HospitalInspections.org

Based on review of Critical Access Hospital (CAH) policies, observation and staff interview the CAH failed to develop an emergency preparedness policy/plan to assure safe evacuation and maintain clear paths to the emergency/fire exit in the operating room suite.

Failure to maintain a clear passageway would delay a safe and immediate evacuation of operating room patients therefore heightening risk of serious injury or death.

1. Review of hospital policy titled " Evacuation " (Dated November 2009) revealed in part ... " Surgery: out the north door in the operating room (OR) area ... " The policy lacked documentation to assure safe evacuation and unobstructed path ways emergency/fire exits in the OR.

2. Observation of the OR suite on 6/9/10 at 4:40 PM, with the OR Interim Director revealed: A hopper sink, a portable laundry cart, portable table and cabinet obstructed the pathway to the north exit OR Interim Director acknowledged the findings. He/she stated, "A stretcher will not fit out the door."

3. Observation of the operating room (OR) suite on 6/14/10 at 4:00 PM with the OR Interim Director revealed: the fire exit corridor in the OR remained obstructed. The Interim Director stated, "I brought this concern to the upper management on January 4, 2010 and nothing has been done. There is no clear access to the fire exit door."

4. During an interview on 6/15/10 at 9:45 AM, the Ancillary Services Director stated, "The safety policy tells you to go out the north fire door in the OR. I don't know of any additional plans to exit with a patient in an emergency due to the fact you can't get a gurney through. I'll have to check if it's not in the hospital evacuation plan."

5. On 6/15/10 at 9:55 AM, the Maintenance Director presented the surveyor with measurement of the obstructed fire exit corridor in the OR. Review of the document revealed a 23 inch passageway between the hopper sink and a portable cart and a 27 inch passageway between a portable table and moveable cabinet. The Maintenance Director stated, "A gurney is 26 and a half inches wide. You're right, we could not evacuate an OR patient in a gurney. "

6. On 6/15/10 at 3:25 PM, the Maintenance Director presented the surveyor with a plan titled "Solution to central fire exit" dated 6/15/10 at 3:15 PM. Review of the document revealed:
"Safety: Central Sterile Corridor Fire exit will remain open at all times. Will write a policy to keep evacuation door unobstructed at all times. Immediate action taken: removed soiled linen tub, hazard linens was moved to the closet, metal surgical cabinet was moved to south side of corridor."

7. On 6/16/10 at 9:30 AM, the Director of Ancillary Services presented the surveyor with a policy titled "Central Sterile Corridor Fire Exit " dated 6/15/10. Review of the policy revealed:
"The central sterile corridor fire exit will remain unobstructed at all time for safe evacuation of patients and staff in the event of an emergency."

I. Based on observations and staff interview, the Critical Access Hospital (CAH) failed to secure medications in an anesthesia cart in the Operating room suite. The CAH reported a case load of approximately 10 surgical cases per week.

Failure to secure anesthesia medications could result in unauthorized access, usage, and distribution of medications.

Findings included:

1. Observation of the operating room (OR) suite on 6/14/10 at 4:00 PM with the OR Interim Director revealed: An unlocked anesthesia cart located in OR suite #1. The Interim Director verified the findings and stated, "That is Staff E's cart and it contains anesthesia medications. Access to these medications could be emergency and operating room staff, people off the street, this is not monitored. This could be potentially dangerous." The Director locked the cart.

2. During an interview on 6/15/10 at 8:00 AM, Staff D, Certified/Registered Nurse Anesthetist (CRNA) stated, "Drugs in the anesthesia cart should be locked at all times except when we're present. These are standards. Everything should be secured. I think of my carts as a personal pyxis machine. Anyone off the street without being observed would have access. Right now we do not have an inventory sheet per say. If someone gained access to the cart there would be no way of knowing aside from the narcotics what was removed."

3. During an interview on 6/15/10 at 12:30 PM, Staff E, CRNA stated, "My last day for work was Friday, June 9th. I would assume my cart was unlocked since last Friday. I would think anybody who works in the emergency room would have access. It should be locked, and it usually is locked. I was disciplined for this a couple of years ago."

II. Based on policy review, observations and staff interview, the CAH failed to ensure medications and supplies available for use are not outdated in the Operating/Endoscopy suites. The CAH reported a case load of approximately 8 endoscopy procedures and 10 surgical cases per week.

Failure to remove outdated medications and supplies from patient care areas could potentially result in patients receiving contaminated, ineffective medications and unusable products.

