HospitalInspections.org

Based on review of policy, personnel files, job descriptions and staff interview, the facility failed to ensure current certification was maintained in Basic Cardiac Life Support (BCLS) for 1 of 3 Certified Nursing Assistant (CNA) personnel files reviewed requiring BCLS certification according to the job description (CNA#4).

The findings include:

Review of 08/02/2024 of hospital policy "Staff Competency Assessment," effective 09/11/2020, revealed, "... 5. Employees required by their job description to have CPR certification must maintain current certification through the American Heart Association. ... 13. Departmental leadership is responsible for ensuring that all competency requirements are met. ..."

Review on 08/02/2024 of CNA#4's personnel file revealed CNA#4 was employed from 11/08/1999 until 04/14/2023. Review of CNA#4's BCLS certification revealed the certification expired on 03/31/2023. Review failed to reveal documentation of BCLS certification renewal after 03/31/2023.

Review on 08/02/2024 of the Job Description for CNA#4 revealed BCLS certification was listed as a requirement under the "Licensure/Registration/Certification" section of the "Job Specifications." Review revealed the Job Description was signed on 09/07/2022 by Nurse Supervisor#5 and was signed on 09/28/2022 by CNA#4.

Review on 08/02/2024 of the Staffing Schedule revealed CNA#4 worked the following dates in April 2023: on 04/03/2023 as a Monitor Tech (Technician), on 04/06/2023 as a CNA, on 04/09/2023 as a CNA, and on 04/11/2023 as a Monitor Tech (4 of 14 days employed in April 2023). Review revealed CNA#4 worked 2 of the 4 scheduled shifts in direct patient care.

Interview on 08/02/2024 at 1150 with the Vice President of Nursing (VPN#6) confirmed CNA#4 had no updated BCLS certification on file after 03/31/2023. Interview revealed nursing leadership was unaware of the expired certification due to a change in the department leadership at that time. Interview revealed department leaders were responsible for ensuring BCLS certification was maintained for each employee.

Based on hospital policy reviews, medical record review, safety event review, and staff interviews, the hospital failed to ensure a patient with signs and symptoms of a stroke had a CT/CTA (Computed Tomography/Computed tomography angiography) performed per facility policy in 1 (one) of 1 (one) stroke patient chart review (Patient #2).

The findings include:

A review on 07/31/2024 of the hospital's policy "Care of Patient Presenting to the ED (Emergency Department) with Acute Stroke Symptoms" effective 07/01/2021 revealed "Purpose: To facilitate the care of patients who develop stroke-like symptoms, using best practice guidelines, efficient diagnosis and timely intervention... Procedure: A. Stroke response ...4. Nursing will facilitate the following: Facilitate transport to CT for a non-contrast head CT (STAT) [urgently]..."

A review on 07/31/2024 of the hospital's policy "Radiology Orders Status Policy and Procedures" effective 04/21/2014 revealed "...Procedure: III. All STAT in-house, ED, or outpatient procedures will take priority over routine and scheduled procedures and be done immediately..."

A review on 07/31/2024 of Patient #2's medical record revealed a 71-year-old male presented to the emergency department on 02/09/2023 at 1426 via Emergency Medical Services (EMS) with complaints of episodes of aphasia (difficulty with speech) and left-sided weakness. The review revealed Patient #2 reported to his primary care provider (PCP) who called EMS for stroke-like symptoms. The review revealed Patient #3 reported an episode 2 to 3 days ago where the entire left side of his body felt weaker than the right and had issues with his grip at the time of ambulation. The Patient Care Timeline revealed the initial triage was completed at 1515 and the medical screening exam (MSE) was done at 1626. The record review revealed the ED provider ordered a STAT CTA of the head and neck with contrast on 02/09/2023 at 1652 and a routine CT of the head without contrast at 1653. The review revealed the CT of the head without contrast was completed at 2013 (5 hours and 27 minutes after arrival and 3 hours and 20 minutes after the order was written). The CTA was completed at 2014 (5 hours and 28 minutes after the patient's arrival and 3 hours and 22 minutes after the order was written). The record review revealed that the staff failed to complete a CT and CTA for Patient #2 per the hospital policy.

