15 at 10:00 a.m. with the head of housekeeping revealed:
*Ecolab Quick-care waterless antimicrobial foaming hand sanitizer had been placed on the walls randomly throughout the hospital for patients and staff to use for sanitizing their hands.
*It would be housekeeping's responsibility to ensure the hand sanitizer was removed when it had expired.
*The housekeepers were not monitoring the hand sanitizers for the expiration dates.
*They had no policy and procedure for monitoring the hand sanitizer for the expiration dates.

2. Observation and interview on 1/21/15 at 10:45 a.m. with the head of housekeeping and employee A in the laundry room revealed:
*The hose connecting the Advacare sanitizer to the automated dispensing system for the wash machine was broken and was not connected.
*They were not aware the hose was broken or how long it had been broken.
*All linens washed in the wash machine were to be washed with the sanitizer. The white linens were also sanitized with chlorine bleach.
*All colored linens were not being sanitized.
*They had no policy and procedure to verify the automated dispensing system that dispensed the detergent, fabric softener, chlorine, and the sanitizer was working correctly when used.
*The service agent came monthly to check the system and was last there in December 2014.
*They relied on the service agent to ensure the equipment was working correctly.



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3. Random observations on 1/21/15 revealed the medication refrigerators in the outpatient and inpatient areas had graph paper and digital readout thermometers. The refrigerator logs revealed the temperatures to be within the correct ranges. Observations of the graph papers revealed the temperatures to have been between 60 to 70 degrees Fahrenheit.

Interview on 1/21/15 at 2:30 p.m. with the director of patient care confirmed they were using digital thermometers within the refrigerators. He was unable to determine if the graph paper was recording the refrigerator temperatures or something else.

Interview on 1/21/15 at 3:15 p.m. with the pharmacist revealed she was not aware of what the graph paper was recording. That day she had contacted the manufacturer and confirmed the graph paper was not the appropriate graph paper. The graph paper had been recording the temperatures of the refrigerators. The manufacturer also confirmed the thermometer had not been re-calibrated since 2005. She had ordered the correct graph paper that day and had sent the thermometers in to be re-calibrated. She revealed the provider did not have a preventive maintenance program or policies for the refrigerator thermometers.

Review of the provider's updated March 2013 Faulkton Area Medical Center Pharmacy Policy and Procedure Manual, Medication Storage in the Medication (med) Room (Nurses Station) policy revealed:: "All refrigerators must be equipped with a thermometer and temperatures maintained with acceptable ranges. The pharmacy tech [technician] will monitor these temperatures and change the device recording graph on a weekly basis. These recording graphs will be kept in the pharmacy." The pharmacist revealed during the above interview there was no pharmacy tech.

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Based on interview and policy manual review, the provider failed to ensure policies were reviewed annually for three of six departments (radiology, pharmacy, and emergency). Findings include:

1. Review of the radiology department's computed tomograph (CT) policy and procedure manual revealed it had last been reviewed in 2011.

Interview on 1/22/15 at 2:00 p.m. with the radiology director confirmed the CT policy and procedure manual had not been reviewed annually as required.

2. Review of the pharmacy department's policy and procedure manual revealed:
*No face sheet indicated the date the policy manual had been reviewed.
*A Table of Contents page indicated it had been updated March 2013.

Interview on 1/21/15 at 1:15 p.m. with the pharmacist confirmed the policy manual had not been reviewed in 2014.

3. Review of the emergency department's policy and procedure manual revealed it had last been reviewed on 9/28/11.

4. Interview on 1/22/15 at 4:15 p.m. with the administrator revealed they reviewed policies as needed. There was no process in place for reviewing policy and procedure manuals annually.

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Based on observation, interview, and policy review, the provider failed to ensure the security of medications for the following locations:
*One of one unlocked unsupervised clean utility room in the outpatient area that had medications stored in there.
*One of one unlocked, unsupervised procedure room crash cart.
*Two of two medication rooms (medical unit and outpatient area).
Findings include:

1. Observation on 1/21/15 at 11:30 a.m. revealed a large unlocked blue plastic tote sitting on the floor in the unlocked, unsupervised clean utility room in the outpatient area. Upon examination the following medications were found in that tub:
*Lyrica (pain medication) 50 milligram (mg) and 75 mg professional sample bottles. That was a class IV (four) (controlled substance) medication.
*Celebrex (antidepressant) 200 mg professional samples.
*Amrix ER (extended release) (muscle relaxant) 15 mg professional samples.
*Cymbalta (antidepressant) 30 mg and 60 mg professional samples.
*Suboxane (used to treat opoid [strong pain medication] dependence) 4 mg/film. That had been labeled with a patient's name, and there were twenty-five films in the box.
*Lexapro (antidepressant) 10 mg professional samples.
*Savella (pain medication) twenty-five mg professional samples.
There had been no nurse or staff on duty in that area that day because of staff call off (staff illness).

