HospitalInspections.org

A. Based on observation, interview, and policy review, the provider failed to ensure controlled substances or medications that were considered a high risk for potential diversion (theft) had been stored securely in:
*One of one anesthesia medication kit in the operating room (OR) cupboard.
*One of one OR sharps container.
Findings include:

Surveyor 42477:
1. Observation and interview on 9/8/21 at 3:00 p.m. with registered nurse (RN) I revealed:
*She had been the surgical nurse.
*Showed surveyors a locked medication kit in a cupboard.
-The medication kit contained all of the anesthesia medications.
*The certified registered nurse anesthetist (CRNA) B was the only one who counted and took care of the medications.
*The following staff had access to the OR:
-Nursing staff.
-Housekeeping staff.
-Sterile processing employee.
-Physicians.
*The key was in a locked cabinet in the post anesthesia care unit (PACU).
*The code was the same code that unlocked the cabinets in the patient rooms.
*That code had been given to this surveyor the day before, by a nurse on the floor.

Surveyor: 32332
2. Observation and interview on 9/8/21 at 3:30 p.m. of director of pharmacy A regarding storage and use of narcotics and anesthesia medications revealed:
*Director of pharmacy A worked full-time in the hospital.
*The provider had recently begun using a pharmacist and a nurse to count and sign for all medication delivery invoices when they were received from the pharmacy distributor.
-That system allowed for medication security from the time the medication arrived at the building.
*Extra narcotics and anesthesia medications not in use were stored in the pharmacy or placed in the Pyxis (electronic medication storage).
-The Pyxis required a code or fingerprint from anyone who utilized it.
-Only licensed staff had access to the Pyxis.
*If more narcotic medication was needed from the pharmacy after hours the licensed staff were required to remove the pharmacy key from the Pyxis.
-That system would require the person entering the Pyxis to document what medication was removed, who had removed it, and when the medication was removed.
*A perpetual inventory of the medications in the Pyxis system was counted when it was entered into the system and throughout the time it remained in the system.
*The medication that went to the OR was signed out in the pharmacy book.
-The CRNA working would check out the medication and deliver it to the OR.

Continued interview with director of pharmacy A at the above time revealed:
*CRNA (B) had maintained an anesthesia medication kit that was kept in an OR cupboard.
-He was the CRNA that worked in the building.
-Other CRNAs were used as needed.
*The CRNAs had not returned the kit containing unused medications to the pharmacy at the end of the day.
-The OR kit remained in the OR room in a cupboard.
-The previous pharmacist had not worked in the early morning when the CRNAs needed access to those medications for surgeries in OR or procedures that were done in the emergency department.
-The above process had not changed when the new director of pharmacy took over.

Observation and interview on 9/8/21 at 5:15 p.m. with director of pharmacy A in the OR revealed:*The OR anesthesia medication kit had been located in a cupboard in OR with a key code lock.
*He stated he:
-Had only been in the OR area two times since he started working in the facility in July 2021.
-Was not aware of the key code to the anesthesia medication kit cupboard.
*This surveyor stated RN I had told another surveyor it was the same code as the key codes used in patient rooms for their private medication supplies and cupboards within the OR area.
*Director of pharmacy A was able to open the OR anesthesia medication kit cupboard with the same code as all other key code cupboards.
-The anesthesia medication kit was locked with a key lock.
-This surveyor told director of pharmacy A the key had been locked in the post anesthesia care unit (PACU) according to RN I.
-He was able to obtain the key from the PACU cabinet using the same key code as the anesthesia medication kit cupboard and unlocked the kit with that key.

Review at the above time of the anesthesia medication kit with pharmacist A revealed:
*The kit contained multiple medications including:
-Twenty-five vials of Midazolam (a sedative used for anesthesia) 2 mg/ml.
-Five vials of Fentanyl (a narcotic for pain) 100 mcg/2 ml.
-Eight vials of Ketamine 500 mg/10 ml.
*The list of medications for the anesthesia kit had listed propofol 200 mg/10 ml, but the kit had not contained propofol.
-He had recalled the propofol had been stored in the emergency Department (ED) Pyxis for use in emergencies.
*Review of the the medication count of the above medications in the OR medication kit and the propofol secured in the ED Pyxis confirmed all of the above medication had been accounted for.

