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Based on observation, Biomedical Equipment Listing and Preventative Maintenance Program Tracking Report review and interview, it was determined one (electrosurgical generator) of two pieces of biomedical equipment located in the Outpatient Services Department was not included in the biomedical equipment program and was overdue for inspection. The failed practice had the potential to affect all patients receiving treatment in the Outpatient Services Department because the safe operation of the equipment was not monitored and not assured. There were no patients receiving patients in the Outpatient Services Department on 07/10/13. The findings follow:

A. On a tour of the Outpatient Services Department on 07/10/13 at 0945 with the Maintenance Director, an electrosurgical generator was observed in Exam Room 2 in the Outpatient Services Department. Observation of the inspection sticker on the equipment revealed the next inspection was due in January 2012.
B. Review of the Biomedical Equipment Listing and Preventative Maintenance Program Tracking Report revealed the equipment was not on the inventory list and there was no documentation of inspection in the most current maintenance tracking report.
C. The Maintenance Director verified the equipment was not included in the preventative maintenance program and was overdue for inspection in an interview on 07/10/12 at 1045.

Based on observation and interview, it was determined the facility did not meet Life Safety Code requirements as follows:

A. The facility did not maintain egress corridors free of obstructions to allow instantaneous use in the event of an emergency. The failed practice had the potential to affect all patient, staff, and visitors due to potential delay in emergency egress presented by the corridor obstructions. See K72.
B. Areas used to store combustible materials were not protected as hazardous areas due to a lack of fire rated construction or sprinklering of a storage room in the Outpatient Services Department and the absence of latching hardware on the Soiled Holding Room door to maintain the door in the closed position. Storing the combustible materials in an unprotected room had the potential to affect all patients, staff and visitors due to the spread of fire and smoke from the room in the event of a fire. SeeK29.
C. The facility utilized roller latches on two corridor doors located in the facility. The failed practice had the potential to affect all patients, staff, and visitors and due to the potential spread of fire and smoke due to the potential failure of the roller latches to maintain the doors in the closed position in the event of a fire event. See K18.

The facility had a census of zero in-patients on 07/08/13 and had an average monthly census of 15 patients.

Based on interview, it was determined the facility did not ensure regular inspections by the local fire department. The failed practice had the potential to affect the health and safety of all patients, staff and visitors because the fire department familiarity of the potential hazards and physical layout of the facility was not assured. The facility had a census of zero in-patients on 07/08/13 and had an average monthly census of 15 patients. The findings follow:

In an interview on 07/09/13 at 0950, the Maintenance Director verified he was not aware of the requirment to maintain dcoumentation of fire department inspection and there was no documentation of fire department inspection available for review.

Based on observation, review of policy and interview, it was determined Intravenous (IV) solutions, irrigation solutions and medications were not secured to prevent access to unlicensed person(s) in two (Medical/Surgical floor and Surgical Services) of three (Medical/Surgical floor, Surgical Services and Emergency Department) areas toured. The failed practice did not ensure IV solutions, irrigation solutions and medications were only available to licensed personnel and could not assure the integrity of the items were maintained. The failed practice had the potential to affect all patients who received these items that were stored unsecured. Findings follow:

A. A tour of the facility on 07/08/13 between 1300 and 1440 revealed the following unsecured IV solutions, irrigation solutions and medications:
1) Medical/Surgical Floor unlocked clean utility room:
a) Ten bags of Dextrose (D) 5%/0.9% Sodium Chloride (NACL) 1000 milliliter(ml) for injection;
b) Eighteen bags of D5%/0.45% NACL 1000 ml for injection;
c) Eighteen bags of D5% 1000 ml for injection;
d) Seven bags of D5% 500 ml for injection;
e) Thirty bags of 0.45% NACL 1000 ml for injection;
f) Sixteen bags of 0.9% NACL 250 ml for injection;
g) Twenty two bags of 0.9% NACL 500 ml for injection;
h) Twenty eight bags of Lactated Ringers 100 ml for injection;
i) Twenty four bottles of 0.9% NACL 500 ml for irrigation; and
j) Twenty one bottles of sterile water 1000ml for irrigation.
2) Surgical Services:
a) Operating Room (unlocked when not in use): Twenty four vials of Dantrolene for injection.
b) Endoscopy Room (unlocked when not in use): One vial Sensorcaine 0.5% 30 ml for injection; one bottle sterile water 500 ml for irrigation; and one bottle sterile water 1000 ml for irrigation.
c) Vestibule (unlocked when not in use): Sixteen bottles of sterile water 1000 ml for irrigation and forty bottles of sterile water 500 ml for irrigation.
B. Review of policy titled "Drug Procurement/Inventory Control" stated "Medications are stored in a secure manner."
C. Findings were verified, through interview, with the Director of Nursing and the Operating Room Nurse Manager on 07/08/13 at 1440.

