HospitalInspections.org

Based on observations and interviews, the facility failed to ensure each patient's right to receive care in a safe setting. This deficient practice was evidenced by failing to ensure the patient's physical environment was free of safety risks and did not afford opportunities for self-injury or harm to others
Findings:

Observation during the facility tour on 11/27/2023 from 10:28 a.m. to 11:30 a.m. revealed the following safety risk:

a. Unsecured toilet seats in 9(Rooms A-I) of 10(Room A-J) patient restrooms which could create a potential ligature risk.
b. A hand rail that was partially detached from the wall in Room D restroom, with 6 anchor screws, not securely fastened in place. The screws could potentially be unscrewed by hand. This created a potential fall risk, ligature risk, and contraband risk.

In an interview on 11/27/2023 at 11:30 a.m. S2DON confirmed the above mentioned findings.

Based on record review and interview, the facility failed to ensure a medical history and physical was documented within 24 hours after admission for 3 (#1-#3) of 3 (#1-#3) sampled patient medical records reviewed.
Findings:

A facility policy review of PC-104: Assessments of Patients revealed in part, the purpose is to define the scope and time frames for patient assessments for each discipline involved in an individual patient's treatment. This plan outlines the elements of the assessments, which must be performed and documented in the patient's medical record. The specified time frame for history and physical completion is within 24 hours of admission.

A medical record review for Patient #1-#3 revealed the following:

Patient #1 was admitted on 10/22/2023 at 7:50 a.m. The history and physical was signed on 10/24/2023 at 10:41 a.m. This history and physical was documented 50.8 hours after admissions.

Patient #2 was admitted on 10/19/2023 at 10:10 p.m. The history and physical was signed on 10/21/2023 at 8:56 a.m. This history and physical was documented 34.7 hours after admissions.

Patient #3 was admitted on 11/21/2023 at 9:10 p.m. The history and physical was signed on 11/23/2023 at 1:51 p.m. This history and physical was documented 40.7 hours after admissions.

In an interview on 11/28/2023 at 11:30 a.m. S2DON confirmed the medical history and physicals of Patients #1 - #3 were not documented within 24 hours of admissions.

Based on record review and interview, the facility failed to ensure all practitioner's orders were contained in patients' medical records. This deficient practice was evidenced by failing to ensure there was an order for capillary blood glucose testing.

Findings:

A medical record review of Patient #3 revealed a secondary diagnosis of Diabetes Mellitus Type II. Admission lab work reveal a Hemoglobin A1C of 8.4% (reference range is 4.8 - 5.6 %) which is indicative of Diabetes. The patient's home medication list included Jardiance 25 mg daily. A review of the physician orders revealed no order for the monitoring of the patient's blood glucose. There was a reference to Diabetes on the medical history and physical.

A review of the facilities log of current diabetic patients revealed Patient #3 as one of the patients receiving a daily capillary blood glucose check from 11/22/2023 to the present day, 11/28/2023.

In an interview on 11/28/2023 at 11:00 a.m. S2DON confirmed there was no physician order on Patient #3's medical record for the performance of a capillary blood glucose level check.

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 having an open multi-dose vial without an opened date written on it and an open multi-dose vial with an expired open date.
Findings:

A review of facility policy PHARM-024 Expiration of Medications, Last Revised: 06/03/2021 revealed in part, the facility uses policies and procedures to prevent administering medications beyond their date of expiration. Further, the policy states, "All multi-patient use medications shall be considered expired 30 days after opening. All such medications shall be labeled with "date opened" upon opening."

An observation on 11/27/2023 at 10:30 a.m. of the medication room's sample medication refrigerator revealed 1 open vial of Tuberculin Purified Protein Derivative 5TU/0.1ml vial with no open date on the box or vial and 1 open vial of Tuberculin Purified Protein Derivative 5TU/0.1ml vial with an open date of 07/26/2023 written on the box it was stored.

In an interview on 11/27/2023 at 10:38 S2DON confirmed the facility policy required multi-dose medications to be discarded after 30 days of being open and all multi-dose medications need to be dated upon opening. S2DON further confirmed the findings of the above mentioned open multi-dose medication vials.