HospitalInspections.org

Based on observation, medical record review, policy review and staff interview, it was determined that the hospital failed to ensure the safety of 3 of 14 (29%) patients in the sample (Patient #'s 11, 17 and 36) observed receiving care. Findings include:

The hospital "Patient's Rights and Responsibilities" given to every patient stated, "...You have the right to...receive care in a safe setting..."

A. Staff failed to ensure the safe administration of intravenous (IV) therapy for 2 patients (Patient #'s 11 and 17) in the sample receiving IV therapy.

The hospital's "IV Competency Self-Learning Packet" stated, "...standards of practices...nursing documentation regarding...IV therapy...It is the policy of Beebe Medical Center to provide safe, quality and effective care...in order to comply with this policy...tubing is to be dated and timed with date tag...IV bags and bottles are to be labeled with date, time initiated and time of expiration..."

1. Patient #11

Observation on 9/6/11 at 2:45 PM revealed that Patient #11's IV tubing was not labeled with the date or time the tubing was initiated. In addition, the IV bag (normal saline) lacked the time the IV bag was initiated or would expire.
Registered nurse (RN) D and RN Quality Analyst A, present at the time of discovery, confirmed the IV bag and tubing should have been labeled with the date and time they were initiated.

2. Patient #17

Observation on 9/7/11 at 11:35 AM revealed that Patient #17's IV tubing was not labeled with the date or time the tubing was initiated.

Interview with RN G on 9/7/11 at 11:45 AM confirmed that the tubing should be labeled with the date and time the tubing was initiated.

B. Staff failed to adhere to current infection control standards of practice for 2 patient care observations (Patient #'s 11 and 36).

The hospital's Job Description for the registered nurse stated, "...Adheres to Policies...and standards...including...Infection Control..."

The hospital policy entitled "Hand Hygiene Recommendations" stated, "...Wash hands...before having direct contact with patients...before donning sterile gloves...before inserting..catheters and other invasive devices that do not require a surgical procedure...after contact with a patient's...skin...If hands are moving from a contaminated body site to a clean site during patient care. After contact with inanimate objects...after removing gloves..."

The hospital policy entitled "Hand Hygiene Practices for the Prevention of Infection" stated, "...Decontaminate hands before having direct contact with patients...[and] after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient..."

1. Patient #11
On 9/6/11 at 4:35 PM, RN C was observed administering a pneumonia vaccination to Patient #11. RN C:

- performed hand hygiene and donned gloves
- opened plastic bag and removed pneumovax vial
- touched cart and picked up ID scanner
- retrieved syringe from cart and withdrew medication into syringe
- touched patient injection site
- applied alcohol and touched injection site
- administered injection
- removed gloves and performed hand hygiene

RN C failed to:
- Decontaminate hands after contact with inanimate objects and prior to direct contact with the patient

RN Quality Analyst A, present at the time of discovery, confirmed that the observed practice was an infection control issue.

2. Patient #36
During a wound observation completed at 11:55 AM on 9/8/11, RN B was observed performing Patient #36's wound care. RN B:

- touched 3 different open wound sites with the same paper measuring tape
- after touching the open wounds and soiled dressings on the left leg, moved the patient's room curtain to obtain a piece of linen from a cart, touching the curtain and the cart with the soiled glove
- after touching the open leg wounds and soiled dressings, removed the soiled linens under the leg and wound
- then lifted the patient's room curtain with the soiled glove, brushed the curtain with the soiled linens and placed them in the dirty linen hamper, located on the other side of the curtain

RN B failed to:
- prevent cross-contamination when measuring wounds
- perform hand hygiene after contact with a patient's wounds
- perform hand hygiene after contact with inanimate objects

Nurse Manager B, present during the wound care observation, confirmed that the observed practice was an infection control issue.

Based on observation, policy review and staff interview, it was determined that staff failed to ensure confidentiality of patient records on 2 of 6 (33%) inpatient care units (Women's Health Unit, Progressive Care Unit) in the sample. Findings include:

The hospital document entitled "What you need to know. Patient & Visitor Information Guide" stated, "...You have the right to...expect that all treatment records and medical care are confidential..."

