HospitalInspections.org

Based on medical record (MR) review, policy and procedure, and staff interview, it was determined the facility failed to ensure patients were informed of the patient's rights prior to receiving care at the facility.

Findings include:

Hospital Policy: Informing Patients of Rights and Responsibilities
Initiated: 12/04
Revised: 7/24
Policy Number: Not listed

Policy:

Patients in all hospital settings are entitled to receive information about their rights and responsibilities while receiving care in that area. A patient representative designated by a patient is also entitled to receive this information.

Inpatients:

All inpatients will be provided a pamphlet at registration entitled "Information for Patients" which contains patients' rights.

Emergency Room (ER) Patients:

All patients who register will be provided a copy of the ER pamphlet "Information for Patients" which contains information on patients' rights.

Outpatient Clinic or Outpatient Surgery Patients:

All patients who register to receive services in an outpatient clinic setting or undergoing Outpatient Surgery will be offered a copy of the pamphlet "Information for Outpatients" which contains information on patients' rights at registration.

Outpatient Diagnostic Testing:

These patients will be furnished a copy on request.

Patient Rights include at least the following:

The ability to refuse care.

Respect for individual end-of-life decisions.

Effective Communication from care-givers.

Privacy, security, and confidentiality.

Environment that preserves dignity.

Freedom from abuse, neglect, or exploitation in any form.

Access to protective and advocacy services.

Ability to have a family member or friend (including same-sex domestic partner) present for emotional support during patient's inpatient stay...

Medical record review revealed, seven out of 10 emergency room records and two out of 20 inpatient records did not have a signed document confirming the patient had received a copy of their rights prior to receiving care at the facility.

An interview was conducted on 9/12/24 at 1:53 PM with Employee Identifier # 2, Director of Nursing, who confirmed the patients did not have a signed document confirming the patient's rights were given prior to receiving care at the facility.





49894

Based on observation and interview, it was determined the hospital failed to ensure:

Expired intravenous (IV) fluids and medications were not available for patient use.

This deficient practice had the potential to affect all patients receiving care at this hospital.

Findings include:

1. During a tour of the Labor and Delivery unit on 9/10/24 at 9:15 AM, with Employee Identifier (EI) # 6, Obstetrics assistant manager, the following IV fluids and medications were observed and available for patient use:

a. One 1000 milliliter (mL) bag of Magnesium Sulfate 40 gram (g) with an expiration date of 5/24.

b. Two 250 mL bags of normal saline with an expiration date of 6/24.

c. Two 10 mL Calcium Gluconate 1000 Milligram (mg) per mL with an expiration date of 5/24.


An interview was conducted on 9/10/24 at 10:15 AM with EI # 6, who confirmed the expired IV fluids and medications were available for patient use.

Based on observations, review of facility policies and procedures, and interviews with staff it was determined the facility failed to ensure:

1. Safe storage of food items in the dietary department.

2. Foods were labeled with the date opened and use by date or expiration date.

3. Expired foods were not available for use.

This had the potential to affect all patients admitted to this hospital.

Findings include:

Facility Policy: Food Storage
Policy Number: SOP #303
Issued: 7/18/22
Revised: None

Policy:

Food items will be stored, thawed, and prepared in accordance with good sanitary practice.

Procedure:

...Use by date shall be marked on all food containers ...

...Frozen Meat/Poultry and Foods:
...Storage: ...Label and date all food items.

1. A tour of the dietary department was conducted on 9/10/24 at 9:20 AM with Employee Identifier (EI) # 10, Dietary Manager, which included observations in the following areas:

a. Dry storage:

A full bin of individual Soy Sauce packs, with no use by or expiration date.

Rice being stored in a zip lock bag, expired on 8/22/24.

Flour, Meal, and Breadcrumbs being stored in separate bins, with no use by or expiration date.

Individual packs of Saltine Crackers, Club Crackers, Wheat Crackers and Honeymaide Graham Crackers being stored in separate bins with no use by or expiration date.

Three packs of Custom Culinary Chicken Flavored Gravy mix, and Seven packs of Brown Gravy mix being stored in separate bins with no use by or expiration date.

b. Cooler:

Thirteen eight-ounce Glucerna Therapeutic Nutrition Shakes, Creamy Strawberry expired on 7/1/24.

One eight-ounce Glucerna Therapeutic Nutrition Shakes, Rich Chocolate expired on 7/1/24.

One eight-ounce Nepro with Carbsteady Therapeutic Nutrition, Butter Pecan expired on 9/1/23.

Nine eight-ounce Nepro with Carbsteady Therapeutic Nutrition, Homemade Vanilla expired on 9/1/24.

The staff failed to ensure foods were labeled appropriately, stored, and discarded when expired or out of date.

An interview was conducted on 9/10/24 at 10:30 AM with EI # 10 who confirmed foods were not stored and labeled per policy.

Based on observations and interviews during a hospital tour with hospital staff and the Life Safety Code surveyor, it was determined the hospital was not constructed, arranged and maintained to ensure patient safety.

This had the potential to affect all patients served by this hospital.

Findings include:

Refer to tags K-0211, K-0223, K-0226, K-0281, K-0353, K-0361, K-0363, K-0372, K-0741, K-0781, and K-0923.

Based on observations and staff interviews, it was determined the facility failed to ensure expired supplies were not available for patient use.

