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Based on record review, interview, and policy review, the provider failed to ensure patients' pain was assessed and managed for 6 of 20 sampled patients (8, 11, 13, 15, 18, and 22) charts reviewed. Findings include:

1. Review of patient 8's medical record revealed:
*She had been admitted on 5/21/13.
*She had a laminectomy (back surgery) procedure.
*She had been discharged on 5/22/13.

Review of patient 8's care plan revealed she was at risk for acute/chronic pain due to the surgical process. Interventions were:
*Instruct the patient regarding reporting pain level to staff.
*Offer comfort measures.
*Administer analgesics (pain medication) per her physician's order.
*Evaluate response to pain management.
*Notify physician of unrelieved pain.

Review of patient 8's medication list revealed she had received oxycodone/acetaminophen (APAP) 5/325 milligrams (mg) once on 5/21/13 and once on 5/22/13.

Review of patient 8's nursing assistant's documentation revealed pain scores on 5/22/13 at 12:00 midnight of zero and at 4:00 a.m. of six.

Review of patient 8's nursing notes revealed:
*On 5/21/13 at 10:00 p.m. - patient reports pain at eight to nine for back pain. Pain medication given.
*On 5/22/13 at 4:00 a.m. - patient complained of lower back pain. Medication given.
*On 5/22/13 at 6:30 a.m. - pain order received and medication given.
*There was no follow-up assessment documentation rating her pain levels after the medications had been given.

2. Review of patient 13's medical record revealed:
*He had been admitted on 4/25/13.
*He had total knee surgery on 4/25/13.
*He had been discharged on 4/28/13.

Review of patient 13's care plan revealed he was at risk for acute/chronic pain due to the surgical process. Interventions were:
*Instruct the patient regarding reporting pain level to staff.
*Offer comfort measures.
*Administer analgesics per his physician's order.
*Evaluate response to pain management.
*Notify physician of unrelieved pain.

Review of patient 13's medication list revealed he had received oxycodone/APAP 5/325 mg:
*Twice on 4/25/13.
*Three times on 4/26/13.
*Three times on 4/27/13.
*Three times on 4/28/13.

Review of patient 13's nursing assistants' documentation revealed:
*No pain score rating the evening of 4/25/13.
*Pain scores on 4/26/13 of five-six at 12:00 midnight and a five at 8:00 a.m.
*Pain scores on 4/27/13 of five at 12:00 midnight and two to three at 4:00 a.m.
*Pain score on 4/28/13 of three at 8:00 a.m.

Review of patient 13's nursing notes revealed:
*On 4/25/13 at 4:30 p.m. - patient was given two Percocet for pain.
*On 4/25/13 at 11:00 p.m.- patient received pain medication.
*On 4/26/13 at 8:30 p.m.- patient received pain medication.
*On 4/27/13 at 5:15 p.m.- patient received pain medication.
*On 4/27/13 at 6:00 p.m.- patient stated he had no pain.
*On 4/28/13 at 12:30 a.m.- patient complained of pain and received one Percocet.
*There was no follow-up assessment documentation rating his pain levels after the above medications had been given.

3. Review of patient 18's medical record revealed:
*She had been admitted on 3/28/13.
*She had total knee surgery on 3/28/13
*She had been discharged on 4/1/13.

Review of patient 18's care plan revealed she was at risk for acute/chronic pain due to the surgical process. Interventions were:
*Instruct the patient regarding reporting pain level to staff.
*Offer comfort measures.
*Administer analgesics per her physician's order.
*Evaluate response to pain management.
*Notify physician of unrelieved pain.

Review of patient 18's medication list revealed she had received:
*Oxycodone/APAP 5/325 mg:
-Three times on 3/28/13.
-Five times on 3/29/13.
-Four times on 3/30/13.
-Four times on 3/31/13.
-Twice on 4/1/13.
*Tramadol (pain medication) 50 mg:
-Twice on 3/28/13.
-Three times on 3/29/13.
-Three times on 3/30/13.
-Twice on 3/31/13.
*Dilaudid (pain medication) 0.1 to 0.2 mg:
-Twice on 3/28/13.
-Once on 3/29/13.

