HospitalInspections.org

Based on medical record review and interview the facility does not ensure that all outpatients are informed of their rights in 6 of 6 patients.

Findings include:

Review of medical records for Patient #'s 24 through 29 revealed no documentation to indicate the patient was provided a copy of the Patient Bill of Rights.

Interview with Staff DD on 06/07/17 at 12:00 PM and Staff EE at 02:15 PM verified that there was no documentation to indicate a copy of the Patient Bill of Rights was provided to Patient #'s 24 through 29.

Interview with Staff HH on 06/07/17 at 02:00 PM at the Occupational Therapy (OT), Physical Therapy (PT), and Speech Therapy (ST) check in counter revealed that a copy of the Patient Bill of Rights is provided to OT, PT and ST outpatients, but only if they ask for a copy.

Interview with Staff C on 06/07/17 at 02:50 PM revealed the facility does not have a policy regarding the provision of patient rights to outpatients.

Based on interview and policy review, the facility failed to ensure safe medication practices in accordance with acceptable standards of pharmacy practice. Specifically, the policy and procedure for approved abbreviations included error-prone abbreviations which should no longer be used when communicating medical information. This has the potential to result in medication error.

Findings include:

Review of Policy and Procedure titled "Approved Abbreviation List 2015" revised 01/2015 revealed the following abbreviations which are considered no longer acceptable according to the American Society of Health-Systems Pharmacists (ASHP) and the Institute for Safe Medication Practices (ISMP). For example the facility policy includes the abbreviations cc, d/c, qhs, sc/sq, TIW, AL, AU, OD, OS, OU. The ISMP correction for these abbreviations are mL, discharge and discontinue, nightly, subcut or subcutaneously, 3 times weekly, left ear, each ear, right eye, left eye and each eye.

Interview with Staff C on 06/09/17 at 01:30 PM verified these findings.

Based on observation and interview, the facility does not ensure the safety and security of sharps containers. This has the potential for staff or patient injury.

Findings include:

Observation on 6/7/17 at 10:30 AM in PACU (post anesthesia recovery unit) revealed (2) sharps containers on counter tops not placed in a safety securing device to prevent tipping and spillage of contents.

Interview with Staff S on 6/7/17 at 10:30 AM verified these findings.

Based on documentation and staff interview, the facility does not ensure that maintenance is performed on the Medivator - DSD Edge, the Scope Buddy or that spill control material is available. Failure to maintain this equipment may result in inadequate disinfection of the endoscopes and failure to provide a spill control may result in patients and staff being exposed to chemical vapors.

Findings include:

Review of the Filter Change Log for the DSD-Edge on 06/06/17 at 11:30 AM revealed that maintenance had not been performed since 03/07/16. Routine maintenance is required monthly, every three months and every six months as noted on the log.

Interview with Staff F on 06/07/17 at 03:00 PM, revealed that maintenance for the DSD-Edge is performed by a contracted company and that documentation would be obtained. On 06/09/17 at 08:55 AM, Staff F provided maintenance documentation for the DSD-Edge which occurred on 09/29/16. Documented maintenance was not provided to verify that routine maintenance was performed between 03/07/16 and 09/29/16 and between 09/29/16 and 06/06/17. Also, the contracted company only performs preventative maintenance once per year and is for electrical safety only.

Interview with Staff C and F on 06/09/17 at 03:00 PM revealed that they did not have knowledge of why the maintenance was not performed per manufacturer's recommendations.

Review of the manufacturer recommendations for the Scope Buddy on 06/06/17 revealed that the Daily Quality Assurance Test be performed at the start of each work day when the device is utilized, a daily flow validation test be performed and a daily decontamination procedure be performed.

Interview with Staff R on 06/06/17 at 11:25 AM, revealed that daily maintenance on the Scope Buddy is not done prior to use.

On 06/09/17 at 08:55, Staff F provided maintenance documentation for the Scope Buddy dated 09/15/16. The report consisted of an electrical inspection only. Review of the Preventive Maintenance Inspection Report on 06/09/17 at 09:05 AM from the 09/15/16 report, revealed that the contracted company only performs preventative maintenance once per year and is for electrical safety only.

Interview with Staff F on 06/09/17 at 03:00 PM revealed they did not have knowledge of why the maintenance was not performed per manufacturer's recommendations.

Based on medical record review and interview a discharge plan assessment was not documented for 2 out of 10 patients prior to discharge from the hospital. This could result in patients with post hospital needs not being identified prior to discharge.

Findings include:

Review of the medical record on 06/06/17 for Patient #6 and 7 revealed no documentation to indicate a discharge planning assessment was conducted prior to their discharge from the hospital.

Interview with Staff I on 06/06/17 at 10:45 AM indicated every patient is to be assessed for discharge needs.

Interview with Staff G on 06/07/17 at 02:55 PM confirmed that it is the standard of care for case workers/social work to do discharge assessment documentation after a patient is admitted to the facility.