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Based on observation, staff interview and documentation review during the survey conducted 10/31/11 to 11/02/11, it was determined the hospital failed to maintain the environment and all equipment to ensure the safety of the patients, staff and public. This determination was based on the volume of life safety code deficiencies issued to the hospital for non-compliance with the 2000 edition of the life safety code and a deficiency generated related to maintaining the physical environment, Therefore, this Condition is not met. Refer to physical environment deficiency identified as tag number C221. Also, life safety code deficiencies identified as tag numbers K017, K018, K052, K062, K077 and K0147.

Based on observation and staff interview it was determined the hospital failed to maintain adequate facilities for decontaminating and cleaning endoscopes.

Findings include:

1. On 11/01/11 at approximately 10:00 a.m., a tour of the hospital operating area was conducted. An interview on this same date and time with the Nurse Manager and the Scrub Technician indicated that endoscopic procedures were performed in operating room #1. This interview also revealed that after a procedure is completed the scope is taken in a container to the soiled utility room in the operating room area for decontamination. The scope is then taken from the soiled utility room in the same container back through the procedure room (operating room #1) to a Steris cleaning unit located outside the procedure room. The soiled utility room that is being used for decontamination of the scopes does not meet the minimum health facility construction design standards for an instrument processing room based on the following concerns:

a. The room is not a dedicated processing room for cleaning and decontaminating scopes.
b. The cleaning area shall allow for flow of instruments from the contaminated area to the clean assembly area then to storage.
c. Only one (1) single bowl sink observed in the room for the cleaning process.
d. No separate hand washing sink provided in room.
e. A flush type hopper was observed in this room.

A. Based on observation, interview and review of policies, it was determined the facility failed to ensure endoscope cleaning and disinfecting procedures are done in accordance with accepted standards of care or with hospital policy. This has the potential to create a situation in which cross-contamination of the clean and dirty endoscopes may occur. It was also determined there are inadequate hand-washing facilities for staff who are participating in the endoscope procedures or the cleaning and disinfecting of the endoscopes.

Findings include:

1. The operating room suite was observed at about 10 a.m. on 11/1/2011. The Nurse Manager and the Scrub Technician were present at the time of the observations. The Nurse Manager stated that operating room #1 is used as the "endoscope procedure room". It was noted there are two (2)entrance doors into the endoscopy procedure room, one on each side of the room. The Scrub Technician stated that after procedures are completed, the dirty endoscope is initially "suctioned" out with enzymatic cleaner, then placed into a covered tub and taken out of one door of the procedure room and taken into the "hopper" room for enzymatic cleaning. The hopper room was observed to have a hopper and one (1) washing sink. The Scrub Technician stated the enzymatic cleaning occurs in that room. She stated the endoscope is placed back into the tub after enzymatic cleaning and is taken back through the endoscopy procedure room and out the other door into a different room where the automatic high level disinfection occurs. She stated there may be another patient and another clean scope already in the procedure room when the dirty scope is taken through.

2. Review of the policy "Cleaning of Endoscopes", last reviewed 5/2011, revealed the policy states "Soiled endoscopes are cleaned in the endoscopy (procedure) room, using Endozyme, according to manufacturer directions for the scope and Endozyme. The cleaned scope is then processed through the Steris machine for complete sterilization. After processing, the scope is stored in a hanging position, in a cabinet in the surgical suite." The policy fails to list complete steps to take to properly clean and high-level disinfect each endoscope.

3. It was also noted during the observations at about 10 am on 11/1/2011 that there is no hand-washing sink located either in the procedure room or in the "hopper room" where currently most of the cleaning occurs.

B. Based on observation and interview it was determined the facility failed to maintain a separately designated post-anesthesia care unit in accordance with accepted standards of care. This has the potential to adversely affect the quality of care of assessment of patients who need close monitoring after recovering from anesthesia. This also creates a situation in which privacy may not be maintained for all patients both pre and post surgical procedures.

Findings include:

1. The operating room suite was observed at about 10 a.m. on 11/1/2011. The Nurse Manager was present during the observations. At the area of the entry alcove into the operating room suite, there was noted to be a room just to the left of the entrance door. The room had three (3) stretchers, with two (2) straight pull curtains in between the first and second stretchers and in between the second and third stretcher. There was a bathroom beside the third stretcher. The Nurse Manager stated the area is used for both pre-operative patients and for post-anesthesia recovery patients. She stated that one (1) Registered Nurse will monitor all those patients. She stated that persons who come in for out-patient procedures will undress in that room behind the straight pull curtain or in the bathroom. Those patients are also discharged from the same room to home after surgery.

C. Based on interview and review of policies, it was determined the facility failed to develop proper policies and procedures for providing emergent care to patients who are undergoing a procedure and develop a need for anesthesia care or a higher level of operative care which is not available at the facility. This has the potential to adversely affect the quality of care and safety provided to all patients who are having procedures performed at the facility.

Findings include:

1. The Nurse Manager of the operating room was interviewed in the morning on 11/2/2011. She stated that the Certified Registered Nurse Anesthetist (CRNA) is present only on certain days when procedures are taking place. She stated the CRNA is not on-call. She stated also that the hospital is not capable of providing a high level of operative care, such as treatment for bowel obstruction or bowel perforation. She stated that for some procedures, the Registered Nurse administers "moderate sedation" under the direction of the operating physician. She stated that in a situation where the patient is in the process of receiving a procedure and developed a need for a higher level of anesthesia care or a higher level of operative care, the patient would be emergently transported to another hospital to receive care. Review of hospital policies revealed there are no written policies to direct staff how to handle such emergencies to provide the safest care possible and meet the needs of the patients.