Findings included:

1. Review of hospital policy titled Expired Products Handling (Approved 2/20/09) revealed in part: ... " All products with a factory outdate will be removed from the shelf one month before the actual expiration date and placed on the outdate pallet ... "

2. Observation in the endoscopy room #1 on 6/10/10 at 10:40 AM with Staff E, Registered Nurse (RN) revealed the following:
a. 3- Tender Wet gel pads expired June 2005.
b. 1- Derma Rite dressing expired April 2004.
c. 4- Non-Adhering dressings expired October 2006.
d. 1- Tegaderm dressing expired September 2009.
e. 1- Eternal Endoprosthesis expired December 2009.
f. 1- RepliCare dressing expired June 2009.
g. 1- Absorbent gel wound dressing expired June 2006.
h. 1- Cetacaine Topical Anesthetic spray expired March 2010.
i. 1- Rotatable snare expired January 2009.
j. 1- Tracheal tube expired June 2006. During an interview on 6/10/10 at 10:45 AM, Staff E acknowledged the expired items in the endoscopy room available for patient use. He/she stated, " OR staff are responsible for monitoring for outdates and we do it monthly. "

3. During an interview on 6/10/10 at 11:00 AM, the OR Interim Director acknowledged the expired items in the endoscopy room available for patient use. He/she stated, " I'll dispose of these right away. There's no excuse for this. I would have no way to track how many of these were used for patients. Our policy would be that all outdated supplies be removed and disposed of immediately when they are expired. This is not per policy. "

4. Observation in the recovery room on 6/14/10 at 4:00 PM, with the OR Interim Director revealed the following:
a. 17- Thirty milliliter (ml) Becton Dickinson syringes expired March 2010.

5. Observation in the anti-room on 6/14/10 at 4:00 PM, with the OR Interim Director revealed the following:
a. 24- Maxon " O " 3.5 metric absorbent sutures expired March 2010.
b. 20- Polysorb 30 " 75 centimeter (cm) sutures expired March 2010.
c. 2- Scrub care Provident Iodine cleansing solutions bottles expired February 2010 and May 2010.
d. 1- bag 0.9 Normal Saline, 100 ml expired September 2009.

6. Observation in OR room #1 on 6/14/10 at 4:45 PM, with the OR Interim Director revealed the following:
a. 1 of 3 Zymar Ophthalmic Solution expired February 2010.
b. 1 of 2 Atropine Sulfate Ophthalmic Solution expired January 2010.
c. 1 of 2 Miochol-E intraocular Solution expired April 2010.
d. 2 of 2 Xylocaine 2% expired February 2010.

7. Observation in OR room #2 on 6/14/10 at 4:45 PM, with the OR Interim Director revealed the following:
a. Con Med 6 inch flat blade #3 expired October 2008. During an interview on 6/14/10 at 5:00 PM, the OR Interim Director acknowledged the expired items in the operating room suite available for patient use. He/she stated, " I will dispose of them immediately. "

Based on observation, staff interview the Critical Access Hospital (CAH) failed to assure proper sanitization/disinfection of all exposed surfaces on doors in OR suite #1 for the prevention of infections and communicable diseases. The CAH reported a case load of approximately 10 surgical cases per week.

Failure to ensure all surfaces are sanitized has the potential to harbor microorganisms that may lead to surgical site infections.

1. The hospital lacked evidence of policies and procedures regarding Infection Control/Sanitization of wooden doors in OR.

1. Initial tour of the OR suite on 6/9/10 at 4:40 PM with the OR Interim Director revealed the following: Unsealed, porous surfaces on the wooden doors in OR suite #1. During an interview on 6/9/10 at 4:40 PM, the Interim Director acknowledged the findings. He/she stated, "Look they're wood doors, they can't even be sanitized."

2. During a subsequent interview on 6/15/10 at 7:35 AM the Interim Director stated, "The surfaces are rough and porous. Microorganisms get into the pores. We're not able to clean it properly. I have requested a remedy for this at least once a month since I arrived (approximately 7 months) with upper management and their response is, we'll get to this, but they never have. The maintenance director may have this information. He/she has acknowledged the fact that it should be non-porous."

3. During an interview on 6/15/10 at 9:55 AM the Maintenance director stated, "I checked the doors this morning, there ' s a finish, somewhat, on them but those doors are old." In a subsequent interview on 6/15/10 at 10:10 AM, he/she stated, "The doors were installed in 1963. Let's be honest there are some surfaces on the inside of the door that could not be sanitized. If they want us to we could get a new door in the existing frame, this would probably be the best solution. I received an e-mail from Ancillary Services Director on 6/7/10, that ' s basically when I first knew about it. There are chips in the veneer. After inspecting the doors we do not disagree with your findings."

