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Based on observation, Safety Policy and Procedure Manual review, Generator Log review, building plan review, and interview, it was determined the facility did not meet Life Safety Code requirements as follows:

A. The Medical Records Room was not protected as a hazardous room by fire rated construction or a sprinkler system as required by NFPA 101 Section 19.3.2.1. Storing the combustible materials in a unprotected room had the potential to affect all patients, staff and visitors due to the spread of fire and smoke from the room in the event of a fire. The facility had a census of 15 patients on 12/03/12. See CMS 2567, K29.
B. The generator was not inspected weekly as required. Failure to perform weekly generator inspections had the potential to affect the health and safety of all patients because the reliability of the generator to provide power to the facility in the event of the loss of normal power was not assured. The facility had a census of 15 patients on 12/03/12. See CMS 2567, K144.

Based on observation and interview, the facility failed to ensure outdated medications were not available for patient use on one of one Malignant Hyperthermia/Emergency Cart located in Surgery. The potential existed for all surgery patients, 8 of 8 since 10/01/12, to receive outdated emergency medications if needed. Findings follow:

A. A tour of Surgery on 12/03/12 at 1500 revealed the following outdated medications were observed on the Malignant Hyperthermia/Emergency Cart.
1) Four 50 milliliter (ml) syringes of Dextrose 50% expired 10/01/12; and
2) Two multidose vials of Furosemide 100 milligrams (mg)/10 ml expired 11/01/12.
B. An interview was conducted with the Quality and Compliance Officer on 12/03/12 at 1515, she verified the medications were outdated and available for patient use.

Based on the review of the Pharmacy and Procedure Manual and interview, the facility failed to ensure there were policies and procedures for use of the Automated Medication Distribution System. The failed practice had the potential to affect four of four pharmacy personnel in maintaining and effective medication distribution system and the potential to affect the average daily census of seven patients. Findings follow:

A. Review of the Pharmacy Policy and Procedure Manual on 12/04/12 at 1500 revealed there were no policies and procedures referencing the Automated Medication Distribution System..
B. In an interview with the Pharmacist In Charge on 12/05/12 at 1025, he revealed the Automated Medication Distribution System had been utilized for approximately two to three weeks. It was also verified there were no policies and procedures for the Automated Medication Distribution System in the Pharmacy Policy and Procedure Manual.

Based on clinical record review and interview, it was determined the facility failed to assure a Registered Nurse supervised and evaluated the care for 3(#21, #28, and #39) of 23 (#18-#40) Emergency Room patients. Without an assessment by a Registered Nurse, it could not be assured the patient's nursing care needs were met. The failed practice affected Patient #21, #28, and #39 and had the potential to affect all patients who presented to the emergency room. The findings were:

A. Review of clinical records on 12/06/12 revealed there was no Registered Nurse assessment for Patient #21, #28, and #39 at the time of treatment.
B. The findings were confirmed at the time of the review 12/06/12 at 1040 by the Quality Compliance Director.

Based on review of an operative report, it was determined three of three (#9, #16, and #17) patient operative reports did not contain the time of the surgery. The failed practice did not allow for determination of which operation came first in the event of multiple surgeries on one day. Findings follow.

A. Review of operative reports for Patient #9, #16, and #17 revealed no documentation of the time of the surgery.
B. Findings were confirmed by the Director of Quality and Compliance on 12/06/12 at 1145.

Based on interview, it was determined the facility failed to have a qualified professional direct the activies of the Swing Bed program. Without a qualified professional to direct the activities, the facility could not be assured the patient activity needs would be met.The failed practice had the potential to affect any patient admitted to a Swing Bed. The findings follow:

In an interview with the Swing Bed Coordinator on 12/06/12 at 1220, she confirmed there was not an activities professional or consultant recreation specialist or occupational therapist designated to serve as the activitiy director or provide consultation.