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Based on observation, interview and document review, the critical access hospital failed to ensure the policy Attire in Operating Room was implemented for 1 of 2 physicians observed in the opertating room.

Findings include:

A physician was observed in the operating room with unsuitable operating room attire which was not designed for maximum skin coverage.

Physician (MD)-A was observed entering the operating room to start a surgical procedure on 9/18/13 at 7:50 a.m. wearing a rubber shoe often seen worn at a beach. The physician wore no socks and both of his heels were bare. The surgical services manager (RN)-A was interviewed on 9/18/13 at 9:50 a.m. and stated MD-A often wore these "water shoes" to more easily use a foot pedal device on a piece of equipment.

A review of the hospital policy, Attire in Operating Room (effective July 1, 1999) , indicated all personnel entering the restricted area of the surgical suite were to use closed-toe and heeled nonfabric shoes. Clogs or fabric-constructed shoes were prohibited.

Based on observation, interview and documentation review, the Critical Access Hospital (CAH) did not ensure medication was disposed of in a secure manner in 1 of 1 operating rooms, and in 1 of 1 endoscopy room.

Findings include:

During a tour of the operating room suite on 9/18/13 at 8:40 a.m., a certified registered nurse anesthetist (CRNA)-A was observed disposing of a vial of medication into a black container which was on a metal rolling stand in the operating room. The container was approximately 24 inches in height, twelve inches in width, and had an opening in the top of the container which measured approximately 8 inches in diameter. The large opening on the top of the container would allow free access to the contents in the container. Many vials and bottles which contained discarded medications were visible in the container.

CRNA-A was interviewed on 9/18/13 at 8:50 a.m., CRNA-A stated any unused medications, except for controlled substances, were discarded in the black containers in the operating room and in the endoscopy room as hazardous waste. He verified the hazardous waste container in the operating room was also used to dispose of anesthesia canisters. He also stated anesthesia medication were also used in the endoscopy room and were discarded in the black hazardous waste container. According to the CRNA-A some of the discarded medications in the container included syringes containing unused Propafol (an anesthetic medication), succinylcholine (a muscle relaxant), Toradol (pain medication used for severe pain) and 500 milliliter bottles which contained epinephrine (a hormone and neurotransmitter).

Another black container was observed in the endoscopy room on 9/18/13 at 10:15 a.m. There was an opening in the top of this container which measured approximately six inches in diameter. This opening would also allow free access to the contents in the container. Numerous vials and bottles of discarded medications were visible also visible in this container.

The surgical services manager, registered nurse (RN)-A was interviewed on 9/18/13 at 10:45 a.m. RN-A confirmed housekeeping staff were unsupervised when cleaning the operating room and the endoscopy room.

The director of pharmacy was interviewed on 9/18/13 at approximately 3:10 p.m. He stated the hospital policy was for all unused medications, except for controlled medications, to be placed in the hazardous waste containers. He stated unlicensed staff, patients and visitors should not have access to these medications.

A review of the hospital's policy, Unit Inspection (last revised February 2013), indicated drugs should be accessible only to responsible personnel designated by the hospital. The hospital policy, Inhaled and IV General Anesthetic Agents (last revised December 2012), indicated IV general anesthetics such as Propafol would have specific controls on access and administration. The policy Neuromuscular Blocking Agents (last revised 1/5/2013) indicated neuromuscular blocking agents would have specific controls on access and administration.

Based on interview and document review, the critical access hospital (CAH) did not ensure a system of maintaining a log for identifying, reporting, investigating and controlling infections for patients who underwent surgical procedures which utilized instruments which had been flash sterilized.

Findings include:

A log which identified the patients who had surgical procedures which utilized instruments which had been flash sterilized had not been maintained.

A review of the hospital's Flash Sterilization Log indicated surgical instruments used for 8 of 16 outpatients who underwent cataract surgery with intraocular lens implants during the months of June, July and August 2013, were not sterilized as per hospital policy. The Flash Sterilization log did not include patient names thus there was no way to identify the patients who had procedures in which surgical instruments were not sterilized per hospital policy. There was no evidence the flash sterilization log had been monitored by the surgical services manager nor by the infection control practitioner. Thus, there was no way to track infections for patients who had procedures using instruments which had only been flash sterilized.

The Surgical Services Manager was interviewed on 9/18/2013 at 9:50 a.m. and verified there was no way to identify patients who had surgical instruments used during procedures which had not been sterilized per hospital policy. The manager stated she had not reviewed the sterilization log in some time.

Based upon staff interview and document review, the critical access hospital (CAH) did not ensure a Registered Nurse (RN) had developed a nursing care plan based upon a nursing assessment for 7 of 15 inpatients (P1, P3, P4, P5, P6, P9, P10) who had received care.

Findings include:

P1 was admitted to the CAH on 4/4/2013 with diagnoses which included recurrent urinary tract infections with chronic kidney disease, a history of a seizure disorder, senile psychosis, urinary incontinence with urinary retention and dementia. The patient underwent a ureteral stent placement during the hospitalization. The nursing assessment, dated 4/5/2013 at 11:00 p.m., indicated the patient had a Foley indwelling urinary catheter in place. A review of the nursing care plan did not address the patient's history of a seizure disorder, senile psychosis, or dementia. Although the nursing assessment indicated the patient had an indwelling urinary catheter, there were no nursing interventions identified to care for the catheter. The chief nursing officer (CNO) was interviewed on 9/19/2013 at 9:30 a.m. and stated the care plan should include interventions related to the patient's seizure disorder, dementia and urinary problems.

