HospitalInspections.org

Based on observation, document review, and policy review, the board failed to hold the executive director (ED) accountable for the executive officer responsibilities for the management of the hospital. Findings include:

1. The ED failed to oversee the day-to-day hospital functions as evidenced by:
a. The provider failed to ensure one of one anesthesia technician (A) had been approved for access to all medications.

Interview on 6/17/15 at 3:30 p.m. with the ED revealed she:
-Was not aware the anesthesia technician position did not have provisions that allowed for access to legend (prescription) and controlled medications.
-Agreed the policy needed to be amended to include the anesthesia technician to have access to the above.

b. The provider failed to ensure the patients' safety and the staff's working environment was maintained in a good, cleanable condition. Refer to tag A701.

Interview on 6/18/15 at 10:45 a.m. with the ED confirmed the observations in tag A701. She revealed she:
-Had purchased those wooden shelves for the materials management store room about three months ago. She had not considered they should have a cleanable surface.
-Was aware of the old cabinet by the nurses station and the raw wooden shelf.
-Was aware of the cracked, broken, and taped laminate on the equipment room door.
-Was aware of the nicks and gouges on the walls in all four operating rooms. She stated they had gotten worse in the past few months.
-Was not aware the wall in post acute care unit room 20 was damaged again. She stated she had it repaired in the past but was not aware of the new damage.
-Was aware of the cracked ceiling in the decontamination room. She had noticed it on her weekly rounds but had not placed a work order to have the ceiling fixed.

c. The provider failed to ensure a preventive maintenance checklist or log was performed or done on a routine occurrence.

Interview on 6/18/15 at 11:00 a.m. with the ED confirmed the above finding. She stated if something was noted by herself on her weekly rounds she would send a work order to the building's owner. She stated she did not keep a log or record of what she checked or reviewed on her weekly rounds.

d. An implemented, effective, and sustainable infection control (IC) program was instituted with infection control tracking logs, IC policies and procedures, quality assurance performance improvement meeting minutes, and staff education.

Interview on 6/17/15 at 3:30 p.m. with the ED revealed:
-There was not one specific person(s) in charge of the IC program.
-She agreed there were parts of the program that had no oversight.
-She agreed a central infection control person would have advantages and stated it was a "hodge podge" of a program.

e. Review of the provider's July 2013 policy for Executive Director revealed:
"d. Monitoring and evaluating care services, and acting on findings accordingly."
"h. Maintaining infection control, safety and disaster plans."

Interview on 6/18/15 at 11:30 a.m. with the ED revealed she wanted no other person to attend the exit conference. She stated she was responsible for the operation of the hospital and patient safety.

Based on observation, record review, interview, and policy review, the provider failed to ensure one of one anesthesia technician (A) had been approved for access to all medications. Findings include:

1. Observation and interview on 6/16/15 at 12:05 p.m. revealed anesthesia technician A was in operating room 1. She cleaned the anesthesia carts and then checked for supplies needed in the cart. The cart had numerous medications inside including legend (prescription) and controlled (narcotic) medications. She stated she cleaned and disinfected all the anesthesia carts between surgical cases for all four operating rooms. She would check if supplies and medications needed to be replaced. She also would date open vials of medication if the anesthesiologists or certified registered nurse anesthetists had not remembered to date them. She had access to all the medications in the Omnicell computerized pharmacy supply.

Review of the provider's undated Anesthesia Monitoring Technician job description revealed no indication of having been allowed to have unsupervised access to legend or controlled medications.

Review of the provider's April 2013 Medication Administration and Documentation policy revealed medications could be safely administered by currently licensed registered nurses (RN). There was no indication of who had access to medications.

Review of the provider's July 2013 Controlled Substances policy revealed no indication of who had access to the controlled medications.

Review of the provider's July 2013 Automated Dispensing Cabinet Medications and Access policy revealed:
*The system was in place to accurately and safely dispense medications and monitor individuals who used that administration delivery method.
*Under policy guidelines that was performed by RNs and supervised nursing students.

Interview on 6/17/15 at 3:30 p.m. with the executive director revealed she:
*Was not aware the anesthesia technician position did not have provisions that allowed for access to legend and controlled medications.
*Agreed having the policy amended to include the anesthesia technician to have access would be necessary.

