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Based on observation and interview the facility failed to ensure that supplies used for treating emergency patients had not exceeded manufacturer's expiration date for safe use. Findings include:

On 3/13/2012 at approximately 0925 during a tour of the emergency department it was revealed the crash cart contained the following supplies outdated for use: (2) trocar thoracic catheters with an outdate of 05-2011, (1) trocar thoracic catheter with an outdate of 02-2011, (1) easy cap CO2 detector with an outdate of 07/2011, (1) pedi cap CO2 detector with an outdate of 06/2011. An interview with staff #B confirmed the outdated supplies were available for patient use. When asked about surveillance of outdated supplies staff #B stated the crash cart is supposed to be checked on a monthly basis and all outdated supplies are to be removed.

Further tour of the emergency rooms revealed the following outdated supplies: (3) quick tap paracentesis kit with an outdate of 09/2010, 12/2006, and 12/2006, (1) thoracentesis kit with an outdate of 06/2008, (2) lumbar puncture kit with an outdate of 06/2010, (1) pediatric lumbar puncture kit with an outdate of 2/2012, and (1) central venous catheter kit with an outdate of 5/2011.

Based on observation and interview the facility failed to ensure narcotic medications remained in a locked area and only accessible to appropriate personal resulting in the potential for medications to be removed by unauthorized employees.

On 3/14/2012 at approximately 0920 during a tour of the surgery department it was revealed medications used for anesthesia were unsecured in the medication dispensary room. An interview with staff #E confirmed the medications were not secured.

Based on interview and record review the facility failed to ensure adequate temperature and humidity was provided in the operating room.

On March 13, 2012 at approximately 10:30 AM during record review, it was noticed that the facility had not recorded temperature or humidity for the operating room for the month of March. Interview with the Director of Support Services revealed that their computer based facility monitoring system had not been operational the past two weeks and they were waiting for parts to fix it. When asked if the facility was taking temperature and humidity readings by a hand held device while waiting for their system to be fixed, it was stated that they had not been.

It was also noticed that the humidity readings in the operating room for throughout the month of February were typically below 30%. Humidity readings in operating rooms should be between 30% and 60%.

Based on document review and interview the governing body failed to ensure that policies are monitored. Findings include:

During review of policy manuals for the hospital, it was noted that some policies have not been review/revised by the facility since 1995.

During an interview with staff C on 03/14/2012 at 1500, she confirmed the findings and stated "we have been working on reviewing and updating all of our policy manuals."

Based on document review and interview the facility failed to ensure appropriate provision of services were met as evidenced by:

1. The facility failed to have an annual review of patient care policies and failed to include a professional outside member of the professional review committee. (see C272)

2. The facility failed to develop a policy describing services provided. (see C273)

3. The facility failed to enforce rules for storage, handling, and dispensation of drugs for patient use. (see C276)

4. The facility failed to ensure practice of infection control within all areas of the hospital and specifically failed to plan, implement, analyze, and investigate infections and enforce infection control practice in the hospital. (see C278)

5. The facility failed to ensure policies were reviewed at least annually by the group of professional personnel. (see C280)

6. The facility failed to ensure testing materials were not used beyond the out date. (see C282)

Based on document review and interview the facility failed to have an annual review of patient care policies and failed to include a professional outside member of the professional review committee resulting in the potential of failing to remain current with standards of practice.

On 3/14/2012 at approximately 1315 during document review it was revealed the facility did not have an annual review of all policies since 1995 and had failed to have a group of professional personnel that included an outside professional member to review policies. During an interview with staff #B and staff #C, the findings were verified.

Based on document review and interview, the facility failed to develop a policy describing services provided. Findings include:

During review of the policy and procedure manuals, the books did not contain a policy describing the services provided at the hospital or by referral.

Staff B confirmed the lack of a developed policy during an interview on 03/14/2012 at 1400.

