The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MASSENA HOSPITAL INC 1 HOSPITAL DRIVE MASSENA, NY 13662 April 27, 2018
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on interview and document review the hospital did not address multiple staff concerns regarding patient safety, (e.g., inadequate monitoring of patients, inadequate staff training and competency) that were brought to Administration's attention by nursing staff. This could impact care of all patients.

Bilevel positive airway pressure (BiPAP) - a non-invasive form of therapy for patients with sleep apnea,
Basic Life Support (BLS) - training to perform cardiopulmonary resuscitation and address other life threatening emergencies
Advanced Cardiac Life Support (ACLS) - advanced training to address life threatening emergencies.
Telemetry Monitoring - cardiac monitoring to identify irregular health rhythms
Protest of Assignment sheets - written document notifying the employer that a nursing assignment is unsafe.

Findings include:

-- Per interview of Staff H, Registered Nurse (RN), Staff G, RN, Staff A, RN, Staff B, RN and Staff I, RN on 4/24/18 and 4/25/18 revealed the following issues have been reported to administration over the past 2 years:

1) Most nursing staff on the medical/surgical/pediatric (MSP) unit are not trained in cardiac dysrhythmias (irregular heart rhythms) and frequently are floated to work in the intensive care unit (ICU) / telemetry unit.
2) Much of the education that nursing receives is on-line training and hospital administration expects nursing staff to complete the training while they have a patient assignment.
3) Care Event Monitoring phones (monitors irregular heart rhythms) which were implemented in July or August of 2017, remotely monitor telemetry patients. The phones alarm if a patient has a critical irregular heart rhythm only. They do not alarm for other abnormal cardiac rhythms. Most staff that carry these phones are not trained in abnormal heart rhythms.
4) Telemetry monitors are available to monitor 28 patients between the ICU and MSP units. No staff is assigned to just observe the monitors. Staff have patient care assignments also.
5) Staff has been assigned to a charge nurse position on the MSP unit for almost 2 years without any training to the charge nurse position
6) Nursing staff recently got new telemetry monitors. The day nursing staff received training and were expected to teach the night shift nursing staff. No education was provided.
7) There is no time to complete on-line training during the shift while having a patient assignment.
8) Nursing staff is required to be certified in BLS and ACLS, but they must do the training on their own time.

Additionally "Protest of Assignment Sheets" are filed with administration. For example on 4/13/18 at 4:30 pm, 7:23 pm, 7:45 pm and 11:30 pm the following Protest of Assignment Sheets were filed:
-"2 patients requiring BiPAP transferred to medical floor from telemetry with desaturations (low blood oxygen concentrations) and unable to monitor"
- "A patient transferred to med/tele unit with positive troponin (a cardiac test that indicates possible damage to heart muscle) and a full code"
- "10 telemetry patients and no one monitoring telemetry monitors"
- "There is no person in telemetry department to watch the 9 people on cardiac monitoring...I am expected to run over to telemetry if someone's phone (alarms) which only alarm for the red alarms (deadly rhythms) but not yellow, such as bigeminy, PVCs (premature ventricular contractions), irregular rhythms"
-"Patients on BiPAP were on medical floor. No person to physically watch cardiac monitors. 10 patients on cardiac monitors"

Concerns (verbal) regarding lack of qualified staff has been reported to the Director of ICU, MSP units for the past two years and nothing has been resolved. "Protest of Assignment" sheets submitted to the nursing supervisor and then they are forwarded to administration but they are not responded to.

-- Per interview of Staff E, Director of ICU and MSP unit on 4/24/18 at 12:40 pm, he/she oversees nursing staff and participates in morning huddles on both units. There is a safety huddle every morning with Administration and Senior Staff to review events in the hospital for the past 24 hours. e.g., patient transfers, sentinel events (unanticipated event resulting in death or serious injury), patient/staff issues. Staffing is sometimes an issue, e.g., during flu season. This is a small facility, any "call ins" by staff impacts staffing. Administration tries to get coverage by calling every available nurse. Annual in-services are available on Healthstream (online education). Staff come to him/her with issues and "Protests of Assignment" after the fact. When a staff member fills out a "Protest of Assignment" it is given to the nursing supervisor and he/she is made aware. He/she brainstorms to find and implement a solution. The "Protest of Assignment" is then forwarded to the nursing office and reviewed with Administration at the daily safety huddle. If the ICU is closed the Care Event Monitoring phone alarms if the patient has a cardiac event with different sounding alarms. The primary nurse has a "buddy". If the primary nurse doesn't respond to an alarm then the "buddy" is alerted to the alarm and if the buddy doesn't respond to the alarm the Charge Nurse is alerted to the alarm. When presented with a staffing assignment sheet from the MSP unit, Staff E could not identify which of his/her RNs were "buddied " with other nurses.

