HospitalInspections.org

Based on the survey completed March 10, 2020, the facility failed to comply with the regulations set forth for Life Safety, therefore, deficiencies were cited under Life Safety Code tags K324 and ,K511. See survey event ID # UUOX21 for full details of the cited deficiencies.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure expired supplies were removed from patient treatment areas. Failure to prevent accidental usage of expired sterile supplies has the potential for patients to be exposed to bacterial contaminants, with possible negative outcomes for all patients cared for by the facility.

Findings include:

Observation of the facility's Adult Crash Cart, located in the Emergency Department, on 02/17/20 at 1:15 PM, revealed two "Pro-vent" Arterial Blood Sampling kits with expiration dates of 09/30/19.

During a brief interview with the Chief Nursing Officer (CNO) on 02/17/20 at 1:20 PM, the CNO viewed the above items in the Adult Crash Cart and confirmed these were sterile items that were expired and should have been removed from the cart.

Observation of the facility's Emergency Department (ED) supply closets, on 02/19/20 at 3:00 PM, revealed two packs of sterile towels with expirations dates of 01/09/20.

During a brief interview with the Chief Nursing Officer (CNO) on 02/17/20 at 3:05 PM, the CNO viewed the above items in the ED and confirmed these were sterile items that were expired and should have been removed from the supply closet.

Observation of the facility's Sterilization Room on 02/18/20 at 10:15 AM revealed the shelves contained 122 sterilized instruments with expiration dates ranging from 04/19 to 11/19.

During an interview with the Certified Nursing Assistant (CNA) 5, who functioned as the facility's reprocessing technician, on 02/18/20 at 10:30 AM, CNA 5 admitted the expired instruments in the Sterilization Room needed to be re-sterilized, but this had not yet been done. CNA 5 stated that nursing staff did have keys to the Sterilization Room and had access to all of the instruments on the shelves. CNA 5 stated the expired instruments were those that were "rarely used," but could be used inadvertently if a nurse did not check the expiration date prior to use.

During a joint interview with the CNO, the Infection Control Nurse, and the Director of Infection Control on 02/18/20 at 2:45 PM, all three staff members agreed they were not aware of the presence of the expired instruments in the Sterilization Room, and also agreed that all expired supplies posed a risk to patients and should be removed from the facility.

Review of the facility's policy titled, "Cleaning in Central Sterile Processing," last revised 09/14, revealed, "The Central Sterile Technician will re-clean and/or sterilize equipment and instruments before placing them back into service per AORN (Association of Operating Room Nurses) sterilization and disinfection standards."

Review of the facility's policy titled, "Guidelines for Stocking & Rotating Nursing Supplies," last revised 02/16, revealed, "Stock will be checked monthly for expired items and expired items will be removed, logged as outdates, and returned to the Purchasing Department."

Based on interview and record review, the facility failed to ensure six of 28 sampled patients (Patients (P) P6, P7, P8, P9, P10, and P11) had a comprehensive, person centered plan of care and treatments that included therapeutic activities. This deficient practice had the potential for the patients to not receive the appropriate care to meet psychosocial needs.

Findings include:

Review of P6's undated "Patient Information" sheet, located in the electronic medical record (EMR), revealed an admission date of 01/31/20 with a diagnosis of acute renal failure. Further review of the EMR revealed an "Activity Assessment" dated on 02/04/20. Review of P6's undated care plan, also located in the EMR, revealed no care plan for activities.

Review of P7's undated "Patient Information" sheet, located in the EMR, revealed an admission date of 02/02/20 with a diagnosis of acute myocardial infarction. Further review of the EMR revealed an "Activity Assessment" dated on 02/08/20. Review of P7's undated care plan, also located in the EMR, revealed no care plan for activities.

Review of P8's undated "Patient Information" sheet, located in the EMR, revealed an admission date of 02/07/20 with a diagnosis of chronic obstructive pulmonary disease. Further review of the EMR revealed an "Activity Assessment" dated on 02/13/20. Review of P8's undated care plan, also located in the EMR, revealed no care plan for activities.

Review of P9's undated "Patient Information" sheet, located in the EMR, revealed an admission date of 02/03/20 with a diagnosis of alcoholism, pressure ulcer, and pulmonary embolism. Further review of the EMR revealed an "Activity Assessment" dated on 02/08/20. Review of P9's undated care plan, also located in the EMR, revealed no care plan for activities.

Review of P10's undated "Patient Information" sheet, located in the EMR, revealed an admission date of 02/03/20 with diagnoses of coronary arteriosclerosis and shortness of breath. Further review of the EMR revealed an "Activity Assessment" dated on 02/08/20. Review of P10's undated care plan, also located in the EMR, revealed no care plan for activities.

Review of P11's undated "Patient Information" sheet, located in the EMR, revealed an admission date of 02/09/20 with a diagnosis of right hip fracture. Further review of the EMR revealed an "Activity Assessment" dated on 02/13/20. Review of P10's undated care plan, also located in the EMR, revealed no care plan for activities.

During an interview on 02/19/20 at 1:30 PM, the Case Manager said it was the responsibility of the Case Manager to create and update the patient care plan. The Case Manager agreed the care plans were not comprehensive and did not include the activities care plan.

During an interview on 02/19/20 at 2:36 PM, the Activities Director (AD) agreed there were no care plans created for the patients. The AD stated that she knew care plans should have been created. The AD said she had not been trained on the program in which the documentation is created and maintained.

Review of the facility policy titled, "Swing Bed Comprehensive Patient Assessment and Care Plan" with a revised date of "8/2018" revealed, "Policy: To ensure that each swing bed patient will have a comprehensive assessment of care needs that will serve as a tool in the development of a comprehensive plan of care ...4. Initial comprehensive assessment will become the basis for the comprehensive care plan ..."

Based on review of documents and staff interview, the facility failed to ensure development and testing of a method of sharing documentation and medical information for patients in the event of an evacuation. This failure could lead to a lack of continuity of care by the receiving facility, with possible negative outcomes for all patients for which the facility maintains responsibility.

Findings include:

During the Entrance Conference conducted 02/27/20 at 9:30 AM with the facility Chief Executive Officer (CEO) and Chief Nursing Officer (CNO), the CNO stated the facility utilized a fully electronic medical record system, with all paper documentation scanned into the electronic record.

Review of the facility's Emergency Operations Plan (EOP) revealed no documented plan for sharing of patient information in the event of a patient evacuation to another facility.

Review of the facility's policy titled, "Emergency Operations Plan," last revised 4/2014, revealed, "All information regarding patients and residents must be recorded in their charts. Charts will remain with patients and/or residents if relocation is needed."

During an interview with the Director of Quality (QA) on 02/18/20 at 9:55 AM, the QA admitted responsibility for the facility's Emergency Operations Plan (EOP) plan. When asked about the facility's plan for transmitting patient information with a receiving facility during a patient evacuation, the QA stated there was no written plan for this. The QA stated, "We've had discussions about how to print the charts, but no decision was made." The QA admitted the plan for patient charts to remain with patients, as stated in facility policy, dated from a time when patient medical records were on paper and maintained in binders.