HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the pharmacy services contract included documentation to indicate that a pharmacist would be available on a 24 hour/day, 7 day/week basis. Findings:

The "Pharmacy Services Agreement" signed by an authorized representative of the hospital and an authorized representative of the pharmacy services provider was reviewed. The signed "Pharmacy Services Agreement" failed to include documentation to indicate that a pharmacist would be available as needed on a 24 hour/day, 7 day/week basis.

The Administrator was interviewed on 1/26/11 at 9:30 a.m. The Administrator reviewed the "Pharmacy Services Agreement" and confirmed that there was no documentation in the agreement to indicate that a pharmacist would be available on a 24 hour/day, 7 day/week basis. The Administrator reported that this was an oversight with the writing of the contract. The Administrator explained that a pharmacist is available to hospital personnel on a 24 hour/day, 7 day/week basis. The Administrator reported that the contract would be revised to reflect the 24 hour/day, 7 day/week availability of a pharmacist.

Based on record review and interview, the hospital failed to ensure verbal orders included a read-back and verification process for 5 of 20 sampled patients reviewed for read-back verification. (#5, #8, #9, #15 & #16) Findings:
Review of the record for Patient #5 revealed a verbal order dated 11/25/10 9:30am with no read-back verification.
Review of the record for Patient #8 revealed verbal orders dated 11/12/10 2pm, 11/13/10 10am, and 11/14/10 8am with no read-back verification.
Review of the record for Patient #9 revealed verbal orders dated 12/10/10 4:15pm, 12/16/10 9am and 5:30pm, and 12/30/10 4pm with no read-back verification.
Review of the Physician's Orders dated 10/31/10 at 9:00 a.m. for Patient #15 revealed a verbal order was received by S9 LPN, and no verbal read-back was done for order verification. Interview with S1 DON on 1/26/11 at 9:55 a.m. confirmed that S9 LPN should have completed and documented a verbal read-back for the order.
Review of the record for Patient #16 revealed verbal orders dated 11/16/10 2pm and 6pm, 11/19/10 11:20am, and 11/23/10 2pm with no read-back verification.
These findings were confirmed by S1, DON on 01/26/11 at 10am who indicated verbal orders should have a read back verification at the time the order is received by the authorized recipient. Further she indicated after review of the hospital policy for "Orders for Treatment" there was no documented evidence of read back verification in the policy and this would be added to the current policy.








16944

Based on record review (medical records, medical staff bylaws) and interview, the hospital failed to ensure a medical history and physical examination (H&P) was completed and documented 24 hours after admission for 2 of 20 sampled patients (Patients #1 & #2).
Findings:

Patient #1: The Medical Record for Patient #1 was reviewed on 01/25/11. Documentation revealed Patient #1 was admitted on 01/21/11 with Diagnoses of Cellulitis Right Lower Extremity, Wound Right Shin, Non-insulin Dependent Diabetes Mellitus. Review of the Multidisciplinary Admission History and Physical Assessment dated 01/22/11, time not legible, revealed the History and Physical was incomplete and left blank for Chief Complaint, Social History, Review of Systems/Physical Exam, and Plan of Care/Recommendations/Treatment/Goals.

In a face to face interview on 01/25/11 at 1pm S1, Director of Nursing confirmed the History and Physical was incomplete and should be completed within 24 hours of admission.

Patient #2: Review of the record for Patient #2 revealed she was admitted to the facility on 10/22/10 at 2:00 p.m. Further review reflected the patient's H & P examination was not completed by S8 APRN until 10/23/10 at 4:30 p.m.

Interview with S1 DON on 1/12/11 at 3:45 p.m. revealed the H & P examination should have been completed within 24 hours of admission to the facility.

Interview with S8 APRN on 1/26/11 at 9:30 a.m. via telephone confirmed she had not completed the H & P within 24 hours for Patient #2. She stated she was not aware they must be done within 24 hours of admission to the facility.

Review of the Southeastern Regional Medical Center, Inc. General Rules and Regulations revealed in part, "3. History and Physical of the patient: The history shall incorporate the Chief complaint, details of present illness, inventory of systems, medical history, and family history. The history shall be a record of information provided by the patient or his agent. The foregoing is to be written or dictated within twenty-four (24) hours after admission. The physical examination shall include all pertinent findings."




