HospitalInspections.org

Based on review of facility policy, medical record review, and interview, the facility failed to ensure the family and/or guardian was notified of a transfer for 1 patient (#12) of 12 transferred patients reviewed of 36 medical records sampled.

The findings included:

Review of facility policy "Transfer to Another Facility" dated 3/21/17 revealed "...notify the patient's family and/or guardian of the transfer..."

Medical record review revealed Patient #12 was admitted to the facility on 10/27/17 with a diagnosis of a Fall and Hypotension (low blood pressure). Further review revealed the patient was transferred to another acute care facility on 10/28/17 for "...specialized care - Nephrology..." Continued review revealed no documentation of notification to the family or guardian of the patient's transfer.

Interview with the Chief Nursing Officer on 2/27/18 at 5:40 PM, in the conference room, confirmed the facility failed to notify the patient's family or guardian of the transfer and failed to follow facility policy.

Based on facility policy review, medical record review, and interview, the facility failed to ensure medical records were accurate for 1 patient (#24) of 36 medical records reviewed.

The findings included:

Review of the facility policy "Coding" revised 5/23/16 revealed "...the entire medical record should be reviewed when coding...All reports should be reviewed and findings and treatment correlated with the diagnoses that are identified..."

Review of the facility policy "Medical Record Content" revised 5/23/16 revealed "...the medical record shall contain sufficient information to identify the patient, support the diagnosis, to justify the treatment, and document the results accurately...The discharge summary or final summary shall include...All procedures performed..."

Medical record review revealed Patient #24 was admitted to the facility on 10/13/17 for a Diagnostic Laparoscopy (diagnostic procedure of the abdomen). Further review revealed the patient was discharged the same day.

Medical record review of an Informed Consent to Operate or Other Procedure dated 10/13/17 revealed the patient consented for the Diagnostic Laparoscopy.

Medical record review of a Patient Summary report dated 10/13/17 revealed "...Procedure...Abortion of Products of Conception, Percutaneous Endoscopic Approach..."

Interview with the Surgery Manager and the Case Manager on 2/27/18 at 4:50 PM, in the conference room, confirmed the patient had a diagnostic Laparoscopy and the procedure documented on the patient summary was inaccurate.

Based on facility policy review, observation, and interview, the facility failed to ensure 2 emergency crash carts (cart containing emergency equipment and medications) were locked of 5 emergency crash carts observed.

The findings included:

Review of facility policy "Emergency Crash Carts Supplies" dated 7/2017 revealed "...Emergency medication supplies are maintained in sealed crash carts...These carts contain medications and supplies...that are commonly used in emergencies...These carts are standardized throughout the hospital with respect to placement of the drugs and supplies within drawers to enhance patient safety...The cart's seal and integrity are checked by a nursing staff member each day...if the seal has been broken, the carts contents are checked against the medication sign out list...any missing items are to be replaced as soon as possible...if any items are used out of the crash cart, a new drawer will be replaced...the used drawer will be picked up by pharmacy from the ER [emergency room] and will replace and restock the drawer...A red numbered seal is placed on the crash cart to be used for sealing the drawer in the crash cart...The plastic may be removed from the crash cart drawer and then discarded so the seal can be placed on the crash cart itself..."

Observation and interview with the Chief Compliance Officer and Registered Nurse (RN) #1 on 2/27/18 at 8:25 AM, in ER room 6, revealed the emergency crash cart was unlocked. Interview with the Chief Compliance Officer and RN #1 confirmed the emergency cart was last used the previous day. Further interview confirmed the emergency cart was unlocked and the facility failed to follow facility policy.

Observation and interview with the Chief Compliance Officer and RN #1 on 2/27/18 at 9:10 AM, in ER room 7, revealed the emergency crash cart was unlocked. Interview with the Chief Compliance Officer and RN #1 confirmed the emergency cart was last used the previous day. Further interview confirmed the emergency cart was unlocked and the facility failed to follow facility policy.

Interview with the Chief Executive Officer on 2/28/18 at 9:45 AM, in the conference room, confirmed the facility failed to ensure the emergency crash carts were locked and the facility failed to follow facility policy.

Based on review of facility policy, observation, and interview, the facility failed to expired medications were not available for patient use in 2 departments (Medical Surgical Unit and the Pharmacy) of 12 departments reviewed.

The findings included:

Review of facility policy "Expired and Other Unusable Medications" dated 2/2017 revealed "...the Pharmacy Department shall monitor all the medications used in the hospital for expiration dating..."

Observation and interview with the Quality Assurance Director and the Housekeeping Director on 2/26/18 at 2:35 PM, in the medical-surgical storage room, revealed 4 liters of Lactated Ringers with Dextrose 5 % (intravenous fluid used for fluid volume expansion) expired 9/2017. Interview with the Quality Assurance Director confirmed the intravenous fluid were expired and were available for patient use.

Observation and interview with the Quality Assurance Director and the Pharmacy Director on 2/26/18 at 3:50 PM, in the pharmacy narcotic storage room, revealed 50 tablets of Tramadol (pain medication) expired 1/2018. Interview with the Pharmacy Director confirmed the pain medication was expired and was available for patient use.

Based on review of facility policy, manufacturer's recommendations, observation, and interview, the facility failed to follow infection control guidelines in 6 departments (laboratory, medical-surgical unit, central sterile supply, operating room, kitchen, and radiology) of 12 departments observed.

The findings included:

Review of the facility policy "Sterile Manufactured Supplies Expiration Process" dated 12/4/16 revealed "...Manufacturer sterilized items must not be used after the marked expiration date...sterile items throughout the hospital must be checked..."

