HospitalInspections.org

04710



Based on observations, and staff interviews, the facility failed to maintain the physical environment of the facility in safe operating condition. Findings include:

1. During the tour of the kitchen's dry storage room on 7/6/10 at 11:06 a.m., the suspended ceiling was noted to have a wet area approximately 24 inches in length and 6 inches in width. Several other ceiling tiles were noted to be discolored. When the environmental engineer was asked on 7/7/10 at 8:30 a.m., if the ceiling leaks were new, he said "Yes." He said due to recent heavy rains, the roof leaked and water drained from the roof down to the ceiling tiles. According to the environmental engineer, the other discolored areas had occurred within the last year. The roof had previously been tarred where nails were loose and cracks appeared. He said the areas above the wet ceiling tiles would need to be looked at again and scheduled for re-tarring.

2. On 7/7/10 at 11:15 a.m., the dirty dish room was toured. The wall beneath the drain board/counter had an eight inch by one inch strip of sheet rock that was crumbling. The paper was pulling away from the sheet rock and a powdery substance was visible on the floor. The vinyl baseboard had come loose and had pulled away from the wall board.

3. On 7/7/10 at 7:30 a.m., the exterior of the building was inspected. There was an area visible from the staff dining room where lathe and plaster had fallen off on the underside of the eaves. The area was approximately 24 by 8 inches in length and width. The environmental engineer was interviewed on 7/7/10 at 8:30 a.m. He said the areas under the eave of the building was affected by heavy moisture from snow and rain, and the lathe and plaster came off.

The eaves on all four sides of the building were inspected on 7/6/10 at 3:30 p.m., and again on 7/7/10 between 8:30 a.m. and 9:30 a.m. There were several areas on the underside of the eaves with seam cracks in the lathe and plaster, or missing sections of lathe and plaster exposing the wood.
-On the Quarry and 4th St. corner of the building, there was a crack that was pulling the plaster and lathe apart.
-At the main entrance to the building, by the nurse's station, there was a 36-inch seam crack, allowing moisture to enter under the eaves.

There were several other areas under the eaves, on the 4th Street side of the building where the lathe and plaster was pulling apart, allowing moisture to enter under the eaves.
---One 3 x 6 inch hole with the lathe and plaster missing.
---One 36-inch crack pulling the lathe and plaster apart.

The entire roof had shingles that were curled on the ends. The environmental engineer stated during an interview on 7/7/10 at 9:30 a.m., that nails had to be tapped down and tar applied to areas of the roof where water had leaked under the shingles and entered the building, causing water damage to the ceiling tiles. He did not know what the plans were for further roof repair.

Based on observation, policy review, and staff interview, the facility failed to store refrigerated drugs and/or biologicals at manufacturers' recommended temperatures. Findings include:

1. During the tour of the emergency room (ER), accompanied by the charge nurse on 7/6/10 at 8:30 a.m., the temperature log of the medication storage refrigerator was reviewed. The temperatures for July were noted to be within the 36 to 46 degree range, but there were days from January through June 2010 where the temperatures were out of range, or where the temperatures were not recorded:
- January had 8 days with temperatures between 32 and 35 degrees, and 1 day with no temperature recorded;
- February had 10 days with temperatures between 32 and 35 degrees, and 2 days with no temperature recorded;
- March had 7 days with temperatures between 32 and 35 degrees, and 3 days with no temperature recorded;
- April had 9 days with temperatures between 32 and 35 degrees, and 3 days with no temperature recorded;
- May had 4 days with temperatures between 32 and 34 degrees, and 3 days with no temperature recorded; and
- June had 4 days with temperatures between 32 and 34 degrees, and 3 days with no temperature recorded.

2. During the tour, the charge nurse stated the night shift nurse checks the temperatures in the medication refrigerator. The charge nurse was asked about the procedure for dealing with temperatures that were out of the manufacturers' recommended ranges. The charge nurse stated when the temperatures were out of range, the temperature was adjusted and rechecked in two hours. Medications in the refrigerator were moved to another refrigerator until temperatures were within the acceptable range. The charge nurse did not have a record of what procedures were done on the days when the temperatures were out of range.

3. The temperature log did not provide an area for noting what interventions were done when the temperatures were out of range. The form had columns with the months, the days of the month, and what the temperatures were for those days.

During the exit with the facility on 7/7/10 at 9:30 a.m., the director of nursing stated their current form did not contain an area for documenting what interventions were done or what the temperatures were after they were rechecked.

Based on observation, staff interview, and policy review, the facility failed to ensure that multidose vials were labeled when opened, discarded within acceptable time guidelines, and not available for patient use in the emergency room (ER). Findings include:

1. During the tour of the ER, accompanied by the charge nurse, on 7/6/10 at 8:30 a.m., the following was observed in the locked medication storage cabinet:
- 1 opened multidose vial of 2% (percent) Xylocaine with no open date.
This vial was placed back into the locked cabinet by the charge nurse.

In the IV (intravenous) tray:
- 1 opened multidose vial of 1% Lidocaine with an open date of 5/30/10. This vial was disposed of by the charge nurse.

2. During the tour, the charge nurse stated that all multidose vials are to be dated when they are opened. The vials are to be discarded on the manufacturer's recommended expiration date.

3. During review of the facility policy on "Use of Multidose Vials," effective on 3/09, showed: "The expiration date for an unopened multidose vial will be the manufacturer's recommended date listed on the vial...When a vial is opened, the date shall be written on the label...After 28 days, the vial is to be discarded regardless of the amount left in the vial."