HospitalInspections.org

This Condition Level deficiency is the result of a Life Safety Code survey completed on March 17, 2015.

Based on observations, review of facility policy and interview with staff (EMP), it was determined that the facility failed to ensure a safe setting by failing to discard expired medical devices in the crash carts

Findings include:

A review of facility policy "Crash Cart Checks," last revised July 2010 revealed, "Emergency crash cart(s) will be fully equipped and ready for use at all times through regularly scheduled equipment and supply checks, as well as replenishment immediately following use. ... ."

Observation on March 24, 2015, of the crash cart in the hallway across from the nurses' station revealed BD Vacutainer Blood Transfer Devices - two expired January 2015, two expired December 2014, one expired November 2014 and one expired April 2012.

An interview conducted on March 24, 2015, at 10:40 AM, with EMP5 confirmed the above medical devices were expired.

Observation on March 24, 2015, of the crash cart in the staff documentation area revealed two gold top Vacutainer tubes with expiration dates of February.

An interview conducted on March 24, 2015, at 11:15 AM, with EMP5 confirmed the above medical devices were expired. Further interview revealed that there was no process in place for the monitoring expiration dates of the medical devices in the two crash carts.

Based on review of facility policy, medical record (MR), and interviews with staff (EMP), it was determined that the facility failed to ensure the patient's care plan was modified for the use of restraints for one of four restraint records reviewed (MR4).

Findings include:

A review on March 25, 2015, of facility policy "Restraints" last revised March 2013 revealed, "Restraints are: ... 7. Used in accordance with a written modification to the patient's plan of care. ... ."

A review on March 24, 2015, of MR4 revealed nursing documentation that the patient was in bilateral soft wrist restraints from February 25, 2015 through March 23, 2015. Further review revealed the patient's plan of care was not modified for the use of restraints until March 14, 2015.

An interview conducted on March 24, 2015, at 2:00 PM with EMP10 and EMP12 confirmed that on March 3, 2015, the patient was in restraints for three weeks without modification to the plan of care with regard to restraint use.

Based on review of facility policy, medical record (MR), and interviews with staff (EMP), it was determined that the facility failed to ensure the use of restraints was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient for four of four restraint records reviewed (MR4 , MR8, MR9 and MR10).

Findings include:

A review on March 25, 2015, of facility policy "Restraints" last revised March 2013 revealed, "All restraints are used only upon the individual order of a physician or other LIP permitted by the State and hospital. ... ."

A review on March 24, 2015, of MR4 revealed nursing documentation that the patient was in bilateral soft wrist restraints on March 3, 2015. Further review revealed no order for the use of restraints on March 3, 2015.

An interview conducted on March 24, 2015, at 2:00 PM with EMP10 and EMP12 confirmed that on March 3, 2015, the patient was in restraints and there was no physician order for the use of the restraints.

A review on March 24, 2015, of MR8 revealed nursing documentation that the patient was in bilateral soft wrist restraints on March 7, 2015. Further review revealed no order for the use of restraints on March 7, 2015.

An interview conducted on March 24, 2015, at 2:15 PM with EMP10 and EMP12 confirmed that on March 7, 2015, the patient was in restraints and there was no physician order for the use of the restraints.

A review on March 24, 2015, of MR9 revealed nursing documentation that the patient was in mitten restraints on March 20, 2015. Further review revealed an order for tied mitten restraints on March 20, 2015.

An interview conducted on March 24, 2015, at 2:30 PM with EMP10 and EMP12 confirmed that on March 20, 2015, the patient was in a different type of restraint than the type ordered and therefore there was no physician order for the restraints.

A review on March 24, 2015, of MR10 revealed nursing documentation that the patient was in bilateral soft wrist restraints on July 7 - 12, 2014. Further review revealed daily orders written as "R & L" with no type of restraint written.

An interview conducted on March 24, 2015, at 2:45 PM with EMP10 and EMP12 confirmed that on July 7 - 12, 2015, the patient was in bilateral soft wrist restraints without a physician order for the use of the restraints.

Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined that the facility failed to ensure that medications ordered were administered for four of nine medical records reviewed (MR1 through MR4).

Findings include:

A review of facility policy "Medication Administration" effective date March 2013 revealed, "Medications are administered in accordance with written orders of the attending physician. ... ."
A review of MR1 revealed an order written on March 14, 2015, "Imipenem & Cilastat Inj 500 mg Primaxin IV Sod Chl minibag + inj 100 ml NS minibag IV every 8 hours RESTRICTED ANTIBIOTIC". Further review revealed the Medication Administration Record (MAR) did not contain documentation that the 5:00 PM dose was given on March 21, 2015.

An interview conducted on March 25, 2015, at 1:00 PM with EMP10 confirmed the nurse had not signed off the medications as administered.

A review of MR2 revealed an order written on March 14, 2015, "Marinol 5 mg po TID - ac (appetite stimulent)". Further review revealed the MAR with no documentation that the 4:30 PM dose was given on March 15, 2015.

An interview conducted on March 25, 2015, at 1:15 PM with EMP10 confirmed there was no documentation to indicate the medication was administered.

