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Based on document reviews and interviews the governing body/medical executive committee failed to provide clear follow up and recommendations for, 3 of 4 patient care incidents (patients #26,27,28,29) reported by nursing staff. The three of the four incident reports filed by the nursing staff, that involved patient care issues, did not contain follow up or resolutions or recommendations by the Quality or Medical Executive Committees.
A review of the documents titled, "Confidential Quality Control Report", revealed the following documentation:
Patient #26 arrived via the city fire department "at 11:00AM with complaints of pain in her chest. When she arrived lab was called to draw lab. Then the EKG machine, after it was attached and connected to the patient, did not turn on. When I realized that the EKG machine would not power on, it was plugged into the red outlet. Still, the EKG machine did not power on. We unplugged it from that socket and tried a different socket. Still the machine did not power on. We paged respiratory tech overhead to get a different EKG machine that would function properly. At 11:13AM, pt. was connected to an EKG machine that worked and an EKG was completed."
The document was dated 8/9/13. The document contained signature spaces for the Department Manager, Director/Administrator, Quality Improvement and Risk Management. All of the mentioned required signatures were left blank. The document contained no evidence of follow up by the Department Manager, Director/Administrator, Quality Improvement or Risk Management.
Patient #27 arrived to the facility on 5/17/2013 to induce labor for her 37 week pregnancy. The Confidential Quality Control Report contained a Narrative (Objective Statement of Facts) that read, "Pt. Transferred to higher level of care for intracranial hypertension and labor."
The document was dated 5/17/13. The document contained signature spaces for the Department Manager, Director/Administrator, Quality Improvement and Risk Management. All of the mentioned required signatures were left blank. The document contained no evidence of follow up by the Department Manager, Director/Administrator, Quality Improvement or Risk Management.

Patient #28 was admitted to ER (Emergency Room) at 0003 (12:03AM) and intubated (a breathing tube placed in the airway for the purpose of protecting the airway and providing oxygen). Pt. was kept in the ER overnight. Extubated (removal of the breathing tube) and discharged home to his mother at 0930AM. Pt's length of stay was 9 hrs and 17 minutes in the ER. Discharge diagnosis was acute alcohol intoxication.
The document was dated 3/23/13. The document contained signature spaces for the Department Manager, Director/Administrator, Quality Improvement and Risk Management. The document contained no evidence of follow up by the Director/Administrator, Quality Improvement or Risk Management.
A review of the Policy and Procedure with Subject: Reporting of Occurrences, Policy Statement: The facility "supports the identification, reporting, analysis and prevention of patient care occurrences as well as other safety concerns in order to investigate and understand the causes that underline such events and make changes in the organization's systems and processes to reduce the probability of the repetition of such events in the future..... All blanks must be completed and the report must be legible."
A review of the Medical Executive Committee Minutes for July 1, 2013 revealed, "Incident Report MR#....., account#..... Physician #33 stated that this incident report had been addressed prior to the meeting."
This incident referred to patient #27 and the incident report contained no evidence of being addressed by physician #33, Department Manager, Director/Administrator, Quality Improvement or Risk Management.
A review of the Medical Executive Committee Minutes for May 13, 2013 revealed, "Old Business, Response from Physicians - Physician #35 read a letter from Dr. #34 in response to the Medical Executive Committee's request regarding the care of a patient, chart number ...., medical record number ..... The committee discussed the issues presented and agreed that Dr. #7 should follow up with Dr. #34 to suggest that perhaps observing such patients overnight might be appropriate to ensure patient safety."
This incident referred to patient #28 and the incident report contained no evidence of being addressed by physician #37, Department Manager, Director/Administrator, Quality Improvement or Risk Management.
An interview with Physician #35 in the Administrative conference Room on 9/12/2013 at approximately 9:00AM, the Dr. confirmed the documentation was not supportive of the Medical Executive Committee's actions taken to address the care concerns of patient #27 and #28.
An interview with staff #18, staff #19 and staff #20 in the Administrative conference Room on 9/12/2013 at approximately 11:00AM, all confirmed three of the four patient Incident Reports #26, #27, and #28 did not contain evidence the Incident Reports were address and closed. Staff #18 and #19 confirmed the Medical Executive Committee Minutes did not contain the documentation that would confirm the Incident Report were addressed and closed.

