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Based on observation, document review, and interview, the facility did not ensure that pediatric emergency resuscitation equipment for the emergency airway management of a pediatric patient is available, in accordance with the hospital's written policy.

Findings include:

The facility policy and procedure titled "Cardiopulmonary Resuscitation," last revised 8/2019, stated:
"For Pediatrics Only:
In addition to the code cart, a tackle box labeled "Pediatric Medications" can be found in (*locations also have an additional Pediatric Equipment Box):
" Operating Room (OR)
" PACU (Post-Anesthesia Care Unit)
" Ambulatory Recovery
" PICU (Pediatric Intensive Care Unit)/Pediatrics
" Endoscopy
" Radiology (Interventional)
" *ER (Emergency Room) 1
" ER 2
" *Psych Inpatient
" *CPEP
Specialty Areas must have Pediatric Emergency Equipment Box."


The "Pediatric Emergency Equipment Box" documented a list of equipment which included but not limited to the following:
-Pediatric sizes of: Suction Catheters, Needles, Intra-osseous needles, Nasogastric tubes, Angio-catheters, Butterfly Cannulas, and Broselow tape (a pediatric emergency tape that is color coded for equipment sizes needed to perform a pediatric resuscitation).
-Pediatric Intubation Tray with Pediatric Endotracheal tube stylet, Endotracheal tubes of graduated pediatric sizes, and pediatric airways.


Observation in the facility's Operating Room (OR) Suite on 9/30/19 at 10:00 AM; Radiology Interventional Suite on 9/30/19 at 3:39 PM; and Comprehensive Psychiatry Emergency Program (CPEP) on 10/1/19 at 9:30 AM, identified each of the unit provides services to Adult and Pediatric patients. The units did not have the Pediatric Emergency Equipment Box for the emergency airway management of a pediatric patient, as per hospital's written policy.

During interview on 9/30/19 at 10:30 AM, Staff P, OR Nurse Manager, stated they never had a pediatric cart and pediatric equipment box in the OR. This finding was acknowledged by Staff R, Vice President of Perioperative Services.

During interview on 9/30/18 at approximately 11:00 AM, Staff Aa, Attending Anesthesiologist, stated that if there is a pediatric code, they utilize the pediatric cart with the pediatric intubation tray, pediatric equipment, and pediatric medication box.

Staff P, Staff Q, and Staff Aa were unable to show a pediatric emergency equipment box if needed for a pediatric code resuscitation until after 15 minutes when a pediatric intubation box was brought to the OR, reportedly from the Anesthesia Storage Room (located at end of corridor).

During interview on 9/30/19 at 3:39 PM, Staff Bb, Director of Radiology and Staff Cc, Assistant Vice President of Clinical Services, acknowledged the lack of Pediatric Emergency Equipment Box in the Radiology Department.

During interview on 10/1/19 at 9:00 AM, Staff Dd, CPEP RN, stated the unit does not have a pediatric cart and pediatric equipment box. This finding was acknowledged by Staff Ee, Director of Regulatory Affairs.

Based on medical record review, document review and interview, in two (2) of eight (8) medical records reviewed, the facility failed to ensure all patients who were admitted, received ongoing assessment for skin integrity based on the facility's protocol. Specifically, the facility failed to identify patients with pressure injuries (Patients #1, #3).

Findings include:

Review of the facility's policy titled, "Standard of Care for the Prevention and Treatment of Pressure Injuries," last revised 7/2019 states: "Risk for pressure injury development is evaluated upon admission to a nursing unit and minimally every shift for all adult and pediatric patients using the Braden Scale (Adult) or Braden Q (Pediatric) Scales. Adult patients with an existing pressure injury or a score of 18 or less on the Braden Scale will be considered "At Risk" for pressure injury."
The policy also states: "Nursing will asses and manage skin integrity for all patients throughout the hospital stay ...Skin will be inspected for changes each shift ... Assess/Reassess skin for pressure injuries on admission, each shift, following transfer and prior to discharge."

Review of the medical record for Patient #1 identified: This 48 year old male patient was admitted to the medical telemetry unit on 3/14/19 for seizures. At 4:58 PM, Staff U, RN, initial nursing skin assessment documentation noted "area of concern, blanchable redness to both buttocks, left buttock skin tear, rash. At 8:20 PM Staff V, RN documented: "Braden scale 12; Indicate level of risk (for skin breakdown) Not at risk."
This patient's skin assessment documentation was repeated for six (6) days.

On 3/19/19 at 6:28 PM, Staff W, RN documented: "Left ventral foot (front side)-deep tissue injury; Left lateral foot (outer side)-deep tissue injury; Left posterior (back) heel-stage II; Left dorsal foot (top part)-deep tissue injury."

There was no documented skin assessment of a change in the patient's skin condition prior to the development of a deep tissue injury and stage II pressure injury.

During interview on 9/27/19 at 10:33 AM, Staff C, Medicine Resident stated: "The patient had blisters on the left lower extremities. Four (4) lesions around the foot. We were about to discharge him and noticed he had a fever. We examined him and noticed he had the blisters. No one noted it before."

