HospitalInspections.org

Based on medical record review and staff interview, the facility failed to protect and promote and inform five (5) of 13 patients reviewed of their Patient Rights, Patient #5, #6, #7, #8 and #9.


Findings Include:


Record review for Patient #5, #6, #7, #8 and #9 revealed no documented evidence that the notice of Patient's Rights was presented to the patient upon or after admission.


During an interview on 2/29/16 at 4:00 p.m. the Quality Assurance/Performance Improvement (QAPI) nurse confirmed there was no signed documentation that the notice of Patient's Rights was presented to these patients or their representative upon or after admission.


During the exit conference on 03/01/16 at 4:59 p.m. these findings were presented. No further documentation was provided.

Based on staff interview, and document review, the facility failed to ensure a working Quality Assessment and Performance Improvement (QAPI) program for the past 12 months.

Findings Include:

On 02/29/16 at 11:00 a.m. and on 03/03/16 at 9:45 a.m. QAPI documents were requested from facility staff. The facility failed to submit any QAPI documentation for the past 12 months.

In an interview on 03/01/16 at 11:15 a.m. the Administrator stated, "I have spent a year on a Performance Improvement project, teaching the staff what a Performance Improvement project is." The facility failed to submit any documented evidence of a Performance Improvement project.

On 03/01/16 at at 11:45 a.m. the Administrator and Risk Manager presented a QAPI plan and stated that since a change of ownership started on this date, 03-01-16, the plan submitted would be implemented.

During the exit conference on 03/01/16 at 4:59 p.m. these findings were presented. No further documentation was provided.

Based on record review, staff interview, and policy and procedure review, the facility failed to ensure a well-organized nursing service with a plan of administrative authority and delineation of responsibilities for patient care.


Findings Include:


Review of the facility's Emergency Crash Box Checklist and Defibrillator Checklist revealed the defibrillator on the crash cart had not been checked for 28 of 58 nursing shifts during the month of February 2016, with the last check being performed on 2/21/16.


During an interview on 3/01/16 at 3:47 p.m. the Quality Assurance/Performance Improvement (QAPI) nurse confirmed the defibrillator had not been checked every shift during February 2016 and had not been checked since 2/21/16.


Review of the facility's "Defibrillation Policy" revealed, "...Policy: The defibrillator is checked every shift by the Nurse Manager or designee ...".


During the exit conference on 03/01/16 at 4:59 p.m. these findings were presented. No further documentation was provided.

Based on observation, staff interview, job description review, and policy and procedure review, the facility failed to ensure outdated medications and biological were not available for patient use.


Findings Include:


Observation of the Nurses Medication Room on 2/29/16 at 11:30 a.m. revealed three (3) expired medications:
(1) A 20 ml (milliliter) vial of Labetalol Hydrochloride injectable with an expiration date of January 2016.
(2) Digoxin injectable ampules with an expiration date of December 2015. (3) Levalbuterol HCL inhalation solution, 16 vials with an expiration date of November 2015.

During an interview on 02/29/16 at 11:45 a.m. the Charge Nurse confirmed the expired medications and stated that Pharmacy checks for expired medications.


On 2/29/16 at 12:15 p.m. observation of the crash cart revealed:
four (4) 10 ml vials of 0.9% Sodium Chloride with expiration dates of 10/1/13; and one (1) 10 ml vial of Sterile Water with an expiration date of 3/1/14. During an interview at that time the Quality Assurance/Performance Improvement (QAPI) nurse confirmed these findings.


An interview with Pharmacy technician on 02/29/16 at 2:15 p.m. revealed that she had only been employed at the hospital for two months and she was unsure who is responsible for checking for expired medications.


Review of the job descriptions for the Pharmacist, Pharmacy Technician and the nurse revealed no documented evidence of who is responsible for checking for expired medications.


Review of the facility's "Safe Storage of Medications" policy, approved by the Governing Body on March 1, 2016, revealed: "...all drug storage areas within the facility shall be inspected monthly by Pharmacy Services ...".


Review of the facility's "Medications" policy, approved by the Governing Body on March 1, 2016, revealed: "...all drug storage areas of the hospital will be inspected for outdated drugs."



During the exit conference on 03/01/16 at 4:59 p.m. these findings were presented. No further documentation was provided.



33616

Based on staff interview, personnel record review, and policy and procedure review, the facility failed to designate in writing an Infection Control Officer who is qualified through education, training, experience or certification and failed to ensure the development and implementation of infection control measures related to hospital personnel.


Findings Include:


During an interview on 2/29/16 at 3:00 p.m., the Quality Assurance/Performance Improvement nurse stated that a Licensed Practical Nurse (LPN) was the facility's designated Infection Control Officer. Written designation of this appointment was requested. No documented evidence was submitted.


During an interview on 3/01/16 at 11:30 a.m. the LPN verbally designated as the Infection Control Officer stated that she did not have training, experience or certification in Infection Control. She stated that the facility had plans to send her for training in the near future. Review of the LPN's personnel record revealed no documented evidence of Infection Control training, experience or certification.


Review of the facility's "Infection Prevention and Control Program" policy revealed, "Infection Prevention and Control Committee-Organization and Function ...Infection Preventionist(s) shall:...Be qualified through education, training, experience or certification in adult or pediatric infections ...".


Review of personnel records revealed seven (7) of seven (7) employees reviewed (Employee #1, #2, #3, #4, #5, #6, and #7) had no documented evidence of an employee physical and Employee #2 and #7 had no documented evidence of having been screened for tuberculosis.


Review of the facility's "Employee Recruitment and Selection Process" policy (approved on March 1, 2016 by the Governing Body) revealed: "...The Department will ensure completion of the appropriate Background Checks, Drug and Health Screenings ...".



Review of the facility's "New Hire Policy" approved by the Governing Body on March 1, 2016 revealed: "Prior to hire, candidates shall complete a preplacement physical exam and tuberculosis skin test ...".


During the exit conference on 03/01/16 at 4:59 p.m. these findings were presented. No further documentation was provided.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure multi-dose vials are discarded within 28 days after opening.


Findings Include:


Observation of the medication refrigerator in the nurse's station medication room on 2/29/16 at 12:05 p.m. revealed that four (4) of seven (7) opened Insulin vials had been opened and dated for greater than 28 days. Opening dates ranged from 12/21/15 to 1/22/16. The Infection Control Officer confirmed these findings.


Review of the facility's "Safe Administration of Medications" policy revealed, " ...For multi dose vials, the expiration will occur 28 days after the vial has been opened/punctured, providing ...".



During the exit conference on 03/01/16 at 4:59 p.m. these findings were presented. No further documentation was provided.