HospitalInspections.org

Citation Text for Tag 0204, Regulation 6R40

Welken, Kathleen
Based on observation, interview, audit reviews, and policy review, the provider failed to ensure the plan of correction (POC) for the 6/8/11 re-certification survey had been completed. Outdated emergency room (ER) supplies and sterile instruments had not been removed. Findings include:

1. Observation on 8/1/11 at 12:30 p.m. revealed:
*In the Broslow/Hinkle PES (pediatric emergency system) color-coded cart were the following outdated supplies:
-Pink/red drawer:
*Intravenous (IV) module - July 2008.
*Intubation module (airway into the trachea) (opened package) - August 2009.
-Purple drawer:
*IV module - June 2008.
*Intraosseous module (IO, within the bone) -April 2011.
*Oxygen module - June 2011.
*Intubation module - August 2009.
-Yellow drawer:
*IV module - July 2008.
*Intubation module - August 2009.
*IO module - April 2011.
*Oxygen module - June 2011.
-White drawer:
*IV module - July 2008.
*Intubation module - July 2009.
*IO module - April 2011.
-Blue drawer:
*Oxygen module - June 2011.
*IV module - June 2008.
*Intubation module - July 2009.
*IO module - April 2011.
-Orange drawer:
*IV module - June 2008.
*Intubation module - July 2009.
*IO module - November 2001.
-Green drawer:
*IV module - July 2008.
*Intubation module - July 2009.
*IO module - April 2011.
*Oxygen module - June 2011.
*Sterile packages and supplies:
-Bone marrow needle (taped to the wall) - February 2011.
-Large needle holder - February 2011.
-Two curved mosquito clamps - June 2011.

Review of the provider's weekly supply checklist for outdates revealed the only time this had been completed was on 6/21/11.

Review of the provider's end of month supply checklist revealed the only time this had been completed was on 7/5/11.

Review of the provider's revised July 2011 outdated medications and supplies policy revealed supplies would be monitored for outdates when taken from the store room and annually when inventory was counted.

Review of the provider's 7/28/11 POC revealed:
*All expired treatment kits and expired packs of sterilized instruments had been taken out of the ER and replaced with updated equipment and supplies.
*The ER would be checked twice monthly for one month, then once a month annually for out-dated supplies.

Interview on 8/1/11 at 1:00 p.m. with the director of nursing (DON) revealed:
*The unit secretary/purchasing individual had been on leave since 5/4/11.
*They had removed some of the out-dated supplies but had left some until new supplies could be ordered.
*She agreed the audits of the ER supplies had not been completed as the POC stated.

Interview on 8/1/11 at 1:45 p.m. with the unit secretary/purchasing person revealed:
*She had advised the DON not to remove some of the out-dated supplies, as they did not have new supplies to replace the out-dated supplies.
*She was the only person who did the ordering of supplies.
*She had just ordered the replacement supplies on 7/29/11.

A. Based on record review, medical staff and governing board minutes, and interview, the provider failed to ensure the plan of correction (POC) from the 6/8/11 re-certification survey had been completed. Five of five sampled physicians (A, B, E, G, and H) and three of three sampled allied health professionals (C, D, and F) had not been credentialed and privileged according to the provider's By-Laws Rules and Regulations. Findings include:

1. Record review revealed physicians A, B, E, G, and H and allied health professionals C, D, and F had not been credentialed and privileged.

Review of the governing board minutes from 6/24/11 and 7/22/11 revealed no documentation of credentialing and privileging for the above physicians and allied health professionals had been presented for approval.

Interview on 8/1/11 at 2:05 p.m. with the human resources director revealed she had organized the credentialing files for physicians A and B and allied health professionals C, D, and F. She was in the process of organizing the other physician's files. She stated she was not aware of the process for credentialing and privileging.

Interview on 8/2/11 at 4:15 p.m. during the exit conference with the administrator revealed:
*He thought the credentialing process had been completed in 2010.
*He agreed the POC from the 2008 re-certification survey had never been completed.
*He had not checked with the human resources director to see if the credentialing process had been completed.
*There had not been a medical staff meeting since 6/2/11 for the credentialing process to be addressed.
*The medical staff only met on a quarterly basis and no special meeting had been called.

Review of the provider's 7/28/11 POC revealed:
*The credentialing process would be completed by 7/28/11.
*The files would have been reviewed by the medical staff and governing body.
*The process would be completed by the administrator and human resource director.

B. Based on observation, record review, and interview, the provider failed to ensure the POC for the re-certification survey completed on 6/8/11 had been completed. Findings include:

1. Review of the provider's POC signed by the administrator on 7/1/11 revealed the POC for C204, C241, C276, C278, C279, C280, C297, and C307 had not been fully completed by 7/28/11.

2. Review of the the governing board 6/24/11 meeting minutes revealed a survey had been completed and "They found deficiencies in our credentialing process, policy and procedure review, QA (quality assurance) program, fire drills, and door latches among other things." There was no further documentation regarding the survey.

