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Based on observation, interviews, and record review the facility failed to ensure that approximately 183 expired patient care supplies were removed from stock and available for patient use.

Findings included:

During a tour of the Radiology Department accompanied by staff member #4 and #29 the morning of 6/25/13 revealed the following expired supplies available for patient use:

1. 5 KY lubrication tubes expired 4/03
2. 1 Compound Benzoin Swabstick expired 7/08
3. 1 Sodium Chloride 2.5 ml prefilled syringe expired 10/08
4. 1 20 gauge IV catheter expired 11/09
5. 1 Steri Strips ? in x ? in package expired 4/11
6. 1 Steri Strips ? in x 4 in package expired 6/11
7. 1 Sodium Chloride 2.5 ml prefilled syringe expired 10/11

It was confirmed by staff member #4 the morning of 6/25/13 that the expired supplies were found in a drawer of the x-ray room and available for patient use.

During a tour of the Rehabilitation Department accompanied by staff member #5 and #29 the morning of 6/25/13 revealed the following expired supplies available for patient use:

1. 100 Sorbsan 4x4 dressings expired 4/06
2. 2 VAC Granufoam Silver Medium Dressing expired 1/08
3. 1 VAC Canister with Gel 500ml expired 2/09
4. 1 VAC Canister with Gel 500ml expired 6/09
5. 5 VAC Standard Dressing Tube Assembly expired 8/09
6. 1 package Neurostimulator electrodes expired 8/09
7. 47 Povidone Iodine Swabsticks expired 12/10
8. 1 Gentamicin ointment expired 11/12
9. 1 package Neurostimulator electrodes expired 12/12
10. 1 Lidocaine/Prilocaine cream expired 2/13
11. 1 package Neurostimulator electrodes expired 4/13

It was confirmed in an interview with staff member #5 the morning of 6/25/13 that the expired supplies were on a shelf in a supply room and available for patient use.

Review of the Hydrocollator log book revealed there was no documentation of temperature checks.

Review of the Manufacturers Manual entitled " Instructions for Use and Operation of Hydrocollator " stated, " Instructions for Patient Care and Comfort: 6. Use care and judgment when applying Steam Packs to infants and elderly. Constantly check the temperature of the packs.

It was confirmed in an interview with staff member #5 the morning the 6/25/13 that the temperature on the hydrocollator was not documented. When the surveyor asked the staff member " How do you know if it ' s too hot for the patient? " the staff member stated, " The patient tells me. " Staff member #5 stated that the temperature was checked just prior to using the hydrocollator, the heat pads were wrapped with 6 terry cloth towel pads and one is removed or added according to the heat. Staff member #5 acknowledged that this was a patient safety issue.

During a tour of the respiratory department on the morning of 6/25/2013 accompanied by staff # 1, 11 CVP Critical Care Gem ampules, (expired 9/2012) were on the shelf available for patient use.

The findings were confirmed in an interview with staff #11 on the morning of 6/25/2013.

Review of facility policy manual revealed there was no policy for expired supplies. The facility was unable to provide a policy to the surveyor for expired supplies that was in place prior to the survey. It was confirmed in an interview with the staff member #1 the morning of 6/26/13 that the facility did not have a policy prior to the survey.

Review of facility policy manual revealed there was no policy for checking the temperature of the Hydrocollator. It was confirmed in an interview with the staff member #1 the afternoon of 6/26/13 this was a patient safety issue.

Based on observation, interviews, and record review the facility failed to remove 14 outdated drugs which were available for patient use in the Emergency Department (ED).

Findings included:

During a tour of the ED with staff member #29 at 9:15am on 6/25/13, the following expired medications were found in the Pyxis (a medication dispensing machine) and available for patient use:

1. 1 Sodium Chloride 2.5 ml prefilled syringe expired 2/12
2. 1 Sodium Chloride 2.5 ml prefilled syringe expired 12/12
3. 3 Sodium Chloride 2.5 ml prefilled syringe expired 3/13
4. Nitroglycerin 250 ml expired 4/13
5. 2 Sodium Chloride 0.9% 500 ml expired 4/13
6. 2 Dobutamine 250ml expired 5/13
7. 2 Sodium Thiosulfate 50 ml expired 5/13 (found in the Cyanide antidote package)
8. 2 Sodium Nitrite 10ml expired 5/13 (found in the Cyanide antidote package)

It was confirmed in an interview with staff member #29 the morning of 6/25/13 that the pharmacy department was responsible for removing expired medications from the Pyxis machine. Staff member #29 confirmed the expired medications were available for patient use.

Facility policy entitled "Inspections: Patient Care and Drug Storage Areas" stated, "IV. The Director of Pharmacy or qualified designee shall conduct at least monthly inspections of all patient care and drug storage area..." "What to inspect: Outdated or otherwise unusable drugs are identified, removed from stock and stored to prevent their distribution and administration."

