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Based on observation, interview and record review, it was determined the facility failed to inform four (4) of eighty-four (84) sampled patients of their rights as patients in the facility. The facility also failed to inform all patients treated at the facility's Pain Clinic of their rights as patients in the facility.

The findings include:

1. Record review for Patient #71 revealed the patient was admitted to the facility's extension facility on 09/04/12 and discharged on 11/27/12. Further review revealed no documented evidence in the record that the patient or his/her representative had had been informed of the facility's patient's rights.

Interview, on 01/14/13 at 10:30 AM, with the Health Information Management (HIM) computer person revealed, after performing a computer search, that there was no documentation in the chart of Patient #71 to show the patient or his/her representative had been advised of the patient's rights.

2. Observation, on 01/14/13 at 1:30 PM, in the lobby of the Emergency Department (ED) of the facility's extension facility revealed no evidence patient rights were posted in the waiting area or in plain view anywhere in the area of the ED.

Interview, on 01/14/13 at 10:50 AM, with the Supervisor of Admitting and ED Registration revealed there was no documentation of patients receiving their rights.

Interview, on 01/15/13 at 3:10 PM, with the Director of Emergency Services revealed she understood that patients were given a copy of their rights and signed for that copy. However, what the patient or their representative was signing was a consent for treatment.

Interview, on 01/14/13 at 3:15 PM, with Patient #61, a patient in the ED, revealed he/she had not been informed of his/her rights prior to entering the ED or since being a patient in the ED.

Interview, on 01/14/13 at 3:25 PM, with Patient #62, an ED patient, revealed he/she had not been informed of his/her rights prior to entering the ED or after being admitted to the ED and given medication for his/her complaint.

Interview, on 01/14/13 at 3:40 PM, with Patient #63, an ED patient, revealed he/she had not been informed of his/her rights prior to entering the ED, during treatment in the ED or prior to discharge from the ED.

3. Review of the forms covered by staff with patients in the Pain Clinic revealed the patients or their representative were not informed of their rights before or after treatment in the Pain Clinic.

Interview, on 01/17/13 at 3:50 PM, with the Patient Relations Assistant II at the extension facility's Pain Clinic revealed the patients in the Pain Clinic were not given any information about their rights.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary nursing care for five (5) of eighty-four (84) sampled patients. Patient #83 was morbidly obese and admitted to the hospital with a fractured femur. Following surgery Patient #83 could only get out of bed with the assist of a mechanical lift. However, no working lift was available for use. The facility's failure to provide the lift kept Patient #83 confined to bed and prevented him/her from engaging in activities which he/she stated were important to him/her and inhibited the progress of his/her physical abilities. Four (4) patients had Physician's Orders the facility failed to follow. In addition, the facility failed to follow nursing protocol related to patient transport from hemodialysis.

The findings include:

1. Record review for Patient #83 revealed the patient was sixty-four (64) years old and initially admitted to the facility on 10/17/12, for a left leg femur fracture following a fall. Review revealed surgery was performed on the patient's leg on 10/25/12. Review revealed the patient was transferred to the facility's extention facility on 12/11/12. Record review revealed the patient had a weight in excess of three hundred and fifty (350) pounds. The record for Patient #83 revealed a Physician's Order dated 12/20/12, to get the patient up to a chair for two (2) hours once per day with a Hoyer lift.

Record review revealed a Nursing Note dated 12/22/12, that indicated the Hoyer lift was broken and the patient wanted to get out of bed. Further review of the Note revealed the nurse was to see if maintenance could fix the Hoyer lift. Review revealed no documented evidence there was a follow up note.

Review of an Occupational Therapy (OT) Note dated 01/03/13, revealed the Hoyer lift was broken and multiple calls had been made to Biomedical. Continued review revealed no documented evidence of a follow up Note or known status of the Hoyer lift. Further review revealed the entry also stated the patient needed to be out of bed every day with exercise or he/she would be unable to stand when able to bear weight on the left lower extremity. Review of a Physical Therapy (PT) Note dated 01/10/13, revealed there was no Hoyer lift available, so PT was unable to be performed.

Observation, on 01/17/13 at 9:40 AM, revealed Patient #83 was in a single room in bed with the head of the bed raised so the patient was sitting up. Observation revealed the bed was larger in size than a standard hospital bed. Continued observation revealed the patient to be obese and well groomed.

Interview, on 01/17/13 at 3:45 PM, with Patient #83 revealed he/she had not been out of the hospital bed for weeks. The patient stated the staff had tried to use a Hoyer lift weeks ago to get him/her out of bed and it broke during use with Patient #83 in the seat (sling). Patient #83 stated that was a very scary experience. According to the patient, he/she had remained in the hospital bed since that time. The patient shared that during his/her time confined to the hospital bed he/she had missed the birth of his/her first greatgrandchild, a graduation, and he/she listed several other events which he/she was not included. Continued interview revealed the previous night Patient #83 felt the walls of the room were closing in on him/her from being in the bed for such a long period of time. Observation revealed the patient then began crying.

Interview, on 01/18/13 at 4:15 PM, with Registered Nurse (RN) #24 revealed when she was assigned to Patient #83's care she knew there was an order to get the patient out of the bed; however, the Hoyer lift was not in working order at that time. She stated she did not inquire as to the status of the Hoyer lift. According to the RN, she did not go look for another lift and therefore the patient remained in bed. RN #24 stated she knew the process was to let the Nurse Manager know if equipment was not working. She stated she did not report it to management when it was reported to her that the Hoyer lift was not working.

Interview, on 01/18/13 at 3:10 PM, with the Physician's Assistant (PA) revealed it would have been ideal to get the patient out of the bed. She stated the patient told her he/she wanted to get out of bed to be with his/her family in the facility for their visit on Christmas Eve. According to the PA, it was important for the endurance of the patient to get out of bed; however, the PA revealed she had followed up on the information she received regarding the lift not working. She stated this had been for about four weeks and the PA stated there was always excuses for why the Hoyer lift did not work. The PA stated, "there was always something," and she did not know if the staff knew how to work the Hoyer lift. She stated getting the patient out of bed as ordered did not occur. Additionally, she stated the staff did not act on the patient's behalf.

Interview, on 01/18/13 at 11:50 AM, with the Fourth Floor Manager revealed it was brought to her attention in December (2012) that the Hoyer lift was not working, but she could not recall a specific date. She revealed there were two (2) Hoyer lifts in the sister facility, however neither one was in working order. She stated a Hoyer lift belonging to another facility which rented space within the sister facility had been borrowed in the past since the sister facility did not have a working Hoyer lift. Continued interview revealed the process for reporting the need for repairs was to notify Information Technology (IT) and IT passed the information to the Biomedical Department. Review of the work orders revealed a work order was not generated until 01/04/13 by the Fourth Floor Manager.

