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Based on review of policy, observation, review of Manufacturer's package inserts and interview, it was determined the facility failed to date Succinylcholine and Rocuronium when removed from refrigerated storage on four (#1, #2, #3 and #4) of five (#1, #2, #3, #4, and #5) anesthesia carts. By not dating the medications once removed from the refrigerator, the facility could not assure the medications wouldn't still be available for patient use beyond the Manufacturer's recommended expired date. The failed practice had the likelihood to affect all patients admitted for surgical procedures. Findings follow:

A. Record review of Facility policy titled "Storage Refrigeration and Freezing," reviewed and approved 07/21/2021, showed drugs requiring refrigeration for long term storage, but stored at room temperature for short periods, shall be dated when removed from the refrigerator and destroyed when the recommended room temperature expiration date is reached.
B. During a tour of the facility on 12/14/2021 from 1:18 p.m. to 3:28 p.m., the following were observed not dated with the day they were removed from refrigerated storage:
1) Anesthesia Cart #1 contained #1 vial of Succinylcholine 200 mg (milligram)/ 10 ml (milliliter) and #2 vials of Rocuronium 50 mg/ 5 ml;
2) Anesthesia Cart #2 contained #1 vial of Rocuronium 50 mg/ 5 ml;
3) Anesthesia Cart #3 contained #1 vial of Succinylcholine 200 mg / 10 ml and #3 vials of Rocuronium 50 mg/ 5 ml; and
4) Anesthesia Cart #4 contained #1 vial of Succinylcholine 200 mg / 10 ml and #1 vial of Rocuronium 50 mg/ 5 ml.
C. Review of package insert for Succinylcholine showed "The multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency".
D. Review of packaging for the Rocuronium showed "Upon removing from refrigerator to room temperature, use within 60 days".
D. During an interview on 12/14/2021 at 3:21 p.m., CRNA (Certified Registered Nurse Anesthetist) verified the findings at B.

Based on review of policy and interview, it was determined the facility failed to follow acceptable standards of practice in that pharmacists did not review the medication orders for appropriateness prior to the first dose being dispensed, for all orders after the pharmacist left for the day for seven out of seven (Sunday through Saturday) days every week. By not allowing a pharmacist to review the order prior to dispensing, the facility cannot assure the order has been reviewed for; therapeutic appropriateness, therapeutic duplication in the patient's medication regimen, appropriateness of the drug, dose, frequency, and route, medication-medication interactions, medication-food interactions, medication-lab interactions, medication-disease interactions, real or potential allergies or sensitivities or other contraindications. This failed practice had the likelihood to affect all patients who received new orders after the pharmacist left for the day. Findings follow:

A. Record review of the facility's policy titled, "Pharmacist Review," reviewed and approved 7/21/2021, showed in the absence of a pharmacist, a healthcare professional determined to be competent by the organization may review the medication order, the hospital would determine a method of validating the healthcare professional's review of the medication order and then a pharmacist would conduct a retrospective review of the order and any medication dispensed as soon as the pharmacy reopened or a pharmacist was available.
B. During an interview on 12/16/21 at 10:45 a.m., the Director of Pharmacy verified a pharmacist does not review every order written after the pharmacist has gone for the day.

Based on observation, review of policy and interview, it was determined the facility failed to secure biologicals and medications in one
(Women's Services) of five (Women's Services, Emergency, Surgical Services, Intensive Care and Medical/Surgical) medication refrigerators observed in that the refrigerator did not lock and its contents were accessible to unauthorized personnel. By not locking the refrigerator, the facility could not assure the safety and efficacy of the medications. The failed practice had the likelihood to affect all Women's Services patients. Findings follow:

A. Record review of the facility's policy titled, "Security," reviewed and approved 7/21/2021, showed all areas occupied by pharmacy shall be capable of being locked by key and/or combination, to prevent access by unauthorized personnel.
B. During a tour of the facility on 12/14/2021 from 1:18 p.m. to 3:28 p.m., observation showed a refrigerator in Women's Services that contained the following and did not have a locking mechanism:
1) #31 Hepatitis B vaccine 0.5 ml (milliliter) vials for injection;
2) #3 Rhophylac 1500 Units for injection; and
3) #2 Curosurf 240 mg (milligrams) vials.
C. During an interview on 12/1420/21 at 2:45 p.m., the Nurse Manager of Women's Services verified the refrigerator was not locked, and unauthorized personnel (Housekeeping) had access to the area the refrigerator was housed.


Based on observation and interview it was determined the Preop (preoperative) staff failed to ensure all drugs and biologicals were not available for unmonitored access in that medications were found unlocked with the key hanging in the door of 1 of 1 medication cabinet in Preop while staff was not on the unit. Failure to keep the medication cabinet locked did not assure unauthorized personnel would not gain access to the medications in the cabinet. The failed practice had the likilihood to affect all patients in the Preop area. Findings follow:
A. During observation of the Preop area on
12/15/21 from 09:08 AM to 10:12 AM, this surveyor observed Preop staff away from unit 2 times for three to four minutes at a time with medication cabinet opened and accessible with key hanging from door. The cabinet contained the following medications:
1) 1-Xylocaine 500mg/50ml Multiple Dose Vial
2) 1-HurriCane Spray 20% Benzocaine Oral Anesthetic 2 oz. bottle
3) 12-Pepcid 20 mg tablets
B. On 12/15/21 when surveyor asked Preop Registered Nurse (RN) #1 about the key hanging from the medication cabinet door she removed the key from the door, did not lock the medication cabinet and placed the key in a drawer under the countertop the medication cabinet was located on. She stated that there were no narcotics located in the cabinet it was just Lidocaine, HurriCane Spray and Pepcid on days that they do Cataract Surgeries.
C. The findings in A and B were verified by interview with the Operating Room (OR) Director on 12/15/21 at 11:30 AM.

Based on review of the Rules for Hospitals and Related Institutions in Arkansas 2021, National Fire Protection Association (NFPA) 101 2012 Edition, NFPA 99 2012 Edition, NFPA 70 2010 Edition, NFPA 80 2010 Edition, NFPA 13 2010 Edition, NFPA 105 2010 Edition, and NFPA 110 2010 Edition, interview, and observation, it was determined the facility failed to maintain a physical environment safe for patient care in that:

