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Based on observation, policy review and interview the facility failed to ensure that emergency supplies were available for treating emergency cases resulting in the potential for poor patient outcomes. Findings include:

On 7/16/12 at approximately 1045 in the radiology corridor, found a crash cart with the following:
a.) a crash cart checklist for July 2012 that had 4 (3rd, 9 th, 10 th and 15 th) of 16 dates completed that were signed by a healthcare worker
b). two 500 ml intravenous bags containing 20% Osmitrol (Mannitol) with a manufacturers expiration date of 3/2013, that had formed crystals in the bags content. A sign placed across both bags indicated "monitor for crystals".

On 7/17/12 at 1630 a review of facility policy titled "Checklists" revealed "all work areas, crash carts and defibrillators are to kept ready for use...checklists will be done by both shifts on a rotating basis by a nurse assigned to that area...Compliance will be monitored monthly...".

The above findings were confirmed with Staff C.

Based on observation and interview the facility failed to ensure that food products are stored under the appropriate temperature for the 7 patients being treated on the medical surgical unit resulting in the potential for ingestion of unsafe food. Findings include:

On 7/16/12 at approximately 1015 during tour of the medical surgical unit, found in the pantry, a refrigerator for storage of patient food and nourishment. The temperature probe was located in the center of the refrigerator however the external mechanism that displays the temperature was turned off. Interview with Staff C regarding who was assigned the the responsibility for monitoring of the refrigerator temperature and where documentation may be found, staff C replied, there is no policy and it appears as though it is not done. Interview with the Dietary Manager on 7/17/12 at approximately 0910 confirms that the monitoring of patient food refrigerators "is typically a nursing duty".


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During observation of the outpatient treatment area on 07/16/2012 at 1300, it was determined that the facility failed to monitor a refrigerator used to store patient nourishments.

The findings were confirmed by staff J at the time of the observation.

Based on observation, policy review and interview, the facility failed to ensure that pre-drawn medications are properly labeled, controlled substances are disposed of according to policy and un-usable medications are not available for patient use: Findings include:

During observation of the surgical area on 07/17/2012 at 1110 with staff D and E, the following was revealed in OR #1 the anesthesia cart contained several pre-drawn medications. One syringe labeled as Fentanyl and one syringe labeled as Ephedrine. The syringes did not contain the strength of the medication, the date or the initials of the person who drew up the medications. There was one syringe with a white colored liquid that did not contain the name of the medication, the date drawn up or the initials of the person who drew up the medication. The cart also contained two opened vials one Ketamine and one Rocuronium Bromide that were not dated when opened.

A review of Schoolcraft Memorial Hospital Policy on 07/17/2012, titled Safe Medication Practices in OR/PAR reads "1. All medications and solutions on and off the sterile field should be labeled even if there is only one medication being used. 2. labeling occurs when any medication or solution is transferred from the original packaging to another container. No more than one medication or solution is labeled at one time. 3. Labels will include the name and strength of the medication or solution, the date, and initials of the person preparing the label. 5. All labels are verified both verbally and visually by two qualified individuals, RN's, LPN's or scrub tech. The RN circulator is responsible for supervision of medication handling administration."

During an interview with staff E (CRNA) on 07/17/2012 at 1115, he stated that the medications were "drawn up for the next patient coming in in just a couple of minutes." The CRNA then left OR #1. When this surveyor completed the observation of the OR at 1135 the next patient still had not come back into the OR.

All findings were confirmed by staff D at the time of the observation.

During further review on 07/17/0212, the document titled Schoolcraft Memorial Hospital Certificate of Disposition of Controlled Substances revealed documentation that on 06/11/2012 there was a 75 mcg waste of Fentanyl and a 1 mg waste of Versed for patient #16 that both lacked a witness signature n the section titled "Losses." On 07/17/2012, a review of the document titled Schoolcraft Memorial Hospital Receipt of Controlled Substances revealed that on 05/10/2012 patient #17 was administered 1 ml of Versed from a 2 ml single dose vial and patient #19 was administered 1 ml from a single dose 2 ml vial. The document contained no documentation of the waste for either patinet in the section titled "Losses."

A review of Schoolcraft Memorial Hospital 's policy titled Controlling of Drugs Subject to Controlled Substance Act of 1970 and Others it reads "When a partical dose is given, the remainder destroyed must be recorded under losses and witnessed by signature."

