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Based on observation, record review, and interview, the facility failed to provide care in a safe setting. This deficient practice was evidenced by:
1) Failure to document quality controls for April - June, 2023;
2) Failure to include all glucose monitors being used by the facility in the quality control logs; and
3) Failure to monitor patients in Rm #A with access to plastic cutlery.
Findings:

1) Failure to document quality controls for April - June, 2023

Review of the facility's policies 3.45 titled "Glucose Monitoring System Procedure" and 3.46 titled "Capillary Blood Glucose," revealed, in part: Quality Control Checks of the system will be done daily and the results documented on the monthly Glucometer Monitoring Log.

Review of the quality control logs on 08/22/2023 at 1:30 p.m. revealed the monthly logs for April 2023 - June 2023 were not available.

In an interview on 08/22/2023 at 4:35 p.m. S2DON confirmed there were no quality control logs available for April 2023 - June 2023.

2) Failure to include all glucose monitors being used by the facility in the quality control logs

Review of the facility's quality control logs revealed documentation for 1 glucose monitor. There were 2 EvenCare ProView Glucose Monitors being used by the facility. The logs did not indicate which glucose monitor quality controls were being performed on.

In an interview on 08/22/2023 at 2:00 p.m. S5LPN confirmed her signature by the days she performed the quality controls on the August Quality Control Log. She had performed quality controls for Unit A's glucose monitor on August 2, 4, 5, 8, 11, 16, 18, and 20 of 2023 and recorded the results on the August Quality Control Log. S5LPN confirmed the August Quality Control Log was for the glucose monitor located on Unit A. S5LPN confirmed the unit labeled at the top of the page was incorrect and was not written by her because her entries on the log were for the Unit A's glucose meter. S5LPN also confirmed the presence of a glucose monitor on Unit B, but was unaware of qualtiy controls being performed and unaware of quality control logs for that monitor.

In an interview on 08/22/2023 at 4:35 p.m. S2DON confirmed she was unaware of which glucose monitor the Quality Control Logs referenced.

3) Failure to monitor patients in Rm #A with access to plastic cutlery

An observation on 08/21/2023 at 10:16 a.m. revealed 5 patients sitting in Rm #A watching a movie. There were no staff members present to monitor the activities of these 5 patients. There was a plastic storage bin of plastic cutlery sets located on a counter and were accessible to patients. The plastic cutlery could pose a risk for self-harm, harm to other patients, and/or staff.

In an interview on 08/21/2023 at 10:16 a.m. S3UR confirmed the 5 patients were not being monitored by staff, the presence of the plastic cutlery sets, and the MHT was making rounds on the other patients.

Based on record review and interview the facility failed to ensure the patient was free from all forms of abuse or harassment as evidenced by failing to conduct criminal background checks for all potential new hires.
Findings:

Personnel record review on 08/23/2023 revealed 1 (S8MHT) of 9 (S2DON, S5LPN, S6RN, S7LPN, S8MHT- S12MHT) personnel records reviewed with no indication of an initial criminal background check being performed prior to hiring.

In an interview on 08/23/2023 at 10:30 a.m. S1CEO indicated there was no record of a criminal background check being completed on S8MHT prior to being hired.

Based on record review and interview the facility failed to maintain medical records for a period of at least five years as evidenced by a missing multidisciplinary integrated treatment plan acknowledgement page.
Findings:

A review of Policy 1.37-Treatment Plan/Treatment Plan Update reveals in part, Procedure IV:A, the treatment plan shall be signed by the physician to ensure continuity of care, coordination, and integration of services provided and all members of the treatment team shall sign and date. Further under Procedure IV: C-14, the treatment plan shall reflect the patient's opportunity for participation in the treatment planning process.

An electronic medical record and paper chart review revealed a missing multidisciplinary integrated treatment plan acknowledgement page in 2 (Pt #1, Pt #3) of 5 (Pt #1 - Pt #5) medical records sampled.

In an interview on 08/22/2023 at 1:45 p.m. S3UR confirmed there was no acknowledgement page in Pt #1 or Pt #3's electronic medical record or paper record.

