HospitalInspections.org

Based on document review the facility failed to adopt Medical Staff Bylaws which give only the Governing Body the authority to grant medical staff privileges. This deficient practice affects all patients in the facility. The facility census was 17.

Findings included:

Review of the facility's Medical Staff Bylaws, conducted on the morning of 06/09/11 showed the following:

Article IV
Categories
Section 10: Temporary Staff:
Temporary clinical privileges may be granted to a physician, podiatrist, or dentist for a limited period of time by the Chief Executive Officer on the recommendation of the Chief of Medical Staff. When either the Chief Executive Officer or Chief of Staff is not available his/her designee or next on organizational chart shall be given authority to grant such privileges.

Based on observation, interview, record review, and policy review, the facility failed to provide a safe care setting for patients by failing to:
- Ensure crash carts (contained emergency medication, medical supplies, and equipment) were checked daily for cart integrity;
- Ensure that expired supplies were removed from patient care areas to prevent use of the expired supplies on patients;
- Ensure that expired medications were removed from patient care areas to prevent administration of the expired medications to patients;
- Ensure that physician orders were transcribed as written by the physician for appropriate administration to the patient for one (#30) of five patient medical records reviewed;
- Ensure that physicians' orders for medication dosages were within safe ranges for one (#9) of four medical patients.
This had the potential to lead to negative patient outcomes and could affect all patients in the facility.

The facility census was 17.

Findings included:

1. Record review of the facility ' s policy titled, " Crash Cart Check " revised on 02/11, showed direction for staff to check the Emergency Boxes and Carts daily to assure availability of medication, supplies, and equipment used for emergency situations.

Record review on 06/07/11 at 2:40 PM of the facility "Crash Cart Checklist" for June 2011, showed the crash cart had not been checked daily for integrity on June 1, 2, 4, and 6, as outlined in the facility policy.

Record review of the facility "Crash Cart Checklist" for January through May, 2011, showed the following missing Crash Cart checks:
- One out of 31 opportunities to check the Adult Crash Cart in May;
- Nine out of 31 opportunities to check the Pediatric Crash Cart in May;
- 15 out of 30 opportunities to check the Adult Crash Cart in April;
-29 out of 30 opportunities to check the Pediatric Crash Cart in April;
- Three out of 31 opportunities to check the Adult Crash Cart in March;
- 22 out of 31 opportunities to check the Pediatric Crash Cart in March;
- 19 out of 28 opportunities to check the Adult Crash Cart in February;
- 22 out of 28 opportunities to check the Pediatric Crash Cart in February;
- Six out of 31 opportunities to check the Adult Crash Cart in January;
- 20 out of 31 opportunities to check the Pediatric Crash Cart in January.

During an interview on 06/07/11 at 2:40 PM, Staff V, Unit Clerk, stated that the Crash Cart checks are to be completed daily.


2. Observation on 06/09/11 at 1:00 PM of the Main OR (Operating Room) contained two IV Infusion tubing sets (used to give a patient hydration or blood during a surgical procedure), Lot #309655, expired 09/06 and ten Cover Sponges (used to cover surgical wounds after surgery), Lot #31915302, expired 07/08.

During an interview on 06/09/11 at 1:00 PM, Staff U, Director of Surgical Services stated that it was the responsibility of the Scrub Technician to removed outdated supplies from the OR and that he/she is responsible for checking for expired supplies once a month.


3. Record review of the facility's policy titled, "AMDS Outdate Maintenance" revised on 01/06, showed that the Pharmacy will follow the policy to insure that drugs stocked on Nursing units are maintained, tracked for expiration, and monitored for general integrity and that each Pharmacy Technician will be responsible for specific Nursing areas where drugs of drug products will be stored.

Observation on 06/08/11 at 8:55 AM of a medication pass, showed Patient #10 received Aggrenox (medication that prevents excessive clotting of the blood), Lot #001106, which expired 06/01/11.

Observation on 06/08/11 at 9:15 AM of the electronic medication dispensary showed 17 Aggrenox tablets, Lot #001106, expired 06/01/11 and ten Calcium Carbonate (medication to reduce stomach acid), Lot #OBE2410, expired 03/30/11.

During an interview on 06/08/11 at 9:30 AM, Staff X, Pharmacy Technician stated that an expired medications report was printed monthly for expired medication removal, and that the Aggrenox and Calcium Carbonate should have been removed from the electronic medication dispensary, but were missed due to human error.

