HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to offer ongoing abuse and neglect training for 8 (A, B, C, D, E, F, G, and AA) of 35 reviewed staff members. Findings include:

During an observation and interview on 1/6/20 at 3:00 p.m., staff member D was seen speaking with patient #1, signing in for therapy, and updating the patient's information.

During an observation on 1/6/20 at 3:07 p.m., staff member A was talking with patient #1, while the patient received physical therapy from staff member N.

During an observation and interview on 1/7/20 at 9:01 a.m., staff member F was in the same day surgery recovery room area. The staff member was observed interacting with patients and overseeing staff. The staff member stated she interacted with patients and assisted in various duties involving patients.

During an interview on 1/9/20 at 9:40 a.m., staff member I stated the training had been missed for staff member AA, and she would receive the training on 1/9/20.

Review of staff member AA's training record for the past year did not include abuse and neglect training.

During an interview on 1/9/20 at 10:05 a.m., staff member I stated managers did not have patient direct contact, so managers were not assigned to take abuse training. The staff member did say the managers were around patients, "It might be a weakness in our process."

During an interview on 1/9/20 at 10:55 a.m., staff member B stated, being a manager, and not having "hands on care of patients," managers were not required to have abuse/neglect training. Staff member B stated she was telling her staff to go to the floor nurse to report any allegations of abuse. Staff member B stated she would need to get advice from "HR," (Human Resources), if she encountered an abuse situation or her staff came to her about an allegation of abuse. Staff member B stated she could benefit from training on abuse.

During an interview on 1/9/20 at 11:15 a.m., staff member C stated she would report to her supervisor, staff member B, if she saw or heard of allegations of abuse. The staff member stated she was trained to report to her immediate supervisor.

During an interview on 1/9/20 at 11:20 a.m., staff member G stated she had not had any abuse and neglect training from the facility. She stated she had rare patient contact, and her staff had been trained on abuse and neglect.

Review of staff training records, for the past year, showed staff members A-G and AA did not have documentation of ongoing abuse/neglect training.

Review of the hospital's policy/procedure titled, "Abuse and Neglect Identification and Assessment," lacked documentation showing staff were required to have continual education/training on abuse/neglect.

Due to the location and degree of the deficient practice, the facility failed to meet the Condition of Participation for Physical Environment.

Based on observation and interview, the facility failed to:

-Provide hard-surface walkways to the public way for 4 marked exits out of the building. (See K271, Building 01 of the Life Safety Code Survey Event ID: 42RM21)

-To maintain oxygen zone valves in the proper location outside the operating room. (See K323, Building 13 of the Life Safety Code Survey Event ID: 42RM21)

1. During an observation on 1/8/2020 at 10:01 a.m., the marked exits from the Medical-Surgical and Postpartum floors in the hospital were inspected. The Med-Surg was on the first floor, the Postpartum corridors were on the second floor with marked exits on each corridor leading to an enclosed stairwell down to the first floor and then outside of the building. Due to ongoing construction, the hard-surface pathways out of each of the first floor exits were destroyed in the construction areas.

In an interview on 1/8/2020 at 10:05 a.m., staff member FF stated the exits had been blocked off for months, since the start of construction, and it was not mentioned during the accreditation survey.

2. During an observation on 1/6/2020 at 4:07 p.m., the Downtown Same-Day Surgery Center was inspected. The zone-valve medical gas shut-off valves were found to be located inside the operating room. NFPA 99 2012 Edition, Section 5.1.4.8 and 5.1.4.8.7, states the zone valves must be able to be operated from a standing position in the corridor, located immediately outside the room the sedation or anesthesia is taking place.

In an interview on 1/6/2020 at 4:15 p.m., staff member GG stated that in the last survey of the building, in 2012, the surveyor let it go because they were going to be moving the surgery center out of the building to another location very soon.

Based on observation, interview, and record review, facility staff failed to effectively implement infection control practices to mitigate the spread of infection in the perioperative setting by wearing artificial nails. This deficient practice had the potential to affect all patients receiving services in the perioperative setting. Findings include:

During an observation and interview on 1/8/20 at 9:40 a.m., staff members K and L, working in the perioperative setting, wore painted nails. Staff member J stated both staff members were "circulator nurses" in the operating room. Staff member J stated the facility policy followed the Association of periOperative Registered Nurses (AORN)¹ guidelines for the use of ultraviolet (UV)- cured nail polish (gel, Shellac...).

