HospitalInspections.org

Based on review of facility policy, medical record review, and interview, the facility failed to ensure an emergency transfer form was complete for 1 patient (#12) of 23 medical records reviewed.

The findings included:

Review of facility policy "Emergency Department Transfers" dated 6/2016, revealed "...the physician will discuss the risk and benefits of appropriate transfer to the patient, family or legal representative and have the consent signed...obtain consent from the patient or family for transfer and release of medical records...complete a Patient Transfer form..."

Medical record review revealed Patient #12 was admitted the facility on 12/20/17 with a diagnosis of possible preterm labor. Further review revealed the patient was transferred to an acute care facility on 12/20/17.

Medical record review of the emergency transfer form dated 12/20/17 revealed the facility failed to document the time the patient was accepted by the physician at the receiving acute care hospital and failed to document the patient was stable prior to the transfer.

Interview with the Director of Quality and Compliance on 2/7/18 at 3:00 PM, in the Administration Conference Room, confirmed there the facility failed to ensure the emergency transfer form was complete and the facility failed to follow facility policy.

Based on review of facility policy, observation, and interview, the facility failed to ensure the patient refrigerator temperature was monitored and maintained for 1 of 10 patient refrigerators reviewed.

The findings included:

Review of the facility policy "Food Storage" dated 6/2016, revealed "...all freezers will be kept at - [negative] 5 degrees to 5 degrees F [Fahrenheit]..."

Observation with the Director of Nursing (DON) and the Hyperbaric Oxygen (HBO) Technician on 2/6/18 at 2:50 PM, in the Wound Care Department, revealed a patient refrigerator/freezer labeled "Water Only." Further review revealed the freezer had a build up of ice particles and contained a container of unfrozen chocolate ice cream. Continued review revealed no thermometer was located inside the refrigerator/freezer.

Interview with the DON and the HBO Technician on 2/6/18 at 2:55 PM, in the Wound Care Department, confirmed the facility failed to monitor the temperature of the refrigerator/freezer and the facility failed to follow facility policy.

Based on review of facility policy, competency checklists, observation, and interview, the facility failed to maintain a sanitary environment in 5 departments (Kitchen, Emergency Department, Obstetrics Department, Wound Care, and Laboratory) of 8 departments observed.

The findings included:

Review of the facility policy "Food Storage" dated 6/2016, revealed "...all open foods in bulk form will be stored in plastic containers with a sealing lid..."

Review of the Stat Strip Competency Checklist (blood glucose checks), last revised 6/23/14, revealed "...QC [quality control] expires 90 days from date opened...please date material when opening as indicated on vials..."

Observation and interview with the Director of Nursing (DON) and the Interim Dietary Manager (DM) on 2/6/18 at 10:55 AM, of the upright freezer in the kitchen, revealed the following opened, undated frozen foods:
15 chicken strips
15 beef patties
6 chicken patties
5 vegetarian patties
2 hamburger patties
8 vegetarian chicken patties
1 pound of vegetarian burger mix
2 bags of tater tots
Interview with the DON and the Interim DM confirmed the food items were available for patient use. Further interview confirmed the food was open and not dated and the facility failed to follow facility policy.

Observation with the DON and the Interim DM on 2/6/18 at 11:05 AM, of the walk-in freezer in the kitchen, revealed the following opened and undated frozen foods:
one 24 ounce bag of frozen peas
one 24 ounce bag of frozen spinach
one 24 ounce bag of frozen hush puppies
Interview with the DON and the acting DM confirmed the food items were available for patient use. Further interview confirmed the food was opened and not dated and the facility failed to follow facility policy.

Observation with the DON and the Interim DM on 2/6/18 at 11:15 AM, of the dry storage room in the kitchen, revealed one 10 pound box of bacon bits undated and open to air with a foam cup located inside the box. Interview with the DON and the Interim DM confirmed the bacon kits were open to air and were available for patient use. Continued interview confirmed the facility failed to date the opened food and to remove a foam cup from the box. Further interview confirmed the facility failed to follow facility policy.

Observation in the Emergency Department (ED) on 2/6/18 at 11:50 AM, in the ED Nurses Station, revealed the low QC solution was not dated to indicate when the control solution was opened.

Interview with the Nurse Manager of the ED on 2/6/18 at 11:55 AM, in the ED Nurses Station, confirmed the low QC control solutions were not dated and the facility failed to follow facility policy.

Observation and interview with the DON and the Obstetrics (OB)/Registered Nurse (RN) Director on 2/6/18 at 1:35 PM, in the OB clean supply room, revealed 36 blue top vacutainer tubes (used for blood collection) expired 12/13/17. Interview with the DON and the OB/RN Director confirmed the vacutainers were expired and were available for patient use.

Observation and interview with the DON and the OB/RN Director on 2/6/18 at 2:20 PM, in the Nursery, revealed 5 green top pediatric vacutainer tubes expired 12/31/17. Interview with the DON and the OB/RN Director confirmed the vacutainers were expired and were available for patient use.

Observation and interview with the DON and the Hyperbaric Technician (HBO) on 2/6/18 at 2:45 PM, in the Wound Care Department, revealed a bedside table was pushed up against the clean linen cart. Continued observation revealed a white laboratory jacket and a large tin of popcorn was stored on top of the bedside table. Further observation revealed the cover on the clean linen cart did not cover the clean linens and the white laboratory jacket was touching the clean sheets and blankets. Interview with the DON and the HBO Technician confirmed the facility failed to ensure clean linen was maintained in a sanitary manner.

Observation and interview with the Director of Quality and Compliance and the Laboratory Director on 2/6/18 at 4:30 PM, in the Laboratory, revealed 1 yellow top vacutainer tube expired 1/18/18. Interview with the Administrative Director of Quality and Compliance and the Laboratory Director confirmed the vacutainers were expired and were available for patient use.