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Based on interview and record review, the facility failed to ensure a registered nurse (RN), assessed the patient needs, as per facility's policy & procedure, when the Admission Assessment to the acute care unit was incomplete, for one of 9 sampled patients (Patient 7). This had the potential to create a substandard level of care.

Findings:

Review of the facility's P&P titled "Guidelines for Admission to the Acute Care Unit'" dated 8/2016, showed the following guidelines are completed for patients admitted to the Acute Care Unit:
*Home residence will include information regarding the patient's current condition and any other relevant information that will be needed to prepare nursing staff or appropriate equipment for care upon the patient's arrival.
*Notify physician of the patient's admission.
*Obtain additional information needed to provide comprehensive care from the home employee, or from the patient's record (shortly after admission). Which may include level of supervision, open behaviors, pertinent health care plans, habits, communication methods, etc.
*A complete Nursing Assessment/Admission.

On 11/14/17 at 1 P.M., record review for Patient 7 was initiated. Patient 7 was admitted to the acute care unit on 10/28/17, with diagnosis including pneumonia.

Review of the Admission: Acute Care Unit (209) form, assessed and reviewed by two RNs, dated 10/28/17, showed:
a. Incomplete documentation for the mode of transfer to the unit.
b. There was no documentation to show the physician was notified of the admission.
c. There was no documentation to show oral assessment condition.
d. All the following information was left blank under Bioethics Directives:
* Advance Directive
* Advance Health Care Planning
* Organ Donor
* Conservatorship
* Name of the family member notified of the admission.
e. There was no documentation to show the patient was informed of her rights and grievance procedure.
f. There was no documentation to show if the patient had any medical health aids.

Review of the Advance Directive Notification signed by a facility's Social Worker, dated 10/30/17 (two days after the patient's admission to the acute care unit) showed Patient 7 had no advance directive. Patient 7 had a designated power of attorney. And had a natural death declaration.


On 11/14/17 at 2 PM, an interview and concurrent record review was conducted with Registered Nurse Supervisor (RNS 1). When asked what type of admission assessment was expected from the licensed nurses from the acute cute care unit (209), the RNS stated, the standard of care for the unit is to perform a thorough initial assessment shortly after the patient arrival to the unit, and the physician should be notified of the new admission. The RNS was asked to review Patient 7's initial nursing assessments. After completing the review, she stated the assessments were incomplete, and the information necessary to fill up the forms is available in the comprehensive care documentation from the patients "home unit."

Based on observation, interview, and record review, the facility failed to ensure Unit 209's emergency cart was stocked according to the facility's policy and procedure titled, "EMERGENCY CARTS AND EMERGENCY SUPPLIES," dated May 2011. This failure resulted in medications being stored in a drawer of the emergency cart which contained supplies, and the potential for emergency supplies not to be readily available when needed.

Findings:

During initial tour of Unit 209, on 11/14/17, at 9:10 AM, escorted by Registered Nurse Supervisor (RNS 1) and Registered Nurse (RN 4), an inspection of the medication room was conducted.

The emergency cart was observed with a locked red box on top of the cart. In a concurrent interview, RNS 1 stated the red box was the emergency kit (e-kit) containing medications that may be needed during an emergency.

The front of the emergency cart was observed to have four drawers. The drawers were held with a yellow plastic tie. RN 4 removed the yellow tie, and the first drawer of the emergency cart was opened.

Inside the first drawer of the emergency cart were disposable gloves and plastic oxygen tubing. The drawer also contained three unopened boxes which indicated: D50 (solution administered directly into the vein to stabilize blood sugar), Lidocaine (medication used for an irregular heart beat) 20% 100 mg/5ml (milligrams/milliliter), and Atropine sulfate (medication to treat heart rhythm problems) 10 ml.

In a concurrent interview with RNS 1 and RN 4, RN 4 stated, "HSS (Health Services Specialist) closed this one and filled it up. Comes back to us locked."