A. The facility failed to test the emergency generator under load monthly or annually in accordance with NFPA 101 and NFPA 110 standards to ensure functionality in the event of an emergency. See A-0710
B. The facility failed to maintain six of six (Emergency Department Soiled Room, Intensive Care Unit Soiled Workroom, Medical-Surgical Unit Soiled Room, Respiratory Safe Room, Medical Records Entrance, Laboratory Reception) fire-rated door assemblies as required by NFPA 101 and NFPA 80 to ensure proper function in the event of a fire in that all six of the fire-rated door assemblies were not arranged for automatically closing and latching when released. There was also no annual inspection or testing of the fire-rated door assemblies as required by NFPA 80. See A-0710
C. The facility failed to maintain all smoke dampers in the building as required by NFPA 101 and NFPA 105 to ensure they operate properly to prevent the transmission of smoke through air ducts in the event of a fire. See A-0710
D. The facility failed to ensure 3 of 3 portable space heating devices were used in accordance with NFPA 101 to prevent fire hazards from being present in that no measure was taken to ensure the heating elements of the portable heaters could not exceed 212 degrees Fahrenheit as required by NFPA 101. See A-0710
E. The facility failed to conduct fire drills on two of three shifts (2nd shift, 3rd shift) once per shift per quarter in accordance with NFPA 101 standards to ensure staff were able to take necessary
life-saving actions in the event of a fire. See A-0710
F. The facility failed to store supplies in one of one Dry Storage room 18 inches below the deflector of the sprinkler in accordance with NFPA 101 and NFPA 13 standards to avoid impairing the function of the sprinkler system in the event of a fire. See A-0710
G. The facility failed to install two of two alcohol-based hand-rub dispensers a safe distance from hazardous locations in accordance with NFPA 101 standards to prevent fire hazards from being present. See A-0710
H. The facility failed to maintain five of five (Administration/Public Bathrooms, Administration/Laboratory, Surgery Hall Near Sterilizer Mechanical Room, Surgery Hall Near Infection Control Office, Women's Center Entrance) fire-rated barriers in accordance with NFPA 101 standards in that penetrations in each barrier were not sealed to prevent the transfer of smoke in the event of a fire. See A-0710
I. The facility used prohibited combustible decorations in nine of nine (Waiting Room, Intensive Care Unit, Medical-Surgical Unit, Rehabilitation Gym, Labor/Delivery Unit, Dining Area, Behavioral Health Unit, Respiratory Unit, Medical Records Office) areas of the hospital. See A-0710
J. The facility failed to prevent ligature risks from being present in twelve of twelve patient rooms (130, 132, 134-143) in the Behavioral Health Unit. See A-0724
K. The facility failed to ensure multiple-receptacle power cords were used in accordance with NFPA 99 standards in two of two (Nursery, Surgery Core) patient care areas in that there was no measure taken to prevent additional devices from being plugged in to the cords and no measure taken to ensure the devices powered by the cords would not exceed 75% of their rated ampacity. See A-0724
L. The facility failed to maintain a 36-inch working clearance around two of two electrical panels in the Kitchen Core as required by NFPA 99 and NFPA 70. See A-0724
M. The facility failed to provide a visua lmechanism for monitoring the air pressure of six of six (1 in Intensive Care Unit, 1 in Emergency Department, 3 in Medical-Surgical Unit, 1 in Rehabilitation Unit) infectious airborne isolation rooms as required by the Rules for Hospitals and Related Institutions in Arkansas 2021. See A-0724
N. The facility failed to ensure a humidity level conducive to a sterile environment was provided in five of five surgical areas (Operating Room (OR) 1, OR 2, OR 3, OR 4, Endoscopy Room) as required by the Rules for Hospitals and Related Institutions in Arkansas 2021. See A-0724
O. The facility failed to provide a space for decontamination in one of one Emergency Department as required by the Rules for Hospitals and Related Institutions in Arkansas 2021. See A-0724

Based on review of the facility's generator logs, NFPA (National Fire Protection Association) codes, and interview, it was determined the facility failed to maintain one of one emergency generator as required by NFPA 101 and 110 in that the emergency generator was not being tested monthly or annually for 13 of 13 months (December 2020 - December 2021) to ensure functionality in the event of an emergency. It was also determined by observation and interview that the facility failed to provide battery-powered lighting at the generator location as required by NFPA 101 and 110. The failed practices had the likelihood to affect all patients, staff and visitors in the event of a power outage emergency the generator may not function properly and could fail to support all equipment and emergency fixtures relying on the life safety branch for emergency power, and the generator location would not be illuminated in the event that it needed to be serviced during an emergency. Findings follow:

A. Review of NFPA 101 2012 Edition: 9.1.3 showed emergency generators must be installed and maintained in accordance with NFPA 110.
B. Review of NFPA 110 Standard for Emergency and Standby Power Systems 2010 Edition: 8.4.2 showed diesel generator sets shall be exercised monthly for 30 minutes using one of the following methods: 1) Loading that maintains the exhaust temperature recommended by the manufacturer 2) Under operating temperature conditions and at not less than 30% of the EPS nameplate kW rating.
C. Review on 12/14/21 at 9:30 AM of the facility's generator testing logs showed no record of the emergency generator being tested under load in the last 13 months (December 2020 - December 2021). This finding was verified with the Director of Plant Facilities at 1:20 PM on 12/15/21.
D. Review of NFPA 110 2010 Edition: 7.3.1 showed outdoor EPS equipment with a walk-in enclosure shall be provided with battery-powered lighting.
E. Observation on 12/16/21 at 2:40 PM of the emergency generator showed no battery-powered lighting was provided at the walk-in enclosure as required by NFPA 110. This finding was verified at the time of observation with the Director of Plant Facilities.


Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition and NFPA 80 Standard for Fire Doors and Other Opening Protectives 2010 Edition, the facility failed to maintain six of six (Emergency Department (ED) Soiled Room, Intensive Care Unit (ICU) Soiled Workroom, Medical-Surgical Unit Soiled Room, Respiratory Safe Room, Medical Records Entrance, Laboratory Reception) fire-rated door assemblies as required by NFPA 101 2012 Edition in that all six of the fire-rated door assemblies were not arranged for automatically closing and latching when released. There was also no annual inspection or testing of the fire-rated door assemblies as required by NFPA 80 2010 Edition. The failed practices had the likelihood for the fire-rated doors to be left open in the event of a fire, allowing smoke and fire to rapidly transfer into the adjacent spaces. The failed practices had the likelihood to affect all patients, staff, and visitors. Findings were as follows:

A. Review of NFPA 101 2012 Edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80. Review of NFPA 80 2010 Edition: 5.1.3.2 showed fire-rated doors shall be kept closed and latched or arranged for automatic closing
B. Review of NFPA 101 2012 Edition: 7.2.1.8.2 showed any door leaf required to be kept closed shall only be held open by a device which automatically releases the door leaf upon operation of a smoke detector and upon loss of power to the device.
C. Review of NFPA 101 2012 Edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80. Review of NFPA 80 2010 Edition: 5.2.1 showed fire door assemblies shall be inspected and tested not less than annually and a record of inspection shall be kept for the Authority Having Jurisdiction.
D. Observation of the ED Soiled Room on 12/14/21 at 1:40 PM showed the doorway was comprised of a fire-rated door assembly which did not latch when closed due to the interior door handle getting stuck.
E. Observation of the ICU Soiled Workroom on 12/14/21 at 2:00 PM showed the doorway was comprised of a fire-rated door assembly which did not latch when closed.
F. Observation of the Medical-Surgical Unity Soiled Room on 12/14/21 at 2:20 PM showed the doorway was comprised of a fire-rated door assembly which did not latch when closed due to no latch being present in the door.
G. Observation of the Respiratory Safe Room on 12/16/21 at 2:30 PM showed the doorway was comprised of a fire-rated door assembly which would not automatically close and latch when released due to no closing device being installed on the door assembly.
H. Observation of the Medical Records Entrance on 12/16/21 at 2:50 PM showed the entry doorway was comprised of a fire-rated door assembly which did not automatically close and latch when released due to no closing device being installed on the door assembly.
I. Observation of the Laboratory Reception room on 12/16/21 at 3:20 PM showed the entry doorway was comprised of a fire-rated door assembly which was held open by a mechanical door-stop and the door would not close unless the mechanical door-stop was manually released.
J. The above findings in D, E, F, G, H, and I were verified with the Director of Plant Facilities at the times of observation.
K. In an interview with the Director of Plant Facilities on 12/15/21 at 1:20 PM it was verified that there was no inspection or testing conducted of the fire door assemblies in the building.