16944

Based on review of pharmacy policy and drug vial labels and interview, the hospital failed to ensure vials of insulin and Tuberculin Purified Protein (PPD) opened greater than 30 days were not available for patient use. Findings.

Observation of the Medication Storage Room on 01/25/11 at 10:45 a.m. revealed the following vials of medication stored in the refrigerator:
a. 1 vial of Humulin R U100 with an open date of 12/16/10
b. 1 vial Humulin 70/30 with an open date of 10/25/10
c. 1 vial of PPD with an open date of 05/12/10

S2, LPN confirmed these findings at this time and indicated the vials should be disposed after 30 days of opening.

Review of the hospital pharmacy policy entitled Multiple Dose vials revealed in part, "The expiration of opened multiple dose vials shall be 30 days."

Review of the vial label of the PPD revealed, "A vial of Tuberculin PPD which has been entered and in use for 30 days must be discarded."

Based on observations and interviews, the hospital failed to ensure that all areas of the hospital, including patient care equipment, were maintained in a manner to ensure an acceptable level of safety and quality. This was evidenced by 1) failing to ensure the floors were cleaned and disinfected with a product that contained disinfecting properties; 2) failing to ensure the nursing call system was functioning in one patient room; 3) failing to ensure that the walls in patient care rooms were in good repair; 4) failing to ensure that the handrails of beds were free of rust; and 5) failing to ensure chairs and blinds in patient rooms were in good repair. Findings:

1. Failing to ensure the floors were cleaned and disinfected with a product that contained disinfecting properties.

Observations on 1/25/11 between 10:10 a.m. and 10:30 a.m. revealed a dirty residue and multiple stains on the floors in the patient rooms. The housekeeper (S4) was interviewed on 1/25/11 at 10:40 a.m. When asked about the product used to clean and disinfect the floors in the hospital, S4 reported that she uses "Fabulosa" to clean and disinfect the floors in the hospital. S4 indicated that she switched to "Fabulosa" after several staff members had voiced complaints of the floor being sticky. When asked if the hospital's infection control officer had approved the use of "Fabulosa" as the product to clean and disinfect the floors in the hospital, S4 indicated that she had not discussed changing to Fabulosa with the infection control officer.

Review of the product information for "Fabulosa" revealed that "Fabulosa" is a multi use cleaner. There was no documentation on the label of the "Fabulosa" to indicate that the product contains any disinfecting properties or to indicate that the product is to be used as a disinfectant.

Review of the hospital approved policy/procedure titled "Infection Control Education/Training Policy" revealed in part "Disinfectant-detergent formulations registered by EPA can be used for cleaning environmental surfaces".


2. Failing to ensure the nursing call system was functioning in one patient room.

Observation of Patient Room (E) on 1/25/11 at 10:30 a.m. revealed the nursing call system was not functioning and would not alarm outside the room or at the nursing station. S2, LPN confirmed this finding and indicated the alarm had been working a couple of weeks ago when a patient was in the room.


3. Failing to ensure the walls in patient care rooms were in good repair.

Observations on 1/25/11 between 10:10 a.m. and 10:30 a.m. revealed a hole measuring approximately 4 inches in diameter on the wall in Patient Room C. In addition, the mirror in the bathroom in this patient room (C) was not securely fastened to the wall. Observations also revealed that the vent cover in Patient Room H was noted to be loose and separated from the wall. In an interview on 1/25/11 at the time of this observation, the unit charge nurse (S3) confirmed the hole in the wall and the loose mirror in Patient Room C and confirmed the loose vent cover in Patient Room H. Patient Room E bathroom was observed with peeling paint on the sheet rock and rust around the bottom of the patient commode.


4. Failing to ensure that the handrails of beds were free of rust.

Observations on 1/25/11 between 10:10 a.m. and 10:30 a.m. revealed multiple sections of rust on the handrails of the beds in Patient Room's A, B, and D. In an interview on 1/25/11 at the time of this observation, the unit charge nurse (S3) confirmed the rust on the handrails of the beds in these rooms.


5. Failing to ensure chairs and blinds in patient rooms were in good repair.

Observation of Patient Room (E) on 01/25/11 at 10:30 a.m. revealed a chair in the room had tears with inside sponge material exposed held together by tape. The blinds on the window were bent and did not provide full privacy for the patient.