HospitalInspections.org

The hospital reported a census of 11 patients. Based on document review and staff interview the hospital failed to document staff training and competency for 12 of 14 personnel records reviewed requiring restraint training (Staff F, H, L, N, O, P, Q, R, S, T, U, and V).

Findings include:

- Review on 6/9/10 of the following personnel files revealed:

1. Staff F, hired 11/16/05, lacked evidence of annual restraint training with demonstration.

2. Staff H, hired 10/22/09, lacked evidence of annual restraint training with demonstration.

3. Staff L, hired 5/10/10, lacked evidence of annual restraint training with demonstration.

4. Staff N, hired 1/26/10, lacked evidence of annual restraint training with demonstration.

5. Staff O, hired 2/09, lacked evidence of an annual restraint training with demonstration.

6. Staff P, hired 12/7/05, lacked evidence of annual restraint training with demonstration.

7. Staff Q, hired 2/19/03, lacked evidence of annual restraint training with demonstration.

8. Staff R, hired 2/19/10, lacked evidence of annual restraint training with demonstration.

9. Staff S, hired 7/1/03, lacked evidence of annual restraint training with demonstration.

10. Staff T, hired 2/21/05, lacked evidence of annual restraint training with demonstration.

11. Staff U, hired 6/22/02, lacked evidence of annual restraint training with demonstration.

12. Staff V, hired 5/10/10, lacked evidence of annual restraint training with demonstration.

- On 6/9/10 at 2:45pm Administrative Staff B acknowledged the hospital-lacked evidence of restraint training and demonstration of competency for staff.

The hospital failed to document staff training provided and failed to provide evidence of return demonstration for competency for use of restraints for 12 of 14 staff personnel records reviewed.

Based on record review and staff interview the hospital failed to ensure medical staff signed, dated and/or timed all orders, including standing orders, for 4 of 6 sampled records in the obstetrical unit (#'s 17, 18, 20, and 21).

Findings included:

- Patient #17's medical record revealed 3 of 3 physician standing orders, initiated 4/12/10 to 4/13/10, lacked date or time when authenticated (signed).

- Patient #18's medical record revealed 4 of 4 physician standing orders, initiated 3/16/10 to 3/18/10, lacked a date or time when authenticated.

- Patient #20's medical record revealed 2 of 2 physician standing orders, initiated on 4/12/10, lacked a date or time when authenticated.

- Patient #21's medical record revealed 2 of 2 physician standing orders, initiated on 3/17/10, lacked a date or time when authenticated.

Administrative staff B on 6/7/10 at 4:30pm acknowledged the hospital required medical staff to date and time signatures on orders.

- Review on 6/9/10 of Medical Staff Rules and Regulations revealed the following: page 9 "...All clinical entries...in the patient's medical record shall be accurately dated and authenticated..." The Medical Staff Rules and Regulations failed to direct medical staff to include the required time of the entry.

- On 6/7/10 at 4:30pm Administrative staff B acknowledged the hospital required medical staff to date and time signatures on orders.

The hospital reported a census of 11 patients. Based on observation, interview and document review, the hospital pharmacist failed to supervise the dispensing of scheduled II drug(a narcotic).

Findings include:

- Policy review on 6/9/10 at 12:20pm revealed ...Pharmacist shall consult with Hospital to the extent necessary to ensure that Hospital provides pharmacological services which are administered in accordance with accepted ethical and professional practices and in conformity and compliance with KAR 28-34-10 (a), ....

- Observations made on 6/07/10 at 3:30pm revealed a hospital Registered Nurse dispensed a medication from the Emergency Room Pixus system, a drug dispensing system, to a Rural Health Clinic (RHC) Registered Nurse, not an employee of the hospital.

Interview on 6/8/10 at 1:15pm with staff H revealed the nurse from the RHC obtained a schedule II medication from the hospital with a physician hand written prescription. The hospital staff enter a patient code of UFP(Ulysses Family Practice) into the Pixus system and dispense the medication to the RHC staff. During the interview, Staff H searched the pharmacy basket where all hand written prescriptions are placed for pharmacy to pick up, but failed to provide evidence of the hand written prescription.

