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Based on record review, the facility failed to authenticate verbal orders on 2 of 30 records as required. (Patient #18, #25).

Findings include:

Patient #18

Patient #18 was admitted to the facility on 12/18/11 with diagnoses including acute myocardial infarction, hypoxemia, anemia, and congestive heart failure. Patient #18 was discharged on 12/25/11.

A review of the medical record revealed at least three telephone orders that had not been signed by the attending physician.


26252

Patient #25

Patient #25 was admitted to the facility on 1/3/12 with diagnoses including left knee advanced degenerative arthritis, total knee replacement. Patient #25 was discharged on 1/9/12.

A review of the medical record revealed at two telephone orders which had not been signed by the attending physician.

Based on record review and interview, the facility failed to ensure informed consents were signed for hospital admission for 1 of 30 patients (Patient #27).

Findings include:

Patient #27

Patient #27 was admitted to the facility on 1/2/12 through the emergency department. Review of Patient #27's record failed to reveal an informed consent for the hospital admission on 1/2/12.

On 1/12/12, the Director of Medical Records was interviewed and reported patients being admitted through the emergency department (ED) signed the consent form in the ED. The Director of Medical Records indicated patients being admitted through the admitting department signed the consent electronically. The Director of Medical records was unable to locate an informed consent for Patient #27's 1/2/12 admission to the hospital.

On 1/12/12, the Director of the Business Office looked through Patient #27's chart and was unable to locate an informed consent for the 1/2/12 admission.

Based on observations and staff interviews the facility failed to ensure medications were maintained in a secure area.

Findings include:

On the initial tour of the facility, taken the afternoon of 1/9/12 and throughout the survey period ending 1/13/12, the AcuDose automated medication storage and dispensing device and associated ancillary devices (medication tower and refrigerator), and the portable medication cart, which were used to maintain medications, including patient medications, injectable's and controlled substances, were kept in an alcove across from the nurse's station on the Med/Surg Unit.

The alcove, which was accessible to staff, patients, and visitors, was approximately 25 to 30 feet away from the nurse's station. The alcove could easily be entered from the right or left, had no doors to limit access, and did not allow direct or clear observation of the area due to the glass block wall in front of the alcove. The alcove was approximately 10 to 15 feet away from the elevator. One corner of the alcove led directly down another hallway, and the back of the alcove (including the refrigerator) could be accessed from a dictation room.

The medication refrigerator, which was a small dorm size refrigerator, was stored on top of the portable medication cart. The refrigerator, was not secured to the cart or the AcuDose device. The refrigerator could easily be lifted off the top of the cart. It was noted, even though the plug to the refrigerator was behind the other items, it could have been unplugged and the connection to the AcuDose be removed which would have allowed the refrigerator to be removed.

On the morning of 1/10/12, while observing the Med/Surg Unit's AcuDose device being restocked by the Pharmacy Tech (Employee #8), the Tech stocked the refrigerator with the controlled substance Lorazepam. It was noted, while the refrigerator was locked, the Lorazepam was not kept in a locked container and was accessible to any staff member having access to the refrigerator.

On the afternoon of 1/10/12, the location of the Med/Surg Unit's AcuDose device, the medication refrigerator and the Lorazepam findings were reviewed with a facility pharmacist (Employee #9) and a quality assurance nurse (Employee #5). Both parties agreed the alcove was easily accessible, not necessarily a secure location, possible removal of the refrigerator was a concern, and the Lorazepam should have been kept in a locked container in the locked refrigerator.

On the afternoon of 1/12/12, accompanied by a Med/Surg Unit staff nurse (Employee 13), the portable medication cart was observed unlocked. At the time there were no medications in the drawers of the cart, however there were needles and syringes which were accessible. The nurse indicated the cart was actively in use, usually there were medications stored on the cart for patient use, there had been problems with the lock on the cart, but she thought it had been repaired. The nurse made several attempts to lock the cart, but was unsuccessful.


22046

Patient #12

Patient #12 was admitted to the hospital on 1/10/12, for a right knee arthroscopy and anterior cruciate ligament surgery repair.

On the morning of 1/10/12 at approximately 9:00 AM, the operating room was observed being prepared for surgery. The anesthesia cart was observed to be unlocked and unattended by the Certified Registered Nurse Anesthetist, Contract Employee #14. The drawers to the anesthesia cart were opened and multiple medications were observed in addition to drawn up syringes containing Propofol, Lidocaine, and Zemuron.

Based on observations and staff interviews the facility failed to ensure controlled substance were kept locked or were in a locked container, and in a secured area to prevent unmonitored access by unauthorized individuals.

Findings include:

On the morning of 1/10/12, while observing the Med/Surg Unit's AcuDose device being restocked by the Pharmacy Tech (Employee #8), the Tech stocked the refrigerator with the controlled substance Lorazepam. It was noted, while the refrigerator was locked, the Lorazepam was not kept in a locked container and was accessible to any staff member having access to the refrigerator.

In addition, the Med/Surg medication refrigerator and AcuDose device, where other narcotics and controlled substances were kept, was stored in an alcove accessible to staff, patients and visitors.

During a later observation, there were a total of 29 ampules of the Lorzapem observed in the Med/Surg refrigerator.