Based on observations, record review, and interviews, the hospital failed to ensure drug storage was administered in accordance with professional principles. This deficient practice is evidenced by having prescribed medications stored on the medication cart and not returned to the PYXIS (automated dispensing unit) when the medication was discontinued or withheld.
Findings:

Review of the facility's policy 12.24 titled, "Storage and Care of Medications" revealed, in part: Procedure 6: medications are to be stored in the containers in which they are received; and
Procedure 11: discontinued medications are to be immediately removed and returned to pharmacy.

An observation on 08/21/2023 at 10:50 a.m. of the medication cart on Unit #A revealed medications in drawer one. This drawer contained medical supplies not associated with the storage of prescribed medications or floor stock medications. Further, these medications were randomly scattered in the drawer between supplies and not assigned to a patient. The following medications were located in drawer one:
a) 1 Haloperidol 5mg/ml vial;
b) 1 Benztropine Mesylate 2mg/2ml vial;
c) 1 Chlorpromazine 25mg/ml ampule; and
d) 2 Ropinirole 1mg tablets individually packaged.

In an interview on 08/21/2023 at 10:52 a.m. S3UR confirmed the medications located in drawer one and confirmed they were on the medication cart not assigned to a patient. S3UR further indicated she was unaware why they were in the drawer.

In an interview on 08/21/2023 at 11:20 p.m. S5LPN confirmed the medications should have been returned the PYXIS (automated dispensing unit) if not administered.

An observation on 08/21/2023 at 11:15 a.m. of the medication cart on Unit B revealed medications in drawer one. This drawer contained medical supplies not associated with the storage of prescribed medications or floor stock medications. Further, these medications were randomly scattered in the drawer between supplies and not assigned to a patient. The following medications were located in drawer one:
a) 1 Olanzapine 10mg single-dose vial;
b) 1 Haloperidol 5mg/ml single-dose vial;
c) 1 Risperidone 1mg tablet individually packaged;
d) 2 Sertraline 50mg tablet individually packaged;
e) 1 Gabepentin 600mg capsule individually packaged;
f) 2 Fluoxetine 10mg dose individually packaged; and
g) 1 Quetiapial 200mb dose individually packaged.

In an interview on 08/21/2023 at 11:20 p.m. S5LPN and S6RN confirmed the medications located in drawer one of the medication cart and were on the medication cart not assigned to a patient. S5LPN and S6RN confirmed the medications should have been returned the PYXIS (automated dispensing unit) if not administered. Both nurses indicated they were unsure why the medications were in the cart.

Based on observation, record review, and interview the facility failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use as evidenced by:

1) Failure to ensure open multi-dose vials had an open date or beyond use date written on the vial and beyond use medications were discarded; and
2) Failure to ensure single-dose vials were discarded after initial use and not available for multiple patient use.
Findings:

1) Failure to ensure open multi-dose vials had an open date or beyond use date written on the vial and beyond use medications were discarded

Review of the facility's policy 12.24 titled, "Storage and Care of Medications" revealed, in part, Procedure 10: Medications stored in multi-dose vials shall be clearly marked with the following information: Date Opened, expiration date, and nurse's initials. All insulins and multi-dose vials expire in 28 days.

An observation on 08/21/2023 at 10:45 a.m. of Unit #A's medication cart revealed:
a) An open Humulin R Insulin multi-dose vial with no open date or beyond use date; and
b) An open Glargine Insulin multi-dose vial with no open date or beyond use date.

In an interview on 08/21/2023 at 10:48 a.m. S3UR confirmed both insulin vials as being open and not having an open date written on the vial.

An observation on 08/21/2023 at 11:15 a.m. of Unit #B's medication cart revealed an open Glargine Insulin multi-dose vial with an open date of 04/11/2023.

In an interview on 08/21/2023 at 11:20 p.m. S5LPN and RS6N confirmed the vial had an open date of 04/11/2023 and it needed to be discarded.

2) Failure to ensure single-does vials were discarded after initial use and not available for multiple patient use.

Review of the facility's policy 12.14 titled, "Safe Medication Administration" revealed, in part, Drug Administration # 13: Vials labeled as single-dose or single-use should not be used on multiple patients. Single-dose vials will be disposed of after use even if the vial still contains medication.
An observation on 08/21/2023 at 10:45 a.m. of Unit #A's medication cart revealed an open single-dose sterile water 10 ml vial open and on top of the medication cart.

