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Based on review of documentation and interviews with staff, the facility governing body failed to approve medical staff rules and regulations that are compliant with the requirement at Tag A0457 CFR482.24(c)(1)(iii) that physician verbal orders are authenticated within 48 hours as the facility rules and regulations did not specify a time frame for authentication of verbal orders. Furthermore, 6 of 29 patient records reviewed contained verbal orders that were not authenticated within 48 hours.

Findings were:
The facility Medical Staff Rules and Regulations dated 8/07 reflected in part "A verbal order shall be considered to be in writing if dictated to a duly authorized person functioning within his/her sphere of competence and signed by the responsible practitioner. All orders dictated over the telephone shall be signed by the appropriately authorized person to whom dictated with the name of the practitioner per his/her own name. The responsible practitioner shall authenticate such orders at the next visit." In an interview on 8/28/12 at 4:00 pm, staff #27 confirmed that the medical staff rules and regulations did not have a specific time frame for authentication of verbal orders. Cross refer to Tag A0457 for more information.

Based on review of records and interviews with facility staff, the facility failed to ensure that verbal orders were dated, timed and authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient as 6 of 29 patient records reviewed contained verbal orders that were not authenticated within 48 hours.

The findings were:
During a review of patient medical records on 8/28-29/12, the medical records of patients #1, #4, #13, and #20, contained verbal orders that were authenticated but not dated or timed. The patient records of patients #21, and #22 contained verbal orders that were not authenticated, dated or timed. In interviews on the afternoon of 8/28/12 and the morning of 8/29/12, staff #4 confirmed the above findings.

Based on observation, review of documents, and interviews with facility staff, the facility failed to keep drugs locked in a secure area as a supply cart containing drugs in the ambulance entrance was unlocked in violation of facility policy.

The findings were:
The facility policy entitled "Eastland Memorial Hospital Emergency Medical Services Policy Title: Equipment, supplies and medication" dated 1/07 reflected in part "Restocking the units will be done from the Uni-Cell in the Emergency Room at EMH (Eastland Memorial Hospital) or from Central Supply after filling out all necessary paper work). The Uni-Cell will remain locked at all times that no one is utilizing it."

During a tour of the emergency department on 8/28/12 starting at 9:00 am in the company of staff # 13, the "Uni-Cell" supply cart located in the left side of the ambulance entrance vestibule was observed to be unlocked. The cart contained medications including epinephrine 1 mg/ml injection and atropine 1 mg/ml injection. There was a sign on the door of the cart: "Keep Locked." The vestibule was immediately inside the sliding glass ambulance entrance doors which were unlocked. The vestibule was unattended by any staff. In an interview on 8/28/12 at 9:40 am, staff #13 stated that the cart was for EMS supplies and confirmed that it was unlocked and contained medications.

Based on observation, review of documentation, and interviews with the pharmacy staff, the facility failed to ensure that only authorized personnel had access to the pharmacy. The pharmacy key was kept in an unlocked draw at the nurses ' station; allowing access for unauthorized personnel and the public to enter the pharmacy.
Findings were:

Review of documentation Pharmacy Policy, index number 733-19.02 stated, " All areas occupied by the pharmacy will be capable of being locked, by key or combination lock, and secured at all times as to limit the access by unauthorized personnel. "
In an interview conducted during a tour of the pharmacy on the morning of 08/28/12 accompanied by staff # 14 and # 4; staff #1 stated the key to the pharmacy is kept at the nurses ' station for access to the pharmacy when the pharmacy is closed.
The findings were confirmed by staff # 1, 14, and 4 during the tour of the pharmacy on the morning of 08/28/12.

Based on observation, review of documents and interviews with facility staff, the facility failed to ensure that specific food and dietetic services organization requirements were met as food and dishwasher temperatures were not documented in accordance with facility policy.

The findings were:
The facility policy entitled "Food Preparation" dated 6/04 reflected in part "Temperatures of hot foods are checked with a food thermometer when food is taken to serving lines and recorded on temperature logs." The facility policy entitled "Dishwashing Procedure" dated 4/12 reflected in part "Make sure that wash-water temperature is at least 140oF. Chlorine should be a minimum of 50 ppm (parts per million)."

During a tour of the dietary department on 8/27/12 starting at 3:30 pm in the company of staff #19 the "Patient Trayline Temperature" form documentation was reviewed for the month of August 2012. There were no temperatures recorded for the following meals: 8/2/12 dinner; 8/10/12 breakfast and lunch; 8/13/12 breakfast and lunch; 8/14/12 breakfast and lunch. The "Dishmachine/Pot Sink Temperature & Sanitizer Test Strip Record" form for the month of August 2012 was reviewed. There were no temperatures or sanitizer test strip readings recorded for the following dates: 8/3/12 morning; 8/4/12 noon and night; 8/5/12 morning, noon and night; 8/10/12 noon and night; 8/11/12 morning; 8/12/12 morning; 8/15-16/12 morning, noon and night; 8/25-26/12 night. In an interview on 8/27/12 at 4:00 pm, staff #19 confirmed that the above listed temperatures were not recorded and that the staff should be recording them.

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 as 9 oxygen cylinders in 2 of 2 storage areas were observed to be unsecured and expired medical supplies were found in 2 of 8 patient care areas available for patient use in violation of facility policy.

The findings were:
The facility policy entitled "Medical Gas Safety Procedures" dated 5/12 reflected in part "All medical gas cylinders are to be kept and stored in the proper rack or cylinder holder at all times."

The facility policy entitled "Outdated Supplies and Drugs" dated 8/10 reflected in part "Commercially manufactured items that are outdated or those that will be outdated within thirty (30) days of inspection will be either discarded or returned to the manufacturer for credit. Reprocessable sterile supplies that are outdated will be returned to the appropriate department for reprocessing."