-- Per interview of Staff J, Director of Performance Improvement/Risk Management on 4/26/18 at 8:30 am he/she reported "staff grumblings" regarding unsafe staffing ratios due to a high volume of call-ins, specifically due to events of 4/13/18. Staff J reported that senior management completed a staffing analysis in January 2018 which showed the facility was overstaffed for the average daily census, as a result of this, some full time positions were reduced to part time. Staff J stated hospital policy for nurse to patient ratio is 7 patients to 1 RN and that patient acuity is not considered when making assignments. A "Culture of Safety" survey was started 4/1/18 and staff were encouraged to complete it. He/she would like staff to be a part of the solution. Staff feed back has indicated that they are concerned that the hospital values money over patient safety.

-- Per review of Nursing Department QA/PI plan and Committee Meeting minutes for 2017-2018, they lacked evidence that staff concerns regarding patient care and staff training and competency were being addressed.

-- Per interview of Staff E, Director of ICU/Telemetry and MSP unit on 4/24/18 at 12:40 pm, he/she acknowledged the above and is "hopeful a situation like this (4/13/18-4/14/18) doesn't happen again."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, document review and medical record (MR) review, the hospital failed to provide adequate numbers of staff to care for complex patients, staff were not adequately trained to provide care to complex patients, the hospital's policies and procedures (P&P) did not address telemetry (cardiac monitoring to identify irregular health rhythms), monitoring of patients on telemetry, including alarm settings, maintaining records of cardiac strips and Care Event Monitoring phones (system to remotely monitor telemetry patients), and hospital job description for medical/surgical/pediatrics (MSP) nurses did not include telemetry monitoring or Bilevel positive airway pressure (BiPAP), (a non-invasive form of therapy for patients with sleep apnea).

These lapses could lead to poor patient outcomes.

See findings in Tag A 286, 392, and 397
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and document review the hospital did not adequately monitor patients on telemetry (cardiac monitoring to identify irregular health rhythms) and two patients (Patients #3 and Patient #4) on bilateral positive airway pressure (BiPAP) a non-invasive form of therapy for patients with sleep apnea, were assigned to be monitored by an RN (Staff A) who was not trained in BiPAP. These lapses could lead to unrecognized cardiac rhythm abnormalities and potential for decline in the patients respiratory status.

Findings include:

-- Per observations on 4/24/18 at 5:15 am and 8:45 am, survey staff presented to the ICU/telemetry unit. No staff were present at the central monitoring station watching the telemetry monitors. The ICU/telemetry unit had 7 patients, 6 on telemetry and one new ICU admission and staffed with two ICU trained nurses (who were attending to the new admission). The Medical/Surgical/Pediatric (MSP) unit which includes medical telemetry patients had 16 patients, one on telemetry. Two staff people (Staff L and Staff M) were observed during the night and day shifts on the MSP unit carrying the Care Event Monitoring phone (a phone that works with the telemetry monitors to notify staff of critical cardiac rhythm abnormalities) .

-- Per interview of Staff L and Staff M on 4/24/18 at 5:30 am and 8:45 am, both indicated they are required to carry the Care Event Monitoring phones when they work. The phones alarm if a patient has a critical irregular heart rhythm only. They do not alarm for other abnormal heart rhythms. Staff L and Staff M stated they did not have training in cardiac rhythm recognition. Additionally, Staff M stated his/her advanced cardiac life support (ACLS) advanced training to address life threatening emergencies, basic life support (BLS) basic training to treat life threatening emergencies and pediatric advanced life support (PALS) pediatric training to treat life threatening emergencies; had all expired.

