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Based on observations and staff interviews, the facility failed to ensure that patient care supplies were maintained to ensure an acceptable level of safety and quality. Findings include:

1. On 4/12/11 beginning at 7:15 a.m., the surveyor noted the following expired patient care items in the Emergency Department:
- 10 1.8 milliliter (ml.) blue top Vacutainer blood collection tubes with the manufacturer's expiration dates of 9/2010 (1), 12/2010 (1), 1/2011 (2), and 2/2011 (6).
- 6 6 ml. pink top Vacutainer blood collection tubes with the manufacturer's expiration dates of 4/2010 (2) and 7/2010 (2).
- 3 14 gauge by 1 1/4 inch (in.) ProcectIV intravenous catheter with the manufacturer's expiration dates of 7/2010 (1) and 1/2011 (2).
- 2 Kendall needle counters with the manufacturer's expiration date of 12/2010.
- 1 Kendall sterile Iodoform packing strip, 1 in. by 5 yards (yds.) with the manufacturer's expiration date of 1/2011.
- 1 Kendall sterile Iodoform packing strip, 1/2 in. by 5 yds. with the manufacturer's expiration date of 1/2011.
- 2 Benzoin single swabsticks with the manufacturer's expiration date of 1/2011.
- 2 1000 ml. glass sterile evacuated containers with the manufacturer's expiration date of 10/2010.
- 4 14 gauge by 1 1/4 in. ProtectIV intravenous catheters with the manufacturer's expiration date of 3/2009.
- 4 16 gauge by 1 1/4 in. ProtectIV intravenous catheters with the manufacturer's expiration date of 12/2009.
- 1 18 gauge by 1 1/4 in. ProtectIV intravenous catheter with the manufacturer's expiration date of 12/2010.
- 1 20 gauge by 1 1/4 in. ProtectIV intravenous catheter with the manufacturer's expiration date of 10/2010.
- 3 22 gauge by 1 1/4 in. ProtectIV intravenous catheters with the manufacturer's expiration dates 7/2010 (1), 10/2010 (1), and 5/2010 (1).
- 1 3/4 ounce foil packet of Povidone-Iodine 10% solution with the manufacturer's expiration date of 7/2008.
- 3 sterile packages of 2-0 Silk suture material on a cutting needle with the manufacturer's expiration date of 1/2011.
- 1 Quick Arterial Blood Gas kit with the manufacturer's expiration date of 2/2011.
- 1 Bannano Suprapubic Drainage Catheter Kit with the manufacturer's expiration date of 10/2010.
- 1 4.0 ml. green top Vacutainer blood collection tube with the manufacturer's expiration date of 2/2011.

During an interview with staff member B, the Special Care Unit manager, and staff member D, the Emergency Department manager, on 4/12/11 at approximately 9:00 a.m., both staff members verified the expiration dates of the supplies identified and stated that staff checked the expiration dates of supplies monthly.

2. On 4/12/2011, beginning at approximately 2:30 p.m., the surveyor noted the following expired patient care supplies in the Operating Room area:
- 1 16 ounce (oz.) bottle McKesson Hydrogen Peroxide, 1/2 used, with the manufacturer's expiration date of 7/2007.
- 4 14 gauge by 1 1/4 in. ProtectIV intravenous catheters with the manufacturer's expiration date of 1/2011.
- 1 Arterial Line Kit with the manufacturer's expiration date of 7/2010.
- 1 500 ml. bag of Normal Saline for infusion with the manufacturer's expiration date of July 2010.

During an interview with staff member E on 4/12/11 beginning at approximately 3:30 p.m., staff member E verified the expiration dates of the expired supplies.

3. On 4/13/11, beginning at approximately 7:15 a.m., the surveyor reviewed the special care unit and observed a Percutaneous Sheath Insertion kit with the manufacturer's expiration date of 10/2010.

During an interview with staff member B on 4/13/11 beginning at approximately 7:30 a.m., staff member B verified the expiration date of the expired kit. Staff member B stated that staff nurses in the special care area check for expired supplies monthly.

