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Based on a review of the hospital's written patient rights, medical records and interview with facility administrative staff, it was determined the hospital did not make available to patients or to patients' representatives the State agency phone number for filing a grievance. This affected 30 of 30 medical records reviewed and had the potential to affect all patients within the hospital.

Findings include:

Review of 30 of 30 medical records revealed no documentation the patients/representatives were informed of their right to voice complaints verbally or in written form to the hospital, nor was there documentation the patients/representatives received information on how to lodge a complaint with the State agency.


Review of the hospital's "Patient Bill of Rights" revealed no documentation on how to lodge a complaint with the State agency.


An interview was conducted on 11/16/11 at 10:00 AM with Employee Identifier (EI) # 6, the Assistant Director of Nurses, who stated they only give the "Patient Bill of Rights" form to Medicare patients.

Based on observations, staff interview and review of the facility's policies and procedures, it was determined the facility failed to ensure the staff:
(1) followed the policies regarding the labeling of opened multidose medications
(2) followed the policies regarding the use of single use sterile medications.

This had the potential to affect all patients treated at the facility.

Findings include:

Facility Policy #5039

Opening/Dating Sterile Vials

Policy:

As set forth by the Clinical Services Committee, sterile items for parenteral use shall be discarded after a specified length of time after opening as follows:

Multiple Dose Vials (with preservatives)
Discard 30 days after opening. (Must be labeled with date of puncture, date of expiration and initials of person puncturing)

... All open vials which do not have the date and initials of person puncturing shall be immediately discarded.


1. On 11/15/11 at 1:45 PM the surveyor made a tour of the procedure room while the room was being cleaned by Employee Identifier (EI) # 3, a housekeeper. There were no more procedures or surgeries scheduled for the day. EI # 3, was the only hospital staff member in the room.

The surveyor observed the following medications on the top of the anesthesia cart and the two movable medication carts during the tour:
1- open 50 Milliliter (ml) bottle of Propofol that was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.
1 - open 20 ml multidose bottle of 1% Lidocaine that was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.
1- 3 ml syringe filled with 3 ml of a clear liquid. The syringe had a piece of tape on it that had a person's name but the syringe was not labeled with the name of the contents or the date the syringe was filled or the initials of the person who filled the syringe.
1- 1 ml syringe with 1 ml of a clear liquid. The syringe was not labeled with the contents of the syringe, the date the syringe was filled or the initials of the person who filled the syringe. There was an open ampule of 50 mg (milligrams)/ml of Epinephrine Sulfate taped to the syringe.
1- Syringe with 5 ml of a clear liquid. The syringe had a red label with Succinylcholine written on it. The label did not have the dose that was in the syringe. The label did not have the date the syringe was filled or the initials of the person who filled the syringe.
1- 10 ml multidose open bottle of Succinylcholine which was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.
1 - 100 mg/10 ml multidose open bottle of Atracurinum which was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.
2 - 500 ml open bottles of 0.9% Sodium Chloride with approximately 350 ml in each bottle. The bottles were not labeled with the date the bottles were opened, date of expiration or the initials of the person who opened the bottles.

The surveyor observed the following in the drawers of the two movable carts:
1 - open single dose ampule of Fentanyl Citrate (a Controlled Substance Schedule II drug) sitting in a box with the other unopened ampules of Fentanyl Citrate. The single dose ampule had not been discarded after opening and use per policy.
1 - 20 ml multidose bottle of 1 % Lidocaine that was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.


2. On 11/15/11 at 2:40 PM the surveyor made a tour of the operating room. There were no more procedures or surgeries scheduled for the day.

During the tour the surveyor observed the following medications were on top of the crash cart and the medication cart:
2 - 20 ml open multidose bottles of 1% Lidocaine that were not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.
2 - 20 ml open multidose bottles of Atropine that were not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.
1 - 50 ml open bottle of Propofol that was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle
1 - Syringe with 1 ml of clear liquid. The syringe was not labeled with the contents of the syringe, the date the syringe was filled or the initials of the person who filled the syringe. There was an open ampule of 50 mg/ml of Epinephrine Sulfate taped to the syringe.
1 - Open multidose bottle of 0.9% Sodium Chloride that was not labeled with the date the bottle was opened, date of expiration or the initials of the person who opened the vial/bottle.
1 - 10 ml open multidose bottle of Neostigmine Methlysulfate that was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.
1 - 100 ml open multidose bottle of Labetalol Hydrochloride that was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.


During an interview on 11/15/11 at 2:45 PM, EI # 4, the Registered Nurse/Operating Room (OR) Manager, confirmed the opened multidose vials should have been initialed by the person who opened the vials/bottles and should have been dated.

During an interview on 11/15/11 at 2:50 PM, EI # 4, confirmed the other afore mentioned findings.

Based on observations, review of facility policies and procedures, and staff interviews, it was determined the facility failed to ensure the staff followed the policy for safe storage of medications in the operating room and in the procedure room. This had the potential to affect all patients served by the facility.

Findings include:

Facility Policy No. 20-01

Requirement for Lockable Storage

Lockable storage units or lockable medication carts, if necessary, shall be provided for medication storage areas throughout the facility. Medications shall be kept in locked storage or be inaccessible to patients, visitors, and unauthorized staff.

Access to Mediation Storage Areas

Access to mediation storage areas is limited to pharmacy personnel and persons authorized to handle and administer these medications.

Medical staff, nursing service, administrative, housekeeping and other personnel are authorized access to medication storage areas only in conjunction with their duties and under supervision.

