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Based on review of policies and procedures and interview, it was determined the facility failed to assure policies for Nursing, Labor and Delivery, Respiratory and Infection Control were reviewed annually. The failed practice did not assure policies were up to date and reflected current practices and was likely to affect all patients admitted to the facility. Findings follow:

A. Review of Nursing policies and procedures revealed the "Annual Approval" signature page, located in the front of the manual was dated 11/13/12.
B. Review of Labor and Delivery policies and procedures revealed the "Annual Approval" signature page, located in the front of the manual had blank spaces with no signatures.
C. Review of Respiratory Therapy policies and procedures revealed the "Revised and Reviewed" signature page, located in the front of the manual was dated 07/22/13.
D. Findings were verified with the Chief Nursing Officer on 10/09/14 at 1030.
E. Review of Infection Control policies and procedures revealed the "Reviewed/Revised" signature page, located in the front of the manual had 2013 dates and signatures. All "2013" were written over with "2014." The signature page for 2012 had "January 2013" written on the top. All "2013" dates were written over with "2012." The signature page for 2011 had "January 2013" written on the top. All "2013" dates were written over with "2011." During interview with the Infection Control Coordinator on 10/08/14 at 1350, when asked about the corrected dates, she answered "it was hard to get the doctors to sign forms or attend meetings and that the policies weren't reviewed."

Based on review of Pharmacy policy "Use of Multiple Dose Vials (MDVs)," observation, and interview, the facility failed to ensure multiple dose vials of medications were dated upon entry so that medications would not be administered 28 days after entry resulting in unusable medications for patient use on two of two (Anesthesia Cart #1, Anesthesia Cart #2) anesthesia carts maintained in surgery. The potential existed for the sterility of the medications to be compromised and to be administered to all surgery patients. Findings follow:

A. Pharmacy policy "Use of Multiple Dose Vials (MDVs)" was reviewed on 10/07/14 at 1030. The policy stated "The healthcare provider shall write the expiration date on the vial, when it is opened" and "For multiple dose vials, the expiration will occur 28 days after the vial has been opened/punctured, etc."
B. The medications on Anesthesia Cart #1 were observed on 10/07/14 at 1400. The following multiple dose vials of medications were not dated with the date of entry:
1) One Labetalol 100 milligrams (mg)/20 milliliters (ml);
2) One Dexamethasone 20 mg/5 ml; and
3) One Atropine 20 ml.
C. The medications on Anesthesia Cart#2 were observed on 10/07/14 at 1340. The following multiple dose vials of medications were not dated with the date of entry:
1) Two Flumazenil 0.5 mg/5 ml;
2) One Neostigmine 10 mg/10 ml;
3) One Labetalol 100 mg/20 ml;
4) One Dopram 20 ml; and
5) One Metoprolol 5 ml.
D. At 1410 on 10/07/14, the findings were verified through interview with the Director of Pharmacy.


Based on manufacturer label review, observation, and interview, the facility failed to ensure anesthetists followed manufacturer guidelines in the storage of Rocuronium Bromide Injectable at room temperature upon removal from refrigeration on two of two (Anesthesia Cart #1, Anesthesia Cart #2) anesthesia carts located in surgery. The failed practice caused the anesthetists to be unable to determine the expiration date of the medication rendering the medication unusable. Findings follow:

A. The medications on Anesthesia Cart #1 were observed on 10/07/14 at 1400. One opened multiple dose vial of Rocuronium Bromide was observed on the cart with no dating as to the date the medication was removed from refrigeration initially nor the date the vial was initially entered.
B. The medications on Anesthesia Cart #2 were observed on 10/07/14 at 1340. One opened and one unopened multiple dose vial of Rocuronium Bromide were observed. The unopened vial did not reflect the date the medication had been removed from refrigeration. The opened vial did not reflect the date the medication was initially removed from refrigeration nor the date the vial was initially entered.
C. The manufacturer label of Rocuronium Bromide was reviewed on 10/07/14 at 1340. The manufacturer label revealed once the medication was removed from refrigeration an unopened vial could be stored at room temperature for 60 days and a vial that had been entered for 30 days.
D. During an interview with the Director of Pharmacy on 10/07/14 at 1410, it was verified anesthetists had not labeled the Rocuronium Bromide with initial dates of removal from refrigeration and if opened, with initial dates of entry into the vial so that the expiration of the medication could be determined.


