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CONDITION: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on October 22 and 23, 2012, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the severity, variety, and number of Life Safety Code deficiencies that were found. Also see C 231

STANDARD: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on Ocotber 22 and 23, 2012, the surveyor finds that the facility does not comply with NFPA 101 - 2000, the Life Safety Code

See Life Safety Code deficiencies that were cited (K-tags dated 10/23/12). Also see C220.

Based on observation, a review of CAH policies, anesthesia controlled substance records, a review of Infection Control Program, a review of Hydrocollator/ Ice Pack Cleaning logs, a review of laboratory refrigerator logs, a review of Flash logs, medical record review, and staff interview, it was determined the CAH failed to ensure blood, drugs and/or biologicals were stored, handled, dispensed, and administered in a safe manner and in accordance with CAH policy. It failed to ensure its infection control practices were followed to prevent the potential for cross contamination, failed to ensure food was stored/labeled appropriately, and failed to ensure oversight of all contracted services. The cumulative effect of these systemic practices has the potential to affect 100% of the patients serviced by the CAH.
Findings include:

1. Failed to ensure Blood Administration policy was followed. Please see deficiency cited at C-271.

2. Failed to ensure outdated drugs and/or biologicals were not available for use in patient care areas. Please see deficiency cited at C-276A.

3. Failed to ensure anesthesia medications were stored in a manner to prevent potential cross contamination in the Anesthesia area. Please see deficiency cited at C-276B.

4. Failed to ensure there was appropriate pharmacy control over C-I and C-II drugs within the surgery department by the pharmacist. Please see deficiency cited at C-276C.

5. Failed to ensure the Hydrocollator and Hot Pack Covers were cleaned monthly, in accordance with its policy. Please see deficiency cited at C-278A.

6. Failed to ensure infection control measures were maintained to prevent potential cross contamination in patients receiving Therapy services. Please see deficiency cited at C-278B.

7. Failed to ensure outlying laboratory refrigerator temperatures were followed up on as per CAH policy. Please see deficiency cited at C-278C.

8. Failed to ensure Flash sterilization was utilized only in emergent situations. Please see deficiency cited at C-278D.

9. Failed to ensure food was stored and/or labeled in accordance with its policy. Please see deficiency cited at C-279A.

10. Failed to ensure its policy for coverage of beards was followed by its male employees. Please see deficiency cited at C-279B.

11. Failed to ensure there was oversight for contracted laundry services. Please see deficiency cited at C-293.

Based on a review of CAH policy, medical record review, and staff interview, it was determined in 1 of 3 (Pt #17) medical records reviewed, in which the patient received blood products, the CAH failed to ensure its Blood Administration policy was followed.
Findings include:

1. The CAH policy titled "Blood Administration" (effective 5/04) was reviewed. It indicated "The product must be hung within 15 minutes of receiving it from the blood bank and must be returned within 30 minutes if not used... One unit of PRBCs and whole blood will be given over 2 to 4 hours... Any variance from the 2-4 hour duration should be indicated as an order by the physician."

2. The medical record of Pt #17 was reviewed on 10/25/12. Pt #17 was admitted to Observation status on 6/8/12 with the diagnosis Recurrent Anemia and required blood administration of 3 units of PRBC. Blood or Blood Component Transfusion documentation indicated "Pre-Transfusion Data: Inspected and Issued... 7:55 PM on 6/8/12; Date of Transfusion: 6/8/12, Time started: 8:00 PM; Post Transfusion Data: Time/ Date Completed: 12:30 AM 6/9/12." The Blood Transfusion Flow Sheet documentation indicated "Pre: 8:10 PM; 15 minutes: 8:25 PM..." Nursing documentation, on 6/8/12 at 9:10 PM indicated "Second unit PRBC started..." and on 6/9/12 at 12:30 AM "Second unit PRBC completed." There was no documentation to indicate why the PRBC was not hung within 15 minutes of release from the laboratory and/or not returned to the lab within 30 minutes if not used.
It was unable to be determined whether the unit of PRBC was hung at 8:00 PM, 8:10 PM, or 9:10 PM. If it was hung at 8:00 PM or 8:10 PM, it hung for greater than 4 hours; would have required a physician order and there was none.