In addition, RNS 1 stated, "The meds (medications) should be in the e-kit and not in the drawer."

On 11/15/17, at 10:25 AM, an interview was conducted with the Assistant Coordinator Nursing Services (ACNS). He stated each unit was responsible for stocking their emergency cart.

In a concurrent record review of the facility's policy titled, "EMERGENCY CARTS AND EMERGENCY SUPPLIES," dated May 2011, the ACNS stated the policy indicated, "The Residence Manager is responsible for the proper storage of this cart and maintaining the equipment ready for use." In addition, the ACNS stated the Residence Manager on Unit 209 was SRN 1.

During the interview, the ACNS stated, "They had a Code (code blue - term used to indicate a patient requiring immediate resuscitation due to respiratory or cardiac arrest) on Unit 209 in October. They were going to use those meds and apparently put those meds in the top drawer. Someone put them there. Apparently an ACNS came and locked the cart. They probably should have checked it, but they missed it. Put the meds in the wrong place."

A review of the facility's policy and procedure titled, "EMERGENCY CARTS AND EMERGENCY SUPPLIES," dated May 2011, indicated, "PURPOSE...To provide a standardized, mobile unit that contains equipment and medications needed to perform emergency life-support procedures...The emergency drug box and emergency equipment that may be needed to perform life-support procedures will be kept on or in these carts. The Residence Manager is responsible for the proper storage of this cart and maintaining the equipment ready for use."

Further review of the policy and procedure indicated, "The cart and the equipment kept on or in it shall be standardized on every residence in the facility...An emergency drug box...sit atop the cart and the remaining emergency equipment and supplies are found in one of the drawers...EMERGENCY CART SUPPLIES...FIRST DRAWER...GLOVES...B/P CUFF...STETHOSCOPE...SUCTION CATHETER TRAY...CPR POCKET MASK...AIRWAY...O2 TUBING...O2 NASAL CANNULA...O2 MASK...NOREBREATHING MASK...TRACHEOSTOMY MASK..."

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

1. The two doors leading into the medication room on Unit 209 were locked.

2. The medication cart on Unit 209 was locked when not in use.

These failures resulted in medications being accessible to unauthorized persons, and the potential for the medications to be used for an unintended purpose.

Findings:

1. On 11/14/17, at 9:10 AM, during initial tour of Unit 209, the medication room was observed to have two doors leading into the room.

One door leading into the medication room was located in the nurse's station. The second door was outside of the nurse's station, down a public hallway, and not within view from the nurse's station. On the outside of each door was a sign that indicated, "PLEASE KEEP IT LOCKED."

Inside the medication room, a removable, locked red box was observed on top of the emergency cart. In a concurrent interview with SRN 1, she stated the red box was an emergency kit (e-kit) containing medications used during an emergency.

On 11/15/17, at 8:10 AM, the two doors leading into the medication room were observed to be unlocked. There was no licensed staff in the medication room, or in the nurse's station.

On 11/15/17, at 8:20 AM, Registered Nurse (RN 4) was observed to exit Patient 9's room, and enter the medication room.

Inside the medication room, RN 4 prepared an IVPB (intravenous piggyback - medication administered directly the vein) for Patient 9. RN 4 then returned to the patient's room to administer the IVPB. RN41 did not lock the doors to the medication room when she exited.

On 11/15/17, at 8:50 AM, RN 4 returned to the nurse's station to document in the computer system. In a concurrent interview with RN 4 she stated, "Once we are here, we leave them unlocked, because we keep coming in and out." In addition, RN 4 stated the doors, "Should really be locked."

On 11/15/17, at 9 AM, an interview was conducted with the Pharmacy Director. The Pharmacy Director stated the pharmacy prepared the e-kit for Unit 209, which contained emergency medications, and "controlled substance."

In addition, the Pharmacy Director stated, "The med (medication) room should be a secured area. Medications left unsecured, someone can walk in and remove it ...The emergency box should be in the med room and the door locked. Has to be secured."

