HospitalInspections.org

Based on observation and interview the facility Respiratory Service staff and the facility Pharmacy staff failed to establish and maintain a distribution and/or storage system providing safety and accountability of medications used for patient emergency and/or respiratory therapy. The facility census was 3 patients.

Findings included:

1. During an interview on 06/02/10 at 3:00 p.m. the Director of Respiratory Services stated the following:
-He/she and Respiratory staff performs pulmonary function tests (PFTs) for patients per physician's orders.
-He/she and respiratory staff administer medications including Albuterol inhalers to patients during the PFTs.
-He/she obtains the medications from the nursing services medication room.
-He/she does not sign for medications.
-He/she does not know if the Pharmacist was aware of the removal of the medications from the nurse's medication room without record of the removal by the Respiratory Services staff.
-He/she said the Pharmacist would not be able to review the medication removal by the Respiratory staff because the Pharmacist does not know the Respiratory staff has the medications.
-The Pharmacist would not be able to retrieve medication used by Respiratory therapy staff when recalled or monitor for expired medications because there were not records indicating the Respiratory staff had removed the medications from the nurse's medication room.


12450

2. Review of a facility policy entitled, "Floor Stock," revised 08/09, revealed medications contained in floor stock are stored in a secured, locked cabinet.

Observation and interview on 06/01/10 at 3:45 p.m. revealed inhalers such as Advair and Flovent kept in drawers in a small cabinet, in the medication room. This small cabinet was unlocked and there was no door on the medication room. The manager of the unit, Registered Nurse (RN) staff member A said he/she was not sure why the inhalers were kept this way.

3. Observation and interview on 06/01/10 at 3:50 p.m. revealed multiple drawers in a crash cart, located at the nurses' station, that contained medications. These drawers were labeled with the names of the medications within each drawer, and the intended quantity of each. There was also an inventory list on the crash cart containing a list of medications and the quantity of each to be stocked. The drawer labels and inventory list did not match. The drawer inventory did not match either of the tools utilized to control quantity. Observation revealed the following:

a) There should have been three Atropine Sulfate 0.4 milligram (mg)/milliliter (ml), and there were only two.
b) There should have been two Dexamethasone vials, and there were none.
c) There should have been one Dopamine 400 mg premixed, and there were none.
d) There should have been six Epinephrine 1 mg/ml, and there were only five.
e) There should have been ten Inderal 1 mg/ml, and there was only eight.
f) There should have been two Epinephrine 10 ml syringes, and there were none.
g) There should have been one Nitroprusside 50 mg, and there were none.
h) There should have been three Atropine Sulfate 0.1 mg/ml, and there were four.
i) There should have been one Magnesium Sulfate 80 mg/ml, and there were two.

RN Staff member A said he/she was not sure why the inventory was not as listed.

4. Observation and interview on 06/02/10 at 1:50 p.m. revealed the Emergency Department (ED) crash cart medications did not match the labels on the drawers or the inventory list. RN Staff member C said the medications were re-stocked by calling the pharmacy tech to give a list of used medications each time the cart is used. Inventory in the crash cart was as follows:

a) There should have been six ampules of Epinephrine 1:1000, 1 mg/ml, and there were seven.
b) There should have been three Metoprolol 5 mg/ml vials, and there were seven.
c) There should have been three Digoxin 0.5 mg/2 ml vials, and there were four.
d) There should have been six Narcan 0.4 mg/ml, and there were eight.
e) There should have been one Magnesium Sulfate 4 grams premixed, and there were two.
f) There should have been two Nitroprusside 50 mg/2 ml, and there were none.
g) There should have been three Inderal 1 mg/ml, and there were five.
h) There should have been eight Epinephrine 1:1000, 1 mg/ml syringes, and there were ten.
i) There should have been five Amidate 40 mg, 2 mg/ml, and there were four.
j) There should have been six Atropine Sulfate 0.1 mg/ml syringes, and there were four.
k) There should have been no Phentolamine 5 mg vials, and there was one.

5. Observation and interview on 06/02/10 at 2:42 p.m., RN staff member X, the surgery manager, said he did not know how the pharmacy tech stocked/inventoried the surgery crash cart. The surgical crash cart had no inventory sheet to compare the drugs. Each drawer was labeled, but no quantity was listed. Surgery staff did not open and monitor quantity of medications in the crash cart, this was the pharmacy tech's responsibility, and Staff member X did not know how this was done, or if the current count of medications was correct.

