HospitalInspections.org

Based on document review and interview, it was determined for 2 of 2 (Medical Doctor-MD #6 and MD #7) physicians whom have the ability to order the use of violent and/or non-violent restraints, the Hospital failed to ensure policies were developed with the requirements for restraint training for physicians. This has the potential to affect all patients who receive care by the Hospital with a current census of 17 patients.

Findings include:

1. The policy titled "Restraint Use (date issued July 21, 2018)", was reviewed on 1/30/19 at approximately 11:00 AM. The policy required "...Staff must be trained and able to demonstrate competency in the application of restraints, monitoring, assessment and providing care for a patient in restraint...."

2. The "Restraint Spreadsheet" was reviewed on 1/29/19 at approximately 1:00 PM. The spreadsheet included an order for restraints on 11/25/18 by MD#6 and an order for restraints on 1/18/19 by MD#7.

3. The files of MD#6 and MD#7 were reviewed on 1/30/19 at approximately 2:00 PM. The files of MD#6 and MD#7 lacked documentation the physicians had been trained on restraint usage.
a. MD#6- reappointed 2/28/18
b. MD#7- reappointed 9/5/18

4. An interview was conducted with Director of Critical Care (E#15) at approximately 11:40 AM on 1/31/19. E#15 verbally confirmed that MD#6 and #7 haven't had restraint training and the policy for restraints is for all other hospital staff but not for physicians. E#15 stated, "The hospital doesn't have a policy for the physicians for restraint training."

Based on record review and interview, it was determined in 1 of 3 (Pt # 12) patients' record reviewed for Organ and Tissue Referral Forms, the Hospital failed to ensure there was complete documentation to determine if the patient was a candidate for The Gift of Hope. This has the potential to affect all expired patients and availability of organ and tissue donations.

Findings include:

1. Pt. #12 Admission date: 12/14/18 Diagnosis: Chronic Obstructive Pulmonary Disease (COPD) Date of Death: 12/24/18. Review of Pt. #12's clinical record on 1/30/19 at approximately 3:00 PM found incomplete documentation by Registered Nurse (E #18) on the "Release of Body/Organ and Tissue Referral Form". Incomplete documentation included: I. 2) Ventilator (status), 3) Blood transfusions Y/N, Crystalloid infusion Y/N. 4) Pretransfused specimen available Y/N/ location, 8) VA/Nursing Home notified? Y/ Date/Time. II (A) Pt is not a candidate for: organ, tissue, cornea donation (nothing marked), Reason for Refusal: (left blank).

2. On 1/30/18 at approximately 3:45 PM, Facility Policy "Release of Body/Organ and Tissue Donor Request" (revised by Hospital 12/14/18) was reviewed. Policy indicated "To ensure accurate documentation of communication with Gift of Hope and release of the patient's body...when a patient expires a Release of Body/Organ and Tissue Referral form is to be completed". Procedure: A. "The Patient Care Coordinator will contact the Gift of Hope Hotline...and will complete Section I - IV.

3. A interview with the Director of Medical/Surgery (E #8) on 1/30/19 at approximately 3:30 PM was conducted. E #8 verbally confirmed the form was incomplete.

Based on document review, observation, and interview, it was determined the Hospital failed to ensure drugs and supplies were maintained in a secure area and not accessible to unauthorized individuals. This has the potential to affect all patients, staff, and visitors.

Findings include:

1. The Hospital policy PC. CP 102.00 titled "Cardiopulmonary Resuscitation Services" (issued by the Hospital on 6/20/18) was reviewed on 1/31/19 at approximately 9:00 AM. On page 3, the policy listed the Cardiac Rehabilitation crash cart under the "Level I Components". On page 11, the policy stated under "Procedure for Checking Crash Carts for Level I... Monthly Check: (See Addendum V)... 1. By the 5th day of each month, each unit that houses a crash cart will be responsible for opening it and checking all drawers..."

2. A tour of the Cardiac Rehabilitation Department was conducted on 1/30/19 at approximately 9:45 AM with the Director of Cardiopulmonary Rehabilitation (E#19). The Department was observed to be accessible to all staff and/or patients/visitors. The crash cart was unlocked and approximately 15 ViaValve Safety intravenous catheters, two syringes with needles attached, two liters of Normal Saline intravenous solution, and various intravenous tubings and saline lock devices were accessible to any individual who entered the Department.

3. An interview was conducted with E#19 during the observation. E#19 stated the Department was not a secure department and was open to staff after hours. E#19 stated, "We should be locking the cart, like the other carts here (in the Hospital), and we haven't."