Interview, on 01/17/13 at 1:40 PM, with the Director of Critical Care and General Nursing revealed she did not know the Hoyer lift was broken and was in need of repairs. She stated she did not know there were patients that could not get out of bed in the sister facility. According to the Director, the process would have been for the Unit Manager to keep her informed and the Unit Manager was responsible to follow up with patient care equipment. She stated if the Unit Manager ran into an obstacle, they were to bring the issue to her and no one did in this case. The Director stated, in this instance the staff was borrowing equipment instead following the process of informing management that the equipment was not available.

Interview, on 01/18/13 at 12:15 PM, with the Director of Enterprise Accreditation revealed the record needed to indicate the status of a work order, such as making Note in the Nurse's Notes. She revealed the breakdown in communication related to the Hoyer lift involved multiple system failures.

Interview, on 01/17/13 at 4:55 PM, with the Certified Biomedical (Bio-Med) Electrical Technician (Tech) revealed a work order to repair the Hoyer lift was placed with the department on 01/04/13. The Certified Biomedical Electrical Tech stated the order was completed on 1/16/13 after being brought to the attention of the facility by the state survey team. The Tech stated the Hoyer lift was missed when the original inventory was done for items on the preventative maintenance (PM) list, but it had been put in the system this month. He stated the lift was examined and had a depleted battery; one was ordered and it was now replaced. He revealed the delay was a work order issue explaining that staff made the decision to the priority for repairs. He stated items of higher priority were completed first, this would be items that would affect patient care or the ability to sustain their life. He stated that there was no urgent notice for repair on the lift, so it was not known to Bio-Med that the lift was the only way Patient #83 could get out of bed.


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2. Review of Patient #27's medical record revealed a Physician's Order dated 01/09/13 for daily weights. Continued record review revealed no documented evidence of a daily weight for the dates of 01/10/13, 01/11/13, and 01/14/13.

Interview, on 01/16/13 at 11:59 AM, with the Director of the Oncology Units revealed daily weights should have been obtained as ordered.

3. Review of Patient #30's medical record revealed a Physician Order dated 01/08/13 for weights every morning. Continued review of the record revealed no documented evidence of the patient's weight on 01/15/13.

Interview, on 01/16/13 at 2:30 PM, with Registered Nurse (RN) #10 revealed the patient's weight should have been obtained on 01/15/13 as ordered.

4. Review of Patient #31's medical record revealed a Physician's Order dated 01/07/13 for weights to be obtained twice a day. Continued review of the patient's record revealed a weight was obtained in the morning of 01/08/13. However, further review revealed no documented evidence of the second weight being obtained later that day.

Additionally, continued review of the patient's medical record revealed a Physician's Order dated 01/15/13 for fingerstick blood sugars (FSBS) before meals and at bedtime; and orders for sliding scale insulin administration as follows: two (2) units for a FSBS of 150-199, four (4) units for a FSBS of 200-249, six (6) units for a FSBS of 250-299, eight (8) units for a FSBS of 300-349, ten (10) units for a FSBS of 350-399, and to call the Physician for a FSBS greater than four hundred (400).

Review of the FSBS revealed on 01/16/13 at 12:50 PM the patient's FSBS was 275, however there was no documented evidence Patient #31 received the six (6) units of sliding scale insulin as ordered.

Interview, on 01/16/13 at 4:00 PM, with RN #10 revealed the second weight should have been obtained on 01/08/13 as ordered. She further stated six (6) units of sliding scale insulin should have been administered as ordered for the FSBS of 275 at 12:50 PM that day.

5. Review of Patient #32's medical record revealed a Physician's Order dated 01/15/13 for daily weights. Continued review of the record revealed no documented evidence a weight was obtained on 01/16/13 as ordered. Additionally review of the record revealed the patient was placed on oxygen at 7:41 PM on 01/16/13 and remained on oxygen on 01/17/13. However, further review of the record revealed no documented evidence of a Physician's Order for the oxygen.

Interview, on 01/17/13 at 9:00 AM, with RN #10 revealed Patient #32's weight should have been obtained on 01/16/13 as ordered. In addition, she stated there should have been a Physician's Order for the oxygen Patient #32 had in use.




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6. During the tour of the hemodialysis unit on 01/17/13, Patient #23 complained of having to stay in the hemodialysis room an hour and a half after treatment yesterday (01/16/13) because no staff would transport him/her back to his/her room. Patient #23 stated he/she had complained to the hemodialysis nurse who had taken care of him that day. Observation and interview of Patient on 01/18/13 revealed he/she was taken off the hemodialysis machine at 1:12 PM. Patient #23 stated after hemodialysis he/she was tired and wanted to go back to his/her room and lay down in the bed. Patient #23 stated he/she was also hungry after treatment, due to missing lunch.

Interview with Registered Nurse (RN) #25, on 01/18/13 at 4:30 PM revealed she was the nurse who took care of Patient #23 on 01/17/13 while in the hemodialysis unit. The nurse stated she had put Patient #23 on the transport board at 1:13 PM, and then called his/her nurse to give report. RN #25 stated at 1:45 PM she had checked the board again and Patient #23 was next in line. She stated because Patient #23 had a cardiac monitor a Registered Nurse had to transport him/her to his/room or in Patient #23's case to have a Echocardiogram. RN #25 stated patients who needed a nurse transporter frequently had to wait. She stated sometimes they would notify the floor nurse for transport or if at the end of the day and there were no other patients, the dialysis staff would take the patient back to their room. She stated the patients would complain of being tired and hungry but it was out of their control.

Interview with the Transport Supervisor, on 01/17/13 at 3:00 PM, revealed that per the facility's protocol, if a patient had to wait an extended amount of time the House Administrator should be notified. She stated at fifteen (15) minute wait would be a normal amount of time a patient should have to wait for transport.

7. Observation of Patient #25 during a Hemodialysis treatment, on 01/17/13 at 1:50 PM, revealed Patient #25 was lying in bed with the remaining time to dialysis being one hour and thirty-nine minutes. The dialysate flow rate was set at 500 milliters per minute. Review of the Physician's dialysis orders for 01/17/13 revealed an order for Patient #25's dialysate to be run at 800 milliters per minute.

Interview with RN #26, on 01/17/13 at 1:55 PM, who had put Patient #25 on the Hemodialysis machine, revealed the dialysate rate should have been change to 800 milliters per minute after she got the patient running on the machine. She stated the reason it was set to 500 instead of 800 was because 500 was the default setting, if the nurse did not change the dialysate flow rate to the ordered flow rate.

Interview with RN #3, on 01/17/13 at 2:00 PM, revealed no reason why the dialysis machine was not set at the ordered dialysate flow rate.

Based on observation, interview, and review of the facility policy for Pharmacy Security, it was determined the facility failed to ensure all drugs were secure and not left unattended. Observation in the ENDO (Endoscopic) room revealed medications were left on top of a unlocked cart, in an unlocked room unattended.