Based on interview and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition and NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protectives 2010 Edition, it was determined the facility failed to maintain all smoke dampers in the building in as required by NFPA 101 Life Safety Code 2012 Edition. The failed practice had the likelihood to affect all patients and staff in that in the event of a fire the dampers could fail to operate properly and allow smoke to spread through the air ducts of the building. Findings follow:

A. Review of NFPA 101 Life Safety Code 2012 Edition: 8.5.5.4.2 showed smoke dampers and combination fire and smoke dampers shall be inspected, tested, and maintained in accordance with NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protectives. Review of NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protectives 2010 Edition: 6.5.2 showed that smoke dampers and combination fire and smoke dampers shall be tested and inspected every 6 years.
B. In an interview with the Director of Plant Facilities on 12/15/21 at 1:20 PM it was verified that no inspection or testing of the facility's smoke dampers was conducted in the last 6 years.


Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition, it was determined the facility failed to ensure 3 of 3 portable space heating devices had heating elements that would not exceed 212 degrees Fahrenheit in accordance with NFPA 101 Life Safety Code. The failed practice had the likelihood to affect all patients and staff in that a fire hazard was present in each of the areas where staff were using the heating devices which had not been evaluated. Findings follow:

A. Review of NFPA 101 Life Safety Code 2012 Edition: 19.7.8 showed portable space heating devices shall be prohibited unless they are used only in nonsleeping staff areas and the heating elements of the devices do not exceed 212 degrees Fahrenheit.
B. Observation on 12/13/21 at 12:00 Noon of the Administration wing showed portable space heaters being used in 3 staff offices.
C. In an interview with the Director of Plant Facilities on 12/15/21 at 1:20 PM it was verified that there was no policy or procedure in place to ensure the heating elements of the portable space heaters in use did not exceed 212 degrees Fahrenheit.


Based on review of the facility's Fire Drill logs and review of National Fire Protection Association
(NFPA) 101:19.7.1.6, it was determined the facility failed to meet the provisions of the life safety from fire requirements in that fire drills were not conducted on the second shift in one (March 2021 through May 2021) of four quarters (December 2020 through November 2021) reviewed, and were not conducted on the third shift in two (December 2020 through February 2021, September 2021 through November 2021) of four quarters (December 2020 through November 2021) reviewed. The failed practice had the potential to affect all staff and patients in that in the event of a fire the staff would not be trained to respond to the emergency, which could result in injury or death if the proper actions were not taken to preserve the lives of patients and staff. Findings follow:

A. Review of NFPA 101:19.7.1.6 showed fire drills were to be conducted by the facility once per shift per quarter.
B. Review on 12/14/21 at 8:30 AM of the facility's Fire Drill logs from December 2020 to November 2021 showed there was no record of a fire drill conducted on the second shift during the months of March 2021 through May 2021, and no record of a fire drill conducted on the third shift during the months of December 2020 through February 2021 or during September 2021 through November 2021 as required per NFPA 101 2012 Edition: 19.7.1.6. This finding was verified in an interview with the Director of Plant Facilities at 1:20 PM on 12/15/21.



Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition and NFPA 13 Standard for Installation of Sprinkler Systems 2010 Edition, it was determined supplies in one of one Dry Storage Room were not stored 18 inches below the sprinkler deflector as required by NFPA 13:8.8.6, 2010 edition and were in the path of the sprinkler spray pattern. The failed practice had the likelihood to affect all patients and staff in that a potential fire in the Dry Storage Room would not be immediately extinguished and could spread to other nearby areas due to the spray pattern of the activated sprinkler being obstructed. Findings follow:

A. Review of NFPA 101 2012 Edition: 9.7.1.1 showed automatic sprinkler systems shall be in accordance with NFPA 13.
B. Review of NFPA 13 2010 Edition: 8.8.6 showed the top of storage must be at least 18 inches below the deflector of the sprinkler.
C. Observation on 12/15/21 at 2:15 PM of the Dry Storage Room showed four boxes of sugar and 2 boxes of coffee stored on the top shelf 10 inches directly below the sprinkler deflector. This finding was verified by the Director of Plant Facilities at the time of observation.


Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition, it was determined the facility failed to install two of two alcohol-based hand-rub (ABHR) dispensers at a safe distance from hazardous locations as required by NFPA 101. The failed practice created a fire hazard in the Clean Utility Room and Emergency Department. Findings follow:

A. Review of NFPA 101 2012 Edition: 19.3.2.6 (8) showed ABHR dispensers shall not be installed above an ignition source within a 1-inch horizontal distance from each side of the ignition source.
B. Review of NFPA 101 2012 Edition: 19.3.2.6 (9) showed ABHR dispensers installed over carpeted floors shall only be permitted in sprinklered smoke compartments.
C. Observation of the Central Supply Room on 12/16/21 at 3:00 PM showed an ABHR dispenser was installed directly above an electrical outlet. This finding was verified with the Director of Plant Facilities at the time of observation.
D. Observation of the Medical Records Office on 12/16/21 at 2:50 PM showed an ABHR dispenser was installed above a carpeted floor in an area not protected as a sprinklered smoke compartment. This finding was verified with the Director of Plant Facilities at the time of observation.


Based on observation, interview and review of National Fire Protection Association (NFPA) 101 2012 Edition Life Safety Code standards, it was determined the facility failed to maintain five of five (Administration/Public Bathrooms, Administration/Laboratory, Surgery Hall Near Sterilizer Mechanical Room, Surgery Hall Near Infection Control Office, Women's Center Entrance) fire-rated barriers in accordance with the requirements of NFPA 101 2012 Edition in that the barriers had penetrations which were not sealed with fire-proof sealant to restrict the transfer of smoke. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA 101 2012 edition: 8.3.5.1 showed penetrations for cables, conduits, pipes, and wires that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.
B. Observation on 12/17/21 at 10:25 AM of the fire-rated barrier separating Administration from the Public Bathrooms showed a penetrating cable that was not sealed by a firestop system or device to prevent the transfer of fire and smoke and a hole with mesh in it that was not sealed by a firestop system or device to prevent the transfer of fire and smoke.
C. Observation on 12/17/21 at 10:30 AM of the fire-rated barrier separating Administration from the Laboratory showed two penetrating silver pipes that were not sealed by a firestop system or device to prevent the transfer of fire and smoke.
D. Observation on 12/17/21 at 10:35 AM of the fire-rated barrier in the Surgery Hall near the Sterilizer Mechanical Room showed 5 penetrating pipes were not sealed by a firestop system or device to prevent the transfer of fire and smoke.
E. Observation on 12/17/21 at 10:40 AM of the fire-rated barrier in the Surgery Hall near the Infection Control Office showed two silver pipes penetrating the barrier that were not sealed by a firestop system or device to prevent the transfer of fire and smoke.
F. Observation on 12/17/21 at 10:45 AM of the fire-rated barrier at the Women's Center Entrance showed two penetrating silver pipes that were not sealed by a firestop system or device to prevent the transfer of fire and smoke.
G. The above findings in B, C, D, E, and F were verified with the Director of Plant Facilities at the times of observation.


