HospitalInspections.org

Based on document review and staff interview, it was determined for 1 of 1 (Pt #1) patient with non-violent restraints, the staff failed to obtain an order for the restraints. This has the potential to affect all patients requiring non-violent restraints.


Findings include:

1. On 07/15/22 at approximately 11:00 AM, the policy titled, "Restraints, Patient (revised 04/2018) was reviewed. The policy stated, "III. Physician Responsibility, Physician Orders and Reassessments. The physician writes an order for each incident requiring a restraint order. The physician is required to give an order at least every 24 hours implementing usage of a restraint. A. For Non-Violent and Non-Self Destructive Behaviors:.... b. Must be time specific with a maximum limitation for 24 hours."

2. On 07/14/22 at approximately 2:00 PM, the medical record of Pt #19 was reviewed. Pt #19 was admitted to the Intensive Care Unit on 5/26/22 with diagnoses of Acute Respiratory Failure, Congestive Heart Failure and pneumonia. A physician's order dated 5/28/22 at 10:13 AM, stated "Initiate Non-Violent Restraints." Documentation in the nursing flow sheets indicated on 5/28/22 at 9:00 AM, non-violent soft right and left wrist restraints were applied. The justification was due to Pt #19 "Interfering with medical care, devices, tubes/drains." Restraint flowsheets indicate restraints were continued until 6/1/22 at 7:00 PM. There was no documentation of physician's orders for soft bilateral ankle restraints. The last physician's order documented was on 5/28/22 at 10:13 AM for soft bilateral wrist restraints.

3. On 7/11/22 at 2:30 PM, an interview was conducted with the Chief Nursing Officer (E#12). E#12 reviewed Pt #19's medical record. E#12 confirmed there was no physician's order for soft bilateral wrist restraints after 5/28/22 and stated, "There should have been."

Based on document review, observation and interview, the Hospital failed to ensure the health and safety of surgical staff who were exposed to radiation. This has the potential to affect all surgical staff who are exposed to radiation.

Findings include:

1. The Hospital failed to ensure surgical staff were monitored for radiation exposure. Please see A-0538

Based on document review, observation and interview, it was determined the Hospital failed to ensure surgical staff were monitored for radiation exposure. This has the potential to affect all surgical staff which are exposed to radiation.

Findings include:

1. The policy titled "Personnel Radiation Monitoring" (not dated) was reviewed on 7/14/22. The policy noted "II. An individual's film badge will be processed immediately when it is suspected that he/she might have received a single exposure greater than 100 mRem (millirem) or an accumulated exposure greater than 300 mRem in one week.

2. During a tour on 7/13/22 at approximately 12:00 PM, Operating Room #2 was observed to have a c-arm (x-ray machine) utilized during Pt #25's left hip fracture repair. The Operating Room (OR) Circulator (E#8), Nurse Educator (E#9), Scrub Technician (E#10), Orthopedic Surgeon (MD#1) and the Certified Registered Nurse Anesthetist (CRNA#1) were observed in OR #2 while the x-ray machine was utilized without donning a dosimeter badge.

3. During an interview on 7/13/22 at approximately 12:30 PM, the Surgical Services Manager (E#11) stated "We were told by (Director of Medical Imaging, E#6) that wearing the badges (dosimeter) were optional."

4. During an interview on 7/14/22 at approximately 9:00 AM, E#6 verbally agreed it was unable to be determined if the surgical staff received a single exposure greater than 100 mREM or an accumulated exposure greater than 300 mRem in one week without wearing a dosimeter badge.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of a Recertification Survey conducted on July 19, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of a Recertification Survey conducted on July 19, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on document review and interview, it was determined the Hospital failed to ensure emergency crash carts were checked per policy. This has the potential to affect all visitors and in patients who receive care in the Hospital.

Findings include:

1. During a tour on 7/12/22 between 12:15 PM and 3:00 PM with the Director of Professional Development (E #5) the following areas were noted to lack daily crash cart checks on the form titled "Daily Crash Cart Checklist":

Medical Imaging (May 2022 lacked 6 of 31 days and June 2022 lacked 4 of 30 days)
OB (July 2022 lacked 1 of 14 days)
Pre-op (May 2022 lacked 9 of 31 days and June 2022 lacked 7 of 30 days)

2. During an interview on 7/12/22 at approximately 3:45 PM with the Director of Professional Development (E #5), E #5 verbally agreed the crash carts were not checked daily.




