HospitalInspections.org

Based on observation, interview, policy review, and manufacturer's guidelines review, the provider failed to ensure safety checks were performed daily on two of two defibrillators (life sustaining equipment) in the emergency department (ED). Findings include:

1. Observation on 7/23/19 at 1:30 p.m. of the ED revealed:
*There had been two separate areas to allow treatment for patients.
*Both of those areas each had a defibrillator.
-One located in the area for six ED patient rooms.
-One located in the area for three trauma unit bays.

Interview on 7/23/19 at 2:30 p.m. with registered nurse (RN) P revealed:
*She confirmed the provider had two defibrillators, one in each of those areas.
*The night shift nursing staff should have performed manual safety checks daily on both of the defibrillators.
*The maintenance department supervisor would have completed a manual safety check on those defibrillators on a weekly basis every Monday.

Review of the daily ED crash cart checklist and defibrillator safety checks from 6/1/19 through 7/23/19 revealed:
*In June there was no documentation to support the safety checks had been performed on five out of thirty days.
-Those dates had been 6/4/19, 6/13/19, 6/17/19, 6/18/19, and 6/24/19.
*In July there was no documentation to support the safety checks had been performed on three out of twenty-three days.
-Those dates had been 6/5/19, 6/12/19, and 6/18/19.

Review of the daily trauma crash cart checklist and defibrillator safety checks from 5/1/19 through 7/23/19 revealed:
*In May there was no documentation to support the safety checks had been performed on four out of thirty-one days.
-Those dates had been 5/4/19, 5/12/19, 5/17/19, and 5/19/19.
*In June there was no documentation to support the safety checks had been performed on eight out of thirty days.
-Those dates had been 6/4/19, 6/7/19, 6/13/19, 6/17/19, 6/18/19, 6/24/19, 6/25/19, and 6/26/19.
*On July there was no documentation to support the safety checks had been performed on five out of twenty-three days.
-Those dates had been 7/5/19, 7/12/19, 7/16/19, 7/17/19, and 7/18/19.

Interview on 7/24/19 at 9:20 a.m. with the director of nursing regarding the above documentation revealed:
*She was aware the staff had not been completing daily safety checks on the defibrillators according to their policy and procedure.
*She stated "We have been reviewing this problem forever in QA [Quality Assurance]."
*She confirmed:
-The ED admitted multiple patients on a daily basis.
-The safety/daily checks on the defibrillator had been important to ensure the safety and necessity of that equipment being available upon demand.

Review of the provider's June 2015 Lifepak 15 Monitor/Defibrillator policy revealed no documentation to support a process for the completion of safety checks.

Review of the provider's 2013 Lifepak 15 Monitor/Defibrillator Operating Instructions manual revealed:
*"Periodic maintenance and testing of the LIFEPAK 15 monitor/defibrillator and accessories are important to help prevent and detect possible electrical and mechanical discrepancies."
*The defibrillator and the accessories should have been checked on a daily basis to ensure proper performance of it would have occurred.

Based on observation and interview, the provider failed to maintain the durability and cleanability of the ceiling in the kitchen due to peeling paint and surface deterioration. Findings include:

1. Observation at 11:00 a.m. on 7/24/19 revealed a large area of the kitchen ceiling had paint damage and was deteriorated above the food cooking and preparation areas. Interview with the dietary manager at 11:05 a.m. on 7/24/19 revealed the roof had been leaking for several years. The ceiling was fixed last year, but the roof continued to leak. There was water dripping through the ceiling just last week.

Based on observation, interviews, policy reviews, and review of the governing board committee meeting minutes, the provider failed to ensure:
*A comprehensive infection control program was implemented under the direction of a fully trained infection control (IC) officer.
*Policies and procedures were evaluated, reviewed, and revised periodically for four of six policy and procedure manuals selected for review (swing bed, nursing, infection control, and emergency department).
*Keys that had allowed access to narcotic medications had been properly stored and monitored for safety in the following areas for:
-One of three anesthesia med and supply carts in the clean supply room located on the labor and delivery wing.
-One of two randomly observed refrigerators in the clean supply room located on the labor and delivery wing.
-Four of four newborn emergency crash carts in four of four labor and delivery rooms.
-Three of four ambulances.
*Care plans had identified all areas of concern for seven of fifteen sampled patients (3, 4, 11, 18, 29, 32, and 38) to ensure proper care and services had occurred
*Safety checks were performed daily on two of two defibrillators (life sustaining equipment) in the emergency department (ED).
*The durability and cleanability of the ceiling in the kitchen due to peeling paint and surface deterioration
Findings include:

1. The governing board had not identified the above areas had remained in compliance and ensured:
*A comprehensive infection control program had been established.
*Policies and procedures had been reviewed on an annual basis.
*Medication security had been monitored.
*Care plans reflected the patients needs.
*Safety checks on the defibrillators had been completed daily in the ED.
*The kitchen ceiling deterioration had been addressed in a timely manner.

Refer to: C204, F225, C270, C276, C298, C334, and C388.

