HospitalInspections.org

Based on clinical record review and interview, it was determined the facility failed to ensure verbal orders were signed, dated, and timed within 96 hours for 10 of 10 (#9 - #18) patients on the Medical/Surgical Units. This failed practice did not ensure the physician had reviewed the orders for correctness and had the potential to affect Patients #9 - #18. Findings follow.

A. The following was confirmed by the Clinical Information Abstractor during clinical record review on 02/27/14 from 1430 to 1540:
1) Patient #9 - six of seven orders were not signed, seven of seven orders not dated and timed.
2) Patient #13 - eight of eight orders were not signed, dated or timed.
3) Patient #15 - five of five orders were not signed, dated, or timed.
4) Patient #16 - two of four orders were not signed, four of four were not dated and timed.
5) Patient #17 - three of three orders were not dated or timed.
B. The following was confirmed by the Director of Quality, Safety, and Risk Management during clinical record review on 02/28/14 from 0845 to 1030.
1) Patient #10 - 10 of 18 orders were not signed, 17 of 18 were not dated or timed.
2) Patient #11 - 27 of 32 orders were not signed, dated, or timed.
3) Patient #12 - two of four orders were not signed, four of four were not dated or timed.
4) Patient #14 - 10 of 11 orders were not signed, 11 of 11 were not dated or timed.
5) Patient #18 - six of six orders were not signed, dated, or timed.

Based on review of Discrepancy Verification Logs and interview, the facility failed to ensure Pyxis Units located in two (#8, #10) of two operating rooms were being reviewed and documented daily for scheduled drug discrepancies. The potential existed for the lack of control of scheduled drugs. Findings follow:

A. Discrepancy Verification Logs were requested for the Pyxis Units located in Operating Rooms #8 and #10. No logs were presented for review.
B. An interview was conducted on 02/26/14 at 1340 with CRNA#1 in which it was verified discrepancy verifications for scheduled drugs were not conducted and documented daily for all Pyxis Units in operating rooms.

Based on review of Weekly Narcotic Count/Inventory Logs and interviews, the facility failed to ensure weekly scheduled drug inventories were conducted at four (one Main Nursing Unit, Two Main Nursing Unit, Operating Room #8, Operating Room #10) of eight (One Main Nursing Unit, Two Main Nursing Unit, Operating Room #8, Operating Room #10, Emergency Department, Geropsychiatric Unit, Two East Nursing Unit, Four East Nursing Unit) patient care areas in which Pyxis Units were utilized for the time period 02/01/14-02/24/14. The potential existed for the lack of control of scheduled drugs. Findings follow:

A. A tour of One Main Nursing Unit was conducted on 02/26/14 at 1510 in which the Weekly Count/Inventory Logs for the Pyxis Unit were reviewed. The logs reflected a weekly inventory had not been conducted on 02/03/14, 02/10/14, and 02/17/14. An interview was conducted with the One Main Nursing Manager in which the findings were verified.
B. A tour of Two Main Nursing Unit was conducted on 02/26/14 at 1530 in which the Weekly Count/Inventory Logs for the Pyxis Unit were reviewed. The logs reflected weekly inventories had not been conducted on 02/03/14, 02/10/14, and 02/24/14. An interview was conducted with the Two Main Nursing Manager on 02/26/14 at 1530 in which the findings were verified.
C. A tour of Operating Room #8 was conducted on 02/26/14 at 1430 in which the Weekly Count/Inventory Logs for the Pyxis Unit were reviewed. The logs reflected weekly inventories had not been conducted on 02/07/14, 02/14/14, and 02/21/14. An interview was conducted with Certified Registered Nurse Anesthetist (CRNA) #2 on 02/26/14 at 1440 in which the findings were verified.
D. A tour of Operating Roo#10 was conducted on 02/26/14 at 1430 in which the Weekly Count/Inventory Logs for the Pyxis Unit were reviewed. The logs reflected a weekly inventory had not been conducted on 02/07/14. An interview was conducted with CRNA#1 at 1340 on 02/26/14 in which the findings were verified.

