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Based on observation, record review and interview, the facility failed to ensure 2 (Medical Surgical Unit and Emergency Room) of 5 units' medication refrigerators were properly monitored for temperature and stored properly. The facility failed to ensure medications were stored securely in the Intensive Care Unit.

The findings included:

1. Review of the policy "Refrigeration and Freezing" from pharmacy dated 10/06, said "Refrigerator and freezer temperatures in patient care areas and in the pharmacy shall be monitored and recorded daily. If temperatures deviate from the acceptable range, an adjustment shall be made. Refrigerators and freezers that will not maintain the acceptable temperature range shall be repaired or replaced."

2. On 2/15/16 at 5:00 p.m., an observation during the tour of the Medical Surgical Unit (med surg), it was noted the medication refrigerator had a sticker on the unit and read "Medication refrigerator - maintain temperature between 36 F (Fahrenheit) and 46 F." Observation in the refrigerator noted several medications including, lantoprost ophthalmic solution 0.005% (a glaucoma medication), said to "Store unopened bottle under refrigeration at 36 F to 46 F." Observation of the external medication refrigerator thermometer noted the thermometer was flashing, no audible alarm was sounding, and said the temperature was 48 F. Observation of the internal compact temperature recorder also said the temperature was 48 F. The Quality Improvement Director and the Pharmacy Director both verified the med surg medication refrigerator was not within the recommended range.

On 2/17/16 at 11:00 a.m., in an interview, the Pharmacy Director acknowledged the medication refrigerator and alarms are not working correctly. He said the refrigerator had an issue about a month ago, where it was too cold and below 36 F. His staff told him about a month ago and he adjusted it. He said no one had notified him of the continued issues and he had not thought to recheck the med surg refrigerator. The Pharmacy Director said this unit has an internal compact temperature recorder which records the temperature 24 hours continuously throughout the day. He said they monitor the temperature wheels weekly and make adjustments as needed.

Record review of the internal compact temperature recorder wheels and interview with the Pharmacist noted from 1/20/16 through 1/27/16, the temperature wheel noted the med surg refrigerator was below 36 F everyday. The Pharmacist said he adjusted the temperatures on 1/27/16, trying to get the temperature between 36 F and 46 F.

Record review of the internal compact temperature recorder wheels and interview with the Pharmacist noted from 1/27/16 through 2/3/16, the temperature wheel noted the med surg refrigerator was above 49 F everyday.

Record review of the internal compact temperature recorder wheels and interview with the Pharmacist noted from 2/10/16 through 2/17/16, the temperature wheel noted the med surg refrigerator was above 48 F everyday.

On 2/17/16 at 11:00 a.m., in an interview, the Pharmacy Director said no staff on the nursing floor notified him there were any issues with the med surg refrigerator for the past month. He said his staff pulls the internal compact temperature logs once a week and none of his staff told him of the issue. He said he has not reviewed the temperature wheels for the past month. He said he does not keep any logs of issues with the medication refrigerator to document the temperature was corrected and monitored to ensure it is within the proper range of 36 F to 46 F. He said the refrigerator will be down for repairs until they can ensure the unit is functioning correctly.

He then added, he was not sure if the internal compact temperature recorder was working correctly since it has not been calibrated since 2009. He said he told maintenance to calibrate it last year, but they never did. He was not aware how to calibrate the external thermometers and said the alarm was not set to the proper range of 36 F and 46 F, and staff turned off the audible alarm on the external thermometer for the med surg refrigerator.

3. On 2/15/16 at 5:13 p.m., an observation during the tour of the emergency room (ER) unit, it was noted the medication refrigerator had a sticker on the unit said "Medication refrigerator - maintain temperature between 36 F and 46 F." Observation in the refrigerator noted several medications, including, diltiazem and infuvite vitamins for intravenous infusion said to "Store under refrigeration at 36 F to 46 F." Observation in the refrigerator also noted tetanus/diphtheria immunizations said to "Store at 36 F to 46 F." Observation of the external medication refrigerator thermometer noted the thermometer was flashing, no audible alarm was sounding, and said the temperature was 48 F. It was noted the range on the alarm was set to alarm between 43.2 F and 47.3 F. There was no internal compact temperature recorder. The Quality Improvement Director and the Pharmacy Director both verified the ER medication refrigerator was not within the recommended range.

On 2/17/16 at 11:00 a.m., in an interview, the Pharmacy Director said no staff on the nursing floor notified him there were any issues with the ER refrigerator for the past month. He said the refrigerator used to have an internal compact temperature recorder, but they got a new refrigerator last year and they did not replace the 24 hour continuous internal recorder. He said pharmacy staff does not monitor the temperature for this unit and staff from the ER should be monitoring the temperatures.

Record review of the ER temperature log for the refrigerator, found on the side of the unit, documents a log was kept from 1/1/16 through 1/21/16. Review of the log noted staff was not completing the form as per the instructions and documenting who checked the temperature and the exact time twice a day. The Quality Improvement Director and the Pharmacy Director both verified staff were not completing this form correctly and confirmed no one has been recording the temperatures from 1/21/16 through 2/17/16.

On 2/17/16 at 11:00 a.m., in an interview, the Pharmacy Director said he was not aware the tetanus immunizations were being kept in the ER refrigerator and said this refrigerator should still have a internal compact temperature recorder to monitor the temperature 24 hours a day. The Pharmacy Director said the alarm was not set to the proper range between 36 F and 46 F and staff turned off the audible alarm on the external thermometer for the ER refrigerator.

On 2/17/16 at 12:00 p.m. the Director of Nursing said "The ER refrigerator should have 24 hour continuous monitoring since they had immunizations within the unit." The Director of Nursing also confirmed this was the only medication refrigerator in the hospital and outpatient facility without an internal compact temperature recorder.