Based on observation, record review, interview, and policy review, the provider failed to ensure:
*The infection control program was integrated into the quality assurance/performance improvement (QAPI) review process.
*Registered nurse (RN) (Q) sanitized the temporal thermometer between two of two randomly observed patients (26 and 27).
*One of one RN (N) completed an intravenous (IV) start, IV medication administration, and port-a-cath flush in a sanitary manner for two of two randomly observed patients (33 and 34).
*One of one licensed practical nurse (LPN) (A) completed a dressing change for one of one sampled patient (13) in a sanitary manner.
*Two of two RNs (B and C) and one of one certified registered nurse anesthetist (CRNA) (D) completed an IV start and wound care in a sanitary manner for one of one randomly observed patient (9).
*One of one certified nursing assistant (J) provided a snack in a sanitary manner for one of one randomly observed patient (9).
*Patient use items were protected from possible contamination in:
-Six of six emergency department (ED) rooms.
-Three of three trauma unit bays in the ED.
Findings include:

1. Interview on 7/25/19 at 2:30 p.m. with RN/risk management/infection control/QAPI I revealed:
*She had been appointed to be in charge of the infection control (IC) program when the previous IC RN had retired July 2018.
*No specialized training had been provided to her on how to manage the IC program.
*Hospital acquired infections were tracked and trended, and pharmacy assisted with antibiotic stewardship.
*QAPI was integrated with the medical staff monthly meetings.
*She only reported to QAPI as needed.
*A new IC certified nurse practitioner (CNP) had been appointed approximately two weeks ago.
*She agreed the IC policies and procedures had not been reviewed since 12/31/17.

Review of the provider's medical staff meeting minutes revealed 2/7/19, 4/4/19, and 7/11/19 had been the only times infection control topics had been reported. Those reported items included:
-Visiting restrictions during an increase of Influenza A.
-The number of influenza A positive tests.
-A new CNP had been appointed the IC infection preventionist.

Review of the provider's revised March 2011 Infection Control Program revealed:
*The infection control person's duties and responsibilities included:
-Developed and annually reviewed and revised hospital-wide infection control policies to include at least visitation, patient placement, traffic control, and employee health.
-Annually coordinated the review of all infection control policies and procedures specific to hospital departments.
-Consulted and directed the development of preventative, surveillance, and control procedures that related to the inanimate hospital environment.
-Developed a practical system for reporting, maintaining, and evaluating records of infections among patients and employees.
-"Collects and analyzes data including at least the following: Q-A plan, patient and employee infections, hospital acquired infections, drug sensitivity/resistance studies, serves on Pharmacy and P & T [pharmacy and therapeutics] Committees, contaminated exposures, improper disposal of waste and employee injuries."

2. Observation on 7/23/19 from 9:25 a.m. through 10:00 a.m. revealed RN Q used a temporal thermometer without sanitizing it between patients. Those observations included:
*She used the temporal thermometer on:
-Patient 26 in the same day surgery (SDS) post anesthesia care unit (PACU).
-Placed the thermometer in her pocket without sanitizing it.
-Then placed the thermometer on the counter.
-Checked patient 27's temperature before he was discharged.
-She placed it in her pocket and had not sanitized it before or after using it.

3a. Observation on 7/23/19 at 10:35 a.m. of RN N starting IV access for patient 33 revealed:
*The patient was seated in a recliner in the SDS/PACU area. She had placed books and her laptop computer on top of one side of the overbed table.
*She placed the supplies to start the IV access on the other side of the overbed table. She put on gloves without sanitizing her hands, opened the IV start kit package, and placed those items on the table without a barrier under them. With those same gloves she:
-Opened a pre-filled syringe of normal saline, primed the tubing, and placed it back on the table.
-Placed the tourniquet on the patient's left arm.
-Cleansed the site with an alcohol pad.
-Used her gloved fingers to palpate for a vein.
-Retrieved the Abbocath that was laying on the overbed table.
-Accessed the vein, held pressure, retrieved a clear dressing, and placed it over the insertion site.
-Retrieved the pre-filled IV tubing and attached it to the Abbocath.
-Flushed the new IV access.
-Removed her gloves and used hand sanitizer.

b. Observation on 7/23/19 at 2:04 p.m. of RN N while she accessed and flushed patient 34's port-a-cath revealed she:
*Placed the port flush kit on the overbed table.
-She had not sanitized the overbed table.
*Sanitized her hands and put on gloves.
*Opened a ten cubic centimeter (cc) syringe.
*Removed the top off a bottle of heparin flush and without sanitizing the septum she punctured it with the needle and withdrew ten CC of heparin.
*Opened a package that contained the port access needle with tubing attached.
*Held the packaging around the tubing, flushed the tubing with normal saline, and placed the opened package on the overbed table.
*Had the patient hold her shirt down to expose the port on her left clavicle area.
*Removed her gloves and without any hand hygiene:
-Opened the sterile port flush kit.
-Put on sterile gloves from the kit.
-Opened the skin antiseptic preparation swab.
-Swabbed the port area.
-Took the pre-primed needle and tubing and accessed the port.
*Checked for patency, flushed the port, removed the normal saline syringe, attached the syringe with the heparin, and removed the access needle.
*Placed a Band-Aid over the site.
*Removed her gloves and sanitized her hands.

c. Interview on 7/24/19 at 1:30 p.m. with the director of nursing regarding the above observations of RN N revealed she:
*Should have sanitized the overbed table or used a barrier prior to placing the IV items on it.
*Sanitized or washed her hands with each glove change.
*Had patient 34 remove her shirt and used a gown to prevent contamination.
*Opened the port flush kit and then dropped the sterile access needle and tubing onto the top of the kit from the package.

