HospitalInspections.org

Based upon on-site observation, document review and interview, by Life Safety Code (LSC) surveyors on 9/9/2014, the facility failed to comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the below cited K-tags on the CMS-2567 dated 9/9/2014 for Life Safety Code.
K-0018
K-0050
K-0052
K-0062
K-0064
K-0073
K-0147

Based on observation, interview and document review, the facility failed to ensure that staff follow policy and procedure for maintenance of intravenous (IV) administration sets for 2 of 3 (#3, #4) patients reviewed, failed to ensure that outdated IV solutions were not available for patient use and failed to ensure that staff use technique according to policy for single dose vials of medication resulting in the potential for poor patient outcomes for all patients treated at the facility. Findings include:

On 09/09/2014 at approximately 1015, observations on the medical/surgical unit revealed that patient #3 had both a primary IV solution hanging and a secondary IV (antibiotic piggy back) solution hanging. The administration sets (primary and piggy back tubings) lacked labels as to when the tubings should be changed.

On 09/09/2014 at 1020, during an interview with staff F (Director Risk Management) when queried about the tubing not beng dated, she stated, "IV tubing is supposed to be dated when it is put up."

On 09/09/2014 at approximately 1030, during review of patients #4's IV's revealed that they had both primary and secondary solutions. The IV administration sets for both the primary and secondary IV's lacked labeling as to when the tubing was put up.

On 09/09/2014 at 1033, staff F stated, "All tubing should be dated."

On 09/09/2014 at 1100, an observational tour of the medical/surgical unit medication room revealed four (4) 1000 ml bags of "10% Dextrose" IV solution with a manufacturer's expiration date of "1 August 2014" and one (1) 1000 ml bag of "Potassium Chloride" solution with a manufacturer's expiration date of "1 September 2014." Each of the above mentioned solutions were available for patient use.

On 09/09/2014 at 1115, during an interview with staff D (Medical Surgical Unit Manager), when queried about the outdated IV solutions, she stated, "We go through these cupboards all the time, I can't believe that we missed all of those."

On 09/09/2014 at 1500, a review of the facility's policy titled, "Intravenous Therapy General Rules, Policy Number: 606111-00-95, date Issued: 02/28/14, #14. Maintenance of administration sets: IV administration tubing, including 'piggyback' tubing, should be routinely changed every 72 hours."

On 09/10/2014 at 1130, a review of the facility's policy/procedure titled, "Procedure for Cleaning Medication Cart and Refrigerator, Procedure: 1. Medication Cart: Check for outdated or discharged patient medications. Refer to pharmacy or destroy as needed."


30988

On 09/09/2014 at approximately 1015, during a tour of the Emergency Department (ED) medication room an opened single dose vial of 1% lidocaine was found in the cupboard and was available for use. Staff D was present when the vial was found, and confirmed the finding. Staff D stated, "that is not our policy, it is supposed to be discarded after one use."

On 09/10/2014 at approximately 0800 during a review of the policy titled "Vial expiration # 607180-00-51 dated 06/12/14" it stated "....2. Single-use vials:.....In patient care areas, single dose vials will be used only once and any remaining unused medication will be discarded."

Based on observation, interview and document review, the facility failed to ensure that staff follow appropriate infection control practices for 1 of 1 patients (#3) to prevent catheter associated urinary tract infection (CAUTI) resulting in the potential for poor patient outcomes. Findings include:

On 09/09/2014 at approximately 1015, observation on the medical/surgical unit revealed that patient #3 had a urinary catheter. During the observation, the catheter bag was noted to be hanging down from the side of the bed with the lower part of the bag and the drainage tubing lying on the floor.

On 09/09/2014 at 1025, during interview with staff F (Director Risk Management), when queried about the catheter bag and tubing touching the floor, she stated, "It is not supposed to be touching the floor, it is supposed to be up so it doesn't touch the floor," staff F then moved the bag.

On 09/10/2014 at 1000, a review of the facility's policy/procedure titled, "Catheter Insertion, Care of Removal, Policy Number: 606111-00-170, Date Issued: 08/21/14," revealed that the policy/procedure lacked instruction to staff to ensure that the catheter bag and tubing are placed in a location that prevents the bag and tubing from making contact with the floor.

