HospitalInspections.org

Based on record review and interview, the hospital failed to document daily operational checks of emergency equipment located on the inpatient nursing unit in 12 of 12 months (4/1/2018-3/31/2019) reviewed and the emergency department in 3 of 3 months reviewed (2/1/2019-4/15/2019). Between April 1, 2018 and April 15, 2019, there were 594 checks left blank out of a total of 3,300 expected checks.

Findings include:

Inpatient nursing unit

Review of untitled documents including headings of "Glucoscan" (sic) [blood sugar machine], "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp" (sic) [temperature], and "Monitor Checks" along the top, with "Date & Initials" numbered 1 to 31 down the left side of the page. The bottom of the untitled document revealed, "The above checks need to be done daily." Each document revealed a month and year written on the form.

Review of the untitled document dated, "April 2018" revealed no initials documented in the "Glucoscan" "d" (day) area 1 out of 30 days (4/11/18); no initials documented in the "Glucoscan" "n" (night) area 6 out of 30 days (4/12/18, 4/13/18, 4/17/18, 4/23/18, 4/27/18, 4/28/18); no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 5 out of 30 days (4/7/18, 4/14/18, 4/16/18, 4/19/18, 4/30/18); no initials documented in the categories of "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 1 out of 30 days (4/25/18); no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", and "Cardiac Tray Sealed" 1 out of 30 days (4/13/18).

Review of the untitled document dated, "May 2018" revealed no initials documented in the "Glucoscan" "d" (day) area 4 out of 31 days (5/13/18, 5/15/18, 5/22/18, 5/31/18); no initials documented in the "Glucoscan" "n" (night) area 2 out of 31 days (5/5/18, 5/24/18); no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 5 out of 31 days (5/12/18, 5/13/18, 5/14/18, 5/17/18, 5/18/18); and no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", and "Monitor Checks" 1 out of 31 days (5/28/18).

Review of the untitled document dated, "June 2018" revealed no initials documented in the "Glucoscan" "d" (day) area 1 out of 30 days (6/6/18); no initials documented in the "Glucoscan" "n" (night) area 3 out of 30 days (6/16/18, 6/18/18, 6/30/18); no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 3 out of 30 days (6/3/18, 6/4/18, 6/12/18).

Review of the untitled document dated, "July 2018" revealed no initials documented in the "Glucoscan" "d" (day) area 2 out of 31 days (7/17/18, 7/23/18); no initials documented in the "Glucoscan" "n" (night) area 6 out of 31 days (7/3/18, 7/5/18, 7/8/18, 7/11/18, 7/15/18, 7/16/18); no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 8 out of 31 days (7/2/18, 7/8/18, 7/12/18, 7/13/18, 7/15/18, 7/18/18, 7/28/18, 7/29/18).

Review of the untitled document dated, "August 2018" revealed no initials documented in the "Glucoscan" "d" (day) area 3 out of 31 days (8/11/18, 8/12/18, 8/17/18); no initials documented in the "Glucoscan" "n" (night) area 5 out of 31 days (8/8/18, 8/17/18, 8/18/18, 8/28/18, 8/29/18); no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 9 out of 31 days (8/3/18, 8/4/18, 8/5/18, 8/9/18, 8/12/18, 8/20/18, 8/21/18, 8/22/18, 8/26/18).

Review of the untitled document dated, "September 2018" revealed no initials documented in the "Glucoscan" "d" (day) area 2 out of 30 days (9/1/18, 9/11/18); no initials documented in the "Glucoscan" "n" (night) area 1 out of 30 days (9/20/18); no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 9 out of 30 days (9/4/18, 9/5/2018, 9/7/18, 9/8/18, 9/9/18, 9/18/18, 9/28/18, 9/29/18, 9/30/18).

Review of the untitled document dated, "October 2018" revealed no initials documented in the "Glucoscan" "d" (day) area 1 out of 31 days (10/5/18); no initials documented in the "Glucoscan" "n" (night) area 2 out of 31 days (10/2/18, 10/8/18); no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 1 out of 31 days (10/9/18); no initials documented in the categories of "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 1 out of 31 days (10/8/18); no initials documented in the categories of "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", and "Monitor Checks" 1 out of 31 days (10/14/18).