Review of the provider's revised May 2012 Nursing Protocol for Port-A-Cath, Accessing and Deaccessing policy included:
*Wash hands thoroughly for two minutes.
*Open central like dressing tray and place on bedside stand. Open second sterile drape and place on patient below port-a-cath site.
*Open syringe, Huber needle, extension tubing, male adapter plug, and drop onto sterile drape being careful to maintain sterile techniques.
*Put on sterile glove on one hand.
*Clean around port-a-cath site with ChloraPrep swab with the sterile gloved hand.
*Put on second sterile glove.
*Connect the Huber needle and male adapter plug to extension tubing.
*Flush extension tubing and Huber needle with normal saline. Clamp tubing.
*Access the port-a-cath site and flush with approximately three milliliters of normal saline.
*Attach syringe with heparin and flush.



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4. Observation on 7/23/19 at 11:10 a.m. in patient 13's room with licensed practical nurse (LPN) A revealed:
*After the surveyor entered the room:
-LPN A had gloves on.
-In her right hand was a 4x4 dressing and a small round foam dressing.
-On top of the night stand was an opened container with 4x4's inside.
-There was not a barrier under the 4x4 container.
-The night stand had multiple items on it.
-She had instructed the patient to turn over to his right side in bed.
-She pulled his night gown back, stated he had a shower earlier, and without cleaning the area applied the foam dressing to his left gluteal area.
-Placed the 4x4 dressing over the foam dressing.
-Tore a piece of tape from the tape roll, layed the tape roll on top of the Chux on the patient's bed near his buttock, placed the tape over the 4x4, and repeated that three more times.
-With her same gloved hands she put the 4x4 container and tape roll into the top night stand drawer.
-At that time removed her gloves and performed hand hygiene.

Interview on 7/25/19 at 9:15 a.m. with LPN A regarding the 7/23/19 at 11:10 a.m. in patient 13's room observed dressing change revealed she should have:
*Placed a barrier down prior to laying items and supplies on them.
*Not placed the tape roll on top of the patient's chux.
*Thrown the tape away instead of placing it into the night stand drawer.
*Had a barrier under the supplies.

5a. Observation on 7/23/19 at 2:35 p.m. in patient 9's room with registered nurse (RN) B revealed:
*Without performing hand hygiene she:
-Had not cleaned or disinfected patient 9's night stand.
-Layed a barrier down and:
--Placed a bottle of hydrogen peroxide and normal saline (NS) on top of it.
--Laid five packaged Q-tips on top of it.
--Opened the bottles of Hydrogen Peroxide and NS and poured the liquids into a medication cup.

RN B performed hand hygiene and at this time put on gloves. Without cleaning or disinfecting the overbed table or laying a barrier down she:
*Placed the medication cup with the Hydrogen Peroxide and NS and five packages of Q-tips on it.
*The patient removed a spray bottle and a lotion bottle from the area.
-Other items on the overbed table had included a water cup, a phone, a coffee mug, books, and a sound machine.
*She then:
-Removed the Q-tips from the packages and placed them into the medication cup with the Hydrogen Peroxide and NS mixture.
-Left several of the Q-tip packages opened with the Q-tips inside.
-Cleaned the pin sites of the patient's right lower leg.
-Discarded the used supplies in the garbage.
-Removed the Chux from under the patient's right leg.
*Removed her gloves and performed hand hygiene.
-Had not cleaned or disinfected the overbed table following the procedure.

b. Observation on 7/23/19 from 3:00 p.m. through 3:45 p.m. in patient 9's room revealed:
*Without performing hand hygiene or putting on gloves RN B:
-Had not cleaned or disinfected the overbed table.
-Had not layed down a barrier on the overbed table.
-Placed the IV antibiotic bag and saline flush syringe on top of it.
-Removed the used IV antibiotic bag from the IV pole and layed it on top of the overbed table next to the new IV antibiotic bag and saline flush syringe.
-Inserted the IV tubing into the new IV antibiotic bag.
-Took the saline flush syringe and inserted it into the patient's left forearm IV site.
--The patient had commented it hurt.
-She stopped the saline flush and stated the IV had infiltrated.
-Removed the saline flush syringe and layed it on the overbed table.
-Picked up the used IV antibiotic bag and without performing hand hygiene left the room.