Based on observation, interview and document review, the facility failed to ensure that staff follow policy/procedures related to safe food storage resulting in the potential for poor patient outcomes. Findings include:

On 09/09/2014 at 1045, during a tour of the nourishment room on the medical/surgical unit, revealed that the refrigerator contained three (3) opened boxes of juice that did not contain a date as to when they were opened or when they would expire. The refrigerator also contained three (3) small cups of canned peaches that also lacked dates as to when they were placed into the refrigerator or when they would expire.

On 09/09/2014 at 1050, when staff D was queried regarding the lack of dates on the containers, she stated, "I know that everything is supposed to be dated."

On 09/09/2014 at 1053, a review of the document hanging on the outside of the refrigerator door read, "Please Note All Food in this refrigerator must be for patient use and dated when Opened,... Juice date when opened/and when expires (4 days)." The document did not contain a date, policy number, title or identify where it came from.

On 09/09/2014 at 1630, during an interview with staff L (Dietary Manager), when queried about the the items being found undated in the refrigerator, she stated, "I am not sure why the fruit cups, that came from the kitchen staff, were not dated. They should have been dated with both the date that they are put out onto the floor and when they expire. As for the boxes of juice, it is up to the nursing staff to date them when they open them. We stock the nourishment room with the juice boxes, but nursing (personnel) are the ones who open the boxes and should be dating them."

On 09/10/2014 at 0900, review of the facility's policy titled, "Patient Food Services. Policy #C034, Date Revised: 3/11," read "Procedures: Food and Nutrition Services Department ...Discard items as follows below: ...Opened juice: if more than 72 hours old ....Opened (canned) Nutritional products: if more than 24 hours old."

On 09/10/2014 at 0915, during an interview with staff D (Medical/Surgical Manager), when queried regarding how the dietary staff are supposed to know when to throw something away when it becomes outdated, if nursing staff are not dating items, such as the juice, when the open it, staff D replied, "There isn't any way for them to know."

Based upon on-site observation, document review and interview, by Life Safety Code (LSC) surveyors on 9/9/2014, the facility failed to comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the below cited K-tags on the CMS-2567 dated 9/9/2014 for Life Safety Code.
K-0018
K-0050
K-0052
K-0062
K-0064
K-0073
K-0147

Based on observation, interview and document review, the facility failed to ensure that staff follow policy and procedure for maintenance of intravenous (IV) administration sets for 2 of 3 (#3, #4) patients reviewed, failed to ensure that outdated IV solutions were not available for patient use and failed to ensure that staff use technique according to policy for single dose vials of medication resulting in the potential for poor patient outcomes for all patients treated at the facility. Findings include:

On 09/09/2014 at approximately 1015, observations on the medical/surgical unit revealed that patient #3 had both a primary IV solution hanging and a secondary IV (antibiotic piggy back) solution hanging. The administration sets (primary and piggy back tubings) lacked labels as to when the tubings should be changed.

On 09/09/2014 at 1020, during an interview with staff F (Director Risk Management) when queried about the tubing not beng dated, she stated, "IV tubing is supposed to be dated when it is put up."

On 09/09/2014 at approximately 1030, during review of patients #4's IV's revealed that they had both primary and secondary solutions. The IV administration sets for both the primary and secondary IV's lacked labeling as to when the tubing was put up.

On 09/09/2014 at 1033, staff F stated, "All tubing should be dated."

On 09/09/2014 at 1100, an observational tour of the medical/surgical unit medication room revealed four (4) 1000 ml bags of "10% Dextrose" IV solution with a manufacturer's expiration date of "1 August 2014" and one (1) 1000 ml bag of "Potassium Chloride" solution with a manufacturer's expiration date of "1 September 2014." Each of the above mentioned solutions were available for patient use.

On 09/09/2014 at 1115, during an interview with staff D (Medical Surgical Unit Manager), when queried about the outdated IV solutions, she stated, "We go through these cupboards all the time, I can't believe that we missed all of those."