Review of the untitled document dated, "November 2018" revealed no initials documented in the "Glucoscan" "d" (day) area 1 out of 30 days (11/3/18); no initials documented in the "Glucoscan" "n" (night) area 8 out of 30 days (11/5/18, 11/13/18, 11/14/18, 11/15/18, 11/19/18, 11/25/18, 11/27/18, 11/30/18); no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 9 out of 30 days (11/3/18, 11/5/18, 11/9/18, 11/10/18, 11/11/18, 11/13/2018, 11/17/18, 11/27/18, 11/30/18).

Review of the untitled document dated, "December 2018" revealed no initials documented in the "Glucoscan" "d" (day) area 4 out of 31 days (12/1/18, 12/6/18, 12/16/18, 12/17/18); no initials documented in the "Glucoscan" "n" (night) area 7 out of 31 days (12/2/18, 12/4/18, 12/5/18, 12/6/18, 12/19/18, 12/22/18, 12/23/18); no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 8 out of 31 days (12/1/18, 12/2/18, 12/6/18, 12/10/18, 12/11/18, 12/21/18, 12/22/18, 12/23/18).

Review of the untitled document dated, "January 2019" revealed no initials documented in the "Glucoscan" "n" (night) area 4 out of 31 days (1/3/19, 1/27/19, 1/30/19, 1/31/19); no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 3 out of 31 days (1/10/19, 1/21/19, 1/23/19).

Review of the untitled document dated, "February 2019" revealed no initials documented in the "Glucoscan" "d" (day) area 2 out of 28 days (2/5/19, 2/28/19); no initials documented in the "Glucoscan" "n" (night) area 4 out of 28 days (2/4/19, 2/7/19, 2/8/19, 2/20/19); no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 4 out of 28 days (2/7/19, 2/24/19, 2/25/19, 2/26/19).

Review of the untitled document dated, "March 2019" revealed no initials documented in the "Glucoscan" "n" (night) area 1 out of 31 days (3/9/19); no initials documented in the categories of "Suction - set up", "Dirty utility closet locked", "Cardiac Tray Sealed", "Crash Cart tested/locked", "Blanket Warmer temp", and "Monitor Checks" 3 out of 31 days (3/16/19, 3/20/19, 3/30/19).

During an interview conducted on 4/17/2019 at 1:50 PM, when asked about the expectations for the daily equipment checks, Manager G stated, "I know there are gaps. I would expect that there is something marked for each day." When asked about policies for the blanket warmer temperature ranges and the daily equipment checks, Chief Nursing Officer (CNO) B stated, "we do not have a specific policy for the blanket warmers...there is no policy about the daily checks. It is an unwritten rule that they are done every day."



41126


Findings include:

Emergency Room

Review of untitled documents from the Emergency Room (ER) including headings of "Glucoscans ER" [blood sugar machine], "Suction ER", "Dirty utility closet locked ER", "Crash carts tested/locked ER", "Cardiac Tray Sealed", "Monitor Checks ER", "Monitor Defib check", "Check fluids dates in warmer", "Fluid warmer temp" and "Blanket warmer temp" across the top, with "Date & Initials" numbered 1 to 31 along the left side of the page. The bottom of the untitled document revealed, "The above checks need to be done daily." "Document any action taken and follow up on this form. Initial each check when it is done." Each document revealed a month and year written on the form.

Review of the untitled document dated, "February 2019" revealed no initials documented in the "Glucoscans ER" "N" (night) area 1 out of 28 days (2/5/19); no initials documented in the category of "Suction ER", "Dirty utility closet locked ER","Crash carts tested/locked ER", "Cardiac Tray Sealed", "Monitor Checks ER", "Monitor Defib check", "Check fluids dates in warmer", 3 out of 28 days (2/4/19, 2/14/19, 4/21/19). The "Fluid warmer temp" and "Blanket warmer temp" had no readings documented for 6 out of 28 days (2/4/19, 2/14/19, 2/18/19, 2/19/19, 2/20/19, 2/21/19).