Based on observation, interview and review of National Fire Protection Association (NFPA) 101 2012 Edition Life Safety Code standards, it was determined the facility failed to prohibit the use of combustible decorations as required by NFPA 101 Life Safety Code. Findings follow:

A. Review of NFPA 101 2012 edition: 19.7.5.6 showed combustible decorations shall be prohibited in any healthcare occupancy.
B. Observation of the Waiting Room on 12/13/21 at 11:45 AM showed an artificial tree with lights and ornaments was present in the patient area. The Director of Plant Facilities verified none of these decorations were non-combustible or flame retardant.
C. Observation of the Intensive Care Unit on 12/14/21 at 2:00 PM showed an artificial wreath with lights and an artificial tree with lights and ornaments was present next to the Nurse Station. The Director of Plant Facilities verified none of these decorations were non-combustible or flame retardant.
D. Observation of Medical-Surgical Unit on 12/14/21 at 2:20 PM showed an artificial tree with lights and ornaments was present next to the Nurse Station. The Director of Plant Facilities verified none of these decorations were non-combustible or flame retardant.
E. Observation of the Rehabilitation Gym on
12/14/21 at 2:30 PM showed an artificial tree with lights and ornaments was present. The Director of Plant Facilities verified none of these decorations were non-combustible or flame retardant.
F. Observation of the Labor/Delivery Unit on 12/14/21 at 2:40 PM showed an artificial tree with lights and ornaments was present near the Nurse Station. The Director of Plant Facilities verified none of these decorations were non-combustible or flame retardant.
G. Observation of the Dining Area on 12/15/21 at 1:50 PM showed an artificial tree with lights and ornaments was present. The Director of Plant Facilities verified none of these decorations were non-combustible or flame retardant.
H. Observation of the Behavioral Health Unit on 12/15/21 at 2:25 PM showed an artificial tree with lights and ornaments was present. The Director of Plant Facilities verified none of these decorations were non-combustible or flame retardant.
I. Observation of the Respiratory Unit on 12/16/21 at 2:30 PM showed an artificial tree with lights and ornaments was present and red stockings were hung on the wall. The Director of Plant Facilities verified none of these decorations were non-combustible or flame retardant.
J. Observation of the Medical Records Office on 12/16/21 at 2:50 PM showed an artificial tree with lights and ornaments was present and red stockings were hung on the wall. The Director of Plant Facilities verified none of these decorations were non-combustible or flame retardant.

Based on policy and procedure review, observation, and interview, it was determined the facility failed to ensure personal radiation dosimeters were stored properly and in a radiation free environment. The failed practice did not ensure the facility could accurately monitor the amount of radiation exposure for each employee. The failed practice affected all employees required to wear a dosimeter. Findings included:

A. Review of Radiology Department's policy and procedure manual showed no policy regarding the proper storage of dosimeters.
B. On 12/14/21 at 9:15 AM during tour of the Radiology Department, surveyor found no designated storage area for employee dosimeters when not use.
C. Interview with Director of Radiology on 12/12/21 at 9:20 AM, he stated employees sometimes leave their dosimeters in a drawer or they may take them home. He stated each month he sends an email for employees to return the dosimeters to measure radiation exposure.
D. The findings in A and B were verified with the Director of Radiology on 12/12/21 at 9:30 AM.


Based on observation and interview it was determined the facility failed to ensure the condition of the hospital environment was maintained in a manner that provided a level of safety and well-being of patients in that ligature risks existed in twelve of twelve patient rooms (130, 132, 134-143) in the Behavioral Health Unit. The ligature risks had the likelihood to affect all patients admitted to the Behavioral Health Unit in that a means to self-harm was present in the rooms where they stay overnight. Findings follow:


Observation on 12/15/21 at 1430 of the Behavioral Health Unit showed that plumbing piping was exposed under the sink in every patient room (130, 132, 134-143) and the patient bathroom doorknobs protruded in a hook shape that presented a ligature risk in every patient room. This finding was verified with the Director of Plant Facilities at the time of observation.



Based on observation, interview, and review of National Fire Protection Association (NFPA) 99 Health Care Facilities Code 2012 Edition, it was determined the facility failed to use multiple-receptacle power cords in accordance with NFPA 99 standards in two of two patient care areas (Nursery, Surgery Core) in that the cords were not permanently attached, there was no measure in place to prevent additional devices from being plugged in to the cords, and there was no measure in place to ensure the devices powered by the cords did not exceed 75% of each cord's rated ampacity. The failed practices had the likelihood to affect all patients receiving care in the vicinity of the power cords in that there were no processes in place to ensure the cords would not exceed their ampacity and cause a fire or electrical shock. Findings follow:


A. Review of NFPA 99 2012 Edition: 10.2.3.6 showed flexible power cords with two or more receptacles shall be permitted to be used provided they are permanently attached to the assembly they are powering, the sum of all appliances connected to the outlets does not exceed 75% of the power cord's ampacity, the electrical and mechanical integrity of the cord are regularly verified and documented, and means are employed to ensure additional devices or nonmedical equipment cannot be connected to the power cords after leakage currents have been verified as safe.
B. Observation on 12/14/21 at 2:50 PM PM of the Nursery showed electrical patient care equipment was being powered by a flexible power cord with more than 2 receptacles which was plugged into a wall receptacle and sitting unsecured on the counter near the wheeled monitor the power cord served. The power cord did not have any means implemented to prevent additional devices from being plugged in to it. The finding was verified at the time of observation with the Director of Surgical Services.
C. Observation on 12/14/21 at 3:30 PM of the Surgery Core showed a flexible power cord with more than 2 receptacles was attached to a wheeled cart with a monitor plugged into it. The power cord did not have any means implemented to prevent additional devices from being plugged in to it. The finding was verified at the time of observation with the Director of Surgical Services.
D. In an interview on 12/14/21 at 4:00 PM with the Director of Plant Facilities, it was confirmed the facility did not have a policy in place to ensure multiple-receptacle power cords were used in patient care areas in accordance with NFPA 99 standards.


Based on observation, interview and review of National Fire Protection Association (NFPA) 99 Health Care Facilities Code 2012 Edition and NFPA 70 National Electric Code 2011 Edition, it was determined that the facility failed to maintain a working clearance in front of two of two electrical panels in the Kitchen Core as required by NFPA 70. The failed practice had the potential to affect all patients, visitors, and staff in the kitchen area because rapid access to the panels could not be gained in the event of an emergency and could prevent an electrical or fire hazard from being addressed quickly. Findings follow:

A. Review of NPFA 99 2012 Edition: 15.5.1.2 showed that electrical equipment shall be in accordance with NFPA 70.
B. Review of NFPA 70 2011 Edition: 110.26 showed that access and working space of at least 36 inches (3 feet) shall be maintained for electrical equipment operating at 600 volts, nominal, or less to ground and working spaces shall not be used for storage.
C. While touring the Kitchen Core on 12/15/21 at 2:00 PM, it was observed that six pallets of plastic soda bottles were stored directly in front of two electrical panels inside the Kitchen Core. This finding was verified with the Director of Plant Facilities at the time of observation.


