HospitalInspections.org

Based on observation and interview, facility staff failed to ensure biologicals available for patient use were not expired. Findings include:

During an observation and interview on 6/12/19 at 10:40 a.m., three 500 milliliter bags of normal saline for patient use, with an expiration date of "4/19," were found among other intravenous bags of normal saline. Staff member D removed the expired bags of normal saline. Staff member D stated an inventory of expired biological items had just been conducted earlier in month by the nursing staff.

Based on observation, interview, and record review, facility staff failed to ensure essential patient-care equipment, an ultrasound machine, donated to the facility, had been inspected and tested for performance and safety prior to use. Findings include:

During an observation and interview on 6/11/19 at 8:21 a.m., a standard General Electric (GE) ultrasound machine was available for use in the radiology department. Staff member B stated the ultrasound machine had been donated to the facility in April 2019, and had been in use since then. The ultrasound machine lacked documentation showing preventive maintenance had evaluated the equipment to ensure it was in safe operating condition.

A review of the facility's Ordered Exams Report, dated 1/1/19 through 6/11/19, showed 14 ultrasound exams had been conducted from 4/30/19 through 6/11/19.

During an interview on 6/11/19 at 3:40 p.m., staff member B stated he did not have a preventive maintenance evaluation performed on the ultrasound machine prior to its use. Staff member B stated he had contacted the contractor and an inspection and performance, and safety evaluation would be conducted on 6/18/19. Staff member B stated the ultrasound machine would not be used until the evaluation had been performed.

A review of the facility's policy, Emergency Medical Services: Supplies and Equipment, read, "...Definition of Maintenance and Testing Protocols; Maintenance and testing protocols, both electrical and operational, are generally specified by the equipment manufacturer. The Maintenance Supervisor in collaboration with the Director of Nursing, and in conjunction with personnel from any appropriate ancillary departments, shall ensure that testing is within manufacturers' recommended..."

Based on interview and record review, facility staff failed to ensure staff member M had been credentialed and privileged by the governing body. Findings include:

During an interview on 6/13/19 at 8:11 a.m., staff member B stated he could not locate the most recent credentialing and privileging to the facility for staff member M; a contracted Pathologist.

A review of staff member M's medical staff privileging had been granted on 5/24/16 for a period not to exceed two (2) years as a member of the Medical Staff of [facility name] Pathology.

Based on interview and record review, facility staff failed to ensure health care policies had been evaluated, reviewed, and revised as part of the annual program evaluation for infection control, radiology, and patient abuse prevention. Findings include:

1. During an interview on 6/12/19 at 8:50 a.m., staff member A stated the policies for the infection control department should have been updated annually.

A review of the facility's policy, Infection Control Program, was last updated 8/2017.

2. During an interview on 6/12/19 at 9:53 a.m., staff member B stated the policies for the radiology department should be reviewed yearly.

A review of the facility's policy, General Radiology and CT Radiology, were last updated 7/2014.

3. During an interview on 6/12/19 at 10:10 a.m., staff member D stated the policies for abuse had not been reviewed in "some time."

A review of the facility's policy, Patient Rights and Responsibilities, was undated.

Based on interview and record review, facility staff failed to ensure the Organ Procurement Organization (OPO) had been integrated into the facility's Quality Assurance (QA) program. This deficient practice has the potential to affect all patients requiring OPO services. Findings include:

A review of the facility's QA improvement projects failed to include the facility's OPO program.

During an interview on 6/12/19 at 9:14 a.m., staff member A stated the facility did not include the OPO program into their QA projects.

Based on record review and interview, the facility failed to complete background checks for 6 of 12 sampled staff members; and failed to ensure staff had on-going abuse training. Findings include:

1. Review of staff members' A, D, E, F, G, H, I, and J's personnel files did not include background checks, which would indicate no criminal activity or actions against the staff members' licenses that would preclude them from being employed.

During an interview on 6/11/19 at 9:40 a.m., staff member C stated she was not 100 percent done with background checks. She thought she had most of the background checks completed for the newer staff members.


34603


2. During an interview on 6/12/19 at 10:00 a.m., staff member K stated she was hired by the facility in 3/2019, but she had not received any abuse training by the facility "yet."

3. During an interview on 6/12/19 at 10:07 a.m., staff member L stated she was hired by the facility in 5/2018. Staff member L stated she could not recall the last abuse training attended at the facility.

4. During an interview on 6/12/19 at 10:11 a.m., staff member I stated she was hired by the facility in 1999. Staff member I could not recall the last abuse training she attended at the facility.

Based on interview and record review, the facility failed to have a designated staff member to provide activities to the swing bed patients. Findings include:

During an interview on 6/11/19 at 9:42 a.m., staff members F, K, and N stated the facility did not provide activities to the swing bed patients. Staff member N stated it was the patient's choice for which activities they wished to participate in. Staff member K stated the facility currently had a patient that enjoyed reading the bible and watching television, and another patient that enjoyed playing card games with family members.

During an interview on 6/12/19 at 3:00 p.m., staff member D stated the facility did not have a designated staff member for providing activities to the swing bed patients. She stated the nurses on the floor provided activities, if needed.

Review of the facility Activities Policy and Procedure showed an Activities Collection Record would be used to develop an individual activity plan that will allow the resident to participate in activities of choice and interest.

Based on interview and record review, the facility failed to provide a comprehensive care plan that included activities provided, a discharge plan and a pressure ulcer for 1 (#2) of 20 sampled residents. Findings include:

Review of resident #2's electronic health record (EHR) showed it did not include a comprehensive assessment or care plan.

During an interview on 6/12/19 at 9:40 a.m., staff member D stated the nurse had not known which assessment to complete for the comprehensive assessment.

During an interview on 6/12/19 at 3:10 p.m., staff member F stated the guideline she used for creating care plans was to incorporate only two areas. The problems included would depend on "what they come in with."

Review of resident #2's Care Plan showed one concern: "risk for infection."

Review of resident #2's EHR showed no discharge plan was documented, no activities were assessed or provided, and no pressure ulcer, which was present, was documented.

During an interview on 6/12/19 at 11:40 a.m., staff member D stated the areas above should "absolutely" be on the care plan. She stated the facility was working on personalizing the care plans.

During an interview on 6/11/19 at 1:40 p.m., resident #2 stated he was treated well at the facility but was discouraged about his deteriorating health.