3. During a staff interview, conducted with the CCO on 10/26/12 at 8:45 AM, it was confirmed that there was no way to determine the time the PRBC was hung, why it was checked out and/or not hung within the parameters of the CAH policy, and/or whether it hung greater than 4 hours.

4. During a staff interview, conducted with the Laboratory Manager on 10/26/12 at 9:30 AM, it was verbalized that blood transfusions are tracked as a Quality indicator for the department. It was confirmed that Pt #17 "slipped thru" and was not followed up on. It was also confirmed that it was unable to be determined whether the blood was checked out and not hung within the parameters set by the CAH or whether the unit hung greater than 4 hours.

A. Based on observation, a review of CAH policies, and staff interview, it was determined the CAH failed to ensure outdated drugs and/or biologicals were not available for use in patient care areas. This has the potential to affect 100% of the patients serviced by the CAH.
Findings include:

1. During a tour of the CAH, conducted 10/23/12 thru 10/24/12, the following outdated drugs and/or biologicals were observed:

In the Laboratory on 10/23/12 at 1:15 PM, the following were observed: In Blood Bank room- one Chlorox Wipes, expired 8/29/12. In the Laboratory drawing room, one Chlorox Wipes, expired 8/29/12. In the Laboratory Check-In room, one bottle of Germ-X expired 11/11.

In the ED department, on 10/23/12 at 1:30 PM, the following outdated biologicals were found in the Airway Boxes in Trauma Room #2: 3 Flex Slip endotracheal guide wires all expired 4/12; 2 packages of EZ lubricating Jelly 0.17 oz, both expired 9/12; EZ lubricating Jelly 4 fluid oz, expired 8/12; 1 Povidone - Iodine Prep Pad, Large, expired 2/03; 1 Compound Benzoin Tincture 10% Swabstick, expired 8/12.

In the medical surgical floor and the medication room, on 10/23/12, at 2 PM, it was observed that the Omnicell Pyxis contained the following outdated supplies: 3 - 16 oz bottles, Betadine (1 - expired 5/08, 1 - expired 2/08, 1 - expired 3/12) and 1 - 16 oz bottle of Hydrogen Peroxide, 3 %, expired 3/10.

In the Surgical Department on 10/24/12 at 8:30 AM, the following items were found to be expired:
In the OR Adult Airway Box = 4 - 5 gram packets, E-Z Lubricating Jelly, expired 1/14/11.
In the OR Pediatric Airway Box = 3 Packets E-Z Lubricating Jelly, expired 1/14/11.
In the OR Housekeeping Closet = 3 Canisters Alcare (2 expired 9/09 and 1 expired 5/11).
Over the OR Scrub Sink = 1 Canister, Alcare, expired 9/09; 2 boxes - 30 Scrub Care Surgical Scrubs (1 expired 7/12 and 1 expired 8/12), and one box of surgical scrub brushes, expired 8/12.
In OR Room #1 = 2 E-Z Lubricating Jelly, expired 1/14/11 and 1 Epinephrine 1:1000 mg, expired 10/1/12.
Adult medication box- one Amiodarone 150 mg/ 3 ml vial, expired 9/12 and 1 Lidocaine 100 mg/5 ml, expired 9/1/12.
In OR Room #1, on/in the Anesthesia Cart: 1- 4 oz E-Z Lubricating Jelly, expired 8/12; 2 - size 3 LMA, expired 4/28/12; and 1 - size 5 LMA, expired 7/11.
On the Case Cart, in the main OR hallway: 3 "case set ups" were observed to be prepared and contained 3-4 packets E-Z Lubricating Jelly, all expired 1/14/11.
In OR Room #2, on the surgery cart, the surgery supplies observed ready for use in a surgical case contained 3-4 packets E-Z Lubricating Jelly, expired 1/14/11.
In OR Room #2, on/in the Anesthesia Cart: 1 tube of E-Z Lubricating Jelly, expired 1/14/11, 1 -open package 5.5 Endotracheal Tube, 1 - open Mucosal Atomization Device, 1 - open Package - Browning, C02 Sampling Tube, 1 - out of package C02 Sampling Tube 2 - open yankauers suctioning tip.
In the OR Fluid Warmer, there was 2- 1000 ml Normal Saline for irrigation, dated 9/16/12.