On the afternoon of 1/10/12, the location of the Med/Surg Unit's AcuDose device, the medication refrigerator and the Lorazepam findings were reviewed with a facility pharmacist (Employee #9) and a quality assurance nurse (Employee #5). Both parties agreed the alcove was easily accessible, not necessarily a secure location, possible removal of the refrigerator was a concern, and the Lorazepam should have been kept in a locked container in the locked refrigerator.

On the afternoon of 1/12/12, accompanied by a fellow surveyor, the medication refrigerator, in the Emergency Department (ED) was inspected along with an ED nurse (Employee #7).

The ED refrigerator was located in a secure area behind the nurse's station. Inspection of the refrigerator revealed Lorazepam was stored in a separate locked box within the refrigerator. The ED's AcuDose device was located next to the refrigerator.

Cross reference Tag 0502.

Based on a review of procedures: Quarantining Recalled Units, Lookback Procedure and Blood-Quarantine of HIV Infected Blood and Notification to Patients Who Have Received Potentially Infected Blood, the laboratory failed to have a system which included all required actions to be taken when the laboratory was notified that blood or blood components it had received were at increased risk of transmitting HIV or HCV.

Findings include:

The system in place in the laboratory of actions to take in the event of notification of potentially infectious blood or blood components did not meet current federal regulatory requirements.

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

Findings include:

On 1/11/12 at approximately 11:00 AM, an observation was done with a Registered Nurse (RN-Employee #7). The RN was using a glucometer to check a patient's blood sugar. The RN explained the glucometer was used for all the patients on the floor who needed blood glucose monitoring. After testing the patient's blood sugar, the RN put the glucometer back in the case and explained she was going to return it to the medication cart.

On 1/11/12 at approximately 11:05 AM, RN-Employee #7 was interviewed and reported the glucometer was cleaned once a day when the controls were done. The RN indicated she had never cleaned the glucometer after each patient use.

On 1/11/12, the Director of Infection Control (Employee #3) was interviewed and reported the hospital policy was for the glucometer to be cleaned after each patient use.





22046

Patient #12

Patient #12 was admitted to the hospital on 1/10/12, for a right knee arthroscopy and anterior cruciate ligament surgery repair.

On the morning of 1/10/12 at approximately 9:20 AM, the certified registered nurse anesthetist, Contracted Employee #14 was observed to drop a syringe on the floor. The syringe was picked up from the floor and placed back on the anesthesia cart with the clean syringes. The syringe was not used on the patient.

Based on policy review and staff interviews, the facility failed to develop and operationalize high-risk screening procedures for patients in need of discharge planning.

Findings include:

On the morning of 1/10/12 an interview was conducted with one of the facility's case managers (CM-Employees # 11). The CM indicated discharge planning is initiated upon admission for all patients. The CM went on to review a current discharge in progress and in so doing demonstrated the Milliman discharge software program used by the facility.

The software program was comprehensive and guided the CM in completing discharge plans and potential needs for the discharge. The CM further indicated and demonstrated daily evaluations and related progress notes, written by the CM were recorded in the patient's progress notes.

When asked, the CM indicated the work completed in the Milliman program was a separate program and was not completely integrated, by way of hard copy print out, into the patient's permanent record.

The facility's patient records were currently in hard copy format.

In conjunction with discharge planning policy review and discussion with the CM on the morning of 1/11/12, the CM confirmed the facility did not have a screening process or policy to follow for identifying and screening patients at high-risk in relation to discharge planning.

Based on interviews with the nuclear medicine personnel (employee #13), review of credentialing files and review of the Professional Services Agreement and department procedure manual, there was no clear designation of the nuclear medicine director qualified in nuclear medicine.

Findings Include:

On 1/10/12 at approximately 2:00 PM, nuclear medicine personnel (employee #13) was interviewed and indicated that the new owner of the contract for imaging services was not credentialed for nuclear medicine in Nevada.

A review of the Professional Service Agreement stated that the "Contractor shall serve as Director of the Service." However, the contractor was not credentialed for nuclear medicine in Nevada and did not have priviledges for nuclear medicine at this facility.

Based on an interview with the nuclear medicine personnel, review of policies and credentialing request for the nuclear medicine personnel, the service director had not specified the qualifications, training, functions and responsibilities of the nuclear medicine staff for approval by the medical staff.

Findings include:

On 1/10/12 during an interview with nuclear medicine personnel (employee #13), a credentialing request for approval by the medical staff for the nuclear medicine personnel was presented. The request had not been signed by the service director.

Based on interview with nuclear medicine personnel (employee #13) and review of procedures, the radio pharmaceuticals were not prepared in-house by, or directly supervised by, a trained registered pharmacist or doctor of medicine or osteopathy.

Findings include:

On 1/10/12 nuclear medicine personnel (employee #13) was interviewed and stated that the in-house radio pharmaceuticals were prepared by the nuclear medicine staff and that there were no trained registered pharmacists on staff who could directly supervise or prepare the radio pharmaceuticals.

There was no doctor of medicine or osteopathy who was responsible for the preparation or supervision of the in-house preparation of radio pharmaceuticals.