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Based upon record review and interview, the hospital failed to ensure Therapeutic Activities were provided by Licensed or Certified Activity Therapist. Findings:

Review of hospital personnel files failed to reveal that the hospital currently had a Certified Activity Therapist employed with the hospital.

S3- Performance Manager was interviewed on 06/09/10 at 10:00 a.m. S3- Performance Manager reported that she could not provide this surveyor with a personnel file for the hospital's Activity Therapist because the hospital did not have a current employed Certified Activity Therapist. S3- Performance Manager reported that S4- Activities Director was currently providing patient activities but he was not certified.

S1- Program Manager was interviewed on 06/09/10 at 11:30 a.m. S1- Program Manager stated that the hospital had been without a Certified Activity Therapist for approximately six (6) months. S1 stated that he instructed S3- Performance Manager that it was not necessary to submit S4's personnel file to the survey team because S4- Activity Director was not certified and therefore the hospital did not meet the requirement of having a Certified Activity Therapist employed with the hospital.

Based on observation and record review the hospital failed to ensure that outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use by failing to ensure that medications and/or intravenous fluids (IV) were not expired and/or labeled. Findings:

Observation of the Medical-Surgical Unit Medication room on 06/08/10 at 11:15 a.m. revealed:
1. A 10 milliliter (ml) multidose vial of Humalog Insulin that was opened. There was no date noted on the vial or vial box to indicate when the vial was opened.
2. A 10 milliliter (ml) multidose vial of Novolin Insulin that was opened. The open date of the vial reflected a date of 10/15/09 (approximately 7 months and 3 weeks since open date).
3.A 10 milliliter (ml) multidose vial of Lantus Insulin that was opened. The open date of the vial reflected a date of 01/17/10 (approximately 4 months and 3 weeks since open date).

Interview with S4- Performance Improvement Director on 06/08/10 at the above time confirmed there was no label or writing on the vial or vial box to indicate when the vial was actually opened. S4 further confirmed that the open date of 10/15/09 and 01/17/10 were accurate for the open date of the vial of Novolin and Lantus Insulin respectively. S4 stated that it was the hospital's policy to date all vials when opened. S4 revealed that when the vials were initially opened then they were good for 90 days.

Review of the Nursing Policy and Procedure Manual for reflected Policy #12:24A, Subject: Multivial Drug Use read: "Policy: Multiple dose sterile products (e.g. vials) shall be used and disposed of in accordance with this policy." LENGTH OF USE OF MULTIPLE USE STERILE PRODUCTS, Multiple use containers of sterile products may be used up to the manufacturer's date of expiration (unless specified differently) provided they contain a preservative, and show no evidence of contamination. Exceptions: Insulin- 30 days.
Multiple use sterile products not meeting these specifications shall be discarded immediately (in accordance with facility policies).

Based on observation and record review the hospital failed to ensure that outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use by failing to ensure that medications and/or intravenous fluids (IV) were not expired and/or labeled. Findings:

Observation of the Medical-Surgical Unit Medication room on 06/08/10 at 10:30 a.m. revealed:
1. A 10 milliliter (ml) multidose vial of Humalog Insulin that was opened. There was no date noted on the vial or vial box to indicate when the vial was opened.
2. A 10 milliliter (ml) multidose vial of Novolin Insulin that was opened. The open date of the vial reflected a date of 10/15/09 (approximately 7 months and 3 weeks since open date).
3.A 10 milliliter (ml) multidose vial of Lantus Insulin that was opened. The open date of the vial reflected a date of 01/17/10 (approximately 4 months and 3 weeks since open date).

Interview with S4- Performance Improvement Director on 06/08/10 at the above time confirmed there was no label or writing on the vial or vial box to indicate when the vial was actually opened. S4 further confirmed that the open date of 10/15/09 and 01/17/10 were accurate for the open date of the vial of Novolin and Lantus Insulin respectively. S4 stated that it was the hospital's policy to date all vials when opened. S4 revealed that after Isulin vials were opened they were good for 90 days.

