Based on observations and interviews the facility failed to ensure the glucometer quality control testing solutions were dated when opened on 2 of 4 patient care floors observed (floors 5 and 6). Findings include: Reference: Nova StatStrip Glucose Control Solution provided by director of quality read, Precautions: use only for 3 months after first opening. When first opening the bottle count 3 months forward and write the date on the label. Discard any remaining solution after that date. Expiration: Once opened solutions will be stable for up to 3 months. Control solution is good for only 3 months after opening. The facility failed to ensure staff dated the glucometer low testing solution when opened. 1. A tour was conducted, on 2/26/18 beginning at 9:28 a.m., on patient care floors 5 and 6. An observation in the nurse medication room revealed one low glucose quality control testing solution was not dated on each floor. A subsequent tour was conducted, on 2/27/18 at 9:25 a.m., on patient care floor 5. An observation in the nurse medication room revealed the same low glucose quality control testing solution was not dated as observed the day before. Additionally, observation of one high glucose quality control solution showed it was not dated when opened. a. Registered Nurse (RN) #24 was interviewed, during the tour on 2/27/18 at 9:25 a.m. She stated the undated glucose quality control solution would have to be thrown away. She then tossed the solution container into the trash can. She reported if there had not been a date on the bottle one would not know when the solution expired. RN #24 stated all the diabetic patients on the floor would have had to be re-tested . She said that was because the diabetic patients tested would not have had accurate results. b. RN #21, who was also the Charge RN, was interviewed on 2/27/18 at 9:38 a.m. She reported all strips, and quality control solutions for the glucometer were to be dated when opened. RN #21 stated the solutions were dated so the staff would know if the solution had expired. She said if the solution had expired the facility could not have ensured the patient received an accurate test. RN #21 stated for patient safety the facility always wanted to perform an accurate test.
Based on the onsite validation survey, completed December 8 through December 11, 2014, the facility failed to comply with the regulations set forth for Life Safety and, therefore, deficiencies were cited under Life Safety Code tags (for building A1) K0011, K0018, K0025, K0027, K0029, K0038, K0050, K0052, K0062, K0074, K0078, K , K0020 (builidng A5), and K0038 (Building A5). See survey event ID #1f5W21 for full details of the cited deficiencies.
Based on observations, interviews and document review, the facility failed to ensure that equipment was maintained and calibrated at an acceptable level to ensure patient safety. Five of ten refrigerators, used to store patient food in patient care units, were found to have temperatures out of range for safe food storage and lack of documentation that the temperatures were adjusted by staff. This failure created the potential for negative outcomes to patients, including illness, if consuming food not stored at an acceptable temperature. FINDINGS: According to facility policy, Patient Refrigerators/Freezers, all refrigerator/freezer temperature checks will be completed and maintained by the departments in which they are located. Food refrigerators will be maintained at a temperature of 33-40 degrees F. Any refrigerator/freezer noted out of temperature range or to be malfunctioning shall be reported immediately to Plant Operations and noted on the log. According to facility log titled, Patient Food, Medication, Breast Milk Refrigerator/Freezer Log, the acceptable temperature range for refrigerators in which patient food is stored is 33-40 degrees Fahrenheit. Per the log, the temperatures will be recorded for the refrigerators each day and if temperatures are out of range, actions by staff will be documented on the log including checking the temperature again after two hours and notifying Plant Operations if necessary. 1. Five of ten temperature logs reviewed for refrigerators in which patient food was stored, revealed temperature logs were not completed each day and actions by staff were not documented on the logs when temperatures were out of range. a) On 11/18/14, observations were made on 10 patient care areas that had refrigerators containing patients' food. The following patient care units had incomplete refrigerator logs for the month of November, 2014: ICU-A, 4 North, 4 Central, 3 Central, and P2. b) The log for ICU-A revealed 4 days from 11/01/14 - 11/18/14 in which there was no documentation that the refrigerator temperatures were checked and recorded by staff. For the 14 days temperatures were recorded, 10 were out of range at 41 or 42 degrees F, meaning the refrigerator temperature was higher than the acceptable high temperature of 40 degrees. There was no documentation by staff that the temperature control on the refrigerator was adjusted to bring the temperature back into the acceptable range and that the temperature was rechecked by staff to ensure safety of patient food. c) The log for 4 North revealed 7 days from 11/01/14 - 11/18/14 in which there was no documentation that the refrigerator temperatures were checked and recorded by staff. For the 11 days temperatures were recorded, 1 was out of range at 41 degrees. There was no documentation by staff that the temperature control on the refrigerator was adjusted to bring the temperature back into the acceptable range and that the temperature was rechecked by staff to ensure safety of patient food. d) The log for 4 Central revealed 8 days from 11/01/14 - 11/18/14 in which temperatures were recorded as out of range at 41 or 42 degrees F. There was no documentation by staff that the temperature control on the refrigerator was adjusted to bring the temperature back into the acceptable range and that the temperature was rechecked by staff to ensure safety of patient food. e) The log for 3 Central revealed 3 days in which temperatures were recorded as out of range at 32 degrees. The log revealed on one of these days, 11/08/14, the temperature control was adjusted to raise the temperature but a second check of the temperature after 2 hours, or at any time afterward was not documented. f) The log for P2 revealed 1 day from 11/01/14 - 11/18/14 in which there was no documentation that the refrigerator temperature was checked and recorded by staff. g) On 11/18/14 at 9:30 a.m., an interview was conducted with Registered Nurse (RN) #12, the ICU-A unit manager, who stated the expectation of staff was that the refrigerator logs would be completed by nursing staff each day and would contain documentation of the refrigerator temperature, what adjustments were made of the temperature control, if needed, and a recheck of the temperature in 2 hours. RN #12 confirmed the logs for the unit were missing documentation and the facility's policy was not being adhered to by staff. h) On 11/20/14 at 10:45 a.m., the Assistant Vice President of Quality confirmed the refrigerator logs in which patient food was stored were not being completed by staff per the facility's policy.
