HospitalInspections.org

1. Based on review of 1 of 1 Patient Rights Policy and Procedure Manual and interview, it was determined there was no developed policies and procedures to address that individuals were not hired or retained who had been convicted of abuse or neglect, staff training on identifing all forms of abuse and neglect, patients were protected during the investigation process, the conduction of investigations of abuse and neglect allegations, and reporting and responding to abuse and neglect allegations. The failed practice had the potential to affect all patients admitted to the facility. Findings follow:

A. There were no policies and procedures to ensure individuals were not hired or retained who had been convicted of abuse or neglect.
B. There were no policies and procedures for training staff to identify abuse and neglect.
C. There were no policies and procedures to ensure patients were protected during the investigation of abuse or neglect allegations.
D. There were no policies and procedures for conducting an investigation of abuse or neglect allegations in a timely manner.
E. There were no policies and procedures for reporting and responding to allegations of abuse or neglect.
G. Findings were confirmed in interview with the Assistant Administrator at 1020 on 03/17/10.

Based on clinical record review and interview, it was determined of the 30 sampled patients 24 required the initiation of a care plan on admission. In 11 (#11, 14, 16, 18, 19, 21-25, and 30) of 24 (#1-8, 11-14, 16, 18-25, 27, 28, and 30) clinical records, the nursing staff failed to initiate a care plan on admission. The failed practice had the potential to affect any inpatient admitted to the facility. The findings follow:

A. The facility failed to ensure a care plan was initiated upon admission to the hospital for the following patients:
1) Patient #11 was admitted on 03/10/10. A care plan document was in the clinical record, but there was no documented date of initiation of the plan.
2) Patient #14 was admitted on 03/16/10. Initiation of the care plan was documented on 03/17/10 at 1650.
3) Patient #16 was admitted on 03/14/10. Initiation of the care plan was documented on 03/17/10 at 1650.
4) Patient #18 was admitted on 03/15/10. There was no documentation of a care plan in the clinical record.
5) Patient #19 was admitted on 03/15/10. Initiation of the care plan was documented on 03/18/10.
6) Patient #21 was admitted on 03/14/10. Initiation of the care plan was documented on 03/17/10.
7) Patient #22 was admitted on 03/14/10. Initiation of the care plan was documented on 03/17/10.
8) Patient #23 was admitted on 03/13/10. Initiation of the care plan was documented on 03/17/10.
9) Patient #24 was admitted on 03/10/10. Initiation of the care plan was documented on 03/17/10.10) Patient #25 was admitted on 03/09/10. Initiation of the care plan was documented on 03/17/10.
11) Patient #30 was admitted on 03/15/10. There was no documentation of a care plan in the clinical record.
B. The findings were confirmed in an interview with the Director of Nursing on 03/19/10 at 1250.

3. Based on observation, review of Succinylcholine packaging insert information, and interview, the facility failed to have a method to ensure five of five vials of Succinylcholine on one of one anesthesia cart in Surgery were not stored at room temperature to exceed 14 days so that the potency of the drug would be diminished.. The potential existed for Succinylcholine with a decreased potency to be administered to surgery patients. Findings follow:

A. A tour of Surgery was conducted on 03/19/10 at 1145 in which five vials of Succinylcholine were observed stored on one anesthesia cart. The Succinylcholine was stored at room temperature with no method established to ensure the storage at room temperature did not exceed 14 days.
B. The package insert information was reviewed on 03/19/10 at 1205. It reflected the medication must be stored between 36-46 degrees Fahrenheit but could be stable for up to 14 days at room temperature without significant loss of potency.
C. An interview ws conducted with Certified Registered Nurse Anesthetist #1 at 1145 on 03/19/10. It was revealed the Succinylcholine was stored up to 30 days at room temperature. The Director of Pharmacy was interviewed on 03/19/10 at 1210 and verified there was no method to ensure Succinylcholine was not stored at room temperature to exceed 14 days as required by the manufacturer.

4. Based on observation, humidity log review and interview, it was determined the facility did not meet Life Safety Code requirements related to humidity levels in anesthetizing locations and protection of penetrations of smoke barrier walls. The failed practice had the potential to affect all patients admitted to the facility. See Tags K-25 and K-78.