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Based on review of policy, Healthcare Event Reporting Forms, review of clinical records and interview, it was determined the facility failed to maintain accurate records in that four of four (#1-#4) incidents of a medication error were not documented in the clinical record for four of four (#23-#26) patients. By not documenting the medication errors, the facility was not keeping an accurate record of the patient's course of treatment and care. The failed practice had the potential to affect all patients that are treated at the facility. Findings follow:

A. Record review of the policy titled, "Medical Record," revised on 10/01/18, showed that all medical records must be accurate and complete for every patient.
B. Review of Healthcare Event Reporting Forms showed the following:
1) Event #1 showed Patient #23 received Lorazepam 0.5 mg by mouth instead of Intramuscular as ordered.
2) Event #2 showed Patient #24 received a dose of Immediate Release Sinemet instead of Controlled Release at bedtime.
3) Event #3 showed Patient #25 received a dose of Warfarin when their INR was high.
4) Event #4 showed Patient #26 did not receive a dose of Nafcillin because the roller clamp was never opened and it wasn't discovered until they went to hang the next dose.
C. Review of clinical record showed the following:
1) Patient #23 did not have an order for the by mouth form of Lorazepam. There was no evidence the physician was notified.
2) Patient #24 received Immediate Release Sinemet instead of the Controlled Release form which was ordered at bedtime. There was no evidence the physician was notified.
3) Patient #25 received a dose of Warfarin when their INR was high. There was no evidence the physician was notified.
4) Patient #26 did not receive a dose of Nafcillin. There was no evidence the physician was notified.
D. During an interview on 06/20/18 at 10:16 AM, the Associate Director of Nursing verified the findings at B and C.

Based on review of policy, observation and interview, it was determined in one of one warmer observed intravenous solutions were stored at temperature that exceeded 104 degrees Fahrenheit. By not storing fluids at the proper temperature, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that had procedures in the facility that required warm fluids. Findings follow:

A. Record review of the policy titled, "Medications Stored in Warmers," dated June 2012, showed that fluids could be stored in a warmer if the temperature did not exceed 104 degrees Fahrenheit.
B. During a tour of the facility on 06/18/18 from 12:30 PM to 3:30 PM, observation showed two Hospira 1000 milliliter (ml) Normal Saline for Intravenous infusion solutions in a warmer with a temperature of 120 degrees Fahrenheit.
C. During an interview on 06/18/18 at 1:10 PM, the Director of Surgical Services verified the fluids were stored at 120 degrees Fahrenheit.

Based on review of Rules and Regulations for Hospitals and Related Institutions in Arkansas (2016), observation and interview, it was determined emergency medications were locked instead of being secured with a breakaway seal (per regulation) in one of one (Malignant Hyperthermia) emergency cart observed. By not maintaining emergency medications in a manner that makes them rapidly available, the facility could not assure they were ready for an emergent situation. The failed practice had the likelihood to affect all patients who needed emergency medications. Finding follow:

A. Record review of the "Rules and Regulations for Hospitals and Related Institutions in Arkansas (2016), Section 12.S.4," showed that emergency type medications were to be secured with a breakaway seal, as opposed to being locked with a key.
B. During a tour of the facility on 06/18/18 from 12:30 PM until 3:30 PM; observation showed the Malignant Hyperthermia emergency cart was a locked cart by key or keypad, and it was not secured with a breakaway seal.
C. During an interview on 06/18/18 at 1:10 PM, the Director of Surgical Services #2 verified the Malignant Hyperthermia medications were being stored in a cart that locked.

Based on review of policy, review of Healthcare Event Reporting Forms, review of Clinical Records and interview, it was determined the facility failed to assure in four of four (#23-#26) patients clinical records, there was evidence the practitioner was notified of the medication error. The failed practice did not assure the physician was aware of the medication error so that treatment, if any, could be altered. The failed practice had the likelihood to affect any patient with a medication error. The findings follow:

A. Review of the policy titled, "Occurrence Reporting," showed that a description of the event including what happened, the patient's condition, physician notification and interventions should be recorded in the patient's chart.
B. Review of Healthcare Event Reporting Forms revealed four medication errors dating from June 2017 through May 2018.
C. Review of Patient #23-26's clinical record showed there was no evidence the physician was notified of the medication error.
D. During an interview on 06/20/18 at 10:16 AM, the Associate Director of Nursing verified there was no evidence the physician was notified of the medication errors.

