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Based on review of the facility's Preventative Maintenance Manual (PMM), observation, and interview, the facility failed to certify the performance of one of one laboratory vent hood. This failed practice had the potential to affect all patients by not maintaining necessary equipment to ensure patient safety during their care. There was a census of 39 patients on 04/06/2015. The findings were:

A. During a review of the facility's PMM on 04/06/15 at 1215, there was no manufacturer recommendation or an Alternative Equipment Maintenance (AEM) plan for inspection and maintenance of the laboratory vent hood available.
B. During a tour of the facility on 04/08/2015 at 1506, it was observed that the vent hood in the laboratory had not been certified since November 2011.
C. During an interview with the Director of Maintenance at the time of the tour it was confirmed that there was no further documentation available pertaining to regular inspection and maintenance of the laboratory vent hood.

Based on review of policy, review of Laminar Flow Hood Certificate of Compliance and interview, it was determined the facility failed to ensure the Laminar Flow Hood was recertified annually per policy since May 2011. By not recertifying the Laminar Flow Hood annually, the facility could not assure a sterile environment in which to compound sterile intravenous products. The failed practice had the likelihood to affect all patients that received intravenous products. Findings follow:

A. Review of policy titled "Sterile Products: Laminar Airflow Hoods" stated "Horizontal airflow hoods shall be checked for operational efficiency by a qualified inspector at least once every twelve (12) months. Biological safety cabinets (vertical flow hoods) shall be checked for operational efficiency by a qualified inspector at least every six (6) months."
B. Review of the Laminar Flow Hood Certificate of compliance that was attached to the outside of the Laminar Flow Hood stated the last inspection was performed on 11/22/10 and it expired May 2011.
C. During an interview on 04/08/15 at 1440, the Director of Pharmacy verified the last certification was 11/22/10.


Based on interview, the facility failed to have policies and procedures in place to ensure annual re-certification of Intravenous (IV) Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood per United States Pharmacopoeia Chapter 797, 2008. By not evaluating the competencies of the personnel, the facility could not assure the sterility or accuracy of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the Laminar Flow Hood. Findings follow:

During an interview with the Director of Pharmacy on 04/08/15 at 1445, the Director verified they do not have policies and procedures in place to ensure annual re-certification of IV Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood.


Based on observation, review of Levalbuterol packaging and interview, the facility failed to ensure floor stock in the Emergency Department was properly controlled in that Levalbuterol was not being dated when opened so it could be monitored for its 2 week expiration once opened according to the manufacturer. The failed practice could not assure Levalbuterol's safety or efficacy in patients who received it under the storage practice and had the likelihood to affect all patients who received it. Findings Follow:

A. During a tour of the Emergency Department on 04/08/15 between 1230 and 1410, observation revealed:
1) An open foil package of Levalbuterol .013% solution containing 7 vials (from a 12 pack foil pouch) for inhalation with no date on the packaging to indicate when it was opened;
2) An open foil package of Levalbuterol .021% solution containing 8 vials (from a 12 pack foil pouch) for inhalation with no date on the packaging to indicate when it was opened; and
3) An open foil package of Levalbuterol .042% solution containing 10 vials (from a 12 pack foil pouch) for inhalation with no date on the packaging to indicate when it was opened.
B. Review of the packaging for Levalbuterol inhalation solution stated " Once the foil pouch is opened, the vials should be used within 2 weeks. "
C. During an interview on 04/08/15 at 1335, the Chief Nursing Officer (CNO) verified the packaging indicated the medication was only good for two weeks. The CNO also verified the packages were not dated when opened.