P3 was admitted to the CAH on 4/28/13 with the diagnosis of small cell lung cancer; terminal pancreatic cancer and end of life measures. Review of the nursing care plan made no mention of end of life care.

P4 was admitted to the CAH on 9/9/13 with the following diagnoses: stool impaction; weakness; weight loss and lung cancer. Review of the nursing care plan made no mention of treatment for ongoing constipation; weight loss or lung cancer education.

P5 was admitted to the CAH on 7/30/13 with the following diagnoses, alcoholic hepatitis, liver cirrhosis; history of kidney stones and chronic pancreatitis. Although review of the nursing care plan only identified pain, it did not interventions related to possible ETOH (alcohol) withdrawal or related issues.

P6 was admitted to the CAH on 9/4/13 for newly diagnosed type 2 diabetes mellitus, stage 4 kidney disease and congestive heart failure (CHF) history. The nursing care plan failed to mention interventions related to the newly diagnosed condition; diabetes.

P9 was admitted to the CAH on 8/3/13 with hypoxia and lung contusion after receiving trauma to her face and chest wall area with increased SOB, bronchial congestion, cough and low pulse oximetry. The nursing care plan failed to identify interventions related to pulmonary function. The care plan only mentioned "fall risk" and "skin integrity".

P10 was admitted to the CAH on 8/30/13 for urinary tract infection (UTI), left basilar opacification and anemia. The care plan was reviewed and made no mention of having a UTI, or the possible need for an lung assessments nor anemia follow-up.

An interview on 9/19/13 at 9:30 a.m. with the chief nursing officer (CNO) verified the majority of the nursing care plans reviewed included goals related to falls and skin integrity but had not always been individualized to reflect the assessed nursing care needs of the patients. The CNO verified that notable diagnoses were lacking in the plan of care and therefore appropriate nursing interventions had not been included.

Based on interview and document review, the Critical Access Hospital (CAH) was found not to be in compliance with the Condition of Participation of Surgical Services 485.639. The CAH did not ensure proper sanitation of surgical instruments for 8 of 16 outpatients reviewed who underwent cataract extraction with intraocular lens implant. This deficient practice had the potential to affect all patients who undergo this surgical procedure at the CAH.

Findings include:

During a tour of the surgical suite on 9/18/13 at 9:45 a.m., the surgical services manager (RN)-A was interviewed regarding the use of flash sterilization. RN-A stated the hospital owned three complete instrument sets used for cataract extractions. She stated the instrument sets were washed and flash sterilized if more than three patients were scheduled per day, as there was not enough time to run a full sterilization cycle between each procedure. RN-A also stated that central processing for surgical instruments was done in the surgical suite.

A review of the hospital's Flash Sterilization Cycle Log revealed 6 patients underwent cataract surgery on 6/19/13, six patients had cataract surgery on 7/24/13 and four patients had cataract surgery on 8/14/13. The flash sterilization log indicated the rational for flash sterilization was marked with a "T" as a code. This code indicated flash sterilization of the instruments was done because there was not enough time for full cycle sterilization of the instruments. RN-A reviewed the flash sterilization log on 9/18/13 at 10:00 a.m. RN-A verified staff had not documented the reason for the use of flash sterilization correctly. She stated staff should have documented that some of the instruments had been run through the flash sterilizer for decontamination and only the instrument trays used after the first three procedures had been flash sterilized. RN-A verified three of six instrument trays had been used on June 19, 2013, three of six instrument trays were used on July 24, 2013, and one of four instrument trays were used on August 14, 2013. She indicate the instrument trays had been flash sterilized, as there was not enough time between the surgical procedures to complete a full sterilization cycle. The Flash Sterilization Cycle Log report also did not indicate the name of the patient the instruments had been used for, thus there was no way to track any problems related to patient infections.

The hospital policy, Processing Unwrapped Items in Steam Sterilizer (FLASH), last revised July 2008, indicated supplies and equipment used for surgical procedures would be sterilized in central processing per established procedure whenever possible. The policy indicated that unwrapped (Flash) steam sterilization would be used for items which must undergo steam sterilization when emergency or unavoidable circumstances prevented an item to undergo a complete wrapped steam sterilization cycle. The policy also indicated a log would be maintained on each unwrapped (flash) steam sterilization cycle, Log information would include the type of item being flashed as well as the rationale for flashing. The policy indicated the log would be routinely reviewed by the department director and infection control practitioner for ongoing monitoring and evaluation, for the purpose of limiting usage of flash sterilization to an urgent or unavoidable basis.

The hospital policy Infection Control for Surgery last revised December 2000, indicated all supplies and equipment used for surgical procedures would be sterilized in central processing using a full cycle wrapped process as per standard procedure whenever possible, with unwrapped (flash sterilization) done only when unavoidable.

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the proper sterilization of instruments used in surgery.