Based on observation, interview, and review of the Rules for Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to provide a visual mechanism for monitoring the air pressure of the room at six of six (1 in Intensive Care Unit, 1 in Emergency Department, 3 in Medical-Surgical Unit, 1 in Rehabilitation Unit) infectious isolation rooms. The failed practice had the likelihood to affect all patients and staff in that an incorrect pressure of an isolation room would not be detected, allowing an infectious disease to be transmitted through he air going out of the room. Findings follow:

A. Review of the Rules for Hospitals and Related Institutions in Arkansas 2021 Section 48-5 showed each airborne infection isolation room shall have a permanently installed visual mechanism for monitoring the pressure status of the room when occupied by infectious patients.
B. Observation of the Emergency Department on 12/14/21 at 1:20 PM showed the airborne infection isolation room was not provided with any mechanism for monitoring the pressure of the room while occupied. This finding was verified with the Director of Plant Facilities at the time of observation.
C. In an interview with the Director of Plant Facilities on 12/14/21 at 1:30 PM it was verified that there were 6 airborne infection isolation rooms in the hospital (1 in Emergency Department, 3 in Medical-Surgical Unit, 1 in Intensive Care Unit, 1 in Rehabilitation) and none of the isolation rooms had a visual mechanism installed to monitor the pressure status of the room.


Based on interview and review of the Rules for Hospitals and Related Institutions in Arkansas 2021 and the facility's Temperature/Humidity log, it was determined the facility failed to provide the required levels of relative humidity for five of five (Operating Room (OR) 1, OR 2, OR 3, OR 4, Endoscopy Room) areas. The failed practice had the likelihood to affect all patients undergoing procedures in these spaces in that a sterile environment was not ensured and an elevated risk of infection was present.
Findings follow:

A. Review of the Rules for Hospitals and Related Institutions in Arkansas 2021 showed operating rooms and endoscopy rooms shall be provided with a relative humidity of 20% - 60%.
B. Review of the facility's Relative Humidity log showed:
1) OR 1 had a relative humidity level greater than the maximum amount of 60% relative humidity for 73 of 80 days recorded in the ten months prior to the survey (March 2021, April 2021, May 2021, June 2021, July 2021, August 2021, September 2021, October 2021, November 2021, December 2021).
2) OR 2 had a relative humidity level greater than the maximum amount of 60% relative humidity for 63 of 80 days recorded in the ten months prior to the survey March 2021, April 2021, May 2021, June 2021, July 2021, August 2021, September 2021, October 2021, November 2021, December 2021).
3) OR 3 had a relative humidity level greater than the maximum amount of 60% relative humidity for 35 of 80 days recorded in the ten months prior to the survey (March 2021, April 2021, May 2021, June 2021, July 2021, August 2021, September 2021, October 2021, November 2021, December 2021).
4) OR 4 had a relative humidity level greater than the maximum amount of 60% relative humidity for 20 of 80 days recorded in the ten months prior to the survey (March 2021, April 2021, May 2021, June 2021, July 2021, August 2021, September 2021, October 2021, November 2021, December 2021).
5) The Endoscopy Room had a relative humidity level greater than the maximum amount of 60%relative humidity for 63 of 80 days recorded in the ten months prior to the survey (March 2021, April 2021, May 2021, June 2021, July 2021, August 2021, September 2021, October 2021, November 2021, December 2021).
C. The above findings in B were verified in an interview with the Director of Plan Facilities on 12/15/2021 at 1:20 PM.



Based on interview and review of the Rules for Hospitals and Related Institutions in Arkansas 2021 it was determined the facility failed to provide a decontamination area as required by the Rules for Hospitals and Related Institutions in Arkansas 2021. The failed practice had the likelihood to affect all patients and staff in the Emergency Department in that a patient who arrived at the unit with hazardous contamination could not be effectively decontaminated and could contaminate the Emergency Department upon entering. Findings follow:

A. Review of the Rules for Hospitals and Related Institutions in Arkansas 2021 Section 55: A: 26 showed a decontamination area shall be provided in the Emergency Suite. The facility's functional program shall define the location of the decontamination area and the types of exposure to be considered. The location
of the decontamination area shall be permitted to be on the exterior perimeter of the facility adjacent to the ambulance entrance or built within the walls of the facility.
B. Observation of the ambulance entrance to the Emergency Department on 12/14/21 at 1:40 PM showed an emergency shower fixture was present that was covered and dirty.
C. In an interview with the Director of Plant Facilities on 12/14/21 at 1:45 PM it was verified that the emergency shower had been out of service for years and that there was no other method in place for decontamination of hazardously contaminated patients.

Based on review of policy and procedures, instructions for use, manufactures recommendations, product label reviews, review of AORN, Guidelines 2011-2021, review of sterilizer log for Autoclave #1, observations, and interviews, it was determined the facility failed to maintain an active infection control program in that:

A. Staff failed to follow policy and procedure and product labels instructions for use for 2 of 2 32 oz. bottles of Hydrogen Peroxide, 1 of 1 8 oz, bottle of Antiseptic Cleanser, 1 of 1 8 oz. bottle of Povidone-Iodine 10%, 1 of 1 single use bottle of 0.9% Sodium Chloride 100 ml, 1 of 1 4 oz. bottle of Betadine 10% solution as they were all opened, not dated and available for patient use. See A-0750.

B. Staff failed to follow policy and procedure and AORN Guidelines in that IUSS was routinely used to sterilize 5 of 5 Cataract Trays in July, 10 of 10 Cataract Trays in August, 8 of 8 Cataract Trays in September, 10 of 10 Cataract Trays in October, 9 of 9 Cataract Trays in November, and 9 of 9 Cataract Trays for December of 2021. See
A-0750.

C. Staff failed to assure supplies were individually packaged in 6 of 6 (#1, #2, #3, #4, #5, #6) PACU Bays. See A-0750.

D. Staff failed to follow policy and procedure and AORN Guidelines to package and store reusable laryngoscope blades and handles after high-level disinfection for 5 laryngoscope blades in Anesthesia Cart #1 and 4 laryngoscope handles in Anesthesia Cart #3 in that they were not packaged after use and cleaning. See A-0750.

E. Staff failed to follow manufacturer's instructions for use for Super Sani-Cloth Disinfectant Wipes by not allowing 1 of 1 stretcher to air dry after use and prior to reapplying clean linen. See A-0750.

F. Staff failed to ensure there was a procedure in place to ensure EKG leads were cleaned between patient use. See A-0750.

G. Staff failed to separate department supplies from food products (ice cream) for patient use in 1 of 1 freezer in Women's Services. See A-0750.

H. Staff failed to separate dishes used for staff food from the area surrounding the microwave used for heating patient trays. See A-0750.

