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Based on observation and staff interview, the facility failed to inspect equipment for safe and accurate functioning and failed to store expired medical equipment in an area where patient care use would not occur.

Findings:

On 9/24/12, a vital signs machine was observed in the emergency room. The machine had a bio med sticker on it which indicated an inspection of the machine was due in April of 2012. The sticker revealed the machine was last checked in April of 2011.

During an interview with the Director of Nurses (DON) on 9/24/12, she reported the facility had a contract with a Bio Med company. The DON attempted to find a policy and procedure addressing the inspection of medical equipment but reported she could not find one.

On the morning of 9/24/12, a purple pouch from the Broselow Pediatric Code Cart was found on top of the pediatric crash cart. The pouch contained expired equipment used in pediatric emergencies including an intraosseus needle, oral airways, a tracheostomy tube and a suction catheter.

During an interview with the emergency room nurse on 9/23/12, she acknowledged the purple pouch contained expired equipment but said the pouch was used for training. The nurse agreed to place the pouch in area away from the crash cart where it could not be mistakenly used.

Based on observation and interview, the facility failed to ensure staff followed infection control policies.

Findings include:

On 9/26/12 at 11:00 AM, a staff nurse was observed during a blood glucose monitoring check. The staff nurse donned gloves in the medication room, then proceeded into the hall and the patient's room to check the blood glucose level. The staff nurse was observed to place the glucometer on the patient's bed before performing the test.

On 9/26/12 at 11:10 AM, a staff nurse was observed drawing up insulin in the medication room. The staff nurse donned gloves prior to the procedure. The staff nurse, wearing the gloves, then went into the hall to find a nurse to confirm the dosage and then to the patient's room to administer the insulin.

On 9/26/12 at 11:20 AM, the Chief Nursing Officer was interviewed and reported the policy was staff were expected to put the gloves on in the patient's room, and not wear them in the hall.




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On 9/25/12, the emergency room nurse, Employee #1, was observed to not wipe an intravenous port with alcohol prior to administering a drug through the port.

Review of the facility policy and procedure entitled "Safe Medication Practices" effective 3/15/2006 and revised 9/26/10 revealed "aseptic technique was to be used to avoid contamination of sterile injection equipment and medications. (Cleanse all puncture ports, IV connections prior to use.)"

Based on record review, policy review, and interview, the facility failed to ensure nutritional screens were completed as per policy (Patient #15, #16), and failed to ensure patients requiring a dietician referral received the referral as requested for 2 of 20 patients (Patient #15, #11).

Findings include:

Patient #15

Patient #15 was admitted to the facility on 4/14/12 with diagnoses including dehydration, near syncope, dementia, hypertension, and kidney disease.

A review of the nutritional screen performed on admission revealed there were no total points compiled. Patient #15 had a positive occult blood test and a low hemoglobin and hematocrit, low total protein and albumin.

A review of the facility policy on nutrition screening revealed that all patients were to receive a screen and points totaled for review by the consulting dietician. There was no evidence the consulting dietician reviewed the nutrition screen on Patient #15.

Patient #11

Patient #11 was admitted to the facility on 8/31/12 with diagnoses including uncontrolled diabetes.

A review of Patient #11's record revealed the nutritional screening done by nursing totaled to a score of five. Patient #11 was referred to the dietician with the comment, "needs registered dietician clinical judgment, obesity." There was no evidence the dietician reviewed the nutritional screen or saw Patient #11.

Patient #16

Patient #16 was admitted to the facility on 7/14/12 with the diagnoses including congestive heart failure, severe weakness, renal insufficiency, and atrial fibrillation.

Review of Patient #16's record revealed a nutritional screening was done by nursing on 7/14/12. The score was not totaled.

On 9/26/12, at approximately 10:30 AM, the dietician was interviewed and reported Patient #16 had been admitted on a Friday evening, and was discharged on the following Monday, before the dietician was able to see the patient.

Based on record review, interview, and policy review, the facility failed to ensure verbal orders from physicians were signed within an appropriate length of time.

Findings include:

Patient #1

Patient #1 was admitted to the facility on 7/29/12 with diagnoses including aggression and uncontrolled psychosis.

On 9/24/12, Patient #1's record was reviewed and revealed verbal orders were taken by nursing on 8/10/12, 8/18/12, 8/29/12, 9/7/12, and 9/11/12. At the time of the review, the verbal orders were not signed.

Review of the facility policy PHM3302, "Verbal and Written Orders-General" from the pharmacy department, revealed the following under the heading Verbal/Telephone Orders:

"The order will be written on the physician order sheet by the person receiving the order and noting the date and time received, the name of the LIP (licensed independent practitioner) issuing the order and the receiver's name and title. The prescriber shall co-sign the order within 24 hours."

Review of the policy HWN 137, "Telephone, Verbal, and Written Orders" with an effective date of 7/25/07, revised 10/13/09, revealed the following under Telephone/Verbal orders:

"II. d. Verbal orders are to be used in emergent situations only and must be co-signed as soon as possible by the prescriber."

On 9/26/12, the director of the pharmacy was interviewed and reported she was not aware of the discrepancy in the verbal order policies.