The findings include:

Review of facility's policy for Pharmacy Security, with a revision date of November 2012, revealed medications in non-pharmacy areas must be secured and not left unattended. There were three (3) levels of securing medications: (a) maintain medication within a locked cabinet, drawer, or automated dispensing cabinet, (b) store medication within a controlled access room, i.e. key access, keypad, or badge, and (c) store medication in a supervised area. If the area is not supervised 24 hours per day, 365 days per year, then the medication shall be secured by an alternate method.

Observation of a colonoscopy procedure, on 01/16/13 from at 9:48 AM, in Endo Room #1 revealed the procedure for Patient #78 ended at 9:48 AM. The Certified Registered Nurse Anesthetist (CRNA), who was administering the anesthesia to the patient left the ENDO room at approximately 9:50 AM. Continued observation revealed an opened bottle of Propofol (a drug that reduces anxiety and tension, and promotes relaxation and sleep or loss of consciousness, used for short diagnostic tests and surgical procedures) was left sitting on top of a blue cart. In addition, observation revealed two (2) syringes filled with medications were left on top of the cart and covered with a blue cloth. The syringes were placed beside the opened bottle of Propofol. Further observation revealed all staff and the surveyor left the room at 9:51 AM and the door to the room was not locked.

The surveyor waited outside the ENDO room and observed three (3) visitors walk down the hallway outside the unlocked ENDO room where the unsecured medications were stored.

After surveyor intervention, interview with Registed Nurse (RN) #32, at 9:55 AM revealed the ENDO room was left unlocked between cases but was locked at the end of the day. She stated she thought all drugs were secured and she did not see the syringes filled with medication on top of the blue cart.

Interview with the CRNA, on 01/16/13 at 10:05 AM, revealed the prefilled syringes contained emergency drugs used in case a patient requires emergency intervention. He indicated it was a normal practice for him to leave the syringe filled drugs in the room because he thought someone was always in the room. He revealed the blue cart was for supplies and could not be locked.

Interview, on 01/16/13 at 10:10 AM, with the Patient Care Manager and another administrative escort, revealed they had observed all staff to leave the ENDO room after the procedure. They stated they were unaware drugs had been left in the room unsecured and unattended. The administrative escort stated she thought the drugs were locked in the blue cart and did not realize the cart could not be locked. She said the room should be locked between cases. She revealed the ENDO room was located on a inpatient unit where patients and visitors had access to the hallway outside the ENDO room.

Interview with the Director of Pharmacy, for the facility's extension facility, on 01/17/13 at 1:20 PM, revealed the blue cart was assigned to the ENDO anesthesia and CRNA staff but it did not lock. He stated the pharmacy did not provide the drugs for the ENDO rooms so the CRNA must have pulled the drugs from the Pyxis system (medication administration system). The Director stated, in surgery, the anesthesiologist have a tray that was picked up from the pharmacy. According to the Director, the ENDO medications come from the Pyxis system and it was a common practice to draw up emergency medications during these types of procedures, prior to the first ENDO case and discard the medication at the end of day. The Director stated the drug Propofol was a standard drug used in this type of procedure. He stated all drugs should be secure when left unattended.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure that established policies and procedures were maintained for safe food handling practices. The facility failed to ensure opened food products were label and dated, a freezer was maintained utilizing sanitary conditions and employees maintained good hand hygiene.

The findings include:

Review of the facility's policy titled "Production, Purchasing, Storage. Food Handling guidelines", dated 01/12, revealed hands should be scrubbed following appropriate hand washing techniques according to facility/community policy (e.g. after toilet use, between food preparation tasks, before putting on gloves). Further review of the policy revealed single use gloves were worn when preparing foods that would not be cooked again (ready to eat foods) or while serving foods. Additional review of the policy revealed gloves were to be changed between tasks and hands washed after gloves were removed. Continued review of the policy revealed all foods being cooled must be identified with a label including date and time food began the cooling process.

1. Observation of the University of Kentucky (main building) kitchen, on 01/14/13 at 2:30 PM, revealed there was a bag of diced light brown meat in a plastic bag on the middle shelf of a cooler identified as the Produce Refrigerator. Interview with the Dietary Director and the Dietary Manager revealed the meat was diced turkey. Further interview confirmed the bag should have been labeled and dated as to when the item was placed in the refrigerator for cooling.

Observation of the freezer next to the egg/cheese cooler, on 01/14/13 at 2:45 PM, revealed an accumulation of dust was noted on the freezer fan. In addition, an accumulation of frozen peas and dried white crumbs were noted to be embedded on the freezer floor beneath the shelves. Interview with the Dietary Manager at that time revealed the freezer floor needed to to be thoroughly cleaned, including underneath the shelves as well as the dust on the fan.

Observation during the evening meal service, on 01/14/13 at 4:15 PM, revealed Food Service Worker (FSW) #1 used his gloved hand to pick up a handful of french fries and placed the french fries on a plate being utilized to serve a patient meal. Further observation revealed FSW #1 walked over to the refrigerator, opened the refrigerator door with the same gloved hand, obtained a sandwich, closed the refrigerator door with the gloved hand, returned to the meal service line and picked up a handful of french fries with the same gloved hand to place on another patient plate. Interview with FSW #1 at that time revealed he had gloves on when directly touching the french fries and was not aware he had touched other objects prior to returning to the meal service and again picking up french fries without changing his gloves and washing his hands. Interview with the Dietary Manager, at that time, revealed FSW #1 should have used tongs to pick up the french fries to prevent cross contamination.

2. Observation at the beginning of tray line service in the kitchen at University of Kentucky Good Samaritan Hospital, on 01/15/13 at 11:00 AM, revealed Catering Associate # 2 obtained food temperatures of beef gravy, beef broth and rice without sanitizing the thermometer between taking each food temperature. Further observation revealed Catering Associate #2 obtained the temperature of green beans that had been seasoned with onions and bacon and then took the temperature of green beans used for special diets which did not contain onions and bacon. Interview with Catering Associate #2 at that time revealed he thought as long as the temperature was hot enough when taking one item it was enough to sanitize it before going to the next item. Interview with the Registered Dietitian Director of Dietary Services, at that time, revealed employees are supposed to sanitize the thermometer between taking food temperatures of each item not only for sanitary purposes but also to prevent cross contamination of food allergens, such as someone who may be allergic to onions.

Based on observation, interview, record review and facility policy, it was determined the facility failed to maintain Hoyer lifts for patient needs. Two (2) of two (2) Hoyer lifts were not available for patient needs, were in need of repair, and not in working order. In addition, the facility failed to ensure expired supplies/supplements were not available for patient use.

The findings include:

1. Review of the policy "Equipment Maintenance Program", revised 08/2011, revealed the University of Kentucky Hospital had established a medical equipment program that included preventative maintenance, repair and documentation of medical equipment. In addition, the policy stated Clinical Engineering was responsible to ensure that all medical equipment was properly maintained or repaired, and that maintenance was properly documented.

