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Based on observation, staff interviews, and review of maintenance records between February 20 and February 21, 2017, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
Hospital
K 133 Multiple Occupancies Construction Type
K 233 Clear Width of Exit and Exit Access Doors
K 251 Dead-End Corridors and Common Path of Travel
K 311 Vertical Openings Enclosure
K 321 Hazardous Areas
K 323 Anesthetizing Locations
K 324 Cooking Facilities
K 341 Fire Alarm System - Installation
K 345 Fire Alarm Systems - Testing and Maintenance
K 351 Sprinklers Installation
K 361 Corridors - Areas Open To Corridor
K 363 Corridor - Doors
K 371 Subdivision of Building Space - Smoke Compartments
K 372 Subdivision of Building Space Smoke Barrier
K 521 HVAC
K 754 Soiled Linen and Trash Containers
K 902 Gas and Vacuum Piped Systems - Other
K 911 Electrical Systems - Other
K 922 Gas Equipment - Other

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation and interview, the facility failed to ensure soiled utility rooms containing biohazards has signage on the door indicating biohazards are in the room, in 1 of 2 soiled rooms observed (Medical/Surgical unit); and failed to ensure all surfaces are sealed, smooth and washable, in 2 of 2 areas observed (Operating Room and Cardiac Rehab). This deficiency potentially affects all patients treated at the facility.

Findings include:

Per observation on 2/20/16 at 12:51 PM the soiled utility room on the Medical/Surgical unit contains a bin for biohazard materials. There is no sign on the door to indicate there may be biohazards in the room. This deficiency is confirmed in interview, during the observation, on 2/20/17 at 12:51 AM with Nursing Supervisor C, who was unaware there should be a sign on the door.

Per observation on 2/20/17 at 3:35 PM the Cardiac Rehab room had a 6 inch crack in the wall, starting and the ceiling and extending down. The crack is located above Cardiopulmonary Coordinator X's desk in the patient area of the Cardiac Rehab room. This was verified by interview with Cardiopulmonary Coordinator X and by Rehab Director Y.

On 2/21/17 between 7:52 AM and 11:33 AM the following was observed in the Operating Room: There is chipped paint and stickers with curled edges on the overhead lights, the corner bump out by the storage room door has chipped paint, there are holes in the wall above and below the thermostat, there are scratches and gouges in the door to the storage room, there is adhesive residue on the window frame, and the the ends of the tape securing the Malignant Hyperthermia protocol to the wall are curling. The above deficiency regarding the lights was confirmed in interview with Nurse T, on 2/21/17 at 7:52 AM, who agreed the stickers should be not be curled. The remaining deficiencies were confirmed in interview with Scrub Tech P on 2/21/17 at 11:33 AM who agreed the surfaces should be smooth and washable.




37421

Based on observation and interviews, the facility did not provide and maintain the proper air pressure relationship between clean and dirty areas.

FINDINGS INCLUDE:

1). On February 21, 12:11 PM observation revealed that the scope cleaning room had airflow coming from the 'dirty' corridor into the clean scope cleaning room. Air flow is to be from clean to dirty. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T, (Director Facilities).

Based on observation, staff interviews, and review of maintenance records between February 20 and February 21, 2017, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
Hospital
K 133 Multiple Occupancies Construction Type
K 233 Clear Width of Exit and Exit Access Doors
K 251 Dead-End Corridors and Common Path of Travel
K 311 Vertical Openings Enclosure
K 321 Hazardous Areas
K 323 Anesthetizing Locations
K 324 Cooking Facilities
K 341 Fire Alarm System - Installation
K 345 Fire Alarm Systems - Testing and Maintenance
K 351 Sprinklers Installation
K 361 Corridors - Areas Open To Corridor
K 363 Corridor - Doors
K 371 Subdivision of Building Space - Smoke Compartments
K 372 Subdivision of Building Space Smoke Barrier
K 521 HVAC
K 754 Soiled Linen and Trash Containers
K 902 Gas and Vacuum Piped Systems - Other
K 911 Electrical Systems - Other
K 922 Gas Equipment - Other

Refer to the full description at the cited K tags.

Based on observation and interview, the facility failed to ensure staff used aseptic technique when administering intravenous medications, in 1 of 3 staff observed (Q). This deficiency directly affects Patient #4 and potentially affects all patients treated at the facility.