Review of patient 18's nursing assistant's documentation revealed one pain score of five recorded on 4/1/13.

Review of patient 18's nursing notes revealed:
*On 3/28/13:
-At 2:20 a.m. patient stated pain was ten out of ten, and she "wanted her leg cut off." Pain medications given.
-At 7:00 p.m. patient rated pain at six out of ten. Pain medication given.
-At 11:00 p.m. patient rated pain at six out of ten.
*On 3/29/13:
-At 3:30 a.m. patient rated pain at 7 out of 10. Pain medications given.
-At 5:30 a.m.patient denied complaints.
-At 6:40 a.m. - patient complained of pain. Pain medication given.
-At 7:35 a.m. - patient continued complaining of pain. Pain medication given.
-At 9:10 a.m. - patient complained of pain. Pain medication given.
-At 12:00 noon - patient complained of pain. Pain medication given.
-At 1:00 p.m. - patient stated pain had decreased.
-At 4:00 p.m. - patient complained of pain. Pain medication given.
-At 8:30 p.m. - pain medications given per patient request.
-At 11:30 p.m. - pain medication given.
*On 3/30/13:
-At 3:00 a.m. - pain medication given.
-At 7:00 a.m. - pain medication given.
-At 9:35 p.m. - pain medication given.
*On 3/31/3:
-At 2:00 a.m. - patient complained of pain in right great toe. Pain medication given.
-At 10:10 a.m. - pain medication given.
-At 2:15 p.m. - pain medication given.
*There was no follow-up assessment documentation rating her pain levels after the medications had been given.



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4. Review of patient 11's medical record revealed:
*She had been admitted on 6/21/13.
*She had a total hip replacement surgery.
*She had been discharged on 6/23/13.

Review of patient 11's care plan revealed she was at risk for acute/chronic pain due to the surgical process. Interventions were:
*Instruct the patient regarding reporting pain level to staff.
*Offer comfort measures.
*Administer analgesics per her physician's order.
*Evaluate response to pain management.
*Notify physician of unrelieved pain.

Review of patient 11's medication list revealed she had received oxycodone/acetaminophen 5/325 mg one tablet on 6/21/13 at 6:15 p.m.

Review of patient 11's nursing assistant's documentation revealed no documented pain scores on 6/21/13.

Review of patient 11's nursing notes revealed:
*On 6/21/13 at 6:00 p.m. - increased discomfort, pain medication given at 6:30 p.m.
*No pain score assessment documented for increased pain level.
*No follow-up assessment or pain score documented.



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5. Review of patient 22's medical record revealed:
*She had been admitted on 2/15/13.
*She had a lumbar decompression (the relief of pressure on one or more pinched nerves of the spinal column) with removal and replacement of screws.
*She had been discharged on 2/17/13.

Review of patient 22's care plan initiated on 2/15/13 revealed she was at risk for acute/chronic pain due to the surgical process. Interventions were:
*Instruct the patient regarding reporting pain level to staff.
*Offer comfort measures.
*Administer analgesics (pain medications) per her physician's order.
*Evaluate response to pain management.
*Notify physician of unrelieved pain.

Review of patient 22's inpatient medication list and comparison with the patient's nurse's notes revealed she had received:
*On 2/15/13 at 11:00 p.m. - Morphine 2 mg for back pain. There was no pain rating or follow-up assessment documented for medication effectiveness.
*On 2/16/13 at 8:40 a.m. - Norco one tablet for right leg pain. There was no pain rating documented.
*On 2/16/13 at 9:05 p.m. - Norco two tablets for pain was documented on the inpatient medication list. The pain rating had not been completed, and the follow-up assessment for medication effectiveness was not done until 11:00 p.m.; approximately two hours later.
*On 2/16/13 at 12:31 p.m. - Norco one tablet had been administered for right leg pain. There was no pain rating documented.
*On 2/16/13 at 12:45 p.m. - Morphine 2 mg had been administered for right leg pain. There was no pain rating or follow-up assessment documented for medication effectiveness.
*On 2/16/13 at 2:55 p.m. - Valium 5 mg had been administered for right leg pain. There was no pain rating or follow-up assessment documented for medication effectiveness.
*On 2/16/13 at 5:15 p.m. - Norco one tablet had been administered for right leg pain. There was no pain rating or follow-up assessment documented for medication effectiveness.
*On 2/17/13 at 3:50 a.m. - Norco two tablets had been administered for right leg pain. There was no pain rating or follow-up assessment documented.
*On 2/17/13 at 5:00 a.m. - Valium (no dosage documented) had been administered for restlessness and right leg pain. There was no pain rating or follow-up assessment documented for medication effectiveness.
*On 2/17/13 at 7:30 a.m. Norco two tablets for pain. There was no pain rating or follow-up assessment documented for medication effectiveness.

