HospitalInspections.org

Based on interview, medical record review, and interview, the facility failed to ensure Patient
#39's plan of care to manage potential fluid imbalances was followed. The sample size was 51 patients both current and discharged.

Findings include:

The medical record review for Patient #39 was completed on 02/03/11. The patient was admitted to the facility on 01/14/11 and had a history and physical (H & P) dated 01/15/11. The H & P revealed that the patient had congestive heart failure and chronic renal failure. The H & P stated that the patient had congestive heart failure partly due to volume overload and chronic renal failure.
During review of the medical record, it was noted that there was a physician's order that was written 01/14/11 at 5:20 P.M. that stated that the patient was to have his/her fluid restricted to 2 liters a day. A subsequent physician's order dated 01/18/11 at 1:00 P.M. stated that the patient was to have "strict" monitoring of how much fluid he/she took and eliminated and a third order dated 01/23/11 that stated the patient was to have 75 milliliters of intravenous fluid every hour.
The medical record review revealed a graphic/fluid balance record ( Intake and Output or I and O sheet) that indicated the patient did not have any intravenous fluids from 01/29/11 from
6:00 A.M. to 2:00 P.M. on 01/30/11. The graphic/fluid balance record indicated that on 01/30/11 from 2:00 P.M. to 10:00 P.M. the patient received 2106 milliliters of fluid.
The review of the nursing care plan for congestive heart failure for 01/31/11, stated the patient was not to have a water pitcher at his/her bedside.
On the afternoon of 01/31/11, the surveyor observed the patient to have a water pitcher at the bedside.
On the afternoon of 01/31/11, the surveyor and Staff P examined the water pitcher together and found it to be half-full of water. Staff P confirmed the patient was not to have had the water pitcher at his/her bedside.
On the morning of 02/01/11, Staff P stated in an interview that they were not sure why there was 2106 milliliters of fluid recorded for 01/30/11 from 2:00 P.M. to 10:00 P.M., except they thought it may have been because the fluids had not been recorded from the prior day.

Based on staff interview and review of the medical staff bylaws, the facility failed to ensure all medical records were completed within 30 days of discharge from the facility. This affected 457 medical records. The facility census was 147 at the time of the survey.

Findings include:

Staff S was interviewed on 02/01/11 at 10:46 AM. Staff B stated that 456 medical records were delinquent or incomplete after 30 days post discharge.
Although during interview of Staff S, Staff S stated that the physicians were suspended if their medical records were incomplete and delinquent, this consequence was not noted to be in either the Medical Staff By-Laws or in the Responsibilities of the Medical Staff.

Based on observations and interviews, the facility failed to ensure that drugs were correctly distributed in the automated medication dispensing machines. This affected two patient care areas, 5 East (a medical surgical unit), and the outpatient surgery center. This incorrect placement of medications would add to the potential of staff making medication errors and would affect all patients in the 2 areas where drugs were placed incorrectly. The facility
in-patient census was 147.


Findings include:


A review of the information from the Safety Officer in regard to medication errors was reviewed on the morning of 02/03/11. The information revealed that the facility was tracking both out-patient and in-patient adverse reactions to medications as one unit. The information revealed that there was a large number of what appeared to be "near misses" of medication errors. During interview of the Safety Officer and the Quality Assurance person on Tuesday, 02/01/11, there were no "near misses" or very few. The information further broke down the data of the types of errors. The types of errors included "administration" errors but did not state if it was wrong patient, wrong dose, wrong medication, wrong route, wrong time or what the actual administrator error was and how the data was being used to help insure fewer medication errors were made.



21521


On 01/31/11 at 4:00 PM, two surveyors observed the contents of the automated medication dispensing machine on 5 East, a medical surgical unit. The two surveyors observed four occurrences where the pockets of the automated medication dispensing machine had more than one medication in them. The surveyors observed pocket #12 to have three different types of intravenous medications: three bags of a five percent dextrose solution with 0.45 normal saline and 30 milliequivalents of potassium, a bag of five percent dextrose solution with 20 milliequivalents of potassium, and three bags of a five percent dextrose with 0.225 saline and 20 milliequivalents of potassium. The surveyors observed six vials of solumedrol (an intravenous steroid) in pocket 12 and 12 vials in pocket 16. The surveyors also observed in pocket 12
an anti-hypertensive.

On 01/31/11 at 4:00 PM in an interview with Staff A, the pharmacy technician confirmed the placement of the above medications. The pharmacy technician stated that the solumedrol found in pockets 12 and 16 was supposed to be in pocket 14 and the anti-hypertensive found in pocket 12 should have been in pocket 15. The pharmacy technician stated that the automated medication dispensing machine was missing dividers to separate the different medications.

On 02/02/11 at 1:22 PM, two surveyors observed the contents of the automated medication dispensing machine located at the facility's outpatient surgery center. The surveyors observed a box of local anesthetic (lidocaine with epinephrine) with a bag of lactated ringer's in drawer eleven, and a box of respiratory aerosol found together in pocket four.

On 02/02/11 at 1:22 PM, Staff B stated the medications should not have been mixed together in one pocket in the automated medication dispensing machine.






