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Based on observations and staff interviews, the facility failed to ensure that patient care supplies were maintained to ensure an acceptable level of safety and quality. Findings include:

1. During the observation of the emergency room on 1/30/12 beginning at 3:45 p.m., the surveyor observed the following outdated or unusable patient care supplies available for use:

-33 3 gm. foil packs of Surgi-Lube with the manufacturer's expiration date of 11/2009.
-1 Sterile Sexual Assault Kit with the manufacturer's expiration date of 11/2011.
-2 16 Fr. Rusch red rubber single use catheters with the manufacturer's expiration date of 5/2010.
-3 18 Fr. Rusch red rubber single use catheters with the manufacturer's expiration date of 5/2009.
-4 14 Fr. Rusch red rubber single use catheters with the manufacturer's expiration date of 7/2010.
-25 14 Fr. Mentor single use sterile self cath catheters with the manufacturer's expiration date of 2/2007.
-18 Povidone-Iodine prep pads with the manufacturer's expiration dates of 09/2001 (12) and 05/2004 (6).
-2 Arrow disposable Pneumothorax kits with the manufacturer's expiration date of 3/2006.
-52 assorted Ethilon sterile suture packets with manufacturer's expiration dates from 7/2003 to 7/2011.
-2 Patil Emergency Cricothyrotomy Sets with the manufacturer's expiration date of 9/2005.
-2 4.0 Fr. Shiley pediatric Tracheostomy tubes with the manufacturer's expiration date of 1/2007.
-1 8.0 Fr. Shiley adult Tracheostomy tube with the manufacturer's expiration date of 1/2007.
-3 Kendall disposable Thoracentesis trays with the manufacturer's expiration dates of 3/2005 (1) and 10/2007 (2).
-8 Insyte Autoguard 16 ga. by 1.75 in. intravenous catheters with the manufacturer's expiration date of 6/2011.

Staff member A verified the expiration dates listed above in an interview on 1/30/12 at 4:15 p.m. and stated that night shift staff nurses check supplies and medications for expiration dates monthly.

Staff member B stated on 1/30/12 at 4:20 p.m., that one CNA has been organizing the supplies in the emergency room and had been checking the expiration dates of supplies. She also stated that she believed that the disposable Thoracentesis trays could be used after the listed expiration date as the only item that expired in the tray was the ampoule of Xylocaine.

2. During the review of the medical floor on 1/31/12 beginning at 7:45 a.m., the surveyor observed the following expired patient care supplies available for use:

-1 open 8 oz. bottle of Hibiclens surgical scrub with the manufacturer's expiration date of 12/2010.
-8 Tegaderm 2 3/4 in. by 3 1/4 in. sterile dressings with the manufacturer's expiration date of 11/2011.
-11 Insyte Autoguard 16 ga. by 1.75 in. intravenous catheters with the manufacturer's expiration date of 6/2011.
-5 Insyte Autoguard 18 ga. by 1.1 in. intravenous catheters with the manufacturer's expiration date of 12/2010.

During an interview with staff member D on 1/31/12 at 8:45 a.m., the staff member verified the expiration dates and stated that the facility nursing staff checked the supplies for expiration dates.


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3. During observation of the main supply room of the purchasing office on 1/30/12 at 11:115 a.m., the surveyor observed the following outdated or unusable patient care supplies available for use.

- 45 packages of 1/8 in. by 3 in. steri strips with the manufacturer's expiration date of 7/2010;
- 31 packages of 1/4 in. by 3 in. steri strips with the manufacturer's expiration date of 9/2010; and
- 15 16 ounce bottles of GenCare Shampoo/BodyWash with the manufacturer's expiration date of 4/2011.

Based on observations and staff interviews, the facility failed to ensure that outdated, mislabeled, or otherwise unusable drugs and biologicals are not available for patient use. The facility failed to ensure that schedule medications were accurately accounted for, and staff followed accepted standards of practice when maintaining the narcotic records. Findings include:

1. During the observation of the emergency room on 1/30/11 beginning at 3:30 p.m. the surveyor noted the following,
-2 open 30 cc. multidose vials of Normal Saline that were not marked with the date when the bottles were first opened.
-1 50 cc. multidose vial of 0.5% Marcaine solution that was not marked with the date when the bottle was first opened.
-1 50 cc. multidose vial of 1% Xylocaine solution that was not marked with the date when the bottle was first opened.

During an interview with staff member B on 1/30/11 at 4:20 p.m., the staff member stated that nursing staff were to label newly opened bottles with the date that they were opened. A Quality Assurance project had recently been completed that included labeling of vials with "opened on" dates.


