HospitalInspections.org

Based on document review and interview the facility failed to :


A. provide evidence of a Quality Program involving all department of the hospital and attended by designated department staff.

On 6/12/2014 at 9:00 AM in the conference room the following documentation was reviewed:
1. The Governing Body By-Laws most recently dated 2012 on page #4 Governing Body meeting; At all quarterly meetings, the Governing Body shall review and report on the following topics: Quality improvement.
2. Quality/Safety meeting minutes dated January 14, 2014 revealed 3 of 7 managers failed to sign the attendance record. Staff #22,#2,#4 (The Quality Medical Director, the Chief Operations Officer and the Director of Nursing) failed to sign the attendance record. There was no other evidence these staff were in attendance.
3. Quality/Safety meeting minutes dated May 13 2014, 4 of 7 signatures were absent. Those who did not sign in for attendance were staff #11, #22, #2 and #12. Staff #12 was responsible to present the Respiratory therapy, Laboratory and Radiology information. Staff #2 was responsible to present the Business office, Case Management, Environmental services, Human Resources, Materials Management, Medical Records, Nutritional/Dietary, Staff Development, and Therapy services. Staff #12 was the Safety Officer, responsible for Plant operation and Safety. (The Quality report did not include a plan for patient safety). Staff #22 was the Medical Quality Director.

On 6/12/2014 at 4:30 PM an interview with the Quality Director revealed the following: The hospital departments submitted their reports either to her, or the managers who were designated to attend the Quality meetings. The Quality Director was asked how discussion occurred when only 3 members of the Quality team showed up? She confirmed it was difficult to discuss department quality issues. The Quality Director was asked if the Department managers ever attend the Quality meeting to present their own material. She replied"yes, but it's been many months ago".

There was no documentation the department managers, who submitted data to quality manager, were in attendance during the meeting to present there findings. There was no documentation the department managers information was discussed. There was no documentation problems identified went up to the Medical Staff/Governing Body and no documentation that recommendations were communicated to the department managers after the meetings.


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B. ensure backlogged medical records were audited and process timely. Failed to ensure the medical records and respiratory department presented deficient quality issues from their departments to quality assurance for monitoring.
Review of medical record audit sheets revealed the following:
June 2013- beginning of the month there was 280 delinquent charts in the department.
August 2013 - 342 delinquent charts in the department.
October 2013 - 369 delinquent charts in the department.
January 2014- 374 delinquent charts in the department.
February 2014 - 429 delinquent charts in the department.
March 2014 - 439 delinquent charts in the department.
May 2014 - 439 delinquent charts in the department.
During an observation on 06/11/2014 at 1:30 p.m., a 6 x 4 foot table was covered with stacks of charts in the medical records room. Some of the stacks were 3-4 feet in height.
During an interview on 06/11/2014 at 1:30 p.m., Staff #14 reported medical records auditing was backlogged from February 2014. Staff #14 confirmed the stacks of charts on the table were the charts that were backlogged. Staff #14 reported one staff was out sick and she fired another staff in January 2014 for not auditing charts correctly. They have a problem with getting the physicians in to sign their records. Staff #14 reported the last time she was a part of the quality program was 6 months to 1 year ago.
During an interview on 06/11/2014 at 10:30 a.m., Staff #11 reported she had two indicators for the respiratory department that they tracked (pneumonia and length of stay) and are the only indicators she reports to Staff #5 (quality). Staff #11 confirmed other problems were found in her department even resulting in changing the way they document. Staff #11 reported the other problems related to documentation were not being monitored nor was this reported to the quality manager.(Staff #5).

Based on observation, interview and record review the facility failed to ensure medical records service was organized and staffed to correct deficient areas in clinical documentation. The facility failed to ensure nursing assessments, nutritional assessments, treatment consents, medication orders, physician treatment orders, standing protocol were complete, accurate, signed, dated and timed. This deficient practice was found in 4 of 4 medical records (Patient #s' 2, 5, 6, and 8).
This deficient practice had the likelihood to cause harm to all patients.
Findings include:

Review of medical record audit sheets revealed the following:
June 2013- beginning of the month there was 280 delinquent charts in the department.
August 2013 - 342 delinquent charts in the department.
October 2013 - 369 delinquent charts in the department.
January 2014- 374 delinquent charts in the department.
February 2014 - 429 delinquent charts in the department.
March 2014 - 439 delinquent charts in the department.
May 2014 - 439 delinquent charts in the department.
During an observation on 06/11/2014 at 1:30 p.m., a 6 x 4 foot table was covered with stacks of charts in the medical records room. Some of the stacks were 3-4 feet in height.
During an interview on 06/11/2014 at 1:30 p.m., Staff #14 reported medical records auditing was backlogged from February 2014. Staff #14 confirmed the stacks of charts on the table were the charts that were backlogged. Staff #14 reported one staff was out sick and she fired another staff in January 2014 for not auditing charts correctly. They have a problem with getting the physicians in to sign their records. Staff #14 reported the last time she was a part of the quality program was 6 months to 1 year ago.


Review of patient records revealed the following:
Review of a nursing "Interdisciplinary admission assessment" sheet revealed Patient #2 was an 82 year old female admitted on 06/06/2014 at 5:00 p.m. with a diagnosis of respiratory failure.
Nurses notes dated 06/06/2014 revealed Patient #2 was on a ventilator, tube feeding, telemetry, and was on the anesthetic agent Diprivan drip.
Review of the consent to treatment form and acknowledgement of receipt of rights dated 06/06/2014 revealed verbal consent from a family member was taken by one facility staff member. According to instructions on the consent if anyone other than the patient signed the form, the facility was supposed to indicate the relationship to the patient. Give the reason the patient was unable to sign the form and provide for two witnesses to sign the form. All of that information was left blank.
Review of a physician history and physical on Patient #2 revealed it was originally done on 05/16/2014 was updated by the physician on 06/09/2014 (3 days after admission).
Review of physician progress notes dated 06/06/2014 and 06/07/2014 revealed they were not signed off by the physician.
Review of physician orders on Patient #2 revealed the following:
Undated "Admit Physician Orders" revealed orders for a tube feeding, lab test, chest x-ray, and arterial blood gases. There were also orders for a finger stick /blood sugar. There was no indication as to how often the finger sticks were to be performed. The physician orders were telephone orders written by nursing and were not dated or signed by the physician.
Review of telephone physician orders dated 06/06/2014 at 8:05 p.m. (3 hours after admission) revealed to discontinue the Accuchecks (fingersticks) because the patient was not a diabetic.

Review of a set of medication orders for Patient #2 included blood pressure medications, seizure medications, respiratory medications, anti-coagulant medications, intravenous fluids, antibiotics and drips. The orders were continued from another facility and signed as telephone orders by nursing on 06/06/2014. The orders were not signed off by the physician. Further review of the chart revealed the following:
*One of the medication orders was for the antibiotic Vancomycin 750 milligrams, intravenous every 24 hours at 9:00 a.m. Review of the chart revealed no Vancomycin protocol order sheet completed on Patient #2 which would direct nursing on lab and how to administer the medication. According to the protocol, once a trough sample has been drawn, hold further dosing until result is known and within the desired range (<15 mcg/ml).
Review of the lab report which was generated on 06/09/2014 at 9:53 a.m. revealed Patient #2 had a Vancomycin Trough of 10.9 (reference range of 5.0-10.0).
During an observation of the medication room on 06/09/2014 after 3:10 p.m., a bag of Vancomycin 750 milligrams belonging to Patient #2 was found in the room. The bag was dated to be administered on 06/09/2014 at 12:26 p.m...
Review of the Medication administration record dated 06/09/2014 revealed the Vancomycin was supposed to be administered at 9:00 a.m., but was not given until 4:10 p.m...
During an interview on 06/10/2014 at 2:30 p.m., Staff #16 confirmed the state of the orders and that Patient #2 should have a completed Vancomycin protocol on the chart.
During an interview on 06/10/2014 at 3:00 p.m., Staff #17 confirmed the Vancomycin was not administered at 9:00 a.m. and that she gave it at 4:00 p.m. Staff #17 reported the reasons for administering the medication late was because of late the lab results and pharmacy had to bring the medication up to the floor. Staff #17 reported the physician was not notified of the medication being administered late.