Based on observation and interview, the facility failed to ensure outdated medications were not available for patient use on two of two (Anesthesia Cart #1, Anesthesia Cart #2) anesthesia carts located in surgery. The potential existed for medications with a decrease in efficacy due to being outdated to be administered to all surgery patients. Findings follow:

A. The medications on Anesthesia Cart #1 were observed on 10/07/14 at 1400 revealing the following were outdated:
1) Two vials of Furosemide 40 milligrams(mg)/4 milliliters(ml) expired 09/01/14;
2) Two Phenylephrine 10 mg/ml expired 09/30/14;
3) One vial of Atropine 10 ml expired 08/14;
4) One ampule Methergine expired 8/14;
5) Two vials Succinylcholine 10 ml expired 09/01/14;
6) One bottle of 25 tablets of Nitrostat 0.4 mg expired 08/14;
7) One vial Metoprolol expired 09/14; and
8) Eight vials Neostigmine expired 09/14.
B. The medications on Anesthesia Cart #2 were observed on 10/07/14 at 1340 revealing the following were outdated:
1) Fourteen vials Metoclopramide expired 06/01/14; and
2) One vial Succinylcholine 10 ml expired 09/01/14.
C. At 1410 on 10/07/14, the findings regarding outdated medications on the two anesthesia carts were verified by the Director of Pharmacy.


Based on review of the anesthesia Narcotic Records maintained in surgery and interview, the facility failed to ensure anesthetists were recording the times of administration of controlled substances on the Narcotic Records as required by the state standard of practice as defined in Section 12.I of the Rules and Regulation for Critical Access Hospitals in Arkansas. The failed practice was reflected on five (Versed, Fentanyl, Morphine, Sufenta, Meperidine) of five Narcotic Records reviewed resulting in incomplete records. Findings follow:

A. On 10/07/14 at 1315, the Narcotic Records maintained by anesthesia services were reviewed. The five Narcotic Records reviewed were for the controlled substances Versed, Fentanyl, Morphine, Sufenta, and Meperidine. Times of administration of the medications were not recorded as required.
B. During an interview with the Director of Pharmacy on 10/07/14 at 1325, it was verified the anesthesia services was not recording the time of administration on the Narcotic Records.

Based on observation and interview, it was determined the facility failed to assure only currently dated disinfecting supplies were available for use in four (Operating Room 1, Operating Room 2, Post Anesthesia Care Unit and Nursery) of seven (Operating Room 1, Operating Room 2, Post Anesthesia Care Unit, Nursery, Emergency Department, Monitor Care Unit, Medical Surgical Unit and Senior Care Unit) areas observed. The failed practice created the potential for disinfectants, used to prevent infection, to be ineffective and was likely to affect all patients admitted to the Facility. Findings follow:

A. A tour of the facility was conducted on 10/07/14 from 1310 to 1510 with the Chief Nursing Officer and revealed the following observations:
1) One Bleach Sani-Cloths (disinfectant) container in Operating Room 1 expired 01/14;
2) Two Bleach Sani-Cloths containers in Operating Room 2 expired 04/14 and 08/14;
3) One Bleach Sani-Cloths container in Post Anesthesia Care Unit (PACU) expired 08/14; and
4) One Bleach Sani-Cloths container in the Nursery expired 06/14.
B. Findings were confirmed with the Chief Nursing Officer at the time of the tour.


Based on observation and interview, it was determined the facility failed to assure mattress covers were not torn in two of two (Emergency Room 1 and 2) Emergency Rooms toured as well as one (in Emergency Room 2) of one cracked baby scale held together with tape. The failed practice did not prevent patient contact with exposed foam padding or taped baby scale (contaminated). The failed practice was likely to affect all patients seen in the Emergency Department. Findings follow:

A. During tour of the Emergency Department on 10/07/14 from 1420-1440 with the Chief Nursing Officer, the following observations were made:
1) In Emergency Room 1, the vinyl covering on the patient exam table had tears in both corners at the foot, which exposed the foam pad underneath. Foam cannot be disinfected due to its absorbent nature and has the potential to harbor contaminants;
2) In Emergency Room 2, the vinyl covering on the patient exam table had a tear in the corner at the foot, which exposed the foam pad underneath. Foam cannot be disinfected due to its absorbent nature and has the potential to harbor contaminants; and
3) In Emergency Room 2, cracks in the base of a baby scale was held together with clear tape. Tape has a sticky residue which cannot be disinfected and has the potential to harbor contaminants.
B. Findings were confirmed with the Chief Nursing Officer at the time of the tour.


