HospitalInspections.org

Based on observations and staff interviews, the facility staff failed to ensure that patient care supplies were maintained to ensure an acceptable level of safety and quality. Findings include:

1. On 4/25/11, beginning at 2:00 p.m., the surveyor observed the radiology and cardiopulmonary departments. The surveyor noted the following supplies were expired or unusable:
-1 24 ga. by .75 in. Insyte intravenous catheter with the manufacturer's expiration date of 1/2011.
-1 Becton Dickson sterile culture tube with the manufacturer's expiration date of 8/2004.
-1 4 ounce bottle of sterile Similac water with the manufacturer's expiration date of 3/2001.

In interviews with staff members D and H on 4/25/11, during the reviews of the departments,
both staff members stated that department staff check supplies for dates. The identified supplies had been missed.

2. On 4/26/11, beginning at 7:30 a.m., the surveyor reviewed the Emergency Department and noted the following expired patient care supplies:
-22 Tincture of Benzoin sterile single swab-sticks with the manufacturer's expiration dates of 12/2010 (14) and 1/2011 (8).
-1 Monoject 25 ga. by 5/8 in. safety needle with the manufacturer's expiration date of 10/2010.
-1 Kendall 3 in. by 8 in. nonadhesive dressing with the manufacturer's expiration date of 10/2010.
-1 3M brand 3 pack of electrode pads with the manufacturer's expiration date of 10/2010.

In an interview with staff member C at approximately 8:25 a.m. on 4/26/11, staff member C stated that all staff in the emergency department check supplies for expiration dates.

3. On 4/27/11, beginning at 10:00 a.m., the surveyor reviewed the Medical/Surgical department and noted a Cook Supra Pubic catheter kit with the manufacturer's expiration date of 8/2010.

The expiration date of the kit was verified by a staff nurse on duty on the Medical/Surgical floor at approximately 10:30 a.m. on 4/27/2011.

4. On 4/27/11, beginning at 1:00 p.m., the surveyor reviewed the Surgery department and noted the following expired patient care supplies:
-3 6 milliliter Red top Vacutainer blood collection tubes with the manufacturer's expiration date of 7/2010.
-3 3 milliliter Green top Vacutainer blood collection tubes with the manufacturer's expiration date of 1/2011.
-1 16 ga. by 1.16 in. Insyte intravenous catheter with the manufacturer's expiration date of 10/2010.

In an interview with staff member F on 4/27/11 at approximately 3:45 p.m., staff member F verified the expired supplies noted in the Surgery area.

Based on observations and staff interviews, the facility failed to ensure that outdated, mislabeled, or otherwise unusable drugs were not available for patient use. Findings include:

1. During the review of the Cardiopulmonary department on 4/25/11 beginning at 3:00 p.m., the surveyor observed the following unusable medications:
-1 30 milliliter (ml.) single use vial of Normal Saline with the manufacturer's expiration date of March 1, 2011.
-6 boxes of Bysystolic 5 milligram (mg.) tablets (7 tablets per box) with the manufacturer's expiration date of 10/2010.

In an interview with staff member H on 4/25/11 at approximately 3:45 p.m., staff member H stated that the boxes of medications were from a sample cupboard belonging to a clinic physician. Staff member H stated the staff of the pharmacy was responsible for checking stock medications for expiration dates.

2. During the review of the Emergency department on 4/26/11, beginning at 7:30 a.m., the surveyor observed the following unusable medications:
-1 20 ml. multi-dose vial 1% Lidocaine with the manufacturer's expiration date of Feb. 2011.
-1 open 20 ml. multi-dose vial of 1% Lidocaine with the open-on date of 10/24/2010.
-1 open 50 ml. multi-dose vial of 0.5% Sensorcaine with the open-on date of 10/24/2010.

During an interview with staff member C on 4/26/11 at 8:25 a.m., staff member C stated that according to facility policy, vials are marked on the date first opened and discarded 30 days after opening. Staff member C verified that the medications were expired.

3. On 4/26/11 beginning at 9:35 a.m., the surveyor reviewed the Obstetrics department. During that review, the surveyor observed a 50 ml. vial of Calcium Gluconate 10% solution with the manufacturer's expiration date of 2/2011, and an open box of Flu vaccine that was not marked as to the date the vial was opened.

During an interview with staff member I on 4/26/11 at 9:55 a.m., staff member I stated that vials are marked on the date first opened and discarded 30 days after opening.

4. During the review of the Surgical services area on 4/27/11 beginning at 1:15 p.m., the surveyor noted the following expired medications:
-1 open, partially used spray can of Hurricaine local anesthetic spray on an anesthesia cart, with the manufacturer's expiration date of 8/2010.
-1 1000 ml. bag of Lactated Ringers solution intravenous fluid with the manufacturer's expiration date of 1 November, 2010.
-1 open 30 ml. multi-dose vial of Normal Saline with no date when the vial was first accessed.

During an interview with staff member F on 4/27/11 at approximately 3:25 p.m., staff member F verified that the identified medications were expired or unusable.