*Patient #2 had a physician order set for the anesthetic agent Propofol (Diprivan) which revealed they were not signed off, timed or dated by the nurse who completed the order nor the doctor. The order set revealed the following instructions:
Awakening is performed a minimum of daily to assess neurologic status as well as to determine the minimum dose of propofol required for sedation.
Decrease propofol infusion by ordered dose every 10 minutes until patient reaches a Ramsey Score of 2.
For awakening, decrease rate by____mcg/kg/min every 10 minutes until patient reaches a Ramsey score of 2 (level of sedation which indicates cooperative, oriented and tranquil).
The amount to decrease the drip was left blank on the order set.
* Review of progress notes dated 06/06/2014 and 06/07/2014 revealed Patient #2 had deep vein thrombosis (DVT).
Review of the "DVT/PE Prophylaxis Orders" revealed a place to assess risk factors, interventions and place for the physician to sign, date and time. The form was left completely blank.
Review of the medication orders which were not signed by the physician revealed Patient #2 was on the anti-coagulant Lovenox every 12 hours.
Review of a physician order dated 06/09/2014 at 9:06 a.m., revealed an order to hold the Lovenox and obtain 2 more stools for occult blood.
Lab value dated 06/10/2014 revealed Patient #2s' stool for occult blood was positive.
During an interview on 06/10/2014 at 2:30 p.m., Staff #16 confirmed Patient #2 was at risk for DVT and the assessment should have been completed by nursing.

*Review of the oral nutritional supplement protocol for Patient #2 revealed a hand written entry that the patient was on a tube feeding (with the admission information). The protocol was to determine if the patient met criteria of high-risk for malnutrition. The protocol was not dated and was not completed by nursing or the physician. There was no indication as to who added the entry on the form.
The next "Enteral Nutrition Order Form" which included an assessment of nutritional needs and the order for the formula was completed by the dietitian on 06/09/2014 (3 days after admission). This form was signed as a telephone order which was written by the dietitian on 06/09/2014. According to the nurses notes Patient #2 had been receiving the tube feeding formula since admission on 06/06/2014.

Review of an admission sheet on Patient #6 revealed he was an 82 year old male admitted on 05/18/2014 with a principal diagnosis of obstructive bronchitis disease.
Review of the chart revealed no signed physician history and physical for Patient #6.
Review of consents for treatment and the acknowledgment of rights form revealed verbal consent was received from a family member two days prior to admission on 05/16/2014 by a facility staff member. According to instructions on the consent if anyone other than the patient signed the form, the facility was supposed to indicate the relationship to the patient. Give the reason the patient was unable to sign the form and provide for two witnesses to sign the form. All of that information was left blank.
Review of consents dated 06/02/2014 for blood transfusions and percutaneous endoscopic gastrostomy insertion revealed no physician signature or date. The attached "disclosure and consent medical and surgical procedure" form was left completely blank.
Review of physician progress notes from 05/24/2014 -06/08/2014 revealed 19 notes from 5 different physicians which were not signed or dated
Review of physician orders on Patient #6 revealed the following:
Undated DVT/PE Prophylaxis orders were left completely blank.
On 05/18/2014, a Potassium Protocol/Physician order, a Decision Grid: Hypoglycemia Treatment Options, insulin sliding scale protocol, the admission physician orders and admit/discharge medication reconciliation and order sheet were all written as a verbal orders and had not been signed by the physician as of 06/11/2014.
On 05/27/2014, a wound protocol was written as a verbal order and had not been signed by the physician as of 06/11/2014.
On 05/30/2014, a consultation for a physician for a PEG placement a wound protocol was written as a verbal order and had not been signed by the physician as of 06/11/2014.
On 05/29/2014, a telephone order was written and had not been signed off by the physician.
On 06/02/2014, a telephone order was written to type and cross and transfuse 2 units of Packed Red Blood cells. It had not been signed by the physician.
A "Pre-op/Procedure orders/checklist" for Patient #6 was not dated or timed.

Review of an interdisciplinary admission assessment dated 05/21/2014 revealed Patient #5 was an 85 year old female admitted on 05/21/2014 with diagnoses of urinary tract infection and altered mental status.
Review of the consent to treatment form and acknowledgement of receipt of rights dated 05/20/2014 (the day before admission) revealed information left off the form. According to instructions on the consent if anyone other than the patient signed the form, the facility was supposed to indicate the relationship to the patient. Give the reason the patient was unable to sign the form. All of that information was left blank.
Review of the PICC (peripherally inserted central catheter) insertion orders revealed they were left completely blank and the physician had not signed, dated or timed them.
On 05/22/2014 a physician order revealed speech pathology wrote Aspiration precautions for Patient #5. The order was written as a telephone order and had not been signed by the physician as of 06/11/2014.
On 05/22/2014 wound care orders written as a verbal order and had not been signed by the physician as of 06/11/2014.
On 05/22/2014 computed tomography order was written as a telephone order and had not been signed by the physician as of 06/11/2014.
On 05/22/2014 a DVT/PE Prophylaxis order was pre- signed off by the physician, but there was no selections made on the preset orders to indicate what treatment he wanted.
Review of intake and output sheets from 05/21/2014-06/07/2014 on Patient #5 revealed 8 out of 18 days nursing staff failed to provide complete documentation.

Review of admit physician orders revealed Patient #8 was an 81 year old female admitted on 05/16/2014 with diagnoses of wound care, intravenous antibiotics and Staph.
Review of the consent to treatment form and acknowledgement of receipt of rights dated 05/16/2014 revealed the patient did not sign the form. According to instructions on the consent if anyone other than the patient signed the form, the facility was supposed to indicate the relationship to the patient. Give the reason the patient was unable to sign the form. All of that information was left blank.
Review of the chart revealed no signed physician's history and physical for Patient #8.
Review of orders revealed the following:
"Insulin Sliding Scale Protocol" and "Admit/Medication Reconciliation and Order Sheet" dated 05/16/2014 ;
Wound care orders dated 05/17/2014;
Diet, lab, and EGD orders dated 05/20/2014;
Medication orders dated 05/22/2014;
All of theses were written as verbal orders which had not been signed by the physician as or 06/11/2014.
Review of DVT/PE Prophylaxis Orders revealed they were left blank and were not completed by the physician or nursing.
Review of the "Debridement Procedure Record" dated 06/04/2014 revealed the time out information for correct patient, order verified, signed consent and site verified were left blank. An excisional debridement was performed on three ulcers. There was no documentation of pre-medication before the procedure, description of the tissue removed, blood loss, and pain. A nurse signed and dated the sheet, but no physician signed the sheet.
Review of a physician consultation report dated 05/18/2014 and 06/06/2014 revealed they were not signed off by the physician.
Review of the "Medical Staff Rules and Regulations", dated 09/01/2011 revealed the following:
A general consent form, signed by or on behalf of the every patient admitted to the hospital, must be obtained at the time of admission.
A complete admission and/or physical examination shall be recorded by the attending physician or his designee within twenty-four (24 hours) (amended to 48 hours April 12, 2013 MEC), of admission to the hospital. This report shall include all pertinent findings resulting from an assessment of all systems of the body.
All orders for treatment and medication shall be in writing and authorized only by a licensed physician, dentist, psychologist, or podiatrist appropriately credentialed pursuant to the medical staff bylaws.
The practitioner's orders must be written, clearly, legibly, and complete, Orders which are illegible or improperly written must be clarified with the ordering physician. Orders to hold medication or treatment will be interpreted as discontinued and require that the order be rewritten, unless hold period is specified.
All clinical entries in the patient's medical record shall be accurately dated and authenticated by person authorized to assess, write orders and treat patients. The medical record must be clear , concise, complete and accurate.
Medical records must be completed within the timeframe's specified in the medical staff bylaws.

