HospitalInspections.org

AIA, (American Institute of Architects) Guidelines for Design and Construction of Health Care Facilities 2.1 General Hospitals 8.2 General Standards for Details and Finishes 8.2.3.4 Ceilings

(3) Semirestricted areas

(a) Ceiling finishes in semirestricted areas such as airborne infection isolation rooms, protective environment rooms, clean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms shall be smooth, scrubbable, nonabsorptive, non perforated, capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.

(b) If lay-in ceiling is provided, it shall be gasketed or clipped down to prevent the passage of particles from the cavity above the ceiling plane into the semirestricted environment. Perforated, tegular, serrated, or highly textured tiles shall not be used.

Based on tour of the surgical suite on 6/19/12 with Staff O (Director of Surgical Services) it was observed that the facility failed to maintain a environment for the taske being provided within it.

Findings include:


During tour of the surgical suite on 6/19/12 it was observed and shown to Staff O that the ceiling tiles located outside the double doors of the surgical suite need to be gasketed or clipped down to prevent the passage of particles from the cavity above the ceiling plane into the semirestricted environment.

AIA (American Institute of Architects) 2006 5.3 Surgery.
5.3.1 Surgical Suites, 5.3.1.2 Layout...(4) The surgical suite shall be divided into three designated areas--unrestricted, semirestricted, and restricted--defined by the physical activities performed in each area....
(b) Semirestricted area

(i) The semirestricted area includes the peripheral support areas of the surgical suite. It has storage areas for clean and sterile supplies, work areas for storage and processing of instruments, and corridors leading to the restricted areas of the surgical suite.

(ii) Traffic in this area is limited to authorized personnel and patients. Personnel are required to wear surgical attire and cover all head and facial hair...

3.9 Gastrointestinal Endoscopy Facilities, 1 General considerations.

1.5.2 Circulation and Restricted Access: The endoscopy suite shall be designed to facilitate movement of patients and personnel into, through, and out of defined areas within the procedure suite. Signs shall be provided at all entrances to restricted areas and shall clearly indicate the proper attire required...

Based on tour of the surgical suite it was observed and shown to staff that the facility failed to maintain a semirestricted corridor for traffic flow and movement of surgical instruments and equipment.

Findings include:

During tour of the surgical suite on 6/19/12 at 2 p.m. it was observed that several work areas failed to be within the semirestricted corridor leading to the surgical suite. The areas that are located in a unrestricted corridor and need to be located in a semirestricted corridor are as follows:

1) Sterile storage and central sterile rooms

2) endoscope processor

3) Decontaminate work areas

4) Equipment storage room

5) Endoscopy suite

All areas written above were confirmed through interview with Staff O (Director of Surgical Services) at the time of finding.

Cross Refer Tag 221 due to change in usage from non restricted to semirestricted




Based on observation and interview with staff it was confirmed that the facility failed to maintain the safety of patients by failing to ensure the access to radiology department is locked and secured during and after regular business hours.

Findings include:

During tour of the Radiology department with Staff P (Director of Radiology) on 6/20/12 it was confirmed through observation and interview that several doors onto the unit were not secure and able to be entered with no notification to the staff. During this time Staff P toured the unit and confirmed through interview and observation that there are multiple access points into the department with no security these areas are as follows:

1) Elevator #5 that enters the radiology department for two different locations. First access is, the main lobby if both buttons are pressed (floor 1 front and rear) you can walk straight through the elevator into the department. Second access is the second floor medical surgical units once in the elevator you can access radiology by doing the same as above hitting the first floor rear.

2) Double doors from the emergency department. You can enter the radiology department from the emergency department with no security swipe card. But you can not exit the radiology department to the emergency department because it has a security swipe card.

3) The double doors from the main corridor into the radiology/surgical hallway can be accessed with no security swipe cards.

All findings were shown to Staff P who confirmed through interview that the unit is not secured during the day and night and the public can walk through anytime they want.

Based on tour and interview of the pharmacy department it was found that the facility failed to ensure that only licensed personnel have access to medication, failed to have accurate records kept of the receipt and disposition of all scheduled drugs, and failed to have outdated medication removed from stock.

Findings include:

During tour on 6/20/12 of the pharmacy department it was found a drawer of outdated medication. The medication was sodium acetate 40 meq 20 ml with an expiration date of 5/1/12, there were 15 vials in total.

Also during tour Staff H (Director of Pharmacy) was questioned on how records are kept to follow the flow of pharmaceuticals from their entry into the facility through dispensation and administration of scheduled medications.

Staff H showed records of the receipt and disposition of all scheduled drugs but was unable to confirmed if the count was accurate. Staff H stated that the nurse is accountable for the count of a scheduled drug when using the pyxis.

