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Based on record review, interview and policy review, the facility failed to conduct a physical abuse allegation investigation for an unsampled patient (Patient #31).

Findings include:

Patient #31

On 4/3/16, Patient #31 was admitted with lower extremity weakness and swelling.

On 4/14/16 at 12:20 PM, a patient concern document showed the patient complained about a nurse who told the patient to "shut up" and two males nurses who turned the patient over and struck the patient's foot a number of times with drumsticks, causing bruising and swelling. The wound care nurse entered a couple notes about the allegations verbalized by the patient's family, which showed attempts to assist the patient and family but which did not constitute an investigation.

On 5/12/17 in the afternoon, the Quality/Risk Director and Unit Manager were unable to provide documented evidence an investigation was completed for the abuse allegation and documented evidence the incident was reported to Elder Protective Services.

Section D of the investigation procedures section of The Allegations Of Abuse policy (RIS-688 last reviewed January 2017) showed the investigation should have included, but was not limited to:

--interview with person reporting the incident.
--interview with alleged victim.
--review of medical record.
--interview of all pertinent staff that may have knowledge of the events surrounding the alleged incident.

The procedure section, part A. of the Patient Abuse policy (1.300 last reviewed January 2017) showed suspected abuse and/or neglect must be reported within 24 hours.

Based on observation, interview and record review, the facility failed to clarify an order for medicated ointment as to what the ointment was used for and where to administer the ointment for 1 of 30 sampled patients (Patient #19).

Findings include:

Patient #19

Patient #19 was admitted on 5/7/17, with diagnoses including congestive heart failure, atrial fibrillation and diabetes.

On 5/10/17 at 840 AM, medication administration observation was conducted with Patient #19 and the Registered Nurse (RN). The RN scanned a tube of ointment labeled Venelex and a tube of Nystatin cream.

The RN asked the patient where the previous nursing staff had been applying the cream and ointments. The patient had thought the Nystatin cream was being applied to a small area to the back but did not recall. The patient was not familiar with the Venelex ointment and did not know where the previous nursing staff had been applying the ointment.

The physician orders dated 5/8/17, documented an order for Venelex ointment. The order did not specify where to place the ointment and what the ointment was being used for the patient.

The physician orders dated 5/7/17, documented an order for Nystatin cream. The order did not specify what the cream was used for and where to apply the cream.

On 5/11/17 in the morning, the Chief Nursing Officer (CNO) confirmed the nursing staff had been documenting the Nystatin cream and the Venelex ointment had been administered. There was no documented evidence on the administration record where the nursing staff had been applying the cream and the ointment.

There was no documented evidence in any of the patient's record on where the Nystatin cream and the Venelex was being applied and why the cream and ointment were ordered.

On 5/11/17 in the morning, the CNO confirmed the nursing staff should have clarified with the physician on why the cream and ointment were being used and where the physician wanted the cream and ointment to be administered on the patient's body.

The facility policy titled Physician Orders and dated 1/2017, documented any unclear or incomplete order must be clarified with the ordering physician.

Based on interview, record review and document review, the facility failed to monitor a patient for proper temperatures while blood was being transfused during hemodialysis for 1 of 3 sampled dialysis patients (Patient #21).

Findings include:

Patient #21

Patient #21 was admitted on 3/10/17, with diagnoses including end stage renal disease, congestive heart failure and hypertension.

On 3/23/17, the patient received one unit of packed red blood cells (PRBC) while receiving hemodialysis in the facility. Hemodialysis started at 5:40 PM and ended at 9:10 PM. The one unit of PRBC was started at 6:15 PM and the blood transfusion was completed at 8:55 PM. There were no body temperatures obtained at the start of the transfusion, during transfusion and when the transfusion of blood was completed.

On 5/12/17 in the morning, the Chief Nursing Officer (CNO) confirmed the blood transfusion policy was not followed when blood was being transfused during hemodialysis. The CNO indicated the nurse did not take temperatures to monitor for complications while Patient #21 was being transfused with one unit of PRBC during hemodialysis on 3/23/17.

