HospitalInspections.org

Based on review of medical records (MR), Medical Staff By-Laws and Rules and Regulations, Combined Board of Directors and Finance Committee Meeting, physician credentialing files and interview, it was determined, the facility failed to ensure that 1 of 3 physicians was credentialed to admit patients to the facility and exercise clinical privileges.

This affected 1 of 11 inpatient/outpatient surgery MR's reviewed, including MR # 12 and had the potential to negatively affect all patients receiving care at this facility.

Findings Include:

Medical Staff By-Laws and Rules and Regulations
Revised: 2016

Article IV: Categories Of The Medical Staff

Section 1. The Medical Staff

The Medical Staff shall be divided into active, provisional, consulting, honorary, emergency service categories, locum tenens and medical students.

Section 2. The Active Staff

A. Qualifications: ...
3. Regularly admits patients to, or is otherwise regularly involved in, the care of patients in this Medical Center.

Section 3. Provisional Staff

A. Qualifications: ...
3. Regularly admits patients to or is otherwise regularly involved in the care of patients in this Medical Center.

Section 4. The Consulting Staff

A. Qualifications: ...
2. Is a recognized specialist who occasionally attends patients in the Medical Center ...

B. Prerogatives: ...
1. ...He shall not be eligible to admit patients to the Medical Center ...

Section 5. Honorary Staff

A. Qualifications: The Honorary Staff shall consist of practitioners recognized for their contributions to the health and sciences or their previous longstanding or otherwise noteworthy service to the Medical Center.

B. Prerogatives: ...They are not eligible to admit patients to the Medical Center or to exercise clinical privileges in the Medical Center.

1. MR # 12 was admitted to the facility on 12/14/18 for an Outpatient Laparoscopic Cholecystectomy.

Review of the Emergency - Outpatient Admitting MR form revealed, "Attending (Name), Employee Identifier (EI) # 24/2nd Physician (Name), EI # 7".

Further review of the MR revealed 8 pending verbal orders dated 12/14/18 obtained from EI # 24.

An interview was conducted on 2/12/19 at 4:45 PM with EI # 1, Chief Executive Officer (CEO), who stated, EI # 24 did not have admitting privileges and verbal orders should not have been given by EI # 24.

2. On 2/12/19 the surveyor submitted a list of 3 physicians for credentialing review.

On 2/13/19 at 7:30 AM a review of the Combined Board of Directors and Finance Committee Meeting dated February 1, 2018 revealed the following:

Old Business: ...

"Dr. (Name), {EI # 24's} letter dated January 9, 2017 (attached) resigning from active status on the Medical Board was not previously recorded in any previous minutes. By these meeting minutes, it is hereby added to the records. Dr. (Name) {EI # 24} will no longer need to be credentialed for reappointment".

On 2/13/19 at 8:30 AM EI # 3, Executive Administrative Assistant, submitted the credentialing files requested and the list which revealed, "EI # 24: Resigned 9 January 2017".

Review of EI # 24's physician's credentialing file on 2/13/19 at 9:55 AM revealed a letter dated 1/9/17 which read, "This letter will serve to notify you that I am ending my status as an active member of the medical staff ... on Febrary (February) 3, 2017".

EI # 24 resigned from the medical staff on 1/9/17 and admitted MR # 12 as the attending physician on 12/14/18, which was 23 months later. The facility failed to ensure EI # 24 was credentialed to admit patients to the facility and exercise clinical privileges.

An interview was conducted on 2/13/19 at 9:55 AM with EI # 3 who confirmed the aforementioned findings.

Based on observations and interview with staff, it was determined the facility failed to provide a safe and ligature risk free environment for geriatric psychiatric patients admitted to the Senior Care Unit (SCU). This had the potential to affect all patients admitted to the SCU.

Findings include:

Please refer to tag A-0144 for findings.

Based on observations in the Senior Care Unit (SCU), policy and procedure, and interviews with staff, it was determined the facility failed to ensure:

a) A safe and ligature risk free environment for psychiatric patients.

b) Medications for discharged patients were disposed of properly.

c) Stock supplies of alcohol and 0.9 % Sodium Chloride were labeled with opened date.

e) Personal care items were stored properly.

f) Personal care products were discarded after patient discharge.

This had the potential to affect all patients served by the SCU.

Findings include:

Policy: Suicide Prevention
Policy Number: None listed
Date Issued: June 2018

Suicide precautions are established for the protection and safety of patients...

Suicide Precaution Interventions:

...e. Patients... and bedroom will be searched thoroughly for any objects which may cause self-harm...

g. The environment will be kept free of potentially dangerous objects...

A tour conducted on 2/12/19 at 7:30 AM of the Medication Room on the SCU revealed the following items located in the storage cabinet for patient medications, sitting to the side of the room labeled drawers:

1) 1 bottle of Loperamide 1 mg (milligram)/ 5 ml (milliliters), opened and no name or date on bottle.

2) Triamcinolone Ointment, opened, no name or date on tube.

3) Proctozone HC (Hydrocortisone) 2.5 %, opened, no name or date on tube.