During telephone interview on 10/1/19 at 9:06 AM, Staff V, RN acknowledged that she made an error when she documented on 3/14/19 at 8:20 PM that the patient had no risk for pressure injury. Staff V stated that a score of below 18 usually put the patient at risk and prevention measures should have been implemented.


Review of the medical record for Patient #3 identified a 54 year old male admitted to the hospital Surgical Intensive Care unit on 8/11/19 at 6:35 PM for seizure disorder. On 8/11/19 at 10:08 PM Staff Z, RN documented: "Braden score 18. Level of risk (for skin breakdown) - At risk."
On 8/12/19 at 2:31 AM, Staff Z, RN documented: No pressure injury.
On 8/13/19 at 12 midnight, the patient was transferred to the Telemetry Unit with Inter Unit Transfer Summary documenting: "Pressure Injury- No. Skin intact, dry, flaky.
On 8/25/19 at 7:43 PM, Staff Y, RN documented: "Healing old sacral ulcer not open 3 X 1 cm. Pressure injury Stage II on right hip.
On 9/25/19 at 1:00PM Staff Ff, RN documented, Right hip still present. Sacrum to stage III from stage II. New pressure ulcer on scrotum stage II.

There was no documentation of a pressure injury, ongoing assessment and monitoring, or identification of a change in the patient's skin condition prior to 8/25/19. There was no documented change in the plan of care or treatment prior to 8/25/19.

These findings were shared with Staff W, VP of Nursing, on 9/30/19 at 11:14 AM.

Based on observation, staff interview and document review, (a) the facility did not ensure compliance with measures governing infection control and prevention within the hospital, and (b) did not maintain a sanitary environment in patient care units, consistent with the hospital's policy.

These breaches in infection control practice may have placed patients and staff at increased risk for hospital acquired infection.


Findings include:

(A) During a tour of the facility, the following were identified in the presence of the Hospital's COO and the Director of Safety who accompanied the state surveyor during the tours:

During a tour of the Operation Suite on 9/25/2019 approximately at 11:00 AM:
a. Stains and sign of leak were observed on a ceiling tile in the sterile storage room.
b. The ceiling tiles of the Sterile Storage Rooms and the sterile corridor were of the regular type and not washable type as required for this type of room. 2010 FGI Guidelines, 2.1-7.2.3.4.
c. There were gaps between the T Grids of the ceiling tiles in the sterile rooms and the sterile corridor, which makes it easy for accumulation of dust and potential for the spread of infection. 2010 FGI Guidelines, 2.1-7.2.3.4.
d. The doors of the Sterile Storage Room in front of OR #3 was not closing and opening properly.
e. The hot water at the scrub sinks serving all Operation Rooms (6) were observed not having the proper temperature. The temperature at the scrub sinks was 84 F.
The Hot water temperature at the scrub sinks should be 105- 120 F as per Table 2.1-5 of FGI Guidelines 2010 edition.
f. A nursing assistant was observed pushing a cart of sterile supplies and an item (Razor Shaver Box) fell from the cart, then the nurse assistant picked the item and put it back on the top of the cart's cover. This action of the staff member is a breach of the infection control.
This was acknowledged by the VP of Pre-Operative Services, who stated that the box should have been thrown away when it fell on the floor.
g. There were 11 carts of sterile supplies (each one is about 6 ft x 4 ft x 2 ft in dimension) on the sterile corridor of the OR suite. Sterile supplies should be stored in sterile supply room to avoid being exposed to dust or touch by stretchers and mobile equipment during the daily activity of staff and equipment.


During tours of the SICU and MICU on 925/2019 approximately at 2:30 PM, the following were observed:
a. One wall in the air borne Isolation Room had many small holes. The room was cluttered and had many IV Poles, Bair Hugger and other items.
b. The doors of Rooms 2C-33, 2C-35 did not open or close with ease and they were jammed when forced to close.
c. Ceiling tiles of the MICU had gaps between the T-Grids, which is a potential for accumulation of dust and the passage of particles from the cavity above the ceiling plane into the room.
d. There was no hot water provided in Room 2C-34.


Ambulatory Surgery Recovery Area:
a. The hand-wash sink and the eye wash station next to the door of this unit, was leaking water and was not working properly.
b. There was no hot water provided at phase 2 Recovery area.

Labor and Delivery Area:
a. A soiled cart full of soiled linen was observed in the corridor outside the L&D area.
b. Stained ceiling tile was observed in the corridor of the L&D Unit, by Room #8.

Mother and Baby Unit - 2nd Floor, SLB1 Building:
a. The Clean Utility Room was found to have a negative air pressure instead of the required positive air pressure for this type of room.
b. There was a stained ceiling tile in the Clean Utility Room, above the hand- wash sink.

