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Based on observation and interview, it was determined that the hospital failed to ensure that patient equipment was maintained in a manner to promote the safety and well-being of patients.

? Call light mechanism was not operable in the main shower room on the third floor

The facility's failure to maintain safety equipment could affect the safety of all patients who used that shower.

The findings were:

During an inspection of the facility's main shower room on 08/19/14 at approximately 11:00 a.m. and 08/20/14 at approximately 10:30 a.m. revealed the shower's call light system was not operable.

Interview with Staff #21 on 08/20/14 at approximately 3:15 p.m. confirmed the main shower room was currently available for patient use. Staff #21 confirmed the shower's call light system was not operable after she tried it. Staff #21 indicated she was not aware how long the call light had not been working. Staff #21 indicated that the shower call light was important for patient safety and would notify the maintenance department to repair.

During the Exit Conference on 08/21/14 at approximately 12:00 p.m., the facility was provided an opportunity to ask questions and provide additional information related to the maintenance of the facility. None was given.

Based on observation, interview and record review, the hospital failed to appropriately store drugs for one of one medication rooms inspected.

? Medication room on the third floor was left unlocked, with door open and unattended by staff.

? Out-dated vial of Novolog insulin was in the medication room's refrigerator and two opened multidose vials of Lantus and Levemir (long-acting) insulin were undated by staff

? Schedule 2 narcotics were stored in a metal cabinet affixed to the wall in the medication room. The metal box had a double lock mechanism. Only one lock was used to secure the narcotics.

The facility's failure to appropriately store drugs could affect the safety of all patients in that area.

The findings were:

Observations of the facility's medication room on the third floor on 08/19/14 at approximately 1:30 p.m. revealed the following:

1. The medication room door was unlocked and opened widely with no staff actively or visibly monitoring the medication room.

2. Inspection of the medication room's refrigerator revealed opened multidose vials of Levemir and Lantus with no indication of when the vials were initially opened to determine manufacturer's recommended expiration date. One expired multidose vial of Novolog Insulin was also observed.

3. Schedule 2 narcotics were stored in a metal cabinet affixed to the wall. The metal cabinet had a double lock mechanism with only one lock being used.

Review of the facility's Use of Multidose Vials policy revised 01/20/11 revealed the expiration date for multi dose vials to be 28 days after initial entry of the vial.

Interview with the facility's Director of Nurses (DON) on 08/20/14 at 1:20 p.m. confirmed that all medications had to be properly secured in the medication rooms according to state and federal regulations and Schedule 2 narcotics were secured using a double lock mechanism. The DON also confirmed that all nursing staff were required to follow the facility's policies for medication administration.

Interview with the facility's Pharmacist on 08/21/14 at approximately 11:00 a.m. confirmed that all medication rooms were required to be locked when no nursing staff was using it, all expired medications to be removed from medication rooms to avoid accidental use, to date all insulin vials when first opened to determine manufacturer's recommended expiration dates and to secure Schedule 2 narcotics using a double lock mechanism as required by state and federal regulations.

During the Exit Conference on 08/21/14 at approximately 12:00 p.m., the facility was provided an opportunity to ask questions and provide additional information related to appropriate drug storage. None was provided.

Based on observation and interview, it was determined that the hospital failed to ensure that patient areas were maintained in a safe and sanitary manner.

? Patient Rooms 304, 305, 312 and 314 were observed to have walls with loose tiles, grape-sized holes, peeling paint and rust stained shower knobs.

? Public restrooms on 3rd floor had walls with loose tiles, holes and peeling paint

? Patient and family room area named the "Solarium" was observed to have grape-sized holes and peeling paint

The facility's failure to maintain a safe and sanitary environment could affect the safety of all patients, family members and staff exposed to that area.

The findings were:

During an inspection of the facility, while accompanied by the facility's Chief Executive Officer (CEO) on 08/19/14 at approximately 09:45 a.m., revealed patient rooms 304, 305, 312 and 314 to have walls with loose tiles, grape-sized holes, peeling paint and rust stained shower knobs. Further inspection of the 3rd floor revealed several public bathrooms to have walls with loose tiles, holes and peeling paint.

Inspection of the facility's patient and family room identified as the "Solarium" on 08/19/14 at approximately 10:00 a.m. revealed walls with grape-sized holes and peeling paint.

Interview with the facility's CEO on 08/19/14 at approximately 10:25 p.m. confirmed that all patient rooms were available for patient care and the "Solarium" was used as a patient and public waiting area. The CEO also confirmed the facility had "... renovated some but not all of the patient rooms."

Interview with Staff #21 and Staff #22 on 08/19/4 at approximately 3:00 p.m. revealed several of the patient rooms on the 3rd floor had been in need of repair for at least six months.

During the Exit Conference on 08/21/14 at approximately 12:00 p.m., the facility was provided an opportunity to ask questions and provide additional information related to the maintenance of the facility. None was given.

Based on reviews of meeting minutes and interviews the CAH does not have an effective quality assurance program to evaluate the quality and appropriateness of the Infection Control program. This requirement is not met as follows.
Findings:
a. In reviews of Quality Assurance meeting from January 2014 until August 2014 there were no infection control information including what is being tracked and performance improvement projects for infection control covered in the Quality Assurance programs specific minutes. The quality assurance program did show oversight of Infection control and showed evidence of evaluating quality of the infection control program before January 2014.
There was no evidence during this period January 2014 to August 2014 that the facility evaluated the quality and appropriateness of the Infection Control program through their Quality Assurance program.
b. In interviewing with staff #20, Quality Assessment Performance Improvement (QAPI) coordinator at 9:30am on August 21, 2014 and staff # 19, Infection Control practitioner at 1:30pm on August 19, 2014 the staff members interviewed could not show evidence that The quality assurance program evaluated infection control monitoring and tracking and performance improvement projects in the quality assurance program from the period of January 2014 until August 2014. There was no evidence that this requirement was met.