HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of three swing bed patients and ten acute inpatients. Based on observations, staff interview, and policy review, the CAH failed to ensure all supplies are maintained to safely meet patients' needs for the day-to-day operations in three of five Emergency rooms, one of two trauma bays, one of one Emergency nursing station sink, one of one Emergency medication refrigerators, one of one Labor and Delivery storage room, one of one central supply room and one of one pre-operative and post-operative supply closet. Failure of the facility to dispose of expired supplies placed all patients at risk for receiving ineffective treatments.

Findings include:

- Emergency Department Room 4 observed on 12/5/2016 at 11:55AM revealed the following outdated supplies:

1) One Irrigation tray with expiration date of 11/2016.

Chief Nursing Officer Staff A interviewed on 12/5/2016 at 11:55 AM acknowledged the Irrigation tray expired and should have been disposed.


- Emergency Department Trauma Bay Room 1 observed on 12/5/2016 at 12:05 PM revealed the following outdated supplies:

1) One Irrigation Tray with expiration date of 11/2016.

Chief Nursing Officer Staff A interviewed on 12/05/2016 at 12:05 PM acknowledged the outdated Irrigation Tray should have been disposed.


- Emergency Department Nurses Station sink observed on 12/5/2016 at 12:20 PM revealed the following outdated supply:

1) Sani-Cloth Bleach container (disinfectant wipes) with expiration date of 12/2014.

Emergency Department Manager Staff B interviewed on 12/05/2016 at 12:20 PM acknowledged the outdated Sani-cloth bleach container should have been disposed.


- Emergency Department Nurses Station medication refrigerator observed on 12/5/2016 at 12:25 PM revealed the following outdated supplies:

1) Five Eclipse Needle 21g 1 ½ TW packages with expiration date of 5/2014.

2) Two Eclipse Needle 21g 1 ½ TW packages with expiration date of 3/2016.

Emergency Department Manager Staff B interviewed on 12/5/2016 at 12:25 acknowledged the needles outdated and should have been disposed. Staff B stated the Pharmacy Department is responsible for any medication or supplies in the refrigerator.

Chief Nurse Officer Staff A interviewed on 12/5/2016 at 12:30 PM acknowledged the Pediatric Code box security tag should have been secured.


- Labor and Delivery storage room observed on 12/5/2016 at 1:35 PM revealed one Wet PVP Pre-operative skin prep tray with expiration date of 8/2016.

Obstetric Manager Staff C acknowledged the skin prep tray was outdated and should have been disposed.


- Emergency Department Room 2 observed on 12/5/2016 at 11:50 PM revealed the following outdated supplies:

1) One Irrigation Tray with expiration date of 11/2016.

Chief Nursing Officer staff A interviewed on 12/5/2016 at 11:50 AM acknowledged the irrigation tray expired and should have been disposed.


- Emergency Department Room 3 observed on 12/5/2015 at 1:30 revealed the following outdated supplies:

1) Two specimen collection containers with expiration date of 11/30/2016.

Chief Nursing Officer staff A interviewed on 12/5/2016 at 1:30 PM acknowledged the specimen collection containers expired and should have been disposed.


- Central Sterile supply room observed on 11/5/2016 at 3:00 PM revealed the following outdated supplies:

1) Five 5 fr. (French) polyurethane ureteral catheters with expiration date of 11/2016.

Certified Surgical Tech staff F interviewed on 12/5/2016 at 3:00 PM acknowledged polyurethane ureteral catheters expired and should have been disposed.


- Supply closet in Pre/Postoperative area of the surgical unit observed on 12/5/2016 at 3:20 PM revealed the following outdated supply:

1) One blue top blood specimen tube with expiration date of 11/2016.

Chief Nursing Officer staff A interviewed on 12/5/2016 at 3:20 PM acknowledged the blue top blood specimen collection tube expired and should have been disposed.

- Policy review on 12/7/2016 revealed the facility failed to provide a policy directing staff on when and how to dispose expired supplies.

The Critical Access Hospital (CAH) reported a census of three skilled swing bed patients and ten acute inpatients. Based on observation, staff interview and policy review the Critical Access Hospital failed to ensure outdated, unusable medications were removed and made unavailable for patient use in one of three anesthesia carts in the surgery unit, one of two operating rooms, one of one locked cabinet in the common area of the pre/postoperative unit, and one of one nursery. Failure to ensure that outdated medications are removed placed all patients at risk for receiving ineffective medications.