At 3:10 p.m. RN B returned to patient 9's room, and she:
*Performed hand hygiene and put on gloves.
*Placed a container holding IV supplies in it on top of the overbed table.
*Opened a 2x2 dressing and roll of tape and placed them on top of the overbed table.
*Removed the dressing from the patient's left forearm IV site and placed it on top of the overbed table.
-Removed the IV catheter from the patient's left forearm and placed it on top of the overbed table.
-Placed a dressing and tape over the IV insertion site.
-Removed her gloves and discarded the soiled items into the garbage.
*Without hand hygiene she placed the new IV supplies Abbo catheter, IV lock, NS 10 cc syringe, and IV start kit on top of the overbed table.
-Without hand hygiene she put on a pair of gloves.

At 3:20 p.m. RN B:
*Opened a new IV start kit and placed a 2x2 on top of the overbed table.
*Took the Opsite dressing out of the package and layed it on top of the overbed table.
*Was unable to restart the IV.
*Discarded her gloves and did hand hygiene.
*Left the room.

At 3:30 p.m. certified nursing assistant (CNA) J entered patient 9's room caring a tray with a cheese stick and she:
*Handed the patient the cheese stick.
*Touched the sound machine on her overbed table.
*Had not performed hand hygiene upon entering or exiting the room.

At 3:32 p.m. RN/nursing supervisor C entered patient 9's room and:
*She did hand hygiene and put on gloves.
*Without creating a barrier or cleaning/disinfecting the overbed table she opened a new IV start kit and layed it on top of it.
-She had not asked RN B if the table had been cleaned or disinfected.
*She tore off pieces of tape and placed them on the side of the overbed table.
-Was unable to start an IV.
-She opened a new IV start kit and placed it on the overbed table,

At 3:40 p.m. certified registered nurse anesthetist (CRNA) D entered patient 9's room and:
*He had not performed hand hygiene.
*RN/nursing supervisor C had inserted the IV into the patient's left arm and then requested CRNA D to finish with the procedure.
*CRNA D approached the bed.
*RN/nursing supervisor C instructed him to put on a pair of gloves.
-CRNA D put on gloves.
--Completed the IV insertion.
--Removed his gloves and had not performed hand hygiene.

At 3:45 p.m. RN B:
*Without performing hand hygiene put on gloves.
*Started the IV antibiotic.
*Took her gloves off, had not performed hand hygiene, went to the electronic medical record (EMR), and began to document.

6. Interview on 7/25/19 at 8:35 a.m. with RN B regarding the observations on 7/23/19 at 2:35 p.m. and again from 3:00 p.m. through 3:45 p.m. for patient 9 revealed she:
*Thought she had used hand gel upon entering the patients room at 2:35 p.m.
*Should have layed a Chux or barrier down before starting the treatments.
*Should have performed hand hygiene before and after removing gloves.
*Agreed she had missed several hand hygiene opportunities in the above observations.

Interview on 7/25/19 at 11:30 a.m. with RN/risk management/infection control/quality compliance I regarding the above observations revealed:
*Her expectations would have been for hand hygiene to have been done prior to entering a patient's room, and before and after glove use.
*She agreed there was a problem with not placing a barrier down prior to doing a procedure or treatment.
*They could have taken a sterile drape and placed it on the overbed table or night stand if they had not cleaned the areas off.
*She agreed there were several missed hand hygiene opportunities.

Review of the provider's undated Hand Hygiene policy revealed:
*Policy:
-"Hand hygiene is generally considered the most important single procedure for preventing health-care associated infections."
*Indications for Handwashing and Hand Antisepsis:
-"A. Decontaminate hands:
--Before having direct contact with patients.
--After contact with a patient's intact skin.
--After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled.
--If moving from a contaminated-body site to a clean-body site during patient care.
--After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
--After removing gloves.

Review of the provider's 2010 Intravenous Therapy policy revealed:
*Policy:
-"A. Use proper hand hygiene during insertions, repairing, accessing or dressing an intravenous catheter."



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7. Observation on 7/23/19 at 1:25 p.m. of the ED revealed:
*There had been six ED rooms and three trauma area patient examination bays.
*Each of those rooms and bays had been set-up for suctioning.
*In all nine of those areas the suction waste containers had suctioning tubing attached to the lids.
*On the end of the tubing were opened packages containing Yankauers.
-Those Yankauers were attached to the tubing and were ready to suction a patient's oral cavity if needed.

Interview on 7/23/19 at 2:30 p.m. with registered nurse (RN) P regarding the above observations revealed:
*She was aware the single-use suction equipment had been opened and set-up for quick access.
*She stated:
-"I know they are not supposed to."
-"Any contents in an opened package is considered dirty."
*She agreed:
-That had not been a good practice, and all supplies should have remained sealed in their original packages until they were used.
-Equipment in an unsealed package should have been considered contaminated.
-There was the potential for cross-contamination and the spreading of bacteria from one patient to another.

Interview on 7/23/19 at 4:10 p.m. with the DON regarding the above observations revealed she had supported the interview of RN P. A policy for the storage of patient single-use items had been requested from her. There was no policy or procedure received prior to exit on 7/25/19 at 1:30 p.m.

