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Based on policy and procedure review and clinical record review it was determined that 15 (#1-15) of 20 (#1-20) patients did not receive their notification of patient rights upon admission. Failure to provide the notification of patient rights had the potential outcome of not allowing patients to understand their rights as a patient, the grievance process and where to lodge a complaint. The failed practice affected patients (Pt) #1-15. Findings follow:

A. Review of policy and procedure titled "Patient Rights and Responsibilities" received 06/26/19 at 3:00 PM showed every patient and/or caregiver will be provided a handout called "How to Become Actively Involved in Your Health Care." After review with the patient and/or caregiver a copy will be placed on the patient's medical record.
B. Review of clinical records for 15 (#1-15) of 20 (#1-20) patients showed no evidence that patients received their patient rights information.
C. The above findings in A and B were verified with the EMR (Electronic Medical Record) System Administrator on 06/26/19 at 3:00 PM.

Based on review of policies, review of current and discharged in-patient clinical records and interview, it was determined the facility failed to ensure patients' responses to PRN (as needed) medications were documented in two (#4 and #5) of three (#3, #4 and #5) in-patient records reviewed. By not documenting a patient's response to PRN medications, physicians and other health care providers were not fully informed of the patient's condition in order to help them make decisions on the provision of care to the patients. The failed practice had the likelihood to affect all patients who received PRN medications. Findings follow:

A. Review of the policy titled, "Assessment and Management of the Patient Requiring Pain Management," revised 07/15/2011, showed that staff were to reassess pain after pain management intervention once sufficient time had elapsed for peak effect.
B. Review of current and discharged in-patient clinical records showed the following:
1) Patient #4: Open clinical record reviewed from 06/21/19 through 06/26/19 showed four of four doses of PRN medication administrations lacked evidence of the patient's response; and
2) Patient #5: Closed clinical record reviewed from 06/15/19 through 06/21/19 showed three of five doses of PRN medication administrations lacked evidence of the patient's response.
C. During an interview on 06/26/19 at 3:44 PM, the Quality/Risk/Compliance Officer verified the findings at A and B.

Based on observation, review of Temperature Check Lists, policy review, and interview, it was determined the facility failed to maintain one (Medical/Surgical) of four ( Intensive Care, Labor and Delivery, Surgical Services and Medical/Surgical) medication refrigerators observed in that there were days the temperature was not checked and recorded; and there were days the temperature was out of acceptable range (36-46 degrees Fahrenheit, per policy) and there was no documentation to the action taken when it was discovered to be out of range. By not maintaining the medication refrigerator temperatures, the facility could not assure medications were stored at the proper temperature (36 to 46 degrees Fahrenheit). The failed practice had the likelihood to affect all patients admitted for procedures. Findings follow:

A. Review of the facility's policy titled, "Refrigerated Medication Storage," revised 02/02/17, showed all refrigerated medication storage areas were to be inspected daily, the temperatures should be between 36 to 46 degrees Fahrenheit; the temperature was to be written on the log outside the refrigerator and if the temperature was outside the range, actions taken to correct it, should be documented on the log.
B. During a tour of the facility on 06/24/19 from 1:22 PM to 3:06 PM, observation showed the refrigerator that Medical/Surgical used, had a Temperature Check List on it with the following observations for the previous 60 days:
1) 21 out of 60 days showed no temperature recorded; and
2) 19 out of 60 days showed the temperature to be below or above the acceptable range of 36-46 degrees Fahrenheit, with no documentation of what action was taken to correct it.
C. During an interview on 06/24/19 at 1:36 PM, the Medical/Surgical Director verified the refrigerator was not being monitored for temperature compliance.