Based on observation, document review and interview, it was determined for 1 of 1 offsite pain clinic, the Hospital failed to ensure expired medications were not available for use. This has the potential to affect all patients who receive care in the pain clinic with an average daily census of 10- 15 patients daily.

Findings include:

1. The Hospital policy titled "Inventory Management (date issued April 12, 2018)", The policy required "All expired product will be removed and disposed of immediately..."

2. On 1/29/19 at approximately 2:30 PM an observational tour was conducted in the Hospital's Pain Clinic with Director of Surgery (E#14). In the medication room four vials of 2% Lidocaine - 100 mg/ml each were available in the drawer for use with an expiration date of 1/1/2019.

3. During the observational tour with E#14, it was verbally confirmed the medication was outdated and should have been removed.

A. Based on observation, documentation, and interview, it was determined that the Hospital failed to ensure an adequate temperature was maintained for 2 of 5 foods being held in the steam table that are available for visitor and employee purchase in the cafeteria. This has the potential to affect all visitors and staff using the cafeteria.

Findings include:

1. On 1/30/19 a tour of the dietary department with the Dietary Manager (E #4) and the Vice-President of Ancillary Services (E #1) was conducted from 10:30 AM to 11:30 AM. Two temperatures taken at the cafeteria steam tables did not meet Facility temperature requirements for Food Service. Temperature for Brussel Sprouts taken by two Dietary thermometers at 10:45 AM indicated a reading of 144 F (Fahrenheit) degrees (Cafeteria Temperature Guide for Vegetables: 165 F degrees). Temperature for Chicken Tenders taken by two Dietary Thermometers at 10:48 AM indicated a reading of 117 F degrees (Cafeteria Temperature Guide for Meat: 165 F degrees).

2. A review of the Daily Temperature Log on 1/30/19 at approximately 11:15 AM was conducted. All foods moved to the cafeteria steam table had been checked for temperature and documented as such in an acceptable range: Brussel sprouts, 174 F degrees and chicken tenders 166 F degrees.

3. An interview with E #4 was conducted on 1/30/18 at 10:45 AM. E #4 removed the Brussels Sprouts and chicken from the steam tables. The chicken was disposed of and the Brussel Sprouts were reheated to an acceptable temperature. E #4 checked the temperature log to make sure both foods had reached an acceptable range prior to transfer to cafe steam table. E #4 stated concern that the steam table was not holding the correct temperature set and called maintenance to evaluate the steam table's efficiency.


B. Based on document review, observation and interview, it was determined the Hospital failed to ensure that all foods were appropriately labeled per policy. This has the potential to affect all patients, staff and visitors who utilize dietary services.

Findings include:

1. The protocol titled "Date Marking Nourishments" was reviewed on 1/31/19 at approximately 11:00 AM. The protocol required a "use by date sticker filled out with the month/date/year on the zip lock bag to mark the nourishment with the expiration date."

2. On 1/29/19 a tour was conducted on the Intensive Care Unit between 3:00 PM and 4:00 PM. The following items were noted in the patient's refreshment area.
a. 2 (two) 0.38 ounce box Rice Krispies without an expiration date
b. 2 (two) 0.81 ounce box Corn Flakes without an expiration date
c. 1 (one) 8 fluid ounce can Glucerna expired 6/1/18

3. On 1/29/19 a tour was conducted on the Special Procedure Unit between 12:30 PM and 1:30 PM. The following items were noted in the patient's refreshment area.
b. 8 (eight) 0.38 box Rice Krispies without an expiration date
c. 10 (ten) 0.71 ounce Hot Cocoa Mix without an expiration date

4. During an interview on 1/29/19 at approximately 4:40 PM, with Director of Infection Control (E#11), E #11 observed the undated food items and stated that the items should have been labeled and dated or discarded.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Recertification survey conducted on February 6 -7, 2019, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Recertification survey conducted on February 6 -7, 2019, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on document review, observation, and interview, it was determined the Hospital failed to ensure patient care equipment was maintained, in accordance with its policy. This has the potential to affect all staff, visitors, and patients serviced by the Hospital.

Findings include:

1. The Hospital policy number 1401.00, titled "Inventory Classification Medical Equipment Management" (issued by the Hospital August 16, 2017) was reviewed on 1/31/19 at approximately 9:15 AM. The policy stated the Biomedical staff "would analyze all medical equipment upon receipt, would enter the equipment into the biomedical tracking system, and would place the equipment into an ongoing preventive maintenance schedule."