Record review for Patient #83 revealed the patient was initially admitted to University of Kentucky Hospital Chandler (Chandler) on 10/17/12 for a left leg femur fracture following a fall. Surgery was performed on his/her leg on 10/25/12. The patient was admitted to Good Samaritan University of Kentucky Hospital (Good Samaritan) on 12/11/12 from Chandler. The patient had a weight in excess of 350 pounds. The record for Patient #83 revealed a Physician's Order dated 12/20/12 to get the patient up to a chair once per day with a Hoyer lift. However, there was not a Hoyer lift in the facility in working order. A nursing note dated 12/22/12 revealed the Hoyer lift was broken and the patient wanted to get out of bed. The note stated the writer would see if maintenance could fix the Hoyer. A Physical Therapy (PT) note dated 01/10/13 stated there was no Hoyer lift so PT was unable to be performed. There was no Hoyer lift in working order in Good Samaritan as of 01/15/13.

Interview, on 01/17/13 at 1:20 PM, with the Physical Therapist revealed all the Hoyer lifts in the hospital (Good Samaritan) were broken. She revealed staff (PT staff) had borrowed a lift from "Select", another facility which rented space within Good Samaritan. However, "Select" did not have a seat (sling) the appropriate size for the patient.

Interview, on 01/17/13 at 3:45 PM, with Patient #83 revealed he/she had not been out of the bed for weeks. The patient stated the staff had tried to use a Hoyer lift weeks ago and it broke during use with him/her in the seat (sling). The patient revealed he/she had remained in bed since that time.

Interview, on 01/18/13 at 11:50 AM, with the Fourth Floor Manager revealed it was brought to her attention in December (2012) that the Hoyer lift was not working but she could not recall a specific date. She revealed there were two Hoyer lifts in Good Samaritan but neither one was in working order. She stated a Hoyer lift belonging to another facility which rented space within Good Samaritan had been borrowed in the past since Good Samaritan did not have a working Hoyer lift.

Interview, on 01/18/13 at 12:00 PM, with the Director of Critical Care and General Nursing revealed the staff should have reported the Hoyer lifts not working to the Fourth Floor Manager. She stated that was the process, then the Fourth Floor Manager would report needed repairs to Information Technology (IT) and IT would pass the need to Biomedical. The Fourth Floor Manager had knowledge of the Hoyer lift not in working order in December 2012. A work order was not received by Biomedical until 01/04/13.

Interview, on 1/17/13 at 4:55 PM, with the Certified Biomedical Electrical Technician (Bio-Med) revealed a work order to repair the Hoyer lift was placed on 01/04/13. The order was completed on 1/16/13 after being brought to the attention of the facility by the survey team. It was revealed that the Hoyer lift was missed when the original inventory was done for items on the preventative maintenance (PM) list, but it had been put in the system this month. He stated what was found wrong with the lift was a depleted battery, and one was ordered and it was replaced. He revealed the delay was a work order issue explaining that the technician made the decision of the priority for repairs. He revealed items of higher priority were completed first, items that would affect patient care or the ability to sustain their life. He stated that there was no urgent notice for repair on the lift so it was not known to Bio-Med that the lift was the only way Patient #83 could get out of bed.

Interview, on 01/17/13 at 5:15 PM, with the Safety Registered Nurse revealed there was a system breakdown in reporting, the follow up and repair of the Hoyer lift. She acknowleged the system breakdown had a negative effect on Patient #83.


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2. Observation, on 01/16/13 at 2:30 PM, revealed eleven (11) two ounce bottles of Similac Sensitive for Fussiness and Gas Infant Formula, with the expiration date of 12/01/12, in the 4 North Pediatric Unit Supply Storage Room, twelve (12) two ounce bottles of Similac Special Care Premature Infant Formula, with the expiration date of 01/01/12, in the 4 North Patient/Family Pantry and four (4) two ounce bottles of Similac Advance Complete Nutrition Infant Formula in the 4 North Patient/Family Pantry.

Interview, on 01/18/13 at 3:10 PM, with the 4 North Patient Care Manager revealed expired supplies should not have been in the Storage Room or the Pantry. She stated expired supplies should not be used. She further stated Material Management was responsible for ensuring expired supplies were not in Storage Rooms.

Interview, on 01/17/13 at 4:15 PM, with the Director of Supply revealed stockers were supposed to rotate stock, newer to the front. She stated expired supplies should not have been available for use, they should have been removed and replaced. She further stated the expired formula was available for use due to employee failure. Further interview revealed the facility did not have a written expired supply policy.

3. Observation of the Cardiac Cath Lab, Consigned Cabinet #2, on 01/17/13 at 11:24 AM, revealed two (2) Trek Coronary Dilatation Catheters, twelve (12) millimeters (mm) and one (1) Trek Coronary Dilatation Catheter, twenty (20) mm each with an expiration date of 12/2012.

Interview with the Cath Lab Technician, on 01/17/13 at 11:45 AM, revealed she routinely counted and checked expiration dates on supplies in Consigned Cabinet #2 on Mondays. She further revealed the last time this was done on this cabinet was on 01/07/13; and, she did not check expiration dates for cardiac catheters on that date. She could give no explanation why expiration dates were not checked.


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4. Observation of the eighth floor, on 01/14/13 at 3:10 PM with the eighth floor Patient Care Manager, revealed suction canister tops were stored in a trash bag that was on the floor and the canister tops were spilling out of the bag onto the floor. Continued observation revealed one suction cannula on the floor, as well as suction tubing without plastic covering on the floor. Also a stack of wash basins and a box of footies were on the floor. There was a one thousand millileter bag of D5NS without a wrapper in with the other intravenous fluids (IVF) as available for use.

Observation of the Patient Care Manager, on 01/14/13 at 3:15 PM, revealed she threw some of the supplies in the trash; put the wash basins, some of the suction cannula tops and the box of footies which were on the floor on the shelves. The Patient Care Manager stated the IVF was all right to use, but would check with the staff.

Interview with the Patient Care Manager, on 01/14/13 at 4:00 PM, revealed the supplies on the floor were an infection control issue. She stated the staff knew not to use contaminated items, and she stated staff would not have used the IVF's without the plastic covering, but did not know who had put it there.

5. Observation of RN #27, on 01/17/12 at 9:30 AM, revealed the RN enter the hemodialysis unit at the facility's extension facility to obtain a finger stick blood sugar. After obtaining the blood for the test and getting the results, the nurse removed her gloves and put on another pair of gloves and took the glucometer out of the room to clean it.

Interview with RN #27, on 01/17/13 at 9:40 AM, revealed the glucometer stick she had just used to obtain the blood sugar had no date as when the bottle had been opened. RN #27 stated the glucometer sticks were good for three (3) months after opening. She stated she would throw those glucomter stick away since there was not way to tell if they had been opened for more than three (3) months.