Based on observation, review of manufacturer recommendations and interview, it was determined the facility failed to follow manufacturer recommendations in that medication was observed to be stored and available for use beyond manufacturer's recommendation in one (Anesthesia #1) of two (Anesthesia #1 and 2) carts. By not following the manufacturer's recommendation, the facility could not assure the safety or efficacy of the medication. The failed practice had the likelihood to affect all patients that have had procedures using the medication. Findings follow:

A. Review of manufacturer's recommendation for storage of Succinylcholine Chloride showed the "multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency." The facility did not have a process to assure the Succinylcholine Chloride was not in use beyond the 14 days, once removed from refrigerated storage.
B. During a tour of the facility on 06/24/19 from 1:22 PM to 3:06 PM, observation showed Anesthesia cart #1 had a vial of Succinylcholine stored and not dated to indicate when it had been taken out of refrigerated storage.
C. During an interview on 06/24/19 at 2:50 PM, Certified Registered Nurse Anesthetist #1 verified the Succinylcholine observed on Anesthesia Cart #1 was not dated and should have been dated to reflect the 14 day manufacturer's recommendation.

Based on policy and procedure review and refrigerator and freezer log review for 06/01/19 through 06/26/19 it was determined the Dietary Manager failed to ensure that employees followed policy in that refrigerator and freezer temperatures (walk in freezer, grill freezer, tray-aide refrigerator, and the out take refrigerator) were documented out of the acceptable range without corrective action. Failure to ensure refrigerator and freezer temperatures were within acceptable ranges did not ensure the food and beverages were kept at safe temperatures to prevent contaminants. Findings follow:

A. Review of policy and procedure titled "Food Production Service Storage and Distribution Standards" received on 06/25/19 at 9:00 AM showed acceptable frozen storage temperature range of -10 degrees to 0 degrees Fahrenheit, and acceptable refrigerator storage temperature range 34 degrees to 41 degrees Fahrenheit.
B. Review of refrigerator and freezer temperature logs for 06/01/19 thru 06/26/19 revealed the following:
1) Walk in Freezer - temperatures were out of range for 24 of 26 days in the AM and 19 of 25 days in the PM with no corrective action documented.
2) Grill Freezer - temperatures were out of range for 16 of 25 days in the AM and 4 of 25 days in the PM with no corrective action documented.
3) Tray -Aide Refrigerator - temperatures were out of range 7 of 25 days in the AM, and 4 of 24 days in the PM with no corrective action documented.
4) Out Take Refrigerator - temperatures were out of range 14 of 25 days in the AM, and 15 of 24 days in the PM with no corrective action documented.
B. The above findings in A and B were verified with the Quality Coordinator on 06/26/19 at 9:15 AM.



Based on interview with the Registered Dietitian (RD) and the Certified Dietary Manager (CDM) it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that food and nutrition services was not under the daily, including weekends, onsite supervision of a qualified dietary manager. The failed practice did not ensure the rules and regulations for nutritional services were followed to ensure patient assessments, counseling's, diet instructions, food preparation and storage were performed according to the facility policies. Findings follow:

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 17.A.1 required Food and Nutrition Services be under daily supervision of a qualified individual, at least a Certified Dietary Manager.
B. During interview with the Registered Dietitian on 06/27/19 at 8:30 AM she stated she worked in the facility on Mondays and Thursdays only.
C. During interview with the Certified Dietary Manager she stated that she worked Monday, Tuesday and Wednesday on one week then Thursday and Friday on the second week.
D. The above findings in A and B were verified with the Quality Coordinator on 06/27/19 at 9:45 AM.


Based on policy and procedure review and clinical record review it was determined that one (Patient #2) of five (Patient #1-5) patients did not received a nutritional assessment by a Registered Dietitian (RD) or a Certified Dietary Manager (CDM) after being identified as at risk. The failed practice did not ensure that patients identified as at risk had their nutritional needs met. Findings follow:

A. Review of policy and procedure titled "Nutritional Assessment of Patients" received 06/25/19 at 3:00 PM showed that upon receiving the referral, RD/CDM/DM would screen the patient within 24-48 hours and complete the Nutritional Assessment if the patient was found to be at nutritional risk.
B. Review of Patient #2's clinical record showed the Nutritional Screen identified Patient #2's diet to be Poor, which classified Patient #2 as "at risk." The clinical record contained no evidence of a nutritional assessment.
C. The above findings in A and B were verified with the EMR System Administrator on 06/25/19 at 3:00 PM.

