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Based on observation, interview and document review, the facility had expired supplies in the pediatric cart and failed to maintain a sterile reprocessing program.

Findings include:

On 4/25/18 at 10:00 AM in the emergency room with the pediatric cart, the following supplies were identified with corresponding expiration dates in the presence of the Pharmacist and Central Supply Technician:

9 pediatric emergency system oxygen delivery modules expired 9/2012.
6 intraosseous modules expired 6/2012.
5 tracheal tube oral/nasal intubation module expired 8/2010 to 7/2012.
4 Lasix 40 milligrams/4 milliliter vials with lot#70-379-DK expired 4/1/18.
4 tracheal tubes expired 7/2002.
3 intravenous delivery module expired 9/2011 and 11/2011 times 2.
2 endotracheal tubes 6.0 expired 10/2003.
2 Rusch tubes 3.5 expired 3/2003.
2 pediatric, latex-free nasogastric tubes 10 french (indicated the size of the nasogastric tube) expired 2/27/2003.
1 Sodium Fluoride/Potassium Oxalate vacutainer on the intubation cart expired 2/28/18.
1 intubation stylet expired 11/2010.
1 intravenous start kit expired 4/2010.
1 duodenal tube ch10 (indicated the size of the tube) expired 2/2006.
1 blueline tracheal tube expired 5/2000.
1 satin cathetar suction set 10 fr. expired 9/10/1996.
1 single patient use Rusch pediatric nose tube 5centimeter (cm) was open to air.

The Pharmacist and Central Supply Technician acknowledged the findings.

On 4/25/17 in the afternoon, a tour was taken with a Registered Nurse (RN) in charge of reprocessing in the facility. The RN walked through and explained the facility's steps for reprocessing. The facility used primarily single hand instruments which were reprocessed in peel packs with a steam reprocessor. The following anomalies were identified with the facility's reprocessing process:

After a procedure, the RN carried the soiled instrument in a red container to the soiled utility room. After hand-cleaning, the RN carried the clean instrument in the same red container to the sterilizer room. The RN acknowledged the cross-contamination practice.

Hand-cleaning procedures were not posted in the soiled utility room. The policies and procedures failed to address specific hands-on cleaning procedures.

Containers and spray bottles with varying levels of cleaning products inside were observed. None of the containers/spray bottles had material safety data sheet information identified on them. The information was not in the vicinity of the containers/spray bottles.

An instrument was soaked for a half hour. The policies and procedures provided failed to address soaking time.

The RN verbalized placing the instrument in a dish pan with 2 ounces of cleaning product with 2 quarts of water for hand-cleaning. There was no delineation of a sink line. The RN was unable to find the facility's cleaning product for some time. Later in the afternoon, the RN provided V. Mueller instrument detergent which revealed the cleaning ratio was a half to one ounce of cleaning product to a gallon of water. The RN acknowledged the difference between the ratio used and the ratio the product manufacturer recommended.

The RN was unable to locate the chemical indicator strips used to measure the strength of the solution and for verification with the recommended use of the product.

The sterilizer leaked water when touring. The facility contacted its preventive maintenance company. The facility discovered a company representative shut the sterilizer off before the sterilizing cycle was completed when a representative was recently onsite at the facility. The sterilizer had not been used since. The RN had to manually empty the water during the tour. The water had been sitting in the sterilizer for two weeks, since the representative had been at the facility.

The sterilizer's maintenance schedule showed multiple weekly tasks to be performed, some of which could not have been performed with the water inside the sterilizer.

While observing sterilized peel pack items in storage, the following anomalies were identified:

2 speci-caths expired 5/2016.
1 tissue retractor in a reprocessed peel pack undated and unlabeled.
20 items in reprocessed peel packs dated 12/2017 but unlabeled as to who processed them.

The RN indicated the facility used mostly disposable items, and the RN had not reprocessed anything since September 2016. The 20 items reprocessed in 12/2017 were probably used in the clinic and not the hospital. The RN did not know who reprocessed the items. There were no reprocessing records for any of the items in the facility.

On 7/26/15, record keeping showed the RN did not document the 24 and 48 hour indicator results.

The RN's employee file lacked documented evidence of any sterile processing education or training. The RN expressed learning from a previous employee who no longer worked at the facility.

