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Based on observation, interview and policy review, the facility 1. failed to provide safe care regarding emergency call light monitoring, and 2. failed to monitor the patients on telemetry in the required ratio as dictated by the hospital's policies and procedures.

Findings were:

On 12/08/15 at 3:00 p.m., the restrooms for outpatient registration in the main facility had no call lights for emergencies.

Interview with the Nurse Manager in the Surgicare area at the above mentioned time confirmed that this was correct and stated that the outpatients used these restrooms before coming back to the pre surgical area to begin assessments and treatment. Further, the restroom for males was quite dirty with fresh stool on and in the toilet. Since the facility does treat patients in the gastro-intestinal lab with laxatives and some patients were elderly, both the Nurse Manager and surveyor agreed that these restrooms should have an emergency call light.

On 12/09/15 at 10:30 a.m., the restrooms for outpatient registration in the off campus Surgicare facility the restrooms had no emergency call lights. Also, in the x-ray department of this facility, the restroom for the Magnetic Resonance Imaging (MRI- special studies done with the use of a magnet), the associated restroom had no call light for emergencies.

Interview with the The Chief MRI Technician for this area at the above date and time, he/ she stated that since the restroom was outside of the actual MRI suite, he/she had asked the safety officer to get a call light for this area, though it had been some time and as yet no action had been taken to fix this.

On 12/10/15 at 12:30 a.m., the restrooms for outpatient treatment of patients in the gastro-intestinal lab (located next door to the Surgicare off-site facility) had no emergency call lights.

An interview with The Nurse Manager for this unit at the above mentioned site confirmed that patients did use these restrooms before coming to the pre surgical area for their procedure(s).

Also, inside the procedure suite area, on the same tour, there were three patient restrooms in the pre surgical and post surgical areas. All three of these had inoperable call lights because the pull cords were wrapped multiple times around the handrail.

The Nurse Manager, upon viewing this, stated that he/she suspected that the wrapping of the cords around the handrail was probably due to housekeeping, and that he/she would talk with housekeeping about this issue. The pull cords were immediately returned to a functional state.

On 12/11/15 the secretary in the administrative suite was asked for a policy on emergency call lights. At 10:30 a.m. the secretary advised that there was no such policy on call lights.

On 12/14/15 at 3:20 p.m., in the Outpatient Registration of the main facility, the only restroom in the area did have an emergency call light, however, the sole registrar was unsure where the call light actually alarmed. When pulling the cord the alarm sounded in a locked room (old closed outpatient blood drawing station) across the hall.

Interview with the registrar at the above mentioned time, he/she stated that registrars did not do patient care and that the call light needed to alarm near direct patient care givers.


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The facility's policy and procedure entitled, "Telemetry Initiation, Monitoring and Troubleshooting," Policy No. PPMH, effective date 07/20/2015, revealed that when one (1) monitor technician has to leave the room, and there are more than forty (40) patients being monitored, one of the following plans of action are taken to attempt to maintain a forty (40) to one (1) ratio (40:1).
1. The EKG (a test which monitors the electrical activity of the heart) technician on duty is beeped and asked to help monitor;
2. The respiratory care charge therapist is beeped on 1456 and requested to help monitor patients. If the charge therapist is unavailable, he or she will ask another therapist to assist telemetry.
3. Floor 4 A/B is contacted to request the nurses monitor the patients on their floor using their monitors for the period of time that only one (1) monitor technician is monitoring greater than forty (40) patients. (This may decrease the telemetry patient load up to a maximum of twenty (20) patients).
4. Critical Care Unit (CCU) is contacted to see if an Registered Nurse (RN) is available to help monitor.

Observation on 12/10/15 at 11:45 a.m. in the hospital's main campus' Telemetry Monitoring Room revealed that one (1) technician was monitoring eighty-two (82) patients on active telemetry.

During an interview on 12/10/15 at 11:45 a.m. in the Telemetry Monitoring Room, the monitor technician (MT) (#46) confirmed that there were eight-two (82) patients being monitored by telemetry at that present time. The MT stated that there was normally another MT, but that he/she was on a break at that time for thirty (30) minutes. The MT indicated that if a patient developed an arrhythmia (an irregular heart beat) that the monitor would display a red indicator light and an alarm would activate. The technician explained that patients on the 3rd, 4th, 5th, 6th, 8th and 9th floors could also be monitored from this location. The MT added that the telemetry room had the capacity to monitor eighty-four (84) patients.