Based on observation, review of manufacturer's recommendations, and interview, it was determined the facility failed to ensure safety and quality of three of five point of care blood glucose testing devices by not documenting open dates of the glucose control solution bottles. The failed practice did not ensure that the control solutions were effective in measuring the quality of the glucose test strips prior to patient use. Findings follow:

A. Review of the manufacturer's recommendation for the Accu-Check Inform II showed "Write the date the bottle was opened on the bottle label. The solution is stable for three months from that date ..." The date was to be written on the label in the area provided when opened.
B. During tour of the Labor and Delivery Unit and Nursery Unit on 06/24/19 at 1:50 PM four of four Accu-Check Inform II Glucose Control Solutions were found without the date of opening or discard date written on the bottles.
C. During interview with the Quality Control Nurse on 06/24/19 at 1:55 PM, the findings in A and B were verified.
D. During tour of the Emergency Department on 06/26/19 at 9:00 AM two of two Accu-Check Inform II Glucose Control Solutions were found without the date of opening or discard date written on the bottles.
E. During an interview with the Director of Emergency Services on 06/26/19 at 9:05 AM, the findings in D were verified.


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Based on observation and interview in two of two (1862 and 1858) respiratory sleep rooms, it was determined the facility failed to follow standards of practice in the organization of building maintenance in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that respiratory patient rooms consisted of bed-side swivel arm lamps with exposed bulbs which were accessible to patients. The failed practice had the potential to affect all patients admitted to the sleep area. Findings follow:

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 72.A.26 required light fixtures to consist of protected covers in patient care spaces.
1) Observations of the 1st floor patient rooms 1862 and 1858 on 06/25/19 at 9:15 AM displayed a wall-mounted swivel lamp with an exposed incandescent light bulb approximately 1' away from the patient bed and 4' from the floor, which could allow someone to touch the bulb causing injury.
2) During an interview with the Respiratory Director on 06/25/19 at 9:22 AM, he stated that the lamps were installed when the building was originally built.
B. The above findings in 1 and 2 were verified with the Director of Maintenance on 06/25/19 at 9:25 AM.

Based on observation and interview it was determined the facility failed to properly identify oxygen tanks in a safe manner required to meet patient needs during day-to-day operations or during an emergency event. The failed practice had the potential to affect all patients needing oxygen. Findings follow:

A. Observation of oxygen tank storage in the medical gas room showed the tanks were not labeled as empty or full per NFPA 99, 11.6.5.3 which would not allow proper identification during an emergency event.
B. The above finding was verified with the Director of Maintenance on 06/25/19 at 8:42 AM

Based on observation it was determined in four of four rooms (2226, 1642, 1326, and OR2), the facility failed to install Alcohol-based hand-rub (ABHR) in a location to ensure the safety of patients and staff to prevent electrical shock or fire. The failed practice had the potential to affect all patients admitted into patient care rooms and surgery. Findings follow:

A. Observation of patient rooms 2226, 1642, 1326 and OR2 on 06/24/19 at 2:49 PM, showed ABHR was located within 1" horizontal distance of an ignition source per NFPA 1, 60.5.2.6(a).
B. The above finding was verified with the Director of Maintenance on 06/24/19 at 2:55 PM

Based on observation, review of APIC (Association for Professionals in Infection Control and Epidemiology) position paper, and interview, it was determined the facility failed to mitigate risks of healthcare related infections by not identifying the practice of storing MDV (Multiple Dose Vials) once opened, in immediate patient treatment areas in two of two (Anesthesia #1 and #2) carts. By not identifying the risk this practice carries, the facility could not assure their patients safety. This failed practice had the likelihood to affect all patients receiving procedures in the facility. Findings follow:

