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Based on review of departmental policies and procedures and interview with staff, the facility failed to follow their policy for review of departmental manuals. This had the potential to affect all patients.

Findings include:

The policy titled, "Departmental Policy and Procedure Manual Guidelines" included, "All departmental policies and procedures will be reviewed annually by the Department Director. The Director will have a cover sheet with the effective date, revision date, and/or review days, and will have the Administrator's signature" .

1. During the tour of the Radiology Department on 6/19/12 at 1:30 PM the Departmental Policy Manual cover sheet revealed, "Policy and Procedure Review. This is to certify the review and approval of this manual. ...Date: 11/12/09". There was no documentation of an annual review of the policies and procedures and no, "updated review" sheet was available for review when requested by surveyor.

An interview with Employee Identifier (EI) # 2, the Radiology Director, on 6/19/12 at 1:30 PM verified the policies and had not been reviewed since 2009.



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2. During the tour of the Pharmacy on 6/19/12 at 1:00 PM the Departmental Policy Manual cover sheet revealed, "Pharmacy Policy and Procedure" documented the review and approval 4/4/11. There was no documentation of an annual review for April 2012 and no "updated review" sheet was available for review when requested by surveyor.

3. During the tour of the Medical Record Department on 6/19/12 at 2:00 PM the Departmental Policy Manual cover sheet revealed, "Policy and Procedure" documented the review and approval on 12/21/06. There was no documentation of an annual review since 12/21/06 and no "updated review" sheet was available for review when requested by surveyor.

An interview was conducted on 6/19/12 at 2:15 PM with EI # 6, the Medical Records Director who verified there was no documentation of a policy review and update since 12/21/06.

4. During the tour of the Laboratory on 6/20/12 at 10:00 AM the Departmental Policy Manual cover sheet revealed, "Policy and Procedure" documented the last dated review and approval on 3/20/11. There was no documentation of an annual review since 3/20/11 and no "updated review" sheet was available for review when requested by surveyor.

An interview was conducted on 6/19/12 at 2:15 PM with EI # 7, the Laboratory Director who verified there was no documentation of a dated policy review and update since 3/20/11.

5. During the tour of the Surgical Suite on 6/20/12 at 10:45 AM the Departmental Policy Manual cover sheet revealed, "Policy and Procedure" documented the last review and approval on 4/2008. There was no documentation of an annual review since 4/2008 and no "updated review" sheet was available for review when requested by surveyor.

An interview was conducted on 6/19/12 at 2:15 PM with EI # 5, the Surgery Director who verified there was no documentation of a policy review and update since 4/2008.

6. During the tour of the Rehabilitation Department on 6/20/12 at 1:30 PM the Departmental Policy Manual cover sheet revealed, "Policy and Procedure" documented the last review and approval in 2004. There was no documentation of an annual review since 2004 and no "updated review" sheet was available for review when requested by surveyor.

An interview was conducted on 6/19/12 at 2:15 PM with EI # 5, the Rehabilitation Director who verified there was no documentation of a policy review and update since 2004.

Based on review of the Emergency Room (ER) records and staff interview, it was determined the ER physicians failed to document the time of the first assessment for 10 of 20 patients who presented to the ER for treatment. This affected ER record #s 1, 2, 3, 5, 9, 14, 16, 18, 19 and 20 and had the potential to affect all patients who presented to the ER for treatment.

Findings include:

Review of 20 ER records from March 2012 through June 2012, revealed there was no documentation of the time the physician performed the first physical assessment for 10 aforementioned ER patients.

During an interview on 6/21/12 at 12:48 AM, Employee Identifier (EI) # 1, Director of Nurses, confirmed the aforementioned findings.

Based on observation, review of policy and interview with facility staff it was determined the facility failed to store medications properly in the Respiratory Department. This had the potential to affect all patients in the facility.

Findings Include:

Facility Policy: Refrigeration

Storage of Food in Drug Storage Refrigerators

The storage of food and other non-drug items in drug storage refrigerators is discouraged. If food and non-drugs must be stored in drug storage refrigerators, they shall be in separate compartments or sealed containers.


During a tour of the Respiratory Department on 6/19/12 at 1:55 PM, the surveyor opened the small refrigerator. The refrigerator door contained several cans of soda and bottled water. The middle opened shelf revealed condiments (ketchup packets) and the following medications, "Sodium Chloride Inhalation Solution 0.9 % (Percent) x (times) 1 box and Perforomist Inhalation Solution 20 mcg (micrograms) / (per) 2 ml (milliliter) vials x 1 box." The bottom shelf of the refrigerator revealed a plate of food covered with a napkin.

Food was not in separate compartments or sealed containers as directed per the facility policy.