20031

A. Based on observation and interview, the provider failed to ensure the patients safety and the staffs working environment was maintained in a good cleanable condition. That included:
*Raw wooden shelves in the materials management store room.
*Locker area by the nurses station:
-A side cabinet that had missing laminate and vinyl flooring used as the top.
-A shelf with a raw wooden finish.
*The equipment room door had broken or missing laminate.
*Four of four operating room walls had gouges and scraped surfaces.
*One of four walls in the post acute care unit (PACU) room 20 had gouges and scraped surfaces.
*The ceiling in the decontamination room of sterilization was cracked and peeling.
Findings include:

1. Random observation from 6/16/15 through 6/18/15 revealed:
*Raw wooden shelves in the materials management store room.
*In the pre-operative locker area by the nurses station:
-A side cabinet had missing laminate and a piece of vinyl flooring had been used for the top of that cabinet.
-A shelf on the wall had a raw wooden finish.
*The equipment room door had broken and missing laminate on the edge of the door that had been taped to the door.
*Four of four operating room walls had nicks, gouges, and scrapes into the gypsum board.
*One of four walls in the post anesthesia care unit (PACU) room 20 had severe gouges and scrapes into the chalk of the gypsum board.
*The ceiling in the decontamination room of sterilization had a large crack about eighteen to twenty-four inches long and an eighth of an inch wide.

Interview on 6/18/15 at 10:45 a.m. with the executive director confirmed the above random observations. She revealed she:
*Had purchased those wooden shelves for the materials management store room about three months ago. She had not considered they should have a cleanable surface.
*Was aware of the "old" cabinet by the nurses station and the raw wooden shelf.
*Was aware of the cracked, broken, and taped laminate on the equipment room door.
*Was aware of the nicks and gouges on the walls in all four operating rooms. She stated they had gotten worse in the past few months.
*Was not aware the wall in PACU room 20 was damaged again. She stated she had it repaired in the past but was not aware of the new damage.
*Was aware of the cracked ceiling in the decontamination room. She had noticed it on her weekly rounds but had not placed a work order to have the ceiling fixed.

B. Based on document review and interview, the provider failed to ensure a preventive maintenance (PM) checklist or log was performed or done on a routine occurrence. Findings include:

1. Review of documents provided by the executive director (ED) revealed the buildings owner kept a PM log of the buildings structural elements such as doors, windows, utilities, and outside surroundings. There was no checklist or log to ensure the buildings environment such as finished walls, flooring, ceilings, shelving units, and furniture was kept in a cleanable, durable condition.

Interview on 6/18/15 at 11:00 a.m. with the ED confirmed the above findings. She stated if something was noted by herself on her weekly rounds she would send a work order to the building's owner. She stated she did not keep a log or record of what she checked or reviewed on her weekly rounds.

26632

Surveyor: 20031
Based on random observation, testing, document review, record review including infection control tracking logs, infection control (IC) policies and procedures, quality assurance performance improvement (QAPI) meeting minutes, and staff interview, the provider failed to ensure:
*There was an active, effective, organized IC program for the prevention, control, identification, and investigation of infectious risks to patients, staff, and visitors.
*An appointed person(s) was in charge of the infection control program.
*A sanitary environment was maintained or achieved for the following items and/or areas throughout the facility to avoid sources and transmission of infections. To include:
-Handwashing was not completed by one of one surgeon (G) and three of four registered nurses (RN) (D, E, and F) for one of two observed patients (15).
-Terminal floor disinfection was not completed for four of four operating rooms (OR) (1, 2, 3, and 4).
-Contact time for the quaternary (quat) disinfectant was not followed.
-Eighteen sterilized hinged surgical instruments were in the closed position.
-An open roll of paper towels was used for two of two handwashing sinks in the women's locker room.
-Cleaning chemicals were stored next to patients' care items in four of four ORs (1, 2, 3, and 4).
-Gel positioning pads were torn, ripped, or taped in three of four rooms (central supply and two of four [1 and 2] ORs.
-Four of four roller transfer boards had frayed vinyl covers in all four ORs.
-Clean linen was stored unprotected in one of one materials management room.
-Four of four metal anesthesia carts were rusted in all four ORs.
-Two rolling stools in one of four ORs (2) had torn, ripped, and frayed vinyl covers.
Findings include:

Surveyor: 26632
1. The hospital failed to ensure the person(s) designated as IC officers accomplished the tasks required for the IC program by implementing policies governing control of infections and communicable diseases.

