HospitalInspections.org

38777


Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure all patient care equipment was maintained in safe operating condition as evidenced by:
1) failing to ensure the functionality of a nurse call button located on the handrails of the beds on the in-patient unit;
2) failing to complete quality checks on the Emergency Department blood glucose meter.
3) failing to ensure an oxygen cylinder was safely secured either by being chained or in a stand.
4) failing to ensure functionality of cameras used to observe PEC patients in the ED.

Findings:

1). Failing to ensure the functionality of a nurse call button located on the handrails of the beds on the in-patient unit.

On 1/7/2019 from 9:50 a.m. to 11:00a.m. an observation was made of the inpatient unit with S1DirQA and S11HK. A nurse call button was noted to be on the handrail of the beds in rooms 104 bed A, 109 bed B, and 111 bed B. The buttons were noted to be non- functional as it failed to activate any type of nurse call system.

S11HK was interviewed at the time of the observation and confirmed the nurse call button located on the handrails of the patient bed in patient room 109 bed B was not functioning when pressed. S11HK indicated that they have a nurse call system which included a cord with a button and reported that patients are instructed to use this call system. When asked if it would be possible for a patient who may be confused or sedated to press the nurse call button on the handrail of the bed thinking they are calling for assistance without the nursing staffs' knowledge due to the call button not working, S11HK confirmed that was possible.

S1DirQA, present during the observation, confirmed the nurse call feature on the handrails of bed B in room 111 was non-functional.


2) Failing to complete quality checks on the Emergency Department blood glucose meter.

On 1/7/2019 a review of the Emergency Department Quality Control Record/ Assure Platinum Blood Glucose Monitoring System log book failed to have documented evidence of performance of quality checks on 10/10/18, 11/8/18 and 12/29/18.

In an interview on 1/7/19 at 10:30 a.m. with S14LPN, she verified there was no documented evidence the quality checks were completed on the above dates. S14LPN also verified staff are required to complete the quality checks daily.


3) Failing to ensure an oxygen cylinder was safely secured either by being chained or in a stand.

On 1/7/19 at 11:20 a.m. an observation was made of an oxygen cylinder laying on the floor, unsecured, in the clean storage room in the ED. S1DirQA was present during the observation and she confirmed the oxygen cylinder should have been secured and verified it was not secured.


4) Failing to ensure functionality of cameras used to observe PEC'd patients in the ED.

On 1/7/19 at 10:43 a.m. an observation was made of 2 video cameras located at ceiling level, in opposing corners, in ED Exam Room #3. S1DirQA reported, during the observation, that the cameras were used to continuously monitor PEC'd patients placed in ED Exam Room #3 for safety along with having staff assigned 1:1 for patient supervision.

On 1/7/19 at 10:45 a.m. in an interview with S14LPN, she revealed only one of the two cameras in ED Exam Room #3 is functioning. An observation was made at this time of one image on the screen.

38777


Based on observation, interview, and record review, and hospital policies and staff interviews, the CAH (Critical Access Hospital) failed to ensure health care services were furnished in accordance with hospital policies as evidenced by:

1) failing to ensure safe and effective care was provided to patients presenting to the hospital's ED who were a potential threat to themselves or others by failing to maintain continuous staff observation of PEC patients when the patients were using a restroom in the ED with identified safety hazards and ligature risks that could be used for potential self harm and/or harm of others.; and

2) failing to ensure all members of the nursing staff maintained current Basic Cardiac Life Support (CPR) certification for 1 (S15LPN) of 8 (S2IntDON, S12RN, S13LPN, S14LPN, S15LPN, S16RN, S17RN, S22RN) personnel files reviewed for current CPR certification..


Findings:


1) Failing to maintain continuous staff observation of PEC patients when the patients were using a restroom in the ED with identified safety hazards and ligature risks

Observations conducted on 1/7/18 at 11:00 a.m. in ED revealed the following safety hazards and ligature risks:

Bathroom used by PEC ED patients:
a. Flanged door handle - potential ligature anchor point
b. Doors that locked from the inside- patient could lock themselves in the bathroom
c. Flanged handles on the sink- potential ligature anchor point
d. Gooseneck faucet on the sink- potential ligature anchor point
e. Exposed plumbing - sink- potential ligature anchor point
f. Exposed plumbing toilet- potential ligature anchor point
g. Open handrails behind and on the side of the toilet- potential ligature anchor point
h. Glass mirror- could potentially be broken and used for self-harm/harm of others
i. Air vent accessible for potential ligature anchor point
j.Plastic bag in garbage can in bathroom- could potentially be used for suffocation.

S1DirQA, present for the observtion, verified the above referenced safety risks/ligature risks.

In an interview on 1/7/19 at 11:15 a.m. with S14LPN she confirmed patients were allowed to use the bathroom with multiple ligature points/ safety risks without being directly visualized by staff. She reported staff remained outside of the closed door while PEC patients were using the restroom to maintain their privacy.

2). Failing to ensure all members of the nursing staff remained current in Basic Cardiac Life Support (CPR) certification.