-- Per interview of Staff H, RN on 4/25/18 at 10:20 am, the Care Event Monitoring phones system was implemented in July 2017. The phones are programmed to identify deadly irregular heart rhythms. Other irregular heart rhythms, that are precursors to deadly rhythms are displayed on the cardiac monitors in the ICU at the central monitoring station. There can be up to 28 patients monitored with an average of 16-20 (other units such as obstetrics also have telemetry capability) and no one designated to watch the monitors. There are also 2 telemetry monitors in the MSP unit that display patients rhythms for patients that are housed on the MSP unit. These monitors do not alarm.

-- Per interview of Staff N, Nursing Supervisor on 4/25/18 at 5:15 am the ICU/Telemetry unit had 6 telemetry patients and 1 ICU patient being admitted . There were 2 ICU nurses and one Health Unit Coordinator (HUC) (unit secretary) working the night shift.

-- Per interview of Staff A, RN on 4/24/18 at 5:30 am, the MSP unit had 16 patients, one on telemetry. No RNs with a patient care assignment on this shift were trained in cardiac rhythm recognition.

-- Per interview of Staff A on 4/24/18 at 5:30 am, on 4/13/18 during the evening shift (3:30 pm - 11:30 pm) the Chief Nursing Officer (CNO) made the decision to close the ICU/Telemetry unit due to lack of staff. Six patients were transferred from the ICU/Telemetry unit to the MSP unit (includes med tele patients.) Staff A was the charge nurse during the night shift (11:30 pm - 7:30 am). Three additional RNs were working with her: Staff O, RN, Staff P, RN and Staff G, RN. Each of these 3 nurses were providing care to 7 patients, none trained in irregular heart rhythms, all carrying a Care Event monitoring phones to remotely monitor patients on telemetry.

-- Per interview of Staff I, RN on 4/24/18 at 6:15 am. On 4/13/18 he/she and one other nurse, Staff H, RN were scheduled to work 7:30 pm-7:30 am in the ICU/Telemetry unit, however, due to staffing issues management decided to close the ICU/Telemetry unit and move those patients over to the MSP unit. All telemetry monitoring screens with alarms are located in the ICU/Telemetry unit, and by moving the staff to the MSP unit, it left no one in the ICU to monitor the telemetry patients. There are two monitors in the MSP unit, but they do not alarm.

-- Per review of the MSP staffing schedule for 4/13/18 on 11:30 pm-7:30 am, Staff O, P and G were assigned to care for a total of 9 patients who were on telemetry.

-- Per review of personnel files for Staff O, P, and G, all lacked evidence of training in cardiac rhythms. Staff P's Basic Life Support (BLS) had expired in 7/2017.

-- Per interview of Staff E, Director of ICU, MSP units on 4/24/18 at 12:40 pm, on 4/13/18 there were many call-ins. He/she along with other directors and the CNO made the decision to close the ICU/Telemetry unit and move the patients and 2 nurses to the MSP unit for "safety in numbers", there was no physician involvement with this decision. Staff complained that staffing was not appropriate and completed protest of assignment sheets and handed them to the nursing supervisor that night. These forms were forwarded to the CNO and labor management. On 4/16/18 during the safety huddle they discussed the events of 4/13/18. He/she is "hopeful that kind of situation won't happen again."

-- Per telephone interview of Staff F, CNO on 4/24/18 at 2:20 pm, on 4/13/18 there were 5 RN call-ins between 3:00 pm and 11:00 pm, and one RN call in on the night shift in the ED. They decided to close the ICU based on staffing and patient acuity (this the 2nd time in one month they had closed the ICU). Staff F reported that a root cause analysis (RCA) had not been completed yet, but would be, due to staff concerns of dangerous working conditions. Three to four protest of assignment sheets were submitted and reviewed with New York State Nurses Association (NYSNA) union and Labor Management; they let staff know they were looking into the situation.