Review of the provider's 2015 Infection Control Plan signed by the executive director on 7/1/14 revealed:
*The provider's main services was surgical services.
*Aseptic principles were part of the basis for excellent surgical care, implemented in patient screening, environment cleaning practices, decontamination, and sterilization of instruments.
*Patients that arrived with symptoms of illness would be isolated as soon as possible and evaluated.
*Staff would follow aseptic principles utilizing gloves and hand hygiene appropriately.
*Staff were to go home when they were ill with a fever, vomiting, and diarrhea to prevent the spread of infection.
*Staff would participate in required infection control education on a quarterly basis or annually as decided by nursing education.
*The provider would participate in data collection that reflected efforts to pursue infection prevention and control as well as quality measures.

Review of the provider's reviewed February 2014 Infection Control General policy revealed:
*Patients with a suspected communicable disease would be examined promptly and either admitted to the hospital or discharged as soon as possible.
*The housekeeping personnel and nursing staff would have been responsible for maintaining a clean environment.
*Employees would follow established procedures for asepsis.
*Physicians were asked to report infections on a monthly basis. The infection data was tabulated and reported to the Board of Directors.

2. Interview on 6/16/15 at 3:00 p.m. with registered nurse (RN) A revealed she:
*Was not aware she had been designated the infection control nurse. *Only compiled data on surgical infections from the information from the surgeons.
*Also compiled data and reported to the national health care safety network (NHSN) on information regarding catheter associated urinary tract infections and central line associated bloodstream infections.
*Knew of two other employees who did handwashing audits but did not review those audits. She was not sure who did.
*Had no contact for employee health and did not keep track of employee illnesses.

Interview on 6/17/15 at 10:00 a.m. with RN C revealed:
*She performed handwashing/sanitizing audits for the pre and post-operative areas.
*She gave those audits to the executive director (ED) who then would talk with staff about the results at the staff meetings.
*The ED would also present the audit results to QAPI if the goals had not been met.

Interview on 6/17/15 at 3:30 p.m. with the ED revealed:
*There was not one specific person(s) in charge of the infection control program.
*She agreed there were parts of the program that had no oversight.
*She agreed a central infection control person would have advantages and stated it was a "hodge podge" of a program.

Observation on 6/16/15 from 10:30 a.m. through 12:05 p.m. revealed:
*Patient 15 was in the pre-operative area with RN D.
*RN D, RN E, and RN F all attempted to insert an intravenous line into patient 15.
*During those attempts there were multiple missed opportunities for handwashing and/or hand sanitizing after removing gloves, putting on gloves, and touching environmental surfaces before and after glove use.
*After the surgical procedure was completed for patient 15 surgeon G removed his surgical gloves, gown, and mask.
*He picked up patient 15's medical chart and walked down the hall to the consultation room to visit with her family.
*He had not washed or sanitized his hands.

Surveyor: 20031
3. Random observation, interview, and testing from 6/23/15 through 6/25/15 revealed:
*Surgical technician B had entered an OR to start the terminal clean for the end of the day. She stated she used a neutral cleaner for all floors throughout the surgical suite. She revealed that was all she had used in over four years. She stated she oversaw housekeeping and had trained other staff to use the neutral floor cleaner as well. She was not aware all OR floors and other clean areas/rooms must be terminally disinfected daily.
-Interview with the ED revealed she was not aware the ORs and other clean room floors were not disinfected daily.
*Employees used a quat disinfectant for all high touch surfaces throughout the facility. Interview with surgical technician B revealed she was not aware of the ten minute contact time for the disinfectant to have been effective.

