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Based on review of contracted Allied Health Professionals' files and interview, it was determined the facility failed to have a policy/procedure to screen potential contracted Allied Health Professionals for a history of criminal/abusive behavior and failed to obtain Criminal Background Checks (CBC) on six of six (Certified Registered Nurse Anesthetists (CRNA) #1-#6) and two of two (Advanced Practice Registered Nurses (APRN) #1 & #2) before hire. By not having a policy/ procedure for obtaining CBC, the facility could not assure they were hiring someone without a history of abusive behavior. The failed practice had the potential to affect all patients who receive services from those not screened. Findings follow:

A. Review of contracted Allied Health Professionals' files showed Certified Registered Nurse Anesthetists #1-#6 and Advanced Practice Registered Nurses #1 & #2 did not have evidence of CBCs in their files.
B. During an interview on 10/13/21 at 10:45, the Facility Compliance Coordinator verified the facility did not have a policy or procedure in place to screen potential contracted Allied Health Professionals and verified there were no CBCs in the six CRNAs' and two APRNs' files.

Based on review of the Patient Tray Assessments Forms from 06/14/21 to 09/16/21 and interview it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that temperatures of foods were documented to be above or below the recommended food temperature 6 out of 9 days. The failed practice did not ensure the safety of food served to patients in the facility. The failed practice had the potential to affect anyone receiving food from the kitchen. Findings follow:

A. Review of the Patient Tray Assessment Forms shows the following:
1) 06/14/21- Hot and cold food and beverage temperatures out of range with
Overall quality unsatisfactory score of 86%. No corrective action.
2) 06/15/21 - Hot and cold food and beverage temperatures out of range with
Overall quality unsatisfactory score of <88%. No corrective action.
3) 06/21/21- Hot and cold food and beverage temperatures out of range with
Overall quality unsatisfactory score of 64%. No corrective action.
4) 08/17/21 - Hot and cold food and beverage temperatures out of range with
Overall quality unsatisfactory score of 72%. No corrective action.
5) 08/23/21 - Hot and cold food and beverage temperatures out of range with
Overall quality unsatisfactory score of 89%. No corrective action.
6) 09/16/21- Hot and cold food and beverage temperatures out of range with
Overall quality unsatisfactory score of 81%. No corrective action.
B. The above findings were verified with the Sodexo General Manager on 10/14/21 at 2:00 PM.




Based on Trayline Temperature Monitoring Form review for 06/01/21 through 09/30/21 and interview, it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that temperatures of foods on the patient trayline were only documented before the meal 9 out of 366 meal times; and temperatures were not documented after meals 357 out of 366 times. The failed practice did not allow the kitchen staff to know if hot foods were above 140 degrees Fahrenheit and cold foods were less than 40 degrees Fahrenheit through the duration of the trayline service. The failed practice had the potential to affect anyone receiving food from the kitchen. Findings follow.

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 17.B.18 stated temperatures of hot and cold foods on patient trayline shall be taken at the beginning of each meal and at the end of each meal in which trayline lasts longer than 15 minutes. Review of Trayline Temperature Monitoring Forms for 06/01/21 through 09/30/21 revealed the following:
1) There was no documentation as to how long trayline lasted at each meal. Therefore, it was unknown as to whether or not food temperatures should be taken at the end of trayline.
2) Temperatures of patient trayline foods were only documented before each meal 9 out of 366 times.
3) Temperatures of patient trayline foods were not documented after each meal 357 out of 366 times.
B. During an interview on 10/14/21 at 2:00 PM, the Sodexo General Manager confirmed the temperatures were not documented.

