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Based on observation and interview, the facility failed to ensure the appropriate safeguards were in place to protect confidentiality of medical records for one (1) of five (5) off-site locations.

Findings include:

Observation on 1/28/14 at 9:30 a.m. of the Quick Med Facility revealed that hard copy patient medical records were stored in an open room at the admissions desk. The records were kept in an open metal cabinet in this room. Both the room and the cabinet had locks. These records were in easy reach of anyone with access to the admissions desk.

Interview on 1/28/14 at 9:30 a.m. the supervising Registered Nurse and the admissions staff confirmed that medical records were not secured and non-licensed housekeeping employees were in the clinic after closing.

Based on observation, record review, and staff interview, it was determined that the facility failed to provide documented evidence of staff competency and training to ensure the safety of one (1) of three (3) patients sampled in physical restraints.

Findings include:

Observation on 2/3/2014 revealed, patient #1 was physically retrained with soft wrist restraints for medical safety, related to altered mental status, and multiple attempts to dislodge lines and tubes.

Record review of patient #1 revealed, a Medical Surgical Restraint Flow Sheet, dated 2/1/2014 that failed to document 24 hour safety checks from 8:00 a.m. on 2/1/2014 to 8:00 p.m. to 2/2/2014. (A total timeframe of 24 hours).

A review of facility policies and procedures revealed, a patient rights policy titled, Restraints and Seclusion that documented the frequency and monitoring for patients placed in Medical Surgical restraints was every 1 hour to ensure safety and circulation.

Interview with the department manager on 2/5/2014 at 3:00 p.m. confirmed the above findings.

Based on observation of the facility kitchen, review of dietary policies and procedures and interview, the facility failed to store food, maintain the dishwasher, clean equipment to prevent the likelihood of food borne pathogens.

Findings include:

Observation on 2/27/2014 at 10:30 a.m. of the kitchen, accompanied by the Food/Nutrition Manager and the Registered Dietician the following:

1. Freezers:
-milk products stored in the meat freezer;
-expired foods;
a large package of french fried potatoes with expiration date of 1/9/2014, a package of Chicken Chunks which expired on 1/26/2014
-unlabeled foods:
opened packages of frozen raw chicken in plastic wrap, (2) large pizzas, eight (8) gallon zip lock bags of raw chicken breast,
-and exposed chicken breast chunks that are freezer burned.

Review of facility policy and procedure # B006, entitled Food and Supply Storage Procedures, last revised on 1/2012 revealed that , all food , non-food items and supplies for food preparation should be stored in a manner to maintain its safety and wholeness for human consumption.

2. Observation on 1/27/2014 at 10:30 a.m. of the dish wash area revealed the following:
-the dish washer was out of service;
-a large stack of food trays soaking in one of three compartment sinks;
- the sanitizer detergent dispenser, hanging on the wall above the sinks was broken, and
-a clogged drainage plate beneath the three compartment sinks with food refuge in standing water.

3. Observation on 1/27/2014 at 10:30 a.m. of the serving line revealed a food service worker did not have a sanitary wipe to clean the food thermometer after calibrating the food thermometer.

Interview on 2/27/2014 at 10:30 a.m. the Food and Nutrition Manager and the Dietician confirmed all of the above findings.

Based on observation and interview, the facility failed to provide a safe environment including emergency call lights in the patient bathrooms for three (3) of five (5) off site care locations.

Findings include:

Observation on 2/3/14 at 12:00 p.m. at the wound care center, one (1) of two (2) patient restrooms had an emergency call device which was not operational. The Supervisor Registered Nurse confirmed the findings.

Observation on 1/4/14 at 11:00 a.m. at an off campus radiology diagnostic site revealed that two (2) of two (2) patient restrooms did not contain emergency call lights. The Radiology Technologist, the only patient care staff on duty during operating hours, confirmed that the restrooms did not have emergency call devices.

Observation on 2/05/2014 at 4:00 p.m. at the Outpatient Rehabilitation Center at 4:00 PM on 02/05/2014 accompanied and confirmed by the Director, that the Automated External Defibrillator (a portable electrical device that when applied, reestablishes normal heart rhythm) pads expired on 09/2012. Continued observation revealed carpet repairs were needed.

Based on observation, record review, and staff interview, it was determined that the facility failed to assure that supplies were maintained which would ensure an acceptable level of safety and quality.

Findings include:

Observation on 1/28/14 at 12:15 p.m. of the outpatient surgical center revealed that the Malignant Hyperthermia Cart (a locked supply cart containing treatment medications and equipment for the treatment of an emergency fever crisis caused by reaction to anesthesia) was opened.