Based on observation, interview, and policy review, the provider failed to ensure keys that had allowed access to narcotic medications (med) had been properly stored and monitored for safety in the following areas for:
*One of three anesthesia med and supply carts in the clean supply room located on the labor and delivery wing.
*One of two randomly observed refrigerators in the clean supply room located on the labor and delivery wing.
*Four of four newborn emergency crash carts in four of four labor and delivery rooms.
*Three of four ambulances.
Findings include:

1a. Observation on 7/23/19 at 9:35 a.m. of the clean supply room on the labor and delivery wing revealed:
*It had been unlocked and allowed for access by visitors, staff, and patients.
*There was a small metal cart on wheels that had several drawers in it.
*The metal cart had been marked and identified as the anesthesia cart for that wing.
*The drawers were secured by a long bar in front of them.
-That bar was secured in place by a small red Ziploc tie.
-The Ziploc tie was not numbered and could be easily moved back and forth for removal of it.
*There was a dorm sized refrigerator in the room.
-The refrigerator door was secured shut and required a key to open it.

b. Continued random observations on 7/23/19 at 9:50 a.m. of the labor and delivery wing revealed four delivery rooms. Inside one of the rooms was a small metal cart on wheels. That cart had been identified as a newborn crash cart. The cart had been secured shut and required the use of a key to open it.

c. Observation on 7/23/19 at 10:10 a.m. with registered nurse (RN) R and certified nursing assistant (CNA) (S) revealed:
*They had been bathing and assessing patient 2 in the nursery area.
*In the nursery area there had been two secured carts that had required a numbered code to unlock them.
-One of those carts had been identified as the intravenous (IV) supply cart.
*RN R had requested CNA S to get the camera for the newborn's photo opt.
*The camera had been locked in a small metal box secured to the wall in the nursing report room.
-That box had required the use of a key to unlock it.
*The key to unlock the metal box had been located inside of the locked IV supply cart.
*RN R gave the numbered code to unlock the IV supply cart.
*Inside of the top drawer of the cart had been:
-Several partitions containing multiple patient supplies.
-One of the partitions contained multiple keys with labels on them.
*CNA S:
-Took one of those keys and used it to unlock the metal box containing the camera.
-Returned the key to the IV supply cart after she had gotten the camera for RN R.

d. Observation and interview on 7/23/19 at 10:20 a.m. with RN C in the clean supply room revealed:
*She had confirmed:
-The room was unsecured and allowed access by staff such as housekeeping, maintenance, visitors, and patients.
-The anesthesia cart and refrigerator had narcotic meds inside of them and were required to be secured from unauthorized access.
*She:
-Agreed the anesthesia cart was not secured shut with the red Ziploc tie that had been currently in place.
-Took a pair of scissors that had been inside of a plastic holder attached to the metal cart and cut off the Ziploc tie.
*The metal bar was easily moved off to the side of the cart and allowed for the drawers in the cart to be opened.
*The metal cart:
-Had a metal box secured inside of the top drawer, and it was locked.
-That box was labeled narcotics and had required a key to open it.
-Had random medications inside of the top drawer.
--Those medications were in vials and had been labeled epinephrine and neosynephrine.
*She did not have the key to open:
-The narcotic box inside of the drawer and called certified registered nurse anesthetist (CRNA) D to open it.
-The refrigerator.

e. Continued observation and interview on 7/23/19 at 10:30 a.m. with RN C and RN R revealed:
*The key to open the refrigerator in the clean supply room was located in the nursery.
*RN C opened the IV supply cart and took a key from the pile of keys inside of it that had been observed above when CNA S had opened it.
*RN R had been in the nursery at the time RN C removed the key for the refrigerator.
*RN R agreed:
-She should not have given CNA S the numbered code earlier that morning to get inside of the IV supply cart.
-When she had given CNA S the code for the IV supply cart she had given her access to the keys to the refrigerator in the supply room.
-CNA S was not authorized to have access to those keys and meds. One of those meds had been liquid Ativan.

f. Observation and interview on 7/23/19 at 10:35 a.m. with CRNA D regarding the anesthesia cart revealed:
*He confirmed:
-The clean supply room was not secured from access by others or unauthorized staff.
-The metal cart in the clean supply room had been used for anesthesia's use in the labor and delivery area.
-The metal cart was to have been secured shut with a red Ziploc tie.
*He had not been aware the Ziploc tie was easily slid open or could have been cut off by other staff, visitors, and unauthorized individuals with the scissors on the cart.
*After he removed the Ziploc tie he could have opened the narcotic box with a key.
-That key was on a ring full of keys and was inside his pants pocket.
*He confirmed that ring of keys stayed on him at all times.
-That had included going home with him after his shift was done for the day.
*He stated: "Yes I know that leaves the meds in here vulnerable should I get in a car accident or something happens to me."
*To his knowledge there was no other process in place to ensure the security of those meds had occurred.
*He agreed the other meds in the cart were considered high risk meds with side effects that when not used properly could have created a negative outcome.

