HospitalInspections.org

Based on observation, staff interview, and review of the policy titled "Infection Control/Safety Procedures-Medication Preparation and Distribution", it was determined the hospital failed to ensure multi dose vials of medication were dated and initialed when opened. The census was nine.

Findings include:

On 12/01/11 between 11:10 A.M. and 12:20 P.M., observations were made by two surveyors and Staff G and I. Observations in the medication room revealed two multidose vials of Xylocaine and Lidocaine (used for numbing, etc) were observed to have been opened and used. There was a red label on the vials to be used by staff to date and initial when the medication was first opened and used. The label was not filled out. It could not be determined when the medications were first used. Further inspection revealed a tube of of Silvadene Cream (cream used for burns to the skin) was noted to have been opened. This tube was intended for single use only and then to be discarded. This was confirmed with Staff I on 12/01/11 at 12:00 P.M.

Review of the policy titled, "Infection Control/Safety Procedure-Medication Preparation and Distribution" was completed on 12/01/11. The policy directed "all multiple dose containers will have a beyond use date of 28 days after opening or entering, unless otherwise specified by the manufacturer.

Based on medical record review, review of the facility's policy on skin assessment, and staff interview, it was determined the hospital failed to conduct ongoing assessments of care for one of one patient (Patient #4) with impaired skin integrity. The sample size was 20. The patient census was 9.

Findings include:

The medical record for Patient #4 was reviewed on 11/30/11 and 12/01/11. The patient was admitted on 11/23/11, with diagnoses which included cerebral vascular accident (stroke). The admission nursing assessment dated 11/23/11, documented the patient's coccyx area was reddened, not open, no odor, and was a purplish color. Review of the nursing notes between 11/24/11 and 12/01/11, revealed no further documentation of assessment had been completed related to the condition of the patient's coccyx area and skin condition. This was verified with Staff G on 12/01/11 at 2:15 P.M.

On 12/01/11 at 2:00 P.M., Patient #4 gave permission for an observation of the pressure area on the coccyx. The coccyx area of Patient #4 was observed with Staff K at 2:00 P.M. on 12/01/11. The patient's coccyx area was observed to be intact, with light to medium pink color, no odor and no complaints of pain by the patient.

Review of the policy titled, "Skin Assessment"was completed on 12/01/11. Under documentation the policy stated "2. Patients for which the Medical/Surgical/Telemetry Flow Sheet is used, complete Pressure Ulcer Prevention section." The policy further directed "any redness or break in the patient's skin must be documented."

Interview with Staff G on 12/01/11 at 3:00 P.M. confirmed the flow sheets did not have any documentation regarding the assessment of the pressure ulcer on Patient #4's coccyx area.

Based on review of the policies and procedures and observations made on a tour of the Echo Lab and staff interview it was determined that the hospital failed to ensure that all documentation that contained patient information was secure. This involved all patients who had undergone an ultrasound at the hospital. The hospital census was 9.

Findings include:

A tour of the Echo Laboratory was conducted on 11/29/11 at 1:30 PM, with Staff G and H. During this tour it was noted that the door to the Echo lab (lab where ultrasounds are conducted) was open and the room was unattended by staff. It was noted that there was a log book that was lying open on the desk that listed the patients' name and type of ultrasound that had been performed. An interview was conducted with Staff H who stated that this room was to remain locked when not in use.

Review of the policy titled "Policy on Confidentiality" issued 09/01/07 and reviewed on 09/10/10 revealed that Doctors Hospital of Nelsonville has the obligation to safeguard each patient's medical information against unauthorized disclosure.