A review on 07/31/2024 of a safety event reported on 02/10/2023 revealed Patient #2 arrived at the ED with neurological stroke-like symptoms at 1426, a STAT CT/CTA was ordered at 1653, and was completed at 2013. The review revealed, "in the setting of an acute stroke, CPG (Clinical Practice Guideline) call for imaging regardless of lab values..." The safety report revealed the policy was not followed.

An interview on 08/01/2024 at 1045 with the Stroke Coordinator revealed that based on the symptoms reported by the patient, the last known well would have precluded the patient from being a code stroke but the CT/CTA should have been done in a more expedited manner.

An interview on 08/01/2024 at 1115 with the ED Director revealed that Patient #2 was an acuity level 3 and did not fall into the code stroke protocol. The interview revealed that the Director did review the safety report from the ED perspective and the almost 6 hours wait time between arrival to the ED to the completion of the CT/CTA was not ideal and the policy was not followed.

Based on policy review, medical record review and staff interview the hospital staff failed to follow policy and procedure to monitor a patient during a blood transfusion for 1 of 2 (Pt. # 17) sampled blood transfusion records reviewed.

Findings include:

Review on 07/31/2024 of the hospital policy "Blood and Blood Product Administration" - PolicyStat ID 15201953, last revised 02/13/2024, revealed "B.8...Obtain baseline VS (vital signs) 15 minutes prior to picking up blood ...B.17. Obtain and record vital signs 5 minutes after initiation ... stay with the patient for the first 15 minutes after the blood reaches the angiocath ...19. Obtain and record vital signs 30 minutes after initiation of blood product and as needed on the Blood Admin flowsheet in the EHR (electronic medical record) ... Observe the patient closely every 30 minutes, along with a set of vital signs during the remainder of the transfusion, for any signs and symptoms of transfusion reaction ...20. Obtain and record the vital signs upon completion ..."

Review of the closed medical record for Patient #17 on 08/01/2024 revealed a 69-year-old female that presented to the Emergency Department on 07/17/2024 and was admitted with a chief complaint of shortness of breath. Review of the medical record revealed Patient #17 received orders on 07/19/2024 to transfuse 2 units of Packed Red Blood Cells (PRBCs). Review of the blood transfusion nursing notes revealed Patient #17 received one (1) of the two (2) units of PRBCs from 1633 to 1922. Review of the nursing documentation revealed the first unit was completed at 1922 and the attending physician was notified of a possible transfusion reaction. The order to transfuse the 2nd unit of PRBC's was discontinued. Vitals signs were documented at 1536, 1630, 1638 (no BP), 1648 and 1922. Review of the medical record failed to reveal documentation of every 30 minutes vital signs from initiation to completion of blood transfusion.

Interview on 08/02/2024 at 1230 with RN #3 (with Manager of Inpatient Services present) revealed she was the nurse that administered the blood to Patient #17 on 07/19/2024, interview revealed there were no documented vitals signs between 1648 and 1922 (2 hours and 34 minutes). The nurse manager asked "Did you have her on the vital sign machine?" and RN # 1 stated "I ' ll be honest, no". Interview revealed the staff failed to follow the hospital policy.

Based on review of job description, observations, review of personnel files, and interviews with staff, the hospital failed to ensure staff was knowledgeable and competent to perform dishwashing tasks for 1 of 1 personnel files reviewed.

The findings include:

Review of the job description titled "FOOD SERVICE ASSOCIATE" dated 03/15/2022 revealed "Job Purpose: The Food Service Associate may work anywhere on property where food is prepared...General Responsibilities: v. May perform other duties and responsibilities as assigned."

Observation on 08/01/2024 at approximately 1120 revealed Dishwasher #12 was standing at the compartment sinks with thin layer of bubbles in the filled sinks of water.

