HospitalInspections.org

Based on document review and staff interview, the hospital failed to measure, analyze, and track quality indicators as evidenced by lack of documentation. to assess processes of care, hospital services and operations.


Findings include:


Document review revealed that the hospital was gathering data, however there was no documented evidence of assimilation of the data and no measurements were offered for review. There was documented evidence that the hospital had looked at quality indicators, but there were no assessments of care and hospital services.


The findings were presented at exit conference on 10/24/12 and further documentation was presented, but there was no complete plan for 2011.

Based on observation, staff interview, and policy review, the facility failed to ensure that medications were administered in accordance with accepted standards of practice as hospital policy.


Findings include:


On 10/23/2012 at 4:00 p.m. observation of a medication administration by a Registered Nurse (RN) revealed that the RN prepared her Intravenous Piggyback medication and took it to the patient's room. She cleaned the hep-lock and hooked up the medication without flushing the hep-lock. The intravenous pump stopped and began alarming three (3) times. I stated, "It may help if you flush it." She stated, "No, it was doing this yesterday."


Review of the hospital's "IV Facts To Remember" policy revealed: "11. Flush INT with 2ml of NS every 8 hours to maintain patency. The devise should also be flushed with 2 ml of NS before and after medication administration."

Based on document review and staff interview, the hospital failed to ensure a way to complete patient's initial consent electronically as evidenced by two (2) of two (2) consents printed.


Findings include:


Review of two (2) patient's electronic record revealed that in one of the two (2) records the initial consent, signed electronically by the patient, lacked the signature of the witness. Both records lacked dates and times.


These findings were discussed with the hospital's administration during the exit conference on 10/24/12. No further documentation was provided.

Based on observation and staff interview, the facility failed to ensure that in order to provide patient safety, drugs and biological must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law.


Findings include:


On 10/23/12 at approximately 11:00 a.m. the Director of Nursing (DON) was assisting with a facility tour. Observation of the West wing's medication room revealed two (2) pill crushers sitting on the cabinet to the left of the refrigerators. The silver pill crusher had brown, crusty material in the area where the medication cup should be placed, as well as on the upper part that crushes the medication. A white residue was observed on both of the pill crushers and on the counter where they were sitting. The DON instructed the charge nurse to "get these cleaned."

Based on policy review, observation and staff interview, the facility failed to ensure that scheduled drugs are kept locked within a secure area.


Findings include:


On 12/23/12 at 11:15 a.m. the emergency department was toured, along with the Director of Nursing (DON). During this tour the DON was asked where their medications were stored. She stopped in front of a room in which the door was propped open. When asked if there were narcotics in the Emergency room, the DON stated that they did store narcotics, "Let me get the keys." She retrieved the keys from underneath the cabinet and opened the narcotics cabinet.


Review of the hospital's undated "Management of Controlled Drugs" policy revealed, "All controlled drugs will be double locked at the nurse's station...Keys to the narcotic cabinet are given to the oncoming medication nurse after the count is verified and signed."

Based on observation, staff interview and policy review, the facility failed to ensure that outdated, mislabeled, or otherwise unusable drugs and biological were not available for patient use.


Findings include:


On 10/23/12 at approximately 11:00 a.m. the hospital's west wing was toured along with the Director of Nursing (DON). Observation inside the medication room revealed two (2) refrigerators. When the DON was asked what was stored in the refrigerators, she opened one of the doors. The refrigerator contained:
1. One vial of Novolin 70/30 insulin with an opened date of 8/3 and no documented expiration date;
2. Novolog insulin with an expiration date of 9/27;
3. Humulin insulin with an expiration date of 9/14.
When asked about a thermometer or temperature log for the refrigerators the DON stated, "To be honest, there is no thermometer in these refrigerators, but I have them ordered."


Review of the hospital's undated "Drug Storage" policy revealed, "Proper environment must be maintained when storing drugs. Proper temperature, light, humidity, ventilation must be controlled. 1. Stock will be examined for out-dated product when removing from the shelf... 4. Temperature of the pharmacy refrigerator will be logged daily in the IV hood cleaning log."