HospitalInspections.org

A. Based on document review and interview, it was determined for 6 of 34 (Pt #2, Pt #3, Pt #4 Pt #5, Pt #6 and Pt #7) patients having a bronchoscopy (a procedure that allows a doctor to look at the patient's airway through a thin viewing instrument called a bronchoscope), the Hospital failed to ensure the bronchoscopy was performed in the negative pressure room to prevent the potential for transmission of infectious agents and as hospital policy requires. This has the potential to affect all patients and staff of the hospital.

Findings include:

1. The policy titled "Bronchoscopy" (New Policy 1/30/17) was reviewed on 3/15/17 at approximately 11:30 AM. The policy states "B. Procedure 1. Inpatients Bronchoscopy will be scheduled to be performed in surgery or ambulatory care department. 2. Emergent ICU patients may be moved to the ICU negative Pressure room 10."

2. The following 6 patients had a bedside bronchoscopy performed.
a) Pt #2 Diagnosis of Chronic Respiratory Failure Performed 2/6/17 in ICU Room #2
b) Pt #3 Diagnosis of Acute Hypoxic Respiratory Failure Performed 2/9/17 in ICU Room #9
c) Pt #4 Diagnosis of Chronic Obstructive Pulmonary Disease Performed 2/8/17 in ICU Room #6
d) Pt #5 Diagnosis of Acute Respiratory Distress/Failure Performed 1/9/17 in ICU Room #6
e) Pt #6 Diagnosis of Respiratory Distress Performed 1/11/17 in ICU Room #6
f) Pt #7 Diagnosis of Chronic Obstructive Pulmonary Disease Performed 1/9/17 in ICU Room #6

3. The Director of Quality (E #7) was informed during an interview on 3/17/17 at approximately 3:00 PM. E #7 stated "We are to be following the policy that bronchoscopes are to be done in a negative pressure room."

B. Based on document review, observation, and interview it was determined for 1 of 1 (E#6) staff observed providing care in the radiology department, the Hospital failed to ensure staff wore personal protective equipment (PPE) appropriately. This has the potential to affect all patients and staff in the Radiology Department.

Findings include:

1. The policy titled "Quality/Patient Safety/Risk Management Infection Prevention and Control" (last reviewed 2/8/17) was reviewed on 3/15/17 at approximately 3:00 PM. The policy indicated under "C. 3. Blood and body secretion precautions must be observed by staff for all patients. Gloves, masks, gowns and eye wear must be worn during procedures that expose the personnel to such secretions."

2. During an observation of a Ultrasound Guided Paracentesis in Radiology department on 3/15/17 on Pt #10 at approximately 10:05 AM, the Ultra Sound Technician (E #6) was observed in the sterile field with facial mask below nose.

3. The Director of Quality (E #7) was informed during an interview on 3/15/17 at approximately 10:30 AM. E #7 stated "The mask should be covering the nose."

C. Based on document review, observation and interview, it was determined for 3 of 3 staff (MD #4, MD#3, and Registered Nurse/E #8) observed providing care in the radiology department, the Hospital failed to ensure proper hand hygiene was performed as per policy. This has the potential to affect all patients and staff in the radiology department.

Findings include:

1. The policy titled "Hand Hygiene" (last reviewed 8/25/16) was reviewed on 3/15/17 at approximately 4:00 PM.
The policy states "B. Basic Principles for Hand Hygiene WHEN Hand hygiene should be performed before and after every patient/resident contact, as in the following, but no limited to: 1. Before entering a patient/resident room or prior to the start of care and before touching the patient/resident surroundings;...7. Before donning sterile or non-sterile gloves;...8. Upon removing sterile or non-sterile gloves;...12. After handling contaminated material or waste;...C. Procedure for Using Hand Sanitizer If hands are not visibly soiled, use an alcohol based hand sanitizer rub for routine decontamination....D. Procedure for Using Soap and Water...10. A paper towel should be used to shut the faucet to avoid recontamination of the hands."

2. MD #4 was observed at 10:00 AM performing hand hygiene after completion of a Ultrasound Guided Paracentesis on Pt #10. MD #4 washed and dried hands with a paper towel, then shut the water off with bare hands.

3. The Director of Quality (E #7) was informed during an interview on 3/15/17 at approximately 10:30 AM. E #7 stated, "That is not proper hand hygiene."

4. MD #3 was observed at 10:30 AM on 3/15/17 during a cardioversion procedure. MD #3 donned gloves before patient contact, however MD #3 did not wash hands or utilize hand sanitizer prior to donning gloves.

5. On 3/15/17, Registered Nurse (E #8) was observed touching a patient without gloves. E #8 then was observed typing on the computer without washing hands or utilizing hand sanitizer after touching the patient. During an observation of a surgical procedure at 11:20, while E #8 was wearing gloves E #8 touched the patient, typed on the computer, talked on the phone, then returned to typing on the computer. E #8 did not change gloves or wash hands throughout this time.

6. An interview conducted with E #2 on 3/15/17 at 11:45 AM. E #2 stated, "MD #3 and E #8 should have washed hands or utilized hand sanitizer."