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Based on observation, staff interview, review of the maintenance check list and policies and procedures, and interview with the manufacturer's technical support specialist, the facility failed to ensure preventive maintenance was implemented according to the manufacturer's recommendations for 1 of 2 anesthesia machines. The findings were:

Observation on 8/22/12 at 7:18 AM revealed the following words were written on the CO2 (carbon dioxide) absorber canister on the anesthesia machine in the procedure room: "Changed 12/15/08." Interviews on 8/22/12 at 9:10 AM with RN #6 and at 4 PM with CRNA #8 revealed neither knew how often the canisters needed to be changed because the biomedical technicians were responsible for preventive maintenance for the anesthesia machines. Both nurses stated this anesthesia machine was rarely used because they primarily used the one in the operating room.
During an interview on 8/23/12 at 11:10 AM, biomedical technician #1 stated the anesthesia machine in the procedure room had been checked and was fully functional. She further stated the CO2 absorbent was an item that was replaced based on use, and the biomedical technicians were not responsible for maintenance of this part of the anesthesia machine.
Review of the 5/30/12 Medical Equipment Planned Maintenance Procedures inspection check list for "anesthesia unit/anesthesia ventilator" showed checking the CO2 absorber canister was not included. During an interview on 8/23/12 at 11:30 AM, the technical support specialist for the company that manufactured the anesthesia machine stated the manufacturer recommended the canisters be checked frequently. He reported this was because over a period of time, even without use, the accumulated moisture in the canister would decrease the effectiveness of the absorber system. He further stated the absorbent in the canisters should be changed more often than every three years to ensure patient safety even though the machine was used infrequently.
Review of the policy and procedure, "Intraoperative Standard of Care", effective 11/22/11, showed the following standard: "All equipment in procedural areas will follow the manufacturer's recommendations for operating, cleaning, disinfecting/sterilizing and storing. All equipment will be inspected for safety and function prior to use."

Based on observation, staff interview, and review of policies and procedures, the facility failed to provide secure storage for medications in the emergency department. The findings were:

Observation of the emergency department on 8/21/12 at 10:15 AM revealed multiple syringes containing sodium chloride were stored in an unsecured drawer, and a box containing individual packets of Bacitracin was in an unsecured cabinet with a sliding glass front. At that time the department manager stated the area was always staffed with licensed personnel. However, observation on 8/22/12 at 5 PM showed no staff were in that area.
Review of the facility's policy and procedure entitled "Medication Security and Storage" effective 8/8/12 revealed secure medications were "locked or under constant surveillance." Further review showed medications kept in an open medication storage area (defined as "without a door, lockable door, or not physically enclosed") were to be "stored in automated dispensing equipment, a locked cabinet, or locked cart."

Based on observation, staff interview, medical record review, and review of manufacturer's instructions and policies and procedures, the facility failed to ensure staff adhered to practices designed to prevent the spread of infections for patients and personnel. This failure affected 1 of 1 sample outpatients (#29) observed during an invasive procedure and 2 of 6 sample inpatients (#2, #5). The findings were:

1. Observation on 8/22/12 at 8:26 AM revealed RN #6 failed to follow the manufacturer's recommendations for presoaking and cleaning colonoscopes after performing a colonoscopy for patient #29. During the observation, the RN added an unmeasured amount of enzymatic cleaner to an unmeasured amount of water in the sink and allowed the scope to soak for three minutes and forty-five seconds. Review of the manufacturer's recommendations for the enzymatic cleaner used by the RN revealed the following instructions: "For presoak and manual cleaning add one to two ounces of solution per gallon of water. For standard cleaning the recommended soaking time is five minutes." During an interview at 8:45 AM, the RN acknowledged her failure to follow the manufacturer's recommendation.