Based on review of policies and procedures and interview, it was determined the facility failed to follow their policy for conducting infection control surveillance. The failed practice did not assure mitigation of infection risk occurred to prevent patient and staff contagion and was likely to affect all persons in the facility. Findings follow:

A. Review of Policy, "Methods of Surveillance" revealed "the intent of any surveillance method, whether it is house wide or focused, shall be to assess the overall quality of care. Direct observation and direct contact with both patients and direct care personnel has been demonstrated to be a reliable source of data."
B. During interview with the Infection Control Coordinator on 10/09/14 at 1030 when asked what type of Infection Control surveillance activities were conducted, she answered, "the Housekeeping Director and I go through the hospital and inspect for cleanliness." When asked if she conducted any type of surveillance to observe and assess staff's hand washing techniques, use of PPE (personal protective equipment), or if she had any surveillance tools she used she answered, "no."


Based on review of Infection Control Committee Meeting Minutes, review of policies and procedures and interview, it was determined there was no evidence the Infection Control Chairman attended 7 (1/12/12, 2/7/13, 6/7/13, 8/8/13, 5/8/25, 7/10/14 and 9/4/14) of 12 (1/12/12, 2/7/13, 5/9/13, 6/7/13, 8/8/13, 10/4/13, 11/8/13, 1/10/14, 3/7/14, 5/8/14, 7/10/14 and 9/4/14) Infection Control Committee meetings. Failure of the Chairman to attend meetings did not assure the Committee consulted the Medical Doctor (MD) Chairman for guidance in Infection Control practices or policies and was likely to affect all persons in the Facility. Findings follow:

A. Review of Infection Control Committee Meeting Minutes revealed no evidence the Chairman attended meetings dated 1/12/12, 2/7/13, 6/7/13, 8/8/13, 5/8/25, 7/10/14 and 9/4/14.
B. Review of policy, "Medical Staff Required Committee Meetings" revealed Risk Management/Safety/Infection Control Committee-(named) Physician #1, was the Chairman of the Committee.
C. Review of policy, "Scope of Care" revealed "the Chairperson of the Infection Control Committee is responsible for medical direction and decisions as indicated. He/She also reviews, analyzes and presents to the medical staff. Each physician assigned to the Committee by the medical staff acts as physician advisor and provides consultation to program director."
D. Findings were confirmed with the Infection Control Coordinator on 10/09/14 at 1030.


Based on interview, it was determined the facility failed to assure volunteers working in the hospital were tested for tuberculosis (TB). Failure to test all healthcare workers for TB prevented the potential spread of infection and was likely to affect all persons in the facility. Findings follow:

During interview with the Chief Nursing Officer and Infection Control Coordinator on 10/08/14 at 1350 when asked if the facility utilized volunteers, the Chief Nursing Officer answered yes. When asked if TB skin testing was conducted for the volunteers, she answered "no."



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Based on observation and interview, it was determined the facility failed to ensure expired, unlabeled, and undated foods were not available for patient use in three of three storage areas (walk in freezer, reach in refrigerator, and Supply Room). The failed practice did not ensure the facility was following first in-first out procedures and created the potential for patients to receive out of date foods; and could affect any patient in the facility. Findings follow.

A. During a tour of the walk in freezer on 10/07/14 at 1400, the following items were observed to not be dated:
1) Okra - two of two bags
2) Broccoli - 10 of 10 bags
3) Spring blend vegetables - seven of seven bags
4) Zucchini - eight of eight bags
B. During a tour of the Supply Room on 10/07/14 at 1405 the following items were observed to be expired:
1) Vanilla ensure pudding - 28 of 28 pudding cups, expired 09/14.
2) Nutren 1.0 cal enteral formula - one of three cases, expired 05/30/14
C. During a tour of the Reach-In Refrigerator on 10/07/14 at 1415, the following items were observed to be not labeled or dated:
1) Chocolate pudding - two of two cups
2) Fruit cup - one of one cups
3) Fruit fluff - two of two cups
4) Potato pie - one of one slices
5) Cookie cream pie - three of three slices
6) Pre prepared mixed greens salad - one of one bags
D. Findings were confirmed by the Foodservice Director at the time of the tour.

Based on Physician Credential Review and interview, it was determined the facility failed to ensure five (Physician #2-#4, #6, and #8) of eight (#1-#8) Physicians had a current TB skin test. The failed practice created the potential for a TB exposure to go unnoticed, and could affect any patient being treated by those physicians. Findings follow.