Based on observation, interview and review of manufacturer's instructions for use, it was determined the facility failed to ensure an acceptable level of safety and quality in that manufacturer's instructions were not followed to discard control solutions within three months after opening for one of one point of care blood glucose testing device on the Medical-Surgical Unit. Failure to adhere to the manufacturer's instructions did not assure control solutions were not deteriorated and that the results were reliable and accurate. The failed practice was likely to affect all patients who required point of care blood glucose testing on the medical surgical unit. Findings included:

A. Record review of manufacturer's instructions for the Nova StatStrip Glucose Control Solution on 06/19/18 at 11:23 AM showed that once the control solution vial was opened, it was stable for up to three months or until the expiration date, whichever came first. The expiration date was to be calculated by counting forward three months after opening and that date was to be written on the label of the control solution vial. Any remaining solution was to be discarded after the date written on the vial.
B. Observation on 06/19/18 at 11:00 AM showed one of one, level one, StatStrip Glucose Control Solution with a written discard date of 05/07/18; one of one, level three, StatStrip Glucose Control Solution with a written discard date of 05/028/18.
C. Registered Nurse #2; Quality Management, and the Associate Director of Nursing confirmed the findings in B on 06/19/18 at 11:13 AM.

Based on observation of the kitchen and interview, it was determined the Infection Control Officer failed to prevent possible sources of infection in that food items were available for use beyond the expiration date in two of two (Walk-in cooler and Walk-in freezer) refrigerated/freezer storage; large accumulation of condensation in one of one walk-in freezer (that had dripped onto packaged food items); one of one dusty fan in use in clean food preparation area; one of one Dessert/salad refrigerator showed foods out of original container and not dated or labeled, and one of three fryers with an accumulation of grease on the outside surface and dark colored grease in the reservoir. The facility could not assure the integrity of the expired items or that likely sources of foodborne illness would be prevented. The failed practice was likely to affect all patients and staff. Findings included:

A. Observation of the kitchen with the Food and Nutrition Services Manager and the Director of Food and Nutritional Services on 06/19/18 from 2:00 PM-3:00 PM showed the following:
1) Walk-in cooler: two of two, one-half gallons of buttermilk (expired 06/15/18); three of three, one gallon containers of milk (expired 06/16/18); Cream of mushroom soup expired 05/16/18. The Food and Nutrition Services Manager confirmed the items were expired on 06/19/18 at 2:09 PM.
2) Walk in freezer: Large accumulation of condensation that had dripped onto shelving, floor, and 25, one gallon size bags of frozen food. The 25 bags of frozen food were stored directly under the freezer fans, out of their original containers and in a bag that was not permanently sealed. The bags of food could become opened and contamination of food contents could occur. The Food and Nutrition Services Manager confirmed the accumulation of condensation in the freezer on 06/19/18 at 2:17 PM.
3) Observation on 06/19/18 at 2:21 PM showed a fan in use that had an accumulation of dust on the blade and housing surfaces. The soiled fan was positioned and blowing across the clean food preparation area at the time of observation.
4) Dessert and salad refrigerator: A total of 17 clear plastic individual desserts, not in original packaging, without a date or label. The Food and Nutrition Services Manager confirmed on 06/19/18 at 2:24 PM the items were not dated and therefore expiration could not be determined.
5) Three individual cakes without a date or label observed in the dessert freezer. One plastic bag of frozen cornbread without a date or label observed in the vegetable freezer. The Food and Nutrition Services Manager confirmed on 06/19/18 at 2:25 PM that the items were not dated and therefore expiration could not be determined.
6) Deep Fryer: layered buildup of grease down the side of one of three deep fryers. The fryer oil reservoir was filled with dark brown oil. An accumulation of grease and oil was observed on the surface of the floor beside the fryer. The Food and Nutrition Services Manager stated on 06/19/18 at 2:30 PM that the fryer had not been working for approximately one to one and one-half years, and that "it hasn't worked the entire time I've been here." Food Service Staff #1 was interviewed on 06/19/18 at 2:35 PM and stated the fryer has not been working for several months.
B. The Director of Food and Nutritional Services was present at the time of the kitchen observation and confirmed the findings in A.


