HospitalInspections.org

Based on review of Board of Trustees (Governing Body) Meeting Minutes for February through September 2014, Medical Staff Meeting Minutes for January through November 2014, Quality Meeting Minutes for March through July 2014, 2014 Quality Assessment and Improvement Plan, and interview, it was determined the facility failed to ensure the QAPI (Quality Assessment Performance Improvement) plan was approved annually by the Governing Body. The failed practice did not ensure the Governing Body was responsible for the QAPI program in the facility, and had the potential to affect any patient in the facility. Findings follow.

A. Review of the 2014 Quality Assessment and Improvement plan revealed, "The QA & I Plan is approved by the Board of Directors annually" and "Baptist Health Medical Center-Hot Spring County Board of Directors and Baptist Health Medical Center Board of Directors have ultimate responsibility for the quality of care the hospital provides."
B. Review of Board of Trustees (Governing Body) Meeting minutes for February through September 2014, Medical Staff Meeting minutes for January through November 2014, and Quality Meeting Minutes for March through July 2014 revealed no evidence of the 2014 QAPI Plan having been approved by the Governing Body.
C. During an interview on 01/07/15 at 0910, the Director of Nursing confirmed the QAPI plan had not been approved.

Based on policy review and interview, it was determined the facility failed to ensure established Radiology policies and procedures were specific to the facility in that blank spaces were not completed. Failure to fully develop policies, procedures or other mechanisms for employees to reference did not allow the facility's employees to be knowledgeable regarding correct policies and procedures in the facility. The failed practices had the potential to affect any patient receiving radiological services. Findings follow.

A. Review of the Radiology Department Policy and Procedure Manual revealed radiology policies were incomplete and not made specific to the facility. Examples include:
1) Policy titled "Medication Administration" stated "The following policies will govern administration of medication in _________ hospital."
2) Policy titled "Emergency Preparedness Program" stated "________ Hospital will utilize Emergency Incident Command System (HEICS) program as the basis for its emergency preparedness program."
3) Policy titled "Radiation Monitoring Badge" stated "Any over-exposures shall be reported to the State of ________ Department of Health Services."
4) Policy titled "Performance Improvement Plan" stated "Clinical Director and the ________ Committee, shall establish standards for compliance with each criterion for all indicators under review;" and "Medical staff committees reviewing the outcome of the Imaging Services Department ' s ongoing PI activities include: ________ Committee, hospital wide Quality Improvement Committee and the Medical Executive Committee."
5) Policy titled " Magnetic Resonance Imaging-Quality Improvement Program" stated, "As a leading provider of medical imaging services, ________ Hospital performs nearly ________ MRI and CT exams each year. This experience has allowed ________ Hospital to implement standards and policies that enhance the quality of service at every level. Detailed information is collected on each patient who is examined with ________ Hospital equipment."
6) Policy titled "MRI-Quality Control" stated "Performance maintenance service to be done by ________ for a minimum of 4 hours."
7) Policy titled "Scanner Quality Control" stated "Scanners will be operated only by personnel meeting all State of ________ and federal licensing requirements."
B. During an interview on 01/07/15 at 1055, the Radiology Supervisor confirmed the policies were incomplete and not specific to the facility.

Based on observation and interview, it was determined the oxygen pulse oximeter and the stethoscope were not disinfected after patient contact for one (Patient #11) of one patient observation. Failure to disinfect point of care devices after patient use did not assure contamination to other patients did not occur and was likely to affect all patients in the facility. Findings follow:

A. On observation 01/08/15 at 1315, Respiratory Therapist #1 took a stethoscope out of his pocket and listened to Patient #11's breath sounds. He then placed the stethoscope back into his pocket. At 1317, he placed a pulse oximeter on Patient #11's finger, measured her oxygen concentration and placed the oximeter onto a mobile computer cart. At 1319, Respiratory Therapist #1 took the stethoscope out of his pocket and listened to Patient #11's breath sounds and then placed the stethoscope back into his pocket. At 1322, he placed the oxygen pulse oximeter back onto Patient #11's finger, measured her oxygen concentration and placed the oximeter onto the mobile computer cart. Upon leaving Patient #11's room, Respiratory Therapist #1 disinfected the computer cart but did not disinfect the stethoscope or the pulse oximeter.
B. Findings above listed as A were verified with the Respiratory Director on 01/08/15 at 1335.

