HospitalInspections.org

Based on interview, it was determined the facility failed to ensure there was a written policy in place regarding abuse of a patient by staff. The failed practice did not allow the facility to be knowledgeable, proactive, and timely in responding to allegations of patient abuse by staff and could affect any patient alleging abuse. Findings follow.

During an interview on 01/24/13 at 1410, the Nurse Educator stated the facility did not have a written abuse policy.

Based on review of Biennial Controlled Substance Inventories and interview, it was determined the facility failed to maintain controlled substance records correctly in that the Schedule II drug inventories were not maintained separately from the Scheduled III, IV and V's for two of two (05/01/11 and 05/01/12) biennial inventories. By not maintaining Biennial Controlled Substance inventories properly, the facility was not following the Arkansas Department of Health, Pharmacy Services and Drug Control, Rules and Regulations Pertaining to Controlled Substances (July 28, 2005). Findings follow:

A. A review of Biennial Controlled Substance inventories on 01/23/13, for 05/01/2011 and 05/01/2012, revealed the facility did not separate Schedule II inventories from Schedule
III, IV and V's.
B. The findings were verified through interview, with the Director of Pharmacy on 01/23/13 at 1045.

Based on review of Controlled Substance invoices and interview, it was determined the facility failed to maintain Controlled Substance invoices properly in that the invoices of Schedule III, IV and V drugs for 12 of 12 months (2012) were not readily retrievable. By not maintaining Controlled Substance invoices properly, the facility was not following the requirements of the Arkansas Department of Health, Pharmacy Services and Drug Control, Rules and Regulations Pertaining to Controlled Substances (July 28, 2005). Findings follow:

A. Review of Controlled Substance invoices on 01/23/13 for January through December 2012 revealed the facility did not maintain the invoices of Schedule III, IV or V drugs in a manner that made them readily retrievable and were not produced during the survey.
B. Findings were verified through interview with the Director of Pharmacy on 01/23/13 at 1045.

Based on interview, it was determined the facility failed to ensure the Diet Manual had been approved by the Medical Staff within the last five years. The lack of an approved, current manual created the potential for patients to receive incorrect meals and snacks and could affect any patient admitted to the facility. Findings follow.

During an interview on 01/23/13 at 0855, the Dietary Supervisor stated she could find no evidence the Medical Staff had approved the Diet Manual.

Based on fire drill documentation review and interview, it was determined the facility did not conduct two of two required fire drills in the third quarter of 2012 and one of two fire drills in the fourth quarter of 2012. Failure to perform quarterly fire drills on each shift prevented the facility from ensuring staff are trained and prepared to respond to fire emergencies with required procedures in a prompt and orderly manner to protect patients from fire and smoke. The failed practice had the potential to affect all patients, staff and visitors. The facility had a census of 17 patients on 01/22/13. See K50.

Based on interview, it was determined the facility did not ensure regular inspections by the local fire control agency. The failed practice had the potential to affect the health and safety of all patients, staff and visitors because the fire department familiarity of the potential hazards and physical layout of the facility was not assured. The facility had a census of 17 patients on 01/22/13. The findings follow:

In an interview on 01/23/13 at 1330, the Director of Maintenance verified there was no documentation of fire department inspection available for review.

Based on review of the Infection Control Policy and Procedure titled "Airborne Isolation Rooms" and review of the TB/Isolation Room Check Sheet Log, the facility failed to follow its policy for negative air pressure room checks in that daily checks were not performed for 5 (11/15, 16, 17 and 18/12 and 01/01/13) of 7 (11/15, 16, 17, 18, 19 and 31/12 and 01/01/13) days the room was occupied and did not perform monthly checks when not use for 8 (March-October 2012) of 10 (January-October 2012) months. Failure to monitor negative air pressure checks had the potential to allow the spread of airborne disease to patients, visitors and staff. The failed practice had the potential to affect all patients, visitors and staff in the facility on the days the isolation rooms were occupied and not checked. Findings follow:

A. Review of the policy and procedure, "Airborne Isolation Rooms" revealed the negative air pressure rooms would be checked daily when in use and monthly when not in use by the Infection Preventionist.
B. TB/Isolation Room Check Sheet Log documentation reflected negative pressure checks were not done daily for 11/15, 16, 17 and 18/12 and 01/01/13 and not done monthly for March-October 2012.
C. The above findings were verified by the Infection Control Nurse at 0945 on 01/25/13.

Based on clinical record review and interview, it was determined nine (#11-#19) of nine (#11-#19) patients who underwent an operative procedure the operative report did not include the time of surgery. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow:

A. Review of 11 operative reports for Patient #11-#19 revealed the operative reports did not include the time the surgical procedure was performed (Patient #16 underwent three surgical procedures).
B. Findings were confirmed by the Director of Medical Records on 01/24/13 at 1440.

Based on review of Respiratory Care Policy and Procedure Manual and interview, it was determined the facility did not have a policy and procedure for the delivery of Pulmonary Function Testing (PFT). Failure to have a policy and procedure in place for PFT did not ensure the facility was offering and performing the testing per current, applicable and appropriate measures. The failed practice affected all patients who received PFT at the facility. Findings follow:

A. Review of the Respiratory Care Policy and Procedure Manual revealed it did not contain a policy and procedure for PFT.
B. The Laboratory/Respiratory Care Director verified the above findings at 1055 on 01/25/13.