HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that each patient (or when appropriate, the patient's representative) was informed of their rights, in advance of furnishing or discontinuing patient care whenever possible. This deficient practice was evidenced by the hospital failing to have evidence that 5 (Patient #21, 22, 23, 24, 25) of 5 patients (or their representatives) reviewed for patient rights were informed of their patient rights from a total sample of 30.
Findings:

Review of Patient #21's closed medical record revealed an admit date of 01/21/2021. Further review failed to reveal documented evidence that the patient/representative was notified of the patient's rights prior to furnishing care.

Review of Patient #22's closed medical record revealed an admit date of 02/21/2021. Further review failed to reveal documented evidence that the patient/representative was notified of the patient's rights prior to furnishing care.

Review of Patient #23's closed medical record revealed an admit date of 04/07/2021. Further review failed to reveal documented evidence that the patient/representative was notified of the patient's rights prior to furnishing care.

Review of Patient #24's closed medical record revealed an admit date of 03/23/2021. Further review failed to reveal documented evidence that the patient/representative was notified of the patient's rights prior to furnishing care.

Review of Patient #25's closed medical record revealed an admit date of 03/20/2021. Further review failed to reveal documented evidence that the patient/representative was notified of the patient's rights prior to furnishing care.

In an interview on 04/21/2021 at 1:30 p.m., S9Case Manager reviewed the medical records for Patients #21, 22, 23, 24 and 25 and acknowledged there was no documented evidence that the patient/representative was notified of the patient's rights prior to furnishing care.

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current, an individualized nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to develop a care plan for 5 (Patient #21, 22, 23, 24, 25) of 5 medical records reviewed for care plans out of a total patient sample of 30.
Findings:

Review of Patient #21's closed medical record revealed an admit date of 01/21/2021. Further review failed to reveal documented evidence that a care plan was in the patient's medical record.

Review of Patient #22's closed medical record revealed an admit date of 02/21/2021. Further review failed to reveal documented evidence that a care plan was in the patient's medical record.

Review of Patient #23's closed medical record revealed an admit date of 04/07/2021. Further review failed to reveal documented evidence that a care plan was in the patient's medical record.

Review of Patient #24's closed medical record revealed an admit date of 03/23/2021. Further review failed to reveal documented evidence that a care plan was in the patient's medical record.

Review of Patient #25's closed medical record revealed an admit date of 03/20/2021. Further review failed to reveal documented evidence that a care plan was in the patient's medical record.

In an interview on 04/21/2021 at 1:30 p.m., S9Case Manager reviewed the medical records for Patients #21, 22, 23, 24 and 25 and acknowledged there was no documented evidence their medical records contained a care plan.

Based on record review and interview, the hospital failed to ensure all patient medical records were promptly completed as evidenced by 1) failing to have completed medical records 30 days after discharge and 2) failing to ensure consent for care was included in the medical record for 5 (21, 22, 23, 24, 25) of 5 medical records reviewed for consent for treatment.
Findings:

I. Failing to have completed medical records 30 days after discharge

Review of the Medical Staff Rules and Regulations revealed that a member of the medical staff shall be subject to corrective action upon a finding that he has consistantly or repeatedly been delinquent in the professional and timely completion of medical records and reports for which he is responsible.

Review of the Medical Records Chart Deficiencies Listing dated 04/21/21 given to surveyor by S1ADM revealed the following providers had delinquent records over 30 days:

S6DON/NP - 59 delinquent records (oldest was 1174 days deficient)
S7Physician - 36 delinquent records (oldest was 143 days deficient)
S8Physician - 30 delinquent records (oldest was 156 days deficient)

Interview with S1ADM on 04/21/21 at 2:30 p.m. confirmed that the Medical Staff Bylaws did not indicate the steps to follow if providers had incomplete medical records. He further stated that there was no medical records policy related to incomplete records over 30 days. Further interview with S1ADM confirmed he was unaware of the deficient medical records until he reviewed the report that was provided to the survey team.

II. Failing to ensure consent for care was included in the medical record

Review of Patient #21's closed medical record revealed an admit date of 01/21/2021. Further review revealed no documented evidence that consent for treatment was in the patient's chart.

Review of Patient #22's closed medical record revealed an admit date of 02/21/2021. Further review revealed no documented evidence that consent for treatment was in the patient's chart.

Review of Patient #23's closed medical record revealed an admit date of 04/07/2021. Further review revealed no documented evidence that consent for treatment was in the patient's chart.

Review of Patient #24's closed medical record revealed an admit date of 03/23/2021. Further review revealed no documented evidence that consent for treatment was in the patient's chart.

Review of Patient #25's closed medical record revealed an admit date of 03/20/2021. Further review revealed no documented evidence that consent for treatment was in the patient's chart.

During an interview on 04/21/2021 at 1:30 p.m., S9Case Manager reviewed the medical records for patients #21, 22, 23, 24 and 25 and acknowledged there was no documented evidence the medical records contained a consent for treatment.

