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Based on observation, interview and review of Hospital policy, the Hospital failed to follow the policy on accepting telephone orders.

Findings included:

According to the Hospital Policy and Procedure titled "Accepting Telephone Orders", the physician signature is required within 48 hours of the telephone orders (TO's). The Clinical Records of Patient #1, #2 and #3 were reviewed on 10/28/13 and indicated several instances of telephone orders. The Clinical Record of Patient #1 indicated of five (5) TO's taken since 10/18/13, one order was signed three (3) days after the TO was given and four of the TO's were signed without a date or time. The Clinical Record of Patient #2 indicated one (1) TO was taken on 10/8/13 was not signed. The Clinical Record of Patient #3 indicated one (1) TO was taken on 10/26/13 at 5:30 A.M., was not signed.

Based on observation and interview, the Hospital failed follow the policy and procedure for medication administration and failed to secure drugs as required.

Findings included:

Observations in the Medication Rooms on the Pulmonary (3rd floor) and Rehabilitation (2nd floor) Units revealed medication rooms were centrally located on each unit. The Surveyor toured the Pulmonary Unit Medication Room at 9:30 A.M. and the Rehabilitation Unit Medication Room at 10:00 A.M., on 10/28/13. The Surveyor observed the unlocked medication rooms were equipped with automated dispensers. The Surveyor observed the medication refrigerators lacked locking devices within the unlocked medication rooms, thus refrigerated medications were unsecured.

The Surveyor observed locked boxes within the refrigerators. The Surveyor interviewed the Director of Nursing (DoN) during the unit tours between 8:30 A.M. and 10:30 A.M. on 10/28/13. The DoN said the secured boxes within the refrigerator were used for controlled substances that required a double lock. The refrigerated lock box was located in an unlocked refrigerator in an unlocked medication room.

The Surveyor observed a medication pass with RN #1 at 9:00 A.M. on 10/29/2013. The Medication Room on the Pulmonary Unit was not locked as required. RN#1 administered eye medication as ordered. RN #1 said the eye medications were stored at the bedside in a cup. According to the Policy and Procedure titled "Medication Administration", medications are not to be left at the bedside.

The Surveyor observed a medication pass with RN #2 at 2:00 P.M. on 10/29/2013. The Medication Room on the Rehabilitation Unit not locked to prevent unauthorized access as required.

Medication Rooms were observed on 10/30/13 on the Pulmonary Unit at 7:15 A.M. and the Rehabilitation Unit at 8:15 A.M., both medication rooms were not locked as required.

Based on observation and interview, the Hospital failed failed to secure a controlled substance as required.

Findings include:

Observations in the Medication Rooms on the Pulmonary (3rd floor) and Rehabilitation (2nd floor) Units revealed medication rooms were centrally located on each unit. The Surveyor toured the Pulmonary Unit Medication Room at 9:30 A.M. and the Rehabilitation Unit Medication Room at 10:00 A.M., on 10/28/13.

The Surveyor observed locked boxes within the refrigerators. The Surveyor interviewed the Director of Nursing (DoN) during the unit tours between 8:30 A.M. and 10:30 A.M. on 10/28/13. The DoN said the secured boxes within the refrigerator were used for controlled substances that required a double lock. The refrigerated lock box was located in an unlocked refrigerator in an unlocked medication room.

The DoN said the key to the refrigerator lock box was secured within the automated medication dispenser, but the medication rooms were not locked.

Based on observation and interview, the Hospital failed to consistently maintain equipment, refrigerator monitoring, and the environment of care at an acceptable level of safety and quality.

Findings include:

1.) The Surveyor was accompanied by the Director of Nursing (DoN) during the tour of the Pulmonary Unit between 8:30 A.M. and 9:30 A.M.on 10/28/13. The Specimen refrigerator did not have a temperature log. The Director of Nursing said the specimen refrigerator on the Rehabilitation Unit was exclusively used to hold specimens waiting for pick-up by the laboratory vendor. The Surveyor toured the Rehabilitation Unit at 10:00 A.M. on 10/28/13 and there was no specimen refrigerator on this unit.

2.) The Surveyor was accompanied by the DoN to the Medication Room on the Pulmonary Unit at 9:30 A.M. on 10/28/13. The ceiling tile was discolored with brown staining.

4.) The Surveyor was accompanied by the DoN during the tour of the Pulmonary Unit between 8:30 A.M. and 9:30 A.M.on 10/28/13. The Surveyor observed a fan in patient room #336 that was visibly soiled with dark debris and dust.

