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Based on review of documentation and interview with staff, the facility governing body failed to approve medical staff bylaws that are compliant with the requirement that verbal physician orders are authenticated within 48 hours for 6 of 6 applicable patients whose records were reviewed.

Findings were:

The facility MEDICAL STAFF RULES AND REGULATIONS, last approved by the Governing Body 7/11/12, state in section D-1 (b) that all orders dictated over the telephone shall be signed, dated and timed within 30 days. This finding was confirmed by staff #33 during an in-person interview the afternoon of 8/22/12. Cross refer to Tag 0457 for more information

Based on review of records and interview with staff, the facility failed to ensure that telephonic orders were dated, timed, and authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of 6 of 6 applicable patients whose records were reviewed.

Findings were:

Review of the medical records of patients #1, 4, 5, 9, 30, and 32 revealed that all of the records contained telephonic/verbal orders which were not dated, timed, and/or authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patients. For example, patient #9 had a telephonic order given on 8/17/12; however it had not been authenticated as of 8/21/12. Additionally, patient #30's record contained a telephonic order that was given 8/3/12 and had not been authenticated. These findings were acknowledged by staff #33 during an interview at midday, 8/22/12.

Based on observation, review of documentation, and interviews with facility staff, the facility failed to maintain facilities, supplies and equipment to ensure an acceptable level of safety as 5 argon cylinders and 5 nitrous oxide cylinders in 2 of 4 storage areas were observed to be unsecured in violation of facility policy. Also, during a tour of the Surgery Department the facility also failed to properly dispose of approximately 52 expired supplies which were available for patient use.

The findings were:

The facility policy entitled "Cylinder and Waste Gas Management Plan" dated 12/11 reflected in part "5. Cylinders (empty or full) should be stored upright and chained or otherwise secured to a support system to prevent falling over. Free-standing cylinders are not allowed in any location."

I. During a tour of the facility on 8/20/12 in the company of staff #11, 12 and 13 at 3:30 pm 5 compressed argon size F gas cylinders were observed in the Main Tank Farm storage room to be unsecured in any manner. In an interview conducted 8/20/12 at 3:30 pm, Staff #13 confirmed the 5 argon cylinders were unsecured and stated that they should have been secured.

II. During a tour of the facility on 8/21/12 in the company of staff #8 at 9:40 am, 5 nitrous oxide size E gas cylinders were observed in the Cath Lab storeroom lying on a table unsecured in any manner. In an interview conducted 8/21/12 at 9:40 am, staff #8 confirmed that the 5 nitrous oxide cylinders were unsecured.

Facility policy entitled, "Malignant Hyperthermia" stated, "8. A Malignant Hyperthermia supply/treatment cart will be maintained in L&D and OR, where succinylcholine (anectine) and/or general anesthesia are most often administered. The MH cart will be locked at all times. The following checks will be completed by anesthesia or nursing and documented in the MH log book: Monthly inventory check (exchange all products that are missing, non-functional, expired or will expire within 60 days)."

III. During a tour of the Surgery Department on 8/21/2012 at approximately 1:15pm, revealed the following expired supplies in the operating rooms and the malignant hyperthermia emergency cart:

1. One Barrel Bur Hollow 12-Flute 5.5 mm disposable arthroscopy blade expired 9/2010.
2. Three Tegaderm 10cm x 12cm expired 10/2010.
3. Three Green top laboratory tubes expired 12/2010.
4. One Barrel Bur Hollow 12-Flute 5.5mm disposable arthroscopy blade expired 1/2011.
5. Three Tiger top laboratory tubes expired 1/2011.
6. One Arthro Wand CoVac 70 Wand 3.0mm expired 1/2011.
7. One Multi-Lumen Central Venous Catheter Kit expired 2/2011.
8. One IntraVenous Catheter 24 gauge expired 2/2011.
9. One IntraVenous Catheter 24 gauge expired 3/2011.
10. Pressure Monitoring Kit w/ Truwave disposable Pressure Transducer expired 5/2011.
11. Four Red top laboratory tubes expired 5/2011.
12. IntraVenous Catheter 24 gauge expired 6/2011.
13. Three Pink top laboratory tubes expired 6/2011.
14. Seven Purple top laboratory tubes expired 8/2011.
15. One Arterial Blood Gas (ABG) Sampler expired 1/2012.
16. Six Aspirator ABG expired 1/2012.
17. Three Radial Artery Catheterization Set expired 1/2012.
18. One Barrel Bur Hollow 6-Flute 5.5mm disposable arthroscopy blade expired 1/2012.
19. Five ABG Sampler expired 3/2012.
20. One Aggressive Plus 5.5mm disposable arthroscopy blade expired 3/2012.
21. Two Compound Benzoin Tincture expired 6/2012.
22. One Resector 3.5 disposable arthroscopy blade expired 7/2012.

The expired supplies were confirmed during the tour of the Surgery Department in the company of staff members #57, #58, #59, and #63 the afternoon of 8/21/2012.

Based on review of documentation, observation, and interviews with staff, the facility failed to identify areas of unsanitary conditions which could lead to infection control issues in 3 areas observed, the Emergency Department (ED), Women's Services, and the Surgery Department. Visible dust, debris, torn mattress covers, and reddish-brown substances which appeared to be blood were found in patient care areas and on equipment available for patient use.

Findings were:

A tour of the Emergency Department (ED) was conducted the afternoon of 8/20/12 in the company of staff #53 and staff #54. In the triage room, treatment room #16, and treatment #17, visible dust was noted on high horizontal surfaces. For example, in the triage room, 2 overhead examination light fixtures had visible dust that fell from the surface when touched. In treatment rooms #16 and #17, visible dust was also noted on equipment. In the ED triage room, there were 2 of 3 mattress covers that had small 1-inch tears in the coverings and small ½-inch diameter holes in the covers. These surfaces could not be cleaned and could become infection control problems.

A tour of the Women ' s Services Department was conducted 8/20/2012 at 1:40 PM in the company of staff #1, the Women ' s Services Director. In Labor and Delivery (L&D) room 1, The arm handle on the side of the bed had smears of a reddish brown substance which appeared to be blood. There was black/brown hair in the radiant warmer. In L&D room 9, a brownish substance which appeared to be blood was found at the end of the bed. Black/brown hair was found in the radiant warmer. In L&D room 11, the placenta bin also had smears of what appeared to be blood. The unit also contains L&D operating rooms. In LDOR 1, there was a reddish brown substance which appeared to be blood on the frame of the OR table and a footprint plate was left in the radiant warmer. Underneath the OR table was also spots of what appeared to be blood. In the LDOR housekeeping room, a rusty disc, broken hose, and a blue latex glove were inside the drain. The isolette in the LDOR had visible dust on the outside coverings. These findings were acknowledged by staff #1 during the tour.

A tour of the Surgical Department was conducted on 8/21/12 at 1:15 PM in the company of the hospital COO, staff #57 and associate COO, staff #58. The surgical bed had a 2-inch tear in the mattress covering which was covered by clear tape. This surface could not be cleaned and could become an infection control problem. Visible dust was noted on high horizontal surfaces in the post anesthesia care unit. These findings were acknowledged by staff #57 and staff #58 during the tour of the department.

According to facility policy 810-404, entitled CLEANING OF THE SURGICAL DEPARTMENT, surgery suites, to include both OR and L&D are to be cleaned on a daily basis. Policy 810-407, entitled ROUTINE DISCHARGE CLEANING OF PATIENT ROOMS, states that all patient rooms will be cleaned when a patient has been discharged or transferred. In the PROCEDURE portion, step 2 outlines the requirements for dusting high surfaces, including the over-bed light.