1. On 11/15/11 at 1:45 PM the surveyor made a tour of the procedure room while the room was being cleaned by Employee Identifier (EI) # 3, housekeeping employee. There were no more procedures or surgeries scheduled for the day. EI # 3 was the only hospital staff member in the room.

The surveyor observed the following medications on the top of the anesthesia cart and the two movable medication carts during the tour:
1- open 50 Milliliter (ml) bottle of Propofol
1 - open 20 ml multidose bottle of 1% Lidocaine that was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.
1- 3 ml syringe filled with 3 ml of a clear liquid. The syringe had a piece of tape on it that had person's name but the syringe was not labeled with the name of the contents or the date the syringe was filled or the initials of the person who filled the syringe.
1- 1 ml syringe with 1 ml of a clear liquid. The syringe was not labeled with the contents of the syringe, the date the syringe was filled or the initials of the person who filled the syringe. There was an open ampule of 50 mg (milligrams)/ml of Epinephrine Sulfate taped to the syringe.
1- syringe with 5 ml of a clear liquid. The syringe had a red label with Succinylcholine written on it. The label did not have the dose that was in the syringe. The label did not have the date the syringe was filled or the initials of the person who filled the syringe.
1- 10 ml multidose open bottle of Succinylcholine which was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.
1 - 100 mg/10 ml multidose open bottle of Atracurinum which was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.
2 - 500 ml open bottles of 0.9% Sodium Chloride with approximately 350 ml in each bottle. The bottles were not labeled with the date of puncture, date of expiration or the initials of the person who punctured the bottles.

The surveyor observed the drawers to the anesthesia cart and the two movable medication carts were not locked.

The surveyor observed the following in the drawers of the two movable carts:
1 - open single dose ampule of Fentanyl Citrate (a Controlled Substance Schedule II drug) sitting in a box with the other unopened ampules of Fentanyl Citrate.
1 - 20 ml multidose bottle of 1 % Lidocaine that was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.


2. On 11/15/11 at 2:40 PM the surveyor made a tour of the operating room. There were no more procedures or surgeries scheduled for the day. During the tour the surveyor observed the crash cart and the movable medication cart were not locked.

During the tour the surveyor observed the following medications were on top of the crash cart and the medication cart:
2 - 20 ml open multidose bottles of 1% Lidocaine that were not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.
2 - 20 ml open multidose bottle of Atropine that was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.
1 - 50 ml bottle of Propofol
1 - Syringe with 1 ml of clear liquid. The syringe was not labeled with the contents of the syringe, the date the syringe was filled or the initials of the person who filled the syringe. There was an open ampule of 50 mg/ml of Epinephrine Sulfate taped to the syringe.
1 - Open multidose bottle of 0.9% Sodium Chloride that was not labeled with the date the bottle was opened, date of expiration or the initials of the person who opened the vial/bottle.
1 - 10 ml open multidose bottle of Neostigmine Methlysulfate that was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.
1 - 100 ml open multidose bottle of Labetalol Hydrochloride that was not labeled with the date of puncture, date of expiration or the initials of the person who punctured the vial/bottle.

During an interview on 11/15/11 at 2:45 PM, EI # 4, Registered Nurse/Operating Room Manager, confirmed the afore mentioned medications were not locked or secured.

Based on observation, policy review and staff interview, it was determined the facility failed to ensure a controlled substance was kept in a locked and secured area in the procedure room. This had the potential to affect all patients who were treated at the facility.

Findings include:

Facility Policy No. 20-01

Requirement for Lockable Storage

Lockable storage units or lockable medication carts, if necessary, shall be provided for medication storage areas throughout the facility. Medications shall be kept in locked storage or be inaccessible to patients, visitors, and unauthorized staff.


1. On 11/15/11 at 1:45 PM the surveyor made a tour of the procedure room while the room was being cleaned by Employee Identifier (EI) # 3, a housekeeper. There were no more procedures or surgeries scheduled for the day. EI # 3 was the only hospital staff in the room.

The surveyor observed the anesthesia cart and the two movable medication carts were not locked. The surveyor observed a box of Fentanyl Citrate ampule's (a Controlled Substance Schedule II Drug) in an unlocked drawer of one of the movable medication carts. The surveyor observed the drawer contained 1 open single dose ampule of Fentanyl Citrate sitting in a box with the other unopened ampule's of Fentanyl Citrate.

During an interview on 11/15/11 at 2:50 PM, EI # 4 , Registered Nurse/Operating Room Manager, confirmed the afore mentioned findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observations and staff interview, it was determined the facility failed to have a policy to assure the operating rooms were monitored for safe parameters of humidity and temperature for 1 of 1 operating rooms. This had the potential to affect all patients served by the facility.

Findings include:

During a tour of the Surgery Department on 11/16/11 at 11:15 AM, the surveyor requested to see documentation of temperature and humidity monitoring for the operating room. Employee Identifier # 4, Registered Nurse (RN)/Operating Room (OR) Manager, stated that EI # 5, RN/Infection Control Nurse kept a record of the temperature and humidity of the OR.

During an interview on 11/16/11 at 11:40 AM, EI # 5, was unable to provide any documentation of the temperature and humidity monitoring for the OR. EI # 5 stated that the OR temperature and humidity were monitored in the past but they are not being monitored now.

On 11/17/11 at 11:25 AM, a list of policies were requested from EI # 1, Director of Nursing. The policy for the OR temperature and humidity guidelines was one of the policies requested. On 11/17/11 at 11:55 AM, policies were received. In the group of policies provided there was no policy for the monitoring of the OR temperature and humidity.