5.) The Surveyor was accompanied by the DoN during the tour of the Pulmonary Unit's Kitchen between 8:30 A.M. and 9:30 A.M.on 10/28/13. The patient's food refrigerator daily temperature log indicated the temperature had not been recorded since 10/24/13 (four days) and there were no temperatures recorded on 10/1 or 10/2/13. The Refrigerator temperature log indicated the temperature range for the refrigerator was between 36 and 41 degrees Fahrenheit. Of the 22 days in October 2013 that the temperature was monitored, 13 of the 22 days (59%) were recorded as below the posted range.

6.) The Surveyor observed the cafeteria at 12:00 P.M. on 10/28/13. The cafeteria exhaust fan was visibly soiled with dark debris and dust.

6.) The Surveyor observed the bathroom in Room 319 at 9:20 A.M. on 10/30/2013. The floor surrounding the toilet had a gap in the flooring tiles of approximately six (6) inches. The wood sub-flooring was visible. This posed a potential trip/fall condition and the wood sub-flooring was not a surface that could be adequately disinfected.

Based on interviews and review of personnel files, the hospital had designated an Infection Preventionist (IP) to manage the Infection Control and Employee Health programs. However, the hospital failed to ensure that the individual designated was qualified through training, experience, or certification.

The Center for Disease Control (CDC) defined "infection control professional" as "a person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control."

The Surveyor interviewed the Infection Preventionist (IP) at 10:40 A.M. on 10/28/13. The IP said she was employed as Manager of Infection Control/ Employee Health since August 2013. Although the IP was a Registered Nurse with over fifteen (15) years of clinical experience, the IP did not have "specialized training" in infection control to meet the needs of this high risk, complex patient population.

Based on observations and interviews, the Hospital failed to consistently meet the standards of care for Personal Protective Equipment (PPE) use, Sharps Safety, Hand Hygiene, Waste Disposal and High Level Disinfection (HLD).
Findings include:

1.) The Surveyor observed Dialysis Nurse #1 performing a dialysis treatment at Patient #1's bedside. Dialysis Nurse #1 was wearing PPE, a yellow gown. Impermeable PPE must be available and accessible for staff during those procedures where body fluid may be anticipated. The yellow PPE gowns were not impermeable to body fluids. Dialysis Nurse #1 was interviewed at 8:40 A.M. on 10/28/13. Dialysis Nurse #1 said the yellow gowns were the only PPE available to her. Dialysis Nurse #1 said she often was scheduled at this hospital.

The Surveyor interviewed Dialysis Nurse #2 at 3:30 P.M. on 10/29/13. Dialysis Nurse #2 said she had seen only the yellow gowns for use as barrier protection during a dialysis procedure.

2.) The Surveyor observed #18 non-safety needles available for use. The # 18 non-safety needles were observed in the dialysis cart at 8:45 A.M. on 10/28/13. Dialysis Nurse #1 thought they were used to draw up medications.

The Surveyor observed a box of #18 non-safety needles at 9:30 A.M. on 10/28/13. The Director of Nursing said she was not certain why the non-safety product was available.

3.) The Surveyor observed a complex dressing changed on a non-sampled patient (NS #1) at 11:50 A.M. on 10/29/13. The Wound Specialist performed incontinence care on NS #1 prior to changing NS #1's dressing. The Wound Specialist changed gloves between incontinence care and the dressing change, however, the Wound Specialist failed to perform hand hygiene between glove changes. The Wound Specialist irrigated the pressure ulcers and caught the solution in an emesis basin. At the completion of the dressing change, the Wound Specialist disposed of the used irrigation solution in the Hand Hygiene sink in NS #1 room instead of the flush rim sink on the unit.

4.) The Hospital used a rhinolaryngoscope (an instrument inserted through the nose, used to to view a patient's upper respiratory tract) as a diagnostic tool at the Hospital. The rhinolaryngoscope was covered by an endo-sheath (a sterile, one-time use covering for the scope) during the procedure. According to the manufacturer's directions for use, the rhinolaryngoscope could be low level disinfected between patients. However, if the rhinolaryngoscope was found to be moist or debris ladened, the rhinolaryngoscope would need to be high level disinfected or sterilized before being used on another patient. The Manager of the Respiratory Services was interviewed at 10 A.M. on 10/29/13. The Manager of Respiratory Services said the Hospital did not have the ability to high level disinfected or sterilized the rhinolaryngoscope.