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

A. The facility failed to maintain the ability of the double fire rated doors leading into the Behavioral Health Unit to self-latch. Failure to maintain the ability for the doors to fully self-latch had the potential to affect the health and safety of patients, visitors, and staff because the doors' inability to fully close and self-latch would allow the passage of fire and smoke through the doors in the event of a smoke and fire event. See K21.
B. The facility failed to seal five of eleven penetrations in two of five fire and smoke rated barriers (between the mechanical room and the corridor near the nurses' station; and the barrier between the nutrition room and the cardio observation room). The failed practice had the potential to affect all patients, visitors, and staff because failure to maintain the fire/smoke resistance rating would allow smoke and fire to pass from one side of the barrier to the other in the event of a smoke and fire event. See K25.
C. The facility failed to perform four of eight fire drills during the second shift for the for the first, second, third, and fourth quarters of 2015. The failed practice had the potential to affect patients, visitors, and staff because the effectiveness of the fire plan and staff training in the event of a fire event could not be evaluated. See K50.

Based on observation and interview, it was determined the facility failed to have a policy and procedure for identifying medications brought from a patient's home and dispensed in the facility. There was no evidence a pharmacy or nursing representative identified the home medications before administering them to seven of seven (#7-9 and 21-24) patients that had home medications in their medication drawer. By not identifying the home medications before administering, the facility could not assure patients received medications as ordered by the physician. The failed practice had the likelihood to affect all patients who are administered their own home medications. Findings Follow:

A. During observation on 03/22/16 from 0910 to 1025, the following home medications were in the medication drawer of Patient #7-9 and 21-24 with no evidence medications were identified:
1) Patient #7-Ziprasidone 20 mg (milligram), Prazosin 1 mg;
2) Patient #8-Hydroxyurea 500 mg, Mexiletine 150 mg;
3) Patient #9-Hydroxychloroquine 200 mg, Pilocarpine 5 mg;
4) Patient #21-Nadolol 40 mg;
5) Patient #22-Oxycontin 10 mg;
6) Patient #23-Cephalexin 250 mg; and
7) Patient #24- Ethosuximide 250 mg.
B. During an interview on 03/22/16 at 1240, the Director of Pharmacy verified the Facility did not have a policy and procedure for identifying patient medications brought from home.


Based on interview, the facility failed to have policies and procedures in place to ensure annual re-certification of Intravenous (IV) Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood per United States Pharmacopeia Chapter 797, 2008. By not evaluating the competencies of the personnel, the facility could not assure the sterility or accuracy of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the Laminar Flow Hood. Findings follow:

During an interview with the Director of Pharmacy on 03/22/16 at 1240, the Director of Pharmacy verified they do not have policies and procedures in place to ensure annual re-certification of IV Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood.

Based on review of policy, review of Medication Error Reports and interview, it was determined for 6 (Medication Error Report # 1, 2, 5, 12, 13 and 14) of 14 (Medication Error Report #1-14) reviewed the facility failed to notify the practitioner of the medication error. By not reporting medication errors to the prescribing physician responsible for the patient's care, the patients' physicians were not being kept abreast of the patient's condition and were not involved in the decisions of what to do after the error occurred. The failed practice had the potential to affect all patients. Findings follow:

A. Review of policy titled Medication Error Reporting stated "Medication Errors shall be reported in a timely manner to the practitioner who ordered the drug."
B. Review of Medication Error Reports from 09/01/2015 through 02/29/16 revealed Medication errors #1, 2, 5, 12, 13 and 14 were not reported to the prescribing physician.
C. During an interview on 03/22/16 at 1420, the Chief Nursing Officer verified there was no evidence the practitioner who ordered the medication was notified on the above mentioned medication errors.

Based on observation, policy and procedure review and interview, it was determined the facility failed to control the spread of infection in that two of four endoscopes were touching a towel on the bottom of the endoscope storage cabinet. The failed practice promoted the spread of infection. The failed practice had the potential to affect all patients on which the endoscopes were used. The findings follow:

A. Observation on 03/22/16 at 0920 revealed four endoscopes were hanging in the endoscope storage cabinet. Two of the endoscopes were touching a towel on the bottom of the storage cabinet. In an interview with the Director of the Operating Room on 03/22/16 at 0920, she confirmed the endoscopes should not be touching the towel on the bottom of the cabinet.
B. Review of the policy "Central Sterilization and Supply Reprocessing of Semi-Critical Equipment" on 03/22/16 revealed "After HLD (High-Level Disinfection), devices shall be: Stored in a manner to protect from damage and contamination." The findings were confirmed in an interview with the Chief Nursing Officer on 03/22/16 at 1345.


