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Based on observation, interview and policy review the facility failed to remove expired supplies from the emergency department (ED) Pediatric Crash Cart (cart with supplies used to care for critically ill pediatric patients such as those not breathing), the emergency department trauma cart (cart used to care for critically injured patients such as severe car accidents) and in the Labor and Delivery Department stock room. These failures indicated that the facility does not have an effective process to ensure that safe, current supplies are available in critical situations. The emergency department has about 500 patient visits per month and the Labor and Delivery department sees an average of approximately 22 patients per month. The facility census was 11.

Findings included:

1. Review of facility policy titled, "Central Service", revised 06/12 showed direction to staff that all manufactured supplies that have reached their expiration date shall be removed from service and returned to Material Management for disposal.

2. Observation on 04/30/13 at 9:45 AM of the ED Pediatric crash cart showed the following supplies:
-Four pediatric Intraosseous needles (used to obtain access to bone for infusion of fluid/medications in critical situations) with a manufacturers' expiration date of 02/2013;
-Five pediatric oxygen delivery module kits containing oxygen mask and airway tube with a manufacturers' expiration date of 03/2013;
-One pediatric duodenal (stomach) tube, 10 French (size of tube width) with a manufacturers' expiration date of 10/2012;
-One pediatric sterile coiled suction (to remove secretions from airway) catheter (tube) with a manufacturers' expiration date of 02/2013;
-Four pediatric intubation modules containing a laryngoscope blade (to place a breathing tube in the throat), an endotracheal tub (breathing tube), suction catheter, and a naso gastric tube (tube that goes into patients' stomach) with a manufacturers' expiration date of 10/2011; and
-Four 24 gauge intravenous (IV) needles (to establish IV access into patient) with a manufacturers' expiration date of 10/2010.

3. Observation on 04/30/13 at 9:45 AM of the ED Trauma Cart showed two bottles of normal saline (salt water) irrigation solution each containing 1000 ml. (milliliters- a unit of measure) with manufacturers' expiration date of 04/2012, and one 16 French urethral catheter tray (to insert tube into bladder) with a manufacturers' expiration date of 01/2009.

4. During an interview on 04/30/13 at 9:50 AM Staff I, ED Nurse Manager, stated that these items should not be in the carts. Staff I stated that the pediatric and trauma carts are not used very often so the outdate checks were probably not done regularly. Staff I stated that the ED nurses have a schedule to check for expired supplies.

5. Observation in the Labor and Delivery Department Stock Room on 05/01/13 at approximately 3:00 PM, showed the following expired supplies:
-Ten 22 gauge intravenous (IV - in the vein) cannulas (used to administer medication or fluids), Lot #001003, with a manufacturers' expiration date of 01/05;
-Three 18 gauge IV cannulas, Lot #6354186, with a manufacturers' expiration date of 12/09;
-Twenty 24 gauge IV cannulas, Lot #804151, with a manufacturers' expiration date of 03/01;
-One fetal scalp electrode (used to monitor a baby's heart rate during labor). Lot #50071, with a manufacturers' expiration date of 06/30/10; and
-One IV tubing extension set, Lot 04115684, with a manufacturers' expiration date of 11/07.

6. During an interview on 05/01/13 at approximately 3:00 PM, Staff V, Director of Obstetrics (OB) stated that the nursing staff are required to stock the department before the unit closes (when all patients have been discharged from the department, and there are no admissions to the department). When stock is replaced, the nursing staff are to remove and dispose of any expired items they find.

7. Record review of the Obstetric "Unit Closing Checklist" dated 04/29/13, showed staff had restocked supplies throughout the Labor and Delivery Unit.

Failure to remove expired supplies from stock has the potential to expose patients to non-sterile, unstable supplies which could cause infection or ineffective use.



29047

Based on record review and interview the facility failed to adopt Medical Staff Bylaws which gave only the Governing body the authority to grant medical staff privileges. This deficient practice had the potential to affect all patients in the facility. The facility census was 11.

Findings included:

1. Review of the facility's Medical Staff Bylaws, conducted on the afternoon of 04/30/13 showed in Article VIII, Part F: Upon the concurrence of the Chief of Staff, the chairman of the Credentials Committee, and the Department Chairman of the appropriate Department, the Administration may grant temporary privileges in accordance with this Part D of Article VIII and the Credentialing and Corrective Action Procedures.