Based on observation, interview and document review, the facility failed to have a process in place which ensured opened food items were labeled and disposed of by the expiration date. This failure created the potential for patients to contract illnesses due to exposure to food borne pathogens if expired and unsafe food was served to patients. FINDINGS: FACILITY POLICY According to the policy, Food Safety Standards and Requirements, upon receiving the facility should date all products to ensure first in-first out procedure. Manufacturer's expiration, use by or sell by dates must be adhered to. All foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers. Date mark ready-to-eat foods that are clearly identifiable do not need to be labeled with the name of the product but must be dated. 1. A tour of the kitchen was conducted on 11/18/14 beginning at 9:50 a.m., with the Food/Dietetic Director (Employee #1). The Food/Dietetic Director was asked what document the facility used for guidance for determining the shelf life of food items. S/he provided a document titled What is the expiration date, which showed the following guidelines for labeling and determining shelf life. - Individual cans/bottles should have the opened date in permanent ink or sticker. - Food prepared for later use = use within 5 days, marked in permanent ink or with sticker. - Food leftover after meals = use within 2 days, marked in permanent ink or with sticker. During the tour numerous food items were observed with no labels to identify when the item was open or prepared and when the item expired and should be discarded. As example, Observation of the tray line cooler revealed an open bag of blue cheese, an open bag of chopped onions and an open bag of hashbrowns with no dates when the items were opened and when they should be discarded. Additionally containers of cut strawberries and oranges were noted with no date identifying when the items were prepared and when they expired. An interview was conducted with Employee #2 (Kitchen Line Staff employee) on the process for labeling and dating food items in the tray line cooler. Employee #2 stated s/he usually dated items before putting them in the cooler but s/he was busy today and didn't do it. The employee acknowledged food items were suppose to be labeled and dated prior to being placed in the cooler. Observation of the tray line bread rack, on 11/18/14, revealed croissants and ciabatta roles in open unlabeled bags with no date of when the items were opened and when they expired. Additionally three loaves of bread had expiration dates of 11/16. Observation of a second bread rack showed seven loaves of bread which had expired 11/13. According to the Food/Dietetic Director the person who delivered the bread was to ensure expired loaves were removed. Observation of the meat cooler revealed a bag of unlabeled meat with no date of when it was received and when it expired. The Food/Dietetic Director stated it looked like a filet but acknowledged it shouldn't be in here. S/he stated all staff would monitor and discard expired items and s/he would do spot checks to see if it was done. 2. Further observations during a subsequent tour of the kitchen on 11/19/14 beginning at 9:40, with the Food/Dietetic Director showed the facility continued to store unlabeled and undated food items. Specifically, The cooler contained an open bag of lettuce, a plastic container of cut pineapple and plastic containers of blueberries and blackberries with no date of when the items were received, prepared and expired. Additionally a plastic container of green melon had an expiration date of 11/17 (two days prior). An opened container of coleslaw dressing had no open date or expiration date noted. The meat cooler contained a bag of chicken with no received or expiration date. According to the Food/Dietetic Director, the kitchen staff probably took the bag out of the box and discarded the box. S/he acknowledged the bag of chicken should have been dated with a received and expiration date.
Based on facility tours, staff interviews and facility documents, the facility failed to maintain medical equipment to ensure an acceptable level of safety and quality. Specifically, there was equipment that did not have timely preventive maintenance performed and equipment that had incorrect due dates for the next scheduled preventive maintenance. The findings were: A tour was conducted on 12/12/11 of surgical services beginning at approximately 1:30 p.m. In the PACU (Post Anesthesia Care Unit) there was a fluid warmer that had a preventive maintenance sticker that was due 9/11 and a Ethicon Endo Surgery UC (Electrosurge) that had a preventive maintenance sticker due 12/7/11. Further observations in PACU and sterile processing revealed there were approximately 11 to 12 SCD (Sequential Compression Device) pumps that were all due for preventive maintenance in 11/11. An interview was conducted with the Director of Biomed on 12/14/11 at approximately 9:00 a.m. The Director stated that the fluid warmer was a Tier 2 item and Biomed had a two month window to perform preventive maintenance. A history of the equipment was supplied by the Director and the fluid warmer was on a could not locate list and continued to be overlooked. However, after being located by a surveyor during the survey process, preventive maintenance was performed on 12/13/11. The history log for the Electrosurge revealed that preventive maintenance had been performed on 12/7/11; however, the technician had failed to put a new sticker on the equipment. The interview was continued with the Director regarding the SCD pumps. The Director stated there are 200 SCD pumps located throughout the facility and they are on a two year cycle for preventive maintenance and are all due in 11/12 not 11/11. It had been determined by the facility during the time that maintenance had been performed on the pumps in 2010 that they would be phased out of service by 9/11. The Director stated that s/he made an error in judgement and had the technicians put the due date of 11/11 on every pump because all the pumps were supposed to be gone before that due date. The Director further stated that s/he regretted this decision and all the SCD pumps should have been tagged with the correct due date of 11/12 rather than the incorrect due date of 11/11. The facility has set 2/2012 as the next date when the pumps are to be phased out.