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Based on observation, interview and review of the facility's Dry and Moist-to-Dry Dressing Procedure (undated) and the facility's Hand Hygiene Policy #A03-015 (revised 11/16/12) revealed the facility failed to develop a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

The findings include:

Review of the facility's Dry and Moist-to-Dry Dressing Procedure (undated) revealed hand hygiene was to be performed after soiled dressings were removed and after gloves were removed. Further review revealed wounds were to be cleansed after soiled dressings were removed.

Review of the facility's Hand Hygiene Policy A03-015 (revised 11/16/12) revealed hand hygiene was to be performed after removing gloves.

1. Observation, on 01/17/13 at 9:40 AM, revealed Registered Nurse (RN) #1 removed a soiled dressing, removed the soiled gloves and donned clean gloves without performing hand hygiene. Further observation revealed the nurse failed to cleanse the wound and periwound area before she applied the clean dressing.

Interview, on 01/17/13 at 10:35 AM, with RN #1 revealed the wound did not have to be cleansed prior to applying the clean dressing because it was a wet-to-dry dressing and would clean the wound by debridement. She further stated the Physician would order a solution, such as Dakins or Hibiclens, if he wanted the wound to be cleansed. She stated she did not think about cleansing the wound but guessed it wouldn't have hurt to cleanse it. She stated she didn't know the facility's policy; however, after she looked at the facility's moist-to-dry dressing policy, she stated she should have cleansed the wound prior to applying the clean dressing. Further interview revealed she didn't perform hand hygiene, after removing gloves, unless she was leaving a patient's room.

Interview, on 01/17/13 at 11:00 AM, with the 3 North Patient Care Manager revealed the RN should have sanitized her hands after removing gloves and she should have cleansed the wound prior to applying a clean dressing.

Interview, on 01/18/12 at 4:00 PM, with the Infection Control RN revealed the RN should have sanitized her hands after removing gloves.


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2. Observation during tour of the 5th floor of the facility's extension facility, on 01/14/13 at 4:15 PM, revealed Patient #76 had been placed in Contract Precautions. There was a sign on the wall outside the patient's room to indicate this with Proper Protective Equipment (PPE) of gowns and gloves provided in pocket container hanging on the patient's door.

Observation of Patient #76 revealed the patient sitting up in bed talking to a staff member (nurse care tech). Nurse Care Tech #15 did not have gloves or gown applied. The tech came out of the patient's room with a water pitcher, went down the hallway to get ice, and returned to the patient's room. The tech was observed to enter the patient's room with the water pitcher without putting on PPE, gown and gloves. The unit manager who was present during the observation told the tech to apply a gown and gloves.

Interview with Nurse Care Tech #15, on 01/14/13 at 4:25 PM, revealed she did not know the patient was in contact precautions and failed to note the sign on the wall. She said the fact the patient was in contact isolation was not communicated to her from the staff on the previous shift. She stated she had been trained on when and how to wear PPE but she had failed to apply that training for this patient. She said she was taught to wash her hands prior to entering a patient's room and after care but she had failed to do that.

Interview with Registered Nurse (RN) #30, on 01/14/13 at 4:30 PM, who was present during the observation, revealed the hospital identified problems with compliance of wearing appropriate PPE. She said all staff had been trained on contact precautions and the appropriate PPE to wear. She stated Nurse Care Tech #15 had just failed to follow those instructions. She stated the nurse tech received information about each patient from conducting rounds between shifts, tech to tech, nurse to nurse. Review of the patient list revealed no information regarding isolation precaution was included for this patient.





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3. Observation of RN #27, on 01/17/12 at 9:00 AM, revealed the RN enter the hemodialysis unit at the facility's extention facility to obtain a finger stick blood sugar. Prior to the procedure RN #27 sanitized her hands and donned gloves. After obtaining the blood for the test and getting the results, the nurse removed her gloves and put on another pair of gloves and took the glucometer out of the room to clean it.

Interview with RN #27, on 01/17/13 at 9:10 AM, revealed she was taking the glucometer out of the room to clean it. She stated she realized she had failed to wash or sanitize her hands after removing her gloves, she stated she was aware that hands were to be sanitized after gloves were removed.

Based on observation, interview, review of facility policy and Association of Operating Room Nurses (AORN) Guidelines, it was determined the facility failed to ensure there were proper temperature and humidity levels in operative areas as evidenced by failure to maintain temperature and humidity logs in four (4) procedure rooms in the Cardiac Cath Lab.

The findings include:

Review of facility policy, "Temperature and Humidity Monitoring," Policy Number OR 06-TBD, effective date 02/2009, revealed each surgical site would document temperature and humidity on days of operation and maintain a log of this within the area.

Review of the 2012 edition of the AORN Perioperative Guidelines revealed established recommended practices for operating rooms to reflect the acceptable relative humidity (RH) ranges of 30-60% and temperature ranges of 68-73 Degrees Fahrenheit (F); for Cardiac Cath Labs the RH parameters were the same but the temperature parameter was between 70 and 75 degrees F. The AORN recommended daily documentation of the temperature and RH levels. The 2012 edition of AORN revealed low humidity levels increased the risk of electrostatic charges, which posed a fire hazard in the oxygen-enriched environment or when flammable agents were in use and increased the potential for dust. High humidity levels increased the risk for microbial growth in areas where surgery or procedures were performed. The facility stated they followed AORN standards and Facilities Guidelines Institute standards.

Observation of the Cardiac Cath Lab, on 01/18/13 at 10:00 AM, revealed, for all four (4) procedure rooms, there was a thermostat which revealed all had temperatures within the required parameters. However, there were no humidity monitors in these rooms.

Interview with the Director of Plant Operations for the Enterprise, on 01/15/13 at 10:04 AM, revealed all the air handlers in the Medical Center had alarms that would sound if the RH level rose above 60 percent and the discharge air temperature was not in the fifty-two (52) degree F range which produced acceptable temperature levels. If the alarm sounded, a work order would be created to fix the deviation.

Interview with the Cardiac Cath Lab Operations Manager, on 01/17/13 at 10:25 AM, revealed daily temperature and humdity logs were not kept for the four (4) procedure rooms. She stated she did not feel the procedure rooms were the same as operating rooms because all of the procedures done in the Cardiac Cath Lab were closed with no open incisions.

Interview with the Cardiac Cath Lab Registered Radiology Technician (RRT), on 01/17/13 at 12:56 PM, revealed this lab was interventional and that typical procedures performed were right and left heart catheterizations; insertion of pacemakers and internal cardiac defibrillator implants; electrophysiology procedures; and cardiac stent insertions.

Interview with the Associate Director for Perioperative Services, on 01/18/13 at 1:45 PM, revealed she did not believe the Cardiac Cath Lab needed to be monitored like operating rooms, with daily documentation of temperature and relative humidity and actions to be taken if the readings were outside the recommended parameters because only closed procedures were done in the Cardiac Cath Lab.