Review of a policy named "Physician orders" dated 09/01/2011 revealed "Verbal order may be accepted by an RN, RT, PT, OT, ST. Such orders will be written by the person accepting the order noting date and time. Verbal orders will be co-signed by the physician within 74 hours.

Based on interview, observation and documentation review the facility failed to exhibit a dietary department organized to insure the safety of food served to the patients, failed to insure the sanitation of food storage and failed to insure a method for the Registered Dietician to supervise and monitor the nutritional needs of patients in the hospital.

On 6/10/2014 during a the initial tour of the building noon meal trays were observed still being passed to patient's at 2:30 in the afternoon. This was confirmed by staff #4.

On 6/11/2014 at 9:30 AM in the office of the Registered Dietician interview with the RD revealed the following. The facility did not maintain a working kitchen and meals were provided for patient's, via contract. The RD indicated the noon food trays would arrive at approximately 11:45 to 12:15. The trays would be served by staff when they were brought to the patient care unit.

Continued interview of the RD revealed the most common complaint from patients was small portions. When asked if she had any way of checking the portion size for accuracy the RD replied "No". When asked if she had ever gone to the contracted provider to problem solve, she said "yes, on the temperature of the food served ". When asked if the problem had been solved yet she replied "No". The RD was questioned as to her participation in the Quality program meeting. The RD indicated she gave her food temperature tests tray documentation to the Quality Director, but otherwise she did to participate in the meetings. The RD was asked if, submitting her test tray data to the Quality Director for inclusion in the Quality meeting, had resolved the problem she replied "no".

On 6/11/2014 at 10:15 AM, following the above the interview, request was made for the RD, to show the area where nutritional supplements and snacks for patient were kept. The following tour was provided. The RD took the surveyor to an area of the old kitchen where the walk in refrigerator and cooler was located. A sheet of heavy black plastic reaching from the ceiling to the floor was observed separating the cooler and refrigerator from the area that previously was the hospital's kitchen. Staff #10 indicated the old kitchen required repair in the concrete floor and black plastic had been draped to control the concrete dust. Once the repair was complete the black plastic had remained and a look behind the drape revealed the old kitchen covered in white dust. The stainless steel work surfaces were moved about and shoved to one end of the room. The floors and flat surfaces had not been cleaned after the completion of repairs and the concrete patch remained exposed. Soda bottles and trash littered the kitchen area.

Upon returning to the walk-in cooler side of the black plastic the following was observed: a free standing popcorn machine was observed immediately adjacent to the walk in cooler. The popcorn machine was observed coated with a greasy substance and a gallon container of partially filled popcorn oil was stored in the popcorn machine. The floor was observed to be very dirty and the paint was peeling off the hi traffic part of the floor. Neither the popcorn machine nor the floor had been properly sanitized.

The door of the walk in cooler, once opened revealed the mid-section of the door void of its metal coating exposing a white surface beneath. The inside surface of the cooler door could not be sanitized. The floor was covered with visible dirt and trash. The left side of the walk-in cooler was being used to store stainless steel racks, trays and 1 plastic bottle of mustard was observed on a tray. The right side of the walk-in cooler contained following ready to serve snacks stored in shipping boxes: 7 cases of orange Jello, 6 cases of pudding, 4 cases of apple sauce, 1 case of grape jelly, and 2 cases of cranberry juice.

· " External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust (AAMI ST46-Section 5.2 Receiving Items).

The walk-in freezer was observed with condensation running down the door and pooling on the floor in front of the freezer, an electrical light switch was observed in the condensation area and was not tested. Upon opening the door the freezer, two (2) small boxes of single serving ice cream was observed in the freezer. There was a very strong musty /mildew odor in the freezer. During an interview, staff #18 insisted the freezer was not in use despite the freezer holding ice cream.

Continuing past the walk in freezer was a room containing paper plates, bowls, cups, napkins and plastic eating utensils. Staff #10 confirmed these products were for patient use. 20 shipping boxes were counted in this storage area. The floor was visibly dirty and red paint was peeled in the hi-traffic area. Fifteen (15) shipping boxes were observed stored with the paper products.

Past this room was a smaller room where the following was observed: A stainless steel shelf with 5 cases of soup in individual serving cans, still in shipping boxes, graham crackers, saltine crackers, 1 case of soda and 3, 1 pound boxes of salt. Below this rack was the following: a fifty (50) pound bag of popcorn. The top of the bag was open to the air. Beside the popcorn was 2 cases of liquid detergent and 1 case of a liquid contained in a silver foil bag with no identification found at all. Staff #10 confirmed there was no identification on the silver bag. She stated the popcorn had not been used since the hospital had closed its' kitchen. The RD was asked who was responsible for the supplements? She replied "The housekeeping supervisor". When asked why she said "She was told by staff #2, they were not her responsibility and that housekeeping would take care of it". The RD was asked if this seemed odd to her and she said "yes".

On 6/11/2014 at 11:55 AM, the process for delivering the contracted patient meal trays was observed. The trays arrived in a minivan. They were observed individually contained in an insulated unit consisting of a fitted bottom with a fitted top. These trays (38) arrived via cart to the second floor for delivery to the patients. Upon arrival to the patient unit the staff was observed delivering patient trays.

With the assistance of the RD, (the facilities food thermometer was used) a test tray was checked for food temperatures. The roast beef was recorded at 105 degrees. Macaroni and cheese was recorded as 110 degrees, green beans were recorded at 128 degrees, tomato soup was recorded at 118, a fruit cup was recorded at 60 degrees and the iced tea was recorded at 42 degrees. Review of recommended food temperature taken from the Texas Food Establishment Rules revealed the following. 229.164(o) "Potentially hazardous food hot and cold holding shall be maintained at, 135 degrees Fahrenheit or above for hot and cold foods shall be held at 41 degrees Fahrenheit or less." No food temperature met the hot or cold requirements for safe service.

Based on observation, record review, and interview, the facility failed to:

A. place patients in proper transmission-based isolation. Three of three patients (#4, 31, and 32) had been placed in droplet isolation when they should have been in contact isolation to properly contain the organism involved. The facility failed to follow its Contact Precautions Policy.