6. During an interview on 06/03/10 at 9:15 a.m., the Pharmacist said the same pharmacy tech had done the inventory/stocking of the crash carts for a very long time and his/her system was not common knowledge. The Pharmacist had no way of knowing if the current medication count in the crash carts was correct. The Pharmacist said some medications were missing because of being backordered. The pharmacy tech had placed extra medications in the carts via staff request in the past, which throws the count off. The crash cart inventory was not something the Pharmacist monitored personally, and/or included in the quality data collected.

Based on observation and interview, the facility failed to preserve a sanitary source of ice procurement from an ice machine located in the dining room of the hospital, potentially affecting the staff, visitors and patient census of three patients.

Findings included:

1. Observation on 6/2/10 at 11:00 A.M. showed no opening in the drain hose or backflow prevention device at the top of the hose plumbed from a dining room ice machine into a floor drain connected to the sanitary sewer system. In the event of a plugged sewer system that could cause the floor drain to over flow; a backflow prevention device could prevent back siphonage of contaminated water from the sewer system from entering and contaminating the storage basin of the ice machine.

During an interview on 6/2/10 at 11:15 A.M., the Director of Facilities said they had more than one ice machine and they were all plumbed with hoses that ran directly from the drain into the open floor drain connected to the sewer system. He ordered maintenance workers to place a "T" connection at the top of the hose to provide a break in the water flow, and prevent surface tension from drawing contaminated water back up the hose into the ice basin of the machines. The facility corrected all deficient ice machines prior to exit on 6/3/10 at 1:00 P.M.

Based on interview and record review facility staff failed to develop a system for identifying, investigating and controlling potential infections and communicable disease for patients admitted to the facility and receiving Respiratory therapy. The facility census was 3 patients.

Findings included:

1. Record review of an abstract (provided during the survey) from a Respiratory journal titled Incidence of Contamination of Metered Dose Inhaler Canisters when used with Multiple Patients Using Spacer Devices, dated 1996 revealed a brief narrative of a study conducted (twenty five patients in three phases) with a conclusion that cross contamination of MDI {metered dose inhalers, a device delivering a specific quantity of medication in a short aerosolized burst} canisters to spacer devices { tube like device that attaches to the MDI that helps deliver medication to the lungs and not just into the mouth} was unlikely when a common canister sanitizing protocol was used (wipe with alcohol pad). Further review of the abstract revealed the common canister study was not used for patients in isolation.

2. Record review of the Medical Staff meeting minutes dated 01/21/03 (several years after the study reported in the abstract) revealed five of seven medical staff members were present and those five approved the use of multi-dose inhalers with patients being issued their own inhaler. Further review of the Medical Staff meeting minutes revealed only two of the five Medical Staff members were still currently on staff.

3. During an interview on 06/02/10 at 2:45 p.m. with the Infection Control Nurse, Staff H; the Infection Control Officer, Staff I; and the Corporate Regional Director of Quality Management the following was stated:
-The facility Infection Control Committee and the Infection Control Staff do not approve of the Respiratory Service practice of using a single multi-dose inhaler with multiple patients.
-The facility had discontinued their policy for routinely screening patients on admission for MRSA (Methicillin-resistant Staphylococcus aureus, antibiotic resistant bacteria, normally found on skin or in the nose that can be spread from person to person through casual contact or through contact with contaminated objects).
-The facility had also discontinued their policy for routinely screening patients on admission for C. Diff (Clostridium difficile, a bacteria that causes diarrhea is found in feces and can be spread by touching contaminated surfaces and touching the mucous membrane or mouth).
-The facility Infection Control staff usually reviewed cleaning practices with Environmental Services staff if there was a possible spread of C. Diff infection.
-Infection Control staff felt there were no increase or spread of C. Diff or MRSA however they did not perform any monitoring of infection after a patient was discharged from the facility.
-The discontinuation for C. Diff and MRSA screening was done because staff physicians felt isolation precautions (used for patients suspected of having C. Diff or MRSA) would cause undue upset for their patients.