Continued observation and interview with director of pharmacy A in the OR revealed a large sharps container beside the anesthesia cart. The sharps container:
*Sat directly on the floor.
*Had not been attached to the wall.*Was approximately twelve inches long by (x) eighteen inches wide x eighteen inches tall.
*Had a large opening approximately six inches x nine inches wide.
*Had not been sealed.
*Contained:
-Intravenous (IV) tubing and multiple used vials of medication.
-Several used vials of propofol contained small remains of white liquid.
-One propofol vial contained a larger amount of white liquid.
*Director of pharmacy A confirmed:
-The above propofol vial had contained three ml or more of the sedative.
-His expectation was the CRNAs should have removed the propofol from all vials and disposed of that medication in the Cactus medication disposal (used for disposing of medication).
-He had not been aware the OR anesthesia medication kit:
--Had been stored in a cupboard that used the same key code as the other cupboards in patient rooms and other areas in the hospital.
--Key had been stored in the PACU cupboard that used the same key code as the other cupboards in the hospital.
*Stated the OR anesthesia medication kit had not been stored securely, but should have been secured.

Interview on 9/9/21 at 11:00 a.m. with the director of patient care services (DPS) E regarding the security of the above OR medications and vials in the OR sharps container. DPS E confirmed:
*The anesthesia medication kit had not been stored securely.
*She was not aware the:
-Cupboard shared the same keycode as the other cupboards in the building.
-Anesthesia medication kit key had been stored in the PACU cupboard that used the same keycode.
*The CRNAs should have disposed of leftover propofol in the Cactus before disposing of the used vials.
*Over the past few months the provider had done an audit of the external medication process before they entered the building, but had not audited the internal security of medication.
*The OR area used another code to enter the area, but unlicensed staff such as maintenance, housekeeping, and the surgical tech were not licensed to have access to medications.

3. Review of the provider's revised September 2021 Control of Narcotics and Propofol in Surgical area policy revealed:
*The purpose was to maintain control and prevent abuse of narcotics and propofol used in surgery.
*All narcotics along with all medication were to have been kept in a locked/secure cart or cupboard and accessible to only authorized personnel.
*All unused narcotics were destroyed according to regulations with two signature authority with a record retained.
*"Propofol/Diprivan: All unused propofol in syringes or vials will be made inaccessible with disposal by use of 1 of the following:
a. All unused propofol in syringes and vials will be made inaccessible by disposing of them in a wall mounted sharps container or
b. All remaining propofol in syringes and open vials will be completely emptied of the medication before being placed in an open floor sharps container."




41088

B. Based on observation, interview, record review, and policy review, the provider failed to ensure a system was in place to support the inventory of medical supplies for one of one crash carts located in ED room 2 had been completed per their policy. Findings include:

1. Observation, interview, and record review, on 9/8/21 at 2:25 p.m. with director of nursing (DON) C in ED room 2 revealed:
*A crash cart that had a numbered zip-tie to secure it shut.
*A black binder on top of the crash cart that was used to track the inventory and outdates of the medical supplies included with the crash cart.
*Upon review of the black binder there was not a completed inventory for August 2021.
*She stated the crash cart inventory should have been reviewed monthly by the RN who she had assigned that task.
*The crash cart zip-tie with number would have been opened and all items inventoried.
-Once completed, a new zip-tie would have been placed with a number recorded on the inventory review sheet.
*The RN assigned was responsible for pulling any outdated items from the cart.
*The monthly assignment list was kept at the nurse's station.
*She stated she had not designated a date for completion of the review but had expected it to be done prior to the last day of the month.
*She was not aware the crash cart inventory review had not been completed for the month of August.
*July 2021 was the last inventory review that had been completed.
*An entry on the inventory list that included a package of pediatric defibrillator pads for an automated external defibrillator had expired on 8/21/21.
*Three 30 milliliter bottles of 0.9% sodium chloride which had expired on 9/1/21.
-She stated the bottles were not supposed to be inside of the crash cart as they did not use them.
-They used pre-loaded syringes instead.
-She was not sure who would have put them inside of the cart.
-Those bottles had not been included on the inventory list but should have been if they were added to the crash cart.
*The list also included a betadine swab that expired 8/2021.

Further review of the ED room 2 crash cart inventory review list revealed:
*The inventory list had not included a spot for a completion date.
*The January 2021 review had been combined with February 2021.
*The March 2021 review had no documentation to support the crash cart was locked with a numbered zip-tie number.
-There was no documentation to support who had completed the inventory review.
*The April 2021 review was combined with May 2021 and had no documentation to support the crash cart had been locked with a numbered zip-tie number.
-There was no documentation to support who had completed the inventory review.
*The June 2021 review had not included the zip-tie number from the crash cart.
*The July 2021 review had not included the zip-tie number from the crash cart.

