HospitalInspections.org

Based on observation it was determined the hospital failed to maintain adequate facilities for decontaminating and cleaning endoscopic procedure scopes. Findings include:

1. On 03/01/10 at approximately 2:00 p.m., a tour of the scope reprocessing room was conducted. At this time, it was observed that this processing room did not meet the minimum health facility construction design standards for an instrument processing room for the following concerns:

a. No hand sink provided in room.
b. Only one (1) double sink in room for cleaning process with no physical barrier separation (between dirty and clean side) to allow for flow of instruments from contaminated area to clean assembly area then to storage. Also, physical barrier would prevent droplet contamination on the clean side.
c. Clean scope storage cabinet in the dirty utility room.

Based on surveyor observations and staff interview, the hospital failed to ensure the laboratory staff maintains appropriate and adequate equipment needed for physician-ordered patient testing. This has the potential to negatively impact all patient care by creating inaccurate test results and the inability to monitor for correct test results due to inadequate equipment. Findings include:

1. During surveyor inspection and observations of the hospital laboratory at 1000 on 3/2/10, there were three (3) phlebotomy baskets sitting on a shelf. Upon inspection of the various empty blood-sampling tubes twelve (12) blue top expired 12/2009, two (2) red tiger top expired 2/2010 and twenty-six (26) red tiger top expired in 1/2010. All of the expired tubes were still in circulation to be used for patient-testing.

2. During surveyor inspection and observations of the hospital emergency department at 1000 on 3/3/10, there were three (3) green top tubes expired 9/2009, fourteen (14) red tiger top expired 1/2010 and nine (9) red tiger top expired 2/2010. Again, all of these expired tubes were still in circulation to be used for patient-testing.

3. During an interview with the laboratory manager in the morning of 3/2/10, when asked how the laboratory can ensure the accuracy of blood tests the manager stated they monitor the patients. The surveyor then asked how they monitor when then the rest of the blood sampling tubes in-use are outdated. The laboratory manager stated there wasn't really an answer for that.

Based on document review, medical record review and staff interview, the hospital failed to ensure the nursing staff followed hospital policy when noting-off physician orders in eight (8) of eight (8) closed medical records (Patients #6, 7, 8, 9, 10, 11, 12, 13) reviewed and four (4) of five (5) open medical records (Patients #15, 16, 19, 20) reviewed. This has the potential to negatively impact all patient care by not providing an accurate timeline of when orders were received and care provided. Findings include:

1. Pocahontas Memorial Hospital policy, Transcription of Orders, last reviewed 10/2009, states in part "...II. 3. RN or LPN reviews all orders for completion. Dates, times and signs."

2. Review of the medical record for Patient #6 revealed physician orders noted-off without a date and/or time on 2/24/09, 2/25/09, 2/26/09, 2/28/09 and 3/31/09.

3. Review of the medical record for Patient #7 revealed physician orders noted-off without a date and/or time on 3/10/09, 3/11/09 and 3/12/09.

4. Review of the medical record for Patient #8 revealed physician orders were noted-off without a date and/or time on 4/12/09 and 4/13/09.

5. Review of the medical record for Patient #9 revealed physician orders noted-off without a date and/or time on 5/19/09 and 5/20/09.

6. Review of the medical record for Patient #10 revealed physician orders noted-off without a date and/or time on 9/20/09.

7. Review of the medical record for Patient #11 revealed physician orders noted-off without a date and/or time on 1/11/10, 1/12/10 and 1/14/10.

8. Review of the medical record for Patient #12 revealed physician orders noted-off without a date and/or time on 2/24/09, 2/25/09, 2/26/09 and 2/28/09.

9. Review of the medical record for Patient #13 revealed physician orders noted-off without a date and/or time on 9/20/09, 9/26/09 and 10/2/09.

10. Review of the medical record for Patient #15 revealed none of the physician orders noted-off by nursing were noted-off with a date and/or time.

11. Review of the medical record for Patient #16 revealed physician orders written on 2/24/10, 2/26/10 and 3/1/10 were noted-off without a time.

12. Review of the medical record for Patient #19 revealed physician orders written on 3/1/10 at 1940 were noted-off with initials only, 3/1/10 at 2028 and 2100 and 3/2/10 at 1115 were all noted-off without a date and time.

13. Review of the medical record for Patient #20 revealed physician orders written on 3/1/10 at 1120 and 3/2/10 at 1020 were noted-off without a time.

14. During an interview with the Vice President of Nursing (VPN) in the afternoon of 3/2/10 and again in the morning of 3/3/10, the medical records were reviewed and the VPN agreed with the above findings.

Based on review of documents, observation and staff interview it was determined the facility failed to ensure surgical procedures are being performed in a safe manner, specifically, in the cleaning and disinfection of endoscopy scopes and the design of the dirty utility room. This has the potential to negatively affect patient care by inadvertently causing infections using equipment that may not be cleaned properly. Findings include:

1. Hospital policy titled; How to Clean The Endoscopy Scope states in part: "Flush germicide through the scope. Soak scope for 20 minutes. Then move scope to water bath, and flush germicide out of the tube. Remove the scope from the bath."

2. During a tour in the afternoon of 3/1/10 of the dirty utility room used to clean endoscopes, it was determined the scopes were being placed in CIDEX Solution and soaked for 20 minutes. The instructions on the CIDEX Solution states instruments should be soaked for 45 minutes to assure proper disinfection.

3. During the same tour in the afternoon of 3/1/10, it was determined the room being used to clean and disinfect the scopes did not contain a hand washing sink. The sink used for the rinsing of the dirty scopes was also used to rinse the clean scopes. The clean scopes were then being stored in the dirty utility room.

4. The CIDEX Solution sitting on the counter was dated as opened on 1/28/10 and to be changed on 2/28/10. The instructions stated the "use period" for activated CIDEX Solution is for a period of up to a maximum of 14 days following activation or as indicated by the CIDEX Solution test strips.

5. The instructions with the CIDEX Solution also indicated the Solution is to be kept at 25 degrees celsius. The facility could not provide logs to indicate the documentation of the temperatures.

6. The instructions with the CIDEX also require the facility to test the activated solution prior to use with CIDEX Solution Test strips. During an interview with the Vice President/Director of Nursing in the morning of 3/3/10, she indicated this was not being done.


7. When asked to present a log with information related to the changing of solutions, the cleaning of the scopes and the temperature of the CIDEX Solutions, the facility was unable to provide this information.

8. During an interview with the Vice President/Director of Nursing in the afternoon of 3/1/10 and again in the morning of 3/2/10, she stated she did not realize the facility had ordered the different CIDEX Solution. She stated the CIDEX instructions the facility had used previously indicated the instruments were to be soaked for 20 minutes and the solution was good for 30 days. The VP/DON agreed with these findings.