Based on observation, review of policy and interview, it was determined the facility failed to ensure Intravenous Solutions (IV) and solutions for inhalation were properly controlled that they were not secured in one (Medical/Surgical floor) of four (Medical/Surgical floor, Surgical Services, Emergency Department and Obstetrics/Gynecology) patient care areas toured. The failed practice did not ensure IV solutions and solutions for inhalation were only available to licensed personnel and could not assure the integrity of the items. The failed practice had the likelihood to affect all patients who received these items that were stored unsecured. Findings follow:

A. A tour of the facility on 04/08/15 between 1230 and 1410 revealed the following unsecured IVs and solutions for inhalation in the Medical/Surgical supply room:
1) 5 bags of Dextrose (D) 5%/0.9% Sodium Chloride (NACL) 1000 milliliter (ml) for injection;
2) 10 bags of D5%/0.45% NACL 1000 ml for injection;
3) 12 bags of D5% 100 ml for injection;
4) 12 bags of 0.9% NACL 1000 ml for injection;
5) 6 bags of 0.45% NACL 1000 ml for injection;
6) 12 bags of 0.9% NACL 50 ml for injection;
7) 12 bags of Lactated Ringers 1000 ml for injection;
8) 6 bags of D5%/0.45%NACL 500 ml for injection; and
9) 24 bottles of sterile water 300 ml for inhalation.
B. Review of policy titled "Security of Staff and Drugs" stated "Drugs shall be kept in locked storage or be inaccessible to unauthorized individuals."
C. During an interview on 04/08/15 at 1410, the Chief Nursing Operator verified the fluids were accessible to unauthorized individuals.

Based on review of policy, review of Medication Variance Reports and interview, it was determined the facility failed to notify the practitioner who ordered the medication of the medication error for 28 (#6-8, 10-17, 20, 21, and 23-37) of 47 (#1-47) incidents in 2014. By not reporting medication errors to the prescribing physician responsible for the patient's care, the patients' physicians were not being kept abreast of the patient's condition and were not involved in the decisions of what to do after the error occurred. The failed practice had the potential to affect all patients. Findings follow:

A. Review of policy titled Medication Errors stated "Drug administration errors shall be reported in a timely manner to the practitioner who ordered the drug."
B. Review of Medication Variance Reports from 01/01/14 through 12/31/14 revealed Medication Errors #6-8, 10-17, 20, 21, and 23-37 were not reported to the prescribing physician.
C. During an interview on 04/08/15 at 1455, the Director of Pharmacy verified the above listed medication variances were not reported to the prescribing physician.

Based on observation, it was determined the facility failed to ensure expired supplies were not available for use in three (Operating Room (OR), Surgery Procedure Room and the Emergency Room (ER) of five areas (OR, Surgery Procedure Room,the ER, Medical Surgical Floor and the Obstretics Unit) observed. Failure to ensure only currently dated supplies were available for use had the potential to affect the efficacy of patient care, treatment and the disinfection of equipment. The failed practice was likely to affect any patient whose care and treatment was rendered in the Operating Room (OR), Surgery Procedure Room and the Emergency Room (ER). Findings follow:

A. During the tour of the facility the following expired supplies were observed:
1) OR #1: one gallon of Betadine opened and undated, 30/47-2-o-30" (inch) silk suture expired 01/15 and 22/22-3-o-30" silk suture expired 01/15.
2) Surgery Procedure Room: Medline Dual Enymatic Detergent Cleaner opened and undated and 2/2 Caltech Dispatch Wipes expired 05/24/14. During an interview with the Director of Surgery at 1310 on 04/08/15 she stated the Medline Dual Enymatic Detergent Cleaner manufacturer's guidelines stated the solution was good for 30 days after opening. B. During an interview at 1310 on 04/08/15 the Director of Surgery verified the above findings.
C. In the ER, the following expired supplies were observed:
1) 36/36-5-o-18" Prolene Blue Monofilament expired 01/15.
2) Accu Check Inform II controls 1 and 2 opened and not dated. Review of the manufacturer's guidelines received from the ER Director at 1400 on 04/08/15 revealed the following: "Write the date the bottle was opened on the bottle label. The control solution is stable for 3 months from that date or until the "Use by" date on the bottle label, whichever comes first."
D. During an interview with the ER Director at 1410 on 04/08/15 she verified the above findings.


