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Based on interview and record review, for one of thirty-sampled patient (Patient #15) and one non-sampled Patient A, the Hospital failed to ensure its medical staff adhered to its By-Laws when psychiatric consultations were ordered and not conducted within twenty-four hours.

Findings include:

The Hospital Medical Staff By-Laws were reviewed and indicated that Active Members of the Medical Staff shall take steps to insure requested consultations are completed within twenty-four hours.

1. Patient #15's clinical record was reviewed. The clinical record contained a physician order for a psychiatric consultation at 10:58 A.M. on 6/12/17.

The Surveyor interviewed Nurse #2 at 12:00 P.M. on 6/14/17. Nurse #2 said that she was the Nurse Manager for Patient #15's unit. Nurse #2 said that Patient #15's psychiatric consultation had not occurred and was anticipated to occur during the afternoon on 6/14/17, about fifty hours after it was ordered by the physician. Nurse #2 said that she thought that consultations needed to be completed within twelve to seventy-two hours and she was not aware that the Hospital Medical Staff By-Laws required consultations to be completed within twenty-four hours.

2. Non-sampled Patient A's clinical record was reviewed. The clinical record contained a physician order for a psychiatric consultation at 9:52 A.M. on 6/13/17.

The Surveyor interviewed Nurse #6 at 1:00 P.M. on 6/14/17. Nurse #6 said that non-sampled Patient A's psychiatric consultation had not occurred and was anticipated to occur during the afternoon on 6/14/17, more than twenty-four hours after it was ordered. Nurse #6 said that she thought consultations needed to be completed within twenty-four to forty-eight hours and she was not aware that the Hospital Medical Staff By-Laws required consultations to be completed within twenty-four hours.

Based on observation and interview, Hospital staff failed to ensure medications were ordered for new admissions, were available, and not borrowed from other patients, as required for 1 of 4 applicable Nursing Unit/Medication Rooms.

Findings include:

During a tour of the 2 West Medication Room on 6/13/17 at 10:26 A.M., Licensed Practical Nurse (LPN) #3 said that if a patient is admitted on a weekend day/night, then gave an example of an admission on either a Friday or Saturday, and medications prescribed for the newly admitted patients were not available, medications are "borrowed" from other patients. LPN #3 said that this was not the Hospital's policy, but it would ensure patients admitted would receive their prescribed medications. LPN #3 said that although nursing staff can contact the Contracted Pharmacy, that the medications are not always available in a timely manner.

Review of the Contracted Pharmacy's agreement (12/2016) indicated that the Contracted Pharmacy would be available 24 hours, 7 days a week. The agreement indicated that the turn around time for delivery of medications ordered, during usual business hours was 1 hour, and on off hours, within two hours.

During interview on 6/14/17 at 12:10 P.M., the Director of Nursing (DON) said that required medications would be available at the Hospital's Pharmacy, or the Contracted Pharmacy and that she would follow-up with nursing staff. The DON said that it has never been the Hospital's medication administration policy to borrow medications from other patients regardless of the circumstances.

Based on review of one of nine sampled Outpatient records (Outpatient #4), the Hospital failed to ensure Outpatient #4's Treatment Plan was updated from the initial treatment, May 2016 to June 2017 to indicate changes, additions and/or modifications to Outpatient #4's modalities for treatment.

Findings include:

The Hospital's Outpatient policy and procedure regarding treatment plans, dated January 2017, indicated that a patient's treatment will be developed after a clinical assessment with the participation of the patient and that treatment team conferences verify and ensure the treatment plan was current.

The Surveyor interviewed the Vice President for Outpatient Services at 9:00 A.M. on 6/12/17 and throughout the survey. The Vice President for Outpatient Services said it was a standard of care to update the treatment plan every 90 days and sooner if needed.

Outpatient #4's medical record indicated a treatment plan that was developed and dated 5/18/16. However, on 6/13/17, Outpatient #4's medical record was reviewed and there was no documentation on the Treatment Plan that the treatment plan had been updated and was current.

Based on record review and interview, the Hospital failed to ensure that all medical record entries were legible for two (Outpatient #7 and #9) outpatient records from a sample of nine outpatient records reviewed.

Findings include:

The Hospital's Outpatient medical records policy and procedure, dated January 2017, indicated that all entries into a patient record were to be dated and signed.

Outpatient #7's Physician Authorization Forms, dated May 2017 and June 2017, indicated illegible physician signatures were documented on the forms.

Outpatient #9' Physician Authorization Forms, dated May 2017 and June 2017, indicated illegible signatures were documented on the forms.