Based on policy and procedure review, observation, and interview, it was determined the facility failed to assure techniques and measures were implemented to eliminate possible contamination of food or supplements in that several boxes of food and nutritional supplements were on the floor in 1 of 1 food storage areas of the kitchen. Failure to assure boxes of food and supplements were not on the floor did not ensure measures were taken to assure food and supplements were free from contaminates. The failed practice had the potential to affect any current and future patients requiring hospitalization. Findings follow:

A. Review of policy and procedure titled "Food storage "showed the following:
Dry and staple foods should be stored on shelving at least 6" off floor in clean ventilated room.
B. During tour of Facility's Kitchen on 10/13/21at 10:00 AM showed the following boxes of food in 1 of 1 food storage area:
1) 7 boxes of Glucerna supplement
2) 5 boxes of Jevity supplement
3)1 box of potatoes
C. The above findings were verified with the Sodexo General Manager at 10:20 AM.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 2012 Edition Life Safety Code standards, it was determined the facility failed to maintain 2 fire-rated barriers in accordance with the requirements of NFPA 101 2012 Edition in that two of two fire-rated barriers (Fire Pump Room, MRI Corridor) had penetrations which were not sealed with fire-proof sealant to restrict the transfer of smoke. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA 101 2012 edition: 8.3.5.1 showed penetrations for cables, conduits, pipes, and wires that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.
B. Observation on 10/12/21 at 1340 of the fire-rated barrier surrounding the Fire Pump Room showed two penetrating pipes were not sealed by a firestop system or device to prevent the transfer of fire and smoke. This finding was verified with the Physical Plant Supervisor at the time of observation.
C. Observation on 10/13/21 at 1015 of the fire-rated barrier near the MRI Corridor showed two pipes penetrating the barrier were not sealed by a firestop system or device to restrict the transfer of fire and smoke. This finding was verified with the Physical Plant Supervisor at the time of observation.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 2012 Edition Life Safety Code standards, it was determined the facility failed to maintain 1 of 1 means of egress (Kitchen Rear Exit) in accordance with the requirements of NFPA 101 2012 Edition in that the exit doorway was obstructed, making it inaccessible to all staff. The obstructed exit had the likelihood to affect all kitchen staff in that in the event of an emergency they would not be able to use the nearest means of egress to escape to safety. Findings follow:

A. Review of NFPA 101 2012 edition: 4.5.3.2 showed means of egress from all parts of an occupied building shall be maintained free and unobstructed.
B. Observation of the Kitchen on 10/12/21 at 0915 showed the Kitchen Rear Exit doorway was blocked by a black shelving unit with items stored on its shelves. This finding was verified with the Physical Plant Supervisor at the time of observation.

Based on observation, interview, and review of NFPA 99 2012 Edition and NFPA 70 2011 Edition, it was determined that four of four (Boiler Room, Electrical Room, Kitchen, and MRI (magnetic resonance imaging) Mechanical Closet) electrical panels did not have a minimum of 36 inches (three feet) working space in front of the panels because of materials and equipment stored in front of the panels. The failed practice had the potential to affect all patients, visitors, and staff because rapid access to the panels could not be gained in the event of an emergency. Findings follow:

A. Review of NPFA 99 2012 Edition:15.5.1.2 showed that electrical equipment shall be in accordance with NFPA 70.

B. Review of NFPA 70 2011 Edition:110.26 showed that access and working space of at least 36 inches (3 feet) shall be maintained for electrical equipment operating at 600 volts, nominal, or less to ground and working spaces shall not be used for storage.

C. While touring the Kitchen on 10/12/2021 at 0930, it was observed that a metal cart holding trays was stored in front of the electrical panel near the corridor leading to the dietary offices. This finding was verified with the Physical Plant Supervisor at the time of observation.

D. Observation on 10/12/2021 at 1340 of the MRI Mechanical Closet showed two chairs were stored in the closet, blocking access to the electrical panels and preventing the door to the MRI Mechanical Closet from fully opening. This finding was verified with the Physical Plant Supervisor at the time of observation.

E. Observation of the Boiler Room on 10/12/2021 at 1415 showed a dolly with equipment on it was parked in front of an electrical panel, preventing access to it. This finding was verified with the Physical Plant Supervisor at the time of observation.

F. Observation of the Electrical Room on 10/12/2021 at 1400 showed a portable fan and mechanical vice were stored in front of an electrical panel, blocking access to the panel. This finding was verified with the Physical Plant Supervisor at the time of observation.