Based on observation and interview, it was determined two of two (Certified Registered Nurse Anesthetist #1 and Circulating Nurse #1) staff failed to disinfect new medication vials after opening and prior to withdrawing the contents. Failure to disinfect new medication vials after opening did not assure contamination did not occur from touching the rubber septum and was likely to affect all persons receiving injectable medication in the facility. Findings follow:
A. On observation 01/06/15 at 1004, Certified Registered Nurse #1 opened a vial of Pepcid and a vial of Reglan, withdrew the contents into syringes and administered them to Patient #23. Certified Registered Nurse #1 did not disinfect the rubber septum of either vial prior to withdrawing the contents.
B. On observation 01/06/15 at 1010, Circulating Nurse #1 opened a vial of Ancef and used normal saline to reconstitute the Ancef. She did not disinfect the rubber septum of the Ancef vial prior to reconstituting it with normal saline.
C. On observation 01/06/15 at 1010 and 1050, Certified Registered Nurse #1 opened new vials of (unknown) medications, withdrew the contents into syringes and administered them to Patient #23 during the surgical procedure. Certified Registered Nurse Anesthetist #1 did not disinfect the rubber septums of the medications prior to withdrawing the contents.
D. Findings above listed as A, B and C were verified with the Director of Surgical Services on 01/06/15 at 1140.


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Based on observation, policy review, and interview, it was determined the facility failed to ensure food items in the walk in freezer were labeled and dated. The failed practice did not allow the facility knowledge as to which food items needed to be used first so as to ensure correct first-in first-out rotation and infection control processes. The failed practice created the potential to affect any patient in the facility receiving those food items. Findings follow.

A. Review of policy titled "Storage of Food and Supplies" revealed under Storage Requirements "First-In, First-Out (FIFO) rule is used when storing;" and "All food items removed from their original containers must be put in a clean, sanitized container and covered and will be labeled, dated with the use by date or expiration date, and covered tightly prior to storage."
B. During a tour of the kitchen on 01/06/15 at 1400, the following food items in the Vegetable Freezer were observed to not be labeled and dated:
1) Five of five bags of onion rings
2) Ten of ten bags of corn nuggets
3) Two of two bags of hush puppies
4) Ten of ten bags of squash
5) Six of six bags of green beans
C. During an interview at the time of the tour, the Certified Dietary Manager confirmed the food items were not dated.

Based on review of 3M Avagard Manufacturer's Directions (MFD), observation and interview, it was determined one (Licensed Practical Nurse #1) of one surgical staff did not perform a surgical hand scrub according to MFD. Failure to follow MFD when performing a surgical hand scrub did not assure hands were disinfected prior to performing sterile tasks requiring surgical hand antisepsis. The failed practice was likely to affect all patients undergoing surgery in the facility. Findings follow:
A. On observation 01/06/15 at 1114, Licensed Practical Nurse #1 came out of Operating Room 2, stood at the scrub sink and dispensed one pump of 3M Avagard Surgical Hand Antiseptic into her hands. She rubbed the product over both her hands, wrists and up her forearms, without dispensing any more product or conducting a three step application process. She then left the scrub sink and entered Operating Room 1, where she donned a sterile gown and gloves.
B. Review of 3M Avagard Manufacturer's Directions revealed, Pump 1: dispense one pump (2 milliliters) into the palm of one hand. Dip fingertips of the opposite hand into the hand prep and work under fingernails. Spread remaining hand prep over the hand and up to just above the elbow. Pump 2: dispense one pump (2 milliliters) and repeat procedure with opposite hand. Pump 3: dispense final pump (2 milliliters) of hand prep into either hand and reapply to all aspects of both hands up to the wrists. Allow to dry. Do not use towels.
C. Findings above listed as A and B were verified with the Director of Surgical Services on 01/06/15 at 1140.

Based on review of policies and procedures, observation and interview, it was determined two (Certified Registered Nurse Anesthetist #1 and Physician #1) of two surgical staff failed to follow facility policy to cover all hair during a surgical procedure. Failure to cover all hair did not assure contamination to a sterile field did not occur and was likely to affect all patients undergoing surgery in the facility. Findings follow:
A. On observation 01/06/15 at 1027 a surgical procedure was begun on Patient #23. Both Certified Registered Nurse Anesthetist #1 and Physician #1 wore surgical skull caps which did not fully cover their hair and allowed hair to be exposed on the backs of their heads.
B. Review of policy, "Surgical Attire" revealed, personnel should cover head and facial hair, including sideburns and necklines when in the semirestricted and restricted areas of the surgical suite.
C. Findings above listed as A and B were verified with the Director of Surgical Services on 01/06/15 at 1140.