HospitalInspections.org

Based on observation, review of documentation, and interview the facility failed to insure the safety of the patient by utilizing two (2) patient identifiers in 6 patient interactions observed.

On 4/11/2011 at 11:00 AM on the nursing unit a respiratory tech was observed to enter patient room #208 and offer the patient the prescribed treatment. The respiratory tech did not ask the patient her name. The respiratory tech did not check the patient's date of birth.

On 4/13/2011 at 11:45 on the nursing unit dietary trays were delivered to the patients. (Room #202, #204, #205, #206, #207, #208) Staff entered the patient rooms greeting the patients with their meal tray however no date of birth was checked. The patients were called by name. Patient #31 was addressed by her first name and asked what her last name was, by this observer. The patient replied, "give me a minute I may be able to tell you." She was not able to say her name.

On 4/13/2011 at 1:00 PM the facility's policy *Patient Identification revised 6/2008 reads: The discipline responsible for administering, collecting or procedure ordered will accurately identify the patient by two (2) identifiers: * Patient's name & * Patient's date of birth.

On 4/13/2011 at 1:30 PM the respiratory supervisor confirmed that date of birth was a patient identifier that staff should use to identify the patient's before treatment is administered.

Based on observation and interview the facility failed to document daily safety checks for 1 of 2 emergency adult crash carts.

On 4/11/2011 at 11:00 AM in the radiology department the adult crash cart check list for March 2011 revealed 9 of 31 daily entries to verify proper working order of the adult crash cart were missing. (Days 6,7,15,20,22,23,and 28 had no signature indicating the adult crash cart had been checked)
The month of February had 28 days yet the adult crash cart check list was initialed as checked for 30 days. 8 daily entries were missing of the 28 days available . (Days 7,8,15,20,21,22,23,and 28 had no signature indicating the adult crash cart had been checked.)
The month of January was missing 6 out of 31 daily entries indicating the adult crash cart had been checked for proper functioning. (Days 10.12.20,26,29,& 31 had no signature indicating the adult crash cart had been checked for proper functioning)

During the same observation time the adult crash cart was observed during testing. The electrocardiograph (EKG) tracing did not work.

On 4/11/2011 at 10:15 AM an interview with radiology staff confirmed the daily adult crash cart checks had not been done. The staff also confirmed the tracing for the EKG did not function.

Based on record review and interview, the facility failed to adequately screen employees for possible histories of abuse. In 6 of 23 (staff#s 1, 6, 10, 11, 16, 22) personnel files reviewed, no employee background check was found.

Findings include:

A review of personnel files revealed no employee background checks.

During an interview on 4/13/11 at 2:00pm in the education room, staff #3 reported that background checks were filed separately from the employees main personnel file. Staff # 3 retrieved background checks requested. However, six employee background checks could not be found.

Based on chart review and interview the facility failed to insure physician orders were timed when written in 9 of 30 records reviewed.

On 4/13/2011 at 10:00 AM in the education room, medical records were reviewed. 9 patient records were found to have a missing time indicating when the physician's order was written. (Patient record #1, #3, #4, #5, #13, #14, #17, #18, and #22)

During this review period an interview with the Administrator confirmed all orders were not timed.

Based on record review and interview, the facility failed to assure safe preventive maintenance of electrical outlets. Electrical outlets in critical areas had been last tested in December 2009.

Findings include:

Review of the policy titled, " Life Safety Maintenance, " revealed that electric receptacle testing would be done annually.

Review of documents titled, " A/C Receptacles in Critical Areas, " revealed the following:
-Receptacles in patient room were last tested on dates ranging from 12/21/09 to 12/30/09
-Receptacles in surgery were last tested on 12/21/09
-Receptacles in the Emergency Department and X-ray were last tested on 12/29/09 and 12/30/09

During an interview on 4/12/11 at 11:00am in the plant operations work area, staff #6 reviewed the documents titled, " A/C Receptacles in Critical Areas. " Staff #6 confirmed that the receptacles in critical areas were last tested during December 2009.

Based on observation and interview, the facility failed to assure expired items were removed from patient care areas. Nineteen (19) expired items were found in the ED (Emergency Department) trauma room.


Findings include:

During inspection of the ED trauma room on 4/11/11, the following expired items were found:
-Pediatric foam electrodes x5 (Expired: 04/2001(2), 09/2005, 04/2007, and 06/2008)
-Pedi-cap carbon dioxide detectors x4 (Expired: 05/2009, 12/2009, 12/2009, and 04/2010)
-Shiley (Trach)- Expired 10/2010
-Adult #3 Laryngeal Mask- Expired 03/2011
-Adult #5 Laryngeal Mask- Expired 01/2011
-Broselow Pink/Red Pediatric Resuscitation Kit- multiple expired items
-Broselow Purple Pediatric Resuscitation Kit- multiple expired items
-Broselow Yellow Pediatric Resuscitation Kit- multiple expired items
-Broselow White Pediatric Resuscitation Kit- multiple expired items
-Broselow Blue Pediatric Resuscitation Kit- multiple expired items
-Broselow Orange Pediatric Resuscitation Kit- multiple expired items
-Broselow Green Pediatric Resuscitation Kit- multiple expired items

The ED RN (staff #19) was interviewed during the inspection and confirmed these items were expired.

Based on observation and interview, the facility failed to assure a sanitary environment for patients and employees. Unused ( " clean " ) biohazard waste boxes were being stored in the same room with used/soiled biohazard waste boxes. These boxes were then used in patient care areas, leading to possible cross-contamination.

Findings include:

During a facility tour on 4/12/11 at 1:45pm, it was observed that unused ( " clean " ) biohazard waste boxes were being stored in the same room with used/soiled biohazard waste boxes.

During the facility tour on 4/12/11 at 1:45pm, staff #6 reported that the biohazard waste contractor delivers new biohazard waste boxes into the room where used biohazard waste boxes are stored until pick-up.

During an interview in the CNO ' s (Chief Nursing Officer) office on 4/12/11 at 3:20pm, the CNO reported that the " clean " biohazard waste boxes were taken to patient care areas, where they are used and returned to the soiled biohazard waste area when full.

Based on observation and interview, the facility failed to post patient rights signage in the main hospital lobby.


Findings include:

During a facility tour on 4/11/11 at 9:05am, it was observed that there was no patient rights signage in the main hospital lobby seating area.

During an interview on 4/14/11 at 10:52am in the education room, staff #1 and #26 confirmed that there was no patient rights signage in the main hospital lobby seating area. Staff #1 reported that when the area was redecorated, the signage had been removed and was not replaced.