Observation and interview with employees H and I on 6/17/15 at 1:30 p.m. while in the sterilization room revealed the following:
*They stated they completed most of the sterilization on the surgical instruments.
*If they were busy other staff would come and help them.
*Observation of the packaged sterilized instruments at the above time revealed:
-Eighteen hinged surgical instruments were found in the closed position.They included Mayo, Meta, Iris, and bandage scissors.
-They both confirmed those findings and stated they were aware all hinged instruments were to have been in the open position for sterilization.
-Employee H stated it might be the other employees that helped with the sterilization. She stated she did not check their work, but it appeared more training and audits were needed.
*An opened roll of paper towels sat on the counter between the two handwashing sinks in the women's locker room. The paper towel dispenser was empty.
-Surgical technician B confirmed that finding. She stated the other employees would wait for her to fill the dispenser instead of doing it themselves.
*Quat disinfectant chemicals were stored next to patient care items in all four of the ORs.
-Surgical technician B confirmed that finding. She stated they were supposed to have been stored in the bottom of the supply cabinet next to the suction containers.
-The ED agreed those chemicals should not have been stored next to patient care items.
*Gel positioning pads for the head, arms, and shoulders were either torn, ripped, or taped in central supply and one of four (2) OR.
-RN J confirmed those findings and stated the gel pads were very expensive, so they had tried to tape them to last longer.
*The vinyl covers on the four roller transfer boards, one in each OR (1, 2, 3 and 4) were thread bare along the edge and had small rips and tears along the edges.
-The ED revealed she was aware of the "well used' transfer board covers and had planned to replace them.
*Clean towels, sheets, and bath robes were stored unprotected in the materials management room.
-Employee K confirmed that finding. She stated they had always stored the overflow of clean linen in the materials store room. She was not aware those clean linens must be covered for protection.
*Four of four metal anesthesia carts, one in each of the four ORs had rusted surfaces. The rusted surfaces were at times covered with towels. -The ED confirmed those findings. She stated she had noticed the rust on all four carts and it had gotten worse. She had planned to replace them over time.
*Two rolling stools in OR 2 had torn, ripped, and frayed vinyl covers that exposed the foam padding beneath the vinyl.
-The ED confirmed those findings and stated she was aware of some of the stools were in that condition but had not removed them.

4. Interview on 6/17/15 at 3:30 p.m. with RN A revealed the hospital used AAMI (Association for the Advancement of medical Instrumentation), AORN (Association of Perioperative Registered Nurses), and their parent hospital infection control guidelines for policies and procedures.

Review of the AORN 2014 guidelines for Environmental Cleaning, pp. 259-264, revealed:
*"Equipment that is difficult to clean may harbor pathogens in crevices that are not amendable [responsive] to disinfection."
*"Disinfectants would be applies and reapplied as needed, pre manufacturer's instruction, for the dwell time required to the kill the targeted organism."
*"II.h. Mattresses and padded positioning device surfaces (eg.[for example] OR beds, arm boards, patient transport carts) should be moisture-resistant and intact. Absorbent or nonintact surfaces may become reservoirs for microorganisms and may harbor pathogens."
*"II.h.1. Damaged or worn coverings should be replaced."
*"All floors in the perioperative and sterile processing areas should be disinfected."
"Terminal cleaning of operating and procedure rooms should include cleaning and disinfecting of all exposed surfaces."

Review of the AORN 2014 guidelines for Hand Hygiene, p.p. 63-64, revealed: "II.b.3. Paper towel dispensers should be designed to prevent recontamination when removing towels. The towel dispenser should dispense cleanly without the need to touch the towel dispenser."

Review of the AAMI 2012 guidelines for Sterilization Processing revealed:
"The scrub person should ensure that hinged instruments are open for proper cleaning. When packaging instruments, be sure to select an appropriate size pouch and to place hinged instruments in an open position to allow sterilant contact."

Review of the provider's policy dated March 2013 for Surgery Room Sanitation revealed:
"d. Terminal cleaning completed in each OR Suite at the end of the day. All corridors, scrub/utility areas and equipment are thoroughly cleaned with germicidal solution."

No other policies were provided in regards to the above notations at the time of the survey.

Interview on 6/18/15 at 11:30 a.m. with the ED revealed she was responsible for the operation of the hospital and patient safety.

Review of the provider's policy dated July 2013 for Executive Director revealed:
"d. Monitoring and evaluating care services, and acting on findings accordingly."
"h. Maintaining infection control, safety and disaster plans."

20031

A. Based on observation and interview, the provider failed to ensure the patients safety and the staffs working environment was maintained in a good cleanable condition. That included:
*Raw wooden shelves in the materials management store room.
*Locker area by the nurses station:
-A side cabinet that had missing laminate and vinyl flooring used as the top.
-A shelf with a raw wooden finish.
*The equipment room door had broken or missing laminate.
*Four of four operating room walls had gouges and scraped surfaces.
*One of four walls in the post acute care unit (PACU) room 20 had gouges and scraped surfaces.
*The ceiling in the decontamination room of sterilization was cracked and peeling.
Findings include:

1. Random observation from 6/16/15 through 6/18/15 revealed:
*Raw wooden shelves in the materials management store room.
*In the pre-operative locker area by the nurses station:
-A side cabinet had missing laminate and a piece of vinyl flooring had been used for the top of that cabinet.
-A shelf on the wall had a raw wooden finish.
*The equipment room door had broken and missing laminate on the edge of the door that had been taped to the door.
*Four of four operating room walls had nicks, gouges, and scrapes into the gypsum board.
*One of four walls in the post anesthesia care unit (PACU) room 20 had severe gouges and scrapes into the chalk of the gypsum board.
*The ceiling in the decontamination room of sterilization had a large crack about eighteen to twenty-four inches long and an eighth of an inch wide.