The Central Processing Services Policies and Procedures (dated 7/2008) revealed the following:

Responsibilities included dating of sterile processed supplies.

Handling of contaminated supplies---decontamination.

Proper methods for sterilization.

Central Processing Services Technician shall be qualified by training and experience.

Manufacturer's recommendation shall be followed exactly regarding care, use and/or repair of equipment.

Sterilizer logs, chart chemical/biological tests and spore tests shall be maintained as required.

Load number and sterilization number shall be placed on each package for later retrieval if needed.

There is a written biological indicator procedure.

Autoclaves and sterilizers will be maintained in operating condition at all times.

Any item sterilized by the hospital shall be identified on the outside of the wrap with: name of item; month, day and year processed/sterilized; sterile expiration date; load number and initials of the central processing services employee who processed and wrapped the item.

Based on observation and interview, the facility failed to store medication and intravenous fluid with current expiration status and failed to maintain an organized, reviewable record of its scheduled drugs.

Findings include:

On 4/25/17 in the late morning, the following was observed in one of the emergency room areas with the Pharmacist:

Storage cabinets with see-through windows took up one wall of the room. One set of cabinets was unlocked. Inside were four medication vials:

2 undated, opened vials of Bupivicaine.
1 undated, opened vial of 2% Xylocaine 400 milligrams/20 milliliters.
1 undated, opened vial of 1% Lidocaine 200 milligrams/20 milliliters.

Two (2) of the 4 vials were single dose vials. The Pharmacist acknowledged the single dose vials should have been discarded and the cabinets locked.

Policy point #16 of the Pharmacy Control: Regulations and Procedures policy (last revised 4/22/05) revealed all vials would be dated and initialed when opened.

On 4/25/17 in the late morning, the following outdated medications and anomalies were identified with the Pharmacist in the pharmacy room:

Aspirin enteric coated 81 milligrams expired 3/2017.
Augmentin tablets stored in an unlabeled container.
Bactrim liquid expired 3/2018.
Diazepam 5 milligram/milliliter vial with NDC#0409-3213-12 was open and unsecured.
Infant Tylenol expired 12/2017, 4 containers.
Ivite container with lot#162386 with no label or expiration date with magic marker written on it.
Losartan 50 milligrams, a patient container expired 2/23/18.
M-Pap liquid expired 5/2017.
Ondansetron stored in an unlabeled container.
Q-Dryl expired 1/2018.
Risperdal stored in an unlabeled container with a patient name.

The Pharmacist acknowledged the above anomalies.

Policy point #3 of the Procurement and Storage of Drugs policy (last revised 6/24/03) revealed outdated drugs would be removed from stock and identified and maintained separately from other stock until disposal.

Policy point #3 of the Accounting for Drugs and Pharmaceuticals policy (undated) revealed outdated drugs were always promptly removed from stock and returned for credit when possible.

Policy point #5 of the Pharmacy Control: Regulations and Procedures policy (last revised 4/22/05) revealed all drugs would be current so that none would be outdated prior to use. These dates were checked every month.

On 4/25/17 in the late morning, the following outdated medications and intravenous fluid bags were identified with the Pharmacist in the intravenous room:

Activated Charcoal 50 grams expired 3/2018.
Dextrose and Normal Saline intravenous liter bags with lot#56-801-FW expired 8/2017 for 7 bags.
Dextrose and Normal Saline intravenous liter bags with lot#63-507-FW expired 3/2018 for a few dozen bags.

The Pharmacist acknowledged the above anomalies.

In the middle of December 2017, the Pharmacist indicated the facility installed its electronic drug dispensing and monitoring system. Prior to December 2017, hard copy narcotic logs were kept. The records were reviewed and showed multiple discrepancies (titled as such in the logs) in terms of individual drug counts at a certain point in time and also the ending counts when the drugs were transferred into the automatic dispenser.

Policy point #2 of the Quality Assurance In Narcotic Documentation policy (last revised 1/7/05) revealed completed narcotic sheets were audited by the pharmacy supervisor and Director of Nursing every two weeks and by the consultant pharmacist monthly.

The written records showed shift counts were not being done on a regular basis (twice daily at the end of shifts).

Policy point #1 of the Quality Assurance In Narcotic Documentation policy (last revised 1/7/05) revealed the narcotic control log was to be counted by two licensed staff at each change of shift at least every 12 hours.