The surveyor asked EI # 9, LPN (Licensed Practical Nurse), to whom did the medications belong. EI # 9 stated "...that patient has been discharged. We keep them for a while to see if the patient returns to get them, but they have been here a while and should have been discarded already."

The upper cabinet contained:

1) 1 liter of 0.9% Sodium Chloride, opened and unlabeled.

2) 1 16 ounce bottle of 70 % Alcohol, opened and unlabeled.

The following nutritional supplements were stored on the floor:

1) 1 case Glucerna 1.5 Cal (Calorie) cans.

2) 1 and 1/2 cases of Jevity 1.5 Cal, 8 ounce boxes.

In an interview conducted on 2/12/19 at 7:50 AM with EI # 9, who was also present on the tour, the above findings were confirmed.

On 2/12/19 at 9:15 AM a tour revealed the following ligature or safety risks in rooms 401 through 408, which was the 8 rooms of the 16 bed unit.

1) Exposed plumbing under bathroom sink and behind toilet. Toilet plumbing exposed to approximately 4 feet high, before making a 90 degree turn and entering wall.

2) Sink faucets have levers and high arching spout.

3) Light above mirror is hard plastic and metal with bare edges. Surveyor was able to reach the light and bare edges.

4) Flat top paper towel holder mounted to wall.

5) Each side of the room, bed A and bed B, contained a set of wooden built in cabinets. The drawers were unsecured from access. Double closet doors, were flat across the top and had regular hinges. Two high cabinet doors were secured with a metal bar, the bar had approximately 1/2 " (inch) to 3/4 " space behind it. The light above the drawers contained a plastic removable cover.

6) The patient beds contained full length open side rails.

7) Both sides of the room contained a small desk, unsecured, and a lightweight chair.

8) Miniblinds, approximately 5 feet tall, hung in two of two windows. Plastic wand attached.

9) Lights over head of bed contained plastic covers, surveyor was able to reach.

On 2/12/19 at 10:05 AM the following was observed in the community shower room, located on the SCU:

In the upper cabinet, new personal care items were stored. Also in the cabinet were personal items brought in by patients/ families:

1- large bottle of Vaseline lotion containing a patient's (pt) name.
1- bottle of bath wash containing a pt's name.
2- opened and used deodorants, no names.
1- bottle lotion containing a pt's name.
1- Degree deodorant, labeled with a name, and a line drawn through the name.
1- hair brush, full of hair.
2- bottles of cologne, open and no name.
1- bottle Super Grow cream, labeled with a pt's name.
1- bottle Ponds cream, labeled with a pt's name.
1- bottle of Skin Bracer after shave.
1- bottle of Mesmerize lotion, labeled with a pt's name.
Multiple opened and unlabeled tubes of toothpaste.

The cabinet shelf was covered in a white, sticky substance and dirty.

In an interview conducted on 2/12/19 at 10:15 AM with EI # 14, RN (Registered Nurse), who was also present on the tour, confirmed personal items should be stored in the plastic bins labeled with the patient room numbers. EI # 14 further confirmed some of the patient's names listed on the bottles had been discharged, and the items should have been discarded.

During an interview on 2/13/19 at 9:30 AM with Employee Identifier (EI) # 5, Nurse Practioner, Director of Nursing, SCU, the above findings were confirmed. EI # 5 further stated a maintenance request had been placed to cover exposed plumbing in bathrooms, but had not been completed.

Based on the review of medical records (MR), policy and procedures, and interview it was determined the facility failed to have the physician to view and assess the patient in restraints and document within an hour or contact the E.R. (emergency room) physician per policy & procedure. This affected patient identifier (PI) # 19, 1 of 1 restrained Intensive Care Unit (ICU) patients.

Findings include:

Subject: Safety Policy-Restraints
Revised Date: 2/2017

Statement of Purpose:
To provide guidelines for the therapeutic interventions necessary to protect a patient from physically injuring self or others and/or others and/or prevent the disruption of a therapeutic environment. Interventions will be limited to clinically justified situations employing the least-restrictive safe and effective restraint method. Protection and preservation of patient's rights, dignity, and well-being are ensured by maintaining a safe environment, assuring the patient's ability to care for him/herself is not compromised, and to assure that the patient maintains a comfortable body temperature, modesty, and visibility to others. Types of restraint with written definition, time frame for use of restraint, and reason for restraint use will be outlined in this policy...

Procedure:
1. There must be a written order for any form of restraints. If, in the nurse's supervisor opinion, the patient needs restraints and she/he is unable to reach the attending physician, she/he will contact the on call physician. The restraint order must be re-newed every 24-hours if restraints continue to be needed. The physician contacted will decide to give a verbal order. To restrain or not restrain: If the order is to restrain he/she will come in and view and assess the patient within an hour or will contact the E.R. physician for further assessment...

PI # 19 was admitted to the facility on 2/8/19 with diagnoses of End Stage Chronic Obstructive Pulmonary Disease (COPD) with an acute exacerbation and subsequent hypoxia and Carbon Dioxide (CO2) retention secondary to End Stage COPD with an acute exacerbation and subsequent hypoxia.

