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Based on observation and interview, it was determined in 1 of 1 OB (Obstetric) Surgical Suites toured, the Hospital failed to ensure medication syringes were labeled and properly stored. This has the potential to affect all patients receiving surgery in the OB department.

Findings include:

1. On 7/24/2022 at approximately 11:45 AM, a tour of the unoccupied OB Surgical Suite was conducted with the OB registered nurse (E#4). During the tour a 10 ml (milliliter) syringe with 4 ml of clear fluid with a needle/cap attached was found on the top of the anesthesia cart.

2. On 7/24/2022 at approximately 11:50 AM, an interview was conducted with E#4. E#4 stated,"the syringe most likely has ephedrine in it, which is used for when the patient becomes hypotensive."

3. On 7/24/2022 at approximately 12:15 PM, an interview with the Chief Nursing Officer (E#1) was conducted. E#1 stated that the syringe should have been discarded.

Based on document review and interview, it was determined that for 1 of 2 (Pt. #26) patient records reviewed for receiving a blood transfusion in the emergency room, the Hospital failed to ensure that the clinical record was accurate and complete. This has the potential to affect all patients receiving care in the emergency room with an with an average daily census of 35-40 patients.

Findings include:

1. On 7/26/2022 at approximately 12:30 PM the clinical record of Pt#26 was reviewed. Pt#26 had a chief complaint of failure to thrive. The "Blood Bank Issue/Transfuse Card" lacked the following documentation.
a. The "Blood Bank Issue/Transfuse Card" for the 1st unit of blood dated 7/16/2022 at 1:38 AM lacked documentation when the blood transfusion ended, BBK (Blood Bank) Bracelet I.D.#, the 2nd 15 minute blood vital signs, and the 1/2 way through blood vital signs.

b. The "Blood Bank Issue/Transfuse Card" for the 2nd unit of blood dated 7/16/2022 at 2:22 AM lacked
documentation of the time the transfusion started, ended, the BBK Bracelet I.D. #, the amount given, if there was a reaction and if this was a rapid transfusion. The "Blood Bank Issue/Transfuse Card " also lacked documentation of the time of the 2nd and 3rd set of 15 minute vitals and the time of the 1/2 way through the blood (#4) vital signs.

2. On 7/26/2022 at approximately 4:00 PM, an interview with the Chief Nursing Officer (E#1) was conducted. E#1 reviewed Pt #26's record and verbally agreed the "Blood Bank Issue/Transfuse Card" lacked the required documentation.

A. Based on document review, observation and interview, it was determined the Hospital failed to ensure staff were protected from unnecessary x-ray exposure by checking for lead apron/collar defects per policy. This has the potential to affect all surgical staff which are exposed to radiation.

Findings include:

1. The policy titled "The Lead Apron Policy" (revised 06/22) was reviewed on 7/28/22. The policy noted "Process Lead aprons, gloves, and thyroid shields shall be checked prior to being placed into service and annually for defects, such as holes, cracks, or tears. A record of the date of the check, the type of the check, and who performed the check... Rejection Criteria... multiple small holes and cracks in cluster... Wearing out or thinning of the lead... If a defect is found... the date of the rejection is documented on Protective Garments Test Log..."

2. The Surgery Protective Garment Test logs were reviewed on 7/27/22 at approximately 11:00 AM. The following log sheets lacked the required documentation:
a) the log sheets lacked documentation of the type of check conducted;
b) the log sheets dated 4/5/22 and 2 dated 4/6/22, lacked the name of who performed the checks;
c) the following log sheets lacked documentation of the Appearance of the lead apron/collar at the time of inspection: 4/6/22 Surgery 5C Blue Collar, Surgery #1S- Red Skirt and the 4/8/22 Douglas Thyroid.
d) the log sheet dated 4/6/22 noted the Surgery #25- Green Skirt's Appearance as "Adequate" and "Poor" due to a tear in the top seam. It was unable to be determined if the skirt was removed from service.
e) the log sheet dated 4/6/22 noted "Thinning on left side and right side edges" for the Troy Green Camo Apron; the log sheet dated 4/6/22 noted "Large tear left and right shoulders, holes along bottom" for the Skulls Tony's Apron; and the log sheets dated 4/8/22 noted "multiple cracks" for the OR (Operating Room) #17 and Feather Blue Vest.

3. During an interview on 7/28/22 at approximately 12:30 PM, the Director of Radiology (E#5) stated the lead shields are only removed from inventory if the lead is cracked.

4. During an interview on 7/28/22 at approximately 2:45 PM, the Vice President of Nursing (E#1) and the Directory of Quality and Regulatory Compliance (E#2) reviewed the Lead Apron Policy and the Protective Garment Test logs and verbally agreed the log sheets lacked the type of check conducted, the name of who performed the check, lacked documentation of the Appearance; lacked documentation if the skirt was removed from service and the lead shield which were thinning, torn or cracked should have been removed from service.






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B. Based on document review and interview, it was determined for 4 of 4 (E #6, E #7, E #8, and E #9) X-ray technicians, 1 of 1 (E #10)Nuclear Medicine Coordinator and 2 of 2 (E #11 and E #12 ) Operating Room staff who required a dosimeter badge, the Hospital failed to ensure the dosimeter badges were monitored per policy. This has the potential to affect all patients and staff who are exposed to radiation.

Findings include:

1. The policy titled "Personnel Dosimeter (reviewed by the facility, 6/22) was reviewed on 7/28/22. The policy noted "Monthly whole body film badges ... are to be used by all occupational personnel monitoring total body and extremity exposures... Monthly and yearly cumulative badge results will be posted..."

2. The Dosimeter Reports from July 2021 to present was requested. The reports were reviewed on 07/27/22 at approximately 9:00 AM. The reports provided were dated as follows:
X-ray technicians - August 11, 2021 and March 31, 2022
Nuclear Medicine - April 14, 2022 and July 7, 2022
Surgical Staff - March 22, 2022

4. During an interview on 7/28/22 at 11:00 AM, the Director of Radiology (E #5) reviewed the dosimeter report and verbally agreed the dosimeter reports are not conducted monthly as per policy.

Based on document review, observational tour and interview it was determined for all condiment substances (mustard, ketchup, mayonnaise and jelly), the Hospital failed to ensure condiments were rotated per policy.

Finding include:

1. The policy titled "Food Storage" (revised 1/19) was reviewed on 7/27/2022 at approximately 2:00 PM. The policy required, "Perishable and non-perishable items are stored using First-In, First-Out, FIFO Inventory System."

2. On 7/26/2022 at approximately 2:00 PM - 4:00 PM an observational tour of the patient nourishment rooms on the Post Critical Care Unit and the Medical-Surgical Unit was conducted with the Director of Quality (E#2). There were unlabeled plastic bags containing approximately 100 individual servings of mustard, ketchup, mayonnaise and jelly which lacked an expiration date or delivery date.

3. On 7/26/2022 at approximately 4:15 PM an interview with the Director of Food Nutrition (E#13) was conducted. E#13 stated that "we use the FIFO system, all these items come in a bulk container and we failed to put the expirations on the plastic bags delivered to the patient care units."


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Based on observations during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on July 26, 2022, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on July 26, 2022, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.