HospitalInspections.org

Based on observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.
Findings include:
The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:
(K-18)- Corridor doors not latching and closing
(K-27)-Smoke barrier doors not closing and latching
(K-38)-Exiting
(K-48)-Fire Safety Plan
(K-62)-Sprinkler maintenance

Based on observation and interview the facility failed to ensure equipment is inspected and maintained in 1 of 7 departments observed (Rehabilitation/Physical Therapy). This deficiency has the potential to affect all patients treated in the Rehabilitation/Physical Therapy area.

Findings include:

Per observation on 9/13/16 at 9:30 AM in the Cardiac Rehabilitation room there are 2 treadmills, 1 arm cycle, 2 nu-step and 1 octane that were moved to the new facility in August and have not been inspected for safety by the biomedical staff.

Interview on 9/13/16 at 9:30 AM conducted with Staff D and Staff J at the time of the observation. Staff D and Staff J confirmed that machines should have been inspected prior to being put into service for patient use.

Based on observation, record review and interview, the facility failed to ensure medications were secured to prevent unauthorized access, in 2 of 7 areas observed (Medical Surgical Unit, Surgery Department) and failed to ensure biologicals are secure and not available to patients, visitors and unauthorized staff in 2 of 7 areas observed (Medical Surgical Unit and Surgery). This deficiency has the potential to affect all patients treated at the facility.
Findings include:
Per review of the facility's policy on 9/14/16 at 10:55 AM titled, "Medication Storage and Security PHA1788" dated 2/11, revised last 8/15, states "A 3. Medications will be under constant surveillance, or upon receipt of the drugs from Pharmacy, will be secured as soon as possible, not to exceed 30 minutes from receipt... C 4. Medication floor stock shall be of minimal risk for diversion and potential error. These storage areas must be located on the inner circle of a Nursing work station to be considered secure. If not, they must be in a locked cabinet."

On 9/12/16 between 1:20 - 2:00 PM an observation of Medical/Surgical patient rooms was completed with Chief Clinical Officer (CCO) D. Observed 10 milliliters (ml) syringes containing normal saline in unlocked drawers (twelve syringes in room 123, twelve syringes in room 124, nineteen syringes in room 130, eleven syringes in room 121, and seven syringes in room 104).
Per interview on 9/12/16 with CCO D at the time of the observations, D stated D didn't know the syringes were kept in the drawers and stated that they would need to be moved.



37420

On 9/12/16 at 1:32 PM the following was observed on the Medical/Surgical unit: Patient Room #123 had 12 prefilled saline syringes and sterile needles in unsecured drawer, room #125 has 10 prefilled saline syringes in unsecured drawer, room # 127 has 11 prefilled saline syringes in unsecured drawer and room #128 has 10 prefilled saline syringes in unsecured drawer. Rehabilitation therapy prep area had 1 multi dose vial of medication in unsecured cupboard.

Staff A confirmed the medications were not secured at the time of the observation.


37421

Per observation on 9/12/16 at 1:10 PM, the Medical/Surgical Unit's soiled utility room was not locked, nor did it have a biohazard sign on the door.

At the time of the observation on 9/12/16 at 1:10 PM, Chief Executive Officer A stated "biologicals are kept in that area and should it be locked."

Per observation on 9/14/16 at 7:10 AM, the Surgical Unit's soiled utility room was not locked, nor did it have a biohazard sign on the door.

At the time of the observation on 9/14/16 at 7:10 AM Manager Z stated, "it should be locked as biologicals are kept in that area."

Based on observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure live safety from fire was safe for patients and staff. The cumulative effects of these deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.
Findings include:
The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:
(K-18)- Corridor doors not latching and closing
(K-27)-Smoke barrier doors not closing and latching
(K-38)-Exiting
(K-48)-Fire Safety Plan
(K-62)-Sprinkler maintenance

Based on observation, record review and interview this hospital failed to ensure care was provided in a safe and effective manner in 7 of 7 (Kitchen, Medical/Surgical, Rehabilitation, Laboratory, Surgery, Pharmacy, Radiology) areas observed/reviewed.