Based on observation and interview, the facility failed to ensure two of four multidose vials of Succinylcholine stored at room temperature on the anesthesia cart in Operating Room #10 were disposed of after being stored out of refrigeration for fourteen days as required by manufacturer guidelines and were available for patient use. The potential existed for the drug to have a decreased potency and to be administered to patients. Findings follow:

A. A tour of Operating Room #10 was conducted on 02/26/14 at 1330. Four multidose vials of Succinylcholine were observed on the anesthesia cart stored at room temperature. Two of the four vials were labeled with a date of 02/24/14. The other two multidose vials were labeled with dates of 03/03/14 and 03/04/14 respectively.
B. An interview was conducted with Certified Registered Nurse Anesthetist (CRNA)#1 on 02/26/14 at 1340. The interview revealed the labeled dates on the multidose vials were expiration dates placed on the vials by Pharmacy since the medication could only be stored at room temperature for fourteen days once removed from refrigeration according to manufacturer guidelines. It was verified through the interview the two multidose vials with labeled dates of 02/24/14 were expired and available for patient use.

Based on observation and interview, the facility failed to ensure one of one syringe of Nitroglycerin on the anesthesia cart in Operating Room #10 was wasted according to hospital procedure and was available for patient use. The potential existed for the drug to have a decreased potency and to be administered to patients. Findings follow:

A. A tour of Operating Room #10 was conducted on 02/26/14 at 1330. A syringe of Nitroglycerin which had been drawn-up for possible patient use on a previous surgery case was observed in the anesthesia cart.
B. An interview was conducted with Anesthesiologist #1 on 02/26/14 at 1335. It was verified the syringe of Nitroglycerin was left from a previous surgery case, and it was hospital procedure to destroy the medication immediately following a surgery case if not used. It was also stated there were no more cases in Operating Room #10 for the day.

Based on Surgery Temperature and Humidity Log review, observation, and interview it was determined the hospital did not meet requirements related to the relative humidity levels and maintaining corridors free from obstructions in the surgery department. The facility performed an average of 800 surgeries per month and had 48 patients scheduled for surgery on 02/24/14. See K78 and K72.

Based on observation and interview, it was determined the facility failed to ensure food and utensil storage areas were free of crumbs, residue, and debris, and failed to ensure foods were refrigerated according to manufacturer's instructions. The failed practice created the potential for a patient to receive contaminated foods and could affect anyone consuming those foods. Findings follow.

A. During a tour of the kitchen on 02/25/14 from 0945-1015 the following was observed:
1) In the production area, a container used to store clean knives had a brown residue.
2) The cook's freezer and salad cooler contained numerous food crumbs in the bottom.
3) Two of two microwaves contained multiple food crumbs and stains.
B. The following opened items were observed to state on the container "refrigerate after opening" but were not stored in the refrigerator:
1) Three of seven gallons soy sauce.
2) One of two gallons Balsamic vinaigrette.
C. During a tour of the 4 East Unit nourishment room on 02/25/14 at 1020, a drawer housing opened plastic utensils was observed to contain a brown, coffee appearing stain that the utensils were lying on.
D. During a tour of the 2 North Unit nourishment room on 02/25/14 at 1030, stains and crumbs were observed in the bottom of the refrigerator.
E. Findings were confirmed by the Registered Dietitian at the time of the tour.

Based on review of 2013 Quality Assessment/Performance Improvement Meeting Minutes and interview, it was determined the facility failed to ensure Organ and Tissue Donation conducted performance improvement activities for the first, third, and fourth quarters of 2013. The failed practice did not ensure opportunities related to organ donation were identified and that actions were implemented and evaluated in an effort to improve the process. The failed practice had the potential to affect all potential organ donors and recipients. Findings follow.

A. Review of 2013 Quality Assessment/Performance Improvement Meeting Minutes revealed no performance improvement activities were conducted for the first, third, and fourth quarters of 2013.
B. During an interview on 02/27/14 at 0930, the Director of Quality, Safety, and Risk Management stated they only do an annual Organ and Tissue report.
C. Findings were confirmed at the time of the interview.

Based on clinical record review and interview, it was determined five of five (#11 - #15) clinical records of patients who underwent operative procedures contained operative reports that did not contain the time of surgery Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow:

A. Review of clinical records on 02/27/14 from 1430 to 1545 revealed the time of surgery was not documented on the operative report for Patients #13 and #15. Findings were confirmed by the Clinical Information Abstractor at the time of record review.
B. Review of clinical records on 02/28/14 from 1000 through 1045 revealed the time of surgery was not documented on the operative report for Patients #11, #12, and #14. Findings were confirmed by the Director of Quality, Safety, and Risk Management at the time of record review.