The physician ordered use of soft wrist restraints for medical immobilization (to keep patient from pulling medical equipment, face mask, trying to get out of bed, etc.) on 2/10/19 at 7:00 PM for 24 hours.

Review of the patient's progress notes dated 2/10/19 at 9:45 PM revealed the following documentation by the nurse, "Physician in room. Update given. EKG completed. Called to physician to update him on status of pt (patient) labs ordered. Pt still agitated. Pt. giving appearance that he may crash at any moment. Crash cart moved into room." There was no other documentation of the physician assessing the restrained patient prior to 9:45 PM. The staff failed to ensure the restrained patient was assessed per facility policy and procedure.

An interview was conducted on 2/13/17 at 1:58 PM with Employee Identifier (EI) # 2, Registered Nurse, Chief Nursing Officer, who confirmed the physician did not view and assess the patient within an hour nor contacted the E.R. physician to assess the restrained patient.

Based on review of medical records (MR), facility policies and procedures, National Pressure Ulcer Advisory Panel (NPUAP) staging system, and interviews, it was determined the facility failed to ensure the staff:

a) Followed the physician's orders for wound care.

b) Performed wound assessments and measured wounds per policy.

c) Staged pressure ulcers per NPUAP staging system.

This affected 2 of 6 inpatient records reviewed including MR # 21, MR # 18 and had the potential to negatively affect all patients served by this facility.

Findings Include:

Facility Policy: Wound Care
Date Issued: 12/13

Purpose: To provide wound care assessments and obtain orders for wound care.

Text:

A. Skin Assessments for all patients will be head to toe.

B. Wounds must be assessed, measured, and characteristics (drainage, smell) documented daily.

1. Wound care and dressing change per MD (Medical Doctor) orders.

Facility Policy: Wound Care/Treatment Guidelines
Date Reviewed: 9/2015

Statement of Purpose: To provide excellent wound care to promote healing.

Guidelines:

1. A daily assessment should be done on all wounds requiring treatment. This should include measurement and a description.

10. Documentation of treatment ... immediately after the treatment.

National Pressure Ulcer Advisory Panel (NPUAP)
2017

Position Statement 4:

The NPUAP Staging System classifies pressure injuries based on the type of tissue loss that can be visualized or directly palpated.

Pressure injuries can be numerically staged (i.e. Stage 1, 2, 3 or 4), if the type of tissue injured can be visualized or directly palpated (e.g., in the case of Stage 4 when exposed bone is visible or directly palpated). The NPUAP also recognizes the very real clinical limitations of being able to visualize the types of tissues exposed by injury. Based on these limitations, the NPUAP staging system provides two additional options: (1) unstageable pressure injuries to address situations where the wound base is obscured by slough and/or eschar and (2) Deep Tissue Pressure Injury (DTPI) where the skin may still be intact, but is purple or maroon indicating deeper tissue damage has occurred. After DTPIs evolve, or unstageable pressure injuries are debrided, these injuries can be numerically staged. Due to the unique anatomy in mucosal membranes, pressure injuries in these tissues should be noted, but can never be staged.

When classifying injuries caused by pressure and/or shear, the clinician has the following options: 1) If the type of tissue in the wound base can be evaluated, numerically classify as Stage 1 or 2 or 3 or 4, based on the deepest tissue type exposed. 2) If the wound base cannot be evaluated, classify as: a) DTPI when the skin is intact with deep red, purple or maroon discoloration or blood blister(s). b) Unstageable when the base is obscured by slough or eschar. 3) If on a mucosal membrane, document, but do not stage.

1. MR # 21 was admitted to the facility on 8/14/18 with diagnoses including Infected Sacral, gluteal decubiti (decubitus), cocycal (coccyx) and Paraplegia.

Review of the MR revealed Routine Admission Orders dated 8/14/18 at 11:00 PM which read:

"15. Other Orders as Follows:
...Saline dressings to decubiti (pressure induced ulcerations). Change qid (4 times a day). Keep moist".

Review of the Nursing Interview and Assessment dated 8/14/18 at 11:45 PM revealed, "A: Decub (Decubitus) sacral area, B: x (times) 3 small Decub, C: Decub Right Buttock -Tunneling, D: Decub Left Buttock - Tunneling". There was no documentation the staff measured and documented a description of the wounds per policy. There was no documentation the staff staged the Decubitus Ulcer's (Pressure Ulcers) per NPUAP staging system.

Further review of the Nursing Interview and Assessment dated 8/14/18 at 11:45 PM revealed, "Wounds to sacral and buttock area cleansed per MD order, photo's taken, dressed per MD order". There were no physician's orders documented for the type of wound cleanser to be used and dressings to be applied to the wounds. The staff failed to document what treatment was provided to the wounds as directed per the facility policy.

Review of the Nurses Notes dated 8/15/18 at 6:38 AM revealed, "Skin Condition: Pressure wound location: to buttocks".

