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Based on clinical record review and interview, it was determined the facility failed to document the time a physician was notified of the patient's presence in the emergency room in four (Patient #5,#7, #9 and #10) of six (Patient #5-#10) clinical records reviewed and failed to assure the time the physician saw the patient was documented for six of six (Patient #5-#10) clinical records reviewed. Without a time the physician was notified or a time the physician saw the patient, it could not be determined if the physician was available and on site within 30 minutes. The failed practice affected Patient #5-#10, and had the potential to affect any patient who presented to the emergency room. The findings were:

A. The emergency visit record for Patient #5 was reviewed on 04/26/12 and revealed the patient presented to the emergency room on 04/24/12 at 1925. The "Emergency Nursing Record" triage time was 1925. The "Physician Notified" and "Time of Arrival" section was blank. The "Time to Room" was documented as 1940. The time of discharge was 2105 on 04/24/12. The "Emergency Physician Record" document had a check mark in the "time seen" section as "on arrival." There was no other date or time listed by the physician.
B. The emergency visit record for Patient #6 was reviewed on 04/26/12 and revealed the patient presented to the emergency room on 04/24/12 at 2015. The "Emergency Nursing Record" triage time was 2015. The "Physician Notified" section revealed a time of 2025 and "Time of Arrival" section revealed "already here." The "Time to Room" was documented as 2025. The time of discharge was 2120 on 04/24/12. The "Emergency Physician Record" document had a check mark in the "time seen" section as "on arrival." There was no other date or time listed by the physician.
C. The emergency visit record for Patient #7 was reviewed on 04/26/12 and revealed the patient presented to the emergency room on 04/24/12 at 2050. The "Emergency Nursing Record" triage time was 2050. A note written by the Registered Nurse on the nursing record stated "Did not see doctor. BS (blood sugar) 127 in ER (emergency room). Voices no complaints. Just wants BS checked." "Do not take P.M. Lantus. Cut a.m. and p.m.. doses in half until you follow-up with your PCP (primary care physician. V/O (verbal order) Dr. (named)." There was no documented date or time of the verbal order. The "Physician Notified" and "Time of Arrival" section was blank. The "Time to Room" was documented as 2105. The time of discharge was 2125 on 04/24/12. There was no "Emergency Physician Record" documented or note by a physician.
D. The emergency visit record for Patient #8 was reviewed on 04/26/12 and revealed the patient presented to the emergency room on 04/24/12 at 2130. The "Emergency Nursing Record" triage time was 2130. The "Physician Notified" time was 2145 and "Time of Arrival" section stated "orders gave at 2145. The "Time to Room" was documented as 2140. The time of discharge was 2240 on 04/24/12. The "Emergency Physician Record" document had a check mark in the "time seen" section as "on arrival." There was no other date or time listed by the physician.
E. The emergency visit record for Patient #9 was reviewed on 04/26/12 and revealed the patient presented to the emergency room on 04/25/12 at 0130. The "Emergency Nursing Record" triage time was 0130. The "Physician Notified" and "Time of Arrival" section was blank. The "Time to Room" was documented as 0140. The time of discharge was 0230 on 04/25/12. There was no "Emergency Physician Record" documented or a note by the physician. The nurse notes revealed "Did not see doctor. Has appointment with her PCP at 1115 in the morning" Medication documentation revealed the patient received MS (Morphine Sulfate) 2 milligrams intramuscularly in the right gluteal on 04/25/12 at 0230. The clinical record did not include documentation the physician was notified or that a verbal or telephone order was received for the medication administered. The patient discharge time was 0230 on 04/25/12.
F. The emergency visit record for Patient #10 was reviewed on 04/26/12 and revealed the patient presented to the emergency room on 04/25/12 at 1043. The "Emergency Nursing Record" triage time was 1050 . The "Physician Notified" and "Time of Arrival" section was blank. The "Time to Room" was blank. The time of discharge was 1145 on 04/25/12. The "Emergency Physician Record" document had a check mark in the "time seen" section as "on arrival." There was no other date or time listed by the physician.
G. The findings were confirmed by the Assistant Director of Nursing at 1320 and by the Quality Coordinator at 1345 on 04/26/12.

