HospitalInspections.org

Based upon observation and interview the facility failed to provide proper storage of food and drink items in the Emergency Department resulting in the potential for patient harm for patients served by the Emergency Department.

Findings include:
On 3/31/15 at approximately 8:15 AM, cans of fruit juice were observed stored on the left side of the ice machine on approximately a 4" section of countertop. On the right side of the ice machine, a coffee dispensing machine was observed. This coffee machine is approximately 6" from the adjacent handwashing sink. Interview with Staff G at approximately 8:15 AM revealed that when the Emergency Department space was renovated within the past year, the juice and coffee were not in the original scope of work and were added to the space afterwards.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on 3/31/15, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated 3/31/15 for Life Safety Code findings for building 1 and building 2..

Building 1
K-0011
K-0029
K-0046
K-0047
K-0050
K-0052

Building 2
K-0011
K-0011

Based on observation, interview and policy review, the facility failed to ensure that pre-drawn medications are properly labeled, that wasted narcotics are disposed of in acceptable manner that meets the best standard of practice and that single dose medication vials are used for only one patient resulting in the potential for poor patient outcomes and possible drug diversion. Findings include:

On 03/30/2015 at 1000, during review of the anesthesia cart located in the hospital's surgical procedure room revealed three syringes that contained a clear liquid in them. Each syringe contained a label that stated only the name of the medication. One syringe was labeled as "Atropine" the second one was labeled as "Ephedrine" and the third one was labeled "Anectine."

In an interview with staff Q, CRNA (Certified Registered Nurse Anesthetist) on 03/30/2015 at 1010, when queried about the three syringes, she stated, "I draw the up in case there is an emergency during a procedure." When queried if they were performing procedures today (Tuesday, 03/30), she stated, "No, we do them on Mondays." When queried if she was aware of what information needs to be on a syringe if the medication is pre-drawn, she stated, "I am not." When queried if she was aware of what the facility's policy stated in regards to pre-drawn medications, she stated, "No, I am not sure what the policy says." When queried as to why the medications are still in the cart if they are not doing procedures this day, to which she did not reply.

On 03/30/2015 at 1030 during review of the anesthesia cart in the operating room (OR), revealed four syringes containing clear liquids. The four syringes contained labels that only identified the name of the medication in each syringe. The syringes contained "Robinul", "Atropine", "Ephedrine" and "Anectine."

On 03/30/2015 at 1130 during observation in the OR, staff Q was observed disposing of a syringe of Fentanyl after completion of the patient's eye surgery. Staff Q showed the syringe to staff X for witness to the waste and was then observed disposing of the entire syringe, with the medication in it, into the sharps container.

On 03/30/2015 at 1145, during an interview with staff J (Pharmacist) when queried about what information staff need to put on a pre-drawn syringe, he stated, "We don't pre-draw medications." When told that pre-drawing of medications was observed in the operating room and procedure room, he stated, "I was not aware of this." When queried if he was aware of what the policy stated regarding what information needs to be on a pre-drawn syringe, he stated, "The policy does not speak to this since we do not pre-draw." When staff J was queried about the procedure for wasting a controlled substance, he stated, "They have to have a witness and they are supposed to document how it was wasted on the bottom of the medication sheet." When the observation was discussed of throwing the syringe containing the medication into the sharps container, he stated, "No, they are supposed to waste it which would mean down the sink or in the trash." When asked if he would agree that the waste of a narcotic medication would mean that it would be wasted in a manner that would not leave the medication available for retrieval, he stated, "Yes."

On 03/30/2015 at 1200, a review of the facility's medication policies revealed that the policy did not specify procedures for pre-drawing of medications or what information would be required on the syringe if this did occur.
Review of the policy titled, "Controlled Substances: Purchase, Storage, Distribution & Disposal, (No policy #), Revised 6/1/2014," read, "H. Destruction: Destruction of any controlled substance outside of pharmacy must be done in the presence of two licensed individuals, (nurses, pharmacist, physicians.) These individuals must be authorized to handle controlled substances. This destruction must be recorded on either the acute E.R.(Emergency Room) wastage form and describe how the medication was destroyed. (The form only contained a single area even though the policy speaks to "either.")
A review of the Controlled substance log for Fentanyl between 12/08/2014 thru 03/04/2015 and Versed for 12/17/2014 thru 03/27/2015 revealed that waste had occurred five times. None of the controlled substance logs contained information in the area titled, "Record of Waste and Spoilage- Item, Date, Quantity, Describe in Detail, Signature #1, Signature #2."

