HospitalInspections.org

Based on review of Swing Bed Policies and Procedures, review of clinical records and interview, the nursing staff failed to assure the care plan for one of one (#1) Swing Bed patient was updated to include the need for feeding assistance as identified in the nutritional assessment. The failed practice had the potential to compromise Patient #1's nutritional status and had the potential to affect all patients admitted to the Swing Bed Unit. Findings follow:

A. Review of Swing Bed Patient #1's "Progress Notes" dated 08/06/12 revealed, "Medical Nutrition Therapy F/U (Follow Up), consuming 5-75% of meals. "My hands are bandaged, making it hard to eat".
B. Review of Swing Bed Patient #1's "Interdisciplinary Plan of Care" dated 08/01/12 revealed it did not have evidence of any barriers (i.e. bandaged hands) the patient had in feeding herself or how it could affect her ability to feed herself. There was no evidence that the Interdisciplinary Plan of Care was updated to include the findings of the nutritional assessment dated 08/06/12.
C. Review of policy, "Swing Bed: Patient Assessment-Nursing Plan of Care" presented 10/25/12 by the Director of Quality revealed, "the written plan of care is a dynamic tool when updated to the plan initiated as the patient's status changes or as goals or interventions are modified. The RN (Registered Nurse) maintains ultimate responsibility for coordinating the planning of care with all care providers adding to the plan and recommending changes in approaches as indicated".
D. Findings were verified with the Director of Quality on 10/25/12 at 1320.

Based on clinical record review and interview, it was determined 4 (#22-#25) of 7 (#5, #7,
#22-#26) pre-surgical assessments did not have evidence of the time they were conducted by the physician. The failed practice did not assure the assessment was performed before the surgical procedure and did not assure the physician was aware of any changes in the patient's condition which could alter the surgical plan. The failed practice affected 4 of 7 surgical patients and had the potential to affect all patients admitted for surgery in the facility. Findings follow:

A. Review of Patient #22's clinical record revealed the "Surgeon's Pre-Operative Notes" dated 10/16/12 did not include the time the assessment was conducted.
B. Review of Patient #23's clinical record revealed the "Surgeon's Pre-Operative Notes" dated 10/12/12 did not include the time the assessment was conducted.
C. Review of Patient #24's clinical record revealed the "Surgeon's Pre-Operative Notes" dated 10/09/12 did not include the time the assessment was conducted.
D. Review of Patient #25's clinical record revealed the "Surgeon's Pre-Operative Notes" dated 10/04/12 did not include the time the assessment was conducted.
E. Findings were confirmed with the Director of Quality on 10/25/12 at 1530.

Based on observation, review of policy and interview, it was determined the facility failed to ensure all high risk/high alert medications were labeled properly in that 9 (Intravenous(IV) Calcium Chloride/ Gluconate; Epidural and Patient Controlled Administration (PCA) infusions; IV Heparin; IV Magnesium Sulfate; Neuromuscular Blocking agents; Concentrated Potassium Chloride/Phosphate/Acetate; Concentrated Sodium Chloride; Total parenteral Nutrition (TPN) solutions and Thrombolytic agents) of 10(Intravenous(IV) Calcium Chloride/ Gluconate; Epidural and Patient Controlled Administration (PCA) infusions; IV Heparin; IV Magnesium Sulfate; Neuromuscular Blocking agents; Concentrated Potassium Chloride/Phosphate/Acetate; Concentrated Sodium Chloride; Total parenteral Nutrition (TPN) solutions; Thrombolytic agents and Insulin) high risk/high alert medications were not labeled with a secondary caution label (high alert label) to reduce the risk of errors. The failed practice had the potential to affect any patients requiring a high alert/high risk medication not labeled. Findings follow:

A. A tour of the pharmacy on 10/24/12 between 0830 and 1040 revealed shelving in the pharmacy, for storing high risk/ high alert medications (not including refrigerated medications); the medications stored on these shelves were not labeled with a secondary caution label. When asked if a cautionary label was placed on the medications at the time of dispensing, the Director of Pharmacy answered "No, only Insulin gets a cautionary label."
B. Review of policy titled "High Risk/High Alert Meds" stated "All high risk drugs and drugs with a higher potential for dispensing error due to look alike/sound alike named will be stored with a secondary caution label (high alert label)."
C. Findings were verified, through interview, with the Director of Pharmacy on 10/24/12 at 1335.

