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Based on observation, interview, and record review, the facility failed to implement a procedure for ensuring expired medications were not accessible and were removed from use in the emergency department. This deficient practice had the potential to affect all patients requiring medication in the emergency department. Findings include:

During an observation on 2/27/24 at 9:12 a.m., staff member Q unlocked the crash cart located in the emergency department. A 250 ml bag of IV fluids containing Heparin 25,000 units was observed. The expiration date on the bag was 1/2024. There were no other IV bags containing heparin located in the crash cart.

During an interview on 2/27/24 at 9:45 a.m., staff member Q stated, "From what I understand, either the pharmacy tech or the Director of Nursing checks for expired medications, and removes them from use. I have not checked for expired medications since I have been here."

During an interview on 2/27/24 at 9:50 a.m., staff member H stated she was being trained as a pharmacy technician by the Director of Nursing. Staff member H stated she had not checked for expired medications in the emergency department.

During an interview on 2/27/24 at 1: 21 p.m., staff member B stated she was ultimately responsible for the pharmacy. Staff member B stated there was a pharmacist on site once a month, but most duties were completed by her. Staff member B stated she should have been checking the emergency department more frequently for expired medications.

Review of a facility document titled, "Omnicell-DISPOSAL OF EXPIRED MEDICATIONS," with an approval date of 12/22/22, showed:

"Expiration of medication stocked in the Omnicell and Emergency Room should be checked on a monthly basis by the pharmacy technician."

Based on observation and interview, the facility failed to implement a procedure for ensuring expired supplies were replaced prior to the expiration date. This deficient practice had the potential to affect any patient receiving care in the emergency department. Findings include:

During an observation on 2/27/24 at 9:12 a.m., staff member Q unlocked the crash cart and storage cupboards in the emergency room. The following supplies were found outdated or had no open or use by dates placed on them:

- Eight (8) pink oral foam swabs with dentifrich: Expiration date of 4/15/2023,
- One (1) pink oral foam swab: Expiration date of 11/1/2023,
- Seventeen (17) pink oral foam swabs laying in the bottom of a zip lock bag unpackaged, and no expiration date noted,
- Five (5) size 18 French 5 cc, ribbed balloon foley catheter: Expiration date of 10/31/23,
- One (1) bottle of Alcon Sterile Eye Irrigation Solution: Expiration date of 11/2023,
- One (1) open bottle hydrogen peroxide, one quarter full: No dates noted,
- One (1) open bottle of betadine solution, one half used: No dates noted, and
- Three (3) open packages of 3M red dot monitoring electrodes: No dates noted.

During an interview on 2/27/24 at 9:45 a.m., staff member Q stated, "From what I understand, either the pharmacy tech or the Director of Nursing checks for expired supplies. I have not checked for expired supplies since I have been here."

During an interview on 2/27/24 at 9:50 a.m., staff member H stated she had not checked for expired supplies in the emergency department.

During an interview on 2/27/24 at 1: 21 p.m., staff member B stated she was ultimately responsible for ensuring supplies were not expired in the emergency department and she should have been checking more frequently for expired supplies.

Based on observation, interview, and record review, the facility failed to ensure all essential mechanical, electrical, and patient-care equipment was identified and included in an inventory list; and failed to ensure all essential medical equipment was identified and maintained through a facility established maintenance strategy. This deficient practice had the potential to affect all patients provided care services by the facility. Findings include:

During an observation in the emergency department on 2/27/24 at 9:12 a.m., the following equipment was observed to not have a periodic maintenance sticker, which identified the equipment had an initial safety inspection prior to being used and/or had received periodic maintenance to ensure the equipment was inspected, tested, and maintained to ensure patient safety:

- One (1) Welch Allyn head lamp, with an engraved metal facility plate with number 1027,
- Two (2) DOT (brand name) thermometers,
- One (1) ultra-violet exam light,
- Traction splints with a handwritten facility number, 59036, and
- LUCAS chest compression machine.

During an interview on 2/28/24 at 3:05 p.m., staff members A and D stated the facility did not have a complete inventory of equipment required to meet patient needs or identify critical-care equipment or equipment essential to patient care.

