HospitalInspections.org

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observations, review of facility policies and procedures, and staff interviews, it was determined the facility failed to ensure the staff followed the policy for safe storage of medications on the crash cart in the Nursing Unit.

This had the potential to affect all patients served by the facility.

Findings include:

Facility Policy: Crash Cart

Purpose:

To provide an effective way of delivering emergency care when a patient's condition deteriorates.

This cart is checked each shift.

Procedure:

1. Cart is stocked and locked.
2. The crash cart is checked each shift to ascertain that the lock is intact. Once the lock has been broken a complete inventory of the cart must be made and a new lock put in place.
3. The crash cart will be restocked immediately after use and relocked.

Review of the Daily Crash Cart Check list dated February 2012 revealed no documentation the nurse checked the crash cart on the following:

2/2/12 - 7:00 AM shift

2/3/12, 2/11/12, 2/12/12, and 2/17/12 - 7:00 PM shift.

Review of the Daily Crash Cart Check list dated March 2012 revealed no documentation the nurse checked the crash cart on the following

3/3/12 - 7:00 AM shift

3/3/12, 3/4/12, 3/10/12, 3/11/12, 3/12/12, 13/3/12 and 3/116/12 - 7:00 PM shift.

Review of the Daily Crash Cart Check list dated April 2012 revealed no documentation the nurse checked the crash cart on the following:

4/1/12, 4/15/12, and 4/29/12 - 7:00 AM shift

4/4/12, 4/14/12, 4/19/12, 4/27/12, and 4/31/12 - 7:00 PM shift.

Review of the Daily Crash Cart Check list dated May 2012 revealed no documentation the nurse checked the crash cart on the following:

5/13/12 and 5/17/12 - 7:00 AM shift

5/1/12, 5/2/12, 5/4/12, 5/5/12, 5/6/12, 5/10/12, 5/22/12, 5/23/12, 5/30/12, and 5/31/12 - 7:00 PM shift.

Review of the Daily Crash Cart Check list dated June revealed no documentation the nurse checked the crash cart on the following:

6/5/12, 6/6/12, and 6/8/12 PM shift.

The crash cart was checked and documented as unlocked on 6/3/12 AM and PM shift, 6/4/12 AM and PM shift, 6/5/12 AM shift.

The surveyor asked EI # 1, the Director of Nurse on 6/12/12 at 10:30 AM why the crash cart remained unlocked for 3 days and the response was, " a patient went bad on Saturday night and the crash cart was opened. There was no pharmacist here to restock and lock the cart back up."

During a tour on the Nursing Unit on 6/12/12 at 10:00 AM the surveyor opened the crash cart to check for expired drugs.

During a tour of the Nursing Unit on 6/13/12 at 8:30 AM the surveyor noted the crash cart was not locked.

Based on observation and interview, it was determined the facility failed to ensure that all medications available for patient use were not expired.

This had the potential to negatively affect all patients served at the facility.

Findings include:

During a tour on the Nursing Unit on 6/12/12 at 10:00 AM the surveyor found 8.4 % sodium bicarbonate 50 meq (milliequivalents) on the crash cart,which expired 5/1/12. Employee Identifier # 1, the Director of Nurses verified the 8.4 % sodium bicarbonate was expired.

During a tour of the Surgical Suite on 6/12/12 at 1:00 PM the surveyor found 3 packages of Xeroform Petrolatum Dressing expired 7/20/11 and 5 vials of epinephrine 1:1000 - 1 mg (milligram)/1 ml (milliliter) which expired 5/1/2012. Employee Identifier # 2, the Charge Nurse for Surgery verified the above expired drugs and dressings.

Based on observations, review of the Refrigerator Logs and procedures, and interviews it was determined the facility failed to ensure the staff followed the their own procedures for checking refrigerator temperatures. This had the potential to negatively affect all patients served by this facility.

Findings include:

Procedure stamped on each Refrigerator Log:

Temperature readings are to be monitored daily and recorded. Temperature range is 35-45 degrees. If intervention is required, record on back of log to include date, time, and action, with name of person completing task.

Review of the Refrigerator Log for the Medication Room in the Nursing Unit dated January 2012 revealed no documentation of a temperature on 1/1/12, 1/7/12, 1/8/12, 1/14/12, 1/15/12, 1/21/12, 1/22/12, 1/24/12, 1/28/12, and 1/29/12.