A. During a tour of Surgical Services on 06/24/19 from 2:27 PM to 3:06 PM, observation showed the following on the anesthesia medication carts:
1) Anesthesia Cart #1:
a. #1 Labetolol 100 mg (milligram)/ 20 ml (milliliter) MDV, opened, dated 07/10/19, stored on the cart, available for another patient's use. Dating the vial indicated it was to be kept and used again on another patient; and
b. #1 Rocuronium Bromide 100mg/ml MDV, dated 06/15/19, stored on the cart, available for another patient's use. Dating the vial indicated it was to be kept and used again on another patient.
2) Anesthesia Cart in OR #2:
a. #1 Neostigmine 10mg/ 10ml MDV, dated 07/17/19, stored on the cart, available for another patient's use. Dating the vial indicated it was to be kept and used again on another patient; and
b. #1 Labetolol 100 mg/ 20 ml MDV, opened, dated 07/10/19, stored on the cart, available for another patient's use. Dating the vial indicated it was to be kept and used again on another patient.
B. Review of APIC position paper, titled "Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016)," showed MDV should never enter the immediate patient care area, and if they do, they must be dedicated for single patient use and discarded immediately after use. Examples given by APIC of immediate patient care areas include operating rooms and anesthesia carts.
C. During an interview on 06/24/190 at 2:50 PM, CRNA #1 (Certified Registered Nurse Anesthetist) verified the findings at A.


40282

Based on review of policies and procedures, review of the manufacturer's recommendations, review of the Metricide OPA Plus Solution Testing Log Sheet, and interview, it was determined the Infection Control Officer failed to control infections by not assuring the policy and procedure and the manufacturer's recommendations for use of Metricide OPA [ortho-Phthalaldehyde] Plus Solution was performed for Quality Control testing of a new bottle of test strips for four of four (1/02/19 to 04/30/19) months reviewed. The failed practice did not assure instruments cleaned by High level Disinfection (HLD) were thoroughly cleaned and disinfected prior to patient use. The failed practice had the potential to affect all patients who came in contact with instruments cleaned by HLD. Findings follow:

A. Review of policy and procedure received 07/03/19 at 10:30 AM titled, "Use of OPA [ortho-Phthalaldehyde] Solution for Disinfection of Instruments," stated testing of positive and negative controls shall be performed on each newly opened test strip bottles of Metricide OPA Plus Solution Test Strips.
B .Review of the Metricide OPA Plus Test Strip manufacturer's recommendations received 06/26/19 at 10:30 AM showed that three test strips should be submerged in a positive and negative control solution. The three strips dipped in the full strength positive control should exhibit a complete magenta color on the indicating pad at 60 seconds. The three strips dipped in the diluted negative control should either remain completely yellow or exhibit an incomplete color change, mixture of yellow and magenta, when read at 60 seconds. It is recommended that the testing of positive and negative controls be performed on each newly opened test strips.
C. Review of the Metricide OPA Plus Solution testing log sheet from 01/02/19 to 04/30/19 showed no documentation of the Quality Control procedure being performed when a new bottle of test strips was opened.
D. During interview with the Manager of the Operating Room 06/26/19 at 10:30 AM she stated there was no log available for the testing of newly opened bottles of Metricide OPA Plus solution available. E. The above findings in A, B, C and D were verified with the Manager of Operating Room 06/26/19 at 1:30 PM.


Based on observation, policy and procedure review, and interview it was determined the facility failed to ensure a sanitary environment in that Licensed Practical Nurse (LPN) #1 failed to follow policy and procedure and safely dispose of a sharp medical lancet and contaminated waste in a puncture proof biohazard container. The failed practice did not provide safety and proper disposal of a sharp instrument and hazardous waste materials in a puncture proof biohazard container. The failed practice had the potential of affecting patients and facility personal by failing to properly dispose of hazardous waste materials in the proper puncture proof biohazard container. Findings follow:

A. Review of the policy and procedure titled "Glucometer Testing Use of Machine" received 06/26/19 at 2:00 PM showed the following "Take the strip out of the meter. Put the lancet and test strip in a puncture proof biohazard container."
B. During observation on 06/26/19 at 11:05 AM of Glucometer testing of Patient #3, LPN #1 after the completion of the test, placed the used test strip and the lancet inside the palm of her glove, removed the glove and placed the glove in the Patient's bedside trashcan.
C. During interview on 06/26/19 at 11:10 AM with LPN #1 she stated she was told that the lancet no longer had to be placed in a biohazard container due to the safety retraction of the needle.
D. Findings in B were verified by LPN #1 at 11:10 AM on 06/26/19.
E. Findings in A were verified by the Quality Coordinator on 06/26/19 at 2:00 PM.