Review of the facility policy titled, "Contact Precautions Policy," revealed patients with Acinetobacter and methicillin-resistant Staphylococcus aureus (MRSA) infections should be placed in contact precautions to prevent the spread of these infections to healthcare workers and other patients.

During a tour of the facility on 6/10/14 at 10:00am the following was observed and noted from the medical records:
-Patients #4, 31, and 32 were found to be in droplet precautions;
-Patient #4 was in precautions due to an Acinetobacter infection (requiring contact precautions per policy);
-Patient #31 was in precautions due to a MRSA infection (requiring contact precautions per policy);
-Patient #32 was in precautions due to a MRSA infection (requiring contact precautions per policy).

During an interview on 6/10/14 at 10:20am, staff #5 confirmed the patients had been placed in the incorrect transmission-based precaution type to prevent the spread of these infections to healthcare workers and other patients.





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B. provide a sanitary environment in Respiratory services, Laboratory services, Housekeeping/Laundry services, Dietary services, Pharmacy services and nursing services.

On 6/10/2014 at 2:50 PM inspection of the room for Respiratory supplies revealed the following: found in a sink, One (1) Foley catheter kit opened with the Foley catheter missing, an opened debridement kit with the scissors missing, an opened debridement kit with the tweezers missing, a bi-pap package which was opened with the bi-pap collar still in the package. It was undetermined if the collar had been used for a patient. Ten oxygen flow meters in an opened box on the bottom shelf with no PM sticker indicating sanitary and in good working order. A suction machine was observed on the counter without a PM sticker indicating sanitation and good working order

On 6/11/2014 at 8:30 AM in the Laboratory department the following was observed: Two (2) portable blood draw kits with single use tourniquets pilled in a corner of the kit. Staff #21 confirmed the tourniquets might have been used on more than one patient. Also there appeared to be a small amount of dark brown sticky residue which looked like cola had been spilt in the blood draw tray. This was also confirmed by staff #21.

On 6/11/2014 at 9:00 AM in the Housekeeping/Laundry storage room the following was observed: Two (2) large three (3) shelf linen carts were observed full of linen and covered with poorly fitting vinyl covers, stored next to floor buffers, trash bins, and other housekeeping chemicals. This observation was confirmed by staff #2.

On 6/11/2014 at 10:15 AM, following was observed in the storage area where nutritional supplements and snacks for patient were kept. In an area of the old kitchen, the walk-in refrigerator and cooler was identified. A sheet of heavy black plastic reaching from the ceiling to the floor was observed 2-3 feet in front of the walk-in's, separating the cooler and refrigerator from the area that previously was the hospital's kitchen. Staff #4 indicated the old kitchen required repair in the concrete floor and black plastic had been draped to control the concrete dust. Once the repair was complete the black plastic had remained and a look behind the drape revealed the old kitchen covered in white dust. The stainless steel work surfaces were moved about and shoved to one end of the room. The floors and flat surfaces had not been cleaned after the completion of repairs and the concrete patch remained exposed. Soda bottles and trash littered the kitchen area.

Upon returning to the walk-in cooler side of the black plastic the following was observed: a free standing popcorn machine was observed immediately adjacent to the walk in cooler. The popcorn machine was observed coated with a greasy substance and a gallon container of partially filled popcorn oil was stored in the popcorn machine. The floor was observed to be very dirty and the paint was peeling off the hi traffic part of the floor. Neither the popcorn machine nor the floor had been properly sanitized.

The door of the walk in cooler, once opened revealed the mid-section of the door void of its metal coating exposing a white surface beneath. The inside surface of the cooler door could not be sanitized. The floor was covered with visible dirt and trash. The left side of the walk-in cooler was being used to store stainless steel racks, trays and 1 plastic bottle of mustard was observed on a tray. The right side of the walk-in cooler contained following ready to serve snacks stored in shipping boxes: 7 cases of orange Jello, 6 cases of pudding, 4 cases of apple sauce, 1 case of grape jelly, and 2 cases of cranberry juice.

· " External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust (AAMI ST46-Section 5.2 Receiving Items).

The walk-in freezer was observed with condensation running down the door and pooling on the floor in front of the freezer, an electrical light switch was observed in the condensation area and was not tested. Upon opening the door the freezer, two (2) small boxes of single serving ice cream was observed in the freezer. There was a very strong musty /mildew odor in the freezer. During an interview, staff #18 insisted the freezer was not in use despite the freezer holding ice cream.

Continuing past the walk in freezer was a room containing paper plates, bowls, cups, napkins and plastic eating utensils. Staff #10 confirmed these products were for patient use. 20 shipping boxes were counted in this storage area. The floor was visibly dirty and red paint was peeled in the hi-traffic area. Fifteen (15) shipping boxes were observed stored with the paper products.

Past this room was a smaller room where the following was observed: A stainless steel shelf with 5 cases of soup in individual serving cans, still in shipping boxes, graham crackers, saltine crackers, 1 case of soda and 3, 1 pound boxes of salt. Below this rack was the following: a fifty (50) pound bag of popcorn. The top of the bag was open to the air. Beside the popcorn was 2 cases of liquid detergent and 1 case of a liquid contained in a silver foil bag with no identification found at all. Staff #10 confirmed there was no identification on the silver bag. She stated the popcorn had not been used since the hospital had closed its' kitchen.

On 6/11/2014 at 11:55 AM on the medical surgical unit observation revealed the following: Noon meals trays were brought to the patient unit and delivered to each patient by staff. Nursing staff consisting of RN's, LVN's and CNA's were observed delivering noon meal trays. Eight (8) of 9 staff were observed entering patient's rooms and exiting the patient rooms without sanitizing their hands between patients. The above observations were confirmed by staff #4.

On 6/12/2014 at 2:00 PM during a tour of the patient care unit the following was observed:: In a multi patient use shower across, from the musses, station razors, cloth tape, a patient gown, a wet towel left on top of a hamper, shampoo, wipes, and powder were identified remaining in the shower. No patient names were identified on the personal care items.

Found in the nutrition room across from the "B" nurses station the following was found: three (3) 3.5 ounce orange Jello with use by date of 4/30/2014, one (1) 12 ounce Grand Ma's molasses's with dark brown sticky residue on the cap and bottle neck. Staff #4 indicated molasses's was one Doctors choice for enema's. Found beneath the sink in the nutrition room was a card board box top with fifteen (15) packets of saltine crackers, and seven (7) packets of sugar. Three (3) baking sheet pans, tongs, round tray and wash basin. Found below the cabinetwas one (1) 10 CC syringe of normal saline. The ice machine filter was gray with dust and below the ice machine was two (2) badly broken floor tiles with large pieces missing.

Found in the soiled utility closet the dirty linen cart was observed with two (2) blankets on the floor of the cart not in bags, many pair of green gloves in the base of the cart.

Finally the wound treatment cart was left unlocked and the top draw revealed topical medication that if they were prescription had a label if over the counter they were not labeled. All topical medication both ointment and powders were in one 4 x 4 inch open topped box. Cross contamination was unavoidable. Unpackaged debridement scissors, were identified in the bottom of the topical medication tray. A 30 cc medication cup of a thick white ointment was seen sitting open on the top drawer.




