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Based on review of policy, review of manufacturer's recommendations, observation and interview, it was determined the facility failed to adhere to accepted professional standards in that they did not follow their policy for storage of fluids in warmers and did not follow manufacturer's recommendations for storage temperature of Mannitol for injection in one (Surgical Services) of two (Surgical Services and Labor and Delivery) areas. By not following policies and manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the solutions/medication available for patient use. The failed practice had the likelihood to affect all patients having procedures in the facility that required warm fluids and the improperly stored medications. Findings follow:
A. Review of the facility's policy titled, "Warmers: Blankets and Fluid," revised on 01/11/18, showed the fluids should be labeled with the removal/expiration date, to identify when they should be removed from the warming cabinet.
B. Review of Manufacturer's storage recommendations for Mannitol for injection showed the medication should be stored at room temperature, between 68 and 77 degrees Fahrenheit.
C. During a tour of the facility on 07/16/18 from 1:04 PM to 2:50 PM, observation showed the following being stored in a warmer reading 102 degrees Fahrenheit in Surgical Services:
1) Six - 3000 ml (milliliter) bags of Sodium Chloride for irrigation, not labeled with the removal/expiration date on them
2) One - Mannitol 12.5 grams/ 50 ml.
C. During an interview on 07/16/18 at 2:45 PM, the Director of Surgical Services verified the fluids were stored without being labeled and the Mannitol was stored in the warmer instead of at room temperature.

Based on observation, policy and procedure review, and interview, it was determined the Infection Control Nurse failed to identify risks which had the potential to lead to infections in that equipment was not cleaned after patient contact, a refrigerator and a freezer designated to store breast milk was not clean and ready to use, one (portable) of eight bronchoscopes was not stored to prevent cross contamination, and staff were observed not washing their hands after patient contact. Failure to ensure equipment was cleaned after patient use, the nursery refrigerator and freezer were clean, the bronchoscope was hung, and not touching other scopes, and staff washed their hands after patient contact had the potential to allow cross contamination between patients, and staff. The failed practice affected Patient #31, and had the likelihood to affect any patient whose care required the use of the portable bronchoscope, glucometer and any infant whose mother's breast milk was stored in the nursery refrigerator or freezer. Findings follow:

A. Review of the policy and procedure titled "Infection Control Guidelines," received from the Infection Control Nurse on 07/18/18, showed employees should perform hand hygiene before and after each patient contact.

B. Observation of a finger stick for blood glucose results at 11:00 AM on 07/16/18 showed Patient Care Technician II #1 (PCT #1) lay the bottle of blood glucose strips and the glucometer on the patient's over bed table without cleansing the over bed table first. After the finger stick was obtained, PCT #1 picked the glucometer up and placed it in the basket which contained the thermometer, then picked up the bottle containing the strips and placed them in her uniform pocket. During an interview with PCT #1 at 11:10 AM on 07/16/18 she stated she should have cleaned the glucometer prior to placing it back in the basket and should not have placed the bottle of strips in her pocket because it contaminated her uniform.

C. Observation on 07/16/18 at 1:25 PM of the nursery refrigerator designated to store breast milk showed multiple brown stains on three of three door shelves, and one large stain on the bottom shelf of the unit. Observation of the nursery freezer designated to store breast milk showed multiple brown stains on three of three door shelves. The above findings were verified with the Nurse Manager at the time of the observation.

D. Observation on 07/16/18 at 2:55 PM of the stored bronchoscopes showed one (small portable battery operated) of eight bronchoscopes was laying on the rack instead of hung in a slot, and was touching the last two bronchoscopes on the right side of the rack. The above findings were verified with Registered Respiratory Therapist #1 at the time of the observation.