Findings include:

1. The hospital failed to ensure policies were reviewed annually in 7 of 7 departments. (See Tag C272)

2. The hospital failed to ensure there are accurate records kept for sample medications in 1 of 1 areas sample medications are stored and failed to follow safe injection practices in 1 of 7 areas medications were administered. (See Tag C276)

3. The hospital failed to ensure a safe and sanitary department in 7 of 7 areas observed. (See Tag C278)

4. The hospital failed to ensure medical records are kept secure in 2 of 6 storage areas. (See Tag C308)

5. The hospital failed to ensure Swing Bed patients were assessed and provided activities in 2 of 2 Swing Bed patients reviewed. (See Tag C385)

The cumulative effect of these deficiencies has the potential to affect all 2 current patients treated at this hospital at the time of this survey.

Based on record review and interview the facility failed to ensure policies are reviewed annually in 10 of 11 department policies reviewed for Human Resources, Environmental Services/Housekeeping, Health Information Management (HIM), Infection Prevention/Infection Control, Emergency Room, Pharmacy and Surgery

Findings include:

Per review of Human Resources policy ADM1617 "Guidelines for Policy and Procedure," dated 4/2016, states the "All policies will: (4) be reviewed or revised annually or as standard of care changes."

Per review of HIM policies on 9/12/16 at 4:15 PM revealed policy COM1610 "Faxing Protected Health Information" was revised and reviewed 5/2006 and policy HIM1000 "Author Amending, Correcting, Clarifying or Adding Documentation in the Medical Record" was revised and reviewed 6/2008.

Per review of policy ER1005 "Sexual Assault" on 9/13/16 at 7:25 AM. This policy was last reviewed 9/13.

Per review of nursing policy on 9/13/16 at 3:15 PM revealed, DSM1247 "Glucose Point of Care Testing Program-Infection Control/Cleaning" was last reviewed on 5/2014.

Per review of housekeeping policies on 9/13/16 at 4:15 PM revealed, HOU1601 "Housekeeping" was revised and reviewed 2/2014 and HOU1600 "Linen" was reviewed 2/2014.

Per review of policy INF1651 (replaces MED1637), "Nursing and Housekeeping Management of Patient Rooms after Discharge", on 9/14/2016 at 8:15 AM. This policy was last reviewed 8/13.

Per review of policy # PHA1788 "Medication Storage and Security" 9/14/2016 at 10:55 AM. This policy was last reviewed 8/15.

Per review of surgery policies on 9/14/16 at 11:15 AM revealed, SUR1294 "Attire and Traffic Control" was last reviewed 3/2015 and SUR1615 "Aseptic Technique" was last reviewed 3/2015, this was confirmed with Director Z.

Per interview on 9/12/16 at 3:04 PM HIM Director DD, stated "policies are supposed to be reviewed annually, but some of ours are old, at least ten years."

Per interview conducted on 9/13/2016 at 12:12 PM with Lead Pharmacist S who stated most of the policy reviews are behind due to the recent move.

Per interview on 9/13/16 at 2:25 PM with Director of Employee Health, Risk Management and Infection Prevention/Environmental Services CC stated "most of my department needs to updated soon."

Per interview conducted with Emergency Room Lead Q on 9/14/2016 at 8:15 AM. Q stated Q was just promoted to Emergency Room Lead and needs to update a few of their policies.













37419

Based on observation, record review and interview staff failed to follow safe and aseptic administration of injectable drugs to patients in 1 of 7 departments (Rehabilitation); and failed to ensure sample medications are logged and accurately accounted for in 1 of 1 area where sample medications are stored (pharmacy). This deficiency has the potential to all patients receiving medication in this facility.

Findings include:

Example in Rehabilitation Department:

Per observation on 9/13/16 at 9:15 AM in rehabilitation prep area a single syringe, out of sterile packaging, is stored in a box located in an unlocked cupboard with a multi dose vial of Dexamethasone (a topical steroid used with iontophoressis to alleviate inflammations), and a pharmacy prepared vial of Dexamethasone.

