HospitalInspections.org

Based on observation during a tour of the hospital, review of records, and staff interviews, the hospital Governing Body was not responsible for services furnished in the hospital, as policy and procedure for crash cart inspection was not followed.

Findings were:

Review of two of two emergency crash cart logs during a tour of the hospital on 8-30-11 revealed that inspection of the crash carts to ensure readiness for a patient emergency, security and accountability of medications had not been completed for the medical surgical unit crash cart 11 of 39 shifts between 8-11-11 and 8-30-11, and the labor and delivery crash cart had not been inspected 32 of 53 shifts between 8-4-11 and 8-30-11. Review of unnumbered hospital policy, "Emergency Crash Cart Security and Accountability" revealed " The nursing personnel shall visually inspect the numbered break-away lock located on the crash cart at each change of shift, documenting that the cart is properly locked with all appropriate contents present and intact. " Review of hospital policy #3009, " Emergency Crash Carts " revealed " Patient care staff is responsible for checking and documentation of the integrity of all equipment on top of the cart. " The above was confirmed in interview with Staff #14.

Based on review of documentation and interview with staff, the facility failed to ensure that non-employee licensed nurses who are working in the hospital complied with the policies and procedures of the hospital. The nursing director did not evaluate 2 of 2 non-employee nurses who administered patient care according to the Registered Nurse Job Description requirements.

Findings were:

The hospital's job description for the RN requires current licensure, current CPR certification, and clinical competency evaluations. Review of the nursing personnel records revealed that Staff #23, an agency nurse, worked in the patient care areas on 7/9/11, 7/10/11, and 8/10/11. Staff #24, also an agency nurse, worked in the facility on 8/25/2011. Neiter of the files contained documentation that the facility verified licensure, certifications, or competencies of the nurses prior to their providing patient care in the hospital.

In an in-person interview conducted 8/31/11, the Chief Nursing Officer (CNO), Staff #14, stated that the facility uses agency nurses when necessary, but does not verify licensure, certifications, or competencies of the agency nurses prior to their working in the hospital or verify that the agency performs these verifications..

Based on review of documentation and interview with staff, the facility failed to place a medical history and physical examination (H&P) in the patient's medical record within 24 hours after admission for 9 of 31 applicable patient records reviewed .

Findings were:

The Rules and Regulations of the Medical Staff of Hereford Regional Medical Center state under Section 2 that each patient will have a written H&P placed in the chart within 24 hours of admission. Review of the medical records of Patients #34-42 revealed that a written H&P was not placed in the charts within 24 hours of admission. These findings were confirmed by Staff # 15 during an in-person interview the afternoon of 8/29/2011.

Based on review of documentation and interview with staff, the facility failed to include a discharge summary within 30 days of the patients' discharge dates, that included outcome of hospitalization, disposition of care and provisions for follow-up care for 17 of 31 applicable patient records reviewed .

Findings were:

The Rules and Regulations of the Medical Staff of Hereford Regional Medical Center state under Section 2E that each patient's chart must have a discharge summary within 30 days from the date of discharge. Patients #17-33 were discharged over 30 days prior to the survey, but their medical records did not contain a discharge summary. These findings were confirmed by Staff # 15 during an in-person interview the afternoon of 8/29/2011.

Based on observation during a hospital tour, and interview with staff, the facility failed to have adequate controls over medications and biologicals, as outdated, mislabeled, and otherwise unusable drugs and biologicals were available for patient use in the medical/surgical unit and the epidural cart.

Findings were:

Observation of medical/surgical unit during a tour of the hospital on 8-30-11 revealed 18 expired blood specimen and Chlamydia transport tubes, with expiration dates ranging from 2-06 to 4-11. Observation in the nursery revealed 2 expired culture swabs (expired 4-11) and 4 benzoin swabs (expired 9-10). Observation in Labor Room #3 revealed 11 culture swabs (expired 2-11), 8 chlamydia transport tubes (expired 8-5-10), and 2 blood specimen tubes (expired 6-11). These items were available for patient use. The above was confirmed in interview with Staff #14.

Observation of the facility during a tour of the hospital on 8-30-11 revealed that the medical/surgical unit contained expired medications, including Depo Medrol expired 5/11, Fosphenytoin Sodium expired 6/11, Influenza vaccine expired 6/11, and a opened Tetanus syringe expired 6/11; vials of medications that were opened but not dated, included Novolin R insulin, Novolin 70/30 insulin, 2 vials of Humalog insulin, Peumococcal vaccine, Novolog insulin, and Tuberculin; one vial of Lantus opened and dated 6/13/11 and one vial of Kenalog opened and dated 7/22/11. All were available for patient use.