During an interview on 2/29/24 at 8:35 a.m., staff member D stated there was not a record of the DOT thermometers, ultra-violet exam light, traction splints, or the LUCAS chest compression machine having been inspected, tested, and maintained by the facility or by their contracted alternative equipment maintenance (AEM) contractor.

During a phone interview on 2/29/24 at 8:57 a.m., NF1 stated they did not have a record of the head lamp, DOT thermometers, ultra-violet exam light, traction splints, or the LUCAS chest compression machine in their list of equipment to be maintained for the facility.

Review of a facility document titled, "Preventative Maintenance Program," with an approval date of 9/30/2021, showed:

"PURPOSE:
To provide for routine and preventative maintenance for the facility's plant, electrical systems, and mechanical systems, and to ensure all essential equipment and systems are maintained in a safe operation [sic] condition.

POLICY:
The routine and preventative maintenance program will be provided by the Maintenance Department either directly or through a contact service or the equipment vendor.

PROCEDURE:
Inspections, routine maintenance, preventative maintenance, and testing of equipment shall be carried out on a regularly scheduled basis ...The [Facility] Maintenance Check List Schedule will be reviewed and updated periodically by the Facility Manager. Check List and Logs will be maintained and kept in the Maintenance Office or at the site of inspection ..."

An initial request for the facility's complete inventory list was made on 2/27/24, with a second request made on 2/28/24. None was received prior to the end of the survey.

Based on observation, interview, and record review, the facility failed to store medications in a temperature-controlled room. This deficient practice had the potential to affect any patient who received medications stored in the pharmacy. Findings include:

During an observation and interview on 2/26/24 at 4:20 p.m., a thermometer gauge was observed sitting on a shelf in the pharmacy. The thermometer was not easily readable. Staff member H stated she was not aware what the temperature parameter was for the medication storage area in the pharmacy. Staff member H stated there was not a way to control the temperature in the pharmacy.

During an interview on 2/28/24 at 8:06 a.m., staff member B stated there was no way to control the temperature in the pharmacy. Staff member B stated the only policy about medication storage was in the swing bed policy.

Review of the facility policy titled, "STORAGE OF DRUGS-INTERMEDIATE SWING BED," with an approval date of 12/22/22, showed:

"PURPOSE: To comply with the proper storage of drugs and pharmaceutical regulations under State and Federal law.

... 3. Drugs should be stored at appropriate temperature. Drugs required to be at room temperature shall be stored at a temperature of not less than 15 degrees C (59 degrees F) or more than 30 degrees C (86 degrees F). Drugs requiring a 'cool place' shall be stored in the refrigerator."

Based on observation, interview, and record review, the facility failed to label medications with a use by date and an open date; failed to ensure that expired medications were replaced; and failed to follow physician's orders resulting in medications errors for 2 (#s 7 and 14) of 16 sampled swing bed patients. This deficient practice had the potential to affect all swing bed patients who receive their medications from staff, and have medications stored in the medication cart. Findings include:

1. During an observation on 2/26/24 at 4:30 p.m., the medication cart in the swing bed area had the following medications which did not have an open date, a use by date, or were expired:

- ondansetron 4 mg, with an expiration date of 1/2023,
- dorzolamide timolol ophthalmic solution,
- timolol maleate 0.05% solution,
- Icy Hot ointment,
- betamethasone 0.05% cream,
- triamcinolone 0.025% cream,
- two (2) Nystatin powder 100,000 units,
- Tylenol 325 mg bottle,
- chewable calcium bottle, 500 mg,
- senna 8.6 mg bottle,
- baby aspirin 81 mg bottle,
- iron 325 mg bottle,
- fluticasone/salmeterol 250 mcg/50 mcg inhaler,
- albuterol inhaler 90 mcg, and
- fluticasone propionate nasal spray 50 mcg.