Review of the untitled document dated, "March 2019" revealed no initials documented in the "Suction ER", "Dirty utility closet locked ER","Crash carts tested/locked ER", "Cardiac Tray Sealed", "Monitor Checks ER", "Monitor Defib check", "Check fluids dates in warmer", 3 out of 31 days (3/3/19, 3/7/19, 3/31/19) and no readings in the "Fluid warmer temp" and "Blanket warmer temp" 8 out of 31 days (3/3/19, 3/7/19, 3/14/19, 3/17/19, 3/18/19, 3/22/19, 3/23/19, 3/31/19)

Review of the untitled document dated, "April 2019" revealed no initials documented in the "Glucoscans ER" "N" (night) area 1 out 16 days (4/1/19) and no readings in the "Fluid warmer temp" and "Blanket warmer temp" 3 out of 16 days (4/3/19, 4/3/19, 4/15/19).

During an interview conducted on 4/17/2019 at 1:00 PM when asked about the expectations for completion of the daily checks, ER Manager P stated, " I would expect that there is something marked for each day." When asked about policies for the blanket warmer temperature ranges and the daily equipment checks, Chief Nursing Officer (CNO) B stated, "we do not have a specific policy for the blanket warmers...there is no policy about the daily checks. It is an unwritten rule that they are done every day."







37420

Based on observation, staff interviews, and review of maintenance records between April 16 and April 17, 2019, the facility did not construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 485.623 Condition of Participation: Physical Environment was NOT MET

Findings include:


K 0161 Building Construction Type and Height
K 0222 Egress Doors
K 0271 Discharge from Exits
K 0281 Illumination of Means of Egress
K 0311 Vertical Openings-Enclosure
K 0323 Anesthetizing Locations
K 0324 Cook Facilities
K 0341 Fire Alarm System - Installation
K 0345 Fire Alarm System - Testing and Maintenance
K 0353 Sprinklers Systems- Testing and Maintenance
K 0361 Corridors - Area Open to the Corridor
K 0363 Corridor - Doors
K 0364 Corridor- Openings
K 0521 HVAC
K0700 Operating Features - Other
K 0712 Fire Drills
K 0911 Electrical Systems - Other
K 0920 Electrical Equipment - Power Cords and Extensions

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interviews, and review of maintenance records between April 16 and April 17, 2019, the facility did not construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 485.623(d)(1) Standard: Life Safety from Fire was NOT MET

Findings include:


K 0161 Building Construction Type and Height
K 0222 Egress Doors
K 0271 Discharge from Exits
K 0281 Illumination of Means of Egress
K 0311 Vertical Openings-Enclosure
K 0323 Anesthetizing Locations
K 0324 Cook Facilities
K 0341 Fire Alarm System - Installation
K 0345 Fire Alarm System - Testing and Maintenance
K 0353 Sprinklers Systems- Testing and Maintenance
K 0361 Corridors - Area Open to the Corridor
K 0363 Corridor - Doors
K 0364 Corridor- Openings
K 0521 HVAC
K0700 Operating Features - Other
K 0712 Fire Drills
K 0911 Electrical Systems - Other
K 0920 Electrical Equipment - Power Cords and Extensions

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, record review and interview, staff failed to adhere to policy and procedures to maintain an environment free from potential contamination.

Findings include:

Hand Hygiene:
On 4/16/2019 at 11:00 AM Staff Q was observed preparing food for facility staff. He/she donned single use gloves, prepared the tray, then removed the gloves and placed them on the counter to deliver the food to the waiting staff member. Upon return to the tray line, no hand hygiene was performed and Staff Q donned the same pair of single use gloves. This same practice was observed again at 11:04 AM performed by Staff Q. Observations were made and verified with Dietary Manager O who stated "that is not our practice, he/she should don new gloves each time." Dietary Manager O also confirmed that "he/she should wash hands between glove use."

On 4/16/19 at 12:10 PM review of facility Dietary policy titled "Cleaning and Sanitation" last review date of 2/19, revealed "#3 wash hands before putting on gloves."

Food Storage:
On 4/17/2019 at 9:30 AM during a tour of the Dietary Department, a styrofoam container was observed to be in the cooler without a date. Dietary Manager O stated "that belongs to a staff member who didn't pick it up yesterday. I will throw it out today if still not picked up by the staff member." Observation and interview at 9:30 AM with Dietary Manager O who stated, "we are a small facility so we all know who it belongs to but I understand that someone not familiar with the facility would not. We should date it and place a name on it." Cheese trays, ham rolls, and chef salads observed in the employee refrigerator without dates. Staff O confirmed that they should have dates on them when prepared.

