HospitalInspections.org

Based on document review and staff interview, it was determined for 2 of 3 (Pt #5, Pt #14) patients with a Central Access Device (CAD) placed prior to admission to the Hospital, the Hospital failed to ensure that an order was obtained prior to use. This has the potential to place all patients admitted to the Facility with a CAD at risk.

Findings include:

1. A request for hospital policy of a physician order for Intravenous Access Devices placed on a patient prior to Facility admission was made on 5/23/17 at 1:00 PM. Quality Director (E #2) indicated that currently there was no such policy.

2. The clinical record of Pt #5 was reviewed on 5/22/17 at approximately 11:45 AM. Pt #5 was a 35 year old admitted on 5/15/17 with a diagnosis of Pancreatitis. Pt # 5's clinical record indicated Pt #5 received 520 ml (milliliters) potassium chloride intravenous (IV) fluids (as ordered) on 5/18/17 at 7:30 PM via a left chest implanted port that was placed prior to Facility admission. No documentation was found for a physician order to access the port prior to Pt #5 receiving the IV fluids.

3. The clinical record of Pt #14 was reviewed on 5/24/17 at approximately 11:30 AM. Pt #14 was a 82 year old admitted on 4/14/17 with a diagnosis of Supra pubic catheter dislodgement. Pt #14 was a direct admit to the Medical Surgical 7th floor, from an outlying hospital with IV Fluids infusing thru a Peripherally Inserted Central Catheter (PICC). Pt #14's record indicated Pt #14 received 0.9 normal saline at 100 ml/hr until transferred to the Critical Care Unit on 4/14/2017 and the IV fluids were changed to 125 ml/hr. There was no documentation a physician order was written to use existing PICC.

4. On 5/25/17 at 9:00 AM an interview with the Quality Director (E #2) and Director of Medical/Surgical Floor (E #7) was completed. Both staff stated a physician order should have been obtained for Pt #5 and Pt #14 prior to staff using the PICC and port.

Based on document review, observation and interview, it was determined the Hospital failed to ensure food products were labeled appropriately as per facility policy. This has the potential to affect all patients, staff, and visitors that utilize the dietary services.

Findings include:

1. Hospital policy "Food Safety Product Labeling & Dating Guide" indicates "FIFO system must be in place". "Date cartons, cases, boxes, etc with "date received"

2. On 5/22/17 at 3:15 PM an observational tour of the hospital's kitchen was conducted with E #4 (Dietary Operations Manager).

It was noted in the dry storage area, (5) one gallon jugs of Roseli canola olive oil were not dated and (4) one gallon bottles of Regina red vine vinegar were not dated.

It was noted in the walk in cooler, approximately 30 undated and unlabeled partially frozen chicken breasts that appeared to be thawing.

3. On 5/22/17 at 3:45 PM, Dietary Operations Manager (E #4) stated that foods that were found undated and unlabeled should have been labeled.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on May 22 - 23, 2017, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on May 22 - 23, 2017, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.