2. During an observation on 2/27/24 at 7: 50 a.m., staff member P was passing medications in the dining area. Staff member P opened the medication cart and pulled out resident #7's medications and began to pop them out of the bubble pack, into a clear medication cup. Staff member P was not logged into the computer and did not verify the physician's orders for medication administration. Staff member P opened the side drawer of the medication cart and grabbed a large bottle of Metamucil. The Metamucil bottle did not have a pharmacy label in place. The only patient identifier was a first name, written on the lid in marker. Staff member P stated patient #7 received 3.4 grams daily. Staff member P grabbed a plastic teaspoon off the medication cart and placed two spoonfuls into a clear, plastic cup, resulting in approximately 10 mls of the medication. The directions on the bottle stated a 3.4 gram dose was two tablespoons. Two tablespoons was approximately 30 mls. Staff member P took the medications over to where resident #7 was sitting, placed the medications in front of her and walked away.

During an interview at 7:55 a.m., staff member P stated, "She (patient #7) is with it, so I can leave her medications with her and she will take them."

Review of patient #7's EMR, dated February 2024, refelcted patient #7 did not have a physician order for self-administration of medication, or an assessment for self-administration of medications.

3. During an observation and interview on 2/27/24 at 9:05 a.m., staff member P took patient #14's insulin out of the top drawer of the medication cart and took it to patient #14's room. The open date on the insulin pen was 1/22/24. Insulin is good for 28 days after opening. Staff member P attached the insulin needle to the insulin pen and stated she had primed the needle with 1 unit of insulin. No residual insulin was noted on the needle, showing it had not been properly primed. Staff member P turned the dial on the insulin pen to 10 units and handed patient #14 the insulin pen. Staff member P cleaned patient #14's abdomen with an alcohol wipe and patient #14 injected the insulin into his abdomen. The insulin pen was eight days past the use by date. Staff member P stated, "It is the nurse's responsibility to check the dates and the medications, not mine."

A request for staff evaluations on medication pass and insulin procedures was requested but was not received prior to the end of the survey.

A request for the facilities policy and procedure for insulin administration and priming was requested but was not received prior to the end of the survey.

A request for the policy and procedure for expired medications for swing bed was requested but was not received prior to the end of the survey.

Review of the facility document titled, "STORAGE OF DRUGS-INTERMEDIATE SWING BED," with an approval date of 12/22/22, showed:

... "5. Drugs shall not be kept on hand after the expiration date ..."

A review of a facility document titled, " Medication And/or Treatments-Self Administered by Swing Bed Patients," with an approval date of 6/23/21, showed:

" ...A. Self-administration of medications or treatments by patients is permitted only by a provider order that includes dosage, route, and any special instructions. ...

Procedure:
A. The admitting nurse will assess intermediate swing bed patient competency to self-administer using "Assessment of Self-Administering of Medications" form...

B. A decision to permit self-administering is made by the Interdisciplinary Care Plan Conference and written order by the Provider after the 'Assessment to Self-Administration of Medication' is completed." [sic]

Based on interview and record review, the facility failed to review death records with the OPO (Organ Procurement Organization) for 3 (#s 19, 20, and 26) of 3 sampled patients who expired in the facility. Findings include:

Review of patient #19's EMR, dated 9/14/23 to 10/6/23, showed the patient expired in the facility on 10/6/23. The EMR showed the OPO was notified of the death in the facility.

Review of patient #20's EMR, dated 5/14/23 to 7/11/23, showed the patient expired in the facility on 7/11/23. The EMR showed the OPO was notified of the death in the facility.

Review of patient #26's EMR, dated 10/26/23, showed the patient expired in the emergency department on 10/26/23. The EMR showed the OPO was notified of the death in the facility.

During an interview on 2/27/24 at 1:40 p.m., staff member B stated she had not reviewed the death records or reviewed the death records with the OPO. Staff member B stated, "Should I be? I have not been doing that."

A review of a facility policy titled, "Organ and Tissue Donation," with an effective date of 3/23/2023, showed:

"In compliance State and Federal Laws, it is the policy of [Facility Name] to recognize the right of every individual to determine the disposition of his/her organs and tissue upon death.

... 10. [Facility Name] works cooperatively with the donation agencies in reviewing death records..."

A request was made on 2/27/24, for the quarterly review of deaths with the OPO. None was received prior to the end of the survey.