Based on observation, it was determined the facility failed to keep equipment clean and in good repair in that equipment was rusted, cushions had the covering missing, intravenous (IV) poles were chipped with missing paint, pillows with rips in the covering and red splatter on a pillow in three (Operating Room (OR) #1, Surgery Procedure Room and Delivery Area (Room #214) areas observed. Failure to ensure equipment was clean and in good repair had the potential for contamination. Findings follow:

A. During the tour of OR #1 at 1230 on 04/08/15 the Infant Warmer was observed to have two large rusted areas where the mattress holder connected to the warmer at the foot of the mattress holder; the OR table cushion was observed to have a ½" (inch) strip of missing vinyl on the right corner at the head; two of two IV (intravenous) pole bases had chipped and missing paint. In the Surgery Procedure Room, one of one IV pole base had chipped and missing paint and one of two pillows had multiple 1" rips on both sides of the pillow. The findings were verified at 1310 on 04/08/15 by the Director of Surgery.
B. During the tour of the Delivery Area, Room #214 at 1340, a pillow on the patient bed was observed to have a 3" by 4" area of red splatter. The findings were verified by the Chief Nursing Officer at 1345 on 04/08/15.


31039

Based on observation, review of policy and interview, the facility failed to maintain one of one therapy mat in the rehabilitation did not allow a thorough cleaning in that there were multiple tears along the perimeter and several gashes on the top exposing the padding beneath (not able to sanitize). By not maintaining therapy equipment in a way that allowed them to be thoroughly cleaned, it could not be assured the therapy mat was sanitary for patient use. The failed practice had the likelihood to affect all patients that receive therapy services on the mat table. Findings follow:

A. During a tour of the rehabilitation area on 04/6/15 at 1440, observation revealed one mat table with multiple tears along the perimeter and several gashes on the top.
B. Review of policy titled Physical Therapy Equipment stated "Preventative maintenance program is implemented through the periodic inspection of all equipment during and after each use ...This includes proper cleaning, disinfecting and sterilizing procedures ..."
C. During an interview on 04/06/15 at 1510, Physical Therapist #1 verified multiple tears along the perimeter and several gashes on the top of the mat table.

Based on clinical record review, it was determined the facility failed to develop comprehensive nursing care plans for four (#12, #15, #17 and #19) of seven (#12, #15-20) in-patients. Failure to develop comprehensive nursing care plans did not allow staff to plan and provide care to attain the patient's highest level of physical and mental well-being. The failed practice affected Patient #12, #15, #17 and #19 on 04/06/15. Findings follow:

A. Review of Patient #12's clinical record revealed admission diagnosis of left hip abscess and subsequent surgical intervention on 11/18/14. Review of the nursing care plan revealed wound care, isolation and inability to perform all activities of daily living were not care planned. During an interview with the Chief Nursing Officer (CNO) at 1300 on 04/09/15, she verified the above findings.
B. Review of Patient #15's clinical record revealed admission diagnosis of "passing out spell." Review of the physician's orders revealed Patient #15 was placed on Dilantin. Review of the nursing care plan revealed non-compliance and pain were not care planned. During an interview with the Director of Medical Records at 1145 on 04/10/15, she verified the above findings.
C. Review of Patient #17's clinical record revealed admission diagnoses of nausea and vomiting, generalized weakness, uncontrolled diabetes mellitus and abdominal pain. Review of the physician's orders revealed orders to check blood sugars before meals and at bedtime with insulin ordered per sliding scale. Review of the nursing care plan risk for falls, Diabetes Mellitus, indwelling urinary catheter and nausea and vomiting were not care planned. During an interview with the Director of Medical Records at 1145 on 04/10/15, she verified the above findings.
D. Review of Patient #19's clinical record revealed admission diagnoses of elevated blood sugar, anxiety and "cannot breathe." Review of the physician's orders revealed orders to check blood sugars before meals and at bedtime with insulin ordered per sliding scale and oxygen at 1½ liters per minute. Review of the nursing notes revealed Patient #19 also had a skin rash and was going outside to smoke. Review of the nursing care plan revealed Diabetes Mellitus, Oxygen Use, Respiratory insufficiency and non-compliance were not problem care planned. During an interview with the CNO at 0845 on 04/10/15, she verified the above findings.

