HospitalInspections.org

The Hospital reported a census of 17 patients. Based on observation and staff interview, the hospital failed to safeguard confidential patient information from possible destruction in the Medical Records storage room. This deficient practice has the potential to affect patients' records in 138 bankers boxes (cardboard boxes used to store medical records) placed directly on the floor.

Findings include:

- The Medical Records storage room observed on 12/10/2015 at 1:40pm revealed 138 Bankers boxes placed directly on the floor.

Medical Records Staff L interviewed on 12/10/2015 at 1:45pm acknowledged the boxes contained patients' medical records and sat directly on the floor with the potential for damage.

Policies reviewed on 12/10/2015 at 4:00pm revealed the hospital failed to develop a policy to ensure the protection of medical records from damage or destruction from flood or pests.

Based on observation, document review, and staff interview, the hospital's pharmaceutical services failed to meet the potential needs of the patient when they failed to ensure a medication used for the treatment of Malignant Hyperthermia (a rare life-threatening condition triggered by drugs used for general anesthesia) was available for use. Refer to A-0505 and Cross Reference A-0951.

The cumulative effect of the hospital's failure to keep the appropriate amount of a rescue drug available for use resulted in a finding by the Centers for Medicaid and Medicare Services (CMS) of Immediate Jeopardy, a situation that is likely to cause serious injury, harm, impairment or death to a patient on 12/9/15 at 1:06pm.
The hospital removed the Immediate Jeopardy on 12/10/15 at 12:14pm by providing an acceptable plan of correction that included suspending all surgical services and placing the hospital on diversion until the medication was obtained and available for use and by putting a system into place to ensure that they can adequately track and check the medication so it does not expire.

The hospital reported a census of seventeen patients. Based on policy review, observation and staff interview, the hospital failed to ensure expired medications were not available for use in one of one Malignant Hyperthermia (a rare life-threatening condition triggered by drugs used for general anesthesia) carts, and in one of one preoperative IV (Intravenous) trays.

The failure to ensure emergency medications are available for use placed the patients at risk of dying from an adverse reaction to anesthesia. The failure to ensure the disposal of used single use syringes placed the patients at risk for infection.

Findings include:

- Malignant Hyperthermia cart observed on 12/9/2015 at 9:30am revealed the following expired medications:

1) 42 vial of Dantrolene (medication used to treat Malignant Hyperthermia) 20mg (milligram) vials with expiration date of 3/2014.
2) Two IV (intravenous) sterile water 1000ml (milliliter) bags expired on 2/1/2013.
3) Two 50% Dextrose (sterile solution used to provide your body with extra water and carbohydrates (calories from sugar) 25 grams vials expired on 6/1/15.
4. Four Furosemide (medication to help decrease extra fluid in the tissues of the body)40mg/4ml vials expired on 9/1/2014.

Registered Nurse (RN) Staff C, Director of Surgical Services interviewed on 12/9/2015 at 9:35am acknowledged the expired patient medications should have been disposed and replaced. Staff C stated the staff is supposed to check all carts monthly for expired dates but no specific person is assigned.

Staff A, Director of Quality interviewed on 12/10/2015 at 2:00pm acknowledged there is no documentation or record of staff checking the Malignant Hyperthermia cart. Staff A stated all medications on all crash carts are checked by the pharmacy department.

Pharmacy Staff N on 12/10/2015 at 2:30pm indicated they are responsible for checking for all medications on every unit. Staff N acknowledged they failed to keep a log to ensure the Malignant Hypothermia medication was checked for outdates.

- The hospital policy titled "Discarding of Sterile Medication Containers" reviewed on 12/9/2015 at 2:30pm directed, "...single-dose vials and multiple-dose vials use within/discard of initial use or after 30 days from date of initial use or manufacturer's expiration date whichever comes first ..."

- The hospital policy titled "Code blue policy and procedure" reviewed on 12/10/2015 at 2:35pm directed, "...Pharmacy department responsibilities shall check expiration dates monthly of crash cart drug content/IV solution as recorded on check sheet ..."

- Preoperative unit at nursing station observed on 12/9/2015 at 8:35am revealed a pre-operative IV tray found on counter unattended with one opened sterile 10cc (milliliter) normal saline (a fluid) syringe attached to the IV tubing lying in tray.

