HospitalInspections.org

Based on observation and interview, the facility failed to ensure expired medications were not available for patient use for one of three anesthesia carts observed.

The findings included:

Observation on March 3, 2015, at 9:50 a.m., in the Operating Room (OR) of Building A, revealed, in the locked anesthesia cart, one 250 ml [milliliter] bottle of Forane [inhalant anesthesia] with an expiration date of September, 2014.

Interview with the OR Nurse Manager on March 3, 2015, at 9:50 a.m., in the OR, confirmed the Forane was expired and was available for patient use.

Based on observation, interview, and record review during a validation survey for Life safety, the facility failed to maintain the physical plant and environment to ensure the safety of patients.

The findings included:

During observation, interview, and record review, with the Maintenance Director, on March 2-3, 2015, it was confirmed the facility failed to ensure corridor fire doors closed to a positive latch and, were undercut no more than 1-inch; failed to ensure self-closing fire doors were held open by approved devices; failed to maintain hazardous area's fire-rated construction; failed to ensure smoke detectors were not in air flow; failed to ensure sprinklers were not corroded or loaded and mis-matched with Quick response and standard response heads and medical gas storage rooms were appropriate; failed to maintain portable fire extinguishers and kitchen hood systems; failed to maintain fire dampers; and failed to ensure GFCI protected outlets were in wet areas.

Refer to Life Safety Tags: K018, K021, K029, K052, K062, K064, K067, K069, K077, and K147.)

Based on observation and interview, the facility failed to ensure expired sutures were not available for patient use in one of one Operating Room (OR) hallways; failed to ensure expired lab collection tubes in one of one Magnetic Resonance Imaging (MRI) rooms were not available for patient use; and failed to ensure expired medical supplies were not available for patient use in one of two ultrasound rooms.

The findings included:

Observation on March 3, 2015, at 9:35 a.m., in the Building A Operating Room (OR) hallway, revealed a suture cart with the following expired sutures: nineteen individually wrapped 3.0 Chromic Gut sutures with an expiration date of January, 2015; eighteen individually wrapped 4.0 Ethilon sutures with an expiration date of January, 2015; thirty-four individually wrapped 5.0 Ethilon sutures with an expiration date of January, 2015; four individually wrapped Vicryl sutures with an expiration date of January, 2015; and forty-seven individually wrapped 2.0 PDS (polydioxanone) sutures with an expiration date of January, 2015.

Interview with the OR Nurse Manager on March 3, 2015, at 9:35 a.m., in the OR Hallway, confirmed the sutures were expired and available for patient use.

Observation on March 3, 2015, at 2:15 p.m., in the MRI room of Building A, revealed fifty green top blood collection tubes with an expiration date of September, 2012.

Interview with the OR Nurse Manager on March 3, 2015, at 2:15 p.m., confirmed the blood collection tubes were expired and were available for patient use.

Observation with the Director of Quality Management (DQM) on March 3, 2015, at 2:20 p.m., in Building B radiology department ultrasound room #1, revealed two hypodermic needle kits with an expiration date of May 2012, and four hypodermic needle kits with an expiration date of May 2013, stored in a cabinet drawer.

Interview with the DQM on March 3, 2015, at 2:20 p.m., in ultrasound room #1, confirmed the hypodermic needle kits were expired and available for patient use.

Based on medical record review, observation, review of facility policy, and interview, the facility failed to follow infection control policy for IV (intravenous) access for one patient (#5) of five patients observed with intravenous lines; failed to follow facility policy related to droplet isolation precautions for one of one patients (#32) observed in droplet precautions; and failed to ensure a sanitary environment for one of three x-ray rooms.

The findings included:

Medical record review revealed Patient #5 was admitted to Building A on February 20, 2015, for diagnosis including Colon Resection.

Observation on March 2, 2015, at 12:30 p.m., in the patient's room, revealed the patient sitting in a chair with IV antibiotics infusing through an IV site inserted in the patient's right forearm. Continued observation revealed the IV insertion site dressing was not labeled with a date, time, or initials of the person who inserted the IV. Continued observation revealed the IV administration tubing was not labeled with a date or time.

Medical record review of a nurses note dated February 23, 2015, revealed "...IV insertion...site...rt [right] forarm [forearm]..." Continued review revealed no further documentation regarding removal of the peripheral IV from the right forearm.

Review of facility policy, IV Catheter Maintenance, last revised May 2012, revealed "...routine restarts and dressing changes will be made in accordance with the following procedure...to reduce the risk for phlebitis, peripheral IV catheters will be rotated every 96 hours (4 days)...dsg [dressing]...care...q [every] 4 days or with restart..."

Review of facility policy, IV Dressing Change, last revised April 4, 2014, revealed "...place a transparent...dressing over the insertion site...label the dressing with the date and time of the procedure and your initials..."

Review of facility policy, IV Tubing Change, last revised April 4, 2014, revealed "...label the administration set...with the date and time..."

Interview with the Nurse Manager on March 2, 2015, at 12:40 p.m., in the patient's room, confirmed the IV had been inserted for seven days and the IV site and the IV tubing was not labeled with a date, time, or initials of the person who started the IV. Continued interview confirmed no physician order was written indicating the IV could remain in the patient's arm for longer than four days without being changed.

Interview with the Director of Quality Management (DQM) on March 3, 2015, at 7:45 a.m., in the conference room, confirmed the facility failed to follow facility policy.

Medical record review revealed patient #32 was admitted to Building A on February 27, 2015, with diagnoses including Influenza. Further review revealed the patient was placed on Droplet Precautions (recommended practices to prevent the transmission of infectious agents).

Observation on March 2, 2015, at 3:25 p.m., on the B Wing in Building A, revealed Patient Care Technician (PCT) #1 in the patient's room with no gown, mask or gloves (PPE-personal protective equipment) in use. Further observation revealed the PCT exited the patient's room and failed to sanitize or wash the hands.

Review of facility policy Precautions-Standard and Transmission Based last reviewed on March, 2014, revealed "...droplet precautions...hand hygiene...wash/sanitize hands upon entry and upon exiting the room...PPE: wear gloves and mask when entering the room...dispose of PPE prior to exiting the room..." Further review revealed "...PPE refers to items which may reduce the risk of exposure of the health care workers to non-intact skin and mucus membranes and to blood/body fluids...these PPE may include but are not limited to...gloves, mask, protective eyewear...gowns and gloves..."

Interview with the PCT on March 2, 2015, at 3:30 p.m., in the B Wing Hallway, confirmed the PCT did not wear the required PPE while in the patient's room and did not wash or sanitize the hands prior to exiting the patient's room.

Interview with the B wing Unit Nurse Manager on March 2, 2015, at 3:35 p.m., in the B Wing nurse's station, confirmed the PCT failed to follow the facility's policy related to the droplet precautions, the use of PPE and standard infection control standards.

Observation and interview with the DQM on March 3, 2015, at 1:15 p.m., in Building B radiology department x-ray room #3, revealed a buildup of dust on the x-ray machine, the x-ray machine cables, and the floor behind the x-ray machine. Continued observation revealed a suction machine was stored on the floor behind the x-ray machine. Interview with the DQM confirmed the equipment was dirty, the floor was dirty, and the suction machine should not be stored on the floor.