HospitalInspections.org

Based on observation, record review and interview, the facility failed to ensure crash carts were prepared for use for one ( Medical/Surgical Floor crash cart ) of one crash carts.

Findings:

On 02/27/25 at 9:45 AM during a tour of the facility, the Medical/Surgical Floor crash cart was observed to be missing the PM check off on 02/26/25.

A review of policy " Emergency Crash Cart Security and Accountability" stated in part, " the nursing staff shall visually inspect the numbered lock located on the emergency crash cart at every change of shift, documenting the cart is properly locked and all appropriate contents are present and intact."

On 02/27/25 at 9:45 AM, Staff J stated the evening check off on 02/26/25 was missed and all crash carts are supposed to be checked every 12 hours or once a shift (day and night).

Based on record review and interview, the hospital failed to ensure:
1. Initiation of the nursing care plans for 15 (Patients #1 - #15) of 15 patients reviewed.
2. Completion of the initial nursing assessment for three (Patients #12 - #14) of 15 patients reviewed.

Findings:

NURSING CARE PLAN:

A review of policy titled " Care Plan - Swingbed" read in part, "Atoka Medical Center shall provide an organized written plan, which shall promote both quality and continuity of care."

A review of policy titled "Care Plan - Nursing" read in part, " the admission care plan will be initiated by the RN and will be used as a guide for care until discharged or goals are met. "

A review of the medical records showed the following:

1. Patient #1 had a hospital stay from 02/23/22 to 03/03/22 and had no documented nursing care plan for eight days.

2. Patient #1 had a hospital stay from 04/05/22 to 05/05/22 and had no documented nursing care plan for 30 days.

3. Patient #2 had a hospital stay from 09/11/23 to 09/12/23 and had no documented nursing care plan for one day.

4. Patient #3 had a hospital stay from 10/11/23 to 10/15/23 and had no documented nursing care plan for four days.

5. Patient #4 had a hospital stay from 12/12/23 to 12/14/23 and had no documented nursing care plan for two days.

6. Patient #5 had a hospital stay from 12/26/23 to 12/30/23 and had no documented nursing care plan for four days.

7. Patient #6 had a hospital stay from 05/25/22 to 05/28/22 and had no documented nursing care plan for three days.

8. Patient #7 had a hospital stay from 06/02/22 to 06/05/22 and had no documented nursing care plan for three days.

9. Patient #8 had a hospital stay from 06/26/22 to 06/30/22 and had no documented nursing care plan for four days.

10. Patient #10 had a hospital stay from 08/26/23 to 09/12/23 and had no documented nursing care plan for 17 days.

11. Patient #11 had a hospital stay from 10/05/23 to 10/16/23 and had no documented nursing care plan for 11 days.

12. Patient #12 had a hospital stay from 11/08/23 to 11/15/23 and had no documented nursing care plan for seven days.

13. Patient #13 had a hospital stay from 12/15/23 to 12/22/23 and had no documented nursing care plan for seven days.

14. Patient #14 had a hospital stay from 10/17/22 to 10/28/22 and had no documented nursing care plan for 11 days.

15. Patient #15 had a hospital stay from 11/29/22 to 12/15/22 and had no documented nursing care plan for 16 days.

On 02/28/25 at 10:00 AM, Staff B stated there were supposed to be nursing care plans for each patient, but they were unable to locate them in the medical record.

INITIAL NURSING ASSESSMENTS:

A review of policy "Assessment-Reassessment" read in part, "all patients will have the initial nursing assessment completed within a maximum of four hours of the patient's arrival to the unit."

1. Patient #12 - Review of the medical record showed a 11/08/23 to 11/15/23 hospital stay and showed no documented initial nursing assessment (> 168 hours past due).

2. Patient #13 - Review of the medical record showed a 12/15/23 to 12/22/23 hospital stay and showed no documented initial nursing assessment (> 168 hours past due).

3. Patient #14 - Review of the medical record showed a 10/17/22 to 10/28/22 hospital stay and showed no documented initial nursing assessment for (> 264 hours past due).

On 02/28/25 at 2:30 PM, Staff B stated that all patients were to have an initial nursing assessment at admission and that the initial nursing assessments were missing on patients #12, #13, and #14.

Based on observation and interview, the facility failed to ensure limited exposure to bloodborne pathogens for one (Emergency Room 2 ) of five emergency rooms.

Findings:

On 02/27/25 at 10:30 AM during a tour of the facility, an open sharps container was observed sitting on the floor and was observed to be half filled with exposed needles, instruments, scissors, and blood tubes.

On 02/27/25 at 10:30 AM, Staff A stated that this has been a problem in the Emergency Room and the sharps container was not supposed to be open on the floor.

Based on observation and interview, the facility failed to ensure molded fruit was removed from one (Atoka County Medical Center) of one kitchen.

Findings:

On 02/27/25 at 10:30 AM during a tour of the facility, a molded lemon was observed in a fruit bin in the kitchen.

On 02/27/25 at 10:30 AM Staff A stated that the molded lemon should not be in the bin.

On 02/28/25 at 2:00 PM, Staff C, stated the fruit bins are to be checked every day and that spoiled or molded fruit should be thrown away when found.