Based on observation, review of policy and interview, it was determined the facility failed to secure the crash cart drug tray with a breakaway seal and failed to check the integrity of the seal each shift and document it on one (Surgical Services) of three (Surgical Services, Emergency Department and Medical/Surgical floor) adult crash carts surveyed in the facility. By not securing the crash cart drug tray with a breakaway seal and checking the integrity of the seal each shift, the facility could not assure all medications were present for patient emergencies. The failed practice had the potential to affect all patients receiving procedures at the facility. Findings follow:

A. During a tour of the facility on 07/08/13 between 1300 and 1440, observation revealed an adult crash cart in the operating room that did not have a break away seal nor was there documentation reflecting the seal had been checked each shift. The drugs were stored on nonsurgical days in the pharmacy in an open tray, not sealed, along with the anesthetic drugs. The emergency drugs were not secured with a breakable seal therefore there was no documentation that the tray's seal was checked each shift.
B. Review of policy titled Crash Carts stated "All Crash Carts at Paris will be checked by the Shift Supervisor/Team Leader or their designee each shift with the exception of those areas that are not open on a daily basis. The word 'closed' is to be written on the check sheet for those dates such as closed on Saturday and Sunday." "Routine checks will be documented on the log sheet on the Crash Cart/Defibrillateor Checklist." "Routine visual checks ensure that: the lock is unbroken."
C. Findings were verified, through interview, on 07/08/13 at 1435 with the Operating Room Nurse Manager.

Based on review of the Infection Control Policy and Procedure Manual, Infection Control Committee Meeting Minutes and interview, it was determined the facility failed to develop and implement: a plan for monitoring and evaluating all aseptic, isolation, and sanitation techniques used in the facility; have a requirement that all disinfectants, antiseptics, and germicides be used per manufacturer's guidelines; and develop employee health policies regarding infectious diseases and when infected employees should not render care. Failure to develop and implement the above requirements did not allow the facility to have a fully functioning infection control program that identified, tracked, investigated and prevented the spread of infections. The failed practice affected all patients, staff and visitors on 07/08/13. Findings follow:

A. Review of the Infection Control Policy and Procedure Manual, Infection Control Committee Meeting Minutes and interview revealed no plan for monitoring and evaluating all aseptic, isolation and sanitation techniques used in the facility, no requirement that all disinfectants, antiseptics, and germicides be used per manufacturer's guidelines, and no employee health policies regarding employees with infectious diseases and when infected employees should not render care.
B. The Infection Control Nurse verified the above findings during an interview at 0900 on 07/10/13.

Based on observation, review of policy and interview, it was determined there was no evidence of temperatures being checked and recorded daily for one of one Cold Pack Unit in Rehabilitation Services according to policy. By not checking the temperatures daily, the facility could not assure the cold packs were safe and at optimum temperature for best patient outcomes during treatment. The failed practice had the potential to affect all patients receiving cold pack therapy. Findings follow:

A. During a tour of the Rehabilitation Services Department on 7/10/13 from 1305 to 1350, a Cold Pack Unit had a temperature reading of 10 degrees Fahrenheit. The Director of Physical Therapy was asked to produce a temperature log in which the surveyor was told they do not keep one.
B. Review of policy titled "Interdepartmental Care of Equipment" stated "Cold Pack Unit: Unit should be grounded and temperature checked daily and recorded on the temperature log. Temperature range is to be 20 to 40 degrees Fahrenheit."
C. Findings were confirmed, through interview, with the Director of Rehabilitation on 7/10/13 at 1345.

Based on radiology policy and procedure review and interview, it was determined the facility failed to ensure a policy was in place for maintenance of employee radiation monitoring badges. The failed practice created the potential for a badge malfunction to go unnoticed and could result in incorrect readings. Findings follow.

During an interview on 07/09/13 at 1325, the Radiology Director stated there was no policy regarding badge maintenance.

Based on review of operative reports and interview, it was determined five of five (#11-#15) patients operative reports did not contain the time of the surgery. The failed practice did not allow for determination of which operation came first in the event of multiple surgeries in one day. Findings follow:

A. Review of operative reports for Patients #11-#15 revealed no documentation of the time of surgery.
B. Findings were verified, through interview, with the Director of Medical Records on 07/11/13 at 1100.

Based on interview, it was determined the facility failed to develop an organized Swing Bed activities program. Failure to develop an activities program did not allow the residents to be knowledgeable of available activities and choose which activities they would like to participate in. Findings follow:

A. During an interview with the Activities Director at 1300 on 07/10/13 she was asked for the activity schedule or list of activities planned and offered to the patients. The Activities Director stated she did not have a list or schedule of planned activities to give patients.