On 04/01/2015 at 1100, during further review of the controlled substance documentation (usage and wastage) of Fentanyl and Versed revealed that CRNA's were using single dose vials of Versed and Fentanyl for more that one patient. Review of the logs for Versed revealed the following: On 12/29/2014 three vials of single dose Versed were used for six patients. On 02/03/15 and 02/09/2015 one vial of single dose vial of Versed was divided between two patient each day. Review of the logs for Fentanyl revealed the following: On 02/02, 02/03 and 02/09/2015 a vial of single dose Fentanyl was divided between two patients on each day.

In an interview with staff J on 04/01/2015 at 1200, when queried if the controlled substance logs were reviewed by pharmacy once they are completed, he stated, "Yes, but we are really only checking the count, if they had 25 vials of Fentanyl that the total count used was 25. We haven't really been checking to see if they are dividing doses or if they are documenting the waste on the bottom of the log. We will need to be looking at these more closely. I can see where we should be looking at these things."

On 04/01/2015 at 1300, review of the facility's policy titled, Review of Controlled Substances & Anesthesia Records, (No policy #), Revised: 4/14/2012," read, "The risk manager and/or pharmacy will review the controlled substances and anesthesia records. The risk manager/and or pharmacy will randomly check the accuracy of all controlled substances and anesthesia documentation monthly for six months to ensure policies and procedures are being followed. Once satisfactory, the risk manger will randomly check records at least four times a year or as otherwise stated."

In an interview with staff C (Director of Quality & Risk) on 04/01/2015 at 1330, the above policy was reviewed and when queried if she was monitoring the controlled substance logs, she stated, "I did not know that I was supposed to be doing this."

Based on interview the facility failed to perform an annual evaluation of its total program resulting in the potential for unmet patient/community needs. Findings include:

In an interview with staff A on 04/01/2015 at 1500, revealed that the facility was unable to produce documentation of an annual program evaluation. When queried if the facility performs an annual or periodic program evaluation, he stated, "We have not."

Based on interview and document review the facility failed to provide medical record reviews that had been evaluated for the quality and appropriateness of the diagnosis and treatment, done by an outside source "Quality Improvement Organization" (QIO) in the last 12-24 months. This has the potential to result in unidentified problems and less than optimal care and treatment for patients served by the facility. Findings include:

On 4/1/2015 at 1300 during review of the quality meeting minutes for the last year, no evidence of the results of record reviews could be found.

On 4/2/2015 at 0900 during interview with staff C the quality and risk manager, she stated, "We have not sent any records out to be evaluated."

Based on interview and document review the facility failed to consider the findings of the evaluation of medical records sent to the Quality Improvement Organization (QIO) and take corrective action when necessary. Findings include.

On 4/1/2015 during review of the quality meeting minutes for the last year 4/1/14-3/31/15, no evidence of the results of record review findings could be found.

On 4/2/2015 at 0900 during interview with staff C the quality and risk manager, she stated, "We have not sent any records out to the QIO to be evaluated, so we have had no record review findings to review."

Based on observation, interview and document review the facility failed to provide an ongoing activity program to meet the physical, mental and psychosocial well-being of each resident, in accordance with the comprehensive assessment in 6 of 6 (#7,#13,#18,#19,#20,#21) swing bed patient records reviewed. This has the potential to result in less than optimal treatment outcomes for patients served by the facility. Findings include:

On 4/1/2015 at 1400 during review of the records of swing beds it was noted that the "Interdisciplinary Team (IDT) Conference Summary" has a single line for "Activities" and simple one line statements are documented by the Occupational Therapist (OT) about patients' ability to participate.

On 4/2/2105 at 1000 two swing bed patients were interviewed (#7, & #13) which revealed that there were no planned activities posted for either patient in their room or at the nursing station.

On 4/2/2105 at 1030 medical record review for patients #18, #19, #20 and #21, who were swing bed patients revealed that there were no planned activities posted for any of the patients in their room or at the nursing station.


On 4/2/2015 at 1030 staff D, the director of nursing (DON) stated, "We do not have planned activities for the skilled care patients."

On 4/2/2015 at 1500 the policy titled, "Skilled Care Activities Guidelines" dated 06/19/13 was reviewed. It stated, "Purpose: The skilled care patient will be involved in an ongoing program of activities which is designed to appeal to his or her interests and to enhance the patients highest practicable level of physical, mental, and psychosocial well-being......... the OT will add activities to the patient task....the nursing staff is to complete and document the task.....an activities calendar will be posted....