Based on observation, review of policy, review of Laminar Flow Hood Daily Cleaning Log and interview, it was determined the facility failed to ensure a clean environment in that one of one Laminar Flow Hood did not show evidence of having been cleaned recently. By not maintaining a sterile environment within the Laminar Flow Hood, the facility could not ensure the safety and sterility of products produced in it. The failed practice had the potential to affect all patients receiving parenteral products or sterile drugs prepared in the Laminar Flow Hood. Findings follow:

A. During a tour of the pharmacy on 10/24/12 between 0830 and 1040, the Laminar Flow Hood was observed to have several areas of dried solutions in various colors and thicknesses on the side panels, roof and work surface, debris that resembled crumbs towards the front of the work surface, and a yellow like discoloration on the two black handles on the left of the Hood.
B. Review of policy titled "Sterile Products: HEPA (High-Efficiency Particulate Air)Filtered Equipment" stated "Clean the working area with a currently approved microbial agent before the first process of the day, after spills, and at least once each shift. Clean the counter, side panels and other accessible surfaces starting at the top/back and working down toward the front. Document the cleaning."
C. Review of the Laminar Flow Hood Daily Cleaning Log during the tour, revealed [initials] signed the log, indicating cleaning was complete on 10/24/12. The Director of Pharmacy was asked if anything had been produced in the hood yet that day (10/24/12), and he replied "Not yet."
D. Findings were verified, through interview, on 10/24/12 at the time of observation, with the Director of Pharmacy.

Based on review of policy, review of Validation Exercise Sterility Log and interview, it was determined the facility failed to provide evidence of annual re-certification of Intravenous (IV) Admixture technique for one (Pharmacist #1) of four (Pharmacist #1 and #2, Director of Pharmacy and Pharmacy Technician) personnel trained to compound in the Laminar Flow Hood and did not have evidence of an annual Validation Exercise in sterility. The facility could not assure they had a process in place to verify the personnel compounding medications in the Laminar Flow Hood were doing so with proper sterile technique. The failed practice had the potential to affect all patients receiving medications compounded by the Pharmacy. Findings follow:

A. Review of policy titled "Orientation, Education, and Training: IV Admixture Training and Validation Program" stated "All personnel will complete annual re-certification including written exams and media fills."
B. Review of Validation Exercise Sterility Logs for October 2011 through September 2012 revealed no evidence Pharmacist #1 was re-certified.
C. Findings were verified, through interview, with the Director of Pharmacy on 10/24/12 at 1335.

Based on observation, review of policy and interview, it was determined the pharmacy failed to store refrigerated controlled substances under double lock in that 200 Lorazepam 2mg (milligram)/ml (milliliter) vials were in a bottom drawer, in a refrigerator, not doubled locked. By not storing the Lorazepam under double lock storage, the facility could not ensure the Lorazepam was properly controlled. Findings follow:

A. During a tour of the facility on 10/24/12 between 0830 and 1040, the refrigerator in the pharmacy had 200 Lorazepam 2mg/ml vials that were stored in a bottom drawer of the refrigerator and was not double locked.
B. Review of facility policy titled "Controlled Substances: General" stated, "Controlled drugs shall be procured, distributed, administered, wasted, and accounted for in compliance with all federal laws, rules and regulations; the laws, rules and regulations of this state; and all CHS corporate policies regarding controlled substances."
C. Findings were verified, through interview, on 10/24/12 at1335 by the Director of Pharmacy.

