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Based on review of policy, review of Medication Variance Reports and interview, it was determined the facility failed to notify the practitioner who ordered the medication of the medication variance (error) for 13 (Medication Errors # 1, 3-5, 7-11, 13-14, and 16-17) of 17 (Medication errors #1-17) reviewed. The failed practice did not assure the patients' physicians were kept abreast of the patient's condition and were not involved in the decisions of what to do after the error occurred. The failed practice had the potential to affect all patients. Findings follow:

A. Review of policy titled Medication Error Reporting stated "When a medication error occurs, three things should occur in this order. Notify the physician and evaluate the patient ..."
B. Review of Medication Variance Forms from 12/01/14 through 12/14/15 revealed Medication Errors # 1, 3-5, 7-11, 13-14 and 16-17 were not reported to the prescribing physician.
C. During an interview on 12/16/15 at 1515, the Director of Pharmacy verified there was no evidence the practitioner who ordered the medication was not notified of Medication Errors # 1, 3-5, 7-11, 13-14 and 16-17.

Based on observation and interview, it was determined the Infection Control Officer failed to control infection in that one of one (Registered Nurse #1) of two (Registered Nurse #1 and Certified Nursing Assistant #1) staff observed failed to disinfect the glucometer device after performing glucose testing and prior to returning it to the nursing station for one of two glucose testing observed. The failed practice promoted the spread of infection and had the potential to affect all patients on which the glucometer was used. The findings follow:

A. Observation on 12/06/15 at 1425 revealed Registered Nurse #1 took the glucometer to the patient's room to perform glucometer testing. Registered Nurse #1 placed the glucometer device on the patient's bedside table. Registered Nurse #1 performed the glucose testing on the patient then returned the glucometer device to the docking station at the nurses' station. Registered Nurse #1 did not disinfect the glucometer device prior to returning it to the nurses' station.
B. In an interview with Registered Nurse #1 on 12/06/15 at 1425, she confirmed she should have disinfected the glucometer prior to returning it to the nurses' station and prior to placing it into the docking station.


Based on observation and interview, it was determined the Infection Control Officer failed to control infection in that one (Surgery Orderly #1) of three (Surgery Orderly #1 and #2 and Anesthesia Technician #1) staff observed failed to dispose of and change cleaning cloths after cleaning each surface of Operating Room Suite #5. The failed practice had the potential to cause cross contamination and had the potential to affect all patients in the Operating Room. The findings follow:

A. Observation on 12/15/15 from 0900 to 0930 revealed Surgery Orderly #1 disinfected the patient operating room bed, the over-head lights, four tables and the legs of the table and the computer table in Operating Room Suite #5. Surgery Orderly #1 used the same rag to disinfect the surfaces of the operating room suite.
B. In an interview with the Operating Room Supervisor on 12/15/15 at 0945, she confirmed Surgery Orderly #1 should have changed her disinfecting rag after each surface.


Based on observation, review of manufacturer's direction for use and interview, it was determined the Infection Control Officer failed to control infection in that one of one "Chemical Indicators for System 1E Processor" bottle containing test strips used for verifying the paracetic acid concentration of the endoscopy cleaning device was not dated as to when it was opened. The failed practice did not ensure the test strips were not used after six months after opening per the manufacturer's directions for use. The failed practice had the potential to affect all patients on which the endoscopes were used. The findings follow:

A. Observation on 12/15/15 at 1115 revealed the bottle of "Chemical Indicators for System 1E Processor" was not dated when the bottle was opened.
B. Review of the manufacturer's directions for use for the "Chemical Indicator for System 1E Processor" revealed, "Instructions for use: Check the expiration date on the bottle. Do not use an indicator beyond the expiration date. If a new bottle is being opened, record the date it was first opened and the new 6 month expiration date on the bottle (See Expiration Date). Expiration Date: The expiration date is stated on the bottle. After first opening the bottle, the shelf life is 6 months from the date opened, or the printed expiration, whichever is shortest. Do not use after the expiration date."
C. The findings of A and B were confirmed in an interview with the Director of Surgical Services on 12/15/15 at 1115.


Based on review of the manufacturer's directions for use and interview, it was determined the Infection Control Officer failed to control infection in that one of one (GI (Gastrointestinal) Technician #1) staff observed had not received color blindness testing to determine the color change for the chemical indicators for the endoscope processors. The failed practice did not ensure GI Technician #1 could determine color changes to verify the presence of the paracetic acid in the endoscope processing. The failed practice had the potential to affect all patients on which the endoscopes were used. The findings follow:

A. Review of the manufacturer's directions for use for the "Chemical Indicator for System 1E Processor" on 12/15/15 revealed "Performance Limitations: The Verify Chemical Indicator strips for the System 1E Processor should not be used by anyone with color blindness specific to the colors in the indicators. Ensure that all users are able to distinguish processed and unprocessed indicator colors."
B. A request for GI Technician #1's color blindness testing was made to the Director of Surgical Services on 12/15/15 at 1140. In an interview with the Director of Surgical Services on 12/15/15 at 1140, he stated GI Technician #1 had not received color blindness testing.