Interview on 9/9/21 at 9:20 a.m. with RN D revealed:
*She:
-Confirmed DON C had been responsible for assigning the monthly task of reviewing the crash carts.
-Had been one of the RNs who was responsible for completing the inventory of the crash carts.
*The assignment sheet had been kept behind the nurse's station.
*The RNs completed the crash cart review when they had time.
*The seal to the crash cart would be broken and every item would be inventoried.
*All outdated items would be pulled before their expiration date and used on the floor to avoid waste.
*Those items that had been pulled would be replaced by central supply.
*There had been times that two RNs would work on the crash cart inventory review to make the process quicker.
*She confirmed the RN assigned would have the entire month to complete the task.
*Another RN had been assigned to complete the August 2021 review of ED 2 and had not signed off that she had completed it.

Review of the August 2021 monthly medication/supply outdate audit assignment sheet revealed:
*The task had been assigned but the form was left blank for inventory completion of the crash cart in ED 2.
*The form stated it was to be completed by the fifteenth of the month.
*The signature line for the date and time the form had been given to the pharmacy was blank.
*The signature line for date and time the form had been given to the DON was blank.

Interview on 9/9/21 at 12:30 p.m. with DON C revealed she:
*Agreed their policy stated the crash cart inventory checklist form was to be completed by mid-month.
*Confirmed the staff had missed completing the task monthly as assigned and would expect it to be done according to their policy.
*Agreed their provider policy had not been followed.
*Stated August had been a busy month and it was missed.

Review of the provider revised July 2021 policy for Monitoring Outdated Supplies revealed:
*"RN staff will be responsible for visual inspection of patient care supplies stocked in emergency carts on a monthly basis- by mid-month."
*"RN staff will be responsible for removal of the supplies due to outdate for the month and restocking of these items in the locked emergency carts by the last day of the month. All outdating supplies will be brought back to purchasing."
*..."The form will be given to the Director of Nursing, who will be responsible for oversight of this process to ensure that all outdated supplies have been removed and restocked in patient care areas by the last day of the month."

Based on observation, interview, and policy review, the provider failed to ensure personal protected health information for one of one patient (1) had been discarded in a manner that maintained the confidentiality of information. Findings include:

1. Observation and interview on 9/7/21 at 4:16 p.m. with patient care technician (PCT) F revealed she had:
*Thrown away patient 1's id bracelet that contained protected health information.
*Thrown it away in the regular, unsecured trash.
*Indicated this was her normal practice.
Refer to C-1200, finding 3, and 5.

Interview on 9/9/21 at 10:10 a.m. with the director of patient services (DPS) E revealed patient id bands were to be placed in the proper shred bin upon a patient's discharge.

Review of the provider's October 2020 Safeguarding Protected Health Information (Facility Controls)- revealed:
*"Confidential information is any information that identifies a patient; this may include name, birth date, social security number, address, or insurance numbers. When disposing of paper forms containing any of this information use the [company name] Shred containers."
*"The [company name] Shred containers are located in secure areas with limited access and the containers are to be locked at all times."

Based on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were maintained for:
*One of one patient (1) who should have been placed on transmission-based precautions for respiratory syncytial virus (RSV).
*Handling contaminated trash and linens by one of one patient care technicians (PCT) F.
*Cleaning and disinfection of one emergency room (ER) and one patient room after discharge by one of one PCT F.
*Surgical lights over one of one operating room (OR) table which contained un-cleanable surfaces.
*Hand hygiene and glove use during one of one observed intravenous (IV) medication administration by one of one registered nurse (RN) (H) for one of one sampled patient (32).
Findings include:

1. Interview on 9/7/21 at 2:00 p.m. with RN G revealed they had one patient (1) who had RSV.
-A highly infectious communicable disease that required transmission-based precautions to prevent transmission.

2. Observation and interview on 9/7/21 at 2:50 p.m. of the ER 4 revealed:
*The room had appeared to be cleaned.
*There had been a suction canister on the wall with milky thick liquid.
-The suction tubing had been hanging on the floor.
*RN H came into ER 4 to check to make sure the suction canister had been changed, because PCT F was new and still considered to be in training.
*RN H stated that patient 1 was in this room two days ago when he was admitted.
-The suction canister still had not been changed, or discarded from that admission.