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Respiratory Storage room
C. During an observation on 06/09/2014 at 2:50 p.m. the following was found on or near the shelves:
An open bottle of hydrogen peroxide which had no open date.
Packages of dressing supplies were opened and placed back into the bins.
The plastic bin which the culture swabs were stored in were soiled with white spills.
The baseboards in the room underneath the dressing supply bins had a buildup of dirt.
A bag of unidentifiable powder was stored on a shelf and the contents were spilling from the bag.
An expired Argyle thoracic catheter had the protective seal broken and it expired 06/2012.
Staff # 15 and 16 confirmed the condition of the respiratory room.
Hallway/ Supplement storage area (2nd floor)
During an observation on 06/09/2014 at 3:00 p.m. the following was found:
The metal basket attached to the Dynamap (equipment used to take vital signs) was rusted and missing paint. The basket was not able to be sanitized.
Cans of patient supplements and formulas were stored on a shelf which was rusted and unable to be sanitized. The floor underneath the shelf was soiled with dust and dirt.

Pharmacy room (Nursing station A side, 2nd floor)
During an observation on 06/09/2014 after 3:10 p.m. the following was found:
The floor in the room had spills, dust and dirt build-up at the baseboards.
The patient medication bins on the wall were soiled with spills and dust.
Drawers inside a medication cart in the room were soiled with spills, dust and debris.
The metal pill crusher was soiled with dried paper towel and a build-up of brown and black substance.
The medication refrigerator was in need of a defrosting and had a buildup of an approximate 1 inch of ice.
Review of the June 2014 "Refrigerator/Freezer Temperature Log" revealed "If the temperature fall outside of the acceptable range -Notify Supervisor immediately and take corrective action." The last recorded temperature taken was on 06/04/2015 (5 days ago).
Open insulin vials of Humulin Regular, Lantus, Levemir, Humalog Mix 75/25 and Humulin 70/30 were found stored in the refrigerator and did not have open dates recorded. According to labels on the vials of insulin staff was to date when opened and discard after 28 days.
Review of a policy named "Health and Safety Plan, Clinical Services" dated 09/01/2011 revealed the following:
Only clean equipment is stored in the clean storage rooms.
Wiping of equipment and /or patient contact surfaces with germicidal solution is done between patients and as needed.
Refrigerator temperatures are recorded and monitored daily, refrigerators are reviewed daily for outdated items and cleanliness and refrigerators are cleaned once a month with germicidal solution.
Storage areas, medication rooms, break rooms, nursing stations and other clinical storage/work areas are maintained in a clean and orderly manner.

Main Pharmacy (1st floor)
During an observation on 06/10/2014 after 3:15 p.m., 40 plus boxes of intravenous fluids and or lipids were found stored on shelves in packing boxes. One box of intravenous fluids was stored on the floor. Boxes of discontinued medications were stored on table inside the room with the unused intravenous fluids.
Staff # 13 confirmed the condition of the boxes.

According to Association for the Advancement of Medical Instrumentation (AAMI ST46-Section 5.2 Receiving Items) the following was revealed:
"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI ST46-Section 5.2 Receiving Items).

Equipment storage room (2nd floor)
During an observation on 06/11/2014 at 8:40 a.m., the backup ventilator and bi-pap equipment were stored in a room with rusting bedside toilets.
During an interview on 06/11/2014 at 8:40 a.m... Staff #15 confirmed the equipment was not supposed to be in the room together.

Based on observation, interview and document review the facility failed to consistently check and accurately record the "Crash Cart Checks" on 2 of 2 crash carts on a daily basis for 6 months.

On 6/11/2014 at 8:30 AM the crash carts for station "A" were inspected. Signature sheets, indicating the crash cart had been checked by nursing staff, indicating the crash cart was in working order and safe for patient use revealed the following:

January 2014 Found in the instruction portion of the form.
1. (all shifts) Check defibrillator on all shifts and initial the checklist box
2. (all shifts) Check portable suction machine (Check intact canister and tubing)
3. (Day shift) Check airway tackle box (check all intact)
4. (All shifts) Check intact seal on the Crash Cart and document the number.
5. (All shifts) Check to assure the Crash Cart is plugged in to the red emergency plug.
6. (all shifts) O2 tank checked and replaced at 500 PSI
7. (Last day of the month) Check Crash Cart contents and pacemaker function and re-lock.

The following was initialed as checked.

Item #1. Defibrillator checked: 16 blanks were identified on the 7A and 8 blanks were identified on the 7P shift.
Item #2. Suction pump: 13 blanks were identified on the 7A shift and 7 blanks for the 7P shift.
Item #3. Airway Box: 6 blanks were identified for the 7A shift and 13 blanks were identified for the 7P shift.
Item #4. Seal: 17 blanks were identified for the 7 A shift and 5 blanks were identified for the 7 P shift.
No other initials indicating checks were identified.

February documentation sheet was not located.

March the following changes were found on the signature sheet instructions:
1. Check defibrillator on all shifts and initial the checklist
2. Check airway tackle box
3. Check for intact seal on the crash cart and document the number
4. Check to assure the crash cart is plugged into the red emergency plug
5. O2 tank checked and replaced at 500 PSI

However, below the instructions, the form had been modified and only captured the following general title, "Crash Cart Checks" and the shift identification 7A or 7P. The nursing staff failed to document any of the above itemized safety checks. Following the general title, Crash Cart Checks and the shift identification for the 31 days of March six (6) blanks were noted for the 7A shift crash cart checks and 7 P shift with 19 blanks noted.

April reflected the same instructions and the same modifications to the form. The general title for "Crash Cart Checks" at 7A or 7P shift revealed the staff again failed to document any of the 5 safety checks for the 30 days of April. Staff failed to initial 21 blanks for the 7A shift and 15 blanks for the 7P shift.

May data sheets were not located.

June data sheet reflected the same instruction for 5 safety checks to be initialed daily. The modified form captured only the general title for Crash Cart Checks and the shift identification of 7 A and 7 P. The nursing staff failed to initial any of the 5 safety checks for the 30 days of June and initialed once for the 7A shift and six time for the 7P shift "Crash Cart Checks"

The crash cart at nurses station "B" was inspected and the following documentation of readiness was found:

No data was located for the January, February and March,

April the same instruction as above (five safety checks daily) and the modified form captured only the general title for Crash Cart Checks and the shift identification of 7 A and 7 P. The following was identified on the April form; "Crash Cart Checks": No shift identified, eight (8) days initialed. The last two (April 4 and 5) indicated the crash cart was open without a seal

May the same instruction as above (five safety checks daily) and the modified form captured only the general title for Crash Cart Checks and the shift identification of 7 A and 7 P. The following documentation was found, "Crash Cart checks": None
For the Month of May 6 different seals were identified on the cart. Each seal indicates the Crash Cart was opened for emergency use during a Code situation .The following were initials indicating a seal was present on the crash cart.
Seal #7086692, four (4) initials present
Seal #7086646, one (1) initial present
Seal #7086677, three (3) initials present
Seal #7086640, two (2) initials present
Seal #8856927, sixteen (16) initials present
Seal #8856985, twenty-two (22) initials present
The six (6) seals listed above indicated the crash cart was used for a patient in a Code situation with no guarantee all necessary components of the crash cart were in working order. No staff initialed indicating the cart had been checked prior to use.

The was no data for May

June the same instruction as above (five safety checks daily) and the modified form captured only the general title for Crash Cart Checks and the shift identification of 7 A and 7 P. The nursing staff failed to document any of the safety checks

On 6/11/2014 at 8:35 a random staff LVN was asked what did the blanks on the crash cart check sheet indicate and she replied "I don't know, you'll have to ask someone else". Staff #4 confirmed blanks on the crash cart check sheet were days the cart was not checked.