Review of hospital policy #1012, " Use of Multiple Dose Vials " revealed that, " the beyond-use date for an opened or entered (i.e., needle-punctured) multiple dose container with antimicrobial preservatives shall be 28 days, unless otherwise specified by the manufacturer. The healthcare provider shall write the expiration date on the vial, when opened ... MDVs [multiple dose vials] shall be discarded when the manufacturer ' s established expiration date is reached ...The Pharmacy Department shall verify that MDVs are stored and labeled correctly when inspecting medication storage areas. " The above was confirmed with Staff #14 on 8-30-11.

Based on observation, review of records and interview with staff, the facility failed to ensure the condition of the physical plant and the overall hospital environment were maintained in such a manner that the safety and well-being of patients were assured, as the newborn nursery and intensive care units had various mattress tears and visible dust and dirt.

Findings were:

Observation in the newborn nursery during a tour of the facility on 8-30-11 revealed 8 pads/mattresses in the infant cribs that were worn or had tears at the edges. Observation in Labor room #3 during a tour of the facility on 8-30-11 revealed a tear in the center of the labor and delivery mattress. Observation in the Delivery room on 8-30-11 revealed that the mattress in the infant radiant warmer, which was prepared and available for use, had clear plastic tape along the entire front edge of the mattress, and a four inch piece of grey duct tape on the horizontal surface of the mattress. There was a sticky area on the mattress where the duct tape had peeled back and rolled up. The worn areas, tears, and use of clear tape and duct tape prevent the mattresses from being properly disinfected after patient use. The above was confirmed in interview with Staff #14.

Observation in the nursery during a tour of the hospital on 8-30-11 revealed the base of the cabinet under the sinks was covered in visible, raised dust and brown and black dirt and debris. Review of hospital policy #8018 revealed that " The Environmental Services Department personnel will clean all areas of the Nursery ...Environmental Services Department personnel and Nursery staff will keep the Nursery clean and dust free. " The above was confirmed in interview with Staff #14.

Observation in the intensive care unit during a tour of the hospital on 8-30-11 revealed a brown spilled substance and black debris and particles on the shelf and the floor of the medication refrigerator behind the nursing station. There were three large areas of brown and black dirt and debris, an area of a brown spilled substance, and substance which appeared to be sawdust were observed on the base of the cabinet under the sink behind the nursing station. Review of hospital policy #8017 revealed that " The Environmental Services Department personnel will clean the Nurses ' Stations on a daily basis. " The above was confirmed in interview with Staff #14.

Based on observation during a hospital tour , and interview with staff, the facility failed to ensure that all surgical instruments were properly processed, mattresses which could not be properly disinfected were removed from patient use, and areas in the newborn nursery and intensive care unit were cleaned to provide a sanitary environment.

Findings were:

Observation in OR Rooms 2 and 3 during a tour of the hospital on 8-30-11 at 9:10 am revealed greater than 75 hemostats and scissors had been sterilized and stored in the closed position and those with lock boxes were in the locked position. Observation in the newborn nursery and delivery suite revealed 6 hemostats/scissors in the closed position and those with lock boxes were in the locked position. When one package of scissors was opened in the nursery, the interior of the closed surface had a reddish-brown appearance. It could not be determined that these surfaces were appropriately cleaned and sterilized. When instruments are closed, the sterilizing agent cannot penetrate all surfaces to ensure complete sterilization of all surfaces of the instruments. The Centers for Disease Control and Prevention (CDC) website article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: , states on page 74 that hinged instruments and instruments that are closed should be opened during the process of sterilization.

The above was confirmed in interview with Staff #14, 15, and 17 during a tour of the hospital on 8-16-11. Interview with Staff # 7, Infection Control nurse confirmed that the CDC is the hospital ' s designated infection control guidelines.
Interview on 8-18-11 with Staff #7, 14, 15 and 17 confirmed that they were not aware of procedures for cleaning, decontamination and sterilizing equipment or instruments.


Observation in the clean linen and supply room during a tour of the hospital on 8-30-11 revealed strings of white dust adhered to the lower shelves, black and brown dirt and debris on the floor and a dead cricket on the floor. Clean linens were stored without a covering on shelves, and the lowest shelf was approximately 3 inches from the floor. Review of hospital policy #7007, Storage, Collection and Transportation of Linen revealed that " Linen must be stored at least eight (8) inches above the floor. " The above was confirmed in interview with Staff #14.

Observation in the medical/surgical unit storage during a tour of the hospital on 8-30-11 revealed a 2x1 inch tear in the vinyl surface of a shower chair which could not be properly disinfected and was available for patient use. This was confirmed in interview with Staff #14.

Based on review of records and interview with staff, the facility failed to be in compliance with Swing Bed requirements for residents rights, as there is not a rights list given to to Swing Bed residents at the time of admission which includes all requirements.

Findings were:

While the facility gives each patient a Patient Handbook upon admission to the hospital, the list of patients rights does not include all the rights required for Swing Bed residents. In an in-person interview conducted 8/31/201, the Swing Bed Coordinator, Staff #7, stated that there was not a separate list of rights for Swing Bed Patients, nor were verbal rights explained to the patients at the time of admission.