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, document review, medical record (MR), and interview, the facility staff did not ensure medications and sharps (devices with sharp points or edges that can puncture or cut skin) in patient care areas were secured.

This lapse in a safe patient setting placed patients at risk for injury.

Findings included:

During observation in the Emergency Department (ED) on 8/28/19 at 3:30PM, a syringe and a vial of 1% Lidocaine were found on a counter in room PA 1R where Patient # 15 was located. This finding was confirmed by Staff K (Nurse Manager) at the time of the observation. Per interview, Staff K stated, "they shouldn't have been left there."

Review of Patient # 15's (MR) revealed the following information: This 7-year old (MDS) dated [DATE] at 1:40PM with complaints of fever, abdominal pain and diarrhea. Lidocaine was not ordered, nor were there any procedures listed requiring the need for those items. This finding was confirmed with Staff K.

Observations in the facility's Labor and Delivery (L&D) Unit during a tour on 8/27/19 at 10:30AM identified that in 3 (three) of 5 (five) L&D Rooms, supply cabinets containing Vitamin K injections, Erythromycin (antibiotic) Ophthalmic (eye) ointment, suturing needles, syringe needles, and phlebotomy (blood drawing) needles were not secured.

This observation was made in the presence of Staff B (Director of Labor and Delivery) who stated that the locking mechanism did not secure the cabinet doors despite being in the locked position. Staff B confirmed that the cabinets should have been locked.

The facility policy and procedure (P&P) titled "Medication Management: Medication and Sharps Security" last revised 12/15/18 stated "All medication / sharps shall be in lockable storage at all times."
Based on observation, document review and interview, the nursing staff did not administer an Intravenous Piggyback (IVPB) medication according to the facility's policy.

This placed patients at increased safety risk.

Findings included:

The facility policy and procedure (P&P) titled "Infusion Therapy-Administration of Intravenous Medication Therapy Guidelines," last revised January 2019, contained the following statements: "In the event that the nurse must prepare the medication...according to instructions, swirl or shake vial until powder is completely dissolved...aseptically connect secondary administration set to IV [intravenous] piggyback bag."

Observations in the facility's Emergency Department (ED) during a tour between 10:45AM and 12:00PM on 8/27/19 identified the following:

Staff E (RN/Registered Nurse) was observed administering an IVPB medication to Patient #4. Staff E removed the secondary tubing from the package, and without removing the protective foil covering the entry port of the bag, spiked (pierced) the bag through the foil.

During the time of observation, Staff E also failed to fully reconstitute (mix the medication per manufacturer's recommendations) the medication prior to reintroducing the mixed medication into the IV bag for administration, until he was intercepted by the surveyor.

This observation was made in the presence of Staff K (ED Nurse Manager), who acknowledged that Staff E should have mixed the medication per the manufacturer guidelines and reintroduced it into the IV bag to allow for proper dosing of the patient.

During interview of Staff M (Director of Infection Prevention) and Staff L (Director of Critical Care) at the time of observation, both confirmed Staff E should have removed the protective foil prior to spiking the bag, and fully reconstituted the medication prior to reintroducing it into the IV bag for patient administration.
Based on Medical Record (MR) review, document review and interview, in (3) three of (5) five MRs, Medical and Nursing staff did not document wounds and pressure ulcers,
as per the facility's Medical Staff Bylaws and policy.

This placed patients at risk for inappropriate or incomplete care.

Findings included:

The facility's Bylaws of the Medical Staff, dated 1/23/18, contained the following statements: "A complete history, physical examination and working diagnosis shall be written...within 24 hours after admission...the history and physical will contain...a review of systems [and] physical examination...the physical examination needs to include the pertinent findings of the examination..."

Review of Patient # 8 's MR identified the following: This patient presented to the Emergency Department (ED) on 8/23/19 with fatigue and shortness of breath. The Registered Nurse (RN) documented at 9:34 PM "patient skin dusky, + (positive) cellulitis, wound to LLE (left lower extremity) being treated by wound MD."

The patient was noted to have dependent edema with local swelling of the extremities and ulcerations. There was a 1.6cm (centimeter) X 1.8cm ulcer on the left midfoot bottom, and a 1.8cm X 1.3cm ulcer laterally at the base of the small toe that was being treated weekly prior to admission. The patient also has a 3.0cm X 1.0cm Stage 2 Pressure Ulcer on the mid sacrum, which was present prior to admission.

The History and Physical completed on 8/24/19 at 12:57AM by Staff O (Attending Physician) stated, "I have performed a physical examination...extremities two plus edema." The note does not include the description of a wound, pressure ulcer, or the presence of a dressing.

During interview of Staff I (Nurse Manager) on 8/28/19 at 10:00 AM, Staff I acknowledged these findings.

Similar findings of missing documentation by physicians of patient's skin condition were observed for patients #20 and #21.

The facility policy and procedure (P&P) titled "Pressure Ulcer: Prevention, Assessment, Management & Documentation," last revised January 2019, contained the following statements: "The registered nurse will utilize a pressure ulcer risk assessment ...this risk assessment tool will be utilized and documented on admission and reassessed every shift ..."

Review of Patient # 21's MR identified the following: The Nursing Admission Assessment, dated 6/11/19 at 3:26AM stated that this patient had a "Stage III Mid-Sacrum Ulcer." On 6/13/19, there was no documentation in the MR indicating the patient's skin was assessed by the day staff nurse, and skin prevention interventions performed.

During interview of Staff N (Director of Performance Improvement) on 8/29/19 at 3PM, Staff N confirmed that there should have been documentation by the nursing staff regarding the patient's skin condition for that shift.