Based on observation and interview, it was determined the facility did not maintain the physical environment in a good state of repair for nine of nine (Patient Room 4, 5, 6, 23, 25, near 14, Exam Room, Treatment Room #2, and Emergency/Fracture Room) patient care areas. The failed practice had the potential to affect the health and safety of all patients, staff, and visitors due to the hazards presented by unclean conditions and disrepair of the physical environment. The facility had a census of three patients on 04/25/12. The findings follow:

A. On a tour of facility with the Director of Nursing on 04/25/12 at 0930 the following observations were made:
1) In Patient Room 4, soap scum was observed in the metal soap dish and around the shower handle in the patient bathroom. An accumulation of dust was observed on top of the patient wardrobe closet. The edge of the patient room door was damaged, leaving exposed unfinished wood and sharp edges. The blanket on the bed had a hole in it. The chair upholstery on a chair had a hole.
2) In Patient Room 5, soap scum was observed in the metal soap dish in the patient bathroom. An accumulation of dust was observed on top of the patient wardrobe closet. The edge of the patient room door was damaged, leaving exposed unfinished wood and sharp edges.
3) In Patient Room 6, the metal soap dish in the patient bathroom was pitted. The edge of the patient room door was damaged, leaving exposed unfinished wood and sharp edges. The chair upholstery on a chair had a hole. The escutcheon rings around the shower handles and shower head was missing. A grab bar outside the shower was missing.
4) In Patient Room 23, dust was observed on a portable fan. The metal soap dish in the patient bathroom was pitted.
5) In Patient Room 25, dust was observed on top of the vital signs monitor and patient wardrobe closet. The metal soap dish in the patient bathroom was pitted. The wall base behind the toilet was damaged and had an accumulation of grime.
6) In the Exam Room, dust was observed on the vital signs monitor. The edge of the door was damaged, leaving exposed unfinished wood and sharp edges. Black mold was observed on a ceiling tile in the change/toilet room.
7) In Treatment Room 2, dust was observed on top of the supply cabinet. The upholstery on a chair was damaged. A section of the wall base behind the toilet was missing and there was an accumulation of grime. There was a section of the wall in the toilet room that had been replaced with plastic laminate. The laminate had pulled away from leaving the void inside the wall exposed. The metal soap dish was pitted.
8) In the Emergency and Fracture Room, dust was observed on two surgical lights. The wall at the doorframe, just above the Pyxis machine was damaged. Two dead insects were observed stuck to the wall near the medication cabinet.
9) In the corridor near Patient Room 14, three stained ceiling tiles were observed. One of the ceiling tiles was bowed downward.
B. In an interview on 04/26/12 at 1430, the Maintenance Supervisor was shown the above observations and verified the conditions present.

Based on generator log review, observation, and interview, it was determined the facility did not meet Life Safety Code requirements as follows:

A. It could not be determined for each monthly load test the generator was run for a total of 30 consecutive minutes due to a lack of documentation of total load run time on the generator log. Failure to run the generator a minimum of 30 minutes per month had the potential to affect the health and safety of all patients, staff, and visitors because the reliable functioning of the generator was not tested or verified. See K144.
B. It was determined the facility failed to maintain the integrity and fire resistance rating for five of five (X-Ray Room, near Patient Rooms 6, 14, and 15, and GI (Gastrointestinal) Lab) smoke barrier walls inspected because of unsealed penetrations of the smoke barrier wall. The failed practice had the potential to affect all patients, staff, and visitors due to the inability of the compromised smoke barrier walls to prevent the passage of smoke and fire from one side of the smoke barrier to the other. See K25.

Based on observation and interview, the facility failed to ensure Intravenous(IV) solutions were locked in 1 (Central Supply) of 4 (Pharmacy, Nursing Station, Emergency Room and Central Supply) areas. The failed practice did not ensure IV solutions were only available to licensed personel. The failed practice had the potential to affect all patients who received intravenous fluids. Findings follow:

A. During a tour on 04/25/12 between 0935 and 1050, observation revealed the Central Supply Room door propped open, no one in the room and several cases of IV solutions being stored. Examples follow:
1) Three cases of 5% Dextrose and 0.9% Sodium Chloride 1000 milliliters (ml) for injection;
2) One case of 5% Dextrose 1000ml for injection;
3) One case of Lactated Ringers and 5% Dextrose 1000ml for injection;
4) One case of Lactated Ringers 1000ml for injection;
5) Two cases of 40 milliequivalent Potassium Chloride in 0.9% Sodium Chloride 1000ml; and
6) Four cases of 0.45% Sodium Chloride for injection 1000ml.
B. Findings were verified, through interview, on 04/25/12 at 1030 with the Pharmacy Technician.