Based on observation, policy review and interview the facility failed to enforce rules for storage, handling, and dispensation of drugs for patient use. This has the potential to affect all patients seen at this facility and the outcome of their care. Findings include:

On 3/13/2012 at approximately 0930 during tour of the facility it was noted that :

The clean storage room contained outdated supplies:
Intravenous fluid:
10- 0.9% Normal Saline 500 cc- 10/2011
11-20 meq Potassium in 1000 cc-10/2011
6- 0.45 Normal Saline 1000 cc-11/2011
1 Lactated Ringers-11/2011
4-Duo derm- 6"x 6"-2008
10 bottles-Iodoform packing- 10/2009
2-Stat Locks- 2/2009

The nursing station medication area contained outdated supplies:

1 vial TB opened 1/20/2012
3-Humalog pens outdated 2/8/2012-not removed from area after discharge of patient
1 vial-Novolin insulin opened and not dated
1 vial-Lantus insulin opened and not dated
3-COPAN(swabs for MRSA) outdated -1/2010 & 12/2011 available for use.

Findings confirmed by staff C during observation.

On 3/13/2012 at approximately 1500 during tour of the Physicians Practice located within the hospital the following was found:
Exam Rooms 101, 104, 110, and 113:
4-Hemoccult developers outdated 3/2011

Procedure Room:
1-Normal Saline 1000 cc bottle for irrigation opened and not dated
1-Lidocaine 1% single dose vial opened and available for use
2-Lidocaine 1% multi-dose vials opened and not dated
2-Lidocaine 2% multi-dose vials opened and not dated
Review of policy #CL 100-007 titled Use of Multiple dose vials reads "The healthcare provider shall write the expiration date on the vial, when opened" and "opened single-dose ampuls shall not be stored for any period of time".

Immunization refrigerator:
staff lunch and pitcher of tea
Review of policy #CL100-006 titled Refrigeration of Medication/Vaccines reads "Food brought in by staff will be kept separately in designated refrigerators".

Medication Sample Room:
More than 30 different Medications past the manufacturer's established outdates for patient use.

Findings were confirmed by staff O&P during the tour.


28273

During observation of the medical floor on 03/13/2012 at 1100 the following items were outdated:
1) Forty Eight (48) blood collection tubes outdated between 09/2008-01/2012.
2) Nine (9) bottles of Similac infant formula outdated 01/2012
3) One (1) bottle of Amoxicillin oral suspension outdated 01/2012
4) One (1) pre-filled syringe containing Heparin Flush outdated 02/01/2012

All outdates were confirmed by staff B who was present during the observation.


29955

On 3/14/2012 at approximately 1700 during a survey of the surgical suite area (3) 24 oz. bottles of Betadine with the outdates of 11/2006, 11/2010, and 11/2011. Staff #J confirmed the findings.

Based on observation and interview the facility failed to ensure practice of infection control within all areas of the hospital and specifically failed to plan, implement, analyze, and investigate infections and enforce infection control practice in the hospital resulting in the potential of the spread of infectious disease within the hospital.

On 3/14/2012 during an interview with staff #B and staff #C it was revealed the facility did not have an infection control program. Review of the infection control meeting minutes did not show coordination of planning, implementing, analyzation, or investigation of infections within the facility. Staff #B stated that the infection control committee had met twice in the year. The documentation lacked any evidence of an infection control program. Staff #I stated they were designated as the infection control preventionist but had not received any scheduled hours to perform infection control program duties. Staff #I was queried to whether they had received any additional training to support being the infection control preventionist for the facility she stated "no".

On 3/14/2012 at approximately 0945 during a tour of the surgical instrument sterilization area a coffee mug was observed sitting on the same table as material used to wrap surgical trays and spilled onto the table. Staff #E confirmed the coffee mug should not have been stored in the area.



28273

During observation of the lab area on 03/13/2012 with staff C at 1200 a refrigerator marked as Bio-hazard/ Blood was noted to contain staff food. When asked about the observation the staff stated "oh we don't use it for blood anymore we put our lunches in it now, the label just hasn't been taken off."

