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Based on review of staff license and certification documentation, policy and procedure review and interview, it was determined there was no evidence of current license or certification for six of six (Licensed Practical Nurse (LPN #1-#2, Respiratory Therapist (RT) #1-#2 and Certified Nursing Assistant (CNA) #1-#2) employees. Failure to have current licensure and or certification of staff did not assure competency to perform patient care activities. The failed practiced affected all patients receiving care from LPN #1 and #2, RT #1 and #2, and CNA #1 and #2 in the facility. Findings follow:

A. Review of policy and procedure titled, "Licensure Compliance," showed a copy of the license or certification was to be maintained in the employee's personnel file in the Human Resources Department.
B. Review of employee files for LPN #1-#2, RT #1-#2 and CNA #1-#2) CNAs showed the search for current licensure and certification did not occur until after this surveyor requested employee files for review.
C. The above finding was verified by interview with the Director of Human Resources on 04/11/18 at 10:05 AM.


Based on review of employee's personnel files, job description review and interview, it was determined the facility failed to ensure Basic Life Support (BLS) or Advanced Cardiopulmonary Life Support (ACLS) certification was current for one (#2) of two (#1-#2) Respiratory Therapists (RT), one (#1) of two Registered Nurses (RN), and two of two (#1 and #2) Licensed Practical Nurses (LPN) employees. The failed practice had the potential to affect any patient whose care required cardiopulmonary resuscitation. Findings follow:

A. Review of the Job Description for respiratory therapists (RT) stated the hospital wide requirement was annually for cardiopulmonary resuscitation (BLS).
B. Review of the Job Description for Registered Nurses (RN) stated ACLS was required.
C. Review of the Job Description for Licensed Practical Nurses (LPN) stated ACLS was required.
D. Review of personnel files showed no current BLS certification for RT #1, no current ACLS for RN #1, and no current ACLS certification for LPN #1-#2.
E. The above findings in A, B, C, and D were verified by interview with the Director of Human Resources on 4/11/18 at 10:00 AM.

Based on review of policy, review of manufacturer's instructions, Hot Pack Temperature Logs, observation and interview, it was determined Rehabilitation Services failed to maintain a piece of equipment (Hydrocollator) by not performing cleaning every two weeks and monitoring the water temperature. The failed practice did not ensure Hydrocollator was in safe operating condition for patient use. The failed practice had the likelihood to affect all patients who receive rehabilitation services. Findings follow:

A. Record review of the policy titled, "Physical Therapy Scope of Service," dated 02/2017, showed that Hot Packs was listed as a procedure the Department offered.
B. Review of manufacturer's instructions showed the Hydrocollator tank was to be cleaned every two weeks; the temperature was to be maintained between 160-165 degrees Fahrenheit.
C. Review of Hot Pack Temperature Logs from 01/29/18 until 03/19/18 (closed weekends) showed the facility was open 36 days. In 36 of 36 temperatures logged showed the temperature was between 145 and 155 degrees Fahrenheit. There was no evidence the Hydrocollator was cleaned every two weeks. The log also showed the unit was unplugged on 3/19/18 because it needed to be relocated.
D. During a tour of Rehabilitation services, observation showed the Hydrocollator unplugged and stored in an alcove in the hallway.
E. During an interview on 04/11/18 at 10:17 AM, the Director of Rehabilitation Services verified the Hydrocollator was not in service, had no evidence of cleaning and temperatures were out of range.