A review of MR3 revealed an order written on March 18, 2015, "Chlorhexidine Glucon 0.12% LIQ 1 PERIDEX UD TOP 3 times a day (oral rinse)". Further review revealed the MAR did not contain documentation that the 9:00 PM dose was given on March 24, 2015. Also an order was written on March 24, 2015, for "Coumadin 10 mg po tonight 3/24/15 at 2000 (blood thinner)." Further review revealed the MAR did not contain documentation that the 8:00 PM dose was given on March 24, 2015.

An interview conducted on March 25, 2015, at 1:30 PM with EMP10 confirmed there was no documentation to indicate the medication was administered.

A review of MR4 revealed an order written on February 22, 2015, "POT CHL 10% UD Peg Every Evening (Potassium supplement)". Further review revealed the MAR with no documentation that the 9:00 PM dose was given on February 26, 2015.

An interview conducted on March 25, 2015, at 1:45 PM with EMP10 confirmed there was no documentation to indicate that the medication was given. Further interview confirmed the staff did not follow the medication administration policy.

Based a review of facility policy, documentation and interview with staff (EMP), it was determined that the facility failed to follow their policy regarding physician completion of medical records.

Findings include:

A review of facility policy 050-31-022 "Medical Records - Completion & Delinquency," Effective Date: January 2009 revealed: "Delinquent Medical records: Definition: Any Medical Record which is incomplete after 30 days, including any missing physician dictation and signatures ... . "Any physician with records incomplete more than 30 days after discharge or delinquent, shall be placed on suspension status until the records are complete."

A review on March 24, 2015, of HIM documentation "Deficiencies by MR# dated Tuesday March 24, 2015, revealed that the physician, EMP16, had missing signatures on progress notes, physician orders and consult report that were 61 days delinquent.

A review on March 24, 2015, of HIM documentation "Deficiencies by MR# dated Tuesday March 24, 2015 revealed that the physician EMP17, had missing signatures on progress notes, physician orders and consult report that were from 47 to 80 days delinquent.

A review on March 24, 2015, of HIM documentation "Deficiencies by MR# dated Tuesday March 24, 2015 revealed that the physician, EMP18, had missing signatures on progress notes, and consult report that were 56 days delinquent.

A review on March 24, 2015, of HIM documentation "Deficiencies by MR# dated Tuesday March 24, 2015, revealed that the physician, EMP19, had missing signatures on a consult report that was 47 days delinquent.

A review on March 24, 2015, of HIM documentation "Deficiencies by MR# dated Tuesday March 24, 2015, revealed that the physician, EMP20, had missing signatures on physician orders and progress notes that were 49 days delinquent.

An interview conducted on March 24, 2015, at 11:00 AM with EMP13 confirmed that EMP16, EMP17, EMP18, EMP19 and EMP20 had missing signatures on medical records which ranged from 47 to 80 days delinquent. Further interview with EMP13 confirmed that the employee had faxed records for signature to the physicians' offices and made repeated phone calls in an attempt to obtain signatures. EMP13 also confirmed that the facility had failed to follow their policy for suspending physicians with delinquent records of more than 30 days.

Based on review of facility policy, observation and interview with staff (EMP), it was determined that the Director of Food Service failed to ensure safety practices for food handling were maintained in the kitchen.

Findings include:

A review on March 23, 2015, of facility policy #B007 "Production, Purchasing Storage," Date Issued: 7/1/13 revealed "To determine the number of days beyond the "sell-by" date that an item is safe for consumption or use in recipes, see charts below. The storage times listed are valid only if food has been properly handled and refrigerated. ... . The "use-by" date is the last date that a food can be consumed; . ... . do not place on patient trays past the date on the product. Do not use products in recipes past the"use-by" date. . ... . Once opened or prepared, products have a limited shelf-life. Refer to the chart at the end of this section to determine the shelf-life of these products."

Observation on March 23, 2015, of the Dry Storage area revealed two bins of potatoes, a 25-lb. container of dry rice and an opened 42-ounce container of oatmeal which did not contain an expiration date.

Observation on March 23, 2015, of the Walk-In refrigerator revealed a five pound bag of shredded carrots that had expired on 3/16/15, a one gallon container of fat-free milk, and lettuce, peppers, oranges, cucumbers and tomatoes in open bins that did not contain expiration dates.

Observation on March 23, 2015, of the Walk-In freezer revealed one plastic wrapped mozzarella cheese, an opened bin of broccoli, a 20 pound plastic bag of mixed vegetables and a 20 pound plastic bag of green beans that did not contain expiration dates.

Observation on March 23, 2015, of the Prep area revealed an opened 5 lb. jar of honey, an 11 oz. container of parsley flakes and a 24 oz. container of garlic that did not contain expiration dates. Also observed were six plastic bags of rolls marked "Sell by Mar. 6."

An interview conducted on March 23, 2015, at 10:00 AM with EMP21 confirmed that the facility had failed to follow their policy for maintaining the storage times for the food items located in the Dry Storage area, Walk-In refrigerator, Walk-In freezer and Prep areas of the kitchen.