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Based on review of hospital policies and procedures, review of hospital Quality Program, review of the Infection Control Program, hospital documentation and staff interviews, it was determined the hospital failed to provide documentation of implementation of preventative actions and interventions that include feedback and learning opportunities throughout the hospital as evidenced by the facility did not provide documentation that the hospital identified all areas of the hospital that utilized similar processes with the potential for a similar risk for two of three cases reviewed related to insulin stickers and patient fall prevention. Failure of the hospital to address the adverse event, incident and or close call beyond the unit where the incident occurred has a high potential risk for the facility not recognizing housewide issues related to adverse events throughout the facility.

Findings:

The Facility Quality Assessment and Performance Improvement Program dated 2015 revealed: "...The measurement, analysis and tracking of quality indicators includes adverse patient events and other performance measures that assess and promote continual improvement in processes of care, inpatient and outpatient services, and operations...Event investigation and resolution are completed at the local level, Aggregate event data are analyzed for patterns and variation. Investigation follows identification of any performance or trends of concern with recommendations for preventive or corrective action and process improvement...."

The Quality Consultant # 9 stated in interviews conducted on 3/11/15, 3/12/15 and 3/13/15, that Case two, of the three specific cases identified on the Quality assessment Performance Improvement Worksheet was about the Humalog Insulin stickers found in a drawer for Regular Insulin stickers in the Medication Administration System. She confirmed there was no documentation of the the hospital identifying all areas of the hospital utilizing these similar Insulin Stickers. The incident report was only on the unit where the discrepancy was found. There was no discussion about any other units, even though the Medication Administration System with Insulin is utilized on all floors and units of the facility. She confirmed that this case has a high potential risk for the facility not recognizing adverse events throughout the facility.

The Quality Consultant # 9 also confirmed that Case #3 of the three specific cases identified on the Quality assessment Performance Improvement Worksheet was about a patient fall in a room on the telemetry floor. She stated that the incident was only investigated at the unit level. This case involving Patient # 13, did not have any documentation in the investigation why the Bed Fall Monitor was turned off. She confirmed that this was not found in the investigation of Patient # 13's fall. She also confirmed that the Virtual Rails were in use at the time of the fall. She confirmed that the Virtual Rails were not included in the investigation, to include who was assigned to monitor the Virtual Rails at the time of the incident The report never went to quality to ensure all preventable measures were taken. The investigation of the fall did not contain information that the implementation with preventive actions and interventions included feedback and learning opportunities throughout the hospital.

The Director of Telemetry #39, confirmed in an interview conducted on 3/13/15, that the virtual rails are a tool used to prevent falls, however, if no one is at the desk to monitor the virtual rails, the patient is able to get out of bed undetected. She confirmed no one is assigned to monitor the virtual rails monitor. These factors were not mentioned in Case # 3, involving Patient # 13's fall investigation.

The facility was unable to provide to the surveyors while on site, the documentation that the hospital identified all areas of the hospital utilizing similar processes with the potential for a similar risk for two of three cases reviewed of adverse events, incidents and close calls.

Based on manufacturer's recommendations, facility Infection Prevention Plan, hospital documents, staff interviews and observation it was determined that the facility failed to provide a sanitary environment to avoid sources and transmission of infections as evidenced by failure to follow directions for use for disinfection of non-porous surfaces according to manufacturer's recommendations which has the potential risk of the spread of contamination on these surfaces.

Findings:

Review of manufacturer's recommendations for Virex II 256 For Use as a One-Step Cleaner/Disinfectant requires: "...Apply use solution to hard, non-porous environmental surfaces. To disinfect, all surfaces must remain wet for 10 minutes ...."

The Infection Prevention Plan 2015 requires: "...It is the responsibility of the Prevention program to: Provide education to ensure clinically and environmentally safe surroundings for patients, visitors, staff, and others within the organization ...."

Operating Room Assistant job description requires: "...maintaining and cleaning the OR and surrounding areas ...."

Clinical Education Consult Nursing requires: "...Ensures that the educational needs of staff are identified, planned for, and met ...."

Observations made while on tour in the operating room on 03/11/15 through 03/13/15 at 0900 hours noted that the Operating Room Technician applying the disinfectant (Virex 256 II) to the operating room table and immediately wiping/drying the solution off. The Technician explained that she always wiped the disinfectant off and did not leave the solution on for any wet-time. The Technician confirmed she was instructed by the Nurse Educator on cleaning the equipment and surfaces in the operating room.

The Nurse Educator confirmed during an interview conducted 03/11/15 at 1000 hours that she was not aware of the 10 minute wet time for the disinfectant.

The Clinical Director of Surgical Services confirmed during an interview conducted 03/11/15 that all the rooms cleaned with the Virex solution and wiped off without any wet-time.