Review of the Refrigerator Log for the Medication Room in the Nursing Unit dated February 2012 revealed no documentation of a temperature on 2/4/12, 2/5/12, 2/11/12, 2/12/12, 2/18/12, 2/19/12, 2/25/12, and 2/26/12.

Review of the Refrigerator Log for the Medication Room in the Nursing Unit dated March 2012 revealed no documentation of a temperature on 3/3/12, 3/4/12, 3/11/12, 3/12/12, 3/17/12, 3/18/12, 3/24/12, 3/25/12, and 3/31/12.

Review of the Refrigerator Log for the Medication Room in the Nursing Unit dated April 2012 revealed no documentation of a temperature on 4/1/12, 4/4/12, 4/7/12, 4/8/12, 4/14/12, 4/15/12, 4/21/12, 4/22/12, 4/28/12, and 4/29/12.

Review of the Refrigerator Log for the Medication Room in the Nursing Unit dated May 2012 revealed no documentation of a temperature on 5/5/12, 5/6/12, 5/12/12, 5/13/12, 5/19/12, 5/20/12, 5/25/12, and 5/26/12.

Review of the Refrigerator Log for the Medication Room in the Nursing Unit dated June 2012 revealed no documentation of a temperature on 6/2/12, 6/3/12, 6/9/12, and 6/10/12.

During a tour of the Recovery Room on 6/12/12 at 1:00 PM the surveyor identified the Refrigerator Log dated June 2012 and found no documentation of a temperature since 6/6/12.

During a second tour of the Recovery Room on 6/13/12 at 12:15 PM the surveyor found the Refrigerator Log dated June 2012 completed up to 6/14/12.

An interview was conducted on 6/13/12 at 1:10 PM with Employee identifier # 3, the Quality Assurance Nurse. The surveyor asked how the employee completed the Refrigerator Log up to tomorrow and the response was, "I have no idea".

Based on observations, interviews and medical record review, it was determined the facility failed to ensure the equipment used for whirlpool was cleaned and disinfected between uses according to their own policy. This affected Medical Record # 282375 and had the potential to negatively affect all patients served by this facility who had treatment with the whirlpool.

Findings include:

Facility Policy: Whirlpool Use

Purpose: To provide guidelines for control of infection while in contact with patients using whirlpool for wound debridement.

Procedure:

Strict aseptic technique shall be applied and maintained for all whirlpool procedures (see policy: Cleaning and Reprocessing of Patient Care Equipment and Medical Devices)...

The water in the deep LE Whirlpool, Hubbard, and Setma tanks is agitated via mechanical means (e.g. turbine). Turbines and mechanical agitators are disinfected after each treatment by running disinfectant through the turbine and then flushing the system with water.

The surveyor conducted a tour of the Nursing Unit on 6/12/12 at 10:35 AM with Employee Identifier (EI) # 1, the Director of Nurses. The surveyor observed a piece of electrical equipment on the floor in the patients' bathroom in the hall. The surveyor asked EI # 1 what the equipment was. The response was it was used for whirlpools. The surveyor requested the chart of the last patient who was treated with the whirlpool.

Medical Record # 282375 was admitted to the facility on 1/28/11 with a diagnosis of Infected Left Heel Ulcer. Review of the culture report for the left heel final report dated 2/1/11 revealed a growth of an Acinetobacter and Bacillus Species.

Review of the physician's orders dated 1/28/11 revealed orders for the nursing staff to provide wound care to the left foot with whirlpool 4 times a day. Review of the nursing documentation between 1/28/11 and the discharge date of 2/1/11 revealed documentation the nursing staff was providing the whirlpool. There was no documentation of the whirlpool being cleaned between uses.


An interview was conducted on 6/13/12 at 1:30 PM with Employee Identifier # 3, the the Quality Assurance Nurse. The surveyor requested the policy titled Cleaning and Reprocessing of Patient Care Equipment and Medical Devices and a log or other documentation the whirlpool had been disinfected. The response was, "I am not sure when it was last clean. There is no log or other documentation the whirlpool has been cleaned and I do not have a policy titled Cleaning and Reprocessing of Patient Care Equipment and Medical Devices".