Based on interview and record review, the facility failed to complete a comprehensive assessment containing the required elements, within 14 days of admission for 2 (#s 15 and 18) and failed to develop and implement a comprehensive, patient-centered care plan for 7 (#s 3, 4, 5, 6, 7, 8, and 14) of 16 sampled swing bed (skilled and intermediate) patients.This deficient practice had the potential to result in a lack of personalized, comprehensive care for individual patients. Findings include:

1. Review of the following EMRs failed to show a comprehensive assessment was completed within 14 days of the patient's admission:

- patient #15, skilled swing bed, dated from 2/8/24 to 2/23/24, and
- patient #18, skilled swing bed, dated from 1/19/24 to 2/9/24.

During an interview on 2/28/24 at 2:22 p.m., staff member B stated there was a form, titled, "LTC Comprehensive Assessment," not dated, within the EMR system which prompted the nurse to assess all of the required areas of the comprehensive assessment. Staff member B stated the comprehensive assessment was done annually, but she was not sure if staff were aware the comprehensive assessment also needed to be completed within 14 days of admission to a swing bed (skilled or intermediate).

A request for the initial comprehensive assessment, for patient #s 15 and 18, was made on 2/28/24. Neither of the assessments were received prior to the end of the survey.

2. Review of patient #3's Care Plan Conference Summary, dated 10/17/23, showed the patient had an admission date of 2/23/23 with diagnoses of depressive disorder, cognitive impairment, diabetes type II, chronic kidney disease stage III, overactive bladder, anxiety, and falls.

Review of patient #3's care plan, dated 10/17/23, failed to show problems, goals, or interventions addressing the resident's diet, psychosocial needs, diabetes monitoring, behaviors, bowel or bladder function, ADL function, code status, medications, or any other type of pertinent information essential to provide ongoing care to the patient.

Review of patient #4's Care Plan Conference Summary, dated 10/17/23, showed the patient had an admission date of 6/28/19 with diagnoses of diabetes type II, hypothyroidism, mixed anxiety and depressive disorder, senile dementia, and insomnia.

Review of patient #4's care plan, dated 10/17/23, failed to show problems, goals, or interventions addressing diet, psychosocial needs, any diabetes monitoring, behaviors, ADL function, code status, medications, or any other type of pertinent information essential to provide ongoing care to the patient.

Review of patient #5's Care Plan Conference Summary, dated 1/22/24, showed the patient had an admission date of 9/17/19 and a diagnosis list which included a TBI, hypertension, sexual disorder, prostate cancer, and impaired cognition.

Review of patient #5's care plan, dated 1/22/24, failed to show problems, goals, or interventions addressing diet, psychosocial needs, behavior monitoring, code status, medications, or any other type of pertinent information essential to provide ongoing care to the patient.

Review of patient #6's Care Plan Conference Summary, dated 11/15/23, showed the patient had an admission date of 5/30/23 and a diagnosis list which included gastrointestinal hemorrhage, TBI, hypertension, renal transplant, A-fib, recurrent UTI's, and failure to thrive.

Review of patient #6's care plan, dated 11/15/23, failed to show problems, goals, or interventions addressing diet, psychosocial needs, behavior monitoring, code status, medications, transplant information, ADL status, or any other type of pertinent information essential to provide ongoing care to the patient.

Review of patient #7's Care Plan Conference Summary, dated 1/22/24, showed the patient had an admission date of 1/20/23 and a diagnosis list which included A-Fib, rheumatoid arthritis, stroke, osteoporosis, and a history of dysphagia.

Review of patient #7's care plan, dated 1/22/24, failed to show problems, goals, or interventions addressing diet, psychosocial needs, behavior monitoring, code status, medications, ADL status, or any other type of pertinent information essential to provide ongoing care to the patient.

Review of patient #8's Care Plan Conference Summary, dated 11/15/23, showed the patient had an admission date of 1/17/22 and a diagnosis list which included Parkinson's disease, hypertension, hypothyroidism, atherosclerosis, breast cancer, and chronic pain.

