HospitalInspections.org

Based on record review and interview the hospital failed to conduct comprehensive pain assessments consistent with the scope of care, services and the patient's condition.

Findings include:

Review of medical records on 3/18/14 revealed no documented evidence of the completion of a comprehensive pain assessment. An initial, preliminary pain assessment is completed however, the comprehensive assessment that responds to the patient's pain assessment, scope of care, and patient condition was not done.

Interview with Staff A (Director of Nursing) confirmed that there was no documented evidence of the completion of a comprehensive pain assessment. An initial, preliminary pain assessment is completed however, the comprehensive assessment that responds to the patient's pain assessment, scope of care, and patient condition was not done. Staff A indicated the current software allows nurses to by pass this form in the Electronic Medical Record.

Based on observation and interview on the initial tour 3/18/14 it was determined that the facility failed to discard outdated glucometer control solutions.

Findings include:

During the initial tour of the "W" wing on 3/18/14 at approximately 8:30 a.m. with Staff A, (Director of Nurses), it was observed that the glucometer control solution was opened 11/1/13 and was to be discarded on 2/1/14. The manufacturer's instructions are for control solutions to be discarded 90 days after opening. Even though the manufacturer's expiration date was 6/14/15, the solution expired 90 days after it was opened and should have been discarded 2/1/14. The glucometers are checked daily.
Interview with Staff A confirmed the above dates and discarded the control solutions.

Based on tour of the facility kitchen and nutrition room with Staff E (Food Services Manager) it was determined through interview and observation that the facility failed to properly administer supplementary products.

Findings include:

On review of the manufacturer's product information sheet related to frozen supplements it states:

"1) Shelf Life: Unopened: 12 months frozen
2) Once thawed, under Refrigeration, 14 days."

During the initial tour of the facility's nutrition room on 03/18/14 at 9:15 a.m. with Staff E it was observed that (9) 8 oz containers of supplements were in the refrigerator. These 9 containers had no date on them so you could not tell when they were thawed. Staff E also stated during observation of the supplementary shakes that this kitchen is not overseen by the dietary department. Staff E explained that the therapist would stock the refrigerators in this department, but also stated these shakes should not be held in the refrigerator not knowing when they were thawed since there are no dates on the 9 containers.

Based on observation on the initial tour 3/18/14 it was determined that the facility failed to regularly check the function of the suction machine in the Nutrition room.

Findings include:

During the initial tour of the Nutrition Room on 3/18/14 at approximately 9:15 a.m. with Staff A, (Director of Nurses), it was observed that the hospital failed to assure that the functionality of a suction machine was regularly checked in the Nutrition room. The Nutrition room is where patients with dysphagia go for restorative dining. The suction machine is only checked annually.

Based on observation and interview it was determined that the facility failed to implement proper infection control measures by staff in compliance with the infection control program requirements.

Findings include:

While touring the therapeutic departments with Staff B (Director of Rehabilitation Services) it was observed that the Patient in room 227 had a precaution cart outside their door. There was a card on the door were the cart was located informing staff that the Patient was on droplet precautions. The card instructed staff that they must wear PPE (Personal Protective Equipment) which includes, gloves, gown, and mask when entering the room.

Room 227 is a private room and the Patient was able to be seen from the doorway by this surveyor from their feet to their mid-body at which time the wall blocked the rest of the Patents body.

Staff D (License Nursing Assistant) was observed at the doorway of room 227 with a mask and gloves on with a gown draped over their arm. Staff D was further observed going to the head of the patient's bed, then walking back across the room toward the sink still with the gown draped over their arm. Staff D again returned to the head of the patient's bed with the gown still draped over their arm. Staff D again walked toward the foot of the bed at which time the gown had been donned.

This observation was brought to Staff C (Director of Infection Control) who was told of the scenario written above who stated that is not the proper practice. Then this surveyor asked if the staff should have been fully gowned (mask, gloves, and gown) before entering the room and Staff C stated "yes". Based on observation and interview, the facility failed to follow the proper protocol for gowning and entering a patient room who is on droplet precautions.