Based on documents reviewed and interview the facility failed to ensure policies were reviewed at least annually by the group of professional personnel. Findings include:

During review of the facility's policy and procedures there was no documented evidence of an annual review by the group of professional personnel. The findings were confirmed during an interview with the Chief Nursing Officer and the Compliance/Risk Manager on 03/14/2012 at 1500.

Based on observation and interview the facility failed to ensure testing materials were not used beyond the out date resulting in the potential to have inaccurate test results impacting the diagnosis and care of all patients receiving glucometer readings and the presence of gastrointestinal bleeding.

On 3/13/2012 at approximately 0925 during the initial tour of the emergency department it was revealed the glucometer controls were not dated with the date opened, (2) seracult developers were outdated on 3/2011, and (1) gastroccult testing developer was outdated on 2/2011. The findings were confirmed by staff #B.


30988

On 3/13/2012 at approximately 1000 during tour of the facility it was found:
At the nursing station and in the lab, controls for the accucheck machine were opened and not dated. Instructions from the manufacturer recommends disposal 90 days after the controls are opened. This was verified during the tour with staff C.

On 3/13/2012 at approximately 1530 during tour of the Physicians Practice nursing station located within the hospital it was found that controls for the accucheck machine were opened and not dated. This was verified during the tour with staff O&P.

Based on medical record review and interview the facility failed to ensure consent for medical treatment was obtained for 1 of 4 patients (#28) resulting in the potential of failing to provided informed consent and for the patient or patient's representative to not be allowed to participate in making medical decisions.

On 3/14/2012 at approximately 1350 it was revealed patient #28 medical power of attorney had not been contacted for consent for treatment. Two forms for consent were located within the patient's chart each stating "unable to sign". The patient's medical power of attorney was listed on the patient's face sheet and the face sheet sent from the skilled nursing home facility. An interview with staff #C confirmed a consent for treatment was never received for the patient during the patient's stay.

Based on record review, policy review and interview the facility failed to ensure that verbal/telephone orders are authenticated per policy by a physician for 11 of 18 records reviewed (#7, 11, 13, 14, 21, 22, 24, 26, 27, 29, 30). Findings include:

Review of policy #CL 100-003 titled Telephone, Verbal and Written Orders for Medication reads on page #3 "The prescribing practitioner must date, time and authenticate the verbal order within 24 hours."

During review of the medical record for patient #7 on 03/13/2012, it revealed two telephone orders written on 01/23/2012 for medications. The orders were signed by a physician but did not contain a date or time as to when the physician signed.
Review of the medical record for patient #11 on 03/13/2012, revealed one verbal order written on 12/31/2011, two verbal orders written on 01/01/2012 and three telephone orders/verbal orders written on 01/02/2012. All orders were for medications orders were signed by a physician but did not contain a date or time as to when the physician signed.
During review of the medical record for patient #13 on 03/13/2012, it revealed one telephone order written on 01/29/2012 for medication. The order was signed by a physician but did not contain a date or time as to when the physician signed.
During review of the medical record for patient #14 on 03/13/2012, it revealed one telephone order written on 11/08/2011, two telephone orders written on 11/09/2011 and one verbal order written on 11/11/2011. All orders were for medications. The orders were signed by a physician but did not contain a date or time as to when the physician signed.
During review of the medical record for patient #21 on 03/13/2012, it revealed one telephone order written on 11/19/2011 and three telephone orders written on 11/23/2011. All orders were for mediations. The orders were signed by a physician but did not contain a date or time as to when the physician signed.
During review of the medical record for patient #22 on 03/14/2012, it revealed one telephone order for a medication written on 11/20/2011. The order was signed by a physician but did not contain a date or time as to when the physician signed.
During review of the medical record for patient #24 on 03/14/2012, it revealed one telephone order written on 11/08/2011 for a medication change. The order was signed by a physician but did not contain a date or time as to when the physician signed.

