HospitalInspections.org

Based on observations, interviews, record reviews and hospital policies, the Governing Body:

1. Failed to implement a Quality Improvement Plan to include quality indicators and collection of data. Refer to A-273

2. Failed to have a quality improvement program in place. Refer to A-283

3. Failed to ensure there was Quality Assurance Plan implemented. Refer to A-308

4. Failed to assure physician credentialing files contain medical staff re-appointment documentation. Refer to A-341

5. Failed to assure the nursing staff followed the orders for vital signs. Refer to A-392

6. Failed to assure the nursing staff developed a careplan for each patient. Refer to A-396

7. Failed to assure the nursing staff administered medications as ordered by the physician. Refer to A-405

8. Failed to assure the nursing staff documented on the Medication Administration Record (MAR) what was given to the patient. Refer to A-405

9. Failed to assure the nursing staff administered medication ordered for patient complaints. Refer to A-405

10. Failed to assure the physicians completed orders, Progress notes and History and Physical (H&P). Refer to A-438

11. Failed to assure an Emergency Department (ED) medical record was maintained for review. Refer to A 449

12. Failed to assure all Emergency Department (ED) medical records documented the patient's condition on discharge from the ED, documented triage times, documented patient's condition on transfer from the ED to another hospital for further care and documented the reason why a patient was transferred from Hill Hospital of Sumter County ED to another hospital for further care. Refer to A-449

13. Failed to ensure the medications were immediately available for administration to patients. The hospital has no pharmacy director responsible for developing, implementing and periodically reviewing and revising policies and procedures governing provision of pharmaceutical services. The hospital does not have a system in place to remove drugs that have been recalled for safety reasons and has no pharmacy person responsible for the procurement, distribution and control of all medication products used in the hospital for inpatient and outpatient care. Refer to A-491.

14. Failed to have a single pharmacist responsible for the overall administration of the pharmacy service and for developing, supervising, and coordinating all the activities of the hospital wide pharmacy service. There was no professional, competent, legally qualified pharmacist to manage the pharmacy or actively involved in committees responsible for establishing medication-related policies and procedures. Refer to A-492

15. Failed to have sufficient numbers and types of pharmacy personnel to provide accurate and timely medication delivery, ensure accurate and safe medication administration and to provide appropriate clinical services as well as the participation in continuous quality improvement programs that meet the needs of the patient population being served. Refer to A-493

16. Failed to have a process in place for medication orders to be received in the pharmacy and dispensed in a safe and timely manner after a review of all medication orders for appropriateness by a hospital pharmacist before the first does is dispensed to the patient. Refer to A-500

17. Failed to assure all medications available for patient use were not expired. Refer to A-505

18. Failed to assure:
a. All food items not stored in the original container was clearly labeled to assure items were identifiable and not out of date.
b. Ice machine was functioning.
c. Frozen food items were kept frozen per manufacturer's directions.
d. Pots and pans were stored clean.
e. Overhead lighting had protective covering and was functioning properly.
f. Dented cans were not placed on shelf for staff use.
g. Grease container was covered to prevent contamination and infestation.
h. Hospital dumpster lids were closed and there was no excessive overflow of garbage.

Refer to A-619

19. Failed to assure:
a. Supplies available for patient use were not expired.
b. Equipment was monitored to maintain safety of patients and staff.
d. Safe integrity of emergency crash carts.
e. Lighting in patient rooms was functioning.
f. Papertowel dispensers were covered to protect papertowels from contamination.
g. Wall plugs were covered properly and in a safe manner.
h. Chairs in patient rooms were in good repair.
i. Exit doors were sealed properly.

Refer to A-724

20. Failed to assure:
a. The staff followed the policy for hand hygiene in the only infection control observation available during the survey. Refer to A-748
b. There was a system developed to evaluate measures governing the identification, investigation, reporting, prevention and control of infections and communicable diseases within the hospital. Refer to A-749

Based on observations, interviews, record reviews and hospital policies, the Governing Body:

1. Failed to implement a Quality Improvement Plan to include quality indicators and collection of data.

2. Failed to have a quality improvement program in place.

3. Failed to ensure there was Quality Assurance Plan implemented.

4. Failed to assure physician credentialing files contain medical staff re-appointment documentation.

5. Failed to assure the nursing staff followed the orders for vital signs.

6. Failed to assure the nursing staff developed a careplan for each patient.

7. Failed to assure the nursing staff administered medications as ordered by the physician.

8. Failed to assure the nursing staff documented on the Medication Administration Record (MAR) what was given to the patient.

9. Failed to assure the nursing staff administered medication ordered for patient complaints.

10. Failed to assure the physicians completed orders, Progress notes and History and Physical (H&P).

11. Failed to assure an Emergency Department (ED) medical record was maintained for review.

12. Failed to assure all Emergency Department (ED) medical records documented the patient's condition on discharge from the ED, documented triage times, documented patient's condition on transfer from the ED to another hospital for further care and documented the reason why a patient was transferred from Hill Hospital of Sumter County ED to another hospital for further care.

13. Failed to ensure the medications were immediately available for administration to patients. The hospital has no pharmacy director responsible for developing, implementing and periodically reviewing and revising policies and procedures governing provision of pharmaceutical services. The hospital does not have a system in place to remove drugs that have been recalled for safety reasons and has no pharmacy person responsible for the procurement, distribution and control of all medication products used in the hospital for inpatient and outpatient care. Refer to A-491.

14. Failed to have a single pharmacist responsible for the overall administration of the pharmacy service and for developing, supervising, and coordinating all the activities of the hospital wide pharmacy service. There was no professional, competent, legally qualified pharmacist to manage the pharmacy or actively involved in committees responsible for establishing medication-related policies and procedures. Refer to A-492

15. Failed to have sufficient numbers and types of pharmacy personnel to provide accurate and timely medication delivery, ensure accurate and safe medication administration and to provide appropriate clinical services as well as the participation in continuous quality improvement programs that meet the needs of the patient population being served. Refer to A-493

16. Failed to have a process in place for medication orders to be received in the pharmacy and dispensed in a safe and timely manner after a review of all medication orders for appropriateness by a hospital pharmacist before the first does is dispensed to the patient. Refer to A-500

17. Failed to assure all medications available for patient use were not expired. Refer to A-505

18. Failed to assure:
a. All food items not stored in the original container was clearly labeled to assure items were identifiable and not out of date.
b. Ice machine was functioning.
c. Frozen food items were kept frozen per manufacturer's directions.
d. Pots and pans were stored clean.
e. Overhead lighting had protective covering and was functioning properly.
f. Dented cans were not placed on shelf for staff use.
g. Grease container was covered to prevent contamination and infestation.
h. Hospital dumpster lids were closed and there was no excessive overflow of garbage.

19. Failed to assure:
a. Supplies available for patient use were not expired.
b. Equipment was monitored to maintain safety of patients and staff.
d. Safe integrity of emergency crash carts.
e. Lighting in patient rooms was functioning.
f. Papertowel dispensers were covered to protect papertowels from contamination.
g. Wall plugs were covered properly and in a safe manner.
h. Chairs in patient rooms were in good repair.
i. Exit doors were sealed properly.

20. Failed to assure:
a. The staff followed the policy for hand hygiene in the only infection control observation available during the survey.
b. There was a system developed to evaluate measures governing the identification, investigation, reporting, prevention and control of infections and communicable diseases within the hospital.

Based on review of the Quality Improvement Plan and interview, it was determined:

a) The facility failed to implement a Quality Improvement Plan to include quality indicators and collection of data.

b) The facility failed to have a quality improvement program in place.

c) The governing body failed to ensure there was Quality Assurance Plan implemented

This had the potential to negatively affect all patients served by this facility.

Findings include:

Refer to A 273, A 283 and A 308 for findings.

Based on review of the Quality Improvement Plan and interview, it was determined the facility failed to implement a Quality Improvement Plan to include quality indicators and collection of data. This had the potential to negatively affect all patients served by this facility.

Findings include:

Quality Improvement Plan: Hill Hospital of Sumter County

The following Quality Improvement Plan serves as the foundation of the committee of Hill Hospital to continuously improve the quality of the treatment and services it provides.

Continuous Quality Improvement Activities. Quality Improvement activities emerge from a systematic and organized framework for improvement. This framework, adopted by the hospital leadership, is understood, accepted and utilized throughout the organization, as a result of continuous education and involvement of staff at all levels in performance improvement. Quality Improvement involves two primary activities:

Measuring and assessing the performance of hospital services through the collection and analysis of data.

Conducting quality improvement initiatives and taking action where indicated, including the design of new services, and or improvement of existing services.

