The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on observation, interview, and record review the hospital failed to ensure expired medications were out of patient care areas, reducing the risk of utilizing these expired items while rendering care. These conditions have the potential to negatively affect patient safety and patient outcomes.

The findings include:

On 8/23/2011 at 8:13am, observation of the emergency department revealed a cabinet marked " procedure cabinet. " The cabinet had the following expired medication: lidocaine 1percent, plain, 20 milliliters, with an expiration date of 4/2011. On 8/23/2011 at 8:13am, interview with the director of the emergency department confirms that the items in this cabinet should be checked, by staff for outdated equipment on a frequent basis.

Based on interview and record review the facility failed to ensure that the performance improvement program for patient safety during procedures to reduce medical errors is implemented, and maintained for four out of five sampled patients(SP) #1, #4, #9, #10.

Findings include:
Sampled patient SP#6, (MDS) dated [DATE], by EMS to the facility ' s ED. The patient had a chief complaint of Shortness of Breath. The medical diagnosis included: an acute pneumothorax. The medical doctor order a chest tube to be placed in the right lung. Review of the medical record noted that the medical team placed a chest tube into the left lung . Facility's Records reveal that the medical doctor was in the patient room and started the procedure without the nursing team present. Therefore there was no informed consent form signed by sampled patient # 6 for the above left chest tube placement . There was also no marking of the incision site, nor did the staff perform the verbal Time Out to verify the surgical site prior to making the incision.

On 8/23/2011 at 7:50am, interview with Sampled Employee (SE) #15 The Registered Nurse in the emergency room , reveals that any procedure which requires a side/site of the body must be marked prior to the start of the procedure. She reports that if the procedure is on the right, it is acceptable to write the word " right " near the incision site. She further reports that a nurse or the patient can write/mark the proposed side/site. On 8/23/2011 at 8:13am, the director of the emergency department confirms that all areas of this form must be completed by appropriate staff involved in the procedure. Review of facility policy and procedure titled Surgical Procedural Site/Side Identification state that the site marking should include, the word " yes, " with or without a line representing the proposed incision; the procedure site is marked by a licensed independent practitioner or other provider who is permitted by hospital to perform the intended surgical or non-surgical invasive procedure; The physician performing the procedure in conjunction with the patient (when appropriate) shall clearly mark the procedural side/site and/or level with a " yes. "
On 8/22/2011 at 10:48am, interview with the Risk Manager reveals that a Root Cause Analysis (RCA) was completed by her team which found a failure of staff to follow the policy and the staff did not perform the protocol prior to chest tube insertion . An action plan was put into place.

On 8/22/2011 clinical record review revealed that on 8/22/2011, SP#1 had a procedure done in the emergency department of the facility. A Correct Side/Site/Procedure Identification Verification Checklist form was initiated by the staff involved for the above procedure. The " Time Out" time was left blank indicating when it took place. On 8/23/2011 at 8:13am, the director of the emergency department confirms that all areas of this form must be completed by appropriate staff involved in the procedure. On 8/23/2011, review of facility policy and procedure titled Surgical Procedural Site/Side Identification also revealed that all components of the process (correct side/site, correct patient, and an accurate consent form) shall be completed and documented on the " verification checklist " prior to the start of the procedure.

On 8/23/2011 clinical record review also revealed that SP#4 was admitted to the facility, through the emergency room department with a diagnosis of pneumonia. The informed consent for the central line placement revealed that a physician order for this procedure was not in the medical record. On 8/23/2011 at 8:13am, the director of the emergency department confirms that a physician order is required for all invasive procedures.
Review of sampled patient # 9 medical record revealed that he had a procedure done on 8/1/2011 and sampled patient # 10 had a procedure done on 7/19/2011. Review of the Correct Side/Site /Procedure Identification Verification Checklist for sampled patients # 9 and SP# 10 revealed that both sampled patients checklists do not have the signatures of the licensed independent practitioners who performed the procedures verifying the completion of the Time Out task.
Review of the policy: Surgical Procedural Site/Side Identification, also revealed that the physician shall discuss the operative/invasive procedure with the patient and the discussion and patient's verbalization shall be documented on the consent form. The policy also stated that a Time Out will be conducted prior to the starting of the procedure to confirm the correct side/site of the procedure.