Review of patient 22's recovery care nursing assessment form documentation dated and timed on 2/15/13 at 3:30 p.m., 2/15/13 at 6:30 p.m., 2/16/13 at 8:00 a.m., 2/16/13 at 6:30 p.m., and 2/17/13 at 7:00 a.m. revealed pain had not been part of the assessment documentation.

6. Review of patient 15's medical record revealed:
*She had been admitted on 4/17/13
*She had back surgery and repair of her lumbar spine.
* She had been discharged on 4/21/13.

Review of patient 15's care plan initiated on 4/17/13 revealed she was at risk for acute/chronic pain due to the surgical process. Interventions were:
*Instruct the patient regarding reporting pain level to staff.
*Offer comfort measures.
*Administer analgesics per her physician's order.
*Evaluate response to pain management.
*Notify physician of unrelieved pain.

Review of patient 15's inpatient medication list and comparison with the nurse's notes revealed she had received:
*On 4/17/13 Morphine 2 mg had been administered at 3:15 p.m., 5:00 p.m., and 6:00 p.m.
*There was no pain rating or follow-up assessment documented for those administrations.
*There was no pain rating or follow-up assessment for medication effectiveness documented for 5:00 p.m. and 6:00 p.m.

*On 4/18/13:
-At 1:45 a.m. Morphine had been administered. There was no pain rating or follow-up assessment documented for medication effectiveness.
-On 4/18/13 OxyContin 20 mg had been administered at 3:30 a.m. and 4:10 a.m. There was no pain location or pain rating documented.
-Scheduled Celebrex 200 mg had been administered at 8:00 a.m. and at 8:00 p.m.
-Percocet two tablets at 8:30 a.m. had been administered. There was no pain rating or follow-up assessment documented.
-On 4/18/13 Valium 5 mg had been administered at 4:45 a.m., at 12:30 p.m., and at 9:15 p.m.
*There was no pain rating or follow-up assessment documented for those times.

*On 4/19/13:
-Scheduled Celebrex 200 mg had been administered at 6:40 a.m. and 9:15 p.m.
-On 4/19/13 oxycodone/APAP 5/325 mg two tablets had been administered at 1:20 a.m., 6:40 a.m., 11:20 a.m., 4:30 p.m., and 11:30 p.m.
-No pain rating or follow-up assessment had been documented for any of the above listed medications.

*On 4/20/13:
-Valium 5 mg had been administered at 7:00 a.m., 5:47 p.m., and at 11:45 p.m.
-Celebrex 200 mg had been administered at 7:00 a.m. and 11:30 p.m..
-Oxycodone/APAP 5/325 mg two tablets at 5:00 a.m., 9:00 a.m., 1:00 p.m., 5:50 p.m., and 11:30 p.m.
-No pain rating or follow-up assessment had been documented for any of the above listed medications.

*On 4/21/13:
-Scheduled Celebrex 200 mg had been administered at 8:00 a.m.
-Oxycodone/APAP 5/325 mg two tablets had been administered at 4:00 a.m.
-Valium 5 mg had been administered at 8:00 a.m. and at 8:00 p.m.
-Valium 5 mg had been administered at 11:45 p.m.
-Valium 5 mg had been administered at 4:00 a.m.
-No pain rating or follow-up assessment had been documented for any of the above listed medications.

Review of patient 15's recovery care nursing assessment form documentation dated and timed on 2/15/13 at 3:30 p.m., 2/15/13 at 6:30 p.m., 2/16/13 at 8:00 a.m., 2/16/13 at 6:30 p.m., and 2/17/13 at 7:00 a.m. revealed pain had not been part of the assessment documentation.

