HospitalInspections.org

Based on observation, review of hospital policies and staff interview it was determined the facility failed to ensure pharmacy is administered with accepted professional principles as evidenced by failing to ensure compliance with standards of practice regarding safe labeling, handling and storage of medications in two of three operating rooms and the procedure room.

The findings include:

During the initial tour of the surgical suite conducted on 4/12/10 and in the presence of the surgical nurse manager, at 10:45 AM an open bottle of sevoflurane 250 mg. (milligrams) was discovered in the anesthesia cart in Operating Room #3 with no date as to time opened. A 250 mg. bag of 0.9% sodium chloride labeled "neosynephrine" was discovered with no label as to date and time drawn up, dosage, and initials as to preparer.

At 10:50 AM in OR #2 an open bottle of sevoflurane 250 mgs. was discovered in the anesthesia cart with no date as to time opened.

At 11:25 AM in the procedure room an open bottle of sevoflurane 250 mgs was discovered with no dates as to time opened. A bottle of esmolol hydrochloride 100 mg/10 ml (milliliters) was discovered with no date as to time opened, and with a manufacturer's expiration date of 12/09.

In an interview conducted on 4/12/10 at 11:25 AM the surgical nurse manager agreed the medications should be properly labeled.

In an interview conducted on 4/12/10 at 10:55 AM the CRNA (Certified Registered Nurse Anesthetist) agreed the medications should be labeled as to time opened or prepared.

Hospital policy "Labeling of medications" (RX 20.105) states "Medications for inpatients shall be labeled with the patient's name, room number, name of medication, medications strength, expiration date, lot number, manufacturer, and pharmacist's initials."

Hospital policy "Dating of sterile and multidose vials" (RX 20.050) states multidose vials "must be dated with a beyond-use date (our expiration date ) of 28 days".

scheduled basis to provide services for:

1. Approval of menus and modified diets;

2. Participation in development of policies, procedures and continuing education programs;

3. Evaluation of dietetic services.


Based on review of facility dietary policies and procedures, personnel contract and administrative staff interview it was determined the facility failed to ensure a registered dietitian is available and readily accessible to meet the needs of the patients.

The findings include:

During the review of the dietetics department policies and procedures, review of the consultant dietitian's contract, and interview with administrative staff, it was revealed a registered dietitian is only available three to four days per week and only available after 4 -5 PM on these days. The consultant dietitians are schedule for eight hours on Saturday and Sunday.

During the hospital survey regulatory non-compliance were found in the areas of food sanitation, menu planning, portion control, food production management, therapeutic diet planning and compliance, and staff in-service training.

Refer to: A 0622

Based on observation, staff interview, and record review, it was determined the facility failed to ensure administrative and technical personnel are competent in their respective duties.

The finding include:

During the observation of the lunch meal tray line assembly in the main kitchen on 04/13/10 at 11:15 AM, the following were revealed:

1) Following a review of the 04/13/10 lunch menu the standardized recipes for the menu were requested by the surveyor. The requested standardized recipes included; Chicken Noodle Soup, Baked Fish & Onions, Seasoned Yellow Rice, Okra & Tomatoes, and Grilled Burger. Following the request it was revealed by the Food Service Director that standardized recipes had not been developed and utilized to ensure the patient's nutritional needs are being met, proper portion control, appearance of food and palatability, retention of nutritional values, and following therapeutic diets. Following the recipe request the surveyor requested the corresponding production sheets for the lunch meal to ensure that the nutritional needs of the patients are being met and menu portion size are being followed. A review of the 04/13/10 lunch production sheets revealed they did not match the approved menu and the lunch items are not documented along with portion size on the sheets.
An observation of the tray line foods revealed that the portions of the Grilled Burgers noted that they were overcooked, burned, and black in color. The cook stated that the Burgers were not grilled and were cooked in the oven. It was also noted that the Baked Fish & Onions were prepared with additional items other than the onions, that include red peppers. All of the fish portions were placed in a steam table on top of each other top with the vegetable mixture, resulting in different temperatures, appearance, and portions of the fish, and vegetables.

2) After it was revealed that standardized recipes and portion controlled production sheets had not been developed and utilized, the surveyor requested a portion control scale to ensure the portion of entree/protein that was being served met the nutritional needs of the patients. It was revealed by the Food Service Director that the food service department failed to have a portion scale which is required for weighing of protein foods/entrees to ensure that nutritional needs of the patients are being met. The lack of a portion scale also revealed that the staff are unable to weigh specific portions of foods to ensure that therapeutic diets are being followed, that would include ADA diabetics diets, calorie controlled diets, and renal diets.

3) During the observation, the cook was questioned concerning the preparation of the Okra & Tomatoes that were being served to patients with physician ordered Sodium restricted diets (1 GM & 2 GM Sodium Diets) . The cook stated only sodium free canned vegetables were utilized during the preparation of Sodium controlled diets. The surveyor requested to see evidence that low sodium canned vegetables are in stock, and it was revealed by the Food Service Director that low sodium canned vegetables and other low sodium food products were not in stock and are not being purchased.

4) During the observation of the lunch food tray line assembly on 04/13/10 and interview with the Food Service Director on 04/14/10, it was revealed the patient menu is non-select, and the patients' therapeutic meal card are supposed to be corrected for accuracy compliance prior to each meal served. It was revealed that these corrections are not being made prior to the meal and therapeutic diets are not being served as per physician orders for low fat, ADA diabetic, calorie restricted, and low sodium. The director further stated that the Registered Dietitians's are required to make the calculations and corrections, however the dietitians are only at the facility after 4 PM, 3-4 days per week and on weekends. The director stated she has been trained by the dietitians to correct the therapeutic menus however she is not available to complete the correction for all meals.

Based on observation and staff interview conducted during the survey, it was determined the sign posted in the emergency department (ED) that specified the rights of individuals with respect to examination and treatment for emergency medical conditions, and women in labor, and that the facility participates in the Medicaid program under the State plan, failed to meet the needs of all the individuals entering the ED.

The findings are:

1) The facility's posted signs at the entrance to the ED, and in the main lobby, are not in a language that is understandable by a large part of the population served by the hospital, who speak Spanish.

Upon inquiry, the ED Director, Risk Manager and the Director of Nursing, on 04/12/10 at 10:15 A.M, confirmed the signs posted are not in a language understood by a large portion of the population served by the hospital.