HospitalInspections.org

Based on interview it was determined the facility failed to ensure laundry services were being provided in a safe and effective manner by meeting sanitary guidelines prior to patient use. Failure to ensure laundry services were provided meeting sanitary standards did not ensure laundry was clean and free of contamination. The failed practice had the potential to affect all patients and staff in the facility. Findings follow:

A. During an interview with the Executive Director of Clinical Services on 07/09/19 at 11:30 AM she stated there was no documentation from their facility of laundry service audits being performed to ensure laundry sanitation.

B. The above findings in A were verified on 07/09/2019 at 11:30 AM with the Executive Director of Clinical Services.

Based on review of personnel records and interview, it was determined the facility failed to assure one of one Respiratory Therapist (RT #1), seven (RN #1-7) of eight Registered Nurses (RN #1-8), and three of three Licensed Practical Nurses (LPN # 1-3) were screened to assure no individuals were hired who had been convicted of abuse or neglect. Failure to perform background checks prior to employment did not assure each patient would be protected from abuse or neglect. The failed practice had the potential to affect all patients admitted to the facility. Findings follow:

A. Review of personnel files for RT #1, RN #1-7, and LPN #1-3 showed no criminal background screen was performed.

B. During an interview with the Facility Administrator and Human Resource Director on 07/09/19 at 10:40 AM they stated criminal background screening was not being performed prior to three months ago.

C. The above findings in A and B were verified with the Facility Administrator on 07/09/19 at 10:45 AM.

Based on clinical record review and interview it was determined a Registered Nurse ( RN) failed to supervise and evaluate the nursing care in that 11 (#2, #7-13, # 15, #17 and #18) of 30 (#1-30) patient's clinical records contained documentation of daily weights performed as ordered by the physician. Failure to perform daily weights as ordered by the physician did not give the physician the information necessary to make clinical decisions. The failed practice affected Patients #2, #7-13, #15, #17 and #18. Findings follow:

A. Review of clinical records showed:
1) PT #2 - Daily weights were ordered on 06/03/19 and there was no evidence of daily weight documentation for 06/06/19, 06/13/19, and 06/16/19.
2) PT #7- Daily weights were ordered on 06/25/19 and there was no evidence of daily weight for 06/27/19.
3) PT #8 - Daily weights were ordered on 06/06/19 and there was no evidence of daily weight documentation for 06/06/19, 06/07/19, 06/08/19, and 06/16/19.
4) PT #9- Daily weights were ordered on 04/30/19 and there was no evidence of daily weight documentation for 05/01/19, 05/02/19, 05/03/19, 05/09/19, 05/13/19, 05/14/19, 05/15/19, 05/18/19, and 06/15/19.
5) PT #10- Daily weights were ordered on 05/20/19 and there was no evidence of daily weight documentation for 05/24/19, 06/06/19, 06/07/19, 06/13/19, 06/16/19, 06/17/19, 06/20/19, 06/22/19, and 06/23/19.
6) PT #11- Daily weights were ordered on 05/17/19 and there was no evidence of daily weight documentation for 05/19/19, 05/22/19, 06/01/19, and 06/06/19.
7) PT #12 - Daily weights were ordered on 05/17/19 and there was no evidence of daily weight documentation for 05/24/19 and 06/06/19.
8) PT #13- Daily weights were ordered on 03/05/19 and there was no evidence of daily weight documentation for 03/05/19, 03/06/19, and 03/07/19.
9) PT #15 - Daily weights were ordered on 01/22/19 and there was no evidence of daily weight documentation for 01/24/19 and 01/25/19.
10) PT #17 - Daily weights were ordered on 12/04/19 and there was no evidence of daily weight documentation for 12/05/19, 12/06/19, 12/08/19, and 12/10/19.
11) PT #18 - Daily weights were ordered on 01/30/19 and there was no evidence of daily weight documentation for 01/31/19, 02/05/19, 02/11/19, and 02/14/19.

B. The above findings in A were verified by interview with the Director of Nursing on 07/10/19 at 12:45 PM.

Based on policy and procedure review and interview, it was determined the facility failed to ensure food and beverages were stored at the correct temperature prior to preparation, and failed to ensure food was prepared at the proper temperature prior to serving the patient population. Failure to ensure food and beverages were stored and prepared according to dietary standards did not ensure food and beverages were kept and prepared at safe temperatures to prevent contaminates. Findings follow.

A. Review of policy titled "Food Service Sanitation," received on 07/09/19 at 9:15 AM showed that food production audits were to be performed on a consistent basis to monitor food quality being prepared and served.

