HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure that all facility and medical equipment is listed under their inventory and included in the facility's preventive maintenance program.

Failure to have all equipment included in the hospital's preventive maintenance program puts patients at risk from malfunctioning equipment.

Findings:

On 10/15/2015 at 9:35 AM, Surveyor #1 interviewed the director of materials management (Staff Member #2) about the hospital's preventive maintenance program and equipment inventory. The surveyor asked to see how diagnostic imaging equipment is listed on the facility's equipment inventory. The staff member was unable to locate any diagnostic imaging equipment and concluded that it was not part of the current facility inventory. S/he reported that the current inventory did not include all facility and medical equipment. Subsequently the surveyor asked to see a list of the facility's critical equipment. The staff member reported that the facility's critical equipment could not be readily identified on the current inventory.

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Based on observation and interview, the hospital failed to fully implement the requirements of the 2013 Food and Drug Administration Food Code.

Failure to comply with food service codes puts patients, staff, and visitors of the facility at risk from food borne illnesses.

Findings:

On 10/15/2015 at 10:52 AM, Surveyor #1 observed two bulk containers of celery and two bulk containers of leaf lettuce without labels and/or dating information. The celery and leaf lettuce were removed from their original packaging and placed in the containers without labeling the containers with the foods expiration dates. When food is removed from its original container or packaging it must be labeled with the manufacturers' dating information. The dietary manager (Staff Member #3) confirmed this finding at the time of the observation.

Reference: 2013 Food and Drug Administration Food Code 3-602.12

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Based on observation and document review, the hospital failed to follow policies and procedures designed to prevent contamination and exposure to infectious agents while providing care to patients on contact precautions.

Failure to follow infection control policies and procedures places the safety of patients and staff members of the facility at risk from infections and/or communicable diseases.

Findings:

1. The hospital's policy and procedure titled "Hand Hygiene" (effective date: 8/3/2015) read in part; "Procedure: Who and when hand hygiene should be performed, L. Before and after removing gloves".

2. The hospital's policy and procedure titled "Guidance For the Selection and Use of Personal Protective Equipment" read in part; "Procedure: II. Elements of Personal Protective Equipment, F. Sequence for Donning PPE. 1. Gown - To put on a gown...secure the gown at the neck and waist".

3. On 10/13/2015 at 11:09 AM, Surveyor #1 observed a certified nurse anesthetist (Staff Member #1) don gloves without performing hand hygiene and don a gown without securing or tying it at the waist. The staff member then entered a patient's room (room #2211) where the patient was on contact precautions.

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Based on review of hospital policies and procedures, medical record review and interview, the hospital failed to ensure staff members followed hospital guidelines for the administration of intravenous (IV) fluids and blood products for 3 of 3 patient records reviewed (Patients #1, #2, #3).

Failure to follow policies and procedures related to the use of IV therapy put patients at risk for fluid overload, as well as an adverse immediate patient response to therapy.

Findings:

1. The hospital's policy and procedure titled "IV Therapy" (Policy: 10167, Revised 04/28/2014), in part reads "II. Procedure A. The nurse should be fully acquainted with and operate within the policies/procedures regarding the following ...5.The nurse is authorized to a. Administer IV fluids, blood and blood derivative and IV medications, TPN and lipids ...I. DOCUMENTATION 2 b. I/O in EMR at end of shift of change of bag ... "

2. On 10/14/2015 at 3:00 PM, Surveyor #2 reviewed closed medical records for patients who had received blood transfusions with the last six months. Patients #1, #2 & #3 received two units of pack red blood cells, intravenously over two hours, as ordered by the provider. All three patient records revealed the documented total IV fluid intake did not included the amount of infused blood.

3. At the time of the record review, the hospital's Director of Nursing (Staff Member #4) confirmed the missing documentation.

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Based on medical record review and review of hospital policies and procedures, the hospital failed to ensure emergency department (ED) staff members documented patient's pain reassessment after intervention for 2 of 2 patient records reviewed (Patients #3, #4).

Failure to complete pain assessments puts patients at risk for inadequate pain relief and negative health outcomes related to pain management.

Findings:

1. The hospital's policy and procedure titled "Pain Management" (Policy: 11073, Reviewed 04/23/2015), in part reads "III. Procedure for Pain Management - All Patients A. Assess for presence of pain and pain history for all patients ...D. Nursing interventions 1. Analgesics and treatments will be administered as prescribed by the physician ...IV. Documentation in EMR A. Document as follows 3. When administering pain medication, document initial pain assessment and reassessment in " IP Assessment Pain ... "

2. On 10/15/2015 at 11:45 AM, Surveyor #2 reviewed closed medical records for patients who had received care in the ED, during the month of August. Medical record review revealed the following:

a. Patient #3 was a 52-year-old patient who was being treated for an abscess. The patient received a non- steroidal medication for pain on 8/6/2015 at 9:00 PM. There was no evidence in the medical record of pain ratings after medication administration to assess adequacy of the treatment for pain.

b. The same observation was revealed for Patient #4, a 69-year-old patient who was being assessed and treated for back pain, following low back surgery. The patient received an oral narcotic for pain. The medical record was missing reassessment after medication administration.
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