3. Review of the governing board 7/22/11 meeting minutes revealed a new quality improvement program policy had been approved. There was no further documentation regarding the survey.

4. Interview on 8/2/11 at 4:15 p.m. with the administrator during the exit conference confirmed:
*He thought all parts of the POC had been completed.
*He was the administrator and chief executive officer (CEO) over all personnel, the condition of the facility, and was the sole peson responsible for the POC.
*He had signed the POC.

Refer to C204, C241, C276, C278, C279, C280, C297, and C307.

Based on observation, policy review, and interview, the provider failed to ensure the plan of correction from the 6/8/11 re-certification survey had been completed for the monitoring of high-risk medications. Findings include:

1. Observation and interview on 8/1/11 at 2:05 p.m. with the pharmacist revealed:
*He had not monitored the use of high-risk medications against the physicians' orders.
*He had not reported any discrepancies to the acute care coordinator or director of nursing.
*He stated he had noted some discrepancies when he had done his perpetual inventory.
*He had only identified potassium chloride and propanofol with a red sticker as high-risk medications.
*He agreed he had not followed the provider's high-risk medications policy for identifying the high-risk medications on a separate shelf in the pharmacy.

Review of the provider's revised June 2011 high-alert (high-risk) medications policy revealed:
*The pharmacy would dedicate a designated shelving area in the pharmacy for high-risk medications.
*That area would be clearly labeled as "High-Risk Medications."
*The pharmacist would place red stickers on high-risk medications to alert nursing staff to use proper precautions.

A. Based on observation, policy review, and interview, the provider failed to maintain an acceptable degree of infection control in the bathing room. The following was noted in the bathing room: personal drinks, bottles of lotion tied to call cords, dirty nail clippers, and a cracked foot rest on the tub transfer chair. Findings include:

1. Observation on 8/1/11 at 1:30 p.m. of the bathing room revealed:
a. A can of opened Monster energy drink on the counter.
b. A small bottle of lotion was tied to the call cord for the bathtub (photo 1).
c. A large nail clipper was found with nail clippings in a plastic basket with other personal care items in the cupboard. Those nail clippings appeared to have dried blood on them(photos 2 and 3).
d. The plastic foot rest on the tub transfer chair was broken and cracked (photo 4).

Interview at 3:30 p.m. on that same day with the long term care (LTC) coordinator confirmed the above findings. She stated staff were aware they could not have food or drink in patient care areas and removed the can at that time. She also stated staff had been told not to tie anything to the call cord of the bathtub. The LTC coordinator revealed staff were aware all nail clippers must be clean and disinfected after each use. She removed the basket of clippers and personal care items from use at that time. She also confirmed the broken and cracked foot rest.

Interview at 4:45 p.m. on 8/2/11 with the acute care (AC) coordinator revealed she did not have a policy for food and drink in patient care areas. She stated she had signs posted at the nurses station that stated no food or drink were allowed in patient care areas. Observation of the nurses station at that time with the AC coordinator revealed no signage could be found regarding the above. The AC coordinator revealed she had a policy at one time regarding how to clean and store nail clippers, but she could not locate the policy at the time of this survey. The AC coordinator also revealed she had taken the tub transfer chair apart last month and had maintenance repaint the chair. She said apparently maintenance had replaced the broken foot rest after painting the chair without letting her know a new one should have been ordered.


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B. Based on interview, the provider failed to ensure all the audits for the plan of correction for the re-certification survey of 6/8/11 had been completed for cleaning and disinfection of the personal care items and the tub. Findings include:

1. Interview on 8/1/11 at 5:00 p.m. with the AC coordinator revealed she was not aware she had been assigned the responsibility for auditing for proper cleaning and disinfection of the facility razor and tub. She stated she had not completed any observations of staff.

Based on observation, testing, record review, audit sheet review, board minutes review, and interview, the provider failed to implement and follow the previous plan of correction. The pantry was found out of the acceptable range of 70 degrees Fahrenheit (F) for dry food storage for the entire month of July 2011. Food temperatures on the serving line were not kept at acceptable limits for cold holding of 41 F or below. The plaster walls beneath the dishwasher and under the soiled and clean drain boards were cracked, broken, and deteriorated. Findings include:

1. Observation on 8/1/11 at 3:15 p.m. revealed the ambient air temperature in the food pantry was very warm. The digital thermometer in the room read 103 F. Testing of the air temperature with the surveyor's thermometer revealed 102.7 F.

Interview on that same day at 3:45 p.m. with the maintenance director revealed he was aware of the high temperatures in the pantry and kitchen. He stated the air handler for the air conditioning that served the kitchen had been up and running a couple weeks ago. The maintenance director revealed the air handler had to be shut down again at the beginning of the last week, so the old one could be torn out and the new one installed.