During an interview on 1/8/20 at 2:25 p.m., staff member J stated artificial nails were not allowed in the perioperative setting. Staff member J stated she was not sure if Gel or Shellacked nails were considered artificial.

During an observation and interview on 1/9/20 at 10:10 a.m., staff member L wore short, thick, purple painted, nails. Staff member L's natural nail could be seen when the staff member turned her hands over. Staff member L stated her nails were Gel/Shellacked with UV light. Staff member L stated she had worked in the perioperative setting for three years, and stated she had never been told her nail attire was a problem in the operating room. Staff member L stated she had her nails manicured every 2 weeks. Staff member L stated artificial nails were not allowed in the perioperative setting.

During an observation and interview on 1/9/20 at 10:17 a.m., staff member K wore painted, black nails, with several nails painted with gold glitter. Staff member K stated her nails were Shellac/Gel painted. Staff member K's natural nail could be seen when the staff member turned her hands over. Staff member K stated she had worked in the perioperative setting for twenty-eight years. Staff member K stated an incident had occurred, in the past, when she could not get blue Gel nail polish off her nail, but had not been told that her current nail attire was a problem in the operating room. Staff member K stated the hospital policy stated acrylic nails were not allowed in the perioperative setting, but regular nail polish was allowed. Staff member K stated she had her nails manicured every 2 weeks.

During an interview on 1/9/20 at 10:55 a.m., staff member Z stated she was fairly new to her position, and was not familiar with types of fingernail treatments, but would initiate and investigate immediately.

A review of the hospital's policy, Surgical Attire, dated 11/2019, read, "...5. Fingernails are to be kept short, clean, and healthy. No artificial nails are permitted..."

A review of the hospital's policy, Hand Hygiene, dated 10/2018, read, "...7. Artificial nails and nail jewels are prohibited for all healthcare workers and providers who provide direct, 'hands-on' patient care, across the continuum of care, including but not limited to:...perioperative services..."

References:

¹ AORN.org

"Artificial nails should not be worn in the perioperative environment. Any nail other than a natural nail is considered artificial. Artificial nails are defined as any substance or device applied or added to the natural nails to augment or enhance the nail, including bonding, extensions, tips, wraps, gel and acrylic overlays, and tapes. Artificial nails have been associated with hand contamination and epidemiologically implicated in outbreaks caused by gram-negative bacteria and yeast."

Updated July 6, 2016

Due to the degree of the deficient practice, the facility failed to meet the Condition of Participation for Anesthesia Services.

Based on observation, interview, and record review:

The facility staff failed to ensure medications used in the preoperative area were free from contamination and fragmentation, and staff failed to report the issues with coring and sheering of the rubber stopper (Refer to A1002).


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Based on observation, interview, and record review, facility staff failed to ensure medications used in the preoperative area, for a patient nerve block, were free from contamination and fragmentation from the rubber cap² secondary to the use of a blunt cannula; and failed to report issues with coring and sheering of the rubber stopper to management staff. This deficient practice had the potential to affect all patients receiving services in the perioperative setting. Findings include:

During an observation and interview on 1/8/20 at 8:18 a.m., a 50 milliliter (mL) multidose vial of Sensorcain 0.25% was found on top of the preoperative cart in the perioperative area. There was approximately 15 mL of fluid in the vial. A macroscopic, black floating particle could be seen inside of the vial. Staff member R stated the floating particle was most likely a fragmentation of the rubber stopper from the blunt tip of the plastic cannula used to draw up medication into the syringe. A second, opened, 50 mL multidose vial of Sensorcain 0.25% was found inside of the same cart. There was approximately 40 mL of fluid in the vial. Floating in the vial was a macroscopic, black particle. A box of BD Blunt Plastic Cannulas was available on the cart for staff to use during the aspiration and preparation for a patient's nerve block. Staff member R stated she was going to discard both vials after showing them to other members of management staff. Staff member R stated the hospital had switched to the BD Blunt Plastic Cannulas approximately 5 years prior.

