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Based on observation and staff interview, the facility failed to ensure all patient care equipment was tested for safe operating conditions.

Findings include:

On 6/4/12, the room used for patient therapies was observed. A hydrocollator was found to be turned on with multiple heat packs inside. The hydrocollator had a label which indicated the last safety check by bio med occurred in 2005 and was due in 2006.

A whirlpool device was also observed in the therapy room and did not have a label to indicate it was ever checked by bio med for safety.

On 6/4/12 at approximately 10:30 AM, the Quality/Risk Manager, was shown the devices and reported she would check with the employee in charge of bio med checks to see if the devices were checked more recently. The Quality/Risk Manager did not present proof of more recent bio med checks on the hydrocollator or whirlpool.

On 6/4/12, the contracted physical therapist, #5, was interviewed and reported he did not use the hydrocollator or the whirlpool for patient care. The therapist did not know why the hydrocollator was turned on. The therapist did not know how the facility maintained the safety of the equipment in the therapy room.

On 6/5/12 at approximately 10:30 AM, the contracted bio med technician was interviewed. The technician reported he did not recall checking the equipment in the therapy room in the past several years. He reported he was called by the facility to check the hydrocollator and the whirlpool today.

Based on observation and staff interview, the facility failed to ensure outdated medications were removed from use, failed to securely store medications and failed to identify a patient's name on wound care medications.

Findings include:

On 6/4/12, the medication cart was observed. A bottle of B12 - 250 mcg. was found in a patient's medication drawer and had an expiration date of 09/2011.

On 6/4/12, a bottle of 0.9% Sodium Chloride solution was found opened and half empty. The bottle of solution did not have a patient's name on it and did not identify the date it was opened. The bottle was found in a box in the therapy room. The therapy room was not locked and was opened to patients and visitors. A plastic baggy was found in the box containing opened packets of Triple Antibiotic Ointment. The plastic baggy and the ointments were not labeled with a patient's name and they were not in a secured area. A pumice stone was found inside a latex glove and was not labled with a patient's name. The pumice stone was also found in the unlabeled box.

On 6/4/12, a bottle of Isopropyl Rubbing Alcohol was found in an unlocked cabinet in the therapy room. The alcohol had an expiration date of 02/2008.

During an interview with the physical therapist, Contracted Employee #5, on 6/4/12, he reported the items found in the box were used for the wound care of a resident in the long term care facility. He acknowledged the box and the items contained in the box were not identified with the resident's name and the box was not in a secured area.

Review of the facility policy and procedure entitled "Medication Storage" effective 1/26/09, revealed the following:

· Drugs are to be stored in an orderly manner in specifically designated cupboard, cabinets, closets or drawers away from public access or locked to prevent unauthorized access to drugs, including sample medications.
· Drugs may not be kept in stock after the expiation date on the label.
· Unused portions of Sterile Saline and Sterile Water for irrigation must be discarded at the time of being opened.

Based on observation and staff interview, the facility failed to follow accepted standards of practices for sterile processing.

Findings include:

On 6/5/12, Employee #4 was observed cleaning and packaging instruments for sterilization. The employee was not wearing a bonnet to cover her hair while packaging instruments. The employee did not wear scrubs, special eye protection or a mask during decontamination of instruments.

Review of the AORN (Association of Perioperative Registered Nurses) Perioperative Standards and Recommended Practices 2012 edition head covers are required for decontamination and preparation and packaging. In addition, decontamination required scrubs, gloves, gown or apron, eye protection, mask or face shield.

On 6/6/12, Employee #4 was asked for the policy and procedures addressing sterile processing but did not provide them prior to the end of survey.

On 6/5/12, the facility's sterilization records were reviewed and revealed Employee #4 was not recording the results of biological testing of each load. The employee reported she did a biological test every time she used the autoclave which was once every one to two months. The employee was observed to place the biological into the load before loading the autoclave. The employee reported no positive results from biological testing.

Record review also revealed Employee #4 did not identify cycle parameters on the sterilization record. The employee did not attach the print out of the sterilization cycle from the autoclave onto the report describing the load. Multiple rolls of sterilization cycle print outs were found on a shelf in the processing room.

Review of AORN 2012 standards revealed documentation of every sterilization cycle should include the results of physical, chemical and biological testing.

Based on interview and record review, the facility failed to provide evidence of an annual evaluation of its overall program which included volume of patients served and types of service, samples of closed and active records, and appropriate utilization of services.

Findings include:

A review of the quality assurance meeting minutes and board of trustees meeting minutes did not reveal an annual evaluation of the overall program of the critical access hospital.

An interview with the quality assurance coordinator revealed there was not an annual meeting held in which the required evaluation of the program could be demonstrated. The facility was able to provide evidence of review and revision of policies and procedures only.

Based on interview and record review, the facility failed to provide evidence of an annual evaluation of its overall program which included volume of patients served and types of service provided.

Findings include:

An interview with the quality assurance coordinator revealed there was no evidence that an annual meeting was held to evaluate the overall program which data on the volume of patients served.

Based on interview and record review, the facility failed to provide evidence of an annual evaluation of its overall program which included samples of closed and active records, and appropriate utilization of services.


Findings include:

An interview with the quality assurance coordinator revealed there was not an annual meeting held in which the required evaluation of the program could be demonstrated.

Based on record review and staff interview, the facility failed to inform a patient of her rights for 1 of 21 patients (Resident #21).

Findings include:

Patient #21 was admitted to the facility on 5/26/12, with diagnoses including deep vein thrombosis and generalized debility.

Record review revealed an incomplete list of patient's rights was provided to Patient #21. During interviews with Registered Nurse (RN), Employee #2 and the manager, Employee #3, they reported patient's who were admitted on weekends mistakenly received an incomplete list of the patients rights form.