Findings include:

Per interview with Infection Preventionist J on 2/21/17 at 1:12 PM, the facility follows both AORN and APIC recommendations.

Per review of the Association of periOperative Registered Nurses (AORN) 2017 on-line recommendations it states VIII.f. Unless the medication is to be administered immediately, all medications removed from the original package and transferred to a secondary container should be clearly marked and easily identifiable.

Per review of the Associations for Professionals in Infection Control and Epidemiology (APIC) Position Paper: Safe Injection, infusion, and Medication Vial Practices in Health Care (2016) "Disinfect catheter hubs, needleless connectors, and injection ports before accessing....Discourage the transporting of medication filled syringes/needles in pockets or clothing...Label all syringes containing medication if not immediately administered. Include patient identification information, names and amounts of all ingredients, and the name or/initials of the person who prepared the (Medication) date and time the (Medication) was prepared, and beyond use date and time."

Per observation on 2/21/17 at 8:29 AM Certified Registered Nurse Anesthetist Q prepared to start an intravenous site for Patient #1. Certified Registered Nurse Anesthetist Q removed gloves, then proceeded to open the intravenous start kit without performing hand hygiene. At 8:37 AM Certified Registered Nurse Anesthetist Q removed a syringe of Versed (amnesia medication) from Certified Registered Nurse Anesthetist Q's scrub pocket and administered to Patient #4 prior to a gall bladder surgery. This deficiency was confirmed in interview with Certified Registered Nurse Anesthetist Q on 2/21/17 at 11:00 AM, who was unaware syringes should not be carried in scrub pockets.

Per observation on 2/21/17 at 8:40 AM fives syringes with medications were observed on the anesthesia cart. One syringe was labeled Rocuromium (relaxant), one labeled Versed (amnesia medication) and one labeled Robinul (used with general anesthesia). None of these syringes had a date, time, or initial of who drew up the medication. A fourth syringe with a clear liquid was labeled "open 2/21 7:15," there was no name or dose of the medication listed. A fifth syringe of a white liquid had no label. Per interview on 2/21/17 at 8:45 AM with Certified Registered Nurse Anesthetist Q, Certified Registered Nurse Anesthetist Q said the medications were drawn up just before seeing Patient #4 in the Pre-Operative Room. Per interview with Infection Preventionist J on 2/21/17 at 1:12 PM, Preventionist J stated the syringes should be labeled.

Per observation on 2/21/17 at 10:35 AM Certified Registered Nurse Anesthetist Q administered Ketorolac (intravenous non-steroidal anti-inflammatory) and Zofran (anti nausea medication) to Patient #4 near the end of a gall bladder and hernia repair surgery. Certified Registered Nurse Anesthetist Q did not clean the intravenous line port with alcohol prior to attaching the syringes and injecting the medication.

This observation was confirmed in interview with Certified Registered Nurse Anesthetist Q on 2/21/17 at 11:00 AM. Certified Registered Nurse Anesthetist Q acknowledged the ports should be cleaned.

A policy on cleaning intravenous ports was requested on 2/21/17 with the response from Director of Quality A that Chief Clinical Officer D was looking for it. No policy was received by exit.

Based on observation, interview, and policy review, the facility failed to ensure safe and sanitary environment to prevent and control the potential spread of infection in 4 of 9 areas observed (Pre-Operative Room, Operating Room, Scope Decontamination, and Lab). This deficiency potentially affects all current patients.

Findings include:


18816


Per review of facility policy titled Hand Hygiene, #ICP 310-009, dated 8/2015, it states "recommendations for health care workers to perform hand hygiene are 1.) Before touching a patient 2.) Before clean/aseptic procedures 3.) After body fluid exposure/risk 4.) After touching a patient 5.) After touching patient surroundings." The policy did not address hand hygiene after glove removal.

Per review of facility policy titled Attire in the Operating Room, #OR 300-005, dated 4/20/16, it states "All head and facial hair is to be covered while in the restricted areas of the surgical suite...Staff not "scrubbing in" shall wear long-sleeved jackets. Jackets are to remain closed (buttoned)...Eye shields shall be considered as routine protective equipment to be worn at all times during the direct care of all patients during surgery."

Per review of facility policy titled Surgical Area Cleaning and Terminal Cleaning in the Operating Room, #Housekeeping 250-008, (n.d.) it states "Staff work high to low and left to right around the room to ensure no area is missed."

