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Based on observation and interview, the facility failed to assure that medical equipment, available for use was not expired, resulting in the potential to use expired medical equipment during an emergent event and poor patient outcomes. Findings include:

On 11/5/2014 at approximately 1126, during the initial tour of the facility two expired endotracheal tubes (one size 7.0 expiration date 6/2013 and one size 8.0 expiration date 2/2014) were found in the surgical procedure room and available for patient use. On 11/5/2014 at approximately 1129 staff C was queried if the endotracheal tubes were expired and available for use. Staff C responded, "Yes."

On 11/5/2014 at approximately 1146, during the initial tour of the facility, three expired endotracheal tubes (one size 7.0 expired 7/2014, two size 7.5 expired 10/2014, and one size 8.0 expired on 2/2014) were found in the emergency crash cart and available for patient use. On 11/5/2014 at approximately 1148 staff C was queried if the endotracheal tubes were expired and available for use. Staff C responded, "Yes."

On 11/5/2014 at approximately 1147 during the initial tour of the facility a multi-lumen central venous catheter kit with an expiration date of 7/2014 was found on the emergency crash cart and available for patient use. On 11/5/2014 at approximately 1148 staff C was queried if the multi-lumen central venous catheter kit was available for use. Staff C responded, "Yes."

Based on observation and interview the facility failed to ensure patient supplies were stored in areas void of potential contamination resulting in the potential for transmission of infectious agents among patients served. Findings include:

On 11/5/2014 at approximately 1120 during the initial tour in the endoscopy procedure room it was revealed that endoscopes were stored in contact with the base of the storage area contaminating the endoscopes. On 11/5/2014 at approximately 1122 staff C was queried if the endoscopes were considered clean. Staff C responded, "Yes." When asked if the endoscopes could touch the base of the storage unit staff C stated "We are not aware that they couldn't touch (the bottom of the storage unit)."

On 11/5/2014 at approximately 1125 during the initial tour in the endoscopy procedure room it was revealed that cleaning fluid for the endoscopes was stored in a urinal located in the same area as patient care items. On 11/5/2014 at approximately 1126 staff C was queried if it was safe practice to store cleaning supplies with patient care items. Staff C replied "No."

On 11/5/2014 at approximately 1128 during the initial tour in the endoscopy procedure room it was revealed that an unmarked styrofoam cup with a clear gel material was stored in the same area with patient care items. On 11/5/2014 at approximately 1129 staff C was asked to identify the contents of the styrofoam cup. Staff C asked staff D to identify the contents. Staff D stated "Oh, that is lubricant we use for the endoscopes with patients."

On 11/6/2014 at approximately 1045 during a tour of the surgery area housekeeping closet it was revealed that a gallon of betadine was stored in the housekeeping closet. On 11/6/2014 at approximately 1046 staff I was queried if the betadine was used for surgical cases. Staff I responded "Yes. We are very challenged for storage."

On 11/6/2014 at approximately 1100 during a tour of the surgery area located in the clean corridor it was revealed that lead aprons were in contact with a trash bin. On 11/6/2014 at approximately 1105 staff I was asked if there was the potential for contamination of the lead aprons touching the trash bin. Staff I stated "Yes. We are very challenged with space."

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on 11/06/14, the facility failed to comply with the applicable provisions of the 2000 Edition of the Life Safety Code. Findings include:

See the following K-tags on the CMS-2567 dated 11/7/14 for Life Safety Code citations.
K-0027
K-0032
K-0038
K-0050

Based on observation and interview the facility failed to keep accurate records of dispensed scheduled medications and failed to dispose of scheduled medications resulting in the risk for unaccounted scheduled drugs. (See tag C 276)

Based on observation and interview the facility failed to keep accurate records of dispensed scheduled medications and failed to dispose of scheduled medications. Findings include:

On 11/5/2014 at approximately 1045 during the initial tour of the emergency room department medication room a vial of 2 mg (milligrams) morphine was found wrapped with a 10 ml syringe of clear fluid laying on the medication sink. On 11/5/2014 at approximately 1048 staff D was queried about the use and disposition of a narcotic. Staff D stated "We just had a code about 20 minutes ago. I haven't had time to waste yet."

On 11/5/2014 at approximately 1100 during the initial tour of the pre-procedure holding area a medication cup with a red substance was laying by the sink area. On 11/5/2014 at approximately 1105 staff M was asked to identify the red substance in the medication cup. Staff M stated "Oh, that is versed. We haven't wasted it yet. The other nurse left it there."

