HospitalInspections.org

Based on document review, observation and interview, it was determined for 2 of 30 (Pts #12 and #21) patients, the Hospital failed to ensure medications were administered as ordered. This has the potential to affect all inpatients and outpatients serviced by the Hospital with a current inpatient census of 23 patients and an average monthly outpatient census of 242 patients.

Findings include:

1. The Hospital policy titled "Vascular Access Device Policy and Protocol Grid" (revised 04/2017) was reviewed on 4/35/17 at approximately 3:00 PM. The policy stated "Saline 5 ml after each use, if not ordered differently by provider."

2. Pt #12's record was reviewed on 4/25/17 at approximately 12:30 PM. Pt #12 was admitted to the Hospital on 4/19/17 for outpatient laboratory testing. On 4/18/17, there was a physician's order for the Mediport (a small medical appliance that is implanted beneath the skin and connects a catheter to a vein) to be utilized for the laboratory testing and the Hospital "Protocol to flush the line pre and post dose" could be used. Nursing documentation stated the Mediport was flushed with 5 ml of Saline "Before Procedure" and lacked any Saline flush after the procedure. There was no order to flush the Mediport prior to the procedure.

3. An interview was conducted with the Vice President of Nursing (E#1) on 4/26/17 at approximately 2:30 PM. E#1 agreed there was no order for the Saline flush prior to the procedure and there was no Saline flush documented after the procedure.

4. A provision of care observation for medication preparation and administration for Pt #21, a CVC patient, was conducted on 4/25/17 at approximately 3:35 PM with the Vice President of Nursing (E#1) present. The Registered Nurse (E#8) was observed utilizing one 10 ml (milliliter) syringe of 0.9% Normal Saline (NS) and one 5 ml syringe of Heparin 500 units per 5 ml to flush a dual lumen CVC. E#8 flushed each lumen with 5 ml of the NS and 2.5 ml of Heparin each.

5. An interview was conducted with the Registered Nurse (E#8) on 4/25/17 at approximately 3:25 PM. E#8 stated Pt #21 was an ongoing patient with a dual lumen (port) CVC (Central Venous Catheter- a catheter that is passed through a large vein and the end sets at the opening of the right atrium of the heart) that is to be flushed daily with NS (Normal Saline) and Heparin. When asked how the medications are obtained, E#8 stated "The pharmacy loads the med's (medications) into the Pyxis (electronic medication dispensing system) once we tell them the patient is here. They load one Normal Saline and one Heparin and we use 1/2 of each for each port (lumen)." When asked if Pharmacy was aware that Pt #21 has a dual lumen CVC and if the medication order was for each lumen, E#8 stated "I don't know (if Pharmacy is aware). The order doesn't say how many ports. We just divide what Pharmacy sends between the two (ports/lumens)." When asked if the physician had been contacted to clarify the CVC flush orders, E#8 stated "I don't think so, but we can."

6. Pt #21's record was reviewed on 4/25/27 at approximately 3:50 PM. Pt #21 was admitted to the Outpatient Services on 4/25/17 with the diagnosis Unspecified Open Wound of Right Great Toe and Left Great Toe without damage to nail and was receiving ongoing daily flushes of the CVC until seen by physician next week to determine whether further intravenous antibiotics would be needed. On 4/14/17, there was a physician's order "ok for med surg (medical surgical) to access cvc line daily for flushes with 10 mls of 0.9% normal saline and 5 mls of heparin 100 units/ml after." The order lacked the number of ports and whether the medication was to be via each port or split between the two.

7. An interview was conducted with the Pharmacist (E#9) on 4/26/17 at approximately 8:30 AM. E#9 stated "I wasn't aware (of Pt #21 having a dual lumen CVC) until E#1 told me about it last evening. We've clarified the order now. Yes, we (the Pharmacy) should have been told there was more than one port. It isn't on the order, so we only filled (the medications) for one."