2. Tours, with concurrent interviews, of the Obstetric Department, Surgical Department, and the Emergency Department were conducted 1/29/19 through 1/30/19. The following are examples of patient equipment that lacked compliance with the Hospital's above mentioned policy:

a. On 1/29/19 at approximately 1:30 PM, in the Obstetrics storage room- a Conair 1875 hair dryer; one Stryker light (serial number 950610419); and three Neo puff machines were without any type of indication that the items had been checked for safety prior to being used. The Director of Obstetrics (E#13) was present during the observations. E#13 stated the following: the hair dryer was used by patients whenever they needed it and "not sure if it's been checked, or not"; "I don't know if the light (Stryker) needs to be checked or not."; and "They (the biomedical personnel) were looking for these (the Neo puffs) a few weeks ago and we couldn't find them. We don't hardly ever use them." E#13 verbally agreed the equipment lacked any indication as to when/if the equipment had been checked.

b. On 1/30/19 at approximately 9:45 AM, in the Sleep Laboratory storage area- three Schwinn stationary bikes, one exercise stepper, and two Conair 1875 hair dryers were without any type of indication that the items had been checked for safety prior to being used. The Director of Cardiopulmonary (E#19) was present during the observation. E#19 stated, "These (the stationary bikes and exercise stepper) aren't in use right now, so I don't know when they were checked. They don't have any sticker on them. As for the hair dryers, we have them for the patients to use if they want to. I don't know if they've been checked, or not."

3. An interview was conducted with the Vice President of Nursing (E#12) on 1/30/19 at approximately 2:20 PM. E#12 presented "Asset Detail Report" sheets for the exercise equipment, the Neo puffs, and the Stryker light and stated, "They either hadn't been checked, or they hadn't been labeled as inactive and they should have been. They (the biomedical personnel) said Maintenance would be responsible for the hair dryers and we haven't found anything on them (to indicate they had been checked and were safe for patient use) yet."


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B. Based on document review, observation, and interview, it was determined the Hospital failed to ensure equipment available for employee use was tested and maintained, in accordance with its policy. This has the potential to affect all employees employed by the Hospital.

Findings include:

1. The policy titled "Emergency Shower and Eye Wash Station" (issued 3/14) was reviewed on 1/30/19 at approximately 4:00 PM. The policy required " B. Testing: Weekly testing of the Eye Wash must be done to ensure proper function."

2. During a tour of the Special Procedure Area on 1/29/19 at approximately 12:30 PM with the Special Procedure Coordinator (E#9), the Eye Wash station in the Special Procedure area and the Eye Wash Station in the Scope Reprocessing Area failed to have a log indicating weekly testing had been performed.

3. An interview was conducted during the tour on 1/29/19 at approximately 12:55 PM with E#9. E#9 stated
"Both of the Eye Wash Stations were newly installed in July 2018 and checking them weekly was over looked."



C. Based on document review, observation and interview, it was determined the Hospital failed to ensure expired supplies were not available for patient use. This has the potential to affect all patients receiving care at the Hospital with a daily census of 17.

Findings include:

1. The policy titled "Inventory Management" (issued 4/12/18) was reviewed on 1/31/19 at approximately 12:00 PM. The policy required, "All end user departments will check inventories supplies on a quarterly basis and at the time of use for outdates. All expired product will be removed and disposed of immediately."

2. On 1/29/19 at approximately 9:30 am to 10:30 AM a tour was conducted in the Radiology Department. In the Storage Area there were 2 (two) expired 10 French Suction Catheters.

3. On 1/29/18 at approximately 12:30 PM to 1:30 PM a tour was conducted in the Special Procedure Area. The following expired supplies were on the crash cart.

a. EEC Electrodes - package of 50 - expired 10/22/18
b. Pediatric Electrodes expired 9/22/18

4. An interview was conducted on 1/29/19 at 2:30 PM with the Director of Infection Control (E#11). E#11 stated "all supplies expired should be discarded."


D. Based on document review, observation, and interview, it was determined the Hospital failed to ensure fluid/blanket warmers were used in accordance with the Association of periOperative Registered Nurses (AORN) standards of practice. This has the potential to affect all inpatients and outpatients serviced by the Hospital.

