HospitalInspections.org

Based on findings from observation, document review and interview, the hospital's outpatient clinic crash (emergency) cart was dusty, not readily available to staff and had not been inspected on a weekly basis as required by hospital policy. Additionally 2 of 2 staff members at the outpatient clinic did not know the policy for medical emergencies in the outpatient clinic.

Findings include:

--During tour of the hospital's outpatient clinic on 7/14/11 at 12:30 p.m., it was observed that the crash cart was dusty and surrounded by office equipment.

--Per review of a document entitled "Crash Cart Inspection Log," in 2011 the crash cart was only inspected for evaluating the functional status of resuscitation equipment twice in April, three times in May and twice in June (not on a weekly basis as required by hospital policy).

--During interview of the outpatient clinic Nurse Manager on 7/14/11 at 1:30 p.m., he/she verified that the crash cart should be checked weekly per hospital policy and that it had not been inspected on a weekly basis.

--Per review of hospital's policy and procedure (P & P) entitled "Code Blue - Clinic," last revised 1/14/09, it states "In the event a clinic patient suffers cardiac or respiratory arrest: 1. Call for assistance... Assist the patient to a flat surface... Start CPR. Use Ambu bag....Obtain and attach AED. ... Call 911 for transport...."

--Per interview of licensed practical nurse (LPN) #1 on 7/14/11 at 1:15 p.m., he/she was not aware that the outpatient clinic had a crash cart and did not know he/she should call 911 (or instruct someone to call 911) during a patient cardiac or respiratory arrest.

--Per interview of registered nurse (RN) #1 on 7/14/11 at 1:30 p.m., he/she did not know he/she should call 911 (or instruct someone to call 911) during a patient cardiac or respiratory arrest.

--During interview of the outpatient clinic Nurse Manager on 7/14/11 at 1:30 p.m., he/she stated that in the event of a cardiac or respiratory arrest 911 would be called.

Based on findings from observation and interview, the hospital does not monitor the temperature of laboratory refrigerator #2 (located in the outpatient clinic) on weekends. Also, the hospital does not have a written policy to address maintenance activities performed above the ceiling where asbestos could be present.

Findings include:

--Per observation on 7/12/11 at 2:10 p.m., there were no 7/2/11 (Saturday) and 7/3/11 (Sunday) entries on the refrigerator temperature log for laboratory refrigerator #2. Therefore, it could not be determined whether the refrigerator maintained the appropriate temperature on these dates.

--During interview of the Laboratory Director on 7/12/11 at 2:10 p.m., he/she verified that the laboratory refrigerator temperature is not monitored on weekends.

-- Per interview of the Director of Plant Operations on 7/12/11 at 11:00 a.m., he/she stated that the hospital does not have a policy that addresses potential worker exposure to asbestos when performing above the ceiling work where asbestos may be present.

Based on findings from document review and interview, in the matter of medical staff activities the hospital's governing body did not ensure compliance with state regulations and its own medical staff bylaws. Specifically, in 1 of 3 physician's credentials files reviewed, a Physician (Physician #1) was not recredentialed every two years as required by state regulation and the medical staff bylaws. Also, in 1 of 3 physician's credentials files reviewed, a Physican (Physician #2) was recredentialed without consideration of peer review as required by the hospital's medical staff bylaws. Additionally, 8 medical staff members have not attended 50 percent of the medical staff meetings held in a year, as required by the hospital's medical staff bylaws.

Findings include:

--Per review of the hospital's document entitled "Bylaws of the Medical Staff," adopted by the active medical staff on 5/11/05, it states "Section 7 Reappointment Process. a. Each Medical Staff member will be reappointed no less frequently than every two (2) years, .."

--Per review of Physician #1's credentials file, his/her appointment to the medical staff was for a period of two years, beginning 5/27/09 and ending on 5/27/11. The credentials file included a form stating, "An extension has been added to the current credentialing for (Physician #1). This is needed to change over the re-credentialing process for all providers to be on the same timeline. This will be in effect from May 27, 2011 to April 4, 2012." The form was signed by Physician #1 and the CEO/Administrator.