Findings include:


- Anesthesia cart in the procedure room of the surgery unit observed on 12/5/2016 at 2:00 PM revealed:

1) One vial of succinylcholine (a muscle relaxant used in surgery) 20mg/ml (milligram/milliliter), 200mg vial opened and marked "do not use after 12/3/2016".

2) One vial of Metoclopramide (a medication used in surgery to prevent nausea and vomiting) 10mg/2ml vial expired 9/2016.

CNO staff A interviewed on 12/5/2016 at 2:30 PM acknowledged the succinylcholine and metoclopramide expired and should have been disposed.


- Locked cabinet in the common area of the pre/postoperative unit observed on 12/5/2016 at 3:20 PM revealed:

1) A box labeled "Pain Clinic Medication Box" with three vials of Depo-Medrol (a medication used to treat inflammation) 80mg/1ml expired 10/2016.

CNO staff A interviewed on 12/5/2016 at 3:20 PM acknowledged the Depo-Medrol expired and should have been disposed.


- Operating Room 2 locked storage cabinet observed on 12/6/2016 at 12:30 PM revealed:

1) Two 3000ml bags of Glycine 1.5% irrigation fluid expired on 12/1/2016.

RN staff G interviewed on 12/6/2016 at 12:35 acknowledged the Glycine expired and should have been disposed.


- Obstetric Department Nursery Room Cabinet observed on 12/5/2016 at 1:45 PM revealed the following medications expired:

1) IV 5% Dextrose and .45 % NaCl (intravenous fluids with glucose and sodium chloride that's given to patients in their vein) 1000cc bag with expiration date of 10/2016.

2) Two Heparin (thins the blood) 500u/5ml (unit/milliliter)filled syringes with expiration dates of 11/2016.

Director of Acute Care Staff C interviewed at 1:45 PM acknowledged the IV fluid and heparin was expired and should have been disposed.

- Policy titled ,"Unit Inspection" reviewed on 12/5/2016 at 4:00 PM directed: "...VI. Drugs shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use..."


- Surgery Department PACU Emergency Crash Cart observed on 12/5/2016 at 12:30 PM revealed a Pediatric Code Utility box with a pharmacy blue tamper evident seal was broken.

Chief Nursing Officer Staff A interviewed on 12/5/2016 at 12:35 PM acknowledged the Pediatric Code Utility box should have had a new seal on it.

- Policy titled, "Emergency Medications" reviewed on 12/5/2016 directed " ...Emergency drug kits are stored in clearly marked portable containers or mobile carts. The drug portion of the cart or box is sealed by the pharmacist or pharmacy technician with a Blue tamper evident seal which must be broken to gain access to the drugs... " "...Emergency medications removed from floorstock shall be replaced promptly to maintain a full stock level ..."

The Critical Access Hospital (CAH) reported a census of three skilled swing bed patients and ten acute inpatients. Based on observation, staff interview and policy review the CAH failed to maintain infection control measures in one of five pre/postoperative rooms, one of two operating rooms, one of three anesthesia carts, and one of one CT scan room in radiology. Failure to maintain infection control measures placed all patients at risk for the spread of infection.

Findings include:

- Register Nurse staff D observed on 12/6/2016 at 8:35 in preoperative Room 3 failed to perform hand hygiene after typing on the computer, preparing IV (intravenous) supplies and prior to putting on gloves to start the IV line in patient # 11.

Register Nurse Staff D interviewed on 12/6/2016 at 8:50 AM acknowledged that hand hygiene was not performed prior to putting on gloves to start an IV. They said the policy was to " foam in and foam out " when they enter the room.


- Certified Nurse Anesthetist Staff E observed on 12/6/2016 between 9:07 AM and 9:17 AM in operating room 1 administered intravenous medication to patient # 11 without cleaning the access hub prior to attaching the syringe to the hub.

Certified Nurse Anesthetist Staff E interviewed on 12/6/2016 at 9:50 AM acknowledged the access hub of the IV was not cleaned prior to injecting medication.

Director of Quality Staff H interviewed on 12/7/2016 at 11:30 PM acknowledged there was no specific policy on cleaning the hub prior to administering medications through IV lines. They provided a document that stated the hospital staff followed Lippincott guidelines.

- Document titled "Intermittent Infusion device drug administration" on 12/7/2016 at 3:30 PM provided by Quality Director Staff D directed: "...Hospital-acquired condition alert: Keep in mind that a vascular catheter-associated infection is considered a hospital-acquired condition because it can be reasonably prevented using best practices. Follow infection prevention techniques (such as performing hand hygiene, using sterile technique, performing vigorous mechanical scrub of needleless connectors, and discontinuing the device as soon as it's no longer needed) when administering a drug through an intermittent infusion device to reduce the risk of vascular catheter-associated infection ..."