A review of the facility's policy and procedure titled, "EMERGENCY CARTS AND EMERGENCY SUPPLIES," dated May 2011, indicated, "PURPOSE ...To provide a standardized, mobile unit that contains equipment and medications needed to perform emergency life-support procedures ...The emergency drug box ...will be kept on or in these carts ...The cart shall be stored in a locked room to that it is not accessible to residents."

2. On 11/15/17 at 8:10 AM, the medication cart inside the medication room was observed to be unlocked. There was no licensed staff present in the room, or in the nurse's station.

On 11/15/17, at 8:20 AM, RN 4 was observed to exit Patient 9's room, and enter the medication room. RN 4 prepared an IVPB for Patient 9.

In addition, medications Levafloxin (antibiotic) and Valproic Acid (antiseizure), were observed in the top drawer of the unlocked medication cart.

After preparing the IVPB, RN 4 returned to Patient 9's room to administer the IVPB. RN 4 did not lock the medication cart when she exited the medication room.

On 11/15/17, at 8:50 AM, RN 4 returned to the nurse's station to document in the computer system. In a concurrent interview with RN 4, she stated, "Once we are here, we leave them unlocked, because we keep coming in and out." RN 4 further stated the medication cart, "Should be locked."

On 11/15/17, at 10:14 AM, an interview was conducted with the RNS 1. She stated, "The medication cart can't be left unlocked. It should be locked at all times on that unit."

A review of the facility's policy and procedure titled, "MEDICATIONS/PHARMACEUTICALS STORAGE," dated February 2017, indicated, "Each residence shall have a means of storing drugs in areas and carts/cabinets which can be secured by lock and key ...All Med carts/cabinets/refrigerator shall be locked ..."

Based on observation, interview, and record review, the facility failed to ensure unlicensed staff did not have a key to the medication room on Unit 209. This failure resulted in medications being accessible to unauthorized staff.

Findings:

On 11/15/17, at 8:10 AM, an observation on Unit 209 was conducted. The two doors leading into the medication room were observed to be unlocked. In addition, the medication cart stored inside the room was also unlocked. No staff was present inside the room, or outside in the nurse's station.

On 11/15/17, at 10:14 AM, an interview was conducted with the Registered Nurse Supervisor (RNS 1) for Unit 209. She stated the janitor had been cleaning the medication room on Unit 209. In addition, the RNS 1 stated the janitor had his own key to the medication room.

On 11/15/17, at 11 AM, an interview was conducted with the Janitor on Unit 209. He stated he had a key that, "Opens all the doors."

The Janitor was observed to unlock one of the medication room doors with his key. He stated, "I don't have to check with nursing first, can just go in."

On 11/15/17, at 1:15 PM, an interview was conducted with the RNS 1. She stated, "(Janitor) has a key to the med (medication) room, but not to the med cart. That is how it's always been. Everyone has a resident's key."

The RNS 1 further stated, "I agree, it shouldn't be that way. Unlicensed staff should not have a key to the med room. It's been like that forever."

A review of the facility's policy and procedure titled, "MEDICATIONS/PHARMACEUTICALS STORAGE," dated February 2017, indicated, "Each resident shall have a means of storing drugs in areas and carts/cabinets which can be secured by lock and key. Only Licensed staff shall have responsibility for medication keys."

Based on observation and interview, the Pharmacy Staff failed to ensure outdated or otherwise unusable drugs and biological's were not available for the patients use.

Findings:

Review of the facility's policy and procedure (P&P) titled "Drug Dosage and Accountability," reviewed on 2/28/17, showed under procedures-responsibilities, all injectable medication in vials would be discarded when sterility is compromised or questionable. In addition, the United States Pharmacopoeia (USP) General Chapter 797 recommends the multi-dose vials of sterile pharmaceuticals: if a multi-dose has been opened or accessed, the vial should be dated and discarded within 28 days.


a. On 11/14/17 at 1030 A.M., tour rounds to the facility's First Aid Clinic was conducted, accompanied by Registered Nurse (RN 1). During an inspection of the medication cabinet drawer the following was observed:

a. One multi-vial of Lidocaine injection 2% (local anesthetic) Lot 60-145, was found with the seal broken, and the label attached to the bottle showed the bottle was opened on 10/11/17.

