HospitalInspections.org

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Based on observation and interview the facility failed to ensure confidentiality of medical records. Findings:

An observation on 7/9/14, in the Oncology Rehabilitation Gym's physical therapy office, revealed patient charts easily accessible and viewable to anyone walking into the office. An interview with Physical Therapist #1 revealed patients who used the gym were brought into the physical therapy office to discuss and sign their admission paperwork.

An interview on 7/9/14 at 1:45 pm with the Privacy Officer confirmed patient medical records in the Oncology Rehabilitation Gym's physical therapy office were not kept in a confidential manner.

Review of the "Patient Rights & Responsibilities" given to patients, revealed "As a patient ...you have the right to: Confidential and secure medical records".

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Based on record review and interview the facility failed to ensure one medical record was complete. Specifically, the medical record failed to sufficiently identify the patient. Findings:


Record review on 7/7-10/14 of Patient #29 revealed the medical record for the visit on 6/4/14 contained a history and physical (H&P) with a different name and age than that of Patient #29. There was no verification of identification in the record. Further review revealed a second medical record number existed for this patient.


During an interview on 7/9/14 at 12:55 pm with QI (Quality Improvement of Children's Hospital) #1 stated there was an alias name and a second medical record number for Patient #29. QI #1 confirmed there was no information or documentation in the Patient's record on 6/4/14 that the facility verified the H&P in the record was in fact Patient #29's.


During an interview on 7/9/14 at 1:15 pm, the Patient Access Manager confirmed the two medical record numbers for Patient #29 should have been merged and the admitting staff did not verify identification of the Patient during the 6/4/14 visit.


Review of facility policy "Patient Identification" dated 9/28/13, revealed "...that all patients are properly identified...Provides a positive method of linking patients to their medical records..."

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Based on observation, record review, and interview the facility failed to ensure equipment was maintained and monitored to assure patient safety. Findings:

Observation on 7/9/14 at 4:20 pm of the Interim Outpatient Rehabilitation Services revealed two pieces of equipment, a splint and a paraffin bath, in Treatment Room 37. The splint bath was used for making patient's custom splints and the paraffin bath was used to facilitate hot paraffin treatments of the body extremities. Both of these equipment required temperature monitoring.

Splint Bath

Observation in Treatment Room 37 revealed a July 2014 temperature monitoring log for the splint bath. The temperatures ranged from 147 to 161. At the bottom of the temperature monitoring log it said, "Temperature Range: 165-180 degrees F If out of range: Unplug, tag "For Repair", contact Biomed at x 5000".

Paraffin Bath

Observation in Treatment Room 37 revealed a July 2014 temperature monitoring log for the paraffin bath. The temperatures ranged from 134 to 136. At the bottom of the temperature monitoring log it said, "Temperature Range: 120-129 degrees F".

Further review of the temperature monitoring log revealed a blank log behind the actual log being used. The blank log had temperatures that ranged from 123 to 138.

During an interview on 7/9/14 at 4:30 pm, the Interim Outpatient Rehabilitation Manager was asked about the difference in the temperatures actually documented and the temperature ranges at the bottom of the temperature logs. She confirmed the temperatures need to be in range and if the temperatures are out of range, the equipment should be unplugged and Biomed should be called.
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Based on observation, interview and record review, the facility failed to ensure: proper food sanitation practices; sanitary patient equipment; and proper storage of cleaning cloths. Findings:

Food Sanitation

An observation of the facility kitchen on 7/7/14 at 9:00 am revealed a Hobart Mixer soiled with dust and crusted food; plastic covered bowls of tomato paste and black beans with use by dates of 7/5/14; spices stored on a wire rack that sprinkled onto the clean utensils used to prepare food that were stored below; and scoops stored in containers of rice, navy beans, barley, and black beans.

During an interview on 7/7/14 at 9:15 am the Food and Nutrition Services (FNS) Manager verified the observations of the soiled mixer, outdated food, spices dropped onto the clean utensils, and stated the scoops should not be stored in the food items.

During an interview on 7/9/14 at 11:25 am the Dietitian stated the Hobart Mixer had not been assigned to the staff s cleaning log and therefore had not been cleaned.

Cool Down Logs

Record review on 7/7/14 at 9:00 am revealed, "Room Service Prep List, #21 Prep Cook" dated 6/25 contained listings for Black Beans, Navy Bean Soup, and Minestrone Soup with cook temps but no cool temperature or time to cool temperature listed. The same form dated 7/1 contained listings for Chicken Noodle Soup, Navy Bean Soup, and Minestrone Soup with cook temperatures but no cool temperature or time to cool temperature.

During an interview on 7/7/14 at 9:35 am the FNS Manager confirmed the Prep Lists were the food cool down logs and they were not complete. The Manager stated the log should include the temperature the food was cooled to and the amount of time it took to get to the cool temperature.

Policy review on 7/7-10/14 revealed "Safe Food Handling and Food Storage", dated 6/13, The purpose of this policy is to establish procedures for safely storing food items and serving them within compliance within Anchorage Municipality food code...Foods will be cooled as rapidly as possible after proper cooking: Potentially hazardous food will be cooled in 1 step: 1. From 135 [degrees] F to 40 [degrees] within 2 hours."