During an interview on 12/10/15 at 4:15 p.m. in the Chief Nursing Officer's (CNO) office, the CNO and Senior Vice President of Operations acknowledged that the policy for telemetry monitoring required a forty (40) patient to one (1) monitor technician ratio (40:1). Both explained that previously, a refrigerator had been provided for the telemetry staff in the telemetry room, however, after the accreditation survey, the facility was told to remove the refrigerator and provide the technicians with a thirty (30) minute break outside of the telemetry area.

During an interview on 12/11/15 at 9:15 a.m. in the telemetry room, MT #47 and MT #48 stated that MT #47 would monitor forty-eight (48) patients and MT #48, would monitor thirty-six (36) patients. The technicians explained that there were two (2) additional monitors which were only used for emergencies and were rarely used. MT #48 stated that they are supposed to have relief for breaks, but that they normally took their meals in the telemetry room. They explained further that after the accreditation survey, they were instructed to take breaks outside of the telemetry room. The technicians stated that beginning last night, they were told to call staff, and they were given a list of staff to call during their breaks.

During a telephone interview on 12/10/15 at 4:30 p.m. in the administrative offices, RN #37 confirmed that there was only one (1) MT observing the eighty-two (82) monitors at that time.

Observation on 12/11/15 at 9:15 a.m. in the telemetry room, revealed a list of on-call relief staff for breaks for each twelve (12) hour shift.

Based on observations, interviews, and policy review the facility failed to prevent outdated medications from being available for patient care in various areas of the facility.

Findings include:

On 12/08/15 at 11:16 a.m. in operating room #1 at the main campus, one (1) vial of Roncuronium (a paralyzing agent for surgery) was opened in the anesthesia cart, and had no date, time or initials of opening of the multi-dose vial. In operating room #10, one 5 cc vial of neostigmine (anesthesia reversal agent) was opened in the anesthesia cart, also without date, time or initials of the opening of the multi-dose vial.

Interview at the above noted time and place, the Chief Certified Registered Nurse Anesthetist confirmed the above and said he/she would check with the accrediting organization to see what is suggested about such medications.

Observation at the off-site jail facility on 12/09/15 at 2:50 p.m., the following was found in the medication room: an opened bottle of insulin, not dated, timed, or initialed. In a cabinet there was one (1) bottle of out of date (10/20/15) iodophor gauze (used as an antiseptic wound packing.

On 12/10/15 at 9:45 a.m. in the main campus medical intensive care unit, two (2) cans of Nutria Pro-Stat (a prescriptive food liquid) were found and noted to be expired 05/21/15 and two (2) cans expired 06/26/14.

Interview with the nurse manager at the above noted time, he/she stated that the facility no longer used the Nutria Pro-Stat.

On 12/11/15 at 10:15 a.m. on the main campus at medical unit 4-A's medication room, the following were found in the automated medication dispenser:
-Two (2) Epinephrine 1:10,000 (a heart stimulant for emergencies), expired on 12/01/15.
-One (1) ampoule of dextrose 50% in water (used to treat low blood sugar in emergencies) expired 08/01/15.
-Three (3) cans of Pro-Stat Nutritional supplement expired on 09/01/15.

On 12/15/15 at 11:00 a.m. in the pharmacy of the North campus facility the following were found to be out of date:
-Ten (10) bags of intravenous fluid with potassium supplement had expired as of 10/2015
-Twenty-one (21) vials of Metformin (medication for injection treatment of diabetes) were out of date as of 10/2015
-Twenty-one (21) vials of aminocaproic acid (medication used to stop post-operative bleeding) expired 01/10/15.

During an interview with The Pharmacy Director for the North campus at the above mentioned date and time, he/she confirmed the above and immediately removed all of these medications from the storage areas for direct patient care. He/She said that the policy for expired medications would be provided.

A review of Policy entitled Medication management, under the section entitled Storage of Medications, item 6. revealed that staff were directed as follows: "it is directed that all inventories will be inspected routinely for out-dated or deteriorated condition: unusable inventory will be returned to the pharmacy (quarantined) for return to the vendor for destruction as deemed appropriate".

Based on observation, confirmation by staff and policy review it was determined the facility failed to maintain supplies to ensure an acceptable level of safety and quality.
Finding were:
On 12/9/2015 at 13:45 during a tour of the jail facility, escorted by the nurse manager, it was revealed that the hospital is contracted to provide nursing services for the inmates. The following supplies were found out of date:
1. Fourteen (14) packages of electrocardiogram (EKG) electrodes (adhesive electrical-conducting disks that stick to patients' chests to pick up heart rhythm) was out of date on 8/31/2015.
2. Three (3) Central Line dressing change kits (supplies used to perform a sterile dressing change as required) was out of date on 7/31/2011.
The above findings were confirmed by the facility Nurse Manager while on tour.
Policy search reveals no policy for supply dates.