Interview on 1/21/15 at 1:45 p.m. with the director of patient care and the pharmacist revealed they were not aware of the tote and its contents. They both agreed those medications were to have been secured and kept locked up. They had determined the tote belonged to a physician that performed an outreach clinic within the outpatient area monthly.

2. Observation on 1/21/15 at 11:20 a.m. revealed an unlocked, unsupervised medication room in the outpatient area that had a medication refrigerator with the following medications in it:
*Neupogen (used for blood disorders), four single dose vials.
*Aranesp (used to blood disorders), one syringe.
*Prolia (used to treat bone loss), one syringe.
There had been no nurse or staff on duty in that area that day because of staff call off (staff illness).

Interview on 1/21/15 at 1:45 p.m. with the director of patient care confirmed that room was to have been locked when no one was present.

3. Observation on 1/21/15 at 11:30 a.m. revealed an unlocked, unsupervised procedure room in the outpatient area. In that area had been a crash cart with the key to unlock it on the left side handle. That key was attached with a removable zip tie. The cart could be moved without difficulty. The door could not be locked, because there was no lock on it. There had been no nurse or staff on duty in that area that day because of staff call off (staff illness).

Interview on 1/21/15 at 1:45 p.m. with the director of patient care confirmed there was no way to lock the above door. The medications in the crash cart were open to anyone who could remove the key. The cart was easily moved from one area to the next by one person.

4. Observation on 1/21/15 at 12:10 p.m. of the inpatient medication room revealed patient 15's bottled home medications were in a white plastic sack in the medication room with the patient's name written on a label. The following medications were in that sack:
*Calcium 600 mg with D3 (Vitamin D 800 international units [IU].
*Potassium Chloride 10 milliequilivents.
*Aspirin 325 mg.
*Omeprazole 40 mg.
*Oxycodone (a controlled pain medication)5 mg.
*Vitamin D 50,000 IU.
*Acyclovir 400 mg.
*Ondansetron 4 mg.
*Meclizine 25 mg.
*Cyclobenzaprine 10 mg.
*Carvedilol 3.125 mg.
*Fludrocortisone 0.1 mg.
*Zantac 75 mg.
*Sertraline 50 mg.
*Unlabeled small brown bottle.
*Slow Magnesium 64 mg.
There were pills in all of the bottles except the Oxycodone. That was a controlled substance. There had been no accounting for the medications in the bottles.

Interview at that time with registered nurse (RN) B confirmed there had been no accounting for the number of pills in each bottle when the above medications had been brought into the building.

Interview on 1/21/15 at 1:15 p.m. with the pharmacist confirmed the above home medications were to have been sent home with the family. If the medications could not have been returned to the family an accounting of the medications should have been done.

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5. Observation and interview in the medication room on the medical unit on 1/20/15 at 11:00 a.m. with RN B revealed:
*There was a cupboard that contained medications that had been brought from home.
*A pill caddy with unidentified medications was in it.
-The pill caddy belonged to patient 12 and had her name written on it.
*RN B confirmed they had not identified or documented what medications were in that pill caddy.
*Patient 12 was no longer in the hospital, as she had been discharged a couple days ago.
-The pill caddy and the medications should have been sent home with the patient when she was discharged.

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6. Review of the provider's updated March 2013 Faulkton Area Medical Center (FAMC) Pharmacy Policy and Procedure Manual, Patient's Own Medications policy revealed a handwritten statement at the bottom of the sheet stating "Count when home medications (med) brought in and on discharge if meds are keep at the hospital."

Review of the provider's updated March 2013 FAMC Pharmacy Policy and Procedure Manual, Narcotics policy revealed "All narcotics (CII-V [class 2-5]) will be secured in a locked cabinet and a perpetual [ongoing] inventory maintained."

Review of the provider's FAMC Pharmacy Policy and Procedure Manual, Director of Pharmacy Position Description and Responsibilities policy revealed she was responsible for:
*"Dispense all narcotic drugs, barbiturates, alcohol, and other restricted or controlled drugs and maintain the required records related thereto."
*"Proper storage of drugs and chemicals to prevent deterioration and development of hazardous conditions."
*"Comply with all federal, state, and local laws."




