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Based on observation, record review, and interview, the provider failed to ensure two of two crash carts in two of two emergency rooms were consistently checked to ensure the defibrillators were working appropriately and the security tabs to the crash carts were checked and recorded on a regular basis.

1. Observation on 3/25/14 from 8:40 a.m. through 9:15 a.m. of emergency room one and two revealed there was an emergency crash cart in each room.

Review of the Emergency/Defib [defibrillator (used in an emergency when the patient's heart beat was irregular or had quit beating)]/Crash Cart Log in ER one and two from 11/8/13 through 3/25/14 revealed:
*11/8/13 through 11/30/13, the defibrillator had only been checked seven out of twenty-three days.
*December 2013 the defibrillator and the crash carts had only been checked six out of thirty-one days.
*January 2014 the defibrillator and the crash carts had only been checked two out of thirty-one days.
*February 2014 the defibrillator and crash cart had only been checked seven out of twenty-eight days.
*3/1/14 through 3/25/14 the defibrillator and crash cart had only been checked seven out of twenty-five days.

Interview on 3/25/14 at 8:20 a.m. during the above observation in emergency room one with registered nurse A regarding the above findings revealed the Life-Pak defibrillators in both emergency rooms were not consistently checked by the nursing staff to ensure the equipment was working properly.

Interview on 3/26/14 at 1:50 p.m. with the director of nursing revealed:
*There were no policy and procedures in place for staff to have consistently checked the defibrillators and the crash carts in the emergency rooms.
*The defibrillators should have been checked consistently to ensure they were in working appropriately in case of an emergency.

Based on record review, interview, and medical staff bylaw review, the provider failed to have a governing board that assumed full legal responsibilities for the development, implementation, and administration of policies to provide quality health care. Findings include:

1. Interview and review of the governing board meeting minutes on 3/26/14 at 1:30 p.m. with the administrator revealed:
*The governing board was their City Council, they met monthly and the meetings were open to the public.
*The provider had to request an executive session if they wanted issues relating to the hospital discussed.
*Executive sessions requested were held separately and become part of the meeting minutes.
*There was one person designated on the City Council as their main contact. That individual had not provided specific oversight or interest in the hospital related to medical care issues.
*The City Council was primarily interested in issues which related to the hospital and community's capital expenditures and/or finances.
*The City Council had not attended Quality Assurance (QA) or policy development and implementation meetings at the hospital.
*The City Council had not reviewed the medical staff bylaws for several years; the last review date was 8/4/08.
*The medical staff bylaws stated the hospital performed surgical and obstetrical services. Those services had been discontinued for several years.

Interview on 3/26/14 at 3:00 p.m. with the director of nursing revealed the governing board had not been invited to or attended the QA meetings.

Review of the October 1999 quality assurance organizational chart revealed:
*The governing board communicated and coordinated with the medical staff.
*All administrative staff including the administrator, department support services, non physician activities, and facility-wide committees were accountable to the governing board.

30170

Based on observation, record review, interview, and policy review, the provider failed to ensure:
*Expired medications were removed from patient use in one of two emergency rooms (emergency room one).
*Multi-dose medications used in the emergency room were appropriately dated when the medications were opened for patient use.
*The refrigerator located in emergency room one that contained intravenous heart medications used in an emergency was monitored, and temperatures were documented consistently to ensure the appropriate temperature had been maintained.
*Medications stored in emergency room two used for rapid sequence intubation were secured.
*The medication cart located at the nurses station was locked when not in use or in direct view.
Findings include:

1. Observation on 3/25/14 at 8:20 a.m. in emergency room one revealed:
*A partial vial of Lidocaine 1 percent (%) (used to numb the skin during suturing) had no date as to when the medication had been opened.
*A partial 100 milliliter (ml) bottle of Viscous Lidocaine 2% (used topically or orally) had no date as to when the medication had been opened.

2. Observation on 3/25/14 at 8:40 a.m. of the refrigerator in emergency room one revealed:
*The following intravenous (IV [medication administered in the vein]) heart medications were in the refrigerator:
-Cardizem 25 milligrams (mg) in 5 ml vial.
-Cardizem 125 mg in 25 ml vial.
-Integrilin 2 mg in 1 ml vial.
-Isuprel ampule taped to the inside of the refrigerator door.

Review of the temperature log from 3/16/14 through 3/25/14 in emergency room one revealed the refrigerator temperature had only been monitored and documented five out of nineteen times.

Todd P. Semla, MS, PharmD, BCPS, FCCP, AGSF et al., Geriatric Dosage Handbook, 16th Ed., 2011, p. 490 and 936, revealed:
*Cardizem should have been stored in a refrigerator between 36 degree Fahrenheit (F) and 46 degree F.
*Isuprel should not have been exposed to air, light, or increased temperatures which might cause instability of the medication.