Record review of the facility's "Item Expiration Tracking Report" for January through June 2011, showed that the Aggrenox did not expire until 06/30/11 and that there was no expired Calcium Carbonate.

During an interview on 06/08/11 at 10:00 AM, Staff R, Pharmacists, stated that when medications are stocked in the medication dispensary, the dispensary computer requests the stocker to electronically enter the soonest date the medication will expire. If the correct date is not entered (as with the Aggrenox), or not entered correctly, the expired medications will not show up on the monthly expired medications report to be pulled from the dispensary.


4. Record review of the facility's policy titled "Medication orders" revised on 02/10, showed direction for the Pharmacist to check for correctness of the drug order and for appropriate dosage, route, frequency, and indications.

Record review of discharged Patient #30's medical record showed the following physician's order written on 04/20/11 at 11:45 AM:
- Transfuse two units PRBC (Packed Red Blood Cells) each over 4 hours;
- Pre-treat with Benadryl (medication to reduce itching) 25 mg (milligrams - unit of measure), PO (by mouth), times one dose and Tylenol (medication used to reduce fever), 650 mg, PO, times one dose;
- Give 20 mg of Lasix (medication used to removed extra fluid from the body), IV (intravenous - in the vein), prior to each unit transfused.

Further review of the patient's medical record MAR (Medication Administration Record) showed the following medications listed to be administered as prn (as needed), which differed from the physician's order:
- Benadryl 25 mg, per physician order as needed, prior to first unit of blood;
- Acetaminophen 325 mg, two tablets per physician order as needed, give prior to first unit of blood;
- Lasix 20 mg, per physician order as needed, give prior to each unit of blood.
The Lasix was administered on 04/20/11 at 2:20 PM, 6:30 PM, and again on 04/21/11 at 4:30 AM, although the physician's order was to administer the medication only twice, before each blood transfusion.

During an interview on 06/09/11 at 11:32 AM, Staff W, Pharmacy Technician stated that medications can only be entered into the electronic system as a scheduled medication (which requires a specific time for the medication to be given) or as a prn. Since blood administration times are not scheduled, the pharmacy cannot place the pre-treatment medication orders for a blood transfusion as a scheduled medication. Therefore, the pre-treatment medication is placed on the MAR as a prn medication, even if the medication is not ordered as prn.

5. Record review of current Patient #9's medical record showed that the patient's home medications included Acetaminophen, 650 mg, two tablets, every four hours prn for pain and fever on the patient's Medication Reconciliation Form, which was not dated. The form was signed by a physician (indicating he/she reviewed the medication and dose) who ordered the medication to be administered to the patient as written.

Review of the online reference, Drugs.com showed that Tylenol dosing should not exceed 1000 mg per dose and that doses exceeding 1000 mg may cause damage to the liver (organ in the stomach).

Record review of current Patient #9's medical record MAR dated 05/26/11 through 05/27/11, showed that Acetaminophen, 1300 mg, was to be administered every 4 hours prn pain or temperature greater than 101. According to the administration documentation, the patient received 1300 mg of Tylenol on 05/26/11 at 8:00 PM and at Midnight, and again on 05/27/11 at 1:50 PM (even though the a physician's order changed the Acetaminophen dose to 650 mg on 05/27/11 at 9:50 AM).

Record review of current Patient #9's medical record showed a physician order written on 05/27/11 at 9:50 AM to clarify the Acetaminophen dose as 650 mg PO or PR (per rectum) every four hours prn pain or fever.

Based on policy review, record review and interview, the facility failed to ensure physicians, dietitians, therapy, and nursing staff authenticated entries in the medical record with date, time and signature for three residents (#9, #16, and #20) of 32 records reviewed. The facility census was 17.

Findings included:

1. Record review of the facility's "Medical Staff Rules and Regulations," revised 06/08, showed direction to ensure documentation was legible, dated, timed, authenticated, and recorded in ink, typewritten or recorded electronically. The medical record documents included progress notes, nurses' notes, and non-physician health care professionals' notes, e.g., dietitian, physical therapist, social worker, discharge planner, occupation and speech therapist, etc.