4. Review of the policy "Security of staff and drugs" from pharmacy dated 10/06 said "Drugs shall be kept in locked storage or be inaccessible to unauthorized individuals."

On 2/15/16 at 5:20 p.m., during tour of the Intensive Care Unit (ICU), it was noted the medication refrigerator padlock was unlocked and the medications were not secure. Observation in the refrigerator noted several medications including: calcitonin, Cardizem, Ppepcid, Sandostatin and insulin.

Also noted on the counter in the ICU, was 1 opened multidose vial of heparin flush - 10 ml - not locked up and left unsecured.

The Pharmacy Director verified the ICU medication refrigerator was not locked and the heparin flush was left unsecured. He confirmed there were no patients or staff currently on this unit. He said the staff from the med surg unit will sometimes use this unit and may have unlocked the refrigerator and left it unlocked for their convenience. He confirmed their policy said all medications should be locked and secured whether patients are on the unit or not since anyone in the hospital could have access to this unit.
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Based on interview and record review, the facility failed to develop an infection control policy for cleaning glucometers after use with each patient to include contact time of the cleaning wipes resulting in a potential for infection from blood or bodily fluids.

The findings included:

On 2/17/16 at 12:58 p.m., during an interview, Registered Nurse (RN) Staff G, said she used Sani-Cloth Plus germicidal disposable cloths to clean the glucometer with each use. Staff G said there was 1 glucometer on the floor and it was used for all patients needing their glucose monitored. Staff G was not aware of contact time of the cleaning solution. She said she would wipe the machine down with the cloth and let it air dry.

Review of the manufacturer's instruction on the label of the product showed, "Open and unfold and use first germicidal wipe to remove heavy soil. Contact Time: Use second germicidal wipe to thoroughly wet the surface. Allow to remain wet for 2 minutes and air dry."

On 2/17/16 at 1:00 p.m., during an interview with Staff H, RN, said she has worked at the hospital for 22 years and she was not aware of contact time for cleaning glucometers.

Review of the laboratory's Policy and Procedure for Cleaning Glucometers dated September 1999 showed, "The meter must be cleaned after each use. Use Sani-Wipe to clean the meter ... allow the meter to air dry." There is no mention in the policy of contact time or following the manufacturer's instructions for cleaning to kill blood borne pathogens.

In an interview RN Supervisor, Staff J verified nurses were responsible for cleaning glucometers after each use. She verified there was no current policy for nurses to clean glucometers. She said the nurses are in-serviced through the current laboratory policy for cleaning glucometers. She verified the laboratory policy did not include the instructions from the manufacturer of the current product being used to clean glucometers to allow for a minimum 2 minute contact time with a second cleaning wipe.
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Based on interview and record review, the facility failed to provide an activities program for 3 (Patients #1, #9, and #10) of the 3 swing bed patients surveyed.

The findings included:

On 2/16/16, Patient #1 was the only swing bed patient on the floor. On 2/16/16 at 9:44 a.m., during an interview with Patient #1, she said the only activity she had was the television.

Review of initial assessment dated 2/15/16, showed under activity title, the resident was assessed as "walks occasionally." Patient #1 did not have a care plan in place for activities.

On 2/16/16 at 10:31 a.m., during an interview RN Supervisor, Staff J said the nursing assistant who worked on the floor was over activities for the swing bed patients. She said there was no particular person over activities. If the CNA was not present, the nurses were responsible for activities. Staff J said there were no scheduled activities for Patient #1.

On 2/16/16 at 10:40 a.m., during an interview RN, Staff I verified she was caring for Patient #1. Staff I said she would document in her notes which activities Patient #1 was doing during her shift. She said as far as activities go, she was aware there were books and magazines and a computer available for the patients.

Review of the closed records for Patient #9 and #10, revealed neither of the patients had been assessed or care planned for activities. No documentation was found in the medical record, either of the patients had been offered scheduled activities.

On 2/16/16 at 2:30 p.m., the Chief Nursing Officer (CNO) said the Activities Director was the Director of Rehabilitation (Staff K) who was a licensed Occupational Therapist. At that time, the CNO verified a lack of documentation of activities for patients in swing beds.

On 2/17/16 at 9:55 a.m., during an interview with the Director of Rehabilitation, he was asked if he was the Activities Director. He said, "Apparently I am." The Activities Director said if a swing bed patient had occupational therapy ordered he would go over the available activities on the floor and assist the patients as they needed assistance with activities. He said he did not assess the patient's activity pursuits and there were no scheduled activities available for swing bed patients. He said he would have to work on ensuring all swing bed patients had activities provided.
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Based on interview and record review, the facility failed to comprehensively assess 3 (Patients #1, #9, and #10) of 3 swing bed patients for activity pursuits.

The findings included:

Review of the initial assessment for Patient #1 dated 2/15/16, revealed under Activities Assessment, "Walks occasionally." No documentation was noted in the medical record of the patient's activity pursuits.

Review of Patient #9's initial assessment dated 12/30/15, revealed under Activities Assessment, "Chair fast." No documentation was noted in the medical record for the assessment of the patient's activity pursuits.

Review of Patient #10's initial assessment dated 4/2/15, revealed under Activities Assessment, "Chair fast." No documentation was noted in the medical record for the assessment of the patient's activity pursuits.

On 2/16/16 at 2:30 p.m., during an interview RN Supervisor, Staff J verified the swing bed patients had not been assessed or care planned for activities.

On 2/17/16 at 9:55 a.m., during an interview with the Activities Director, he said he did not assess the patient's activity pursuits.
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