Review of the hospital policy titled," CPR/ACLS/PALS Nursing Staff Requirements- Code Blue Team", Policy Number: 1005 last revised 8/12/2012; last reviewed 12/4/2012 revealed in part:
Purpose: It is the desire and intent of St. Helena Parish Hospital to require all members of the nursing staff to remain current in Basic Cardiac Life Support (CPR).
Policy: Nursing Staff CPR Requirements: 1. All licensed and non- licensed nursing staff shall maintain a current CPR card.

Review of S15LPN's personnel file revealed no documented evidence of current CPR certification.

In an interview on 1/9/19 at 11:45 a.m. with S2IntDON, she verified there was no documented evidence of a current CPR certification for S15LPN.

Based on observation and interview, the CAH failed to ensure the compounding drug handling area was managed with accepted professional principles. This deficient practiced is evidenced by failing to secure the compounding drug handling area and allowing access to the handling area by unauthorized individuals.

Findings:

On 1/7/19 at 2:35 p.m. an observation of the nursing medication room revealed S10LPN entered an unlocked door in the nursing medication room which entered the room which housed the pharmacy isolator.

On 1/9/19 at 7:45 a.m. in an interview with S1DirQA, she revealed she was aware there was a door in the nursing station medication room that lead to the restricted pharmacy room which housed the isolator. She stated she thought the door was locked and unauthorized staff did not enter the pharmacy isolator room.

Based on record review and interview, the CAH failed to ensure that the physician was notified of identified medication errors and that the errors were documented in the patient's medical record for 1 (#R2) of 2 (#7, #R2)hospital identified medication errors reviewed.

Findings:

Review of the hospital policy titled, "Medication Variances", presented as current policy, revealed in part:
All medication errors will be reported by completing the Hospital Occurrence Report. The physician will be notified immediately upon discovery. An entry, including the medication administered and the drug reaction, and the time of notification of the physician shall be entered into the patient's medical record.

Review of the hospital policy titled, "Occurrence Reporting", presented as current policy, revealed in part:
Staff shall document the occurrence in the medical record.


Review of Patient #R2's medical record revealed she was an 81 year old admitted on 12/5/18 with a diagnosis of status post hypoxemic respiratory failure and pneumonia.

Review of an Occurrence Report for Patient #R2, dated 12/14/18, revealed Patient #R2 was administered Lovenox (anti-coagulant) 30 mg subcutaneous without a physician's order. "Gave Lovenox 30 mg by mistake, not ordered for this patient. Med intended for another patient."

On 1/8/19 at 12:40 p.m. review of Patient #R2's medical record, with the assistance of S18Risk- medical record navigator, revealed no documented evidence of the medication variance and no documented evidence that the physician was notified. S18Risk verified the findings at the time of the record review.

38777




39791

Based on observations and interviews the CAH (Critical Access Hospital) failed to ensure there was a system in place for identifying, reporting, investigating and controlling infections and communicable diseases in patients. This deficient practice was evidenced by:
1) Failure to ensure a safe and sanitary environment was maintained;
2) Failure to ensure opened, unlabled/expired medications/supplies were not available for patient use; and
3) Failure to maintain a sanitary kitchen environment.

Findings:

1) Failure to ensure a safe and sanitary environment was maintained

On 01/07/19 between 9:45 a.m. and 11:00 a.m. observations of the hospital with S1DirQA revealed the following:

Patient Care Unit
a. Room 101: Rust to thermostat
b. Room 104: Rust to thermostat; blue pillow in the closet was torn- unable to disinfect
c. Room 108: Rust to thermostat; Chair/bed with rip to arm; peeling paint on wall above bed; patient bed with large amount of rust to arm rails; window track was dirty; a portable air filtration system was not connected to the wall vent and daylight could be seen through the vent;
d. Room 109: Rust to thermostat; peeling paint on wall above both patient beds; bathroom rails with rust; missing electrical socket face plate;
e. Room 112 (used as a Supply Room which contained wound care cart and Code Cart): Rust to thermostat; missing wall socket faceplate; phone face plate not secure and hanging; rust noted to code cart; toilet in bathroom with pink matter noted in the bowl of the toilet; 6 floor tiles with brownish matter on them; Code Cart was rusty; floor had rust colored substance spattered on it ( located on the area below the room sink).
f. Chapel: Contained uncovered hoyer lift and a trapeze bed bar with sled base. S1DirQA confirmed, during the observation, that the equipment was not stored properly (should not be stored in the chapel) because there was a clean storage room where the equipment should have been kept.

Emergency Room:
a. Exam Room #1 contained a pelvic exam table with tears on the corners of the cushion- unable to effectively disinfect due to tears in cushion;
b.The pelvic table also contained 3 drawers noted to have drips of a redish brown substance;
c.Wheelchair stored against the wall at ED entrance with armrest cushion torn- unable to disinfect properly;
d. Trauma Room contained a dirty Stryker Stretcher with a broken digital scale, held together with a clear tape; balanced on top of the stretcher. The tape on the scale prevented proper disinfection;
e. Clean Storage Room: Dirty Spine Board; hopper/sink with a bucket located under the sink which contained a small amount of dark liquid;
f. Personal protective equipment storage cart with isolation supplies stored in the hopper room (storage of clean and dirty together).