I. The facility failed to have a trained or certified individual overseeing the infection control program. See A-0748.

J. The facility failed to mitigate the risk of healthcare associated infections in that they did not identify the practice of storing a used SDV (Single Dose Vial) instead of discarding unused portions (per manufacturer) which allowed the SDV to be reused in one (Pre-Op) of three (Pre-Op, Post-Op, and Surgery) three surgical services areas toured. See A-0749.

K. The facility failed to mitigate risks of healthcare related infections by not identifying the practice of storing MDV (Multiple Dose Vials) once opened, in immediate patient treatment areas in one (#3) of five (#1, #2, #3, #4 and #5) anesthesia carts observed. See A 0749.

L. The facility failed to follow standards of practice of maintaining a sanitary environment and to avoid sources and transmission of infection in that there was no implementation of the Arkansas rules and Regulations for Hospitals and Related Institutions for Table 9 in that laundry water temperature was found to be below 120 degrees Fahrenheit (F) in two of two washers. See A-0750.

M. The Facility failed to follow standards of practice of maintaining a sanitary environment in that there was no implementation of the Arkansas rules and Regulations for Hospitals and Related Institutions for Table 9 in that there was no evidence that the laundry water consisted of chlorine beach at 150 parts per million in two of two washers. See A 0750.

Based on employee file review and interview it was determined the Infection Control Preventionist had no training or certification in infection prevention or control. The failed practice did not allow the facility to have a trained or certified individual overseeing the infection control program and had the potential to affect all patients in the facility and employees.

A. Review of the Infection Control Preventionist employee file on 12/13/21 revealed no evidence of infection control training or certification.
C. During interview on 12/16/21 at 2:00 PM with the Director of Nurses (DON) and the Infection Control Preventionist they stated that the Infection Control Preventionist had not attended infection control training in person or online or taken a certification course.
D. Findings in A were verified by DON and the Infection Control Preventionist on 12/16/21 at 2:00 PM.

Based on observation, review of manufacture's recommendations and interview, it was determined the facility failed to mitigate the risk of health-care associated infections in that they did not identify the practice of storing a used SDV (Single Dose Vial) instead of discarding unused portions (per manufacturer) which allowed the SDV to be reused in one (Pre-Op) of three (Pre-Op, Post-Op, and Surgery) three surgical services areas toured. By not identifying this practice, the facility could not assure the use of SDVs were only being used one time and discarded after use. The failed practice had the likelihood to affect all patients receiving services in Surgical Services. Findings follow:

A. Record review of the manufacturer's recommendation for Ropivacaine SDV (Single Dose Vial) for injection showed the vial was not to be reused and the unused portion was to be discarded. Also, this product did not contain bacteriostat or antimicrobial, therefore organisms could have grown in it if not given immediately.
B. During a tour of the facility on 12/14/2021 from 1:18 p.m. to 3:28 p.m., observation showed a 30ml (milliliter) vial of Ropivacaine 0.5% SDV, opened, multiple punctures in the septum stored in the anesthesia block cart in Pre-Op area, available for further use in patients.
C. During an interview on 12/14/2021 at 3:02 p.m., the Operating Room Director verified the SDV was opened, had multiple punctures in the septum, stored in the anesthesia block cart in Pre-Op area and was available for further use in patients.



Based on observation, review of APIC (Association for Professionals in Infection Control and Epidemiology) position paper and interview, it was determined the facility failed to mitigate risks of healthcare related infections by not identifying the practice of storing MDV (Multiple Dose Vials) once opened, in immediate patient treatment areas in one (#3) of five (#1, #2, #3, #4 and #5) anesthesia carts observed. By not identifying the risk this practice carries, the facility could not assure their patients safety. This failed practice has the likelihood to affect all patients receiving procedures in the facility. Findings follow:

A. Review of APIC position paper, titled "Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016)," showed MDV should never enter the immediate patient care area, and if they do, they must be dedicated for single patient use and discarded immediately after use. Examples given by APIC of immediate patient care areas include operating rooms and anesthesia carts.
B. During a tour of Surgical Services on 12/14/2021 from 2:57 p.m. to 3:28 p.m. observation showed an opened vial of Succinylcholine 200 mg (milligram/ 10 ml (milliliter), half full, stored in anesthesia cart #3 and available for further patient use.
C. During an interview on 12/14/2021 at 3:21 p.m., CRNA (Certified Registered Nurse Anesthetist) #1 verified the findings at B.

Based on policy and procedure review, observation, and interview it was determined the facility failed to follow standards of practice of maintaining a sanitary environment and to avoid sources and transmission of infection in that there was no implementation of the Arkansas rules and regulations for Hospitals and Related Institutions for Table 9 in that laundry water temperature was found to be below 120 degrees Fahrenheit (F) in two of two washers. The failed practice did not ensure textiles and fabrics were free from contaminants and had the potential to affect all patients and staff. Findings follow:

A. Review of Facility's Policy titled "Infection Control -Laundry" on 12/16/21 at 1:00 PM showed the following:
"Water temperature of least 160 degrees."
B. On 12/15/21 at 10:25 AM, during tour of the Laundry Room showed the following:
Two of two washing machines were running with Facility laundry. Each with separate hot water lines with temperature gauges installed on both hot water lines. The front washer's temperature gauge read 76 degrees Fahrenheit. The rear washer's temperature gauge read 79 degrees Fahrenheit.
C. At 11:00 AM a new load of Facility surgical attire was loaded into the second (rear) washer. As the washing cycle started, the hot water temperature gauge for the second (rear) washer read 72 degrees Fahrenheit. The hot water temperature gauge for the first (front) washer read 70 degrees Fahrenheit.
D. During interview with Environmental Services Director on 12/15/21 at 10:45 AM, he stated he did not know how long the temperatures had been running in the 70's for both washers. During interview with Environmental Services Director on 12/15/21 at 10:46 AM, he stated he did not know which washer was being checked for hot water temperature daily on the washer During interview with Environmental Services Employee #1, on 12/16/21 at 1:00 PM, she stated that she only checks one washer, and it varies each day, and she only checks one time per day. Surveyor asks Environmental Services Employee #1: "Have you ever noticed either washer with a temperature of 70 degrees or around that temperature?" She stated, "no."
E. The findings in A and B were verified with the Environmental Services Director on 12/15/21 at 11:00 AM.


Based observation and interview it was determined the Facility failed to follow standards of practice of maintaining a sanitary environment in that there was no implementation of the Arkansas rules and regulations for Hospitals and Related Institutions for Table 9 in that there was no evidence that the laundry water consisted of chlorine beach at 150 parts per million. in two of two washes. The failed practice did not ensure textiles and fabrics were free from contaminants and had the potential to affect all patients and staff. Findings follow:

A. On 12/15/21 at 10:25 AM, during tour of the Laundry Room showed the following:
A mechanical device was delivering chlorine bleach for two of two washing machines running with facility laundry.
B. During interview with Environmental Services Director on 12/15/21 at 10:45 AM, he stated he did not know how much chlorine bleach is being delivered into the washers that it is monitored by an outside company.
C. During interview with Environmental Services Director on 12/17/21 at 10:00 AM he stated there is no documentation of how many parts per million of chlorine bleach are being distributed into the washers.
D. Findings in A were verified with the Environmental Services Director at 10:45 AM on 12/15/21.