2. Observation on 8/20/12 at 10:25 AM showed a sign for contact isolation precautions posted outside the door of patient #2. Review of the medical record showed the patient was in isolation for shingles. Observation that evening at 5 PM showed staff wore isolation gowns and gloves while providing care. At 5:20 PM, an unidentified environmental services technician (housekeeper) entered the room and donned personal protective equipment (PPE). While donning the gown, the technician stated she was unable to tie it, so she left the neck and waist ties open. When the technician bent over to pick up the large trash container, the gown fell off her shoulders. Without changing gloves, the technician pushed it back up to the tops of both shoulders, touching her own clothes in the process. She then placed the open bag of trash onto the floor, removed her PPE, and placed everything inside the bag. Without regloving, the technician picked up the bag and placed it in the container outside the door. She then left the patient's room without performing hand hygiene.
Interview with the ICP on 8/20/12 at 5:45 PM revealed she would prefer staff wear gloves while gathering the trash, but she was unsure if there was a policy to that effect. On 8/21/12 at 8:10 AM the ICP stated there was no specific policy for glove use when gathering trash. She stated trash pickup was specified in the policy for Standard Precautions. Review of the facility's 5/22/09 policy and procedure, "Trash Removal," confirmed it did not address the use of PPE. Review of the 3/14/12 policy and procedure "Standard and Transmission Based Precautions" for contact precautions showed gloves should be worn when touching "...contaminated items or environmental surfaces" and hands should be washed or sanitized "after contact with any...items in the patient environment."

3. On 8/21/12 at 8:25 AM RN #4 was observed wiping her stethoscope with a CaviWipe and then placing it around her neck prior to entering the room of patient #5 to assess his/her heart and lungs. When asked, the RN stated she used the CaviWipe to disinfect the stethoscope. The RN further stated the wet contact time required for disinfecting the stethoscope was three minutes; she acknowledged placing it around her neck did not meet the requirements. Review of the manufacturer's instructions on the label of the CaviWipe container verified a three minute wet contact time was required to disinfect clean objects.

Based on observation, staff interview, and review of policies and procedures, the facility failed to ensure staff provided care to meet the needs of 2 of 24 sample patients. This failure affected 1 of 2 surgical inpatients (#18) and 1 of 2 inpatients (#5) observed for incontinence care. The findings were:

1. Review of the medical record revealed patient #18 underwent a surgical procedure with epidural anesthesia on 7/30/12. The patient was transferred to the post anesthesia care unit (PACU) at 9:41 PM and remained there until 10:18 PM. Review of the PACU documentation showed no evidence the Aldrete Scoring System was ever performed. On 8/23/12 at 3:55 PM, RN #9, who cared for the patient in PACU, stated that patients remained in PACU until they met the discharge criteria for the Aldrete Scoring System. During that interview, the RN verified lack of evidence indicating the scoring system was implemented. According to the facility's policy and procedure, "Perianesthesia: Banner Health Perianesthesia Standard of Care", effective 4/1/11, the post-procedural assessment included "Aldrete Scoring System on admission, discharge and whenever a change occurs."

2. On 8/21/12 CNAs #2 and #5 were observed providing care for patient #5 at 7:45 AM. After determining the patient had been incontinent of urine, CNA #2 provided incontinence care. However, she only cleansed the patient's anterior groin. When interviewed at 8:03 AM, CNA #2 confirmed the patient had been incontinent of urine and that she had not cleansed his/her buttocks.

Based on observation, medical record review, and staff interview, the facility failed to ensure medications were administered appropriately for 2 of 20 sample patients (#8, #11) reviewed for medication administration. The findings were:

1. Observation on 8/21/12 at 9:15 PM showed RN #7 administered Tylenol to patient #11, a newborn infant. The RN used a regular luer lock syringe and stated she had drawn up 3.5 milliliters of Tylenol. Observation of the syringe showed it was not marked in one half milliliter increments so an accurate dose could not be ascertained. When questioned, the RN stated she used the same syringe to measure and administer the medication instead of a syringe specifically marked in one half milliliters because any difference in the accuracy of the dose would be minuscule and would not matter. Interview with the pharmacy director on 8/24/12 at 9:50 AM revealed the RN should have used a syringe specifically marked for one half milliliters to obtain an accurate dose. The pharmacist further stated the RN should have used an oral syringe instead of a leur lock syringe to administer the medication.

2. According to the medical record, the physician ordered pentoxifylline 400 milligrams for patient #8 twice daily. Review of the medication administration record showed it was not administered at 9 PM on 8/21/12 or at 9 AM on 8/22/12. Further review of the record showed no evidence the physician was notified the medication had not been administered. After reviewing the record on 8/22/12 at 11:30 AM, RN #3 verified the lack of physician notification.