g. Continued observation and interview on 7/23/19 at 10:45 a.m. with the pharmacist regarding the unsecured meds above in the labor and delivery area revealed she:
*Had not been aware of the process the anesthesia department used to secure their meds from unauthorized staff.
*Agreed the observations of the anesthesia cart and refrigerator had left all of those meds unsecured and vulnerable for access by unauthorized and licensed personnel.
*Stated: "We just started doing a random spot check on the anesthesia department and their carts."-She had not been able to provide supporting documentation of those recent spot checks.
*Stated: "Yes I am responsible for all the pharmaceuticals in the facility."
*She kept repeating "We are a small facility and community there's nothing to really worry about."

h. Continued observation and interview on 7/23/19 at 10:55 a.m. with RN C in one of the labor and delivery rooms revealed:
*She confirmed there had been four labor and delivery rooms, and this one was not currently being used.
*She confirmed:
-The metal cart in the room was a crash cart used for newborns in an emergency.
-Inside of the cart were narcotics and high risk meds such as Narcan, epinephrine, sodium bicarbonate, and numbing meds such as bupivacaine
-In order to open that cart she had to get the key from the IV supply cart in the nursery.
-All four of the labor and delivery rooms had a cart exactly like that one.
-All four of those carts and meds were now at risk and vulnerable for unauthorized access since CNA S had been given the code to open the IV supply cart.

i. Interview on 7/23/19 at 1:20 p.m. with the director of nursing (DON) regarding the above observations revealed she:
*Had not been aware of all the concerns identified above for the security of narcotic and high risk meds.
*Agreed:
-The meds were unsecured from unauthorized access of others and those processes needed to be reviewed.
-The pharmacist was responsible for the pharmaceuticals in the facility and the processes to ensure they remained secured from unauthorized access.

2. Observation and interview on 7/23/19 at 3:00 p.m. with paramedic T in the ED ambulance parking garage revealed:
*There were two ambulances inside the garage.
*The provider had two more ambulances in a building in the back of the facility.
*Three of the ambulances had been stocked with meds and supplies to support those patients who required advanced cardiac life support (ACLS).
*Two of the ambulances had a small black metal box secured on one of the shelves inside of them.
-Those boxes had been locked and required the use of a special hex type key to open them.
*Paramedic T:
-Removed a ring full of keys from inside of his pants pocket.
--The hex type key had been with the other keys he had.
-Used that key to open the small black metal box.
-Inside of the box were vials of narcotics and sedation/mind altering medications.
-Those meds had been: Fentanyl, morphine, ketamine, etomidate, valium, and versed.
-There was a narcotic report log inside the box, and the count of the vials was reviewed with the paramedic.
--No concerns with the count were identified.
-Kept that hex key with him at all times.
--That had included going home with him after his shift had ended for the day/night.
-Stated one of the ambulances outside had the same set-up as this one, and he could use the same key to open it.
*The third ambulance had:
-A large cabinet that was separated in two by two doors.
-Inside of the top cabinet and laying on the shelf was a black key.
*Paramedic T opened that cabinet, got the key, and used it to open the bottom cabinet right below it.
*Inside of that cabinet was a small clear plastic container secured shut with a numbered Ziploc tie.
*There was a narcotic count sheet attached to the container and identified the same meds as in the above observed black box.
*Paramedic T:
-Confirmed the third ambulance with the key in the cabinet above the narcotics cabinet left those meds unsecured and allowed for unauthorized access and for med diversion to have occurred.
-Would not confirm the other two ambulances for accessing and securing their meds in the black boxes had been unsecured.
-Would not confirm that taking the hex key home with him created a vulnerable situation for access to meds that required security from access of unauthorized and unlicensed staff, visitors, and patients.

Observation and interview on 7/24/19 at 3:20 p.m. with paramedic student U and paramedics V and W revealed they:
*Confirmed and supported the observations of the ambulances above and the security of their meds.
*Agreed the processes above allowed for the meds to be unsecured and easily accessed by unauthorized staff or for drug diversion to have occurred.

Interview on 7/25/19 at 9:15 a.m. with the pharmacist regarding the observations of the ambulances and interviews with the paramedics revealed:
*She was not aware of the process they used to ensure the security of the meds on the ambulances had occurred.
*She agreed she should have been aware of their processes and would have to start doing spot checks on them.
*She stated, "But we are a small facility and small community with really not much to worry about I think."

3. Review of the provider's January 2019 Drugs in Patient Care Areas policy revealed:
*"Medication cabinets or rooms and controlled-drug compartments should be kept locked and the keys should be available only to authorized personnel."
*Drug cabinets:
-"Should be examined weekly or more often by the nurse in charge."
-"Monthly inspections should be made by pharmacy and nursing service or their agents."

Review of the provider's undated Pharmacist Job Description revealed: "The pharmacy director is responsible and accountable with the duty of organizing and providing pharmaceutical services to all hospital services and disciplines."