2. The CAH policy titled "Emergency Medications" (reviewed 8/12) was reviewed. It indicated "3. The emergency medications shall be inspected by the pharmacy department no less frequently than every thirty days..." The policy titled "Drug Returns" (revised 3/12) was reviewed. It indicated "Medication areas will be checked on a regular basis for expired medications. These areas include..."

3. The policy titled "Fluid Warming in the OR" (dated 2/11/10) was reviewed. It indicated "All solutions should be dated when placed in the fluid warmer and used or discarded within 14 days."

4. During an interview conducted on 10/23/12 at 2:30 P.M. with the Case Manager, Quality Director, it was confirmed that the medical supplies should have been removed from the patient care area.

5. During a staff interview, conducted with the Surgery Manager on 10/24/12 at 11:00 AM, it was confirmed that all outdated drugs and/or biologicals were expected to be removed from use. The Surgery Manager also verbalized that the 1000ml Normal Saline in the OR fluid warmer should have been removed, as they are only good for 2 weeks once they are put in the warmer.

B. Based on a review of CAH policy, observation and staff interview, it was determined the CAH failed to ensure anesthesia medications were stored in a manner to prevent potential cross contamination in the Anesthesia area. This has the potential to affect 100% of the patients serviced by Anesthesia services.
Findings include:

1. The CAH's policy and procedure titled "Infection Control" dated 8/27/12, was reviewed. It indicated under "Anesthesia Set-up For All Cases:... All medicines opened and unused are discarded at the completion of the case. All disposable equipment is promptly discarded at the completion of the case..."

2. During a tour of the Surgery Department, conducted on 10/24/12 at 8:35 AM with the Surgery Manager, the following was observed. In OR Room #2 at 11:00 AM, on the Anesthesia cart, one 5 ml syringe with Succinycholine, one 5 ml syringe of Fentanyl, and one syringe of Rocurium were observed on the cart and one syringe of Robinal was observed in the anesthesia cart. It was also observed that an open LMA was lying next to the right side of the patient's head.

3. During a staff interview, conducted with CRNA #1 on 10/24/12 at 11:00 AM, it was verbalized "I haven't had to use this (LMA) yet, so I wouldn't have thrown it away." When asked when items are disposed of, it was verbalized "at the end of the day." When asked about the syringes of medications, CRNA #1 verbalized that "I draw them up ahead of time so that I have them if I need them in an emergency." When asked when the syringes of medication are disposed of, it was verbalized that they are disposed of at the end of the day. The syringes were observed on the top of the Anesthesia Cart and the CRNA was observed moving back and forth from the patient to the cart.

4. During a staff interview, conducted with the Surgery Manager on 10/24/12 at 11:00 AM, it was verbalized that any unused medications or equipment that were prepared for a case were to be disposed of at the end of the case, and are not to be left out for the following cases.

C. Based on a review of the CAH's policy and procedure, a review of the anesthesia controlled substance records, and staff interview, it was determined that the CAH failed to ensure there was appropriate pharmacy control over C-I and C-II drugs within the surgery department by the pharmacist. This has the potential to affect 100% of the patients who receive anesthesia services.
Findings include:

1. The CAH's policy and procedure titled, "Policy for Control of Narcotics" with a sign off date of 8/27/12, was reviewed. It indicated under "Procedure: 1. The C.E.O. or C.C.O. shall order narcotics of class I and II on a D.E.A. 222 form for floor stock... Procedure: 5. All floor stock narcotics are to be checked by two nurses at the end of each shift and the Narcotic Sign Out sheet shall be signed by them." There was no specific policy related to the control of narcotics for anesthesia.