During an interview with RN 1, at the time of the observation, she stated if the expiration date of the vial is 30 days after opened, the Lidocaine multi-dose vial should have been discarded.

On 11/15/17 at 10 A.M., an interview was conducted with the Director of the Pharmacy, he was informed of the opened vial found and the dates it was opened. The Director stated, "The medications are only good for 28 days after opening." He confirmed the above findings

Based on observation, record review, and interview, the hospital's Radiology Department failed to ensure the safety of radiological services was provided, creating the increased risk of radiation hazards to the staff and patients in the radiology.


Findings:


Review of the facility's "Procedure for Annual Examination of Leaded Personal Protective Ware," undated, showed under the supervision of the radiologist, radiology personnel will pass matching lettered gowns, gloves, thyroid and gonadal shielding devices while under fluoroscopic imaging (x-ray technic) in the pulse phase to limit radiation exposure. The Radiologist will observe shielding for cracks or abnormalities in leaded protective gear and make the necessary recommendations.

On 11/14/17, at approximately at 0915 A.M., an inspection of Radiology Department leaded aprons and shields (lead x-ray protective ware are used to reduce radiation exposure to both patients and personnel), accompanied by Radiology Technologist 1 (RT 1) was conducted. RT 1 stated the radiology staff was responsible for the maintenance, and the annual inspections of the lead aprons and shields in the Radiology Department.

A rack of lead aprons and shields was observed in the procedure room. Several aprons were hung on the rack. Some of the aprons and shields were matched with the same identification number, and others were not. The RT stated there should be a total of 6 aprons and shields in the Radiology Department. However, when the RT counted the aprons, she found 6 aprons and only two thyroid shields.

Review of the Fluoroscopy of Lead Apron and Gloves documentation, dated 1/16/16, showed, at that time, under fluoroscopy control, the x-ray beam was passed through the five fluoroscopic aprons, lead gloves of the dental clinic, and two pair of lead gloves and six aprons from the Radiology Department. All gloves and aprons revealed no defects. However, there was no documentation evidence the thyroid shields were screened for defects.


On 11/14/17 at 0930 a.m., during an interview with RT 1, she confirmed the leaded thyroid shields were not consistently screened by the facility's procedures, nor tagged/marked, or replaced, which would prevent an accurate accounting of these shields for inspection and quality control.

Based on observation and interview, the facility failed to maintain one outpatient dental clinic's crash cart (a cart containing equipment and medications for use during medical emergencies), the crash cart contained expired supplies. This failure had the potential for staff to use expired supplies that might no longer be sterile for the patients.

Findings:

On 11/14/17 beginning at 1045 A.M., the hospital's outpatient dental clinic was toured. During a random crash cart inspection, the nursing staff was asked to open a crash cart. The drawers containing medical supplies were opened by breaking a breakaway plastic lock.

A concurrent observation, and review of the crash cart non-medication checklist contents (these lists are used when staff checks to ensure medications and supplies are available for use and not outdated), was conducted with RN 1. Inside the crash cart the following medical supplies were found outdated:

*Six peripheral intravenous catheter, 26 G, (small, flexible tube, placed into a vein for intravenous therapy) , with expiration date of 2017/06.
*Three peripheral intravenous catheter, (20 G), with the expiration date 2017/05.
*Two intravenous extension set, with expiration date of 2017/06.
*Two intravenous tubing, with expiration date of 2016/08.

On 11/14/17 at 11 A.M., during an interview with RN 1, at the time of the observations, when asked she stated it is the hospital's policy for the unit staff to inspect and maintain the crash cart under proper conditions. RN 1 confirmed the above findings.