--Per interview of the Medical Staff Specialist on 7/13/11 at 12:20 p.m., he/she verified that Physician # 1's credentials had expired on 5/27/11 and the re-credentialing of Physician # 1 would be 11 months after the required two year re-credentialing timeframe.

--Per review of the hospital's document entitled "Bylaws of the Medical Staff," adopted by the active medical staff on 5/11/05, it states "Section 7 Reappointment Process... Each recommendation concerning the reappointment of a Medical Staff member and clinical privileges to be granted upon reappointment shall be based upon such member's: ....Input of at least 3 peers..."

--Per review of Physician #2's credentials file, he/she was recredentialed on 1/10/11. However, information in the file reveals that the only peer reviews completed were done on 4/5/11, 3 months after Physician #2 was recredentialed.

--During interview of the DON and the Director of Quality Management on 7/13/11 at 3:30 p.m., the above finding was verified.

--Per review of the hospital's document entitled "Bylaws of the Medical Staff," adopted by the active medical staff on 5/11/05, it states "The Medical Staff of River Hospital Functions as a Committee of the Whole...Members of the active medical staff are required to attend at least 50% of Medical Staff meetings."

--However, per review of the document entitled "2011 Medical Staff Attendance" provided on 7/13/11 by the Medical Staff Specialist, Physicians #3, #4, #5, #6, #7, and Physician Assistants (PAs) #1, #2, and #3 have not attended any of the 5 medical staff meetings conducted in 2011. Physican #2 has only attended one of the 2011 medical staff meetings.

Additionally per review of a document entitled "2010" provided by the Medical Staff Specialist, in 2010 Physicians #5 and #6 did not attend any medical staff meetings. Physicians #7, #2 and PA #1 attended only one of 8 medical staff meetings in 2010.

--During interview of the Medical Staff Specialist on 7/14/11 at 11:00 a.m., the above findings were verified.

Based on findings from observation, document review, and interview, numerous outdated medications and supplies were available for patient care use in the emergency department (ED), inpatient nursing units, and the outpatient clinic.

Findings include:

--Per review of the hospital policy and procedure (P & P) entitled "Inspections: Patient Care and Drug Storage Areas," issued by the Pharmacy Department and effective 9/13/96, it states "The Supervising Pharmacist or qualified designee shall conduct at least monthly inspections of all inpatient care and drug storage areas ...Inspections shall include the main pharmacy, all nursing care units, drug storage units, emergency boxes and emergency carts, and all other areas of the facility where drugs are dispensed, administered or stored (including drugs in areas that do not obtain their stock from the pharmacy)."

--Per review of the hospital P & P entitled "Expiration Dates," issued by the Pharmacy Department and effective 9/13/96, it states "...Expiration dates of drugs and devices shall be checked during the monthly medication area inspections and all drugs and devices scheduled to expire during the next month shall be removed from stock. "

--During a tour of the ED on 7/12/11, the following medications and supplies were found to be expired:

*Medication storage room

14 - 30 ml bottles of Bacteriostatic water (expired on 7/1/11)
3 - bottles of Cetacaine spray (expired on 4/11 and 6/11)
4 - 20 ml bottles of 2% Lidocaine Hydrochloride injection (expired on 4/11 and 6/11)

*Intravenous (IV) solution floor stock area

1 - 500 cc bag of Dextrose (expired 7/1/11)

*ED Emergency Box:

3 - 10 ml IV pre-filled syringes containing 0.9% Sodium Chloride (expired on 4/11 and 5/11)

--During interview of the ED Charge Nurse on 7/12/11 at 9:30 a.m., the above findings were verified.

--During a tour of the inpatient nursing unit on 7/12/11 at 12:00 p.m., the following medications and supplies were found to be expired:

*Medication Room

1 - 10 ml bottle of Humulin 70/30 insulin (expired 5/11)

*Medication cart

1 - 1 ml bottle of injectable haloperidol (expired 6/11)

--During interview of LPN #2 on 7/12/11 at 12:10 p.m., the above findings were verified.

