HospitalInspections.org

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based on records reviewed the facility failed to ensure medical histories and physicals were completed no more than 30 days prior to admission for 3 of 4 surgical records of a total of 20 records reviewed. Findings include:

**The document entitled; "Rules and Regulations of the Medical Staff of Huron Medical Center", specifies in regard to patient history and physical; "This report (admission history and physical examination) should include all pertinent findings resulting from an assessment of all the systems of the body."

MR #16: The patient was admitted 6/8/10 for right knee degenerative joint disease and a posterior-stabilized right total knee arthroplasty procedure. The documents included as patient history prior to 6/8/10 included a history and physical dated 8/14/09 and an office visit on 5/26/10. The "Short Term Stay History & Physical/Medical Clearance for Surgery" dated 6/8/10 documents; "Advanced degenerative joint disease right knee." The document failed to include all pertinent findings relative to an assessment of all the systems of the body.

MR #18: The patient was admitted for a laparoscopic cholecystectomy on 6/9/10. The patient's history and physical dated 6/9/10 noted a past medical history of miscarriage, endometriosis with exploratory laparoscopy and a hypercoagulability condition. The content of the history and physical failed to represent an assessment of all systems of the body.

MR #19: The patient's was admitted on 6/8/10 for left knee degenerative joint disease and a posterior-stabilized left total knee arthroplasty procedure. The documents included as patient history prior to 6/8/10, represented office visits dated 1/6/10 and 4/21/10 in which the patient received Kenalog injections. The "Short Term Stay History & Physical/Medical Clearance for Surgery" dated 6/8/10 documents; "Advanced degenerative joint disease left knee." The document failed to include all pertinent findings relative to an assessment of all the systems of the body.

Based on observation and interview, the facility failed to maintain records of staff who had access to narcotics and ensure that they were stored in a locked compartment in a locked cart. Findings include:

Facility policy 707.1000.1401, Narcotic Drugs, states: "A separate locked compartment for narcotic drugs is provided within a locked medication cart. The compartment has a special lock and key and must be kept locked at all times."

On 6/7/10 at 1300 the Obstetrics unit was toured with the Director of Acute Care. In the Medication Room, an unlocked cart labeled "Epidural Cart" was observed. The cart contained narcotics and other medications used by Anesthesia staff. The following narcotics were observed in the unlocked cart, in an unlocked compartment:
1) One box, 5 units, Morphine Sulfate 5 mg (milligram) injectable units
2) Eleven vials Fentanyl 100 mcg/2 ml vials
3) Four vials Morpheme Sulfate 5 mg/10 ml vials

The Director of Acute Care stated that the medications on the cart were under the supervision of Anesthesia staff and not administered by nursing staff. There were no Anesthesia staff present. The Director of Acute Care stated that all nurses working on the Obstetrics unit had access to the Medication Room where the unlocked Anesthesia medication cart was stored. Nursing staff did not count or sign-off from shift to shift although they had unsupervised access to narcotics on the Anesthesia cart.

On 6/10/10 at 0940 the Director of Anesthesia was asked how long the Epidural Medication cart had been unlocked. She stated that it had been unlocked for approximately 8-9 days.

Based on observation, policy review and interview, it was determined that the facility failed to ensure outdated drugs were removed from patient use areas. Findings include:

Policy 707.1000.1904, dated 11/04 states: "All drugs that appear to have deteriorated, exceeded their expiration date, are improperly labeled or are not being used shall be returned to the pharmacy for disposition by the Pharmacist."

During the tour of the emergency department trauma room, on 6-7-10 at approximately 1215 hours, the following was observed: one bag of intravenous Lidocaine solution with an expiration date of 6-1-10 was found in the locked medication storage cupboard and one bag of intravenous Lidocaine solution with an expiration date of 6-1-10 was found in drawer #5 of the crash cart. During an interview on 6-7-10, at approximately 12:15 p.m., the Chief Nursing Officer confirmed these expired medications were still available for patient use.



18299



During the initial survey observation tour of the facility on 6/7/10 at approximately 11:50am, it was observed in the medical-surgical unit medication room; 1 box (10ea) phenergan suppositories had expired in April 2010.
Also, while observing in the critical care unit (also 6/7/10) the crash cart had 5 vials of Adenosine 6mg/2ml that expired in May 2010.
Also, 3-500ml bottles of normal saline irrigation had expired January 2010 in the OB unit medication room.