Based on review of policy, observation of the laundry and interview, it was determined the Infection Control Officer failed to identify and control possible sources of infection in that: clean laundered items were stored beside soiled items in one of one soiled processing area; five of five transport and storage bins for clean linen were soiled and three of three tables used to fold clean laundry had an accumulation of cloth type tape, which created a porous surface and did not allow the table to be cleaned and sanitized. The facility could not ensure clean laundry would be processed, transported and stored to protect from likely sources of contamination. The failed practice was likely to affect the patient census of four on 06/19/19, and any patient admitted to the facility. Findings included:

A. Record review of the facility's policy titled,"Linen Handling," dated 03/04/16, showed linen was to be delivered to units in clean, covered carts and that linen was stored in a manner and location to prevent contamination from dirty items and from dust.
Observation of the laundry area on 06/19/18 from 1:20 PM-1:50 PM showed:
A. The soiled laundry processing area held shelves that contained clean mops and towels. The shelves were not covered to prevent contamination of the contents. To the left and right of the shelves, that contained clean mops and towels, was one bin labeled dirty microfiber mops and one labeled dirty flat mops and towels. The Support Services Director and Laundry Supervisor confirmed on 06/19/18 at 1:27 PM the contents of the partially covered shelves were clean and located within the soiled processing area and that the bins located on each side contained soiled items.
B. The clean laundry processing area had five of five laundry bins used to transport clean laundry . The bins were constructed of plastic type material, attached to the metal frame by rope through metal grommets. The rope attaching the bins was discolored and porous and unable to be sanitized. The frames of five of five bins were disty and had an accumulation of rust on the surfaces.The rust on the metal frames created an irregular surface and was likely to harbor bacteria.
C. Three tables in the clean laundry processing area were observed with a cloth type tape along a portion of the edge on each of the three tables. The tape was porous and discolored and did not allow the table to be cleaned and sanitized. The Laundry Supervisor stated by interview on 06/19/18 at 1:42 PM that the table was used to fold clean laundry items.


Based on review of policies, observation, and interview, it was determined the Infection Control Officer failed to prevent likely sources of infection and maintain a sanitary environment in that four of four patient care areas observed (Medical/Surgical, Outpatient Services, Radiology, Maternal Child) had an accumulation of dust in patient rooms, on computers, keyboards, computer mobile stands and opened single use suction connection tubing. The facility could not be assured patients would be protected from likely sources of infection and affected all patients treated at the facility. Findings included:

A. Review of the policy titled,"Cleaning of Computers and/or Electronic Equipment," 12/2012, showed computer workstations on wheels frames were to be cleaned a minimum of one time per shift. Keyboards/mouse/scanner/monitors in patient rooms and on workstations on wheels that were labeled "seal shield" could be cleaned with hospital approved disinfectant wipes and should be cleaned at least once per shift.
B. Review of the policy titled, "Seven-Step Cleaning Procedure" showed that all horizontal surfaces above shoulder height were to be high dusted, beginning at the room door and working systematically around the room and then returning to the door. The high dusting process included induction units, televisions, pipes, ledges, widows, drapes, blinds, lights, corners and door frames. Damp wiping to disinfect all surfaces (top, bottom, and sides) below shoulder height. Clean all furniture, including closets, cabinets, and inside drawers.
C. Observation on 06/18/18 from 12:30 PM-3:29 PM of areas identified as clean and ready for patient use showed:
1) Medical/Surgical Unit: dust observed on closet doors, induction units, and high dust surfaces in Rooms 211, 212, 214 and 217. The findings were confirmed at the time of observation by the Associate Director of Nursing.
2) Outpatient Services: suction connection tubing open and attached to a suction canister mounted on the wall in Rooms 2-6 and 10; It could not be assured the opened suction connection tubing was single use. Welch Allyn vital sign equipment that was dusty and had and accumulation of tape residue on the equipment (room #10) which created a porous surface and did not allow the equipment to be cleaned. The findings were confirmed at the time of observation by Registered Nurse (RN) #1.
3) Maternal Child Unit: Rooms 133-136 had an accumulation of dust on the computer keyboards, closet doors and induction units. Overbed light cords that were porous, string like material and therefore could not be sanitized between patients. The findings were confirmed at the time of observation by the Nurse Manager of Maternal Child.
D. Observation of the Radiology Department on 06/21/18 from 2:05 PM-2:36 PM showed Room #3 with suction tubing that was opened and attached to wall suction. It could not be assured the suction tubing was clean and single use The finding was confirmed by the Director of Radiology at the time of observation.
E. Observation on 06/19/18 from 9:45 AM-10:31 AM of Environmental Services Technician #1 cleaning a discharged patient room showed the induction unit, door handles, closet doors and bottom of Intravenous (IV) pole were not cleaned or dusted when Environmental Services Technician #1 stated she had completed the room cleaning. The findings were confirmed by the Associate Director of Nursing at the time of observation.