During observational tours conducted on 9/6/11, the following confidentiality issues were identified:

A. Women's Health Unit - 11:00 AM

- Six (6) medical records were stored on a rolling cart at the nurses station at the entrance to the unit.
- Two (2) of the medical record chart spines were facing the hallway/walkway next to the nursing station. The spines of the charts had the patients' first and last names which were visible to all staff and visitors in the area.

Quality Outcomes Analyst A and registered nurse (RN) A, present during the observation, confirmed that the patients' names were visible to anyone in the immediate area including unauthorized individuals.

B. Progressive Care Unit - 12:02 PM

- Two (2) medical records were sitting on a counter top at Nurses Station 2 with patients' first and last names visible to all staff and visitors in the immediate area.
- Eight (8) medical records were stored on a rolling cart at Nurses Station.

All of the chart spines were facing the adjacent hallway exposing the patients' first and last names to staff and visitors.

Nurse Manager F and RN H, present during the observation, confirmed that the patients' names were visible to anyone in the immediate area including unauthorized individuals.

C. Women's Health Unit - 3:55 PM

- Four (4) medical records were sitting on a counter top adjacent to room 211 with patients' first and last names visible to staff and visitors.

Director of Facilities A, Director of the Emergency Department and All Patient Units A and Security Supervisor A, present during the observation, confirmed that the patients' names were visible to anyone in the immediate area including unauthorized individuals.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 1 (100%) restrained patients in the sample (Patient #1), a restraint was applied without a physician's order. Findings include:

The hospital policy entitled "Restraint Use" stated, "...A physician's order for initiation of restraint must be obtained, verbal or written prior to the application of the protective restraint...In an emergency situation, the order must be obtained either during the emergency or immediately after (within a few minutes)..."

Review of 7/14/11 Emergency Department "Nurse Notes" documentation revealed the following:

2:52 PM
- Patient #1 ambulating in hallway attempted to exit hospital
- Attempted to "throw a punch" at the assigned one to one (1:1) sitter
- Security called to bedside; Repeated attempts to redirect, calm unsuccessful
- Asked to sit in bed; Verbal redirection unsuccessful
- Patient #1 refused to remain in bed, continued to try to "push through staff"
- Attempted to "punch and kick" security guards on two occasions
- Patient #1 placed back in bed by staff
- Patient #1 continued to "kick and punch and holler" at staff

2:57 PM
- Staff notified Physician A of Patient #1's behavior
- Anti-anxiety medication administered as ordered
- Anti-psychotic medication administered as ordered

2:58 PM
- Patient #1 placed in "3 point restraint, bilateral ankles and right wrist"

3:50 PM
- Resting
- Restraints removed

Review of the medical record revealed no physician's order for the application of the 7/14/11 restraint.

Interview with Nurse Manager E on 9/8/11 at 2:00 PM confirmed there were no physician's orders for the use of a restraints.

Based on observation, review of medical records, review of policies and other hospital documentation and staff interview, it was determined that for 2 of 4 (50%) patients (Patient #'s 12 and 36) in the sample with wounds, nursing staff failed to assess and document wounds as required. Findings include:

During an interview with Nurse Manager B on 9/8/11 at 1:00 PM, Nurse Manager B reported that nursing staff used "Lippincott's Nursing Procedures Fifth Edition" as the standard for wound care assessment and documentation. Written guidance included, "...Document the pressure ulcer's location and size (length, width, and depth) color and appearance of the wound bed; amount, odor, color and consistency of drainage; and condition of the surrounding skin..."

The hospital's job description of the Wound Care Registered Nurse stated, "...expected responsibilities...documents assessment...assessments are very accurate and all items are addressed..."

The hospital's Job Description for the registered nurse stated, "...Adheres to Policies...consistently...documents assessment...Assessments are very accurate and all items are addressed..."

