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Based on employee file review, policy and procedure review, and interview, it was determined the facility failed to assure five (Registered Nurse (RN) #4, #5, #8, Director of Surgical Services, and Senior Care Director) of nine (RN#3-8, Director of ER, Director of Surgical Services, and Senior Care Director) licensed nursing personnel possessed current, valid licensure. Failure to provide evidence of primary verification for current nursing licensure did not assure that competent, unencumbered RNs were providing patient care at the facility. The failed practiced affected all patients receiving care from RN #4, #5, #8, Director of Surgical Services, and Senior Care Director in the Facility. Findings follow.

A. Review of policy and procedure dated 03/30/17 titled, "Verification of Job Credentials", stated that Human Resources will complete primary source verification on positions which require licensure, and that Nursing Administration was responsible for ensuring all licenses were maintained in current status.

B. Review of employee files showed RN #4, #5, #8, Director of Surgical Services, and Senior Care Director did not have evidence of primary verification reports of current licensure.

C. The findings in A and B were verified by Chief Nursing Officer (CNO) on 03/09/23 at 9:30 AM.

Based on policy and procedure review, observation, and interview, it was determined the hospital failed to provide or assign nursing care in accordance with the patient's needs and the specialized qualifications and competence of the staff available in that telemetry monitoring was not performed for nine of nine patients (Patients #24 and #31-38) in the ICU (Intensive Care Unit) and medical surgical unit. The failed practice had the likelihood to affect any patient in need of qualified telemetry care in the ICU and medical surgical unit of the facility. Findings follow.

A. Review of policy dated 04/06/18, titled "Telemetry Monitoring Station", showed the charge nurse, monitor technician, patient's nurse, or ICU nurse monitored and responded to the central monitor alarms, the cardiac telemetry monitoring system.

B. Observation of the ICU on 03/07/23 from 12:35 PM to 12:45 PM, showed multiple telemetry monitor alarms were audible and visible on two of two (Monitor #1 and #2) telemetry monitors in the nurse's station. Monitor #1 showed five (Patient #31, #33-36) of six medical surgical unit patients (Patient #31-36) with active alarms that showed "check all leads". Observation showed no patient care staff responded to the active telemetry alarms. Observation showed Patients #24 and #31-38 were on the screens of the monitors but there were no staff observing the monitors.

C. During an interview with Registered Nurse (RN) #2 on 03/07/23 at 12:45 PM, RN #2 verified the findings in A and B. When asked about the responsibility of monitoring telemetry alarms, RN #2 stated that oversight of the telemetry monitors was a group-effort of the RNs staffed in the ICU and not designated to an assigned staff member. When asked the location of the patients with active alarms, RN #2 stated "I do not know where these patients are."

Based on patient clinical record review and interview, it was determined the facility failed to assure the accuracy of patient information in two (Patient #6 and #7) of 38 (Patient #1-#38) clinical records reviewed. By not accurately recording the demographics (race), per policy the facility could not ensure the that the charts were accurate and this had the likelihood to affect patient care. Findings follow.

A. Clinical record review on 03/08/23 at 2:10 PM, showed Patient #6 and #7's race was not accurately documented. Patient #6's race was documented as Caucasian when Patient #6 was actually African American. Patient #7's race was documented as African American when Patient #7's was actually Indian/Jewish/Caucasian.

B During an interview with Director of Nursing on 03/08/23 at 2:10 PM, the findings in A were confirmed.

Based on review of policy, observation, and interview, it was determined the facility failed to properly store warm fluids (not to exceed 110 degrees per policy) in one (Surgical Services) of four (Surgical Services, Intensive Care Unit, Labor and Delivery and Endoscopy) areas toured. By not storing fluids at the proper temperature, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that had procedures in the facility that required warm fluids. Findings follow:

A. Record review of the facility's policy titled, "Blanket and Fluid Warmer," revised 07/05/2022, showed that fluids could be stored in a warmer if the temperature does not exceed 110 degrees Fahrenheit.

B. During a tour of the facility on 03/07/23 from 12:19 PM to 2:15 PM, observation showed the following irrigation solutions stored in a blanket warmer whose temperature was currently 131 degrees Fahrenheit, which was above the policy maximum of 110 degrees Fahrenheit:
1) #4- 1000 ml (milliliter) bottles of Sterile Water manufactured by B. Braun;
2) #3- 500 ml bags of 0.9% Sodium Chloride manufactured by B. Braun;
3) #2- 1000 ml bottles of 0.9% Sodium Chloride manufactured by B. Braun;
4) #4- 500 ml bottles of 0.9% Sodium Chloride manufactured by B. Braun; and
5) #7- 1000 ml bags of 0.9% Sodium Chloride manufactured by Baxter.