E. Observation of the pre-operative care of Patient #31 showed the following: Physician #1 completed the pre-operative assessment of Patient #31 which included placing a stethoscope on the patient's chest and back areas, then palpating the areas where an old port was to be removed and a new port inserted. Physician #1 then drew with a skin marker onto the right shoulder of Patient #31. Physician #1 then left the room without performing hand hygiene with hand sanitizer and passed a sink without performing hand hygiene before leaving the area. During an interview with Registered Nurse #2 at 12:15 PM on 07/18/18 the above findings were verified.

F. Observation of the pre-operative care of Patient #21 showed the following: Certified Registered Nurse Anesthetist #1 (CRNA) completed the pre-operative assessment of Patient #31 and left the room without performing hand hygiene and passed a sink without performing hand hygiene. CRNA #1 was stopped and asked if hand hygiene was supposed to be performed after patient contact. During an interview with CRNA #1 at 12:40 PM on 07/18/18 he stated he planned to wash his hands once he got to the OR (Operating Room).


Based on observation and interview, it was determined the facility failed to ensure only currently dated supplies were available for patient use in two of two crash carts in the ambulatory surgery unit and one of two scrub sink areas toured. Failure to ensure only currently dated supplies were available for patient use had the potential to allow unsterile items to be utilized in patient care. The failed practice had the potential to affect any patient whose care required the use of the expired supplies. Findings follow:

A. Observation of the crash cart in the Holding and PACU (Post Anesthesia Care Unit) at 10:15 AM on 07/18/18 showed two of two Multi-Lumen CVC (Cardiovascular) kits with expiration dates of 03/31/18 and 06/30/18; and three of three ABG (Arterial Blood Gas) Kits expired 05/18. During an interview with the Director of Surgical Services at 10:20 AM on 07/18/18 the above findings were verified.

B. Observation of the two scrub sinks between Operating Room #2 and #4 showed four of four Povidone Scrub brushes lying on the sink which expired 04/18. During an interview with the Ambulatory Surgery Unit Coordinator at 10:35 AM on 07/18/18 the above findings were verified.

C. Observation of the Operating Room crash cart showed one of two Multi Lumen CVC kits expired 06/30/18, one of three Intubation Stylet 7.5 mm (millimeter) expired 02/18 and 4 of 8 ABG Line Draw Kits with expiration dates of 01/18, 04/18 and two dated 05/18. During an interview with the Director of Surgical Services at 10:45 AM on 07/18/18 the above findings were verified.


Based on review of policy and procedure, annual Infection Control staff training, and physician and allied health credential files, it was determined two (Physician's #10 and #11) of eleven (two Certified Registered Nurse Anesthetists, one Physician's Assistant, and eight physicians) credentialed staff members did not have a current Tuberculosis (TB) test. Failure to ensure all staff had a current TB screening had the potential to allow TB exposure to other staff members, patients and visitors. The failed practice had the likelihood to affect patients, staff and visitors who were in contact with Physicians #10 and #11. Findings follow:

A. Review of the policy and procedure titled "Facility Health Program," received from the Regulatory Specialist at 11:50 AM on 07/16/18 showed employment screenings included TB skin test and review of the annual Infection Control training received from the Regulatory Specialist on 07/16/18 showed an annual TB test was required of all employees.

B. Review of Physician #10's credential file showed no evidence a TB screening had been performed. During an interview with the Director of Quality and Regulatory at 3:35 PM on 07/17/18 the above findings were verified.

C. Review of Physician #11's credential file showed a TB screening performed on 04/11/17 which expired on 04/13/18. During an interview with the Director of Quality and Regulatory at 4:10 PM on 07/17/18 the above findings were verified.


31039

Based on review of policy, observation and interview, it was determined the Infection Control Officer failed to identify the unsanitary condition of a patient ice machine in that one of one Outpatient Rehabilitation ice machines had stains and residue on the face of the machine where the cup is placed to receive the ice, and the chute that dispenses the ice had a white residue buildup. The failed practice had the likelihood for ice to become contaminated and could affect any patient receiving ice that had been dispensed from the ice machine. Findings follow.

