HospitalInspections.org

Based on observation, interview, and record review the facility's
infection control officer failed to effectively implement policies
to control infections and communicable diseases in the following
hospital locations:The facility failed to ensure:

1. Endoscopes were stored in accordance with professional standards.

2. Patient care supplies were stored in a manner to prevent infection in the following locations: Intensive Care Unit, Birthing Suite, Operating Room # 1 and Operating Room # 2.

Findings include:

During tour of Operating Rooms, Suites and at 11:00 AM on 08/2/2012 the surveyor along with Scrub Technician, Employee ID # 57 observed 2 colon and 2 gastro scopes hanging with the scope tubing looped around in a circle. Scopes were observed hanging in an open area in the Operating Room # 1, uncovered and were not secured in a cabinet.

Operating Room # 1:

1-Bone Marrow Biopsy and Aspiration Tray, Lot # LOC268, Expiration date 2011/09
1-Box 100 Sterile Cotton Tipped/ 2 per package, Lot # L31524, Expiration 2012-04
1-Precisor Hot Disposable Biopsy Forceps, Lot # 1002081, Expiration 2012-02

Operating Room # 2:
2- 16 ounce bottles Isopropyl Rubbing Alcohol Lot # 28565, Exp 09/2011
2-Kendall Iodoform Packing Strips ? inch x 5 yards. Lot # 91760300, Exp 2011-06

During observation by the surveyor and Employee ID # 52 on 07/31/2012 at 11:00 AM in the Special Care Unit multiple expire items were identified among the active stock.

Chest Tube Tray/Cart:
1-Pneumothorax Kit AK-01500 Lot # RF9114808 Exp. 2012-5
3- Adaptic 2015 Non-adhering dressing Lot # 1063751, Exp. 2011-09
Kendall Curity 4 " x 4 " gauze :1- Lot # 71649503, Exp 2012-06 1- Lot # 60139500, Exp 2011-01
1-Allergard II Synthetic Copolymer gloves size 7 ? Lot # 8232921 Exp. 2005-05
Kendal Monoject Needle 18 gage x 1 inch:
2- Lot # 718357, Exp. 2012-05
7-Lot # 705033, Exp. 2012-02
1- Lot # 507387, Exp. 2010-03
2-Lot # 519601, Exp. 2010-01
9--Kendal Monoject Magellan 22 Gauge x 1 inch Safety needle Lot # 705737 Exp. 2021-02, 2011-11, Exp 2012-01
3-Kendall Monoject Magellan 25 Gage x 5/8 inch needle Lot # 627538, Exp. 2011-09, Exp. 2012-2
Suture:
2-3.0 Ethilonx # 1683 Nylon Suture. Lot TME366, Exp. July-09
1-2.9 Ethilon # 593 Black Mono Filament Nylon Suture. Lot # 705737, Exp. July 2007
2-Kendal Vaseline Petrolatum Gauze Dressing 1 inch x 8 inch Lot # 533428A, Exp.2010-06
2-Kendall Vaseline Petrolatum Gauze Overwrap 3 inch x 9 inch Lot # 515831, Exp 2010-06
1-Aplicare Povidone-Iodine Swab Stick 4 inch Lot # C4G058, Exp. 07-06
1-Surgical Gown XL (extra-large)- Barrier Lot # 04465462, Exp 2009-11
1-Pneumothorax Kit Expired 05/2012 found stored in the cabinet behind bed # 1.
Interview by the surveyor at 11:20 AM on July 31, 2012 with Employee ID # 52 revealed: her response was " I can't believe this and further stated the last time a patient was in that unit was July 22, 2012.

During observation and tour of the Birthing Room at 11:55 AM on July 31, 2012 with Assistant Director of Nursing, Employee # 52 the following items were found to be expired:
2-20 gage needles Exp. 5-2012
2-22 Gage Exp 2012-1
3-New Gertic Max Needle Exp 2012-01
1 -Lost of Resistance device (syringe) expired 2009-11
2-Op Sites Exp 2010-10
3-Op Sites Exp 2012-06

Interview with Assistant Director of Nursing, Employee ID # 52 revealed they had a patient in the birthing suite earlier today. Employee ID # 52 stated the CRNA was responsible for ensuring current supplies was maintained in the anesthesia cart.