Based on observation and interview, it was determined the Infection Control Officer failed to prevent and control likely sources of infection in the Surgical Services Department in that single use items were open and available for use in three of three (Urology Room, Operating Rooms #1 and #2) operating rooms observed and tape and rust were observed on an infant warmer (Urology Room). The presence of tape residue and rust did not allow the surface of the warmer to be cleaned and sanitized. Patients would not be protected from likely sources of infection. The failed practice was likely to affect any patient who had a surgical procedure. Findings included:

A. Observation on 06/18/18 at 1:03 PM-1:45 PM of Surgical Services Department identified as clean and ready for use showed :
1) Urology Room: Air shield infant warmer with an accumulation of tape residue on the sides of the unit, and rust on the bottom. The presence of tape and rust created an irregular surface and did not allow the surface to be cleaned and sanitized. On a shelf beside the anesthesia cart, there were two Shiley Intubation Stylets, size 14 French that were open and not in a package. The label printed on the catheter stated it was s single use.
2) Operating Room #1: On the Anesthesia Cart, one disposable, single use laryngoscope blade, open and attached to a laryngoscope handle.
3) Operating Room #2: opened and attached suction tubing.
B. The findings in A were confirmed on 06/18/18 at the time of observation by the Director of Surgical Services.



Based on review of MetriCide OPA solution policy and procedure, manufacturers' instructions, MetriCide OPA documentation log and interview, it was determined the Infection Contorl Officer failed to ensure staff adhered to policies and procedures for testing the minimum effective concentration (MEC) of the solution prior to use for high level disinfection of endoscopes in five of thirty times of use from 05/01/18-05/31/18. Failure to test the MEC prior to each use did not ensure high level disinfection of the endoscopes would be achieved and that patients would be protected from likely sources of infection. The failed practice was likely to affect any patient the endoscopes were used on in which the MEC was not checked prior to high level disinfection. Findings included:

A. Record review of the undated policy, "MetriCide OPA Plus Solution Before Each Use Testing," on 06/20/18 showed that testing of MetriCide OPA Plus solution was to be performed before each use: results were to be read (color reaction) on the pad at 60 seconds; if any yellow appeared on the test pad that the solution was below the MEC; solution should be discarded and results were to be recorded in the logbook.
B. Record review of the MetriCide OPA Plus Solution manufacturer's instructions on 06/21/18 showed that MetriCide OPA Plus Solution MEC was to be verified prior to each use to guard against dilution that may lower the orthPhthalaldehyde level. If any yellow color showed on the test strip pad, the solution should be discarded. The results of the testing should be recorded on the MetriCide OPA testing log sheet.
C. Record review of the Metricide OPA Documentation Log provided on 06/20/18 showed no documentation the Metricide OPA solution MEC was checked prior to use for high level disinfection of endoscopes on 05/17/18 at 10:35 AM; 05/25/18 at 8:10 AM; 05/30/18 at 8:15 AM, 8:47 AM and 9:17 AM.
D. The Director of Surgical Services confirmed the findings in C. on 06/21/18 at 9:53 AM.


Based on review of policy, observation and interview, it was determined the Infection Control Officer failed to prevent and control possible sources of infection in the Surgical Services Department in that personnel did not utilize utility gloves for decontamination and handling contaminated instruments and the tops of two of four soiled instrument transport bins were cracked and broken. The facility could not ensure personnel were protected from exposure to potentially infectious blood or body fluids and likely affected any staff who transported or processed instruments. Finding included:

A. Record review of facility infection control policy and procedure titled, "Decontamination/Disinfection/Sterilization," dated 08/2016, showed staff were to wear personal protective equipment for decontamination and physical cleaning of instruments that included general purpose utility gloves and the policy specified "not exam gloves".
B. Observation on 06/21/18 at 9:24 AM showed Licensed Practical Nurse (LPN) #1 removed soiled instruments and proceeded to decontaminate instruments wearing protective gown and eyewear, and exam gloves. The gloves utilized by LPN #1 were removed from a box labeled Flexal Nitrile Exam gloves. The gloves were cuff length and not specified as puncture resistant or labeled as general purpose utility gloves as required per policy. LPN #1 stated at the time of observation that the gloves used for decontamination were exam gloves.
C. Observation on 06/21/18 at 9:41 AM showed lids on two of four bins, labeled and identified by staff as used to transport contaminated instrument were cracked and broken.
D. The Director of Surgical Services confirmed the findings in A and B at the time of observation.