D. Based on observation, interview and review of policy it was determined the facility failed to follow policy in regards to having emergency equipment and medications immediately available in situations where the Registered Nurse is administering medications for moderate sedation during surgical procedures. This has the potential to adversely affect the quality of care and monitoring for all patients who receive moderate sedation.

Findings include:

1. Review of policy "Sedation/Analgesia", last reviewed 5/2011, revealed the policy states "A code cart with reversal agents must be located in the room where the procedure will be performed." The operating room suite was observed on 11/1/2011 at about 10 a.m. The Nurse Manager was present during the observations. The Nurse Manager stated the operating room suite has one crash cart. It was observed the crash cart is located in the post anesthesia care unit room. In the morning on 11/2/2011, the Nurse Manager was again interviewed. She stated that when the Registered Nurse is administering moderate sedation, there is no Certified Registered Nurse Anesthetist in the room and may not be available in the hospital. She stated that the resuscitative equipment and medications on the anesthesia cart are for anesthesia personnel use only. She stated that in the event of an emergency, the crash cart would have to be brought into the operating room for use by the Registered Nurse and physician.

E. Based on observation and interview it was determined the facility failed to ensure supplies and equipment are arranged and stored in a manner which promotes a safe environment of care. This has the potential to create a situation which hinders the flow of traffic between the central storage area and the operating rooms.

Findings include:

1. The operating room suite was observed at about 10 a.m. on 11/1/2011. In the entry alcove area, there were two large reclining type chairs. One chair was sitting beside the small door leading into the central sterile area, the other chair was sitting between the doors to room #1 and room #2. The Nurse Manager was present at the time of the observations. She stated the chairs are permanently stored in those areas. She stated that occasionally a patient is administered intravenous infusions on an out-patient basis. She stated those two chairs are used for that purpose, and the pre-operative/post-anesthesia care nurse will administer those medications. Those chairs could potentially hinder the flow of traffic to various areas of the operating room suite.

F. Based on review of records and interview with staff, it was determined the facility failed to ensure a qualified anesthesia practitioner evaluated patients for proper anesthesia recovery prior to discharge from the surgery department or from the hospital. This occurred in five (5) of five (5) cases reviewed for patients who received anesthesia during a procedure (patients #12, 13, 14, 16 and 17). This has the potential to negatively affect the quality of care provided to all patients receiving any level of anesthesia during a procedure.

Findings include:

1. Review of the medical records for patient #12, 13, 14, 16 and 17 revealed those patients received anesthesia care provided by a CRNA (Certified Registered Nurse Anesthetist). For all patients, there was no post-anesthesia evaluation conducted by the CRNA. The records were discussed with the Nurse Manager of the Operating Room in the afternoon on 11/2/2011 and she concurred. The CRNA was not available at the time of the survey for interview.

Based on staff interview and medical records, the facility has failed to ensure an activities program is developed and followed for the residents in a swing bed status in (3) three of (3) three medical records reviewed (records #7, #8 and #9). This has the potential to negatively affect all swing bed residents by not incorporating the physical, mental and psychosocial well-being of the residents.
Findings include:

1. Resident #7 was admitted to swing bed status on 10/31/11. There is no documented evidence found in the medical record to indicate activities being offered.

2. Resident #8 was admitted to swing bed status on 10/22/11. There is no documented evidence found in the medical record to indicate activities being offered.

3. Resident #9 was admitted to swing bed status on 10/19/11. There is no documented evidence found in the medical record to indicate activities being offered.

4. During an interview with the Clinical Nurse Manager, the Certified Occupational Therapy Assistant and the Director of Nursing (DON) in the afternoon of 11/1/11, they agreed with these findings. The DON stated when the nursing home located on the third floor closed, they lost their activity director. She stated the activity director always developed a monthly plan and incorporated the swing bed residents into the activities on the third floor.

Based on review of medical records and staff interview, it was determined the facility failed to ensure the staff developed a comprehensive care plan for each resident to include measurable objectives and timetables nor did they have interdisciplinary team meetings to include the resident/family member or the physician. This affected three (3) of three(3) residents (7, 8 and 9). This has the potential to negatively affect residents by staff being unable to use the objectives to adequately assess a residents progress.
Findings include:

1. Resident #7 was admitted to swing bed status on 10/31/11. There is no comprehensive care plan in the medical record, nor was there any documentation found of any interdisciplinary team meetings.

2. Resident #8 was admitted to swing bed status on 10/22/11. There is no comprehensive care plan in the medical record, nor was there any documentation found of any interdisciplinary team meetings.

3. Resident #9 was admitted to swing bed status on 10/29/11. There is no comprehensive care plan in the medical record, nor was there any documentation found of any interdisciplinary team meetings.

4. During an interview conducted in the afternoon of 11/1/11 with the Clinical Nurse Manager, she agreed with these findings. She also revealed the Care Plans were not developed using the interdisciplinary team.

Based on review of medical records and staff interview, it was determined the facility failed to ensure Comprehensive Care Plans were being developed by the interdisciplinary team in three (3) of three (3) swing bed records reviewed (#7, 8 and 9). This has the potential to leave residents without a care plan developed with all disciplines involved in their care.

Findings include:

1. Resident #7 was admitted to swing bed status on 10/31/11. There was not a comprehensive care plan developed by the interdisciplinary team in the medical record.

2. Resident #8 was admitted to swing bed status on 10/22/11. There was not a comprehensive care plan developed by the interdisciplinary team in the medical record.


3. Resident #9 was admitted to swing bed status on 10/27/11. There was not a comprehensive care plan developed by the interdisciplinary team in the medical record.

4. During an interview in the afternoon of 11/2/11 with the Clinical Nurse manager, she revealed the facility did not develop care plans with the interdisciplinary team.