6/11/2014 at 11:00 in the conference room a policy/procedure for checking the crash cart was requested and no policy was provided.

Based on document review and interview the facility failed to follow its policy that required signature by the patient or legal guardian indicating consent for admission to the hospital. They failed to provide signature by the patient or legal guardian indicating consent for procedures after admission for 32 of 32 patient's medical record's (MR) reviewed.

This deficient practice had the likelihood to cause harm to all patients.
Findings include:
On 6/10 through 6/12/2014 in the conference room the MR for pt's 1-32 were reviewed and revealed the following: All consents for admission were co-signed by two (2) staff, indicating "verbal consent" had been given by the patient. The "Verbal consent" was given days before the actual admission occurred. The co-signatures appeared on the signature line reserved for the patient/guardian. No documentation was included explaining why the patient/guardian was unable to sign the consent the day of admission or why the "verbal consent" was signed prior to the patients actual date of admission. Further MR review found no documentation of attempts to obtain the patient's signature or to contact the family or guardians.

On 6/12/2014 at 2:30 PM in the conference room staff #2 was interviewed and indicated the consents for admission were often obtained prior to admission by the intake coordinator and when pre screenings were completed at other facilities. When asked for clarification as to why verbal consent was obtained and two staff co-signed the consent and not a patient/guardian, staff #2 indicated the patient's were not always able to sign. "We have to get consents to admit when we can". Staff #2 was then asked, if the patient was unable to sign, how could the facility be sure the patient understood or had actually given consent? Staff #2 gave no further remarks.

On 6/12/2014 at 4:00 PM in the conference room the policy for Patient Rights and Responsibilities was reviewed and revealed the following:

Found on page 1 of 2, under Procedure. "Upon admission to the facility, patient (sic) will be provided a copy of the Patient Handbook which will be reviewed with the patient/support person by the Social Worker/Case Manager. Topics reviewed include but are not limited to the following:
Patient Orientation
Advanced Directives
Grievance Process
Medicare Rights
Patient Rights and Responsibilities
Note: In the case of incompetent adult patient, the patient's legal representative shall be provided the Patient Rights and Responsibilities."

Found on page 2 of 2, "Acknowledgement of the patient having received the Patient Rights and Responsibilities is noted via patient or legal representative signature on the bottom of the form.

The patient receives a copy of the Patient Rights and Responsibilities and the original signed form becomes a permanent part of the medical record."

Based on observation, interview and record review the facility failed to provide each patient correct information on whom to contact for filing grievances.
This deficient practice had the likelihood to cause harm to all patients.
Findings include:
During an observation on 06/09/2014 at 1:40 p.m., the incorrect number for complaint reporting to the State Agency was posted in the front entrance of the facility (elevator).
Review of patient admission packet information revealed the incorrect number was being provided.
During an interview on 06/10/2014 at 8:50 a.m., Staff #2 confirmed the incorrect number was posted. Staff #20 confirmed the incorrect number was being provided in the patient admission information.

Based on interview and record review the facility failed to ensure nursing staff provided ongoing and accurate assessments on patients and provided interventions as needed. Nursing failed to ensure they had complete and accurate physician orders prior to administering medications and treatments. This deficient practice was found in 4 of 4 patients (Patient #s' 2, 5, 6, and 8).
This deficient practice had the likelihood to cause harm to all patients.
Findings include:
Review of a nursing "Interdisciplinary admission assessment" sheet revealed Patient #2 was an 82 year old female admitted on 06/06/2014 at 5:00 p.m. with a diagnosis of respiratory failure.
Nurses notes dated 06/06/2014 revealed Patient #2 was on a ventilator, tube feeding, telemetry, and was on the anesthetic agent Diprivan drip.
Review of physician orders on Patient #2 revealed the following:
Undated "Admit Physician Orders" revealed orders for a tube feeding, lab test, chest x-ray, and arterial blood gases. There were also orders for a finger stick /blood sugar. There was no indication as to how often the finger sticks were to be performed. The physician orders were telephone orders written by nursing and were not dated or signed by the physician.
Review of telephone physician orders dated 06/06/2014 at 8:05 p.m. (3 hours after admission) revealed to discontinue the Accuchecks (fingersticks) because the patient was not a diabetic.

Review of a set of medication orders for Patient #2 included blood pressure medications, seizure medications, respiratory medications, anti-coagulant medications, intravenous fluids, antibiotics and drips. The orders were continued from another facility and signed as telephone orders by nursing on 06/06/2014. The orders were not signed off by the physician. Further review of the chart revealed the following:
*One of the medication orders was for the antibiotic Vancomycin 750 milligrams, intravenous every 24 hours at 9:00 a.m. Review of the chart revealed no Vancomycin protocol order sheet completed on Patient #2 which would direct nursing on lab and how to administer the medication. According to the protocol, once a trough sample has been drawn, hold further dosing until result is known and within the desired range (<15 mcg/ml).
Review of the lab report which was generated on 06/09/2014 at 9:53 a.m. revealed Patient #2 had a Vancomycin Trough of 10.9 (reference range of 5.0-10.0).
During an observation of the medication room on 06/09/2014 after 3:10 p.m., a bag of Vancomycin 750 milligrams belonging to Patient #2 was found in the room. The bag was dated to be administered on 06/09/2014 at 12:26 p.m...
Review of the Medication administration record dated 06/09/2014 revealed the Vancomycin was supposed to be administered at 9:00 a.m., but was not given until 4:10 p.m...
During an interview on 06/10/2014 at 2:30 p.m., Staff #16 confirmed the state of the orders and that Patient #2 should have a completed Vancomycin protocol on the chart.
During an interview on 06/10/2014 at 3:00 p.m., Staff #17 confirmed the Vancomycin was not administered at 9:00 a.m. and that she gave it at 4:00 p.m. Staff #17 reported the reasons for administering the medication late was late lab results and pharmacy had to bring the medication up to the floor. Staff #17 reported the physician was not notified of the medication being administered late.
*Patient #2 had a physician order set for the anesthetic agent Propofol (Diprivan) which revealed they were not signed off, timed or dated by the nurse who completed the order nor the doctor. The order set revealed the following instructions:
"Awakening is performed a minimum of daily to assess neurologic status as well as to determine the minimum dose of propofol required for sedation.
Decrease propofol infusion by ordered dose every 10 minutes until patient reaches a Ramsey Score of 2.
For awakening, decrease rate by____mcg/kg/min every 10 minutes until patient reaches a Ramsey score of 2 (level of sedation which indicates cooperative, oriented and tranquil)."
The amount to decrease the drip was left blank on the order set.
* Review of progress notes dated 06/06/2014 and 06/07/2014 revealed Patient #2 had deep vein thrombosis (DVT).
Review of the "DVT/PE Prophylaxis Orders" revealed a place to assess risk factors, interventions and place for the physician to sign, date and time. The form was left completely blank.
Review of the medication orders which were not signed by the physician revealed Patient #2 was on the anti-coagulant Lovenox every 12 hours.
Review of a physician order dated 06/09/2014 at 9:06 a.m., revealed an order to hold the Lovenox and obtain 2 more stools for occult blood.
Lab value dated 06/10/2014 revealed Patient #2s' stool for occult blood was positive.
During an interview on 06/10/2014 at 2:30 p.m., Staff #16 confirmed Patient #2 was at risk for DVT and the assessments should have been completed by nursing.