Based on document review and staff interviews, the facility failed to ensure that facility policies included training in Infection Control for all staff. Findings include:

During the review of the infection control program on 4/26/11 beginning at approximately 10:45 a.m., the facility infection control manual was reviewed. The facility policies did not address orientation of new employees or contract staff to the infection control program, or to employee health activities. The facility policies did not include measures for the screening and evaluation of employee health.

During an interview with staff member G, the Infection Control officer, on 4/26/11 at approximately 11:30 a.m., staff member G stated that there was no time allotted during new employee orientation for the infection control program. The facility provided the survey team with a copy of the new employee orientation materials given at the time of hiring. There was no information addressing infection control or employee health included in the material provided to new employees.

Based on observation and staff interview, the facility failed to ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. Findings include:

During the review of the Medical/Surgical area on 4/27/2011, the surveyor noted the following expired foods available to patients:
-6 single serving cans of Campbell's Vegetable soup with the manufacturer's expiration dates of 10/17/10 (4) and 12/18/10 (2).
-1 individual serving container of Wheaties cereal with the manufacturer's expiration date of 10/19/10.
-6 8 ounce cans of Glucerna 1.0 calorie supplement with the manufacturer's expiration date of 1 September, 2010.

The presence of the expired foods was verified by an un-named kitchen worker on 4/27/11 at approximately 10:00 a.m. She stated that she would notify the dietary manager when she returned to the department.

Based on review of the governing body by-laws, the quality assurance review by the governing body, and staff interview, the facility failed to ensure that contracted services met all conditions of participation and standards for contracted services. Findings include:

The Annual Program Evaluation for the period from 1/1/09 through 12/31/09 did not contain documentation of a review of contracted services.

Governing Body Minutes dated from 3/22/10 through 3/28/11 did not contain documentation of a review of contracted services.

The Governing Body By-laws did not include a requirement for an annual review of contracted services.

At 4:30 p.m. on 4/27/11, staff member B, executive assistant, was asked if there had been a review of contracted services. She said no review was documented.

Based on review of medical staff by-laws, medical records policies, and staff interview, the facility failed to implement the policies relating to physicians completing medical records in a timely manner. Findings include:

The Bylaws, Rules and Regulations of the Combined Medical-Dental Staffs contained the following, "At the end of the thirty (30) day period, if the medical record is not complete, the Medical Record Technician will notify the hospital administrator of this incomplete record. The hospital administrator will notify the chief of the Medical Staff on that day, if possible and they both will sign and send a letter to the staff member who is delinquent with his/her charts, notifying the physician that he/she has seven (7) calendar days in order to complete the delinquent records. If, at the end of the seventh (7th) calendar day, the records are not completed, then the physician will have his/her admitting privileges automatically suspended until all delinquent records are completed."

The policy for record processing/assembly/analysis/retrieval contained the following, "Completion of documentation is a legal and ethical responsibility. If a record is determined to be incomplete health care providers will be subject to suspension of privileges, except for the ability to care for patients already admitted. Doctors will be notified that a record is delinquent and given 7 days to complete the record. if the record is not complete within the 7-day time frame the healthcare provider will be suspended. the administrator and chief of staff will receive documentation of all suspensions. Privileges will be reinstated upon record completion."

At 3:15 p.m. on 4/26/11, staff member N, the medical records manager, was asked if there were any closed medical records that were more than 30 days delinquent. She said there were 25 incomplete records over 30 days and 7 incomplete records over 60 days. She said the physicians had not been notified of the delinquent records and had not had their admitting privileges suspended.

Based on document review and staff interview, the facility failed to ensure that a current roster listing each practitioner's specific surgical privileges was available in the surgical suite and area/location where the scheduling of surgical procedures is done. Findings include:

During the review of the Surgery Services area on 4/27/11 at approximately 1:15 p.m., the surveyor requested to see the surgical privileges manual for the operating room. Staff member F took the surveyor into her office and provided the manual. While reviewing the manual's contents, the surveyor noted that the approved privileges for two surgeons were dated 2007 and 2006.

During the interview with staff member F at that same time, staff member F stated that she had not received updated surgical privileges for the staff surgeons. Staff member F stated that the manual was kept in her office, not at the scheduling desk area.

Based on staff interviews, the facility failed to ensure staff received education on prevention of abuse and neglect. Findings include:

From 9:00 to 9:40 a.m. on 4/27/11, three staff members were interviewed about abuse prevention. They were staff members K, a certified nursing assistant (CNA), L, a ward clerk, and M, a registered nurse. Three of three interviewed staff members could not name all the types of abuse and said they had received no training about abuse at the facility. One of the three did not say abuse should be reported if observed.

At 11:10 a.m. on 4/27/11, staff member C, the director of nursing (DON), was asked if there was a policy about abuse prevention. She said there was no policy. She was asked what type of training about abuse was provided to staff. She said she had recently added the brochure on abuse created by the state survey agency (SA) to the orientation packet, but said there was no special training about abuse recognition, reporting, and prevention.