HospitalInspections.org

Based on observation, interview, and policy review the facility failed to ensure emergency equipment was ready for a patient emergency in two of two crash carts in the Obstetrics (OB [labor, delivery and post delivery patients, and newborn nursery]) Department and one of two emergency boxes in the OB Department. The average monthly deliveries were 19. The facility census was 27.

Findings included:

1. Record review of the facility policy titled, "Checking the Crash Cart, Each Shift, Monthly and Restocking," revised 03/12 showed the following direction:
-Each nursing unit will maintain a fully stocked crash cart at all times to ensure that the needed equipment and supplies are readily available in case of an emergency.
-The crash carts are to be checked monthly for any outdated supplies.
-Be sure nothing is expired. If it is going to expire in the month it is being checked the item should be removed, even though technically it does not expire until the end of the month. However, if a product is expired it must be replaced immediately.
-Technically pharmacy is responsible for medication and IV fluids. They have started including a list of products with their expiration dates. These are usually found on to on the top of the cart or in the code blue book. It is always a good idea to scan this list to make sure nothing is expired.

2. Observation on 06/04/12 at 2:25 PM showed the following in the OB Department crash cart:
-A multi-lumen CVC (central venous catheter-a tubular surgical instrument that is inserted into a cavity of the body and used to introduce fluid or withdraw it) kit which expired on 04/12.
-A Dobutamine (medication to stimulate heart function in a liquid form) bag, 250 milligrams (mg) expired 06/01/12.

Record review of the monthly Crash Cart Check Sheet showed the OB crash cart contents were last checked on 05/04/12. Expiration dates listed on the check sheet for the two expired items were documented as 09/12 for the multi-lumen kits and 06/12 for the Dobutamine.

During an interview on 06/04/12 at 2:45 PM Staff F, Pharmacy Technician stated that the crash cart is checked monthly for expired medications and the Dobutamine should have been removed from the cart.

During an interview on 06/04/12 at 2:45 PM Staff D, OB Department Director, confirmed that the CVC kit and the Dobutamine were both expired.

3. Observation on 06/04/12 at 2:50 PM of the contents of an emergency box, called the "hot box" by OB staff, showed;
-A Foley (a catheter that is introduced into the bladder to drain out the urine) tray expired 08/11.
-A bag of 1,000 milliliters (ml) of Lactated Ringers (LR) (a type of Intravenous (IV) fluids) expired 06/01/12.

During an interview on 06/04/12 at 2:55 PM, Staff D confirmed that the Foley tray and the LR were both expired.

Record review of the Monthly Outdates (Outside of Pharmacy) showed the hot box was last checked by pharmacy staff on 05/08/12.

4. Observation on 06/04/12 at 3:32 PM of the "newborn" crash cart showed an Umbilical Catheter (a flexible tubular device used to put into the umbilical artery of a newborn to introduce fluid withdraw it) expired 04/2012. Staff D confirmed that the Umbilical Catheter Tray was expired.

Record review of the Newborn Crash Cart Check Sheet showed the newborn crash cart was last checked on 05/04/12. The Umbilical Catheter Trays were documented to expire on 10/12 and 06/13.

Based on interview and record review the facility failed to have policies in place regarding agency staff orientation, and failed to maintain documentation of one of one agency staff reviewed (Registered Nurse-RN) Staff R. This had the potential to affect any agency staff utilized. The facility census was 15.

Findings Included:

1. Review of agency RN Staff R's personnel file showed Staff R was hired on 04/30/12 to work in the Intensive Care Unit. The personnel file showed no evidence of orientation to the facility.

2. During an interview on 06/06/12 at 8:40 AM, RN Staff C stated Staff R was employed by the facility for a six-week period; however, Staff R could not find documented evidence of his orientation. Staff R stated this was the only agency staff utilized in several years. Staff R also stated there were no policies regarding agency staff use and/or orientation.

Based on observation, interview and record review the facility failed to ensure multi-use bottles/vials/ointments/solutions were not available for use in one refrigerator and in two of two surgical suites reviewed, according to their own policy. The facility census was 15.