4. On 4/13/11 at 2:00 p.m., the surveyor reviewed the same day surgery area and observed the following expired patient care supplies:
- 1 32 oz. bottle Chlorhexadine 4% solution with the manufacturer's expiration date of 11/2010.
- 1 24 gauge by 3/4 in. ProtectIV intravenous catheter with the manufacturer's expiration date of 1/2010.
- 1 18 gauge by 1 1/4 in. ProtectIV intravenous catheter with the manufacturer's expiration date of 11/2010.

During an interview with staff member E on 4/13/11 beginning at approximately 2:30 p.m., staff member E verified the expiration dates of the expired supplies.

Based on observations and staff interviews, the facility failed to ensure that drugs in the facility were properly controlled and labeled. Findings include:

1. On 4/12/11, beginning at approximately 2:30 p.m., the surveyor reviewed the operating room areas and observed the following:
- 1 500 milliliter (ml.) bag of normal saline for infusion with the manufacturer's expiration date of July 2010.
- 1 1000 ml. open bottle of sterile saline for irrigation that was not labeled as to the date that the bottle had been opened.

2. In operating rooms 2 and 3, there were medication boxes labeled "A" and "B" observed in the anesthesia machine drawers. The boxes contained multiple medications used in the operating room including paralytic medications. The anesthesia machine drawers did not have the capability of being locked or secured to prevent unauthorized access. The operating rooms did not have the capability or capacity to be locked to prevent unauthorized access.

3. During an interview with staff member E, the operating room manager, on 4/12/11 at approximately 3:30 p.m., staff member E verified the expired and unlabeled supplies. Staff member E stated that the anesthesiologists that worked in the facility wanted the drug boxes accessible outside of the Pyxis system and kept them in the anesthesia machine drawers after hours.

On 4/14/11 at 10:15 a.m., the surveyor conducted an interview with staff member C, the pharmacy director. During the interview, staff member C stated that he was unaware that the drug boxes were being kept outside of the Pyxis machines and was uncomfortable with the practice. Staff member C brought a sample medication box to the interview. The medication box had been modified with a plastic slip lock to provide a minimal level of security to the medications.

Based on observation and staff interview, the facility failed to ensure that safe food handling practices were followed. The findings include:

1. On 4/11/11 at 1:45 p.m., during the initial walk through of the kitchen area with the dietary manager, the walk in cooler contained the following:
-A container of taco meat with an expiration date of 4/4/11;
-A container of Gyro meat with an expiration date of 1/11/11;
-A container of corn beef with an expiration date of 3/17/11;
-A container of cooked turkey meat with an expiration date of 4/9/11;
-A container of Chorizo with an expiration date of 4/10/11;
-A container of tomatoes with an expiration date of 4/9/11;
-A container of Wasabi with no open date or expiration date;
-A container of fresh strawberries with an expiration date of 4/6/11; and
- Red cabbage that was cut, wrapped in plastic wrap, and was not labeled with an open date or use by date.

During this observation, staff member M, the Dietary Manager, stated that all the food items were either served on the weekend, or were to be served during the week of survey. Staff member M stated all food containers need to be marked with an open date and used by the expiration date.

2. During the same initial tour, the prep refrigerator contained the following:
-A covered container of liquid eggs with a metal ladle not dated or labeled; and
-A covered container of pancake batter with a metal ladle not dated or labeled.

Staff member M stated "ladles should never be stored in batter." The ladles should always be removed before the items are placed in the refrigerator. Staff member M did not know when the batters were last served.

3. During the same initial tour, the walk-in freezer contained the following:
-A bag of Boca burgers with no open date and was not sealed;
-A plastic bag containing a chunk of ice cream without a date or label; and
-A box of beef hamburger patties which did not have an open date, and was not sealed. The beef patties were exposed to the air.

Based on record review and staff interview, the facility failed to ensure that the clinical records for 13 (#s 1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) of 15 reviewed emergency department records were complete and contained completed and authenticated consent forms. Findings include:

During the review of emergency room records on 4/14/11 beginning at 7:15 a.m., the surveyor noted the following incomplete elements for emergency department clinical records:

1. Patient #1 presented to the emergency department for treatment on 3/13/10. The facility consent for treatment form did not include the time when the consent for treatment was obtained. The patient was transferred to another facility for further treatment. The facility transfer form did not include the time when the consent to transfer the patient was obtained.

