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Based on observation and interview, it was determined the facility failed to ensure the entrance to the patient shower located in the Nursing Unit hallway was maintained in that the non-skid strip was peeling up from the floor. The failed practice placed the patients who utilized the shower at risk of falling and had the potential to affect all patients who utilized the shower. The findings follow:

A. During a tour of the Nursing Unit on 06/19/12 at 1430, observation revealed the non-skid strips on the floor leading to the shower were peeling up which could cause a patient to trip and fall.
B. The findings were confirmed in an interview with the Director of Clinical Services on 06/19/12 at 1430.

Based on Surgical Services Daily Checklist log review and interview, it was determined the humidity level in the single Operating Room in the facility was regularly maintained above the required humidity range of 60%, and the humidity level was not monitored in the Endoscopy Room in accordance with the Rules and Regulations for Hospitals and Related Institutions in Arkansas (2007 edition) for 18 of 39 days surgery was performed from March 2012 to June 2012. Humidity levels outside the required range had the potential to affect the health and safety of all patients admitted for procedures due to the risk of mold and mildew creation. The facility had four patients scheduled for procedures on 06/19/12. The findings follow:

A. Review of the Surgical Services Daily Checklist log on 06/19/12 at 1345 revealed humidity in the Operating Room was documented above 60% on 18 of 39 days surgery was performed from March 2012 through June 2012. There was no documentation of humidity for the Endoscopy Room in the log.
B. In an interview on 06/19/12 at 1415, the Surgical Services Supervisor verified the high humidity documented in the log.
C. In an interview on 06/20/12, the Maintenance Technician verified there was no current documentation of corrective action in response to the high humidity available for review.

Based on interview, it was determined the facility did not have provisions for the determination of the volume of water needed for potable and non-potable use for patients, staff, and visitors in the event of normal water supply disruption. The failed practice had the potential to affect the health and safety of patients due to the risk of dehydration in the event of a loss of the normal water supply. The failed practice had the potential to affect all patients admitted to the facility, staff, and visitors, and 11 of 11 patients on census the first day (06/19/12) of the survey. The findings follow:

In an interview on 06/20/12 at 1425, the Certified Dietary Manager verified the facility did not have a written policy for estimating the volume of water required to meet patient, staff and visitor needs in the event of normal water supply disruption.

Based on observation, Backup Emergency Light and Exit Light Checks documentation review, and interview, it was determined the facility did not meet Life Safety Code requirements as follows:

A. The facility failed to test the batteries of emergency light fixtures monthly and annually which had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the emergency light to illuminate the emergency egress in the event of a loss of normal power was not assured. See K46.
B. The facility failed to test the batteries of exit signs monthly and annually which had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the exit lights to indicate the location of emergency exits in the event of a loss of normal power was not assured. See K47.
C. The facility failed to maintain the fire door for the Soiled Linen Room to ensure the door was self-closing due to a missing closure arm on the fire door which had the potential to affect the health and safety of all patients, staff, and visitors due to the potential spread of smoke and fire from the open door of the room if the door was not maintained in the closed position. See K29.
D. The facility failed to maintain the fire door at the discharge from the exit stairwell to the exterior of the building to ensure the door would open properly and easily. The failed practice had the potential to affect the health and safety of all patients, staff, and visitors due to the potential of delayed exiting of the building from the difficulty in opening the door. See K33.
E. The facility failed to ensure the interior fire door from the corridor to the stairwell remained closed at all times due to the use of a chair to prop the fire door open. The failed practice had the potential to affect the health and safety of all patients, staff, and visitors due to the potential spread of fire and smoke into the exit stairwell from the open door. See K33.

Based on interview, it was determined the facility did not ensure regular inspections by the local fire department since the last documented inspection was 2009. The failed practice had the potential to affect the health and safety of all patients, staff and visitors because the fire department familiarity of the potential hazards and physical layout of the facility was not assured. The facility had a census of 11 patients on 06/19/12. The findings follow:

In an interview on 06/21/12 at 1040, the Maintenance Technician verified the most recent documented fire department inspection occurred in 2009.

Based on observation and interview, the facility failed to ensure outdated medications were not available for patient use in three (Surgery Endoscopy Procedure Room, Nursing Unit Central Supply, Emergency Department) of three patient care areas. The potential existed for these outdated medications to be administered to the average daily patient census of 2.6. Findings follow:

