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Based on observation, interview, and review of the facility's policy and procedure, the facility failed to ensure emergency supplies with a current expiration date were available for immediate use in the Medical Surgical unit. This failure could result in a delay of staff response during an emergency, placing all in-patients and observation patients in this unit at risk of negative outcomes.

Findings include:

On 10/14/19 at 12:15 PM, examination of the contents of the emergency crash cart in the Medical Surgical unit revealed the entire contents of each drawer were wrapped in clear plastic wrap with the date of the first expired item labeled on the plastic wrap. In the fourth/bottom drawer of the cart the expiration date written on the plastic wrap read "9/30/19 Multi-Lumen CVC (central venous catheter, an intravenous catheter used to administer medications to a patient using a major vein near the heart) Kit." Examination of the CVC kit in the drawer confirmed the kit had an expiration date of 9/20/19.

During an interview with the Medical Surgical Unit Manager (UM) on 10/14/19 at 12:15 PM, the UM viewed and verified the CVC kit in the crash cart had expired. The UM stated the contents of the cart were supposed to be checked monthly by the Materials department but the Clinical Supervisor was also responsible to check the cart. The UM stated facility expectation was for all expired materials to be removed from patient care areas and replaced with useable supplies.

During an interview with the Clinical Supervisor on 10/14/19 at 12:20 PM, the Clinical Supervisor verified the CVC kit in the crash cart had expired. The Clinical Supervisor confirmed the CVC kit should had been removed and replaced with a useable kit.

Review of the facility's policy titled. "Materials," last revised 1/1/19, revealed, "For items in original manufacturers' packaging ...and having reached its expiration date, shall be removed from inventory and disposed of via appropriate measures. Department staff will monitor expiration dates in all supply areas monthly and remove all expired supplies."

Based on document review and staff interview, the facility failed to ensure mid-level providers were involved in the development and review of facility policies and procedures. This failure could lead to a missed opportunity to gain insight into issues of patient treatment and care by all facility providers, with possible negative outcomes for all patients treated at this facility.

Findings include:

Review of the facility's meeting minutes of the Medical Executive Committee (MEC) dated November 15, 2018 revealed the "Annual review and approval of Patient Care Policies," was the most recent policy review.

Review of the facility's Medical Staff Bylaws, approved by the Governing Body 11/15/2018, revealed the MEC consisted of "Three members of the Active staff elected at-large by the Medical Staff Members ...One elected representative from each of the following specialties: Anesthesiology, Emergency Medicine, Family Practice, Pathology, Hospitalist and Radiology ..."

During a joint interview with the Medical Surgical Nurse Manager and Director of Quality and Risk Management (QA) on 10/15/19 at 8:00 AM, both the Medical Surgical Nurse Manager and QA agreed the facility employed mid-level providers, such as Nurse Practitioners (NP) and Physician Assistants (PA). The Medical Surgical Nurse Manager and QA confirmed the development and review of facility policies and procedures was conducted by the MEC and NPs or PAs were not represented on the MEC. The facility was unable to provide documentation showing involvement of the NPs and/or PAs in policy development and/or review. The Medical Surgical Nurse Manager and QA agreed the facility did not have a policy addressing the need to involve mid-level practitioners in policy development and/or review.

Based on record review, staff interview, and review of the facility's policy and procedure, the facility failed to ensure patient care plans were based on issues relevant to the patient's condition, for 4 of 15 medical records requiring care plans, Patient (P) 2, P4, P5, and P6. Failure to develop care plans based on appropriate nursing care needs could lead to ineffective care of all patients admitted for in-patient and observation care in this facility, with possible negative outcomes.

Findings include:

1. Review of P2's the medical record revealed an admission date of 10/09/19. Review of the History and Physical dated 10/09/19 revealed, "Impression: 1. Acute hypoxemic (lack of oxygen in the blood) respiratory failure." Review of the care plan initiated 10/09/19 revealed the entries: "Acute Confusion," "Risk for Impaired Skin Integrity," and "Stress Urinary Incontinence."

During an interview with the Director of Quality (QA) on 10/15/19 at 10:10 AM, the QA agreed P2's care plan did not refer to the patient's respiratory status and confirmed respiratory interventions should had been included in P2's plan of care. The QA confirmed the admitting nurse was responsible for initiating the care plan, and all subsequent nurses caring for the patient were responsible for reviewing and updating the care plan as needed.

2. Review of P4's medical record revealed an admission date of 10/10/19. Review of the History and Physical dated 10/10/19 revealed, "Impression: 1. Right hand wound/cellulitis (inflammation), 2. Right lower extremity cellulitis in the shin area." Review of the Care Plan initiated 10/10/19 revealed the single entry, "Acute Pain."

During an interview with the QA on 10/15/19 at 10:20 AM, the QA agreed the Care Plan in the medical record of P4 failed to address the patient's skin condition. The QA agreed skin care interventions should had been included in P4's plan of care.

3. Review of P5's the medical record revealed an admission date of 10/12/19. Review of the patient's admitting diagnosis revealed, "Chronic Obstructive Pulmonary (lung) disease/Right Leg Swelling." Review of the Care Plan initiated on 10/12/19 revealed the sole entry, " Impaired Gas Exchange."

During an interview with the QA on 10/15/19 at 10:30 AM, the QA agreed the Care Plan should have included interventions for skin care based on the patient's condition at admission.

4. Review of the "Admissions Summary Sheet" revealed P6 was admitted to the facility on 10/12/19 with a diagnosis of pancreatitis and the sex was marked as male.

Review of the Electronic Health Record (EHR) care plan from 10/12/19 through 10/14/19 under Action - Pain Management; and under Intervention - Alleviation/attenuation of physical and/or behavioral symptoms occurring during the luteal phase of the menstrual cycle.

Review of the "MedSurg [medical surgical] Admission Assessment" dated 10/12/19 at 03:53 AM indicated: reproductive male within normal limits (WNL) - no discharge, no pain.

During an interview on 10/15/19 at 8:10 AM the Nurse Manager Med-Surg verified P6 was a male.

Interview on 10/15/19 at 1:15 PM, Registered Nurses (RN)7 and RN8 said the electronic care plan was initiated by clicking on pre populated areas in the EHR. RN7 and RN8 said the pain management identifier in P6's EHR was clicked in error. RN7 and RN8 said the error should have been identified and corrected by the nurse caring for the patient within 24 hours and the care plan revised.

Review of the facility's policy titled, "Plan of Care," last revised 01/01/19, revealed, "After initial admission assessment by all disciplines, problems identified are listed on the care plan ...Goals are developed based on the problem with behaviorally stated objectives."