HospitalInspections.org

Based on review of documentation and interview, it was determined that PRN medications were administered according to facility policy and accepted standards.

Findings were:

Facility policy entitled "As Needed (PRN) Medication Orders" stated in part "As needed (PRN) orders will have frequencies specified. Nurses will document reasons for administration if the medication can be used for more than one indication and effectiveness of each dose of PRN medication administered to the patient."

Medication Order for Patient # 12 dated 8/26/15 stated "Ativan 2mg/ml Slow Push IV 1mg (0.5 syringe) q 2hrs PRN for agitation."

On 8/31/15, the Medication Administration Record (MAR) indicated that at 21:40 Patient # 12 was given 1 mg of Ativan IV. There was no note detailing what behavior the patient exhibited to indicate need for this medication, nor was there documentation in the medical record describing the patient's response.

The lack of documentation concerning the above administration of medication was confirmed by the Director of Quality on 9/2/15.

Based on review of documentation and interview, it was determined that the facility failed to complete the "Crash Cart / Defibrillator Check Sheet" as per hospital policy and procedure.

Findings were:

Defibrillator Inspection Policy Rule
LIFEPAK 20 Crash Cart Defibrillator/ Monitor; stated in part;
1. "The Charge Nurse/designee will inspect the defibrillator each day a unit functions as a patient care area.
2. The defibrillator will be inspected and tested according to the instructions on the LIFEPAK 20 Defibrillator/Monitor Operator's Checklist Guide (PS 40 82-053).
LIFEPAK 500 Automated External Defibrillator (AED); states in part;
1. The Charge Nurse/designee will inspect the defibrillator each day a unit functions as a patient care area.
2. The defibrillator will be inspected and checked according to the instructions on the LIFEPAK 500 AED operator's Checklist Guide (PS 40 82-053)."

Tour of the facility on 09/01/2015, revealed facility failed to maintain the accountability checklist of the Crash Cart in the emergency treatment room and nurses station area.

· Crash Cart /Defibrillator Check Sheet in the nurses station area was not checked a total of 14 times between the month of May 2015 to August 2015 the following dates:
May - 5/23, 5/24, 5/25, 5/30.
June - 6/17, 6/19, 6/25, 6/26, 6/27.
July - 7/1, 7/2.
August - 8/6, 8/7, 8/31.
· Crash Cart/Defibrillator Check Sheet in the emergency treatment room was not checked a total of 12 times between the month of May 2015 to August 2015.
May - 5/1, 5/2.
June - 6/18, 6/19, 6/24, 6/25, 6/26, 6/27.
July - 7/1, 7/2.
August - 8/7, 8/31.
In an interview with the Chief Nursing Officer on 9/1/15, it was acknowledged that the Crash Carts were not always checked daily according to facility policy.

Based on observation and interview, it was determined that the facility failed to provide a sanitary environment in all areas of the hospital.

Findings were:

"OSHA/Blood borne Pathogen Regulations Policy #138-030-060 " stated in part " The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

Policy Procedure Area Patient Care:
Environmental Services - Environmental Services are provided by the host as part of the Purchased Services Agreement. The routine cleaning of the patient rooms and work areas is the responsibility of the environment Services Department who will be notified by nursing of all admissions and discharges.

Tour of the hospital on 6/16/15 revealed the following infection control concerns:

· Nourishment Room
The top of ice machine was dusty/dirty, several drawers contained loose food particles, and a plastic bag with food was not dated. This indicated improper cleaning of the area.

· Patient Room # 19
Cardiac monitor was dusty and rust was noted on corners of bed frame. This rust made cleaning of the bed frame impossible.

· Shower Room
Strip of tape was noted on the arm of a shower chair and a dark adhesive mark where tape had been removed was also evident. Top of cabinet was dusty which indicated improper cleaning of the area.

· Environmental Room that contained multiple housekeeping chemicals was found to be unlocked. These chemicals could be a safety hazard to patients.

· Material Management Room
Contained multiple shipping boxed that were stored with clean medical supplies. Storing dirty items with clean items can lead to cross contamination.

· Medication Room
Omnicell medication cabinet was dusty
Biohazard large trash container was completely full above the rim. This indicated improper maintenance of the area.
Biohazard sharps container was more than ¾ full
Top of the large Refrigerator was dusty and in need of cleaning.

· Central Supply Room
Contained three (3) Shipping boxes, two of which were in the cabinet that contained sterile urinary catheters.

In an interview with the Chief Nursing Officer on 9/01/15, the above findings were confirmed.