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Based on observation, interview, and policy review, the provider failed to ensure the

Based on observation and interview, the provider failed to ensure an environment free from cross contamination had been maintained during the storage of three of three endoscopes (lighted tubes to look inside the body) stored in the dirty utility room in the outpatient area. Findings include:

1. Observation on 1/21/15 at 11:30 a.m. revealed two endoscopes had been hung in a closet in the soiled utility room. The longer endoscope was touching the floor of the cabinet. That cabinet did not have ventilation for those endoscopes. There was one endoscope sitting on the floor of the cabinet stored in a black case.

Interview on 1/22/15 at 9:30 a.m. with unlicensed assistive personnel (UAP) C revealed she was the staff member that cleaned, performed the high level disinfection, and stored the endoscopes. She confirmed the following:
*The endoscopes were stored in the soiled utility room, because that was "where they are cleaned and disinfected."
*She was not aware the cabinet needed ventilation.
*She was not aware the endoscopes could not touch the floor of the cabinet even if the tip had a cover on it.
*She was not aware of when or how the endoscope stored in the black case had been cleaned and disinfected.
*She was not aware if the endoscopes had not been used within fourteen days they needed to be reprocessed.
At that time a policy for cleaning, disinfecting, processing, and reprocessing of the endoscopes along with storage of the endoscopes had been asked for. She was unable to provide a policy by the end of the survey on 1/22/15 at 5:00 p.m.

Interview on 1/22/15 at 10:10 a.m. with the director of patient care confirmed infection control had been breached. He confirmed the endoscopes stored within the cupboard needed to be vented. The endoscope should not be touching the floor of the cabinet. The endoscopes should have been reprocessed if not used within fourteen days of high level disinfecting. The potential for cross contamination was high due to the endoscopes being stored in the soiled utility room.

Based on medical record review and interview, the provider failed to ensure a nursing care plan had been implemented for 12 of 12 sampled inpatients (15, 17, 18, 19, 20, 21, 22, 29, 30, 31, 32, and 33). Findings include:

1. Review of patient 15's medical record revealed:
*He had been admitted on 1/20/15.
*His diagnoses were:
-Syncope (fainting) three times.
-Sinusitis (infection of sinuses).
-Multiple myleoma (MM [a disease of the bone marrow]).
-Orthostatic hypotension (blood pressure falls when position changed).
-GERD (reflux).
-Depression (feeling down).
-DJD (degeneration of joints).
-Coronary artery disease.
-Immunosuppressed (decreased ability to fight infections) secondary to MM.

Review of the medical record revealed he did not have a nursing care plan in either the paper or electronic charts.



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2a. Review of patient 17's medical record revealed:
*She had been admitted as an inpatient on 2/5/14 and discharged on 2/18/14.
*There had been no nursing care plan documented.

b. Review of inpatients 18, 19, 20, 21, 22, 29, 30, 31, 32, and 33's medical records revealed no care plan documentation.

3. Interview on 1/21/15 at 2:00 p.m. with registered nurse B revealed:
*She was unable to locate patient 17's care plan.
*She stated care plans were no longer used.

Interview on 1/22/15 at 2:15 p.m. with the director of nursing revealed:
*A work list was used to provide the care for patients.
*The paper care plans had been discontinued.
*There was no policy stating how the work lists would have been used to provide patient care.

A. Based on record review, interview, and policy review, the provider failed to ensure:
*The consent form for one of six surgical patients (10) indicated the surgical procedure and the time the consent form had been signed.
*The Transfer Consent Form was completed accurately and indicated what medical record information had been sent with one of one sampled emergency room (ER) patient (5) that had been transferred to another healthcare facility.
Findings include:

1. Review of patient 10's medical record revealed:
*She had been admitted on 1/20/15.
*The surgical consent form had been signed by the patient on 1/20/15. The form had not indicated:
-The procedure that was going to be performed.
-The time the consent had been signed.

Interview on 1/22/15 at 10:58 a.m. with the director of nursing (DON) confirmed:
*She would have expected the surgical consent to have been completed and would have included:
-The procedure description to be written out and in easy to understand language.
-The time the consent had been signed.
*They did not have a policy on obtaining consents.