Review of facility policy "Nutritional Services," undated, revealed "...opened food containers are to have the date...opened..." Further review revealed "...scoop handles may become contaminated via handling. Storage of scoops in bins may contaminate the stored food if the handles come in contact with the food..."

Review of the facility policy "Point of Care (POC) Glucose Testing, Free Style, Precision Pro" dated 5/16/17 revealed "...Quality control [QC] testing will be performed with 2 levels of control (low and high) each day of patient testing...Opened QC is stable for 3 months (90 days)...Opened QC must be labeled with open date and modified expiration date..."

Review of the manufacturer's recommendations for quality control solutions dated 2010-2015, revealed "...Discard control solution 3 months after opening or on the expiration date printed on the bottle, whichever comes first..."

Observation and interview with the Chief Compliance Officer and the Laboratory Director on 2/26/18 at 2:10 PM, in the laboratory, revealed 32 green top blood collection tubes expired 12/31/17. Interview with the Chief Compliance Officer and the Laboratory Director confirmed the blood test tubes were expired and were available for patient use.

Observation and interview with the Quality Assurance Director and the Housekeeping Director on 2/26/18 at 2:35 PM, of the medical-surgical department supply room, revealed 5 urinary catheter kits expired 12/31/17. Interview with the Quality Assurance Director confirmed the urinary catheter kits were expired and were available for patient use.

Observation and interview with the Chief Nursing Officer (CNO) and the Surgery Manager and on 2/26/18 at 2:36 PM, of the central sterile room, revealed 2 unopened packages packing strip (used to pack wounds) expired on 1/2018. Interview with the Surgery Manager confirmed the packing strips were expired and were available for patient use.

Observation and interview with the Surgery Manager on 2/26/17 at 3:17 PM, of the anesthesia supply cart located in Operating Room (OR) #2, revealed two 4.5 millimeter (mm) cuffed endotracheal tubes (ET) (breathing tube) with an expiration date of 11/2017 and two 5.0 mm cuffed ET tubes with an expiration date of 10/2017. Interview with the Surgery Manager confirmed the ET tubes were expired and were available for patient use.

Observation and interview with the CNO and the Surgery Manager on 2/26/18 at 4:00 PM, of the OR anesthesia work room, revealed:
*One Video Guided Intubation Kit with an expiration date of 6/2016
*Six 6.0 mm nasal ET tubes (breathing tube placed through nose) with an expiration date of 8/2014
*Nine 6.0 mm nasal ET tubes with an expiration date of 8/2016
*Seven 5.5 mm nasal ET tubes with an expiration date of 2/2015
*Seven 5.5 mm nasal ET tubes with an expiration date of 5/2014
*Seven 5.5 mm nasal ET tubes with an expiration date of 5/2017
*Ten 5.5 mm nasal ET tubes with an expiration date of 9/2017
*Two 5.5 mm nasal ET tubes with an expiration date of 2/2017
*Three 3.5 mm nasal ET tubes with an expiration date of 3/2014
*Five 3.5 mm nasal ET tubes with an expiration date of 9/2017
*One 3.5 mm nasal ET tube with an expiration date of 5/2016
*One 4.0 mm nasal ET tube with an expiration date of 5/2016
*Six 4.5 mm nasal ET tubes with an expiration date of 4/2017
*Two 4.5 mm nasal ET tubes with an expiration date of 10/2017
*One 4.5 mm nasal ET tube with an expiration date of 9/2017
*Two 4.5 mm nasal ET tubes with an expiration date of 2/2017
*Four 5.0 mm nasal ET tubes with an expiration date of 6/2014
*Seven 5.0 mm nasal ET tubes with an expiration date of 3/2015
Interview with the CNO and the Surgery Manager confirmed the supplies were expired and were available for patient use.

Observation and interview with the Surgery Manager on 2/26/18 at 4:46 PM, of a supply cabinet in the OR Post Anesthesia Care Unit (PACU), revealed 8 breathing treatment solution kits with an expiration date of 1/2017. Interview with the Surgery Manager confirmed the kits were expired and were available for patient use.

Observation and interview with the Certified Dietary Manager (CDM) and the Housekeeping Director on 2/27/18 at 8:30 AM, in the kitchen, revealed a large bin of self-rising cornmeal with a scoop located inside the bin. Further observation of the walk-in freezer revealed the following opened and undated frozen foods: 2 bags of breaded okra and 2 bags (25 patties) of precooked hamburger patties. Continued observation of the dry storage area revealed an opened and undated 3 pound bag of egg noodles. Interview with the CDM confirmed the facility failed to remove the scoop from the cornmeal and failed to date opened packaged foods.

Observation and interview with the Radiology Director and the Housekeeping Director on 2/27/18 at 9:25 AM, of the radiology department, revealed 1 adult lumbar puncture trays expired 5/21/17. Further review revealed 5 large green top vacutainers (blood collection tubes) expired 5/2016. Interview with the Radiology Director confirmed the adult lumbar puncture tray and the vacutainers were expired and were available for patient use.

Observation and interview with the Chief Compliance Officer and Registered Nurse (RN) #2 on 2/27/18 at 9:30 AM, in the emergency room, revealed 1 Lo Control Glucose and Ketone control solution labeled and 1 Hi Control Glucose and Ketone control solution labeled opened 11/1/17 and expired 2/1/18. Interview with the Chief Compliance Officer and RN #2 confirmed the solutions were expired and the facility failed to follow the facility policy.