On review of the facility's Policy dated 3/12 it states "Whenever and wherever possible, drug distribution will occur by automated dispensing machine (Pyxis). This will improve safety, accountability and convenience in the drug distribution process. Pharmacy will manage the Pyxis system".

III. Medication Administration:

3) "....The inventory count must be entered when accessing controlled drugs or other medication deemed an accountability risk. If a count is inaccurate, a discrepancy will be recorded. Discrepancies will be resolved as described in the DISCREPANCY SECTION".

VII. DISCREPANCIES

A discrepancy occurs when the physical count does not match the calculated count from PYXIS. Discrepancies may be identified during any Pyxis transaction. The discrepancies will be displayed on the screen until they are resolved.

As soon as possible, but before the end of each shift the nurse causing the discrepancy and the Charge Nurse are responsible for resolving all discrepancies in the PYXIS cabinet.

1) Select the "Document Discrepancy" tab from the screen
2) Touch the discrepancy to be resolved
3) Ascertain the reason for the discrepancy and document by touching a preprinted reason or touch "other" and free text the reason.
4) Touch the "Accept" Button

VIII. Inventory count

Controlled substances will be inventoried during each pocket access and at least weekly by two nurses.

After review of the facility policy and above interview with Staff H it was confirmed that the nursing staff are failing to document either through the free text screen or by having two nurses access the pocket to verify the inventory.



18010

Observation on 6/21/12 at approximately 8:30 a.m. with Staff E (Registered Nurse) revealed that two vials of Acetadote 200 mg/ml were located in the locked Pyxis system on the Medical/Surgical/ICU/CCU medication room. Further observation revealed that these two medication vials had an expiration date of "Nov 2011".

During interview at the time of this observation Staff E confirmed that the two Acetadote medication vials were outdated.

Observation on 6/21/12 at approximately 9:15 a.m. with Staff F (Registered Nurse) revealed that the medication Arixtra 10 mg. was located in the locked Pyxis system in the Emergency Room medication room. Further observation revealed that this medication listed above had an expiration date of "01-2012".

During interview at the time of this observation Staff F confirmed that the Arixtra medication was outdated.

During this observation an individual entered the locked Emergency Room medication room and placed some supplies in a closet located in the medication room. During this observation Staff F confirmed that this individual was a hospital stock/supply employee who "has the code" to access the medication room.

Based on interview and review of facility policy it was determined that the facility failed to provided laboratory services to meet manufacture recommendation with the use of glucose blood testing.

Findings include:

CDC (Centers for Disease Control and Prevention) (http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html) pg 2 of 8 States "Unsafe Practices during Blood Glucose Monitoring and Insulin Administration".

"Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put persons at risk for infection include:

1) Using fingerstick devices for more than one person

2) Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses

3) Using insulin pens for more than one person

4) Failing to change gloves and perform hand hygiene between fingerstick procedures.

On tour of the PACU (Post Anesthesia Care Unit) on 6/19/12 Staff A (Registered Nurse) was interviewed on how the blood glucose meter was cleaned between use with patients. Staff A stated that the glucometer is cleaned when there is observed blood on the unit with soap and water. But if there is no blood observed the unit is not cleaned.

Facility's policy called "Blood Glucose Monitoring, Point of Care" with a Revised dated of 11/11 pg 3 under cleaning:
1. clean the outside of the meter with a cloth moistened with water. Dry thoroughly....
2. Cleaning the test strip holder:
a. Remove the test strip holder by pressing down on the left side and sliding it to the right.
b. May be cleaned under running water with soap and water

Manufacture policy for the Glucometer called Lifescan first step which the facility uses house wide under Page 16 Cleaning states:
Cleaning the outside of the Meter: Clean the outside of the meter with a cloth dampened with a 10% bleach solution. Follow with a cloth moistened with water to remove residual bleach. Dry thoroughly.

Cleaning the Test Strip Holder:
1. Remove the test strip holder by pressing down on the left side and sliding it to the right.
2. Wipe the test strip holder cover and base with a cotton swab dampened with a 10% bleach solution. Follow with a swab dampened with water to remove residual bleach.



26364

On tour of the OB Unit (Obstetrics Unit) on 6/19/12 Staff B (Registered Nurse Director of OB) was interviewed on how the blood glucose meter was cleaned between use with patients. Staff B stated that the glucometer is cleaned with Disinfectant 256 after use. Dinfectant 256 is an abrasive disinfectant. After each time the patient is tested the staff is to remove the test strip holder and clean the area with the Disinfectant solution.

Based on record review and interview it was determined that the hospital failed to follow the professional standard of practice for the physician orders. (Patient identifiers are #1 and #8.)

Findings include:

Reference for the professional standard of practice is, "Fundamentals of Nursing, 7th Edition, Potter-Perry, Mosby, Elsevier, Evolve, 2009."

On page 336 - Physicians' Orders states, "The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders and if you find one to be erroneous or harmful, further clarification from the physician is necessary ..."