-- Per MR review, Patient #1, an [AGE]-year-old male presented to the emergency department (ED) on 4/13/18 at 10:28 am with complaints of increased shortness of breath . He was a full code (full resuscitation). At 12:30 pm he was admitted to in-patient status to the MSP unit. At 3:05 pm, the patient was moved to the ICU/Telemetry unit. At 4:35 pm, he was transferred back to the MSP unit, per hospital request. Nursing documented a "paced" (pacemaker function) rhythm. Nursing documentation noted that at 5:34 am an RN found the patient unresponsive, gasping, cyanotic lips, and without a pulse. At 5:35 am a code 99 (patient experiencing a life threatening cardiac or respiratory event) was called, cardiopulmonary resuscitation (CPR) was started and the nocturnist (doctor that works at night) and ED physician were notified. At 5:43 am the patient had a detectable rhythm (heart beat) , the physician reported rhythm as a "NSTEMI" (non-ST elevation myocardial infarction) (heart attack). At 7:55 am, after initial stabilization the patient was transferred to the ICU where he ultimately deteriorated and expired. He was pronounced dead at 11:29 am.

-- Per review of the "Philips Event Transcript Selection," ( a record of all irregular heart rhythms) dated 4/13/18, 7:00 pm - 4/14/18, 7:00 am and verified as Patient #1's telemetry activity; indicates beginning on 4/13/18 at 8:54 pm he was consistently having paired many irregular heart beats up until 4/14/18 at 5:34 am when he went into ventricular fibrillation (deadly heart rhythm) and required resuscitation (life saving measures).

-- Per interview of Staff G on 4/25/18 at 9:25 am, he/she was the primary nurse for Patient #1, who had been transferred to MSP unit from the ICU earlier that evening. Staff G was assigned to carry a Care Event Monitoring phone during his/her shift from 11:30 pm to 7:00 am. Staff G reported that he/she was supposed to have a "buddy" assigned to work with him/her who could respond to the Care Event Monitoring phone alarm in the event he/she could not. Staff G could not recall who his/her buddy was that shift, (it was not identified on the assignment sheet). Staff G was alerted to Patient #1's ventricular fibrillation (deadly heart rhythm) when Care Event monitoring phone alarmed as he/she walked in into Patient # 1's room. Staff I was at the bedside. A code was over head paged. Staff started CPR and the patient was resuscitated. There was a delay in a physician arriving to the code. It took approximately 6 minutes for the hospitalist to arrive, and 3 staff members going to the call room to request his help. The ED physician responded after 10 minutes, he/she had assumed the hospitalist would respond to the code. There was no one available to intubate (insert breathing tube) Patient #1 had he needed it. The Director of the Respiratory Department came to the hospital after being called at home. Staff G has had no training in cardiac rhythm recognition and reported that he/she carries a Care Event Monitoring phone every time he/she works. Staff G also reported getting "floated" (assigned to work somewhere other then usual unit) to the ICU/Telemetry unit to care for telemetry patients and does not feel qualified to care for these patients. Staff G had signed a protest of assignment sheet at 11:30 pm that evening, prior to starting his/her shift.

--Per interview of Staff A on 4/24/18 at 5:30 am, on 4/13/18 during the night shift, he/she was providing care to two patients (Patients #3 and #4) who were both on Bilevel positive airway pressure (BiPAP)- a non-invasive form of therapy for patient's with sleep apnea, that had been transferred from the ICU/Telemetry unit to the MSP unit during the evening shift. Staff A reported having no training in BiPAP.

--Per review of the "Staff Assignment sheet, for 4/13/18 at 11:30 pm -7:30 am, Staff A was assigned to provide care to two patients (Patients #3 and 4) on BiPAP who were transferred from ICU/Telemetry to the MSP unit (per hospital request).

-- Per review of Staff A's personnel file, it lacked documentation indicating education/orientation was received for providing care to a patient on BiPAP. Also, there was no documentation describing evaluation of competency to care for a patient on BiPAP prior to performing this task independently.

-- Per review of the Job Performance Description and Evaluation for the job title "Registered Nurse-Medical/Surgical/Pediatrics," it lacks description of telemetry monitoring or BiPAP requirements.
VIOLATION: LICENSURE OF NURSING STAFF Tag No: A0394
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the hospital did not ensure that a Registered Nurse (RN), Staff R, a recent RN graduate, functioning in the role of a RN Orientee in the emergency department (ED), had at least one year of clinical experience per New York State Regulation 405.19 (9) (2) (iii). This could lead to inadequate patient evaluations and care.

