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Based on review of records and interviews with staff, the facility failed to ensure that each patient was informed of their rights in advance of furnishing patient care, as 33 of 33 patients whose records were reviewed did not receive a copy of the patient rights document.



Findings were:


The hospital has a document entitled PATIENT RIGHTS AND RESPONSIBILITIES, which includes all required rights for the patient. One of the listed rights states, "As a patient, you have the right to receive at the time of admission, information about your rights as a patient ..."

Review of the records of Patients #1-33 revealed that none of the patients had received a copy of this document.

In-person interviews were conducted the morning of 11/19/13 with admissions personnel (Staff #36 and Staff #37) responsible for admitting patients to surgery, inpatient services, and the emergency department. Both staff members stated they do not give patients a copy of the rights document unless they ask for it; neither do they verbally explain the rights to the patients at the time of admission.

Based on review of records and interviews with staff, the facility failed to ensure that each patient was informed of the process for prompt resolution of patient grievances or whom to contact to file a grievance, as 33 of 33 patients did not receive a copy of the patient rights document which contains information about the grievance process.

Findings were:

The hospital has a document entitled PATIENT RIGHTS AND RESPONSIBILITIES, which includes the process for filing a complaint or grievance regarding care at the hospital. The document contains the contact information for filing a complaint and states " As a patient, you have the right to receive at the time of admission, information about your rights as a patient and the mechanism for filing a complaint or grievance ..."

Review of the records of Patients #1-33 revealed that none of the patients had received a copy of this document.

In-person interviews were conducted the morning of 11/19/13 with admissions personnel (Staff #36 and Staff #37) responsible for admitting patients to surgery, inpatient services, and the emergency department. Both staff members stated they do not give patients a copy of the rights document that contains the grievance process unless they ask for it; neither do they verbally explain the process to the patients at the time of admission.

Based on observation, review of documentation and interviews with facility staff, the facility failed to assure that outdated or unusable drugs were not available for patient use as outdated and undated multi-dose medications were found in 2 of 7 patient care areas available for patient use. This was in violation of facility policy and could potentially result in patients receiving unsafe medications.

The findings were:

The facility policy entitled Pharmacy Multiple Dose Vials with a review date 8/12 reflected in part "All multiple dose vials will be initialed and dated when opened. This includes bacteriostatic sodium chloride vials used for flushed (sic), all insulins and vaccines. There are no exceptions. These can be used for 28 days. After 28 days they have to be discarded."

During a tour of the surgery department on the afternoon of 11/18/13 in the company of the surgery manager, staff # 27, an opened multi-dose bottle of tropicamide ophthalmologic solution 1% dated 8/2/13 was found in the pre-op medication cart. This finding was confirmed in an in-person interview with Staff # 27 during the tour on 11/18/13 at 2:00 pm.


21021

During a tour of the outpatient therapy area on the afternoon of 11/18/13 in the company of the Director of Quality Improvement, Staff # 38, an opened multi-dose vial of insulin was found in the medication refrigerator. The vial was undated. This finding was confirmed in an in-person interview with Staff # 38 during the tour on 11/18/13.

Based on observation, review of documentation and interviews with facility staff, the facility failed to maintain supplies and equipment to ensure an acceptable level of safety and quality as expired medical supplies were found available for patient use. In addition, sterilized surgical instruments that were processed in the closed or clamped position were found available for patient use. This was in violation of facility policy and could have resulted in potentially unsafe medical supplies or equipment being used for patient care.

The findings were:

The facility policy entitled Materials Management Infection Control #675-I-2, with a revised date 2/06 reflected in part "Dated Supplies: To ensure that no outdated sterile supply is utilized for patient care purposes: 1. No outdated sterile supply shall be maintained in stock or on the units at any time. Dated items are checked periodically as needed to be sure all supplies are in date." The facility policy entitled OR Scope of Service #660-1 with a revised date 5/08 reflected in part "The main objective(s) of Sterile Central Supply shall include ...3. That no outdated sterile supplies or equipment is utilized."

The facility policy entitled Sterile Central Supply Instruments, Care Of, with a revised date 12/85 reflected in part "1.d. Keep locks, joints and hinges freely movable ...2c. Tips of instruments are protected with 4 x 4 ' s or tip protectors if indicated. 2d. Instruments, except for towel clips, are sterilized in the open position for adequate steam penetration." The facility policy entitled Sterile Central Supply Packs, Assembly/Wrapping #660-P-2 with a revised date 4/08 reflected in part " All instruments are wrapped in the open position utilizing racks or clips."

During a tour of the Surgery Department on the afternoon of 11/18/13 in the company of the surgery manager, Staff # 27, the following expired supplies were found available for patient use:
? In OR #2, providone iodine solution packet, expired 10/13; providone iodine swabstick, 3 packages expired 10/12; BSS irrigation solution, expired 11/14/13.
? In OR #3, providone iodine swabstick, 2 packages expired 9/11 and 4 packages expired 10/12.
These findings were confirmed in an in-person interview with Staff # 27 on 11/18/13 at 2:15 pm.
During a tour of the Sterile Processing area on the afternoon of 11/18/13 in the company of the surgery manager, Staff # 27 and the sterile processing tech, Staff # 26, a sterilized tenaculum and a sterilzed Kelly clamp were found in the clamped position and approximately 20 sterilized scissors and clamps were found in the closed position. These findings were confirmed in an in-person interview with Staff # 26 and 27 on 11/18/13 at 2:40 pm.



