HospitalInspections.org

Cross-refer to:

A0057

Based on an interview with staff, a review of clinical records and personnel files, the governing body failed to appoint a chief executive officer who is responsible for managing the hospital and for ensuring that facility policies and procedures regarding annual evaluations and administration of blood and blood products were followed (impacting 17 of 28 staff members):

Findings were:

Facility policy titled "Seymour Hospital Personnel Policy and Employee Handbook" stated, in part:
"J. PERFORMANCE EVALUATIONS: Employees'performance will be evaluated by their immediate supervisor annually."

Review of documentation provided, signed and dated by Staff #28 revealed the following dates on which staff members had received their most recent evaluations:
· Staff #5 - 9-16-12
· Staff #6 - 8-6-04
· Staff #19 - 5-19-11
· Staff #8 - 4-27-09
· Staff #9 - 8-13-12
· Staff #11 - 8-7-12
· Staff #12 - 7-1-13
· Staff #13 - 5-27-05
· Staff #14 - 2-28-05


Facility policy and procedure titled "BLOOD TRANSFUSION" stated, in part:
"7. Two Nurses who have been approved by the Medical Staff to administer IV and blood will:...
8. Administer blood...

An undated and unsigned document titled "IV THERAPY" was provided to the surveyors. The heading read as follows:
"The Seymour Hospital Medical Staff has approved the following nurses to perform the procedures of venipunctur, administration of IV fluids, medications, and blood transfusions, or transfusion of blood products:" The list contained the names of 14 Registered Nurses and 18 Licensed Vocational Nurses.

A review of Medical Staff Meeting Minutes for 2013 and 2014 revealed no discussion of approving nursing staff members contained in the "IV THERAPY" listing, and in an interview with staff #6 on
1-28-15, staff #6 was unable to provide an exact date that the "IV THERAPY" listing and policy had been approved.

Review of personnel files revealed that training for "Administration of Blood" had been provided to:
· Staff #18 on 6-18-14
· Staff #19 on 6-18-14
· Staff #20 (date unknown)
· Staff #21 on 6-18-14
· Staff #22 on 11-12-14
· Staff #23 (date unknown)
· Staff #25 on 6-18-14
· Staff #26 on "11-4-18"
· Staff #27 on 11-8-14

Review of clinical records for 5 patients that received blood or blood products in 2014 and 2015 (patients #1 - #5) revealed the following:
· Nurse #19 administered blood to patient #1 on 1-13-15
· Nurse #23 administered blood to patient #3 on 12-23-14
· Nurse #27 administered blood products to patient #4 on 3-1-14 and 3-2-14


The above was confirmed in an exit conference was held with the facility Chief Nursing Officer, Chief Executive Officer, Director of Quality Improvement/Risk Management and Director of Health Information Management on the evening of 1-28-15.

Based on observation and a tour of the facility, outdated biologicals were present and available for patient use.

Findings were:

During a tour of the ER patient room on 1-28-15, the following outdated items were found:
· 7 of 7 3.2% black top sodium citrate blood draw tubes had expired 12-30-14 but were still available for patient use
· 1 of 5 gold top 5ml blood draw tubes had expired 5-2014 but were still available for patient use
· 8 of 9 pink top 6.0 ml blood draw tubes had expired 12-2014 but were still available for patient use


The above was confirmed in an exit conference was held with the facility Chief Nursing Officer, Chief Executive Officer, Director of Quality Improvement/Risk Management and Director of Health Information Management on the evening of 1-28-15.

Cross-refer to:

A0701
A0724
A0726

Based on observation and staff interview the facility failed to maintain the physical plant to ensure the safety and well being of the patients in all locations in the facility involved in patient care.

Findings were:

During a tour of the facility on 1/27/15 and 1/28/15 the following maintenance and safety issues were noted:
* No emergency call light in the patient dressing room/restroom in the C/T scan area and in the x-ray room and patient restroom in the hallway outside the laboratory;
* Wall covering on the patient dressing room wall was loose and peeling; an electric heater was sitting on the floor in front of the shower in the dressing room along with multiple unused electrical heaters stored in the shower stall;
* Floor tiles were cracked and missing around the door frame and door entryway exposing concrete flooring in the x-ray room not allowing for adequate cleaning;
* Pipes penetrating through the ceiling were not closed off in the electrical room in the x-ray department and in the maintenance room outside the kitchen storage room;
* Multiple patient care areas throughout the facility had water stained ceiling tiles, broken ceiling tiles, and missing ceiling tiles;
* Electrical breaker box panel and emergency shut off valves for kitchen equipment was covered by a shelf containing food and other supplies in the kitchen storage room;
* Wall covering was noted to be loose and detached from the wall in the nursery area;
* Vinyl floor tiles throughout the facility in patient rooms and hallways were maintained in such a manner that they looked dirty and stained.

