HospitalInspections.org

Based on record review and interview, the Governing Body failed to ensure the members of the medical staff were accountable to the Governing Body for quality of care provided to patients. This deficient practice was evidenced by medical staff members not monitoring high risk/alert medications for 1 (#2) of 2 (#1, #2) patients reviewed for high risk/alert medications out of a total sample of 5.

Findings:

Review of the hospital's policy titled, "Monitoring of High Risk/Alert Medications" revealed in part, psychopharmacological medications used in the treatment of patients admitted to inpatient status will conform to organization's guidelines under the direction of the medical staff regarding safe and effective use. Further review of this policy revealed in part, RN completes a requisition for specific urine and serum lab orders. Completes within 24 hours of admission or earlier based on LIP orders, specific serum test include liver profile, thyroid profile, osmolality, CBC, CMP, Coronary Risk, RPR, and Lithium, Dilantin, Tegretol, Phenobarbital, Valproic Acid, and PT/INR.

Review of Patient #2's physician order/admission medication reconciliation dated 02/05/2022 revealed the order Carbamazepine ER 300mg PO (by mouth) TID (three times per day) last dose on 02/04/2022 indication bipolar disorder. Further review of Patient #2's admission orders revealed the physician did not order Tegretol levels to be conducted.

In an interview on 04/27/2022 at 3:06 p.m. S1Adm and S2DON both confirmed Patient #2's Carbamazepine ER (Tegretol) levels were not ordered by the physician and were not conducted during the patient's hospital stay.

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by failing to document turning of the patient every two hours for 1 (#2) of 1 patient reviewed for documentation of turning of the patient every two hours from a total patient sample of 5.
Findings:

Review of the hospital's policy titled, "Skin/Wound Care" revealed in part:
Bed-Bound Individuals:
a.) Reposition at least every 2 hours- from supine position to the 30-degree lateral position. Avoid side-lying position. This position exerts intense pressure directly over the trochanter. Use the 30-degree lateral position instead, which does not exert pressure on any bony prominence.
Chair-Bound Individuals:
a.) Reposition at least every hour.

Review of Patient #2's medical record revealed a physician's order dated 02/05/2022 turn every two hours per posted turn schedule. Review of the multi-disciplinary notes revealed no documentation of turning of Patient #2 every two hours on 02/05/2022 - 02/19/2022 and 02/22/2022 - 02/24/2022.

In an interview on 04/28/2022 at 8:59 a.m. S2DON confirmed the staff did not document turning of Patient #2 every two hours on the above stated dates.

Based on record review, observations and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by the hospital failing to maintain a sanitary environment.

Findings:

Review of the hospital's policy titled, "Environmental Services Cleaning Guidelines" revealed in part, facility shall provide the necessary services required to maintain a clean, sanitary, and safe environment in accordance with industry best practices.

Observations were conducted on 04/25/2022 at 9:24 a.m. - 10:35 a.m. with S1Adm and S2DON.

Room "a": Numerous dead bugs in between the window and plexi-glass covering the window.

Room "b" Bathroom: Numerous dead bugs could be seen in the light fixture.

Room "c": Bathroom: Numerous dead bugs could be seen in the light fixture.

Room "d": Bathroom: Numerous dead bugs could be seen in the light fixture.

Room "e": Rust along the wall beside the toilet.

Room "f": Numerous dead bugs could be seen in the light fixture above tables and in between the window and plexi-glass covering the window.

In an interview during the observation, S1Adm and S2DON confirmed the above stated findings.

This deficiency was previously written on 06/09/2021.