HospitalInspections.org

Based on review of facility policy, medical record review, and interview, the facility failed to ensure the family and/or guardian was notified of a transfer for 1 patient (#6) of 5 transferred patients reviewed of 19 medical records sampled.

The findings include:

Review of facility policy "Transfer to Another Facility" revised 10/10/18 revealed "...notify the patient's family and/or guardian of the transfer..."

Medical record review revealed Patient #6 was admitted to the facility on 3/7/19 with a diagnosis of Hypotension (low blood pressure). Further review revealed the patient was transferred to another acute care facility on 3/8/19 for "...ICU [intensive care unit] CCU [critical care unit] services..." Continued review revealed no documentation the patient's family or guardian was notified of the transfer.

Interview with the Chief Nursing Officer on 3/12/19 at 3:06 PM, in the conference room, confirmed the facility failed to notify Patient #6''s family or guardian of the transfer and failed to follow facility policy.

Based on observation and interview, the facility failed to ensure supplies were stored in a safe manner in 1 of 2 radiology department (x-ray room #2) restrooms of 12 departments observed.

The findings include:

Observation and interview with the Chief Compliance Officer (CCO) on 3/11/19 at 3:55 PM, of x-ray room #2, revealed 1 unopened vacutainer blood collection kit with needle (kit used to obtain a blood specimen) stored on top of the paper towel dispenser. Interview with the CCO confirmed the restroom was accessible to the public and the facility failed to ensure supplies were stored in a safe manner.

Based on review of facility policy, review of facility checklist, observation, and interview, the facility failed to maintain a sanitary environment in 4 departments (Medical Surgical Unit, Kitchen, Radiology Department, and Anesthesia Stock Room) of 12 departments observed.

The findings include:

Review of facility policy "Storage and Use of Leftovers" dated 4/23/18 revealed "...food for storage in refrigerator is placed in storage containers...marked with name of items, date and initials..."

Review of facility policy "Expired and Other Unusable Medications/Supplies" revised 2/2017, revealed "...Medications/supplies are removed from use if they are: a. Expired (outdated)...Storage areas for expired unusable medications/supplies must be separated from active stock. The medications/supplies must be clearly labeled 'Outdated and/or Unusable-Do Not Dispense, Administer, or Use' or another similar warning..."

Review of a Dietary Department Checklist, undated, revealed "...all foods covered, labeled, dated...all equipment cleaned and sanitized...dispose of all outdated items..."

Observation and interview with the Chief Nursing Officer (CNO) and the Housekeeping Director on 3/11/19 at 12:30 PM, of the Medical/Surgical Unit patient refrigerator, revealed:
*1 unlabeled and undated plastic container of lettuce
*1 unlabeled and undated container of pickle spears
*1 unlabeled and undated container of croutons
*1 unlabeled and undated container of shredded yellow cheese
*1 unlabeled and undated container of salad dressing
*1 unlabeled and undated container of green olives
Interview with the CNO and the Housekeeping Director confirmed the facility failed to date and label the food items.

Observation and interview with the CNO, the Housekeeping Director, and the Dietary Cook, on 3/11/19 at 3:45 PM, in the kitchen, revealed a covered meat slicer with meat on and under the slicer. Interview with the Dietary Cook confirmed the meat on the slicer was ham and the meat slicer was last used on 3/10/19 (1 day earlier). Further interview confirmed the meat slicer was not clean and was stored dirty.

Observation and interview with the Chief Compliance Officer (CCO) on 3/11/18 at 3:54 PM, in the Radiology Department, revealed 1 opened and undated 1900 milliliter (half full) container of Barium Sulfate Suspension (used to diagnose certain disorders of the esophagus, stomach, or intestines). Interview with the CCO confirmed the Barium Sulfate Suspension was opened and undated. Further interview confirmed the facility failed to ensure the suspension was properly labeled.

Observation and interview with the CNO and the Housekeeping Director, on 3/11/19 at 4:00 PM, of the walk in cooler in the kitchen, revealed 1 cooling fan with a buildup of dust. Interview with the CNO and the Housekeeping Director confirmed the facility failed to ensure the cooling fan was clean.

Observation and interview with the CNO and the Housekeeping Director, on 3/11/19 at 4:05 PM, in the kitchen, revealed 1 return air vent with a buildup of dust. Interview with the CNO and the Housekeeping Director confirmed the facility failed to ensure the air vent was clean.

Observation and interview with the CNO and the Housekeeping Director, on 3/11/19 at 4:10 PM, inside the walk in freezer in the kitchen, revealed:
*a 32 ounce (oz) bag of broccoli florets opened and undated
*a 40 oz. bag of diced potatoes opened and undated
*a 32 oz. bag of french fries opened and undated.
Interview with the CNO and the Housekeeping Director confirmed the facility failed to date and label the opened frozen foods.

Observation and interview with the Director of Surgical Services (DSS) and CCO on 3/11/19 at 5:00 PM, of the anesthesia stock room, revealed:
*Three 8.5 endotracheal tubes expired on 1/2019
*One #3 laryngeal mask airway (LMA) (a medical device to keep a patient's airway open during anesthesia or unconsciousness) expired on 5/20/18
*Nine #3 LMAs expired on 7/28/18
Interview with the DSS confirmed the endotracheal tubes and the LMAs were expired and were available for patient use.