6. Review of the provider's February 2012 Pain Management policy revealed:
*"Pain slows down and/or complicates the recovery period. It is our goal that pain shall be assessed and documented frequently, that the patient shall determine the intensity of pain using the 0-10PSL (Pain Scale Level), that narcotic pain relief shall be administered quickly by IV (intravenous) route (unless contraindicated), that narcotic pain relief assessment shall be done at frequent intervals, and that the patient shall be provided with oral analgesic for home use prior to dismissal."
*"Patients shall be asked if pain is present each time VS (vital signs) are taken, beginning in recovery room."
*"Patients shall be asked to use the 0-10 pain scale. Zero indicates no pain; ten indicates the worst pain possible."
*"Pain assessment documentation is built into the post-op graphic record so that the PSL (Pain scale level) is part of VS measurements."
*Nursing judgment shall determine which narcotic to use in light of the patient history, current routine post-op orders, and surgeon orders.
"Assessment of pain relief shall be determined after 5 minutes by the patient."
*Patients shall be encouraged to take their potent analgesics on a routine schedule for the first 24 to 48 hours since patients are expected to have pain after surgery. Thereafter, the PRN (as needed) schedule can be adopted."

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, MO, 2005, pp. 1242-1246, revealed "Assessment of common characteristics of pain helps the nurse form an understanding of the type of pain, its pattern, and types of interventions that may bring relief." The nurse should ask questions regarding:
*The onset and duration of pain.
*The location of the pain.
*The intensity of the pain.
*The quality of the pain.
*The pain pattern.
*Relief measures.
*Contributing symptoms that cause pain to worsen.

Based on observation and interview, the provider, failed to ensure two of two anesthesia medication carts and one of one portable anesthesia narcotic lock box were secured when not in use for patient care. Findings include:

1. Observation on 7/9/13 at 7:25 a.m. in operating room (OR) 6 revealed:
*Upon entering the OR there were no staff members present.
*The craftsman anesthesia medication cart was unlocked and medications stored in that cart were assessable to unauthorized individuals.
*At 8:35 a.m. the patient's procedure was completed, and there were no staff present in OR 6. The craftsman anesthesia medication cart was unlocked and medications stored in that cart were assessable to unauthorized individuals.
*At 8:45 a.m. staff arrived with a new patient for OR 6.

Observation on 7/9/13 at 8:46 a.m. in OR 7 revealed:
*There were no staff members present in OR 7.
*The craftsman anesthesia cart was unlocked, and this surveyor had access to medications stored in that cart.
*On top of the anesthesia medication cart was the portable locked anesthesia narcotic box. The anesthesia box was not secured and could have been easily transported by unauthorized individuals.
*At 9:10 a.m. a non-licensed staff member entered the room to prepare for the next patient.

Interview on 7/10/13 at 2:30 p.m. with the director of nursing revealed the anesthesia medication carts and portable narcotic boxes should have been secured when not actively in-use by staff.

Based on observation, interview, and policy review, the provider failed to ensure food service met necessary requirements for one of one contracted food service providers. Findings include:

1. Observation on 7/8/13 at 1:45 p.m. of the contracted food service area revealed:
*Two light fixtures without covers or protective sleeves over the fluorescent light bulbs.
*The general manager/cook had not worn a beard guard.
*A food service staff member had no hair covering on.

Interview on 7/10/13 at 1:30 p.m. with the general manager/cook revealed:
*The light fixture covers had broken on 7/5/13.
*He was not aware the light bulbs should have been covered or in protective sleeves.
*He had been told by a previous food inspector staff member hair only needed to be pulled back and not covered.
*His ServSafe certificate had expired in September 2012.
*He had just completed the four hour ServSafe recertification class.
*He had been told the four hour class was the required class.

Review of the provider's Sanitation in the Contracted Restaurant policy revised 2/26/13 revealed food prepared for the provider would be prepared in a sanitary manner that met all standards of the South Dakota Department of Health.