Review of the Nursing Policy and Procedure Manual for reflected Policy #12:24A, Subject: Multivial Drug Use read: "Policy: Multiple dose sterile products (e.g. vials) shall be used and disposed of in accordance with this policy." LENGTH OF USE OF MULTIPLE USE STERILE PRODUCTS, Multiple use containers of sterile products may be used up to the manufacturer's date of expiration (unless specified differently) provided they contain a preservative, and show no evidence of contamination. Exceptions: Insulin- 30 days.
Multiple use sterile products not meeting these specifications shall be discarded immediately (in accordance with facility policies).

Based on observation and interviews the hospital failed to ensure that all supplies and/or equipment were maintained in a manner to ensure the safety and well being of patients and/or maintained in a manner to ensure quality assurance. Findings:

Observation on 06/08/10 between 10:15 a.m. and 11:30 a.m. with the S2- Director of Nursing, and S3- Performance Improvement Director revealed the following:
-Patient Room (a) revealed multiple areas of dried reddish brown substance on the wall behind the toilet. The space between the wall and the grab bar were greater that 1 1/2 inches that were mounted in patient bathroom.
-Patient Room (b) revealed dried brown substance on the toilet seat and the wall behind the toilet, the patient bathroom had a strong odor of urine. Electrical receptacles were noted to be uncovered, energized and non ground-fault- interrupters. The space between the wall and the grab bar were greater that 1 1/2 inches that were mounted in patient bathroom.
-Patient Room (c) revealed electrical receptacles were noted to be uncovered, energized and non ground-fault- interrupters. The space between the wall and the grab bar were greater that 1 1/2 inches that were mounted in patient bathroom.
-Patient Room (d) revealed electrical receptacles were noted to be uncovered, energized and non ground-fault- interrupters. The space between the wall and the grab bar were greater that 1 1/2 inches that were mounted in patient bathroom.
-Patient Room (f) revealed a dried brown substance on the side of the toilet. Electrical receptacles were noted to be uncovered, energized and non ground-fault- interrupters.
-Patient Room (g) revealed a dried brown substance at the entrance of the patient shower stall. Electrical receptacles were noted to be energized and non ground-fault- interrupters.
-Patient Room (h) revealed a dried brown substance on the side of the toilet and on the wall behind the toilet. Electrical receptacles were noted to be energized and non ground-fault- interrupters.
-Patient Room (i) revealed a dried brown substance on the side of the toilet. Electrical receptacles were noted to be uncovered, energized and non ground-fault- interrupters.

In a face to face interview on 06/08/10 at 11:00 a.m. with S1- Program Director, S2- Director of Nursing, and S3- Performance Improvement Director verified the findings of dried brown substance on the Patient Room walls, uncovered, energized non-ground-fault receptacles and grab bars with a distance greater that 1 1/2 inches between the wall and the grab bar.

Based on observation and interviews the hospital failed to ensure that all facilities, supplies and/or equipment were maintained in a manner to ensure the safety and well being of patients and/or maintained in a manner to ensure quality assurance. Findings:

Observation on 06/08/10 between 10:15 a.m. and 11:30 a.m. with the S2- Director of Nursing, and S3- Performance Improvement Director revealed the following:
-Patient Room (a) revealed multiple areas of dried reddish brown substance on the wall behind the toilet. The space between the wall and the grab bar were greater that 1 1/2 inches that were mounted in patient bathroom.
-Patient Room (b) revealed dried brown substance on the toilet seat and the wall behind the toilet, the patient bathroom had a strong odor of urine. Electrical receptacles were noted to be uncovered, energized and non ground-fault- interrupters. The space between the wall and the grab bar were greater that 1 1/2 inches that were mounted in patient bathroom.
-Patient Room (c) revealed electrical receptacles were noted to be uncovered, energized and non ground-fault- interrupters. The space between the wall and the grab bar were greater that 1 1/2 inches that were mounted in patient bathroom.
-Patient Room (d) revealed electrical receptacles were noted to be uncovered, energized and non ground-fault- interrupters. The space between the wall and the grab bar were greater that 1 1/2 inches that were mounted in patient bathroom.
-Patient Room (f) revealed a dried brown substance on the side of the toilet. Electrical receptacles were noted to be uncovered, energized and non ground-fault- interrupters.
-Patient Room (g) revealed a dried brown substance at the entrance of the patient shower stall. Electrical receptacles were noted to be energized and non ground-fault- interrupters.
-Patient Room (h) revealed a dried brown substance on the side of the toilet and on the wall behind the toilet. Electrical receptacles were noted to be energized and non ground-fault- interrupters.
-Patient Room (i) revealed a dried brown substance on the side of the toilet. Electrical receptacles were noted to be uncovered, energized and non ground-fault- interrupters.