Findings include:

-- Per New York State regulation 405.19 (9) (2) (iii), registered professional nurses in emergency services shall be licensed and currently registered professional nurses who possess current, comprehensive knowledge and skills in emergency health care. They shall have at least one year of clinical experience, have successfully completed an emergency nursing orientation program.

-- Per review of the hospital's "Job Performance Description and Evaluation Registered Nurse - Emergency Services," dated 3/2016, the RN in the ED is required to have one year of medical/surgical experience along with certification in Critical Care Nursing.

-- Per review of Staff R's personnel file, he/she graduated from a nursing program in 5/2017 and submitted a job application to the hospital on [DATE]. Staff R's New York State RN license was issued on 8/9/17 and he/she was hired into a position as a RN in the hospital's ED on 8/14/17.

-- Per interview of Staff S, Director Emergency/Perinatal Services on 4/25/18 at 9:15 am, Staff R is a new graduate RN orienting in the ED since 8/2017 without previous nursing experience. He/she acknowledged the above findings.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on document review, medical record (MR) review and interview, in 7 of 10 MRs (Patient's # 1, #2, #3, #4,
#5, #6, and #7) reviewed a fall risk assessment was not done and/or fall risk interventions were not documented. In 2 of 10 MRs (Patient's # 3 and #5) skin breakdown prevention interventions were not documented. These lapses could lead to adverse outcomes to patients.

Findings include:

-- Per review of the hospital's P&P titled "Fall Risk Survey," dated 10/2017, a Fall Risk Summary should be completed and kept as part of the medical record (as part of the Admission Assessment). A fall risk survey should also be completed every 24 hours as part of the day shift assessment. The P&P lacks instruction to staff to document fall risk interventions that were implemented (e.g., siderails, bed alarm, call bell in reach, etc.)

-- Per review of Patient #2's MR, she was identified as a high fall risk. Her MR lacked documentation of what fall preventions were initiated and/or implemented from 4/11/18-4/13/18.

-- Per review of Patient #3's MR, she was identified as a high fall risk. Her MR lacked documentation of what fall preventions were initiated and/or implemented from 4/3/18-4/19/18.

-- Per review of Patient #5's MR, he was identified as a high fall risk. His MR lacked documentation of what fall preventions were initiated and/or implemented from 4/11/18-4/27/18.

The same lack of documentation of fall preventions initiated and/or implemented was noted in Patient's #1, #4 and #6 MRs, all identified as high risk to fall. Patient #7's MR lacked a fall risk assessment.

-- Per review of the hospital's P&P titled "Skin Care Team and Protocol," dated 1/2014, (includes "Skin Care Nursing Care Guidelines,") patients should be assessed on admission and daily using the Braden scale to identify patients at high risk for skin breakdown. Patients who are rated as a "15" or less should be considered high risk. Management of potential alteration in skin integrity includes but not limited to for example, to turn and position patients at risk every 2 hours, propping with pillows for support, positioning heels off the bed with pillows, etc. For management of a patient with Stage II or Stage III pressure ulcer a wound care consult should be initiated.
The P&P lack instruction to staff to document initiation and/or implementation of preventive measures in the MR.

-- Per review of Patient #3's MR, she was identified as a high skin risk with scores of "11" and "12" on the Braden scale. However, her MR lacked documentation preventive skin interventions from 4/3/18 to 4/19/18.

-- Per review of Patient #5's MR, he was identified as a high skin risk with score of "15" on the Braden scale from 4/22/18 to 4/27/18. He developed a Stage II pressure ulcer on his coccyx during his hospitalization . His MR lacked documentation of initiation and/or implementation of preventive skin interventions.

-- Per interview of Staff M, RN on 4/24/18 at 9:52 am, revealed Patient #5 had developed a Stage II pressure ulcer to his coccyx.

-- During interview of Staff U, RN on 4/26/18 at 4:55 pm, he/she acknowledged the above findings.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on document review and interview the hospital failed to ensure that nursing staff were trained to meet the specialized needs of the patients they were caring for. Also the hospital's job description for registered nurses (RN) working on the medical/surgical/pediatric (MSP) unit lacked pertinent job responsibilities for that position. Additionally, the hospital's polices and procedures (P&P) related to cardiac monitoring were inadequate. These lapses could lead to poor patient outcomes.