Based on observation, review of USP (United States Pharmacopeia), work orders and interview, it was determined the facility failed to maintain the temperature in the pharmacy within the currently recommend temperature of 68-77 degrees Fahrenheit in that the temperature in the Pharmacy was below the recommended temperature for two of two (4/11/18 and 04/12/18) inspections of the Pharmacy. By not maintaining the temperature in the pharmacy, the facility could not assure the safety and efficacy of the medications stored within it. The failed practice had the likelihood to affect all patients in the hospital. Findings follow:

A. Review of the USP definition of Controlled Room Temperature showed the pharmacy should have been between 68-77 degrees Fahrenheit.
B. Observation revealed the temperature in the Pharmacy to be 66 degrees Fahrenheit on 04/11/18 at 1:00 PM and 64 degrees Fahrenheit on 04/12/18 at 9:06 AM.
C. Review of Facility's Maintenance Work Orders showed the following:
1) 06/22/17-a work order was placed due to air conditioning problems; and
2) 09/18/17-a work order was placed showing the temperature in the Pharmacy was out of range and the drugs were being stored above the recommended temperatures.
D. During an interview on 04/12/18 at 9:06 AM, the Director of Pharmacy verified the temperature in the Pharmacy was not being maintained between 68-77 degrees Fahrenheit.

Referenced Code: 42 CFR 485.623(d)

Based on observation and interview, it was determined three of three (Operating Rooms (ORs) #1, and #2 and the endoscopy procedure room) procedure rooms were not protected by either isolated power or Ground-Fault Circuit Interrupters (GFCIs); nor, was there evidence presented a risk assessment had been performed to indicate the ORs were not to be considered as "wet locations" in which the receptacles need to be protected. The failed practice had the potential to affect all patients and staff in the ORs because it could not be assured that any electrical equipment connected to the receptacles would not present a shock hazard. Findings follow:

A. While touring the facility on 04/10/18 at 2:00 PM, observation showed:
1) The receptacles in OR#1 were neither connected to an isolated electrical panel; nor, were they Ground Fault Circuit Interrupting (GFCI).
2) The receptacles in OR#2 were neither connected to an isolated electrical panel; nor, were they GFCI.
3) The receptacles in the Endoscopy Procedure Room were neither connected to an isolated electrical panel; nor, were they GFCI.
B. During the tour, the Director of Plant Operations verified the receptacles were not protected by either an isolation panel or were they GFCI and no evidence was presented to indicate that a risk assessment had been performed to determine that the receptacles did not need to be protected in the above manner.
C. See K913.

Referenced codes: NFPA 99, 2012 Edition, Sections: 6.3.2.2.8.4, 6.3.2.2.8.7; NFPA 70, 2011 Edition, Article: 517.20

Based on review of Medical Staff Bylaws, Physician's Credentialing Files, and interview, it was determined the Governing Body failed to monitor the expiration dates of licenses for two (#1 and #5) of five (#1-#5) physician's. By not having evidence the physicians were licensed, the facility could not assure the services provided were by a qualified professional. The failed practice had the likelihood to affect all patients receiving healthcare. Findings follow:

A. Review of Medical Staff Bylaws showed all credential files were to contain evidence of valid and current licensure.
B. Review of Physician's Credentialing Files showed the following:
1) Physician #1's DEA (Drug Enforcement Agency) license had expired 7/31/17; and
2) Physician #5's State License had expired on 12/31/17.
C. During an interview on 04/10/18 at 1:56 PM, the Medical Staff Coordinator verified Physician#1 and #5 had expired licenses.

Based on review of policy, observation and interview, it was determined the emergency medications were locked instead of being secured with a breakaway seal (per policy) on two (Emergency Department and Surgical Services) of three (Emergency Department, Surgical Services and Medical Surgical) departments toured. By not maintaining emergency medications in a manner that makes them rapidly available, the facility could not assure they were ready for an emergent situation. The failed practice had the likelihood to affect all patients who needed emergency medications. Finding follow:

A. Record review of the policy titled, "Emergency Carts Security," revised 03/2017, showed that emergency type medications were to be secured with a breakaway seal, as opposed to being locked with a key.
B. During a tour of the facility on 04/09/18 from 12:32 PM until 1:52 PM; observation showed the following:
1) In the Emergency Department, in Trauma room #1, the medications in the emergency cart were locked instead of being secured with a breakaway seal; and
2) In Surgical Services, the emergency cart did not contain medications in it, but the emergency medications were locked on the anesthesia cart instead of being secured on the emergency cart with a breakaway seal.
C. During an interview on 04/09/18 at 12:37 PM, RN (Registered Nurse) #2 verified the medications in the emergency cart were locked, in the Emergency Department.
D. During an interview on 04/09/18 at 01:42 PM, the Director of Surgical Services verified the emergency medications were locked in the anesthesia carts, in Surgical Services.