An interview was conducted with Employee Identifier (EI) # 7, Registered Nurse/ Utilization Review on 3/2/17 at 1:50 PM. EI # 7 stated the Quality Improvement Activities were divided among three (3) staff members. The surveyor requested to see the Quality Improvement documentation and the response was there was none. The surveyor asked when was the last Quality Improvement Meeting and EI # 7 stated, "Not since the last QA (Quality Assurance) Nurse left". The surveyor asked when the last QA nurse left and the response was Oct, 17, 2015.

Based on the review of the Quality Improvement Plan and interview, it was determined that the facility failed to have a quality improvement program in place. This had the potential to affect all patients served by the facility.

Findings include:

Quality Improvement Plan: Hill Hospital of Sumter County

The following Quality Improvement Plan serves as the foundation of the committee of Hill Hospital to continuously improve the quality of the treatment and services it provides.

Continuous Quality Improvement Activities. Quality Improvement activities emerge from a systematic and organized framework for improvement. This framework, adopted by the hospital leadership, is understood, accepted and utilized throughout the organization, as a result of continuous education and involvement of staff at all levels in performance improvement. Quality Improvement involves two primary activities:

Measuring and assessing the performance of hospital services through the collection and analysis of data.

Conducting quality improvement initiatives and taking action where indicated, including the design of new services, and or improvement of existing services.

An interview was conducted with Employee Identifier (EI) # 7, Registered Nurse/ Utilization Review on 3/2/17 at 1:50 PM. EI # 7 stated the Quality Improvement Activities were divided among three (3) staff members. The surveyor requested to see the Quality Improvement documentation and the response was there was none. The surveyor asked when was the last Quality Improvement Meeting and EI # 7 stated, "Not since the last QA (Quality Assurance) Nurse left". The surveyor asked when the last QA nurse left and the response was October 17, 2015.

Based on the review of the Quality Assurance Plan and interview, it was determined the governing body of the facility failed to ensure there was Quality Assurance Plan implemented. This had the potential to negatively affect all patients served by this facility.

Findings include:

Quality assurance Plan:

Purpose: Hill Hospital of York is pledged to provide optimum medical care to the community consistent with available resources. To achieve this, a Quality Assurance Program is implemented to assure that evaluation of quality of care and clinical performance is performed.

Authority: The Governing Body has overall responsibility for the Quality Assurance Program and delegate authority through the Chief Executive Officer to the Medical Staff, which delegates authority to the Quality Assurance Committee. Authority and delegation of authority for Quality Assurance are established in accordance with Medical Staff by-laws.

An interview was conducted with Employee Identifier (EI) # 7, Registered Nurse/ Utilization Review on 3/2/17 at 1:50 PM. EI # 7 stated the Quality Improvement Activities were divided among three (3) staff members. The surveyor requested to see the Quality Improvement documentation and the response was there was none. The surveyor asked when was the last Quality Improvement Meeting and EI # 7 stated, "Not since the last QA (Quality Assurance) Nurse left". The surveyor asked when the last QA nurse left and the response was October 17, 2015.

Based on review of physician credentialing files, Medical Staff Policies and Procedures and By-Laws and interview, it was determined 2 of 3 physician credentialing files failed to contain medical staff re-appointment documentation. This affected Employee Indentifer (EI) # 1, # 2, and had the potential to negatively affect all patients served by the facility.

Findings include:

Medical Staff Policies and Procedure Manual and By-Laws
Reviewed/Revised/Updated: 01/01/2017
Signed by the Administrator and the Board of Directors

Section 2. Medical Staff

...Initial appointments to the Medical Staff shall be made...Healthcare Authority upon receipt of a request in writing, using the official prescribed application blank approved for this purpose. All subsequent appointments shall be made by the...Healthcare Authority, who will consider all applications properly filed from eligible applicants and who have been recommended by the Medical Staff for appointment or reappointment. Appointments to the Medical Staff shall be for a period of one (1) year or until the end of the calendar year when all re-appointments shall be made.

1. Review of EI # 1's credentialing file on 3/2/17 revealed a Privileges Authorization Form signed by the Chief Executive Officer (CEO) on 2/28/13 included the following, "These privileges are in effect beginning on the date below of the signature of either the CEO or Chief of the Medical Staff, and continue until 02 (month), 28 (day), 2015 (year). These privileges may not be extended except by the Medical Staff. This was a two (2) year period and not a one year term as directed in the Medical Staff Policies and Procedure Manual and By-Laws.

Review of the next Privileges Authorization Form for EI # 1 revealed it was signed by the Credentialing Coordinator on 2/28/17. This Privileges Authorization Form included, "These privileges are in effect beginning on the later of the two dates below of the signature of either the CEO and/or Chief of the Medical Staff, and continue until 02/28/17. There was no documentation of a signature or date of the CEO and/or Chief of the Medical Staff.

2. Review of EI # 2's credentialing file on 3/2/17 revealed a Privileges Authorization Form signed by the CEO on 2/28/13 included the following, "These privileges are in effect beginning on the date below of the signature of either the CEO or Chief of the Medical Staff, and continue until 02 (month), 28 (day), 2015 (year). These privileges may not be extended except by the Medical Staff. This was a two (2) year period and not a one year term as directed in the Medical Staff Policies and Procedure Manual and By-Laws. There was no documentation of a current Privileges Authorization Form.

An interview was conducted on 3/2/17 at 2:00 PM with EI # 4, Administrator who verified the above findings.

Based on the review of medical records, facility's Policy and Procedure and interviews, it was determined the facility failed to ensure:

a) The nursing staff followed the orders for vital signs.

b) The staff developed a careplan for the patients.

a) The nursing staff administered medications as ordered by the physician.

b) The nursing staff documented on the Medication Administration Record (MAR) what medications were given to the patient.

c) The nursing staff administered medication ordered for patient complaints.

This had the potential to affect all patients served.

Findings include:

Refer to A 392, A 396 and A 405 for findings.

Based on the review of medical records and interviews, it was determined the facility failed to ensure the nursing staff followed the orders for vital signs (VS) in 2 of 2 complete active medical records reviewed, which affected Patient Identifier (PI) # 25, # 26. This had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 25 was admitted to the facility on 2/14/17 with diagnoses including Alcohol Abuse, Cocaine Abuse, and Rheumatoid Arthritis.

Review of the physician's orders dated 2/14/17 9:05 PM revealed orders for VS every 4 hours x 24 hours (9:10 PM on 2/14/17 to 9:10 PM 2/15/17); then every 4 hours while awake.

Review of the Nursing Note dated 2/14/17 at 9:10 PM revealed the patient arrived on the nursing floor.

Review of the VS worksheet and the VS form revealed no documentation of VS between:

Arrival to the nursing floor and 8:00 AM 2/15/17.
2/15/17 - 8:00 AM and 4:00 PM
2/15/17 - 4:00 PM and 9:10 PM
2/17/17 - 8:00 AM and 8:00 PM

An interview was conducted with Employee Identifier (EI) # 5, Director of Nursing, on 3/2/17 at 10:56 AM. EI # 5 verified the above findings.

2. PI # 26 was admitted to the facility on 2/11/17 with diagnoses including Medical Stabilization Cocaine Withdrawals.

Review of the physician's orders dated 2/11/17 revealed orders for VS every 4 hours x 24 hours; then every 4 hours while awake.

Review of the Nursing Note dated 2/11/17 at 1:15 AM revealed the patient arrived on the nursing floor.

Review of the Vital Signs Notes revealed no documentation of vital signs (VS) until 8:00 AM, which was 6 hours and 45 minutes between arrival and VS.

Review of the VS worksheet and the VS form revealed no documentation of VS between:

2/11/17 - 12:00 PM and 7:46 PM
2/12/17 - 12:00 PM and 8:12 PM
2/14/17 - 8:00 AM and 4:00 PM
2/15/17 - 5:35 AM and 4:18 PM

An interview was conducted on 3/2/17 at 10:45 AM with EI # 5. EI # 5 verified the above findings.

Based on the review of the facility's Policy and Procedure, medical records and interview, it was determined the facility failed to ensure the staff developed a careplan on 7 of 7 records reviewed. This included Patient Identifiers (PI) # 22, # 23, # 24, # 25, # 26, # 27, # 28 and had the potential to affect all patients served by this facility.

Findings include:

Facility Policy and Procedure: Master Treatment (Care) Plan
Policy #: 12
Reviewed: 1/20/15

Purpose: To develop a written, individualized treatment based on each patient's assessment of his/her clinical needs. An individualize treatment plan shall be developed for each patient, reflecting the staff belief in individualized treatment.

Review of PI # 22, # 23, # 24, # 25, # 26, # 27, and # 28 medical record revealed no documentation of a care plan.