Based on Environment of Care Function Manual review and interview it was determined the facility did not ensure regular inspections by the local fire department. The failed practice had the potential to affect the health and safety of all patients, staff and visitors because the fire department familiarity of the potential hazards and physical layout of the facility was not assured. The facility had a census of 13 patients on 10/22/12. The findings follow:

A. In an interview on 10/23/12 at 1400, the Plant Operation Director verified there was no documentation of fire department inspection available for review.
B. Review of the Environment of Care Function Manual on 10/24/12 at 0930 revealed there were no local or state fire marshal visits in the last three years.

Based on review of policies and procedures, review of manufacturer's recommendations, observation and interview, the infection control officer failed to assure infection control practices were followed in that sterilization policies and procedures did not conform to manufacturer's recommendation for a 30 day expiration for the wrapping product used in sterilizing instrument sets and that staff did not wipe down horizontal surfaces in the operating rooms at the beginning of each surgical day. The failed practices did not assure instrument sets were not used past the expiration date and did not assure a sanitary environment in the operating rooms. The failed practices had the potential to affect all patients undergoing surgical procedures in the facility. Findings follow:

A. A tour of the Surgical Services Department was conducted on 10/23/12 from 1330-1450 with the Director of Surgical Services. In the Central Sterile Supply Room, the following instruments sets were on shelves, past the manufacturer's expiration time limit of 30 days and available for patient use:
1) Two eye sets expired 08/16/12 and 09/19/12;
2) Three Eye Utrata expired 09/09/10;
3) Two Phaco expired 09/19/12 and 10/18/12;
4) Three Catarac Sets expired 08/16/12, 09/19/12, and 10/18/12; and
5) Three basins expired 10/17/12.
B. During interview with the Director of Surgical Services at the time of observation, she stated she "was not aware of a 30 day expiration date" for the sterilization wrap products. When asked if the OR (Operating Room) staff wiped down the rooms at the beginning of the surgical day, she stated, "no, housekeeping cleans the rooms at night."
C. Review of policy, "Housekeeping Standards for OR Sanitation" revealed, "3. At the beginning of each surgical day, all horizontal surfaces, including overhead lights and equipment, are cleaned with a suitable germicide by OR staff."
D. Review of Kimberly-Clark manufacturer's directions for use revealed, "Real-time testing simulating clinical use supports maintenance of package sterility for at least 30 days."
E. Review of policy, "Guidelines for Cleaning, Disinfection, and Sterilization of Patient Care Items - Surgical instruments and devices sterilized in the hospital" revealed, "follow manufacturer's instructions for use and storage times."
F. Review of policy "Processing Procedure" revealed "12. Sterility of items will be event related" which did not conform to manufacturer's recommendations of 30 day expiration.
G. Review of policy "Event Related Shelf Life" revealed "Sterility of items will be event related rather than date related. All items sterilized by Central Sterile will be considered sterile unless the package/pack/tray/container is damaged or wet. No expiration date will be routinely assigned" which did not conform to manufacturer's recommendations of 30 day expiration.
H. Findings were confirmed with the Director of Surgical Services on 10/24/12 at 1430.

Based on clinical record review and interview, it was determined 7 of 7 (Patient #5, #7, #22-#26) operative reports did not include the time of the surgery. Failure to record the time of surgery on the operative report did not support a time line of events in the clinical record nor allow the record to be complete. The failed practice affected 7 of 7 patients and had the potential to affect all patients undergoing a surgical procedure in the facility. Findings follow:

A. Review of Patient #5's clinical record revealed the "Operative Report" dated 10/09/12 did not include the time of the procedure.
B. Review of Patient #7's clinical record revealed the "Operative Report" dated 10/23/12 did not include the time of the procedure.
C. Review of Patient #22's clinical record revealed the "Operative Report" dated 10/16/12 did not include the time of the procedure.
D. Review of Patient #23's clinical record revealed the "Operative Report" dated 10/12/12 did not include the time of the procedure.
E. Review of Patient #24's clinical record revealed the "Operative Report" dated 10/09/12 did not include the time of the procedure.
F. Review of Patient #25's clinical record revealed the "Operative Report" dated 10/04/12 did not include the time of the procedure.
G. Review of Patient #26's clinical record revealed the "Operative Report" dated 09/18/12 did not include the time of the procedure.
H. Findings were confirmed with the Director of Quality on 10/25/12 at 1530.

