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Based on policy and procedure review, review of the Authorization and Consent form, review of the patient Handbook and Rights and interview, it was determined the facility was not following its own policy to provide the State Agency address and phone number for lodging a complaint or grievance to patients or their representatives. The failed practice did not allow patients or their representatives to be informed of their right to file a complaint or grievance with the State Agency. The failed practice affected all patients admitted to the facility. Findings follow:

A. Review of policy and procedure titled, "Patient Rights," showed patients were to be informed in writing of the State Agencies addresses and phone numbers for patient complaints, grievances, etc. The information was to be clearly posted with phone number and address of the the State Agency.
B. Review of the Authorization and Consent form showed: "Abuse, Complaints or Grievances: I have been given information on filing a complaint, grievance or reporting abuse. I am aware that the Medicare Hotline is 1-800-327-3419." There was no evidence the form include the State Agency's address and phone number.
C. Review of the Patient Handbook and Rights showed the patient or patient representatives only received the number of the hospital and not the phone number and address of the State Agency for filing a complaint or grievance.
D. During interview with the Director of Nursing (DON), the above findings in A ,B and C were verified at 8:30 AM on 05/30/18.

Based on review of the 2018 Medication Refrigerator Log and interview, Pharmacy Services failed to ensure medications requiring refrigeration were stored between 36 and 46 degrees Fahrenheit according to the accepted professional standard of the United States Pharmacopeia (USP) for one of one Nursing Unit. The likelihood existed for the integrity of the medications to be compromised resulting in decreased stability of the medications. Findings follow:

A. On 05/29/18 at 12:30 PM, the 2018 Medication Refrigerator Log at one of one Nursing Unit was reviewed for the time period 01/01/18-05/29/18. The review showed in 147 of 149 days the temperature of the Medication Refrigerator was less than 36 degrees Fahrenheit. The temperature range for 147 days was between 30 and 34 degrees Fahrenheit.
B. In interview with Registered Nurse (RN) #1 on 05/29/18 at 12:40 PM, she verified medications were stored at a temperature less than 36 degrees Fahrenheit for 147 of 149 days between 01/01/18 and 05/29/18 at the one Nursing Unit.

Based on observation and interview, it was determined the facility failed to maintain the building physical structure, environment and equipment in a state of good repair (chipping on wooden handrail and a power strip was standing in water) in two (Activity Room and the Laboratory [Lab]) of nine areas observed. The failed practices had the potential to affect all patients and staff due to the potential for injury to presented by the observed conditions. Findings follow:

A. During a tour of the facility on 05/29/18 at 12:05 PM, observation showed chipping on the wooden handrail for the patients' stair steps in the Activity Room.
B. During the tour, the Corporate Executive Officer verified the chip in the handrail.
C. During an inspection of the Lab on 05/30/18 at 10:00 AM, observation showed a power strip in standing water from a leak on the floor of the Lab.
D. During the inspection, the Infection Control Nurse verified the power strip was in water on the floor of the Lab.

Based on observation, review of manufacturer's recommendations and interview, it was determined the facility failed to ensure supplies were maintained to assure their level of safety and quality as follows:
1. Contour Glucose solutions were not dated when opened to ensure that they were not used past six months after opening.
2. Six of six Arterial Blood Gas (ABG) Samplers were expired.
3. Two of two Chloraprep sponges were expired.

The failed practices did not ensure the integrity of the glucose control solutions, ABG samplers, and Chloraprep sponges were not compromised prior to patient testing or use. Findings were:

A. Review of policy and procedure titled Infection Control and Employee Health showed sterile supplies would be properly maintained in their assigned department.
B. Review of the manufacturer's recommendation for the Contour Glucose Control Solutions showed it was important not to use the control if the expiration date printed on the bottle label and carton has passed or it has been six months since the bottle was first opened and would be helpful to write the six month date on the label in the area provided when the control was opened.
C. During tour of the storage room on 05/30/18 at 10:00 AM, 6 of 6 ABG samplers were found expired. 3 ABG samplers expired 11/16, 2 expired 10/17, and 1 expired 07/16. Two of two Chloraprep sponges were found expired 02/18.
D. During interview with the Infection Control Nurse on 05/30/18 at 10:10 AM, the above findings in A and C were verified.
E. During tour of the medication room on 05/30/18 at 1:15 PM, the Contour Glucose Control Solutions were found without the date of opening or discard date written on the bottles.
F. During interview with the Infection Control Nurse on 05/30/18 at 2:35 PM, the findings in B and E were verified.

Based on observation and interview, it was determined the facility failed to ensure proper temperature control in one of one laboratory specimen refrigerator in that no temperature was being monitored or logged for temperature control. The failed practice did not assure patient specimens were stored at the proper temperature needed for accurate test results. The failed practice had the potential to affect any patient who needed laboratory specimen collection. Findings follow:

A. During tour of the laboratory area on 05/30/18 at 10:00 AM, the specimen refrigerator was found with no method of monitoring or documenting the temperature of the refrigerator.
B. During interview with the Infection Control Nurse on 05/30/18 at 10:10 am, the above finding in A was verified.

Based on observation, policy and procedure review, interview and manufacturer's recommendation, it was determined the Infection Control Nurse failed to identify and control infections in that two of two laryngoscope blades were found unwrapped in the crash cart and had not been high level disinfected. The failed practice did not assure the equipment had been cleaned or sterilized and stored in a manner to ensure protection from damage or contamination. The failed practice had the potential to affect all patients who needed the use of a laryngoscope for intubation. Findings follow:

A. Review of policy and procedure titled Infection Control and Employee Health shows " All chemicals used will be accordance with manufacturers direction.
B. During tour of the Rehabilitation Unit on 05/29/18 at 12:30 PM, 2 of 2 laryngoscope blades were found unwrapped in the top drawer of the crash cart.
C. During interview with Registered Nurse #1 on 05/29/18 at 12:45 PM, she stated that the laryngoscope blades were cleaned using Zogics Antibacterial Surface Wipes.
D. Review of the Zogics Antibacterial Surface Wipes manufacturer's recommendations showed the Zogics Wipes were a hazard to humans and domestic animals. The directions for use of the Zogics Wipes stated "This product is not for use on critical and semi critical medical device surfaces."
E. The findings in A, B, C and D were verified with the Infection Control Nurse on 05/29/18 at 1:00 PM.