Review of the Nurses Notes dated 8/15/18 at 3:30 PM revealed the following:

"Type of Wound: Decubitis. Notes: wound care done at this time, removed old dressings moderate amount of serosanguineous drainage noted, cleansed wounds to right buttock and sacrum wound (Site: A) with NS, packed wound to sacrum with 1 small roll of gauze, covered sacrum wound and wound to right buttock (Site: C) with NS soaked 4x4's and covered with ABD (abdominal) pad and secured with tape. Cleansed left buttock (Site: D) with NS, packed wound ... covered with ABD pad".

There was no documentation which wound was assessed on 8/15/18 at 3:30 PM. The Skilled Nurse (SN) failed to assess, measure and stage all wounds as directed per policy and NPUAP staging system.

There was no documentation all wounds (Site: B - 3 small Decubiti) were assessed were per facility policy.

There was no documentation of a physician's order for the type of solution used (NS) to cleanse the wounds and the ABD pads used to cover the wounds.

Review of the Nurses Notes dated 8/15/18 at 6:05 PM revealed the following:

"Pressure Ulcer/Wound Location: See Unisex Body documentation: Site A: Location: Sarum (Sacrum) ..., Site B: Location: right buttock (previously documented as Site: C), ... Site C: Location: left buttock (previously documented as Site: D): ...
Drainage: Moderate amount.
...Pressure Ulcer Condition: Opened with tunneling, beefy, foul odor.
Wound Interventions: Performed as ordered, areas cleansed with NS, left and right buttocks wounds with saline soaked kerlix, two 4x4 wet gauze placed ABD pads and paper tape".

There was no documentation which wound was assessed on 8/15/18 at 6:05 PM. The SN failed to assess, measure and stage all wounds as directed per policy and NPUAP staging system.

There was no documentation wound care was provided to the sacral wound (Site A) and Site B (previously assessed as 3 small Decubiti wounds) as directed per the physician's orders.

Further review of the MR revealed the staff failed to perform wound care qid on 8/15/18 as directed per the physician's orders.

Review of the Nurses Notes dated 8/16/18 at 1:33 AM revealed the following:

"Pressure Ulcer/Wound Location: See Unisex Body documentation: Site A: Location: Sacral area ..., Site B: Location: right buttock (previously documented as Site C ..., Site C: Location: left buttock (previously documented as Site D) ...
Pressure Ulcer Condition: ... Tunneling - approx (approximately 5 cm (centimeters in depth of right decub, left decub 3 cm in depth, slight odor.
Drainage: Sanguinous, Moderate amount.
Description of Wound: Beefy red granulation tissue, moist, light odor.
...Dressing: Damp gauze packing with ABD pad and paper tape.
Wound interventions: Performed as ordered, Cleansed with NS, both buttock wounds packed with saline soaked ..."

There was no documentation which wound was assessed on 8/16/18 at 1:33 AM. The SN failed to assess, measure and stage all wounds as directed per policy and NPUAP staging system.

There was no documentation the staff performed wound care to all wounds as directed per the physician's orders.

Review of the Nurses Notes dated 8/16/18 at 6:55 AM revealed the following:

"Pressure Ulcer/Wound Location: See Unisex Body documentation: Site A: Location: Lt (Left) buttock (previously documented as Site D & C) ..., Site B: Location: sacrum (previously documented as Site A) ..., Site C: Location: right buttock ((previously documented as Site C & B)
Pressure Ulcer Condition: Tunneling.
Drainage: Serosanguinous.
Description of Wound: Moist, no odor...

There was no documentation which wound was assessed on 8/16/18 at 6:55 AM. The SN failed to assess, measure and stage all wounds as directed per policy and NPUAP staging system.

Review of the MR revealed a Physician's Order dated 8/16/18 at 9:55 AM which read: "Dressing change BID (twice a day) with 1/2 (half) strength Dakins soaked gauze, pack cover & (and) secure with tape".

Review of the Nurses Notes dated 8/16/18 at 10:25 AM revealed the following:

"Notes: wound care ... right buttock and sacrum ... left buttock".

There was no documentation wound care was provided to the 3 small Decubiti (previously documented as Site B) on 8/16/17, 8/17/18 and 8/18/18.

Review of the MR revealed a Physician's Order dated 8/16/18 at 7:22 PM which read: "Add to dressing change. Clean wounds with NS (Normal Saline). Cover wounds with 1/2 strength Dakins 1/2 NS soaked gauze. Cover with dry 4 x (by) 4's secure with tape".

Review of the Nurses Notes dated 8/16/18 at 7:30 PM revealed the following:

"Pressure Ulcer Condition: Granulation present ... Tunneling.
Description of Wound: ... No odor.
Dressing: Clean wounds from coccyx to right buttocks ... Coccyx packed wound bed ... right buttocks packed wound bed".

There was no documentation which wound was assessed on 8/16/18 at 7:30 PM. The SN failed to assess, measure and stage all wounds as directed per policy and NPUAP staging system.

There was no documentation the staff provided wound care to all wounds as ordered per the physician's orders.