Based on observation and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area as evidenced by the crash cart medications being stored in the unlocked doors of the unoccupied ICU.
Findings:

On 04/19/21 at 10:00 a.m., observation of the ICU revealed the doors to enter the unit were unlocked and the unit was empty and not in use. Further observations revealed a crash cart in the unit with multiple emergency medications in the cart. The cart had a plastic tab on it that was easily removed to access the medication.

On 04/19/21 at 2:00 p.m., interview with S10Pharmacist confirmed that the crash cart and medications should not be stored in the unlocked and unoccupied ICU.

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use as evidenced by 1) Having expired and/or unusable medications available for patient use and 2) Having multi-dose vials of medication that were unlabeled with first puncture date and/or had gone beyond the time frame allowed for use after the first puncture.
Findings:

I. Having expired and/or unusable medications available for patient use

On 04/21/21 at 9:15 a.m., observation of the anesthesia cart in Operating Room 1 revealed four 5mL vials of Metoclopramide that had expired (two expired 02/01/21 and two expired 04/01/21).

II. Having multi-dose vials of medication that were unlabeled with first puncture date and/or had gone beyond the time frame allowed for use after the first puncture

On 04/19/21 at 10:20 a.m., observation of the 3rd floor medication room revealed an opened multi-dose 50mL vial of Lidocaine 1%, with an open date documented as 02/17/21. At that time, interview with S14LPN revealed that opened multi-dose vials should be discarded 30 days after being opened.

On 04/19/2021 at 10:40 a.m., observation in the Nuclear Medicine Exam room revealed a vial of Kinevac 5 micrograms open and unlabeled with first puncture date. At that time, interview with S13Director of radiology acknowledged the bottle was not labeled with the date and time of the first puncture.

On 04/21/21 at 9:15 a.m., observation of the anesthesia cart in Operating Room 1 revealed and opened multi-dose bottle of glycopyrrolate that was not labeled with the opening date. An interview at this time with S3SurgDir confirmed that there was no documentation on the above medications to indicate when they would open or when they would expire.



20310

Based on observation and interview, the hospital failed to ensure that the director of food and dietetic services ensured the daily management of dietary services as evidenced by 1) failing to know the recommended temperature ranges and sanitizer levels for the dishwasher and 2) failing to ensure the safe storage of foods.
Findings:

On 04/19/21 at 1:35 p.m., interview with S5Dietary Manager revealed that the patients had returned to eating on non-disposable plates and utensils for approximately one month (due to Covid-19 pandemic). At that time, the surveyor requested for S5Dietary Manager to check the sanitizer concentration in the dishwasher. S5Dietary Manager stated that he did not have any strips to check the sanitizer concentration, but staff monitored the temperature. When asked what the appropriate temperature was supposed to be to sanitize the dishes, he stated that he thought it was to be 120 degrees on the wash and rinse cycle. At that time, S5Dietary Manager ran the dishwasher and the wash cycle measured 100 degrees Fahrenheit and the rinse cycle measured 116 degrees Fahrenheit. The dishwasher log was observed hanging on the door near the wash room. Review of this log revealed that temperatures were obtained on the wash, rinse and final rinse cycles, three times a day. The log revealed the same temperatures every day from 04/02/21 to present which was: wash temperature (120 degrees), rinse temperature (120 degrees) and final rinse temperature (100 degrees). At that time, S5Dietary Manager stated that he was unsure how the staff obtained these temperatures and confirmed he did not review the log. There were multiple missed days on the log and no sanitizer concentration checks on the log. Further interview with S5Dietary Manager confirmed that he was unsure if the dishes were being adequately sanitized. When asked if there was a policy or procedure for the operating/monitoring the dishwasher, he stated no.

On 04/19/21 at 2:00 p.m., observation of the walk in refrigerator with S5Dietary Manager revealed the following food items in opened containers/packages and not dated when opened:
- plastic bag of ham pieces
- large pot of soup
- 9 bowls of broccoli salad with no coverings over them
- opened 5 pound package of hamburger meat
- bowl of unknown yellow colored food
Interview with S5Dietary Manager during this time confirmed the above food items should have been dated when opened.

Based on observation, interview and record review, the hospital failed to ensure that proper ventilation and temperature controls were in the surgical suites and sterile supply storage room in the surgery area.
Findings:

On 04/21/21 at 9:15 a.m., observation of the surgical suites and in the sterile supply storage room in the surgery area revealed no monitoring panels for temperature or humidity. At that time,an interview with S3Surgical Director revealed that the temperature and humidity levels in the surgical suites were monitored by the maintenance department.

On 04/21/21 at 11:00 a.m., S4Engineering Director presented the monitoring log for the temperature levels in the surgical suites, which confirmed the temperature monitoring of the two operating rooms and the endoscopy room. He stated that the enclosed sterile supply storage room had no temperature sensor, nor was there any monitoring of the humidity levels for any areas within the surgical suites.