Findings include:

-- Per review of the Job Performance Description and Evaluation for the job title "Registered Nurse-Medical/Surgical/Pediatrics," it lacked requirement for training and competency in telemetry monitoring (cardiac monitoring to identify irregular health rhythms) or Bilevel positive airway pressure (BiPAP), (a non-invasive form of therapy for patients with sleep apnea) monitoring.

-- The hospital's P&P titled "Scope of Service, Medical/Surgical/Pediatric Division," last revised 11/2017, required RN staff to have a current Basic life support (BLS) (basic training to treat life threatening emergencies) certification.

-- Per review of hospital's P&P titled "Care Event Smartphone Monitoring Phone," submitted by Staff E, Director of ICU/MSP, dated 12/2017 (with no governing body approval); (a system to remotely monitor telemetry patients), indicated staff carrying phone must have completed the HealthStream Rhythm Recognition Course (a course to recognize irregular heart rhythms - dysrhythmias).

-- During telephone interview of Staff F, Chief Nursing Officer (CNO) on 4/24/18 at 2:20 pm, he/she reported all staff carrying Care Event Monitoring phones should be certified in a dysrhythmia course

-- Per interview of Staff A on 4/24/18 at 5:30 am, Staff L was providing care to a telemetry patient that shift. Staff L lacked dysrhythmia training.

-- Per interview of Staff M, RN on 4/24/18 at 8:45 am, he/she reported no education in cardiac dysrhythmias and was carrying a Care Event Monitoring phone and had one patient on his/her assignment that required telemetry monitoring.

-- Per interview of Staff G, RN on 4/25/18 at 9:25 am, he/she had no education in cardiac dysrhythmias and carries a Care Event Monitoring phone every time she works. He/she also reported getting floated (assigned to work in) to the Intensive Care Unit (ICU) / Telemetry unit to care for telemetry patients and does not feel qualified to care for these patients

-- Per interview with Staff H, RN on 4/25/18 at 10:20 am, he/she reported most nursing staff carrying the smart phones are not trained in cardiac dysrhythmias and rely on the nurses in the ICU to respond to alarms at the cardiac monitors in the ICU (which are unmanned).

-- Per review of HealthStream Course Completion Report for MSP RNs, it revealed twelve out of twenty-six MSP RNs and six out of twelve ICU RNs had not completed the online dysrhythmia training.

-- Per review of personnel files and HealthStream Course Completion Report, Staff G, Staff O, Staff P (MSP nurses) lacked documentation of training and competency in dysrhythmia training.

-- Per review of personnel files for Staff M and Staff P, (MSP nurses) both lacked current BLS.

-- Per review of Staff A's personnel file, (RN charge nurse provided care to BiPAP patients) it lacked documentation indicating education/orientation was received for providing care to a patient on BiPAP. Also, there was no documentation describing evaluation of competency to care for a patient on BiPAP prior to performing this task independently.

-- Per review of the Job Performance Description and Evaluation for the job title "Director, Medical / Surgical / Pediatrics / ICU," this person orients new employees, lend clinical expertise .It requires certification in BLS and ACLS (advanced training to address life threatening emergencies). However, review of the HealthStream Course Completion Report revealed that Staff E had not completed education in dysrhythmia recognition. Review of Staff E's personnel file lacked evidence of ACLS certification.

-- Per review of hospital's P&P titled "Telemetry Patients in the ICU,'' last revised 6/2016, it did not require staff to have completed training in cardiac dysrhythmias and it did not contain instructions on how to manage alarms, how or what to document in the medical record (MR) as it pertains to cardiac dysrhythmias or how rhythm strips become part of the MR.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation, document review and interview, expired medications were available for patient use and an open vial of insulin was not discarded within 28 days of the opening date.
This could potentially result in the administration of an expired medication and the potential of reduced efficacy and safety of the insulin.

