HospitalInspections.org

Based on supply observation and staff interview, the hospital failed to ensure that outdated supplies were not available for patient use. This failed practice has the potential to affect all patients of the hospital. Hospital census on entrance day was 31.

Findings are:

A. Observation and tour (10/19/2023 at 1030 AM) of the bronchoscopy cart/storage room revealed the following outdated supplies:
3 - Fiberoptic Bronchoscope Swivel Adapter expired 12/2022
3 - 30 milliliter (ml) Syringe slip tip expired 8/31/2023
1 - Nasopharyngeal Airway 6 millimeter (mm) expired 8/27/2019
1 - Nasopharyngeal Airway 7mm expired 6/6/2021
4 - Laryngo-Tracheal Mucosal Atomization Device expired 9/22/2019
1 - Oral Care Prep Pack expired 3/1/2022
5 - Olympus Single Use Biopsy Valve expired 10/31/2022
2 - Radial Jaw 4 2.0mm expired 11/24/2022
1 - Radial Edge 2mm expired 2/2013
1 - Disposable Cytology Brush 2.0mm expired 11/2016

B. Interview with the Respiratory Therapist Supervisor (10/19/2023 at 11:00 AM) confirmed the above outdates that were located in the bronchoscopy cart and in the storage area that is used for restocking the bronchoscopy cart. The Respiratory Therapist Supervisor stated that staff is expected to look for outdates when restocking cart after each procedure.

Based on observations, staff interviews and record review, the facility failed to address and develop needed strategies for emergency events identified by facilty risk assessments for security/safety strategies to provide ongoing facility protection for surveillance system monitoring, training of staff on campus security team and related policy development and staff education. The Lincoln campus serves two hospital units, a long term care facility, an outpatient program. The facility cares for vulnerable populations of rehabilitation care for spinal cord injury, traumatic brain injury, medically complex patients, and dementia patients. Hospital census on entrance day was 31.

Findings are:

A. Review of Governing Board meeting minutes (Dated 12/7/2022) revealed a security risk assessment was completed by an "outside contracted company for strategic security guidance." The results and areas of concern were discussed and the governing board directed the safety staff to review the report/recommendations and develop an action plan to bring the discussion back to the governing board once the plan is finalized.

B. Review of the security risk assessment by the contracted company (Reported on 11/7/22) revealed the vulnerabilities of the campus and identified the following concerned areas: Public access concerns with the open campus, weak access control for badges, lack of a sign in procedure for visitors, limited security presence and needed staff situational awareness training.

-Recommendations by the contracted company included:
1. Security policy manual formalized and staff training provided;
2. Hire a professional security manager;
3. System developed for reporting troubled individuals and troubling situations;
4. Development of workplace violence prevention;
5. Analysis of Response by lone worker to medical emergency and physical attacks;
6. Assign Security Department Leader to identify negative security events and trends to mitigate incidents;
7. Create long term Return on Investment opportunities to strengthen data gathering through enhanced security services;
8. Migrate from a contract to a proprietary security program;
9. Enhanced employee personal security training.

C. Review of the Environmental Safety Committee Meeting (Dated August 28, 2023) stated "updates on needed and identified security improvements - still stuck with current model of facility maintenance staff also serving as facility security - unfortunately cannot be improved due to lack of funding, looking to improve building security, even though cannot improve by providing dedicated security personnel."

D. Review of facility current model at time of survey (October 23, 202) for building safety stated "Facility Maintenance staff have dual role of providing both facility maintenance as well as being the primary provider of Security for the hospitals, but staff have no formal training in security aspects."

E. Interview with Facility Emergency Coordinator (10/18/23 at 3:20 PM) stated that "security team development and funding remain the greatest need for facility ongoing safety development".

F. Interview with Physical Plant Manager (10/17/23 at 11:50 AM) stated "Goal is to hire a security coordinator once funding approved and have one security person per shift to monitor and be a roving officer, but until Security is funded we calculate outliers of safety events, near misses and try to protect staff and patients".