An interview was conducted on 3/2/17 at 11:00 AM with Employee Identifier # 5, Director of Nurses, who verified the above findings.

Based on the review of medical records and interviews, it was determined the facility failed to ensure the nursing staff:

a) Administered medications as ordered by the physician

b) Documented on the Medication Administration Record (MAR) what was given to the patient.

c) Administered medication ordered for patient complaints

This occurred in 3 of 5 current records reviewed, which affected Patient Identifier (PI) # 25, # 26 # 24 and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 25 was admitted to the facility on 2/14/17 with diagnoses including Alcohol Abuse, Cocaine Abuse, and Rheumatoid Arthritis.

Review of the physician's orders dated 2/14/17 9:05 PM revealed orders for:

Prilosec 40 mg (milligrams) po (by mouth) every day.
Thiamine 100 mg po daily for vitamin replacement.
Motrin 200 mg 1-3 po every 4 - 6 hours prn (as needed) pain.
Toradol 60 mg Q (every) 12 hours PRN pain times 5 days, then discontinue.
Vistaril 25-50 mg po Q 4 hours prn agitation
Tylenol 650 mg po prn every four hours for pain.

Review of the MARs dated 2/15/17, 2/16/17, 2/22/17, and 2/23/17 revealed an NA (not applicable) under Prilosec.

Review of the MARs dated 2/23/17 and 2/24/17 revealed an NA under Thiamine.

An interview was conducted with Employee Identifier (EI) # 5, Director of Nurses on 3/2/17 at 10:56 AM. EI # 5 stated a PRN nurse worked 2/15/17, 2/16/17, 2/22/17, and 2/23/17. The PRN nurse did not know the Prilosec was out at the nurses' station and she/he needed to go to the Emergency Room to obtain the Prilosec. The Prilosec was not given on the above days.

EI # 5 also stated the facility was out of Thiamine on 2/23/17 and 2/24/17.

Review of the Nurse Note dated 2/18/17 at 8:20 PM revealed the patient was complaining of hurting all over. The nurse documented, "will administer prn pain medication as prescribed for pain". Review of the MAR for 2/18/17 revealed no documentation pain medication had been administered.

Review of the Nurse Note dated 2/20/17 at 1:17 AM revealed the patient requested something for sleep and pain. Review of the MAR for 2/20/17 revealed no documentation the nursing staff administered anything for sleep or pain.

Review of the Nurse Note dated 2/20/17 at 9:44 AM states, "Administered Colace for bowel. Pt. (patient) tolerated well".

Review of the Nurses Note dated 2/20/17 at 12:00 PM stated, "Mom (milk of magnesium) given no results at this time on BM (bowel movement), monitoring".

Review of the MAR for 2/20/17 revealed documentation the patient received MOM. There was no documentation of the amount given. There was no documentation the patient received the Colace.

Review of the Nurse Note dated 2/21/17 at 2:32 PM revealed the patient was complaining of a headache at a 6 on a pain scale of 1-10, 10 being the worst pain. Review of the MAR for 2/21/17 revealed no documentation the nursing staff administered pain medication.

Review of the Nurse Note dated 2/21/17 at 11:00 PM revealed the patient was complaining of pain all over and Motrin 600 mg was given. Review of the MAR for 2/21/17 revealed no documentation the nursing staff administered the Motrin.

Review of the Nurse Note dated 2/27/17 revealed the patient was complaining of general body pain and the nursing staff administered Toradol 30 mg IM (intramuscular). Review of the physician orders revealed the Toradol was ordered 2/14/17 times 5 days (expired on 2/19/17) and the order was for 60 mg. There was no documentation of a physician's order for the Toradol 30 mg.

An interview was conducted with EI # 5 on 3/2/17 at 10:56 AM. EI # 5 stated the hospital was out of Toradol 60 mg and that is why the nurse administered Toradol 30 mg.

Review of the Nurse Note dated 2/28/17 at 2:00 AM revealed the nursing staff administered Vistaril 50 mg po for anxiety and Tylenol 650 mg for pain. Review of the MAR dated 2/28/17 revealed no documentation the nursing staff administered Vistaril 50 mg or Tylenol 650 mg.

Review of the Nurse Note dated 2/28/17 at 8:00 PM revealed the nursing staff administered Vistaril 50 mg for anxiety. Review of the MAR dated 2/28/17 revealed no documentation the nursing staff administered Vistaril 50 mg.

An interview was conducted with EI # 5 on 3/2/17 at 10:56 AM. EI # 5 verified the above findings.

2. PI # 26 was admitted to the facility on 2/11/17 with diagnoses including Medical Stabilization Cocaine Withdrawals.

Review of the physician's orders dated 2/11/17 revealed the following:

Multivitamin 1 po daily
Thiamine 100 mg po daily
Folic Acid 1 mg po daily

Clonidine 0.1 mg - 0.2 mg PO x 1 if BP (blood pressure) 160/90 or higher. Notify MD (Medical Doctor) if no response.

Review of the physician's order for 2/17/17 revealed the following:

Trazadone 50 mg po every night
Prozac 20 mg po every night.

Review of the MARs from 2/11/17 to 3/1/17 revealed no documentation the patient received the Multivitamin, Thiamine or the Folic Acid.

Review of the MARs from 2/18/17 to 2/28/17 revealed a circle around the initials for Prozac, indicating the patient did not get the Prozac (antidepressant).

Review of the Nursing Note 2/17/17 at 8:02 PM revealed the following statement from the patient, "feeling anxious and depressed" and the patient rated the level of depression/anxiety as 10.

Review of the Nursing Note 2/18/17 at 8:46 PM revealed the patient was complaining of depression.

Review of the MARs dated 2/19/17, 2/23/17, 2/24/17, 2/25/17, 2/26/17, 2/27/17 and 2/28/17 revealed a circle around the initials for Trazadone, indicating the patient did not get the Trazadone. There was no documentation in the medical record stating why the patient did not get the Trazadone.

An interview with EI # 5 was conducted on 3/2/17 at 10:45 AM. EI # 5 stated the circle did indicate the patient did not get the Prozac or Trazadone. EI # 5 stated the hospital was out of Prozac and there was no documentation in the medical record stating why the patient did not get the Trazadone.

Review of Nursing Note dated 2/18/17 at 4:30 PM revealed the nursing staff administered Clonidine 0.2 mg PO for BP of 165/106. Review of the MAR for 2/18/17 revealed no documentation the nursing staff administered the Clonidine on 2/18/17.

An interview was conducted on 3/2/17 at 10:45 AM with EI # 5. EI # 5 verified the above findings.

3. PI # 24 was admitted to the facility on 2/12/17 with diagnoses including Withdrawals; Substance and Congestive Heart Failure.

Review of the physician's orders dated 2/12/17 revealed the following:

Multivitamin 1 po daily
Thiamine 100 mg po daily
Folic Acid 1 mg po daily
Seroquel 50 mg PO at night
Protonix 40 mg IV (intravenous) every 12 hours (PO, OK)

Review of the physician's orders dated 2/13/17 revealed orders for K+ (Potassium) 20 mEq (milliequivalents) PO bid (twice a day).


Review of the physician's orders dated 2/15/17 revealed the following:

Cipro 500 mg PO every 12 hours
Bactrim DS (double strength) PO bid

Review of the MAR for 2/15/17 revealed NA under Protonix, K+, and Seroquel was left blank for the evening dose.

Review of the MAR revealed NA under Protonix and Cipro for the morning dose.

An interview was conducted with EI # 5 on 3/2/17 at 10:50 AM. EI # 5 stated the medication could have not been in the hospital or the nurse overlooked them.

Based on record review, interview and hospital policy it was determined the facility failed to ensure the physicians completed orders, Progress notes and History and Physical (H&P) completely. This affect 4 of 5 active records reviewed, which included Patient Identifier (PI) # 24, # 23, # 25, and # 22. In addition, the facility failed to assure an Emergency Department (ED) medical record was maintained for review. This affected one of 21 ED medical records requested. These deficient practices had the potential to affect all patients served by this hospital.

Findings include:

1. PI # 24 was admitted to the facility on 2/12/17 with diagnoses including Medical Stabilization.

Review of the Adult VTE (Venous thromboembolism) Prophylaxis/Risk Assessment orders dated 2/12/17 revealed no documentation of the date and time the physician signed the orders. Further review of the Adult VTE Prophylaxis/Risk Assessment orders revealed no documentation of the patients name or a medical record number.

Review of the Physician Orders: Inpatient Hospitalist PRN (as needed) Orders, Medical Stabilization Routine Orders revealed no documentation of the patients name or a medical record number.