Interview on 08/01/2024 at approximately 1130 with Dishwasher #12 revealed Dishwasher #12 was assigned to wash dishes on 08/01/2024. Dishwasher #12 was unable to demonstrate correct water level, amount of soap to be added to the water and use of pH test strips. (Chemical strips to determine correct balance of soap in the water). Interview revealed Dishwasher #12 stated he "was not trained to wash dishes."

Review of the personnel file for Dishwasher #12 revealed a hire date of 02/06/2023 with no documentation of a dishwashing competency.

Interview on 08/01/2024 at 1140 with the Director of Nutrition Services #13 revealed Dishwasher #12 was trained for stock room; but was moved to dishwasher. Interview revealed Dishwasher #12 is a utility worker, which includes dishwashing.

Based on observations, review of policies, interviews with staff, the dietary staff failed to date and label open containers of food and failed to document daily calibration of food thermometers on the thermometer calibration log.

The findings include:

1. Observation on 08/01/2024 at 1050 revealed an opened bag of Basmati Rice wrapped in cellophane sitting on the storage shelf with no opened date. Observation revealed an opened box of Cream of Wheat with no opened date or expiration date. Observation revealed a plastic tub of granola with lid partially off of the tub with no expiration date. Observation revealed a box of opened baking soda sitting in a plastic sandwich bag with expiration date of 10/16/2025, 14 months later."

Review on 08/01/2024 of the "(Dietary Contract Name) Food Safety Management System" with a revision date of 01/28/2022 revealed "Rice, flavored or herb" with dry storage date of 6 months. Keep tightly closed after opening...Grits with dry storage date of 12 months and store in airtight container after opening. Cereals, ready-to-eat with dry storage of 6-12 months. Refold Package liner tightly after opening....Baking soda with shelf life of 6 months opened."

Review on 08/01/2024 of the policy titled "Food Storage" with revision dated of 06/18/2024 revealed "...Procedure: 1. The Receiving Clerk is responsible for storage of food and non-food items. 2. Foods are regularly inspected for signs of damage due to spoilage...4. Stock is rotated to support use of a 'First-In, first-Out (FIFO) approach....7. Products are labeled and dated per (Dietary Contract Name) and regulatory standards....All Foods: Must be in food grade containers. Dry Bulk Foods: Store in non-reactive metal or plastic containers with tight fitting lids."

Interview on 08/01/2024 at 1245 with Director #13 revealed the bag of rice, cream of wheat and granola did not have a date and should have been dated. The interview revealed the rice, cream of wheat and granola should have been in airtight containers. The interview revealed the baking soda was incorrectly dated. The baking soda should have been dated only 6 months from opened date. Interview revealed all of these food items have been discarded. Interview revealed the safety date policy had not been followed.

2. Review on 08/01/2024 of the procedure titled "Thermometer Calibration Log" dated 3-10-2023 revealed "Instructions: 1. Use this log to document the accuracy checks of the operation's food thermometers that are in use. 2. Check the accuracy of all in use food thermometers daily. 3. Calibrate thermometer using one of the following calibrations procedures: 3.1. Ice Point Method (if thermometer will be used for refrigerated product): 32F (Fahrenheit) (+/-2F) or 0C (+/-0.5C). 3.2. Boiling Water Point Method (if thermometer will be used for hot product items...4. Discard/replace thermometers that do not meet the calibration requirements. 5. Manager must review log within seven days."

Review of the log titled "Thermometer Calibration Log" revealed 3 entries for 07/18. Review revealed no other entries for the days of the month. Review revealed the first entry was titled "(Name)" thermometer in the Thermometer ID column with results of 32.3 actual temperature reading. The word "Ice" was handwritten in the column of Target Temperature Reading. Review revealed the second entry for 07/18 reads "front line" and 32 as actual temperature. The third and final entry on the log revealed "07/18" with "Cook's" thermometer and "32.2" actual temperature reading. The line on the bottom of the log read "Reviewed by: Manager or Person-in-charge" remains blank and without a signature.

Interview on 08/02/2024 at 0945 with Director #13 revealed there were no more temperature logs available. Interview confirmed the logs were incomplete and should have been completed.


NC00186552; NC00194338; NC00199408; NC00210532; NC00211225; NC00214434