HospitalInspections.org

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure medications were secure in 2 of 7 storage units (Operating Room (OR) crashcart, Intensive Care Unit (ICU) storage unit). The findings were:

1. Observation on 11/15/22 at 9:30 AM showed the OR area crash cart had a thick string tucked under the upper lip of the cart. There was another thick string that came up from under the bottom of the cart. The two strings had loops where they met in the front of the drawers and were secured together with a pharmacy numbered band. Further observation showed there was a key lock on the front of the cart. However, the drawers could be pulled open. Interview with the OR manager at that time confirmed the cart had emergency medications in it and the cart was not secured.

2. Interview with the DON on 11/15/22 at 2:10 PM revealed the crash cart lock had a broken key in it. Therefore, the facility had it secured with the thick string and pharmacy band. Further, she stated the crashcart was a problem.

3. Observation on 11/16/22 at 2:35 PM of the ICU unit showed no staff present with multiple people walking down the corridor by the open doors. Further observation showed assorted medical supplies and a large supply of intravenous (IV) fluids stored on wire shelving in the corner by one of the doors. The IV fluids ranged from 5% Dextrose in 0.225% Saline (D5 1/4) to Dextrose 10 % in Water (D10W), and varied strengths of sodium chloride IV solutions and volumes.

4. Interview with the DON on 11/16/22 at 4:26 PM confirmed the medical supplies and IV solutions were accessible to the public. Further,she stated the nurses were to log the fluids out through the medication Omnicell.

5. Review of the policy "Control of Crash Cart Supplies" hand delivered on 11/15/22 at 2:10 PM showed "The crash cart will be banded, dated, and initialed to insure that it is properly supplied. ...The cart will be checked monthly for supplies and expiration dates of medications, IV fluids... ...The cart will of course be checked, restocked and rebanded after each use."

6. Review of the policy "Nursing Medications (Including Omnicell Use)" last reviewed 7/21 showed "...JCHC uses the Omnicell system is a point of use inventory management system that provides drug security, product control, inventory management and increased patient medication safety for acute care and emergency room. It is an adjunct to the unit dose system. The Omnicell system will be utilized for floor stock medications including controlled substances."

Based on review of facility policies and procedures, staff interview, and medical record review, the facility failed to ensure patients (or their support person) were informed of their visitation rights for 19 of 19 sample patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #14, #16, #17, #18, #19, #20, #21 and #22). The findings were:

1. Review of the medical records for residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #14, #16, #17, #18, #19, #20, #21 and #22 showed no evidence the patients (or their support person) were fully informed of their visitation rights. Review of each medical record showed a "Statement of Acknowledgement" consent form, which indicated the patient had received a copy of patient rights. Review of the patient rights information provided to patients showed only "...You have the right to unlimited contact with visitors and others." There lacked evidence the patient was informed of the facility's visitation policy, including any clinical restrictions to visitation rights. In addition, there lacked evidence the patient was informed of their right to receive any visitors whom s/he designated, and their right to withdraw consent at any time.

2. Review of the facility's policy "Visitors" (June 5, 2018) showed "Visitors may include, but are not limited to, a spouse, a domestic partner (including same sex partner), family members, and friends. The patient may withdraw your consent for visitors at any time during your stay." In addition, the policy stated "...Visitors may be limited or restricted only when visitation would interfere with the care of the patient and/or the care of other patients." The policy included examples of when the facility may need to restrict visitors.

3. During an interview on 11/15/22 at 2:43 PM the DON confirmed patients were not fully informed of the facility's policy on visitation. She stated they needed to "beef up" the information patients received on visitation rights.

Based on review of policy and procedures, staff interview, and review of the facility's staff COVID-19 vaccination records, the facility failed to ensure 100% of staff were vaccinated against COVID-19, held an approved exemption, or had a temporary delay. One out of 184 current employees was not fully vaccinated, held an approved exemption, or had a temporary delay, for a percentage of 99.46 in compliance. The findings were:

1. Review of the facility's documentation to track COVID-19 vaccination for staff showed RN #1 had an approved medical exemption dated 11/23/21.

2. Review of the medical exemption for RN #1 dated 11/23/21 with the Director of Administration on 11/16/22 at 2:50 PM revealed the medical exemption was temporary, because the employee had COVID-19. Interview with the Director of Administration at that time revealed the medical exemption was temporary and expired in February 2022.

3. Interview with the Director of Administration on 11/16/22 at 3:02 PM revealed she spoke to RN #1, who stated she thought she filled out a religious exemption form, but couldn't remember.

4. During an interview on 11/17/22 at 8:12 AM, the infection preventionist confirmed RN #1 did not have a current approved exemption and "...it got missed." She stated the medical exemption granted in November 2021 was only temporary because the employee had COVID-19.

5. Review of the facility's policy "COVID-19 Vaccination" (effective 11/15/21, reviewed 1/26/22) showed "...Reasons for a temporary medical exemption include: ...Recent COVID-19 infection and within the isolation period or continued symptoms and advised by medical provider to defer vaccination. (90-day exemption)"

Based on staff interview, the facility failed to ensure the periodic review of a representative sample of discharge plans, including patients who were readmitted within 30 days. The findings were:

1. Interview with the discharge planner on 11/15/22 at 3:30 PM revealed the facility did not review a sample of discharge plans, including patients that were readmitted. She further stated there would be no documentation to review to show the facility did periodic reviews of discharge plans.

2. During an interview on 11/17/22 at 7:50 AM the Director of Administration stated a representative sample of discharge plans, including patients who were readmitted within 30 days, was not something that the facility included in its quality assurance program. She stated readmissions to the emergency room were reviewed, but not inpatient readmissions.