Per interview during the observation on 9/13/16 at 9:15 AM, Staff J stated that one syringe and one needle were being used to draw up the Dexamethasone for multiple patients. Staff J stated "I would have no idea how many patients that syringe has been used on."




37419


Example in Pharmacy:

Per review of the Baldwin Area Medical Center policy #PHA 1710 dated 6/04, last Revised 10/05, it states under Procedure, D. "Receiving Medication Samples from Pharmaceutical Representatives: 1) Pharmaceutical representatives will log their sample medications on the BAMC Clinic Sample Medication Receipt and Distribution Log sheets... E. 1) Only licensed prescribers and registered pharmacists may dispense samples of prescription medications. 2) The prescriber, supervised agent or prescriber (LPN/CMA) or pharmacist will complete the BAMC Clinic Sample Medication Receipt and Distribution Log for all prescription medication samples dispensed."

Per observation on 9/13/16 at 2:10 PM there were four shelves of sample medications that were not logged. There was a paper across the aisle from the shelves labeled "samples" dated 9/6/16 numbered 1) & 2) with a patient name and medication listed.

Per interview with lead Pharmacist S at the time of the observation on 9/13/16 at 2:10 PM, S stated there is no log for the sample medications and pharmacy does not track for expiration dates or recalls.

Based on observation, record review and interview this facility failed to maintain an environment free of potential contamination to patients and other staff by not adhering to infection prevention expectations of the facility and nationally recognized standards of practice in 5 of 7 departments observed (Kitchen, Medical/Surgical Unit, Radiology, Laboratory, Surgery). This deficiency has the potential to affect all patients receiving care at this facility.
Findings include:
Per review on of facility policy #DIE1624 titled Safe Food Handling it states under Procedure " 1. Food Storage a. Dry Goods Storeroom:.. All products will be date marked when opened... Expiration dates of products will be checked on a consistent basis per cleaning schedule. Expired products will be disposed of immediately, including those that are stored in alternate locations (i.e. nourishment stations, dessert freezer, etc.) and replaced with new products."
Per review of facility Policy #INF 1651 titled Nursing and Housekeeping Management of Patient Rooms after Discharge, reviewed 8/13, it states the nursing staff "is responsible for the initial preparation of the room and will complete the following steps prior to Housekeeping cleaning... 6. Dispose of all supplies (used and/or unused) such as gauze, tape, syringes, etc."
Per review of facility policy #DIE1634 titled Dishes, revised on 7/16, it states under Washing Dishes 3.h. " When racks are full, put through machine. Be sure wash and rinse temperatures have reached and remain at the required degree of 150 degrees for wash and 180 degrees for rinse."
Per Associate for Professionals in Infection Control and Epidemiology (APIC) Text of Infection Control and Epidemiology, Volume 3, edition 4, page 108, Laboratory Services " Protective laboratory coats, gowns, smocks, or uniforms designated for laboratory use must be worn while working with hazardous materials. Remove protective clothing before leaving for non-laboratory areas (e.g., cafeteria, library, administrative offices. " Per Director of Infection Prevention CC on 9/13/16 at 11:00 AM, this facility used APIC as a Standard of Practice for Infection Control.