The facility policy titled Blood Product Administration and last dated 10/2016, documented the patients vital signs would be taken before the start of the transfusion, every 15 minutes for the first 30 minutes, every 30 minutes during the transfusion and upon completion.

Based on interview and record review, the facility failed to have staff stop using out-dated blood product administration record forms and to use the approved electronic medical records process for monitoring blood transfusions for 2 of 3 patients receiving blood transfusions (Patient #16, #17).

Findings include:

On 5/12/17 in the morning, the Chief Nursing Officer (CNO) indicated the patients transfusion charting was to be documented in the electronic medical records. The CNO indicated the process had been implemented 2 years ago. The CNO confirmed the nursing staff had been using the out-dated unapproved hard copy form titled Blood Product Administration Record. The CNO indicated the staff had been in-serviced several times to stop using the form. The CNO indicated the facility had stopped using the form 2 years ago.

The CNO had been attempting to find the out-dated forms in the nursing stations and throw them away but the staff continue to use the form due to the convenience of documenting the vital signs. The CNO indicated the electronic charting had an area to place vital sign and monitor complications when administrating blood products but the staff were resistant on using the electronic process.

Patient #16

Patient #16 was admitted on 4/11/17, with diagnoses including chronic kidney disease, pneumonia and acidosis.

On 4/15/17, one unit of red blood cells was transfused to the patient. The monitoring of the patient's vital signs and transfusion times were being documented in an out-dated unapproved form titled Blood Product Administration Record.

There was no documented evidence the transfusion information was documented in the patient's electronic charting.

Patient #17

Patient #17 was admitted on 3/21/17, with diagnoses acute kidney disease, duodenal ulcer and hypertension.

On 5/3/17, Patient #17 received a transfusion of blood products. The monitoring of the patient's vital signs and transfusion times were being documented in an out-dated unapproved form titled Blood Product Administration Record.

There was no documented evidence the transfusion information was documented in the patient's electronic charting.

Based on observation, interview, record review and policy review, the facility failed to follow its process for using a compounded and repackaged medication consistent with its own policies for 3 of 30 sampled patients (Patient #2, #14 and #25) and 13 of 14 unsampled patients (Patient #31 and #33 through #44).

Findings include:

On 5/10/17 in the afternoon, the Pharmacist provided a requested container of Wound Paste. The Pharmacist explained the compounding formula and record document, which showed Wound Paste was mixed on a glass plate in a 1:1:1 ratio with three ingredients: Mupirocin Ointment 2%, Miconazole Cream 2% and Calmoseptine Ointment. The resulting Wound Paste was then placed into a 1 ounce jar with an expiration date of 14 days from the date of compounding. The use of Wound Paste had been going on for 6 months or so.

The facility formulary lacked documented evidence of a Wound Paste listing.

The Nonformulary Drugs policy (40.0714 last revised October 2016) revealed non-formulary drugs should not be stocked routinely by the pharmacy. Only those drugs included in the medical staff approved formulary should be maintained in the pharmacy inventory.

The Nonformulary Drugs policy (40.0714 last revised October 2016) revealed non-formulary drugs (including new drugs and drugs obtained pursuant to a non-formulary request) could be stocked and dispensed by the pharmacy pending medical staff review and acceptance.

The Hospital Drug Formulary policy (3.890) revealed non-formulary requests were reviewed and presented to the Medical Executive Committee.

The last two Medical Executive Committee Meeting Minutes documents were reviewed, dated 11/9/16 and 2/9/17 respectively. No formulary issues were presented at the meetings.

The Pharmacist explained the technician's initials were printed on the jar's label as evidence of who mixed the Wound Paste and as part of the lot number created for labeling. The label showed the technician mixed the Wound Paste in April 2017 with an expiration date in June 2017. The label was not initialed by the Pharmacist.