A. Based on document review, observation and interview, it was determined for 2 of 30 (Pts #11, #21) patients, the Hospital failed to ensure documentation was accurate and legible. This has the potential to affect all inpatients and outpatients serviced by the Hospital with a current inpatient census of 23 patients and an average monthly outpatient census of 242 patients.

Findings include:

1. Pt #11's outpatient intravenous record was reviewed on 4/26/17 at approximately 9:10 AM. Pt #11 was admitted to the Hospital on 4/25/17 with the diagnoses Pressure Ulcer of Left Buttock, Stage 4 and Chronic Multifocal Osteomyelitis, Other Site, and was receiving daily intravenous antibiotic therapy. A physician order dated 4/20/17, which had been scanned into the computer, was illegible. There was an "Additional Orders/Instructions" which was illegible for the date or order.

An interview was conducted with the Vice President of Nursing (E#1) on 4/26/17 at approximately 11:30 AM. E#1 stated "Any written orders or electronic orders that come in are scanned into the computer. Once they are scanned in, the original is thrown away. I was trying to read these (Pt #11's order) and couldn't. We're having the issue addressed now."

2. A provision of care observation for medication preparation and administration for Pt #21, a CVC (Central Venous Catheter) patient, was conducted on 4/25/17 at approximately 3:35 PM with the Vice President of Nursing (E#1) present. The Registered Nurse (E#8) was observed utilizing one 10 ml (milliliter) syringe of 0.9% Normal Saline (NS) and one 5 ml syringe of Heparin 500 units per 5 ml to flush a dual lumen CVC. E#8 flushed each lumen with 5 ml of the NS and 2.5 ml of Heparin each.

Pt #21's record was reviewed on 4/25/27 at approximately 3:50 PM. Pt #21 was admitted to the Outpatient Services on 4/25/17 with the diagnosis Unspecified Open Wound of Right Great Toe and Left Great Toe Without Damage to Nail. On 4/26/17 at approximately 11:30 AM, nursing documentation for 4/25/17 visit was reviewed and lacked documentation that Pt #21 had two lumens. The Medication Detail report stated one syringe of Heparin and one syringe of NS was administered; however, the detail lacked documentation that 5 ml of NS and 2.5 ml of Heparin were administered to each lumen.

3. An interview was conducted with E#1 on 4/27/17 at approximately 9:00 AM. E#1 had reviewed Pt #11 and #21's records and agreed Pt #11's orders were illegible and Pt #21's record did not accurately reflect the number of lumens and the amount of medications administered to each lumen.



32189

B. Based on document review and interview, it was determined in 5 of 5 (Pts #4, #17, #18, #22, #30) records reviewed, the Hospital failed to ensure approved abbreviations were utilized per facility policy. This has the potential to affect all inpatients and outpatients serviced by the Hospital with a current inpatient census of 23 patients and an average monthly outpatient census of 242 patients.

Findings include:

1. The "Glossary of Abbreviations" (reviewed 3/14) was reviewed on 4/27/17.

2. The clinical record of Pt #4 was reviewed on 4/25/17 at approximately 2:00 PM. Pt #4 was admitted on 4/19/17 with a diagnosis of Pneumonia. The following unapproved abbreviations were documented:
a) Nurse Note dated 4/26/17- C/I

3. The clinical record of Pt #17 was reviewed on 4/25/17 at approximately 3:30 PM. Pt #17 was admitted on 3/30/17 for Cardiac Rehabilitatin (CR). The following unapproved abbreviations were documented:
a) CR Note dated 4/6/17- TM, RPE, MI and CR
b) CR Note dated 4/7/17- SE

4. The clinical record of Pt #18 was reviewed on 4/25/17 at approximately 3:00 PM. Pt #18 was admitted on 3/7/17 for CR. The following unapproved abbreviations were documented:
a) CR Note dated 3/10/17 and 3/17/17- SE
b) CR Note dated 3/13/17- TM
c) CR Note dated 3/24/17- RPE