The Surveyor interviewed the Vice President for Outpatient Services at 9:00 A.M. on 6/12/17. The Vice President for Outpatient Services said he was aware of the illegible physician signatures and the Hospital developed corrective actions, which included a method to establish the identity of the physician, however, the actions had not yet been implemented.

Based on observation, interview, document and policy review, the Hospital staff failed to ensure current and accurate records were kept of medications dispensed from Emergency Medication Kits (E-kits), in accordance with the contract pharmacy's E-kit policy. The E-kits were stocked and maintained by the contracted pharmacy to ensure medications were available for patient use when the hospital pharmacy was not open or for immediate use when ordered STAT. Findings include:

Review of the Contracted Pharmacy policy entitled: "Emergency Medication and Antibiotic Kit (not dated)" indicated:

- Each E-kit shall be prepared by a Registered Pharmacist.

- After each E-kit is opened it shall be restocked by a Registered Pharmacist.

- Each Nurse should familiarize him/herself with the contents of the emergency medication and antibiotic E-kits.

- A list of emergency contents shall be posted on the outside of each E-kit so that the information is readily available.

- When an emergency medication or STAT (ordered for immediate administration) is needed, the nurse shall access the E-kit container and remove the prescribed medication.

- As soon as possible, the nurse shall record the medication usage, and place the form she recorded the information on inside the E-kit.

- When a E-kit is opened, the nurse responsible shall inform the Contracted Pharmacy as to which kit was opened, which medication has been removed and to whom the medication was removed for.

- The Pharmacy shall exchange a restocked E-kit for the opened kit.

1. During inspection of 4 of 4 Medication Rooms, nursing staff did not ensure that medications removed from the Insulin, Topical and Commonly Used Medication E-kits had been recorded, included patient's names and dates when the medication had been removed, and failed to inform the Consultant Pharmacy to ensure E-kits would be exchanged, restocked and replaced in accordance with the Contracted Pharmacy's policy as follows:

2. During a tour of the 2 East Medication Room on 6/13/17 at 10:04 A.M. with Licensed Practical Nurse (LPN) #2, the Surveyor observed 2 E-kits in the refrigerator. The Insulin E-kit contents inventory label included 3 vials of the long lasting Insulin Lantus, and 2 vials of a shorter acting Insulin, Humalog. The Lantus and Humalog Insulin were not in this E-kit. The Topical Medication E-kit indicated the contents included 1 tube of Mupirocin (topical antibiotic ointment also known as Bactroban) ointment and 1 jar of Silvadene cream (a topical antibiotic typically used as an adjunct for the treatment of second and third-degree burns.) The E-kit was missing the Mupirocin ointment. The Commonly Used Medication E-kit was missing 1 Ropinerole 0.5 milligram (mg) tablet (also known as Requip used to treat Restless Leg Syndrome). There were no forms completed/recorded to identify when or for whom these medications from the E-kits had been removed, or if the Pharmacy had been notified.

3. During interview on 6/13/17 at 10:06 A.M., LPN #2 said that she had no idea when or for whom the Insulins, Mupirocin ointment or Ropinerole had been removed. She said that the Pharmacy was new, but that the process was unchanged for nursing staff to complete a slip indicating what had been removed, including the patient's name, and date, then informing the Pharmacy immediately so that the kit and/or whatever medications had been removed could be restocked/replaced. LPN #2 said that the Contracted Pharmacy comes in twice a week to replace all kits, and that the Insulin, Topical Medication and Commonly Used Medication E-kits had not been restocked and replaced, in accordance to the Contracted Pharmacy's instruction.

4. During a tour of the 4 East Medication Room with LPN #4 on 6/13/17 at 10:40 A.M., the Surveyor observed the Topical Medication E-kit contained 2 tubes of Erythromycin (Topical antibiotic) eye ointment, and a tube of Mupirocin ointment. The E-kit contents label did not include the 2 tubes of Erythromycin Eye ointment stored inside. Furthermore, there was no jar of Silvadene cream, which was identified on the contents label posted on the outside of the kit. There was no form recorded as to whom the Silvadene had been removed or when.

5. During interview on 6/13/17 at 10:49 A.M., LPN #4 said that she had no idea how the 2 tubes of Erythromycin eye ointment had been stored inside the Topical Medication E-kit, since they were not even listed as being on the contents inventory label for this E-kit.

6. During interview on 6/14/17 at 12:10 P.M., the DON said she was responsible for and takes full responsibility for ensuring E-kits were appropriately stocked. The DON said that nursing staff should follow policy and procedure for documenting and recording when E-kits are opened, when medications are removed, and the name of the patient and date that the E-kits were opened. The DON said that she would follow-up accordingly with the Contracted Pharmacy and nursing staff.