Interview on 3/25/14 at 8:20 a.m. during the above observation in emergency room one with registered nurse (RN) A regarding the above findings revealed:
*She used to work the night shift and would check for outdated supplies and medications.
*She thought the night shift nurse was to have checked for any outdates.
*The pharmacist would change the security tabs after the nurses had opened the crash cart. The nurse would have notified the pharmacist who then would return to the hospital to secure the crash cart. The nurses had not checked and recorded the security tab number to ensure there had been no tampering with the crash carts.

3. Observation on 3/25/14 at 9:15 a.m. in the nurses medication room revealed:
*There was no consistent monitoring of the temperature of the refrigerator.
*The refrigerator contained two tuberculin vials.

Review of the nurses medication room refrigerator log from 3/16/14 through 3/25/14 revealed the temperature had only been monitored and recorded four out of nineteen times.

4. Observation on 3/25/14 at 1:25 p.m. of emergency room two revealed the following:
*There were keys in a drawer below the Rapid Sequence Intubation cupboard that opened the cupboard that contained:
-One Atropine 1 mg/ml vial (used in a cardiac emergency to control a patient's heart rate.)
-One Lidocaine 1% 50 mg injectable syringe (used in a cardiac emergency for irregular heart beats.)
- Five Versed 2 mg/2 ml vials (a controlled substance used for sedation).
-Two Vecuronium Bromide 10 mg vials (a muscle relaxant).
*There was a housekeeper in the emergency room cleaning during the above observation.

Surveyor: 26632
5. Observation on 3/26/14 from 8:30 a.m. through 8:45 a.m. revealed:
*The medication cart was unlocked throughout this time.
*The medication cart was located around the corner from the nurses station and not in sight of the nurses seated at the nurse's station.
*A housekeeper was in the hallway by the medication cart during that time.

Interview on 3/26/14 at 8:45 a.m. with RN A and RN B when this surveyor opened the medication cart revealed they were unaware the medication cart was unlocked. RN A stated she had retrieved medications earlier but was sure she had locked the cart. RN A stated the pharmacist had accessed the cart after she had retrieved medications and had probably left it unlocked.

Surveyor: 30170
6. Interview on 3/26/14 at 1:50 p.m. with the director of nursing revealed:
*The refrigerators had not been monitored or temperatures recorded regularly to ensure the stability of medications.
*There were no staff in charge of ensuring outdated medications were removed from patient care areas.
*There was no documentation of the security tabs on the crash carts to ensure those medications were secure. The pharmacist had insisted on the control of the security of the medications in the crash carts.
*The key to the Rapid Sequence Intubation container in emergency room two should have been kept secured from patients, visitors, and unauthorized staff.

Review of the provider's 12/17/08 Refrigerated Drug Storage policy revealed:
*All refrigerated drug storage areas would have been inspected routinely to ensure compliance with the drug storage standards.
*The drug storage refrigerators would have been inspected twice daily by the nurse or the pharmacist.
*A record log of temperature readings would have been maintained on the outside door of the refrigerator.
*Inspection of drug storage refrigerators outside pharmacy including the emergency rooms and the nurses station would have been inspected daily and logged according to the above procedure by individuals designated by the area supervisor.

Review of the provider's 12/14/10 Medication Security policy revealed:
*All drugs in the hospital should have been only accessible to authorized personnel.
*All drugs, except those that were intended for crash cart use, would have been stored in lockable containers or areas.
*Controlled drugs would have been double-locked at all times.

Review of the provider's 6/17/09 Emergency Medication policy revealed:
*The nurse or licensed healthcare professional would inspect the seals integrity on a daily basis and would indicate that on the inspection log sheet.
*The nurse would document the integrity and the number on the seal. The lock number on the crash cart was provided by the pharmacy department.

Review of the provider's 6/7/09 Emergency Crash Cart Security and Accountability policy revealed:
*The nursing personnel should have visually inspected the numbered break-away lock located on the crash cart daily.
*The nurse should have documented the cart was properly locked with all contents present and intact.

On 3/26/14 at 3:00 p.m. upon request to the director of nursing there was no policy or procedure provided for dating opened multi-dose medications.

Based on record review, interview, and medical staff bylaws review, the provider failed to ensure all sampled medical record entries from different patient service areas were authenticated with signatures, date, or times. A sample of forty-two medical records reviewed revealed:

1. Review of twelve emergency room sampled records revealed:
*Four out of twelve physician's history and physicals were not signed, dated, or timed.
*One of twelve physician's order were not signed, dated, or timed.
*One of twelve had no documentation when the physician had been notified, when the physician arrived, and when the patient had been discharged.
*One of twelve had no documentation of the condition of the patient upon discharge and the disposition (where the patient had gone) of the patient.
*One of twelve had no documentation of the condition of the patient upon admission to the emergency room.
*One of twelve emergency records had no date on the emergency room form.

2. Review of thirty sampled inpatient and swing bed patient sampled medical records revealed three had no signed, dated, and timed physician's progress notes.

Review of the provider's 2008 signed medical staff bylaws revealed they had not addressed signing, dating, and timing of the patient's medical records.

Upon request for a policy and procedure for documentation of medical records there was none provided.