5. The clinical record of Pt #22 was reviewed on 4/26/17 at approximately 3:10 PM. Pt #22 was admitted on 4/23/17 with a diagnosis of Pulmonary Embolism. The following unapproved abbreviations were documented:
a) Nurse Note dated 4/25/17 and 4/26/17- BSC
b) Nurse Note dated 4/25/17- s/I
c) Nurse note dated 4/24/17- insp

6. The clinical record of Pt #30 was reviewed on 4/26/17 at approximately 2:45 PM. Pt #30 was admitted on 4/24/17 with a diagnosis of Suicidal Ideation. The following unapproved abbreviations were documented:
a) History and Physical dated 4/24/17- ROS
b) Emergency Room (ER) Note date 4/24/17- EMS, SAAS, HPI, ADHD and unkn

7. During an interview on 4/27/17 at approximately 3:00 PM, E#2 (Director of Care Management) reviewed Pt #4, #17, #18, #22 and #30's record and verbally agreed the abbreviations were unapproved and should not have been documented.

Based on observation, document review and interview, it was determined the Hospital failed to ensure the Expired Narcotic Record was accurate. This has the potential to affect all inpatients and outpatients serviced by the Hospital with a current inpatient census of 23 patients and an average monthly outpatient census of 242 patients.

Findings include:

1. The policy titled "Schedule II Control Drugs, Wastage" (revised 6/16) was reviewed on 4/27/17. The policy noted "... when a controlled drug is returned to pharmacy for wastage and this drug cannot be returned to the manufacturer for credit, it may be necessary to waste the drug in the pharmacy... documentation should be made in regards to the date, name of patient's medication and patient name, amount wasted and the individual wasting.

2. The Expired Narcotics Log was reviewed during a tour of the Pharmacy on 4/26/17 at approximately 11:45 AM. The log lacked documentation of the date and the quantity of medications that were removed from the Hospital by the Drug Enforcement Administration (DEA) supplier. The log did not note the current expired narcotic inventory.

3. During an observational tour of the Pharmacy on 4/26/17 at approximately 11:45 AM, the Expired Narcotics' cabinet was observed with E#9 (Director of Pharmacy). E#9 stated "We just had our narcotics picked up so there is only a Fentanyl 75 mcg (microgram) patch in here." and demonstrated the Fentanyl 75 mcg patch on the Expired Narcotic Log. The cabinet contained the following expired narcotics: 2 boxes of 25 count (50 total) Hydromorphone 2 mg (milligram)/ml (milliliter), 1- 20 ml vial of Morphine 100 mg/2 ml, 1- 10 ml vial of Morphine 25 mg/ml and 1- 100 ml bottle of Hydrocodone labeled with a patient's name.

4. During an interview on 4/26/17 at approximately 11:50 AM, E#9 stated the Morphine 20 ml and 10 ml vials "Must have been missed on the pick up... I didn't know they were there." E#9 verbally agreed the Expired Narcotics Log did not identify which Narcotics were in the expired inventory and which Narcotics had been removed and should have. E#9 stated the expired bottle (2015) of Hydrocodone was a returned bottle from a Hospice patient and was not on the log because the DEA supplier would not take it with a patient label on it. E#9 verbally agreed the Hydrocodone and the amount had not been inventoried, wasted or monitored and should have been. On 4/26/17 at approximately 3:30 PM, E#9 demonstrated the Expired Narcotics Log entry on 6/23/16 of 72 vials of Hydromorphone 2 mg/ml were removed from inventory and placed in the expired narcotic's cabinet. E#9 demonstrated a DEA supplier receipt dated 1/9/17 that 22 Hydromorphone vials were removed from the Hospital. E#9 stated 50 vials had not expired and could not be picked up by the DEA supplier at that time. E#9 verbally agreed the Expired Narcotics Log did not note the 50 existing Hydromorphone vials and should have.