Findings include:

-- During observation of the Medical/Surgical/Pediatric (MSP) unit's emergency cart on 4/24/18 at 5:45 am, the emergency cart contained the following expired medications:

- 2 Propranolol vials expired 3/2018
- 2 Procainamide Hydrochloride vials expired 3/2018
- 4 Metoprolol Tartrate vials expired 3/2018
- 2 Mannitol 25 % vials expired 4/1/18

-- During tour of the OB unit's medication refrigerator on 4/25/18 at 10:20 am, the medication refrigerator contained an opened vial of Humulin Regular insulin dated 3/15/18, 41 days after the vial was opened and not discarded after 28 days.

-- Per review of the hospital's P&P titled "Emergency Cart Policy," dated 11/2017, crash carts are inspected by pharmacy personnel at least once a month and documented on the Crash Cart Inspection form attached to the cart. Missing drugs or drugs which show evidence of tampering are replaced by pharmacy. The P&P did not address who is responsible for checking expiration dates and how to handle expired medications.

-- Per review of the hospital's P&P titled "Insulin Use/Glycemic Control," dated 9/2017, insulin vials should be discarded 28 days from when it is first accessed.

-- Per interview of Staff B, RN on 4/24/18 at 8:45 am, revealed the day Charge Nurse checks the emergency cart daily to make sure the "yellow tag" (security lock) is intact. Staff from the pharmacy checks medications for expiration dates daily.

-- Per interview of Staff X, Pharmacy Technician on 4/24/18 at 9:40 am, he/she checks the hospital's emergency carts monthly for expired medications and keeps a hand written note of medications that are due to expire attached to a notebook kept in the pharmacy.

-- Per interview of Staff Y, Pharmacist on 4/24/18 at 10:55 am, the pharmacy technicians check the emergency carts for medication expirations every month.

-- Per interview of Staff Z, Director of Pharmacy on 4/25/18 at 11:50 am, the pharmacy technicians are responsible to check the hospital's emergency carts daily, monthly and if medication/s have been used. He/she would have the pharmacy technicians remove a medication 1 month before its expiration date but now removes a medication a couple of weeks before its expiration date due to difficulty getting some medications. The pharmacy technician is also responsible to check refrigerated medications on the hospital's units and discard them if opened after 28 days. Insulin is to be discarded 28 days after it is opened. He/she acknowledged the above findings.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on interview, the hospital failed to protect each patient's right to safe care. Specifically, an EKG (electrocardiogram) machine was left unplugged in the Emergency Department (ED) resulting in a dead battery. This may have prolonged time to get an EKG.

Findings include:

-- Per interview of Staff J, Director of Performance Improvement/Risk Management on 4/26/18 at 10:30 am, on 4/13/18 during the Code 99 (patient experiencing a life threatening cardiac or respiratory event) involving Patient #1, staff went to ED to obtain the EKG machine. When located, it was not working. The battery was not charged as it had not been plugged in after the last use. Staff had to locate another EKG machine.

-- Per interview of Staff K, Bioengineer on 4/26/18 at 11:30 am, on 4/13/18-4/14/18 one EKG machine in the ED had been left unplugged and the battery was dead. No work order had been completed to have the EKG machine restored. On Monday, 4/16/18, the EKG machine on the Medical/Surgical/Pediatric (MSP) unit was found with a dead battery in a closet. Staff K encouraged nurses to complete a work order whenever there is an equipment malfunction.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on document review and interview, hospital staff lacked knowledge of proper cleaning and disinfecting of a glucometer. This could lead to contaminated patient equipment available for patient use.

Findings include:

-- Per review of hospital's policy and procedure (P&P) titled "Freestyle Precision Pro Testing," dated 2/2017, to clean and disinfect the glucometer following use on each patient. Cleaning should be performed using "Dispatch" wipes (ready to use EPA registered bleach towels) and disinfection should be done with a separate "Dispatch" wipe.

-- Per interview of Staff B, RN on 4/24/18 at 8:45 am, glucometers are wiped with alcohol after use.

-- Per interview of Staff D, RN on 4/24/18 at 9:55 am, glucometers are wiped with alcohol after use.

-- Per interview of Staff Z, RN on 4/24/18 at 10:20 am, glucometers are wiped with Caviwipes (surface disinfectant) after use.

-- During interview of Staff E, Director of Intensive Care Unit and Medical/Surgical/Pediatric Unit on 4/27/18 at 2:00 pm, he/she acknowledged the above findings.