On 12/13/11 at approximately 11 a.m., during a tour of the intensive care unit with the nurse manager and the assistant director of nursing, the #3 crash cart was inspected. Inspection of the defibrillator revealed that it contained a note stating requisition sent to Biomed(ical Engineering) 12/10 to check for low battery print out. The nurse manager and the assistant director of nursing confirmed that the defibrillator should have been switched out for a working replacement, rather that leaving the defibrillator on the cart, since the performance of the machine was in question. They stated that they would address the situation immediately to ensure that a working replacement was placed on the cart and the other defibrillator removed to Biomedical Engineering. During a tour of an equipment storage area on the unit, two portable pulse oxygen monitors were found stored in a cabinet. One of the monitors had been inspected on 12/10 and was due to be inspected 12/11. The other monitor had not been inspected since 12/08. The findings were confirmed with the nurse manager and the assistant director of nursing. They stated that the monitor with an old inspection date would be brought to the attention of Biomedical Engineering that day for inspection.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, staff interviews, and review of the hospital's policies/procedures the hospital failed to ensure that all outpatient departments adhered to the hospital's policies for medication storage and disposal. A hospital policy titled Expiration Dating (Beyond Use Dating) for Injectable Medications in Vials and Ampuls last revised 1/3/2011 stated the following, in pertinent parts: ...The maximum period in which a solution containing a preservative may be used once the stopper has been punctured will be 28 days unless the manufacturer specifies a Beyond Use Date (BUD) that is shorter unless contamination is evident or suspected... 1.2.3. Vials containing preservative - BUD of 28 days with the following exceptions... 1.2.3.3. Vial should be labeled with BUD and discarded at expiry. Vials not labeled with BUD will be discarded immediately... A hospital policy titled Warming IV and Irrigation Fluids last reviewed 9/27/2010 stated the following, in pertinent parts: ...Procedure Pour Fluids: 1. For warmed pour fluids, these bottles can be stored in a warming cabinet at a temperature not to exceed 110 degrees F (43 degrees C) no longer than 14 days... 3. Pour fluid bottles must be dated, stored and rotated according to manufacturers' instructions to ensure the integrity of the fluids. 4. All pour fluids bottles that have been warmed for 14 days will be discarded. Bagged Fluids: 1. Bagged fluids in the overwrap may be in a warming cabinet with a temperature not to exceed 110 degrees F (43 degrees C) no longer than 14 days... 3. Bagged fluids must be dated, stored and rotated according to manufacturers' instructions to ensure the integrity of the fluids. 4. All bagged fluids that have been warmed for 14 days will be discarded... A tour of the Family Medicine clinic that served as an outpatient department of the hospital on [DATE] at approximately 12:35 p.m. with the clinic's Operations Manager revealed that the clinic administered medications occasionally which included the use of multidose vials. A vial of Novolog insulin was found in the clinic's medication refrigerator. The vial had written indication on the bottle that it had been opened on 11/19/2011 and was to be discarded on 12/19/2011. The written indication was not consistent with the hospital's policy to discard multidose medication vials after 28 days. A vial of tuberculin skin testing solution was found in the clinic's refrigerator that had written indication that it had been opened on 10/10/2011 and was to be discarded 11/10/2011. The bottle had a manufacturer's direction that the solution be discarded 30 days after being opened. The vial remained available for patient use beyond the manufacturer's recommended beyond use date. A vial of 2% Lidocaine was found in a drawer that had written indication that it had been opened on 12/1/2011 and was to be discarded 1/1/2012. The written indication was not consistent with the hospital's policy to discard multidose medication vials after 28 days. A tour of the hospital's Post-Anesthesia Care Unit on 12/12/2011 at approximately 2:00 p.m. with the Director of Surgical Services revealed that the department utilized a warming cabinet for intravenous fluids. The cabinet contained nine bags of normal saline solution that had written indication that the bags needed to be removed from the cabinet on 1/1/2012 (19 days after the date of the observations). The staff of the Post-Anesthesia Care Unit (PACU) as well as the PACU's Nurse Manager were asked what the facility's policy on the storage of fluids in the warming cabinets. They were initially unable to state what the policy was, but were able to confirm that the facility's policy was that fluid was to be removed from the cabinet after 14 days. The PACU's Nurse Manager confirmed that the written indication on the nine bags of normal saline solution was inconsistent with the facility's policies. A tour of the hospital's Obstetrical Surgical area on 12/12/2011 at approximately 3:55 p.m. with the Obstetrical Technician revealed that a warming cabinet in the surgical area contained both intravenous fluids and pour fluids. None of the fluids were dated in accordance with the facility's policy. The obstetrical technician stated that the anesthesia staff stocked the fluids in the warmer and confirmed that the fluids did not have a written indication when they were placed in the warmer or when the fluids needed to be removed from the warmer.
On 12/13/11 at approximately 9:30 a.m., during a tour of the main medication room for the medical/telemetry unit the patient individual medication drawers were inspected and revealed the following: Examination of the drawer for patient room 404 revealed a previously opened multiple dose vial of Heparin that had no label of when the vial had been opened, initials of the staff member who had opened the vial, or the date that the vial would reach the 28-day after opening date that required the vial to be discarded, per facility policy/procedure. The clinical pharmacist stated that the medication should have been labeled at the time of opening, so that the 28-day discard date would have been determined to ensure that the medication did not reach a patient after the exceed the beyond use date (BUD). S/he removed and discarded the medication, after it was presented to her. Examination of the drawer for patient room 423 revealed that it contained a patient's own outpatient prescription bottle containing Warfarin. The bottle was not labeled with a bar code and evidence that it had been inspected by the pharmacy and approved for hospital administration. The clinical pharmacist stated that the medication should not have been stored in the patient medication drawer on the unit unless it was inspected, barcoded and approved for use in the hospital per a physician order. S/he stated that it appeared to be a patient's prescription bottle brought in at the time of admission. S/he stated that the medication should have been sent home with family or sent to the pharmacy for storage until discharge. Examination of the drawer for patient room 426 revealed a previously opened multiple dose vial of Heparin that had no label of when the vial had been opened, initials of the staff member who had opened the vial, or the date that the vial would reach the 28-day after opening date that required the vial to be discarded, per facility policy/procedure. The clinical pharmacist stated that the medication should have been labeled at the time of opening, so that the 28-day discard date would have been determined to ensure that the medication did not reach a patient after the exceed the beyond use date (BUD). S/he removed and discarded the medication, after it was presented to her. Examination of the drawer for patient room 440 revealed that it contained a plastic bag containing five bottles of the patient's own medications from home. The bag contained one prescription bottle of Metoprolol ER 25 mg, and four over-the-counter bottles for a multivitamin, famotidine, aspirin 81 mg and NAC (N-acetyl cysten). The patient's nurse was questioned why the medications were in the medication drawer, since they contained no evidence of a bar code or inspection/approval by pharmacy. S/he stated that the medications were not being administered to the patient and that s/he would send them home with the patient's spouse that day. The clinical pharmacist stated that the medications should not have been stored in the patient medication drawer on the unit unless it was inspected, barcoded and approved for use in the hospital per a physician order. S/he stated that the medication should have been sent home with family or sent to the pharmacy for storage until discharge. During the inspection of the medication room, a plastic grocery bag was found stored on the top of the medication refrigerator, behind two large bottles of liquid nutritional supplements. The unlabelled bag contained a ripped paper bag that contained what appeared to be 14 sample boxes containing bottles of Aciphex 20 mg. No nursing staff on the unit knew who the samples belonged to or how long they had been stored on top of the refrigerator. The clinical pharmacist stated that the hospital did not allow sample medications. S/he stated that s/he had no explanation for why the apparent samples were found in the medication room. S/he theorized that the medications were probably samples brought in by a patient at the time of admission, but they should have been labelled and sent home with family or sent to the pharmacy for storage until discharge. S/he removed and discarded the medication, after it was presented to her. The findings were confirmed with the nursing manager for the unit, the assistant director of nursing and the clinical pharmacist for the unit.