The Prepackaged and Repackaging of Medications policy (40.0918 last revised January 2005) revealed all labels were prepared by a pharmacist or pharmacy technician. If prepared by a technician, the pharmacist would check and initial the label.

Physicians ordering the Wound Paste were interviewed:

On 5/10/17 in the afternoon, a Wound Care Physician did not name the ingredients when asked. The Wound Care Physician proceeded to discuss additional ingredients (such as Gentamycin) to be used with the wound paste, requiring an additional physician order.

On 5/10/17 in the afternoon, the Physician who initiated the use of Wound Paste was unable to name the third ingredient without prompting.

On 5/11/17 in the morning, a Physician was unable to describe how the Wound Paste originated in the facility or the ingredients.

On 5/11/17 at 10:25 AM, a Physician was unable to name the third ingredient without prompting.

On 5/11/17 at 2:00 PM, the Chief Executive Officer and the Chief Nursing Officer acknowledged the Wound Paste was not brought forward to the Medical Executive Committee for review.

On 5/11/17 at 2:35 PM, the Pharmacist reviewed the hospital policy on compounded drugs. The Pharmacist reported per policy all drugs should be approved by the Medical Executive Committee prior to use, and should be included in the hospital drug formulary. The Pharmacist disclosed he did not seek approval for Wound Paste to be included in the formulary as a compounded drug, via the Medical Executive Committee, prior to use, because each separate component of the paste was already included in the hospital drug formulary, and did not need further approval. The Pharmacist stated he did not believe the compounded drug needed to be listed on the formulary as "Wound Paste." The Pharmacist further reported the components of the Wound Paste were not listed in each physician's order, but that was not necessary because each of the component medications was included in the hospital formulary.

The Medication Orders policy (3.930) revealed orders for compounded drugs were acceptable if they were listed in the facility formulary [under the compounded name], such as, "Magic Mouthwash," [or "Wound Paste" for instance] or if the components and concentration of the compounded drug was specified in the physician order.

On 5/11/17 in the afternoon, the Pharmacist provided a current list of patients with Wound Paste orders, including Patient #2, #14, #25, #31 and #33 through #44. In each instance, the order was written as Wound Paste without the specificity of the ingredients.

On 5/12/17 in the afternoon, the Chief Executive Officer verbalized the Wound Paste would be reviewed by the Medical Executive Committee later that day.

Based on observation, interview and document review, the facility failed to ensure a Director of Food Services was responsible for the daily management of dietary services, resulting in multiple food preparation and storage issues.

Findings include:

On 5/9/17 from 11:00 AM to 12:00 PM, a tour was conducted of the facility's kitchen revealing the following:

At 11:00 AM:

--air vent on an ice machine was visibly filthy from a distance across the kitchen.

--cooler door did not close properly and the gasket around the door was torn adjacent to the handle area.

--food temperature log book was missing dozens of meal temperatures. No temperatures were provided prior to 2/13/17. The cafeteria steam table did not have a temperature log.

--portable cooler (with 4 wheels) lacked a temperature log.

--several dented cans, including chicken noodle soup, corned beef hash (3 cans), diced peaches, sliced apples and sliced ripe olives.

--several undated/unlabeled/opened items, including a tray of chicken cordon bleu, chips, cranberry sauce, Nestle butterscotch chips, french fries, noodles, Philly meat, round steak cuts, seasoned bread crumbs, shredded cole slaw, turkey burger patties and yams.

--several unrefrigerated items which should have been refrigerated, including buttermilk ranch dressing, creamy Caesar dressing, soy sauce, spicy Thai chili sauce and Teriyaki marinade sauce.

The Nutrition Service Supervisor (NSS) indicated the portable cooler should have had a temperature log, dented cans were removed upon delivery, opened items were properly sealed and dated, cold food was maintained at 41 degrees Fahrenheit or below and hot food was maintained at 140 degrees Fahrenheit or above and food temperatures were documented for each meal, including the cafeteria steam table. The NSS had not seen the Dietary Department Cleaning Maintenance Schedule until shown.