B. During an interview with the Registered Dietitian (RD#1) on 07/09/19 at 9:45 AM, she stated there was no documentation of dietary audits being performed to ensure food safety and sanitation. RD #1 further stated the contracted dietary service did not provide food safety and sanitation documentation to the Facility.

C. The above findings in A and B were verified with the Administrator on 07/09/19 at 1:15 PM.

Based on observation and interview, it was determined the facility failed to ensure the condition of the hospital environment was maintained in a manner that provided a level of safety and well-being to patients, staff and visitors on one of one fire barrier wall in that the fire barrier wall was not sealed with fire-proof sealant located in corridor adjacent to the pharmacy. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Observations on 07/09/19 at 10:00 AM of the corridor fire barrier wall adjacent to the pharmacy showed a piece of white paper towel inserted into a non-sealed hole surrounded by electrical cables which were not fire-proof sealed per NFPA 1, 12.9.6.2 to prevent the migration of fire and smoke.

B. The above finding in A was verified 07/09/19 at 10:00 PM by the Director of Maintenance.

Based on observation and interview, it was determined the facility failed to ensure the condition of the hospital environment was maintained in a manner that provided a level of safety and well-being to patients, staff and visitors in one of one patient room (#111) in that the love seat was not manufactured from hospital grade materials. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Observations on 07/08/19 at 1:17 PM of room 111 showed a brown fabric sofa with no Underwriters Laboratory (UL) rating per NFPA 1, 12.6.3.1(1) to prevent the migration of fire and smoke.

B. The above finding in A was verified 07/08/19 at 1:20 PM by the Director of Maintenance.

Based on observation it was determined the Infection Control Officer failed to ensure a sanitary environment in that one of one Registered Nurses (RN #9) failed to clean the septum of two of two vials of medication prior to withdrawing medication and failed to clean one intravenous port two of two times prior to medication administration. Failure to clean the septum of the medication vials prior to puncture and clean the Intravenous (IV) port prior to administering the medication did not ensure the vial or the port were free of contaminants. The failed practice affected Patient #3 on 07/09/19 at 11:10 AM. Findings follow:

During observation of RN #9, on 07/09/19 at 11:10 AM, it was observed she failed to clean the septum of two of two vials of Furosemide 40mg/4ml on one entry into each vial for the delivery of the medication IV. RN #9 also failed to clean the injection port prior to IV flush and IV administration of the medication.


Based on observation and interview, it was determined the facility failed to assure patient rooms and care equipment were clean and tidy in two of two Medical Surgical Unit Rooms (#109 and #111). Failure to assure patient care rooms and equipment were clean did not ensure these areas to be clean and ready for patient care. The failed practice had the potential to affect any patient whose care was rendered and received in those Medical Surgical Unit Rooms. Findings follow:

A. Observation in Medical Unit Room #109, (patient ready room) on 07/08/2019 at 1:00 PM showed a small section of cob webs in the right corner of the window seal and on the floor under the window. Observation of the top of the bed mattress showed several soiled areas. The Executive Director of Clinical Services verified these findings at 1:00 PM on 07/08/19.

B. Observation in Medical Unit Room #37, (patient ready room) showed a fabric love seat with a large dark colored soiled area underneath approximately 12 x 24 inches. Observation of the headboard of the bed showed two long dark strands of hair. Also, observation of the Intravenous Pole showed rusted wheels. Findings were verified at 1:15 PM on 07/08/19 by the Executive Director of Clinical Services.

Based on review of the Operating Room Register, it was determined the facility failed to include seven (patient's identification number; total time of operation the including beginning and end; name of any surgical assistant; name of nursing personnel (scrub and circulating); type of anesthesia used and name of person administering it; pre and post-op diagnosis; and any complications) of the eleven (patient's name; patient's identification number; date of the operation; total time of the operation including beginning and end; name of the surgeon and any assistant(s); name of nursing personnel (scrub and circulating); type of anesthesia used and name of person administering it; operation performed; pre and post-op diagnosis; age of patient, and complications) required elements on the operating room log. Failure to include all required elements in the operating room log did not allow the facility to track and trend potential problems. Findings follow:

A. Review of the Operating Room Register showed it did not contain documentation of the patient's identification number; total time of operation the including beginning and end; name of any surgical assistant; name of nursing personnel (scrub and circulating); type of anesthesia used and name of person administering it; pre and post-op diagnosis; and any complications.

B. The above findings were verified by the RN #1 on 07/10/19 at 9:00 AM.