Based on credential file review, review of the facility's medical staff delineation of privileges sets, and staff interview the facility failed to ensure that practitioners were granted specific privileges when placed on the medical staff. Specifically, the facility failed to delineate what tasks/activities/procedures the practitioners were granted privileges to do. The findings were: Review of the provided delineations of privileges for the various medical specialty areas of the medical staff revealed the following, in pertinent parts: Classification of Privileges in the Department of Medicine. Each staff physician will be classified as having certain professional privileges, as outlined below. You are asked to request the privileges you deem appropriate to your training and skills. The requests will be reviewed by various committees and final decision will be made by the Board, upon recommendation of the Medical Executive Committee. It is understood that any physician may take appropriate emergency action in a situation where, in the best judgement of the attending physician, such immediate action is necessary for the patient's welfare. Class of Privileges (PLEASE CIRCLE the group you are requesting.) CLASS 1 Competent to handle all medical conditions of mild to moderate degree. Physicians in this class are required to request consultation in all cases in which doubt exists as to the diagnosis, or in cases in which improvement in the patient's condition is not soon apparent. CLASS 2 Competent to handle medical conditions and consultations of greater severity or complexity, requiring specialized knowledge. This category will generally include physicians certified by or with training and experience required for certification by the American Board of Internal Medicine. Such physicians will be expected to request consultation when hazardous treatment procedures are contemplated; when unexpected complications arise; in cases in which treatment response seems unduly delayed. CLASS 2A Competent to handle medical conditions, but no consultations, of greater complexity. This category may include physicians who are certified by the American Board of Family Practice, and who furthermore have demonstrated sufficient postgraduate training and competence in the management of more complex illnesses in the field of internal medicine. Such physicians will be expected to request consultation when hazardous treatment procedures are contemplated; when unexpected complications arise; in cases in which treatment response seem unduly delayed. CLASS 3 Competent to handle the most difficult procedures and conditions in certain areas requiring unusually specialized knowledge. Generally comparable to certification by, or with training and experience required for certification by a specialty board. This includes the following categories: Allergy/Immunology Cardiovascular Diseases Dermatology Endocrinology Gastroenterology Hematology/Oncology Infectious Disease Nephrology Neurology Psychiatry Pulmonary Diseases Rheumatology Toxicology... Attached to the Medical delineation of privileges were additional specialty privileges, including General Procedures, which included the following: Arterial Puncture, Arthrocentesis, Lumbar Puncture, Paracentesis, Skin Biopsy, Subclavian Catheterization, Thoracentesis... Cardiovascular Procedures... Endocrinology Procedures... Gastroenterology... Nephrology... Neurology... Psychiatry Procedures... Pulmonary Procedures... Rheumatology... Sedation Analgesia (For Non-Anesthesiologists)... Moderate Sedation Analgesia... If you wish to perform any procedure not listed on this form, please contact your department chairman or the medical staff office... The additional sets of delineated privileges, which all included core or block privileges, were also reviewed: Emergency Medicine Physician (EP) Core Privileges, Anesthesia Privileges, Radiology Privileges, Pathology Privileges, Certified Registered Nurse Anesthetist, Physician Assistant, Nurse Practitioner/Clinical Nurse Specialist, Certified Nurse Midwife, Orthopedic (Surgery) Clinical Privileges, Surgery - General, Colorectal and Pediatric, Cardiovascular and Thoracic Surgery Privileges, Oral and Maxillofacial Surgery Clinical Privileges, Ophthalmology Clinical Privileges, Otolaryngology Clinical Privileges, Podiatry Privileges, Urology Clinical Privileges, Vascular Surgery Privileges, Internal Medicine, Cardiology, Dermatology, Endocrinology, Hematology, Infectious Disease, Nephrology, Neurology, Psychiatry, Pain Management, Physical Medicine and Rehabilitation, Rheumatology. Review on 12/15/11 of the privilege delineation sets revealed that they all started with a large description of core or block privileges, which were presented in such a format that there was no way to select or delete components of the core or block privileges to accommodate the skills and needs/wishes of the individual physician as required. Some delineation sets also had additional groupings of other privileges, some were listed as a group allowing no choice, and some were provided in a menu format that allowed for individual choice. An interview with the Associate Chief Nursing Officer conducted on 12/14/2011 at approximately 4:15 PM revealed that the Clinical Administrator on Duty (CAD) utilized a computer program to review the privileges granted to practitioners when necessary to ensure that surgeons had privileges to perform specific procedures. S/he was asked to retrieve the privileges for a specific surgeon. S/he was able to utilize a software system which contained scanned copies of the sheet(s) of paper that were filled out by practitioners when applying for inclusion on the medical staff. The plastic surgeon reviewed at that time had been granted the privileges of Cosmetic Surgery and Reconstructive Surgery. The privileges were not specified any further than those two categories and did not list any specific procedures that would be included under those broad categories. The medical staff office staff member stated that the information obtained was the same in both systems. An interview with the hospital's Director of Medical Staff on 12/15/2011 at approximately 7:50 a.m. confirmed that the Medical Staff Office staff and the hospital's staff had access to the system that was described the Associate Chief Nursing Officer. S/he confirmed that the hospital granted core privileges and did not further specify privileges for most practitioners. A subsequent interview with the hospital's Director of Medical Staff and the corporate Director of Credential Support Center conducted on 12/15/2011 at approximately 9:23 AM revealed that the hospital and the governing body were unaware of a need to grant specific privileges rather than groups or more general privileges.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations and staff interview the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure that expired supplies were not available for patient use. The findings were: 1. Expired Laboratory Supplies A tour of the pre-operative patient care area on 12/12/2011 at approximately 2:15 PM with the Director of Surgical Services revealed that in the pre-operative area there was a cupboard with laboratory test tubes. There were approximately 20 yellow laboratory tubes that had a manufacturer's expiration date of 11/2011 that were available in the cupboard for patient use. The date on the tubes was confirmed by the Pre-operative/Post-operative Nurse Manager. A tour of the infusion center patient care area on 12/13/2011 at approximately 9:45 AM with the Director of Surgical Services revealed that in one of the patient rooms, a drawer contained laboratory tubes for patient laboratory draws. Thirteen lavender laboratory tubes were found that had a manufacturer's expiration date of 11/2011. The date on the tubes was confirmed by the Infusion Center Nurse Manager. 2. Expired Glucometer Controls A facility policy titled Ancillary blood glucose monitoring: Accu-Chek inform last revised 6/22/2011 stated the following, in pertinent parts: ...All units providing the service of Accu-Chek Inform blood glucose monitoring shall comply with the established quality control measures... Quality Control Guidelines 1. Two levels of Roche Diagnostics Quality Control material will be run on each day that patient testing is to be done, on each Accu-Chek Inform Glucose Meters.... 2. Storage of Controls and Test Strips 2.1 Glucose Control Solutions must be stored at room temperature. Do not refrigerate or freeze. Glucose Control Solutions are stable for three months after opening or until the expiration date that is printed on the vial, whichever comes first. The date opened, expiration date, and user's initials must be written on the vial label. 2.2 Any outdated Glucose Control Solutions must be discarded... A tour of the outpatient eye surgery center that functioned as an outpatient department of the hospital on [DATE] at approximately 10:40 AM revealed that the glucose control solutions available for use had written indication that the bottles were opened on 9/6/2011 and were to be discarded 12/6/2011. The manager of the surgery center confirmed that the glucose control solutions were labeled to be discarded on 12/6/2011. S/he confirmed with the nurse on duty that the control solutions labeled to be discarded on 12/6/2011 were used on 12/13/2011 for the quality control check. Cross reference tag A0505 for findings related to the hospital's failure to ensure that outdated and unusable drugs were not available for patient use.