Observations in Nutrition Center and Kitchen:
The following was observed in the Nutrition Center on 9/12/2016 at 1:05 PM:
2 containers of Thick-It Instant Food and Beverage Thickener expired 5/2015, 1 carton of milk expired 9/09/2016, one package white bread expired sticker of 9/09/2016, 118 single serving chicken broth packets expired 10/26/15 and 69 single serving beef broth packets expired 3/25/2016.
12 single serving grape jelly containers, 6 honey and 9 peanut butter containers out of original packaging had no expiration dates.
Per interview on 9/12/2016 at 1:20 PM with RN C acknowledged the food items and undated packets should be removed.
The following was observed in the kitchen on 9/12/16 at 7:45 AM:
1 box of Tapioca pudding expired 8/31/16, 1 open bag of brown sugar that was not dated and 1 container of whipped topping expired on 9/10/16.
Per interview on 9/13/2016 at 7:45 AM Lead Cook O stated undated and expired foods should be replaced.
Per review of dishwasher temperature and sanitizer logs on 9/13/16, the temperature of the dishwasher did not reach 150 degrees on 9/1, 9/2, 9/3, 9/5, 9/8 and 9/13/2016. Observation of dishwasher temperatures in wash cycles on 9/13/2016 at 12:45 PM, showed the temperature gauge at 146, 145 and 145 degrees consecutively.
Per interview with Culinary Service Manager N on 9/13/2016 at 9:45 AM, Manager N stated that they should call their dishwasher service company back in to check on the temperature of the washer.




Observations of Medical/Surgical Unit:
Per observation on 9/12/16 1:05 PM rolls of transparent and paper tape were found in drawers in rooms 104, 121, 123, 124 and 130, the tapes did not have the tab attached indicating they are new rolls.
Per interview on 9/12/16 at 1:20 PM, Registered Nurse C acknowledged the tape is not disposed of after patient use and reused for more than one patient.
On 9/12/2016 1:05 PM the following patient rooms have chips and divots exposing sheet rock: 121, 123, 124, 125, 127, 128 and 130.
Per interview with Chief Clinical Officer D, on 9/12/2016 during observation Chief Clinical Officer D stated "We will need to take care of that".



37420

Observations in radiology:
Per observation of Nuclear Medicine Room on 9/13/16 at 2:34 PM, blue disposable drapes are located on countertop under the isotope (radioactive medication) preparation shield, that are wrinkled. When asked in interview at the time of the observation, how often the drapes are changed out, Staff G stated "The drapes get changed weekly", and agreed they should be changed after each patient's procedure is completed.
Examples in laboratory:
Per observation in the Laboratory on 9/13/16 at 3:40 PM, 3 glass bottles containing blue liquid were sitting on counter top unlabeled and uncovered.
Lab coats were observed on 9/13/16 at 3:40 PM hanging on a rack along one wall in the Laboratory. Lab Technician GG was working in the lab without a lab coat on.
Per interview with Staff F, at time of observation, Staff F stated "The bottles have DI (distilled water) in them" and should be capped and labeled, and stated "coats are available some wear them some don't."


37421

Based on observation and interview, the facility failed to keep medical records secure in 2 of 6 storage cabinets in the Medical Records area. This deficiency has the potential to affect all patients with medical records at this facility.

Findings include:

Facility policy COM1604 "Notice of Privacy Practices" states, "We are required by law to maintain the privacy of protected health information."
On 9/12/16 at 3:30 PM observation of the Medical Records Department, employee EE and employee FF stored 10 patient medical records in cabinets that were not lockable. The cabinets are located in a room with no lockable doors and an unattended elevator is able to reach the floor at all times during the day, allowing all staff and visitors potential access to these records.
Interview on 9/12/16 at 3:40 PM with Health Information Management (HIM) Director DD stated "this room could be accessed by anyone at any time."

Based on record review and interview, the facility failed to provide activities for swing bed patients in 2 of 2 swing bed patients reviewed (#9 and #10), out of a total 21 records reviewed. This has the potential to affect all patients Swing Bed patients.

Findings include:

Per review of Patient #9's record on 9/14/2016 10:00 AM, Patient #9 was admitted to swing bed 4/16/16 and discharged on 4/22/16. The record review revealed there is no documentation of swing bed activities being assessed or provided to the patient.
Per review of Patient #10's record on 9/14/16 10:10 AM, Patient #10 was admitted to swing bed 8/8/16 and expired on 8/21/16. The record review revealed there is no documentation of swing bed activities being assessed or provided to the patient.
The above was confirmed in interview with Staff L on 9/14/2016 11:30 AM who acknowledged activities should be provided to all swing bed patients.