Findings Included:

1. Review of a facility policy titled, "Medication Administration," revised 07/03, showed the following:

-Multi-vial doses will not be used on other patients once opened, and will be discarded after the patient has been discharged.

2. Observation and concurrent interview on 06/04/12 at 3:00 PM, showed the following:

-In the Emergency Department (ED) refrigerator, inside the medication room, there were three vials (all antibiotics) of opened and portions used of the following=
-Cephalexin 125 milligrams (mg) per milliliter (ml), dated 06/11;
-Amoxicillin 400 mg/5 ml, dated 06/11;
-Augmentin 400 mg/5 mg/5 ml, dated 06/13.

The Director of the ED, RN Staff O stated this type of vial is dated and initialed as to when opened and then discarded two weeks after opening. Staff failed to date the vial as to when opened (the only date on the vials was the date to discard), and failed to initial the vials.

Contrary to what the ED director stated, during an interview on 06/04/12 at 4:15 PM, the Chief Nursing Officer stated multi-dose vials were not to be used in this facility at all. All vials were be discarded after use. Staff failed to know and follow the facility policy regarding these antibiotics, making them available for further use.

3. Observation and concurrent interview on 06/06/12 at 11:10 AM showed the following:

-In a surgical suite, on a shelf, two tubes of KY (a lubricant) four and one-fourth ounces each; and one four-ounce bottle of Povidone Iodine (an antiseptic) both opened and used.

The Director of Surgery, RN Staff U confirmed these items should not be kept for re-use. Staff failed to discard after opening and use.

4. Observation and concurrent interview on 06/06/12 at 11:30 AM showed the following:

-In the obstetric (OB) surgical suite, on a shelf, one tube of KY.

The Director of OB, RN Staff D confirmed these items should not be kept for re-use. Staff failed to discard after opening and use.

Based on interview and record review, the facility failed to authenticate (with date and time) entries in three (#9, #21 & #22) of three current patients' medical records reviewed for authentication of orders and three (#23, 25 & 26) of five discharged records reviewed for authentication of orders. The facility census was 15.

Findings included:

1. Record review of the facility's "Medical Staff Bylaws," revised 05/10, showed the following direction:
- Verbal orders shall be authenticated by the ordering practitioner as soon as possible, but no later than 48 hours after the order is given.

Record review of a select number of medical records showed the facility signed the verbal and telephone orders, but failed to time and date the signature of the orders. Review of the following medical records showed the following:

2. Record review of Patient 9's medical record showed that the patient was admitted to the facility on 06/01/12.
-The verbal orders dated 06/01/12 at 5:30 PM for the following medications failed to be authenticated with a date and time of the physician's signature:
Norco 5/375 - 1 tablet every 4 hours for pain;
-Zantac (medication used to treat ulcers) 150 milligrams (mgs) (PO) by mouth (BID) twice daily.
-K-Dur (potassium medication used to treat a potassium deficiency) 20 millequivalents - Hold
-MOM (milk of magnesia - used for constipation) 30 cc (centimeters) by PO BID

-The telephone order dated 06/01/12 at 6:24 PM for Rocephin 1 gram (gram) IV (intravenous) Q 24 (every 24 hours) failed to be authenticated with a date and time of the physician's signature.

- The telephone order dated 06/04/12 at 2:52 PM for Discharge planning for 06/05/12 to (named) nursing facility failed to be authenticated with a date and time of the physician's signature.

3. Record review of Patient 21's medical record showed that the patient was admitted to the facility on 05/30/12:
- The telephone orders dated 05/30/12 at 8:37 AM for the following medications failed to be authenticated with a date and time of the physician's signature:
-Discontinue Bicarb IV (Sodium Bicarbonate - household baking soda - used to treat excessive body acid, increase PH of urine, etc) given intravenous
-Ample calcium gluconate (a calcium supplement used to treat a calcium deficiency) IV
-Recheck blood sugar if greater than 200, give insulin Regular at 10 Units IVP.
-Normal Saline (a solution made from salt and used to re-hydrate a patient or provide fluids) at 150 cc (centimeters) per hour.
-Lasix ( a water pill used to reduce swelling and fluid retention) 40 mg IV in one hour.