Review of the Physician's Progress Notes dated 2/24/17, 2/25/17, and 2/26/17 revealed no documentation of the time they were completed.

An interview was conducted on 3/2/17 at 10:50 AM with Employee Identifier (EI) # 5, Director of Nurses, who verified the above findings.

2. PI # 23 was admitted to the facility on 2/27/17 with diagnoses including Opiate Addiction.

Review of the Adult VTE Prophylaxis/Risk Assessment orders dated 2/27/17 revealed no documentation of the patients name or a medical record number.

Review of the H&P dated 2/27/17 revealed no documentation of the time the physician completed or of the patient's vital signs.

An interview was conducted on 3/2/17 at 10:47 AM with EI # 5, who verified the above findings.

3. PI # 25 was admitted to the facility on 2/14/17 with diagnoses including Alcohol Abuse, Cocaine Abuse and Rheumatoid Arthritis.

Review of the Physician's Progress Notes dated 2/19/17, 2/24/17, 2/25/17, and 2/26/17 revealed no documentation of the time they were completed.

An interview was conducted on 3/2/17 at 10:53 AM with EI # 5, who verified the above findings.

4. PI # 22 was admitted to the facility on 2/27/17 with diagnoses including Cocaine Abuse.

Review of the H&P dated 2/27/17 revealed no documentation of the time the physician completed or of the patient's vital signs.

An interview was conducted on 3/2/17 at 10:46 AM with EI # 5, who verified the above findings.



21056

On 3/01/17 the surveyor reviewed the Emergency Department (ED) log book and selected a sample of patient records for review. Included on the list of requested records was a patient that presented to the ED on 12/16/16 for the treatment of penile discharge.

A copy of the ED medical records list was given to Employee Identifier (EI) # 9, Medical Records Manager, to pull the ED records for surveyor review.

EI # 9 was unable to locate the medical record for the above ED patient that presented for care on 12/16/16.

Hospital Policy:

Maintenance of Medical Records

VI. Preservation of medical records
"Medical Records will be preserved in hard copy, microfilm or microfiche permanently."

Based on record review, hospital policy and interview the hospital failed to assure all Emergency Department (ED) medical records documented the patient's condition on discharge from the ED, documented triage times, documented patient's condition on transfer from the ED to another hospital for further care and documented the reason why a patient was transferred from Hill Hospital of Sumter County ED to another hospital for further care. This had the potential to affect all patients served and did affect ED Medical Records (MR) #12, # 9, # 6, #20, and # 18, which was 5 of 21 ED records reviewed.

Findings include:

1. A review of MR # 12 revealed the patient presented to the ED on 11/26/16 for treatment of a dog bite. A review of the physician order sheet revealed there was no signature of the ED physician.

On 3/02/17 at 10:35 AM, in an interview with Employee Identifier (EI) # 5, Director of Nursing, confirmed there was no physician signature.

2. A review of MR # 9 revealed the patient presented to the ED on 11/14/16 for treatment following a motor vehicle accident. A review of the ED nursing documentation revealed there was no triage time documented by staff.

On 3/02/17 at 10:30 AM, in an interview with EI # 5, it was confirmed nursing staff failed to document the triage time.

3. A review of MR # 6 revealed the patient presented to the ED via ambulance on 6/24/16 for treatment related to vomiting, shortness of breath and unresponsiveness. The patient was transferred to another hospital for further treatment and care, but Hill Hospital of Sumter County staff failed to document the patient's condition on transfer.

On 3/03/17 at 10:32 AM, EI # 5 confirmed staff failed to document the patient's condition on transfer.

4. A review of MR # 20 reveled the patient presented to the ED for treatment of shortness of breath and chest tightness. A review of the hospital transfer forms revealed there was no documentation of the reason for transfer or the patient's condition on transfer.

5. A review of the MR # 18 revealed the patient presented to the ED for treatment of shortness of breath and edema to the feet. A review of the physician physical exam revealed there was no documentation of the patient's condition on discharge from the hospital.

On 3/03/17 at 10:40 AM, EI # 5 confirmed the physician did not document the patient's condition on discharge.

Hospital Policy:

Maintenance of Medical Records
"Medical Records are an important tool in the practice of medicine. They serve as a basis for planning patient care and they provide a means of communication between the physician and other professional groups contributing to the patient's care. They furnish documentary evidence of the course of the patient's illness and treatment and they serve as a basis for review, study and evaluation of the medical care rendered to the patient.

"For these reasons and many more, the quality of the medical record is an important indication of the quality of patient care given in the hospital."

Signatures:
Every entry made in the medical record will be signed by the physician making the entry. No rubber stamps are permitted. Physicians will sign verbal/telephone orders within 24 hours.

Based on interviews, observations, written response to Alabama Board of Pharmacy, Alabama Board of Pharmacy renewal application, narcotic administration records, hospital formulary and review of the hospital policies, the hospital failed to ensure the medications were immediately available for administration to patients. The hospital has no pharmacy director responsible for developing, implementing and periodically reviewing and revising policies and procedures governing provision of pharmaceutical services. The hospital does not have a system in place to remove drugs that have been recalled for safety reasons and has no pharmacy person responsible for the procurement, distribution and control of all medication products used in the hospital for inpatient and outpatient care. Refer to A-491.

The hospital failed to have a single pharmacist responsible for the overall administration of the pharmacy service and for developing, supervising, and coordinating all the activities of the hospital wide pharmacy service. There was no professional, competent, legally qualified pharmacist to manage the pharmacy or actively involved in committees responsible for establishing medication-related policies and procedures. Refer to A-492

The hospital failed to have sufficient numbers and types of pharmacy personnel to provide accurate and timely medication delivery, ensure accurate and safe medication administration and to provide appropriate clinical services as well as the participation in continuous quality improvement programs that meet the needs of the patient population being served. Refer to A-493

The hospital failed to have a process in place for medication orders to be received in the pharmacy and dispensed in a safe and timely manner after a review of all medication orders for appropriateness by a hospital pharmacist before the first does is dispensed to the patient. Refer to A-500

The hospital failed to ensure all medications available for patient use were not expired. Refer to A-505

This deficient practice affects all patients that present to the hospital for care and treatment.

Findings include:

Refer to A-491, A-492, A-493, A-500 and A-505 for findings.

Based on interviews, observations, written response to Alabama Board of Pharmacy, Alabama Board of Pharmacy renewal application, narcotic administration records, hospital formulary and review of the hospital policies, the hospital failed to ensure the medications were immediately available for administration to patients. The hospital has no pharmacy director responsible for developing, implementing and periodically reviewing and revising policies and procedures governing provision of pharmaceutical services. The hospital does not have a system in place to remove drugs that have been recalled for safety reasons and has no pharmacy person responsible for the procurement, distribution and control of all medication products used in the hospital for inpatient and outpatient care. This deficient practice affects all patients that present to the hospital for care and treatment.

Findings include:

Refer to A-505 for additional findings related to expired medications.

On 2/28/17 at 2:15 PM, during the entrance conference with Employee Identifier (EI) # 4, Administrator, informed survey staff that the hospital did not currently have a pharmacist and that the Alabama Board of Pharmacy had been on-site to the hospital, conducted an inspection and removed the keys to the hospital pharmacy from hospital premises.

A copy of a written response to the Alabama Board of Pharmacy (ABP) submitted by EI # 4 in response to the ABP review was provided to the survey staff. The written document titled, "Statement of Occurrences" documented Employee Identifier (EI) # 10, former Supervising Pharmacist (number 1), failed to work out a 30 day notice and resigned as the hospital Pharmacist effective 11/10/16. After EI # 10 resigned, the hospital contracted with EI # 11, former Supervising Pharmacist (number 2) until 12/24/16 when EI # 11 resigned. The written document stated on 1/17/17, EI # 4 received a letter from ABP informing the hospital did not have a license pharmacist. On 2/07/17, EI # 4 documented she contacted a Pharmacy staffing company and they sent over EI # 12, former Contracted Supervising Pharmacist (number 3). EI # 12 resigned as the Contracted Supervising Pharmacist effective 2/14/17.

In the "Statement of Occurrences" document were emails provided to the ABP related to the hospital's response. There was an email from EI # 4, Administrator, to EI # 11, dated 1/04/17 that documented, "We are very low in the drugs necessary for the Detox patients." Another email from EI # 4 to a pharmacy staffing company representative dated 1/19/17 documented, "Also, doctors are reluctant to admit patients because we are out of meds that only a license pharmacist can supply. Right now we are getting by with doctors writing RX (prescriptions) and going to the local pharmacist for filling. (EI # 11) is no longer willing to assist."

