HospitalInspections.org

Based on document review, observation and interview, the registered nurse failed to ensure policies were followed related to the follow up/reassessment after pain medication administration for 2 of 2 ICU (intensive care unit) patients, Patients #3 and #4; and related to the lack of documentation of a 3 month expiration date on glucose control solutions once they are opened for use in one area toured.

Findings Include:
1. Review of the policy Pain Management, no policy number, with effective date of 11/00, indicated under Policy, in item 4.: "Patient's pain will be reassessed within 60 minutes after interventions utilizing the appropriate pain scale."

2. Review of ICU patient medical records indicated:
A. Patient #3 received "Pain Medication", per the nursing flowsheet, at 3:20 PM on 11/21/16 for pain scored at 8 out of 10, with follow up reassessment noted at 5:24 PM and received "Pain Medication" at 7:59 PM on 11/21/16 for pain scored at 6 out of 10 and reassessment made at 9:52 PM.
B. Patient #4 received "Pain Medication", per the nursing flowsheet, at 7:30 AM on 11/20/16 for pain of 5 out of 10 with reassessment at 10:00 AM; "Pain Medication" given at 12:00 PM on 11/20/16 for pain scored at 7 out of 10 and with reassessment noted at 4:00 PM; and "Pain Medication" given at 6:00 AM on 11/21/16 for pain scored at 5 out of 10, with follow up reassessment done at 7:40 AM.

3. At 10:30 AM on 11/22/16, interview with staff member #57, the ICU director, confirmed that the reassessment of pain for patients #3 and #4 after receiving pain medication was not per facility policy that requires reassessment within 60 minutes of an intervention.

4. Review of the policy "Glucose Monitoring: Accu-Chek Inform II Blood Glucose Test", no policy number, effective date of 5/20/94, indicated under the section "Quality Control", on page 2: "...Q.C. (quality control) material is stable for 3 months once opened...upon opening a new bottle of Q.C. material, document the date it was put into use, the expiration date, is 3 months from the date opened for Q.C. material, or expiration date on the bottle, whichever is sooner) (sic), and your initials on the vial."

5. At 1:35 PM on 11/21/16, while on tour of the outpatient surgery area in the company of staff member #56, the director of surgery, and #55, a surgery nurse, it was observed that the control solution (vial #1) was not dated when opened, had no 3 month expiration date noted, and was not initialed.

6. At 1:35 PM on 11/21/16, staff member #55 felt that the information (listed in 5 above) had been noted on the vial previously but had rubbed off. It could not be determined when the 3 month expiration date may occur, or may have occurred.

Based upon document review, observation and interview, the facility failed to follow their policy/procedure ensuring that medical records (MR) were not accessible to unauthorized individuals for 1 of 2 off-site locations.

Findings include:

1. The policy/procedure Accessibility to the HIM (Health Information Management) Department (approved 9-14) indicated the following: "To protect patient confidentiality, access to the Health Information Management (HIM) department is limited... paper medical records are (only) accessible via department personnel... the housekeeping staff will clean during the HIM department's open hours..."

2. During an off-site visit to a family practice clinic on 11-22-16 at 0845 hours, MR folders containing confidential patient information were observed to be occupying 2 shelves of an open bookcase in the business office area adjacent to the patient waiting room.

3. On 11-22-16 at 0845 hours, the office staff A22 and office manager A23 confirmed that the contracted housekeeping personnel provided cleaning services in the building during the evening/night hours. Staff A22 and A23 confirmed the patient records were not secured in locked storage when housekeeping services were provided and accessible to unauthorized persons when the clinical and office staff were not present.

Based on document review, observation and interview, the infection control committee failed to: ensure the approval of cleaning/disinfecting products used at the two off site locations, failed to approve of the cleaning processes used by the contracted cleaning company, failed to ensure the proper laundering of cleaning cloths and rag/string head mop heads used by the contracted cleaning company, and failed to ensure a clean/orderly environment in relation to dust on the crash cart in the outpatient surgery area, and dust on the wall vents in the endoscopy procedure room #1.

Findings Include:
1. Review of the contracts for cleaning services at the two off site locations indicated under "Equipment and Supplies": "M&M custom Cleaning (sic) will provide all cleaning equipment and chemicals used to clean...".

2. Review of the document of cleaning products used by the contracted cleaning company indicated there was no EPA (environmental protection agency) registered, hospital grade disinfectant product listed to disinfect the exam rooms and laboratory areas of the two off site locations.

3. Review of the document "M & M Custom Cleaning, LLC", (limited liability company) indicated that both off site physician office locations would be cleaned as follows: "Bathroom: Spray and wipe down sink, Spray and wipe down toilet, Wipe down fixtures and mirrors, Sweep and disinfect floors; Labs: Wipe down counter tops, Wipe sinks, Sweep and disinfect floors; Exam Rooms: Spray and wipe down sink, Wipe down counter tops, Sweep and disinfect floors."