Based on review of Sage Essential Bath washcloths package instructions for use, observation, and interview, it was determined the facility failed to maintain a sanitary environment in the ER (Emergency Room) in that the facility failed to follow package instructions for warming the Sage Essential Bath washcloths by warming them in a blanket warmer. Failure to follow package instructions and warm the cloths in a Sage Warmer did not assure the Sage Essential Bath washcloths were free from contaminates and safe for patient use. The failed practice had the potential to affect all patients receiving care in the ER. Findings follow:

A. Review of Sage Essential Bath washcloths package instructions showed the Sage Essential Bath washcloths should be warmed in a Sage Warmer.
B. Observation during a tour of the ER on 12/14/21 at 1:42 PM showed 3 of 3 packages in 1 of 1 blanket warmer.
C. The above findings in A and B were verified with ER Registered Nurse# 1 on 12/14/21 at the time of observation.


Based on policy and procedure review, observation, and interview, it was determined the facility failed to maintain a sanitary environment in the ER by not assuring expired agents and single use agents were not available for patient use in 1 of 1 (Trauma #2) Trauma room and 1 of 1 (Room #6) Patient room in the ER. Failure to ensure only currently dated and single use agents were available for use did not assure the agents were free from contaminates and safe for patient use. The failed practice had the potential to affect all patients receiving care in the ER. Findings follow:

A. Review of Policy and Procedure Usage of multiple use Agents (i.e., Alcohol, Betadine, Hydrogen Peroxide, and CHG (Chlorhexidine gluconate) showed: "1. Agents such as but not limited to alcohol, betadine, hydrogen peroxide, and CHG: to ensure the quality of the product and that the ingredients are active should be utilized within 90 days or the expiration date, whichever is earliest. 2. When opening one of the above agents, staff should label the bottle with expiration label available from the pharmacy with the date of opening and the date of which the agent should be discarded."
B. During a tour of Trauma #2 in the ER on 12/14/21 at 1:40 PM, 2 of 2, 32 oz. bottles of Hydrogen Peroxide, 1 of 1, 8 oz. bottle of Antiseptic Skin Cleanser, and 1 of 1, 8 oz. bottle of Povidone-Iodine 10% Topical Solution were observed under the sink to be opened and not dated.
C. During a tour of Trauma #2 in the ER on 12/14/21 at 1:40 PM 1 of 1 (single use) bottle of 0.9% Sodium Chloride 1000 ml (milliliters) was observed under the sink opened.
D. During a tour of Room #6 in the ER on 12/14/21 at 1:35 PM, 1 of 1, 4 oz. bottle of Betadine 10% Solution was observed to be open and not dated.
E. The above findings in A, B, C, and D were verified with the ER Director at the time of the observation.


Based on policy and procedure review, review of sterilizer log for Autoclave #1, review of Association of periOperative Registered Nurses (AORN) Guidelines 2011-2021, and interview it was determined the Operating Room (OR) Director failed to maintain a sanitary environment in Surgical Services by routinely using Immediate Use Steam Sterilization (IUSS) every month (July to December 2021) to sterilize Cataract Instrument Trays. Failure to assure a sanitary environment did not assure patients would be free from all sources of potential infection. The failed practice had the potential to affect all patients having Cataract Surgery. Findings follow:

A. Review of policy and procedure Immediate Use Steam Sterilization showed Purpose: "This policy outlines the procedure for the adequate sterilization of surgical instruments and equipment using immediate use autoclave in the instance of emergency situations and/or when there is insufficient time to sterilize an item by the preferred prepackaged method and/or manufacturer's recommendation. Policy: The use of immediate use steam sterilization shall be kept at a minimum. Use strict aseptic technique to transport immediately sterilized item to sterile field."
B. Review of sterilizer log for Autoclave #1 showed the following:
July-
7/7/21, 5 of 5 Cataract Trays placed in IUSS cycle and 5 of 5 Cataract Trays removed from IUSS cycle on 07/08/21 for patient use. 7/28/21 3 of 3 Cataract Trays placed in IUSS cycle with no removal date documented.
August-
08/11/21, 10 of 10 Cataract Trays placed in IUSS cycle and 10 of 10 Cataract Trays removed from IUSS cycle on 08/13/21 for patient use.
September-
9/1/21, 8 of 8 Cataract Trays placed in IUSS cycle and 8 of 8 Cataract Trays removed from the IUSS cycle on 09/2/21 for patient use.
October-
10/6/21, 10 of 10 Cataract Trays placed in IUSS cycle and 8 of 10 Cataract Trays removed from the IUSS cycle on 10/7/21 for patient use.
November-
11/3/21, 9 of 9 Cataract Trays placed in IUSS cycle and 8 of 9 Cataract Trays removed from the IUSS cycle on 11/4/21 for patient use. December-
12/1/21, 9 of 9 Cataract Trays placed in IUSS cycle and 8 of 9 Cataract Trays removed from the IUSS cycle on 12/2/21 for patient use.
C. Review of AORN Guidelines 2011-2012, showed, "Use items processed by IUSS immediately and do not store them for future use or hold them from one procedure to the next." AORN Guidelines updated August 15, 2018 showed, "It is only acceptable to perform IUSS if the item will be use immediately."
D. In an interview with the OR Director on 12/14/21 at 3:21 PM, she stated they do Cataract Surgery once a month and they only have 4 Cataract Trays, they use IUSS to sterilize the trays. She confirmed the findings in A, B, and C on 12/17/21 at 10:00 AM.



Based on observation and interview, it was determined the facility failed to assure a sanitary environment in the PACU (Post-Anesthesia Care Unit) in that 4x4 gauze pads were opened and available for patient use in 6 of 6 (#1, #2, #3, #4, #5, #6) PACU bays and oral airways were opened and out of the packages and available for patient use in 3 of 6 (#1, #5, #6) PACU Patient Bays. The failed practice did not assure did not assure patients would be free from potential sources of infection. The findings had the liklihood to affect all patients in the PACU. Findings follow:

A. During a tour of the PACU on 12/14/21 at 3:00 PM, PACU Bays #1, #2, #3, #4, #5, #6 were all noted to have a stack of 4X4's eight inches tall in a basket at the head of each bay near the oxygen and suction outlets.
B. During a tour of the PACU on 12/14/21 at 3:00 PM, PACU Bays #1, #5, #6 each had a Styrofoam cup in a basket containing oral airways that were not in individual packages Bay #1 had 2 of 3 oral airways not packaged, Bay #5 and Bay #6 each had 5 of 5 oral airways not packaged. These Styrofoam cups containing unpackaged oral airways were in a basket at the head of the PACU Bays near the oxygen and suction outlets.
C. During the tour of the PACU on 12/14/21 at 3:00, the Styrofoam cup containing the unpackaged oral airways in PACU Bay #6 had a dead insect in the bottom of the cup.
D. The findings in A, B, and C were confirmed with the Chief Nursing Officer (CNO) and Operating Room (OR) Director at the time of the observations.