Observation on 9/7/21 at 3:30 p.m. revealed:
*There had not been any signs on patient 1's door.
*RN G had:
-Been going into patient 1's room.
-Not put on a gown.
-Not disinfected her face shield or removed her mask after exiting patient 1's room.

3. Observation and interview on 9/7/21 at 4:16 p.m. with RN G and PCT F revealed:
*Patient 1 had been discharged and they were cleaning his room.
*RN G came in and took down his IV medications, she:
-Had brought the IV solution to the handwashing sink and drained the fluid.
-Had not been wearing gloves, and did not clean out the sink after draining the IV fluid.
-Then left the room.
*PCT F:
-Took patient 1's id bracelet off the computer cart and threw it in the trash.
--The id bracelet contained confidential information for patient 1.
-Removed trash and soiled linens.
-Had not disinfected her hands and put on a pair of gloves.
-Disinfected the pillows and placed them back on the soiled bedside table.
*PCT F stated she was not exactly sure what she was supposed to clean and what housekeeping cleaned.
*There had been no one in the room to ensure she had been aware of the correct disinfection process.
*There had been a visitor chair that pulled out into a bed, she had not reclined the bed to ensure it had been disinfected.
*PTC F went into the adjoining bathroom, she:
-Had disinfected the inside of the toilet bowl, and toilet seat.
-Had used the same wipe to clean the handrail.
-Cleaned off the stethoscope and pulse oximeter with the same gloves she cleaned the toilet with.
-Cleaned off the dresser and bedside table with the same gloves.

4. Observation and interview of on 9/7/21 at 2:34 p.m. with PCT F revealed:
*She had just finished cleaning an ER.
*She was not wearing any gloves and she:
-Began bagging contaminated trash, and soiled linens.
*After tying the bags she carried them past the nurse's station to the laundry room.
*Inside the laundry room there were three bags of garbage and two bags of soiled linens on the floor.
*Surveyors asked about laundry and garbage on the floor, she then grabbed the bags and walked to the outside trash.
*After discarding trash outside she came back through the building, sat down at the nurse's desk, and sanitized her hands.
-That was the only time she had sanitized her hands from cleaning the ER, removing the trash/laundry, and returning to the nurse's station.
*She believed the contact time for their disinfectant was ten minutes, but she was not sure.

Observation and interview on 9/8/21 at 3:00 p.m. with RN I revealed:
*She had been the surgical RN.
*They had one OR in their facility.
*They had two surgical lights over the operating table.
*The lights contained cracks.
-Some lights had deep cracks that were unable to be disinfected.
*RN I agreed that some cracks in the lights were not cleanable.

5. Interview on 9/9/21 at 10:10 a.m. with the director of patient services (DPS) E revealed:
*She had been overseeing the infection control program.
*Her expectation was for patient 1 to be on contact precautions.
-Multiple shifts had missed this.*Staff competencies were done annually and upon hire.
*Director of nursing (DON) C oversaw the training effectiveness of employees.
*She believed DON C had completed audits, she had not been able to complete many due to COVID-19.
*She stated staff should have been following their policy and wearing a gown and gloves when caring for someone with RSV.

Interview on 9/9/21 at 11:00 a.m. with DON C revealed:
*She had been overseeing the education of employees.
*Long term care employees had been educated by an educator on the long term care side.
-PCT F had transferred to the hospital from the long term care center.
*She assumed she was competent in her training since she had been working for the long term care.
*She had not completed any audits.
*RN I had completed hand hygiene audits.
*Floor nurses were to be helping with training and monitoring the effectiveness of training.
-This had not been documented anywhere.
-It had been more of an informal process.

Review of the provider's April 2021 Transmission Based Precautions policy revealed:
*Contact precautions should have been used for someone with known or suspected RSV.
*Contact precaution sign should have been on the door.
*Staff were to perform hand hygiene prior to entering the room.
*Gowns were worn when entering and discarded prior to exiting.
*Gloves were to be worn when entering the room, and while having contact with the material.

Review of RN I's audits revealed:
*Not all observation areas had been marked or audited.
*There had been some breaks in hand hygiene.
-There had not been comments for all the breaks observed.
*They had been marked based on observed tasks, not off of the total that needed to be observed.

Review of PCT F's Competency Achievement Checklist revealed:
*It was to be completed by an employee's three-month evaluation.
-PCT F had been working for about a month..
*There were three places to have documentation:
-On hire, self assessment.
-Orientation (preceptor).
-Annual (evaluator)
-There was a verification spot at the end of the chart.
-Staff were supposed to date and initial all entries.
*Nothing had been filled out for the orientation column.
*Self assessment was missing "outbreak control policy" and "respiratory etiquette"
*Not all the on-hire self-assessments contained initials.
*None of the on-hire self-assessments contained dates.