C. During the tour a sign on the blanket/fluid warmer showed fluids should not be stored above 110 degrees Fahrenheit.

D. During an interview on 03/07/23 at 1:29 PM, the Operating Room Director verified the fluids were stored at 131 degrees Fahrenheit.

Based on observation, review of policy and interview, it was determined the facility failed to ensure floor stock was properly controlled in one (Endoscopy) of four (Surgical Services, Intensive Care Unit, Labor and Delivery and Endoscopy) areas toured in that prescription medications were observed in a cabinet that did not have the means to be locked. These prescription medications were unsecured and accessible to unlicensed personnel. By not controlling floor stock, the facility could not assure the safety, integrity, or efficacy of the uncontrolled medications. The failed practice had the likelihood to affect all patients that were admitted into the facility for procedures. Findings follow:

A. Record review of the facility's policy titled, "Medication Security," revised 08/31/2020, showed all drugs and biologicals stored in the hospital shall be kept in a secure area, locked when appropriate and accessible only by licensed personnel.

B. During an interview on 03/08/2023 at 9:30 AM, the Director of Pharmacy verified the policy at A.

C. During a tour of the facility on 03/07/23 from 12:19 PM to 2:15 PM, observation showed the following prescription medications in an unlockable cabinet:
1) #23- Prochlorperazine 10mg (milligram) /2ml (milliliter) vial for injection;
2) #6- Xylocaine 1% 5ml vial for injection; and
3) #18- Ondansetron 4mg/2ml vial for injection.

D. During an interview on 03/08/2023 at 1:44 PM, the Operating Room Director verified the prescription medications observed in an unlockable cabinet.

Based on observation, review of policy and interview, it was determined the facility failed to ensure outdated medications were not available for patient use in one (Surgical Services) of four (Surgical Services, Intensive Care Unit, Labor and Delivery and Endoscopy) areas toured. By not removing outdated medications the facility could not assure the integrity and efficacy of the medications. The failed practice had the likelihood to affect all patients who receive medications from the facility. Findings follow:

A. Record review of the facility's policy titled, "Outdated Pharmaceuticals," revised 09/01/2020, showed all pharmacy stock is to be inspected for outdated products, monthly.

B. During an interview on 03/08/2023 at 9:30 AM, the Director of Pharmacy verified the policy at A.

C. During a tour of the facility on 03/07/2023 from 12:19 PM to 2:15 PM, observation showed the following expired irrigation solutions stocked and available for patient use:
1) #5- 0.9% Sodium Chloride 1000 ml (milliliter) bottles expired 11/2022 in the refrigerator;
2) #3- 0.9% Sodium Chloride 1000 ml (milliliter) bags expired 02/2022 in the refrigerator; and
3) #12- 0.9% Sodium Chloride 1000 ml (milliliter) bags expired 01/2023 on a shelf.

D. During an interview on 03/07/2023 at 13:24 PM, The Certified Scrub Technician verified the expired fluids found on the shelf.

E. During an interview on 03/07/2023 at 1:34 PM, The Operating Room Director verified the expired fluids found in the refrigerator.

Based on policy and procedure review, National Fire Protection Agency (NFPA) 101 2015 standards, observation and interview, it was determined the facility failed to formulate and implement policies and procedures regarding annual scheduled polarity and tension testing and labeling emergency receptacles. The failed practice did not ensure emergency power was available to the receptacles in the event of a power outage. The failed practice had the likelihood to affect all patients in the facility. Findings follow:

A. Review of NFPA 99 standards, referred by NFPA 101 2015 edition, showed the receptacles in patient areas must be tested after initial installation, replacement or service at intervals determined by the facility based documented performance data or grade tested at least annually.
B. Review of the facility's policies and procedures on 03/06/23 showed there was no evidence of a policy for annual scheduled polarity and tension testing or labeling emergency receptacles.
C. Observation on 03/06/23 of the emergency receptacles throughout the facility showed there was no evidence the emergency receptacles were labeled as tested.
D. The findings in A and B were confirmed in an interview with the Maintenance Supervisor on 03/06/23 at 5:00 PM.

Based on observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure that the fire rated doors were maintained in a manner to ensure the safety and well-being of patients in that the fire rated doors did not completely close in the Sales Representative Storage Area or latch when closed in the Endoscopy Suite. The failed practice did not ensure smoke and fire did not spread and had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of the NFPA 101 standards showed doors in a smoke barrier or hazardous area enclosure were to be self-closing and kept in the closed position, unless held open by a release device.

B. On 3/06/2023 observation of the fire rated doors leading into the Sales Representative Storage Area showed that the fire rated doors connecting this area to the corridor did not close or latch completely.

C. On 3/06/2023 at 2:15 PM observation of the the fire rated doors leading in the Endoscopy Suite showed that the fire rated doors did not latch and remain closed when shut.