Based on observation and interview, it was determined the facility failed to control the spread of infection in two of two (#1 and #2) Operating Rooms (OR) in that two cautery devices had a buildup of rust and the hand washing sink in the supply room for the Acute Unit had a large buildup of corrosion. The failed practice promoted the spread of infection due to the porous nature of the rust and corrosion which cannot be disinfected. The failed practice had the potential to affect all patients on which a surgical procedure was performed and all patients admitted to the Acute Unit. The findings follow:

A. Observation on 03/22/16 at 0920 revealed the cautery device in OR 1 had a buildup of rust on the exterior surfaces of the device. The findings were confirmed in an interview with the Director of the OR on 03/22/16 at 0920.
B. Observation on 03/22/16 at 0930 revealed the cautery device in OR 2 had a buildup of rust on the exterior surfaces of the device. The findings were confirmed in an interview with the Director of the OR on 03/22/16 at 0930.
C. Observation on 03/22/16 at 0955 revealed the hand washing sink in the supply room on the Acute Unit had a large buildup of corrosion on the top of the sink around the faucet. The findings were confirmed in an interview with the Chief Nursing Officer on 03/22/16 at 0955.


31039

Based on observation and interview, the facility failed to control the spread of infection in that one (#2) of two (#1-#2) Treatment Tables had tears in the mat exposing the foam beneath which cannot be cleaned or disinfected between patient use. By not maintaining therapy equipment in a way that allowed them to be thoroughly cleaned, the facility could not assure a sanitary environment when patients used those items. The failed practice had the likelihood to affect all patients that receive therapy services using the equipment. Findings follow:

A. During a tour of Rehabilitation Services on 03/22/16 at 1400, observation revealed Treatment Table #1's mat was torn in 2 places, one tear was 1/2" (inches) and the second tear was approximately 2 and ½ " with foam exposed which cannot be cleaned or disinfected between patient use.
B. During an interview on 03/22/16 at 1410, the Physical Therapist verified the Treatment Table tears, and they are not able to be thoroughly cleaned.

Based on clinical record review and interview, it was determined the facility failed to ensure ordered daily weights were documented in the clinical record for two of two (#2-#3) in-patients. The failed practice did not ensure patients nutritional status was being monitored and created the potential for weight loss to go unnoticed and could affect any patient. Findings follow.

A. Review of the clinical record of Patient #2 revealed an order for daily weights beginning on 03/19/16. At the time of record review on 03/23/16, only one weight was documented on 03/20/16.
B. Review of the clinical record of Patient #3 revealed an order for daily weights beginning on 03/18/16. At the time of record review on 03/23/16, no weights had been documented.
C. During an interview on 03/23/16 at 1355, the Chief Nursing Officer confirmed the weights were not documented.

Based on observation, policy review, and interview, it was determined the facility failed to ensure food items in the freezer were labeled and dated to ensure first-in-first-out rotation of foods was utilized. The failed practice created the potential for outdated foods to be served and could affect any patient receiving foods from the freezers. Findings follow.

A. During a tour of the two kitchen freezers on 03/22/16 from 0930-0945 the following items were observed to not be labeled and dated:
1) Broccoli-nine of nine bags
2) Beef tips-three of three bags (two bags opened)
3) Chicken strips-one of one bags (opened)
B. Review of policy stated "All food items that are brought into the kitchen will have the date they were stored written on them."
C. During an interview at the time of the tour, the Certified Dietary Manager confirmed the foods were not dated.

Based on clinical record review and interview, it was determined the facility failed to ensure operative reports included the time of surgery for seven of seven (#9-#15) surgical patients. The failed practice did not allow knowledge of which surgery happened first in the event of multiple surgeries in one day, and created the potential to affect any patient receiving an operation in the facility. Findings follow.

A. Review of the operative reports revealed the time of the surgery was not documented for Patients #9-#15
B. During an interview on 03/23/16 at 1335, the Chief Nursing Officer confirmed there was no time of surgery documented on the operative reports.

Based on Swing Bed clinical record review and interview, it was determined the facility failed to ensure ordered daily weights were documented in the clinical record for one of one (#1) Swing Bed patient. The failed practice did not ensure patients nutritional status was being monitored and created the potential for weight loss to go unnoticed and could affect any Swing Bed patient. Findings follow.

A. Review of the clinical record of Patient #1 revealed an order for daily weights beginning on 03/18/16. At the time of record review on 03/23/16, only one weight had been documented on 03/18/16.
B. During an interview on 03/23/16 at 1050, the Swing Bed Coordinator confirmed the weights were not documented.