A. Review of the facility's policy titled, "Cleaning and Disinfection of Equipment," revised on 03/18/17, showed ice machines were to be wiped down daily and terminally cleaned by maintenance on an as needed basis.
B. During a tour of Outpatient Rehabilitation on 07/18/18 from 10:25 AM to 10:42 AM, the ice machine showed stains and residue on the face of the machine where the cup is placed to receive the ice, and the chute that dispenses the ice had a white residue buildup.
C. During an interview on 07/18/18 at 10:37 AM, Occupational Therapist #1 verified the stains, residue and white buildup and verified the ice is used for patient's drinks in Outpatient Rehabilitation.

Based on policy and procedure review, observation and interview, it was determined the facility failed to follow its policy and procedure and selected national practice guidelines in that it failed to ensure one of one (#1) Surgeon changed his scrubs prior to performing a surgical procedure, one (Pre-operative Area) of two (Pre-operative Area and Operating Room) areas toured failed to follow policy and procedure in that scrub uniforms were being worn outside and back into the Pre-operative Area and one of one employee wore scrub uniform outside and back into the Operating Room (OR) suite. The failed practice had the potential to affect Patient #31 and had the potential to allow contamination into the operative area and the operative suite. Findings follow:

A. Review of the policy and procedure titled "Surgical Attire for Operating and Recovery Rooms," received from the Regulatory Specialist at 11:50 AM on 07/16/18 showed the policy pertained to all Operating Room, Recovery Room and Patient Receiving Area staff. Review of the policy showed staff were to wear short sleeved scrub uniforms provided by the laundry and medical and nursing personnel were not to wear attire home or outside the hospital.

B. Observation on 07/18/18 at 10:05 AM showed the Director of Surgical Services wore ceil blue scrubs out of the operating suite, outside, across the street to the ambulatory surgery unit, and into the surgical suite. During an interview with Director of Surgical Services at 10:55 AM on 07/18/18 the above findings were verified.

C. Observation at 12:05 PM on 07/18/18 showed Physician #1 performing the pre-operative assessment on Patient #31 while wearing navy scrub uniforms.

D. Observation from 8:45 AM to 12:45 PM on 07/18/18 showed multiple Pre-Operative Area employees wearing scrub uniforms of various colors. During an interview with Registered Nurse #2 (RN) at 12:20 PM on 07/18/18, RN #2 stated Pre-Operative Area staff scrub uniforms were not furnished and Pre-Operative employees were allowed to wear their own uniforms from home. RN #2 stated OR and Recovery Room employees were furnished scrubs by the facility.

E. During an interview with the Director of Surgical Services and RN #1 at 2:45 PM on 07/18/18 both stated OR staff were allowed to launder their scrub uniforms at home and bring them to the facility to change into. The Director of Surgical Services stated the national guidelines the facility chose to adhere to was AORN (Association of Perioperative Nurses). Review of the 2018 AORN guidelines received from RN #1 at 2:50 PM on 07/18/18 showed clean surgical attire laundered in a health-care accredited laundry facility should be worn, personal clothing that cannot be contained within the scrub attire should be laundered in a health-care accredited laundry facility, and surgical staff should change into street clothes whenever going outside.

F. Observation of Patient #31's surgical procedure on 07/18/18 showed Physician #1 wearing navy scrubs. During an interview with Physician #1 at 3:07 PM on 07/18/18 he was asked where his scrub uniforms were laundered. Physician #1 stated his wife laundered them at home, he put them on and wore them to the facility, which included performing Patient #31's surgical procedure while wearing the scrubs which were laundered at home and worn outside of the facility.

G. Review of the 07/18/18 surgical schedule received from the Regulatory Specialist on 07/17/18, showed Physician #1 had seven patients scheduled for surgical procedures and Patient #31 was the third patient, scheduled at 10:45 AM.