During a tour of the facility on 8/27/12 starting at 2:00 pm in the company of staff #15, 3 size E oxygen cylinders and 4 size D oxygen cylinders were observed to be unsecured in any manner in the gas storage building located behind the hospital building. In an interview on 8/27/12 at 2:20 pm, staff #15 confirmed that the cylinders were unsecured.

During a tour of the emergency department on 8/28/12 starting at 9:00 am in the company of staff # 13, 1 size D oxygen cylinder and 1 size E oxygen cylinder were observed standing in the right side of the ambulance entrance vestibule to be unsecured in any manner. In an interview on 8/28/12 at 9:40 am, staff #13 confirmed that the cylinders were unsecured.

During a tour of the radiology department on 8/27/12 starting at 2:45 pm in the company of staff # 16, a package containing sterilized bandage scissors with an expiration date of 4/1/09 was observed in a cabinet in the x-ray room. In an interview on 8/27/12 at 2:55 pm, staff # 16 confirmed that the scissors were expired.

During a tour of the emergency department on 8/28/12 starting at 9:00 am in the company of staff # 13 the following expired supplies were observed in treatment room #1 available for patient use: lidocaine jelly, 30 ml tube, expired 3/10; 0.9% NaCl for inhalation, 1 ampule expired 5/10 and 1 ampule expired 3/11; povidone iodine swabsticks, 1 package expired 3/11, 2 packages expired 4/11, 2 packages expired 4/12; sterilized thoracotomy tray expired 1/20/11; sterilized burn pack expired 6/12/12; and sterilized chest tube instrument pack expired 7/28/12. The following expired supplies were observed in the ER crash cart available for patient use: 2 packages of Ethicon cotton umbilical tape expired 7/12. In an interview on 8/28/12 at 10:00 am, staff #13 confirmed that the above listed supplies were expired.

Based on observation, review of documentation, and interviews with the facility staff; the facility failed to provide an active infection control program. There was no documentation or evidence of participation from the infection control medical director, or the infection control manager, no documentation or evidence of infection control committee meetings, no documentation of the hospital departments ' participation, no documentation or evidence of quality improvement program participation, and there was no documentation of surveillance, identifying, monitoring, corrective action plans and continuous educational training for the hospital staff. 18 closed and 8 hinged instruments in locked positions were observed in surgery room 2, which had been sterilized, wrapped and where available for patient use.
Findings were:
The administrator, medical staff and chief nursing officer failed to ensure and be responsible for the hospital wide quality assurance program, training programs and implementation of the infection control policies. Cross refer A0756
18 closed and 8 hinged instruments in locked positions were observed in surgery room 2, which had been sterilized, wrapped and where available for patient use.
Cross refer to A0748

Based on observation, review of documentation, and an in-person interview with the facility staff on the afternoon of 08/27/12 the facility failed to implement the infection control policies. 18 closed and 8 hinged instruments in locked positions were observed in surgery room 2, which had been sterilized, wrapped and where available for patient use.
Finding were:
During a tour of surgery room # 2 on the afternoon of 08/27/12, the surveyor accompanied by staff # 14 observed Review of documentation Sterilization Process, index number 676.19.16, revision date 5/12 stated, " Steam sterilization is the preferred method of sterilization and is done on reusable items that can withstand high temperatures, moisture, and pressure.

The Centers for Disease Control and Prevention (CDC) article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf, states on page 74 that hinged instruments and instruments that close should be opened during the process of sterilization.

The findings were confirmed in interview with Staff # 14 on the afternoon of 08/27/12.

Based on review of documentation and an interview with staff # 14; the facility administrator, chief nursing officer, and the medical staff, failed to implement and be responsible for an active infection control program. There was no documentation or evidence of participation from the infection control medical director, medical staff, or the infection control manager. There was no documentation or evidence of infection control committee meetings, no documentation of the hospital departments ' participation, no documentation or evidence of quality improvement program participation.
Findings were:
Review of documentation Infection Control Plan, index # 1.1revision date 11/06 stated, " Each department in partnership with the Medical Staff will be responsible and accountable for its role in the infection Control Program. In addition to reporting isolation cases, suspected infections, positive cultures and follow-up information, each department will be responsible for full and timely cooperation with the infection control physician advisor and infection control manager to develop and implement remedial; corrective action. "

Review of the PAC (professional activities committee) meeting minutes Jan - Dec 2011 and Jan -August 2012 revealed no documentation or evidence of participation of the infection control officers or infection control committee meeting or any hospital participation.

In an in-person interview with staff # 25 the infection control nurse, on the morning of 08/28/12 at the facility; staff # 25 stated " she receives reports from the lab and the nurses. The reports are then given to staff # 26 and staff # 14. "
The surveyor asked staff # 25 did she attend infection control committee meeting or communicate with the infection control medical director staff # 3. Staff # 25 stated " the facility does not have an infection control committee; they have a PAC (professional activities committee) that meets once a month and she does not attend and has not communicated with staff # 3 the infection control medical director. " Staff # 25 stated she does not make surveillance rounds, " the department heads are responsible for surveillance and reporting to the infection control program. " Staff # 25 stated she does not do any follow up training with facility personnel. Staff # 25 stated, " new employees are instructed to read the infection control manual during the 5 day orientation program and the staff managers are responsible for continuous infection control training of employees. No documentation or evidence of the facility department mangers providing continuous infection control training to the facility personnel was provided to the surveyor.
In an in person interview with staff # 14 on the afternoon of 08/28/12 the findings were confirmed.