HospitalInspections.org

Based on observation and interview, the provider failed to ensure intravenous (IV) solutions in one of one warming cabinet in the emergency suite (ES) had been stored according to the manufacturer's specifications.
Findings include:

1. Observation on 3/1/11 at 1:50 p.m. of a warming cabinet in the ES revealed it contained thirteen bags of IV solutions and one plastic pour bottle of irrigation solution. The temperature reading of the unit was 101 degrees Fahrenheit (F). Observation of the IV solution bags and the bottle of irrigation solution revealed none had been labeled with the date they had been placed in the warming unit. No containers had a date stating when they should have been removed from the unit.

Interview at the above time with director of nursing (DON) A revealed he was not aware the manufacturer's specifications for warming IV and irrigation solutions. He was not aware they were to have been warmed for only a limited amount of time and then removed from the warmer. He could not say when the solutions had been placed in the warmer.

Interview on 3/2/11 at 11:30 a.m. with the consultant pharmacist B revealed she was not aware the solutions could only be stored in the warming cabinet for a limited amount of time. She stated the central supply or nursing service had stocked the solutions in the cabinet.

Interview on 3/2/11 at 1:30 p.m. with DON A revealed the provider did not have a policy for handling warmed IV or irrigation solutions.

Review of a letter from the manufacturer for IV and irrigation solutions dated 11/3/09 revealed:
*Solutions of large volume IVs could have been warmed in their plastic overpouches to temperatures not to exceed 104 degrees F and maintained for a period no longer than 14 days.
*Plastic pour bottles of irrigation solutions could have been warmed to temperatures not to exceed 150 degrees F and maintained for a period no longer than 72 hours or to temperatures not to exceed 104 degrees F and maintained for a period of 30 days.
*The IV and irrigation solutions could have been removed from the warmer once the maximum number of days was reached and used until the manufacturer's expiration date. The solutions could not be warmed more than once.
*After removal from the warming cabinet the IV and irrigation solutions should have been identified as having been placed in the warming cabinet.

Based on record review, interview, and policy review, the provider failed to identify the correct cleaning agent and develop a policy and procedure for cleaning environmental surfaces after contact with patients with Clostridium difficile infections (CDI). Findings include:

1. Review of the provider's undated Housekeeping Cleaning Information Sheet revealed a quaternary disinfectant was used for routine hospital cleaning and for disinfecting equipment and the environment.

Interview on 3/1/11 at 1:00 p.m. with head housekeeper C and maintenance director D revealed the provider used a quaternary disinfectant throughout the hospital for cleaning all environmental surfaces. Further interview revealed all isolation rooms were cleaned with a quaternary disinfectant. They knew what CDI was and thought the quaternary disinfectants were effective against all germs including CDI. They were not aware only bleach was effective against CD spores.

Review at the above time with head housekeeper C of the quaternary disinfectant manufacturer's labels revealed CD spores were not listed as one of the organisms it would have destroyed.

Interview on 3/2/11 at 10:15 a.m. with director of nursing A confirmed the provider used a quaternary disinfectant throughout the hospital for cleaning all surfaces. He was not aware of what disinfectant would destroy CDI. He was not aware bleach was the only effective cleaner for killing CD spores.

Review of the provider's infection control/contact isolation policy and procedure revealed:
*Blood and body fluid spills would be cleaned and followed by disinfection of the contaminated surface with a fresh solution of 5.25% bleach diluted with water at a 1:10 ratio or an EPA registered quaternary ammonium disinfectant.
*All occupied rooms would be routinely cleaned in the same manner on a daily basis regardless of the diagnosed disease.
There were no guidelines specific to the disinfection of rooms occupied by patients with CDI.

Based on interview, record review, and policy review, the provider failed to ensure 6 of 11 sampled employees (A, D, G, H, I, and J) received performance evaluations annually. Findings include:

1. Review of the performance evaluations for employees A, D, G, H, I, and J revealed their last performance evaluations had been done on the following dates:
*A on 3/30/09.
*D on 3/30/10.
*G on 1/4/10.
*H was not found.
*I was not found.
*J on 8/14/09.

Interview on 3/2/11 at 1:45 p.m. with director of nursing A revealed he was behind in getting the performance evaluations done. He had not had a performance evaluation for a couple of years himself.

Review of the provider's undated policy for performance evaluations revealed:
*"Performance evaluations provide information to you [employees] concerning your success in accomplishing the responsibilities of your jobs."
*A performance review would be done "at the end of the probationary period and once each year thereafter."