Interview with Scrub Tech, Employee # 57 at 11:30 AM on 08/2/012 verified the scrub technicians are responsible for disinfection of the scopes. Employee # 57 stated once the scopes had gone through the disinfection/cleaning process they are hung in OR # 1 with scope tubing wrapped around to prevent tubing from touching floor. Employee # 57 stated the scopes are blown out with air prior to hanging the scopes in the OR. Employee # 57 further stated the scopes are hand carried uncovered from the OR to the disinfection room.

Interview with Assistant Director of Nursing, Employee ID # 52 at 13:00 PM on 08/02/2012 confirmed the above expired items and the expired items should have been pulled and not be available to use. Employee ID # 52 confirmed that scopes should not be hung in the operating room, nor carried after use from the OR to the disinfection area by hand, uncovered. Employee ID # 52 confirmed the OR was used last on July 31, 2012.

Record review of the policy titled "Safety policy Statement", 04/2000. "Employee at all leverls have aprimary responsibility for the safety, health and well being of all patients, visitors and the hospital staff. This responsibility can be met by working together continuously to maintain property and equipment in a safe working condition."




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Observation during a tour of the operating area on 08-02-12 at 11 a.m. revealed the following:

Operating Room (OR) # 1:

Three (3) expired Laryngeal Mask Airways (LMA) {expired 4/08; 8/06; 05/09} located in the anesthesia cart.

Two (2) opened LMAs located on top of the anesthesia cart.

One (1) opened Endotracheal (ET) tube located in the anesthesia cart.

OR # 2:

Two (2) expired LMAs (both expired 05/09)

Four (4) opened ET Tubes located in the anesthesia cart.


Interview on 08-02-12 at 11: 25 a.m. with Scrub Tech #59 she stated it was anesthesia ' s responsibility to check the carts . Scrub Tech # 59 said it was unknown if the opened ET tubes had been used and they should have been thrown away.

Interview on 08-02-12 at 12:15 p.m. with the Assistant Director of Nurses ( ADON /ID # 52) she stated if any single- use sterile package (including as ET tube or LMA ) were to be opened and not used; it should be immediately discarded due to infection control issues. She went on to say it was not acceptable to have opened or expired ET tubes and LMAs in the anesthesia carts.

Based on interview and record review, the facility failed to ensure that 2 of 7 active staff physicians (ID # 73 ; ID # 77 ) had delineated privileges for surgeries they performed.

Findings include:

On 08-01-12, review of the facility Operating Room Log (2012) revealed the following:

Physician ID # 73 performed Cesarean sections (C-section) on 07-19-12; 06-14-12; and 03-09-12.

Physician ID # 77 performed a Cesarean section and a bilateral tubal ligation on 06-13-12.

On 08-01-12, review of the active medical staff credential files & privileges revealed the following:

Physician ID # 73 was reappointed to the medical staff on 03-28-11; his current privileges did not include C-sections.

Physician ID # 77 was reappointed to the medical staff on 09-26-11 her current privileges did not include tubal ligation (sterilization).

Physician # 73 and # 77 both had specialties / training in Family Practice.

Interview on 08-02-12 at 1:10 p.m. with Staff ID # 85, she stated she was responsible for the credentialing process. She was not aware Physician # 73 did not have C-section privileges; or that Physician # 77 did not have privileges to perform tubal ligation.

On 08-02-12 review of the " Bylaws of The Medical Staff of ( ) Medical Center, " revised March 18, 2009, read: " 7.02 Delineation of Clinical privileges: A. A staff appointment shall confer on the appointee only such clinical privileges as are specified in the notice of appointment. ...B. Evaluation of privileges by the Medical Staff for initial appointment shall be based upon the applicant ' s licensure, training, current competence, experiences, references, and other relevant information ... "