2. Review of current Swingbed Resident #9's medical record showed the following:
- A physician progress note dated 05/26/11. The note was signed and dated, but was not timed.
- Occupational therapy notes documented observations for 05/26/11, 05/27/11, 05/31/11, 06/01/11, 06/03/11, 06/06/11, 06/07/11, and 06/08/11. The notes were signed and dated, but were not timed.
- Activity progress notes dated 05/31/11 and 06/06/11 were signed and dated, but were not timed.

3. Review of current ICF (Intermediate Care Facility) Resident #16's medical record showed a nursing note dated 05/24/11. The note was signed and dated, but was not timed.

4. Review of current ICF Resident #20's medical record showed the following:
- A physician progress note written 06/02/10. The note was signed and dated, but was not timed.
- A physician progress note written 08/2010. The note was signed by the physician, but was not timed, and did not indicate a specific day of the month.

5. During an interview on 06/09/11 at 2:45 PM, Staff O, RN (Registered Nurse), confirmed that the above noted entries were not timed.

Based on interview and "Medical Staff Rules and Regulations" review facility staff failed to ensure physicians orders were dated, timed and authenticated in four ( #10, #11, #30, and #31) of six discharged patient's medical records, and two (#9, #14) of 19 current patient's medical records reviewed for dated, timed and authenticated orders. The facility census was 17.

Findings included:

1. Record review of the facility's "Medical Staff Rules and Regulations" revised 06/08 showed direction for facility physicians to ensure documentation was legible, dated, timed, authenticated, and recorded in ink, typewritten or recorded electronically.

2. Record review of discharged Patient #11's admission orders showed the patient was admitted on 04/27/11 with diagnosis of hyponatremia (low sodium in the blood).

Further review of the patient's physician's orders showed the following:
-Untimed admission orders dated 04/27/11.
-Untimed, undated authentication of the admission orders.
-A Medication Reconciliation Form and Physician's Order Sheet for Medication with an undated, untimed authentication.
-An insulin order form with an untimed authentication.
-An order to change tub e feeding, discontinue some medications, administer other medications with and untimed, undated authentication.
-An untimed order dated 04/28/11 to discontinue some medications, add others, consult physical therapy and occupational therapy and obtain laboratory testing with an un dated, untimed authentication.
-An order for laxatives and decrease intravenous solution administration rate with an undated, untimed authentication.
-An order to ask a family to provide a home medication with an undated, untimed authentication.
-An order to discontinue intravenous fluids with an undated, untimed authentication.
-A second insulin order form with an untimed authentication.
-An untimed order to transfer the patient to a local nursing home with an undated, untimed authentication.
-An undated, untimed second page with a continuation of orders from the previous page with an untimed, undated authentication.

During an interview on 06/09/11 at 10:50 AM Staff B, the Director of Health Information Management (HIM) reviewed the orders and stated the physician was required to date and time orders as well as the authentication of orders and failed to do so.

3. Record review of discharged Patient #14's admission orders showed the patient was admitted on 05/18/11 for hypoxia (low oxygen in the blood) and COPD (chronic obstructive pulmonary disease) exacerbation (worsening of shortness of breath).

Further review of the patient's physician's orders showed the following:
-An order to admit the patient, measure intake and output, obtain vital signs, provide oxygen, medications, obtain chest x-rays, laboratory studies, intravenous fluids with an untimed, undated authentication.
-An order for ambulation, daily weights, chest x-ray, laboratory studies and abdominal ultrasound with an undated, untimed authentication.
-An undated, untimed order to discharge the patient, provide medications and follow up in clinic with an undated, untimed authentication.
-An undated, untimed Patient's Personal Medications form with an undated, untimed authentication.
-An untimed Prednisone Reducing Schedule form with and undated, untimed authentication.

During an interview on 06/09/11 at 11:00 AM, Staff B reviewed the orders and stated the physician was required to date and time orders and authentication of orders and failed to do so.


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4. Record review of current Swingbed Resident #9's medical record showed the following:
-A physician order dated 05/26/11 for two medications. The order was dated and signed, but was not timed.
- A physician order dated 05/26/11 for four medications. The order was dated and signed, but was not timed.


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5. Record review of discharged Patient #31's medical record showed the following:
- A physician's telephone order dated 03/26/11 at 6:35 PM. The order was signed, dated, and timed, but not until 04/12/11 at 8:30 AM, 17 days after the order was received;
- A physician's telephone order dated 03/26/11 at 9:55 PM. The order was signed, dated, and timed, but not until 04/12/11 at 8:30 AM, 17 days after the order was received.