4. At 9:00 AM on 11/22/16, while on tour of the Butler off site location in the company of the off site manager, staff member #58, it was observed that the only cleaning product found in the janitor's closet was NRFC 64 (no rinse floor cleaner) by Wayne, and a wet rag type mop head.

5. At 9:00 AM on 11/22/16, while on tour of the Garrett off site location in the company of the nurse manager, staff member #23, and a staff nurse, #22, it was observed that the cleaning products on site were a bottle of Windex and a spray bottle of Great Value All Purpose Cleaner with Bleach.

6. Review of the "Training Documentation" form for M & M indicated 10 persons were listed as having June 29, 2016 training in general safety rules, bloodborne pathogens, confined space awareness, electrical safety, emergency action and file, back safety/injury prevention, hazard communication, lockout/tagout affected, and PPE (personal protective equipment).

7. At 2:00 PM on 11/22/16, interview with staff members #54, the ICP (infection control practitioner), and #59, the EVS (environmental services) director, confirmed that:
A. EVS and safety rounds are performed at both off sites, but no observation of the contracted cleaning staff is done to ensure proper PPE, appropriate cleaning/disinfecting products are used, and that hospital approved cleaning processes are performed.
B. There is no training of contracted cleaning staff by hospital personnel, nor any knowledge of the cleaning processes taught by the cleaning company to assure that cleaning processes meet the needs of the hospital and ensure appropriate disinfection of the off site facilities.
C. The infection control committee has never approved of the cleaning products used at the off sites and was not aware that there was no disinfectant on site, or used at either off site facility.
D. The M & M document, listed in 3. above, indicated areas that would be disinfected, but no disinfectant product was found at either off site location.
E. It was not known what laundry facility cleans off site cleaning cloths and rag head mop heads that are used, and the infection control committee has not been monitoring this.

8. Review of the policy "Crash Cart: Exchange, Cleaning, Restocking", no policy number, last revised 1/21/16, indicated the process for restocking and the checking of expiration dates of supplies and medications, but does not address the responsibility for cleaning the cart.

9. At 1:25 PM on 11/21/16, while on tour of the outpatient surgery area in the company of staff member #56, the surgery director, it was observed that there was an accumulation of dust on the top of the crash cart behind the defibrillator, on the shelves above the front wheels, and on the suction machine on the top of the cart.

10. Review of the document "Housekeeping - OPS (outpatient services) 3rd Shift", indicated the week of 11/14/16 the various rooms/areas that were cleaned Monday through Friday by the EVS (environmental services) staff.

11. At 1:25 PM on 11/21/16, interview with staff member #56 confirmed that the crash cart was dusty in the areas listed in 2. above and stated that the code cart, at this time, is only cleaned after a code in which the cart would then be sent to materials management to restock and clean the cart.

12. At 11:35 AM on 11/23/16, interview with the EVS manager, staff member #59, confirmed that currently the code/crash cart was not on the 3rd shift cleaning list of responsibilities (document listed in #3 above) and was not being attended to routinely.

13. Review of the policy "Environmental Services", "RE: Cleaning Surgical Services", policy number 3200 HK, last revised 5/6/13, indicated on page 3 that "Cycle Cleaning to be completed by Housekeeping Dept." Cycle cleaning will be rotated so that the entire Surgery Department is covered in a week...Wash all fixtures attached to the ceiling, walls, door, door jambs, electrical outlets, rubber hoses, fixtures attached to the walls,...with an (EPA) (environmental protection agency) registered hospital approved disinfectant-cleaner solution...Wash the ceiling and walls in all other areas of the operating suite an (EPS) registered hospital approved disinfectant-cleaner solution."

14. At 1:35 PM on 11/21/16, while on tour of endoscopy room #1 in the company of the surgery director, staff member #56, it was observed that the two louvered wall air vents had an accumulation of dust present.

15. At 1:35 PM on 11/21/16, staff member #56 confirmed that dust was present on the wall mounted air vent/face plates.

16. Review of the document "Housekeeping - OPS 3rd Shift" for the week of 11/8/16 indicated "All" Endo rooms were cleaned on 11/8/16.

17. At 11:35 AM on 11/23/16, interview with staff member #59 confirmed that:
A. It was unknown what "Cycle Cleaning", listed in the policy of #13 above, means and could not explain this terminology.
B. Endoscopy cleaning is not specified in the policy.
C. Documentation of cleaning "All" of the Endo rooms included washing down the walls, including the air vent/face plates.
D. Endoscopy rooms are not cleaned terminally on a daily basis as are the surgical suites.
E. With dust being found on the air vents, the Endoscopy rooms may need to be cleaned (terminally) more frequently.