Based on observation and interview, the hospital failed to employ methods for preventing and controlling the transmission of infections as evidenced by failing to maintain a sanitary environment in patient rooms and surgical areas.
Findings:

On 04/19/21 at 9:00 a.m., observation of the patient rooms revealed the following:
Cloth gauze strips were tied to and hanging from the light pull cords above the beds in rooms a, b, c, i, j, k, m, n and ICU rooms d, e, and f.
Room g had a black substance covering length of a cord that was attached to the bed.
Room h had a chair with a cloth covering on the seat and back, plus one chair with a cloth covering on the back.
Room l had rips/tears to the vinyl covering on the left arm and right face of the recliner and rips/tears to the vinyl mattress cover.
Room o had old tape stuck to the siderails of the bed and had two chairs with cloth coverings on the seat and back.
On 04/19/21 at 9:30am, interview with S11RN confirmed that the above items were not able to be cleaned and disinfected.

On 04/21/21 at 9:00a.m., observation of the surgical suite revealed the following:
In Operating Room 1, an IV pole had a taped on label that was peeling off in several areas around the pole.
A large chair had several tears in the covering on the seat, back and arms, exposing the foam cushion underneath.
Observation of the anesthesia cart revealed several peel packs of anesthesia supplies expired 07/22/18 and 08/20/16.
Observation of the anesthesia cart in Operating Room 1 revealed the drawer labeled, Airway, had brown splatters inside the drawer. Interview with S3SurgDir at that time confirmed the drawer was in need of cleaning.

On 04/21/21 at 9:15 a.m., observation of the wall cabinet in Operating Room 1 revealed the following expired surgical sutures:
Prolene ethicon 1, box expired 02/28/21
Prolene ethicon 2.0, box expired 03/31/21
Vicryl 0, box expired 02/28/21
Permahand silk 0, box expired 02/28/21
Interview with S3SurgDir on 04/21/21 at 9:25 a.m. confirmed the above expired surgical supplies.
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On 04/21/21 at 9:30 a.m., interview with S12Scrub Tech during observation of the endoscope cleaning process revealed that after each procedure, the endoscopes are covered with a towel and transported from the Endoscope Room, across a narrow hallway that contained a storage rack of clean supplies, and into the decontamination room. Further interview revealed that after decontamination, the scope is covered with a towel and transported back through the hallway into another room for high level disinfection. Observation of the room used for high level disinfection revealed it contained a hopper sink. Interview with S3SurgDir at this time confirmed that the hopper is currently in use, as it is the only hopper available for the surgical area.

Observation on 04/21/21 at 9:45 a.m. revealed an endoscopy procedure was ending in the endoscopic room. At this time observation revealed the scope was wiped and flushed, wrapped in a towel and transported across the hallway to the decontamination room. The tubing of the scope was not completely covered, and was sticking out of the towel in several places during the transporting process. Interview with S3SurgDir confirmed that the endoscope cleaning and disinfection procedures allowed for several opportunities for potential contamination and spread of infection.


17450

Based on record review and interview, the hospital failed to ensure that a medical history and physical examination that was completed within 30 days before a procedure requiring anesthesia services had an updated examination completed and documented in the medical record of the patient prior to surgery for 3 (Patient #11, 13, 14) of 4 (Patient #11, 12, 13, 14) surgical records reviewed..
Findings:

Review of the medical record for Patient #11 revealed the patient had an endoscopic procedure on 04/19/21 requiring anesthesia services. Review of the history and physical revealed it was dated 04/15/21. Further review of the record revealed there was no updated examination documented in the medical record prior to the procedure.

Review of the medical record for Patient #13 revealed the patient had an endoscopic procedure on 04/19/21 requiring anesthesia services. Review of the history and physical revealed it was dated 04/01/21. Further review of the record revealed there was no updated examination documented in the medical record prior to the procedure.

Review of the medical record for Patient #14 revealed the patient had an endoscopic procedure on 04/19/21 requiring anesthesia services. Review of the history and physical revealed it was dated 04/01/21. Further review of the record revealed there was no updated examination documented in the medical record prior to the procedure.

On 04/21/21 at 3:00 p.m., interview with S3SurgDir confirmed that she had reviewed the above medical records and was unable to locate documentation of an update to the history and physicals that had been performed prior to admission.

Based on review of the hospital's policy, observation and interview, the hospital failed to ensure radioactive materials were prepared, labeled, used, transported, stored and disposed of in accordance with acceptable standard of practice. This deficient practice was evidenced by the Nuclear Medicine Services exam room and its nuclear material storage area being readily accessible.
Findings:

Review of the hospital's policy Nuclear Medicine (Reference #7005) revealed in part:
Environment: All radiation areas are to be properly labeled and as such are to be restricted from entrance by unauthorized personnel.

Observation on 04/19/2021 at 10:40 a.m. revealed the Nuclear Medicine Service exam room unlocked and readily available to access. Further observation revealed an interior room with the door open and two nuclear medication containers located on the counter top.

Interview on 04/19/2021 at 10:50 a.m., S13Director of radiology acknowledged the radioactive material was not secure.