2. During an interview on 05/01/13 at 4:45 PM, Staff N, Chief Executive Officer (CEO), stated he had, in the past, granted physicians temporary privileges.

Based on policy review and interview the facility failed to ensure that a pharmacist reviewed patient medication profiles and physicians medication orders prior to administration of the medication. These failures had the potential to cause medication errors or drug interactions and could affect all patients that required medications while being cared for at the facility. The facility census was 11.

Findings included:

1. Review of the facility policy MS6000 titled, "Orders: Verbal, Written and Telephone", reviewed 09/27/11 showed direction that the "Physician writes order. . .,Ward Clerk enters medication order into the order entry in the computer, Licensed Nurse shall double check the order and initial that it is correct, Pharmacy verifies all medication orders".

Review of facility policy PHA III titled, "Medication Administration Process", reviewed 03/16/12 showed direction that:
-All orders entered in the EMR (electronic medical record) shall be double checked against the practitioner's order before the drug is administered;
-Orders entered by the Ward Clerk shall be double checked by a nurse. The double check shall be documented by "verifying" the order in the EMR. A Pharmacist may also perform the double check;
-Orders entered by a nurse shall be double checked by a second nurse. A Pharmacist may also perform the order entry, the acknowledgement function or the chart double check (sic).

2. During an interview on 04/30/13 at 3:15 PM Staff L, Director of Pharmacy, stated that the Pharmacy hours are 7:00 AM to 4:00 PM, Monday through Friday. Staff L stated that orders written during those hours are verified by the Pharmacist and orders written when the pharmacy is closed are verified by the Registered Nurse (RN) and checked the next time the Pharmacist is on duty. Staff L stated that the pharmacist reviewed orders for proper dose, diagnosis related to medication use, duration (is order time limited), drug/drug interactions, drug/patient interactions, drug/fluid interactions, to be sure medication is on hospital formulary, and patient allergies. Staff L stated he didn't think nurses checked for the same elements as the pharmacist (proper dose, diagnosis related to medication use, duration, drug/drug interactions, drug/patient interactions, drug/fluid interactions) when the RN verified the order. Staff L stated that nurses mainly checked that the entered order is what the the physician wrote. Staff L stated he is not aware of any formal nurse education or policy related to the elements that the pharmacist verified. Staff L stated that patients admitted during the night or on weekends received medication prior to the order being verified by the pharmacist and that sometimes patients were discharged from the facility prior to medication orders being reviewed and verified by the pharmacist. Staff L stated that he estimated that if a patient was admitted during the night there were 20 new medication orders, if there were no admissions there may be eight new medication orders and that the number of orders on the weekend depended on how many new admissions occurred. Staff L stated that some medication errors might be prevented if pharmacists reviewed the orders prior to medication administration.

3. During an interview on 05/01/13 at 11:00 AM Staff S, RN, stated that nurses check to ensure the medication order entered is what the physician wrote. Staff S stated that when medication is administered to the patient the RN verifies the patients' identity, the right medication, dose, route, and allergies. Staff S stated that she has not received any education on how to verify orders from the pharmacy perspective.

4. During an interview on 05/01/13 at 1:30 PM Staff J, Chief Nursing Officer (CNO), stated that the nurses have not received any education about how medication orders are verified by the pharmacy. Staff J stated that medications are regularly administered by the nurses prior to verification of the order by a pharmacist. Staff J stated administration was aware this issue was going to come up and solutions are being discussed.

Based on observation, interview, and policy review the facility failed to ensure a sanitary environment was maintained in the Operating Rooms (OR) by allowing a linen cart, a stool and a biohazard waste bucket with rusted casters to remain in the OR's. In addition, the floor in one OR was worn through to the sub surface. Rusted equipment and floors that are worn through in the Operating Room rendered those items to be functionally uncleanable and become a source of contaminants to transmit infections. This occurred in two of three Operating Rooms which were observed. The facility had three operating rooms.
The facility census was 11.