Review of the Nurses Notes dated 8/17/18 at 7:40 AM revealed the following:

"Pressure Ulcer Condition: Opened Blister. Redness around perimeter, slight odor.
Drainage: Serous, small amount.
Wound Dimensions: x 6
...Wound Interventions: Regular Dressing Change".

There was no documentation which wound was assessed on 8/17/18 at 7:40 AM. The SN failed to assess, measure and stage all wounds as directed per policy and NPUAP staging system.

There was no documentation the staff provided wound care to all wounds as ordered per the physician's orders or the specific wound care provided.

Review of the Nurses Notes dated 8/17/18 at 6:04 PM revealed the following:

"Pressure Ulcer/Wound Location: See Unisex Body documentation: Site A: Location: Pressure Ulcer: Notes: small bloody/purulent drainage, 6 cm circum (circumference)..., Site B: Location: raw abrased wound: Notes: 6 cm x 4 cm, Site C: Location: Pressure Ulcer: Notes: small bloody/purulent drainage, 6 cm circum...
Wound Dimensions: # 1: 6 cm, # 2: 6 cm, # 3: 6 cm x 4 cm.
Dressing: # 1 Damp to dry gauze packing ... 1/2 dakins and 1/2 sterile water ... # 2 Damp to dry gauze packing ... 1/2 dakins and 1/2 sterile water ... # 3 Covered with damp 4 x 4 and dry ABD pad".

The SN provided 1/2 Dakins with sterile water and not NS as ordered for wound # 1 and # 2. The SN failed to provide wound care as ordered to wound # 3.

The SN failed to assess, measure and stage all wounds as directed per policy and NPUAP staging system.

Review of the Nurses Notes dated 8/18/18 at 6:55 AM revealed the following:

"Pressure Ulcer Condition: Tunneling, Opened blister, Redness around perimeter.
Drainage: Purulent, Sanguinous, Large amount, bleeding and exudate noted.
Skin Graft: Dressing changed per orders, x 6 decubs to sacral/buttocks, dressing change clean with normal saline apply 1/2 strength dakins 1/2 normal saline soaked gauze to wound beds, cover with dry 4x4 ...
Wound Interventions: Deluxe dressing change".

There was no documentation which wound was assessed on 8/18/18 at 6:55 AM.

There was no documentation what wound care was provided as directed per the facility policy.

The SN failed to assess, measure and stage all wounds as directed per policy and NPUAP staging system.

An interview was conducted on 2/13/19 at 1:45 PM with Employee Identifier (EI) # 2, Chief Nursing Officer (CNO), who stated, the staff failed to clarify and follow the physician's orders for wound care and staff failed to assess/measure/stage and document wounds.




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2. PI # 18 was admitted to the facility on 2/8/19 with diagnoses of Abscess of left buttock with cellulitis failing outpatient treatment.

Review the physician orders dated 2/10/19 revealed the following wound care order, "Apply Bactroban to left buttock BID (twice a day) and PRN (as needed) if soiled, may apply 4 x (by) 4 if needed."

Review of the patient's progress notes dated 2/11/19 at 7:14 AM revealed the following documentation under Dressing: "ABD (abdominal) pad. Wound Interventions: simple dressing change." There were no documented physician's order to apply ABD pad dressing. The facility staff failed to provide PI # 19's wound care per physician's order.

An interview was conducted on 2/13/19 at 2:19 PM with EI # 2 who confirmed the above findings.

Based on review of medical records (MR), facility policy and interviews, it was determined the facility failed to ensure verbal orders were signed by the ordering physician within 30 days after discharge.

This did affect 1of 4 Outpatient Surgery (OPS) records reviewed, including MR # 12 and had the potential to affect all patients who are provided care at this facility.

Findings include:

Facility Policy: Contents and Timeliness Of A Completed Patient Record
Date Revised: April 2007

Statement of Purpose: To define the contents and timeliness of a completed record.

Text:

The medical record must be completed within 30 days after discharge.

All entries must be dated, timed and authenticated in a timely fashion.

1. MR # 12 was admitted to the facility on 12/14/18 for an Outpatient Laparoscopic Cholecystectomy.

Review of the MR on 2/12/19 revealed the following verbal orders were "pending" and not signed, dated and timed by the physician within 30 days of discharge as directed per the facility policy:

12/14/18: 6:00 AM
1. NPO (Nothing by mouth) or Hold: all
Which meal?: all
2. Lact (Lactated) Ringers: 1000 ml (milliliters) IV (intravenous)
30 ml/hr (hour) IV
3. Reglan/Metoclopramide 10 mg (milligrams) tab (tablet) x (times) 1 po (by mouth)
4. Nozin Nasal Sanitizer 3 ea (each) x 1 nasal
5. Zantac/Ranitidine 150 mg tab x 1 po

12/14/18 8:00 AM
1. Outpatient Surgical
2. Hibiclens Shower
3. Obtain Consent for Procedure

An interview was conducted on 2/12/19 at 1:55 PM with Employee Identifier (EI) # 2, Chief Nursing Officer (CNO), who verified the aforementioned findings.