4. During an interview on 06/02/10 at 3:28 p.m. the Director of Respiratory Services stated the following:
-As a cost containment measure, he/she had elected to provide patients receiving MDI treatments each with a spacer.
-He/she attached a multi-dose container of medication to the spacers and administered the medication from the same container to multiple patients.
-He/she felt this practice was permissible because staff were directed to sanitize the multi-dose containers between patients.
-He/she did not have any monitoring methods to ensure staff were actually sanitizing the multi-dose containers between patients.
-He/she felt the practice was permissible due to a study reported in a Respiratory journal (from 1996).
-He/she felt the Medical Staff was aware of the practice and approved of it (approval was in 2003).
-He/she stated the Respiratory staff had been doing this (practice) for years.

5. During an interview on 06/03/10 at approximately 10:00 a.m. the Director of Respiratory Services stated current medical staff members may not be aware of the practice of using multi-dose inhalers and spacers with multiple patients.

Based on observation, interview and record review Dietary staff failed to store foods to protect against cross contamination, failed to serve safe, uncontaminated foods at appropriate temperatures to prevent the growth of food borne illness causing bacteria, failed to establish and maintain a current therapeutic diet manual approved by the dietitian and readily available to medical, nursing and food service staff for reference and the clinical dietitian failed to supervise nutritional care by failing to approve the written therapeutic menus served. The facility census was 3 patients.

Findings included:

1. Record review of the United States Department of Health and Human Services. Public Health Service, Food and Drug Administration 2005 Food Code directed in part the following:
-Chapter 3-304.12 In-use utensils, between use storage. In food that is not potentially hazardous with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar or flour.
-Chapter 3-305.12 Food storage food shall be protected against contamination by storing, in a clean, dry location, not exposed to splash, dust, or other contamination.
-Chapter 3-501.16 Potentially hazardous food shall be maintained at or above 135 degrees Fahrenheit or at or below 41 degrees Fahrenheit.
-Chapter 5-501.110 Refuse shall be stored in receptacles so that they are inaccessible to insects and rodents.
-Chapter 5-501.113 Refuse and waste handling containers shall be kept covered if they contain food residue and are not in continuous use.

Observation on 06/01/10 from 3:50 p.m. through 4:10 p.m. revealed Dietary staff failed to store foods to protect against cross contamination including:
-A bulk bin of flour stored with a soiled scoop imbedded into the surface of flour and scoop handle touching the surface of the flour.
-An undated, opened, partial thirty-two ounce package of rice cereal stored on a shelf in the dry food store room.
-An undated, opened ten pound package of pasta stored on the shelf of the dry food storeroom.
-An undated, opened five pound package of fettuccini stored on a shelf in the dry food storeroom.
-An undated, opened four and a half pound package of chocolate cake mix stored on a shelf in the dry food storeroom.
-An undated, opened five pound package of white cake mix stored on a shelf in the dry food storeroom.
-An undated, opened five pound package of dinner roll mix stored on a shelf in the dry food storeroom.
-An undated, opened package of chocolate cake frosting stored on a shelf in the dry food storeroom.
-An opened to air case of chicken strips stored in the walk-in freezer.
-An unlabeled, undated stainless steel container of white powdered food (identified by staff as flour) stored on the cooks table.

Observation on 06/01/10 at 3:55 p.m. in the facility dish washing area revealed staff failed to cover a partially filled fifty gallon trash can.

During an interview on 06/02/10 at 9:00 a.m. the Director of Dietary, Staff D stated all of the Dietary department trash containers have holes in the lids and the one in the dish washing area did not have a lid.

2. Observation on 06/02/10 at 11:31 a.m. on the patient unit revealed Dietary staff served a test meal tray with foods including:
-Baked chicken at 129 degrees Fahrenheit.
-One half of a baked potato with a foreign body (considered a cross contaminant) on the cut surface of the potato (identified as a sliver of aluminum foil produced when Dietary staff cut the aluminum foil covered potato with a knife prior to serving)..
-A carton of milk at 44 degrees Fahrenheit.

During an interview on 06/02/10 at 11:31 a.m. the Director of Dietary, Staff D stated the following:
-He/she felt the chicken should be served at or above 145 degrees Fahrenheit.
-He /she felt the milk should be served at 45 degrees Fahrenheit (inconsistent with Food Code parameters of 41 degrees or below).
-He/she state the sliver of foil should not be served and might be a problem for an elderly patient or a patient with poor vision.