Review of Administrative Rules of South Dakota Article 44:04 Medical Facilities 44:04:07:07 revealed "The dietary manager and at least one cook must successfully complete and possess a current certificate from a ServSafe Food Protection Program offered by various retailers or the Certified Food Protection Professional's Sanitation Course offered by the Dietary Managers Association, or successfully completed equivalent training as determined by the Health Department."

Review of Administrative Rules of South Dakota Article 44:02 Food Service Code revealed:
*44:02:07:14. General employee practices.
-(6) Food employees must wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair. The hair restraints must be designed and worn to effectively keep hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.
*44:02:07:78. Lighting. Lighting must meet the following specifications for intensity and protective shielding:
-(2) Lighting must have protective shielding as follows:
Light bulbs must be shielded or coated or must be otherwise shatter-resistant in areas where there is exposed food, clean equipment, utensils, linens, or unwrapped single-service and single-use articles.

A. Based on observation, interview, and policy review, the provider failed to ensure:
*High-level disinfected endoscopic scopes were protected from potential cross-contamination for all colonoscopy procedures and esophagastroduodenoscopy (EGD) procedures performed in one of one operating room (OR) suite.
*The surgical team participating in colonoscopy and EGD procedures wore appropriate personal protective equipment (PPE) to prevent potential cross-contamination and spread of communicable diseases for one of one observed patient's (29) colonoscopy and EGD surgical procedure.
*Endoscopy processing technicians wore appropriate PPE while cleaning contaminated colonoscopy and EGD scopes in one of one endoscopic processing room.
Findings include:

1. Observation on 7/9/13 at 7:15 a.m. of patient 29's colonoscopy and EGD procedure revealed:
*There were no staff in attendance when the patient was brought into OR 6.
*On the working backtable a colonoscopy scope was attached to the video monitoring equipment and covered with a blue cloth towel.
*On a second backtable close to the wall were three additional endoscopes covered with a blue cloth towel.
*During the patient's colonoscopy and EGD procedure the colonoscopy scope attached to the video monitoring equipment and one of the endoscopes from the second backtable were used. Those other two endoscopes remained covered in the room during the patient's entire procedures and when staff cleaned the room at the end of the procedures.
*Numerous clean supplies (blue towels used to cover endoscopes, absorbant pads [Chuxs], and gauze pads) were stored in bins unprotected during the patient's procedures.
*Appropriate PPE had not been worn by the surgical staff participating in the colonoscopy and EGD procedure.
*Surgeon C had worn a sleeveless plastic apron over his surgical attire, a pair of clean gloves, and his watch.
*Endoscopic technician G had worn a pair of clean gloves, no fluid protective barrier over his surgical attire, and no face shield to protect against splatter.

Observation on 7/9/13 at 8:25 a.m. in the scope reprocessing room of endoscopy technician G revealed:
*He put on a pair of clean gloves and a sleeveless plastic apron and then proceeded to preclean contaminated endoscopes used during patient 29's colonoscopy and EGD procedure.
*He did not put on a face shield to fully protect his face from potential liquid splatter.

Interview on 7/9/13 at 8:25 a.m. with processing technician G revealed:
*Endoscopes were high-level disinfected, placed on a backtable in the OR, and covered with a blue towel. Endoscopes on the second backtable remained covered until ready to use. If the endoscopes were not used during a procedure they remained there and were used on proceeding surgical procedures. As long as he could remember that had always been the practice at the facility.
*The endoscopes were left in the room for availability and convenience.
*The endoscopy staff assisting with procedures did not wear PPE when assisting with colonoscopy or EGD procedures. He had only worn gloves when assisting the surgeon, and the surgeon had worn a sleeveless apron.
*The chance of liquid splatter was very low so the endoscopy staff wore gloves, and a sleeveless plastic apron when pre-cleaning contaminated endoscopes. If the technician wore prescription glasses there was no need for additional eye protection.

Observation and interview with processing technician D on 7/9/13 at 8:46 a.m. in procedure room 7 revealed:
*There were no staff in the room.
*The backtable had an endoscope covered with a blue towel.
*Not all patients were comfortable seeing the scopes and suction containers, so those items were covered.