6. Record review of discharged Patient #30's medical record showed the following:
- A physician's Emergency Department orders were not signed, dated, or timed by a physician;
- A physician's telephone order dated 04/22/11. The order was signed and dated but was not timed;
- A physician's telephone order dated 04/22/11. The order was was not signed, dated, or timed by a physician.

7. Record review of current Patient #10's medical record showed a physician's telephone order dated 06/06/11. The order was signed and dated but was not timed;

Based on interview, medical record review and "Medical Staff Rules and Regulation" review facility staff failed to ensure physician's verbal orders were authenticated within forty eight hours as required for two (#9 and #14) of 16 medical records reviewed for authenticated verbal orders. The facility census was 17.

Findings included:

1. Record review of the facility's "Medical Staff Rules and Regulations" revised 06/08 showed direction for facility physicians to date, time, and authenticate all verbal orders within forty eight hours from the date the order was written.

2 Record review of discharged Patient #14's admission orders showed the patient was admitted on 05/18/11 for hypoxia (low oxygen in the blood) and COPD (chronic obstructive pulmonary disease) exacerbation (worsening of shortness of breath).

Further review of the patient's physician's orders dated 05/18/11 showed a telephone (verbal) order for regular diet authenticated on 06/06/11.

During an interview on 06/09/11 at 10:58 AM Staff B, the Director of Health Information Management (HIM) reviewed the patient's verbal order and stated the authentication was later than forty eight hours after the order was given.


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3. Record review of current Swingbed Resident #9's medical record on 06/08/11 showed a telephone order dated 05/27/11 at 9:50 AM, clarifying admission medication orders. The order was not authenticated by the physician. Record review on 06/09/11 showed the order was signed and dated 05/27/11, but was not timed.

During an interview on 06/09/11 at 9:15 AM, Staff Q, Ward Clerk, confirmed that the telephone order dated 05/27/11 was signed by the physician on 06/09/11.

Based on interview and record review facility staff failed to maintain a current diet manual for use by medical, nursing and dietary personnel. The facility census was 17.

Findings included:

1. During an interview on 06/07/11 at 2:05 PM Staff A, the Director of Dietary stated the facility maintained the Missouri Diet Manual for use by medical, nursing and dietary personnel.

2. Record review of the facility copy of the Missouri Diet Manual showed the publication date was 2003 and the manual was approved for use in the facility by the medical staff and the dietitian on 02/08/11.

Based on observation, interview and record review the facility failed to ensure
- Dietary department staff used appropriate food sanitation methods including hand hygiene, gloving and manual cleaning of small equipment;
- Patient care staff perform hand hygiene and use PPE (Personal Protective Equipment) appropriately when caring for two (#1 and #10) of two patients observed;
- OR (Operating Room) staff used appropriate techniques for the sterilization of surgical instruments.
This had the potential to affect all patients in the facility as well as those who had surgical procedures completed as outpatients in the OR.

The facility census was 17.

Findings included:

1. Record review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code showed the following direction:
-Chapter 2-301.14 food handlers should wash hands before donning gloves for working with food.
-Chapter 4-301.12 Manual Ware washing staff should use a three compartment sink method (wash, rinse by immersion, sanitize) for manual ware washing of small equipment and utensils.

Record review of the facility's policy titled, Proper Food Handling, revised 01/06, provided by the Director of Dietary showed the following direction:
-Dietary staff should wear gloves when handling raw/cooked foods that will be consumed by patients.
-All equipment will be cleaned and sanitized each use.
-Food contact surfaces and equipment were to be sanitized with bleach.

Record review of the facility's Dietary department policy titled, Hand Washing Procedures, revised 02/07 showed the following direction:
-One of the most important times to wash hands is after removing gloves.
-One of the principle steps for hand washing was to turn off the water faucets with a paper towel because faucets were highly contaminated.
-Dry hands well using paper towels.

2. Observation on 06/08/11 at 10:16 AM in the facility kitchen showed Staff G, Cook performed the following:
-Pureed vegetables in a blender.
-After transferring the purred vegetables into a pan, took the blender cup to a three compartment sink area.
-Manually washed the blender cup in soapy water.
-Rinsed the blender cup in a stream of water from the faucet.
-Failed to immerse the blender cup in rinse water.
-Failed to sanitize the blender cup.
-Carried the still wet blender cup to the work table.
-Used the blender cup to puree veal for patient meal service.