3. Record review of the facility policy titled Diet Manual, reviewed and revised 06/09 directed in part, the following:
-The facility diet manual was the ADA Manual of Nutrition Care.
-The manual was available on line.
-The manual was continually updated.
-A hard copy of the most used diets was kept in the Diet Office in the kitchen and at the nurse's station.
-A pathway to get online was maintained on the hard copy of the selected diets.
-The diet manual was submitted to the Medical Staff annually for approval.
-The policy was authenticated by the Director of Dietary and the Clinical Dietitian but not by the Medical Director.
-No written approval of the ADA Manual of Nutrition Care was attached.

Record review of a letter from the facility Clinical Dietitian to the facility Medical Staff, dated 12/24/09 revealed the following:
-The diet manual currently used was the ADA Nutrition Care Manual.
-The ADA Nutrition Care Manual was available on the facility computer system.
-He/she was not allowed to print an entire hard copy of the ADA Nutrition Care Manual.
-He/she had printed off the most commonly used diets and placed them in a binder at the nurse's station.
-The binder also had a user identification and password to gain access to the entire diet manual on-line.

Record review of the minutes of the Medical Staff meeting dated 01/12/10 revealed the Medical staff unanimously approved (name of manual not indicated in the minutes) a diet manual.

During an interview on 06/02/10 at 9:00 a.m. the Clinical Dietitian, Staff E stated the facility diet manual was the American Dietetic Association, Nutrition Care Manual and was maintained on the computer system.

Observation on 06/03/10 T 9:16 A.M. revealed the Unit Clerk provided a blinder with selected pages of various diets when asked to provide the diet manual.

Record review of the diet manual provided by the Unit Clerk revealed the following
-Photocopies of pages downloaded from an Internet site.
-The copies were from the Nutrition Care Manual of the American Dietetic Association.
-Untitled copies of sections of diets.
-Loose leaf binder dividers with topical headings that did not identify the diet material under the tab.
-No indication of any approvals by the facility Clinical Dietitian or the facility Medical Staff.
-A cover sheet that directed use of a user identification and password to get to the on-lone copy of the entire diet manual.

Observation on 06/03/10 at 9:21 a.m. revealed the Unit Nurse Manager, Staff A attempted to gain computer access (using the user identification and pass word indicated on the front of the loose leaf binder/diet manual) and found he/she could not gain access (web site was to a pass word protected Internet site for the American Dietetic Association and not a diet manual.

4. During an interview on 06/02/10 at 9:00 a.m. the Director of Dietary, Staff D stated the Clinical Dietitian, who was on site two days a week, had not approved the current therapeutic menus used to serve patient foods.

Record review of a copy of the current therapeutic menus (a list of foods to serve in specific amounts for restricted diets including low salt, low fat, pureed, low residue, carbohydrate controlled) revealed the Clinical Dietitian failed to authenticate the menus indicating approval and directing types and amounts of foods to serve for nutritional care.

Based on interview and record review the facility failed to follow the physician's orders for oxygen for one of three patients (Patient #3) reviewed. The facility census was three.

Findings Included:

1. Review of Patient #3's History and Physical dated 06/01/10 revealed the patient was admitted that day with diagnoses of chest discomfort, anxiety and an increased heart rate.

Review of physician's orders dated 06/01/10 revealed an order for oxygen at two liters per nasal canula.

Review of a flow sheet dated 06/02/10, timed at 4:00 a.m., revealed the patient received three liters of oxygen instead of two liters.

During an interview on 06/02/10 at 9:24 a.m., Registered Nurse staff member A confirmed there was no order to change the oxygen to three liters, and no evidence the physician had been contacted to get a different order.

Based on record review the facility failed to develop and/or update care plans to reflect current problems for two of three patients (Patients #3, and #2) reviewed. The facility census was three.

Findings Included:

1. Review of a facility policy entitled, "Care Plan Procedure," revised 07/09, revealed the care plan will be individualized to meet the identified needs of the patient. The care plan is based on diagnoses, orders, assessment data, physical/safety needs, comfort level, etc.

Review of Patient #3's History and Physical dated 06/01/10 revealed the patient was admitted that day with diagnoses of chest discomfort, anxiety and an increased heart rate. The patient routinely received an anti-anxiety medication called Xanax.