Based on credential file review, review of the facility's Medical Staff Bylaws, Rules/Regulations, and staff interview the facility failed to ensure surgical privileges were delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The facility failed to ensure the surgical service was able to maintain a roster of practitioners specifying the specific surgical privileges of each practitioner. Specifically, the facility granted general core privileges that only specified the type of practitioner (such as General Surgery, Orthopedic Surgery, etc.) category. The findings were: Cross Reference to A 0355: Medical Staff Privileging - for findings related to the facility's failure to ensure practitioners were granted specific privileges when placed on the medical staff. Specifically, the facility failed to delineate what tasks/activities/procedures the practitioners were granted privileges to do. An interview with the Director of Surgical Services and the Operating Room Manager conducted on 12/12/2011 at approximately 1:15 p.m. revealed the operating room staff would contact the medical staff office or the Clinical Administrator on Duty (CAD) to inquire about what privileges a surgeon had been granted if there was any question if a surgeon was able to perform a procedure in the operating room. An interview with the Associate Chief Nursing Officer conducted on 12/14/2011 at approximately 4:15 p.m. revealed the CAD utilized a computer program to review the privileges granted to practitioners when necessary to ensure surgeons had privileges to perform specific procedures. When asked to retrieve the privileges for a specific surgeon, it was revealed that the system was not currently available due to downtime. The medical staff office staff member present was also unable to access the system. S/he was able to utilize another system that was available which contained scanned copies of the sheet(s) of paper that were filled out by practitioners when applying for inclusion on the medical staff. The plastic surgeon that was reviewed at that time had been granted the privileges of Cosmetic Surgery and Reconstructive Surgery. The privileges were not specified any further than those two categories and did not list any specific procedures that would be included under those broad categories. The medical staff office staff member stated that the information obtained was the same in both systems. An interview with the hospital's Director of Medical Staff on 12/15/2011 at approximately 7:50 a.m. confirmed that the Medical Staff Office staff and the hospital's staff had access to the system that was described the Associate Chief Nursing Officer. S/he confirmed that the hospital granted core privileges and did not further specify privileges for most practitioners. A subsequent interview with the hospital's Director of Medical Staff and the corporate Director of Credential Support Center conducted on 12/15/2011 at approximately 9:23 a.m. revealed that the hospital and the governing body were unaware of a need to grant specific privileges rather than groups or more general privileges.
Based on observations during tour, staff interviews and facility documentation, the infection control officer failed to mitigate risks contributing to healthcare-associated infections including the monitoring of compliance with policies and procedures, requiring the proper use of detergents and/or germicides used in endoscopy high-level disinfection in accordance with manufacturer's guidelines and terminal cleaning of the obstetrical surgical areas. The findings were: 1. Endoscopy scope cleaning: On 12/13/2011 at approximately 10:05 a.m., a tour of the area utilized to clean endoscopy scopes with a nurse that was responsible for cleaning the scopes revealed that the scopes were precleaned with a detergent. The nurse stated that the scopes are placed in the sink and the sink is then filled in order to cover the scope allowing 1-2 inches of water above the scope and then three squirts of the enzymatic detergent was then added to the water. When asked if s/he had an ability to measure the amount of water added to the sink, s/he stated that it was approximately three gallons of water, but confirmed that there was not a way to measure the amount of water. The nurse stated that the instructions on the enzymatic detergent stated to add one squirt of enzymatic detergent to each gallon of water. An interview with the Director of Surgical Services on 12/13/2011 at approximately 10:30 a.m. revealed that the amount of water had been measured previously and the sink had been marked to indicate where three gallons of water would reach. S/he stated that the line was present three weeks prior to the observations on 12/13/2011. A subsequent observation with the Director of Surgical Services of the sink used for precleaning of endoscopes on 12/13/2011 at approximately 11:30 a.m. revealed that the line was not present. 2. Terminal cleaning of obstetrical surgical areas A policy from the hospital's contracted housekeeping service titled Surgical/Invasive Areas and Delivery Rooms - Terminal Cleaning at the end of each day stated the following, in pertinent part: ...Surgical and invasive procedure rooms and scrub/utility areas should be terminally cleaned daily. Terminal cleaning of operating and invasive procedure rooms should be done at the end of each day when the scheduled procedures are completed or should occur each 24-hour period during the regular work week. Unused rooms should be cleaned once during each 24-hour period during the regularly scheduled work week... An interview with the obstetrical technician during a tour of the surgical suites used for obstetrical surgeries conducted on 12/12/2011 at approximately 3:55 p.m. revealed the suites were not routinely terminally cleaned on a daily basis. S/he stated s/he thought the rooms were terminally cleaned every couple of months. A subsequent interview with the Director of Women's Services on 12/14/2011 at approximately 8:45 a.m. revealed the surgical suites used for obstetrical surgeries were expected to be terminally cleaned every day procedures are performed in the rooms. S/he stated s/he would have the Manager of Housekeeping provide the cleaning log and explain the process to the surveyor. An interview with the Manager of Housekeeping conducted on 12/14/2011 at approximately 10:52 a.m. revealed the surgical suites for obstetrical surgeries were to be terminally cleaned Monday through Friday. S/he stated it was expected that the housekeeping personnel would document the terminally cleaning in the log provided for staff to do so. A review of the log with the Housekeeping Manager revealed the log indicated that on 12/9/2011 only one of the three surgical suites were terminally cleaned. The log for the month of October indicated that on 10/4, 10/5, 10/6, 10/11, 10/14, 10/19, 10/26, 10/27, and 10/28 only one of the three surgical suites were terminally cleaned. The log also indicated that on 10/7 and 10/13 only two of the three surgical suites were terminally cleaned.