During an interview on 06/08/11 at 10:16 AM Staff G stated he/she usually took the blender cup to the dish washing machine for washing (automatic rinsing and sanitizing) however did not do so today.

Further observation on 06/08/11 at 10:20 AM showed a column to soap bubbles slid down the handle of the blender cup and dripped into an open container of powdered food thickener positioned under the handle.

Further observation on 06/08/11 from 10:23 AM through 10:45 AM showed Staff G repeated the process of manual ware washing (without rinsing by immersion and without sanitizing) the blender cup twice.

3. Observation on 06/08/11 showed the following:
-At 10:18 AM Staff G, Cook manually washed a blender cup with a glove on his/her left hand, failed to remove the left glove then, returned to the preparation table and pureed other foods with the same glove on the left hand.
-At 10:26 AM Staff G donned gloves on both hands without hand washing.
-At 10:30 AM Staff G retrieved a container of food thickener from the store room, washed hands, opened the container then, donned gloves.
-At 10:36 AM Staff H, Diet Aide with gloved hands, used a moist cloth to clean a table top, removed gloves, washed hands, touched the rim of the trash can, then handled patient menus (would be placed on the patient meal trays).
-At 10:37 AM Staff H washed hands, turned off the water faucet with bare hands then, dried hands with paper towels.

4. During an interview on 06/09/11 at 8:45 AM Staff C, Infection Control Officer stated he/she would expect Dietary staff to wash hands before gloving and after removing soiled gloves.


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5. Record review of the facility's policy titled, "Hand Hygiene" revised on 03/11, showed the following direction for staff to perform hand hygiene:
- Before direct patient contact;
- Before placing gloves on;
- After contact with inanimate objects in the immediate vicinity of the patient.

Record review of the facility's policy titled, "Personal Protective Equipment" without date, showed that all employees shall wear appropriate PPE when the tasks require it and that accessibility of the PPE (this includes gloves) is readily available in all departments.

Observation on 06/08/11 at 8:55 AM showed Staff F, RN (Registered Nurse), administered medications to Patient #10. Staff F did not wash his/her hands prior to administering the oral medications and did not place gloves on prior to administering a Lovenox (medication to prevent the blood from clotting) injection. After the injection was completed, a small drop of blood formed at the site of the injection, which the nurse wiped away with his/her bare thumb.

Observation on 06/08/11 at 9:15 AM showed Staff F, RN, administered medication to Patient #1. Staff F did not place on gloves prior to administering a Lovenox injection.

Observation on 06/08/11 at 11:05 AM showed Staff Y, Phlebotomist, draw Patient #10's blood. Staff Y did not wash his/her hands prior to placing gloves on or between glove changes, after the first blood draw was unsuccessful.

During an interview on 06/08/11 at 2:42 PM, Staff C, Director of Quality Improvement and Infection Control stated that nursing staff are required to wash or sanitize their hands prior to touching a patient or their surroundings, and that nursing staff should wear gloves when administering injections.

6. Record review of the facility's policy titled, "Flash Sterilization" dated 10/92, showed that flash sterilization (rapid sterilization of instruments that are to be used immediately) should be used only when time does not permit sterilization by the preferred wrapped procedure (full sterilization).

During an interview on 06/09/11 at 1:00 PM, Staff U, Director of Surgical Services, stated that:
- The facility only performed cataract surgeries (removal of a clouded lens in the eye);
- The procedures take approximately 15 minutes per cataract, which is not long enough to complete a full sterilization cycle between cases;
- The facility owned only two instrument sets to complete up to 12 procedures per day;
- Buying enough instrument sets to do all of the cataract cases instead of flashing in-between cases, wouldn't be cost effective;
- The instrument sets were always flashed between procedures, and never put through a full sterilization cycle, even at the end of the day.

Record review of the facility's "Daily Sterilization Record" showed on the eye instruments were flashed six times for five cataract surgeries on 06/09/11, indicating that the instrument sets were flashed for each procedure and at the end of the day.

Record review of the Centers for Disease Control "Guidelines for Disinfection and Sterilization in Healthcare Facilities" dated 2008, showed that flash sterilization should not be used for reasons of convenience, as an alternative to purchasing instrument sets, or to save time.