On 09/09/2014 at 1500, a review of the facility's policy titled, "Intravenous Therapy General Rules, Policy Number: 606111-00-95, date Issued: 02/28/14, #14. Maintenance of administration sets: IV administration tubing, including 'piggyback' tubing, should be routinely changed every 72 hours."

On 09/10/2014 at 1130, a review of the facility's policy/procedure titled, "Procedure for Cleaning Medication Cart and Refrigerator, Procedure: 1. Medication Cart: Check for outdated or discharged patient medications. Refer to pharmacy or destroy as needed."


30988

On 09/09/2014 at approximately 1015, during a tour of the Emergency Department (ED) medication room an opened single dose vial of 1% lidocaine was found in the cupboard and was available for use. Staff D was present when the vial was found, and confirmed the finding. Staff D stated, "that is not our policy, it is supposed to be discarded after one use."

On 09/10/2014 at approximately 0800 during a review of the policy titled "Vial expiration # 607180-00-51 dated 06/12/14" it stated "....2. Single-use vials:.....In patient care areas, single dose vials will be used only once and any remaining unused medication will be discarded."

Based on observation, interview and document review, the facility failed to ensure that staff follow appropriate infection control practices for 1 of 1 patients (#3) to prevent catheter associated urinary tract infection (CAUTI) resulting in the potential for poor patient outcomes. Findings include:

On 09/09/2014 at approximately 1015, observation on the medical/surgical unit revealed that patient #3 had a urinary catheter. During the observation, the catheter bag was noted to be hanging down from the side of the bed with the lower part of the bag and the drainage tubing lying on the floor.

On 09/09/2014 at 1025, during interview with staff F (Director Risk Management), when queried about the catheter bag and tubing touching the floor, she stated, "It is not supposed to be touching the floor, it is supposed to be up so it doesn't touch the floor," staff F then moved the bag.

On 09/10/2014 at 1000, a review of the facility's policy/procedure titled, "Catheter Insertion, Care of Removal, Policy Number: 606111-00-170, Date Issued: 08/21/14," revealed that the policy/procedure lacked instruction to staff to ensure that the catheter bag and tubing are placed in a location that prevents the bag and tubing from making contact with the floor.

Based on observation, interview and document review, the facility failed to ensure that staff follow policy/procedures related to safe food storage resulting in the potential for poor patient outcomes. Findings include:

On 09/09/2014 at 1045, during a tour of the nourishment room on the medical/surgical unit, revealed that the refrigerator contained three (3) opened boxes of juice that did not contain a date as to when they were opened or when they would expire. The refrigerator also contained three (3) small cups of canned peaches that also lacked dates as to when they were placed into the refrigerator or when they would expire.

On 09/09/2014 at 1050, when staff D was queried regarding the lack of dates on the containers, she stated, "I know that everything is supposed to be dated."

On 09/09/2014 at 1053, a review of the document hanging on the outside of the refrigerator door read, "Please Note All Food in this refrigerator must be for patient use and dated when Opened,... Juice date when opened/and when expires (4 days)." The document did not contain a date, policy number, title or identify where it came from.

On 09/09/2014 at 1630, during an interview with staff L (Dietary Manager), when queried about the the items being found undated in the refrigerator, she stated, "I am not sure why the fruit cups, that came from the kitchen staff, were not dated. They should have been dated with both the date that they are put out onto the floor and when they expire. As for the boxes of juice, it is up to the nursing staff to date them when they open them. We stock the nourishment room with the juice boxes, but nursing (personnel) are the ones who open the boxes and should be dating them."

On 09/10/2014 at 0900, review of the facility's policy titled, "Patient Food Services. Policy #C034, Date Revised: 3/11," read "Procedures: Food and Nutrition Services Department ...Discard items as follows below: ...Opened juice: if more than 72 hours old ....Opened (canned) Nutritional products: if more than 24 hours old."

On 09/10/2014 at 0915, during an interview with staff D (Medical/Surgical Manager), when queried regarding how the dietary staff are supposed to know when to throw something away when it becomes outdated, if nursing staff are not dating items, such as the juice, when the open it, staff D replied, "There isn't any way for them to know."