Based on policy and procedure review, observations and interview, it was determined the facility failed to prevent infections in that patient care equipment was stored under one (Endoscopy Room) of two (Emergency Room Trauma 1 and Endoscopy Room) sinks. Failure to ensure patient care equipment was stored where it could not get wet had the potential for contaminated items to be used in the care of patients. The failed practice had the likelihood to affect any patient undergoing a procedure in the Endoscopy Room. Findings follow:

A. Review of the policy and procedure titled "Cleaning Environment, Patient Equipment and Medical Devices," received on 04/10/18, showed equipment was not to be stored on or immediately around a sink to avoid contamination.
B. Observation in the Endoscopy room at 1:20 PM on 04/09/18 showed two gallons of distilled water, five connection tubings and ten suction canisters stored under the sink. During an interview with Scrub Technician #1 at 1:30 PM on 04/09/18 the findings were verified.


Based on policy and procedure review, observations and interview, it was determined the facility failed to prevent and control infections in that it failed to ensure laryngoscope blades in one (Recovery Room) of two (Recovery Room and Emergency Room) crash carts observed were stored unpackaged so that cross contamination of the blades could occur. Failure to ensure laryngoscope blades were stored packaged did prevent contamination from other blades, items in the same drawer and employee hands had the potential for contaminated or dirty blades to be used during patient care. The failed practice had the potential to affect any patient who care required a laryngoscope blade in the Recovery Room. Findings follow:

A. Review of the policy and procedure titled "Cleaning Environment, Patient Equipment and Medical Devices" received on 04/10/18 showed Semi-critical items, as defined by the CDC (Centers for Disease Control) should be cleaned and then disinfected with a high level disinfectant. Examples listed in the policy and procedure were endoscopic equipment, laryngoscope blades, some respiratory and anesthesia equipment, and vaginal ultrasound probes.
B. Observation at 1:45 PM on 04/09/18 showed nine unpackaged laryngoscope blades lying loose in a cracked, plastic bin in the top drawer of the crash cart located in the Recovery Room. The laryngoscope blades were not separated, covered or protected to avoid touching each other. During an interview with the Director of Surgical Services at 1:45 PM on 04/09/18 the findings were verified.


Based on observation, review of manufacturer's directions and interview, it was determined the facility failed to prevent and control infections in that it failed to monitor the temperature of the room where the Rapicide Strips were stored. Failure to ensure the Rapicide Strips were stored between 43 to 86 degrees Fahrenheit had the potential to affect the efficacy of the Rapicide Strips which were used to check the efficacy of the solution used to clean scopes used in the Endoscopy room. The failed practice had the likelihood to effect any patient whose care and treatment required the use of a scope. Findings follow:

A. Review of the Rapicide Strips bottle manufacturer's guidelines showed the temperature of the room where the strips were stored should be 43 to 86 degrees Fahrenheit.
B. Observation of the Scope Room at 1:15 PM on 04/09/18 showed no monitoring of the room temperature where the Rapicide Strips were stored. During an interview with Scrub Technician #1 at 1:20 PM on 04/09/18, the findings were verified.