29937

During a tour of the outpatient treatment area on the morning of 11/18/13 accompanied by the Director of Nursing (DON), Staff # 1, 5 blue-top lab tubes which expired in 8/2010 and 3 blue-top lab tubes which expired in 8/2011 were found available for patient use. The finding was confirmed by Staff #1 in an in-person interview conducted during the tour.

A tour of the physical therapy department was conducted the morning of 11/18/2013 in the company of the physical therapy assistant (PTA), Staff # 2. During the tour, 57 telfa dressing with expiration dates of 5/2013 and 12/2012 were found, and 24 tongue blades with expiration dates of 9/2010 and 7/2012 were found in the supply cabinet. These supplies were available for patient use. The findings were confirmed by Staff # 2 in an in-person interview conducted during the tour of the department.

Also during the tour of the physical therapy department, 3 sterile surgical instruments observed in the supply cabinet were closed and clamped, and available for patient use, causing a potential for transmission of infections. The findings were confirmed by the PTA, Staff # 2, in an in-person interview conducted during the tour of the physical therapy department.
During a tour of the obstetrical department on the afternoon of 11/18/13 with the DON, Staff # 1, 69 surgical instruments were observed in the supply room closed and clamped, available for patient use, causing a potential for transmission of infections. The findings were confirmed by Staff # 1 in an in-person interview conducted during the tour of the obstetrical department.


21021

During a tour of the outpatient therapy area on the afternoon of 11/18/13 in the company of the Director of Quality Improvement, Staff # 38, 61 sterile needles were found that were out of date; these supplies were available for patient use. Twenty-two expired in 2008; 22 expired in 2009; 10 expired in 2010; 4 in 2011; and 3 in 2012. Additionally, 5 sterile tongue depressors were found with an expiration date of 2/2010 and a package of casting material with an expiration date of 9/2012. These findings were acknowleded during an interview with Staff #38 conducted during the tour of the department the afternoon of 11/18/13.

Based on observation, record review and interviews with the facility staff, the infection control officer failed to ensure staff practiced infection control techniques to prevent transmission of infections in 2 patient care areas.


Findings were:


During a tour of the physical therapy department at the facility on the morning of 11/18/13 in the company of the physical therapy assistant (PTA), Staff #2, a pair of tweezers in an open sterilization package was observed in the supply cabinet. Staff # 2 reported that the tweezers are used when performing dressing changes for patients, then cleaned and put back into the package. The tweezers are used on open wounds and should be sterilized, not just cleaned, in order to prevent patient infections. The findings were confirmed by Staff # 2 in an in-person interview conduced during the tour.

During a tour of the obstetrical department on the afternoon of 11/18/2013 in the company of the Director of Nursing (DON), Staff #1, 2 pediatric laryngoscopes with blades were observed lying on the infant warmer in the hall next to the surgery entrance and in the obstetrical patient room. Both scopes were uncovered and exposed to elements such as dust, and available for patient use. This could cause the potential for the transmission of infection to patients. The findings were confirmed in an in-person interview with Staff # 1 during the tour of the obstetrical department.

The hospital's Infection Control Plan states that "The infection control program seeks to identify, monitor, and prevent the transmission of potentially infectious diseases to patients, employees, volunteers, visitors, family members and physicians. This program evaluates the potential for diseases transmission and promotes the improvement of patient and employee health and prevents the spread of disease."

In an in-person interview with the infection control coordinator, Staff #5, the afternoon of 11/19/2013, it was confirmed that the physical therapy and obstetric departments had not had monitoring or surveillance activities which would have revealed the above findings. Staff #5 was unaware of the instruments improperly handled in the 2 departments.

Based on review of documentation and interview with staff, the facility failed to ensure that residents in the Swing Bed Program were informed of their rights, as 15 of 15 residents whose records were reviewed were not advised of their rights when admitted to the program.

Findings were:

Facility policy entitled SWING BED PATIENT RIGHTS lists 10 rights for Swing Bed residents, including the right to be fully informed of any charges they may be responsible for; the right to be informed about their medical condition; transfer and discharge rights; the right to be free from abuse; confidentiality rights; the right to personal mail and visitors; the right to not be required to perform work for the facility; the right to participate in activities of their choice; the right to personal clothing and possessions; and the right to privacy for spousal visits and room sharing. The document has the statement "I hereby acknowledge that I have read (or had read to me) and understand the above rights of Swing Bed patients." There is a signature line for the patient or patient representative to sign.


Although there was no evidence that patient rights were violated, review of the records of Patients #3 - 17 revealed that none of the records contained a signed copy of the SWING BED PATIENT RIGHTS according to facility policy. Patient #11 was admitted to the Swing Bed Program 2/24/12 and Patient #6 was admitted 11/9/13. All other Swing Bed patients were admitted between those dates; none had a signed Bill of Rights in their medical record.

An in-person interview was conducted with the Swing Bed Coordinator, Staff #3, the morning of 11/19/2013. According to Staff #3, the Swing Bed patients/residents have not been informed of their rights since the hospital began using electronic medical records in February 2012. The Coordinator stated that in the past, they would deliver the patient Bill of Rights to the patient and go over it with them and have them sign it. Staff #3 verified that the 15 patients whose records were reviewed had not been informed of their rights as Swing Bed residents.