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2. During observation of the main supply room of the purchasing office on 1/30/12 at 11:15 a.m., the surveyor observed there were three 250 cc. bags of 5% Dextrose solution with a manufacturer's expiration date of 5/2011.

3. During inspection of the medication room on the medical floor on 1/31/12 at 1:00 p.m., the surveyor observed the narcotic lock up and the narcotic log book with staff member A. Staff member A opened the narcotic lock up and counted the injectable morphine and then showed the surveyor the log book for the injectable morphine. The count for the amount viable in the lock up and the amount listed on the narcotic log book did not match.

Staff member A then called the other licensed staff member to the medication room. At 1:30 p.m. on 1/31/12, staff member stated she had given the morphine earlier and had forgotten to sign it out on the narcotic log book. The staff member then signed out the morphine on the narcotic log book.

Staff member A stated in an interview that the licensed staff did not routinely perform a narcotic count at the end of each shift. She stated that night shift usually counted the narcotics.?

Staff member H was interviewed on 2/1/12 at 9:00 a.m. Staff member H stated that 2 licensed staff members do not count the narcotics after the end of each shift. She further stated that both licensed staff members on shift use the same narcotic lock up.?

A copy of the facility policy for counting narcotics was obtained. The policy "Security of the Pharmacy" included:
... when counting narcotics at the change of shift, both nurses shall:
-- View the sign-out sheet
-- Examine packaging for damage..., following procedure shall be used when removing controlled substances from floor stock:
-- Document removal on the control log as to patient, date, time, and amount given and only remove and sign out the quantity you need at that dosing time...

A copy of the facility policy "Disposal of Unused Controlled Substances" was obtained. The policy included:
... All controlled substances must be fully accounted for on the control log and verified every shift change...

?At the beginning of each shift, two nurses must count all of the narcotics in the locked cabinet and record the count on a narcotic administration record. Perry, A.G. and Potter, P.A. (2002). Clinical Nursing Skills and Techniques. (5th ed.) St Louis, Missouri: Mosby, pg. 450.

Based on observation and staff interview, the facility failed to store, prepare, distribute, and serve food under acceptable sanitary conditions. Findings include:

a. The surveyor observed the kitchen on 1/31/12 at 9:00 a.m. The surveyor observed an uncovered meat slicer and kitchen aid mixer that had a film of dust.

b. The surveyor observed the kitchen walk in refrigerator had five 32 ounce containers of Dannon Light and Fit yogurt with an expiration date of 1/3/12.

Based on clinical record review and staff interview the facility failed to ensure that medications ordered by the physician were given for 1(#6) of 39 sampled hospital inpatients. Findings include:

1. The surveyor reviewed the medical record for inpatient #6. The patient had physician orders including Glucosamine/Chondroitin 1 pill daily ordered January 10, 2011. The medical record for 1/11/11 had "not here" documented in the space for licensed staff to initial the medication had been given. The MAR for 1/12/11, 1/14/11, 1/15/11, and 1/17/11 had "NA" documented in the space for licensed staff to initial the medication had been given. The medical record for 1/13/11 and 1/16/11 had licensed staff initials that were circled.

The patient did not receive the ordered medication for 7 consecutive days, and the facility failed to notify the physician that the medication was not available.

During an interview with staff member B on 2/1/12 at 1:15 p.m., she stated NA means the medication was not available to the licensed staff.

Based on observation, the facility failed to ensure that clinical records were safeguarded against loss, destruction, or unauthorized access. The findings included:

The medical records storage was observed on 1/30/12 at 1:00 p.m. The surveyor observed the medical records were on several metal shelf units. The shelf units were located directly under the automatic fire sprinkler system. The shelf units were open and did not have doors or covers on them. The medical records were at risk for water damage if the sprinkler system was triggered by a fire.

Based on document review, policy review, and staff interview, the facility failed to ensure that the annual review of the hospital's policies and procedures was completed. Findings include:

During the entrance conference with the facility administrative team on 1/30/12 beginning at 1:00 p.m., the survey team presented the request for information to the administrator. The request included the documentation of the complete annual program evaluation and the annual policy review. The facility staff brought the policy and procedure manuals from all departments.

The policy manuals for the organ donation program and nursing services did not include documentation of the date of the last review of the manual.

Review of the document labeled "Phillips County Hospital Association, Inc. Annual Program review/report 2011" was completed on 1/31/12. The surveyor was unable to locate documentation or reporting of the annual policy review in the annual program review document provided by the facility.

During the end of the day meeting with the facility administrative team on 1/31/12 at 4:45 p.m., the issue of the annual policy review was raised. Staff member B stated that the administrative team had been working on reviewing all of the facilities policies. The review had not been completed.