Per interview with Infection Preventionist J on 2/21/17 at 1:12 PM, the facility follows AORN guidelines.
Observations in the Pre-Operative Room:

On 2/21/17 at 7:46 AM, Registered Nurse R was admitting Patient #4 for gall bladder surgery. Nurse R removed gloves and left the room without performing hand hygiene.

On 2/21/17 at 8:32 AM, Nurse R removed gloves to tape an intravenous line in place without performing hand hygiene.

The above findings were discussed in interview with Infection Preventionist J on 2/21/17 at 1:12 PM, who acknowledged hand hygiene should be done when removing gloves.

The following was observed in the Operating Room:

On 2/21/17 at 7:52 AM, Registered Nurse T, while not wearing a jacket, reached over the sterile table to drop supplies on the surface and with exposed skin, and no sterile gown. Nurse T's hair was not completely encased in a bonnet, Nurse T's ears were not covered and not all sideburns or facial hair was covered.

On 2/21/17 at 8:40 AM, in the Operating Room, Scrub Tech V's hair was not encased in a bonnet, and Scrub Tech V's ears were not covered, Certified Registered Nurse Anesthetist Q's hair was not encased in a bonnet. Surgeon S did not have on protective eyewear.

On 2/21/17 at 10:15 AM, Nurse T's scrub jacket was not snapped up exposing chest hair.

On 2/21/17 at 11:30 AM, while cleaning the Operating Room, Scrub Tech P did not clean the four hooks at the top of the intravenous pole.

The above findings were discussed in interview with Infection Preventionist J on 2/21/17 at 1:12 PM, who acknowledge staff should have hair and ears covered, open supplies in an aseptic manner, and clean all surfaces in the Operating Room.

Observations in the Scope Decontamination Room #302:

On 2/21/17 at 9:30 AM the Decontamination Room's door was open to the corridor. This finding was confirmed in interview with Scrub Tech V on 2/21/17 at 9:30 AM, who was unaware the door should be kept closed.

On 2/21/17 at 12:28 PM, after pre-cleaning a colonoscopy scope, Scrub Tech V, removed the gown, gloves and face shield/mask worn during the cleaning, donned new gloves, without performing hand hygiene. This deficiency was discussed in interview with Infection Preventionist J on 2/21/17 at 1:12 PM, who acknowledged hand hygiene should be done when removing gloves.



32670

Observations in the Lab:

On 2/21/17 at 9:35 AM observed Lab Tech W eating an apple in the clean supply storage room. Also observed a microwave, refrigerator, personal clothing (coats) and personal bags in the clean supply storage room.

On 2/21/17 at 9:40 AM observed refrigerator in clean supply room that contained employee lunches co-mingled with unopened lab supplies (five 10 milliliter bottles of Glucose Tolerance Test Beverages).

An interview was conducted with Lab Director U on 2/21/17 at 9:45 AM. Lab Director U stated the facility does not have a policy related to co-mingling clean supply storage with non-clean supply items. Lab Director U stated the clean supply room is multi-purpose at this time and that staff use this room to store personal supplies, take breaks and eat lunches. Lab Director U also stated the facility does not have a policy for storing employee food separate from medical supplies in the refrigerator. Lab Director U acknowledged that these items should be stored separately.

Based on record review and interview, staff at this facility failed to provide activity assessments for 1 of 3 Swing Bed patients (Patient #18). Failure to complete activity assessments for Swing Bed patients has the potential to affect all patients in Swing Bed status serviced by this facility (there was 1 present at the time of this survey).

Findings include:

An interview was conducted 2/21/17 at 9:00 AM with Quality Education Specialist E. Quality Education Specialist E stated that swing bed patients have activities daily and these are to be documented by the Activities Coordinator.

Patient #18's closed Swing Bed medical record was reviewed on 1/21/2017 at 9:55 AM. Patient #18 was admitted to Swing Bed on 12/13/2016 for strengthening needs due to a fall with a wrist injury and shortness of breath. Patient #18 was to have Physical and Occupational Therapies. Patient #18 was discharged on 12/21/2016.

There is no activity assessment documented and only 1 of 9 days of documented activities for Patient #18. This was verified by Quality Education Specialist E and by Nursing Supervisor C.