HospitalInspections.org

Based on observation and interview the hospital failed to ensure the Kansas State food code regulations were implemented for preventing the potential contamination of food when an airgap was not installed on the kitchen preparation sink to prevent the backflow of sewage, gas or other contaminates. This failed practice potentially placed all patients and visitors at risk for food contamination.

Findings Include:


Observation of the hospital kitchen 8/22/2016 at 11:30 a.m. it was noted that the sink used to prepare fresh food did not have an air gap to prevent contamination of the sink and potentially food in the event of a backflow of sewage, gas or other contaminates.


The dietary manager and maintenance staff member confirmed the sink was without an air gap.


A backflow prevention device was installed on the prep sink on 8/24/2016.


According to the Kansas State Food Code 2012 regulation 107 5-203.14 Backflow Prevention Device, states " A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT (includes, but is not limited to: ...cafeterias, public or nonprofit organizations routinely serving food ... " )


.

Based on policy review, staff interview, and observation, the Critical Access Hospital (CAH) failed to ensure staff removed all expired supplies and medications in the medical supply storage area, one trauma room, and one crash cart. The CAH also failed to ensure policies and procedures were established in writing for the storage, maintenance and distribution of supplies and equipment. This deficient practice of outdated medical supplies and sterile medical instruments had the potential to expose patients to ineffective medications/treatments and healthcare associated infections.

Findings Include:

- Observations on 8/22/16 at 12:00pm revealed the following:

Supply Storage Area: 22 Single use PDI Lubricating Jelly with an expiration date of 5/16, 6 Enfamil (baby formula) 5% Glucose Water 2 ounces (oz) each with an expiration date of 8/1/16, 6 Enfamil Preemie Formula 20 calories 2 oz. each with an expiration date of 8/1/16, 50 sterile (St.) gloves size (sz.) 7 with an expiration date of 2/15, 6 St. Gloves sz. 7 ½ with an expiration date of 2/16, 3 St. gloves sz. 6 ½ with an expiration date of 2/15, 6 St. Gloves sz. 8 ½ with an expiration date of 4/14, 1 St. Glove sz. 7 with an expiration date of 1/16, one 1000cc (milliliter) Dextrose 5% and 1/2 Sodium Chloride (IV fluid) with an expiration date of 1/16, one 250cc D5W (IV fluid) with an expiration date of 3/16, three 500cc Lactated Ringers (IV fluid) with an expiration date of 2/16, eight Bone Marrow Bore Needles (special needle used to drill out the core of the bone marrow) with an expiration date of 8/11/16, six Insyte catheter (needle in the vein to infuse medications/fluid) #18gauge/1 ½ "(inches) with an expiration date of 8/15.

Trauma Room Crash Cart Outdated (expired) supplies included; 1 Shiley Tracheostomy (airway) Tube 7.6mm (millimeter) with an expiration date of 3/16, 1 Shiley Tracheostomy Tube 6.4mm with an expiration date of 1/16, 1 Shiley Tracheostomy Tube 5.0mm with an expiration date of 1/16, 2 Intraosseous Needle Set (needle injected directly into the bone marrow to infuse fluid/medications) 15mm, 15 with an expiration date of 11/15, 1 IV start kit with an expiration date of 3/16, 1 Pediatric Electrodes (heart rate monitoring) with an expiration date of 3/16.

Trauma Room Chest Tube Insertion Box Outdated (expired) medical supplies included; 1Sutures Monofilament with an expiration date of 1/15, 1 Sutures 0 Silk with an expiration date of 2/15, 1 Sutures 0 Prolene with an expiration date of 11/10, 1 Scalpel #10 with an expiration date of 8/12, 1 Scalpel #15 with an expiration date of 9/13, 4 BD safety Glide Needle (IV cath) 18g 1 ½ with an expiration date of 10/11, 1 BD Safety Glide Needle 25g 5/8" with an expiration date of 10/11, 1 Accuvance Plus Safety Cath (IV cath) 16g 1 ¼" with an expiration date of 10/11, 2 Accuvance Plus Safety Cath 16g 1 ¼" with an expiration date of 9/15, 3 Accuvance Plus Safety Cath 18g 1 ¼" with an expiration date of 4/15, 1 Arrow Sheath Peal Away (IV cath) 14g 1 ¼" with an expiration date of 10/13.

Trauma Room Storage Cabinets Outdated (expired) medical supplies included; 1Pleurovac Adult/Ped Chest Tube with an expiration date of 4/16, 1 Pleurovac Adult/Ped Chest Tube with an expiration date of 3/16, 1Nasogastric Tube (tube inserted into the stomach that removes fluid and bile) with an expiration date of 11/14, 2 Arrow Cath Multi Lumen CVC Kit (non tunneled IV cath) with an expiration date of 4/16, 1 Lumbar Puncture Kit (insertion for testing spinal fluid) 21g 2 ½" with an expiration date of 3/16, 2 Thoracentesis Tray 7" with an expiration date of 4/16, 1 Heparin vacutainer (lab sampling device) with an expiration date of 7/16.


