HospitalInspections.org

Based on observation, interview and document review, the hospital failed to develop and implement policies and procedures for hand hygiene and the use of chemicals for disinfection according to manufactures guidelines to prevent the spread of potential infections. The deficient practice affected one of one patient's with multiple wounds and dressing changes.

Findings include:

- Patient #5 medical record reviewed on 10/26/10 at 9:35am revealed an admission date of 8/6/10 with diagnoses including osteomyelitis and stage IV decubitus ulcer.

Observation of wound care on 10/25/10 at 2:45pm revealed staff C put on protective gloves and removed five dressings to five separate wounds. Staff C cleaned the right lower buttock wound, removed the protective gloves, put on new protective gloves and applied a dressing to the wound. Staff C failed to perform hand hygiene after removing the protective gloves. Staff C applied new protective gloves and cleaned the sacral wound. Staff C removed the protective gloves, put on new protective gloves then applied a dressing to the wound. Staff C failed to perform hand hygiene after removing the protective gloves. Staff C cleaned the ulcer, applied a medicated ointment into the wound, removed the protective gloves, put on a new pair of protective gloves and applied the dressing. Staff C failed to perform hand hygiene after removing the protective gloves. Staff C cleaned the other two wounds after applying protective gloves, removed the gloves, applied new protective gloves and applied a dressing to the wounds without performing hand hygiene.

Review of the hospital's "Hand Hygiene" policy on 10/27/10 at 4:55pm revealed staff should perform hand hygiene, "After removing gloves".

Administrative staff C, interviewed on 10/27/10 at 4:45pm, confirmed the staff should perform hand hygiene each time they remove protective gloves.

Staff C's failure to perform hand hygiene each time they removed protective gloves created a potential risk for the spread of infection.

- Review of the "Product Specification Document" provided by the Hospital on 10/26/10 at 8:30am revealed for disinfection/cleaning/deodorizing, "Let solution remain on surface for minimum of 10 minutes."




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- Observation on 10/25/10 at 2:50pm revealed Staff E cleaning room 505. Staff E, wearing gloves, sprayed the sink in the room and the outside of the toilet and toilet seat in the bathroom with the hospital approved, Dispatch Disinfectant with Bleach. Staff E wiped the sprayed surfaces with a dry microfiber cloth three minutes after application of the disinfectant.

Staff E interviewed on 10/25/10 at 3:00pm stated the surfaces need to remain wet for two minutes to achieve complete disinfection.

Staff E failed to allow the Dispatch Disinfectant with Bleach to remain on surfaces for 10 minutes to achieve the desired disinfection as directed by the manufacturer.

- Observation on 10/25/10 at 3:15pm revealed Staff E cleaning room 500. Staff E, wore gloves, sprayed the sink in the room and the outside of the toilet and toilet seat in the bathroom with the hospital approved, Dispatch Disinfectant with Bleach.

Staff E wiped the sprayed surfaces with a dry microfiber cloth three minutes after application of the disinfectant. Staff E wet mopped the floor using the Dispatch Disinfectant with Bleach that dried within two to three and a half minutes of the initial contact time.
Staff E interviewed on 10/25/10 at 3:15pm indicated the floor remained wet for two to two and a half minutes after the application of the disinfectant instead of the required 10 minutes.

- Observation on 10/26/10 at 11:35am revealed Staff G cleaning room 503, an isolation room. Staff G with the same gloves and a disposable gown on reached in and out of the isolation room two different times to obtain items from the cleaning cart potentially contaminating the cart.

Staff G stepped out in the hall by the cleaning cart and obtained the mop to clean the floor with the same gown and gloves on and returned to the room.

Staff G failed to remove the contaminated gown and gloves when they left the isolation room.

Staff H interviewed on 10/27/10 at 4:35pm acknowledged the Hospital failed to follow the manufacturer's directions to let the solution remain on the surfaces for 10 minutes to achieve the desired disinfection.

- Random observation on 10/25/10 at 2:30pm revealed Staff E with gloved hands walking out of patient room 500 with a linen bag. Staff E carried the linen bag to the soiled utility room, opened the door with gloved hands, deposited the linen bag, removed gloves and walked out of the soiled utility room. Staff E failed to perform hand hygiene after handling soiled linens..

Based on observation, document review and interview, the hospital failed to assure medications are administer according to manufacturer's instructions and physician orders. The deficient practice affected two of four patients with intravenous medications (patient #'s 3 and 6) and one of twenty patients with medication orders changed during hospitalization(patient #5).

Findings include:

- Patient #3's medical record reviewed on 10/25/10 at 3:30pm revealed an order for Ceftazidime (an antibiotic) 1 gram intravenous every eight hours.

Licensed staff I observed on 10/26/10 at 12:45pm administered the antibiotic, Ceftazidime in less than one minute.

Review of the hospital's reference manual "Mosby's Nursing Drug Reference, 22nd Edition, 2009" revealed on page 251, staff should administer Cedtazidime IV over three to five minutes.

Pharmacy staff J, interviewed on 10/27/10 at 1:20pm, confirmed staff should administer the Ceftazidime IV over three to five minutes. The hospital staff failed to safely administer the medication Ceftazidime to achieve the desired results from the medication.

- Patient #6 medical record reviewed on 10/26/10 at 11:30am revealed an admission date of 10/9/10 for a foot wound. The physician ordered Dilaudid 4 mg (milligrams) intravenously (IV). Staff I observed on 10/26/10 at 3:10pm administered the Dilaudid through patient #6's IV in less than one minute. Review of the hospital's reference manual "Mosby's Nursing Drug Reference, 22nd Edition, 2009" revealed on page 549, the medication Dilaudid "2mg or less is to be administered over 3-5 minutes".

Pharmacy staff J, interviewed on 10/27/10 at 1:20pm, confirmed staff should administer Dilaudid IV, diluted and over at least three to five minutes.

The hospital staff failed to safely administer the medication Dilaudid to achieve the desired results from the medication.

- Patient #5 medical record reviewed on 10/26/10 at 9:55am revealed an admission date of 10/15/10 for wounds, osteomyelitis, obesity and mental retardation. The physician ordered Omeprazole (a stomach acid medication) 20mg (milligrams) on 8/6/10 to be given each day. On 10/11/10, the physician changed the medication order to twice a day. Nurses administered the medication twice a day on 10/11/10 through 10/14/10. From 10/15/10 to 10/27/10, the nurse administered the medication one time a day.

Patient #5, interviewed between 10/25/10 and 10/28/10, complained of "stomach pain" or abdominal discomfort.

Staff B, interviewed on 10/26/10 at 1:50pm confirmed the nurses administered the medication one time a day instead of two times a day as ordered.

Review of the hospital policy titled "Medication Management/Administration - Compliance with Drug Orders" on 10/26/10 revealed "Drugs shall be administered in accordance with the orders of the prescriber...and accepted standards of practice."

The hospital staff failed to follow the physician's orders for Omeprazole to be given twice a day to patient #5.