Review of a physician's Progress Note dated 06/01/10 revealed the patient suffered from anxiety.

Review of the Physician's Orders dated 06/01/10 revealed an order for Xanax 0.25 milligrams daily at bedtime.

Review of the Medication Administration Records revealed the patient received the above medication as ordered on 06/01/10 at 10:00 p.m.

Review of the patient's care plan revealed staff failed to identify the anxiety, and failed to establish a goal and interventions regarding the medication usage.

2. Review of Patient #2's Surgery Intraoperative record dated 06/01/10 revealed the patient had his/her gall bladder removed.

Review of Nurses' notes revealed the following:

a) The patient complained of pain rated at "6" on a scale of 1-10, with 10 being the worst pain at 7:50 p.m.
b) The patient's pain was the same at 8:50 p.m. An order for a pain medication called Percocet was received.

Review of the Pain Management Flow Sheet revealed the patient received the following pain medications:

a) On 06/01/10 at 11:48 a.m., received Demerol intravenously (IV).
b) On 06/01/10 at 2:00 p.m., received Demerol IV.
c) On 06/01/10 at 3:47 p.m., received Demerol IV.
d) On 06/01/10 at 7:50 p.m., received Lortab.

Observation on 06/01/10 at 4:25 p.m. revealed Patient #2 received a Toradol injection for pain rated at a "4".

Review of the patient's care plan revealed staff failed to identify the patient's pain, and failed to establish a goal and interventions regarding the pain and pain medication usage.

Based on observation, interview and record review the facility failed to ensure each Swing Bed resident was provided with an ongoing program of activities planned by a qualified Activities Director, according to a comprehensive assessment encompassing the resident's interests and in consideration for the resident's physical, mental and psycho-social status. The facility census was 3 patients.

Findings included:

1. During an interview on 06/02/10 at 3:30 p.m. the Swing Bed Activities Director stated the following:
-He/she had been in position for six months.
-He/she was a Certified Nurse Assistant.
-Worked Monday through Friday from 7:00 a.m.. to 3:30 p.m.
-Did not work Saturday or Sunday.
-Had taken an Internet course regarding activities (The Activities Director was asked to provide documentation of attendance to the surveyor however no specific documentation was provided by time of exit.)
-Felt the Internet course dealt mainly with nursing home residents and was not applicable to the facility Swing Bed residents.
-Did not maintain an Activities calendar and usually "just made it up as we go".
-Did perform an activities assessment for Swing Bed residents.
-Offered books, magazines and cards.
-Did not have a specific room designated for Swing Bed activities.
-Did have a place to store materials for some activities.
-Placed the activities assessment in the medical record of each Swing Bed resident.
-Did not complete an Activities Care Plan.
-Did not attend Care Plan meetings to discuss Activities for each Swing Bed resident.
-Did not discuss activities for any Swing Bed residents with nursing staff.
-Usually just discussed activities with each resident.
-Felt bathing was an activity.
-Felt lotion bath, back rub and foot rub were all activities.
-Felt ambulation in the corridors was an activity.
-Did not work the last holiday so did not know if the Swing Bed residents had special activities.

2. Observation on 06/02/10 at 3:44 p.m. in the activity supply storage room revealed the following:
-The activities equipment was stored in a corner of the physician dictation room on a shelf over collapsed wheelchairs, walkers and consisted of three stereos and one light with images of fish in it.
-The activities supplies was stored in drawers and consisted of pediatric coloring books, some large print reading material, regular print paperback books, some knitting supplies and some video cassettes.

3. During an interview on 06/02/10 at 3:44 p.m. the Activities Director stated the following:
-There was a large screen television however it was removed from the unit and taken to the facility basement after the room was converted to a physician's dictation room.
-He/she thought there was an Activities budget however he/she had never asked for anything.
-The budget monies were maintained by the Chief Nursing Officer.

4. Record review of the Activities Director's personnel file revealed no specific documented training or education showing qualification as an activities professional.








12450

5. Review of Patient #12's closed record revealed the following:

a) He/she was admitted to the Swing Bed unit on 01/04/10 and discharged on 01/08/10.
b) The patient had a diagnosis of pneumonia.
c) The activity assessment for this patient was blank as of 06/02/10.
d) The staff failed to develop a care plan for activities.