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Based on observation, interview and record review, it was determined the facility failed to provide the necessary nursing care for five (5) of eighty-four (84) sampled patients. Patient #83 was morbidly obese and admitted to the hospital with a fractured femur. Following surgery Patient #83 could only get out of bed with the assist of a mechanical lift. However, no working lift was available for use. The facility's failure to provide the lift kept Patient #83 confined to bed and prevented him/her from engaging in activities which he/she stated were important to him/her and inhibited the progress of his/her physical abilities. Four (4) patients had Physician's Orders the facility failed to follow. In addition, the facility failed to follow nursing protocol related to patient transport from hemodialysis.

The findings include:

1. Record review for Patient #83 revealed the patient was sixty-four (64) years old and initially admitted to the facility on 10/17/12, for a left leg femur fracture following a fall. Review revealed surgery was performed on the patient's leg on 10/25/12. Review revealed the patient was transferred to the facility's extention facility on 12/11/12. Record review revealed the patient had a weight in excess of three hundred and fifty (350) pounds. The record for Patient #83 revealed a Physician's Order dated 12/20/12, to get the patient up to a chair for two (2) hours once per day with a Hoyer lift.

Record review revealed a Nursing Note dated 12/22/12, that indicated the Hoyer lift was broken and the patient wanted to get out of bed. Further review of the Note revealed the nurse was to see if maintenance could fix the Hoyer lift. Review revealed no documented evidence there was a follow up note.

Review of an Occupational Therapy (OT) Note dated 01/03/13, revealed the Hoyer lift was broken and multiple calls had been made to Biomedical. Continued review revealed no documented evidence of a follow up Note or known status of the Hoyer lift. Further review revealed the entry also stated the patient needed to be out of bed every day with exercise or he/she would be unable to stand when able to bear weight on the left lower extremity. Review of a Physical Therapy (PT) Note dated 01/10/13, revealed there was no Hoyer lift available, so PT was unable to be performed.

Observation, on 01/17/13 at 9:40 AM, revealed Patient #83 was in a single room in bed with the head of the bed raised so the patient was sitting up. Observation revealed the bed was larger in size than a standard hospital bed. Continued observation revealed the patient to be obese and well groomed.

Interview, on 01/17/13 at 3:45 PM, with Patient #83 revealed he/she had not been out of the hospital bed for weeks. The patient stated the staff had tried to use a Hoyer lift weeks ago to get him/her out of bed and it broke during use with Patient #83 in the seat (sling). Patient #83 stated that was a very scary experience. According to the patient, he/she had remained in the hospital bed since that time. The patient shared that during his/her time confined to the hospital bed he/she had missed the birth of his/her first greatgrandchild, a graduation, and he/she listed several other events which he/she was not included. Continued interview revealed the previous night Patient #83 felt the walls of the room were closing in on him/her from being in the bed for such a long period of time. Observation revealed the patient then began crying.

Interview, on 01/18/13 at 4:15 PM, with Registered Nurse (RN) #24 revealed when she was assigned to Patient #83's care she knew there was an order to get the patient out of the bed; however, the Hoyer lift was not in working order at that time. She stated she did not inquire as to the status of the Hoyer lift. According to the RN, she did not go look for another lift and therefore the patient remained in bed. RN #24 stated she knew the process was to let the Nurse Manager know if equipment was not working. She stated she did not report it to management when it was reported to her that the Hoyer lift was not working.

Interview, on 01/18/13 at 3:10 PM, with the Physician's Assistant (PA) revealed it would have been ideal to get the patient out of the bed. She stated the patient told her he/she wanted to get out of bed to be with his/her family in the facility for their visit on Christmas Eve. According to the PA, it was important for the endurance of the patient to get out of bed; however, the PA revealed she had followed up on the information she received regarding the lift not working. She stated this had been for about four weeks and the PA stated there was always excuses for why the Hoyer lift did not work. The PA stated, "there was always something," and she did not know if the staff knew how to work the Hoyer lift. She stated getting the patient out of bed as ordered did not occur. Additionally, she stated the staff did not act on the patient's behalf.

Interview, on 01/18/13 at 11:50 AM, with the Fourth Floor Manager revealed it was brought to her attention in December (2012) that the Hoyer lift was not working, but she could not recall a specific date. She revealed there were two (2) Hoyer lifts in the sister facility, however neither one was in working order. She stated a Hoyer lift belonging to another facility which rented space within the sister facility had been borrowed in the past since the sister facility did not have a working Hoyer lift. Continued interview revealed the process for reporting the need for repairs was to notify Information Technology (IT) and IT passed the information to the Biomedical Department. Review of the work orders revealed a work order was not generated until 01/04/13 by the Fourth Floor Manager.

Interview, on 01/17/13 at 1:40 PM, with the Director of Critical Care and General Nursing revealed she did not know the Hoyer lift was broken and was in need of repairs. She stated she did not know there were patients that could not get out of bed in the sister facility. According to the Director, the process would have been for the Unit Manager to keep her informed and the Unit Manager was responsible to follow up with patient care equipment. She stated if the Unit Manager ran into an obstacle, they were to bring the issue to her and no one did in this case. The Director stated, in this instance the staff was borrowing equipment instead following the process of informing management that the equipment was not available.

Interview, on 01/18/13 at 12:15 PM, with the Director of Enterprise Accreditation revealed the record needed to indicate the status of a work order, such as making Note in the Nurse's Notes. She revealed the breakdown in communication related to the Hoyer lift involved multiple system failures.

Interview, on 01/17/13 at 4:55 PM, with the Certified Biomedical (Bio-Med) Electrical Technician (Tech) revealed a work order to repair the Hoyer lift was placed with the department on 01/04/13. The Certified Biomedical Electrical Tech stated the order was completed on 1/16/13 after being brought to the attention of the facility by the state survey team. The Tech stated the Hoyer lift was missed when the original inventory was done for items on the preventative maintenance (PM) list, but it had been put in the system this month. He stated the lift was examined and had a depleted battery; one was ordered and it was now replaced. He revealed the delay was a work order issue explaining that staff made the decision to the priority for repairs. He stated items of higher priority were completed first, this would be items that would affect patient care or the ability to sustain their life. He stated that there was no urgent notice for repair on the lift, so it was not known to Bio-Med that the lift was the only way Patient #83 could get out of bed.


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2. Review of Patient #27's medical record revealed a Physician's Order dated 01/09/13 for daily weights. Continued record review revealed no documented evidence of a daily weight for the dates of 01/10/13, 01/11/13, and 01/14/13.

Interview, on 01/16/13 at 11:59 AM, with the Directo

Based on observation, interview, record review and facility policy, it was determined the facility failed to maintain Hoyer lifts for patient needs. Two (2) of two (2) Hoyer lifts were not available for patient needs, were in need of repair, and not in working order. In addition, the facility failed to ensure expired supplies/supplements were not available for patient use.