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

Findings include:

1. A tour of the Surgical Department was conducted on 9/10/24 at 10:15 AM with Employee Identifier (EI) # 19, Operating Room (OR) Manager, and EI # 3, Quality Manager.

In the OR Supply Room the following items were observed on the shelf and available for patient use:

a. One Silicone Foley Catheter with an expiration date 10/30/23.

b. Two PDS II (Brand) Violet Monofilament suture material with an expiration date of 2/28/23.

An interview was conducted on 9/10/24 at 10:30 AM with EI # 19 who confirmed the expired supplies were available for patient use.

2. A tour of the Medical/Surgical (MS) Floor was conducted on 9/10/24 at 10:15 AM with EI # 4, MS Case Manager.

In the MS Medication and Supply Room the following items were observed in the drawers and cabinets and were available for patient use.

a. Two 18 Gauge (G) Needles with an expiration dare of 12/31/22.

b. One 18 G Needle with an expiration date of 6/30/22.

c. Four 30 G Needle with an expiration date of 10/31/23.

d. Two Hollister 14802 Ostomy Barriers with an expiration date of 2/24.

e. Five Hollister Wound Drainage Collectors with an expiration date of 1/22.

An interview was conducted on 9/10/24 at 10:30 AM with EI # 4, who confirmed the expired supplies were available for patient use.

3. A tour of the Obstetrics unit was conducted on 9/10/24 at 10:15 AM, with EI # 5, Obstetrics Manager.

In the hemorrhage cart and supply cart the following supplies were observed and available for patient use.

a. Four 16 gauge needles with an expiration date of 6/22.

b. Two boxes of sterile gloves with an expiration date of 3/24.

An interview was conducted on 9/10/24 at 10:28 AM, with EI # 5, who confirmed the expired supplies were available for patient use.






49797




50417

Based on observations, facility policy and procedure, and interviews, it was determined the facility failed to ensure the staff performed hand hygiene per facility policy.

This deficient practice affected five of nine observations of care and did affect Patient Identifier (PI) # 3, PI # 5, one unsampled patient and had the potential to affect all patients admitted to this facility.

Findings include:

Facility Policy: Hand Hygiene

Policy Number: not listed

Revised Date: 4/24

...Purpose: To provide guidelines to promote hand hygiene practices and reduce the transmission of pathogenic microorganisms to patients and staff...

When to wear gloves:

When needed for Standard Precautions (when you anticipate that you will come in contact with blood or other infections materials, ... or contaminated equipment)...

If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings.

Always clean your hands after removing gloves...

When to change gloves and clean hands:

... If gloves become soiled with blood or body fluids after a task.

If moving from work on a soiled body site to a clean body site...

If they look dirty or have blood or body fluids on them after completing a task.

Before exiting a patient room...


1. An observation of medication administration was conducted on 9/10/24 at 9:34 AM. EI # 11, Registered Nurse (RN), administered intravenous (IV) push Morphine to PI # 3. No hand hygiene or gloves were utilized before or during procedure.

An interview was conducted on 9/10/24 at 9:45 AM with EI # 4, who confirmed staff failed to perform hand hygiene per facility policy.

2. An observation of medication administration was conducted in the Emergency Department on 9/10/24 at 10:20 AM. EI # 9, RN, administered IV antibiotics to an unsampled patient. EI # 9 handled the computer equipment, scanned the IV medication to be given, touched the patient's bed, and scanned the patient's identification bracelet. Then, without changing gloves and performing hand hygiene, EI # 9 hung the medication and connected the IV line to the patient's IV.

An interview was conducted on 9/12/24 at 1:30 PM with EI # 1, who confirmed staff failed to change gloves and perform hand hygiene between tasks per facility policy.

3. An observation of medication administration was conducted in the Intensive Care Unit, Room 203, on 9/10/24 at 3:40 PM. EI # 8 administered IV antibiotics to PI # 5. EI # 8 handled the computer equipment, scanned the IV medication to be given, touched the patient's bed, bed covers, and scanned the patient's identification bracelet. Then, without changing gloves and performing hand hygiene, EI # 8 hung the IV medication and connected the line to the patient's IV.

An interview was conducted on 9/12/24 at 1:30 PM with EI # 1, who confirmed staff failed to change gloves and perform hand hygiene between tasks per facility policy.

4. An observation of terminal cleaning of an Operating Room (OR) was conducted on 9/10/24 at 2:30 PM.

EI # 17, Environmental Services, wiped the anesthesia cart, trash receptacle, and work station with a cloth with disinfecting solution. EI # 17 exited the OR room, then reached into his/her pockets with soiled gloves on to retrieve the keys to the cleaning cart. EI # 17 then removed a new cleaning cloth from the cart, re-entered the OR room and continued cleaning surfaces.

EI # 17 failed to remove gloves and perform hand hygiene when exiting the OR, before and after reaching into pockets, and before retrieving items from the clean cart.

An interview was conducted on 9/12/24 with EI # 3, Quality Manager, who confirmed the staff failed to perform hand hygiene per facility policy.

5. During a tour of the Labor and Delivery unit on 9/10/24 at 10:34 AM with EI # 5, Obstetrics manager, and EI # 6, Obstetrics assistant manager, an open box of Cervidil with a substance that appeared to be blood on the box was noted in the refrigerator with two unopened boxes of Cervidil and was available for patient use.

An interview was conducted on 9/10/24 at 10:34 AM with EI # 5 who confirmed the substance was blood and the Cervidil was available for patient use.



49797




49894




50417