Based on interview and review of the Rules for Hospitals and Related Institutions 2021 and interview, it was determined the facility failed to ensure Operating Room 1 (OR 1) and Operating Room 2 (OR 2) were maintained at the required temperature range of 68-73 degrees Fahrenheit for the 3 months prior to the month of the survey (July 2021, August 2021, September 2021). The failed practice had the likelihood to affect all patients undergoing procedures in these spaces during this timeframe in that an elevated risk of infection was present because there was no practice in place to ensure a temperature conducive to a sterile environment was provided.
Findings follow:

A. Review of the Rules for Hospitals and Related Institutions 2021 showed operating rooms and endoscopy rooms shall be provided with a dry bulb temperature of 68-73 degrees Fahrenheit.
B. In an interview on 10/13/21 at 0915 the Operating Room Director stated the temperatures of the operating rooms are recorded by staff daily.
C. In an interview on 10/13/21 at 0950 the Director of Perioperative Services stated the facility's temperature logs were lost 3 months ago and there was no process in place for staff to monitor the temperatures of OR 1 or OR 2 since the date the logs were lost.

Based on observation, policy review, and interview it was determined the Infection Control Nurse failed to assure a clean and sanitary environment and avoid sources of transmission by not identifying, controlling, and performing surveillance of terminal cleaning of 1 of 1 discharged patient's room. The failed practice had the potential to affect all patients requiring hospitalization in the facility. Findings follow:

A. Observation of the Environmental Services Tech #1 clean a discharge room (Intensive Care Unit /Room # 323) on 10/14/21 at 11:00 AM showed the following:
1) With gloves on removed trash from the room and changed gloves.
2) Obtained a new wet cloth. The following is the observed cleaning process in order as it occurred: wiped the side rails of the bed, underneath the bed mattress, top of the mattress, side rails, the headboard, top of the bedside table, telephone, call light, Intravenous Fluid Pole top to bottom with cloth hitting the floor. Continued cleaning going back to the bedside table wiping the inside of bedside table, top of the table, dry erase board, back of computer monitor, computer screen, patient ID bracelet scanner, sharps container then changed her cloth and continued cleaning by wiping the doorknobs then the light switch.
3) Next, Environmental Services Tech #1 removed gloves, used the hand sanitizer, obtained a clean wet cloth, and began in the bathroom in the following order: wiped the inside of the sink, then the light switch, paper towel dispenser, the top of the bedside commode, then the seat portion, next the shower chair, railing leading to the shower, the showerhead, shower knobs, side railing around the toilet, then the toilet seat and under the toilet seat.
B. Review of Facility's Discharge Clean Standard Work Activity Sheet showed the following:
1) Task Description: Hand Hygiene
Contact Enteric rooms require the use of soap and water for hand hygiene.
Key Point: Wash and/or sanitize hands prior to entering patient room. Donn gloves.
2) Task Description: Place a wet floor· sign at the door to mark the room in progress.
Key Point: blank
3) Task Description: Check patient room to ensure room is ready to be cleaned.
Key Point: Patient has vacated room/ patient belongings removed.
l.V. bag and lab specimens removed. Commode emptied. Top hat/urinal emptied.
Mobile medical equipment removed.
4) Task: Follow the facility process to communicate the room Is in progress.
Key Point: Log into bed tracking software if applicable.
5) Task: Collect trash and linen.
Key Point: Remove large debris. Gather trash and linen in room, paying specific attention to closets, cabinets, and drawers. Place the trash in a covered container. Gather all linen and stage in the center of the bed. Once gathered, place it in a soiled linen bag. (Note: Any unused linen that has been taken into a patient room prior to cleaning must be considered soiled and sent to the laundry for processing he door of the patient room. Raise bed to waist level and position the head and foot in a "l. Gather all linen and stage in the center of the bed. Once gathered, place it in a soiled linen bag. (Note: Any unused linen that has been taken into a patient room prior to cleaning must be considered soiled and sent to the laundry for processing)
6) Task: High Dusting
Key Point: Collect duster handle and dry microfiber sleeve from cart. Follow wall clockwise or counterclockwise, finishing in restroom. Dust all items at eye level and above. Pay Particular attention to horizontal surfaces: equipment, TV; s, cabinets, and door frames. Ceiling items to dust include lights, curtain tracks, comers, edges, and vents. Place a duster handle by te door with sleeve pointing up to be disinfected at a later point.
7) Task: Perimeter Surface Cleaning/Disinfecting: Specialty rooms such as ICU, isolation, labor & delivery, post-partum, LTAC, etc. may use more than 4 blue wipers as needed. Apply 3M #2A heavy duty multisurface cleaner on any hardened bioburden or bio-burden that was not 8. removed during the disinfecting process. Disinfect the area/surface.
Key Point: Collect 4 blue disinfectant/cleaner charged wipers from cart. 2 blue wipers will be placed on the bed. 1 wiper will be placed at the halfway point of the perimeter. Keep one wiper in hand and begin the cleaning/disinfecting process at the entrance door. Use one side of the wiper to disinfect a separate surface for a total of 8 surfaces per wiper. Perimeter cleaning/disinfecting will start at the door and end at the door as you follow a clockwise or counterclockwise path through the room. Clean and disinfect all high touch surfaces following the same path toward the window and carrying through to the side of bed opposite the door. While maneuvering through the room check walls and spot clean as necessary. All items should be wiped in a unidirectional manner utilizing the "S stroke" or "figure 8" method of wiping. Items to wipe down ·should include, but are not limited to: door handles, light switches, dispensers, sharps containers, keyboards, ac units, inside drawers, dressers, cabinets, chairs, couches, over-bed tables, phone, and all cords.
8) Task: Bed Cleaning/Disinfecting: If a rental or specialty bed has been used or broken bed needs repair it must be disinfected before being removed 9. from the room. The standard bed must be disinfected prior to being placed in a clean patient room. ? Use 3M #2A Heavy Duty Multi-) Surface cleaner to remove any hardened bio-burden or bio-burden that that was not removed during the disinfecting process. Disinfect the area/surface Clean and disinfect any additional bed attachments including stirrups, positioning devices, trapeze, LV. pole... ETC.
Key Point: The bed will be cleaned in two vertical halves beginning at he head of the bed and moving toward the footboard. Disinfect half of headboard including frame underneath.
Moving down the vertical half toward the footboard, clean and disinfect the mattress top and bottom including bedframe surface. Clean and disinfect bedside rails moving back toward the headboard. Once back at the headboard, clean and disinfect remaining bed frame including wheels moving toward the footboard. Using 2nd wiper clean and disinfect entire footboard surface from top to bottom including frame underneath. Clean and disinfect remaining mattress top and bottom including bedframe surface from foot to head. Clean and disinfect the second half of the headboard. Moving back toward footboard, clean and disinfect bedside rails. Once back at footboard clean and disinfect remaining bed frame including wheels.
9) Task Description: Perimeter Surface Cleaning/Disinfecting Continued Follow Facility Service Level Agreement for cleaning bedside toilets and other mobile medical equipment. Use 3M 2A Heavy Duty Multi-Surface cleaner to remove any hardened bio¿ burden or bio-burden that that was not removed during the disinfecting process. Disinfect the area/surface.
Use glass cleaner to clean glass as needed.
Key Point: Continue disinfecting all perimeter high touch surfaces through the remainder of the room, following the clockwise/counterclockwise path, working back to the entrance door.
While maneuvering through the room check walls and spot clean as necessary. Items to wipe down should include, but are not limited to door handles, light switches, dispensers, sharps containers, keyboards, ac units, drawers, dressers, cabinets, chairs, kick buckets, sofas, over-bed tables, phone, all cords, and trash cans. Finish the cleaning/disinfecting process at the door. Place soiled microfiber wipers appropriately in the cart.
10) Task Description: Restroom Cleaning/Disinfecting
Key Point: Collect toilet brush, 3M 40 A Disinfectant Cleaner and 2 orange disinfectant charged wipes. 1 orange wiper will be placed at the toilet handle/top. Keep one wiper in hand and begin the cleaning/disinfecting process at the entrance door.
Perimeter cleaning/disinfecting will start at the door and end at the door as you follow a clockwise or counterclockwise path through the restroom. Clean/disinfect the following: door, door handle, light switch, handrails, shower and curtain, sink, dispensers, faucet, countertop, and cabinetry. Clean mirror with glass cleaner and wipe with dry paper towel. Clean/disinfect inner toilet bowl with bowl mop by applying disinfectant to the bowl mop and cleaning top to bottom starting at the toilet rim. (Bowl mop should never touch the toilet seat or any surface outside the toilet bowl.) Use second orange wiper to disinfect outer toilet surfaces from top to bottom starting at the toilet handle. Place soiled microfiber wipers appropriately in the cart.
C. Findings above were verified with the Quality Manager/Senior Infection Control Cordinator on 10/14/21 at 1:00 PM.