Based on tour of the facility, staff interviews, and review of policies/procedures, the facility failed to ensure drugs were stored in accordance with accepted professional principles and in accordance with their own policies and procedures. Specifically, the facility did not monitor refrigerator temperatures consistently. The hospital did not indicate what actions were taken when temperatures were found to be out of range. This failure created the potential for a negative outcome. The findings were: A facility policy titled: Refrigerators last revised 9/23/2011 stated the following, in pertinent parts: ...3. Refrigerator temperature checks shall be completed and logs maintained by the department in which they are located... 5. Medications (See Refrigeration of Medications policy in Medication Management Chapter. 6. Any refrigerator noted out of temperature range or to be malfunctioning shall be reported immediately to Plant Operations and noted on the log... A facility policy titled: Refrigeration of Medications, Patient Food, and Human Milk last revised 12/21/2010 stated the following, in pertinent parts: ...Purpose: To provide for proper storage of drugs, patient foods and human milk requiring controlled temperature storage and to alert the appropriate staff when a storage refrigerator is outside of the acceptable temperature range... 3.2 Nursing Staff shall be responsible for checking medication storage requirements and for storing them properly while they are on the unit... 6. Temperatures must be maintained as follows: Medication Refrigerators: 35 to 46 degrees F... 7. All refrigerators must be monitored to assure appropriate temperatures are maintained. 7.1. Refrigerators and freezers containing pharmaceuticals, patient food or human milk are monitored either via an electronic - computer network system linked to the Pyxis Med station or a manual temperature log... 7.3 Medications, Food or Human milk storage refrigerators and freezers which are not monitored by the electronic system will be monitored by the department in which they are located and shall maintain and complete logs of daily refrigerator temperature checks. 7.4. Any refrigerator noted out of temperature range or to be malfunctioning shall be reported immediately to Plant Operations and noted on the log... 7.7 If the temperature in a medication refrigerator cannot be brought into the appropriate range within 6 hours, or if the temperature has dropped below freezing the Plant Operations Engineer will contact the Pharmacy...to notify Pharmacy staff of the incident... 7.13 Manual refrigerator logs will be maintained on the unit for a minimum of 12 months... A tour of the facility's outpatient Post-Anesthesia Care Unit (PACU) on 12/12/2011 at approximately 2:22 p.m. revealed that the outpatient PACU had a medication refrigerator that was not connected to the computer monitoring system. On the front of the refrigerator there was a magnetic clip with temperature log sheets. Additionally there was a clipboard on top of the medication refrigerator with temperature log sheets. A closer review of the temperature log sheets revealed that the logs on the front of the refrigerator and on top of the refrigerator were both for recording the temperature of the medication refrigerator. Furthermore, the temperature log sheets were for the same months of October, November, and December 2011. The PACU's Nurse Manager stated that the temperature logs on the clipboard on top of the medication refrigerator were completed by the outpatient PACU staff while the temperature logs on the front of the medication refrigerator were maintained by the pharmacy staff. The temperature log maintained by the pharmacy did not have recorded readings for the following dates in December: 12/3, 12/4, 12/6, 12/10, and 12/11. The temperature log had a temperature of 32 degrees F logged on 12/1 and a temperature of 33 degrees F on 12/9, but did not have any documentation of corrective action where documentation was to be placed on the temperature log form. The temperature log maintained by the PACU did not have recorded readings for the following dates in December: 12/3, 12/4, 12/10, and 12/11. The temperature log had a temperature of 34 degrees F logged on 12/1, but did not have any documentation of corrective action where documentation was to be placed on the temperature log form. An interview with a staff pharmacist on 12/12/2011 at approximately 2:42 p.m. revealed that the pharmacy department was in the process of ensuring that the temperature of the medication refrigerator was monitored daily. S/he stated that the facility had discovered that the refrigerator was not being monitored on days when the surgical department did not utilize the outpatient PACU. S/he stated that the facility was in the process of purchasing a new device that would be placed in the refrigerator that could track the temperature over a month-long period. However, s/he stated that the new devices were not currently in place.