21893

On 01/31/11 at 11:00 AM, Staff R was interviewed and stated there were not many medication errors or near misses, but could not give an exact number. Staff R stated that near misses and medication errors were tracked, monitored, and reported to the Quality committee.

Based on observation, staff interview, and policy review, the facility failed to ensure that all dishes, utensils, and other equipment were properly disinfected and sanitized prior to use. This had the potential to affect all patients who received a meal tray from dietary services. The facility had a census of 176 patients and prepared 421 patient trays on 02/02/11.

Findings include:

A tour of the dietary department and kitchen was conducted on 02/02/11 at 3:00 PM. Staff A stated the dish machine was not working properly since 02/01/11, the sanitation by hot rinse was not reaching the desired temperature. Staff A stated the patient trays and plate covers were being washed and then sanitized in a sink using bleach or quatinary disinfectant. Staff A was questioned regarding testing for desired disinfectant level in the water. Staff A was not aware of where the test tapes were or the policy for this procedure. Staff A stated the staff had not been logging the testing of the sanitation rinse since the dish machine broke down.

On 02/03/11 at 11:00 AM, Staff A was interviewed regarding the sanitation of dishes while the dish machine was down. Staff A stated that on 02/02/11 at approximately 6:30 AM, the staff started sanitizing dishes in the sinks using Oasis 146 Multi Quat Sanitizer. Staff A stated that around 3:00 PM on 02/02/11, after the surveyor toured the kitchen area, he/she spoke to Staff C and obtained the test strips for testing the disinfectant levels. Staff A stated the sinks were tested at that time and the value was in the desired range. Staff A provided a log sheet that documented the disinfectant levels at 3:00 PM and 5:30 PM on 02/02/11 and at 7:00 AM on 02/03/11. Staff A stated that two sinks in the prep area of the kitchen and one sink in the dish room were used and each of the three sinks were filled twice per meal with fresh water and disinfectant. Staff A verified that the staff had not documented the disinfectant level for every sink of sanitizer, just once per meal. Staff A verified the disinfectant levels were not documented or tested prior to the surveyor's tour of the kitchen areas on 02/02/11. Staff A stated the following items were disinfected and used for patient meals on 02/02/11 and breakfast on 02/03/11: trays, plates, plate covers, silverware, bowls, and coffee cups. Staff A stated the dish machine was repaired and working as of the morning of 02/03/11 and all items were now disinfected through the dish machine.

The policy for Pot and Pan Washing was reviewed on 02/03/11. The policy stated that proper washing and sanitizing of utensils and equipment used in Nutritional Services was essential. The policy also stated that sanitizing in a sink required disinfectant at 50-200 parts per million for one minute and must be tested to verify the concentration.

The Condition of Physical Environment is NOT MET.

Based on the observations made during the survey by Life Safety Code, staff interviews and review of documentation presented by the facility, the facility failed to ensure that all of the areas of the hospital and the off-site locations were constructed and maintained to ensure the safety of the patients. The hospital had a census of 147 patients.

Findings include:


During review of facility documentation, observations made during the survey and staff interview and verification, the facility failed to ensure that the hospital met the applicable provisions of the Life Safety Code of the National Fire Protection Association with regard to certificate of occupancy approvals.

On 01/31/11 information regarding the buildings of the facility was provided by Staff T. The information indicated that new buildings of the main hospital campus included the south building opened in 1985, a carpenter shop in the 1990's and an emergency department and intensive care area opened in 2006. Older buildings of the campus were dated from 1920 until 1970. Staff T and Staff I was asked to provide information on the newer buildings, especially the newest emergency department. Staff T and I were asked to provide certificates of occupancy for the buildings.
On 02/02/11 and 02/03/11 Staff T and I were again asked to provide the certificate of occupancy especially for the newest emergency building. Staff T indicated that a certificate of occupancy was not issued by the local building inspector but a verbal approval was given to occupy the building. On 02/04/11 Staff T stated calls were made to the local inspector and the office in an attempt to secure written approval to occupy the newest building on the campus.
On 02/08/11 at the exit conference Staff K verified the facility did not have the certificate of occupancy for the newest emergency building. Staff K indicated there had been many administrative changes in the facility and it was not clear if the certificate of occupancy had not been received or if it had been misplaced.

Please see the Life Safety Code Survey for a full explanation of the findings under: K12, K21, K25, K27, K29, K38, K44, K50, K62, K103, K130, K154, K155. In addition, please see the LSC survey for a full explanation of the findings for Building 4 of 6, offsite Ambulatory Surgery Center, under K130.

Based on the results of the survey from Life Safety Code which included observations, interviews and review of documentation presented by the facility, the facility failed to meet the provisions of Life Safety Code of the National Fire Protections Association. The facility had a current census of 147 patients.

Findings include:

Please see the Life Safety Code Survey for a full explanation of the findings under: K12, K21, K25, K27, K29, K38, K44, K50, K62, K103, K130, K154, K155. In addition, please see the LSC survey for a full explanation of the findings for Building 4 of 6, offsite Ambulatory Surgery Center, under K130.