In an interview with the CEO, CNO, and maintenance at the time of discovery all agreed with the above findings. Staff #28 stated the floors in the facility had not been waxed in about 18 months.

Based on a tour of the facility and staff interview the facility failed to ensure supplies and equipment was maintained to ensure an acceptable level of safety.

Findings were:

Tour of the surgical suite on 1/27/15 revealed the following:
* Expired supplies were stored on a countertop in the sterile supply room;
* Outdated and unused equipment was stored in the middle of the sterile supply room and was dusty;
* Roll up door was up about 3 inches and a cord was run through it to a room on the opposite side of the roll up door; dust was noted on the countertop;
* Air vent in OR #1 was open and falling into the ductwork; a second air vent was dusty; wall tiles were missing on the wall beside a clock;
* Old unused equipment was stored throughout the room in the OR treatment room; this equipment was dusty and shoved against other equipment in the room;
* Medical waste container and trash container was located under the window in the sterile storage room window where clean sterile supplies were placed;
* Rechargeable batteries and biohazard suits used by the emergency medical personnel were stored on the counters and on the floor in the surgical sterile supply room;
* Handwashing sink in the surgical reprocessing room had a nonfunctioning hot water faucet handle; the hot water could not be turned on with the current handle; and
* 2 doors leading into the sterile processing room from the hallway did not close completely.

Interview with the CEO, CNO, surgical nurse, and maintenance confirmed the above findings at the time of the finding.

Tour of the nursery on 1/28/15 revealed a "Bubble Bipap" machine that was set up with an expired 500cc bag of 0.9% Sodium Chloride solution with an expiration date of April 2014. There was also fluid in the humidifier of the machine.

Interview of the respiratory therapist confirmed the finding and the therapist stated she did not know how long the sodium chloride solution had been hanging or how long the fluid was in the humidifier. The respiratory therapist stated she was not sure what kind of fluid was in the humidifier.

Tour of the hospital supply storage room on 1/28/15 revealed there were supplies and shipping containers stacked within 6 inches of the ceiling and light fixtures. Open boxes of clean supplies were stored beside and below unopened shipping boxes allowing for dirt and debris from shipping containers to contaminate the clean supplies.

Staff #28 and #29 confirmed the findings in the storeroom at the time of the findings.

Based on observation, best practice standards and a tour of the facility, the facility failed to provide proper temperature controls for the storage of drugs.

Findings were:

During a tour of the nursing station in the patient care area on 1-28-15, temperature checks (for the month of January 2015) for the medication refrigerator had been performed once a day but only on weekdays (Monday through Friday). No temperature checks had been performed on Saturdays or Sundays. The refrigerator contained several vials of influenza vaccine.

According to the Centers for Disease Control, "Proper temperature monitoring is key to proper cold chain management. Thermometers should be placed in a central location in the storage unit, adjacent to the vaccine. Temperatures should be read and documented twice each day, once when the office or clinic opens and once at the end of the day. Temperature logs should be kept on file for >3 years, unless state statutes or rules require a longer period. Immediate action must be taken to correct storage temperatures that are outside the recommended ranges. Mishandled vaccines should not be administered.

One person should be assigned primary responsibility for maintaining temperature logs, along with one backup person. Temperature logs should be reviewed by the backup person at least weekly. All staff members working with vaccines should be familiar with proper temperature monitoring."

The above was confirmed in an exit conference was held with the facility Chief Nursing Officer, Chief Executive Officer, Director of Quality Improvement/Risk Management and Director of Health Information Management on the evening of 1-28-15.

Based on medical record review and staff interview the person administering anesthesia to 3 out of 4 patients did not document a post anesthesia evaluation for anesthesia recovery in the patient's medical record within 48 hours after surgery.

Findings were:

Medical record review on 1/27/15 and 1/28/15 revealed 3 of 4 patients who had received general anesthesia did not have a post anesthesia evaluation by the anesthetist for anesthesia recovery within 48 hours after surgery. Patient # 6, #8, and #9 did not have a documented post anesthesia evaluation in their record.

The CNO confirmed the findings on 1/28/15 and stated the patients are to have a documented post anesthesia evaluation in their medical records.