Based on tour of the facility, staff interviews, and review of policies/procedures, the facility failed to ensure that proper temperature controls were utilized in pharmaceutical storage areas. Specifically, the facility did not monitor refrigerator temperatures consistently. The hospital did not indicate what actions were taken when temperatures were found to be out of range. This failure created the potential for a negative outcome. The findings were: A facility policy titled: Refrigerators last revised 9/23/2011 stated the following, in pertinent parts: ...3. Refrigerator temperature checks shall be completed and logs maintained by the department in which they are located... 5. Medications (See Refrigeration of Medications policy in Medication Management Chapter. 6. Any refrigerator noted out of temperature range or to be malfunctioning shall be reported immediately to Plant Operations and noted on the log... A facility policy titled: Refrigeration of Medications, Patient Food, and Human Milk last revised 12/21/2010 stated the following, in pertinent parts: ...Purpose: To provide for proper storage of drugs, patient foods and human milk requiring controlled temperature storage and to alert the appropriate staff when a storage refrigerator is outside of the acceptable temperature range... 3.2 Nursing Staff shall be responsible for checking medication storage requirements and for storing them properly while they are on the unit... 6. Temperatures must be maintained as follows: Medication Refrigerators: 35 to 46 degrees F... 7. All refrigerators must be monitored to assure appropriate temperatures are maintained. 7.1. Refrigerators and freezers containing pharmaceuticals, patient food or human milk are monitored either via an electronic - computer network system linked to the Pyxis Med station or a manual temperature log... 7.3 Medications, Food or Human milk storage refrigerators and freezers which are not monitored by the electronic system will be monitored by the department in which they are located and shall maintain and complete logs of daily refrigerator temperature checks. 7.4. Any refrigerator noted out of temperature range or to be malfunctioning shall be reported immediately to Plant Operations and noted on the log... 7.7 If the temperature in a medication refrigerator cannot be brought into the appropriate range within 6 hours, or if the temperature has dropped below freezing the Plant Operations Engineer will contact the Pharmacy...to notify Pharmacy staff of the incident... 7.13 Manual refrigerator logs will be maintained on the unit for a minimum of 12 months... A tour of the facility's outpatient Post-Anesthesia Care Unit (PACU) on 12/12/2011 at approximately 2:22 p.m. revealed that the outpatient PACU had a medication refrigerator that was not connected to the computer monitoring system. On the front of the refrigerator there was a magnetic clip with temperature log sheets. Additionally there was a clipboard on top of the medication refrigerator with temperature log sheets. A closer review of the temperature log sheets revealed that the logs on the front of the refrigerator and on top of the refrigerator were both for recording the temperature of the medication refrigerator. Furthermore, the temperature log sheets were for the same months of October, November, and December 2011. The PACU's Nurse Manager stated that the temperature logs on the clipboard on top of the medication refrigerator were completed by the outpatient PACU staff while the temperature logs on the front of the medication refrigerator were maintained by the pharmacy staff. The temperature log maintained by the pharmacy did not have recorded readings for the following dates in December: 12/3, 12/4, 12/6, 12/10, and 12/11. The temperature log had a temperature of 32 degrees F logged on 12/1 and a temperature of 33 degrees F on 12/9, but did not have any documentation of corrective action where documentation was to be placed on the temperature log form. The temperature log maintained by the PACU did not have recorded readings for the following dates in December: 12/3, 12/4, 12/10, and 12/11. The temperature log had a temperature of 34 degrees F logged on 12/1, but did not have any documentation of corrective action where documentation was to be placed on the temperature log form. An interview with a staff pharmacist on 12/12/2011 at approximately 2:42 p.m. revealed that the pharmacy department was in the process of ensuring that the temperature of the medication refrigerator was monitored daily. S/he stated that the facility had discovered that the refrigerator was not being monitored on days when the surgical department did not utilize the outpatient PACU. S/he stated that the facility was in the process of purchasing a new device that would be placed in the refrigerator that could track the temperature over a month-long period. However, s/he stated that the new devices were not currently in place.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, staff interviews, review of facility policies/procedures and Medical Staff Clinical Rules, the facility failed to ensure its Emergency Department (ED) Staff followed its policies and procedures. Specifically, prior to discharge from the ED, the staff failed to document the patient's status related to his/her chief complaint, therefore the medical record did not contain evidence that the patient's discharge was safe. This failure created the potential for a negative patient outcome. The findings were: Facility policies/procedures, as well as Medical Staff Rules and Regulations (Clinical Rules) were reviewed on 9/7/11. They revealed the following, in pertinent part: CLINICAL RULES OF THE MEDICAL STAFF, amended February 2011: ARTICLE VIII. Medical Records... 8.5 Emergency Medical Services Records The Emergency Medical Services Department medical records must contain a pertinent history of illness or injury including the patient's vital signs; diagnostic and therapeutic orders; clinical observation to include the results of treatment; diagnostic impression, and conclusion at the termination of evaluation/treatment including final disposition; the patient's condition at discharge; and instructions for follow-up care given to the patient and/or family... The facility's policy titled PLAN FOR PROVISION OF PATIENT CARE, dated 2009: IX. POLICIES AND PROCEDURES... 6. PLAN FOR PATIENT CARE SERVICES... B. Patient Care Services occur through organized and systematic processes designed to ensure the delivery of safe, effective, and timely care and treatment... Nursing staff and allied healthcare professionals function collaboratively with physicians and other professionals as part of an interdisciplinary team to achieve positive patient outcomes. When a patient is referred to other internal or external providers of care pertinent information is shared prior to the hand-off of care. II. HOSPITAL DEPARTMENTS A. Direct Patient Care Departments include the following: ...Emergency Department... C. Support Services include the following: ...Social Worker... F. Integration of Patient Care and Support Services... 2. A collaborative, interdisciplinary team approach serves as a foundation for integration of Patient Care and Support Services. Positive interdepartmental communications are strongly encouraged among patient care areas, support services, and ancillary services in order to ensure continuity of patient care, maintenance of the patient's environment and positive patient outcomes... Review of sample medical records #1 was conducted on 9/6/11. The patient (MDS) dated [DATE] at 22:47 (10:47 p.m.), via ambulance and was discharged on [DATE], at approximately 10:45 a.m. The patient had a CT scan of the head, EKG (Electro Cardiogram), lab testing, and a blood alcohol test completed upon presentation to the ED, all of which revealed no acute process. The admitting physician documented, in pertinent part: Chief Complaint: DECREASED MENTAL STATUS. This started unclear and is still present. [S/he] has been disoriented and confused. No alcohol recently or recent drug use... The patient was cared for by three physicians throughout his/her time in the ED. The discharging physician documented the following, in pertinent part: ...At this point we are awaiting case management to assure [s/he] has a safe place to go... case management has seen here in the ED, Sending to day shelter, ambulatory and taking pos [orals], Patient counseled in person regarding the patient's stable condition, diagnosis and need for follow-up. Disposition: Condition: stable. discharged . Discharge decision based on the following: patient's condition is stable; patient's condition is improved; patient is ambulatory; patient's exam is improved; no seriously abnormal test results; improving condition on repeat