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Based on observation and interview, it was determined the facility failed to mitigate the risk of cross contamination in that clean rehabilitation equipment was stored in a functioning bathroom in one of one Inpatient Rehabilitation Gym. By not storing clean separate from dirty, the facility could not assure the clean equipment would not get contaminated by being stored in a bathroom (dirty area). The failed practice had the likelihood to affect all patients that are treated in the Inpatient Rehabilitation Gym. Findings follow:

A. During a tour of the Inpatient Rehabilitation Gym 04/11/18 from 9:20 AM until 9:35 AM, observation showed rehabilitation equipment being stored in a functioning bathroom. Examples of items being stored were four walking assistance devices, a transfer board and an Electrical Muscle Stimulator machine.
B. During an interview on 04/11/18 at 09:32 AM, Occupational Therapy Assistant verified the clean equipment was being stored in the bathroom.


Based on review of policy, observation and interview, it was determined the facility failed to mitigate the risk of cross contamination in that they did not immediately take used Laryngoscope blades back to Central Sterile, but instead placed them in a container of yellowish solution, unlabeled and dated 03-12-18, that was attached to one (Cart #1) of two (Carts #1 and #2) anesthesia carts. By placing the laryngoscope blades in an unlabeled solution, and not knowing how long the solution was in the container, the facility could not assure there was no cross contamination of other contents on the anesthesia cart, and the facility could not assure the laryngoscope blades were being cleaned according to facility policy. The failed practice had the likelihood to affect all patients that came in for procedures. Findings follow:

A. Record review of the policy titled, "Laryngoscope Blades," dated 02/2017, showed that after each use, the Laryngoscope Blades were to be immediately taken to the Central Sterile Department and placed in the sink with an enzymatic solution.
B. During a tour of the facility on 04/09/18 from 12:32 PM until 1:52 PM, observation showed a quart size clear container unlabeled which held a yellowish solution. It was attached to the Anesthesia Cart, on the left side and the lid had a date of 03/12/18.
C. During an interview on 04/09/18 at 1:26 PM, the Director of Surgical Services stated the solution was to place the used laryngoscope blades in. She did not know if the date on the lid was the date it was filled or the expiration date and she also verified the solution container was not labeled with the contents.

Based on review of policy, review of Physician's TB (Tuberculosis) records, and interview, the Infection Control Officer failed to mitigate risks of TB transmission to patients and staff by not annually screening three (#2, #4 and #5) of five (#1-#5) Physicians for TB. By not assuring the Healthcare workers were screened annually, the facility couldn't assure they were controlling infections and communicable diseases of patients and personnel. The failed practice had the likelihood to affect all of the employees and patients in the facility. Findings follow:

A. Record review of the policy titled, "Employment TST Skin Test & Immunizations," showed that all employees were to be tested and or screened for TB upon hire and annually thereafter.
B. Review of the Physician's Tuberculosis records showed the following:
1) Physician #2-showed the date of the last annual screening was 02/20/17. The form used was only partially completed;
2) Physician #4-showed the date of the last annual screening was 11/27/13; and
3) Physician #5-showed the date of the last annual screening was 10/21/15.
C. During an interview on 04/10/18 at 1:56 PM, the Medical Staff Coordinator verified Physician #2, #4 and #5 did not have evidence of TB screening in the past 12 months.


Based on observation and interview, it was determined the facility failed to control potential infections in that the facility failed to keep syringes and needles sterile until use in that one (Cart #2) of two (Carts #1 and #2) Anesthesia Carts had needles and syringes opened, and stored for future use. By not using immediately when removed from sterile packaging, the facility cannot assure the sterility when they use them after they have been stored opened. The failed practice has the likelihood to affect all patients who receive anesthesia services. Findings follow:

A. During a tour of the facility on 04/09/18 from 12:32 PM until 1:52 PM, observation showed the following in Anesthesia Cart #2:
1) Three 3 ml (milliliter) syringes opened, with needles attached to them;
2) Three 3 ml syringes opened, with needles attached to them with a Versed label on them;
3) Two 3 ml syringes opened, with needles attached to them with Sublimaze labels on them; and
4) One 10 ml syringe opened, with a needle attached to it.
B. During an interview on 04/09/18 at 1:16 PM, the Director of Surgical Services verified the syringes and needles were out of their sterile wrappers.