2. The "Controlled Substance Record - Anesthesia" sheets for the dates of 7/30/12 to 10/25/12 were reviewed. There was no documentation to indicate the narcotics were counted by 2 nurses at the end of each shift. The Pharmacist signature line at the bottom of the Controlled Substance Records was blank.

3. During an interview with the CAH anesthetist, conducted on 10/25/12 at 11:30 PM, it was verbalized that he orders the controlled drugs that are administered in surgery through administration from the CCO or the CEO, which consist of Fentanyl, morphine sulfate, Versed, and Ketamine. When the medications come in he places them in a double locked cabinet in surgery. It was further verbalized that in the anesthesia department, he is the only one that counts the narcotics at the end of the shift and that the last sign-out at the end of each day is the narcotic count. When asked if the pharmacist checks or monitors his use of the narcotics, he stated that they do not to the best of his knowledge.

4. During an interview with the CCO and the CEO, conducted on 10/26/12 at 12:15PM, they verbalized that they were not aware pharmacy was not involved in the oversight of the narcotics being administered.

A. Based on a review of CAH policy, observation, a review of Hydrocollator/ Ice Pack Cleaning logs, and staff interview, it was determined the CAH failed to ensure the Hydrocollator and Hot Pack Covers were cleaned monthly, in accordance with its policy. This has the potential to affect 100% of the patients who receive Therapy services.
Findings include:

1. The CAH policy titled "Specific Cleaning and Checking Schedule for Patient and Staff Equipment" (revision date January 2012) was reviewed on 10/23/12. It indicated "Hydrocollator: ...clean thoroughly one time per month with hospital approved disinfectant...Documented and recorded in cleaning logbook... Hot Pack Covers: Wash and dry monthly. Documented and recorded in cleaning logbook..."

2. During tour of the PT department on 10/23/12 at 1:30 PM, one Hydrocollator with Hot Packs and one Ice Pack Machine was observed in the PT department. The Cleaning logs for January 2012 thru October 2012 were reviewed on 10/23/12. There was no documentation to indicate the Hydrocollator and Hot Pack Covers were cleaned, in accordance with its policy.

3. During a staff interview, conducted with the PT Manager on 10/24/12 at 1:45 PM, it was confirmed that there was no documentation to indicate when or whether the Hydrocollator and Hot Packs were cleaned.

B. Based on observation and staff interview, it was determined the CAH failed to ensure infection control measures were maintained to prevent potential cross contamination in patients receiving Therapy services. This has the potential to affect 100% of the patients serviced by the Therapy services.
Findings include:

1. On 10/23/12 at 1:30 PM, in the PT department, an open vial of Dexamethasone was observed in the locked cabinet with a syringe and needle sticking out of the vial.

2. During a staff interview conducted with the PTA on 10/23/12 at 1:30PM, it was verbalized that the syringe is used to remove the amount of Dexamethasone needed for the treatment. The needle and syringe is then returned to the vial and used with the next treatment. During a staff interview, conducted with the PT Manager on 10/24/12 at 1:45 PM, it was confirmed that this was the practice.

3. On 10/23/12 at 1:30 PM and on 10/24/12 at 1:45 PM, a soccer type ball was observed in the PT area. The ball had a cracked covering with pieces of the covering missing and the foam center exposed preventing the product from being appropriately disinfected between patients.

4. During a staff interview conducted with the PT Manager on 10/24/12 at 1:45 PM, it was verbalized that the ball is cleaned with spray cleanser in between uses. It was confirmed that the shell of the ball was missing several pieces and the foam was showing in several areas and that the entire ball and foam center is sprayed with the cleanser.