Continued observation revealed that all twenty-four (24) of the endotracheal tubes (a plastic tube put in the mouth and then into the airway of the lungs to help with breathing) were expired. The supervising Registered Nurse and the supply technician present both confirmed the findings.

Based on record review, observation and staff interviews the facility failed to develop a policy related to expired supplies, and failed to assure Personal Protective Equipment (PPE) was available as needed on eight (8) care units.

Findings include:

Review of Policy:5-408 entitled Infection Prevention Program dated 8/19/13 revealed that the Infection Prevention Staff participate in environmental health programs that ensure the safety of patients from potential environmental hazards. Environmental tours, unit, and bedside rounds are conducted to address Infection Prevention issues at the direct patient care level.

1. Observation on 2/5/2014 at 12:05 p.m. a staff member dressed in scrubs with facility identification, was observed entering the Corner Cafe, with a N-95 Mask (facial mask used to prevent transmission of respirator infection) hanging down from the staff's facility badge.

Interview on 2/5/2014 at 12:30 p.m., the Infection Preventionist Director acknowledged that the appropriate use of PPE was an on going challenge and continually being addressed, especially with signage.


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Review of policy/procedures revealed no evidence of a process for checking and removing expired supplies in the patient care areas, however, review of a memorandum dated 2/4/14 from the CNO (Chief Nursing Officer) to Nursing Leadership and Supply Chain Leadership was reviewed. Review of the memorandum revealed a corrective action plan for removal of expired supplies in patient care areas.

Observation on 1/27/14 at 2:30 p.m. in the General Pediatric floor nourishment room, revealed an open can of Gerber Goodstart baby formula, four (4) packages of Gerber string bean and carrot flavor baby food with an expiration date of 11/13.

Observation on 1/27/14 at 2:40 p.m. in the General Pediatric floor revealed were two (2) patient rooms with contact isolation precautions including gloves and PPE cart outside the door.

Observation on 1/28/14 at 10:35 a.m. in the cardiac procedural floor clean supply room revealed a double lumen central venous catheter bundle with an expiration date of 1/15/14, and a transverse pacing electrode tray with an expiration date of 2010.

Observation on 1/28/14 at 11:10 a.m. in the cardiac short stay unit clean supply room revealed an Arrow Pleura-Seal thorocentisis kit with an expiration date of 03/2013, a tracheotomy tray with an expiration date of 2/2012, and a Tranverse pacing electrode tray with bipolar balloon pacing electrode with an expiration date of 11/2012.

Observation on 1/28/14 at 11:30 a.m. in the Invasive cardiology clean supply room revealed a triple lumen central venous catheter kit with an expiration date of 5/2011, a pericardiocentesis 6.0f kit with an expiration date of 4/2011 and a Aryle Salem slump tube with anti-reflux valve with an expiration date of 01/2013.

Observation on 2/3/14 at 10:30 a.m. in the Cardiovascular Intensive Care Unit (CVICU), revealed two (2) patient rooms with isolation precautions however, there were no gloves available.

Observation on 2/4/14 at 3:30 p.m. in the Neurological Intensive Care Unit (Neuro ICU)revealed four (4) 0.9% Saline solution for inhalation packs with an expiration date of 12/13.

Observation on 2/5/2014 at 10:00 a.m. in the Emergency Center revealed an expired tracheostomy tray with an expiration date of 2/2012. Observation in the pediatric area revealed six (6) vacutaneur blood culture holders with an expiration date of 2/2012, two (2) pediatric lumbar puncture needles with an expiration date of 2/2013, pediatric nasogastric tube with an expiration date of 11/2013, and three (3) purple pediatric blood tubes with an expiration date of 11/2013.

Observation on 2/5/14 at 10:50 a.m. in the general medical surgical floor in the nourishment room revealed five (5) packets of expired Banatrol Plus prebioticsupplements with an expiration date of 11/13.

Based on observation, review of facility policies and procedures and staff interview, it was determined that the governing body failed to have a policy in place to ensure that staff would respond effectively to the management of Malignant Hyperthermia (MH-an emergency fever crisis caused by a reaction to anesthesia).

Findings include:

Observation of the trauma bay level 1 on 2/5 /2014 at 10:00 a.m. accompanied by the Director of the Emergency Center (EC) and Manager of the (EC) failed to demonstrate evidence that Dantraline (a medication used for the treatment of a person in malignant hyperthermia crisis) was available for patient care.

Review of facility policy # 3-020, entitled Malignant Hyperthermia, detailed that Dantroline sodium (a medication used for increases in body temperature and muscle stiffness for a person with malignant hyperthermia) should be obtained and mixed with distilled water according to the person's weight and administered into their vein.

Interview on 2/5/14 at 10:15 a.m. with the Emergency Center Manager and the Director revealed no recall or verbalization of indications for the use of Dantraline.