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2. Review of patient 5's ER medical record and his undated ER Transfer Consent form revealed:
*He had presented to the ER on 11/22/14 for treatment of a head trauma and scalp laceration.
*He had been transferred by private automobile accompanied by his mother to another healthcare facility for additional treatment.
*His ER Transfer Consent form had not indicated if any of his medical record information had been provided to the patient at the time of his transfer.
*There was no documentation the receiving healthcare facility had been provided or had access to the patient's medical record.

Review of patient 10's Patient Education form revealed the patient had been transferred to another healthcare facility. The form indicated "Patient has consented to be transferred to another facility for care. All appropriate information and documentation will be sent to the receiving facility." The patient's medical record had not indicated what information had been sent nor a date and time when the information had been sent to the receiving facility.

Interview on 1/23/15 at 2:00 p.m. with the ER manager regarding patient 10's transfer documentation confirmed:
*The Transfer Consent Form had not been completed per hospital policy.
*There was no documentation in the medical record what patient information had been provided to the receiving hospital.
*The patient had signed the transfer form in the section titled "Patient Refusal to Consent to Transfer."
*The patient should have signed the Transfer Consent form in the section titled "Patient Request to Transfer."
*The Transfer Consent form had not been dated and timed by the practitioner or the patient.

Review of the provider's Transfers and EMTALA (Emergency Medical Treatment and Labor Act) policy dated 9/28/11 revealed:
*The transferring hospital was responsibility to ensure the receiving hospital was provided all medical records or copies related to the emergency medical condition.
*Emergency medical information included but was not limited to the "...individual's emergency condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of studies, treatment provided and the informed written consent or certification required..."
*Any records that were not available at the time of the patient's transfer would have been sent to the receiving healthcare facility when available.

B. Based on record review, interview, and policy review, the provider failed to ensure the level of sedation was documented for three of three surgical patients (7, 9, and 11) that received conscious sedation for their surgical procedures.
Findings include:

1. Review of the surgical records for patients 7, 9, and 11 revealed the section to document the sedation level of each patient had been left blank. During patients 7, 9, and 11's surgical procedures vital signs had been documented that included time, blood pressure, pulse, respirations, and oxygen saturation. There was no documentation of the patients' sedation level or pain level during their surgical procedures.

Review of the intraoperative procedure form revealed the nurse responsible for monitoring the patients should have documented the sedation level numerically as follows:
*0-there was no sedation, and the patient was alert
*1-mild - the patient was "Occasionally drowsy; easy to arouse."
*2-moderate - the patient was "Frequently drowsy; easy to arouse."
*3-severe - the patient was "Stuporous; difficult to arouse."

Interview on 1/22/15 at 2:30 p.m. with the director of patient care services confirmed:
*Nursing staff monitoring the above listed patients had not documented each patient's sedation level.
*Each patient receiving conscious sedation should have had a sedation level documented throughout the procedure.
*Each of the above listed patients received Versed and Propofol as sedating agents during their endoscopic surgical procedures.
*Assessing the patient's sedation level would assist with determining the patient's level of consciousness.

Review of the provider's Nurse-Administered Propofol Sedation policy dated June 2011 revealed:
*The "Sedation Nurse will decide when to give bolus based on the following:
-Coughing or gagging of patient.
-Aversive body language.
-What is going on with the patient post procedure.
-Request of the medical provider if the safety of the patient is not an issue."
*The policy did not address documentation of the patient's level of consciousness (LOC) as outlined on the intraprocedure vitals form.

Review of the Association of periOperative Registered Nurses, Perioperative Standards and Recommended Practices, 2014 Edition, revealed:
*Page 474 - "The patient's LOC and ability to respond to verbal commands should be a routine assessment indicator, except in patients unable to respond (eg [for example], young children, mentally impaired, dental surgery)."
*Page 474 - "Assessing the patient's LOC by his or her verbal responses at regular intervals during the procedure can quickly determine if the patient is also breathing well."

Based on observation and interview, the provider failed to ensure patient confidentiality had been maintained by leaving confidential information including name, picture, and medication in one randomly observed unlocked room (outpatient area). Findings include:

1. Observation on 1/21/15 at 11:30 a.m. revealed a large unlocked blue plastic tote on the floor of the unlocked clean utility room in the outpatient area. Stored in the tub were:
*A box of Suboxone (used to treat strong pain medication dependence) with a patient's name label on it that contained a patient's name.
*A money receipt book that listed patients' names and amounts of money paid to the provider.
*A picture of a patient in a gown with a name on the back of the picture.