On 4/17/2019 at 9:40 AM during a tour of the Dietary Department, the following spices were observed to be open without dates; onion powder, garlic powder, salt, Montreal steak seasoning, cinnamon, oregano, nutmeg, thyme, pumpkin spice, vanilla, dill, sage, basil, paprika, curry, parsley, poppyseed and cream of tartar. Additionally butterscotch and white chocolate chips were in containers without dates. Observation and interview at 9:40 AM with Dietary Manager O who stated "they should be dated."

Review of facility policy "Procedure for Receiving and Food Storage" last review date 8/2018 revealed "c. Food prepared for "vending" will be given an outdate of 7 days with day one being the date it was prepared. Each morning food will be checked for outdates and freshness, and discarded as necessary."

Based on record review and interview the facility failed to ensure that a comprehensive care plan that is individualized, and based on assessing the patient's nursing care needs, treatment goals, admitting diagnosis', has current, appropriate nursing interventions with ongoing assessments of patient's needs and response to interventions. In 3 of a total of 12 medical records reviewed (Patient #'s 1, 7, 12).

Findings include:

The facility policy titled "Multidisciplinary Care Plan" last reviewed 5/18 was reviewed on 4/17/19 at 2:00 PM. This document revealed under "PROCEDURE: 3. As other disciplines work with the patient and the plan of care is initiated or changed, it is that disciplines responsibility to initiate and or update the plan of care by documenting changes on the care plan. 4. Upon any condition changes by the patient, the plan of care will be updated and kept current by the responsible discipline. 5. When the referring disciplines have seen the patient, they will document their visits on the care plan and make any changes on the plan of care related to their discipline by entering their assessments into the electronic health record."

Patient #12's medical record was reviewed on 4/17/19 at 9:25 AM. Patient #12 was admitted on 4/14/19 with fever, cough, wheezing and shortness of breath for 7 days was evaluated in the Emergency Room and admitted to the Medical/Surgical floor as an inpatient. Physician orders documented blood glucose's were to be obtained four times a day (before each meal and at bedtime) and that Patient #12 was receiving insulin injections from nursing staff at each meal and at bedtime.

There was no documented nursing care plan problem for Patient #12's diabetic diagnosis and nursing interventions of monitoring blood glucose'


38763


Patient #7's medical record was reviewed on 4/17/19 at 2:30 PM. Patient #7 was admitted on 02/28/19 for a Left Total Hip arthroplasty (hip replacement) and discharged home on 03/03/19. Patient #7 has medical history of type 2 Diabetes mellitus.

There was no documented nursing care plan problem for Patient #7's diabetic diagnosis and nursing interventions of monitoring blood glucose's.




41126


Patient #1's medical record was reviewed on 4/17/19 at 3:00 PM. Patient #1 was admitted on 1/3/19 as a direct admit with a diagnosis of bacteremia (the presence of bacteria in the blood) and discharged home on 1/11/19. Patient #1 has medical history of type 2 Diabetes mellitus.

There was no documented nursing care plan problem for Patient #1's diabetic diagnosis and nursing interventions of monitoring blood glucose's.

An interview was conducted with Medical Surgical Manager G on 4/17/19 at 3:30 PM, when asked about the care plans not having a diabetic nursing problem G replied "I would expect that there should be one and there is not."

Based on record review and interview, the hospital failed to ensure practitioners met the required education criteria designated by the governing body in 2 of 2 (Medical Doctor [MD] L and Physician Assistant [PA] M) personnel files reviewed out of a total universe of 8 personnel files reviewed.

Findings include:

Review of document titled, "Job Description...Position Title: Medical Orthopedist / Spine Specialist", prepared March 2, 2018 revealed, "Education / Experience Requirements: ...Current Provider card in Basic Life Support (BLS)." MD L's personnel file was reviewed with Manager N and Chief Nursing Officer (CNO) B. No documentation of BLS certification was found.

Review of document titled, "Physician Assistant Job Description" (no date) revealed, "II. Education Requirements: ...Current Provider card in Basic Life Support (BLS)." PA M's personnel file was reviewed with Manager N and CNO B. No documentation of BLS certification was found.

During an interview conducted on 4/17/2019 at 3:31 PM, CNO B confirmed, "there is no CPR card on file for the Ortho Surgeon and the PA. They should be there. They probably fell through the cracks."