Staff F on 6/8/10 at 1:30pm acknowledged the pharmacy failed to obtain a written prescription for the scheduled II drug dispensed in the Emergency Room to the RHC on 6/7/10.

Staff F on 6/9/10 at 8:55am provided the survey team with a copy of a written prescription fo the narcotic dispensed from the ER to the RHC on 6/7/10.

Interview with staff E,on 6/9/10 at 12:40 pm indicated they were unaware the hospital nursing staff dispensed medication from the Pixus system to the RHC.

- Observation on 6/7/10 at 3:45pm revealed an unlocked and unattended anesthesia cart in the hallway of the Obstetrical Unit that contained the following medications:

Eight 10ml (milliliter) vials of lidocaine 2% (a numbing agent).
One 5ml vial of lidocaine 1.5% test dose.
Two 1ml vials Ephedrine Sulfate (a stimulant).
One open 30ml vial of Sensorcaine 0.25% (a numbing agent).
Three 30ml vials of Sensorcaine 0.25%.
An epidural kit containing one 5ml vial of 1% lidocaine and one 5ml vial of 1.5% lidocaine
with epinephrine.

Staff L on 6/7/10 at 3:50pm acknowledged the unlocked, unattended anesthesia cart in the hallway with the unsecured medications. Staff L acknowledged unauthorized persons could access the area without hospital staff knowledge.







28996

The hospital reported a census of 11 patients. Based on observation, document review, and interview the hospital failed to keep drugs secured for one of three emergency carts and one of two anesthesia carts.

Findings include:

- Review of Hospital pharmacy policy on 6/9/10, directs staff that drugs are to be stored securely.

- Observation made on 6/8/10 at 1:15pm revealed an unlocked, unattended emergency crash cart in the Emergency Room hallway. The cart contained multiple emergency drugs including Valium, a Schedule II Narcotic. Multiple construction workers and maintenance staff were working in the same hallway.

- Interview on 6/8/10 at 1:15pm with Staff H, confirmed the crash cart was unlocked and unattended. Staff H verified unauthorized persons could access the medications without staff knowledge.

- Observations made on 6/7/10 at 3:00pm of the Emergency Room Crash Cart revealed a 50 milliliter bag of Sodium Chloride with an expiration date of 5/1/10.

Staff H interviewed on 6/7/10 at 3:00pm verified the outdated medication.

- Policy Review Number 09-04 revealed,....The pharmacy shall identify outdated and other unusable drugs and devices and prevent their distribution and administration.....










25604


Based on observation and interview the hospital failed to ensure that unusable drugs and biologicals are not available for patient use in one of one contrast media warming cabinet observed, one of one fluid warming cabinets observed, and one of three crash carts observed.

Findings included:

- Document review on 6/9/10 of the information sheet provided by the manufacturer of the Isovue (an intravenous dye) directed under storage "...may be stored in contrast media warmer at 37 degrees Celsius (98.6 degrees Fahrenheit) for up to one month..."

- Observation on 6/8/10 at 11:40am revealed a contrast media warming cabinet in the Cat Scan (CT) room contained ten 100mL vials of Isovue and twenty 50mL vials of Isovue. The temperature registered at 99.3 degrees Fahrenheit. These solutions lacked a date when placed in the warmer or when to be removed from use.

Interview on 6/8/10 at 11:40am with staff K acknowledged the 30 vials of Isovue lacked the date when placed in the warmer and were unaware of the length of time Isovue remained stable in a warming cabinet.

- Observation on 6/9/10 at 2:15pm revealed a fluid warming cabinet in the sub-sterile area of the operating room contained three 50mL vials of Isovue. The temperature in the warming cabinet registered at 111 degrees Fahrenheit. These vials lacked a date when placed in the warmer or when to be removed from use.

Interview on 6/8/10 at 11:40am with staff X acknowledged the three vials of Isovue lacked the date when placed in the warmer or when to be removed from use.

The hospital reported a census of 11 patients. Based on observations and interview the hospital failed to ensure all drugs and supplies were maintained to safely meet patients' needs for both day to day operations and in emergency situations.

