HospitalInspections.org

Based on observations and interviews, the hospital failed to ensure patients were provided care in a safe setting as evidenced by failing to ensure the patient environment was free of safety and ligature risks.

Findings:

On 3/18/19 at between 9:40 a.m. and 9:55 a.m. a tour of the hospital revealed the following potential ligature points where patients could drape or tie something such as clothing and use as an anchor point for potential hanging.

a) B Hall Quiet Activity Room revealed the door was open without staff around and the door has 3 individual open hinges which could be used as a ligature point for tying a piece of clothing or other object for hanging. Further observation of the room revealed an upright three legged projector screen with an approximate 1-inch-wide web carry handle approximately 4 feet off the floor which could be used for hanging.

b) A Hall women's shower room revealed the water line from the wall to the toilet was approximately 10 inches off the floor and not covered which could be used as a ligature point.

c) A Hall seclusion room bathroom revealed a wall mounted toilet push button mechanism for flushing the toilet protrudes from the wall a finger width behind the mushroom head of the button and could be used as an anchor point for ligature for potential hanging.

On 3/18/19 at 9:55 a.m. S1CEO confirmed the above ligature points which could be utilized for potential hanging creating a patient safety risk. He also confirmed the Activity door should have been locked when not in use with staff present.

Based on policy review, observations and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards of practice as evidenced by:
a) staff storing personal food in the medication refrigerator,
b) staff storing personal food in patient nourishment refrigerator,
c) failure to ensure expired or opened and undated medications were not available for use; and
d) failure to maintain a sanitary environment in the hospital.

Findings:

a) Staff storing personal food in the medication refrigerator

On 3/18/19 an observation of the B Hall Medication Refrigerator revealed 2 small Styrofoam containers with what S6LPN verified was salsa, 1 Styrofoam container of guacamole and 1 opened 8 oz. container of low fat milk stored with medication in the refrigerator.
On 3/18/19 at 9: 45 a.m. S6LPN confirmed the staff food was in the medication refrigerator with medications present.

b) Staff storing personal food in patient nourishment refrigerator

On 3/19/19 at 9:45 a.m. an observation of the A Hall patient nourishment refrigerator revealed a box of Churche's Chicken, a container of partially eaten macaroni and cheese and a container of salsa stored with patient nourishments.
On 3/19/19 at 9:45 a.m. S2 DON confirmed the chicken, macaroni and cheese and salsa were for hospital staff and should not be stored with the patient nourishments.

c) Failure to ensure expired or opened and undated medications were not available for use

A review of the hospital's policy Parenteral Medications last reviewed 1/28/19 revealed in part:
A. Medication Vials
Medication vials must contain an opened by date if the vial has been opened. All opened medication will expire within 30 days of vial being opened (or sooner if manufacturer expiration date expires sooner). Medication vials must be discarded in appropriate sharps container.

A review of the hospital's policy Storage of Topical Medications last reviewed 1/31/19 revealed in part:
4. Date opened must be documented on the actual tube, jar, etc. of the medication.

On 3/18/19 at 9:45 a.m. an observation of the B Hall medication room revealed:
a) 1 Novolin N 100 units/ ml unopened and expired on 10/2018 sored in the small medication refrigerator.
b) 1 tube Mupricocin 2% opened and not dated and 2 tubes of 1oz triple antibiotic opened and not dated stored in the medication cart.
On 3/18/19 at 9: 45 a.m. S6LPN confirmed the expired and opened undated medications.

On 3/18/19 at 9:55 a.m. an observation of the A Hall medication refrigerator revealed the following expired and opened undated medications:
a) 1 Levemir 100 units/ml opened and expired on 2/28/19,
b) 11 Lantus 100 units/ml opened and not dated,
c) 1 Novolin R 100 units/ml opened and expired 2/15/19,
d) 1 Novolog 100 units/ ml opened and expired 3/11/19.
In an interview on 3/18/19 at 9:55 a.m. S7LPN confirmed the expired and opened undated medication.

On 3/19/19 at 9:20 a.m. an observation of the A Hall med cart revealed 1 opened undated tube of triple antibiotic.
On 3/19/19 at 9:20 a.m. S11LPN verified the triple antibiotic was opened and undated.


d) Failure to maintain a sanitary environment in the hospital.

A tour of patient room 108 bathroom revealed the wall behind the toilet was peeling. Also, around the base of the toilet was a brown substance.
In an interview on 3/18/19 at 9:35 am S1CEO verified the peeling wall and brown substance around the base of the toilet.

On 3/18/19 at 9:55 a.m. a tour of the A Hall Women's community shower room revealed the hand rail next to the toilet to be dirty and have hair located on the plate between the wall and railing.
On 3/18/19 at 9:55 a.m. S1CEO confirmed the findings in the A Hall shower room.

On 3/19/19 at 9:00 a.m. a tour of the B Hall revealed the patient nourishment refrigerator shelving was dirty with a brown and red substance.
On 3/19/19 at 9:00 a.m. S2DON confirmed the refrigerator was dirty.

On 3/19/19 at 9:15 a.m. a tour of the hospital kitchen revealed the following:
a) The Blodgett oven in the kitchen was dirty,
b) The floor under the triple sink and prep table was dirty.
On 3/19/19 at 9:15 a.m. S10Cook verified the oven and floor was dirty. He also confirmed the oven is utilized and should be cleaned daily.

On 3/19/19 at 9:40 a.m. a tour of the A Hall Men's community shower revealed the windowsill was dirty and contained hair.
On 3/19/19 at 9:40 a.m. S2DON confirmed the findings in the A Hall Men's community shower.

On 3/19/19 at 9:45 a.m. an observation of the A Hall patient nourishment room revealed the floor was dirty and sticky when walked upon.
On 3/19/19 at 9:45 a.m. S2 DON confirmed the above findings.