Findings included:

1. Review of the AORN (Association of Perioperative Registered Nurses) Perioperative Standards and Recommended Practices, May 2009, showed: A safe, clean environment should be reestablished after each surgical procedure. Routine cleaning and disinfection reduces the amount of dust, organic debris and microbial load in the environment. Following scientifically based recommendations for cleaning and disinfection practice in health care organizations helps to reduce infections associated with contaminated items.

Review of the facility policy HKPG (Housekeeping) titled "Procedure for Daily Cleaning Surgical Suite" reviewed 05/12 showed:
-Supplies needed are germicidal detergent, stainless steel cleaner, mop, bucket wringer with germicidal detergent.
-Policy: The Surgical area is to be treated as a critical area. At the end of the day rooms are to be cleaned and prepared for surgery.
-Procedure: Wash interior and exterior of waste cans, wipe dry. Reline waste cans in this area with proper liner. Wring out cloth in germicidal solution. Starting with overhead lights clean first, damp wipe all items in the room. Clean the surgery table. Damp wipe stools, shelves, door fixtures, door frames, and all items on the walls.
-Wet mop floor with germicidal solution.

2. Observation in OR #3 on 04/30/13 at 2:05 PM showed two carts (one linen and one waste bucket) with rusted casters. Each cart had four casters and the rust continued up the legs where the casters attach to the cart. Carts were made of stainless steel. Casters scraped with fingernail showed visible rust particles. In addition, the floor in OR #3 had deteriorated on the right side of where the operating table was located. The floor surface had eroded in ten separate areas. These sub surface areas were black as opposed to the light colored floor. Four areas of degradation were approximately one and a half centimeter round and six areas were approximately one centimeter round.

3. Observation in OR #2 on 04/30/13 at 2:15 PM showed one stainless steel stool with rust covered casters. The stool had four casters and the rust continued up the legs where the casters attach to the cart. Casters scraped with fingernail showed visible rust particles.

4. During an interview on 04/30/13 at 2:15 PM Staff K, Director of Surgical Services, stated that the carts and stool are not removed from the OR. Staff K stated that the deterioration of the floors and rust would prevent the floor and equipment from being cleaned properly. Staff K stated that staff usually reports rusted equipment to her.

5. During an interview on 04/30/13 at 2:15 PM Staff X, Infection Control Nurse in training, offered no objection to Staff K's statement that rusted casters could not be cleaned properly.

6. Staff U, Director of Housekeeping, was on vacation on 04/30/13, the day of the OR tour, and unavailable by phone for interview.

Based on interview, record review, and policy review, the facility failed to ensure that all entries into the medical record were signed, dated, and timed for four current patients (#1, #2, #3, and #4) and two discharged patients (#19 and #20) of nine patient records reviewed for authentication. The facility census was 11.
Findings included:
1. Record review of the facility's Medical Staff Rules and Regulations dated 12/19/07, showed that all clinical entries in the patient's medical record shall be accurately dated, timed and authenticated.
Record review of the facility's policy titled, "Legibility of Medical Record Documentation" revised 04/13, showed that all documentation in the medical record shall be legible, dated, authenticated and recorded in ink, typewritten or recorded electronically.
Record review of the facility's policy titled, "Orders, Verbal, Written & Telephone" reviewed 09/27/11, showed that practitioners shall write all orders legible, with date, time or (sic) order, medication dosage, frequency and duration, if applicable, and then signed by the physician.
2. Review of current Patient #1's medical record showed "General (admission) Orders" were signed by a physician, but were not dated or timed. Physician orders dated 04/29/13 were signed by a physician, but were not timed.
3. Review of current Patient #2's medical record showed "General Orders" were signed by a physician, but were not dated or timed.

4. Review of current Patient #3's medical record showed the following:
-Physician's telephone orders, transcribed by a speech therapist on 04/24/13, were not timed. The orders were signed by a physician, but did not include the date or time of the physician's signature;
-Physician orders dated "04/26", were signed by the physician but were not timed;
-Physician's telephone orders, transcribed by a nurse on 04/24/13 at 12:30 PM, were signed by a physician, but did not include the date or time of the physician's signature;
-Physician orders dated 04/24/13, were signed by the physician but were not timed;
-Physician's telephone orders, transcribed by a speech therapist on 04/24/13, were not timed. The orders were signed by a physician but did not include the date or time of the physician's signature;
-Physician's "General Orders", were signed by a physician but were not dated or timed.