A copy of the Alabama State Board of Pharmacy renewal application for years 2017/2018 was reviewed. There is no name listed for the registered pharmacists, only "Pending" is documented in the section of the form where a name is to be written.

During tours of the hospital on 2/28/17 and 3/01/17 survey staff observed expired medications in the Emergency Department (ED) medication room, crash carts in the ED, Medical / Surgical medication room and crash cart on the Medical / Surgical hall.

Employee Identifier (EI) # 5, Director of Nursing, informed survey staff she complied a list of all medications that the hospital was either completely out of or had a low volume left in the hospital available for patient use. A copy of the list prepared by EI # 5 was obtained by survey staff.

A review of the document prepared by EI # 5 and updated on 3/02/17, listed the following narcotics the hospital was completely out of:

1. Ativan, 2 milligrams (mg) tablets (tab)
2. Tranxene, 3.75 mg tab
3. Tranxene, 7.5 mg, tab
4. Valium, 5 mg, tab
5. Klonopin, 0.5 mg, tab
6. Phenobarbital, 30 mg, tab
7. Morphine injection (no specific dose was listed)
8. Nubain injection (no specific dose was listed)

A review of the ED nursing station narcotic administration record was reviewed by survey staff on 2/28/17. The following narcotic medications were not available to be administered to the patients that presented to the hospital for treatment, but were not included on the list formulated by EI # 5:

1. Ativan, 1 mg (used to treat anxiety)
2. Hydromorphone (Dilaudid) 2 mg injection (used to treat pain)
3. Morphine 2 mg injection (used to treat pain)
4. Morphine 10 mg injection (used to treat pain)
5. Nalbuphine Hydrochloride 10 mg injection (used to treat pain)
6. Vecuronium (Norcuron) 10 mg injection (adjunct to general anesthesia-induced muscle relaxation for endotracheal intubation, mechanical ventilation)
7. Midazolam (Versed) 5 mg injection (Midazolam is used to sedate a person who is having a minor surgery, dental work, or other medical procedure.)
8. Succinylocholine (Anectine) 200 mg injection (Relaxing muscles during surgery or when using a breathing machine (ventilator). It is also used to induce anesthesia or when a tube must be inserted in the windpipe.)
9. Lortab (Hydrocod-Acet) 2.5 mg/167mg elixr (used to treat pain)

A review of the Medical / Surgical nursing station narcotic administration record was reviewed by survey staff on 3/2/17. The following narcotic medications were not available to be administered to the patients that were admitted to the hospital for treatment, but were not included on the list formulated by EI # 5:

1. Ativan 1 mg (used to treat anxiety)
2. Hydromorphone (Diaudid) 2 mg injection (used to treat pain)
3. Morphine 2 mg injection (used to treat pain)
4. Morphine 8 mg injection (used to treat pain)
5. Phenobarbital 60 mg tab (used alone or with other medications to control seizures)
6. Klonopin (Clonazepam) 0.5 mg (used to treat certain seizure disorders)
7. Tranxene (Clorazepate Dipotassium) 3.75 mg (used to treat anxiety, acute alcohol withdrawal, and seizures)
8. Tranxene (Clorazepate Dipotassium) 7.5 mg

A review of the document prepared by EI # 5 and updated on 3/02/17, listed the following narcotics the hospital was low on were:

1. Phenobarbital, 60 mg, tab
2. Demerol injection (no specific dose was listed)

A review of the document prepared by EI # 5 and updated on 3/02/17, listed the following
medications the hospital was completely out of:

1. Melatonin, 10 mg tab
2. Clonidine, 0.1 mg, tab
3. Lisinopril (no dosage listed)
4. Lactulose (no dosage listed)
5. Mylanta (no dosage listed)
6. Diflucan (no dosage listed)
7. Claritin (no dosage listed)
8. Singulair (no dosage listed)
9. Purified Protein Derivative (PPD) Stain Test
10. Hum-R insulin
11. Metformin (no dosage listed)
12. Zofran injection (no dosage listed)
13. Phenergan injection (no dosage listed)
14. Depo-medrol injection (no dosage listed)
15. Decadron injection (no dosage listed)
16. Toradol 30/60 injection
17. Seroquel 100/300 mg tabs
18. Prozac, 20 mg tab
19. Sertralazine, 50 mg tab
20. Ceftriaxone, 250/500/ 1 gram (gm) injection
21. Amoxil, 250/500 mg tabs
22. Ancef injection (no dosage listed)23. Ampicillin injection (no dosage listed)
24. Clindamycin injection (no dosage listed)
25. Gentamycin injection (no dosage listed)

A review of the document prepared by EI # 5 and updated on 3/02/17, listed the following
medications the hospital was low on:

1. Folic acid (no dosage listed)
2. Prilosec (no dosage listed)
3. Albuterol nebulizer
4. Duo nebulizer
5. Robaxin (no dosage listed)
6. Vistaril (no dosage listed)
7. Celexa (no dosage listed)
8. Dilantin injection (no dosage listed)
9. Keflex (no dosage listed)
10. Norvasc (no dosage listed)
11. Solu-medrol injection (no dosage listed)

All of the above medications were listed on the current hospital formulary that were to be available for physicians to order and staff administer to patients.

An interview was conducted with the hospital Medical Director, Employee Identifier # 2 on 3/02/17 at 2:40 PM. During the interview with EI # 2 the following was identified:
1. EI # 2 was not aware who at the hospital had been designated to be responsible for pharmacy services or if administration was working on this issue.
2. EI # 2 was not sure how long the hospital had been without a pharmacist.
3. EI # 2 was not sure how medications were ordered to restock medication supplies, but stated it was his understanding the hospital was not allowed to order medications without a pharmacist on staff.
4. EI # 2 did not know if medications had not been given to patients due to the medication being out of stock.
5. EI # 2 stated processes were still in place to identify if medications were recalled or discontinued for safety reasons, but confirmed there was no pharmacist at the hospital to identify these medications. The hospital would rely on physicians for drug recalls, but physicians may not know about all recalls.
6. EI # 2 was not sure if the hospital had scheduled drugs (narcotics) on hand, but stated he thought the hospital was out of Dilaudid.
7. EI # 2 stated nursing staff would be next in line to identify outdated, mislabeled or unusable drugs and that the physicians were also responsible.
8. EI # 2 confirmed no one at the hospital had the keys to the pharmacy to remove drugs.
9. EI # 2 confirmed the physician would review medications for drug interactions and that nursing staff in the ED had an electronic system to enter medications into, but was not sure if all nursing staff had access to that system to check for drug interactions.

On 3/02/17 at 3:15 PM, EI # 5 was interviewed. During the interview with EI # 5 the following was identified:
1. EI # 5 confirmed no one at the hospital was responsible for pharmacy services, but stated it fell to nursing.
2. EI # 5 stated the last time she remembered the hospital having a pharmacist was December 23, 2016.
3. EI # 5 stated if the Pharmacy Supply Room is out of a medication then staff were to get the physician to write a prescription for the medication. The patient would pay their co-pay, a hospital staff person would carry the prescription to the local pharmacy to be filled and return with the medication to the hospital. The nursing staff would place the medication in the patient's medication drawer to be used during medication pass. When the patient is discharged from the hospital, the prescription medication is sent home with the patient. EI # 5 also confirmed a local doctor wrote a prescription for hospital stock medications, took the prescription to the local pharmacy where the medications were provided and then placed them in the medication room for nursing staff to use on multiple patients. EI # 5 confirmed the stock medications received by this ordering method were Seroquel, Trazadone, Thiamine and Folic Acid. EI # 5 stated to her knowledge this has only happened one time; physician writing an order for stock medications.
4. EI # 5 confirmed the hospital had been without medications that were listed on the drug list she formulated above and stated the hospital was without Thiamine, Folic Acid and Multivitamins for about 15 to 16 days. These drugs are on the standing orders for patients admitted to the hospital's detoxification (detox) program.
5. EI # 5 confirmed there was no one designated at the hospital to be responsible for maintaining current and accurate pharmacy records.
6. EI # 5 stated no one at the hospital had been designated to be responsible for assuring medications that were recalled or discontinued for safety reasons were removed from the hospital's medication supply. EI # 5 stated one recall had come in and those medications were taken to the local pharmacy.
7. EI # 5 confirmed there was no one specific person at the hospital that was responsible for assuring outdated, mislabeled or unusable drugs were not available for patient use. EI # 5 stated it was a shared duty between nursing staff and pharmacy staff.
8. EI # 5 confirmed there was no one formally responsible for reviews of medication drug interactions, but stated it was ultimately the responsibility of the physician.

