HospitalInspections.org

Based on findings from observation and staff interview, 2 janitor's closets lacked required ventilation vents that are needed to maintain proper environmental infection control measures.

Findings include:

-- Per observation in the Emergency Department on 6/16/15 at 2:15 pm and the Acute/Swing Bed Patient Unit at 3:00 pm, the janitor's closets in the corridors on both floors lacked exhaust ventilation grills. Staff #1 (Director of Facilities) was present during these observations and verified these findings.

Based on findings from policy and procedure review and staff interview, the hospital lacked a policy and procedure that addressed triage in the emergency department (ED).

Findings include:

-- Per review of the hospital's policies and procedures during survey (6/16/15 - 6/18/15), the hospital did not provide evidence that it had a policy and procedure that addressed the triage process in the ED. During interview with the Staff #2 (Director of Nursing) on 6/17/15 at 3:30 pm, he/she acknowledged this finding.

Based on findings from policy and procedure review and staff interview, the hospital lacked a policy and procedure that addressed the use of multi-dose medication vials by hospital staff.

Findings include:

-- Per review of the hospital's policies and procedures during survey (6/16/15 - 6/18/15), the hospital did not provide evidence that it had a policy and procedure that addressed the use of multi-dose medication vials. During interview with the Staff #3 (Infection Preventionist) on 6/18/15 at 2:00 pm, he/she confirmed this finding.

Based on findings from medical record (MR) review, policy and procedure review, and staff interview, in 6 of 14 MRs reviewed, medication orders for prn (as needed) medications did not include all necessary elements (e.g., indication for use). Also the hospital's medication administration policy and procedure did not address timing of medication administration. Additionally, in 1 MR, a physician order for a blood transfusion was incomplete.

Findings include:

-- Per review of Patient A's MR, it contained a medication order for ondansetron HCL 4 milligram (mg) every 8 hours prn. The order did not include an indication for this medication.

-- Per review of Patient B's MR, it contained a medication order for Morphine Sulfate 2 mg every 2 hours prn. The order did not include an indication tor this medication.

The same lack of documentation in medication orders of the indication for a prn medication was found in Patient C's, Patient D's, Patient E's and Patient F's MRs.

-- Per review of hospital's policy and procedure titled "Medication Administration," dated 7/2014, it does not address medication administration timing based on the nature of the medication and its clinical application.

During interview with Staff #4 (pharmacist) on 6/16/15 at 4:00, he/she acknowledged this finding.

-- Per review of the hospital's policy and procedure titled " Whole Blood and /or Packed Cells Transfusion of, in Adults," last revised 5/2012, it indicated that a physician order for a blood transfusion should indicate the length of time for the transfusion.

-- However, per review of Patient G's MR, a physician order dated 6/17/15 at 7:39 am, by Staff #5 (Physician Assistant) stated "Transfuse 2 units of packed rbc's (red blood cells)." The length of time of the transfusion was not indicated in the physician order.

During interview with Staff #2 on 6/18/15 at 4:00 pm, he/she acknowledged the above findings.

Based on findings from observation and staff interview, 2 janitor's closets lacked required ventilation vents that are needed to maintain proper environmental infection control measures.

Findings include:

-- Per observation in the Emergency Department on 6/16/15 at 2:15 pm and the Acute/Swing Bed Patient Unit at 3:00 pm, the janitor's closets in the corridors on both floors lacked exhaust ventilation grills. Staff #1 (Director of Facilities) was present during these observations and verified these findings.

Based on findings from policy and procedure review and staff interview, the hospital lacked a policy and procedure that addressed triage in the emergency department (ED).

Findings include:

-- Per review of the hospital's policies and procedures during survey (6/16/15 - 6/18/15), the hospital did not provide evidence that it had a policy and procedure that addressed the triage process in the ED. During interview with the Staff #2 (Director of Nursing) on 6/17/15 at 3:30 pm, he/she acknowledged this finding.

Based on findings from policy and procedure review and staff interview, the hospital lacked a policy and procedure that addressed the use of multi-dose medication vials by hospital staff.

Findings include:

-- Per review of the hospital's policies and procedures during survey (6/16/15 - 6/18/15), the hospital did not provide evidence that it had a policy and procedure that addressed the use of multi-dose medication vials. During interview with the Staff #3 (Infection Preventionist) on 6/18/15 at 2:00 pm, he/she confirmed this finding.

Based on findings from medical record (MR) review, policy and procedure review, and staff interview, in 6 of 14 MRs reviewed, medication orders for prn (as needed) medications did not include all necessary elements (e.g., indication for use). Also the hospital's medication administration policy and procedure did not address timing of medication administration. Additionally, in 1 MR, a physician order for a blood transfusion was incomplete.

Findings include:

-- Per review of Patient A's MR, it contained a medication order for ondansetron HCL 4 milligram (mg) every 8 hours prn. The order did not include an indication for this medication.

-- Per review of Patient B's MR, it contained a medication order for Morphine Sulfate 2 mg every 2 hours prn. The order did not include an indication tor this medication.

The same lack of documentation in medication orders of the indication for a prn medication was found in Patient C's, Patient D's, Patient E's and Patient F's MRs.

-- Per review of hospital's policy and procedure titled "Medication Administration," dated 7/2014, it does not address medication administration timing based on the nature of the medication and its clinical application.

During interview with Staff #4 (pharmacist) on 6/16/15 at 4:00, he/she acknowledged this finding.

-- Per review of the hospital's policy and procedure titled " Whole Blood and /or Packed Cells Transfusion of, in Adults," last revised 5/2012, it indicated that a physician order for a blood transfusion should indicate the length of time for the transfusion.

-- However, per review of Patient G's MR, a physician order dated 6/17/15 at 7:39 am, by Staff #5 (Physician Assistant) stated "Transfuse 2 units of packed rbc's (red blood cells)." The length of time of the transfusion was not indicated in the physician order.

During interview with Staff #2 on 6/18/15 at 4:00 pm, he/she acknowledged the above findings.