5. Review of current Patient #4's medical record showed "General Orders" were signed by a physician, but were not dated or timed.
6. Review of discharged Patient #19's medical record, showed the following:
-Physician's telephone "Antepartum (before delivery) Vaginal Delivery Orders", transcribed by a nurse on 04/27/13 at 3:00 AM, were signed by a physician but did not include the date and time of the physician's signature;
-Physician telephone "Pitocin (medication used to start contractions) Induction Orders (Vaginal Delivery)", transcribed by a nurse on 04/27/13 at 9:00 AM, were signed by a physician but did not include the date and time of the physician's signature;
-"Obstetric (related to childbirth) Regional Anesthesia Orders", which were signed by a physician, did not include the date or time of the order;
-"Postpartum (after delivery) Vaginal Delivery Orders" dated 04/27/13, which were signed by a physician, did not include the time of the order;
-Physician telephone orders, transcribed by a nurse on 04/27/13 at 2:30 PM and 3:00 PM, and on 04/28/13 at 9:25 AM, were signed by a physician but did not include the date or time of the physician's signatures;
-Physician orders dated 04/29/13, which were signed by a physician, did not include a time of the physician's order.
-"Obstetrical Discharge Summary" was signed by a physician, but did not include the date or time of the entry; and
-"Summary of Labor and Delivery" was signed by a physician, but did not include the date or time of the entry.

7. Review of discharged Patient #20's medical record, showed the following:
-"Perioperative (during an operative procedure) Orders" were signed by a physician, but did not include the date or time of the order;
-Physician's telephone "Antepartum Cesarean Section Orders", transcribed by a nurse on 04/26/13 at 1:45 PM, were signed by a physician but did not include the date or time of the physician's signature; and
-"Summary of Labor and Delivery" was signed by a physician, but did not include the date or time of the entry.

8. During an interview on 04/30/13 at 3:30 PM, Staff A, Health Information Director, stated that all entries in a patient's medical record should include the provider's signature with the date and time of the entry as well as the date and time the physician signed the entry, if the entry was not written by the provider, such as with a telephone or verbal order. Staff A added that the facility did not have a policy that shows how long a provider has to authenticate entries made in the medical record.

Based on observation, interview and policy review, the facility failed to ensure medical records were protected against loss, destruction, unauthorized use, and unauthorized access and or tampering. The facility census was 11.
Findings included:
1. Record review of the facility's policy titled, "Accessibility of the Medical Record" reviewed 04/13, showed that when the Medical Records department is closed, any appropriate individual requesting a medical record must contact the Nursing Supervisor and provide the patient's name and medical record number if known. The Nursing Supervisor may delegate another employee, such as the Ward Clerk to retrieve the record from Medical Records. The Nursing Supervisor or designated person will unlock the Medical Records Department and obtain the requested medical record.
Record review of the Facility's policy titled, "Secure filing of Medical Records" reviewed 04/13, showed that the Medical Records Department is responsible for safeguarding both the record and its content against loss, defacement or tampering. They are also responsible to safeguard the medical records against use by unauthorized individual. File rooms located in the medical Records Department lower level shall remain locked at all times and accessed only by Medical Records personnel or Nursing personnel for patient care.
2. During an interview on 04/30/13 at 3:30 PM, Staff A, Health Information Director stated that she was responsible for ensuring the medical record storage areas within the hospital are secured. Staff A stated, "I believe" the Medical-Surgical Department ward clerks, House Supervisors and Emergency Department (ED) staff have access to the Medical Records storage areas and "I believe" Maintenance Staff and Materials Management staff also have access to the downstairs records area. Staff A stated that she wasn't sure exactly who had access to the medical storage areas.
3. Observation during an interview on 04/30/13 at 4:15 PM, showed the ED staff pull a key out of a drawer in the ED nurses station. Staff W, ED Unit Secretary, stated that the key is used to access the medical records department, is kept in the unlocked drawer, and that any staff in the ED had access to the key and could obtain records form the Medical Records Department. Staff W added that the Unit Secretaries are the ones who usually get the records from the Medical Records Department.