--During interview of the Pharmacist on 7/12/11 at 11:30 a.m., he/she verified that it is the pharmacy's responsibility to ensure during the monthly inspections that expired drugs are removed from care areas and returned to the pharmacy.

--During a tour of the hospital's outpatient clinic on 7/14/11 at 12:30 p.m., the following drugs and supplies were expired:

*Procedure room #1

1 -20 ml bottle of Lidocaine Hydrochloride 2% / epinephrine 1:100.000 injectable
(expired 7/1/11)

*Exam Room #2

1 - bottle of rubbing alcohol (expired 7/07)
2 - 3 X 9 inch vaseline petroleum gauze (expired 8/06)

*Exam room #3

16 - single use packets of bacitracin zinc ointment (expired 12/10)
1 - 3 X 9 inch vaseline petroleum gauze (expired 5/11)
1 - package of povidone iodine swabsticks (expired 2/09)

*Exam room #4

5 - single use packets of bacitracin zinc ointment (expired 12/10)
6 - 3 X 9 inch vaseline petroleum gauze (expired 5/11)

*Exam Room #5:

2 - bottles of Iodoform packing strips (expired 1/11 and 3/11)
2 - specimen collection kits for chlamydia/gonorrhea (expired 5/09)

*Lab #1:

1 - specimen collection kit for chlamydia/gonorrhea (expired 5/09)
2 - urine transport containers (expired 12/09)
4 - bottles of Cytology Fixative (expired 8/24/08)
3 - Red topped blood tubes (expired 5/11)

*Hallway Cabinets

1- multi dose vial of Lidocaine HCL 1% dated as opened on 2/10/11 (expires after 30 days of opening)
1 - container of sanicloths (expired 6/2011)

--Per interview of the Outpatient Clinic Nurse Manager on 7/14/11 at 1:15 p.m., the pharmacy technician inspects the medication storage room on a monthly basis. The nurses are responsible for checking for outdated supplies in the examination and procedure rooms. Additionally, multidose vials are dated when they are opened and are supposed to be discarded within 30 days. He/she acknowledged the above findings.

Based on findings from document review and interview, 2 of 2 nursing staff interviewed did not know the hospital's policy and procedure (P & P) for intravenous (IV) site preparation. Additionally, the hospital P & P for IV therapy did not describe the specific procedures for preparing a site for venipuncture. Also, the hospital's infection control program does not monitor and evaluate hospital staff's practices in using aseptic techniques.

Findings include:

--Per review of hospital P & P entitled "Intravenous Therapy," last reviewed 5/10, it states "...strict aseptic techniques shall be employed during implementation of all aspects of IV therapy."

--Per interview of the Infection Control Nurse (ICN) on 7/14/11 at 9:00 a.m., the procedures for venipuncture site preparation are the directions on the Chloraprep box (product that is used by the hospital).

--Per review of the directions on the Chloraprep One Step box, they state "...Use repeated back-and-forth strokes of the applicator for approximately 30 seconds. Completely wet the treatment area with antiseptic. Allow the area to air dry for approximately 30 seconds."

--Per interview of RN #2 on 7/14/11 at 12:00 p.m., he/she was unsure of the hospital's P & P for IV site preparation, however, he/she cleanses sites for 30 - 60 seconds prior to venipuncture.

--Per interview of RN #3 on 7/12/11 at 9:35 a.m., IV site preparation is a 2-3 minute scrub in a circular motion and up and down motion, although he/she did not know if this was the hospital's P & P.

--Per interview of the hospital's ICN, on 7/14/11 at 9:00 a.m., he/she does not formally observe staff for aseptic practices, such as glove use, hand hygiene, or IV site preparation, etc. Environmental rounds are preformed routinely, however, they do not include observation of staff infection control practices.

Based on findings from document review and interview, many of the hospital's policy and procedure (P & P) manuals have not been reviewed and/or revised in a number of years, as required by this regulation. Additionally, many P & Ps lack effective dates, reviewed/revised dates and signatures.

Findings include:

--Per review of the Physical Therapy (PT) P & P manual, a form entitled "Physical Therapy Policy and Procedure Manual" stated "This Policy and Procedure manual was revised and updated on ...1/4/07..."