- Anesthesia cart in the procedure room on the surgery unit observed on 12/5/2016 at 2:00 PM revealed the following opened sterile supplies:

1) One large bore needle opened and out of package.
2) One syringe with needle attached opened and out of package.
3) One 7.5 mm (millimeter) ETT (endotracheal) tube in an opened sterile package.
4) One opened package with a laryngoscope.

Chief Nursing Officer staff A interviewed on 12/5/2016 at 2:30 PM acknowledged the open supplies should have been disposed and the laryngoscope should have been sent back for reprocessing.

- Medical Surgical Floor in Room 122 Patient # 20 observed on 12/6/2016 at 11:20 AM revealed Staff I was unsuccessful drawing patient #20's blood on their first attempt. Staff I immediately grabbed new supplies in their lab tote with their contaminated gloves potentially contaminating the clean supplies.

Lab Technician Assistance Staff # I interviewed on 12/6/2016 at 11:22 AM. Surveyor asked Staff I if their lab tote supplies are used for other patients and Staff I stated "Yes". Staff I verified they did not remove their gloves and perform hand hygiene before obtaining new supplies.


- Radiology Department CT Scan room observed on 12/6/2016 at 1:15 PM revealed one IV sterile start kit package (Intravenous-into vein using a needle or tube to administer fluid or medications) open in drawer.

Radiology Technician Staff J interviewed on 12/6/2016 at 1:15 PM acknowledged the sterileIV kit was open but unused.

- Policy review on 12/7/2016 revealed the facility failed to provide a policy directing staff to discard open sterile items if not used immediately after opening package.


- Terminal clean of Operating Room 1 observed on 12/6/2016 between 2:45 PM and 4:30 PM, Staff V failed to clean the Anesthesia Cart and Pyxis (an automated medication dispensing system) cart and covered them with cloth sheets prior to starting the terminal clean and did not clean the 2 overhead operating room light lens.

Staff V interviewed on 12/6/2016 at 3:00 PM revealed nurses are responsible for cleaning the equipment, including the anesthesia cart, Pyxis cart and the overhead operating room lights lens. They said they were afraid of ruining the anesthesia cart and Pyxis system and was told housekeeping is not supposed to get the underside of the operating room overhead lights wet.

Chief Nursing Officer Staff A interviewed on 12/7/2016 at 4:30 revealed there were no policies that says what the housekeeping or surgery staff are supposed to clean during terminal cleaning of the operating rooms.

- Policy review on 12/8/2016 at 9:30 AM, the facility failed to provide a policy directing staff on how to perform terminal cleaning of the operating rooms.

- Policy Titled "STANDARD CLEANING" reviewed on 12/8/2016 at 10:00 AM directed: "...G. SURGERY IS CLEANED MONDAY - FRIDAY: 1. Daily post surgery cleaning involves thoroughly cleaning OP area floors after surgery schedule is completed. Shelves and equipment are cleaned by the OR staff..."

The Critical Access Hospital (CAH) reported a census of three skilled swing bed patients and ten acute inpatients. Based on observation, staff interview and policy review the Critical Access Hospital failed to keep patient information in the electronic medical record confidential in the hallway of one of one Medical/Surgical Units. This deficient practice placed patient's confidential medical information at risk for access by unauthorized people.


Findings include:


- Electronic Medical Record computer observed on 12/7/2016 at 10:30 AM left unattended with patient #21 medical information in view of anyone walking by in the hallway of the medical/surgical unit.


House Supervisor RN Staff T interviewed on 12/7/2016 at 10:34 acknowledged staff are supposed to log off the computer when the EMR is left unattended.


Registered Nurse Staff U interviewed on 12/7/2016 at 10:40 saying that they usually minimize the screen and fold down the computer screen when the computer is left unattended and that it takes too long to log back into if they log off. They said "I just got up to answer a light."


- Policy titled Safeguarding Protected Health Information reviewed on 12/8/2016 at 8:30 AM directed: "... 1. Computer monitors must be positioned away from the direct view of the general public ..."


- Document titled Confidentiality and Security Agreement reviewed on 12/8/2016 at 8:30 AM directed: "... Doing My Part-Personal Security...""...4. I will practice good workstation measures such as locking up diskettes when not in use, using screen savers with activated passwords, positioning screens away from public view..."