Physical Therapy Gym
a. The staff bathroom sink faucets were observed to have corrosion and peeling;
b. The wall near the hand rail had multiple holes in the wall;
c. Edges of over bed table were missing the surface covering in spots making the table difficult to disinfect;
d.Soiled wipe (with grayish residue) noted hanging on elliptical machine.


2) Failure to ensure opened, unlabled/expired medications/supplies were not available for patient use.

Observations of the inpatient unit wound supply cart on 1/7/19 at 11:00 a.m. revealed the following:
a.1 disposable skin marking measuring tool - package opened, available for use;
b. Hydrofiber dressing: 3 dressings- expired 10/2018;
c.1 bottle- Ketoconizole shampoo- open, unlabeled, expired 3/2018;
d.4 - Iodine pads expired 7/2018;
e.1- 3 ounce tube of Curasol- open, not labeled;
f. 6 pouch clamps- expired 3/2017;
g. 3 Hollister ostomy bags loose in drawer, not in any type of packaging to maintain cleanliness of equipment;
h. 1-0.17 ounce tube of Hypergel, opened, unlabled;
i. 1- 1.5 ounce Silver wound gel opened, unlabeled;
j. 3 - 1 ounce tubes of Triple Antibiotic Ointment opened, unlabeled;
k. 3 - Silvercel dressings, expired 2/2018.

S1DirQA was present for the observation and confirmed the findings referenced above during the observation. S1DirQA verified the opened supplies should have been dated and timed and that the expired medications/supplies should not have been available for patient use.

On 1/7/19 at 2:30 p.m. an observation was made in the medication room and an open, unlabeled 8oz. bottle of hydrogen peroxide was noted in the medication room cabinet.

On 1/7/19 at 2:30 p.m. S10LPN verified the findings of the opened, undated bottle of hydrogen peroxide available for patient use.


3) Failure to maintain a sanitary kitchen environment

A tour of the kitchen on 1/8/19 at 11:00 a.m. with S9DietMgr revealed the following infection control concerns:
a. 1- Metal Yellow Lock Box with cleaning chemicals covered in rust and peeling paint;
b. Metal cabinet where the bread is stored and a cabinet below with stored clean pots has peeling paint and rust;
c. The rubber coating on the dish drying rack is peeling and rusty;
d. The steel cabinet containing clean patient plates, bowls, and saucers also contained 1 Styrofoam food container with an employee's food and 1 plate covered with clear plastic containing several slices of cake belonging to an employee. An employee's car keys were also noted on the cabinet with the clean dishware;
e. One Hobart Mixer with rust in the base, shaft, and neck;
f. Walk in freezer contained 4 gallon bags of cornbread which was not dated;
g. One small chest freezer with rust on the front and a black substance on the gasket;
h. The large double door upright freezer had rust on the front door and side panels;
i. The large double door upright refrigerator had a brownish colored substance on the lower front which was able to be removed by S9DietMgr with a damp cloth.
j. One 3 tiered steel rolling cart with rust on all shelves;
k. The vent above the Autochlor System for washing the dishes contained peeling paint, rust and a bluish colored substance above where the clean dishes exit the system;
l. The ceiling had visible peeling paint.
m. 5 square ceiling vents were rusty and dirty.

During the observation a delivery man was noted to be walking through the food preparation area wearing a baseball type cap which did not completely cover his hair. He also had a beard which was not covered.

In an interview S9DietMgr verified the above findings and observations. She also confirmed they do not have a cleaning or maintenance policy or schedule.

Based on record review and interview, the hospital failed to ensure all medications were administered in accordance with physician's orders and accepted standards of practice for 1 (#R2) of 2 ( #7, #R2) patients reviewed for medication administration errors out of a total sample of 22 patients (20 sampled and 2 random sampled).

Findings:

Review of the hospital policy titled, "Administration of Medication", presented as current policy, revealed in part:
Prior to administration use the eight rights of medication administration (right patient, right medication, right dose, right time, right route, right documentation, right reason, and right response).
Anti-coagulants (intravenous or subcutaneous) require the documentation of a second nurse who is to review the physician's order of the medication and physically check the medication (dosage, route, time and content).

Review of Patient #R2's medical record revealed she was an 81 year old admitted on 12/5/18 with a diagnosis of status post hypoxemic respiratory failure and pneumonia.

Review of an Occurrence Report for Patient #R2, dated 12/14/18, revealed Patient #R2 was administered Lovenox (anti-coagulant) 30 mg subcutaneous without a physician's order. "Gave Lovenox 30 mg by mistake, not ordered for this patient. Med intended for another patient".

On 01/8/19 at 12:40 p.m. review of Patient #R2's medical record, assisted by S18Risk -medical record navigator, revealed no documented evidence of an order for Lovenox. S18Risk verified there was no order for Lovenox in the medical record for Patient #R2.