HospitalInspections.org

Based on review of quarterly Performance Improvement Monitors for 2013 and interview, it was determined the facility failed to include the services for Central Sterilization and Environmental Services in the performance improvement program. The failed practice did not assure problems identified in the Central Sterilization and Environmental Services Departments were documented and monitored for improvement opportunities and had the potential to affect all patients admitted to the facility. Findings follow:

A. Review of Performance Improvement Monitors for the first, second, third and fourth quarters of 2013 revealed there was no evidence the services of Central Sterilization and Environmental Services were included in performance improvement monitors or projects.
B. Findings were confirmed by the Director of Quality on 03/12/14 at 1345.

Based on observation, manufacturer label review, and interview, the facility failed to ensure a mechanism was in place for the storage of Rocuronium Bromide at room temperature once removed from the refrigerator per manufacturer's guidelines for three of three anesthesia carts located in Operating Room #3, #4 and #6. In addition, the facility failed to ensure the unusable medication was not available for patient use. The potential existed for the medication to have a decrease in potency and be administered to patients when ordered. Findings follow:

A. Surgery was toured on 03/10/14. At 1400, two vials of Rocuronium Bromide were observed in Operating Room (OR) #3 on the anesthesia cart with no evidence as to how long the medication had been stored at room temperature. OR#5 and OR#6 were toured at 1405 and 1410 respectively. One vial of Rocuronium Bromide was observed on the anesthesia cart in OR#5 and three vials of Rocuronium Bromide were observed on the anesthesia cart in OR#6 with no evidence as to how long the medications had been stored at room temperature. The unusable medications were available for patient use.
B. The manufacturer label was reviewed on 03/10/14 at 1400. Once removed from refrigeration, the label reflected unopened vials of Rocuronium Bromide could be stored for 60 days at room temperature and opened vials for 30 days.
C. An interview was conducted with the Director of Nursing at 1410 in which the findings were verified.

Based on observation and interview, the facility failed to ensure outdated mediations were not available for patient use in two (Anesthesia Workroom, Endoscopy Room) of eight (Unit 300, Emergency Department, Intensive Care Unit, Senior Care, Surgery, Pre-Operative Area, Endoscopy Room, Anesthesia Workroom) medication storage areas. The potential existed for patients to receive outdated medications from these two medication storage areas. Findings follow:

A. A tour of the Endoscopy Room on 03/10/14 at 1415 revealed two single dose vials of Atropine were observed with expiration dates of 12/31/13.
B. A tour of the Anesthesia Workroom on 03/10/14 at 1420 revealed expired medications were observed. Three vials of Phenylephrine 10 milligrams (mg)/milliliter (ml) expired 02/18/14, seven vials of Flumazenil 0.5mg/5ml expired 01/31/14 and five vials of Metoclopropamide 10mg/2ml expired 03/01/14.
C. An interview was conducted with the Assistant Director of Nursing on 03/10/14 at 1425 in which the findings were verified.

Based on review of the Pharmacy After-Hours Entrance Report, review of the list of approved nursing supervisors allowed into the department after it closes, and interview, the facility failed to ensure 13 of 21 entries on the Pharmacy After-Hours Entrance Report were by approved nursing supervisors. The failed practice created the potential for the integrity of the Pharmacy to be compromised by allowing unauthorized supervisors to enter after closing. Findings follow:

A. The Pharmacy After-Hours Entrance Report for the time period 02/13/14-03/12/14 and the list of nursing supervisors approved to enter the Pharmacy after the department closed was reviewed on 03/12/14 at 1400. It was revealed 13 of 21 entries were made by unauthorized nursing supervisors.
B. An interview was conducted with the Chief Nursing Officer on 03/12/14 at 1500 in which the findings were verified.

Based on Record of Relative Humidity log review and interview, it was determined the facility failed to maintain relative humidity in four of four (3, 4, 5 and 6) Operating Rooms above 30% relative humidity (RH) per Rules and Regulations for Hospitals and Related Institutions in Arkansas (2007 edition). Humidity levels outside the required range had the potential to affect the health and safety of all patients admitted for surgery due risk of sparks from static electricity build-up associated with low humidity. The facility had five patients scheduled for surgery on 03/10/14. See K78.

Based on interview and review of the surgeon's privileges received from the Operating Room (OR) Nurse Manager at 0945 on 03/11/14, it was determined the roster of
surgeon's privileges located in the OR and available to staff was not kept current every two years. Failure to ensure the surgeon's privileges in the OR were kept current did not allow OR staff to be knowledgeable regarding which surgical procedures the individual surgeon was credentialed to perform. The failed practice affected every patient who underwent a surgical procedure in the facility. Findings follow:

A. Review of the surgeon's OR privileges received from the OR Nurse Manager at 0945 on 03/11/14 revealed the privileges were dated October 2010.
B. The above findings were verified by the OR Nurse Manager at 0945 on 03/11/14.

Based on clinical record review and interview, it was determined 12 of 12 (#1, #6, #7, #10, #11, and #21-#27) operative reports did not include the time of surgery. The facility failed to ensure 5 (#7, #11, #21, #26, and #27) of 12 (#1, #6, #7, #10, #11, and #21-#27) operative reports were signed by the physician. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day; and failure of the physician to sign the operative report did not indicate he had reviewed the report. Findings follow:

A. Review of clinical records revealed the time of surgery was not documented in the operative report for Patient #1, #6, #7, #10, #11, and #21-#27. Patient #10 received four surgical procedures.
B. Review of clinical records revealed the physician did not sign the operative report for Patient #7, #11, #21, #26, and #27.
C. Findings were confirmed by the Director of Nursing on 03/14/14 at 1205.

Based on interview and review of the Swing-Bed discharge notice form, it was determined the facility failed to include the reason for discharge/transfer, name, address and phone number of the state long term care ombudsmen; the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. Failure to include the above information on the discharge notice form did not allow the patient and/or family to be knowledgeable regarding the reason for discharge, and the names, addresses and phone numbers of organizations able to assist the patient and/or his family in appealing the discharge/transfer. The failed practice affected the one swing bed patient on 03/14/14. Findings follow:

A. Review of the Swing-Bed discharge/transfer notice form revealed it did not include the reason for discharge/transfer, name, address and phone number of the state long term care ombudsmen; the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act.
B. The above findings were verified by the Chief Nursing Officer at 0910 on 03/14/14.

Based on interview, policy and procedure review and clinical record review, it was determined the activities calendar for one of one (#1) swing bed patient had not been developed and placed on the unit or in the patient's room. Failure to develop an activities calendar did not allow the swing bed patient and/or family to be knowledgeable of available activities and choose which activities they would like to participate in. Findings follow:

A. During an interview with the Swing Bed Activity Director and Chief Nursing Officer at 1415 on 03/12/14, the Swing Bed Activity Director stated she had not developed the Activity Calendar for March and that she usually placed the Activity Calendar in the clinical records of the swing bed patients.
B. Review of the policy and procedure titled "Swing Bed Activity Program" received from the Chief Nursing Officer on 03/11/14 revealed under the first bullet "... A calendar of events shall be posted on the unit where the patient is housed and in the patient's room. The calendar should reflect the actual activity programs for one month ..."
C. Review of the Patient #1's Swing-Bed clinical record revealed it did not contain an activity calendar.