Based on record review and interview the facility failed to ensure the self- administration of medication policy and procedure was complete.
This deficient practice had the likelihood to affect all patients with the desire to self administer
Findings include:
Review of a policies /procedure with a subject name of "Self-administered medications are safely and accurately administered" revealed the following:
Pharmacy Policy dated 02/2004
"2. No self-administration of medication is allowed, except when PCA is ordered for pain management."
Nursing Policy dated 07/09
"Self-Administered Medications Are Safely and Accurately Administered" dated 07/09 revealed the following:
2.0 No self-administration of medication is allowed when there is a specific order by the physician except when PCA is ordered for pain management and concurrent Respiratory Therapy treatments by Cardiopulmonary.
3.0 Patient receiving PCA should receive training and appropriate information about the following:
3.1 The nature of the medications to be administered.
3.2 How to administer medications, such as the appropriate frequency, route of administration, and dose.
3.3 The expected actions and side effects of the medication to be administered.
3.4 Patient is determined to be competent at medication administration by nursing staff before the patient is allowed to administer medications."
The policy and procedure did not address assessment, training, security, and documentation for usage of medications outside of PCA pump.
During an interview on 09/11/2013 at 2:00 p.m., Staff #31 confirmed the policy.

Based on observation and interview the facility failed to ensure expired medications were discarded in 1 of 1 pharmacies.
This deficient practice had the likelihood to affect all patients.
Findings include:
Review of a policy/procedure with a subject name of "Outdated and unusable medications" dated 11/14/2003 revealed the following:
"All outdated or unusable medications are to be removed from dispensing stock and are quarantined together until such drugs are disposed of by a licensed waste management company."
During an observation on 09/11/2013 at 1:40 p.m. the following expired intravenous fluids were found stored on a shelf ready for use:
One bag of Dextrose 10 percent expired January 2013;
Eleven bags of Dextrose 10 percent expired July 2013.
During an interview on 09/11/2013 at 1:40 p.m., Staff # 31 confirmed the fluids were expired.

Based on observation and interview the facility failed to ensure patients' radiology records were maintained in a secure location.
This deficient practice had the likelihood to affect all patients.
Findings include:
During an observation on 09/11/2013 at 4:02 p.m., rows of patient x-ray films were found stored in a room that was not locked.
During an interview on 09/11/2013 at 4:02 p.m., Staff #30 confirmed the room was unlocked.

Based on observation and interview the infection control officer failed to evaluate and identify areas of potential cross contamination in 5 of 5 units (Dietary, Medical/Surgical, Emergency Department (ED), Laboratory and Intensive Care Unit (ICU).

Findings include:

*Dietary

On 9/10/2013 at 9:45 am during a tour of the dietary department being given by the Food Service Manager, food items were observed in shipping boxes stored inside the refrigerator, freezer and in the walk in cooler. "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust (AAMI ST46-Section 5.2 Receiving Items).
Also during the tour of the kitchen a large standing Hobart mixer was observed with areas where the paint was chipped and broken making sanitation unlikely. Also observed was a small Hobart mixer with areas of broken paint and build up of kitchen grease was observed. Both of these kitchen implements were in need of cleaning, sanding and repainting to insure proper sanitation for the preparation of patient meals.

Also observed, during the tour of the dietary department with the Food Service Manager, a stainless steel wire storage rack which held 19, 24 count cupcakes pans with heavy carbon build up and baked on oil, 15 sheet pans with carbon build up and baked on oil.

Further observation revealed a large grill. The facility's Chef indicated the grill had been used the previous night for preparation of the meat. The grill was observed with a heavy layer of black charred residue and the stainless steel storage areas below the grill was very heavily soiled with oil and debris.

The above mentioned observations of the food preparation and storage areas in the dietary department presented a risk for cross contamination of food which likely would be served to hospital patient placing them at risk of food born contaminates.





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*Medical/Surgical unit
During an observation on 09/10/2013 at 10:19 a.m. the pediatric crash cart on the Medical-Surgical unit had a Trocar Thoracic catheter expired on 02/2011.
During an interview on 09/10/2013 at 10:19 a.m., Staff #5 confirmed the observation.

During an observation on 09/10/2013 at 10:32 a.m. the mattress on the bed in the wound care room had tears.
During an interview on 09/10/2013 at 10:32 a.m. Staff #5 confirmed the observation.

*ED unit
During an observation of the ED on 09/10/2013 at 11:43 a.m. the following was found:
*Room #3 had a mattress on the patient bed that had a plastic covering which had a tear. The area was taped up with masking tape which had dried stains on it.
*A container of plastic mask and a bag of blankets used for children were stored on the floor in a storage room.
During an interview on 09/10/2013 at 11:43 a.m. Staff #5, confirmed the observations.

*Laboratory
During observation of the lab on 09/11/2013 at 3:45 p.m., the Vent-a-hood was found with dried brown spills
During an interview on 09/11/2013 at 3:45 p.m., Staff #29 confirmed the condition of the hood.

*ICU unit
During an observation on 09/10/2013 at 10:59 a.m. the ICU intubation box had umbilical tape expired 01/2013 and topical anesthetic expired 10/2012.
During an interview on 09/10/2013 at 10:59 a.m., Staff #5 confirmed the observation.