HospitalInspections.org

THIS IS A REPEAT DEFICIENCY FROM 04/26/2018:
Based on review of hospital policies and procedures and observation on tour, it was determined that the administrator failed to ensure that medications used for patient care were not expired. This deficient practice poses a potential
risk to the health and safety of patients when the hospital cannot ensure the safety, and efficacy of expired medications.

Findings include:

Policy titled 'Code Cart Security', #4871523, Rev. 07/2019, revealed: "...All outdated or expiring items are replaced when appropriate...All facility code carts will be checked on a regular, routine basis...The Pharmacy Department is responsible
for checking all medication integrity and expiration dates. The Pharmacy Department will replace all outdated medications...The checks will be performed at least monthly...."

Policy titled 'Emergency Medications', #4657192, Rev. 03/2016, revealed: "...The pharmacy shall establish a monitoring and inspection system to ensure the integrity and ready availability of emergency medication supplies...Pharmacy Inspections -- The pharmacy or the pharmacy's designee shall inspect emergency medication containers routinely (preferably monthly)...to
remove deteriorated and outdated medications...Departments, units, and users shall notify the pharmacy when...Other irregularities
are identified or suspected...The pharmacy shall replace missing, expired, and unusable medications as soon as possible...."

Policy titled 'Expiration and Beyond-Use Dates', #4657187, Rev. 03/2016, revealed: "...Stock shall be rotated so that items with longer expiration dating are placed at the rear or on the bottom. Stock with the shorter expiration dating shall be used first...Expiration dates of medications and devices shall be checked during the routine medication area inspections and all medications and devices scheduled to expire during the next month shall be removed from stock...."Observation of the PACU code cart on 06/03/2021 revealed six (6) each 10mg/mL Sodium Chloride injectable's, expired 11/2019.

Based on review of policies and procedures and staff interviews, it was determined that the provider failed to require that the Medical Record Review Function is performed by the Medical Records Department. This failure to review medical records poses a potential risk that the quality of documentation in the medical record is not being met.

Findings include:

Review of the policy titled 'Medical Record Review Function', #9050339, Approved 04/2021, revealed: "...the Medical Records Department will perform a Medical Record Review Function designed to assure the appropriateness of clinical information, timely entry, timely completion and legibility of medical records. The focus of medical record review is on the quality of documentation
in the medical record...A random sample of medical records (at least 20% of monthly hospital discharges) will be reviewed for the Medical Record Review Function on a quarterly basis...The Medical Record Review Function is performed by the Medical Records
Department...Conclusions, recommendations, actions and evaluation of action effectiveness of the Medical Record Review Function will be documented in the Medical Records Department...."

Employee #10 relayed during interview on 06/03/21, that s/he was unable to provide documentation that the Medical Record Review
Function is being conducted. Employee #10 relayed that the person responsible for medical record review is Employee #12.

Employee #12 relayed during interview on 06/03/21, that s/he was unable to provide documentation that the Medical Record Review
Function is being conducted. Employee #12 relayed that the person responsible for medical record review is Employee #6.

Employee #6 relayed during interview on 6/03/21 at 14:20 that s/he was unable to provide documentation that the Medical Record Review Function is being conducted. Employee #6 relayed that the person responsible for medical record review is Employee #10.

Based on review of hospital policies and procedures and observation on tour, it was determined that the administrator failed to require
that medical supplies used for patient care were not expired. This deficient practice poses a potential risk for the health and safety of the patients, including risk for infection and/or negative outcomes when the hospital cannot ensure that expired supplies are being discarded, and are not being used for patient care.

Policy titled 'Infection Control in Environmental Services', #8830430, Approved 02/21, revealed: "...2. Nonpatient Areas...B. Soap dispensers shall be maintained per established procedure...."

Policy titled 'Infection Control in Cat Scan', #7045386, Approved 01/2020, revealed: "...each department in the hospital contributes to the
infection control effort...to the protection of patients, employees and community...Radiology/CT scan personnel and personnel from outside services will follow infection control procedures...."

Policy titled 'Infection Control in Radiology/X-Ray', #7045394, Approved 01/2020, revealed: "...each department in the hospital contributes to the infection control effort...to the protection of patients, employees and community...Radiology
personnel and personnel from outside services will follow infection control procedures...."

Observation on tour of the CT/Radiology/Lab areas on 06/01/21, revealed seventy-three (73) expired supplies from the following departments:

CT SCANNER ROOM: A total of seventy (70) expired supplies were found in the CT room. Expired items included: Sixty-six (66) disposable syringe fill tubes, expired 09/2013; One (1) SPO2 Peds Sensor, expired 03/07/2016; One (1) SPO2 Neonatal/Adult Sensor, expired 05/16/2016; Two (2) Pulse Oxy Finger Sensors, expired 06/2018.

RADIOLOGY AREA AND LAB: Three (3) Alcohol Based Hand Sanitizers, mounted in their dispensers, and during the COVID-19 pandemic, which expired 10/2019.

Employee #3 confirmed during tour of the above areas on 06/01/21, that the above supplies were expired.

Based on review of facility's policy and procedure, medical record review and staff interview, it was determined that the administrator
failed to ensure swing bed resident comprehensive care plans were in the medical record. This deficient practice poses a risk to the
health and safety of the patients when there is no are plan to follow while providing care to residents.

Findings include:

Policy titled "Swing Bed Resident Care Plan" PolicyStatID 9054700, revealed: "A comprehensive care plan will be developed on all
new Swing Bed residents within 48-72 hrs of admission."

Review of three (3) out of three (3) medical records revealed that patient #15, patient #16, and patient #17 have no documented evidence that a comprehensive care plan was developed.

Employee #18 confirmed during an interview conducted on 06/03/2021 (1313), that patient #15, patient #16 and patient #17 have no
documented evidence that a comprehensive care plan was developed. Employee #18 in the same interview added when a patient is admitted to a swing bed a comprehensive care plan will be developed within 48-72 hours of admission.

Based on observation, staff interview and record review the facility did have emergency preparedness policies and procedures, but failed to have water per the emergency plan at the facility. Failure to have an emergency supply if water at the facility during an emergency could cause harm to staff and patients.

Based on observation, staff interview and record review on June 2, 2021, revealed the facility did have emergency policies and procedures in place for subsistence needs for staff and and patients but failed to have a supply of emergency water at
the facility.

During the exit conference on June 3, 2021 the above findings was again acknowledged by the management staff.