Interview on 7/9/13 at 1:00 p.m. with infection control preventionist J revealed:
*The endoscopes that were not used and covered on the backtable during patient 29's colonoscopy and EGD procedure should have been high-level disinfected prior to use on another patient.
*Instruments/equipment exposed during a surgical procedure required high-level disinfection or autoclave/Sterrad sterilization prior to use to prevent potential cross-contamination and spread of communicable diseases.
*Staff should have been removing contaminated gloves and performed hand hygiene after coming in contact with contaminated items.
*Staff should have been wearing full PPE when there was a potential for contamination.
*The staff completing colonoscopy and EGD procedures should have worn PPE with sleeves, a face shield, and gloves.
*The surgical team completing colonoscopy and EGD procedures should have worn PPE over their surgical attire to prevent contamination.

Review of the provider's March 2013 surgical instrument decontamination policy revealed:
*The principle of standard precautions should have been followed in the decontamination area by all staff working in the operating room and decontamination areas.
*Protective techniques were necessary when cleaning instruments known to be contaminated with fecal material.
*PPE was required by all employees working in designated dirty areas in decontamination.
*Required PPE included a fluid resistant gown, eye and face shield protection, and gloves.
*Prescription eye glasses were not considered protective eyewear unless they were safety glasses designed to protect the eyes from all angles.

Review of the provider's March 2013 dress code for surgery policy revealed:
* Appropriate face and eye protection should have been worn when splashes, sprays, spatters, droplets of blood, or potentially infectious materials posed a hazard to the eye, nose, or mouth.
*No visible jewelry was allowed for staff members scrubbed in.

B. Based on observation and interview, the provider failed to ensure staff followed manufacturer's recommendations for use of disinfectant wipes for one of one observed patient's (26) surgical procedure. Findings include:

1. Observation on 7/9/13 at 9:45 a.m. of patient 26's surgical procedure revealed:
*The patient was taken to the OR by stretcher and placed outside OR 14. There was a surgical procedure in progress.
*At the end of the case surgical technicians entered OR 14 with sterile equipment and clean supplies while the room was being disinfected.
*The backtable was wiped with a 3M disinfectant wipe and the sterile pack was immediately opened on that table.
*At the end of the case the contaminated drapes were discarded, and the backtable was still wet from the disinfectant used earlier.

Random observation on 7/9/13 at 10:21 a.m. of OR 14 revealed the surgical procedure ended and before the patient was removed from the room staff took in the sterile equipment and supplies. At that same time other staff members were disinfecting the room.

Interview on 7/9/13 at 1:00 p.m. with infection control preventionist J revealed the manufacturer's directions for use should have been followed for the disinfectant wipes. The table surface should have been allowed to air dry before putting on drapes.

Interview on 7/9/13 at 2:30 p.m. with the director of nursing (DON) confirmed the 3M manufacturers' direction for use required wetting the surfaces thoroughly and allowing them to air dry. The DON stated the wipes had a one minute kill time to be effective.

Review of the 3M disinfectant manufacturer's directions for use revealed surfaces should have been thoroughly wet and allowed to air dry prior to use.

C. Based on observation and interview, the provider failed to ensure staff followed manufacturer's directions for use of detergent cleaners in one of one soiled receiving room. Findings include:

1. Observation and interview on 7/8/13 at 3:04 p.m. with certified processing technician D in the soiled utility room revealed:
*The technician was cleaning surgical instruments in the sink filled with a clear solution.
*Certified processing technician D stated the solution was a mixture of water, Endozime Bio-Clean, and Lapcholyzme.
*The technician did not know how much water had been put in the sink prior to adding the Endozime Bio-Clean and Lapcholyzme detergent.
*The technician stated one pump of each detergent would be added to the water in the sink. If there were a lot of instruments to process then more detergent would be added. There was no measuring of the amount of water used to fill the sink or the number of pumps from the detergent bottles.

Review of the detergent cleaner manufacturers' directions for use revealed one pump of the disinfectant should have been added to one gallon of water.

Interview on 7/9/13 at 2:30 p.m. with the DON revealed:
*Staff should have followed the manufacturer's directions for use for the detergent cleaners.
*She was not aware staff were not using the Endozime Bio-Clean and Lapcholyzme detergent according to the manufacturer's instructions for use.
*The amount of water used to fill the sink should have been measured to ensure the correct water to detergent ratio was accurate.