- The telephone orders dated 05/30/12 at 2:50 PM for NPO (nothing by mouth) after midnight and Consent for gamma nail placement left hip failed to be authenticated with a date and time of the physician's signature.

- The verbal order dated 05/30/12 at 3:20 PM for wound care consult failed to be authenticated with a date and time of the physician's signature.

- The telephone orders dated 05/30/12 at 4:54 PM for Discontinuing K-Exalate ( a medication used to increase potassium in the body and can be used as an enema) and to give Lasix 20 mg IV now failed to be authenticated with a date and time of the physician's signature.

-The telephone order dated 05/31/12 at 3:18 PM for a change respiration rate on vent from 16 to 12 failed to be authenticated with a date and time of the physician's signature.

4. Record review of Patient 22's medical record showed that the patient was admitted to the facility on 06/03/12.

-The telephone orders dated 06/04/12 at 12:54 AM for a Clear liquid Diet at 6:00 AM, then NPO - test will be late morning failed to be authenticated with a date and time of the physician's signature.

5. Record review of Patient 23's medical record showed that the patient was admitted to the facility on 04/26/12.

-The telephone orders dated 04/30/12 at 11:59 PM for Ativan (used for anxiety) 0.5 mg PO BID PRN (as needed) failed to be authenticated with a date and time of the physician's signature.

6. Record review of Patient 25's medical record showed that the patient was admitted to the facility on 03/05/12.

-The telephone orders dated 03/05/12 at 11:50 PM for the following medications failed to be authenticated with a date and time of the physician's signature:
200 ml (milliliters) Free water per peg tube (a plastic tubing that can be used in providing gastric or post-surgical drainage or can be used as a feeding tube) after meals at 8:00 AM, 12:00 PM and 7:00 PM.
-Jevity 1.0 per peg tube continue at 70 ml per hour.

-The telephone order dated 03/06/12 at 4:25 AM for Ativan 1 mg SIVP (slow intravenous push) Q6h PRN for anxiety failed to be authenticated with a date and time of the physician's signature.

-The telephone order dated 03/06/12 at 5:20 AM for Lasix 20 mg SIVP x1 now (one time only) failed to be authenticated with a date and time of the physician's signature.

7. Record review of Patient 26's medical record showed that the patient was admitted to the facility on 04/06/12.
-The telephone order dated 04/09/12 at 6:20 AM for the following medication failed to be authenticated with a date and time of the physician's signature:
Discontinue Neurontin (a drug used for treating seizure disorders, shingles, fibromyalgia, neuropathy, etc), patient has not been taking at home et (and) causes n/v (nausea/vomiting) et tremors.

-The telephone orders dated 04/09/12 at 9:39 AM for the following failed to be authenticated with a date and time of the physician's signature:
OxyContin (medication used for pain) 20 mg ER PO BID.
-Do not release to home until pain under control.

-The telephone order dated 04/09/12 at 10:15 AM for a change in OxyContin 20 mg ER times to 1000 then Q8hrs TID (three times daily) failed to be authenticated with a date and time of the physician's signature.

-The verbal order dated 04/10/12 at 6:48 AM for Fleet enema PRN for constipation failed to be authenticated with a date and time of the physician's signature.

-The order dated 04/10/12 (no time) for physical therapy prior to discharge failed to be authenticated with a date and time of the physician's signature. The order also failed to contain a time of the order and it failed to contain type of order (whether verbal or telephone).

8. During an interview on 06/06/12 at 9:05 AM, Staff Q, Director of Health Information Management (HIM), confirmed that the facility was not in compliance with the regulations. She stated that the facility's rules and regulations and by-laws stated that the physicians should dated and time their verbal and telephone orders within 48 hours after the order is given to ensure they were done within the 48 hours time frame.