Based on interview and record review, the provider failed to ensure three of three registered nurses (RN) (K, L, and M) did not pronounce death for three of three sampled swing bed patients (11, 14, and 15).
Findings include:

1. Review of patient 11's medical record documentation revealed:
*Date/time of death: 7/23/19 at 11:44 a.m.
*Pronounced by: RN K.

2. Review of patient 14's medical record documentation revealed:
*Date/time of death: 4/19/19 at 8:35 p.m.
*Pronounced by: RN L.

3. Review of patient 15's medical record documentation revealed:
*Date/time of death: 2/23/19 at 6:15 p.m.
*Pronounced by: RN M.

4. Interview on 7/24/19 at 9:00 a.m. with the director of nursing regarding the above records revealed:*Nurses pronounced patients' deaths.
*Two nurses would validate the death.
*They would notify the physician.
*She was unaware nurses could not pronounce death.
*She used the South Dakota Board of Nursing for professional standards.

Review of the South Dakota Board of Nursing 8/4/14 letter clarifying the intent of SDCL 34-25-18 and 34-25-18.1 pronouncement of death revealed: "The Board of Nursing has been advised by legal counsel that in order for pronouncement of death to be effective it must be accompanied by a certificate, which the law recognizes, stating the party died with the cause of death and since a nurse cannot sign a death certificate, a nurse cannot pronounce death."

Based on record review, interview, and policy review, the provider failed to ensure the care plans had identified all areas of concern for 6 of 15 sampled patients (3, 4, 18, 29, 32, and 38) to ensure proper care and services had occurred. Findings include:

1a. Review of patients 3 and 18's medical records and care plans revealed:
*They had:
-Both been mothers' of new born infants.
-Both tested positive for drug use in their blood stream at the time of delivery for those infants.
*There was no documentation to support what individualized interventions and focus areas they had required to ensure:
-The stability of their health had occurred due to the inability to use non-prescribed drugs during their stay in the facility.
-What physical and mental health support services they might have required during their stay in the facility due to the recent use of those drugs.

b. Review of patients 4 and 38's medical records and care plans revealed:
*They were infants delivered from the above mothers 3 and 18.
*Patient:
-Four's umbilical cord tested positive for illegal drugs in the form of methenphetamines in his blood stream.
-Thirty-eight's mother tested positive for marajuana in her blood stream.
*There was no documentation to support what individualized interventions and focus areas they had required to ensure:
-No further child abuse had occurred from the use of those illegal drugs by their mothers.
-What they required medically to ensure the stability of their health would occur after they were born and during their stay in the facility.
-What safety measures were put in place to support an attempt at a safe and healthy discharge from the facility and out into the community occurred.

c. Interview on 7/24/19 at 11:15 a.m. with the director of nursing regarding the above patients' medical records review revealed:
*She confirmed:
-The facility admitted and treated mothers and newborns who tested positive for illegal drugs in their system.
-That was a form of child abuse and required special steps and interventions by the facility to ensure they had made every attempt at a safe discharge into the community for them both.
*The facility was provided a list of focus areas and interventions from the current software they used.
-Those focus areas and interventions did not have the capability to be individualized for each patient.
*There were no focus areas and interventions for the facility to choose from that had supported and assisted them to care for those patients who tested positive for illegal drugs in their system.



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2a. Review of patient 29's medical record revealed he had been admitted on 3/28/19 from the emergency department with acute cholecystitis.

Review of patient 29's physician's discharge summary revealed:
*He had a cholecystectomy on 3/29/19.
*His discharge diagnoses included:
-Severe sepsis with acute organ dysfunction.
-Elevated liver enzymes.
-Alcoholism.
-Acute cholecystitis.
-Abdominal pain.

Review of his care plan revealed only two nursing diagnoses:
*Alteration in comfort.
*Risk for falls.

b. Review of patient 32's medical record revealed she had been admitted on 5/21/19 for a planned cesarean section.

Review of her care plan revealed only one nursing diagnosis for how to quit smoking.

c. Interview on 7/25/19 at 9:00 a.m. with RN/risk management/infection control/QAPI I during the chart reviews confirmed the above diagnoses and care plans. She agreed the care plans did not reflect all of the problems, goals, or interventions required for those diagnoses. Both patient 29 and 32 had been at risk for many different problems. She stated there was only a limited amount of care plan topics that could be selected from. She also confirmed those items were the only educational references that had been sent home with them upon discharge.

Review of the provider's revised December 2007 Discharge Instruction Plan - Same Day Surgery policy revealed that was the only discharge policy the provider had.

Review of the provider's December 2014 Care Planning policy revealed:
*Purpose: "An individualized plan of care for each patient is developed by the Patient Care Team in order to meet the following patient care goals:
-1. Implement and maintain the medical treatment plan.
-2. Keep the patient safe during the hospital stay.
-3. Keep the patient comfortable during the hospital stay.
-4. Complete the patient education."

