HospitalInspections.org

Based on medical record review and policy review, the facility failed to ensure every 15 minute checks were performed in accordance with physician orders and accordance to the facility's policy for two (Patient #27 and #28) of two medical records reviewed for every 15 minute checks. The facility census was 111.

Findings include:

1. The medical record review for Patient #27 revealed an order on 05/16/16 at 5:02 PM for every 15 minute checks for safety and agitation. The medical record contained a Special Precautions form dated 05/26/16 which did not have every 15 minutes checks documented from 3:45 PM through 5:00 PM. The medical record contained an order to discontinue the every 15 minute checks on 05/27/16 at 11:52 AM.

2. The medical record review for Patient #28 revealed an order on 07/15/16 at 4:35 PM for every 15 minute checks for safety. The medical record contained a Special Precautions form dated 07/16/16 which did not have every 15 minute checks documented from 11:15 PM through 11:45 PM. The medical record contained an order to discontinue the every 15 minute checks on 07/18/16 at 10:08 AM.

The facility's policy titled Special Precautions - Management of Patients Identified as Being At High Rick For Dangerous Behaviors #4.51 was reviewed. The policy stated staff will directly observe patients every 15 minutes and document on the Special Precautions Log the patient's location/behavior.

Based on observation and interview, the facility failed to ensure the pharmacy and/or drug storage/preparations areas were maintained in accordance with the facility's policy and free from food/drink. This had the potential to affect all of the facility's 111 active patients.

Findings include:

The facility's pharmacy was observed on 08/01/16 at 12:47 PM. One counter, where medications were prepared, was observed to have a toaster located on the middle of the counter and a microwave located on the left of the counter. There was also drug dispensing equipment on the counter. The counter was also observed to have a bottle of coffee creamer and a dirtied spoon on it.

The findings were verified with Staff A at the time of the observation.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 111 patients and a capacity of 152 beds.

Findings include:

K11 Failed to ensure the two hour fire barrier between nonconforming buildings were free of penetrations.

K18 Failed to ensure each corridor door could close and latch.

K22 Failed to have exit and directional signage in accordance with 7.10.

K25 Failed to ensure smoke barriers were free of penetrations.

K29 Failed to protect hazardous areas in accordance with 8.4.

K33 Failed to ensure barriers protecting stairways were free of penetrations.

K52 Failed to ensure its alarm system was maintained in accordance with NFPA 72.

K67 Failed to ensure each damper was tested.

K130 Failed to ensure compliance at 39.3.1 (vertical openings), 9.6.1.4 (alarm system), and 39.2.10 (marking of means of egress).

Based on observation, interview, and document review, the facility failed to ensure expired supplies were not available for use. This had the potential to affect all of the facility's 111 active patients.

Findings include:

1. On 08/02/16 at 12:44 PM, observation of the facility's Dental Office (Room 136) revealed two containers of Sani Cloth AF Germicidal Disposable Wipes, Lot #A11300492, with an expiration date of 03/2015.

The findings were verified with Staff A at the time of the observation.

2. On 08/02/16 at 12:56 PM, observation of the facility's Dental Office (Room 136) revealed a dispenser with Purrell 1200ml TGX Refill, Lot #276962, with an expiration date of 02/2009.

The findings were verified with Staff A at the time of the observation.

3. On 08/02/16 at 12:50 PM, observation of the facility's Dental Office (Room 136) revealed three boxes of 24 - 1 ounce tubes of Colgate Sensitive Pro-relief, Lot #1264MX1134, with an expiration date of 09/2013.

The findings were shared with Staff A at the time of the observation and confirmed.

The facility's Environmental Rounds Worksheet was reviewed. The worksheet stated each unit would be inspected for outdated medications, equipment, treatments or supplies to protect patients, employees and visitors from facility associated infections.

Based on observation, policy review, and interview, the facility failed to ensure blood glucose checks were performed in accordance with the facility's policy for three (Patients #29, #30, and #31) of three blood glucose checks conducted. The facility census was 111.

Findings include:

1. On 08/01/16 at 10:54 AM, Staff B was observed performing glucometer checks on two patients (Patients #29 and #30). Staff B performed Patient #29's blood glucose check then placed the dirty glucometer on the medication cart. Staff B immediately performed a glucometer check on Patient #30 following the glucometer check of Patient #29. Staff B was observed to perform Patient #30's blood glucose check, change gloves, not perform hand hygiene, don new gloves and then administer insulin. Staff B also did not perform hand hygiene after the removal of the gloves.

The findings were verified with Staff A and Staff B at the time of the observations.

The facility's policy titled Insulin Administration #09.005 was reviewed. The policy stated step number one of the procedure was to wash hands.

The facility's policy titled Blood Glucose Monitoring/Nova Stat Strip Meter #07.002 was reviewed. The policy stated to clean the outside of the meter after each patient with Sani-Cloth.





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2. On 08/04/16 at 11:00 AM Staff C was observed performing a glucometer check on Patient #31. During the observation, Staff C used an alcohol swab to clean the area where the test strip was to be put into the glucometer and then again after the glucometer check for Patient #31. Staff C placed the glucometer back into its holder. Staff C then removed his/her gloves and immediately gathered supplies to administer insulin coverage without cleansing his/her hands. Staff C placed a new glove on his/her right hand only and administered the insulin coverage. Staff C did not cleanse his/her hands between the glucometer check and administering the insulin. These findings were verfied with Staff D immediately after the observation.