The hospital policy entitled, "Pressure Ulcer Treatment Plan" stated, "...document ulcer thoroughly..."

A. Patient #12
8/26/11 - "Standard Orders for all Stages of Pressure Ulcers" documented three (3) ulcers:

- One sacral (lower back)
- Two coccyx (tail bone area)

9/6/11 - "Wound Evaluation" documented identified two (2) wounds:

- One coccyx
- One right buttock: one on the patient's coccyx and one on the right buttock.

Review of nursing documentation from 8/29 - 9/7/11 revealed that the nurse failed to assess and/or provide a wound description (wound appearance, drainage, and/or odor), on the following dates:

8/30, 8/31, 9/1, 9/2, 9/3, 9/4, 9/5, 9/6 and 9/7/11

Nurse Manager B confirmed these findings on 9/9/11 at 2:30 PM.

B. Patient #36

9/6/11 - "Wound Evaluation" documented five (5) wounds:

- No documented assessment for Wound #'s 4 and 5

Nurse Manager B confirmed this finding on 9/8/11 at 12:52 PM. Nurse Manager B reported that it was the expectation that all wounds be assessed and documented on the wound evaluation form.

Based on medical record review, policy review and staff interview, it was determined that the hospital failed to accurately file medical record information for 1 of 35 (3%) patient records (Patient #9) in the sample. Findings include:

The hospital policy entitled "Medical Record Review on Patient Care Units" stated, "...Medical record review will be performed to determine if the record is accurate..."

Review of the medical record for Patient #9 revealed a discharge summary dated 9/3/11 for a patient with a similar first name and the same last name.

On 9/7/11 at 10:05 AM, Nurse Manager D and Executive Director of Heart and Vascular Services A, present at the time of discovery, confirmed this finding.

Based on medical record review, policy review and staff interview, it was determined that for 9 of 35 (26%) patients (Patient #'s 1, 9, 10, 12, 14, 32, 33, 35 and 36) in the sample, the medical record entries failed to contain the required elements as required by policy. Findings include:

I. The hospital policy entitled "Medical Record Review on Patient Care Units" stated, "...Medical record review will be performed to determine if the record is accurate, legible and complete...Timing of Documentation...Documentation of restraints..."

A. Patient #9
- One (1) entry by a registered diagnostic medical sonographer on the "Physician Orders" failed to include the time of note entry.

Interview with the Executive Director of Heart and Vascular Services on 9/7/11 at 10:45 AM confirmed this finding.

B. Patient #1
- No physician's order for the use of restraints on 7/14/11 from 2:58 PM -
3:50 PM

Interview with Nurse Manager E on 9/8/11 at 2:00 PM confirmed this finding.

II. The hospital policy entitled "Legal Health record" stated, "...documentation of healthcare services provided...compiled of individually identifiable data...patient information will be retrieved directly from the Legal Health Record...Expiration Record..."

A. Patient #'s 32, 33 and 35
The form entitled "Patient Expiration/Release Record" stated, "...This form must be completed on all deaths and included as part of the patient's permanent medical record..."

1. Patient #'s 32 and 35
- Form was not in the medical record

2. Patient #33
- Staff failed to sign and date the form at the time of completion

Interview with Nurse Manager A on 9/7/11 at 10:50 AM confirmed these findings.

III. The hospital policy entitled "Physician Requirements for a Complete Medical Record" stated, "...All verbal/telephone orders must be authenticated within 48 hours..."

A. Patient #14
1. The "Physician Orders" dated 9/3/11, contained a telephone order that was not authenticated by the physician.

Interview with Nurse Manager A on 9/6/11 at 1:35 PM confirmed this finding.

IV. The hospital policy entitled "Close Observation Patient Protocol" stated, "...A physician order is required for the initiation or cancellation of all Patient Safety Attendants [PSA]...A Registered Nurse (RN) will evaluate the patient's behavior and the need to continue or discontinue the use of the PSA..."