On 11/6/2014 at approximately 1030 during a tour of the post anesthesia care area a verification of narcotics was conducted. During the verification of narcotics it was found the count for 50 mg of versed in syringes was inaccurate with a count of 2 and the narcotic log showing the availability of 3. On 11/6/2014 at approximately 1032 staff I was asked about the discrepancy. Staff I stated "the nurse probably took one for the surgical case and forgot to record it."

Based on document review and interview the facility failed to ensure the quality assurance performance initiative program identified and addressed facility deficiencies. (See tag C 342)

Based on document review and interview the facility failed to ensure the quality assurance performance initiative program identified and addressed facility deficiencies. Findings include:

On 11/7/2014 at approximately 0900 during a review of the quality assurance performance initiative program from 10/2013 through 9/2014 it was discovered the facility failed to identify performance improvement initiatives. On 11/7/2014 at approximately 1300 an interview was conducted with staff B. Staff B was asked if any departments in the facility were participating in the quality assurance improvement initiative program. Staff B responded "There are no departments that have any projects at this time." Staff B was then asked it was an expectation to have facility initiatives to address deficiencies and to identify areas in need of improvement. Staff B responded "Yes. We realize the need."

Based on record review, interview and policy review, the facility failed to develop a plan of care for 3 of 3 (#17, #18, #19) swing bed patients that included interventions and timetables for meeting goals resulting in the potential for unidentified/unmet patient needs. Findings include:

On 11/06/2014 at approximately 1300 during an interview with staff J (Swing Bed Coordinator), revealed that the facility had no current patients in swing beds.

On 11/06/2014 approximately 1330-1530 during review of the electronic medical records for discharged patients #17, #18 and #19, staff J was unable to locate the identified interventions and timetables for attaining them in the patients' respective care plans.

The record review for patient #17 revealed that the patient had problems identified for "skin Integrity-Actual Impairment, At Risk for Injury Secondary to Sensory Perception and Sensory Perception Disturbed."

Record review for patient #18, identified problems related to fall risk, skin integrity, and ability to perform ADLs (activities of daily living-such as bathing, dressing, eating).

Review of the record for patient #19 revealed identified problems related to fall risk and skin integrity.

On 11/06/2014 at 1530, staff J stated, "I cannot find them any where in the record, so I am going to say that there were none put in."

On 11/06/2014 at 1530 review of the facility's policy titled "Interdisciplinary Care Plan, Issued By Swing Bed Committee, Reviewed Jan 2004," reads, "#8. The Interdisciplinary Care Team will devise a plan of care that is designated to meet needs of the patient. #9. The date a specific problem is addressed in the Care Plan is entered onto the form along with the nature of the problem. #10. Next, enter the goal, or the 'objective' that the patient needs to attain. This goal should be measurable and attainable, such as 'The patient will be able to ambulate 150 feet with the use of a wheeled walker.' Goals such as 'The patient will perform their own ADLs' are not measurable or attainable for a patient with a recent CVA (cerebral vascular accident). The goal must be specific to the patient's needs and requirements; the goal must also be realistic to the patient's ability. #11. Interventions specifically designed to aid the patient in obtaining their objective are entered on the form along with the discipline/person responsible for making sure that they are completed."

Based on record review and interview, the facility failed to develop a plan of care for 2 of 5 (#15, #16) swing bed patients resulting in the potential for unidentified patient needs. Findings include:

On 11/06/2014 at approximately 1300 during an interview with staff J (Swing Bed Coordinator), revealed that the facility had no current patients in swing beds.

On 11/06/2014 at approximately 1330, during review of electronic medical records for discharged patients #15 and #16 who had been placed into swing beds revealed that both medical records lacked comprehensive care plans.

Patient #15 was identified in the physical therapy assessment with "Decreased functional mobility, difficulty walking and generalized weakness."

Patient #16 was identified in the nursing assessment as "Decreased functional/ADL (activity of daily living), decreased functional mobility, difficulty walking. Pain with activity, shortness of breath"

On 11/06/2014 at 1400, the above findings regarding patient # 15 and #16 were confirmed by staff J. When queried about the lack of care plans for the two patients, staff J stated, "I cannot find them anywhere in the record." When queried about when the care plans are supposed to be developed, staff J stated, "they are started at the time of the patient's admission. Things like fall risk, skin issues or assistance needed with ADLs, that are known at the time of admission should initiate nursing care plans."