HospitalInspections.org

Based on policy and procedure review, refrigerator log review, and staff interview, the facility failed to improve their implementation of staff, patient and medication refrigerator checks, as per policy, in both December 2011 and January 2012.

Findings:
1. at 11:20 AM on 2/13/12, review of the policy and procedure "Refrigerator and Freezer Medication Temperature Checks", policy stat ID 116076, with an expiration date of 8/2012, indicated:
a. under "Policy Statement", it reads: "To ensure that medications are stored at the proper temperature in the medication refrigerator, a chart will be kept on the outside of the refrigerator. A department staff member will check the thermostat in the refrigerator each day and write the temperature and initials on the chart. At any time the refrigerator is not at 36 - 46 degrees F, the manager will make out a maintenance work order, and document a description of actions taken to correct the problem..."

2. at 2:35 PM on 2/13/12, review of the medication temperature logs indicated:
a. in December (2011):
A. the wrong form was used--the form says "Food Refrigerator Log" and has a temperature range of 33 to 41 degrees, but has "medication fridge" written by staff at the top
B. 2 of 31 days lacked any documentation of having been checked by staff (12/20 and 12/29/11)
C. the "pyxis fridge" was also documented on the "Food Refrigerator Log" (incorrectly) and lacked being checked 3 out of 31 days in December (12/15, 12/20, and 12/29)
b. in January (2012):
A. 7 of 31 days are lacking any documentation of having been checked by staff (1/1, 1/2, 1/8, 1/9, 1/13, 1/22, and 1/23/12)
B. the "pyxis fridge" was not checked for 6 of 31 days (1/1, 1/2, 1/8, 1/9, 1/22, and 1/23/12) and was out of range on 1/10/12, with no documentation of corrective action taken or of notification to the manager to make out a work order, as per policy

3. at 11:20 AM on 2/13/12, review of the policy and procedure "Food Services Refrigerator and Freezer Temperature Checks", policy stat ID 116797, with a last revised date of 07/2011, indicated:
a. under "Policy Statement", it reads: "To ensure that food is stored at the proper temperature in the FOOD refrigerator a chart will be kept on the outside of the refrigerator. A department staff member will check the thermostat in the refrigerator 2 times a day, once when reporting to work in the am and again at 4:00 PM. temperature and initials should be written on the chart. At any time the refrigerator is above 41 degrees F, for more than 1 hour a maintenance associate should be called..."

4. at 2:35 PM on 2/13/12, review of the food temperature logs indicated:
a. the patient refrigerator for December 2011 lacked documentation of being checked by staff for 3 of 31 days (12/6, 12/15 and 12/27/11)
b. the patient refrigerator for December 2011 had a notation by staff on 12/21/11 that the temperature was 27 degrees (below the allowed 33 degrees on the form), but lacked any indication of adjustment or notification of a maintenance associate
c. the patient refrigerator for January 2012 lacked documentation of being checked by staff for 4 of 31 days (1/1, 1/2, 1/3, and 1/23)
d. the patient refrigerator for January 2012 was out of range 4 of 31 days and lacked documentation by staff of what action was taken for 3 of the 4 days (1/12, 1/23 and 1/24)
e. the staff/associate refrigerator for December 2011 lacked documentation of being checked for 4 of 31 days (12/15, 12/27, 12/29, and 12/31/11)
f. on 12/20/11, the associate refrigerator was noted as being out of compliance (44 degrees), but lacked documentation of what action was taken by the staff to bring the temperature back into compliance
g. the January 2012 log for the associate refrigerator lacked documentation of refrigerator checks on 5 of 31 days (1/1, 1/2, 1/3, 1/22 and 1/23/12)
h. on 1/10, 1/24, 1/25 and 1/30/12, the associate refrigerator temperature was out of compliance, but staff failed to document any "action taken" to correct the faulty temperature reading

5. interview with staff member NA at 11:30 AM on 2/13/12 indicated:
a. the two refrigerator policies do not match the log/grid being used by staff to document refrigerator temperatures
b. staff are only to check refrigerator temperatures once per shift, not twice as policy now states
c. staff are to recheck the refrigerator temperature two hours after an adjustment, if found to be out of range with the first check of the day (current policy does not reflect this)

6. interview with staff members NA and NE at 5:30 PM on 2/13/12 indicated:
a. it is unclear why staff who have been retrained, are not completing the daily refrigerator temperature checks
b. the current policies do not reflect the expectations for what to do if the refrigerators are out of compliance