27065

On 6/7/10 at 1400 the Pharmacy was toured with the Pharmacy Director. The following expired medications were noted during a tour of the Pharmacy:

Policy 707.1000.1904, dated 11/04 states: "All drugs that appear to have deteriorated, exceeded their expiration date, are improperly labeled or are not being used shall be returned to the pharmacy for disposition by the Pharmacist."

1) One ampule of Amyl Nitrate, in the Chemo refrigerator, expired 8/06
2) One ampule of Amyl Nitrate, in the Chemo refrigerator, expired 10/07
3) One 200 mg. vial of Doxorubicin Hydrochloride, on a shelf, expired 5/17/10
4) One bottle of Isopropyl Rubbing Alcohol a counter top, expired 2/08

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on June 9, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated June 9, 2010, for Life Safety Code.

Based on observation and interview, it was determined that the facility was not ensuring an acceptable level of safety and quality for cleaning practices and for surgical services. The findings include:

1. During observation and interview with the director of surgical services relative to proper replacement of needed instruments, the following was noted:
a. Reportedly the first option is to " flash " sterilize, even though AORN and AAMI strictly limit " flashing " to only meeting immediate/emergent needs and most instruments have properly reprocessed replacements available in the adjoining sterile processing department which could be accessed in seconds versus minutes to complete " flashing " ;
b. By interview this " flashing " process would reportedly not involve decontaminating the instrument first to remove various types and quantum of microbial loading or physical debris prior to placing the instrument in the sterilizer;
c. When asked if and where instruments would be cleaned before going into the sterilizer the director of surgical services indicated that they would be washed in the scrub sinks which would contaminate the scrub sink and possibly any scrubbing personnel;
d. Note that the scrub sinks were not designed or equipped to support proper decontamination of surgical instruments as evidenced by a lack of brushes, stoppers to hold solution to allow for soaking, enzymatic cleaning detergent, test strips to ensure proper concentration of the water/detergent solution, documentation that the proper concentration of the water/detergent solution has been provided, or calibration of the sinks or dispensing of the detergent to allow for proper concentration of the water/detergent solution is provided;
e. Note that no other sinks are available in the surgical suite for instrument decontamination;
f. Only a single sterilizer setting is used for all instruments, regardless of the instrument ' s mass, presence of crevices, or possible concerns for proper penetration of channels;
g. Note that instrument manufacturer ' s instructions for proper reprocessing was not available in the surgical suite.

2. It was observed that no calibration of the sinks or dispensing of the enzymatic cleaning detergent was provided to allow for delivery of the proper concentration of the water/detergent solution.

3. Mop buckets were found next to the clinical sinks that are used to dispose of various bodily fluids/solids inside soiled utility rooms in the emergency department, radiology department, 3rd floor sleep/physical therapy department, and 2nd floor inpatient nursing unit. As such aspiration from the flushing of the clinical sink and splash from emptying into the clinical sinks could contaminate mops and mopping solutions that would be spread infectious materials throughout the facility.

Based on interview and record review, the facility failed to ensure that referrals to the Organ Procurement Organization (OPO) were made in a timely manner following patient deaths for three (#12, #13, and #14) of 19 patients in 2010. Findings include:

On 6/8/10 at 0920 the CNO (Chief Nursing Officer) was interviewed regarding patient death and Organ Procurement Organization (OPO) data for 2010. The CNO confirmed that it was facility policy to make referrals to the OPO within one hour of patient deaths. This time frame is noted in facility policy 054.700.49, Anatomical Donation, and in Section three of the agreement between the facility and the OPO. The CNO confirmed that referrals to the OPO were late, over one hour past the time of death for patients # 12, #13 and #14.

Based on observation, documents reviewed and interview the facility failed to ensure drugs were administered under accepted standards of practice. Findings include:

The facility's policy entitled "Multiple Dose Vial Policy" (number: 707.1113.01) specified that; "All multidose vials shall be dated and signed when initially opened."

During the initial survey observation tour of the facility it was observed in the medical -surgical unit medication room 5 of 7 multi-use vials of insulin had been opened without opening dates documented on the vial. An interview conducted with the Director of acute care services personnel # 1 on 6/7/10 at 11:51 am, confirmed that it was the facility's expectation that staff date multi-use medication bottles after opening them.



27065

On 6/7/10 at 1255, on the Continuing Care Unit, in a tray labeled local anesthetics, one uncapped multi-dose vial of Xylocaine 1% was noted, with no date opened marked on the vial. This finding was confirmed by the Director of Acute Care.