Based on observation and interview, Hospital staff failed to ensure unusable drugs and biologicals were not available for patient use in 1 of 4 applicable Medication Rooms, and failed to ensure drugs were stored appropriately.

Findings include:

During a tour of the 3rd floor Medication Room on 6/13/17 at 9:42 A.M. with Licensed Practical Nurse (LPN) #5, the Surveyor observed 2 opened multidose vials of Thiamine (Vitamin B1 supplement) for intramuscular (IM) injection. One was stored in a cabinet and was available for use. The vial was not dated when opened. The second opened multidose vial was stored in the refrigerator (this had been dated when opened). According to the Thiamine packaging instruction label, Thiamine should be stored at 20° to 25°C (Centigrade), or 68° to 77° F (Fahrenheit)/Room temperature. The refrigerator temperature at this time was 46° degrees F. The second vial of Thiamine was not stored at room temperature per the manufacturer's directions for use, compromising its integrity.

LPN #5 said she was not really sure if the Thiamine could be refrigerated or not and would have to check. LPN #5 said that the opened, undated IM Thiamine medication vial stored in the cabinet, should not be available for use, as it was not dated when opened, and there was no way to tell if it had expired.

During interview on 6/14/17 at 12:10 P.M., the Director of Nursing (DON) said that the undated vial of Thiamine should not have been stored and available for use. The DON said that she would check the package insert for storage of Thiamine in the refrigerator, and re-education would be provided to nursing staff regarding appropriate storage of medications.

Based on observation and interview, the Hospital failed to consistently maintain equipment and supplies at an acceptable level of safety and quality in the Food and Nutrition Services Department.

Findings include:

The Hospital Staff failed to consistently maintain the kitchen equipment free of dust and debris and in good repair. During the kitchen tour on 6/13/17, the Surveyor made the following observations in the Main Kitchen and the Nourishment Kitchens:

A. At 9:00 A.M., during the Kitchen Tour with the Corporate Food Service Director, the Surveyor observed the following:

1. The lights and light fixtures in the exhaust hood above the food preparation equipment, had a build up of dust. Four light bulbs were not working and one bulb was missing.

2. A ceramic tiled cabinet top located by the ovens had broken tiles at the corners.

3. The surfaces of three utensil drawers, the bottom shelf of a food preparation table and the bottom shelf of the steamtable were not in good condition as the surfaces were not smooth and left a residue when touched.

4. The ice scoop was stored in an open metal holder that did not protect the scoop from splash and dust. The metal of the holder had a rough surface and the holder could not be removed for cleaning.

5. The cold water faucet at the sanitizer bay of the 3 bay sink did not work. The quaternary ammonium sanitizer instructions read that the sanitizer should be mixed at 75 degrees F. With only the hot water working and no cold water to mix in, the water temperature registered 115 degrees F., which exceeded the water temperature requirement of the sanitizer.

6. The radiator in the dishmachine room was observed with paint worn and chipped.

7. The knife holder was attached to the side of a food preparation counter making cleaning difficult as food debris had accumulated in the space between the holder and the counter top.

8. The cutting boards were stored in a metal type holder that had a build up of dust and dirt. The surfaces of 3 cutting boards had deep scratches which prevented adequate cleaning and sanitizing.

The Corporate Food Service Director, present with the Surveyor, acknowledged the above observations.

B. At 10:35 A.M., during the Nourishment Kitchen Tour with the Assistant Food Service Director, the Surveyor observed the following:

1. The 2 East nourishment refrigerator had a loose gasket.

2. The 3 East cereal shelf did not have a smooth surface as it was worn in several spots which prevented adequate cleaning.

3. The 4 East cabinet drawers had worn surfaces, which prevented adequate cleaning.

The Assistant Food Service Director, present with the Surveyor, acknowledge the above observations.

Based on observation and interview, the Hospital staff failed to ensure adequate lighting in all food service areas.

Findings include:

On 6/13/17 at 9:00 A.M., during an observation of the Main Kitchen, the Surveyor observed that not all the lights in the food preparation area were working. Observation of the Kitchen Exhaust Hood indicated several lights were not working and one was missing. The Surveyor asked the Corporate Food Service Manager how many lights in the exhaust hood above the ovens were not working and he indicated "4".

On 6/13/17 at 2:10 P.M., the Surveyor observed the oven hood with the Hospital Food Service Director, who acknowledged that 4 lights in the exhaust hood were not working and 1 light was missing.