Based on observation, review of medical records, staff interview, and review of standards of care, the facility failed to develop appropriate care plans for 3 of 20 sample inpatients (#2, #11, #19). The findings were:

1. Observation on 8/20/12 at 5 PM showed patient #2 required contact precautions prior to receiving care. Further observation revealed the patient was incontinent of urine and used oxygen. During the provision of care, the patient complained of a "big pain" in his/her shoulder. Review of the nursing assessment confirmed the aforementioned areas were identified as issues. Review of the care plan with RN #3 showed none of these issues were addressed. At 1:27 PM on 8/21/12 the RN confirmed the issues should have been included in the care plan.

2. According to standards of care provided by RN #3 on 8/22/12 at 1:38 PM, the care plan for well newborn infants should include: 1) Knowledge deficit. 2) Risk for injury. 3) Risk for infection. 4) Ineffective thermoregulation. 5) Potential for ineffective breathing patterns. 6) Potential for ineffective tissue perfusion. 7) Potential for ineffective urinary and bowel elimination. Each of the problems included specific goals and interventions. Failure to implement the care plans was identified as follows:
a. Review of the 8/20/11 care plan for patient #11 showed interventions were only developed for two problem areas, thermoregulation and risk for infection.
b. Review of the 3/13/12 care plan for patient #19 showed staff had developed care plan interventions for only two problem areas; thermoregulation and extra uterine environment.
On 8/22/12 at 1:38 PM the RN stated care plans for newborn infants should include all the specified problem areas.

Based on medical record review and staff interview, the facility failed to ensure a properly executed Advance Directive for 1 of 17 sample inpatients (#9) who required that directive. In addition, the facility failed to ensure an accurate medical record for 1 of 24 sample patients (#16) whose records were reviewed. The findings were:

1. Review of medical record #9 on 8/21/12 at 1:48 PM revealed the patient was admitted to the facility on 6/16/12 for a surgical procedure. Further review revealed the Advanced Directive form had been scanned into the electronic medical record. The form was signed and stated the patient requested full resuscitation in the event it was necessary. The form, however, was neither dated nor timed. Interview with the HIM manager on 8/22/12 at 9:48 AM revealed the directive should have been dated and timed by nursing staff when the patient was admitted.

2. Medical record review for patient number #16 on 8/21/12 at 2:48 PM revealed the patient was admitted to the facility on 6/21/12 for cataract surgery. Signed informed consent forms and other admission documentation stated the surgery was to be performed on the patient's right eye. However, review of the Final Operative Report dated 6/21/12 stated "Operative Diagnosis: Cataract of left eye. Procedure: Left phacoemulsification with posterior chamber intraoccular lens." Interview with the HIM manager on 8/22/12 at 9:48 AM revealed the Final Operative Report was a transcription error and should have been caught and corrected by medical records staff.

Based on medical record review, staff interview, and review of the medical staff rules and regulations, the facility failed to ensure the History and Physical (H&P) for 1 of 24 sample patients (#10) whose medical records were reviewed was completed in a timely manner. The findings were:

Review of the medical record for patient number #10 revealed the patient was admitted to the facility on 8/25/11 with an admission diagnosis of chronic obstructive pulmonary disease. Review of a physician's progress note dictated 8/26/11 at 3:37 AM detailed the treatment the patient received as well as the decline of the patient during his/her hospital stay. The progress note ended by stating the patient expired at 3:10 AM on 8/26/11.
Further review of the medical record revealed an H&P that stated, "We will continue his CPAP and [s/he] is started on pneumonia antibiotics and pneumonia protocol." The H&P, however, was dictated and transcribed on 8/30/11, four days after the patient's death. According to the "Medical Staff General Rules and Regulations", approved on 12/8/11, "A complete history and physical examination in all cases shall be recorded within 24 hours of admission." Interview with the HIM manager on 8/22/12 at 9:48 AM confirmed the H&P was late. The HIM manager also acknowledged the standard for completion of the H&P was within 24 hours of admission on the date this patient was admitted.