At 2:00 p.m. on 8/23/2016 a tour of the Senior Behavioral Health (SBH) Unit was toured. Inspection of the SBH crash cart contained outdated (expiration date 2013) medical supplies that included several types of angiocatheters (Intravenous start kits) for intravenous infusions.


Staff members in the SBH Unit thought that pharmacy staff were responsible for ensuring the medical supplies on the crash cart were not outdated. The Assistant Director of Nursing (ADON) confirmed nursing staff were responsible for ensuring nursing staff members were responsible for removing outdated medical supplies.


Interview with pharmacy staff on 8/24/2016 revealed staff inventory pharmacy stock throughout the hospital on a monthly basis and remove outdated items. Each crash cart had a label on it with a date in large numbers to indicate the date when the pharmacy supplies were outdated so that staff would know to replace the outdated items.


The pharmacy staff stated they only inventory pharmacy items throughout the hospital

Assistant director of nursing RN (staff C) acknowledged the outdated medications, supplies, and instruments. Policy review revealed monthly inventory of all emergency department medications and supplies is to be taken and outdated medications and supplies are to be removed from inventory for disposal. Pharmacy maintains inventory of crash cart and refrigerator medications. All other inventory is to be performed by the emergency department staff.

Assistant director of nursing RN (staff C) removed all outdated medications and supplies from the clinical care area.

During interview and observation on 8/22/16 at 2:00 p.m.with assistant director of nursing RN (staff C) s/he revealed the emergency department staff are responsible for inventory of all medications and supplies in the emergency department monthly. Inventory of medications and supplies includes rotation of outdated medications and supplies out of the department for disposal and replacement with current in date medications and supplies.

During review of the monthly infection control report, all medications and medical supplies were checked monthly by the emergency department staff.

Observations revealed:

During interview and observation with assistant director of nursing RN (staff C) s/he revealed the emergency department staff are responsible for cleaning and sterilization of all instruments used in the emergency department.

Observations on 8/22/16 at 12:00 revealed the table top steam autoclave in the emergency department was not functioning and was labeled "out of order" . Assistant director of nursing RN (staff C) revealed the CAH policy is to re-sterilize all instruments every two years from the previous sterilization date.

42 sets of instruments without notation of processing date and/or identifier of who processed the instruments, missing sterilization indicators, areas of visible rust on instruments, and hinged instruments processed in the closed position.

No logs were available for autoclave testing of sterilization completeness or leak test.

Assistant director of nursing RN (staff C) and ARNP (staff L) acknowledged the presence of rust and outdates of sterilized instruments.

Assistant director of nursing RN (staff C) removed all of the sterilized instruments from the emergency department on 8/22/16.

Interview with surgical central supply staff supervisor RN (staff N) on 8/24/16 at 1:30 p.m. revealed "no cross training for sterilization of instruments has been performed by surgery staff to emergency department staff. They have done their own sterilization for years. Surgery gave them the table top autoclave a number of years ago."

Based on observation and interview the Critical Access Hospital (CAH) failed to ensure the physical environment of the Central Supply storage area was uncluttered and safe for staff to function safely. Failure to keep the Central Supply area with exposed pipes, drainage onto the floor, loose floor tiles and un-cleanable surfaces placed all patients at risk for potential contamination of supplies.


Findings Include:


On 8/24/2016 at 8:00 a.m. the Central Supply room was inspected and found to have sterile and clean patient supplies in the same area as a climate control unit. This unit was approximately 4 feet high and 2.5 feet wide and about 3 feet deep and made of galvanized steel. Several furnace type filters were stored on and around the unit.

Several pipes exited the unit and were wrapped in a white material that was torn off in one area. Copper colored pipes connected to the unit were rusted. A drain pipe drained directly onto the floor and not into a drain in the floor inches away from the drain pipe. The floor tiles under the area of the drain pipe were buckled and loose from the floor rendering the area un-cleanable.

An electrical panel on the back wall of the Central Supply room was open and was unable to latch shut. A piece of black duck tape dangled from the door latch.

Interview with the Central Supply director indicated that this area of storage of sterile and clean patient items hsd been unchanged for several years.

Based on interview and record review the Critical Access Hospital (CAH) failed to ensure that all medical records were processed in a timely manner and the policies and procedures were reviewed and revised as needed. Failure to ensure the processing of all patient records in a timely manner according to applicable policies and procedures resulted in potential delay of medical record retrieval and medical information.


Findings include:

Interview with the Medical Records Director Staff Q on 8/24/2016 at 11:00 a.m. revealed the hospital recently implemented electronic medical records (May 2016).

Staff Q stated that she was unsure if there were delinquent medical records (not completed within 60 days) because a report had not been retrieved from the new system.

On 8/25/2016 at 10:30 a.m. Staff Q stated that there were several delinquent medical records from July 2016.

Review of the policies and procedures for the processing of medical records reflected information, direction to staff for the processing of paper medical records and did not include direction or processes for the electronic medical record. The last time the policies and procedures were reviewed or revised for accuracy was in 2015. This was confirmed by Staff Q on 8/24/2016 at 1:55 p.m.
.