Based on policy and procedure review and observation, it was determined the facility failed to ensure one of one patient care rooms were cleaned following the facility's policy. Failure to ensure rooms were cleaned per policy did not ensure a clean and sanitary environment for patient care. The failed practice had the potential to affect any patient who would be receiving care in the facility. Findings follow:

A. Review of the policy and procedure titled "Patient Room Cleaning- Discharges & Transfers" on 6/25/19 showed "When you remove germs from one surface, we don't want the germs on that cloth to spread to other surfaces, in other words, we want to PREVENT CROSS CONTAMINATION."
B. Observation on 06/25/19 at 12:35 PM showed Environmental Tech #1 cleaning room #2352
(a discharged patient room) using a damp cloth cleaning all surface areas without preventing the "cross contamination" process. Examples:
1) Using a damp cloth, cleaned bottom of the bed and the wheels with the cloth touching the floor. Then, cleaned the middle portion of the bed then the mattress (top and sides) without changing the cloth or gloves.
2) Using a damp cloth, cleaned the inside of the sink then wiped the counter top and front of the shelves above the sink without changing the cloth or gloves.
C. The above findings were verified by the Infection Control Nurse on 06/25/19 at 12:50 PM.

Based on policy and procedure review and clinical record review it was determined the facility failed to perform an activities assessment or provide activities for one (Patient # 20) of five (#16-20) Swing-Bed patients. Failure to perform an activities assessment and provide activities did not allow the swing bed patient and/or family to be knowledgeable of available activities and choose which activities they would like to participate in. The failed practice had the potential to affect any Swing Bed patient. Findings follow:

A. Review of policy and procedure titled "Swing Bed Activities" received 06/24/19 at 2:00 PM showed the Activities Director shall complete a comprehensive assessment to reflect each Swing Bed patient's need or desires.

B. Review of clinical records showed one (Patient #20) of five (Patients #16-20) did not have a comprehensive activity assessment completed and no documentation of activities.

C. The above findings in A and B were verified with the EMR (Electronic Medical Record) System Administrator on 06/26/19 at 1:40 PM.

Based on policy and procedure review and interview, it was determined the facility failed to provide Dental services to its Swing Bed patients. Failure to provide dental services to its Swing Bed patients did not allow patients to receive dental care for routine or emergency needs. The failed practice had the potential to affect all patients admitted to the Swing Bed Unit. Findings follow:

A. Review of the Swing Bed policy and procedure manual showed the facility had no policy for providing a Dentist on staff or by contractual agreement.
B. During an interview with the Swing Bed Coordinator on 06/24/19 at 2:30 PM she stated that the previous Dentist retired and the facility did not have a Dentist on staff or a Dentist contracted to provide dental services for routine or emergency care.
C. The above findings in A and B were verified with the Quality Coordinator on 06/25/19 at 9:00 AM.


Based on policy and procedure review and interview, it was determined the facility did not have a policy for identifying circumstances when the loss or damage of dentures is the facility responsibility and may not charge residents for the loss or damage of dentures. The failed practice did not ensure patients would have their dentures replaced or repaired when the loss or damage was the fault of the facility. Findings follow;

A. Review of the Swing bed policy and procedure manual showed no policy for identifying the circumstances when the loss or damage of dentures is the facility's responsibility and may not charge the patient.
B. During an interview with the Quality Director on 06/25/19 at 9:10 AM, she stated the facility does not have a policy regarding loss or damage of patient's dentures.
C. The above findings in A and B were verified with the Quality Director on 06/25/19 at 9:10 AM.

Based on document review and interview, it was determined the facility failed to follow the Emergency Preparedness plan in that the plan was not reviewed on an annual basis. The failed practice had the potential to affect all patients and staff. Findings follow:

A. Observation of emergency preparedness plan showed that the plan was not reviewed on an annual basis.
B. During interview with the Director of Facilities on 06/25/19 at 9:41 AM he/she stated that the plans were reviewed but had no documented evidence of the review.
C. The above findings in A and B were verified with the Director of Maintenance on 06/25/19 at 9:45 AM.