Findings include:

1. The AORN Guidelines for PeriOperative Practice, 2018 Edition, was reviewed on 1/31/19 at approximately 11:00 AM. On pages 251 to 252, the Guidelines stated the following:

a. "Recommendation V... Precautions should be taken to avoid thermal injuries related to warming solutions, blankets... in blanket- and solution-warming cabinets...Injuries to the patient can result from irrigation solution being warmed to high temperatures.... V.a. Solutions, blankets, and patient linen should be stored in separate warming cabinets... Fluids should not be warmed to the same temperature as blankets... V.b. Warming cabinet temperatures should be set, maintained, monitored, and documented according to organizational policy..."
b. The guidelines, "V.e... blankets and other patient linens should not exceed 130 degrees Fahrenheit (F)."
c. The Guidelines stated, "V.f. Solution manufacturers' instructions for use should be followed regarding the maximum temperature and length of time solutions should remain in the warming cabinet... and for usability after removal..."

2. Tours, with concurrent interviews, of the Obstetric Department, Surgical Department, and the Emergency Department were conducted 1/29/19 through 1/30/19. The following are examples of fluids (both intravenous (IV) and/or irrigation solution) that were in warmers in all three Departments:

a. On 1/29/18 at approximately 2:40 PM, in the Obstetrics surgery room- a blanket warmer contained 1 liter of Normal Saline IV solutions, 2 liters of Normal Saline irrigation solution, and patient blankets. The warmer was set at 100 degrees. There was no external temperature monitor and there was no thermometer in the warmer. The solutions lacked a date as to when they were put into the warmer. The IV and irrigation solutions and the patient blankets were in the same warmer.

On 1/29/19 at approximately 2:40 PM, an interview was conducted with the Director of Obstetrics (E#13). E#13 stated that the Surgery Department was responsible for maintaining the supplies in the warmer. E#13 stated, "We don't keep a log of the temperature (of the warmer)." At approximately 2:50 PM, the Director of Surgery (E#14) observed the Obstetrics warmer and concurred with E#13. E#14 stated that the Hospital did not have policy on the use of IV and/or irrigation warmers.

b. On 1/29/19 at approximately 3:05 PM, in the Surgery Department- (1) warmer in the main corridor of the Surgery Department contained 6 liters of Sterile Water for Irrigation, 8 liters of Normal Saline for Irrigation, and 15- 500 milliliter Normal Saline for Irrigation. The temperature was set at 100 degrees F. No thermometer was in the warmer. (2) In Operating Room #2, a warmer contained 2 liters of Sterile Water for Irrigation and 11- l liter bags of IV solutions. The warmer was set at 100 degrees F and the thermometer inside the warmer read 103 degrees F. The solutions lacked the date as to when they were placed in either of the warmers.

E#14, present during the observation, stated that the Hospital has fluid warmers in each of the 6 Operating Rooms and that there were no logs for any of the warmers. E#14 stated, "I did know that is (the IV and irrigation solutions) expiration dates would change (from being in the warmer), but we go through it so fast." E#14 was unable to state how long the fluids/solutions were good once placed in the warmer, and stated that the Hospital follows AORN guidelines.

c. On 1/30/19 at approximately 1 PM, in the Emergency Department- one fluid warmer was contained 4 liters of Sterile Water for Irrigation, 6- 500 ml Sterile Water for Irrigation, and several bags of various IV solutions. There were no dates on the IV and/or irrigation solutions as to when they were placed in the warmer, no temperature log, and no thermometer in the warmer.

The Director of Surgery (E#14) present during the observation stated, "I just learned that we should only have these (IV fluids and irrigation solutions) in here for 14 days."

3. The Baxter manufacturer guidelines were presented and reviewed on 1/31/19 at approximately 11:40 AM. The guidelines stated, "Warming Recommendations for Large Volume Intravenous (IV) Solutions in plastic bags... to a temperature not exceeding 40 C (Celsius- 104 degrees F), and for a period no longer than 14 days... Warming of Irrigation Solutions in Plastic Pour Bottles... (1) Solutions can be warmed to temperatures not exceeding 50 C (122 degrees F) and for a period no longer than 60 days."

4. The policy titled "Nursing- General Equipment- Safety" (date issued 4/23/2014) was reviewed on 1/31/19 at approximately 10:00 AM. The policy required, "Blanket warmer temperature not to exceed 130 degrees."

5. During a tour of the Barium Kitchen in Radiology on 1/30/19 at approximately 9:30 AM with the Radiology Supervisor (E#17), the blanket warmer log was reviewed. The January monthly log indicated the temperature range was 157 degrees to 159 degrees for the month of January 2019.