Based on review of medical staff rules and regulations, patient medical record review, and staff interviews, the medical staff failed to ensure the implementation of their rules and regulations, related to history and physicals within 24 hours of admission, for 3 of 6 patient records reviewed. (N1, N2 and N5)

Findings:
1. at 5:00 PM on 2/13/12, review of the medical staff rules and regulations indicated:
a. on page 21, in section 4.2.18, it reads: "Physician Examination and Medical History. All Medical Staff members shall ensure that a comprehensive history and physical (H & P) examination is completed within 24 hours of admission to inpatient services...The history and physical must be completed no more than thirty (30) days before or twenty-four (24) hours after admission to the Hospital...When the history and physical is completed within 30 days before the patient's admission...the Member must update the medical record entry documenting an examination for any changes in the patient's condition..."

2. at 1:15 PM on 2/13/12, review of the newly created form "SVM303" indicated this was created as a one page "Swing Bed Program History and Physical Addendum" to allow physicians to check that there are no changes to the acute care H & P, or that the acute care H & P "requires revisions as below", where comments can be made by the practitioners on admission to Swing Bed status

3. at 3:30 PM on 2/13/12, review of patient medical records indicated:
a. pt. N1 was a direct admit to a Swing Bed status on 1/25/12, but had a H & P dated 1/21/12 that was not updated within 24 hours of admission to Swing Bed status
b. pt. N2 was admitted as an acute care patient on 1/10/12 and became Swing Bed status on 1/13/12, but only had the 1/11/12 H & P with no noted update within 24 hours of Swing Bed admission
c. pt. N5 was admitted as a Swing Bed patient on 1/19/12, but had a H & P dated 1/15/12 with no update within 24 hours of admission to Swing Bed status

4. Interview with staff members NA and NB at 4:10 PM on 2/13/12 indicated:
a. there were no updates to H & Ps for patients N1, N2 and N5, as noted in 3. above
b. the physicians requested the form SVM303 for ease in noting updates, if needed, to acute care H & Ps
c. it is unknown why physicians are not utilizing the form they requested
d. staff member NB reported that form SVM303 is stapled to the Swing Bed admission order page making it easy for physicians to see/complete
e. it seems physicians are removing the SVM303 page from the Swing Bed admission order page and disposing of it
f. previous reviews by the nurse manager indicated physicians had improved with updates to H & Ps

Based on policy and procedure review, IDT (interdisciplinary team) meeting minute review, and staff interview, the facility failed to ensure that Ad Hoc members participated in the IDT meetings, or submitted patient information, as needed for comprehensive patient care.

Findings:
1. at 4:00 PM on 2/13/12, review of the policy and procedure "Multi-Disciplinary Patient Care/UR [utilization review] Committee (Treatment Team)", with policy stat ID number 128355, indicated:
a. under "Policy", it reads: "...4. Ancillary services involved in the care of Swing Bed patients will be represented on the Patient Care/UR Committee or their input sought in advance and documented in the minutes as 'per the person, disciplines input'."
b. on page 2 under "AD Hoc Representative:", it reads: "The following hospital personnel may be asked to attend the bi-weekly Patient Care/UR Committee for Swing Bed patients on an as-needed basis: 1. Occupational Therapists 2. Respiratory Therapist..."

2. at 1:25 PM on 2/13/12, review of the December 2011 and January 2012 bi-weekly minutes of the IDT Care Plan meetings indicated:
a. there were 5 meetings in which at least one patient was noted as receiving "RT" (respiratory therapy) care, but no RT representative was present at these meetings, nor was there "input sought" from this discipline for reporting (and documenting) at the committee meeting (meeting dates = 1/9/12, 1/20/12,1/23/12, 1/27/12 and 1/30/12) b. there were 7 of 8 meetings that at least one patient was noted as utilizing OT (occupational therapy) services, but no OT representative was present at these meetings, nor was there "input sought" from this discipline for reporting, and documenting, at the committee meeting (meeting dates = 12/2/11, 12/9/11, 12/30/11, 1/20/12, 1/23/12, 1/27/12, and 1/30/12)

3. At 2:40 PM on 2/13/12, interview with staff member ND indicated:
a. RT has been delinquent lately in attending the IDT meetings
b. OT used to write notes that could be shared at IDT meetings, but has discontinued that process
c. it is not clear, by lack of information in the IDT meeting minutes, how RT and OT are working with other disciplines in the continuity of care of Swing Bed patients