Based on observation, review of Medical Records policy and interview, the facility failed to ensure Physician #1 completed 258 delinquent clinical records within 15 days after the patient was discharged as required by policy. By not completing medical records within 15 days it did not enusre patient records were complete. The failed practice had the likelihood to affect all Patients. Findings follow:

A. During a tour of Medical Records on 04/06/15 at 1245, observation revealed shelves with delinquent Medical Records. Physician #1 had 258 charts waiting for signatures, stacked, and dated back to January 2013. There were 81 charts from 2013, 163 charts from 2014 and 14 charts from the first two months of 2015.
B. Review of Medical Records policy revealed "Medical Records must be completed within 15 days after patient's discharge from the hospital or upon request of hospital to meet a third party payor request."
C. During an interview on 04/06/15 at 1300, the Medical Records Director verified Physician #1 had 258 charts that were delinquent.

Based on clinical record review, Medical Staff Rules and Regulations review, and interview, it was determined the facility failed to ensure verbal orders were timed and dated by the ordering Physician within 72 hours for 9 of 9 (#9-#12 and #15-#17, #19, and #20) in-patients and 11 of 11 (#1-#8, #12, #19, and #20) Emergency Department patients. The failed practice did not indicate the Physician had reviewed the chart to assure the verbal order was transcribed as directed and created the potential to affect any patient under the care of those Physicians. Findings follow.

A. Review of Medical Staff Rules and Regulations stated, "All verbal orders must be transcribed in the proper place in the medical record and include the date, time, and the name of the responsible Practitioner. The responsible Practitioner should authenticate (sign, time and date) any verbal or telephone orders within 72 hours."
B. Review of inpatient clinical records revealed the following (all entries were outside the 72 hour window at the time of record review on 04/10/15):
1) Patient #9-four of four verbal orders were not dated and timed.
2) Patient #10-10 of 10 verbal orders were not dated and timed
3) Patient #11-5 of 5 verbal orders were not dated and timed
4) Patient #12-8 of 8 verbal orders were not dated and timed
5) Patient #15-1 of 1 verbal orders were not dated and timed
6) Patient #16-2 of 2 verbal orders were not dated and timed
7) Patient #17-9 of 9 verbal orders were not dated and timed
8) Patient #19-3 of 3 verbal orders were not dated and timed
9) Patient #20-7 of 7 verbal orders were not dated and timed
C. Review of Emergency Department records revealed all orders were not dated and timed for 11 of 11 (#1-#8, #12, #19, and #20) Emergency Department patients.
D. In an interview on 04/10/15 at 1215, the Medical Records Director confirmed the orders were not dated and timed.

Based on observations and interview during the facility tour conducted at 1230 on 04/08/15, it was determined there was not a tracheotomy kit in the operating suite. Failure to ensure a tracheotomy kit was available in the operating suite did not allow the facility to be prepared to meet the patient's medical needs in the event of an emergency. The failed practice affected all patients who have undergone procedures in the operating rooms of the facility. Findings follow:

A. During the facility tour at 1230 on 04/08/15, the Director of Surgery stated a tracheotomy kit was not located in the operating suite and the nearest one available was located in the Emergency Room.
B. The above findings were verified by the Director of Surgery at 1255 on 04/08/15.


30634

Based on clinical record review and interview, it was determined the facility failed to ensure the date and time of surgery was included on the operative report for 6 of 6 (#9-#14) surgical patients. Failure to include the date and time of surgery did not allow knowledge of when surgical procedures took place, or which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow:

A. Review of operative reports revealed the date and time of the operation was not documented on the operative report for surgical Patient #9-#14.
B. In an interview on 04/10/15 at 1215, the Medical Records Director confirmed there was no date and time on the operative reports.