Based on review of policy and interview, it was determined the facility failed to conduct controlled substance inventories once monthly as required by policy. By not doing monthly controlled substance inventories, the potential existed for discrepancies to be present and unresolved. Findings follow:

A. A review of the facility policy titled "Pyxis Medication Policy" on 04/25/12 at 1300 revealed "Controlled substances will be inventoried by the pharmacy once monthly."
B. During an interview with Pharmacist #1 on 04/26/12 at 0940, the controlled substance monthly inventories were requested so they could be reviewed. During this interview, Pharmacist #1 could not produce the controlled substance inventories and verified they do not conduct monthly controlled substance inventories.

Based on observation, review of policy and interview, it was determined the facility failed to utilize the Unit-Dose/Modified Unit-Dose Distribution System correctly by not providing one dose of medication in an identified ready-to-use package per policy and procedure. Failure to follow the facility's policy and procedure regarding Unit Dose/Modified Unit-Dose Distribution System had the potential to cause medication errors due to not providing drugs in individual packaging. Findings follow:

A. During a tour of the facility on 04/25/12 between 0935 and 1050, baggies containing multiple doses were observed in the Medicine Room Pyxis. Findings follow:
1) A single baggie contained 4 Levaquin 750milligram(mg) tablets;
2) A single baggie contained 10 Detrol Long Acting capsules;
3) A single baggie contained 7 Generic Augmentin 875mg/125mg tablets;
4) A single baggie contained 8 Keflex 500mg capsules; and
5) A single baggie contained 8 Famvir 500mg tablets.
B. Review of facility policy titled "Unit-Use Distribution System" on 04/25/12 at 1300 revealed, "The Pharmacist will provide the nurse with a quantity of medication sufficient for one dose in an identified, ready-to-use package ... ....Each dose is identified with the drug name, strength, lot number and expiration date. The drug is maintained in a sanitary form."
C. The findings were verified, through interview, on 04/25/12 at 1315 by Registered Nurse #2.

Based on review of policy, review of Narcotic Count Sheets, observation and interview, the facility failed to ensure two nurses provided signatures at the change of shifts to reflect discrepancies of narcotics were monitored on two (Medicine Room Pyxis and Emergency Room (ER) Pyxis) of two Pxyis machines' Narcotic Count Sheets. The potential existed for discrepancies in the narcotic inventories to be present without resolution. Findings follow:

A. A review of policy titled "Pyxis Medication Policy" on 04/25/12 at 1300 revealed "Before each shift, the Pyxis is checked to see if a discrepancy is showing. If there is a discrepancy showing, an activity report must be run by each nurse to find and resolve the discrepancy. When the discrepancy is resolved, both Team Leaders from each shift must sign the log. If there are no discrepancies found when observing the Pyxis, the two team leaders may sign the log without any activity reports being run."
B. Review of the Narcotic Count Sheet for the Medicine Room Pyxis on 04/25/12 at 0945 revealed between 04/01/12 and 04/24/12, 11 of 48 shifts were without two Team Leaders' signatures verifying the discrepancy report was run and verified.
C. During a tour of the Emergency Room on 04/25/12 at 0955, it was observed there was no Narcotic Count Sheet being kept for the ER Pyxis.
D. Findings were verified, through interview, on 04/25/12 at 1330 by Charge Nurse #1.

Based on observation, review of policy and interview, it was determined the facility failed to store controlled substances under double lock. The failed practice could not ensure controlled substances were being properly controlled. Findings follow:

A. During a tour on 04/25/12 between 0935 and 1050, observation revealed the refrigerator in the pharmacy stored controlled substances that were not meeting the double lock storage requirement as required by policy. Found were:
1) Nine Lorazepam 4milligram(mg)/milliliter(ml) 10 ml vials for injection;
2) One hundred Lorazepam 2mg/ml 1ml vials for injection; and
3) Twenty Five Lorazepam 2mg/ml 1 ml vials for injection.
B. Review of facility policy titled "Storage of Medications" on 04/25/12 at 1300 revealed, "All controlled substances shall be under double-locked storage."
C. Findings were verified, through interview, on 04/25/12 at 1015 by the Pharmacy Technician #1.

Based on review of infection control documentation and interview, it was determined the facility failed to assure a system was in place to identify, report, and assess illness or infection of health care personnel. Without an identification process, the facility could not assure patients and other staff would be protected from infection or illness. The failed practice affected all patients and staff of the facility. The findings were:

A. On 04/25/12, the facility process for employee illness reporting and infection prevention was requested from the Director of Nursing. A copy of a blank form titled "Absence Reporting" was provided at 1210 on 04/25/12. The form was void of information.
B. The Director of Nursing confirmed by interview on 04/27/12 at 1030 that there was no other information available or a process in place for identifying and assessing facility staff for potential infection.