*Review of the oral nutritional supplement protocol for Patient #2 revealed a hand written entry that the patient was on a tube feeding (with the admission information). The protocol was to determine if the patient met criteria of high-risk for malnutrition. The protocol was not dated and was not completed by nursing or the physician. There was no indication as to who added the entry on the form.
The next "Enteral Nutrition Order Form" which included an assessment of nutritional needs and the order for the formula was completed by the dietitian on 06/09/2014 (3 days after admission). This form was signed as a telephone order which was written by the dietitian on 06/09/2014. According to the nurses notes, Patient #2 had been receiving the tube feeding formula since admission on 06/06/2014 without assessment or physician orders for the enteral feedings.


*Review of an admission sheet on Patient #6 revealed he was an 82 year old male admitted on 05/18/2014 with a principal diagnosis of obstructive bronchitis disease.
Review of physician orders on Patient #6 revealed the following:
Undated DVT/PE Prophylaxis orders were left completely blank.
On 05/18/2014, a Potassium Protocol/Physician order, a Decision Grid: Hypoglycemia Treatment Options, insulin sliding scale protocol, the admission physician orders and admit/discharge medication reconciliation and order sheet were all written as verbal orders and had not been signed by the physician as of 06/11/2014.
On 05/27/2014, a wound protocol was written as a verbal order and had not been signed by the physician as of 06/11/2014.
On 05/30/2014, a consultation for a physician for a PEG placement and a wound protocol was written as a verbal order and had not been signed by the physician as of 06/11/2014.
On 05/29/2014, a telephone order was written and had not been signed off by the physician as of 6/11/2014.
On 06/02/2014, a telephone order was written to type and cross and transfuse 2 units of Packed Red Blood cells. It had not been signed by the physician as of 6/11/2014.

*Review of an interdisciplinary admission assessment dated 05/21/2014 revealed Patient #5 was an 85 year old female admitted on 05/21/2014 with diagnoses of urinary tract infection and altered mental status.
On 05/22/2014 wound care orders were written as a verbal order and had not been signed by the physician as of 06/11/2014.
On 05/22/2014 a DVT/PE Prophylaxis order was pre-signed off by the physician, but there was no selections made on the preset orders to indicate what treatment he prescribed.
Review of intake and output sheets from 05/21/2014-06/07/2014 on Patient #5 revealed 8 out of 18 days nursing staff failed to provide complete documentation.

*Review of admit physician orders revealed Patient #8 was an 81 year old female admitted on 05/16/2014 with diagnoses of wound care, intravenous antibiotics and Staph.
Review of orders revealed the following:
"Insulin Sliding Scale Protocol" and "Admit/Medication Reconciliation and Order Sheet" dated 05/16/2014 ;
Wound care orders dated 05/17/2014;
Diet, lab, and EGD orders dated 05/20/2014;
Medication orders dated 05/22/2014;
All of theses were written as verbal orders which had not been signed by the physician as or 06/11/2014.
Review of DVT/PE Prophylaxis Orders revealed they were left blank and were not completed by the physician or nursing.
Review of the "Debridement Procedure Record" dated 06/04/2014 revealed the time out information for correct patient, order verified, signed consent and site verified were left blank. An excisional debridement was performed on three ulcers. There was no documentation of pre-medication before the procedure, description of the tissue removed, blood loss, and pain. A nurse signed and dated the sheet, but no physician signed the sheet.

Review of a policy named "Asessment/Re-Assessment, Interdisciplinary" dated 04/12/2012 revealed:
"Patients receiving inpatien service will have initial assessment and appropriate follow-up assessments based upon their individual needs inlcuding physical, psychological and social/cultural status.
Assessment provided by health care professional will be based upon and include:
a. Data collected to assess the needs of the patient.
b. Analysis of data to develop a plan to meet the patient's care or treatment needs.
c. Prioritization of decision based upon analysis of data regarding patient care needs. Decisions made regarding patient care or treatment are prioritized based on analysis of the information collected.

Review of the "Medical Staff Rules and Regulations", dated 09/01/2011 revealed the following:
All orders for treatment and medication shall be in writing and authorized only by a licensed physician, dentist, psychologist, or podiatrist appropriately credentialed pursuant to the medical staff bylaws.
The practitioner's orders must be written, clearly, legibly, and complete, Orders which are illegible or improperly written must be clarified with the ordering physician. Orders to hold medication or treatment will be interpreted as discontinued and require that the order be rewritten, unless hold period is specified.
All clinical entries in the patient's medical record shall be accurately dated and authenticated by person authorized to assess, write orders and treat patients. The medical record must be clear , concise, complete and accurate.
Medical records must be completed within the timeframe's specified in the medical staff bylaws.

Review of a policy named "Physician orders" dated 09/01/2011 revealed "Verbal order may be accepted by an RN, RT, PT, OT, ST. Such orders will be written by the person accepting the order noting date and time. Verbal orders will be co-signed by the physician within 74 hours.

Based on interview and record review the facility failed to ensure 1 of 5 patients (Patient #5) reviewed for blood transfusions received post transfusion vital signs.
This deficient practice had the likelihood to cause harm to all patients.
Findings include:
Review of an interdisciplinary admission assessment dated 05/21/2014 revealed Patient #5 was an 85 year old female admitted on 05/21/2014 with diagnoses of urinary tract infection and altered mental status.
Review of a physician order dated 06/09/2014 revealed staff was to Type and Cross and transfuse 2 units of Packed Red blood cells.
Review of the "Blood /Blood Components Transfusion Record" revealed the 1st unit of blood was administered on 06/09/2014 from 11:00 p.m.-12:30 a.m. The post transfusion vital signs were performed at 2:10 a.m. (06/10/2014). The 2nd unit of blood was started on 06/10/2014 at 1:15 a.m. and stopped at 2:45 a.m. The second unit was started before post vital signs could be taken.

During an interview on 06/11/2014 after 1:00 p.m., Staff #4 confirmed the vital signs were not considered post vital signs.
Review of the policy named "Blood Administration" dated 09/2011 revealed the following:
Continue to evaluate patient for possible transfusion reaction for at least one hour post transfusion.

Based on observation, and document review the facility failed to insure the Pharmacist supervised the safe storage of medications in two (2) of 2 emergency crash carts.


On 6/11/2014 at 8:30 AM the crash carts for station "A" were inspected. Signature sheets, indicating the crash cart had been checked by nursing staff, indicating the crash cart was in working order and safe for patient use revealed the following:

January 2014 Found in the instruction portion of the form.
Check defibrillator on all shifts and initial the checklist box
Check portable suction machine (Check intact canister and tubing)
Check airway tackle box (check all intact)
Check intact seal on the Crash Cart and document the number.
Check to assure the Crash Cart is plugged in to the red emergency plug.
O2 tank checked and replaced at 500 PSI
Check Crash Cart contents and pacemaker function and re-lock.

The following was initialed as checked.

Defibrillator checked: 16 banks were identified on the 7A and 8 blanks were identified on the 7P shift.
Suction pump: 13 blanks were identified on the 7A shift and 7 blanks for the 7P shift.
Airway Box: 6 blanks were identified for the 7A shift and 13 blanks were identified for the 7P shift.
Seal: 17 blanks were identified for the first 7 A shift and 5 blanks were identified for the 7 P shift.
No other initials indicating checks were identified.

February documentation sheet was not located.