Pre-operative RN Staff H interviewed on 12/9/2015 at 8:35am acknowledged she placed the opened 10cc normal saline syringe in the tray. Staff H stated she intended to use the normal saline syringe on a patient but the surgery case was cancelled and she had planned to use the syringe on her next patient. Staff H stated she did not realize she needed to discard the 10cc normal saline syringe after opening it and not using it.

- The hospital policy title "Discarding of Sterile Medication Containers" reviewed on 12/9/2015 at 2:30pm directed, "...single-dose vials and multiple-dose vials use within/discard of initial use or after 30 days from date of initial use or manufacturer's expiration date whichever comes first ..." and "...to discard the vial if there is any knowledge that aseptic technique has not been adhered to during use ..."

Based on life safety code survey findings, the hospital failed to meet the applicable provisions of the current Life Safety Code when they failed to provide exit access from the Northwest OB (obstetrics) Unit located on the second floor of the hospital. (Refer to A-0710)


The hospital's failure to provide exit access from the second floor of the hospital's Northwest OB Unit placed patients, staff, and visitors at risk for delays in leaving the buidling in case of fire.


These deficiencies resulted in representatives of the state fire marshal's office notifying the facility's administration that the Centers for Medicare and Medicaid Services (CMS) identified this as an Immediate Jeopardy situation on December 10, 2015 at 8:30am that was removed by exit on 12/10/15 at 12:14pm.

Based on observation and life safety code survey review, the hospital failed to meet the applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA) when they failed to provide an exit access from the second floor Northwest Obstetrics unit.


Failure to provide exit access from the second floor placed all patients, staff and visitors at risk for delays in exit in case of fire.


Findings include:


The facility had a current census of 17 at the time of the state fire marshal's survey.


The state fire marshal's review indicated that on 12/7/15 the northwest OB (obstetrics) Unit exit was found to be equipped with a special locking device that prevents patients, staff, and visitors from exiting the building unless they had knowledge of how the lock worked. It was necessary to alert nursing staff using a push button device if anyone needed out of the unit. Since the nurse's station was not always monitored, this delayed exiting the unit.


This constituted an immediate jeopardy situation on 12/10/15 at 8:30am. The hospital administration immediately implemented a fire watch and disabled the magnetic locking device. By observation, health surveyors onsite verified the lock had been disabled and the immediate jeopardy was removed on 12/10/15 at 11:10am.


See the results of the LSC survey at tag K-038 dated 12/8/2015.

The hospital reported a census of 17 patients. Based on observation, document review and staff interview the facility failed to maintain supplies within manufacturers' end use date in the respiratory therapy room, two of three phlebotomy rooms (room #'s 1 and 3), five of five laboratory supply carts, seven of seven laboratory supply trays, the Surgical Unit's malignant hyperthermia carts, one of two Surgical Unit emergency supply carts, one block cart, and one Medical/Surgical's clean utility rooms. This deficient practice placed all patients at risk for inadequate drug therapy or supplies.


Findings included:


- Respiratory Therapy Room observed on 12/7/2015 at 2:30pm revealed 10 Neonatal Expiratory Filters (a disposable filter used for babies on a ventilator) with an expiration date of 2013, and 11 Neonatal Expiratory Filters with an expiration date of 2/2014.

Staff A, Director of Quality interviewed on 12/7/2015 at 2:40pm acknowledged the expired Neonatal Expiratory Filters and indicated that each department is responsible for checking and disposing of outdated supplies.

- Phlebotomy Room #1 observed on 12/8/2015 at 11:45am revealed 14 blood culture tubes with expired date of 11/2015 and five Blue topped lab tubes with expired date of 10/2015.

- Phlebotomy Room #3 observed on 12/8/2015 at 11:40am revealed three Tongue depressors with an expiration date of 12/2014.

- Laboratory Technicians cart (labeled with a staff members first name) observed on 12/8/2015 at 11:20am revealed eight sterile yellow topped laboratory tubes with an expiration date of 11/2015 and seven Blood culture tubes with an expiration date of 11/2015.

- Laboratory Technicians cart (labeled with a staff members first name) observed on 12/8/2015 at 11:30am revealed two finger stick tubes with an expiration date of 2/2014 and two with an expiration date of 2/2015.

- Laboratory Technicians cart (labeled with a staff members first name) observed on 12/8/2015 at 11:15am revealed three blue topped laboratory tubes with an expiration date of 10/2015 and two yellow topped laboratory tubes with an expiration date of 9/2015.

- Laboratory Technicians cart (labeled with a staff members first name) observed on 12/8/2015 at 11:10am revealed two sterile yellow topped tubes with an expiration date of 11/2015.