Based on interview and document review, it was determined the Hospital failed to ensure Pharmaceutical Services established, implemented and maintained an ongoing competency evaluation process in compliance with current USP (United States Pharmaceuticals) <797>. This has the potential to affect all inpatients and outpatients receiving Pharmaceutical Services from the Hospital.

Findings include:

1. The "Rules for Compounded Sterile Preparations (CSPs)" (provided by E#10 (Pharmacist) was reviewed on 4/27/17. The rules require in Section Vl. Records, Documents and Reports page 11 "6. Orientation and training records of all personnel who supervise or compound CSPs shall be maintained. This will include but not be limited to:... c. Aseptic Media qualifications d. Fingertip and thumb testing... g. Cleaning & Disinfecting of Controlled environments..."

2. An interview was conducted with E#10 on 4/27/17 at approximately 3:00 PM. E#10 stated the Pharmacy performs an annual competency for IV (intravenous) compounding, in which the staff are observed to withdraw IV solution and aseptically place a few drops in the broth (growth media). Then the broth is placed in an incubator for a two or three days and checked visually to "see if it appears hazy or unclear." E#10 stated they do not perform surface testing or gloved finger testing.

Based on document review and staff interview, it was determined the Hospital failed to ensure all radiation personal protection equipment was safe, potentially affecting all radiology staff and patients.


Findings include:

1. The policy titled "Lead Apron Policy " (original date 2010, revision date 12/16) was reviewed on 4/28/17 at approximately 10:50 AM. The policy included..."If a defect is found at the time of the annual check or any other occasion, the device shall be removed from service immediately and disposed of properly...Rejection Criteria...Multiple small holes."

1. On 4/26/17 at approximately 12:00 PM the "Protective Garments Test" form from surgery was reviewed, the form included 5 lead aprons listed as not adequate and containing holes. The form lacked information regarding if the lead aprons were taken out of service or for repairs.

2. During the interview with E#11 (Radiology Manager) on 4/26/17, it was stated, "there was no policy for tracking lead apron disposal and repair". It was also stated, "was unsure if the lead aprons were still in use in the surgery department or not".

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on April 25 - 26, 2017, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on April 25 - 26, 2017, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

A. Based on document review, observation and interview, it was determined for 1 of 1 (Pt #23) isolation patient, and for 1 of 1 (Pt #21) patient with a CVC (Central Venous Catheter) access flush, the Hospital failed to ensure infection control measures were maintained to prevent the potential for cross contamination. This has the potential to affect all inpatients and outpatients serviced by the Hospital with a current inpatient census of 23 patients and an average monthly outpatient census of 242 patients, staff and visitors of the Hospital.

Findings include:

1. The Hospital policy titled "Contact Precautions" (reviewed 03/2017) was reviewed on 4/26/17 at approximately 3:30 PM. The policy stated "use Contact Precautions for specified patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient.... or indirect contact (touching) with environmental surfaces or patient-care items in the patient's environment."

2. A provision of care observation of Pt #23, a contact isolation patient, was conducted on 4/25/17 at approximately 2:50 PM. The Intensive Care Unit (ICU) Registered Nurse (RN) (E#6) and the ICU/Post Coronary Unit (PCU) Manger (E#7) were observed. E#6 donned Personal Protective Equipment (PPE- gown and gloves), drew up Human Lispro insulin 35 units, reached right gloved hand under the PPE gown into E#6's right scrub top pocket looking for an alcohol wipe, requested E#7 to obtain an alcohol wipe, opened the alcohol wipe, wiped Pt #23's left arm with the alcohol wipe and administered the Lispro insulin, all without removing gloves, performing hand hygiene, and applying new gloves.

An interview was conducted with E#7 on 4/25/17 at approximately 3:00 PM. The Vice President of Nursing (E#1) was present. E#7 agreed E#6 had reached into scrub top pocket and back to patient care without removing gloves, performing hand hygiene and applying new gloves, which did not follow Contact Precautions.