4. During an interview on 6/15/10 at 2:30 PM the Housekeeping supervisor stated, "I cleaned the doors as best I could. There are areas on the doors that could not be properly disinfected or sanitized. I agree with the maintenance director."

5. On 6/17/10 the Ancillary Services Director presented the surveyor with a memo dated 6/17/10. Review of the memo revealed in part: ... " Replacement of the 2 wooden doors leading into the operating room. The doors will be ordered and installed as soon as possible ... "

Based on review of personnel files, standards set by the Society of Gastroenterology Nurses/Associates, hospital policies and staff interview the Critical Access Hospital (CAH) failed to document education/competency/evaluation for five of five registered nurses assisting with endoscopic procedures.

The CAH ireported a case load of approximately 8 endoscopy procedures per week.

Failure to insure nursing competency with endoscopic procedures puts patients at an increased risk for injury and or complications.

1. The hospital lacked evidence of policies and procedures regarding training and competency of nursing staff assisting with endoscopic procedures.

2. During an interview on 6/9/10 at 2:45 PM the Operating Room (OR) Interim Director stated, "None of the nurses are qualified for endoscopy." In a subsequent interview on 6/15/10 at 7:40 AM he/she stated, "No, the nurses do not having training with performance of flexible sigmoidoscopy. Their personal files lack evidence of on the job training or training competencies as required by the Society of Gastroenterology (SGNA). The Director of Education confirmed this with me in the last couple of days. I have identified and brought up these issues to administrative staff on several occasions."

3. During an interview on 6/14/10 at 2:10 PM the CEO acknowledged personnel records lacked documentation of education/competency for successful performance of gastroenterology procedures. He/she stated, "There is nothing documented for on the job
training under the auspices of the physician. I would be surprised if there was. We do not have a hospital policy regarding this but would follow SGNA guidelines."

4. On 6/9/10 at 4:30 PM the OR Interim Director presented the survey team with the SGNA guidelines, copyright 2009. Review of the SGNA guidelines revealed in part: ... "The society of Gastroenterology Nurses and Associates supports the position that registered nurses educated and experienced in gastroenterology nursing and trained in techniques of flexible sigmoidoscopy may assume this responsibility ... " ..."Registered nurse performing flexible sigmoidoscopy in any practice setting must maintain qualifications and competencies as well as continuous quality improvement programs ..."

5. During an interview on 6/15/10 at 8:20 AM, Staff D, Certified Registered Nurse Anesthesiologist (CRNA) stated, " I observed Staff B pushing and pulling out the scope during a procedure under the direction of a doctor yesterday (6/14/10)."

6. During an interview on 6/16/10 at 1:20 PM, Staff B, RN in OR/Endoscopy acknowledged she/he lacked formal training/certification/competencies for manipulating the endoscope to facilitate an endoscopic procedure. Staff B stated, "I've been assisting with scopes for about 10 years. We may do three or four sometimes even five a day. I have not had any gastroenterology formal training, no. I feel very confident with what I do, if they offered it I would take it."

7. During an interview on 6/17/10 at 8:45 AM, Staff C, RN in OR/Endoscopy acknowledged she/he lacked formal training/certification/competencies for manipulating the endoscope to facilitate an endoscopic procedure. Staff C stated, "The nurses would assist with scopes. I've done that since I worked here for ten years now. The physician's taught me. I have not had formal training or certification for this, no."

8. On 6/17/10 at 10:30 AM the CEO presented the surveyor with a letter dated 6/17/10. Review of this document revealed in part: ... "After discussions with endoscopists and review of literature, we are updating our policy for gastroenterology services at Ellsworth Municipal Hospital to include guidance on nurses advancing the scope during an endoscopic procedure. We feel this will give us a better and more complete policy for the future."

9. Review of the policy titled "Manipulation of Endoscopes during Endoscopic Procedures" dated 6/16/10 revealed in part: ... "The nurse who assumes this role must have knowledge of the techniques of endoscope manipulation and understand the complications associated with endoscopy. He or she must be competent to identify the associated symptom(s) and will initiate appropriate interventions under the direction of a physician ..."

10. During an interview on 6/21/10 at 2:30 PM, Staff A, Registered Nurse (RN) in OR/Endoscopy acknowledged she/he lacked formal training/certification/competencies for manipulating the endoscope to facilitate an endoscopic procedure. Staff A stated, "I've assisted with advancing the scope under the direction of a doctor for seven years. I have not had any formal training or certification."