The above findings were all confirmed by staff C on 03/14/2012. During an interview with Staff G on 03/14/2012 at 1500 in the medical records department, she stated that "we do not track the physician's orders for date and time."


30988

During review of the medical record for patient #26 on 03/14/2012, it revealed one telephone order written for medication on 03/01/2012, one telephone order written for medication on 03/02/2012, and one telephone order written for medication on 03/03/2012 . The orders were signed by a physician but did not contain a date and time as to when the physician signed.
During review of the medical record for patient #27 on 03/14/2012, it revealed one telephone order written for medication on 01/08/2012, four telephone orders written for medications on 01/09/2012, and two telephone orders written for medications on 01/10/2012. The orders were signed by a physician but did not contain a date and time as to when the physician signed.
During review of the medical record for patient #29 on 03/14/2012, it revealed three telephone orders written for medication on 10/29/2011, four telephone orders written for medications on 11/02/2011, one telephone order written for medication on 11/03/2011, one telephone order written for medication on 11/04/2011, two telephone orders written for medications on 11/05/2011, and one telephone order written for medication on 11/10/2011. The orders were signed by a physician but did not contain a date and time as to when the physician signed.

The above findings were all confirmed by staff C on 03/14/2012.

Based on document review and interview the facility failed to ensure pre-anesthesia assessments occurred for 1 of 4 patients, consents for surgery were completed with the date and time of the physician's signature, a witness signature was obtained for consents, and medications used for anesthesia purposes were pre-drawn without the proper identification of medication, date and time drawn, and initials of personel pre-drawing medication. (see tag C322)

Based on observation and interview it was revealed the facility failed to ensure 1 of 4 (#30) surgical patients received an anesthesia risk assessment and evaluation prior to surgery resulting in the potential of adverse reaction to anesthesia..

On 3/14/2012 at approximately 1115 during medical record review it was revealed that 1 of 4 surgical patients (#30) had not been evaluated by the certified registered nurse anesthetist prior to surgery being performed. Review of the consent for admission showed the patient signed the consent for admission and consent for surgery. Further review of the records showed the consent for anesthesia was not signed by the patient but stated "implied consent by the patient". An interview with staff #C confirmed the patient had signed the consent for admission and consent for surgery but had not signed the consent for anesthesia. Review of the post anesthesia evaluation for patient #30 revealed the form indicated anesthetic complications with no further documentation. The form was also lacked the time the complications occurred and the time of authorization of release for discharge by the CRNA.

Further tour of the surgical area revealed a pre-drawn white substance without identification of medication, patient name, date drawn, time drawn, or the initials of staff member who drew the medication. Staff #E stated she had thought they were from the previous patient.
During an interview with staff #L it was confirmed the medication had been pre-drawn for the next surgical case while the previous patient was in the suite and that labeling of medication, patient name, date and time, and initials of staff who drew the medication were not present.

On 3/14/2012 at approximately 1145 during medical record review it was revealed 3 of 4 patients' surgical consents (#30,#31,#32) lacked the date and time signed by the physician. An interview with staff #C and staff #E confirmed the physician failed to date and time the consent for surgery.

Based on document review and interview, the facility failed to carry out an annual periodic evaluation of the services and programs provided.
During review of documentation provided by staff C, the facility was unable to produce a documented review (program evaluation) of the utilization of services for 2009 or 2010.
The facility failed to carry out a review of the utilization of services, including the number of patients served and the volume of services.
The facility failed to review and update policies and procedures annually. A review of the facilities health care policies revealed that policies for the emergency department, medical records and several patient care policies had not been reviewed and/or updated since 1995 and 1999.
Due to the lack of a program evaluation, the facility was unable to take into consideration the results of an evaluation to determine if any changes were needed.

During an interview with the Chief Nursing Officer (CNO) and the Compliance/Risk manager on 03/14/2012 at 1500, the findings were discussed and confirmed.