2. Patient #2 presented to the emergency department for treatment on 4/8/10. The facility consent for treatment form was not signed by the patient or family at the time of admission. The time of the signature was not documented.

3. Patient #4 presented to the emergency department for treatment on 3/24/11. The facility consent for treatment form was not signed by the patient or family at the time of admission. Facility staff did not document a reason that the consent was not signed by the patient, representative or family. The time of the witness signature was not documented.

4. Patient #5 presented to the emergency department for treatment on 2/24/11. The facility consent for treatment form was not signed by the patient or family at the time of admission and contained a reference that the patient "came by ambulance." The time of the witness signature was not documented.

5. Patient #6 presented to the emergency department for treatment on 12/14/10. The facility consent for treatment form did not include the time when the consent for treatment was obtained. The time of the witness signature was not documented.

6. Patient #7 presented to the emergency department for treatment on 12/5/10. The facility consent for treatment form was not signed by the patient or family at the time of admission. Facility staff documented that the patient was unable to sign the consent for treatment form. Facility staff did not document a reason that the consent was not signed by the patient, representative or family. The time of the witness signature was not documented. The consent for transfer form was signed by the patient, but the time when the patient's signature was obtained was not documented.

7. Patient #8 presented to the emergency department for treatment on 10/6/10. The facility consent for treatment form was signed by the husband, but did not include the time that the signature was obtained. The time of the witness signature was not documented.

8. Patient #9 presented to the emergency department for treatment on 9/8/10. The facility consent for treatment form was signed by the mother of the patient, but did not include the time when the consent was signed by the mother. The time of the witness signature was not documented. The transfer consent form was signed by the mother, but the time that the signature was obtained was not documented.

9. Patient #10 presented to the emergency department for treatment on 8/15/10. The facility consent for treatment form did not include the time when the consent for treatment was obtained. The time of the witness signature was not documented. The consent for transfer form was signed by the patient, but the time when the patient's signature was obtained was not documented.

10. Patient #11 presented to the emergency department for treatment on 8/14/10. The facility consent for treatment form did not include the time when the consent for treatment was obtained.

11. Patient #12 presented to the emergency department for treatment on 7/27/10. The facility consent for treatment form did not include the date and time when the consent for treatment was obtained. The form was not witnessed by a member of the staff. The facility transfer request form included signatures by the patient for transfer to another facility and a refusal to be transferred by ambulance. There was no documentation of the times when the consent and refusal signatures were obtained.

12. Patient #13 presented to the emergency department for treatment on 6/29/10 at 11:15 p.m. The facility consent for treatment form did not include the date and time when the consent for treatment was obtained from the patient. The consent form witness signature was dated 6/30/10 and included the time of 8:50 a.m. However, the clinical record included a consent for a procedure that was appropriately dated and timed on 6/29/10.

13. Patient #14 presented to the emergency department for treatment on 6/3/10. The facility consent for treatment form did not include the time when the consent for treatment was obtained. The time of the signature was not documented. The consent for transfer form was signed by the patient, but the time when the patient's signature was obtained was not documented.

During an interview with the facility management team on 4/17/11 at 10:30 a.m., staff member B stated that she was not aware that the signature times were not being obtained.

Based on record reviews and staff interviews, the facility failed to assess for the use of restraints, obtain complete physician orders for the use of restraints, and re-assess the continued use of restraints for 3 (#s 26, 27, and 28) of 3 reviewed swing bed medical records. Findings include:

The facility restraint policy documented that a patient was to be treated in the least restrictive environment, and that when a restraint was used, it was to be justified by "a clinical assessment, preservation of patient's rights, dignity, and well being will be highest priority. Restraint use will be based on an assessment of patient needs and not on history. Restraints will be used only after consideration of alternatives. The least restrictive measures that are effective should be used. A physician order should include date, time, type of restraint, a specific time limit. Such order shall be effective for no more than 24 hours." The section titled Monitoring documented that "restraints will be ended at the earliest possible time based on continuous assessment and re-evaluation of the patients' condition." The facility restraint policy meets the requirements stipulated in the State Operations Manual Appendix W.?