Based on policy and procedure manual reviews and interview, the provider failed to ensure policies and procedures were evaluated, reviewed, and revised periodically for four of six policy and procedure manuals selected for review (swing bed, nursing, infection control, and emergency deparment). Findings include:

1. Review of the provider's Swing Bed policy and procedure manual revealed:
*Most of the swing bed policies had been updated in 2001.
*A document in front of the swing bed polices stated:
-"Policies and/or procedures in this section have been reviewed and revised as indicated.
-It had been signed and documented on 12/17/18 by licensed practical nurse (LPN)/swing bed coordinator F as "updating."

Interview on 7/24/19 at 2:30 p.m. with LPN/swing bed coordinator F regarding the swing bed policy and procedures revealed:
*They had not been updated.
*She was responsible to update the Swing bed policies and procedures.
*She had been new to the position August 1, 2018.
*She had not had time to update the Swing bed policies and procedures.

Interview on 7/24/19 at 3:33 p.m. with the director of nursing regarding the Swing Bed policy and procedures revealed they should:
*Have been updated.
*Not have been as old as 2001.



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2a. Review of the provider's emergency department's Restraint/Seclusion Death Reporting policy revealed it had not been reviewed or revised since July 2016.

b. Review of the provider's LifePak Monitor/Defibrillator policy revealed it had not been reviewed or revised since June 2015.

c. Review of the provider's Care Planning policy revealed it had not been reviewed or revised since December 2014.

d. Interview on 7/24/19 at 4:15 p.m. with the director of nursing (DON) regarding the reviewing and revising of the above policies revealed:
*She confirmed the policies had not been updated.
*She stated:
-"They are a work in progress."
-"I've started to update some."



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3. Review of the provider's three Nursing Department policy and procedure manuals revealed:
*A document in front of the nursing department polices stated:
-"Policies and/or procedures in this section have been reviewed and revised as indicated.
-They had been signed and documented on:
*Book 1 on 12/31/17.
*Book 2 on; 12/1/17.
*Book 3 on 1/20/18.

Interview on 7/24/19 at 2:30 p.m. with the director of nursing regarding the above policy and procedures revealed she agreed:
*They had not been updated.
*She was responsible to update the nursing department policies and procedures.
*Had started to update some of the nursing policies and procedures.

4. Review of the Infection Control policy and manual revealed it had not been reviewed or updated since 2017.

Interview on 7/24/19 at 3:00 p.m. with RN/risk management/infection control/QAPI I confirmed those above policies had not been reviewed or updated since 2016.

Based on interview, record review, and policy review, the provider failed to update and revise one of six sampled swing bed patient's (11) care plan to reflect her current needs. Findings include:

1. Review of patient 11's medical record revealed:
*Diagnosis of acute myeloid leukemia.
*A 6/27/19 physician's order for comfort care.
*A 7/23/19 physician's order for "intravenous morphine as an option in case the oral morphine becomes inadequate or she is unable to take it."

Review of patient 11's care plan with the following evaluation dates with interventions listed revealed:
*On 6/24/19:
-Activity intolerance.
-Impaired physical mobility.
-Risk for falls.
*On 7/23/19:
-High risk for injury.
-Impaired skin integrity.
*There were no interventions or descriptions listed for pain management or care and comfort.

Interview on 7/24/19 at 2:30 p.m. with LPN/swing bed coordinator regarding patient 11's care plan revealed:
*It was incomplete.
*It had not included interventions or goals for pain or care and comfort measures.
*She had not done anything with the care plans.
*It was the nurses responsibility to update the care plans.
*The director of nursing oversaw the swing bed care plans.

Interview on 7/24/19 at 3:33 p.m. with the director of nursing regarding patient 11's care plan revealed:
*She was responsible to oversee the care plans.
*The nurses were responsible to complete the care plans.
*She agreed pain and care and comfort measures had not been included on patient 11's care plan.
*She would have expected the care plan to have been updated and revised.

Review of the provider's undated Multidisciplinary Care Plan Policy for Swing Bed Patients policy revealed:
*Purpose:
-"The Patient Care Committee is the interdisciplinary team responsible for the overall assessment, planning, and evaluation of care for each patient and for the coordination of services to provide continuity of care."
*Policy:
-"1. The committee reviews all new admissions to the swing bed program within one week of admission and weekly thereafter.
-2. Existing and potential problems are identified and goals for resolution determined and recorded on the kardex.
-3. Specific objectives for care, interventions, and evaluations are documented on the Nursing Care Plan.
-4. The Nursing Care Plan is reviewed and revised every thirty (30) days thereafter, and more frequently as patient status dictates."

Based on document review and interview, the provider failed to maintain the emergency preparedness plan as required (contact information). Findings include:

1. Document review of the emergency preparadness plan at 4:45 p.m. on 7/24/19 revealed the list of Region II points of contact was dated 2010. Several of the contacts were known to not be at the facilities listed due to retirement or other circumstance. Further document review and interview with the registered nurse/risk management/infection control/quality compliance staff person at 4:55 p.m. on 7/24/19 revealed eighteen of forty-five staff contacts were no longer employed by the hospital.