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Based on interview, it was determined the facility did not did not have arrangements with local utilities and other water suppliers for the provision of emergency sources of water in the event of normal water supply disruption. The failed practice had the potential to affect the health and safety of patients due to the risk of dehydration in the event of a loss of the normal water supply. The failed practice had the potential to affect all patients admitted to the facility, staff, and visitors. The facility had a census of 10 patients on 07/23/12. The findings follow:

In an interview on 07/24/12 at 1440, the Dietary Manager verified the facility did not have agreements with local providers for emergency water supply.

Based on interview and review of the Infection Control Policy and Procedure Manual, it was determined the facility did not have a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. Failure to have a system in place did not allow the facility to be knowledgeable, track, trend, identify infections and their possible causes and establish resolutions for any identified problems in the facility. Findings follow:

During an interview with the Infection Control nurse at 1535 on 07/25/12 and again at 0835 on 07/26/12, she was asked how she tracked, trended, and identified infections in patients and employees and employed solutions for identified problems. The Infection Control Nurse did not produce any evidence of tracking, trending, and identifying infections, their possible causes and established resolutions for any identified problems by the time of the exit conference.

Based on observation and interview, it was determined the facility did not maintain 2 of 2 (#1 and #2) air handler units (AHU), 3 (#33, #37 and #38) of 9 patient room bathtubs, and pest control in order to provide a safe environment and failed to maintain inspection documentation of patient care biomedical equipment to ensure all devices received regular inspection. The failed practices had the potential to affect all patients in the facility due to unsafe and unsanitary environment. The facility had a census of 10 patients on 07/23/12. The findings follow:

A. On a tour of the facility on 07/25/12 at 0930 with the Maintenance Director, two AHU (#1 and #2) located in Boiler Room #2 were observed with rust and holes on the metal cooling coil housing. The housing was rusted and several holes were observed in the housing. On AHU #2, water from the chilled water supply line was observed flowing inside the coil housing due to several rusted holes in the housing. Water from the holes was also leaking onto the floor and created puddles around the unit. The coil housing on AHU #1 was also rusted and chilled water was leaking onto the floor around the unit. The Maintenance Director confirmed the damaged air handler units at the time of observation.
B. On a tour of the facility on 07/25/12 at 1315 with the Maintenance Director, stained bathtubs were observed in Patient Rooms #33, #37, and #38. Stains stretching the length of the bathtub to the drain. The Maintenance Director verified the stains at the time of observation.
C. On a tour of the facility on 07/25/12 at 1315 with the Maintenance Director, insects were observed in patient care areas as follows:
1) A cricket was observed in the bathroom in Patient Room #37.
2) A dead insect was observed on the bathroom floor in Patient Room #34.
3) In Patient Room # 33, a cricket was observed in the patient room and bathroom.
4) Dead insects were observed in the bathroom in Patient Room #32.
5) In Patient Room # 24, a cricket and dead bugs were observed.
6) In Patient Room #3, two crickets were observed in the shower.
7) The insects were verified by the Maintenance Director at the time of observation.
D. In an interview on 07/25/12 at 0920, the Maintenance Director verified there was no current inspection documentation of patient care biomedical equipment available for review.

Based on Sprinkler System Inspection documentation review, Generator Log review, Fire Drill documentation review and interview, it was determined the facility did not meet Life Safety Code requirements as follows:

A. The facility failed to repair a water flow alarm that failed the most recent inspection. The failed practice had the potential to affect all patients, staff, and visitors because building occupants would not be immediately notified of sprinkler system activation, which had the potential to delay fire plan implementation. See K62.
B. The facility failed to ensure two of two generators were tested under load for at least 30 minutes monthly for 11 of 18 months from January 2011 through June 2012. The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the generator to provide emergency power to the facility in the event of the loss of normal power was not evaluated and could not be assured. See K144
C. The facility failed to test the batteries of exit light fixtures monthly and annually which had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the exit light to illuminate to mark the emergency exit in the event of a loss of normal power was not assured. See K47.
D. The facility failed to ensure the fire alarm system was activated as part of 5 of 12 fire drills from January 2011 through June 2012. The failed practice had the potential to affect all patients staff, and visitors, because the reliability of the fire alarm system to automatically contact the fire department monitoring station and provide audible and visual alarms to building occupants was not evaluated and could not be assured. See K50.