Interview on 6/18/15 at 10:45 a.m. with the executive director confirmed the above random observations. She revealed she:
*Had purchased those wooden shelves for the materials management store room about three months ago. She had not considered they should have a cleanable surface.
*Was aware of the "old" cabinet by the nurses station and the raw wooden shelf.
*Was aware of the cracked, broken, and taped laminate on the equipment room door.
*Was aware of the nicks and gouges on the walls in all four operating rooms. She stated they had gotten worse in the past few months.
*Was not aware the wall in PACU room 20 was damaged again. She stated she had it repaired in the past but was not aware of the new damage.
*Was aware of the cracked ceiling in the decontamination room. She had noticed it on her weekly rounds but had not placed a work order to have the ceiling fixed.

B. Based on document review and interview, the provider failed to ensure a preventive maintenance (PM) checklist or log was performed or done on a routine occurrence. Findings include:

1. Review of documents provided by the executive director (ED) revealed the buildings owner kept a PM log of the buildings structural elements such as doors, windows, utilities, and outside surroundings. There was no checklist or log to ensure the buildings environment such as finished walls, flooring, ceilings, shelving units, and furniture was kept in a cleanable, durable condition.

Interview on 6/18/15 at 11:00 a.m. with the ED confirmed the above findings. She stated if something was noted by herself on her weekly rounds she would send a work order to the building's owner. She stated she did not keep a log or record of what she checked or reviewed on her weekly rounds.

26632

Surveyor: 20031
Based on random observation, testing, document review, record review including infection control tracking logs, infection control (IC) policies and procedures, quality assurance performance improvement (QAPI) meeting minutes, and staff interview, the provider failed to ensure:
*There was an active, effective, organized IC program for the prevention, control, identification, and investigation of infectious risks to patients, staff, and visitors.
*An appointed person(s) was in charge of the infection control program.
*A sanitary environment was maintained or achieved for the following items and/or areas throughout the facility to avoid sources and transmission of infections. To include:
-Handwashing was not completed by one of one surgeon (G) and three of four registered nurses (RN) (D, E, and F) for one of two observed patients (15).
-Terminal floor disinfection was not completed for four of four operating rooms (OR) (1, 2, 3, and 4).
-Contact time for the quaternary (quat) disinfectant was not followed.
-Eighteen sterilized hinged surgical instruments were in the closed position.
-An open roll of paper towels was used for two of two handwashing sinks in the women's locker room.
-Cleaning chemicals were stored next to patients' care items in four of four ORs (1, 2, 3, and 4).
-Gel positioning pads were torn, ripped, or taped in three of four rooms (central supply and two of four [1 and 2] ORs.
-Four of four roller transfer boards had frayed vinyl covers in all four ORs.
-Clean linen was stored unprotected in one of one materials management room.
-Four of four metal anesthesia carts were rusted in all four ORs.
-Two rolling stools in one of four ORs (2) had torn, ripped, and frayed vinyl covers.
Findings include:

Surveyor: 26632
1. The hospital failed to ensure the person(s) designated as IC officers accomplished the tasks required for the IC program by implementing policies governing control of infections and communicable diseases.

Review of the provider's 2015 Infection Control Plan signed by the executive director on 7/1/14 revealed:
*The provider's main services was surgical services.
*Aseptic principles were part of the basis for excellent surgical care, implemented in patient screening, environment cleaning practices, decontamination, and sterilization of instruments.
*Patients that arrived with symptoms of illness would be isolated as soon as possible and evaluated.
*Staff would follow aseptic principles utilizing gloves and hand hygiene appropriately.
*Staff were to go home when they were ill with a fever, vomiting, and diarrhea to prevent the spread of infection.
*Staff would participate in required infection control education on a quarterly basis or annually as decided by nursing education.
*The provider would participate in data collection that reflected efforts to pursue infection prevention and control as well as quality measures.