At 11:15 AM:

The Cook and a Nutrition Services Aide were observed wiping the serving line and the bottom of soup bowls/plates/trays with a rag full of sanitizer, alternating back and forth with the same rag and same gloves on. The same Nutrition Services Aide was observed in the kitchen touching counters, doors, handles and returning to the serving line using the same rag and same gloves.

--the dietary staffers were observed serving the lunch meal throughout, and lunch temperatures were not documented. The Cook indicated temperatures were taken prior to serving but not documented. Temperatures were then documented afterward for 6 items. The breakfast temperatures were copied prior to lunch. After lunch, the breakfast temperatures were rewritten on a new log sheet along with the lunch temperatures, and six temperatures were documented instead of the original seven. None of the breakfast temperatures written on the new log sheet matched the temperatures written for breakfast on the previously copied log sheet. Some differed by 20 to 30 degrees.

At 11:35 AM: a dietary staff member checked a sanitizer bucket for concentration and it was 100 parts per million. The dietary staff member indicated the correct concentration was 200 parts per million, but then left the sanitizer bucket in tact instead of changing it out.

At 11:35 AM, the ranch dressing was temped at 50 degrees on the cafeteria serving line.

At 11:40 AM:

A Nutrition Services Aide was observed slicing cucumbers with gloved hands, touching the sliced cucumbers, touching the soiled apron, touching the garbage lid twice, touching the cucumbers and placing the cucumbers onto a patient tray.

A second Nutrition Services Aide was observed picking up pudding containers from the floor, handling a container of olive oil and then handling new plastic lids with the same gloves.

On 5/10/17 at 9:00 AM, a Nutrition Services Manager (NSM) from another facility- licensed location explained the facility had operated without a Food Services Director since mid January 2017. The current Nutrition Services Supervisor started employment in mid February 2017. During the current search for a Nutrition Services Director, The Chief Financial Officer was in charge. A couple months ago, the NSM started coming to the facility's kitchen 2-3 times weekly to oversee things, but the NSM had not been at the facility's kitchen in about a month.

The NSM did not train the current Nutrition Services Aides when at the facility. The NSM indicated opened/leftover food should be properly sealed and dated during storage in dry goods or while in the cooler/freezer. Two-hundred parts per million was the acceptable concentration for sanitizer. Food should be temped on the steam table well before being plated. The dozens of blank meals in the temperature logs were unacceptable. The facility did not have to temp the cafeteria steam table. The NSM had not seen the Dietary Department Cleaning Maintenance Schedule before until the interview. The schedule revealed the ice machine was supposed to be wiped in the morning daily.

On 5/12/17 at 1:55 PM, the Human Resources Director provided a report indicating the Nutrition Services Supervisor, hired in mid February 2017, first signed a job description acknowledgment 3/5/17. The Cook had not yet signed a job description acknowledgment.

According to the Nutrition Services Director (which was vacant during the inspection) Job Description, responsibilities included the following:

--Maintains sanitation and proper temperature as well as correct food handling techniques...

--Determines quality (taste, temperature and appearance), quality and portion size of food required and ensures proper handling of food.

--Checks routine maintenance and requests work orders, as necessary.

According to the Nutrition Service Supervisor Job Description, responsibilities included the following:

--Maintains sanitation and proper temperatures as well as correct food handling techniques in department to ensure compliance with all regulatory agencies.

--Ensures that in-service education meetings are held and courses are completed as required.

According to the Cook's Job Description, responsibilities included the following:

--Covers, labels, and dates all left-over or opened foods and effectively uses left-overs.

--Monitors and records refrigerator and freezer temperatures as well as temperatures on patient and cafeteria steam table.