On page 713 - "Correct Transcription and Communication of Orders.
The nurse or a designated unit secretary writes the prescriber's complete order on the appropriate medication form (e.g., the MAR) or enters the order into the client's electronic medical record. Other institutions have computerized prescribed order entry. In these systems, the prescriber enters the order directly into the computer. Computerized systems automatically transfer medication information to the MAR, the pharmacy record and the automated dispensing system. Whether it is handwritten, printed out from a computer, or in an electronic version, the MAR includes the client's name, room, and bed number, medical record number, medical and food allergies and other client identifiers... medication name, dose, frequency, and route and time of administration... A registered nurse compares the list of medications on the MAR against the original orders for accuracy and thoroughness. If an order seems incorrect or inappropriate, the nurse consults the prescriber. The nurse who gives the wrong medication or an incorrect dose assumes legally responsibility for the error.."

Patient #1
Record review on 6/20/12 of the "PHYSICIAN ORDERS" for Patient #1 dated 2/9/12 revealed an order for:
"1 Fentanyl/Duragesic patch 50 mcg ... change q (every) 72 ...(hours) Dispense 1 patch (dispensed yesterday)."

During interview with Staff J (Registered Nurse) on 6/20/12 after Staff J reviewed the above listed physician order and record for Patient #1, Staff J confirmed that there was no documented evidence of a physician order for 2/8/12, referring to the physician order for a Duragesic patch dispensed yesterday dated 2/9/12.

During interview with Staff H (Pharmacy Director) on 6/20/12 at approximately 10:45 a.m., Staff H reviewed the order for 1 Duragesic patch dispensed for Patient #1. Review of the pharmacy "Controlled Substance Record" log dated 2/7/12 showed that 1 Fentanyl patch had been dispensed from the pharmacy for Patient #1.
Staff H confirmed during this interview that Staff H had a telephone conversation with the physician on 2/7/12 regarding 1 Fentanyl patch for Patient #1. Following this physician telephone conversation Staff H confirmed that 1 Fentanyl patch was dispensed to Patient #1 with no documented evidence of a telephone physician order for this medication.

Patient # 8
Record review on 6/20/12 of the "PHYSICIAN ORDERS" for Patient #8 dated 6/16/12 showed no documented evidence that the multiple written physician orders were noted, dated and signed by a Registered Nurse.

During interview with Staff I (Registered Nurse) on 6/20/12 at approximately 12:00 noon after Staff I reviewed the multiple hand written physician orders for Patient #8 Staff I confirmed that these orders were not dated, signed and noted by a Registered Nurse.

Based on record review and interview it was determined that the hospital failed to ensure that the patient medical record is complete and accurate. (Patient identifiers are #8, #19, #20, #21, #22 and #23. )

Findings include:

Patient #8.

Record review on 6/20/12 of the "PHYSICIAN ORDERS" for Patient #8 dated 6/16/12 showed no documented evidence that the multiple written physician orders were noted, dated and signed by a Registered Nurse.

During interview with Staff I (Registered Nurse) on 6/20/12 at approximately 12:00 noon after Staff I reviewed the multiple hand written physician orders for Patient #8 Staff I confirmed that these orders were not dated, signed and noted by a Registered Nurse

Record review on 6/21/12 of the "TRANSFER CERTIFICATION" patient records revealed the following sections not completed:
Patients' #19 (dated "6/6/12'), #20 (dated "6/1/12), #21 (dated 6/10/12) and #22 (dated "5/12/12") showed that the section titled "NOTICE OF RISKS AND BENEFITS OF TRANSFER" was not completed by the physician.

Patient #23 (dated "6/4/12") showed that the section titled "PHYSICIAN'S CERTIFICATE OF TRANSFER" was not completed by the physician.

During interview on 6/21/12 with Staff C (Medical Records Supervisor) at approximately 10:45 a.m., after Staff C reviewed the above listed "TRANSFER CERTIFICATION" records, Staff C confirmed that the sections listed above for Patients #19, #20, #21 and #22 were not filled in and complete with the risks, benefits and the date and physician signature.

Based on observation and interview during tour of a building the staff refer to as the "Brown Building", the facility failed to secure storage of medical records against loss, destruction, or unauthorized use.

Findings include:

During tour of the "Brown Building", which is a 2-story house on 6/19/12, with Staff C, Supervisor (interim) Medical Records and Staff D, Director of Maintenance it was observed that medical records are placed on shelves in one room. On top of the stairway sitting on a chair was a box labeled "STS" , which contained patients medical information. The only person having access to the building is maintenance personnel. Observation of the building revealed no sprinkler system in place to protect the records from fire.

Interview with Staff D, on 6/19/12 revealed that no water has been to the building since the power went out and something happened to the boiler about 1 ? to 2 years ago,during one storms; with no plans to fix the system.