Review of patient 1's nursing isolation assessment tool revealed:
*Nurses were to assess pediatric patient for isolation needs to be based on symptoms and ordered laboratory testing.
*The assessment had nothing filled out.




29354

6. Observation and interview on 9/8/21 at 10:00 a.m. with RN H during medication administration with outpatient 32 revealed:
*Without performing hand hygiene she went into the medication room.
*She:
-Went to the Pyxis medication system and removed two vials of clindamycin.
-Picked up a 500 milliliter normal saline (NS) IV bag.
-Placed the above items on the medication room counter.
-Went to the hand sink and washed her hands.
-Opened the lid of a plastic container on the wall with her wet hands and removed paper towels.
-Dried her hands, turned off the water, and discarded the used paper towels into the garbage.
-Used hand gel and put on gloves.
--She continued to wear the same pair of gloves throughout the entire observation.
-Took a spray bottle containing 70% alcohol and sprayed the top of the medication counter.
-Took clean paper towels located on the medication counter and wiped it off.
-Placed the IV supplies and medication vials on the medication counter without laying down a barrier.
-Drew up the clindamycin medication from the vials into a syringe and injected it into the NS bag.
-Went over to the sink, placed the IV bag on a hook, and drained a small amount of solution into the hand sink.
-Opened a cupboard and removed two syringes.
-Gathered the remaining medication supplies and went to outpatient 32's room.
*Without disinfecting an overbed table or laying down a barrier she:
-Laid a clipboard down on the overbed table.
-Laid the IV supplies on top of the clipboard on the overbed table.
*With those same gloves on removed a dressing from his right forearm IV site and discarded it into the garbage.
*She then:
-Went to the computer.
-Dropped four alcohol wipes on the floor.
-Picked up the alcohol wipes and placed two alcohol wipes on the overbed table and two alcohol wipes on the table by the computer.
--The two alcohol wipes by the computer fell onto the floor again.
--She picked up those two alcohol wipes and placed them into her pocket.
-Removed the alcohol wipes that had dropped on the floor earlier from her pocket and cleaned the end of the IV site on his right forearm.
-Began the administration of the IV antibiotic.
-Documented the above medication administration on the computer.
-Removed her gloves and performed hand hygiene.

Interview on 9/8/21 at 3:10 p.m. with RN H regarding the above observation revealed:
*The paper towels were lint free.
-They always used lint free paper towels in the medication room.
*They had always removed the paper towels from the plastic box.
*The dressing on outpatient 32's right forearm was "just a protective dressing."
*She had worn the same gloves throughout the above observation.
*She agreed she:
-Had missed some hand hygiene opportunities.
-Should not have picked the alcohol wipes up from the floor and used them.

Interview on 9/8/21 at 3:20 p.m. with DPS E regarding the above observation of RN H revealed:
*She agreed she should have laid down a barrier or disinfected the areas before laying down IV supplies.
-There were missed hand hygiene opportunities.
*The facility did not have a policy for the lint free paper towels.
*Best practice was to have a clean surface before laying any type of medications or supplies on a surface.
*There were breaches in infection control during the above observation such as dropped alcohol wipes and hand hygiene and glove use.

Review of the provider's August 2021 Hand Hygiene policy revealed:
*"B. Hand Hygiene with Alcohol Hand Rub (Antisepsis):
-1. If hands are not visibly soiled, use the system approved alcohol-based hand rub for routinely decontaminating hands in most other clinical situations:
--a. Before each patient contact."
--"d. After routine patient care where there is no contact with body fluids.
--e. After contact with inanimate objects (including medical equipment, patient belongings) in the immediate vicinity of the patient.
--f. After glove removal.
--g. Before touching clean supplies.
--h. Prior to preparing/dispensing medications."

Review of the provider's January 2021 Compounding Sterile Medications policy revealed:
*Compounding:
-"5. Ensure medication preparation area is clean-clean with 70% isopropyl alcohol and allow to dry.
-6. Wash hands.
-7. Don Non-sterile chemo gloves initially disinfected with 70% isopropyl alcohol-repeated disinfection is indicated especially if you touch non-sterile items."

Review of the provider's September 2016 Wound Care - Dressing Changes policy revealed after a dressing had been removed, discard dressing, remove gloves, perform hand hygiene, and Don clean gloves.