HospitalInspections.org

Based on interview, it was determined the facility failed to provide evidence that all medical staff were qualified, credentialed and appointed as medical staff to practice in the facility by the Governing Body.

The findings included:

On 7/2/13 at 8:30 AM the Quality Director (QD), who was identified as the facility contact person for the survey, was asked to provide 5 Physician and 5 Allied Health files to review for credentials and appointment to practice at the facility.

At 9:00 AM on 7/2/13, on the way to the kitchen, the QD was notified that the survey would be completed and the exit conference was tentatively set for 12:00 PM.

At 11:50 AM on 7/2/13 the QD was notified, by telephone, that the survey process was completed and the exit conference would be at 12:00 PM as previously scheduled. The QD stated the credential files had just been gathered and were at another hospital. There were no Physician or Allied Health files available on site for the survey team to review.

Based on facility policy review, observation and interview, it was determined the facility failed to ensure measures were implemented to control the spread of infections.

The findings included:

1. The facility's "Point of Care Testing Bedside Glucose Monitoring" policy documented, "...Dispose of the lancing device in a sharps container...Remove the test strip from the meter and discard it according to the infection control policy...Gloves are to be worn throughout the testing process and changed between patients..."

2. The facility's "Disposal of Biohazardous Waste" policy documented, "...The following materials shall be defined and processed as infectious or biohazardous waste...Any materials or items, which have been contaminated or contain visible soiling by blood [test strips] or other body fluids...Red can liners/or containers and bags labeled 'Biohazardous Waste' are used to collect biohazardous waste in all...patient care areas..."

3. Observations on 7/2/13 at 8:05 AM revealed RN #1 conducted an accucheck glucose test to Random Patient #1. RN #1 donned gloves and conducted the accucheck glucose test using a lancet and test strip that came in contact with the patient's blood. RN #1 then disposed of the lancet and test strip in the regular garbage can instead of an appropriate biohazardous/sharps container.

4. Observations on 7/2/13 at 8:30 AM revealed RN #2 conducted an accucheck glucose test to Random Patient #2. RN #2 donned gloves and conducted the accucheck glucose test using a lancet and test strip that came in contact with the patient's blood. RN #2 used mild pressure on the patient's finger at the stick site to promote enough blood to perform the test. RN #2 then disposed of the lancet and test strip in the regular garbage can instead of an appropriate biohazardous/sharps containers.

RN #2 then conducted a second glucose test on the patient. Wearing the same dirty/contaminated gloves that were used to perform the first glucose test, RN #2 reached into a zip lock bag containing the clean supplies of alcohol packets, gauze pads, finger stick lancets and a bottle of test strips. RN #2 retrieved supplies to perform the second glucose test on the patient, contaminating all the supplies in the zip lock bag. After the second test, RN #2 again disposed of the used test strip and lancet in the regular garbage can.

Followinf testing, RN #3 took the zip lock bag, containing the remainder of the supplies, to the pharmacy area. RN #3 removed the bottle of testing strips from the zip lock bag and placed them in a clean testing kit that was stored with the clean machines ready for use. RN #3 left the remaining contaminated supplies of alcohol pads, gauze pads and finger lancets in the zip lock bag, on the counter with the other zip lock bags for the next patient use.

5. Observations during the initial tour on 7/1/13 beginning at 11:00 revealed 3 anesthesia trays with red locks were on the counter in the anesthesia supply room. During an interview at this time, The Nurse Manager stated these were anesthesia trays "for patient cases." They were stocked with several medications that may be used by anesthesia.

During an interview in the pharmacy on 7/1/13 at 11:20 AM the Pharmacy Technician (PT) stated the anesthesia trays are prepared in the pharmacy and placed in the anesthesia supply workroom. The PT stated anesthesia staff pick them up from the workroom and take them to surgery for their cases. The PT stated, after the patient's surgery anesthesia staff brings them back and places them back on the counter in the anesthesia supply room where Pharmacy picks up the trays, accounts for any used medications and restocks them for another case.

Observations of Operating Room (OR) #2 on 7/2/13 at 10:55 AM revealed Random Patient #3 on a bed, being rolled from OR #2. The patient's anesthesia tray had been placed in the patient's bed, next to their legs as staff rolled the patient back to her room.

Observations in the anesthesia supply room on 7/2/13 at 11:10 AM revealed the patient's anesthesia tray was placed back on the counter in the anesthesia supply room, along with 4 other anesthesia trays that had already been used in surgery.

During an interview in the anesthesia supply room at 11:10 AM the Pharmacist stated the anesthesia trays are cleaned once a week. The pharmacist stated the anesthesia trays are prepared in pharmacy with a red lock on the tray. The trays are then supposed to be placed in the cabinet, under the counter in the anesthesia room, with the exception of specialty prepared trays, such as latex allergies. The specially prepared trays are placed on the counter so they can be readily seen. The pharmacist stated the trays that have been taken to surgery and used are supposed to be placed on the counter when they return.

There was no system in place to prevent cross contamination of the dirty anesthesia trays that had been used in surgery, the clean anesthesia trays that had not yet been used in surgery and the clean specialty trays. The trays are used for multiple surgery cases and only cleaned one time a week.