Based on review of medical records (MR) and interview with staff, it was determined the facility failed to ensure the physician updated the History and Physical (H&P) 24 hours after admission or prior to procedures requiring anesthesia services. This affected 2 of 21 records reviewed and did affect MR # 12, MR # 16 and had the potential to affect all patients served by the hospital.

Findings include:

1. MR # 12 was admitted to the facility on 12/14/18 for a Laparoscopic Cholecystectomy.

Review of the MR revealed a H&P dated 12/7/18. There was no documentation the H&P was updated by the physician prior to the procedure on 12/14/18.

An interview was conducted on 2/13/19 at 1:55 PM with Employee Identifier (EI) # 2, Chief Nursing Officer (CNO), who confirmed the physician failed to update the H&P prior to surgery.



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2. PI # 16 was admitted to the facility on 2/7/19 with diagnoses of Hypertension, Diabetes Mellitus, Chronic Kidney Disease, Anemia, and Thrombocytopenia.

Review of the MR revealed a H&P dictated dated of 7/14/17 and a transcribed date of 7/17/17. There was no documentation the H&P was recorded or updated by the physician within 24 hours of the patient's admission per facility policy.

An interview was conducted on 2/13/19 at 2:24 PM with EI # 2, who confirmed the physician failed to record and/or update PI # 16's H&P.

Based on observations and interviews, it was determined the hospital failed to ensure food was stored and prepared in a safe and sanitary manner, expired food was disposed of properly, and prepared foods were labeled as to content and date. This had the potential to negatively affect all patients served by the hospital.

Findings include:

1. A tour of the Emergency Department was conducted on 2/11/19 at 12:55 PM. The surveyor observed the following expired nutritional products:

Clean Utility Room Refrigerator: 4 cartons Fat Free Skim Milk with a "Best By" date 2/8/19, which was 3 days prior.

An interview was conducted on 2/11/19 at 1:20 PM with Employee Identifier (EI) # 6, Registered Nurse, who verified the aforementioned findings.

2. A tour of the dietary department was conducted on 2/11/19 at 1:52 PM. Observations in the food service area revealed the following:

The puree table contained a Hamilton Beach machine covered in dried food particles, food particles were also on the counter. A clear bag of cups containing a yellow liquid drizzled over the bag and cups, was also on the counter.

1- plate of prepared meat salad, unlabeled with content or date was in the patient services refrigerator.

The patient silverware trays, next to the steam table, contained food crumbs, paper scraps, and gym clips. The shelves beside the silverware trays were dusty and contained food crumbs.

The employee wash sink near the prep (preparation) table was dirty with a dried white substance. Shelf above wash sink contained dust and crumbs. Located on shelf above prep table was 1- 5 lb box of pancake mix, unlabeled with date, and unsealed.

Attached to the prep table was a can opener which was covered in black grime.

In the 5 shelf warmer, there was dirt and crumbs, and the plastic shelf coating was peeling off and hanging down in multiple places.

The toaster oven had a dried brown substance and crumbs all over.

The shelf beneath the tea containers contained brown liquid. Shelves were dusty and contained crumbs.

In the dry storage area the following was observed:

1- jar of molasses, labeled opened 10/27, exp (expired) 1/27, with no year listed.
1- gallon of olive oil, labeled opened 1/9, exp 8/9, with no year listed.
1- 7 oz (ounce) bottle fish sauce, labeled opened 2/8, exp 8/8, with no year listed.
1- gallon of vinegar, opened and unlabeled.
1- bag dry pasta, opened 2/5, exp 12/5, with no year listed.
1- bag dry pasta, opened 2/11, exp 3/11, with no year listed.
1- 25 lb (pound) box mini chocolate chips, opened and unsealed, opened 1/9, exp 4/9, with no year listed.
1- box fish fry seasoning, opened and unsealed, labeled 1/10, no exp or year listed.
1- 6.6 lb tub Nutella, opened 9/12, exp 12/15, no year listed. Manufacturer's exp date 12/17/18.
1- 5 lb box sun dried tomatoes, opened 6/21, exp 12/21, no year listed, opened and unsealed.
1- case of boxed raisins, exp 2018.

The following was observed in the walk in refrigerator:

11- individual pies, unlabeled with date or content.
3- cups yellow pudding, unlabeled with date or content.
3- salad bowls, unlabeled with date or content.
1- bag of boiled eggs stored on bottom shelf next to raw eggs.
1- bag of bread, opened and not sealed.
1- bag potato skins, unlabeled with date, opened and unsealed.

In the assistant director's office the following was observed:

3- large bins on wheels, containing rice, sugar and a flour substance, unlabeled as to contents and date.

During an interview on 2/11/19 at 3:30 PM with EI # 15, Dietary Director, who was also present on the tour, the above findings were confirmed.

3. A tour of the Senior Care Unit patient refreshment room was conducted on 2/12/19 at 10:30 AM. The following items were observed in the refrigerator:

2- pints Milk, "Best By" date 2/2/19, which was 10 days earlier.
1- pint Milk, "Best By" date 2/9/19, which was 3 days earlier.
1- pint Skim Milk, "Best By" date 2/9/19, which was 3 days earlier.