Interview on that same day at 4:30 p.m. with the dietary manger (DM) confirmed those findings. She stated the temperature in the pantry had not been anywhere near the allowable 70 F for the entire month of July 2011. The DM stated the temperature in the pantry the week before had averaged about 92-93 F. She said she had told her staff to monitor the food in the pantry very close. She said she had to discard some cans due to bulging containers. The DM stated she had requested a portable air conditioning unit for the pantry. But the DM stated she had been told it would be too hard to vent. The DM stated the air temperature had been so hot in the kitchen that employees had been sick. The DM also showed the surveyor a bin of chocolate chips with a clear lid. That bin of chocolate chips had melted into globs of chocolate inside the bin.

Continued observation and testing on 8/2/11 at 9:00 a.m. revealed the ambient air temperature in the pantry was 98 F.

Note: The outside air temperature was 104 F on 8/1/11 and 88 F on 8/2/11 according to the National Weather Service.

2. Observation and testing at 5:50 p.m. on 8/1/11 revealed the cold corn salad on the serving line was found at 56 F and the cold turkey sandwiches were found at 56 F. Interview with cook N revealed she had taken the food temperatures on the serving line about 30 minutes prior to the surveyor's testing. She was aware the temperatures might be out of the correct range, because it was so hot in the kitchen. Testing of the ambient air in the kitchen revealed it was at 98 F. The window air conditioning unit in the kitchen was producing warm air and was no longer cooling.

Review of the plan of correction dated 7/28/11 revealed: "Portable air conditioning units have been installed in the kitchen area as of 6/30/11 and the main chiller for the entire facility has been activated as of 6/15/11."

At the exit interview on 8/2/11 at 4:25 p.m. the administrator stated there was a portable air conditioner installed in the kitchen. The surveyor relayed to the administrator the air conditioner in the kitchen was a window air conditioner and had been installed spring of 2011. It was not the portable air conditioning units he had stated would be installed as of 6/30/11 in the plan of correction dated 7/28/11.

3. Observation on 8/1/11 at 4:00 p.m. revealed the plaster walls beneath the dishwasher and under the soiled and clean drain boards were cracked, broken, and deteriorated (photos 4, 5, 6, 7, 8, and 9). Broken tiles and pieces of plaster lay on the floor. Interview with the DM at the time of the observation confirmed that finding. She stated she was aware the walls had not been repaired. She stated she was unaware materials had been ordered and were on hand prior to the initial survey on 6/8/11. The DM was told the dishwasher must be pulled away from the wall to completely repair the wall, and it might take up to 2 days.

Exit interview on 8/2/11 at 4:25 p.m. with the director of nursing and the long term care and the acute acre coordinator confirmed the above findings. They also confirmed the materials had been on hand prior to the initial survey.

Review of the plan of correction dated 7/28/11 revealed: "Plaster and wall in dishwasher room will be repaired by 7/28/11. Administrator and Maintenance Director will perform monthly inspection of dietary department to monitor the department of needed repair."

4. Review of the 7/2011 monthly audit sheet revealed the following items had not been checked by the administrator: food temperatures (salad bar); storage room temps (too warm); and dishwasher area (walls, plaster, and pipes).

Review of the 7/22/11 governing board meeting minutes revealed:
*On 7/25/11 a demonstration of the air handling systems that supplied the dietary area and nursing home dining room with air-conditioning would be completed.
*The administrator was working on an emergency air-conditioning plan in case of extreme heat.
*The board requested the emergency equipment be in place before the demolition and down time began.

Based on record review and interview, the provider failed to ensure the plan of correction (POC) for the re-certification survey 6/8/11 had been completed for the review of the radiology and pharmacy manuals. Findings include:

1. Review of the radiology and pharmacy policy manuals revealed they had not been reviewed by the administrator, director of nursing, medical staff, pharmacist, radiology, and governing board.

Interview on 8/2/11 at 4:15 p.m. during the exit conference with the administrator confirmed those policy manuals had not been reviewed as per the POC that had a completion date of 7/28/11.

Based on interview, the provider failed to ensure the plan of correction for the re-certification survey completed on 6/8/11 had been completed. The medical director failed to instruct all medical providers on authenticating all verbal orders, and all emergency room medication orders were to be dated, timed, and signed. Findings include:

1. Interview on 8/2/11 at 8:20 a.m. with the medical director revealed:
*There had not been a medical staff meeting since 6/2/11.
*Medical staff meetings were held on a quarterly basis.
*He was aware he was to have instructed all the medical staff providers on the authentication of orders.

Interview on 8/2/11 at 4:15 p.m. with the administrator during the exit conference confirmed no medical staff meeting had been conducted.

Based on interview, the provider failed to ensure the plan of correction for the re-certification survey completed on 6/8/11 had been completed. The medical director failed to ensure all medical providers had been instructed on dating, timing, signing, and authenticating. Findings include:

1. Interview on 8/2/11 at 8:20 a.m. with the medical director revealed:
*There had not been a medical staff meeting since 6/2/11.
*Medical staff meetings were held on a quarterly basis.
*He was aware he was to have instructed all the medical staff providers on the authentication of orders.

Interview on 8/2/11 at 4:15 p.m. with the administrator during the exit conference confirmed no medical staff meeting had been conducted.