Based on observation and interview, it was determined the Infection Control Officer failed to control infection in that one of one (GI (Gastrointestinal) Technician #1) staff observed wore the gown she used for processing dirty endoscopes into the procedure room where an endoscopic procedure was being performed. The failed practice promoted the spread of infection through cross contamination and had the potential to affect all patients undergoing an endoscopic procedure. The findings follow:

A. Observation on 12/15/15 at 1140 revealed GI Technician #1 wore a gown while performing rinsing and disinfection of an endoscope used for an endoscopic procedure (dirty task). GI Technician #1 did not remove her gown and don a clean gown prior to entering the Procedure Room to assist with another endoscopic procedure (clean task).
B. The findings of A were confirmed in an interview with the Director of Surgical Services on 12/15/15 at 1140.


Based on observation and interview, it was determined the Infection Control Officer failed to control infection in that one of one (GI (Gastrointestinal) Technician #1) staff observed removed her gown used to rinse and disinfect endoscopes and hung the gown on the door to the cabinet where processed (clean) endoscopes were stored. The failed practice promoted the spread of infection through cross contamination and had the potential to affect all patients undergoing an endoscopic procedure. The findings follow:

A. Observation on 12/15/15 at 1135 revealed GI Technician #1 removed her gown used to rinse and process endoscopes that were used in a procedure (dirty task) and hung the gown on the door of the cabinet where processed (clean) endoscopes were stored.
B. The findings of A were confirmed in an interview with the Director of Surgical Services on 12/15/15 at 1140.


Based on observation, policy and procedure review and interview, it was determined the Infection Control Officer failed to control infection in that 3 of 11 endoscopes stored in a storage cabinet were touching the pad on the bottom of the cabinet. The failed practice promoted the spread of infection through cross contamination and had the potential to affect all patients undergoing an endoscopic procedure. The findings follow:

A. Observation on 12/15/15 at 1130 revealed 3 of 11 endoscopes stored in a storage cabinet were touching the pad on the bottom of the cabinet. The findings were confirmed in an interview with the Director of Surgical Services on 12/15/15 at 1130.
B. Review of the policy "Cleaning, Disinfection and Storage of Gastroscopes and Colonoscopes" on 12/15/15 revealed "Storage of the endoscopes and reusable parts: Hang the endoscopes in the storage cabinet with the distal end hanging freely. Make sure that the insertion section hangs vertically and as straight as possible." The findings were confirmed in an interview with the Director of Surgical Services on 12/15/15 at 1300.


Based on observation and interview, it was determined the Infection Control Officer failed to control infection in that one of one rolling computer cart was not disinfected after taking into a patient's room and prior to taking it to the nurses' station. The failed practice promoted the spread of infection through cross contamination. The failed practice had the potential to affect all patients the rolling computer cart was taken into their rooms. The findings follow:

A. Observation on 12/16/15 at 1505 revealed Registered Respiratory Therapist (RRT) #1 took a rolling computer cart into patient Room #5203. RRT #1 performed a respiratory therapy treatment on Patient #31. RRT #1 documented on the rolling computer cart using the keyboard and the computer mouse without performing hand hygiene after documenting. After completing of the treatment, RRT #1 removed the rolling computer cart from the patient room and returned it to the nurses' station. RRT #1 did not disinfect the rolling computer cart prior to returning the cart to the nurses' station.
B. In an interview with RRT #1 on 12/16/15 at 1520, she confirmed she should have disinfected the rolling computer cart after removing the cart from the patient room and prior to returning it to the nurses' station.


Based on observation, review of manufacturer's directions for use and interview, it was determined the Infection Control Officer failed to control infection in that one of one bottle of Sterile Water for Irrigation observed labeled as single patient use was not disposed of or discarded after single patient use. The failed practice promoted the spread of infection through cross contamination and had the potential to affect all patients on which the single use item was used. The findings follow:

A. Observation on 12/16/15 at 1515 revealed Registered Respiratory Therapist (RRT) #1 completed a respiratory therapy treatment on Patient #31. RRT #1 rinsed the updraft nebulizer with water from a 1000 ml (milliliter) bottle of Sterile Water for Irrigation. The bottle of Sterile Water for Irrigation had approximately 30 ml of water remaining in the bottle. In an interview with RRT #1 on 12/16/15 at 1515, when asked when the bottle of Sterile Water for Irrigation was discarded, she stated "When the bottle was empty."
B. Review of the "Sterile Water for Irrigation" manufacturer's direction for use on 12/17/15 revealed "After opening container, its contents should be used promptly to minimize the possibility of bacterial growth or pyrogen formation. Discard unused portion of irrigating solution since it contains no preservative. Single unit container. Discard unused portion."
C. The findings of B were confirmed in an interview with the Chief Nursing Officer on 12/16/15 at 0905.