Review of the provider's reviewed February 2014 Infection Control General policy revealed:
*Patients with a suspected communicable disease would be examined promptly and either admitted to the hospital or discharged as soon as possible.
*The housekeeping personnel and nursing staff would have been responsible for maintaining a clean environment.
*Employees would follow established procedures for asepsis.
*Physicians were asked to report infections on a monthly basis. The infection data was tabulated and reported to the Board of Directors.

2. Interview on 6/16/15 at 3:00 p.m. with registered nurse (RN) A revealed she:
*Was not aware she had been designated the infection control nurse. *Only compiled data on surgical infections from the information from the surgeons.
*Also compiled data and reported to the national health care safety network (NHSN) on information regarding catheter associated urinary tract infections and central line associated bloodstream infections.
*Knew of two other employees who did handwashing audits but did not review those audits. She was not sure who did.
*Had no contact for employee health and did not keep track of employee illnesses.

Interview on 6/17/15 at 10:00 a.m. with RN C revealed:
*She performed handwashing/sanitizing audits for the pre and post-operative areas.
*She gave those audits to the executive director (ED) who then would talk with staff about the results at the staff meetings.
*The ED would also present the audit results to QAPI if the goals had not been met.

Interview on 6/17/15 at 3:30 p.m. with the ED revealed:
*There was not one specific person(s) in charge of the infection control program.
*She agreed there were parts of the program that had no oversight.
*She agreed a central infection control person would have advantages and stated it was a "hodge podge" of a program.

Observation on 6/16/15 from 10:30 a.m. through 12:05 p.m. revealed:
*Patient 15 was in the pre-operative area with RN D.
*RN D, RN E, and RN F all attempted to insert an intravenous line into patient 15.
*During those attempts there were multiple missed opportunities for handwashing and/or hand sanitizing after removing gloves, putting on gloves, and touching environmental surfaces before and after glove use.
*After the surgical procedure was completed for patient 15 surgeon G removed his surgical gloves, gown, and mask.
*He picked up patient 15's medical chart and walked down the hall to the consultation room to visit with her family.
*He had not washed or sanitized his hands.

Surveyor: 20031
3. Random observation, interview, and testing from 6/23/15 through 6/25/15 revealed:
*Surgical technician B had entered an OR to start the terminal clean for the end of the day. She stated she used a neutral cleaner for all floors throughout the surgical suite. She revealed that was all she had used in over four years. She stated she oversaw housekeeping and had trained other staff to use the neutral floor cleaner as well. She was not aware all OR floors and other clean areas/rooms must be terminally disinfected daily.
-Interview with the ED revealed she was not aware the ORs and other clean room floors were not disinfected daily.
*Employees used a quat disinfectant for all high touch surfaces throughout the facility. Interview with surgical technician B revealed she was not aware of the ten minute contact time for the disinfectant to have been effective.

Observation and interview with employees H and I on 6/17/15 at 1:30 p.m. while in the sterilization room revealed the following:
*They stated they completed most of the sterilization on the surgical instruments.
*If they were busy other staff would come and help them.
*Observation of the packaged sterilized instruments at the above time revealed:
-Eighteen hinged surgical instruments were found in the closed position.They included Mayo, Meta, Iris, and bandage scissors.
-They both confirmed those findings and stated they were aware all hinged instruments were to have been in the open position for sterilization.
-Employee H stated it might be the other employees that helped with the sterilization. She stated she did not check their work, but it appeared more training and audits were needed.
*An opened roll of paper towels sat on the counter between the two handwashing sinks in the women's locker room. The paper towel dispenser was empty.
-Surgical technician B confirmed that finding. She stated the other employees would wait for her to fill the dispenser instead of doing it themselves.
*Quat disinfectant chemicals were stored next to patient care items in all four of the ORs.
-Surgical technician B confirmed that finding. She stated they were supposed to have been stored in the bottom of the supply cabinet next to the suction containers.
-The ED agreed those chemicals should not have been stored next to patient care items.
*Gel positioning pads for the head, arms, and shoulders were either torn, ripped, or taped in central supply and one of four (2) OR.
-RN J confirmed those findings and stated the gel pads were very expensive, so they had tried to tape them to last longer.
*The vinyl covers on the four roller transfer boards, one in each OR (1, 2, 3 and 4)