In a face to face interview on 06/08/10 at 11:00 a.m. with S1- Program Director, S2- Director of Nursing, and S3- Performance Improvement Director verified the findings of dried brown substance on the Patient Room walls, uncovered, energized and non-ground-fault receptacle and grab bars with a distance greater that 1 1/2 inches between the wall and the grab bar.

Observation of the Nursing Station Medication Room on 06/08/10 at 11:15 a.m. revealed the following:
-A 10 milliliter (ml) multidose vial of Humalog Insulin that was opened. There was no date noted on the vial or vial box to indicate when the vial was opened.
- A 10 milliliter (ml) multidose vial of Novolin Insulin that was opened. The open date of the vial reflected a date of 10/15/09 (approximately 7 months and 3 weeks since open date).
-A 10 milliliter (ml) multidose vial of Lantus Insulin that was opened. The open date of the vial reflected a date of 01/17/10 (approximately 4 months and 3 weeks since open date).

Interview with S4- Performance Improvement Director on 06/08/10 at the above time confirmed there was no label or writing on the vial or vial box to indicate when the vial was actually opened. S4 further confirmed that the open date of 10/15/09 and 01/17/10 were accurate for the open date of the vial of Novolin and Lantus Insulin respectively. S4 stated that it was the hospital's policy to date all vials when opened. S4 revealed that after Insulin vials are opened, they were good for 90 days.

Review of the Nursing Policy and Procedure Manual for reflected Policy #12:24A, Subject: Multivial Drug Use read: "Policy: Multiple dose sterile products (e.g. vials) shall be used and disposed of in accordance with this policy." LENGTH OF USE OF MULTIPLE USE STERILE PRODUCTS, Multiple use containers of sterile products may be used up to the manufacturer's date of expiration (unless specified differently) provided they contain a preservative, and show no evidence of contamination. Exceptions: Insulin- 30 days.
Multiple use sterile products not meeting these specifications shall be discarded immediately (in accordance with facility policies).

S4- LPN was observed on 06/08/10 at 11:05 a.m. walking out of the Med Room with a blood glucose monitor in hand. S4-LPN was interviewed at 11:05 a.m.after being observed walking out of the Med Room with a blood glucose monitor in hand. When asked, S4- LPN reported that she had patient accu checks due and was on her way to get the accu checks done. When asked by this surveyor, S4- LPN stated that the blood glucose monitor in her hand was the primary glucometer used by the hospital and the brand name of the glucose monitor was "Quintet".

Review of the hospital's Blood Glucose Monitoring System: Daily Quality Control Record revealed that test strip lot #44781 had been used on 06/06/10 and 06/07/10 to check quality control of the hospital's glucometer but did not match the test strip lot number for the "Quintet" glucometer which S4- LPN had in her hand. S4-LPN stated that the hospital had run out of test strips so the "night nurse" used a glucometer of brand name "optium". S4- LPN verified that the glucometer that she was using had not had a quality control run on it in three days.

S2- Director of Nursing (DON) was interviewed on 06/08/10 at 11:25 a.m. S2- DON confirmed that the hospital currently used the brand "Quintet" Blood Glucose Monitoring Device as the hospital's primary blood glucose monitor. S2- DON confirmed that the hospital's P&P contradicted each other in reference to what brand of blood glucose monitoring device the hospital used. S2- Director of Nursing further confirmed that the hospital did not have a P&P for the use of a glucometer brand "optium" and the hospital staff should only be using the "Quintet" brand glucometer.

In a face to face interview on 06/08/10 at 11:35 a.m. S2- Director of Nursing verified at present, there is no policy in place addressing the blood glucose monitor "Quintet".