Review online of the Anchorage Municipality Food Code accessed 7/14/14 at revealed, "To limit bacterial growth, cooling must be done as rapidly as possible. Potentially hazardous foods must be cooled from 135°F to 70°F within 2 hours and from 70°F to 41°F within 4 additional hours."


Equipment for patient use

Observation on 7/7/14 at 11:00 am in the clean storage area in the Pediatric Unit revealed a soiled IV pole with dried substances on the base.

During an interview on 7/7/14 at 11:00 am the Hospital Tech confirmed the IV pole was stored in the clean storage area because it was ready for patient use. During the same interview, the Pediatrics Assistant Clinical Manager confirmed the IV pole was dirty and would need to be cleaned prior to being used for a patient.

Policy review on 7/7-10/14 revealed "Cleaning and Disinfecting Non-Critical Patient Care Equipment", dated 6/3/14, "To minimize the risk of hospital-acquired infection by establishing guidelines for the cleaning and disinfection of shared patient care equipment ...Patient Care Equipment managed by patient care units must be cleaned after each patient use..."

Cleaning Cloths

Observation of the Environmental Services (EVS) supply/storage room on 7/9/14 during the EVS department tour revealed multiple large clear plastic bags, filled with blue cleaning cloths, piled on the floor of the supply/storage room. Some of the bags were torn open with the cloths spilling out onto the floor.

An interview was conducted with the EVS Supervisor. She explained the cleaning rags, inside the large clear plastic bags, were what the EVS staff used for cleaning the hospital. She further stated the clean rags should not be on the floor.




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Based on observation, interview and record review the facility failed to ensure monitoring of the operating rooms for temperature and humidity. This failed practice had the potential for increased risk to both patients and staff for fire and infections. Findings:

An observation on 7/9/14 at 2:05 pm in Day Surgery suite #4 revealed no humidity monitor was identified.

During an interview on 7/9/14 at 2:05 pm the Operating Room Manager stated the humidity level was monitored centrally by maintenance.

Operating room 16

Record review on 7/10/14 of the minimum and maximum humidity measurement log for operating room 16, from 3/23/14 - 4/20/14, revealed the humidity range was from a negative (-) 1.06 to 15.31 percent. Further review revealed, on April 5, 7, 15, 16, 17, 18, the humidity rose to just over 20 percent.

Record review on 7/10/14 of the surgery schedule from 3/23/14 - 4/ 20/14, revealed 28 cardiovascular surgeries had been scheduled in operating room #16.

Operating room 17

Record review on 7/10/14 of the minimum and maximum humidity measurement log for operating room 17, from 3/23/14 - 4/20/14, revealed the humidity range was from a negative (-) 1.28 to 19.71 percent. Further review revealed, on April 18 and 19 the humidity rose to just over 20 percent.

Record review on 7/10/14 of the surgery schedule from 3/23/14 - 4/20/14, revealed 12 cardiovascular surgeries had been scheduled in operating room #17.

During an interview on 7/10/14 at 1:00 pm the Lead Maintenance Staff #1, responsible for centralized monitoring of humidity and temperatures within the operating rooms, stated the humidity had been out of range in rooms 16 and 17 from mid-March to mid-April.

During an interview on 7/10/14 at 1:30 pm the Director of Surgical Services stated he had not been aware of the low humidity in operating rooms 16 and 17. In addition, the Director stated provisions would have been made to not have done the surgeries in those rooms given the low humidity and high fire risk, if he had been aware.

Operating rooms - Obstetrics

During an interview on 7/10/14 at 12:15 pm the Deputy Fire Marshal stated the obstetrical operating rooms did not have a means of monitoring humidity levels.

During an interview on 7/10/14 at 1:20 pm, the Clinical Manager of Obstetrics stated there were no humidity monitors in the Obstetric operating rooms and no monitoring of humidity had been done since the rooms opened on 12/9/13.

Record review of the surgery schedule from 12/9/13-7/10/14 for the obstetric operating rooms revealed > 50 surgeries in room #1 and > 500 surgeries had been performed in room #2 with no monitoring of humidity for fire risk.

During an interview on 7/10/14 at 1:50 pm, the Infection Preventionist #1 stated no surveillance of the temperature and humidity monitoring in the operating rooms was being done by Infection Prevention.

Record review of the facility policy "#FS-800 Infection Control Guidelines", revision date 4/14, revealed "3) if relative humidity falls outside of normal operation parameters...[20 - 60 % and] not readily repaired, personnel shall notify the Building Maintenance Supervisor who will contact the Charge nurse of the affected area..."

Based on the Center for Clinical Standards and Quality /Survey & Certification Group letter
Ref: S&C: 13-25, dated April 19, 2013, "Center for Medicare & Medicaid (CMS) is issuing a categorical LSC waiver permitting new and existing ventilation systems supplying hospital and critical access hospital (CAH) anesthetizing locations to operate with a RH [relative humidity] of =20 percent, instead of =35 percent. We are also recommending that RH not exceed 60 percent in these locations."

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