D. The finding were verified with the Maintenance Supervisor on 3/06/2023 at 5:00 PM.




Based on above ceiling observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure that the hospital was maintained in a manner to ensure the safety and well-being of patients, visitors and staff in that one fire barrier wall was not sealed and one fire barrier wall was not sealed with fire proof foam. The failed practice did not ensure smoke and fire did not spread and had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA 101 standards showed a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

B. Observation of above ceiling walkthrough on 3/06/2023 at 4:45 PM showed that pipes in the ceiling above the exit sign in the corridor leading to the cafeteria failed to be protected by a system or material capable of restricting the transfer of smoke.

B. . Observation of above ceiling walkthrough on 3/06/2023 at 4:45 PM showed that the pipes in the ceiling near the cafeteria contained fire caulk and spray foam that was a flammable type of caulk and foam.

C. The finding in A and B were verified by the Maintenance Supervisor on 3/06/2023 at 5:00 PM

Based on observation of the Respiratory Therapy Suite, Sub Sterile Equipment Room, and Endoscopy Suite and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practices promoted the spread of infection and had he likelihood to affect all patients, staff and visitors, Findings follow:

A. Observation of the Respiratory Therapy Suite on 03/06/23 from 12:22 PM to 12:50 PM showed the following:
1) Mold was present on the ceiling tiles.
2) Brown stained ceiling tiles were present.
3) The equipment room had chipped and peeling wall paint.
4) The equipment room had sagging ceiling tiles due to humidity and moisture.

B. Observation of the Sub Sterile Equipment Room on 03/26/23 from 1:07 PM to 1:27 PM showed the following:
1) A missing and damaged sprinkler head in the ceiling.
2) Mold was present on the ceiling.
3) Broken breaker box with no lock.
4) Multiple penetrations in north facing fire walls .
5) Uncleaned exhaust fans in the ceiling.
6) Missing base boards around the perimeter of room.
7) Rust present on back flow pipes.

C. Observation of Treatment Room #2 of the Endoscopy Suite on 03/06/23 from 1:41 PM to 3:30 PM showed the following:
1) Mold was present on the ceiling tiles.
2) Sagging ceiling tiles due to humidity and moisture.
3) The back plate of the electric blanket warmer was removed.
4) Chipped and broken counter tops.

D. These findings of A, B and C were verified by the Maintenance Supervisor on 03/06/26 at 5:00 PM.



Based on policy and procedure review, review of National Fire Protection Agency (NFPA) 101 2015 standards and interview, it was determined the facility failed to formulate and implement policies and procedure regarding scheduled electrical panel infrared testing for the breaker boxes throughout the facility, for monthly scheduled emergency door checks, for quarterly kitchen vent hood maintenance and for ice machine maintenance. The failed practice placed the patients at risk of fire due to overheating of the breaker box. The failed practice had the likelihood to affect all patients, staff and visitors. Findings follow.

A. Review of NFPA 70E standards, referred by NFPA 101 2015 edition, showed infrared inspections of the electrical distribution systems must be conducted on an annual basis.

B. Review of the NFPA 80 standards, referred by NFPA 101 2015 edition, showed inspection and testing of doors equipped with panic hardware or fire exit hardware must be conducted on a monthly basis.

C. Review of the NFPA 90 standards, referred by NFPA 101 2015 edition, showed the kitchen exhaust system must be checked on a quarterly basis.

D. Review of the facility's policies and procedures on 03/06/23 showed there was no evidence of a policy for scheduled electrical panel infrared testing for the breaker boxes.

E. A request was made on 03/06/23 for evidence of electrical panel infrared testing. In an interview with the Maintenance Supervisor on 03/06/23 at 5:00 PM, the Maintenance Supervisor stated the facility had not conducted electrical panel infrared testing. The Maintenance Supervisor confirmed the findings of A.

F. Review of the facility's policies and procedures on 03/06/23 showed there was no evidence of a policy for monthly scheduled emergency door checks.

G. A request was made on 03/06/23 for evidence of monthly emergency door checks. In an interview with the Maintenance Supervisor on 03/06/23 at 5:00 PM, the Maintenance Supervisor stated the facility had not conducted monthly emergency door checks.

H. Review of the facility's policies and procedures on 03/06/23 showed there was no evidence of a policy for quarterly kitchen vent hood maintenance.

I. A request was made on 03/06/23 for evidence of quarterly kitchen vent hood maintenance. In an interview with the Maintenance Supervisor on 03/06/23 at 5:00 PM, the Maintenance Supervisor stated the facility had not conducted quarterly kitchen vent hood maintenance.

J. A request was made on 03/06/23 for policies and procedure regarding the maintenance of ice machines. In an interview with the Maintenance Supervisor on 03/06/23, the Maintenance Supervisor confirmed the facility did not have a policy regarding the maintenance of the ice machines.