6. An interview was conducted during the tour on 1/30/19 at approximately 10:00 AM with E#17. E#17 stated "unsure of the acceptable temperature range".



E. Based on documentation, observation and interview, it was determined the Hospital failed to ensure staff followed established policies and procedures for maintaining refrigeration temperatures. This has the potential to affect all patients receiving care at the Hospital with a daily census of 17.

Findings include:

1. The policy titled "Recording Floor Stock Refrigerator Temperatures" (issued by Hospital 6/8/2018) was reviewed on 1/31/19 at approximately 11:00 AM. The policy required, "Temperatures found out of recommended range should be reported to Maintenance and indicated on the form. Maintenance will determine status of refrigerator and plan of action will be based on their recommendations."

2. On 1/29/19 at approximately 1:00 PM the "Same Day Surgery and Special Procedure Daily Freezer/Refrigerator Temperature Log" dated for the month of January 2019 was reviewed. The temperature log required: Refrigerators should be between 36 degrees Fahrenheit and 41 degree Fahrenheit. The log contained documentation the refrigerator was out of range for 16 of 21 days:

1/3/19 the refrigerator temperature was 31 degrees
1/5/19 the refrigerator temperature was 30 degrees
1/7/19 the refrigerator temperature was 30 degrees
1/9/19 the refrigerator temperature was 32 degrees
1/11/19 the refrigerator temperature was 30 degrees
1/14/19 and 1/15/19 the refrigerator was 30 degrees
1/17/19 the refrigerator temperature was 34 degrees
1/18/19 refrigerator temperature was 32 degrees
1/21/19 and 1/22/19 refrigerator temperature was 30 degrees
1/23/19 the refrigerator temperature was 32 degrees
1/24/19 the refrigerator temperature was 30 degrees
1/28/19 the refrigerator temperature was 42 degrees

3. During an interview on 1/29/19 at approximately 4:40 PM, with Director of Infection Control (E#11), (E#11) acknowledged the freezer was out of range after reviewing the log and stated that there is no documentation that dietary or engineering was notified the refrigerator was out of range.

4. A tour, with a concurrent interview, was conducted of the Obstetrics Department on 1/29/19 at approximately 1:15 PM with the Director of Obstetrics (E#13). In a patient refrigerator the freezer was at 0 degrees Fahrenheit (F) and the refrigerator was at 36 degrees F. There were no temperature monitoring logs. E#13 verbally agreed the patient refrigerator temperature was not being monitored.

5. A tour, with concurrent interview, was conducted of the Sleep Laboratory on 1/30/19 at approximately 10:00 AM with the Director of Cardiopulmonary Rehabilitation (E#19). A patient refrigerator had no temperature monitoring logs. E#19 stated, "We don't have one (a temperature log for the patient refrigerator)."

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Based on observation, documentation and interview, it was determined that the Facility failed to ensure patient equipment was maintained to prevent cross-contamination. This has the potential to affect all patients receiving care at the Hospital with a current census of 17 patients.

Findings include:

1. An observation of surgical room 4 was completed on 1/29/19 at approximately 12:30 PM. In the Anesthesia cart second drawer a non-disposable #4 Mac Laryngoscope with a 2 X 2 inch hole in the package was available for patient use. A disposable 7.5 mm high volume low pressure Endotracheal Tube was also found opened with a syringe attached in the second drawer. A red box of additional patient equipment contained two oral catheters opened and attached to suction equipment. It was unable to be determined when the items were opened or if they had been used and contaminated.
During the tour an interview was conducted with the Operating room assistant (E #6), E#6 stated "The oral catheters have not been used and were not to be disposed, they are available for emergency use."

2. Hospital Policy "Cleaning in the PeriOperative Setting (revised by Hospital 6/22/18)" was reviewed on 1/31/18 at 12:00 PM. The Policy indicated III. I) "Reusable items that are contaminated with blood or tissue will be removed by OR or OB, and anesthesia staff and transported for reprocessing".

3. An interview with the Director of Surgical Services (E #5) was conducted on 1/30/19 at 2:50 PM. E #5 stated "aware of the findings from the staff".

4. A tour, with concurrent interview, was conducted of the Obstetrics Department on 1/29/19 at approximately 1:15 PM with the Director of Obstetrics (E#13). In the nursery, the neonatal crash cart was had 4 laryngoscope blades laying in the cart, unpackaged. E#13 stated, "I don't know why those (the neonatal laryngoscope blades) are not in packages. They should be."


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