The following changes were found on the signature sheets beginning in March. These changes were noted in the instruction portion of the form.
Check defibrillator on all shifts and initial the checklist
Check airway tackle box
Check for intact seal on the crash cart and document the number
Check to assure the crash cart is plugged into the red emergency plug
O2 tank checked and replaced at 500 PSI
However, these changes were printed to reflect the changes on the documentation portion of the form. The form reflected the following documentation: "Crash Cart Checks" 7A or 7P. Six (6) blanks were noted for the 7A shift checks and Seal 7 P with 19 blanks were noted for the 7 P time.

April reflected the same changes in instructions and the following documentation for "Crash Cart Checks at 7A or 7P with 21 blanks for the 7A shift and 15 blanks for the 7P shift.

Seal checks for 30 days reflected the following:
seal #7086699 documented 9 initials
seal #7086683 documented 15 initials
seal #8856918 documented 16 initials
One line documented 11 initials but no seal number. For seventeen (17) days two seals were documented as present on the crash cart.

No data sheet was located for May

June data sheet reflected the following:

Crash Cart Checks:
7 A one (1) initial
7 P six (6) initials

Seal Checks:
7 A two (2) initials
7 P four (4)

All of the above mentioned Crash Cart checks sheets for nurses station "A" were observed to include space for a "Pharmacy inventory once a month: Pharmacist signature, line and date" No Pharmacist signature or date was found on any of the above mentions check sheets.

The crash cart at nurses station "B" was inspected and the following documentation of readiness was found:

No data was located for the January, February and March,

April

Crash Cart Checks
Seal # 7086690, (No shift identified) eight (8) initials the last two (April 4 and 5) indicated the crash cart was open without a seal
Seal # 7086678, (No shift identified), five (5) initials present
Seal # 7086679, (No shift identified), four (4)
Seal # 7086692, (No shift identified) twenty three (23) initials
Seal # 8856927, 7A, twenty -eight (28) initials present
7P, twenty-six (26) initials present,
The April signature sheets indicate the Crash cart was seals with multiple seals as signature over lapped on 9 days with 4 different seals documented as present on 15 days. Documentation reflected three seals present on 16 days and on two days, two seals were present on the crash cart.

May

Crash Cart checks
Seal #7086692, four (4) initials present
Seal #7086646, one (1) initial present
Seal #7086677, three (3) initials present
Seal #7086640, two (2) initials present
Seal #8856927, sixteen (16) initials present
Seal #8856985, twenty-two (22) initials present

The May signature sheets indicates the crash cart was secured with multiple seals as signatures overlapped on 21 days with 4 days with 4 seals initialed as present on the cart, 10 days having 3 seals initialed as present, 5 days with two seals present. and 5 days when no initials were present.

June
Crash Cart Checks
Seal # 7086640, five (5) initials
Seal #8856985, nine (9) . Twenty days had no initials present to indicate the crash cart was checked.

On 6/11/2014 at 8:35 a random staff LVN was asked what did the blanks on the crash cart check sheet indicate and she replied "I don't know". Staff #4 confirmed blanks on the crash cart check sheet were days the cart was not checked.

6/11/2014 at 11:00 in the conference room a policies for checking the crash cart was requested and no policy was produce.

All of the above mentioned Crash Cart checks sheets for nurses station "B" were observed to include space for a "Pharmacy inventory once a month: Pharmacist signature, line and date" No Pharmacist signature or date was found on any of the above mentions check sheets.

Based on observation, interview and record review the facility failed to have a procedure for counting narcotics used on the nursing units.
This deficient practice had the likelihood to cause harm to all patients.
Findings include:
During an observation on 06/09/2014 after 3:10 p.m., the facility was noted to have an automated medication dispensing machine. Staff #16 confirmed the narcotics were stored in the machine also. She reported they counted narcotics at the end of the shift, but there were no set days. They also counted narcotics after discrepancies.
Review of the "End of shift count history" from 05/01/2014 to 06/10/2014 revealed the narcotics were counted 5 times during this timeframe. On 05/04/2014, 8 days later on (05/12/2014, 15 days later on 05/27/2014, 11 days later 06/07/2014 and 2 days later on 06/09/2014.
Review of "Operator Discrepancies" Reports that were kept in main pharmacy revealed the following:
06/04/2014 at 3:17 p.m., a discrepancy was found with Lortab 5 milligrams and there was no documentation of how the discrepancy was corrected.
06/04/2014 at 8:27 p.m., a discrepancy was found with Lortab 5 milligrams and there was no documentation of how the discrepancy was corrected.
06/06/2014 at 8:05 p.m., a discrepancy with Lortab 5 milligrams and in the resolution staff documented "resolved previous discrepancy." There was no clear explanation of how the discrepancy was corrected.
Review of a policy named "Controlled Substance Administration" dated 09/2011 revealed:
Completed Controlled Substances Administration Records (CSARs) shall be examined for deficiencies upon return to the pharmacy.
CSAR deficiencies (e.g., incorrect or incomplete entries and absence of a current, valid physician's order, discrepancies) shall be reported to the Director of Nursing or designee (e.g., the supervisor of the responsible patient care unit).
In addition, Nurses with a discrepancies/deficiency will be notified immediately by pharmacy. The nurse will have 24 hours to resolve the discrepancy. If not resolved, the nurse will be restricted from administering controlled substance and removed from the schedule until the discrepancy is resolved.
During an interview on 06/10/2014 after 3:15 p.m., Staff #13 reported his way of keeping up with discrepancies was the "Operator Discrepancies" Reports. Staff #13 confirmed the missing documentation on the reports and confirmed there was no true policy and procedure addressing nursing counting narcotics.

Based on observation and interview the facility failed to ensure preventative maintenance checks were performed on patient care equipment.
This deficient practice had the likelihood to cause harm to all patients.
Findings include:

During an observation on 06/09/2014 after 3:10 p.m. the Arterial Blood Gas (ABG) machine was found in the 2nd floor medication room with a preventative maintenance (PM) sticker dated 11/2012 (last date performed).
During an interview on 06/09/2014 after 3:10 p.m., Staff #16 confirmed the date on the equipment and that it was being used by respiratory to obtain ABGs.
During an interview on 06/11/2014 after 8:00 a.m., Staff #2 confirmed the PM had not been performed on the ABG equipment.









28659

Based on observation, record review, and interview, the facility failed to place patients in proper transmission-based isolation. Three of three patients (#4, 31, and 32) had been placed in droplet isolation when they should have been in contact isolation to properly contain the organism involved. The facility failed to follow its Contact Precautions Policy.

Findings include:

Review of the facility policy titled, "Contact Precautions Policy," revealed patients with Acinetobacter and methicillin-resistant Staphylococcus aureus (MRSA) infections should be placed in contact precautions to prevent the spread of these infections to healthcare workers and other patients.

During a tour of the facility on 6/10/14 at 10:00am the following was observed and noted from the medical records:
-Patients #4, 31, and 32 were found to be in droplet precautions;
-Patient #4 was in precautions due to an Acinetobacter infection (requiring contact precautions per policy);
-Patient #31 was in precautions due to a MRSA infection (requiring contact precautions per policy);
-Patient #32 was in precautions due to a MRSA infection (requiring contact precautions per policy).

During an interview on 6/10/14 at 10:20am, staff #5 confirmed the patients had been placed in the incorrect transmission-based precaution type to prevent the spread of these infections to healthcare workers and other patients.