--Per review of PT P & Ps addressing Paraffin Bath, Hot Pack Protocol, Ice Packs and Spinal Traction, all lacked effective dates and revised/ reviewed dates. They also were not signed to evidence approval by the V.P. for Clinical Services, the person whose name appears on the form.

--Per review of Anesthesia Services P & Ps, (e.g., "Narcotic Administration and Documentation, Anesthesia Responsibilities and Management of patient with Malignant Hyperthermia), all lacked effective dates and reviewed/revised dates.

Additionally, the Anesthesia Services P & P manual contained P & Ps that were outdated. For example a policy entitled "Subacute Bacterial Endocarditis (SBE) Prophylaxis," not dated, indicates it was adapted from "Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association by the Committee of Rheumatic Fever, Endocarditis and ....JAMA 1990" (which has since been updated in 1997 and 2007).

Also, per review of the Anesthesia P & P manual and the Ambulatory Surgical Unit (ASU) P & P manual, both had policies addressing Malignant Hyperthermia. However, the treatment differed in the 2 policies, (i.e., Anesthesia P & P states "Treat dysrhythmias with Procainamide (Pronestyl). The recommended loading dose is 15 mg per kg IV." The ASU P & P states "Dysrhythmias usually respond to treatment of acidosis and hyperkalemia. If they persist...standard anti-arrhythmic agents, including lidocaine may be used.").

--Per review of the Pharmacy Services P & P manual, many policies were old and had not been reviewed/revised for many years. For example, a P & P entitled "Inspections: Patient Care and Drug Storage Areas," effective 9/13/96, had not been reviewed. Also a P & P entitled "Expiration Dates," effective 9/13/96, had not been reviewed. Additionally, the headings on both of these policies were inaccurate, " Edward John Noble Hospital - Samaritan Alexandria Bay, New York."

--During interview with the DON on 7/14/11 at 2:30 p.m., these findings were acknowledged.

Based on findings from document review and interview, in 6 of 9 medical records (MRs) reviewed, hospital staff did not, upon triage in the Emergency Department (ED), document information related to whether the patients had any advance directives (e.g., do not resuscitate / DNR, do not intubate / DNI) or a health care proxy (HCP).

Findings include:

--Per review of the hospital's policy entitled "Guidelines for the ED Nursing Record," last revised 10/2/10, it states "...Document any DNR, DNI or HCP paperwork or orders ..." Also, the hospital form entitled "Emergency Nursing Record" contains a section for documenting the patient's DNR / DNI / HCP information.

--During interview of the Director of Nursing on 7/12/11 at 4:15 p.m., he/she verified that a patient's DNR/DNI/HCP information (or lack of) should be obtained and documented at time of triage.

--Per review of the Emergency Nursing Records for Patients A, B, C, D, E, and F, the section for DNR, DNI, HCP is blank, indicating information was not obtained.

--During interview of the Director of Nursing on 7/14/11 at 2:00 p.m., the above findings were acknowledged.

Based on findings from document review and interview, nursing documentation did not meet generally accepted standards of nursing practice in that nursing staff did not document the site of administration of subcutaneous injections.

Findings include:

--Per review of Patient B's medical record (MR), the Medication Administration Record (MAR) indicates that heparin 5,000 units subcutaneous (SQ) every 12 hours was ordered on 5/4/11. Under the order is written "chart site." However, on 5/4/11 at 9:30 a.m., and on 5/5/11 at 10:00 a.m. and 10:00 p.m., the nurse initialed the injection as being given but did not document the injection site.

--During interview of DON on 7/13 /11 at 2:00 p.m., the above findings were verified.

Based on findings from document review and interview, the Health Information Management Department lacked a current list of authenticated physicians' signatures. Specifically 8 physican names lacked signatures.

Findings include:

--Per review of the form entitled "Signature Log Physicians," not dated, 8 physician printed names lacked signatures (Physicians #1, #5, #6, #7, #8, #9, #10, #11).

--During interview of the Director of Nursing on 7/13/11 at 10:10 a.m., he/she verified that the authenticated physician signature log lacked the above listed physicians' signatures.