C. Based on observation, a review of laboratory refrigerator logs, a review of CAH policy, and staff interview, it was determined the CAH failed to ensure outlying laboratory refrigerator temperatures were followed up on as per CAH policy. This has the potential to affect 100% of the patients serviced by the Laboratory.
Findings include:

1. During a tour of the Laboratory department conducted on 10/23/12 at 1:15 PM with the Laboratory Manager, the Microbiology refrigerator was observed with Temp Chex Temperature Record hanging on the side. The Record indicated "Temperature Range 2 degrees to 8 degrees." The Record was for January 2012 thru October 2012. Examples of outlying temperatures are as follows: June- 3 out of 30 days were 1 degree; July- 4 out of 30 days were 1 degree and one day had no temperature documented; August- 5 out of 31 days were 1 degree and one day was 0 degrees; and September- 5 out of 30 days were 1 degree. There was no documentation to indicate any corrective action had been taken.

2. The CAH policy titled "Temperature Monitoring" (adopted 5/11) was reviewed on 10/24/12. It indicated "3. Procedure: A. All thermometers are read daily... B. Corrective actions listed below are taken when a temperature reading exceeds the posted acceptable range..."

3. During a staff interview, conducted with the Laboratory Manager on 10/23/12 at 1:30 PM, it was confirmed that the temperatures were outside of the recommended range and action should have been taken and documented.

D. Based on observation, a review of Flash logs, a review of CAH policies, and staff interview, it was determined the CAH failed to ensure Flash sterilization was utilized only in emergent situations. This has the potential to affect 100% of the patients serviced by the CAH surgery department.
Findings include:

1. During a tour of the Surgery Department, conducted on 10/24/12 at 8:35 AM with the Surgery Manager, the following was observed. In the sterilizing room, the sterilization technician was observed performing Flash sterilization of a Genitourinary (GU) Cysto instrument set.

2. The Flash Log dated November 2011 thru October 2012 was reviewed. On 9/13/12, it indicated 3 times which GU Cysto instrument sets were Flash sterilized. On 10/3/12, it indicated 1 time which the GU Cysto instrument set was Flash sterilized.

3. The CAH policy titled "Sterilization of Instruments: Flash Sterilization" (effective 9/5/12) was reviewed. It indicated "Flash sterilization may be used only when there is an immediate or emergent need for an individual item..." The policy titled "Sterilization of Instruments and Supplies" (2/12/10) was reviewed. The newer policy indicated a change in the sterilization time from 3 minutes to 5 or 10 minutes and also removed the requirement that the staff member removing the item was to complete the Flash log at that time.

4. A staff interview was conducted with the Surgery Manager on 10/14/12 at 10:00 AM. When asked about the use of Flash sterilization, it was initially verbalized that Flash sterilization "is only used in emergencies and is very rarely used here." When asked about the sterilizing technician performing Flash sterilization on the GU instruments today, it was verbalized that "we have to Flash sterilize the GU instruments because we do not have enough to do the number of cases we have. The GU surgeon comes here about once a month, or so."


26336

A. Based on observation, a review of CAH policy, and staff interview, it was determined the CAH failed to ensure food was stored and/or labeled in accordance with its policy. This has the potential to affect 100% of the patients and/or visitors who utilize the Dietary services.
Findings include:

1. During a tour of the CAH Dietary department on 10/23/12 at 1:45 PM, the following was observed.
In the Walk-In Cooler: Examples of items not marked with dates as to when opened and/or when prepared: one open bag of Hard Cooked Eggs with clear yellow colored liquid in the bag; one tray of orange colored Jello with the plastic wrap partially off of the tray (date 10/6); 2 trays of Cherry Cobbler with no date to indicate when they were prepared; 4 bags of open cheese with no date as to when opened; and one tray of 6 pork chops with nothing over them.
In the Walk-In Freezer: Examples of items not marked with dates as to when opened and/or when prepared: one open bag of frozen potatoes; one open bag of hamburger patties; one open bag of sausage patties; one bag of bananas- brown- with no date as to when frozen; and one open bag of breadsticks. A pan of Italian Beef with the edge of the pan uncovered on a storage rack.
In the Dry Storage Room: there was no way to determine what items were "First In; First Out". Examples: several packages of Jet Puffed Miniature Marshmallows were observed with one expired February 2013 in the front and one expired November 2012 in the back. There were open packages of dry food ingredients with no dates as to when they were open.