Based on observation, review of documentation and an interview with staff # 1, the facility fail to provide a system for potential infections in handling linen; during a tour of the facility on the morning of 6/25/13, uncovered linen was observed in the linen and respiratory department exposed to the elements causing a potential for cross contamination, and was available for patient use.
Findings
During a tour of the linen and laundry department at the facility on the morning of 6/26/13 accompanied by staff # 1, 3 metal racks with 6 shelves contained uncovered linen.
During a tour of the respiratory therapy department on the morning of 6/26/13 a wheeled cart contained 3 shelves of uncovered linen and was available for patient use.
Review of documentation " Infection Control, Policy Number IC00.020, Revision date 5/12/2011, Mitchell County Hospital utilizes the CDC guidelines for environmental control in health care facilities, page 101, After washing, cleaned and dried textiles, fabrics and clothing are pressed, folded and packaged for transport, distribution and storage by methods that ensure their cleanliness until use. "
The findings were confirmed in an interview with staff # 1during a tour of the linen and respiratory department on the morning of 6/25/13.

Based on review of documentation and interviews with staff, the facility failed to ensure that care to patients is provided in accordance with the competence of the nursing staff that is required by the hospital, as 4 of 12 nursing department staff did not have current basic cardiopulmonary resuscitation (CPR) certification which is a requirement of their job descriptions.

Findings were:

Review of the hospital's Job Descriptions for Registered Nurse and Nursing Assistant revealed that the position requires current basic CPR certification.

Review of the personnel records of RN staff #8 and #11 revealed that the nurses' CPR certifications both expired 5/31/13. The record of Nurse Assistant staff #18 contained CPR certification that also expired as of 5/31/13. Nurse Assistant staff #19's personnel record did not have evidence of CPR certification.

An in-person interview was conducted with both the Chief Nursing Officer and Human Resources Manager the afternoon of 6/26/13 in a facility conference room. Both administrators acknowledged that current CPR certification is required for nursing department staff, and that staff members #8, #11, #18, and #19 did not have current certification.

Based on record review and interview the facility failed to evaluate the care of 1 (#16) of 2 blood transfusion records reviewed.

Findings included:

Review of the clinical record for patient #16 revealed the following:

Blood Transfusion Unit #1 the baseline vital signs were obtained on 5/29/13 at 6:45pm. The record revealed the next documented vital signs were at 8:30pm (45 minutes later).

Blood Transfusion Unit #2 the baseline vital signs were obtained at 9:50pm. The record revealed the next documented vital signs were at 10:55pm (1 hour and 5 minutes later).

It was confirmed in an interview with staff member #6 the morning of 6/26/13 that the nursing staff failed to assess the patient and obtain vital signs 15 minutes after the blood transfusion was initiated for both transfusions. Staff member #6 confirmed that the policy stated that the nurse was to obtain the baseline vital signs, stay with the patient for the first 15 minutes, then assess the patient after the 15 minute post-transfusion and obtain vital signs, then every hour or more frequently if needed.

Review of facility policy entitled "Blood Transfusion/Platelets/Plasma (Fresh or Fresh/Frozen)" stated, "Procedure: K. A licensed nurse will stay with the patient for the first 15 minutes of the transfusion to assess the patient ' s tolerance; L. Document baseline vital signs and vital signs 15 minutes post initiation of transfusion, and hourly thereafter, or more frequently as warranted by the patient's condition, on the blood transfusion record..."

Based on review of documentation and interviews with staff, the facility failed to ensure that clinical records were maintained according to medical staff bylaws, as 8 of 16 applicable patient records did not comply with the requirements for completing History and Physical (H&P) exams or Discharge Summaries.

Findings were:

Review of the RULES AND REGULATIONS OF THE ORGANIZED MEDICAL STAFF, last approved by the Governing Body 1/22/2013, revealed that in section B (1), "A complete, electronic medical record, on every patient admitted to the hospital is the sole responsibility of the attending physician." This section requires that the History and Physical examination be completed within 24 hours of admission. Section B (11) requires the physician to complete the medical record within 21 days of a patient's discharge, including the Discharge Summary.

Review of the medical records of 4 patients revealed that the H&P reports were not placed on the medical record within 24 hours of admission. Patient #2 was admitted to the hospital on 4/1/13; however the H&P was not placed on the chart until 4/16/13. Patient #5 was admitted to the facility on 11/15/12; however the H&P was not placed on the chart for approximately 2 months, 1/18/13. Patient #6's H&P was placed on the chart 5/29/13, over a month after admission on 4/26/13. Patient #10 was admitted on 3/28/13, and the H&P was placed in the chart on 4/1/13.

Review of the medical records of 6 patients revealed that the Discharge Summaries were not placed on the medical record within 21 days of the patient's discharge. Patient #3 was discharged on 4/15/13; however, the discharge summary was not completed until over a month later, on 5/29/13. Patient #5 was discharged on 11/23/12 and the summary was not completed until 1/18/13. Patient #7 was discharged on 3/4/13 and the discharge summary was completed 3 months later, on 6/3/13. The discharge summary for Patient #9 was completed on 6/3/13; the patient had been discharged on 4/21/13. Patient #10's discharge summary was completed 6/2/13, 2 months after discharge on 3/31/13. Finally, Patient #16 was discharged on 12/14/12, and the discharge summary was not completed until over 4 months later, 4/24/13.

An in-person interview was conducted with the Chief Nursing Officer (CNO) the afternoon of 6/26/13 in a facility conference room. The CNO acknowledged that 8 patient records did not comply with the requirements for completing H&P exams or Discharge Summaries as outlined in the Medical Staff Rules and Regulations portion of the bylaws.