1. Patient #26 was admitted to swing bed status on 8/31/10 with a diagnosis of dementia. Review of the medical record documented patient #26 was restrained up to discharge on 9/4/10. The record contained an Admission Orders/Swing Bed Form and documented "restrain for safety." The medical record lacked the following required documentation:
- less restrictive intervention prior to the use of a restraint;
- an assessment prior to the use of a restraint;
- a complete physician's order that included a clinical medical symptom;
- re-assessing the use of the restraint after 24 hours; and
- obtaining new physician orders after 24 hours.
The medical record documented daily use of restraints up to the time of discharge on 9/4/10.

On 4/13/11 at 9:27 a.m., the Swing Bed Coordinator, staff member N, was interviewed and stated prn (as needed) restraint orders were routinely used to prevent patients from falling. Staff member N stated that he completed the Admission Orders/Swing Bed form and that he wrote "restrain for safety." Staff member N stated that patient #26 was restrained up to the time of her discharge because she had dementia and had a history of falls at home. "Using restraints would keep her safe at the hospital." The surveyor asked what type of restraints were used on patient #26 and was told ankle, wrist, and vest restraints. Staff member N stated that a less restrictive intervention was not used.

2. Patient #27 was admitted to a swing bed on 7/23/10 with diagnoses including dementia, atrial fibrillation, hypertension, coronary artery disease, and aortic stenosis. Review of the Admission Orders/Swing Bed Form documented "may use soft restraints in bed & chair." The medical record lacked the following required documentation:
- a less restrictive intervention prior to the use of a restraint;
- an assessment prior to the use of a restraint;
- a complete physician's order, including a clinical medical symptom;
- re-assessing the use of the restraint after 24 hours; and
- obtaining new physician orders after 24 hours.
The medical record documented daily use of restraints up to the time of discharge on 8/6/10.

Staff member N was interviewed at this time and stated that patient #27 had a history of behaviors and using restraints would keep him safe. A less restrictive intervention was not used prior to the start of the restraints. Wrist, and a vest restraint were used on patient #27.

3. Patient #28 was admitted to a swing bed on 1/7/11 with diagnosis of metastatic lung cancer. Review of the medical record documented on the Admission Orders/Swing Bed was "restraint protocol." The medical record lacked the following required documentation:
- a less restrictive intervention prior to the use of a restraint;
- an assessment prior to the use of a restraint;
- a complete physician's order including a clinical medical symptom;
- re-assessing the use of the restraint after 24 hours; and
- obtaining new physician orders after 24 hours.
The medical record documented daily use of restraints up to the time of discharge on 1/17/11.

On 4/13/11 at 9:47 a.m., staff member N stated that he writes "prn restraint for safety" for patients with dementia and patients who had a history of falls. "It is what we do to keep patients safe." The surveyor was informed by staff member N that restraint orders are not discontinued after 24 hours and that a new physician order was not obtained after 24 hours. Staff member N stated he was unsure of the facility's prn restraint policy and procedure and that he would need to read the policy.

On 4/12/11 at 3:13 p.m., the Nursing Service Manager, staff member O was interviewed. Staff member O stated that a physician would write an order for prn restraints for patient safety. If a patient had a history of falls or dementia, restraints were used. When staff member O was asked what less restrictive intervention would be used prior to using a restraint, she stated a family member doing a 1:1 and the use of side rails.

?State Operations Manual Appendix W - Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals (CAHs) and Swing-Beds in CAHs Revision 49, 6/12/09. C-360, ?485.645(d) SNF Services; The CAH is substantially in compliance with the following SNF requirements contained in subpart B of part 483 of this chapter.
Item #3, Resident Behavior and facility Practices (?483.13 of this chapter).
Hospital Regulation A-0169 ?483.13: Orders for restraint or seclusion must never be written as a standing order or on an as needed (PRN) basis.