2. The policy titled "Food and Supply Storage" (revision date 7/1/08) was reviewed on 10/23/12. It indicated "Storeroom Guidelines: 2. Stock will be rotated using the first-in-first-out (FIFO) principle. Products removed from original boxes will be labeled with receipt date to insure FIFO... 5. All pre-portioned foods, left-overs, and foods transferred out of original containers will be labeled with product identity and dates..."

3. During a staff interview, conducted on 10/23/12 at 2:00 PM with the Dietary Manager, it was confirmed that open containers of food were to be labeled with dates, FIFO process was to be followed, and food was to be covered when being stored.

B. Based on observation, a review of CAH policy, and staff interview, it was determined the CAH failed to ensure its policy for coverage of beards was followed by its male employees. This has the potential to affect 100% of the patients/ visitors serviced by the CAH dietary department.
Findings include:

1. During a tour of the Dietary department, conducted on 10/23/12 at 2:00 PM with the Dietary Manager, 2 male employees were observed in the food preparation area preparing food. Both had beards and moustaches with no beard covers/ nets being worn.

2. The CAH policy titled "Sanitation Procedures for Employees" (implemented 7/13/12) was reviewed. It indicated "All food service male personnel will be expected to wear beard nets while cooking and serving..."

3. During a staff interview, conducted with the Dietary Manager on 10/23/12 at 2:30 PM, it was confirmed that male employees were to wear beard nets while cooking and serving.

Based on review of CAH's Infection Control Program (ICP) and staff interview, it was determined that the CAH failed to ensure there was oversight for contracted laundry services to ensure linen was transported and disinfected appropriately. This has the potential to affect 100% of the patients serviced by the CAH.
Findings include:

1. The CAH's ICP was reviewed on 10/24/12. There was no documentation in the ICP to indicate that the CAH's laundry services, which are processed by a local provider, were monitored. This would include the transportation of clean/dirty linen, disinfection of the linen by heat and/or chemical processing and preventative maintenance of the facilities laundry equipment.

2. During an interview with the Infection Control Officer, conducted on 10/24/12 at 2:00 PM, it was verbalized that her ICP does not include the surveillance of the handling and processing of the CAH's laundry. She was unaware of the manner in which the linen was transported to and from the processing facility, whether disinfection consisted of heat, chemical or both. She could not state if the minimum thresholds required for heat and/or chemical disinfection were achieved during the processing of the laundry.

Based on medical record review and staff interview it was determined that the Hospital failed to ensure 1 of 1 patients (Pt. #8) with decubitus wounds, that wound care orders were obtained upon admission.
Findings include:

1. Documentation indicated that Pt. #8 was admitted to the CAH on 1/26/12 with diagnosis of Major Gastrointestinal Disorders and Peritoneal Infections, Intestinal Infection due to Clostridium Diff, Dehydration, Hypertensive Chronic Kidney Disease, Chronic Kidney Disease, USPEC, Anemia, Diabetes Without Complications Type 2 Unspecified, Long Term Current Use of Insulin, Hypotassemia, Urinary Tract Infection. Documentation on the "Patient Admission Assessment Sheet" under 'SKIN" indicated Pt. #8 had a "Stage II on coccyx". Documentation in the Nursing Notes on 1/26/12 at 1845 hours indicated "Duoderm removed from Stage II pressure ulcer on coccyx. Site was cleaned with soap and water and barrier cream was applied to area." There is no documentation to indicate physician orders were written for decubitus wound care on Pt. #8.

2. On 10/25/12, at 11:30 A.M., an interview was conducted with the CCO. It was confirmed that Nursing staff should have notified the Physician and provided wound care in accordance with written and or verbal orders.