Based on policy and procedure review, review of Association of Peri-Operative Registered Nurses (AORN) Guidelines 2012-2021, observation, and interview, it was determined the Certified Registered Nurse Anesthetists (CRNAs) failed to provide a sanitary environment for the storage of 5 of 5 laryngoscope blades and 4 of 4 laryngoscope handles in 2 of 2 Anesthesia Carts (#1 and #3) in the Surgical Services Area as the blades and handles were observed in the drawer opened with no sterile packaging observed. The failed practice did not assure patients would be protected from infection and had the likelihood to expose all patients treated in the Surgical Services area to potential sources of infection. Findings follow:

A. Review of Infection Control Policy and Procedure Infection Prevention and Control Program showed, "Mena Regional Health System Infection Prevention and Control Program shall be conducted in accordance with all applicable federal and state rules and regulations, accrediting body standards, as well as nationally recognized infection control practices and guidelines, including evidence-based guidelines and recommendations from the following organizations: Centers for Disease Control and Prevention (CDC), Association for Professionals in Infection Control and Epidemiology (APIC), Society for Healthcare Epidemiology of America (SHEA), Infectious Diseases Society of America (IDSA), Association of perioperative Registered Nurses (AORN), Occupational Health and Safety Administration (OSHA), Centers for Medicare and Medicaid Services (CMS), Institute for Healthcare Improvement (IHI)."
B Review of AORN Guidelines 12. Laryngoscope Blades and Handles showed, 12.4 "Package and store reusable laryngoscope blades and handles that have been high-level disinfected or sterilized in a manner that prevents contamination and identifies them as ready for use."
C. During a tour of Surgical Services on 12/14/21 at 3:27 PM, there was 1-McIntosh 4 blade observed with no packaging in Anesthesia Cart #1 and 3-Miller 2 blades, 1-Miller 00 blade, and 4 handles observed with no packaging in Anesthesia Cart #3.
D. The findings in A, B, and C were verified with the OR (Operating Room) Director and CNO (Chief Nursing Officer) at the time of the observations.


Based on observation and interview, it was determined (Preoperative) Preop RN #1 failed to maintain a sanitary environment in Preop by not following Manufacturer's Instructions for Use of Super Sani-Cloth Germicidal Disinfectant Wipes in that after the product was applied and was not allowed to dry prior to new linens being applied. Failure to follow Manufacturer's Instructions did not assure the stretcher was disinfected and had the potential to affect all patients receiving care in Preop. Findings follow:

A. During observation in the Preop Area on
12/15/21 at 9:56 AM, the Preop RN #1 was observed wiping down 1 of 1 stretcher in Preop Bay #2 with Super Sani-Cloth Germicidal Disinfectant Wipes and immediately applying clean linens prior to allowing the stretcher to dry.
B. Review of Super Sani-Cloth Germicidal Wipes Instructions for Use showed "Allow treated surface to remain wet two minutes. Let air dry."
C. The findings in A and B were verified with the Operating Room (OR) Director on 12/15/21 at 11:00 AM.


Based on observation and interview, it was determined CRNA #2 (Certified Registered Nurse Anesthetist) failed maintain a sanitary environment in the Preoperative (Preop) area by not assuring dirty EKG Leads were not available for use. Failure to assure the EKG
(electrocardiogram) Leads were sanitized appropriately did not assure the EKG Leads were free from contaminates and safe for patient use. The failed practice had the potential to affect all patients receiving care in Preop. Findings follow:

A. During observation in the Preop Area on 12/15/21 at 9:45 AM, CRNA #2 was observed walking into Preop with a set of EKG Leads draped over his right shoulder. CRNA #2 placed the EKG leads on a hook hanging on the wall in Preop. At 9:50 on 12/15/21 Preop RN #1 entered the Preop area and hung her lab coat on the same hook containing the EKG leads.
B. At 10:10 AM on 12/15/21, CRNA #2 brought another set of EKG leads and placed them on top of the lab coat hanging on the hook in Preop.
C. In an interview with Preop RN #1, on 12/15/21 she stated CRNA #2 usually hands the EKG leads to her and they are always sanitized after use and prior to placement on another patient. She stated that sometimes CRNA #2 would sanitize the EKG leads.
D. The above findings in A, B, and C, were verified with the Operating Room (OR) Director on 12/15/21 at 11:10 AM. She confirmed there was no process to ensure the EKG leads are cleaned between patient use.


Based on observation and interview, it was determined the facility failed to assure a sanitary environment in the Women's Services Department in that 1 of 1 freezer had 20 icepacks in the same freezer space as 10 of 10 of ice cream containers available for patient use. Failure to separate the ice packs and ice cream did not assure the items would not come in contact causing contamination. The failed practice did not assure avoidance of sources and transmission of infection to patient nourishments or vaccines. The failed practice had the potential to affect all patients receiving care in the Women's Services Area. Findings follow:

A. During a tour of the Women's Services Patient Nourishment Room on 12/14/21 at 2:32 PM, the Patient Nourishment Freezer was noted to have 20 ice packs in the same freezer space as 10 individual ice cream cups. 3 of 20 of the ice packs had a noticeable reddish-pink and white substance on them.
B. In an interview with the Nurse Manager of Women's Services during the tour of the Patient Nourishment room, she stated the ice packs were used for transport of the department's Hepatitis B vaccine and in case of a power outage to keep the Hepatitis B vaccine cold.
C. The findings in A and B were confirmed with the Chief Nursing Officer (CNO) at the time of the observation.


Based on observation and interview, it was determined the facility failed to assure a sanitary environment in the Women's Service Department in that 1 of 1 microwave used for heating patient trays and nourishments was observed to be covered and surrounded by dishes that had been used for staff food, washed, placed to dry on top of and around the microwave on the countertop. The failed practice did not assure avoidance of sources of transmission of infection to patient nourishments. The failed practice had the potential to affect all patients receiving care in the Women's Services Area. Findings follow:

A. During a tour of the Women's Services Patient Nourishment Room on 12/14/21 at 2:32 PM, 1 of 1 microwave was noted on the counter with dishes upside down on top of the microwave to dry after being washed. Dishes were also noted on the countertop surrounding the microwave.
B. In an interview with the Nurse Manager of Women's Services during the tour of the Patient Nourishment Room, she stated the staff washed their dishes in the sink next to the microwave and used the area on top and surrounding the microwave to dry their dishes. She also stated the microwave was used to heat patient nourishments and food trays. She stated the staff used this area to do their dishes because the
"staff breakroom" was not close to the unit. She also stated this room was used as a Physician dictation room and that staff would keep their personal drinks in this room.
C. The findings in A and B were confirmed with the (Chief Nursing Officer) CNO at the time of the observation.

Based on review of the Emergency Preparedness Plan and interview, it was determined the facility failed to biennially review and update the Emergency Preparedness Plan. The failed practice did not assure the plan was still current and did not ensure all staff were knowledgeable of the plan. The failed practice had the potential to affect all patients and staff. Findings follow:

A. Review of the facility's Emergency Preparedness Plan on 12/15/21 at 1:00 PM showed there was no record of the Emergency Preparedness Plan being reviewed or updated.
B. The finding in "A" was verified during an interview with the Safety Officer at 1:20 PM on 12/15/21.