42990

Based on observation and interview, it was determined the facility failed to assure a sanitary environment in the Respiratory Department for 12 of 12 portable oxygen tanks and 12 of 12 980 Puritan Bennett ventilators in that the oxygen tanks were being stored and the 980 Puritan Bennett ventilators were being cleaned/prepared for next use in the same room which was being used for I-Stat 1 Analyzer point of care sample processing and with a hand washing sink mounted on the wall. The failed practice did not assure avoidance of sources and transmission of infection to portable oxygen tanks or ventilators from splashes of dirty water from the hand washing sink or blood from the processing of samples. The failed practice had the potential to affect any patient who received portable oxygen or 980 Puritan Bennett ventilator support. Findings follow:
A. During a tour of the Respiratory Department on 10/14/21 at 1:30 PM, 12 of 12 portable oxygen tanks were stored in the same room (approximately 3 feet) from the hand washing sink and I-Stat 1 Analyzer point of care equipment.
B. In an interview during a tour of the Respiratory Department on 10/14/21 at 1:30 PM, Respiratory Therapist (RT #1) stated the process for cleaning the 980 Puritan Bennett ventilators started with removing the disposable parts from the ventilator and discarding them in the patient's room. Once the 980 Puritan Bennett ventilator was outside of the patient's room, it was wiped down with Sani-Cloth AF3 Germicidal Disposable Wipes. The 980 Puritan Bennett ventilator was then taken to the I-Stat 1 Analyzer point of care processing room, wiped down again, new disposable parts placed, and covered with a plastic bag. The 980 Puritan Bennett ventilator was then taken to the clean supply room for storage until use.
C. In an interview with the Quality Manager/Senior Infection Control Coordinator on 10/14/21 at 1:20 PM she stated the facility had no policy for 980 Puritan Bennett ventilator cleaning.
D. In an interview with the Market Vice-President of Quality and Professional Services on 10/14/21 at 1:45 PM she verified the findings in A and B and C.

Based on review of the facility's Emergency Preparedness Policies and Procedures, interview, and observation of the emergency supply storage containers, it was determined the facility failed to meet the emergency subsistence needs of patients and staff in that the facility failed to provide a provision for an emergency supply of water. Findings follow:

A. Review of the facility's Emergency Preparedness Policies and Procedures and interview with the Physical Plant Supervisor showed that an emergency supply of bottled water was kept on-site to provide for the subsistence needs of patients and staff in an emergency.
B. In an interview with the Physical Plant Supervisor on 10/11/21 at 1330 he stated that several pallets of bottled water were kept in the storage containers outside of the building along with other emergency supplies.
C. Observation of the facility's emergency supply storage containers on 10/11/21 at 1400 showed no emergency supply of bottled water was present on-site. This finding was confirmed with the Facility Supervisor at the time of observation.