Based on review of Swing Bed Policies and Procedures and interview, the facility failed to include the patient's right to refuse treatment or refuse to participate in experimental research in their Patient Rights Policy and in the Patient Guide. The failed practice did not assure patients were made aware of their rights during their hospitalization and had the potential to affect all patients admitted to the Swing Bed Unit in the facility. Findings follow:

A. Review of Swing Bed Policies presented by the Director of Quality on 10/25/12 revealed they did not have Patient Rights Policies specific to the Swing Bed Unit.
B. Review of policy, "Patient Rights" presented by the Director of Quality on 10/25/12 revealed it did not address the patient's right to refuse treatment or refuse to participate in experimental research.
C. Review of the "Patient Guide" presented by the Director of Quality on 10/25/12 revealed it did not address the patient's right to refuse treatment or refuse to participate in experimental research.
D. On interview with the Director of Quality on 10/25/12 at 1320, she confirmed there were no policies specific to Patient's Rights for the Swing Bed Unit and stated, "We use the same Patient Rights policies for all patients, whether they are in Swing Bed or Acute Care. A copy of them is included in the Patient Guide which is given to all patients at admission."

Based on review of Swing Bed Policies and Procedures and interview, the facility failed to include the patient's right to work or refuse to work in their Patient Rights Policy and in the Patient Guide. The failed practice did not assure patients were made aware of their rights during their hospitalization and had the potential to affect all patients admitted to the Swing Bed Unit in the facility. Findings follow:

A. Review of Swing Bed Policies presented by the Director of Quality on 10/25/12 revealed they did not have Patient Rights Policies specific to the Swing Bed Unit.
B. Review of policy, "Patient Rights" presented by the Director of Quality on 10/25/12 revealed it did not address the patient's right to work or to refuse to work.
C. Review of the "Patient Guide" presented by the Director of Quality on 10/25/12 revealed it did not address the patient's right to work or to refuse to work.
D. On interview with the Director of Quality on 10/25/12 at 1320, she confirmed there were no policies specific to Patient's Rights for the Swing Bed Unit and stated, "We use the same Patient Rights policies for all patients, whether they are Swing Bed or Acute Care. A copy of them is included in the Patient Guide which is given to all patients at admission."

Based on review of Swing Bed Policies and Procedures and interview, the facility failed to include the patient's right to receive mail that was unopened or to have access to writing implements in their Patient Rights Policy and in the Patient Guide. The failed practice did not assure patients were made aware of their rights during their hospitalization and had the potential to affect all patients admitted to the Swing Bed Unit in the facility. Findings follow:

A. Review of Swing Bed Policies presented by the Director of Quality on 10/25/12 revealed they did not have Patient Rights Policies specific to the Swing Bed Unit.
B. Review of policy, "Patient Rights" presented by the Director of Quality on 10/25/12 revealed it did not address the patient's right to receive mail that was unopened or to have access to writing implements.
C. Review of the "Patient Guide" presented by the Director of Quality on 10/25/12 revealed it did not address the patient's right to receive mail that was unopened or to have access to writing implements.
D. On interview with the Director of Quality on 10/25/12 at 1320, she confirmed there were no policies specific to Patient's Rights for the Swing Bed Unit and stated, "We use the same Patient Rights policies for all patients, whether they are Swing Bed or Acute Care. A copy of them was included in the Patient Guide which was given to all patients at admwassion."