An observation of a medication pass was conducted on 3/01/17 at 10:30 AM, with Employee Identifier (EI) # 6, Registered Nurse. During the observation EI # 6 was to administer Lasix 40 mg to a patient. EI # 6 stated the medication was out of stock on the Medical / Surgical floor and she went to the ED where she removed two 20 mg Lasix tabs and administered to the patient. EI # 6 was asked if the ED did not have the Lasix, what would she do. EI # 6 stated she would have to call the doctor, get an order for Lasix filled at the local pharmacy, have a staff person from the hospital go to the local pharmacy to pick up the Lasix and then administer to the patient.

At the time of the survey the hospital had five in-patients that were all being treated on the detox medical / surgical floor. The survey staff reviewed the medical stabilization routine orders (standing orders) for each of these patients and the following medications were listed for all five patients:

1. Multivitamin 1 tab, by mouth, every day for vitamin replacement.
2. Thiamine 100 mg, by mouth, every day for vitamin replacement.
3. Folic Acid, 1 mg, by mouth, every day for vitamin replacement.

The medical stabilization routine orders (standing orders) included a list of PRN (as needed -pro re nata) medications to be given to the patients on the detox medical / surgical floor. Included on the list of PRN medications that EI # 5, Director of Nursing, had identified the hospital was completely out of were the following:

1. Claritin 10 mg, by mouth, four times a day, PRN.
2. Mylanta/Maalox 30 cubic centimeters (cc), by mouth, PRN.
3. Phenergan 25 to 50 mg, by mouth or intramuscular (IM), every 6 hours, PRN for nausea.
4. Clonidine 0.1 mg to 0.2 mg, by mouth if blood pressure 160/90 or higher.

For in-patients that required the use of any above PRN medication the hospital staff would have to obtain a prescription from the physician, have the patient pay their co-pay, send a staff person to the local pharmacy to have the prescription filled and return to the hospital to administer the medication to the patient. Once the prescription was filled the remaining doses of the medication would remain in the patient's medication drawer at the hospital for future use, if needed, or until the patient was discharged.


Hospital Policy
Subject: Medication Administration
Department: Medical Surgical Unit
Policy:
Questions regarding medication compatibility will be referred to the Pharmacist or researched in available compatibility references.

The Charge Nurse will send copies of the physician's orders sheets to the Pharmacy as soon as possible after a medication or discharge order is written.

Drug reactions will be reported immediately to the attending physician and Pharmacy...

Errors in administration of medication will be reported immediately to the attending physician, ... and the Pharmacy Department by the end of the shift in which the error was committed.

Hospital Policy
Subject: Medication Administration
Department: Medical Surgical Unit
Policy:
Questions regarding medication compatibility will be referred to the Pharmacist or researched in available compatibility references.

The Charge Nurse will send copies of the physician's orders sheets to the Pharmacy as soon as possible after a medication or discharge order is written.

Drug reactions will be reported immediately to the attending physician and Pharmacy...

Errors in administration of medication will be reported immediately to the attending physician, ... and the Pharmacy Department by the end of the shift in which the error was committed.


Summary:

The hospital failed to have a pharmacist on staff or available to oversee the pharmacy services at the hospital. There was no hospital staff person responsible for developing, implementing and periodically reviewing and revising policies and procedures governing provision of pharmaceutical services. The hospital does not have a means to identify drug recalls and assure these drugs are removed and not administered to patients. Without a pharmacist on staff the hospital has no pharmacy person responsible for the procurement, distribution and control of all medication products used in the hospital for inpatient and outpatient care. Nursing staff are required to call the physician to obtain a prescription for out of stock medications. There is no designated hospital staff person that tracks medication levels, outside of EI # 5, Director of Nursing, who tracks what medications the hospital is out of or low on. The hospital has no method of determining ahead of time if an admitted patient will have all medications on hand that are ordered prior to medication administration to assure timely administration of all patient ordered medications.

The hospital had no process in place at the time of the survey to review patient medications for:
1. Therapeutic appropriateness of the medication ordered.
2. Therapeutic duplication of medication orders.
3. Appropriateness of the drug, dose, frequency, and route of administration.
4. Actual or potential medication-medication, medication-food, medication-laboratory test and medication-disease interactions.
5. Actual or potential allergies or sensitivities.

In addition, the hospital had no system in place to reconcile medications that were not administered when the pharmacy restocks patient medications to be administered by nursing staff.

Based on interviews and observations the hospital failed to have a single pharmacist responsible for the overall administration of the pharmacy service and for developing, supervising, and coordinating all the activities of the hospital wide pharmacy service. There was no professional, competent, legally qualified pharmacist to manage the pharmacy or actively involved in committees responsible for establishing medication-related policies and procedures. This had the potential to affect all patients served by the hospital.

Findings include:

Refer to A-0491 for findings.

Based on interviews and observations the hospital failed to have sufficient numbers and types of pharmacy personnel to provide accurate and timely medication delivery, ensure accurate and safe medication administration and to provide appropriate clinical services as well as the participation in continuous quality improvement programs that meet the needs of the patient population being served. This had the potential to affect all patients served.

Findings include:

Refer to findings at A-0491

Based on observation, interview and policy the hospital failed to have a process in place for medication orders to be received in the pharmacy and dispensed in a safe and timely manner after a review of all medication orders for appropriateness by a hospital pharmacist before the first does is dispensed to the patient. This had the potential to affect all patients served.

Findings include:

Refer to A-0491 for findings.

Based on observations and interviews, it was determined the facility failed to ensure all medications available for patient use were not expired. This had the potential to negatively affect all patient served by this hospital.

Findings include:

A tour of the Emergency Department (ED) was conducted on 2/28/17 at 3:05 PM. An observation of the crash cart was conducted and the following was observed:

1 - Epinephrine 1 mg (milligram)/10 ml (milliliter) (1:10,000) expired 2-1-2016
3 - Epinephrine 1 mg/10 ml (1:10,000) expired 2-1-2017
3 - Lidocaine 100 mg/5 ml expired 2-1-2017
2 - Sodium Bicarbonate 50 mEq (milliequivalent) /50 ml expired 2-1-2017
3 - Atropine 1 mg expired 2-1-2017
2 - Dextrose 50% 0.5 mg/50 ml expired 2-1-2017
13 - Epinephrine 1:1000 expired 1-1-2017

An observation of the Mini Pharmacy in the ED was conducted on 2/28/17 at 3:30 PM and the following was observed:

1 - Ibuprofen 100 mg/5 ml one pint exp 1-2017
1 - Hydroxyzine HCl (Hydrochloride) Syrup 10 mg/5 ml 4 ounces expired 1-2016
1 - Prednisone Syrup 15 mg/5 ml 480 ml expired 10-2016
6 - Ammonia Inhalant expired 5-2016
10 - Ammonia Inhalant expired 9-2016
1 - Cetirizine HCl Oral Solution 1 mg/ml expired 10-02-2011
1 - Promethazine HCL 6.25 mg/5 ml 16 fluid ounces expired 10-2016
1 - Clotrimazole and Betamethasone Dipropionate 1%/0.05% 15 gm expired 1-2017
1 - Afrin Nasal Spray 1/2 fluid ounces expired 5-2015
1 - Loperamide HCL 1 mg/5 ml 4 fluid ounces expired 7-21-2016
1 - Sodium Polystyrene Sulfonate 15 g/60 ml 500 ml expired 10-2016

A tour of ED Exam Room 1 was conducted on 2/28/17 at 3:45 PM and the surveyor observed the following:

1 - Povidone Iodine 10% solution 1 pint expired 7-2015

A tour of ED Exam Room 2 was conducted on 2/28/17 at 3:50 PM and the surveyor observed the following:

1 - Hydrogen Peroxide 8 fluid ounces expired 9-2016
1 - Povidone Iodine 10% solution 1 pint expired 11-2016

An interview was conducted on 2/28/17 at 4:00 PM with Employee Identifier (EI) # 5, Director of Nurses, who verified the above findings.