In an interview on 08/21/2023 at 10:48 a.m. S3UR confirmed the open single-dose sterile water vial and it should have been discarded after the initial use.

An observation on 08/21/2023 at 11:15 a.m. of Unit #B's medication cart revealed an open single-dose sterile water 10 ml vial open and on top of the medication cart.

In an interview on 08/21/2023 at 11:20 p.m. S5LPN and RS6N confirmed the open single-dose sterile water vial and it should have been discarded after the initial use.

Based on observation, policy review, and interview, the facility failed to ensure the hospital environment was maintained in a sanitary condition and to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by:
1) Failing to ensure the hospital was maintained in a sanitary condition; and
2) Failing to ensure expired supplies were not available for patient use.
Findings:

1) Failing to ensure the hospital was maintained in a sanitary condition

An observation on 08/21/2023 at 10:30 a.m. revealed 2 chairs in Rm #B with tears and peeling seat coverings. This creates a surface that cannot be cleaned adequately.

In an interview on 08/21/2023 at 10:30 a.m. S3UR confirmed the tears and peeling seat coverings.

Review of the facility's policy 6.12 titled "Infection Control" revealed, in part: Procedure Cleaning and Disinfecting-7) Patient bathtubs/showers are cleaned with disinfectant spray or wipes per hospital staff before each use.

An observation on 08/21/2023 at 10:55 a.m. of the Rm #C on the male hall of Unit #A revealed:
a) Shower 1: 3 wet wash clothes, 3 plastic medicine cups and 5 paper medicine cups placed on top of the hand railing of the shower; and
b) Shower 2: 1 wet wash cloth, 3 plastic medicine cups and 1 paper medicine cup placed on top of the hand railing of the shower.

In an interview on 08/21/2023 at 10:56 a.m. S3UR confirmed the items in the shower room and indicated housekeeping cleans the showers daily.

An observation on 08/21/2023 at 11:05 a.m. of Rm #D on the male hall of Unit #A revealed:
a) The shower had 2 paper medicine cups placed on top of the hand railing of the shower; and
b) The shower floor edge contained pinkish stains.

In an interview on 08/21/2023 at 11:06 a.m. S3UR confirmed the observations in Rm #D and indicated housekeeping cleans the shower daily.

An observation on 08/22/2023 at 2:05 p.m. of Rm #C on the male hall of Unit #A revealed:
a) Shower 1: 1 wet wash cloth and 1 bar of soap placed on top of the hand railing of the shower;
b) Shower 2: the floor of the shower was littered with 4 paper medicine cups and 5 plastic medicine cups; and
c) Rm #C had a stale, pungent odor.

In an interview on 08/22/2023 at 2:06 p.m. S3UR confirmed findings of Rm #D and indicated housekeeping cleans the showers daily and had not been to this room today.

2) Failing to ensure expired supplies were not available for patient use.

Review of the facility's policy 12.24 titled, "Storage and Care of Medications" revealed, in part, Quality Control Solutions expire in 90 days. Procedure 11: Discontinued and outdated medications are to be immediately removed from stock.

An observation on 08/21/2023 at 10:45 a.m. of Unit #A's medication cart revealed the following
a) 1 vial of True Metrix Test Strips, 50 strips with no open date or beyond use date on vial; and
b) 4 vials of EvenCare ProView Glucose Control Solutions (2 vials Level 2 and 2 vials Level 3) did not have an open date on the bottles.

In an interview on 08/21/2023 at 10:48 a.m. S3UR confirmed the open supplies did not contain an open date written on the container or vial.

An observation on 08/21/2023 at 11:15 a.m. of the medication cart on Unit B revealed the following expired quality control solutions in drawer one:
a) Medline Harmony Glucose Control Solutions Set Level 1vial and Level 3 vial with an expiration date on each vial of 6/03/2022; and
b) EvenCare ProView Glucose Control Solution Level # 2 with an expiration of 12/09/2022.

In an interview on 08/21/2023 at 11:20 p.m. S5LPN and RS6N confirmed the expiration dates on the quality control solutions.