Based on review of policies and procedures and interview, it was determined the facility failed to assure the Emergency Department, Health Information Management, Infection Control, and Nursing Department Policy and Procedure Manuals were reviewed on an annual basis. Without an annual review, the facility could not be assured the policies and procedures used by staff reflected current practices. The failed practice had the potential to affect all patients admitted to the facility. The findings were:

A. On 04/25/12, the facility policies and procedures were requested. The Emergency Room Policy and Procedure Manual was reviewed on 04/26/12 and the first page "The Procedures for Emergency Room Department were reviewed and revised as needed." The last signature and date was 02/11. Policies were outdated and did not reflect current practice. Examples were:
1) The policy "Infection Control Emergency Room and Out-Patient " stated "Cleaning of instruments and trays is done by department personnel. All instruments used or opened during a case are washed free of all secretions, then bagged and sent for reprocessing. Suction bottles are cleaned daily and tubing replaced following use by each patient."
2) Review of the "Spore Test" log from the surgical services area (not in use at present) revealed on 10/26/11 the statement "Plumbing issues. Sterilizer shut down." That was the last entry on the sterilizer spore test log.
3) The Director of Nursing on 04/25/12 at 0920 confirmed the findings in an interview and stated the facility had not sterilized instruments "since the fall (2011)" and on 04/27/12 at 1020 confirmed all suction containers in use at the facility were disposable.
B. The Health Information Management Policy and Procedure Manual was reviewed on 04/27/12 and the signature page reflected it was last reviewed on 02/16/11. The Director of Medical Records confirmed the findings on 04/27/12 at 0855.
C. The Infection Control Policy and Procedure Manual was reviewed on 04/25/12. The signature page reflected a review date of 01/08. The policies were outdated in that Infection Control "Transmission-Based Precautions" referenced CDC (Center for Disease Control) 2000 guidelines. CDC has a revised revision of transmission based precautions in the "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" The findings were confirmed by interview with the Director of Nursing on 04/27/12 at 1030.
D. The Nursing Services Policy and Procedure was reviewed on 04/26/12 and there was not a signature page with an annual review date. The Director of Nursing confirmed the findings in an interview 04/27/12 at 1030.

Based on clinical record review and interview, it was determined 10 (#1-2, #11-13, #15, and #17-20) of 20 (#1-20) clinical records contained physician's verbal orders which were not dated and timed or signed by the physician. Failure to date and time orders did not assure physician's verbal orders would be followed in the sequence intended by the ordering physician. The failed practice had the potential to affect any patient admitted to the facility. Findings follow:

A. The facility did not provide Surveyor #2 with a policy stating what the time frame was for having verbal orders signed. During an interview on 04/26/12 at 1330 the Assistant Director of Nursing stated the policy was 24 hours. On 04/27/12 at 1110 the Director of Nursing stated the facility did not have a policy for verbal orders.
B. Review of clinical records revealed the following:
1) Patient #1-five of five physician's verbal orders from 04/24/12 to 04/28/12 were without date and time of physician's signature, and two of five physician's verbal orders were without physician signature.
2) Patient #2-three of three physician's verbal orders from 04/22/12 to 04/26/12 were without date and time of physician's signature, and one of three was without physician's signature.
3) Patient #11-six of six physician's verbal orders on 02/28/12 were without date and time of physician's signature.
4) Patient #12-two of two physician's verbal orders on 01/07/12 were without date and time or physician's signature.
5) Patient #13-18 of 18 physician's verbal orders from 01/10/12 to 01/21/12 were without date and time of physician's signature.
6) Patient #15-one of one physician's verbal order on 03/05/12 was without date or time of physician's signature.
7) Patient #17-one of one physician's verbal order on 03/14/12 was without date or time of physician's signature.
8) Patient #18-eight of eight physician's verbal orders from 04/14/12 to 04/15/12 were without date and time of physician's signature, and seven of eight were without physician's signature.
9) Patient #19-two of two physician's verbal orders from 04/19/12 to 04/21/12 were without date or time of the physician's signature, and one of two physician's verbal order was without physician's signature.
10) Patient #20-eight of eight physician's verbal orders from 01/12/12 to 01/13/12 were without date and time of physician's signature, and two of eight physician's verbal orders were without physician's signature.
B. Findings were confirmed by the Director of Nursing on 04/27/12 at 1135.