3. A provision of care observation for medication preparation and administration for Pt #21, a CVC patient, was conducted on 4/25/17 at approximately 3:35 PM with the Vice President of Nursing (E#1) present. The Registered Nurse (E#8) was observed holding the dual lumens in the left hand and holding both syringes (one 10 ml- milliliter syringe of 0.9% Normal Saline-NS and one 5 ml syringe of Heparin 500 units per 5 ml) and two disinfecting swabs in the right hand. E#8 proceeded to disinfect one lumen; tossed the disinfecting swab (with hand full of other items) approximately 2 1/2 to 3 feet towards a garbage can; manipulated syringes and remaining disinfecting swab to removed caps from NS and Heparin syringes using left hand that was holding the dual lumens; flushed with 5 ml of NS and 2.5 ml of Heparin; manipulated syringes in hand; disinfected the remaining port with disinfecting swab; and flushed with the remaining 5 ml of NS and 2.5 ml of Heparin from the same syringes. It was unable to be determined that the disinfecting swabs and syringes were kept sterile due to the manipulations and "tossing" of one of the disinfecting swabs.

An interview was conducted with E#1 on 4/25/17 at approximately 3:50 PM. E#1 had observed the above and agreed it was difficult to assure the items were kept sterile due to the manipulations and that the nurse did use the same syringe to flush both ports.





32822

B. Based on observation and interview, it was determined for 1 of 1 (Pt #16) surgical patient observed, the hospital failed to ensure infection control measure were followed to prevent the potential of cross contamination. This has the potential to affect all inpatients and outpatients serviced by the Hospital with a current inpatient census of 23 and an average monthly outpatient census of 242, staff and visitors of the Hospital.

Findings include:

1. On 4/25/17 at approximately 12:20 PM, in Operating Room (OR) #4, the Anesthesiologist (MD#6) was observed wearing gloves on both hands holding the oxygen mask on Pt#16's face. MD#6 then took a cell phone out of pocket with gloved right hand, responded, placed cell phone back in pocket and resumed holding the oxygen mask with gloved hands on Pt#16's oxygen mask. At 12:30 PM MD#6 exited OR#4 without removing gloves or sanitizing hands.

2. An interview was conducted with the Director of Surgery (E#4) on 4/24/17 at approximately 12:35 PM. E#4 stated MD#6 should have removed gloves and performed hand hygiene after answering cell phone and donned a new pair of gloves before resuming patient care, as well as removing gloves and performing hand hygiene prior to leaving OR #4.

Based on document review, observation and interview, it was determined for 1 of 1 (Pt #16) surgical patient observed, the Hospital failed to ensure a surgical fire risk assessment was completed prior to the start of surgical cases. This has the potential to effect all patients receiving surgical services, with an average monthly censes of 309 surgical patients, staff and visitors of the hospital.
Finding include:

1. The policy titled "Fire Safety in an Oxygen Rich Environment " (approved March 2017) was reviewed on 4/26/17 at approximately 11:00 AM. The policy indicated the "Circulating RN (Registered Nurse) will complete the surgical fire risk assessment guide at the start of the procedure."

2. On 4/25/17 Pt #16 was admitted to the surgery area for a Right total Knee Arthroplasty. The surgical case began at 1:00 PM. It was observed, the circulating Registered Nurse (E #5) failed to perform a fire safety risk assessment.

3. An interview was conducted with the Director of Surgery (E#4) on 4/25/17 at approximately 1:05 PM. E#4 verbalized a Fire Risk Policy had been written but has not been approved so we have not started the fire risk assessment.

4. The "Graham Forms Committee Minutes" dated 4/25/17 3:30 PM, were reviewed on 4/26/17 at 1:40 PM. It indicated "Surgical Site Fire Risk Assessment Form was needed."