Maternity and Newborn Unit -SLB1 Building:
On 9/26/2019 at 2:30 PM, the following were found:
a. The Soiled Utility Room didn't have a negative pressure as required for this type of room.
b. Admission kits were observed being stored over the counter and very close to the hand-wash sink, exposing those kits to splash.
c. The baby formula supplies were stored in the Soiled Utility Room, which imposed a potential for infection.

Endoscopy Suite:
On 9/27/2019 at 11:30 AM, tube connections (Soiled Items) were observed in the hand-wash sink of the processing room.

Cardiac Cath Lab:
During a tour of the Cardiac Catherization Lab on 9/27/2019 approximately at 2:00 PM it was identified that the scrub sink did not have hot water. The water temperature at the scrub sink was 71.5 F.
The Hot water temperature at the scrub sinks should be 105- 120 F as per Table 2.1-5 of FGI Guidelines 2010 edition.


Wound Unit - Outpatient Clinic - Spellman- 3rd Floor:
During a tour of the wound unit on 10/1/2019, the following were identified in the presence of the Safety Officer/Emergency Preparedness Coordinator and the RN of the unit.
a. The sharp container was observed on the counter in close proximity to the hand-wash sink, which is an infection control concern.
b. The metal portion (Leg Extension) of the patient examination chair was noted to be rusty.


Hyperbaric Room:
During a tour of the Hyperbaric room on 10/1/2019 at 10;20 AM, the following were identified in the presence of the Safety Officer/Emergency Preparedness Coordinator:
a. A step-in stool used by patient to get to the hyperbaric chambers was noticed to have a broken leg and the legs were affixed to the stool by a wound adhesive tape.
b. A soiled linen bag full of soiled linen and gowns was observed on the floor next to the clean linen cart.
When asked about the proximity of storing the soiled linen to the clean cart, the nurse took the soiled bag with bare hands to the outside of the unit and came back and sat by her desk. The nurse did not wash hands after returning to the unit and when asked, she said that she didn't touch anything dirty.


Dialysis Unit:
During a tour of the Dialysis Unit on 10/1/2019 at approximately 11:30 AM, the following was identified and shared with the facility leadership:

The facility treats (dialyzes) Hepatitis AG -Positive patients in the same unit with other patients who may be susceptible for the transmission of infection.

Per CDC Guidelines (CDC MMWR (Morbidity and Mortality Weekly Report) April 27, 2001 /50(RR05); 1-43
"While hospitalized, HBsAg- Positive chronic hemodialysis patients should undergo dialysis in a separate room and separate machines, equipment, instruments, supplies, and medications designated only for HBsAg-positive patients (see Prevention and Management of HBV infection).While HBsAg- Positive patients are receiving dialysis, staff members who are caring for them should not care for susceptible patients"





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(B) The facility policy and procedure titled "Dating of Medication Containers after Use," revised 4/2019 states: "All opened medication containers will be dated as follows: Multi-Dose vial for a maximum of 28-day expiration once opened, or less if suggested by manufacturer's data."

The facility policy and procedure titled "Sanitation in the Operating Room," revised 11/13, states: "Environmental Services:
-Operating rooms should be cleaned after each surgical and invasive procedure.
-All receptacles (bins and buckets), work surfaces, and tables should be cleaned and disinfected."


During a tour of the SICU and MICU Medication Rooms, on 9/30/19 between 10:00 AM through 12:30 PM. the following were identified:

-In the SICU medication refrigerators, five (5) thirty (30) cubic centimeters (cc) vials of unlabeled acetylcysteine (a medication that clears mucus in the respiratory tract) were available for patient use.

-In MICU medication refrigerator, one (1) thirty (30) cc vial of unlabeled acetylcysteine was available for patient use.

Review of the Manufacturer's data (Drug Literature) for Acetylcysteine, provided by Pharmacy, documented oral and inhalation must be discarded after 96 hours.


-In SICU and MICU the faucets in the handwashing centers were not functional. The handwashing center did not have the running water, handwashing soap, and paper towels.

Observation in the facility's Operating Room (OR) #2, on 9/30/19 at 11:00 AM, identified OR equipment were dirty with white and brown stains and rust on the lower frames and bases. The equipment included three (3)intravenous poles; two (2) seats with casters; one (1) instrument table; one (1) OR table; one (1) Anesthesia supply cart; three (3) OR buckets.

During interview, on 9/26/19 at 11:30 AM, Staff I, Nurse Manager, SICU and MICU indicated that it is the expectation from the nursing staff to label all medication vials as per policy.
Staff I, and Staff Ee, Director of Regulatory Affairs acknowledged the lack of water supply and handwashing soap and paper towels in the medication rooms.

During interview with Staff N, Pharmacist on 9/27/19 at 1:30 PM, she stated that any vials opened must be appropriately labelled in accordance with the manufacturer's recommendation and pharmacy policy. Staff N explained that Acetylcysteine must be discarded after 96 hours once opened, per manufacturer's recommendation.

During interview with Staff R, Vice President of Preoperative Services on 9/30/19 at 11:15 AM, she stated that it is the expectation that the OR equipment are maintained clean in accordance with the facility's policy.