Based on personnel record review and interview, it was determined the facility did not employ a qualified professional to direct the Swing-Bed Activities program. Failure to employ a qualified professional did not ensure the Swing-Bed patients received activities designed to meet the interests, physical, mental and psychosocial well-being of each patient. The failed practice was likely to affect all Swing Bed patients on 04/9/15. Findings follow:

A. Review of the personnel file of the Infection Control/Swing-Bed/Employee Health/Discharge Planner revealed the employee was not a qualified therapeutic recreation specialist, was eligible for certification as a therapeutic recreation specialist or activities professional by or after 10/01/90, was a qualified occupational therapist or completed a State approved training course.
B. During an interview with the Chief Executive Officer (CEO) at 1210 on 04/07/15 she verified the Infection Control/Swing-Bed/Employee Health/Discharge Planner had not attended any training for the Swing Bed-Activities Director position.
C. During an interview conducted with the Infection Control/Swing-Bed/Employee Health/Discharge Planner at 1045 on 04/10/15 she verified she had been the Swing-Bed Activities Director for "only a couple of months" and had not attended any training.

Based on interview, it was determined the activities calendar for Swing-Bed patients had not been developed and placed on the unit or in patient rooms. Failure to develop an activities calendar did not allow the swing bed patient and/or family to be knowledgeable of available activities and choose which activities they would like to participate in. The failed practice affected three (#1-3) Swing-Bed patients on 04/09/15. Findings follow:

A. An activities calendar was requested at the entrance conference conducted on 04/06/15 and none was received by the end of the exit conference on 04/10/15.
B. During an interview with the Chief Executive Officer (CEO) at 1210 on 04/07/15 she verified an activities calendar was not prepared for Swing-Bed patients.
C. During an interview with the Infection Control/Swing-Bed/Employee Health/Discharge Planner at 1045 on 04/10/15 she verified an activities calendar was not prepared for the Swing-Bed patients.


Based on interview, it was determined the facility failed to document activities for three of three (#1-#3) Swing-Bed patients. Failure to document activities did not allow the physician and other staff to be knowledgeable regarding the patient's emotional and physical progress of the plan of care. The failed practice affected Swing-Bed Patient #1-3 Swing-Bed on 04/10/15. Findings follow:

During an interview with the Chief Nursing Officer and the Infection Control/Swing Bed/Employee Health/Discharge Planner at 1045 on 04/10/15, both stated Swing-Bed patient activities were not documented in the clinical records.

Based on clinical record review and interview, it was determined the facility failed to develop comprehensive nursing care plans for two (#2 and #3) of three (#1-#3) Swing-Bed patients. Failure to develop comprehensive nursing care plans did not allow staff to plan and provide care to attain the patient's highest level of functioning and effect optimal care and treatment. The failed practice affected Swing Bed Patient #1 and #2 on 04/10/15. Findings follow:

A. Review of Patient #2's nursing notes and nursing care plan at 1025 on 04/10/15 revealed the plan did not include the dressing change to a wound on the right lower extremity or being pre-medicated prior to the dressing change, patient's assistance with feeding; their incontinence status; broken left arm in a brace, and in isolation for MRSA (Methicillin Resistant Staphlococcus Aureus) as identified in the nursing documentation. During an interview with the Chief Nursing Officer (CNO) at 1025 on 04/10/15, she verified the above findings.
B. Review of Patient #3's nursing notes and nursing care plan at 1000 on 04/10/15 revealed there was no evidence the plan included the patient's constipation; indwelling urinary catheter; incontinent of bowels; edema in the back and both lower extremities; and was disoriented as identified in the nursing documentation. During an interview with the CNO at 1025 on 04/10/15, she verified the above findings.

Based on interview and policy and procedure review, it was determined the facility did not have a dentist on staff or agreement to provide 24 hour emergency dental care. Failure to ensure the availability of dental care to the Swing-Bed patients did not ensure the needs of the patient would be met. The failed practice was likely to affect all Swing-Bed patients on 04/10/15. Findings follow:

A. Review of the policy and procedure titled "Swing-bed - Emergency Dental Care" received from the Chief Operating Officer on 04/07/15 revealed the following under Policy: #2. "An agreement is established and maintained with a local dentist to provide such care on an as-needed basis..."
B. During an interview with the Chief Operating Officer at 1210 on 04/07/15 she verified the facility did not have a dentist on staff or an agreement with a dentist to provide dental care to the Swing-Bed patients.