Review of patient #8's care plan, dated 11/15/23, failed to show problems, goals, or interventions addressing diet, psychosocial needs, behavior monitoring, code status, medications, ADL status, or any other type of pertinent information essential to provide ongoing care to the patient.


41652


Review of patient #14's Care Plan Conference Summary, dated 1/15/24, showed the resident was admitted on 1/3/24 and had diagnoses which included a left below the knee amputation with a prosthesis, atrial fibrillation, congestive heart failure, diabetes, and hypertension.

Review of patient #14's care plan, dated 1/15/24, failed to show any problems, goals, or interventions related to the amputation, mobility, diabetes care, psychosocial needs, or medications.

During an interview on 2/28/24 at 8:53 a.m. staff member B stated the sheet in front of the care plan was the comprehensive assessment and care plan summary. Staff member B stated she knew there was a lot of work to be done in this area. Staff member B stated there had been a few policies which had been retired and new ones were not approved yet.

Review of the facility's policy titled, "Care Planning," dated 7/19/21, showed it was the responsibility of the admitting RN to initiate the care plan based on a thorough patient assessment. The policy also showed it was the responsibility of the RN to review and update the care plan as needed.

Based on interview and record review, the facility failed to inform patients and/or their representatives of their rights prior to providing or discontinuing care 12 (#s 2, 13, 15, 16, 17, 18, 21, 22, 23, 24, 25, and 26) of 26 sampled patients. This deficient practice had the potential to affect the exercise of rights for all patients receiving care in the facility. Findings include:

Review of patient #2's medical record showed the patient had come to the emergency department on 2/25/24 and was discharged on 2/26/24. No acknowledgement of patient rights was in the medical record.

Review of patient #13's EMR, showed the patient was admitted to swing bed on 1/10/22. Review failed to show an acknowledgement of patient rights was in the medical record.

Review of patient #15's EMR, showed the patient was admitted to swing bed on 2/8/24. Review failed to show an acknowledgement of patient rights was in the medical record.

Review of patient #16's EMR, showed the patient was admitted to swing bed on 2/13/24. Review failed to show an acknowledgement of patient rights was in the medical record.

Review of patient #17's EMR, showed the patient was admitted to swing bed on 1/24/23. Review failed to show an acknowledgement of patient rights was in the medical record.

Review of patient #18's EMR, showed the patient was admitted to swing bed on 1/19/24. Review failed to show an acknowledgement of patient rights was in the medical record.

Review of patient #21's medical record showed the patient was seen in the emergency department on 2/22/24 and was transferred to another facility on the same date. No acknowledgement of patient rights was found in the medical record.

Review of patient #22's medical record showed the patient had come to the emergency department on 2/12/24 and was transferred to another hospital on the same day. No acknowledgement of patient rights was in the medical record.

Review of patient #23's medical record showed the patient was seen in the emergency department on 2/7/24 and was transferred to another facility on the same date. No acknowledgement of patient rights was found in the medical record.

Review of resident #24's medical record showed the patient had come to the emergency department on 11/14/23 and was admitted into an inpatient bed. No acknowledgment of patient rights was in the medical record.

Review of patient #25's medical record showed the patient was seen in the emergency department on 11/3/23. The patient, who had abdominal pain, was placed in observation and subsequently discharged home on 11/4/23. No acknowledgement of patient rights was found in the medial record.

Review of patient #26's medical record showed the patient had come to the emergency department on 10/26/23 and expired on 10/26/23. No acknowledgement of patient rights was in the medical record.

During an interview on 2/28/24 at 2:03 p.m., staff member H stated when she had patients sign the required paperwork in the emergency department, there was not a copy of the patient's rights in the packet. Staff member H stated she had not been giving the patients copies of the patient rights form.

During an interview on 2/28/24 at 2:20 p.m., staff member B stated, "A new form will be added in the packets going forward, and I will be looking at the policy and procedure for this."

