HospitalInspections.org

Based on observation and interview, the facility failed to ensure cleaning supplies were not stored with patient supplies in 1 of 1 respiratory storage cabinets observed.

The findings included:

Observation and interview with the Nurse Director on 5/16/17 at 10:58 AM, of the respiratory storage cabinets on the Medical Surgical Unit, revealed one 19 ounce can of disinfectant spray 3/4 full stored with patient respiratory supplies. Interview with the Nurse Director confirmed the facility failed to ensure patient supplies and cleaning supplies were stored separately.

Based on facility policy review, observation and interview, the facility failed to ensure expired oral thickener was not available for patient use in 1 of 1 Medical Surgical nursing units and failed to ensure outdated and unlabeled biological supplies were not available for patient use in 1 of 1 Emergency Departments (ED).

The findings included:

Review of a facility policy ACCU-CHEK Inform II Whole Blood Glucose-Testing Procedure dated 1/6/16 revealed "...Controls expire 3 months after opening (unless this is past the manufacturers expiration date). Do not use after the new 3 month expiration date that will occur from the date that you open the controls. The new expiration date should be written on the bottles...glucose quality control solutions are stable for three months after opening or until the expiration date, whichever comes first. Write the open and expiration dates on the new bottles and initial..."

Observation and interview with the Nurse Director on 5/16/17 at 11:00 AM, in the Medical Surgical Unit medication room, revealed 1 plastic container of oral fluid thickener labeled 3/9/17-4/9/17 and a second plastic container of oral fluid thickener labeled 3/13/17-4/13/17. Interview with the Nurse Director confirmed the containers of thickener were expired and were available for patient use.

Observation with Registered Nurse (RN) #1 on 5/17/17 at 9:00 AM, in the ED Trauma Room, revealed control testing strips and control solutions used for a blood glucose monitor were opened and unlabeled with the date and time opened. Interview with RN #1 confirmed the control strips and the control solutions were open and undated and the facility failed to follow facility policy.

Based on facility policy review, medical record review, and interview, the facility failed to obtain a signed consent for treatment form for 1 patient (#10) for 23 patients reviewed.

The findings included:

Review of the facility policy Patient Consent/Authorization for Treatment/HIPAA [Health Insurance Portability and Accountability Act] Consent dated 11/2011, revealed "...ensure appropriate signatures are obtained for all Consents to Treatment...staff...responsible for obtaining consents to treatment...on all patients seeking treatment...condition of admissions form is to be completed and signed by the patient..."

Medical record review revealed Patient #10 was admitted to the facility on 11/8/16 for Chest Pain, Decreased Oxygen Saturation, and Anemia. Continued review revealed the consent for medical treament was not signed by the patient.

Interview with the Nurse Director on 5/17/17 at 8:35 AM, in the conference room, confirmed the facility failed to ensure the consent for treatment was signed by Patient #10 and the facility failed to follow facility policy.

Based on facility policy review, medical record review, and interview, the facility failed to document the type of restraint used for 1 restrained patient (#13) of 23 patients reviewed.

The findings included:

Review of the facility policy Restraints/Protective Devices dated 1/2017, revealed "...assess the patient for type and size of restraint to prevent harmful behavior...documentation must be made on the Clinical Justification Documentation form..."

Medical record review revealed Patient #13 was admitted to the facility on 12/3/16 at 8:39 PM for Altered Mental Status, and Hyperglycemia. Further review revealed the patient was transferred on 12/3/16 at 10:50 PM.

Medical record review of an Emergency Record Nursing Observations/Orders/Interventions form dated 12/3/16 at 8:39 PM revealed "...combative...restraints placed per MD [medical doctor] order...combative and uncooperative..."

Medical record review of ED Assessment Sheet dated 12/3/16 at 9:00 PM revealed "...restless...combative...on restraint...confused..."

Medical record review of a Clinical Justification and Documentation for Medical/Surgical Restraints form dated 12/3/16 at 9:00 PM revealed the type of restraint used was not documented for Patient #13.

Interview with the Nurse Director on 5/17/17 at 9:35 AM, in the conference room, confirmed the facility failed to document the type of restraint used for Patient #13 and failed to follow facility policy.

Based on review of the facility bylaws, facility policy review, medical record review, and interview, the facility failed to ensure the physician signed a swing bed recertification form for 1 patient (#5) and failed to ensure physician orders were signed and dated for 2 patients (#5 and #15) for 23 patients reviewed.

The findings included:

Review of Rules and Regulations of the Medical Staff (bylaws) dated 11/2008, revealed "...All orders...must be dated, timed, and authenticated by the prescribing physician..."

Review of the facility policy Verbal and Telephone Orders dated 6/2014, revealed "...prescribing physician must sign all verbal orders...order should include...month, day, year, and time of day the orders are written..."

Medical record review revealed Patient #5 was admitted to the facility on 1/19/17 with a diagnosis of Right Ankle Fracture with Open Reduction Internal Fixation. Continued review revealed the swing bed recertification forms dated 4/13/17 and 4/27/17 were not signed by the physician. Continued review revealed physician telephone orders dated 1/19/17, 4/22/17, and 4/29/17 were not signed by the physician.

Interview with the Nurse Director on 5/16/17 at 3:10 PM, in the conference room, confirmed the facility failed to ensure the recertification form and the telephone orders for Patient #5 were signed by the physician and the facility failed to follow facility policy.

Medical record review revealed Patient #15 was admitted to the facility on 9/28/16 for Generalized Abdominal Pain. Continued review revealed physician's orders dated 9/28/16 and 9/29/16 were not timed by the physician.

Interview with the Nurse Director on 5/17/17 at 10:25 AM, in the conference room, confirmed the facility failed to ensure orders were timed by the prescribing physician for Patient #15 and the facility failed to follow facility policy.

Based on review of the facility bylaws, medical record review, and interview, the facility failed to complete a discharge summary for 1 patient (#15) of 23 patients reviewed.

The findings included:

Review of the facility bylaws Rules and Regulations of the Medical Staff dated 11/2008, revealed "...discharge summary...lengths of stay 48 hours or less...a final progress note...for the discharge summary...as the discharge summary it must contain the following...Reason for hospitalization...Significant findings/procedures performed...Patient's condition at discharge...Follow-up care provided to patient and/or family...Diet...Activity...Medications...Next Appointment..."

Medical record review revealed Patient #15 was admitted to the facility on 9/28/16 for Generalized Abdominal Pain and discharged from the facility on 9/29/16. Continued review revealed no discharge summary or final progress note was contained in the medical record.

Interview with the Nurse Director on 5/17/17 at 10:25 AM, in the conference room, confirmed the facility failed to complete a discharge summary for Patient #15 and the facility failed to follow facility policy.