Based on review of Swing Bed Policies and Procedures and interview, the facility failed to include the patient's right to retain or use personal possessions, including furnishings or clothing in their Patient Rights Policy and in the Patient Guide. The failed practice did not assure patients were made aware of their rights during their hospitalization and had the potential to affect all patients admitted to the Swing Bed Unit in the facility. Findings follow:

A. Review of Swing Bed Policies presented by the Director of Quality on 10/25/12 revealed they did not have Patient Rights Policies specific to the Swing Bed Unit.
B. Review of policy, "Patient Rights" presented by the Director of Quality on 10/25/12 revealed it did not address the patient's right to retain or use personal possessions, including furnishings or clothing.
C. Review of the "Patient Guide" presented by the Director of Quality on 10/25/12 revealed it did not address the patient's right to retain or use personal possessions, including furnishings or clothing.
D. On interview with the Director of Quality on 10/25/12 at 1320, she confirmed there were no policies specific to Patient's Rights for the Swing Bed Unit and stated, "We use the same Patient Rights policies for all patients, whether they are Swing Bed or Acute Care. A copy of them is included in the Patient Guide which is given to all patients at admission."

Based on review of Swing Bed Policies and Procedures and interview, the facility failed to include the patient's right to share a room with their spouse, if admitted to the same facility and both consent to the arrangement, in their Patient Rights Policy and in the Patient Guide. The failed practice did not assure patients were made aware of their rights during their hospitalization and had the potential to affect all patients admitted to the Swing Bed Unit in the facility. Findings follow:

A. Review of Swing Bed Policies presented by the Director of Quality on 10/25/12 revealed they did not have Patient Rights Policies specific to the Swing Bed Unit.
B. Review of policy, "Patient Rights" presented by the Director of Quality on 10/25/12 revealed it did not address the patient's right to share a room with their spouse if admitted to the same facility and both consent to the arrangement.
C. Review of the "Patient Guide" presented by the Director of Quality on 10/25/12 revealed it did not address the patient's right to share a room with their spouse if admitted to the same facility and both consent to the arrangement.
D. On interview with the Director of Quality on 10/25/12 at 1320, she confirmed there were no policies specific to Patient's Rights for the Swing Bed Unit and stated, "We use the same Patient Rights policies for all patients, whether they are Swing Bed or Acute Care. A copy of them is included in the Patient Guide which is given to all patients at admission."

Based on review of Swing Bed Policies and Procedures and interview, it was determined the facility failed to assure the activities program for Swing Bed patients was on-going in that activities were started after 14 days of admission to the Swing Bed Unit. The failed practice prevented those patients admitted to the Swing Bed Program from participating in activities throughout the course of their stay and had the potential to affect all patients admitted to the Swing Bed Unit. Findings follow:

Review of "Case/Resource Management Swing Bed Program" policy presented by the Director of Quality on 10/25/12 at 1320 revealed, "...because only short duration of stays in Swing Bed are all that is needed to meet skilled needs of the patients, activities may be started after a 14 day stay is met in the Swing Bed program."

Based on review of the Physician Roster, review of policies and procedures and interview, the facility failed to assure a dentist was credentialed on the Medical Staff for patients needing dental services on the Swing Bed Unit. The failed practice prevented Swing Bed patients, who did not have a private dentist, from receiving needed dental care and had the potential to affect all patients admitted to the Swing Bed Unit. Findings follow:

A. Review of policy, "Swing Bed: Dental Services" presented by the Director of Quality on 10/25/12 revealed, "If the patient develops acute dental problems while in the facility, arrangements will be made for the patient to see his private dentist, if possible. Otherwise, dental services may be provided by a consulting dentist with clinical privileges at (named facility)."
B. Review of the Physician Roster presented by the Director of Quality on 10/23/12 revealed it did not include a dentist.
C. On interview with the Director of Quality on 10/25/12 at 1320, she confirmed the facility did not currently have a dentist credentialed on the Medical Staff.