Findings included:

- Tour of the Emergency Department on 6/07/10 at 2:30pm with staff H revealed the following:

Two - Thoracentesis Trays with an expiration date of 10/09
One - 6.0 millimeter (mm) Tracheal tube with an expiration date of 10/1999
One - 6.5 mm Tracheal tube with an expiration date of 9/2000
Three - 24 gauge Intravenous Catheter (IV): one with an expiration date of 1/07 and two with an expiration date of 3/07
Five - 18 gauge IV catheter with an expiration date of 4/2005 and four with an expiration date of 3/07
Seven - 20 gauge IV catheters: one with an expiration date of 6/06, one with an expiration date of 7/06, one with an expiration date of 7/07, and four with an expiration date of 3/07
Seven - 22 gauge IV catheters: two with an expiration date of 9/07, two with an expiration date of 6/06, and three with an expiration date of 3/07
Three - Bone Marrow needles: two with an expiration date of 7/09 and one with an expiration date of 2/10
Eight - Sterile IV prep kits, seven with an expiration date of 3/07 and one with an expiration date of 7/09
One - 3.5mm endotracheal tube and stylet with an expiration date of 4/08
One - 5.0mm endotracheal tube and stylet with an expiration date of 4/08
Three - Uncuffed endotracheal tubes and stylets: one with and expiration date of 12/09, one with an expiration date of 10/09 and one with an expiration date of 4/08
One - eight inch suction catheter with an expiration date of 4/08
One - eight inch nasogastric tube with an expiration date of 4/08
Three packages of two-ply 3x3 sterile gauze sponges with an expiration date of 3/10
One - Laryngoscope blade, size Miller #2 with an expiration date of 4/08
Six - 15 gauge Iliac aspiration needles, five with an expiration date of 2/10 and one with an expiration date of 3/07
Three - sterile extension sets with an expiration date of 2/10
One - 10 French suction catheter with an expiration date of 4/08
One - 10 French Nasogastric tube with an expiration date of 4/08
Four - Sterile extension sets with an expiration date of 3/07
Two - Duodenal tubes: one with an expiration date of 8/09 and one with an expiration date of 7/09
Two - Suction catheters with an expiration date of 3/10
Two - endotracheal tube stylets: one with an expiration date of 2/10 and one with an expiration date of 3/10.
Three - Suction catheters with an expiration date of 3/10

Staff J interviewed on 6/7/10 at 3:45pm confirmed they were aware of the outdates.




28996

- Four shoulder pack oxygen tanks and one e-cylinder oxygen tank were found unsecured setting directly on the ground in an outside fenced enclosure behind the hospital. On 6/7/10 at 12:20pm

- On 6/7/10 at 12:20pm Staff C and Staff D acknowledged unsecured oxygen tanks in the fenced enclosure behind the hospital and verified the danger of unsecured oxygen.

Based on observations, staff interview and document review, the hospital's infection control officer failed to ensure hospital personnel followed basic infection control practices for 1 of 1 observed cleaning of the operating room and one of four observed soiled utility rooms.

Findings included:

Review of the manufacturer's guidelines for "Virex 256" disinfectant cleaner instructed staff to allow surfaces to remain wet for 10 minutes to assure disinfection.

- Observation of staff cleaning of the operating room on 6/9/10 between 2:15pm and 3:10pm revealed staff W and staff X, used "Virex 256" cleaning solution, wet wiped the anesthesia cart, over head lights, stainless steel table, instrument stand, cabinets, patient table and monitors. These areas remained wet for a contact time between four to eight minutes not the required 10 minutes for total disinfection.

Staff J, staff W and staff X acknowledged the "Virex 256" cleaner required a contact time of 10 minutes to achieve disinfection and the surfaces on the equipment in the operating room failed to remain wet for the 10 minutes required for disinfection.

- Observation on 6/7/10 at 4:10pm in the Obstetrical Unit of the hospital revealed two red plastic trash bags and two yellow plastic trash bags resting directly on the floor in the soiled utility room in the northwest hallway.

Staff L on 6/7/10 at 4:15pm acknowledged staff should not place biohazard trash bags on the floor because of the potential for contamination.