- Unlabeled Laboratory Technicians cart observed on 12/8/2015 at 11:35am revealed three culture swabs with expirations dates 4/2014, 7/2014, and 1/2013, and one blue topped tube with an expiration date of 4/2015.

- Seven laboratory supply trays observed on 12/8/2015 at 11:40am revealed eight pink topped laboratory supply tubes with expiration date of 7/2015 and 8/2015, six red topped tubes with expiration dates of 6/2015 and 7/2015, and three Holder devices (device used to hold laboratory tube during blood collection) with expiration dates of 10/2015, 1/2014, and 10/2015.

Laboratory Staff D interviewed on 12/8/2015 at 11:50 acknowledged the expired Laboratory supplies should have been disposed. Staff D indicated each person is responsible for their own cart and supplies but they failed to inventory the carts of staff that are no longer employees. Staff D acknowledged the supplies are still available for patient use. Staff D reported they do not have an assigned staff member responsible for conducting inventory throughout the Laboratory.

Surgical Unit's malignant hyperthermia cart observed on 12/9/2015 at 9:30am revealed the following expired supplies:
1) Two Provent arterial blood sampling kit expired dates on 2/2013 and 12/2014.
2) One Easy cap CO2 (carbon dioxide) detector package (to verify endotracheal tube placement) expired on 3/2014.
3) Eight Ventilating Needles (used for venting glass vials) expired on 5/2014.
4) Two Portex arterial blood sample syringes expired on 5/2012.
5) One Foley catheterization tray (to empty urine from bladder) expired on 4/2013.

Registered Nurse (RN) Staff C, Director of Surgical Services interviewed on 12/9/2015 at 9:35am acknowledged the expired patient supplies should have been disposed and replaced. Staff C stated the surgical staff is supposed to check all carts monthly for expired dates but no specific person is assigned.

- Surgical Units emergency supply cart in the preoperative area observed on 12/9/2015 at 9:10am revealed the following expired supplies:

1) Six LMA (Laryngeal Mask Airway) sizes 1.5, 2, 3, 4, 5, 6 expired on 10/28/2013.
2) One Provent Arterial blood sampling kit expired on 6/2013.
3) Three Nasopharyngeal airway (inserted into the nasal passageway to secure an open airway) expired dates of 4/2015, 8/2015, and 11/2015.
4) One Irrigation tray (to flush wounds or bladder) expired on 11/2015.

RN Staff C interviewed on 12/9/2015 at 9:15am acknowledged the expired patient supplies should have been disposed and replaced. Staff C stated the PACU nurse just checked the crash cart recently for outdates.

- One of the Surgical Unit's anesthesia block cart in the preoperative unit observed on 12/9/15 at 9:45am revealed two surgical gloves size 6 and 8 expired on 12/2014.

RN Staff C interviewed on 12/9/2015 at 9:45am acknowledged the expired patient supplies should have been disposed.

The Medical/Surgical Units clean supply room observed on 12/7/2015 at 1:45pm revealed the following expired supplies:
1) One bottle of Betadine solution (solution used to clean the skin) with an expiration date of 8/2014.
2) Two Insyte IV shielded intravenous catheter) sets with expired dates of 1/2015 and 10/2015.

Staff A interviewed on 12/7/2015 at 1:55pm acknowledged the expired supplies should have been disposed.

RN Staff E interviewed on 12/7/2015 at 2:00pm indicated inventory is performed at least every three months in the clean supply room and the last one was in October 2015.

Policy titled "Outdates- Checking of Supplies" reviewed on 12/9/2015 at 5:06pm directed staff "...By the end of the month each department must check all patient care supplies not stocked by Materials Management i.e. direct order items ... and By the end of the month Materials Management will check the supplies in the warehouse and on the PAR (unit supply)carts that are stocked by Materials Management ..."

The hospital reported a census of seventeen patients. Based on policy review, observations and staff interview, the hospital's Infection Control Officer failed to ensure the infection control practices were followed to ensure hand hygiene was performed properly during 2 of 5 observed hand hygiene opportunities observed and failed to ensure a surgical technician wore proper PPE (personal protective equipment) in the OR (operating room) instrument cleaning room. This deficient practice has the potential to expose all patients and healthcare workers to infectious diseases.

Findings include:

- Anesthesiologist Staff J observed on 12/9/2015 at 8:43am entering and leaving pre/post-surgical room 128 and 129 after speaking to pre-surgical patients without performing hand hygiene.

