HospitalInspections.org

Based on review of documentation and interviews with facility staff, the facility failed to periodically conduct appraisals of its members as 3 out of 11 credential files reviewed did not have documentation of reappointment being done in the last two years in violation of facility policy.

The findings were:
The credential files of personnel #3, #12, and #21 were reviewed on the afternoon of 1/31/12. The last documented reappointment appraisal entitled "Executive Committee/Board of Managers Evaluation Reappointment to the Medical Staff" of personnel #3 was dated "December 16/18, 2009" and signed by the chief of the medical staff on 12/16/09 and the chairman of the board on 12/17/09.

The last documented reappointment appraisal entitled "Executive Committee/Board of Managers Evaluation Reappointment to the Medical Staff" of personnel #12 was dated "December 16/18, 2008" and was signed by the chief of the medical staff on 12/16/08 and by the chairman of the board on 12/24/08.

The last documented reappointment appraisal entitled "Executive Committee/Board of Managers Evaluation Reappointment to the Medical Staff" of personnel #21 was dated "December 16/18, 2009" and was signed by the chief of the medical staff on 2/18/10 and by the chairman of the board on 2/18/10.

The facility medical staff bylaws dated 10/17/11 reflected that "All Regular Medical Staff reappointments shall be for a maximum of two (2) years. Reappointment ...shall be determined by the Governing Body during the month of December at the regular scheduled meeting of the Governing Body. Reappointments ...shall be made in writing."

In an interview with the facility CEO, personnel #33, he acknowledged that the reappointments of personnel #3, #12, and #21 were overdue, and stated that documentation of a more recent reappointment could not be found.

Based on review of documentation and interviews with facility staff, the facility failed to ensure that all patient medical record entries were dated and timed as 5 out of 31 patient medical records reviewed had written physician orders that were not dated and timed.

The findings were:
The medical records of thirty-one patients were reviewed on 1/31/12 and 2/1/12. The medical records of patients #12, 13, 15, 27, and 29 contained written physician orders that were not dated and timed.

In an interview with the facility chief nursing officer on 1/1/12 at 10:00 am in the conference room, she acknowledged that the above listed medical records contained written physician orders that were not dated and timed.

Based on review of documentation and interviews with facility staff, the facility failed to ensure that verbal orders were authenticated within 48 hours as 12 out of 31 patient medical records reviewed had verbal orders that were either not authenticated or authenticated but without the date or time of authentication documented.

The findings were:
The medical records of thirty-one patients were reviewed on 1/31/12 and 2/1/12. The medical records of patients #1, 3, 4, 19, 20, 25, 26, 27, 28, and 30 contained one or more verbal orders that were authenticated but without the date or time of authentication documented. In addition, the medical records of patients #21 and 24 contained verbal orders that were not authenticated.

In an interview with the facility chief nursing officer on 1/1/12 at 10:00 am in the conference room, she acknowledged that the above listed medical records contained unauthenticated verbal orders and authenticated verbal orders without the date and time of authentication noted.

Based on observation, documentation, and an in-person interview, the facility failed to secure the patients' schedule II and III home medications in a secure locked area.

Findings were:
During a tour of the pharmacy, on the afternoon of 01/30/12 at 2:15 pm with the pharmacy LVN (licensed vocational nurse) technician, staff # 3; 3 zip-lock bags containing the patients' home medications were observed on a bottom shelf in the pharmacy. 2 of the 3 zip-lock bags contained scheduled medication containers.

1.) The surveyor observed the home medications of patient # 3 in a zip-lock bag. The bag contained one empty brown pill container labeled hydromorphone; a potent schedule II controlled opioid agonist.
2.) The surveyor observed the home medications of patient # 4 in a zip-lock bag; the bag contained one medication container labeled clonazepam (klonopin) a schedule III narcotic. There were 41 pills in the container labeled klonopin, which were counted by the LVN, staff # 3 during the tour. No documentation was provided to the surveyor to indicate that the count of the schedule and non schedule medications was done upon receipt in the pharmacy.

Review of the facility policy titled: Medication Brought into the Hospital stated "3.2.1.2 Narcotics shall be locked in the pharmacy narcotic closet. 3.2.1.3 If medications are kept in the pharmacy throughout the patients stay, each medication shall be counted by two licensed personnel and totals entered on the Pharmacy designated reconciliation form."

In an in-person interview with the LVN technician, staff # 3 on the afternoon of 01/30/12, it was confirmed that patients # 3 and # 4, scheduled and non scheduled home medications were not counted by two licensed personnel when received into the pharmacy.

Based on observation, review of documentation, and interview with staff it was determined the facility failed to maintain a sanitary environment to avoid the transmission of infections and communicable diseases. The facility also failed to follow facility policies and procedures.

Findings included:
A review of facility policy entitled, "Routine Cleaning of Paraffin Bath," stated, "2.0, The paraffin bath will be routinely cleaned when necessitated by accumulation of foreign material in the bath. Foreign material may be, but not limited to: cornified epidermis that is at times sloughed off when removing paraffin; lint, and other foreign substances such as hair."

A review of facility policy entitled, "Equipment Calibration & Maintenance," stated "2.2, Any defective or potentially defective equipment will be immediately removed from service." Further review of the policy revealed, "4.1, Department Director will assure appropriate corrective action on any potentially defective and/or defective equipment."

During a tour of the rehabilitation department the afternoon of 1/31/2012 with staff members #4 and #33, the following infection control issues were revealed:

1) A Paraffin bath was found on the back counter of the rehabilitation department. When the surveyor removed the lid, unknown substances were floating on the warm solution. There was also an unknown substance, on the bottom of the Paraffin Bath, in the solution. A cleaning log was not provided to the surveyor at the time of the survey that the Paraffin bath had been cleaned recently.

2) The Recumbent bike seat was torn on both sides. On the right side the seat was torn approximately 20 cm by 3 ? cm, and on the left side the seat was torn 19 cm by 2 ? cm.

3) A blue treatment table was found to have 5 puncture holes on the left side approximately a ? cm each.

4) A blue treatment table was torn on the left side approximately a ? cm.

In an interview and a tour of the rehabilitation department with staff members #4 and #33 the afternoon of 1/31/2012, it was confirmed the equipment was torn and the Paraffin Bath had not been cleaned. In an interview with staff member #32 the morning of 2/1/2012, it was confirmed the equipment was torn and it was also confirmed the facility did not have a cleaning log for the Paraffin Bath.