During an interview and document review on 2/28/24 at 2:22 p.m., staff member B provided the admission paperwork for swing bed skilled, swing bed intermediate, acute, observation, and emergency department. The paperwork for the swing bed intermediate stays included an admission agreement, dated November of 2023, which specifically referenced a policy on swing bed patient's rights titled, "C-XXX Swing Bed Patient's Rights and Responsibilities." Upon request for this policy, staff member B stated the identified document was not a policy. The form in the facility's policy management system was the Patient Rights and Responsibilities form which was given to acute and swing bed skilled admissions, not emergency department or swing bed intermediate admissions. Staff member B stated the swing bed intermediate admissions were usually long term admissions and a different rights form was being used.

A request for the patient rights form given to emergency department patients was submitted on 2/28/24 and was not received prior to the end of the survey.

A request for the patient rights form given to swing bed skilled admissions was submitted on 2/28/24 and was not received prior to the end of the survey.




41652

Based on interview and record review, the facility failed to inform all patients whom to contact to file a grievance for 6 (#s 13, 15, 16, 21, 23, and 25) of 26 sampled patients. The deficient practice had the potential to limit a patient's right to submit a grievance to the facility. Findings include:

1. Review of patient #13's EMR showed the patient was admitted to an intermediate swing bed on 1/10/22. The review failed to show documentation the resident had not been given the patient rights form which included information regarding the process for submission of a grievance, but not who to contact to submit a grievance.

During an interview and document review on 2/28/24 at 2:22 p.m., staff member B provided the admission paperwork for swing bed skilled, swing bed intermediate, acute, observation, and emergency department encounters. The paperwork for the swing bed intermediate stays included an admission agreement, dated November of 2023, which specifically referenced a policy on swing bed patient's rights titled, "C-XXX Swing Bed Patient's Rights and Responsibilities." Upon request for this policy, staff member B stated the identified document was not a policy. The form in the facility's policy management system was the Patient Rights and Responsibilities form which was given to acute and swing bed skilled admissions, not swing bed intermediate admissions. Staff member B stated the swing bed intermediate admissions were usually long term admissions and a different rights form was being used. The patient rights form being given to swing bed patients did not contain information regarding who was to be contacted in order to submit a grievance. Staff member B stated she could not find any documentation in patient #13's EMR which showed he or his representative had been informed of the process for submitting a grievance to the facility.

2. a) Review of patient #15's EMR, with a swing bed skilled admission date of 2/8/24, failed to show documentation the patient was informed of her right to submit a grievance to the facility. The acknowledgement of receipt of patient rights form included information regarding the submission of a grievance. The resident's EMR did not contain this acknowledgement.

b) Review of patient #16's EMR, with a swing bed skilled admission date of 2/13/24, failed to show documentation the patient was informed of her right to submit a grievance to the facility.

During an interview on 2/28/24 at 2:22 p.m., staff member B stated the Consent for Care form had a statement of acknowledgement the patient had received the Notice of Patient Rights which provided information regarding the submission of a grievance. Staff member B stated, "If the Consent for Care form was not in the record, there was no other way to determine if the patient was informed of their rights."

3. a) Review of patient #21's EMR, with an emergency department admission date of 2/22/24, failed to show documentation the patient was informed of her right to submit a grievance to the facility.

b) Review of patient #23's EMR, with an emergency department admission date of 2/7/24, failed to show documentation the patient was informed of his right to submit a grievance to the facility.

c) Review of patient #25's EMR, with an emergency department admission date of 11/3/23, failed to show documentation the patient was informed of his right to submit a grievance to the facility.

During an interview on 2/28/24 at 2:03 p.m., staff member H stated when she had patients sign the required paperwork in the emergency department, there was not a copy of the patient's rights in the packet. Staff member H stated she had not been giving the patients copies of the resident rights form.

During an interview on 2/28/24 at 2:20 p.m., staff member B stated, "A new form will be added in the packets going forward, and I will be looking at the policy and procedure for this."

During an interview on 2/28/24 at 2:22 p.m., staff member B stated the Consent for Care form had a statement of acknowledgement the patient had received the Notice of Patient Rights which provided information regarding the submission of a grievance. Staff member B stated if emergency department patients were not being given a copy of the patient rights form, they would not have been given the necessary information about how to submit a grievance.

A request for the patient rights form given to emergency department patients was requested on 2/28/24 and was not received prior to the end of the survey.