HospitalInspections.org

Based on medical record review, policy and document review and staff interview, it was determined that the hospital failed to provide care in a safe environment for 1 of 3 patients (Patient #5) that received care in the Emergency Department (ED). Findings included:

The hospital policy entitled "Patient Rights and Responsibilities" stated, "You Have the Right To ...receive care in a safe setting including freedom from all forms of abuse, neglect or harassment ..."

Patient #5
Emergency Department date of service 8/17/21

A. Medical record review revealed:
1. Document entitled "Medication Reconciliation" dated 8/17/21 indicates known allergies: anticholinergics.
2. GI Cocktail (Donnatal 5ml+Maalox 30ml+Lidocain 10ml) ordered on 8/17/21 at 7:41 PM.
3. GI Cocktail (Donnatal 5ml+Maalox 30ml+Lidocain 10ml) documented as given to patient on 8/17/21 at 7:42 PM.

B. Review of facility's medication reference material "Lexicomp" revealed:
- pharmacologic category for Donnatal is anticholinergic agent.

C. Patient received medication that was listed as an allergy in medical record.

Interview on 8/26/21 between 11:30 AM and 11:35 AM with Assistant Vice President of Nursing A confirmed this finding.

Based on observation, policy review and staff interview, it was determined that the hospital failed to ensure that facilities, supplies and equipment were maintained to ensure an acceptable level of safety, quality and cleanliness in 4 of 13 patient care/support areas. Findings included:

The hospital policy entitled "Safety Management Plan" stated, "...the programs used to manage the Safety Management Program to reduce the risk of injury for patients, staff and visitors...All Beebe Healthcare staff...vendors. Contractors have a responsibility of maintaining a safe and secured environment...Safe working conditions and practices are established by using knowledge of safety principles...Safety is dynamic..."

The hospital policy entitled "Contamination Control- Responsibilities, cleaning and stocking" stated, "...The following defines the contamination control responsibilities .... Check sterile expiration dates or integrity of package on all sterile goods ... Damp dust and wash all shelves on which sterile supplies are stored, on a monthly basis..."

The hospital document entitled "EOC (Environment of Care) Rounding Tools (revised 8 13 20)" stated, "...The EOC Chair coordinates a team approach to regular environmental tours to identify environmental deficiencies, hazards and unsafe practices... Is the area ... clean and free of dust...free of cracked caulking or water damage ...No rust...free of dirty ...stained..."

The hospital policy entitled "Storage of Sterile Supplies" stated, "All storage areas shall be clean, dry, protected from moisture...Stock shall be rotated so that items do not outdate ... "

The hospital policy entitled "Expiration Dated Products" stated, "Storeroom inventory stock that has an expired date is to be removed from the bin location and issued out to the obsolete inventory account.... Each Storeroom employee should check the Storeroom bin's locations on a regular basis for expired product..."

A. During an environmental tour of the Beebe Main Campus and the South Coastal Campus on 08/24/21 between 11:29 AM and 2:58 PM , the following observations were made and confirmed by Lead Mechanic A and Corporate Safety Officer A at the time of the finding:

11: 38 AM: Loading Dock Office
- 2 brown stained /moist absorbent socks by the Air Conditioner

11:54 AM: Central Supply Room
- 5 Needle + Stabilizer kit expired 12/31/2020
- 2 Needle + Stabilizer kit expired 01/31/2021
- dead bug in bin that stored Deodorant Roll 1.5 oz (Ounces)
- dead bugs in bin that stored Dual Lumen Stomach Tubes 18 French
- dead bugs in bin that stored Dual Lumen Stomach Tubes 16 French
- rusty irrigation pipe with minor leakage
- brown sediment left on the wall from the resty irrigation pipe and going down the wall behind the metal storage rack of supplies
- a lot of dust on the metal shelves of Storage V, T and W.
12:49 PM: 5th floor Med Surg CDU (Clinical Decision Unit) clean Supply Room
- dead bug in the supply bin that stored Catheter Kit Suction 14 French

1:13 PM: 3rd Floor Clean Storage # 3067
- dead bugs in 2 of the supply bins