D. Based on observation, interview, and policy review, the provider failed to ensure:
*Staff removed hair clippings in a sanitary manner to prevent cross-contamination between patients with contaminated tape rolls for one of one observed patient's (30) pre-surgical hair removal.
*Staff disinfected intravenous (IV) ports and the rubber septum of vials prior removal of fluid/medication for two of two patients' (30 and 32) care observations.
*Staff performed appropriate hand hygiene:
-After starting one of one patient's (30) intravenous (IV) infusion and prior to obtaining medications from the portable anesthesia narcotic box.
-After handling the specimen from one of one patient's (30) surgical procedure.
-After removal of surgical scrub attire for one of one surgeon (C) at the completion of the surgical procedure.
Findings include:

1. Observation on 7/8/13 from 1:55 p.m. to 2:30 p.m. of patient 30's surgical procedure revealed:
a. While wearing clean gloves registered nurse (RN) A:
*Used clippers to shave the patient's abdomen.
*Pulled a strip of tape out from the roll and without tearing that strip off used that tape strip to remove the shaver clippings from the patient's abdomen.
*Contaminated the roll of tape by allowing it to touch the patient's bare skin.
*Tore the piece of tape from the tape roll, placed the tape roll on a sitting stool, then placed the roll on the countertop in the operating room (OR) for future use.

Observation of the roll of tape at the end of the case revealed hair clippings had stuck to the sticky sides of the tape roll.

Interview on 7/9/13 at 1:00 p.m. with infection control preventionist J revealed: revealed the staff should have torn a strip of tape off the tape roll to prevent contamination of the entire roll. That roll of tape was contaminated and should have been discarded.

b. While wearing clean gloves certified registered nurse anesthetist B started the patient's intravenous infusion (IV), did not remove her gloves, and removed medications from the narcotic medication box with her contaminated gloves. Anesthestist B was observed numerous times reusing the same alcohol pad to clean vial septums and IV ports prior to removing medications or administering medications. Anesthetist B wore the same pair of gloves from the beginning of the case until the end of the surgical procedures.

Interview on 7/9/13 at 1:00 p.m. with infection control preventionist J revealed:
*Staff should have removed contaminated gloves and performed hand hygiene after coming in contact with contaminated items.
*Staff should not have reused contaminated alcohol pads when disinfecting IV ports or the rubber septum on vials before withdrawing or administering medications/fluids. Once the alcohol wipe has been used it was considered contaminated.

c. At the end of the surgical procedure surgeon C removed his contaminated outer surgical attire, his contaminated gloves, and then left the OR without performing hand hygiene. Observation of the surgeon revealed he walked towards the OR control station.

Interview on 7/9/13 at 1:00 p.m. with infection control preventionist J revealed surgeon C should have performed hand hygiene prior to leaving the OR suite.

2. Observation on 7/8/13 at 3:32 p.m. in the post-anesthesia care unit of patient 32 and patient 34's laboratory blood draw by medical technician E and registered nurse F revealed:
*Medical technician E wore a clean glove on her right hand and no glove on the left hand.
*Turned on the light switch, lowered the patient's siderail, and placed her laboratory supply bin on the patient's bed.
*Placed a tourniquet on the patient's arm, cleansed the site with an alcohol pad, and palpated the arm site with her ungloved fingers.
*Released and replaced the tourniquet on the patient's arm, recleaned the site with an alcohol pad, removed a glove from her uniform pocket, and placed it on her left hand.
*The attempt to withdraw blood was not successful. She removed the tourniquet and put it on top of the clean supplies in the supply bin.
*Removed her contaminated gloves but did not perform hand hygiene.
*Requested assistance from RN F in obtaining a blood sample. RN F without performing hand hygiene put on clean gloves and was successful in obtaining the blood sample.
*The contaminated tourniquet was placed in the community supply bin carried by medical technician E.
*Technician E left patient 34's bedside and went over to patient 32 to obtain a blood sample. She placed the supply bin on patient 32's overbed table, handed RN F the contaminated tourniquet, RN F put it around patient 32's arm, realized he did not need the tourniquet, removed the tourniquet, and handed it back to medical technician E. Withdrew blood from the patient's Heplock for her blood sample.
*RN F without disinfecting the IV port with alcohol withdrew IV fluids from patient 32's IV bag. Without disinfecting the Heplock port with alcohol he flushed the patient's Heplock in her left arm.

