HospitalInspections.org

Based on record review and interview, the provider failed to maintain separate patient medical records for each admission for two of two sampled patients' (8 and 15) records reviewed. Findings include:

1. Review of patient 8's medical record revealed she was admitted on 4/7/11. Documentation from March 2011 was found in her 4/7/11 admission record. Patient 8 had previously been discharged to another hospital and returned on 4/7/11.

Interview on 4/15/11 at 11:30 a.m. with the director of health information revealed a new patient medical record was not started when patients discharged to another hospital and return was anticipated. Interview at 5:00 p.m. confirmed they had no policy related to maintaining separate medical records for each time a patient was admitted.

Based on observation and interview, the provider failed to ensure medications administered were stored appropriately and labeled with an expiration date for two of two medication carts. Findings include:

1. Observation on 9/14/11 at 10:30 a.m. of the medication carts revealed:
*Patient 1's:
-Carbamide peroxide 6.5 percent (%) the pharmacy label covered the expiration date on the container.
-Tylenol oral solution had been opened on 7/10/11. There was no expiration date documented on the pharmacy label or on the bottle after it had been opened.
*Patient 3's diphenhydramine did not have an expiration date on the pharmacy label or the syringe the medication had been repackaged in.
*Patient 5's Lacri-lube eye ointment was stored in the same bin with his bisacodyl suppositories, skin protectant lotion, ear cream, and hydrocortisone face cream.
*Patient 6's eye drops were stored in the same bin as his antifungal cream and triple antibiotic ointment.
*Patient 7's fluticasone nasal spray was stored in the same bin as her Refresh lubricating eye drops.

Interview on 9/14/11 at the time of the above observation with care coordinator H revealed:
*Eye drops should have been stored separately from external creams and ointments. At that time she separated the above patients' eye medications and external creams and ointments.
*There was a potential for cross-contamination when those medications were stored together. *The expiration dates were not always visible on all medications in the medication cart.

Interview on 9/15/11 at 11:10 a.m. with pharmacist I confirmed:
*All medication should have an expiration date.
*If medications were repackaged by the pharmacy the pharmacist should have established a new expiration date, and it should have been part of the pharmacy label.
*The pharmacy label should not obstruct the manufacturer's expiration date on medication containers.
*Patient 1's medications had been repacked by the pharmacy, and there should have been an expiration date listed on the label.

A. Based on observation, interview, and policy review, the provider failed to maintain a safe and sanitary environment for two of two patient care facilities (main hospital campus and the hospital's off-site rehabilitation center). Findings include:

1. Observation on 9/14/11 from 1:10 p.m. through 4:30 p.m. at the off-site rehabilitation center revealed:
*In the children's play area located in the waiting room revealed a bin of plastic blocks of various shapes and sizes, and a standing toy with colored balls that moved on a wire rack.

Interview on 9/14/11 at 4:30 p.m. with program director D revealed the toys in the waiting room play area were disinfected once a week. Director D agreed the toys should have been disinfected after each use to prevent cross-contamination between children.

*In the rehabilitation therapy sensory gym:
-One mattress with a plastic protective top cover. The felt covering around the mattress sides was not cleanable surfaces.
-One weight made with felt material did not have a cleanable outer protective covering.
-One blue swing crib had numerous white discolored stains on the cloth surface (photo 34).
-One blue floor mat had numerous cracks in the protective padding (photo 35).
-One medium sized ball pit with numerous round plastic balls. The padding forming the walls were cracked at the edges (photo 36).
-One large hanging inner tube swing with duct tape in the sensory gym and two medium sized inner tubes with peeling duct tape stored under a trampoline unit (photos 37 and 38).
-Numerous tumble forms in various sizes with small to medium sized tears in the outer plastic protective covering. The tears exposed the foam padding underneath creating uncleanable surfaces (photo 39).

Interview on 9/14/11 at the time of the above observations with program director D revealed:
*Not all the items listed above had cleanable surfaces, some needed repair because of tears, and not all were disinfected after each patient use.
*She was not aware if work orders had been placed to repair the torn outer protective padding of play equipment used.
*The ball pit was cleaned by the therapist if they noticed kids had drooled on them. Otherwise the balls were cleaned weekly.
*The swinging crib was sent to the cleaners when dirty. She confirmed there were numerous white dried stains in the fabric.

2. Random observation on 9/14/11 and on 9/15/11 on the main hospital campus revealed:
*In the medication room:
-Patient 5 and 7's glycopyrrolate vials had a needle attached to a syringe lying on top of the vials. The syringe for patient 5 was dated 8/16 (August 16 no year indicated), and the syringe for patient 7 was dated 8/6/11.

Interview at the time of the above observation with care coordinator H confirmed both syringes and needles were reused for patients 5 and 7. She was not sure if the timeframe of reuse was for a week or 30 days. She was not sure if there was a facility policy for reusing syringes and needles. A review of the manufacturer's package instructions revealed the syringe was non-reusable. Care coordinator H revealed the syringes were reused, because they were not giving intramuscular injections. They were used to administer medications through the patients' gastrotomy tubes. The care coordinator did not realize the potential for cross-contamination of the medication cart with the reuse of the syringe and needles after providing patient medication administration via the gastrotomy tubes.