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B. Based on observation and interview, the Hospital failed to ensure expired biological's were not available for patient use. This has the potential to affect all patients who receive surgical services with an average of 7 patients per day.

Findings include:

1. During a tour of the surgical services area on 7/14/22 at approximately 10:00 AM, the following items were expired:
a) Pediatric Crash Cart- 2 Medline IV (Intravenous) start kits, expired 2/2020; 1 ARS (Air Release System) 14 g by 3.25 inch Needle Compression Kit, expired 3/2022; Pad Pro Radiotranslucent Electrodes, expired 3/2019; and Dover Urine Drainage Bag 200 ml (milliliter), expired 10/2020.

2. During an interview on 7/14/22 at approximately 10:05 AM, the Surgical Service Manager (E#11) verbally agreed the items were expired and should not have been available for patient use.

C. Based on observation and interview, the Hospital failed to ensure equipment available for patient use was maintained. This has the potential to affect all patients who receive surgical services with an average of 7 patients per day.

1. During a tour of the surgical services area on 7/14/22 between 10:00 AM and 12:45 PM, the following equipment lacked a maintenance sticker:
a) Pre-operative Storage Room- Endoscope STORZ C-mac and Cell Saver
b) Hallway Orthopedic Storage- Glidescope

2. During an interview on 7/14/22 at approximately 4:15 PM, the Vice President/Chief Nursing Officer (E#11) displayed an email from the facilities maintenance staff which stated the STORZ endoscope, Cell Saver and Glidescope had not been added to the inventory list and had not been maintained, although the equipment had been added to the inventory list and inspected on 7/14/22. E#11 verbally agreed the equipment had not been maintained and should have been.

Based on observation and interview, it was determined the Hospital failed to ensure that tables with vinyl coverings were intact for proper cleaning to avoid the potential for cross contamination. This has the potential to affect all patients who receive services at the Hospital.

1. An observational tour of the Rehab Department (Physical and Occupational Therapy) was conducted on 7/13/22 at approximately 10:00 AM with the Director of Professional Development (E #5) and the Rehab Services Director (E #7). During the tour, 2 tables with a puncture or tear in the vinyl, approximately one inch each was noted.

2. During an interview with E #5 and E #7 on 7/13/22 at approximately 10:30 AM, both agreed the tables the rips in the vinyl could create the potential for infection control breaches.

A. Based on observation, document review and interview, it was determined the Hospital failed to ensure a clean and sanitary environment to prevent cross contamination. This has the potential to affect all staff members and surgical patients with an average of 7 patients per day.

Findings include:

1. During a tour on 7/13/22 at approximately 11:30 AM of the Surgical pre-operative holding area with the Surgical Services Manager (E#11), the pre-operative area was observed to have hanging curtains between the patient bays. E#11 was asked about the cleaning schedule for the curtains which would be deferred to the contracted housekeeping staff.

2. The Infection Control Meeting Minutes dated 7/19/21, 10/26/21, 1/24/22 and 4/18/22 were reviewed on 7/14/22. The meeting minutes lacked documentation of the curtain cleaning.

3. During an interview on 7/14/22 at approximately 4:15 PM, the Vice President/Chief Nursing Officer (E#12) stated after a discussion with the contracted housekeeping, a curtain cleaning schedule had not been maintained and should have been. It was unable to be determined when the curtains had been cleaned.

B. Based on document review, observation and interview, it was determined the Hospital failed to ensure instruments were appropriately sterilized to prevent transmission of infections. This has the potential to affect all patient who receive surgical service with an average of 7 patients per day.

Findings include:

1. The CDC (Center for Disease Control) infection control guidelines for sterilization practices was reviewed on 7/14/22. The guidelines noted "hinged instruments" should be opened.

2. During a tour on 7/14/22 at approximately 10:30 AM, the sterilized instrument storage room was observed to have multiple individually packed sterile packages of hinged instruments (instruments which have the ability to be closed or opened/ the following were observed: Ring Forceps, Stats, Towel Clips, Scissors and Tenaculums) which were in sterilized packages in the closed position.

3. During an interview on 7/14/22 at approximately 10:35 AM, the Nurse Educator (E#9) verbally agreed the instruments were not unhinged (opened) during the sterilization process and should have been. E#9 stated the Hospital followed the CDC guidelines and had identified the best practice for sterilization had not been conducted although had not implemented a plan of correction.