During an interview conducted on 2/12/19 at 10:35 AM with EI # 14, Registered Nurse, who was also present on the tour, the above findings were confirmed.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations and A- 724 for findings.

Based on observation, review of facility policy, Occupational Safety & (and) Health Administration (OSHA) guidelines, Crash Cart Check Sheets and interviews with facility staff it was determined the facility failed to:

a) Ensure Oxygen cylinders stored in the facility were secured and protected.

a) Ensure safe operation and integrity of the emergency crash cart in the Emergency Department (ED).

This had the potential to affect all patients served by this facility.

OSHA: Compressed Gas Safety General Safety Guidelines

2. Cylinder Storage

Gas cylinders must be secured at all times to prevent tipping.

Use appropriate material, such as chain, plastic coated wire cable, commercial straps ... to secure cylinders.

... Cylinders must be stored where they are protected from the ground to prevent rusting...

Subject: Crash Carts
Revised Date: 8/2016

Statement of Purpose:

To establish an organized system to check and maintain crash carts, to ensure an adequate supply of emergency drugs and equipment readily available when needed.

Text:

II. Each Crash cart shall be checked once per shift ...

During a tour of the ED on 2/11/19 at 12:55 PM the surveyor observed the following:

Ambulance Bay:

1 Oxygen (O2) tank lying on its side on the shelving of a metal cabinet. The tank was not secured to prevent from tipping or protected to prevent from rusting.

An interview was conducted on 2/11/19 at 1:20 PM with Employee Identifier (EI) # 6, ED Registered Nurse, (RN) who confirmed the O2 tank was not secure.

Trauma Room:

A review of the Crash Cart Check Sheets revealed there was no documentation the crash cart was checked for the following shifts: 12/13/18 PM, 12/16/18 AM, 12/18/18 AM, 12/20/18 AM, 12/28/18 AM, 1/15/19 AM and 2/1/19 AM for a total of 7 shifts.

An interview was conducted on 2/11/19 at 1:58 PM with EI # 6 who verified the staff failed to check the crash cart each shift as directed per the facility policy.

Based on observations, review of facility policy, Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQ's) regarding Safe Practices For Medical Injections and interviews with the staff, it was determined the facility failed to ensure the staff:

a) Followed the facility policy and procedure for proper hand hygiene.

b) Cleaned the septum of medication vials prior to piercing the vial per CDC guidelines and facility policy.

c) Cleaned reseal site of adapter with clean/new alcohol prep pad.

d) Checked patency of IV (intravenous) catheter with at least 10 ml (milliliter) saline.

e) Cleaned/disinfected equipment surfaces between patient use.

This affected 3 of 11 active medical records (MR) reviewed and 5 unsampled patients (UP) and did affect MR # 14, MR # 15, UP # 5, MR # 16, UP # 1, UP # 2, UP # 3, and UP # 4, and had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Indication For Handwashing and Hand Antisepsis
Reviewed Date: 1/2/2018

Indications for Handwashing and Hand Antisepsis:

... Decontaminate hands before having direct contact with patients.

... Decontaminate hands after contact with a patient's intact skin (i.e., when taking a pulse or blood pressure and lifting a patient).

... Decontaminate hands after removing gloves.

CDC Frequently Asked Questions (FAQ's) regarding Safe Practices For Medical Injections

"Medication Preparation Questions

1. How should I draw up medications?

Parenteral medications should be accessed in an aseptic manner. This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it."

Subject: IV therapy
Date Issued: 1/15/19

Purpose: To establish criteria for the management and nursing care of a patient undergoing IV therapy in the hospital...

Procedure:
Process to administer medication
1. Gather a normal saline filled syringe.
2. Cleanse reseal site of adapter with alcohol.
3. Check patency of IV catheter with at least 10 ml saline. (Aspirate for blood return.)...
5. When medication is infused, clear line with 10 ml saline.

Subject: Medical Equipment User/Maintainer Orientation/Education
Revised Date: 1/2/18

Policy: All new staff and employees of contract agencies utilized by the hospital shall receive appropriate training during orientation on all medical equipment he/she will be expected to use as an employee...
To include cleaning equipment surfaces in accordance with instructions from both the equipment manufacturer and the chemical manufacturer...
Avoid unnecessary touching of the equipment during care delivery, especially with contaminated hands or gloves...

1. An observation was conducted on 2/11/19 at 6:45 AM in Endoscopy Room # 1 on MR # 14 for an Esophagogastroduodenoscopy (EGD).

At 6:55 AM Employee Identifier (EI) # 7, Physician, completed the procedure and removed his/her gloves without performing hand hygiene.

At 6:58 AM the surveyor then observed EI # 12, Scrub Technician, performing cleaning and disinfection of the Endoscopy scope. EI # 12 placed the EGD scope in the processor and removed his/her gown and gloves without performing hand hygiene.