Interview on 7/9/13 at 1:00 p.m. with infection control preventionist J revealed:
*All IV ports should have been disinfected with an alcohol pad prior to use.
*The tourniquet should have been discarded after use or disinfected.
*To prevent cross-contamination clean gloves should not be carried in staff pockets.
*To prevent cross-contamination the community supply bin should not have been placed on the patient's bed.

3. Observation on 7/9/13 at 8:05 a.m. of patient 29's colonoscopy procedure revealed while RN I attempted to put a specimen in the specimen container it fell on the backtable. RN I picked it off the backtable with her gloved hands, and put it into the specimen container, and did not change her contaminated gloves. She returned to the patient's side to assist with patient positioning wearing her contaminated gloves.

Interview on 7/9/13 at 1:00 p.m. with infection control preventionist J revealed staff should have removed the contaminated gloves and performed hand hygiene after coming in contact with contaminated items.

F. Based on observation, record review, and interview, the provider failed to ensure incubator temperatures used for biological cultures were documented prior to use for one of one clean receiving room.
Findings include:

1. Observation on 7/9/13 at 10:23 a.m. in the clean receiving room revealed an incubator on the counter.

Review of the sterilization record documentation revealed the incubator temperature should have been 58 degrees Fahrenheit. There was no documentation on the records of the incubator temperatures for June 2013 or July 2013.

Interview on 7/9/13 at the time of the above observation with certified registered central sterilization technician revealed:
*The incubator was used to maintain a specific temperature of biological spores after they had been processed in the steam sterilizers or Sterrad sterilizers.
*The manufacturer required the incubator temperature to be at 58 degrees Fahrenheit.
*Staff in clean receiving did not document the incubator temperature prior to use. The incubator temperature should have been documented prior to putting processed biological spores on the sterilization record form.

Based on record review, interview, and policy review, the provider failed to identify discharge planning needs for 4 of 20 sampled patients (1, 8, 11, and 22). Findings include:

1. Review of patient 1's medical record revealed:
*He had been admitted on 5/17/13 for laminectomy (back surgery) surgery.
*He had been discharged on 5/21/13.
*He had not been assessed for his discharge planning needs.

2. Review of patient 8's medical record revealed:
*She had been admitted on 5/21/13 for laminectomy surgery.
*She had been discharged on 5/22/13.
*She had not been assessed for her discharge planning needs.



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3. Review of patient 11's medical record revealed:
*She had been admitted on 6/21/13 for a total hip replacement surgery.
*She had been discharged on 6/23/13.
*She had not been assessed for her discharge planning needs.



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4. Review of patient 22's medical record revealed:
*She had been admitted on 2/15/13 for a lumbar decompression (the relief of pressure on one or more pinched nerves for the spinal column).
*She had been discharged on 2/17/13.
*She had not been assessed for discharge planning needs.

5. Interview on 7/10/13 at 9:25 a.m. with the registered nurse discharge planner revealed:
*The pre-operative (pre-op) phone call sheets were used to determine what a patient's discharge needs were.
*The pre-op phone call sheets asked patients if there was a need for home care assistance, concerns following discharge, support group available, and concerns with transportation home.
*If areas of concern were marked on the pre-op phone call sheets then the patient was referred to her.
*She reviewed the patient logs daily and visited with those patients she felt might have had discharge needs.
*The pre-op phone call sheets had not been completed as intended.

Interview on 7/10/13 at 10:15 a.m. with the director of nursing confirmed the pre-op phone call sheets were not completed for the patient's discharge planning needs.

Review of the provider's Discharge Planning - Case Management policy revised 2/15/13 revealed:
*The initial discharge assessment utilized information from the patient and/or family during the pre-op phone call.
*Reassessment of a patient's needs should have occurred when the patient had been an inpatient.