HospitalInspections.org

Based on observation and interview, the facility does not ensure that the Dundee extension clinic is compliant with Americans with Disabilities Act (ADA). Failure to provide ADA accommodations may limit the access to the facility for persons with a disability.

Findings include:

Observation on 06/15/16 at 11:00AM at the Dundee extension clinic revealed ADA access was not provided at the entrance of the facility. ADA access must be provided at a minimum of 50% of the entrances into the facility and must consist of an opening device that allows the door to remain open for a minimum of five seconds.

Interview on 06/15/16 at 03:00PM with Staff #26 and #27 verified this finding.

Based on policy review, document review and interview, staff did not ensure daily crash cart inspections were completed per hospital policy. This lapse of daily crash cart inspection could potentially lead to emergency equipment being unavailable or non-functioning when needed.

Findings:

Review on 06/14/16 of policy # MM. 040260 "Emergency Medications, Supplies and Crash Carts Code 99/Code Blue Response" last revised 06/15 revealed all crash carts and emergency drug containers will be inspected daily to verify that the seal is intact, the number is correct and that the medications and supplies are in date regardless of the location. The inspection will be documented on the log found on the top of each emergency cart/container.

Review on 06/14/16 of the radiology daily crash cart inspection logs from March-June 2016 revealed missing crash cart inspection documentation for April 11-15, 21, 22.

Interview on 06/14/16 at 10:45AM with Staff #32 verified this finding.

Based on observation, interview and policy review, the facility does not ensure sharps containers are secured. This lapse of security could potentially lead to theft and/or spillage of sharps contents.

Findings:

Observation on 06/13/16 at 11:40AM in the emergency department medication room revealed a sharps container located on the floor, opened, half full and unsecured. At 12:30 PM in the medical/surgical unit medication room there were 2 small sharps containers located on the counter and another larger sharps container sitting on the floor. All were opened, half full and unsecured. Interview with Staff #2 and Staff #3 verified these findings.

Observation on 06/14/16 at 11:45AM in the pharmacy revealed a partially filled sharps container located on the floor, without a lid and unsecured. Interview with Staff #15 verified this finding.

Observation on 06/16/16 at 11:00AM in surgical suite procedure room #1 revealed a large sharps container located on the floor was unsecured. Staff #39 and Staff #40 verified this finding.

Review on 06/16/16 of the Finger Lakes Health Bloodborne Pathogens Exposure Control Plan Exposure document last reviewed 04/04/16 revealed disposable sharp containers are are closable and are maintained upright throughout use.

Based on observation and interview, the facility does not ensure that the hot water is maintained at a safe temperature at the Dundee extension clinic, floors are not maintained in the endoscopy procedure room and/or that hot water is not available in the staff toilet room.

Findings include:

Observation on 06/15/16 at 11:20AM of the Dundee extension clinic revealed the hot water located in the examination room sinks was greater than 120 degrees Fahrenheit. Interview with Staff #26 verified these findings.

Observation on 06/16/16 10:30AM revealed the floor in endoscopy site procedure room "B" had dirt build up and required maintenance. Interview with Staff #40 and #48 indicated that the floor wax needed to be removed and re-applied.

Observation on 06/17/16 at 11:30AM revealed hot water was not available in the rehab staff toilet room. Interview with Staff #26 and #27 verified these findings.

Based on policy review, observation and interview, the facility does not ensure that outdated, mislabeled, discontinued, expired, or otherwise unusable drugs and biological's are not available for patient use and/or that all patient medications are secure. This practice has the potential to result in patient receiving inadequate treatment.

Findings include:

Review on 06/13/16 of facility policies revealed the following:
- Policy "Vaccine Storage" last revised 05/15 indicates vaccine expiration dates will be checked monthly and at time of administration. Outdated vaccines will be promptly removed and not administered.
- Policy #MM.004.2601 "Dating Vials for Injectable Products" last revised 02/2016 indicates vials can be used for 28 days once punctured and the expiration date to be placed on the product.
- Policy #MM.011.2601 "Medication Management" last reviewed 04/15 indicates medications needed for administration during the hospital stay will be stored in a locked cabinet in the medication room.

Observation on 06/13/16 revealed the following expired products:
- At 11:45AM in the Emergency Department there were 2 thoracentesis trays expired on 04/30/16, 1 Dextrose 5% IV bag expired on 04/20/16, 5 Blood collection tubes expired on 04/2015, 4 specimen collection swabs expired on 06/30/15 and 5 sterile gloves sets expired on 03/2016. Interview with Staff #2 and #3 verified these findings.
- At 12:30PM in the Intensive Care Unit/1st Acute medical floor there were 3 IV bags of 5% Dextrose expired on 01/2016, 1 Iodine multi-use bottle not dated when opened, 2 sterile glove sets expired on 03/2016, 3 blood collection tubes expired on 05/2016, 5 blood collection tubes expired on 04/2016, one 20% Acetylcysteine multi-dose vial not dated when opened and 4 culture swabs expired 03/31/16. Interview with Staff #2 and #3 verified these findings.
- At 12:45PM in the Medical/Surgical medication room, one bottle of Xalatan 0.005% ophthalmology drops was found inside of an old, unused and unlocked medication cart. Interview with Staff #2 verified that the medication was Patient #4's and indicated he brought it from home. She stated the medication should not have been housed in the old medication cart.

Observation on 06/15/16 at 09:00AM at the Dundee extension clinic revealed 1 bottle of Acu-check test strips, 1 multi-dose Influenza vaccine bottle, 1 multi-dose Tuberculin vaccine bottle and 1 multi-dose Poliovirus vaccine bottle that where all in use but not dated when opened. Interview with Staff #33 verified these findings.

THIS IS A REPEAT DEFICIENCY FROM THE 09/04/07 FEDERAL VALIDATION SURVEY.

Based on policy review, document review and interview, the facility does not ensure that biological spore testing is performed per policy. Failure to perform routine spore testing may result in inadequately sterilized instruments.

Findings include:

Review on 06/15/16 of policy SS-IP-001 "Biological Indicator" last reviewed 09/2015 indicates that biological spore testing will be done daily (on days of use)...

Review on 06/14/16 02:45PM of the biological spore testing reports revealed that spore testing was not performed on the Getinge autoclave during the following weeks: 01/25/16, 02/14/16, 03/28/16 and 04/17/16.

Interview on 06/16/16 at 09:10AM with Staff #40 and #48 verified this finding. Staff #48 stated that the facility only utilizes the autoclave once per week and that is when the biological indicator is tested.

Based on policy review, medical record review and interview, the facility does not ensure a copy of the patient bill of rights is given to 2 of 7 outpatients (Patient #23 and #24). This lapse of notice could potentially lead to patients being unaware of their rights prior to treatment.

Findings include:

Review on 06/15/16 of emergency department policy # RI.9.3001 "Patient Rights Policy" last reviewed 07/15 indicates that registration staff will provide each patient with a copy of the patient bill of rights. This policy does not address the need to provide inpatients, outpatient's and/or swingbed patient's with a copy of the patient bill of rights.

Medical record review on 06/15/16 revealed no evidence Patient #23 and #24 received a copy of the patient bill of rights.

Interview on 06/15/16 at 10:45AM with Staff #43 verified this finding.