Staff J interviewed on 12/9/2015 at 8:55am acknowledged not doing hand hygiene when entering and leaving a patient's room. Staff J stated he did not touch the patients so no need to do hand hygiene.

- Surgeon Staff K observed on 12/9/2015 at 8:45am leaving pre/post-surgical room 129 after speaking to a pre-surgical patient without performing hand hygiene.

Staff K interviewed on 12/9/2015 at 9:00am acknowledged of not doing hand hygiene when leaving a patient ' s room. Staff K stated okay really, I will do that now on.

- Hospital policy titled "Handwashing" reviewed on 12/9/2105 at 2:15pm directed "...Use the hand rub upon entering and exiting a patient ' s room ..."

Scrub Technician Staff M observed on 12/92015 at 10:00am in the OR instrument cleaning room emptying a pan of bloody fluid into the hopper (a deep basin with water for rinsing) without a face shield.

Staff M interviewed on 12/9/2015 at 10:00am acknowledged of having no face shield when disposing the bloody fluid into the hopper. Staff M states she was not aware that she is to wear a face shield. Staff M states she has only been in this position for a few months.

- Hospital policy titled "Decontamination: Receiving and handling " reviewed on 12/9/2015 directed " ...in addition to normal dress code requirements the personnel working in this area shall wear long sleeve gowns, rubber gloves, masks and protective eye coverings ..."

Based on observation, document review, and staff interview, the hospital failed to provide surgical services in accordance with nationally accepted standards of practice when they failed to maintain dantrolene (a medication used for rescue of a patient who develops malignant hyperthermia, a life threatening reaction to general anesthesia that can quickly result in death). See further evidence at A-0951.

The cumulative effect of the hospital's failure to keep the appropriate amount of a rescue drug available for use resulted in a finding by the Centers for Medicaid and Medicare Services (CMS) of Immediate Jeopardy, a situation that is likely to cause serious injury, harm, impairment or death to a patient on 12/9/15 at 1:06pm.

The hospital removed the Immediate Jeopardy on 12/10/15 at 12:14pm by providing an acceptable plan of correction that included suspending all surgical services and placing the hospital on diversion until the medication was obtained and available for use and by putting a system into place to ensure that they can adequately track and check the medication so it does not expire.

The hospital reported 83 surgical procedures per week in the past year. Based on observation, document review, and staff interview, the hospital failed to provide adequate amounts of usable Dantrolene (a medication used for rescue of a patient who develops malignant hyperthermia, a life threatening reaction to general anesthesia that can quickly result in death). This failed practice created the potential for the hospital's inability to manage patient survival in a malignant hyperthermia crisis (rapid rise in body temperature as a result of medications used during general anesthesia). An immediate jeopardy situation was identified on 12/9/2015 at 1:06pm at which time the hospital's administration halted all surgical procedures and the hospital placed themselves on diversion until the required medication was available for use. The immediacy was removed on 12/10/15 at 12:14pm with the receipt of the Dantrolene and an acceptable plan of correction including an adequate system for tracking and cheking to ensure the medication did not expire.

Findings include:

- Malignant Hyperthermia cart observed on 12/9/2015 at 9:30am revealed 42 vials of Dantrolene 20mg (milligram) vials with expiration dates of 3/2014.

Registered Nurse (RN) Staff C, Director of Surgical Services interviewed on 12/9/2015 at 9:35am acknowledged the expired patient medications should have been disposed and replaced. Staff C stated the surgical staff is supposed to check all carts monthly for expired dates but no specific person is assigned that task.

Administrative Staff I interviewed on 12/10/2015 at 8:45am acknowledged the facility failed to ensure the required Dantrolene was available. Staff I indicated they self-imposed a suspension of surgical services throughout the hospital immediately after the expired vials were identified until the minimum requirement of 36 vials was available for use in the Surgical Unit.

- Malignant Hyperthermia Association of the United States "Proposed Protocol for Management " reviewed on 12/9/2015 at 8:15pm revealed "...To maintain an emergency cart stocked with all the drugs and supplies needed during a critical situation ...Dantrolene -36 (20 milligram) vials ..."

- Policy titled "Management of Patient with Malignant Hyperthermia" reviewed on 12/9/2015 at 2:30pm directed, "...As a large quantity may be necessary, a sufficient supply must be available. Thirty-six (36) vials are available in the Surgical Services Department. The pharmacist is responsible for obtaining extra Dantolene as needed ..."