Based on record review of policy, observation, and interview it was determined the Infection Control Officer failed to assure the cleaning and disinfection practices of environmental services personnel within the operating room (OR) suite were monitored and evaluated to assure a compliance with policies. The failed practice did not ensure surgical patients and staff would be protected from likely sources of infection and was likely to affect all patients and staff. Findings included:

A. Record review of the undated facility policy for cleaning, titled "Seven-Step Cleaning Procedure," showed that staff were to disinfect the inside, the rigid liner and the outside of the biohazard waste container as necessary. Record review of Infection Prevention training, titled "Infection Prevention"copy dated 06/18/18, showed gloves were to be kept clean.
B. Record review of the document provided on 06/22/18 by the Director of Nursing, titled "Cleaning of the OR Suite" by the Perioperative Nurse Educator for Registered Nurses, Scrub technicians, cleaning Aides, and porters showed that after each procedure a clean environment should be re-established.
C. Continuous observation on 06/20/18 from 11:10 AM through 11:57 AM showed Environmental Service Technician #2 perform cleaning of Operating Room #2. Environmental Service Technician #2 had on a gown and gloves and damp dusted equipment and horizontal surfaces. At 11:31 AM, Environmental Service Technician #2 wiped the inside of a red biohazard waste container, then used the same gloves and cleaning cloth to wipe the outside of the container. After discarding the soiled cloth, the floor was mopped twice while continuing to wear the same soiled gloves. Technician #2 touched six pieces of equipment in the room, two different times while mopping. Technician #2 did not change gloves or perform hand hygiene from 11:31 AM to 11:45 AM prior to mopping the floor or touching clean equipment.
D. The findings in C. were confirmed on 06/20/18 at 11:57 by interview with Environmental Service Technician #2 and Quality Management.


Based on record review of policies, national standards, observation and interview, it was determined the Infection Control Officers failed to monitor and evaluate the laundering process surgical scrub attire worn in the semi-restricted and restricted areas of Surgical Services. Failure to perform surveillance activities to assure staff compliance with infection prevention policies for laundering scrubs at home did not ensure patients and staff would be protected from bloodborne pathogens or other infectious materials. The failed practiced likely affected all patients and staff. Findings included:

A. Record review of a document provided by the facility on 06/22/18, dated 08/23/17, "Instructions for Laundering Scrubs," showed that scrubs were to be washed separately from other clothes, hot water and laundry detergent were to be used to wash the scrubs, scrubs were to be dried in the dryer and scrubs were to be stored in a manner to ensure continued cleanliness and minimize fungal growth. The policy referenced the Center for Disease Control and Prevention, Guidelines for Environmental Infection Control in health care facilities, MMWR Rep 2003;52.
B. Record review of undated document provided by the facility on 06/22/18, Home Laundered vs Hospital Laundered Scrubs in the OR shows scrub use considerations included cleanliness of scrubs and that the dress code requires clean clothing.
C. Record review of the facility's policy titled, "Dress Code," dated 04/10/18, showed that staff in the procedural areas (Surgery, Cath Lab, Labor and Delivery, Special Procedures) were responsible for providing and laundering their own scrubs and scrubs could be worn to and from the hospital.
D. Record review 06/22/18 of the 2016 Guidelines for PeriOperative Practice, by the Association of PeriOperative Registered Nurses (AORN) showed that using health care-accredited laundry facilities was recommended because they meet industry standards to minimize patient, staff and community risk of exposure to potential bloodborne pathogens and other infectious disease.
E. In an interview with the Infection Control Officer on 06/19/18 at 3:30 PM it was stated that staff laundered their own scrubs for surgery; that an equal number of national organizations recommended home laundering versus the number against home laundering. From 06/18-18-06/22/18, the facility provided no evidence that staff home laundering processes were monitored by the facility to ensure policy compliance and that surgical scrubs were: washed separately from other clothes; hot water and laundry detergent were used to wash the scrubs; scrubs were dried in the dryer and scrubs were stored to ensure continued cleanliness and minimize fungal growth.
F. Environmental Services Technician #2 (observed working in Surgical Services) stated on 06/20/18 at 11:57 AM that scrubs worn were obtained from the facility laundry and not home laundered scrubs.
G. The Director of Surgical Services on 06/21/18 at 2:30 PM stated staff are allowed to wash their surgical scrubs at home.
H. Surgical Services Licensed Practical Nurse (LPN) #1 on 06/21/18 at 9:24 AM stated scrubs worn were not home laundered and that LPN #1 saved the worn scrubs and sent them one time per week to the hospital laundry.
I. Scrub Technician #1 stated by interview on 06/21/18 at 9:25 AM that their scrubs were worn into the facility and then laundered at home.