A. A tour of the three patient care areas was conducted on 06/19/12 between 1300 and 1500 and completed on 06/20/12 between 0830 and 0900. The following outdated medications were observed:
1) Surgery Endoscopy Procedure Room
a) Two Epinephrine 1 milligram (mg)/10 milliliters (ml) expired 05/01/12;
b) Eight Sodium Chloride 0.9% 100 ml Intravenous Solution expired 06/01/12; and
c) One Sodium Chloride 0.9% 1000 ml Intravenous Solution expired 03/01/12.
2) Nursing Unit Central Supply
a) Four Lactated Ringers 1000 ml Intravenous Solution expired 04/01/12; and
b) Three Dextrose 5% 1000 ml Intravenous Solution expired 12/31/11.
3) Emergency Department
a) One Dextrose 5% 500 ml Intravenous Solution expired 02/01/12;
b) One Sodium Chloride 0.9% 1000 ml Intravenous Solution expired 03/01/12;
c) One Dextrose 5% 1000 ml Intravenous Solution expired 02/01/12;
d) Eight Dextrose 5% 100 ml Intravenous Solution expired 06/01/12; and
e) Two Epinephrine 1 mg/10 ml expired 05/01/12.
B. The following interviews were conducted for verification of outdated medications:
1) Verification of outdated medications in Surgery Endoscopy Procedure Room by the Surgical Services Supervisor on 06/19/12 at 1345;
2) Verification of outdated medications in Nursing Unit Central Supply by the Assistant Director of Nursing on 06/19/12 at 1435;
3) Verification of outdated Dextrose 5% 500 ml Intravenous Solution in Emergency Department by the Director of Clinical Services on 06/19/12 at 1450;
4) Verification of outdated Sodium Chloride 0.9% 1000 ml Intravenous Solution, Dextrose 5% 1000 ml Intravenous Solution, and Epinephrine 1 mg/10 mg by the Emergency Room Registered Nurse #1 on 06/20/12 at 0840; and
5) Verification of Dextrose 5% 100 ml Intravenous Solutions by the Assistant Director of Nurses on 06/20/12 at 0850.

Based on review of the "T.B. (tuberculosis) Room 108-Negative Air Test Monthly Checks", Policy and Procedure Manual review and interview, it was determined the facility failed to ensure the negative air test for the TB isolation room was checked on a monthly basis since 03/14/12. The failed practice did not ensure the TB isolation room was maintained to prevent the spread of tuberculosis and had the potential to affect all patients admitted to the facility since 03/14/12. The findings follow:

A. Review of the "T.B. Isolation Room 108-Negative Air Test Monthly Checks" documentation on 06/19/12 revealed the last documented date the negative air test was performed was 03/14/12.
B. Review of the policy "T.B. Isolation Room Negative Air Test" on 06/19/12 revealed "Isolation Room 108 is to be tested monthly."
C. The findings were confirmed in an interview with the Infection Control Coordinator on 06/19/12 at 1255.

Based on clinical record review, Policy and Procedure Manual review and interview, it was determined the facility failed to ensure the patient's plan of care was updated and kept current to include wound care and the placement of an indwelling urinary catheter for two (#4 and #6) of seven (#1-#7) inpatient records reviewed. The failed practice did not allow for changes to be made to the patient's care as the patient's needs changed. The failed practice had the potential to affect all seven inpatients and all patients admitted to the facility. The findings follow:

A. Review of Patient #4's clinical record on 06/21/12 revealed the patient was admitted on 06/14/12 with the diagnosis of respiratory failure and COPD (chronic obstructive pulmonary disease) exacerbation. Review of the Wound Assessment documentation dated 06/14/12 revealed the patient had a Stage I wound on their right outer ankle and upper right buttock. Review of the "24-hour Nursing Flow Record" dated 06/17/12 revealed a Foley catheter was placed. Review of the patient's care plan revealed there was no evidence the patient's plan of care was updated to reflect the wounds or the placement of the Foley catheter. The findings were confirmed in an interview with Registered Nurse #1 on 06/21/12 at 1010.
B. Review of Patient #6's clinical record on 06/21/12 revealed a physician's order for a Foley catheter placed on 06/18/12. Review of the patient's care plan revealed there was no evidence the patient's plan of care was updated to reflect the placement of the foley catheter. The findings were confirmed in an interview with Registered Nurse #1 on 06/21/12 at 1045.
C. Review of the policy "Care Plan: Nursing" on 06/21/12 revealed, "Nursing Care Plans will be initiated on all patients at the time of admission to General Nursing Unit or Monitored Care Unit. This plan of care will be kept current on a daily basis and will be individualized based on the patient's needs and problems, and will indicate nursing care needed, how it is to be accomplished and goals as related to each problem/need."
D. The findings were confirmed in an interview with the Assistant Director of Nursing on 06/21/12 at 1320.

Based on review of the Quality Assurance/Performance Improvement (QAPI) Program for 2011 and 2012 and interview, the facility failed to ensure four patient care services (Facilities/Safety, Physical Therapy, Respiratory Therapy, Social Services) were involved in one (1st quarter of 2012) of five quarters. The potential existed for problems affecting the average daily patient census of 2.6 patients to go undetected and produce negative patient outcomes. Findings follow:

A. The QAPI Program was reviewed on 06/21/12 at 1030. There was no evidence the patient care services of Facilities/Safety, Physical Therapy, Respiratory Therapy, and Social Services had reported QAPI to the QAPI Committee the first quarter of 2012.
B. During an interview was conducted with the Surgical Services Supervisor, who was the hospital wide QAPI coordinator, on 06/21/12 at 1110, it was verified the four departments were not involved in the QAPI Program for the first quarter of 2012 and made no reports to the QAPI Committee.

Based on policy and procedure review and interview, it was determined the facility failed to develop policies and procedures related to patient abuse by an employee. The failed practice created the potential for an abuse violation to go unreported and uninvestigated and could affect any patient admitted to the facility. Findings follow.

A. Review of Policy and Procedure Manual revealed there was no written process in place on how an abuse of patient from an employee would be handled.
B. During an interview on 06/21/12 at 0935, the Social Worker stated their policy was if an abuse allegation occurs, an event report was filled out and then sent to the Director of Clinical Services, then to Medical Staff, then it becomes a part of the facility's QAPI (Quality Assessment/Performance Improvement). When asked if that policy was in writing, the Social Worker said "no."