-A plastic wash basin in the sink was filled with water. Interview at the time of the observation with care coordinator H revealed that basin contained a bleach solution for disinfecting dirty dishes. The solution was tested daily before use by the night staff and discarded after use. Care coordinator H revealed the bleach solution should have been 50 parts per million (ppm) when tested. Testing of the bleach solution by registered nurse (RN) L revealed the solution tested at 100 ppm. The care coordinator and the RN that tested the solution agreed the bleach solution was too strong. A review of the bleach log testing documentation revealed it had been tested at 50 ppm early that morning. The care coordinator did not know for sure if there was a facility policy for mixing and testing the bleach solution for disinfecting patient care equipment.

*In the therapy kitchen:
-The microwave had a moderate amount of dried food splatter, and the interior top surface of the microwave had a large area of rust (photo 40).
-The dishwasher rack protective coating had a moderate amount of rust, the heating element was rusty, and the plastic water jet had a small melted area (photo 41 and 42).
-A large area of linoleum under the sink had peeled away from the floor creating an uncleanable surface (photo 43).
-A long strip of cabinet edging was loose and dangling from the cabinet (photo 43).

Interview on 9/15/11 at 3:00 p.m. with vice-president of administration confirmed the above therapy kitchen environmental findings.

*In the laundry room:
-A large amount of dried debris was noted in the door of the washer, and the rubber seal was coated with a moderate amount of moist brown sludge (photo 44).
-The wall behind the dryer pipe had a medium sized unpainted area that exposed the plaster beneath (photo 45).
-Two ceiling tiles had a large amount of brown discoloration (photo 46).
-The oxygen storage room had a large area of black mold on the wall and behind the oxygen tanks. There was debris on the floor, a rug stored between the two oxygen tanks, and crumpled linen in one corner of the room (photos 48, 49, 50, and 51).

*In patient room 1216 the wash basins were stored on the bathroom floor (photo 47).

*In room 1205 the examination table padding had a medium sized torn edge exposing the foam beneath (photo 3).

*In the shower room:
-Two green chairs had uncleanable fabric upholstery (photo 4).
-One lap tray was stored on the shower room floor (photo 5).
-One chair padding had been repaired with a strip of black tape (photo 6).

*In the dirty utility room trash cans blocked access to the eye wash station (photo 7).

Interview on 9/15/11 at the time of the above observations with the director of environmental services confirmed:
*The ceiling tiles were discolored from pipe condensation in the ceiling.
*The wall behind the dryer pipe needed repair.
*The mold in the oxygen storage room needed to be taken care of.
*The green fabric upholstered chairs in the shower room were not cleanable and should not have been in the shower room.
*The patient's wash basins should not have been stored on the bathroom floors.
*There was a facility preventative maintenance plan, but she was unaware of the above observations.

Interview on 9/15/11 at 3:15 p.m. certified nursing assistant (CNA) G confirmed there was no cleaning schedule for the surfaces of the washer and dryer used for patient care laundry. The CNA stated once a month the cleaning packet was run in the washer to prevent a moldy odor.

B. Based on random observation, interview, and policy review, the provider failed to ensure medical supplies were not being used beyond their manufacturer's expiration dates:
*In one of one hospital off-site rehabilitation therapy center.
*In the main hospital campus for two of two supply storage areas (store room and examination).
Findings include:

1. Random observation on 9/14/11 at 4:00 p.m. of the crash cart at the provider's rehabilitation therapy center revealed the following expired medical supplies:
*One opened vial of 0.9 percent (%) sodium chloride without a date and staff member initials when the vial had been opened.
*Medtronic Refill Kits:
-Two expired on 6/29/11.
-One expired on 7/7/11.
-Two expired on 8/4/11.
-One expired on 9/2/11.
-One expired on 9/10/11.
*One bottle of hydrogen peroxide without a date and staff member initials when the bottle had been opened.

Interview on 9/14/11 at the time of the above observation with facility director D and registered nurse (RN) E confirmed the supplies were expired. Both stated the crash cart was checked on a daily basis. RN E stated she was responsible for checking the crash cart daily for expired medications, but she did not check for expired medical supplies.

2. Random observation on 9/15/11 from 11:45 a.m. to 5:00 p.m. on the main hospital campus revealed the following areas with expired medical supplies:
*Crash cart:
-Tracheal tubes one each expired March 2004, April 2004, and December 2005.
-Expired intubation stylets one each in November 2004 and March 2005.
*Examination room 1205:
-One box of cotton tipped applicators expired in August 2008.
-One Tegaderm dressing expired in March 2005.
-Two Medtronic Refill Kits expired on 4/29/11.
*Main clean supply storage had one J-tube that had expired October 2010.