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Based on observation, interview and policy review, the facility failed to document Crash Cart Checks in accordance with Hospital Policy to ensure availability of Emergency Supplies and Equipment if needed. Findings include:

On 5/26/10 at approximately 10:30 AM, while accompanied by ER Staff RN, the Crash Cart in the ED was opened and inspected for contents, supplies and equipment. The May, 2010 Crash Cart Quality Control Record was reviewed which included a check completed by hospital staff on May 21, 2010 as confirmed with ER Staff RN. Hospital Policy -Nursing-General Crash Cart Checks states: 6. Review of the crash carts will be performed item by item against the Crash Cart Quality Control Record at the following times: A. Twice each month on the 1st and 15th. Bi-monthly check to include outdating of all items with expiration dates, i.e. medications, sterile trays. Confirmation of Hospital Policy and May 2010 checks were verified with the ED Manager.

On 5/27/10 at approximately 1:20 PM, while accompanied by staff Respiratory Therapist the Crash Cart in the CCU was opened and inspected for contents, supplies and equipment. The Crash Cart Quality Control Record for April and May of 2010 were reviewed with the CCU Staff RN, who verified that checks completed in April, 2010 and May, 2010 were not in compliance with hospital policy.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See C-231

Based on observation and interview, it was determined that the facility failed to provide a safe and clean environment. Findings include:

During a tour of the facility on the morning of May 26, 2010 it was observed there was about 10 pieces of medical tape about two feet long on the floor in the corridor outside the sterile storage room in the Operation Suite. Interview with the Plant Operations Manager on May 26, 2010 at approximately 3:00 PM, he stated that staff in that department indicated to him that they had put the tape in the corridor after the floor was waxed because they were worried about slipping.


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On 5/25/10 at approximately 1140, during a tour of the CCU (Critical Care Unit) clean storage room, five boxes of clean, unused medical equipment (for patient use) were stored in cardboard boxes on the floor. One pillow with a reddish-brown dried substance was also observed. These findings were confirmed by the Manager of Risk Management/Corporate Compliance.

Based on interview and record review, the facility failed to ensure that proper ventilation was provided in airborne isolation rooms. Findings include:

During an interview with the Plant Operations Manager on May 26, 2010 at approximately 1400, it was discovered that the facility was not monitoring air pressure daily with visual indicators when the room in use by a patient on Airborne Precautions as required by CDC guidelines. Record review confirmed that the facility was not using a visual indicator when monitoring its air pressure in the airborne isolation rooms.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on May 27, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated May 27, 2010, for Life Safety Code.

Based on interview, policy review and document review, the facility failed to provide necessary oversight of clinical practices. See C-241.

Based on interview, policy review and document review, the governing body did not ensure the development, implementation and monitoring of polices related to oversight of clinical practices for Respiratory Therapy. Findings include:

On 5/26/10 at approximately 1345, the Cardiopulmonary Department Manager (CDM) and Risk Manager (RM) were interviewed in the second floor office. During review and discussion of staffing and services provided by the department, the following hospital policies/protocols were reviewed and discussed:
1) Cardiopulmonary-Scope of service last revised 9/11/07
2) Respiratory Consult Services last revised 5/1/07 and last reviewed 9/1/09
3) Protocol Frequency Guidelines last revised 5/1/07 and last reviewed 7/30/09
4) Medicated Aerosol Administration last revised 11/20/06 and last reviewed 7/30/09
5) Incentive Spirometry last revised 9/12/07 and last reviewed 9/12/07 and
6) Oxygen Administration last revised on 9/1/07 and last reviewed on 9/1/07.

Hospital staff present verified that the Respiratory Therapist may initiate protocols (volume expansion, Bronchial Hygiene, Aerosolized Medication and/or Oxygen) without a physicians order. It was further verified that if the admitting physician does not want his/her patients to receive protocol implementation by RT that the physician is to write an order for that patient stating "Do not initiate respiratory protocols."

The protocols and policies reviewed do not contain specific parameters for medications identified which include: Beta Adrenergic agents, Anticholinergic agents, Anti-inflammatory agents, Mediator-modifying compounds, Mucokinetics and Palliative pain management. When asked what physician oversight is present for RT to practice in this manner, staff present stated that these policies/protocols have been included in the hospital By-Laws. Surveyor requested a copy of the related By-Laws and any related Committee Meeting minutes.

On 5/27/10 at approximately 0930, in second floor conference room, a copy of Medicine Section/CCU Committee meeting minutes dated May 3, 2007 from the RM was received and reviewed. The following is
included in the meeting minutes: "Respiratory Therapy Protocols - CDM presented a policy titled Protocol Frequency Guidelines. She explained that this policy provides guidelines for the frequency of treatments given under the RT protocols based on objective scoring of patient severity. Further, it should reduce the number of times physicians are contacted during the night on treatment protocols. Physicians will still have to countersign this type of standing order." When asked for additional documentation of approval, implementation, oversight or monitoring of these practices by physicians, RM verified that the policies/protocols are not present in the hospital By-Laws, and there is no additional documentation which provides oversight by physicians or governing body.

Based on observation and interview, the facility failed to remove expired drugs from a medication storage area and failed to label medications for two patients (#4 and #17) in accordance with professional standards. Findings include:

On 5/25/10 at approximately 1150, three 250 milliliter bottles of 5% Dextrose Solution, expired 3/10, were observed in the Critical Care Unit Medication Room. This finding was confirmed by the Manager or Risk Management/Corporate Compliance.

On 5/26/10 at approximately 0900 the following was observed in the pharmacy:
1) One vial of Diptheria Tuberculin and Pertussis toxin vaccine expired 5/15/10.
2) One vial of 2% Acetic Acid solution expired 2/10.
3) Four bottles of white liquid labeled with a pharmacy prepared label containing only the patient #4's name.
4) Seven bottles of pink liquid, with pharmacy label stating patient #17's name and Pepto Bismol, with no expiration date.

These observations were confirmed by the Pharmacy Director. On 5/26/10 at approximately 0930, the Pharmacy Director stated that there was no policy for preparation and labeling of pharmacy poured medications.

Based on observation the facility failed to ensure drugs, biologicals and intravenous medications were administered in accordance with accepted standards of practice and failed to obtain a witness signature for a consent. Findings include:

1) During the survey observation tour of the critical care unit (CCU) on 5/25 at 11:50am, it was noted in the refrigerator 3 of 5 multi-use vials (N, Novalog and Lantus) were undated as to when they were opened.

2) On 5/27/10 at 10:00am the observation in the pre-op holding area noted open and undated bottles of Childrens Motrin and Tylenol.

3) For MR #9: The "Consent to Whole Blood and Blood Components Transfusion" document dated 2/7/10 noted for signature of patient the person obtaining consent documented; "Verbal consent (patient MR #9 + dtr (Patient's daughter)"(sic). Under the signature of the person obtaining consent a signature was present. The space for a witness was left blank.

Based on interview and record review it was determined that the facility failed to contact the designated Organ Procurement Organization (OPO) in a timely manner for two (#22 and #23) of 16 deceased patients records reviewed. Findings include:

The agreement between the facility and the OPO, last revised 12/17/10, states:
A) Page 1- The facility will report all deaths to the OPO.
B) Page 2- Report to OPO all individuals who meet clinical triggers or have been declared dead within one hour.

On 5/26/10 at 1025, OPO referral data was reviewed with the Director of Patient Outcomes. The facility identified two referrals that were not made within one hour following patient deaths. The Director of Patient Outcomes stated that patient #22's nurse was late in placing the call to the OP) and that the Supervisor responsible for calling the OPO after patient #23's was unaware of the requirement.