A. Review of Physician Credential Files revealed Physicians #2-#4, #6, and #8 did not have a current TB skin test.
B. Findings were confirmed by the Administrative Assistant on 10/08/14 at 1405.

Based on clinical record review and interview, it was determined the facility failed to ensure operative reports included the time of surgery for three of three (#18-#20) surgical patients. The failed practice did not allow knowledge of which surgery happened first in the event of multiple surgeries in one day, and created the potential to affect any patient receiving an operation in the facility. Findings follow.

A. Review of the operative reports revealed the time of the surgery was not documented for Patients #18-#20.
B. Findings were confirmed by the Chief Nursing Officer on 10/10/14 at 0935.

Based on Quality Assessment (QA) Meeting Minutes review for November 2013 through October 14 and interview, it was determined the facility failed to ensure QA was reported for 2 (Case Management and Infection Control) of 13 departments. The failed practice did not ensure the two departments had an effective QA process to identify, monitor and trend outcomes to improve patient care services. Findings follow.

A. Review of QA Meeting Minutes for November 2013 through October 2014 revealed QA was not reported for Case Management (Discharge Planning) or Infection Control for the past 12 months.
B. Findings were confirmed by the Director of Respiratory/QA on 10/08/14 at 1415.

Based on review of Governing Board Meeting Minutes for October 2013 through September 2014 and interview, it was determined the facility failed to provide evidence of Quality Assurance (QA) being evaluated by the Governing Body. The failed practice did not ensure the Governing Body was knowledgeable as to the status of the quality indicators, and thus were not aware of which items needed corrective action. Findings follow.

A. Review of Governing Board Meeting Minutes for October 2013 through September 2014 revealed Quality Assurance was not being evaluated by the Governing Body.
B. Review of the Medical Staff Bylaws and the QA plan did not specify to whom the data was to be reported.
C. Findings were confirmed by the Director of Respiratory Therapy/QA on 10/09/14 at 0940.

Based on review of Swing-Bed policies and procedures and interview, it was determined the facility failed to assure there were policies and procedures addressing patients' rights to work in the facility during their hospitalization. The failed practice did not assure patients with a need for therapeutic work rehabilitation were allowed to work or were allowed to refuse to work during their hospitalization and was likely to affect all patients needing work rehabilitation in the facility. Findings follow:

A. Review of Swing-Bed policies and procedures revealed no evidence of policies addressing patients' working or refusing to work while admitted to the facility.
B. Findings were verified with the Chief Nursing Officer on 10/08/14 at 1415.

Based on review of Swing-Bbed policies and procedures and interview, it was determined the facility failed to assure there were policies and procedures addressing when married couples admitted to the facility could room together. Failure to assure policies allowing married couples to room together did not assure married couples' choices to room together were honored and was likely to affect all married couples admitted to the facility. Findings follow:

A. Review of Swing-Bed policies and procedures revealed no evidence of policies addressing married couples rooming together while admitted to the facility.
B. Findings were verified with the Chief Nursing Officer on 10/08/14 at 1415.

Based on review of Swing-Bed policies and procedures and interview, it was determined the facility failed to assure there were policies and procedures to assure criminal background checks were conducted for patient care staff. Failure to conduct criminal background checks for patient care staff did not assure persons with criminal histories of abuse were not hired to work in the facility and was likely to affect all patients admitted to the facility. Findings follow:

A. Review of Swing-Bed policies and procedures revealed no evidence of policies addressing criminal background checks would be conducted for any person hired to work in the facility.
B. During interview with the Director of Human Resources on 10/09/14 at 1525, she confirmed criminal background checks were not conducted.

Based on review of Swing-Bed policies and procedures and interview, it was determined the facility failed to assure there were policies and procedures that specialized rehabilitative services (i.e. speech-language pathology and mental health rehabilitative services) would be provided for those patients requiring them. Failure to provide specialized rehabilitative services prevented patients needing speech-language pathology services or mental health rehabilitative services from receiving care which could help them improve their health outcomes. This failed practice was likely to affect all persons needing specialized rehabilitative services admitted to the facility. Findings follow:

A. Review of Swing-Bed policies and procedures revealed no evidence of policies addressing speech-language pathology and/or mental health rehabilitative services for patients needing them while admitted to the facility.
B. Findings were verified with the Chief Nursing Officer on 10/08/14 at 1415.