The findings include:

1. Review of the policy "Equipment Maintenance Program", revised 08/2011, revealed the University of Kentucky Hospital had established a medical equipment program that included preventative maintenance, repair and documentation of medical equipment. In addition, the policy stated Clinical Engineering was responsible to ensure that all medical equipment was properly maintained or repaired, and that maintenance was properly documented.

Record review for Patient #83 revealed the patient was initially admitted to University of Kentucky Hospital Chandler (Chandler) on 10/17/12 for a left leg femur fracture following a fall. Surgery was performed on his/her leg on 10/25/12. The patient was admitted to Good Samaritan University of Kentucky Hospital (Good Samaritan) on 12/11/12 from Chandler. The patient had a weight in excess of 350 pounds. The record for Patient #83 revealed a Physician's Order dated 12/20/12 to get the patient up to a chair once per day with a Hoyer lift. However, there was not a Hoyer lift in the facility in working order. A nursing note dated 12/22/12 revealed the Hoyer lift was broken and the patient wanted to get out of bed. The note stated the writer would see if maintenance could fix the Hoyer. A Physical Therapy (PT) note dated 01/10/13 stated there was no Hoyer lift so PT was unable to be performed. There was no Hoyer lift in working order in Good Samaritan as of 01/15/13.

Interview, on 01/17/13 at 1:20 PM, with the Physical Therapist revealed all the Hoyer lifts in the hospital (Good Samaritan) were broken. She revealed staff (PT staff) had borrowed a lift from "Select", another facility which rented space within Good Samaritan. However, "Select" did not have a seat (sling) the appropriate size for the patient.

Interview, on 01/17/13 at 3:45 PM, with Patient #83 revealed he/she had not been out of the bed for weeks. The patient stated the staff had tried to use a Hoyer lift weeks ago and it broke during use with him/her in the seat (sling). The patient revealed he/she had remained in bed since that time.

Interview, on 01/18/13 at 11:50 AM, with the Fourth Floor Manager revealed it was brought to her attention in December (2012) that the Hoyer lift was not working but she could not recall a specific date. She revealed there were two Hoyer lifts in Good Samaritan but neither one was in working order. She stated a Hoyer lift belonging to another facility which rented space within Good Samaritan had been borrowed in the past since Good Samaritan did not have a working Hoyer lift.

Interview, on 01/18/13 at 12:00 PM, with the Director of Critical Care and General Nursing revealed the staff should have reported the Hoyer lifts not working to the Fourth Floor Manager. She stated that was the process, then the Fourth Floor Manager would report needed repairs to Information Technology (IT) and IT would pass the need to Biomedical. The Fourth Floor Manager had knowledge of the Hoyer lift not in working order in December 2012. A work order was not received by Biomedical until 01/04/13.

Interview, on 1/17/13 at 4:55 PM, with the Certified Biomedical Electrical Technician (Bio-Med) revealed a work order to repair the Hoyer lift was placed on 01/04/13. The order was completed on 1/16/13 after being brought to the attention of the facility by the survey team. It was revealed that the Hoyer lift was missed when the original inventory was done for items on the preventative maintenance (PM) list, but it had been put in the system this month. He stated what was found wrong with the lift was a depleted battery, and one was ordered and it was replaced. He revealed the delay was a work order issue explaining that the technician made the decision of the priority for repairs. He revealed items of higher priority were completed first, items that would affect patient care or the ability to sustain their life. He stated that there was no urgent notice for repair on the lift so it was not known to Bio-Med that the lift was the only way Patient #83 could get out of bed.

Interview, on 01/17/13 at 5:15 PM, with the Safety Registered Nurse revealed there was a system breakdown in reporting, the follow up and repair of the Hoyer lift. She acknowleged the system breakdown had a negative effect on Patient #83.


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2. Observation, on 01/16/13 at 2:30 PM, revealed eleven (11) two ounce bottles of Similac Sensitive for Fussiness and Gas Infant Formula, with the expiration date of 12/01/12, in the 4 North Pediatric Unit Supply Storage Room, twelve (12) two ounce bottles of Similac Special Care Premature Infant Formula, with the expiration date of 01/01/12, in the 4 North Patient/Family Pantry and four (4) two ounce bottles of Similac Advance Complete Nutrition Infant Formula in the 4 North Patient/Family Pantry.

Interview, on 01/18/13 at 3:10 PM, with the 4 North Patient Care Manager revealed expired supplies should not have been in the Storage Room or the Pantry. She stated expired supplies should not be used. She further stated Material Management was responsible for ensuring expired supplies were not in Storage Rooms.

Interview, on 01/17/13 at 4:15 PM, with the Director of Supply revealed stockers were supposed to rotate stock, newer to the front. She stated expired supplies should not have been available for use, they should have been removed and replaced. She further stated the expired formula was available for use due to employee failure. Further interview revealed the facility did not have a written expired supply policy.

3. Observation of the Cardiac Cath Lab, Consigned Cabinet #2, on 01/17/13 at 11:24 AM, revealed two (2) Trek Coronary Dilatation Catheters, twelve (12) millimeters (mm) and one (1) Trek Coronary Dilatation Catheter, twenty (20) mm each with an expiration date of 12/2012.

Interview with the Cath Lab Technician, on 01/17/13 at 11:45 AM, revealed she routinely counted and checked expiration dates on supplies in Consigned Cabinet #2 on Mondays. She further revealed the last time this was done on this cabinet was on 01/07/13; and, she did not check expiration dates for cardiac catheters on that date. She could give no explanation why expiration dates were not checked.


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4. Observation of the eighth floor, on 01/14/13 at 3:10 PM with the eighth floor Patient Care Manager, revealed suction canister tops were stored in a trash bag that was on the floor and the canister tops were spilling out of the bag onto the floor. Continued observation revealed one suction cannula on the floor, as well as suction tubing without plastic covering on the floor. Also a stack of wash basins and a box of footies were on the floor. There was a one thousand millileter bag of D5NS without a wrapper in with the other intravenous fluids (IVF) as available for use.

Observation of the Patient Care Manager, on 01/14/13 at 3:15 PM, revealed she threw some of the supplies in the trash; put the wash basins, some of the suction cannula tops and the box of footies which were on the floor on the shelves. The Patient Care Manager stated the IVF was all right to use, but would check with the staff.

Interview with the Patient Care Manager, on 01/14/13 at 4:00 PM, revealed the supplies on the floor were an infection control issue. She stated the staff knew not to use contaminated items, and she stated staff would not have used the IVF's without the plastic covering, but did not know who had put it there.