Interview on 1/21/15 at 1:45 p.m. with the director of patient care confirmed he was not aware of the blue plastic tub and the contents within the tub in the clean utility room of the outpatient area. The provider was asked for a patient confidentiality policy on 1/22/15 at 10:10 a.m. and one was not provided prior to leaving on 1/22/15 at 5:00 p.m at the end of the survey.

Based on interview, the provider failed to ensure an annual review of active or closed medical records had been completed. Findings include:

1. Interview on 1/22/15 at 1:15 p.m. with the director of patient care services revealed:
*They did not have a committee that reviewed medical records for:
-Necessity of admissions to the hospital.
-Length of stay in the hospital.
*They discussed each patient during the admission process.
*They had discussed the need for a review of admissions and hospital utilization.
-They had never formalized this process.
*They had no minutes or policies regarding utilization review.

Based on record review, interview, and policy review, the provider failed to complete an activity assessment and provide an activity program for six of six sampled swing bed patients (23, 24, 25, 26, 27, and 28). Findings include:

1. Review of the medical records for patients 23, 24, 25, 26, 27, and 28 revealed there had not been an individual activity assessment completed on admission.

Interview on 1/21/15 at 9:15 a.m. with resident 23 revealed he:
*Had been admitted to the swing bed unit on 1/19/15 with leg and back pain.
*Remained in his room most of the day.
*Left his room to go to therapy.
*Had spent most of his time watching television and reading the newspaper. He had not been offered any other type of activity.

Interview on 1/21/15 at 1:10 p.m. with the activity coordinator revealed:
*She had been the activity coordinator since 2008.
*She had not developed a formal assessment to be reviewed with the patient upon admission. All interviews had been informal and not documented.
*She had not developed an activity program nor a calendar of events for the patients to select from.
*The staff would have offered the patients cards, puzzles, word search, or to watch a movie.
*Most of the patients preferred to remain in their rooms, watch television, and read. She had no documentation to support those interviews.
*She had not planned or offered any group activities for the patients.
*She had not been aware of any provider policy and procedure for activities or an activity program.

Interview on 1/21/15 at 3:30 p.m. with the registered nurse care coordinator confirmed the staff were expected to offer the above mentioned activities to the patients. She stated they did no assessments related to activities, had no formal activity program, and had no policies or procedures in place regarding activities that she was aware of for an activity program.




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Review of the provider's undated Swingbed Activity Program policy revealed "Discuss with the patients what their interests are, what they would like to do while at [name of facility] and assess each patient's illness limitations etc."

Review of the provider's admission packet revealed "Activities are a part of the Swing Bed Program and the Activity Coordinator will be in to talk with you and help meet your social and personal needs while you are at the [name of facility.]"

Based on record review, interview, and policy review, the provider failed to ensure comprehensive care plans were in place for six of six sampled swing bed patients (23, 24, 25, 26, 27, and 28). Findings include:

1. Review of patient 27's medical record revealed:
*She had been admitted on 1/19/15.
*Her diagnoses were left tibial plateau fracture (broken leg), diabetes mellitus (uncontrollable blood sugar levels in the blood), hypoxia (low level of oxygen in the blood), and hypertension (high blood pressure).

Review of her medical record revealed no nursing care plan in either the paper or the electronic charts.

2. Review of patient 28's medical record revealed:
*He had been admitted on 1/19/15.
*His diagnoses were right total knee replacement, anemia (low levels of iron in the blood), degenerative joint disease, and hyponatremia (low levels of sodium in the blood).

Review of his medical record revealed no nursing care plan in either the paper or the electronic charts.

Interview on 1/21/15 at 1:30 p.m. with the director of nurses revealed the provider had discontinued the use of care plans a week ago. They had been informed the complete medical record was considered the patient's care plan.



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3. Review of patient 23's medical record revealed he had been admitted to a swing bed on 1/17/15. He did not have a care plan in his record.

4. Review of patient 24's medical record revealed she had been admitted to a swing bed on 6/13/14 and discharged on 8/1/14. There was not a care plan in her record.

5. Review of patient 25's medical record revealed she had been admitted to a swing bed on 1/16/15. She did not have a care plan in her record.

6. Review of patient 26's medical record revealed she had been admitted to a swing bed on 1/17/15. She did not have a care plan in her record.

7. Review of the provider's undated Swing Bed Program/Nursing policy revealed:
*"The nursing care plan found in front of the nurses notes will be reviewed and updated as necessary.
*It will be implemented on admission.
*It will coincide with the medical care plan including: problems, interventions, and evaluation of plan of care.
-Evaluation of care plan will be done twice a week, preferably every Wednesday and Sunday."