30580

Based on observation and interview, it was determined the facility failed to assure expired suture was not available for patient use in two of two (Operating Room, Emergency Room) areas. The failed practice did not prevent unsterile surgical products to be introduced into a body cavity, subcutaneous tissue and/or skin which increased the risk of infection. The failed practice was likely to affect all patients admitted to the facility. Findings follow:

A. Observation in the Emergency Room on 12/15/15 at 1445 revealed the following expired sutures were located behind the nurses' station on a suture cart:
1) 2-0 Vicryl expired 07/2015;
2) 6-0 Vircyl expired 07/2015;
3) 4-0 Monocryl expired 01/2014;
4) 0 Prolene expired 01/2014; and
5) 2-0 Silk expired 01/2014.
B. Findings were verified with the Chief Nursing Officer at the time of observation.


Based on review of package labeling, observation and interview, it was determined the Infection Control Officer failed to control infections by not assuring 40 Anesthesia breathing circuits were not open and available for patient care in three of three (Operating Rooms #3, Anesthesia Supply Room, Sterile Corridor) areas. The failed practice did not assure patients were not exposed to contaminants. The failed practice was likely to affect all patients admitted to the hospital. Findings follow:

A. Observation 12/15/15 at 1414, 20 Anesthesia breathing circuits were hanging from shelving in the Anesthesia Supply Room, 12 were hanging on the back of the Anesthesia Supply cart in the sterile corridor and eight were hanging on the back of the Anesthesia cart in Operating Room #3.
B. Review of the Anesthesia breathing circuit package labeling revealed "do not use is package is damaged."
C. Findings were verified with the Director of Surgical Services at the time of observation.



31039

Based on observation, review of policy and interview, the Infection Control Officer failed to ensure therapy equipment was maintained in a manner that prevented cross contamination between patients in Rehabilitation in that six (Walkers #1-6) of six and one (Cane Walker #1) of one In-patient walkers had colored tape and/or stickers on them (not able to sanitize). The failied pracitice could not assure a sanitary environment when patients used these items. The failed practice had the likelihood to affect all patients that receive therapy services using the walkers. Findings follow:

A. During a tour of Rehabilitation Services on 12/15/15 at 1000, six Walkers and one Cane Walker had colored tape and/or stickers on them in a storage closet. The tape and/or cannot be cleaned or disinfected.
B. Review of policy titled Infection Control Policies- Rehabilitation Services stated "All walkers, canes, crutches and wheelchairs are to be cleaned by wiping thoroughly with approved disinfectant solution after contact with infectious material. All equipment as described above should be cleaned with detergent solution when visibly soiled."
C. During an interview on 12/15/15 at 1015, the Chief Nursing Officer verified the six Walkers and one Cane Walker had colored tape and/or worn stickers on them.

Based on review of employee file, Director of Rehabilitation job description, review of Rules and Regulations for Hospitals and Related Institutions in Arkansas 2007 and interview, it was determined the Facility failed to follow state law in that the Director of Rehabilitation Services (whose responsibilities include directing the work of Physical Therapists) was not a Physical Therapist (Rules and Regulations for Hospitals and Related Institutions in Arkansas 2007). By not having a Physical Therapist supervise Physical Therapy Services, the Facility was not abiding by state law. The failed practice had the likelihood to affect all patients who received Physical Therapy Services at the Facility. Findings follow:
A. Review of the Director of Rehabilitation Services employee file revealed the Director is a licensed Occupational Therapist.
B. Review of the Director of Rehabilitation Services job description revealed the General Description of the Job Class is as follows: "Plans and directs the work of various rehabilitative healthcare professionals such as Physical Therapists, Occupational Therapists, Speech Therapists ...".
C. Review of Rules and Regulations for Hospitals and Related Institutions in Arkansas 2007, Section 21.B. stated "Physical Therapy Services shall be supervised by a Physical Therapist licensed by the Arkansas State Board of Physical Therapy."
D. During an interview on 12/15/15 at 1330, the Chief Nursing Officer verified the Director of Rehabilitation Services was not a Physical Therapist.