According to the Nutrition Services Aide Job Description, responsibilities included the following:

--Maintains proper temperature for both hot and cold foods.

--Monitors and records temperatures, as necessary.

--Cleans and sanitizes all assigned areas.

Section 3 of the Cleaning and Sanitation Schedule policy (9.040 revised January 2011) revealed the Food Services Manager would make daily inspections of the department to ensure the schedule was followed.

The Food Storage and Handling section of the Infection Control in Food & Nutrition Services Department/Infection Control Program revealed all perishables were stored in refrigerators; all perishable items stored in a refrigerator were labeled with the date it was made and if frozen, labeled with the date thawed; and no markedly dented, rusted, and/or bulging canned product would be used.

Section 1 of the Identification of Sanitation Responsibilities policy (9.150 revised January 2011) revealed the Food Services Manager would be responsible for the supervision of sanitation and housekeeping procedures within the Food Services Department.

Section 2 of the Identification of Sanitation Responsibilities policy (9.150 revised January 2011) revealed the Food Services Manager and Dietitian were responsible for training personnel in the proper sanitation procedures in storing, preparing and serving food...

The In-services policy (9.190 revised January 2011) revealed in-services were held for Food Service Department employees monthly concerning pertinent matters.

The current Nutrition Services Supervisor, who started work in mid February 2017, provided documented evidence of two in-services: 3/5/17 and 5/9/17 (the first day of the inspection).

The Labeling of Opened Food Containers or Leftovers (9.220 revised January 2011) revealed all opened packages of food must be kept sealed and labeled with product name and date product was opened.

Procedure 2 of the Safety, Temperature Check policy (9.450 revised January 2011) revealed refrigerated storage temperatures were checked and recorded to be kept on file every morning.

Based on interview and record review the facility failed to complete a physician ordered dietary consult and weights for 1 of 30 sampled patients (Patient #20).

Findings include:

Patient #20

Patient #20 was admitted on 4/28/17, with diagnoses including chronic kidney disease, cerebrovascular accident, hypertension, anemia, obesity and gout.

The patients physician orders dated 4/29/17, documented for a dietary consult for an evaluation and recommendations. The physician also ordered for weights to be taken every Sunday and Wednesday.

On 5/9/17, there was no documented evidence a dietary evaluation was completed or weights taken every Sunday and Wednesdays.

On 5/10/17 in the afternoon, the Chief Nursing Officer (CNO) confirmed the Dietitian was not notified to complete a dietary evaluation on the patient. The CNO confirmed the initial admission weight was obtained but the following weights were not obtained on Wednesdays and Sundays.

Based on record review, interview, observation and policy review, the facility failed to ensure a policy requiring the use of intravenous solution bags, medication administration tubing and associated connectors for only one patient and failed to ensure an employee performed hand hygiene at an interval required by policy.

Findings include:

On 5/12/17 in the morning, the facility's clinical, Infection Control and Medication Administration policies lacked documented evidence of a policy requiring intravenous solution bags, medication administration tubing and associated connectors to be used for only one patient.

On 5/12/17 in the morning, the Infection Control Officer was unable to provide a policy requiring intravenous solution bags, medication administration tubing and associated connectors to be used for only one patient.


32828

On May 10, 2017 in the afternoon, it was observed that the Respiratory Therapist performed hand hygiene, donned gloves, performed scanning of medications and electronic medical record documentation, and went to the patient bedside and moved a wheelchair next to the bed in order to access the mask above the bed to administer the breathing treatment without again performing hand hygiene.

The facility policy titled Hand Hygiene Technique, last revised on 11/2015, stated to follow the CDC [Centers For Disease Control] Guidelines for Hand Hygiene in Healthcare Settings.

During an interview on May 11, 2017 in the morning, the Infection Control Officer stated that the facility followed the CDC Guideline for Hand Hygiene.

The CDC Guideline for Hand Hygiene in Health-Care Settings stated on page 32, section 1. I to decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.