Based on observation, review of Evaluation paperwork of the Intravenous (IV) Hood, and interview, the facility failed to ensure the IV Hood was able to maintain a sterile environment since the previous inspection, in that the certification expired 01/2012. The potential existed for any IV medication prepared in the hood after 01/2012, not to be sterile. Findings follow:

A. During a tour of the pharmacy on 07/25/12 between 0930 and 1030, a Performance Evaluation Label on the IV Hood, placed there from (named) was observed to have an expiration date of 01/12.
B. Review of the "Performance Evaluation for Biological Safety Cabinet, Fume Hood & Clean Air Device" revealed (named) stated next inspection due date was "Jan-12.".
C. Findings were verified through interview with Director of Pharmacy on 07/25/12 at 1020.

Based on observation, review of policy and interview, the facility failed to ensure Intravenous (IV) solutions were locked in three (Station III, Rehabilitation Unit and Central Supply Outbuilding) of six (Station III, Rehabilitation Unit, Central Supply Outbuilding, Respiratory Therapy, Emergency Department and Wound Care) areas toured. The failed practice did not ensure IV solutions were only available to licensed personnel and could not assure the integrity of the IV solutions was maintained. The failed practice had the potential to affect all patients who received IV fluids. Findings follow:

A. During a tour on 07/24/12 between 1000 and 1345, and 07/25/12 between 0840 and 1030, Station III, Rehabilitation Unit and Central Supply Outbuilding had IV solutions stored and the areas were unsecured. Examples follow:
1) Station III Supply Closet
a) 17 bags of Sodium Chloride 0.9% for injection 1000 ml (milliliter);
b) 8 bags of Sodium Chloride 0.9% for injection 250 ml;
c) 18 bags of Sodium Chloride 0.9% for injection 50 ml; and
d) 12 bags of Sodium Chloride 0.9% for injection 100 ml.
2) Rehabilitation Unit Supply Closet
a) 4 bags Sodium Chloride 0.9% for injection 1000 ml;
b) 4 bags Sodium Chloride 0.45% for injection 1000 ml;
c) 5 bags of Sodium Chloride 0.9% for injection 100 ml; and
d) 4 bags of Dextrose 5% for injection 50 ml.
3) Central Supply Outbuilding
a) 5 cases (96 bags/case) of Sodium Chloride 0.9% for injection 50 ml;
b) 6 cases (96 bags/case) of Sodium Chloride 0.9% for injection 100 ml;
c) 4 cases (96 bags/case) of Dextrose 5% for injection 100 ml; and
d) 3 cases (12 bags/case) of Dextrose 5%/ Sodium Chloride 0.2% for injection 1000 ml.
B. Review of policy titled "Storage of Pharmaceuticals" stated "All pharmaceuticals must be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation and security."
C. Findings were verified through interview as follow:
1) Station III findings by Licensed Practical Nurse #1 on 07/25/12 at 0850;
2) Rehabilitation Unit findings by Director of Inpatient Rehabilitation on 07/24/12 at 1345; and
3) Central Supply Outbuilding findings by Director of Materials on 07/25/12 at 1027.

Based on observation, review of policy and interview, the facility failed to ensure outdated medications were not available for patient use in four (Station III, Rehabilitation Unit, Emergency Department and Radiology) of six (Station III, Rehabilitation Unit, Emergency Department, Radiology, Wound Care and Respiratory) patient care areas toured. By not disposing of the expired medication, the facility could not assure the safety and efficacy of the medication past the expiration date. The failed practice had the potential to affect any patient who was to receive these medications. Findings follow:

A. A tour of the facility on 07/24/12 between 1000 and 1345 and 07/25/12 between 0840 and 1030 revealed outdated medications in the following areas:
Emergency Department
1) 2 Sodium Chloride 0.9% 500 ml (milliliter) for injection expired 06/31/12;
2) 1 Labetalol 100 mg (milligram)/20 ml Multi Dose Vial (MDV) opened and dated "8/28/11" ;
3) 1 Naloxone 0.4 mg/ml 10 ml MDV opened and dated "05/17/12";
4) 1 Naloxone 0.4 mg/ml 10 ml MDV opened and dated "12/26"; and
5) 1 Depo-Medrol 80 mg/ml 5 ml MDV opened and dated "02/15.".
Station III
1) 1 Sodium Chloride 0.9% for injection 500 ml expired 06/2012;
2) 1 Lantus 100 Units/ml opened and dated "06/24/12";
3) 4 Morphine 10 mg/ml 1 ml vial for injection expired 06/12; and
4) 6 Sodium Chloride 0.9% 50 ml for injection expired 06/12.
Rehabilitation Unit- 0 Lyrical 25 mg capsules expired 03/12.
Radiology-1 Sodium Chloride 0.9% for irrigation expired 02/11.
B. A review of policy titled "Outdated Drugs" stated "...Medications will be pulled from stock the month prior to their expiration date or monitored closely to assure they are utilized before the expiration date."
C. Findings verified through interview as follows:
1) Emergency Department by Assistant Director of Nursing (DON) on 07/24/12 at 1040;
2) Station III by DON on 07/24/12 at 1110;
3) Rehabilitation Unit by Director of Inpatient Rehabilitation on 07/24/12 at 1320; and
4) Radiology by Director of Radiology on 07/25/12 at 1025.

Based on review of Pharmacy Monthly Medication Area Inspections, review of policy and interview, the facility failed to ensure monthly inspections were conducted two (Radiology Department and Wound Care) of six (Station III, Rehabilitation Unit, Central Supply Outbuilding, Respiratory Therapy, Emergency Department and Wound Care) areas toured. By not inspecting medication areas monthly, the facility could not assure medications were properly stored to maintain their integrity, stability and efficacy. Findings follow:

A. Review of the Pharmacy Monthly Medication Area Inspection logs on 07/23/12 revealed no inspections of Radiology Department occurred from 07/11 through 06/12. Review also revealed no inspection of Wound Care occurred 03/12 or 04/12.
B. Review of policy titled "Inspection of Code Carts/Nursing Stations and Other Departments" stated "Pharmacy Services will provide an inspection monthly of all code carts, nursing stations and other Departments of DRMC (DeQueen Regional Medical Center) where medications are stored for expired pharmaceuticals."
C. Findings were verified through interview with the Director of Pharmacy on 07/25/12 at 1000.

Based on observation, review of policy, and interview, it was determined the facility could not ensure medications from Multiple Dose Vials (MDV's) were not made available for patient use beyond 28 days once opened. The practice was observed in one (Emergency Department (ED) of six (Station III, Rehabilitation Unit, ED, Radiology, Wound Care and Respiratory) areas toured. The practice had the potential to affect any patient receiving medications from a MDV. Findings follow:

A. A tour of the facility was conducted 07/24/12 between 1000 and 1345. Mislabeled MDV's were observed in the ED as follows:
1) Lidocaine 1% 20 ml (milliliters) MDV for injection opened, "08/21/12 (initials)" wrong date, not timed or initialed;
2) Labetalol 100 mg (milligrams) / 20 ml MDV for injection opened, "08/28/11", not initialed or timed;
3) Labetalol 100 mg/20 ml MDV for injection opened, not dated, initialed or timed;
4) Naloxone 0.4 mg/ml 10 ml MDV for injection opened, "05/17/12", not initialed or timed;
5) Naloxone 0.4 mg/ml 10 ml MDV for injection opened, "12/26", incomplete date, not initialed or timed; and
6) Depo Medrol 80 mg/ml 5 ml MDV opened, "02/15", incomplete date, not initialed or timed.
B. A review of policy titled "Expiration Labeling of Multidose Vials" stated "All multidose vials (including sterile water and sodium chloride for injection, USP [United States Pharmacopeia]) are to be labeled when opened with date, time and initials."
C. Findings were verified through interview on 07/24/12 at 1040 with the Director of Nursing.

Based on review of the Swing Bed policy and procedure manual and interview, it was determined the Facility did not have written policies and procedures that prohibited mistreatment, neglect, and abuse of residents as well as misappropriation of resident's property. Failure to have policies and procedures did not allow the facility to have an effective system to prevent abuse, neglect, mistreatment and misuse of resident's personal items. Findings follow:

A. Review of the Swing Bed Policy and Procedure Manual did not reveal a policy and procedure addressing mistreatment, neglect, abuse and misappropriation of resident property.
B. During an interview with the Case Management Registered Nurse at 0915 on 07/26/12 she stated the facility did not have a policy and procedure addressing mistreatment, neglect, abuse and misappropriation of resident property.