Policy point #16 of the Accounting for Drugs and Pharmaceuticals policy (undated) revealed the controlled drug count by the two medication nurses would account for all such medications as used.

Policy point #5 of the Accounting for Drugs and Pharmaceuticals policy (undated) revealed an ongoing inventory should be maintained and documented on all Schedule II, III and IV drugs.

Based on record review, interview and policy review, the facility failed to ensure a nurse provided care in accordance with a patient's needs for 1 of 4 acute care patients (Patient #19).

Findings include:

On 4/20/18, Patient #19 was admitted with recent fall, abdominal pain and diverticulitis.

On 4/22/18 at 5:41 PM, Patient #19 was administered a one time order of Miralax oral powder solution, which was ordered to establish bowel regimen.

The medical record lacked documented evidence a nurse followed up with the patient regarding results of a bowel movement until 12:21 AM on 4/25/18. The patient went over 4 days without a bowel movement being recorded.

On 4/26/18 in the morning, the Chief Nursing Officer acknowledged nursing should have followed up after the administration of Miralax.

The facility's Bowel Training policy revealed a daily bowel movement was not necessary, but the patient should not be allowed to go for more than three (3) days without one.

Based on record review and interview, the facility failed to ensure a nursing care plan was developed and kept current for 4 of 4 acute care patients (Patient #3, #12, #15 and #19).

Findings include:

Patient #3

On 4/20/18, Patient #3 was admitted with pneumonia, Chronic Obstructive Pulmonary Disease (COPD) and congestive heart failure.

Patient #12

On 4/3/18, Patient #12 was admitted with hip fracture, blood loss anemia, COPD and seizures.

Patient #15

On 4/22/18, Patient #15 was admitted with pneumonia, chronic bronchitis and moderate COPD.

Patient #19

On 4/20/18, Patient #19 was admitted with recent fall, abdominal pain and diverticulitis.

On 4/26/18, all four of the medical records lacked documented evidence of nursing care plans.

On 4/26/18 in the late morning, the Chief Nursing Officer acknowledged acute care patients did not have nursing care plans developed.

Based on observation, interview and document review, the facility failed to provide safeguards against possible loss, destruction or unauthorized use of medical record information for multiple patients.

Findings include:

On 4/24/17 in the afternoon, the Lab Manager revealed a huge binder in which the facility stored laboratory (lab) test information. Every patient's lab test ordered and completed was recorded in the binder for the past 10 years. Later during the day and week, the binder with the lab information was observed unsecured with the lab door open to other employees.

On 4/25/17 in the afternoon, a tour was taken with a Registered Nurse regarding reprocessing in the facility. During the tour, several binders were observed stored on a portable rack outside one of the emergency room areas near a scrub sink.

The Registered Nurse paged through one of the binders marked Infection Control. Sensitive lab results of patients were identified inside the binder. The Registered Nurse acknowledged the lab results should not be stored unsecured on a portable rack in a hallway.

An unsecured closet was located a short distance away from the above described location. Inside the closet, there were dozens of patients' radiology films being stored.

On 4/26/17, the Chief Nursing Officer (CNO) was shown the closet with radiology films and the portable rack in the hallway with several binders stored on it. The CNO acknowledged any patient information should be secured.

The facility's Code of Ethics was reviewed in unison with its health information packet.

Section III stated Health Information Management professionals preserve, protect, and secure personal health information in any form or medium and hold in the highest regards the contents of the records and other information of a confidential nature obtained in the official capacity, taking into account the applicable statutes and regulations.

Section III.1 Protect the confidentiality of patients' written and electronic records and other sensitive information. Take reasonable steps to ensure that patients' records are stored in a secure location and that patients' records are not available to others who are not authorized to have access.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed within 7 days after completion of the comprehensive assessment for 1 of 4 acute care patients (Patient #12).

Findings include:

On 4/3/18, Patient #12 was admitted with hip fracture, blood loss anemia, COPD and seizures.

On 4/26/18, Patient #12's medical record lacked documented evidence of a comprehensive nursing care plan developed within 7 days after completion of the comprehensive assessment.

On 4/26/18 in the late morning, the Chief Nursing Officer acknowledged acute care patients did not have nursing care plans developed.