HospitalInspections.org

Based on medical record review and staff interview, the facility failed to ensure verbal orders were authenticated by the physician within forty-eight hours for 3 of 30 sample patients (#10, #24, and #25). The findings were:

Review of the medical records for patients #10, #24, and #25 showed the following verbal orders were not authenticated within forty-eight hours by the physician: A verbal order written on 3/11/11 at 3:25 PM for patient #10 was not authenticated at the time of the review on 3/15/11( ninety-six hours). A verbal order written on 11/26/10 at 11 AM for patient #24 was not authenticated until 11/29/10, with no specific time documented approximately (seventy-two hours). Verbal orders for patient #25 were written on 11/11/10 at 6:05 PM and authenticated on 11/17/10 at 10 AM (one hundred forty-four hours). Further review showed orders for this patient written on 11/12/10 at 5 PM were not authenticated until 11/15/10 at 10:40 AM (more than sixty-five hours); and orders written on 11/26/10 at 11:10 AM were not authenticated until 11/29/10 at 10 AM (seventy-one hours). Interview with the medical records manager on 3/16/11 at 3:30 PM verified physicians did not consistently authenticate orders within forty-eight hours, especially after the weekends.

Based on observation, staff interview, and review of the FDA guidelines, the facility failed to ensure safe and consistent disposal of medications when discarded. The findings were:

Observation on 3/15/11 at 12:48 PM revealed approximately five different colored, partially dissolved pills in the counter sink of the pharmacy department. Interview with the director of pharmacy at that time revealed she did not know who had placed the pills in the sink. Upon being aware of the pills, however; the director removed the pills from the sink using a paper towel and disposed of them in the garbage container. During an interview on 3/16/11 at 8:40 AM, she stated her expectation was for staff to dispose of medications in the facility sharps containers, but it would be acceptable to dispose of medications in a soiled brief or in used coffee grounds and thrown in the trash, but not in the sink or water supply. She stated that the facility had no policy for disposal of non-scheduled medications, and she expected scheduled medications to be discarded in the sharps containers. However, she also confirmed that staff had not been educated concerning disposal of non-scheduled medications. She stated that there was no way to determine if the medications observed in the medication room sink were scheduled.

According to the FDA, not all medications should be flushed down the sink or toilet: "Do not flush all medications down the toilet. The FDA recommends that most medicines be disposed of the household trash after mixing them with some unpalatable substance (e.g., coffee grounds) and sealing them in a container. Unused portions of medicines must be disposed of properly to avoid harm. " - Disposal by Flushing of Certain Unused Medicine: What You Should Know." Available at: http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm. Accessed March 22, 2011.

Based on medical record review and interviews with staff and the servicing blood bank manager, the facility failed to monitor transit time and temperatures of 2 of 2 blood component shipments. the findings were:

Medical record review on 3/125/11 at 1:45 PM showed patient #13 was transfused with two units of packed red blood cells (pRBC) on 3/5/11. The facility received blood components from a local blood bank; the blood bank packed requested units on ice in an insulated container and the blood was picked up by the facility staff and delivered to the hospital. Detailed review of patient #13's record revealed the transfusion process was documented in the patient's record, but there was no evidence to show the facility monitored the transit time of of the pRBC (time from release in the laboratory until the transfusion is started) or the temperature of the blood when the shipping container was opened.

The chief nursing officer stated in interview on 3/16/11 at 4:25 PM that her staff performed a visual inspection of pRBC units prior to initiating a transfusion, but did not monitor the time required to receive blood from the servicing blood bank or the temperature inside the shipping container upon receipt at the hospital. Telephone interview with the laboratory manager for the blood bank service on 3/17/11 at 7:35 AM revealed her expectation that time and temperature of blood components be monitored as a safety check for these components. She further stated that blood was packed in a manner approved for a 3-hour delay, but reiterated her expectation that the receiving facility monitor the condition of blood prior to transfusion.

The Code of Federal Regulations Title 21, Part 600, requires blood components be monitored for acceptable storage temperatures prior to transfusion, particularly when these components are distributed outside the controlled refrigeration system required of blood banks.

Based on observation, policy and procedure review, staff interview, and medical record review, the facility failed to ensure staff adhered to aseptic techniques during 3 of 3 observations of patient care. These observations included wound care and care provided to patients (#3, #13) on precautions for epidemiologically significant pathogens. The findings were:

Medical record review showed patient #13 had diagnoses including congestive heart failure and left knee replacement. During an observation on 3/16/11 at 6:15 AM, the patient was seated in his/her wheelchair. At that time, COTA #1 sat on the floor in front of the patient and unwrapped six ace wraps from the patient's legs, three on each leg just below the knee. The COTA placed the ace wraps on the floor and performed passive range of motion exercises to both of the patient's legs. Immediately afterward, the COTA prewrapped the patient's legs with the six ace wraps from the floor. The top of one wrap was touching the bottom of the patient's suture line just below the knee. During the interview immediately after the observation, the COTA stated he did not think about placing the wraps anywhere else because he was sitting on the floor. He further stated that placing the wraps on the patient's bedside stand would have been the appropriate thing to do.

Observations from 3/14/11 -3/17/11 revealed precautionary signage which required specific actions on the part of staff and visitors to minimize the risk of transmission of infection was posted on the door of patient #3's room. Observation on 3/14/11 at 2 PM revealed PT #1 placed a plastic container of ice on the floor inside the patient room. She donned the PPE; moved the container of ice from the floor to the patient's bedside table; and placed it beside the patient's pitcher of water. After physically assisting the patient to reposition in the wheelchair, PT #1 poured ice into the pitcher of water. The PT did not change gloves or perform hand hygiene until she completed all of the above tasks. Observation on 3/15/11 at 8:30 AM revealed RN #1 placed a notebook on the floor in patient #3's room prior to donning PPE. The RN then moved the notebook that contained a closed bag of the patient's medications from the floor to the bedside table. The RN administered the medications and completed a physical assessment of the patient while wearing the same gloves used to lift the notebook from the floor. Review of the facility's Patient Care Policy and Procedures, updated 2/11/09 did not identify the above described practice as acceptible.

Based on staff interview, the facility failed to secure medical records from unauthorized personnel in 1 of 1 storage area. The findings were:

Interview with the medical records custodian on 3/15/11 at 9:20 AM and again on 3/16/11 at 3:30 PM revealed the plant operations manager had access to the medical records storage room. The medical records custodian stated that plant operations might need to access the room to perform maintenance. Subsequent interviews with the administrator and the plant operations director on 3/16/11 at 2:15 PM and 4:45 PM, respectively, confirmed the medical records storage room was accessible by the plant operations director.