During an interview on 1/8/20 at 10:23 a.m., staff member W stated he began swapping out the BD Blunt Plastic Cannulas for the Covidien Needleless Med Pre Cannula in the perioperative setting. He stated the hospital was waiting for their ordered supplies to arrive from the distributor.

During an interview on 1/8/20 at 2:55 p.m., staff member R stated she had spoken with staff member X and stated, "[Staff member X] has seen the floating particles many times, but never told anyone."

During an interview and record review on 1/9/20 at 9:40 a.m., staff member S stated the Products Committee had recommended and approved a switch from the BD Blunt Plastic Cannulas to the Covidien Needleless Med Pre Cannula on 12/2/19. Staff member S stated he was told it, "Makes drawing up meds [sic] very easy and efficient." Staff member S stated an order for the new needleless cannulas was submitted to the distributor on 12/5/19. He stated the new order would take 2-3 weeks before it would be received, and hospital staff had access to other supplies of Covidien Cannulas kept in other hospital departments. Staff member S stated he would begin distributing a case of Covidien Needleless Cannula from the distributing department, which was readily available, to the perioperative setting. Staff member S stated he was not aware of fragmentation from the rubber cap resulting in macroscopic, black particles to be seen floating in opened multidose vials of Sensorcain 0.25% that were observed to be used.

During an interview on 1/9/20 at 10:30 a.m., staff member T stated she had observed floating, black particles in multidose vials of Sensorcain 0.25% in the past, but was careful not to aspirate a particle into the syringe. She stated the preoperative department "goes through several [multidose vials] of Sensorcain daily." Staff member T stated she had not reported the incident of floating particles to anyone, when discovered, and discarded the vial of Sensorcain. Staff member T stated she would inform members of management if any macroscopic particles were seen in multidose vials of Sensorcain in the future. Staff member T stated possible complications of injecting a particle into a patient could result in infection.

During an interview on 1/9/20 at 10:45 a.m., staff member V stated he had been recently trained on administering a nerve block to patients receiving Sensorcain 0.25%. Staff member V stated he had noticed macroscopic black particles floating in the multidose vials in the past. Staff member V stated his process for administering injectable medications included "checking" the vial for contaminants, discarding the vial if there was a problem, and replacing the vial with an unopened vial when needed. Staff member V stated he did not report the incident of floating particles to members of the management team when it was discovered in the Sensorcain, but discarded the vial, and replaced it with a new vial. Staff member V stated possible complications of injecting a particle into a patient could be an infection.

During an interview on 1/9/20 at 1:02 p.m., staff member X stated she had observed black particles floating in multidose vials of Sensorcain in the past. Staff member X stated the macroscopic particles were too large to be injected into a patient, if a particle or fragment was accidently aspirated into a syringe. She stated she had not reported any macroscopic particles to anyone, and discarded the vial of Sensorcain when particles were seen. Staff member X stated nerve blocks were usually injected with a 24-guage, or narrower, needle.³

A review of a hospital policy, Multidose Medication-Use Of," read, "...The integrity of the stopper is checked and the vial checked for any particulate matter prior to use...If contamination is suspected, a new vial is to be used."

References:

² https://www.apsf.org/article/coring-and-fragmentation-may-occur-with-rubber-cap-and-blunt-needles/

"The issue of coring, the shearing off of a portion of the rubber stopper from a medication vial as it is pierced has been described in the past. The frequency of such incidents seems to be rising as the use of blunt plastic tips increases. Per one study, the incidence of coring was 29% with blunt plastic needles as opposed to only 4% with acutely beveled sharp steel needles. ...Exposure to the macro and microscopic rubber fragments has been linked to latex allergy as well as embolization into small vessels causing ischemia."

³ "Aspiration of a cylinder shaped rubber core back into the syringe followed by introduction into a patient's blood stream might seem an unlikely combination of events. A case of near-embolization of the rubber core from a propofol vial that lodged itself into the 24-gauge angiocath interrupting the propofol infusion and setting off the high-pressure pump alarm during a rigid bronchoscopy has been reported."