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Based on observation, review of manufacturer's recommendations, and interview it was determined the facility failed to ensure the accuracy of two (Intensive Care Unit and Radiology) of three (Intensive Care Unit, Radiology and Senior Care) glucometers by not writing the expiration date on glucose controls and test strips. The failed practice did not ensure the glucose test results were accurate beyond the expiration date and had the likelihood to affect all patients requiring blood glucose tests. Findings follow:

A. Review of the manufacturer's instructions for use for the Nova Glucometer Control Solutions showed the solutions expire three months after opening and should be marked as such.
B. Review of the manufacturer's instructions for the Nova Glucometer Test Strips showed the strips expire six months after opening and should be marked as such.
C. Observation of the Radiology Department on 03/08/23 at 9:25 AM showed two of two glucose controls and one of one bottle of test strips were found not to have been marked with expiration dates.
D. Observation of the Intensive Care Unit on 03/08/23 at 11:00 AM showed two of two glucose controls and one of one bottle of test strips were found not to have been marked with expiration dates on them.
E. During an interview with Director of Radiology on 03/08/23 at 9:25 AM, the findings in A, B, and C were verified.
F. During an interview with Director of Nursing on 03/08/23 at 11:00 AM, the findings in A, B and D were verified.




Based on observation and interview, it was determined the facility failed to ensure the safety of one of one (Endoscopy Suite) blanket warmers by not documenting the temperature daily in the blanket warmer temperature log. The failed practice did not ensure the blanket warmer was functioning properly and had the likelihood to affect all patients who required a warm blanket. Findings follow:

A. Observation of the Endoscopy Lab on 03/08/23 at 1:35 PM showed a temperature log marked Endo March 2023 which was checked only one day (03/01/23) of 8 possible days (03/01/23-03/08/23).
B. During an interview with Director of Operating Room on 03/08/23 at 1:35 PM, the findings in A were verified.

Based on policy and procedure review and interview, it was determined the facility failed to formulate and implement policies regarding steps to minimize the growth and transmission of Legionella and other waterborne pathogens in the building water system. The failed practice placed the patients, visitors and staff at risk of infection from water borne pathogens. The failed practice had the likelihood to affect all patients, visitors and staff. Findings follow:

A. Review of the facility's policies and procedures on 03/06/23 showed there was no evidence of a policy for steps to minimize the growth and transmission of Legionella and other waterborne pathogens.
B. A request was made on 03/06/23 for Legionella water testing conducted at the facility. In an interview with the Maintenance Supervisor on 03/06/23 at 5:00 PM, the Maintenance Supervisor stated the facility had not conducted testing for Legionella or other waterborne pathogens in the building water system. The Maintenance Supervisor confirmed the findings of A.

Based on review of Memorandum of Agreement with ARORA (Arkansas Regional Organ Recovery Agency), patient expiration charts and interview, it was determined the facility failed to provide notification of a death in accordance with the terms of the agreement in that one (#12) of three (#11, #12 and #13) patient expiration charts reviewed, was not reported to ARORA. By not reporting the death to ARORA, the facility could not assure they were fulfilling their Organ Procurement responsibilities. The failed practice had the likelihood to affect all persons who pass away at the Facility. Findings follow:

A. Review of Memorandum of Agreement with ARORA, Terms and Conditions #2.8, dated 06/17/2020, showed one of the duties of the hospital were to provide timely referral to ARORA of all deaths by calling the ARORA referral line.

B. Review of Patient #12's expiration chart showed no evidence of a referral to ARORA.

C. During an interview on 03/08/23 at 11:00 AM, the Chief Nursing Officer verified the findings at A and B.

Based on review of the surgeon roster of privileges maintained in the surgical suite, it was determined that the facility failed to maintain a current roster of credentialed practitioners with approved, specified, and current surgical privileges for 18 of 18 (Surgeon #1-18) surgeons listed in the Surgical Services Privileges Binder. Failure to provide perioperative staff with a current roster of surgeon privileges approved by the governing body did not assure that perioperative staff were knowledgeable of the specific surgical procedures approved for each surgeon. The failed practice had the likelihood to affect any surgical patient whose procedure was performed by Surgeons #1-18. Findings follow.

A. Review of the Surgical Services Privileges Binder records showed undated, expired, incomplete, and unidentifiable records of surgical privileges. Findings follow.
1) 63 of 89 total pages in the binder showed no identification of the surgeon associated with the approved procedures listed on those pages.
2) Surgeon #3, #4, #6, #8, and #10-18's privileges forms showed expired approval dates beyond two years.
3) Surgeon #1-18's privileges showed no evidence of governing body approval.

B. The findings in A were verified by Chief Nursing Officer (CNO) on 03/08/23 at 2:50 PM.