During an interview conducted on 6/19/12 at 2:05 PM, with Employee Identifier (EI) # 3, the Director of Respiratory and EI # 1, the Director of Nursing, confirmed this refrigerator was used for food items and should not have medications stored in it.

Based on observations during facility tour with hospital staff and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observation and interview with facility staff, it was determined the facility failed to assure all medical supplies available for patient use in the Emergency Room (ER) and Surgery Suite were not expired and were stored in a safe manner.

This had the potential to affect all patients.

Findings include:

1. A tour was conducted on 06/20/12 at 9:50 AM in the ER. The surveyor found the following expired supplies:

ER Bay Laboratory Trays:
Intravenous (IV) Catheter 14 gauge (g) 1 1/4inch times (x) 4 expires (exp) 10/08
IV Catheter 16 g 1 1/4 inch x 6 exp 10/09
IV Catheter 16 g 1 1/4 inch x 1 exp 2/04

Exam Room - Ear Nose and Throat (ENT) Tray
Lubricating Jelly x 8 exp 1/10
Lubricating Jelly x 2 exp 3/09

Trauma Room - Adult Crash Cart:
Multilumen Central Venous Catheter (CVC) Kit
Secondary IV Set x 1 exp 5/11
Suction Connecting Tubing x 1 exp 6/09
HotLine Fluid Warming Set x 1 exp 9/10
Lubricating Jelly x 3 exp 1/11
Lubricating Jelly x 10 exp 8/10

Pediatric Crash Cart:
Pediatric Ultrasil Foley Catheter 6 French (Fr) 3 centimeter (cc) x 1 exp 11/03
Rate Flow Regulator Extension Set x 1 exp 8/05
Horizon Pump Burette Set x 1 exp 4/11
Horizon Pump Burette Set x 1 exp 11/11
Red Dot Pediatric Electrodes x 3 10/96
Urinary (U) Bag x 1 exp 8/05
Tuberulin (TB) Syringes 25 g 5/8 inch x 2 exp 8/09
TB Syringes 25 g 5/8 inch x 2 exp 7/11
TB Syringes 25 g 5/8 inch x 2 exp 12/08
TB Syringes 25 g 5/8 inch x 2 exp 12/11
Small Bore Extension Set x 1 exp 6/06
Small Bore Extension Set x 1 exp 5/08
Blood Collection Set 23 g x 1 exp 11/11
Ultrasite Valve x 1 exp 6/07

During an interview on 6/19/12 at 10:45 AM with Employee Identifier (EI) # 1, the Director of Nursing, confirmed the aforementioned supplies were expired in the ER.



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2. An initial tour was conducted on 6/19/12 at 9:30 AM of the Surgery Suite. The surveyor noted:

Several cardboard boxes stored on the floor in the Steris Room.

The Surgical Refrigerator contained a bottle of Rocuronium Bromide 50 mg (milligrams)/5 ml (milliliters), a bottle of Anectine 200 mg/10 ml opened and not dated and a bottle of Vecuronium Bromide 10 mg/10 ml which expired 7/1/2010 .

The Blanket Warmer contained 2 opened bottles of 0.9% Sodium Chloride 1000 ml opened and not labeled.

The Anesthesia Cart contained Vecuronium Bromide 10 mg which expired 7/1/2010.

The Operating Room Cabinet contained 4 bottles of Bupivacuine Hcl and Epinephrine 1:200,00 which expired 4/1/12. The Cabinet also contained 1 bottle of 2% Lidocaine Hcl 20 ml and 1 bottle of Lidocaine Epinephrine 1:100,000 which were opened and not labeled.

An interview was conducted on 6/19/12 at 9:45 AM with EI # 5, the Director of Surgery who verified the above.

Based on observation and a tour of the surgical suite and the pharmacy, interview with the Director of Nursing and review of the standards from the Malignant Hyperthermia Association of the United States, it was determined the hospital failed to ensure there was an adequate amount of Dantrolene in stock. This had the potential to affect all patients served by this facility.

Findings include:

On 6/19/12 at 9:30 AM, during a tour of the surgical suite the surveyor requested to see the Dantrium(Dantrolene). Employee Identifier (EI) # 5, the Director of Surgery stated the Dantrolene was in the Pharmacy.

During the tour of the Pharmacy on 6/19/12 at 1:00 PM, the Surveyor asked EI # 4, the Pharmacist how much Dantrolene was available and the response was, "We have 18 vials and the rest are at another hospital 30 minutes away."

Review of the standards from the Malignant Hyperthermia Association of the United States revealed the following documentation, "The full 36 vials of dantrolene should be available within five minutes of the diagnosis of MH (Malignant Hyperthermia)."

An interview was conducted on 6/21/12 at 12:00 PM with Employee Identifer # 1, the Director of Nurses who verified the hospital did not have the 36 bottles of Dantrolene.