A tour of the Pharmacy Supply Room on the Medical / Surgical floor on 3/1/17 at 4:00 PM revealed the following expired medications:

9 - Levofloxacin 250 mg (milligrams) in 50 ml (milliliters) of 5% Dextrose expired 2-2107
1 - Benzonate 200 mg expired 1-2017
9 - Allopurinol 100 mg expired 1-2017
18 - Atenolol 50 expired 1-2017
25 - Baclofen 10 mg expired 1-2017
2 - Bisacodyl 5 mg expired 1-2017
20 - Captopril 12.5 mg expired 1-2017
7 - Plavix 75 mg expired 1-2017
9 - Diltiazem HCl E.R. (extended release) 120 mg expired 12-2016
22 - Famotidine 20 mg expired 2-2017
53 - Glyburide 5 mg expired 2-2017
8 - Labetalol HCl 100 mg expired 5-2016
2 - Levetiracetam 500 mg 1-2017
5 - Metformin 500 mg expired 10-2016
12 - Metoclopramide 10 mg expired 2-2017
6 - Metronidazole 250 mg expired 1-2017
15 - Olanzapine 10 mg expired 1-2017
10 - Tamsulosin 0.4 mg expired 2-2017
8 - 0.9% Sodium Chloride 10 ml vials expired 1-2017
1 - Cetirizine HCl 1 mg/ml 120 ml bottle expired 2-2017
2 - 8.4% Sodium Bicarbonate Injection 50 mEq expired 1-2017
1 - Povidone Iodine 10% solution 1 pint expired 11-2016
3 - Nicotine Transdermal System Patch 7 mg expired 11-2016
15 - Xopenex 1.25 mg Nebulizer expired 11-2016
2 - Xopenex 1.25 mg Nebulizer expired 12-2016
1 - Xopenex 1.25 mg Nebulizer expired 6-2016
1 - Hurricane Topical Anesthetic Spray 20% Benzocaine expired 12-2016
1 - Gentamycin Sulfate Opthalmic Solution 0.3% expired 1-2017
1 - Ampicillin 500 mg vial expired 12-2016
3 - Ampicillin 500 mg vial expired 11-2016
2 - Ampicillin 500 mg vial expired 1-2017
2 - Haloperidol in 5 mg/ml expired 1-2017
5 - Heparin 5000 units/ml expired 12-2016
14 - Metoclopramide Injection 10 mg 5 mg/ml expired 2-1-2017
1 - Metoclopramide Injection 10 mg 5 mg/ml expired 12-1-2015


An observation of the crash cart on 3/1/17 at 4:45 PM revealed the following:

10 - Epinephrine 1:1000 1 mg/ml expired 1-2017
1 - Dobutamine 500mg in 250 ml 5% Dextrose expired 1-Jan-2017
7 - Epinephrine 1:10,000 1 mg (0.1 mg/ml) 10 ml vials expired 1-FEB-2017

A tour of the IV Room was conducted on 3/1/17 at 4:55 PM and the following was found:

6 - Diltiazem 25 mg/5 ml 5 ml vials expired 1-Jan-2017
1 - Levemir 10 ml vial expired 2-2017
1 - Humulin 10 ml vial expired 2-2017
6 - Acetaminophen Suppositories 325 mg expired 2-2017

An interview was conducted on 3/1/17 at 5:15 PM with EI # 5, who verified the above findings.

Based on observations and hospital policies the hospital failed to assure:

1. All food items not stored in the original container was clearly labeled to assure items were identifiable and not out of date.
2. Ice machine was functioning.
3. Frozen food items were kept frozen per manufacturer's directions.
4. Pots and pans were stored clean.
5. Overhead lighting had protective covering and was functioning properly.
6. Dented cans were not placed on shelf for staff use.
7. Grease container was covered to prevent contamination and infestation.
8. Hospital dumpster lids were closed and there was no excessive overflow of garbage.

This had the potential to affect all patients served by the dietary department.

Findings include:

A tour of the dietary department was conducted on 2/28/17 at 2:10 PM, with Employee Identifier (EI) # 8, Acting Dietary Manager. During observations of frozen and refrigerated food storage areas the following was observed by survey staff:

1. One gallon clear plastic Zip-lock bag with no date or label identified as "biscuits" by EI # 8.
2. One gallon clear plastic bag with no date or label identified as "rolls" by EI # 8.
3. Loosely wrapped tin foil with no date or label, opened and identified as "beef patties left over from Friday." by EI # 8.
4. Plastic bags of vegetables identified by EI # 8 who stated, "All veggies came in box and had to take out of box." to fit into deepfreeze unit since walk in freezer was not functioning. None of the plastic bags had a date or label.
5. Plastic bags of meat items identified by EI # 8 as beef, pork and fish. None had a date or label.

During the above tour survey staff opened the ice machine in the dietary department. EI # 8 stated the ice machine had been broken, but staff buy ice and place it in the broken ice machine for use. EI # 8 stated a man was going to come and fix the machine, but did not know a date.

Survey staff continued the tour of the dietary department and identified the walk-in refrigerator had a layered cake and juice items that were labeled on the manufacturer's container to "keep frozen" that were not stored per manufacturer's directions.

On 2/28/17 at 2:35 PM, survey staff observed the clean pots and pans storage area and identified the following items stored and available for use:

1. Stock pot for cooking food stored with a sticky brown substance on the handle.
2. Cooking pots and pans stored with a tan oil substance and food crumbs.
3. Large mixing bowel stored with food debris and grim in the bottom of the bowel.

During the above time frame a ceiling fluorescent light fixture in the dietary department near the area where clean pots and pans were stored, just outside of the dish washing area, had no protective light shield cover.

The overhead light in the dishwashing area where the dish machine is located was not functioning and one of the two ceiling light fixtures in this area had no light bulbs or protective shield.

Survey staff observed the dry food storage area and identified a dented can of applesauce dated 11/03/16 on the shelf stored with non-dented can food items.

Survey staff observed the grease pit storage area located just outside of the dietary department near the rear entrance of the building. EI # 8 pointed out a 50 gallon drum where the grease was to be poured. There was no lid or covering over the grease container.

On 3/01/17 at 11:05 AM, survey staff observed the hospital dumpster area and noted the garbage dumpster was full with garbage hanging out of the sides and over the top. The top and side covers were open and not able to be closed due to the amount of garbage noted.

Hospital Policies:

Storage of Food and SuppliesPolicy: All food and supplies must be stored according to approved storage method.
Procedure:
All items are stored in containers other than the original container must be clearly labeled.
Perishable foods are placed in freezer or proper refrigeration upon delivery. All freezer foods are dated upon delivery and are rotated properly.

Subject: Unused Food Portions
Policy: Food portions not utilized in the service of a meal will be handled in one of the following ways.

Procedure:
All unused portions stored in containers other than original container must be dated.

Policy: Trash and Garbage Disposal
Purpose:
To provide for safe disposal of trash.
To avoid overflowing trash receptacle.

Facility Policy: Preventive Maintenance Strategy
Policy #: PM.II-4
Effective Date: August 1, 2002

Purpose: "The maintenance department's major goal is to schedule preventive maintenance for all equipment, and the facility physical plant, so that breakdown or failure is avoided."

Standard:

Four types of maintenance may be identified:
1. Preventive Maintenance - maintenance done on a routine basis with the emphasis on preventing maintenance problems, rather than correcting existing problems. It is the most orderly and organized of the maintenance efforts, and may lower the rate of failures, decrease severity of failures, increase efficiency, protect assets, and add to safety.

Process:
a) Maintenance schedules should be developed in order to prevent system failure or service interruption.

Based on observations during a facility tour with hospital staff by the Fire Safety Compliance Officer it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. In addition, the facility failed to ensure:

a) Supplies available for patient use were not expired.

b) Equipment was monitored to maintain safety of patients and staff.

d) Safe integrity of emergency crash carts.

e) Lighting in patient rooms was functioning.

f) Papertowel dispensers were covered to protect papertowels from contamination.

g) Wall plugs were covered properly and in a safe manner.

h) Chairs in patient rooms were in good repair.

i) Exit doors were sealed properly.

This had the potential to affect all patients served by this facility.

Findings include:

Refer to Life Safety Code violations and A-724 for findings.

Based on observations, review of facility policy and interviews with facility staff it was determined the facility failed to ensure:

a) Supplies available for patient use were not expired.

b) Equipment was monitored to maintain safety of patients and staff.

d) Safe integrity of emergency crash carts.

e) Lighting in patient rooms was functioning.

f) Papertowel dispensers were covered to protect papertowels from contamination.

g) Wall plugs were covered properly and in a safe manner.

h) Chairs in patient rooms were in good repair.

i) Exit doors were sealed properly.

This had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Preventive Maintenance Strategy
Policy #: PM.II-4
Effective Date: August 1, 2002

Purpose: "The maintenance department's major goal is to schedule preventive maintenance for all equipment, and the facility physical plant, so that breakdown or failure is avoided."

Standard:

Four types of maintenance may be identified:
1. Preventive Maintenance - maintenance done on a routine basis with the emphasis on preventing maintenance problems, rather than correcting existing problems. It is the most orderly and organized of the maintenance efforts, and may lower the rate of failures, decrease severity of failures, increase efficiency, protect assets, and add to safety.

Process:
a) Maintenance schedules should be developed in order to prevent system failure or service interruption.