evaluation; social support is good; transportation is arranged; follow-up is available; clinical impression is consistent with outpatient treatment. CLINICAL IMPRESSION: Changed mental status. clinical picture [DIAGNOSES REDACTED] The patient was instructed to follow-up with a community medical clinic. The admitting nurse documented, in pertinent part: Acuity: LEVEL 2. Chief Complaint: ALTERED MENTAL STATUS... Alert... The patient is disoriented to place, time and situation. Patient's speech is abnormal... The patient was cared for by three different nurses throughout his/her time in the ED. The final documented mental status assessment was done by the second nurse at 1:36 a.m. It stated, in pertinent part: best verbal response- disoriented... best motor response- obeys commands... The discharging nurse documented the following, in pertinent part: pt sitting upright on stretcher, eating food... Case Management called, awaiting until 10 a.m... The patient is sleeping... SW (Social Worker) at bedside for eval of patient. Pt answers questions by mumbling... Condition at departure: unchanged and stable. Patient reports pain level on departure as 0/10. Fall risk assessment completed. No fall risk identified. No learning barriers present. Discharge instructions provided and reviewed with the patient. Patient verbalized understanding. Written instructions provided in English. The patient was discharged home and unaccompanied at time of discharge. The patient left the Emergency Department ambulatory and via taxi and with fare provided... pt discharged to Shelter. The only entry by the Social Worker that saw the patient stated the following, in pertinent part: SW met with pt in ED. Perpt [s/he] is homeless and has no family or friends to call. SW asked pt about emergency contact on face sheet..... Pt stated that person is no longer around. SW called number, it was disconnected. Pt agreed to go to .... day shelter at d/c, cab voucher provided to nursing. An interview with the Director of Case Management was conducted on 9/6/11, at approximately 12:00 p.m. The Director stated a patient may be referred to Adult Protective Services on many conditions, one of which could be when we see there is a situation that puts themselves or others at risk. When asked why Adult Protective Services was not consulted in this patient's case, s/he stated, By all indications, [s/he] was up moving around, dressing, having no pain, and by what was documented it didn't seem [s/he] was disoriented. When asked if there was documentation that stated s/he was oriented, she stated there was not. A telephone interview with the physician that discharged the patient was conducted on 9/7/11, at approximately 5:40 p.m. When asked the physician's involvement, s/he stated that s/he vaguely remembered the patient. The physician stated that the patient's off-going/previous physician told me at 6:30 a.m. the plan was to have Case Management see the patient when [s/he] got in that morning to determine a place for the patient to go. When asked if the physician fully evaluated the patient upon taking over care, s/he stated, Everyone is different. I go and lay eyes on them. I can't remember for sure, but I think [the patient] was sleeping when I assumed... When asked if the physician evaluated the patient's chief complaint prior to discharge, as such was not specifically documented, s/he stated, I usually do. In [this patient's] case of changed mental status, I spoke with [him/her] at least on one occasion and made an assessment on mental status... The physician stated that his/her general approach to a reassessment of a patient's mental status would be to ask how the patient is doing, if the patient is hurting, where the patient is, what the date is, and where the patient is going to go. When asked if this is usually documented, s/he stated, I try to. I don't know if I did in this case. When asked specifically about the patient's orientation prior to discharge, as it was not clearly documented, the physician stated, I can't recall specifically... I feel comfortable saying I would not have discharged this patient if a danger to self. When asked about the documentation that existed, which stated the patient had improved and had social support, the physician stated that they were canned computer documentation entry responses that could be chosen from in the medical record system. S/he stated that when the patient came in, s/he was not capable of handling self, but upon discharge the patient was walking and feeding self. S/he also stated that because the patient was being referred to a shelter, that the social support was improved from the patient's baseline. The physician also stated, I assessed [the patient] to the extent I thought I needed to... There are basically three options with a patient like this: A) discharge to street at midnight, B) let the patient sleep for the night, provide a hot meal, and see what we can do to help, or C) admit the patient for confusion. The physician stated that although s/he didn't document the patient's mental status carefully upon discharge, that his/her clinical assessment was the patient was improved from the initial presentation to the ED. An interview with the nurse that discharged the patient was conducted on 9/7/11, at approximately 3:00 p.m. When asked about the patient, s/he stated, I don't remember this patient, to be honest. When asked about the documentation that the patient was unchanged, s/he stated, I'd imagine I meant [s/he] was stable to be discharged ... unchanged from when I met [him/her]. When asked if the nurse evaluated the patient's initial complaint prior to discharge, as such was not specifically documented, s/he stated, Generally the initial complaint is re-documented or referred to again prior to discharge... If I didn't think the patient was safe to go to a shelter, I would have intervened... When asked how a patient is determined safe for discharge, s/he stated, They are ok if they are walking, eating, vital signs are stable, and they know where they're going... A telephone interview with the social worker/case manager that discharged the patient was conducted on 9/7/11, at approximately 9:45 a.m. When asked his/her involvement with the patient, s/he stated, I was asked to meet with the patient a find a place for [him/her] to go. I was told [s/he] was ready to be discharged ... The patient agreed to go to a day shelter and I explained to [him/her] from there they could direct [him/her] to an evening shelter. When asked if s/he called the shelter prior to the patient leaving the ED, s/he stated that s/he did not and does not do so unless it is a night shelter where a bed needs to be secured. When asked if s/he calls the case workers at the shelters, s/he stated, No, I never have. When asked the procedure for the clients to get from a day to a night shelter, s/he stated, The day shelter has no pull. They give options and tell them the time to be there... They are basically traffic directors. When asked if the s/he assessed the patient's mental status, s/he stated the patient answered basic questions, but was difficult to understand. S/he stated that the nurse and doctors normally do a full mental exam on the patient and that s/he had never been asked to do that. When asked if any financial resources were addressed for the patient, s/he stated s/he did not make any referrals. When asked if there were any other resources or discharge options available for the patient, s/he stated, There were no others given that [s/he] had nowhere to live... I do not believe [s/he] had any other options... If the patient had Medicare, perhaps if s/he had a home returning to, I may have tried to get Home Health... When asked if the patient would have been referred to Adult Protective Services, s/he stated s/he did not feel that there was a need for it at that time and that APS is limited in what they can do to help elderly people... services depend on want or willing for the patient to participate or if a doctor states they need a guardian... In summary, although all discharging staff interviewed stated they would not have discharged the patient had it been unsafe, there is no documentation which clearly evidenced the patient's condition at discharge (as required by the Medical Staff Rules and Regulations) and that ancillary services were utilized to ensure the patient's continuity of care and outcome were positive (as stated in the facility's Provision of Patient Care policy). The patient's chief complaint was changed mental status and neither the nurse nor the physician, primarily responsible for the patient's discharge, who last cared for the patient documented that the patient's mental status was assessed to ensure a safe discharge.
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