Based on policy and procedure review, clinical record review and interview, it was determined that nursing services failed to evaluate and supervise the care of six (#1-#5 and #7) of seven inpatients and three of three (#22-24) Swing-Bed patients in that daily weights were not performed and recorded as mandated per facility policy and procedure. Failure to obtain and record daily weights as mandated per the facility's policy and procedure, did not allow nursing to identify and implement interventions and had the potential for adverse reactions and prolonged hospitalizations. The failed practice affected Patient #1-#5, #7, and #22-#24. Findings follow:

A. Review of the policy and procedure titled, "Daily Weights," received from the Compliance Officer at 12:00 PM on 04/10/18 showed all patients were to be weighed on admission and daily at 6:00 AM, and the weight documented in the electronic medical record.
B. Review of Patient #1's clinical record showed no weights documented three (04/07/18 - 04/09/18) of four (04/06/18 - 04/09/18) days. During an interview with the Chief Nursing Officer (CNO) at 11:54 AM on 04/12/18 the findings were verified.
C. Review of Patient #2's clinical record showed no weights documented one (04/09/18) of three (04/08/18 - 04/10/18) days. During an interview with the CNO at 11:52 AM on 04/12/18 the findings were verified.
D. Review of Patient #3's clinical record showed no weights documented three (04/07/18 - 04/09/18) of five (04/06/18 - 04/10/18) days. During an interview with the CNO at 11:50 AM on 04/12/18 the findings were verified.
E. Review of Patient #4's clinical record showed no weights documented three (04/05/18 - 04/10/18) of six (04/05/18 - 04/10/18) days. During an interview with the CNO at 11:53 AM on 04/12/18 the findings were verified.
F. Review of Patient #5's clinical record showed no weights documented two (04/08/18 and 04/09/18) of five (04/06/18 - 04/10/18) days. During an interview with the CNO at 11:51 AM on 04/12/18 the findings were verified.
G. Review of Patient #7's clinical record showed no weights documented one (03/26/18) of three (03/25/18 - 03/27/18) days. During an interview with the CNO at 11:54 AM on 04/12/18 the findings were verified.
H. Review of Patient #22's clinical record showed no weights documented two (04/08/18 and 04/09/18) of six (04/05/18 - 04/10/18) days. During an interview with the CNO at 12:00 PM on 04/12/18 the findings were verified.
I. Review of Patient #23's clinical record showed no weights documented seven (03/30/18, 03/31/18, 04/02/18-04/04/18, 04/08/18 and 04/09/18) of thirteen (03/30/18 - 04/10/18) days. During an interview with the CNO at 11:57 AM on 04/12/18 the findings were verified.
J. Review of Patient #24's clinical record showed no weights documented seven (03/29/18-03/31/18, 04/02/18 - 04/04/18 and 04/08/18) of thirteen (03/27/18 - 04/09/18) days. During an interview with the CNO at 11:55 AM on 04/12/18 the findings were verified.

Based on interview and policy and procedure review, it was determined the facility did not employ a qualified professional to direct the Swing-Bed Activities program. Failure to employ a qualified professional did not ensure Swing-Bed patients received activities designed to meet the interests, physical, mental and psychosocial well-being of each patient. The failed practice affected the six (#22-27) Swing-Bed patients on 04/11/18. Findings follow:

A. Review of the policy and procedure titled, "Activities Program," received on 04/10/18, showed the Activities Program would be directed by the case management Social Worker.

B. During an interview with the Swing-Bed Activities Director and the Chief Nursing Officer at 10:15 AM on 04/11/18, the Swing-Bed Activities Director stated that she performed the Activities Assessment at the same time the Social Assessment was performed. During the interview, the Swing-Bed Activities Director stated that her credentials to direct the Swing-Bed Activities Program was a Licensed Master Social Worker.