Based on observation and interview, the facility failed to prevent the potential for spread of infections for patients in the emergency room and patients on the medical surgical unit resulting in the potential for spread of infectious agents among patients and staff. Findings include:

On 7/16/12 at approximately 1035 in the Emergency Department, found the patient in the cubicle marked "Bed 4" was coughing without covering his cough. The cubicle curtain that separated the patient treatment area from the clean linen cart was left open as was the linen cart cover, leaving a potential for airborne and droplet contamination of the clean laundry. This was confirmed by Staff C, who indicated that "we will have much more space in our new facility (that is currently being built)...that laundry cover should be down".

On 7/16/12 at approximately 1015 found in the patient refrigerator located in the pantry of the medical surgical unit, drawers that were soiled with a sticky reddish material and a freezer door shelf with blackish gray soiling visible. This refrigerator also contained unmarked food items that were not issued from from kitchen. This was confirmed by Staff C at approximately 1020.

On 7/16/12 at approximately 0920 in the medication room found a Precision blood glucose testing machine with a pen-like lancet device with insert lancets. Staff C confirmed the findings and discarded the device into the sharps container.

Based on medical record review, interview and policy review the facility failed to establish measurable goals for patient's plans of care nor establish disposition of achievement of goals for 6 (#6, #7, #9, #15, #19 & #20) of 9 patients reviewed resulting in the potential for poor patient outcomes. Findings include:

On 7/17/12 between 1100 and 1500 a review of medical records revealed the following:
1. Patient #6 was admitted for ventral hernia repair, whose weight was 320 pounds, for whom no dietary consult was initiated nor was education for weight control listed as a problem
2. Patient #7's medical record revealed that a care plan had not been developed however a problem list was written that failed to establish patient goals nor was final disposition on whether the patient had achieved any care plan goals
3. Patient #9's medical record revealed that a care plan had not been developed for the patient
4. Patient #15's medical record revealed that a care plan had not been developed for the patient, however a problem list was developed that lacked measurable goals nor was final disposition on whether the patient had achieved any care plan goals
5. Patient #19's medical record revealed that a care plan had not been developed for the patient, however a problem list was developed that lacked measurable goals nor was final disposition on whether the patient had achieved any care plan goals
6. Patient #20's medical record revealed that a care plan had not been developed for the patient, however a problem list was developed that lacked measurable goals nor was final disposition on whether the patient had achieved any care plan goals.

Interview with Staff B revealed that they have "just revised the care planning process" between patients that have been admitted directly and those who are admitted from an outpatient procedure and admitted that they "are working on this improving process". Staff B admitted that "I can see that we have some room for improvement in this care planning process".

A review of facility policy titled "Individual Nursing Care Plans" reviewed 8/18/11 revealed "Care plans will be appropriate to the patient's needs. strengths, limitations and goals. Nursing goals are based on the nursing assessment, and are realistic, measurable and consistent with the therapy prescribed by the patient's physician. Nursing care plans will incorporate all multi-disciplinary treatment planned for each patient including: interventions, patient response, and patient outcome to the care provided.".

Based on medical record review, and interview the facility failed to ensure that all physician orders are dated and timed for 2 ( #6 & #8) of 4 patients reviewed resulting in the potential for patient harm. Findings include:

On 7/17/12 between 1100 and 1500 during a review of medical records revealed the following:
1. Patient #6's closed medical record revealed that "Outpatient Extended Post-Op Recovery" orders were initiated on 1/3/12 however none of the detail boxes were checked by the ordering physician. The document was signed by the physician on 1/11/12 at 0800, three days after the patient was discharged.
Additionally, a document titled "Dr. Bell Outpatient Pre and Post-Op" orders was completed, initiated and checked, however was signed by the physician on 1/11/12 at 0800, three days after the patient was discharged.

2. Patient #8's closed medical record revealed a document titled "Anesthesia CRNA PACU Orders" that were signed by the CRNA however a date and time were left blank.. A physician signed the document 1/23/12 at 1400, the patient was discharged 1/17/12, six days after the order was signed.

The above findings were confirmed by Staff B and C on 7/17/12 at 1500.

Based on observation and interview, the facility failed to protect medical records from unauthorized use. Findings include:
During an observation of the medical record department on 07/16/2012 at 1100, it was revealed by staff F that the facility had additional storage of medical records in a garage located on the property. An observation of the storage garage revealed that the room did not contain a ceiling make it open to the maintenance equipment storage area.
Staff F confirmed the findings at the time of the observation and stated that " I had never noticed that that was opened up there. "