************

Facility's Preventive Maintenance and Electric Safety Check
Date: May 2009

Maintenance Department Policies:

Preventive Maintenance:

A preventive maintenance program established for all equipment related to patient care and building service is carried out on a scheduled basis. This program ensures that all equipment is kept clean, calibrated and adjusted, and in good working order...

A tour of the Emergency Department was conducted on 2/28/17 at 3:15 PM. The surveyor observed the following supplies expired:

4 - red top laboratory tubes
4 - blue top laboratory tubes
3 - Trocar Catheter Kit expired 4/2/13

A tour of the Emergency Department was conducted on 2/28/17 at 3:15 PM. The surveyor observed the following equipment with outdated preventative maintenance (PM) stickers:

Suction machine with a PM sticker dated last checked 10-2015
Goose Neck Lamp with a PM sticker dated last checked 12-2009
Boxed Fan stuck between a desk and a wall with no PM sticker
Defibrillator with a PM sticker dated last checked 1-2016
MCT Injector System (a tool used by Physical Therapist to perform multiple facial and body treatments) with a PM sticker dated last checked 1-2016
Kramex Portable X-Ray with a PM sticker dated last checked 1-2015

On 2/28/17 at 3:30 PM, during a tour of the medical/surgical patient rooms the surveyor observed a mobile Vital Sign equipment (for blood pressure and temperature) which was taped around the middle to hold it together.



21056

On 2/28/17 at 3:30 PM, during a tour of the medical / surgical patient rooms the following was observed:

1. Room 101 - the overhead light and light over the patient bed did not work. There was no papertowel dispenser cover to prevent papertowels from contamination.

2. Room 105 - the overhead light did not work, no papertowels in room.

3. Room 107 - the seat cushion on the visitor chair was torn exposing foam and there was no papertowel dispenser cover to prevent the papertowels from contamination.

4. Room 109 - the wall plug at the head of the patient bed had no cover and wires were coming out of the wall. Staff had placed paper tape over the wall plug opening. There was no papertowel dispenser cover to prevent the papertowels from contamination.

5. Room 111 - there was no papertowel dispenser cover to prevent the papertowels from contamination.

On 3/01/17 at 4:00 PM, survey staff observed the Exit Door across from the medical / surgical nursing station had two holes (old screw holes) at the top of the door that allowed air in and out of the hospital. Mosquitoes were observed through the glass in the door outside of the hospital that the holes would have provided an entrance into the hospital.

Based on the review of the Infection Control/Blood Utilization Committee Meeting Minutes and interview, it was determined the facility failed to ensure:

a). The staff followed the policy for hand hygiene in the only infection control observation available during the survey.

b). There was a system developed to evaluate measures governing the identification, investigation, reporting, prevention and control of infections and communicable diseases within the hospital.

This had the potential to negatively affect all patients served by this faciltiy.

Findings include:

Refer to A 748 and A 749 for findings.

Based on the review of the policy, observations and interviews, it was determined the facility failed to ensure the staff followed the policy for hand hygiene. This affected 5 of 5, medication passes, which included Patient Identifier (PI) # 23, # 22, # 26, # 25, # 24 and had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Hand Hygiene
Policy #: none
Date: none

Purpose:

To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs, and infections.

Policy:

All personnel will use the hand-hygiene techniques, as set forth in the following procedure...

When hands are soiled

Before each patient encounter...

Soap and water must be used when hands are visibly soiled.

If hands are not visibly soiled, hands may be disinfected with either an alcohol-based hand rub (ABHR) or soap and water...

Alcohol-based hand rub gel dispensers shall be placed outside of patients' rooms in egress corridors under the following conditions:

Corridor width is six (6) feet or greater

Dispensers are at a minimum four (4) feet apart

A tour was conducted on 2/28/17 at 4:20 PM of the patient care areas. There were no alcohol-based hand rub gel dispensers outside any of the patients' rooms.

1. An observation of medication pass was conducted on 3/1/17 at 8:40 AM with Employee Identifier (EI) # 6, Registered Nurse (RN) for PI # 23. EI # 6 went to the Pharmacy Supply room, gathered the patient's medications, went to a door down the hall from where the medications were gathered, used a key to unlock the door labeled IV (intravenous) Room, went in, washed hands at the sink, left the IV Room, went back to the Pharmacy Supply room to obtain forgotten medications, called PI # 23 to the nurses station and administered the medications. EI # 6 did not perform hand hygiene before the encounter with PI # 23.

2. An observation of medication pass was conducted on 3/1/17 at 9:00 AM with EI # 6 for PI # 22. EI # 6 went to the IV Room began to unlock the door, when the surveyor asked if that was the only place for the staff to perform hand hygiene. EI # 6 stated I can use the bathroom in the hallway. EI # 6 went to the bathroom in the hallway, performed hand hygiene, unlocked the control substance cabinet, obtained medication, locked the cabinet with keys kept in the pocket of EI # 6's lab coat. EI # 6 went to the Pharmacy Supply room, obtained medications, called patient to the nurses station and administered the medication. EI # 6 did not perform hand hygiene before the encounter with PI # 22.

3. An observation of medication pass was conducted on 3/1/17 at 9:20 AM with EI # 6 for PI # 26. EI # 6 went to the Pharmacy Supply room, obtained the patient's medications, went to the nurses station, obtained the patient's medication from the medication cart. EI # 6 went to the bathroom in the hallway, performed hand washing, picked up the telephone, called to patient's room. The patient came to the nurse's station and EI # 6 administered PI # 26's medication. EI # 6 did not perform hand hygiene before the encounter with PI # 26.

4. An observation of medication pass was conducted on 3/1/17 at 9:40 AM with EI # 6 for PI # 25. EI # 6 pulled the patient's drawer out of the medication cart and placed the drawer on top of the medication cart. EI # 6 went to the bathroom in the hallway and performed hand washing. An unidentified person came to the nurses' station with a white paper bag and asked EI # 6 to lock it up for another employee. EI # 6 took the white bag and locked it in the controlled substance cabinet. EI # 6 then went to PI # 25's room to try to awaken the patient. EI # 6 gently shook patient to try to awaken. PI # 25 did not want to get up. EI # 6 then went back to the nurses' station to obtain the patient's medication, returned to PI # 25's room and checked the patient's wrist for a name band, which the patient did not have. There was no water for the patient to take the medication. EI # 6 left the room, went back to the nurses' station, obtained a glass of water. EI # 6 went back to PI # 25's room and administered the medication. EI # 6 did not perform hand hygiene before the encounters with PI # 25.

5. An observation of medication pass was conducted on 3/1/17 at 10:00 AM with EI # 6 for PI # 24. EI # 6 told the surveyor there were no potassium (K+) pills in the hospital and she/he had to go to the Emergency Room (ER) to obtain liquid K+. EI # 6 went to the ER, picked up the bottle of liquid K+ and obtained the desired amount. EI # 6 stated her/his hands were sticky and wiped them off with a paper towel. EI # 6 borrowed a pen for the ER staff to sign the K+ out on the log, walked back to the nurses' station with the open medication cup of liquid K+. EI # 6 told the surveyor she/he had washed hands when left the last patient's room, picked up the telephone, called the patient to the nurses' station and told the patient she/he had to get two more pills and would call back. EI # 6 went to the Pharmacy Supply room, unlocked the door with the set of keys in her/his lab coat pocket, obtained the patient medication and poured the liquid K+ in apple juice. EI # 6 picked the phone up again and called the patient back to the nurses' station and administered the patient's medication. EI # 6 did not wash hands when they were "sticky" or before the encounter with PI # 24.

An interview was conducted with EI # 5, Director of Nurse/Infection Control Officer on 3/2/17 at 11:05 AM. EI # 5 stated EI # 6 did not follow the facility policy for Hand Hygiene.

Based on the review of the Infection Control/Blood Utilization Committee Meeting Minutes and interview, it was determined the facility failed to ensure there was a system developed to evaluate measures governing the identification, investigation, reporting, prevention and control of infections and communicable diseases within the hospital. This had the potential to negatively effect all patient served by this facility.

Findings include:

A review of the Infection Control Program for the hospital was conducted with Employee Identifier (EI) # 5, Director of Nurses/Infection Control Officer on 3/2/17 at 11:05 AM.

The surveyor requested all the infection control monitoring tools used to identify, investigate and report all infections in the hospital. There were no tools submitted. There was no documentation the hospital had developed or implemented a system to evaluate measures governing the identification, investigation, reporting, prevention and control of infections and communicable diseases within the hospital, including both healthcare-associated infections and community-acquired infections.

Review of the Infection Control/Blood Utilization Committee Meeting Minutes revealed the last documented meeting was 1/30/2015.

An interview was conducted with EI # 5 on 3/2/17 at 11:20 AM, who verified the above findings.