5. Observation of RN #27, on 01/17/12 at 9:30 AM, revealed the RN enter the hemodialysis unit at the facility's extension facility to obtain a finger stick blood sugar. After obtaining the blood for the test and getting the results, the nurse removed her gloves and put on another pair of gloves and

Based on observation, interview and review of the facility's Dry and Moist-to-Dry Dressing Procedure (undated) and the facility's Hand Hygiene Policy #A03-015 (revised 11/16/12) revealed the facility failed to develop a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

The findings include:

Review of the facility's Dry and Moist-to-Dry Dressing Procedure (undated) revealed hand hygiene was to be performed after soiled dressings were removed and after gloves were removed. Further review revealed wounds were to be cleansed after soiled dressings were removed.

Review of the facility's Hand Hygiene Policy A03-015 (revised 11/16/12) revealed hand hygiene was to be performed after removing gloves.

1. Observation, on 01/17/13 at 9:40 AM, revealed Registered Nurse (RN) #1 removed a soiled dressing, removed the soiled gloves and donned clean gloves without performing hand hygiene. Further observation revealed the nurse failed to cleanse the wound and periwound area before she applied the clean dressing.

Interview, on 01/17/13 at 10:35 AM, with RN #1 revealed the wound did not have to be cleansed prior to applying the clean dressing because it was a wet-to-dry dressing and would clean the wound by debridement. She further stated the Physician would order a solution, such as Dakins or Hibiclens, if he wanted the wound to be cleansed. She stated she did not think about cleansing the wound but guessed it wouldn't have hurt to cleanse it. She stated she didn't know the facility's policy; however, after she looked at the facility's moist-to-dry dressing policy, she stated she should have cleansed the wound prior to applying the clean dressing. Further interview revealed she didn't perform hand hygiene, after removing gloves, unless she was leaving a patient's room.

Interview, on 01/17/13 at 11:00 AM, with the 3 North Patient Care Manager revealed the RN should have sanitized her hands after removing gloves and she should have cleansed the wound prior to applying a clean dressing.

Interview, on 01/18/12 at 4:00 PM, with the Infection Control RN revealed the RN should have sanitized her hands after removing gloves.


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2. Observation during tour of the 5th floor of the facility's extension facility, on 01/14/13 at 4:15 PM, revealed Patient #76 had been placed in Contract Precautions. There was a sign on the wall outside the patient's room to indicate this with Proper Protective Equipment (PPE) of gowns and gloves provided in pocket container hanging on the patient's door.

Observation of Patient #76 revealed the patient sitting up in bed talking to a staff member (nurse care tech). Nurse Care Tech #15 did not have gloves or gown applied. The tech came out of the patient's room with a water pitcher, went down the hallway to get ice, and returned to the patient's room. The tech was observed to enter the patient's room with the water pitcher without putting on PPE, gown and gloves. The unit manager who was present during the observation told the tech to apply a gown and gloves.

Interview with Nurse Care Tech #15, on 01/14/13 at 4:25 PM, revealed she did not know the patient was in contact precautions and failed to note the sign on the wall. She said the fact the patient was in contact isolation was not communicated to her from the staff on the previous shift. She stated she had been trained on when and how to wear PPE but she had failed to apply that training for this patient. She said she was taught to wash her hands prior to entering a patient's room and after care but she had failed to do that.

Interview with Registered Nurse (RN) #30, on 01/14/13 at 4:30 PM, who was present during the observation, revealed the hospital identified problems with compliance of wearing appropriate PPE. She said all staff had been trained on contact precautions and the appropriate PPE to wear. She stated Nurse Care Tech #15 had just failed to follow those instructions. She stated the nurse tech received information about each patient from conducting rounds between shifts, tech to tech, nurse to nurse. Review of the patient list revealed no information regarding isolation precaution was included for this patient.





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3. Observation of RN #27, on 01/17/12 at 9:00 AM, revealed the RN enter the hemodialysis unit at the facility's extention facility to obtain a finger stick blood sugar. Prior to the procedure RN #27 sanitized her hands and donned gloves. After obtaining the blood for the test and getting the results, the nurse removed her gloves and put on another pair of gloves and took the glucometer out of the room to clean it.

Interview with RN #27, on 01/17/13 at 9:10 AM, revealed she was taking the glucometer out of the room to clean it. She stated she realized she had failed to wash or sanitize her hands after removing her gloves, she stated she was aware that hands were to be sanitized after gloves were removed.

Based on observation, interview, review of facility policy and Association of Operating Room Nurses (AORN) Guidelines, it was determined the facility failed to ensure there were proper temperature and humidity levels in operative areas as evidenced by failure to maintain temperature and humidity logs in four (4) procedure rooms in the Cardiac Cath Lab.

The findings include:

Review of facility policy, "Temperature and Humidity Monitoring," Policy Number OR 06-TBD, effective date 02/2009, revealed each surgical site would document temperature and humidity on days of operation and maintain a log of this within the area.

Review of the 2012 edition of the AORN Perioperative Guidelines revealed established recommended practices for operating rooms to reflect the acceptable relative humidity (RH) ranges of 30-60% and temperature ranges of 68-73 Degrees Fahrenheit (F); for Cardiac Cath Labs the RH parameters were the same but the temperature parameter was between 70 and 75 degrees F. The AORN recommended daily documentation of the temperature and RH levels. The 2012 edition of AORN revealed low humidity levels increased the risk of electrostatic charges, which posed a fire hazard in the oxygen-enriched environment or when flammable agents were in use and increased the potential for dust. High humidity levels increased the risk for microbial growth in areas where surgery or procedures were performed. The facility stated they followed AORN standards and Facilities Guidelines Institute standards.

Observation of the Cardiac Cath Lab, on 01/18/13 at 10:00 AM, revealed, for all four (4) procedure rooms, there was a thermostat which revealed all had temperatures within the required parameters. However, there were no humidity monitors in these rooms.

Interview with the Director of Plant Operations for the Enterprise, on 01/15/13 at 10:04 AM, revealed all the air handlers in the Medical Center had alarms that would sound if the RH level rose above 60 percent and the discharge air temperature was not in the fifty-two (52) degree F range which produced acceptable temperature levels. If the alarm sounded, a work order would be created to fix the deviation.

Interview with the Cardiac Cath Lab Operations Manager, on 01/17/13 at 10:25 AM, revealed daily temperature and humdity logs were not kept for the four (4) procedure rooms. She stated she did not feel the procedure rooms were the same as operating rooms because all of the procedures done in the Cardiac Cath Lab were closed with no open incisions.

Interview with the Cardiac Cath Lab Registered Radiology Technician (RRT), on 01/17/13 at 12:56 PM, revealed this lab was interventional and that typical procedures performed were right and left heart catheterizations; insertion of pacemakers and internal cardiac defibrillator implants; electrophysiology procedures; and cardiac stent insertions.

Interview with the Associate Director for Perioperative Services, on 01/18/13 at 1:45 PM, revealed she did not believe the Cardiac Cath Lab needed to be monitored like operating rooms, with daily documentation of temperature and relative humidity and actions to be taken if the readings were outside the recommended parameters because only closed procedures were done in the Cardiac Cath Lab.



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