HospitalInspections.org

Based on observation and staff interview, the governing body failed to ensure the hospital environment is maintained and safe for patients.

Findings Include:

Cross Refer to A0700 / 482.41 for the governing body's failure to ensure there was a functioning call light in every patient room on the second floor medical surgical unit, a functioning dome light outside in the hallway of each room and a functioning call light system at the nurse's station.

Based on medical record review, policy and procedure review, and staff interview, the facility failed to ensure all orders, including verbal orders, were dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient.

Findings Include:

Review of the electronic medical record (EMR) for Patient #1, on 1/13/16 at 2:35 p.m., revealed no documented evidence in the EMR "Order History Drop-Down Box", of the credentials of the staff member who received the telephone order, the time the telephone order was received and/or the physician who gave/authorized the telephone.

Review of the facility's "Verbal/Telephone Orders" Policy and Procedure 210-019 (dated March 2014), revealed, "1. Purpose and Applicability. This policy defines the process for nurses accepting verbal or telephone orders directly from credentialed (name of hospital) physicians or nurse practitioners. This policy applies to all clinical nurses in all programs of (name of hospital) ...3. Procedure ... C. The nurse receiving the verbal/telephone order will transcribe the order on the physician order sheet and verify accuracy by reading back the complete order to the physician/nurse practitioner ..."

Review of the facility's "Transcribing/Noting Physician's Orders" Policy and procedure 210-016 (dated January 2014), revealed, " ...2. Policy. Physician's Orders will be transcribed and noted by a licensed nurse using proper procedure. Where EHR is implemented nurses will follow the established nursing workflow ... D. Signing Off Orders. (1) After orders have been transcribed, the nurse noting the orders will sign, using initial, last name, and title."

During an interview on 1/13/16 at 2:40 p.m., Registered Nurse (RN) #3 confirmed that the "Order History Drop-Down Box" in the EMR for Patient #1 did not contain the credentials of the staff member, the time the telephone order was received and/or the physician who gave the telephone order. She stated, "This is the same in all our patient records."

During an interview on 1/14/16 at 10:10 a.m., Information Management (IM) Staff #1 and IM Staff #2 both revealed that the current EMR system has been in use for one month and they are in the process of working on correcting the problems in the system. They both confirmed the "Order History Drop-Down Box" does not contain the option for credentials of the staff member, the time the telephone order was received and/or the physician who gave the telephone order.

Based on medical record review and staff interview, the facility failed to obtain properly executed informed consent forms for procedures or treatments, containing the name of the hospital where the procedure or other type of medical treatment is to take place for 16 of 16 patient records reviewed. (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16.)

Findings Include:

Review of medical records for Patient #1 through #16 revealed no documented evidence of an informed consent form for treatment, containing the name of the hospital where the procedure or other type of medical treatment is to take place.

During an interview on 1/14/16 at 11:00 a.m. the Administrator confirmed there was no documented evidence in the medical records, of an informed consent form for treatment, containing the name of the hospital where the procedure or other type of medical treatment is to take place.

Based on observation and staff interview the facility failed to ensure all drugs and biological are kept in a secure area.

Findings Include:

Observation on 1/12/16 at 11:05 a.m. revealed the medication room, located at the nursing station, had a half door with a lock. The nursing station door did not have a lock and an employee was not designated to be at the nursing station at all times.

An interview with the Director of Nursing (DON) on 1/12/16 at 11:05 a.m. confirmed these observations. The DON stated, "We are in the process of correcting the door per our (name of accrediting association) survey."

Based on observation, staff interview, and policy review, the facility failed to ensure outdated medications are not available for patient use.

Findings Include:

Observation of the Crash Cart on 1/12/16 at 11:30 a.m. revealed three (3) expired medications:
(1) A 15 milliliter (ml) bottle of Flumazenil 0.5 milligram (mg) with an expiration date of December 2015;
(2) Protamine Sulfate injectable 250 mg/25 ml with an expiration date of December 2015; and
(3) Fosphenytoin injectable 50 mg/ml with an expiration date of February 2015.

An interview with the Charge Nurse on 1/12/16 at 11:30 a.m. confirmed the expired medications. She stated, "The crash cart is checked monthly by the pharmacy and restocked."

During an interview on 1/13/16 at 1:45 p.m.the Pharmacist revealed that the Pharmacy Technician responsible for checking the crash cart left hospital employment in December 2015 and the new Pharmacy Technician had not checked the cart for January 2016. She stated, "The crash carts are usually checked the last Friday of the month."

Review of the "Pharmacy Inspections" Policy, dated October 2014, Procedure A-5 revealed: "Emergency boxes will be checked for expiration."

Based on observation and staff interview, the facility failed to ensure and/or maintain a safe hospital environment for patients. There was no functioning electric nurse call system on the second floor for every patient bed, no functioning dome light outside in the hallway of each room, and no functioning call light system at the nurse's station.


Findings Include:

On 01/12/16 at 11:10 a.m. observations of the facility, made with the Company Unit Officer (CUO), revealed two (2) square holes located in the housekeeping closet next to the X-ray and Laboratory waiting area. The CUO stated that the holes were cut to install computer cable and had not yet been repaired. Observation also revealed paint peeling on the walls in Patient Rooms #205, #207, #208, #209, and #210; paint peeling in the day room; paint peeling in the main hallway of the Medical Surgical Unit; and a brown stain on the bathroom ceiling tile in Patient Room #201.


On 1/12/16 at 11:40 a.m. observation revealed there was no functioning call light on the second floor medical surgical unit in Patient Room #201, #207, #208, #209, #211, #212, #213, #214, #215, and #216. There was no functioning dome light outside in the hallway of each of these rooms and no functioning call light system at the nurse's station. The Director of Nursing (DON) confirmed these observations. She stated, "We are currently working on getting our call light system bids." The DON stated that patients who are assessed with a cognitive status have a hand held bell at their bedside and patients who are assessed as non-cognitive are being checked every 15 minutes by any staff member." The DON also stated, "The call light system has not been functional since 1992." At 11:45 a.m. observation revealed there were no hand held call bells in any of the patient rooms where patients were admitted, Room #201B, #201C, #201D and #216.


On 1/12/16 at 3:00 p.m. an interview was held with the facility's Administrator to discuss all of these observations and findings. He stated, "I will handle this now."


During an interview on 1/12/16 at 4:15 p.m. the Maintenance Director stated, "If something does not work, a work order is placed." When asked, "When was the last maintenance check on the call light system?" he stated, "Six and a half (6 ½) years ago. Nothing works and there is nothing to check." A copy of the last maintenance checks for the nurse call light system and a policy and procedure for equipment maintenance repair was requested. No further documentation was submitted for review.


A copy of the policy and procedure for the nurse call system and for the equipment maintenance procedure were requested. No documentation was submitted for review.

Based on observation and staff interview, the facility failed to ensure and/or maintain an environment in a manner to ensure the safety and well-being of patients.


Findings Include:


Cross Refer to A0700 for the facility's failure to ensure there was a functioning call light in every patient room on the second floor medical surgical unit, a functioning dome light outside in the hallway of each room and a functioning call light system at the nurse's station.




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