2. An observation was conducted on 2/11/19 at 7:15 AM in Operating Room (OR) # 2 on MR # 15 for a Removal of an Infusaport.

At 7: 26 AM the surveyor observed EI # 10, Certified Registered Nurse Anesthetist, (CRNA) open the top of the following medication vials and withdraw the medication into a syringe without cleaning the vial top with an alcohol sponge as directed per CDC guidelines:

Lidocaine 2 % (percent) 1000 mg (milligrams) / 50 ml (milliliters) IV (intravenous)
Propofol 200 mg / 20 ml IV
Fentanyl 100 mcg (micrograms) IV
Cefazolin 1 gram/vial IV

At 7:50 AM EI # 10 retrieved a 2nd vial of Propofol, opened the vial and withdrew the medication into a syringe without cleaning the vial top with an alcohol sponge as directed per CDC guidelines.

At 7:59 AM EI # 10 removed his/her gloves without performing hand hygiene as directed per the facility policy.

An interview was conducted on 2/11/19 with EI # 4, Surgery Manager, who confirmed the aforementioned findings.



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3. On 2/12/19 at 7:51 AM an observation of care for UP # 5, room (RM) 607 Medical/Surgical unit was conducted with EI # 21, Registered Nurse.

EI # 21 entered UP # 5's room with a COW (computer on wheels). EI # 21 opened a alcohol prep pad and cleaned the medication injection port, then instilled 5 ml of NS. EI # 21 proceeded to used the same alcohol prep pad to clean the medication port again before injecting 40 mg/4 ml of Lasix into the medication port. EI # 21 proceeded to used the same alcohol prep pad again to clean the medication port to instill the remainder 5 mls of NS. EI # 21 used the same alcohol prep pad 3 times during the administration of medication. EI # 21 failed to use a clean/new alcohol prep pad before injecting medication and normal saline into the medication port, and check IV patency by instilling 10 ml saline per policy.

EI # 21 returned the COW (computer on wheels) to a storage area next to the nurse's station without cleaning or disinfecting the equipment surfaces.

4. On 2/12/19 at 8:18 AM an observation of care for MR # 16 was conducted with EI # 19, Patient Care Technician (PCT).

EI # 19 entered the patient's room with vital sign equipment. EI # 19 donned a glove on his/her right hand to pick up a thermometer probe cover off the floor. EI # 19 throwed the probe cover into the trash can and removed his/her gloves. EI # 19 continued to take the oxygen saturation machine off MR # 16's finger and documented the patient's vital signs. EI # 19 did not wash or sanitize his/her hand after glove removal per facility's policy.

EI # 19 returned the vital sign equipment to a storage area next to the nurse's station without cleaning or disinfecting the equipment surfaces.

An interview was conducted on 2/13/17 at 2:00 PM with EI # 2, who confirmed the staff is expected to clean the COW and vital sign equipment between patient care.



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5. On 2/12/19 at 8:15 AM the following observations were made during medication passes on the Senior Care Unit (SCU):

a) Prior to preparing and administering oral medications to UP # 1, EI # 9, LPN (Licensed Practical Nurse), failed to perform hand hygiene.

b) UP # 2 was to receive 1/2 tablet of an ordered medication. EI # 9 used bare hands to open the oral medication, then used her/his bare fingernail to brake the tablet in half. The half tablet was placed in a medication cup and administered to UP # 2. The other half tablet was disposed in the paper garbage bag taped to the medication cart. The surveyor asked EI # 9 where the paper bag would be disposed. EI # 9 stated it would be placed in the garbage bin on the housekeeper's cart.

c) EI # 9 then prepared medications for UP # 3. After several unsuccessful attempts to open the individual unit dose oral medications, EI # 9 used her/his ball point pen to puncture and tear open the 3 medications.

d) Prior to preparing and administering UP # 4's oral medication, EI # 9 assisted another patient to the standing position by placing both hands under the patient's arms. EI # 9 failed to perform hand hygiene after contact with a patient, and prior to preparing UP # 4's oral medication for administration.

During an interview on 2/13/19 at 9:30 AM with EI # 5, Nurse Practioner, Director of Nursing, SCU, the above findings were confirmed. EI # 5 further confirmed oral medication tablets for waste should be disposed in a sharps container.

Based on review of the Emergency Preparedness plan, and interview with staff, it was determined the facility failed to ensure the plan was reviewed and updated annually. This had the potential to affect all persons served by the hospital.

Findings include:

A review of the Emergency Preparedness plan revealed no documentation the plan was reviewed or updated annually.

During an interview conducted on 2/13/19 at 1:41 PM with Employee Identifier # 1, Chief Executive Officer, the above findings were confirmed.

Based on review of the Emergency Preparedness plan, and interview with staff, it was determined the facility failed to document a facility based all hazards risk assessment. This had the potential to affect all persons served by the facility.

Findings include:

Review of the Emergency Preparedness plan revealed no documented facility or community based risk assessment for all hazards.

During an interview on 2/13/19 at 1:41 PM with Employee Identifier # 1, Chief Executive Officer, the above findings were confirmed.