The hospital document entitled "One-To-One Supervision Record" was utilized by PSA staff to document hourly behaviors and activities. The document was to be signed by the RN at 7:00 AM and 7:00 PM.

A. Patient #14
- There were no physician's orders for the provision of one-to-one supervision from 9/4 - 9/6/11.

- The RN failed to sign the "One-to-One Supervision Record" on the following dates: 9/4 and 9/7/11.

Interview with Nurse Managers A and B on 9/8/11 at 10:45 AM confirmed these findings.

B. Patient #10
- The RN failed to sign the "One-to-One Supervision Record" on the following dates: 8/28, 8/29, 8/30, 8/31, 9/1, 9/2 and 9/3/11.

Interview with Nurse Manager B and RN C on 9/7/11 at 9:55 AM confirmed this finding.

V. The hospital's job description of the Wound Care Registered Nurse stated, "...expected responsibilities...documents assessment...assessments are very accurate and all items are addressed..."

A. Patient #12
- No wound assessment documentation on the following dates:

8/29, 8/30, 8/31, 9/1, 9/2, 9/3, 9/4, 9/5, 9/6 and 9/7/11

Interview with Nurse Manager B on 9/9/11 at 2:30 PM confirmed this finding.

B. Patient #36
- 9/6/11 "Wound Evaluation" failed to contain wound assessments for 2 of 5 identified wounds (Wound #'s 4 and 5)

Interview with Nurse Manager B on 9/8/11 at 12:52 PM confirmed this finding.

Based on closed medical record review, policy and medical staff bylaw review and staff interview, it was determined that the inpatient medical record for 2 of 4 (50%) discharged patients (Patient #'s 33 and 34) in the sample, failed to contain a final diagnosis within 30 days of discharge. Findings include:

Review of the hospital policy entitled "Physician Requirements for a Complete Medical Record" stated, " ...Records are considered delinquent at 30 days...Discharge Summary...must be dictated at or shortly after the patient's discharge...exceptions...unusual situations when awaiting pathology or autopsy results..."

A. Patient #33 - Review of the medical record revealed that Patient #33 was admitted to the hospital on 4/7/10.

Review of Patient #33's "Discharge Summary" documentation revealed that Patient #33 was pronounced dead on 4/11/10 at 2:33 AM and an autopsy was ordered and completed on 4/12/10.

Review of the "Autopsy Report" revealed that Pathologist A discussed Patient #33's case with Physician B on 4/11/10 prior to autopsy and the preliminary post autopsy findings were discussed with Physician B on 4/12 and 4/13/10.

The "Discharge Summary" which included the discharge diagnosis was dictated by Physician B on 5/21/10 at 1:14 PM (10 days late).

On 9/12/11 at 10:13 AM, Surveyor A and Director of Quality A reviewed Patient #33's "Discharge Summary" in the electronic medical record. Director of Quality A confirmed that the medical record, which included Patient #33's final diagnosis, was not completed within 30 days of discharge and that the delay was not as a result of awaiting autopsy results.

B. Patient #34 - Review of the medical record revealed that Patient #34 was admitted to the hospital on 11/16/10.

Review of Patient #34's "Discharge Summary" documentation revealed that Patient #34 was pronounced dead on 11/27/10 at 3:50 PM (no autopsy ordered).

The "Discharge Summary" which included the discharge diagnosis was dictated by Physician C on 12/30/10 at 4:47 PM (3 days late).

On 9/12/11 at 10:17 AM, Surveyor A and Director of Quality A reviewed Patient #34's "Discharge Summary" in the electronic medical record. Director of Quality A confirmed that the medical record, which included Patient #34's final diagnosis, was not completed within 30 days of discharge.

Based on observation, policy review and staff interview, it was determined that in 2 of 7 (29%) patient care units (Progressive Care Unit, Emergency Department), medication refrigerators were not appropriately locked. Findings include:

The hospital policy entitled "Medication Carts, Cabinets, And Refrigerators" stated, "...Medication Rooms, and Refrigerators are to be locked at all times except while being used...Refrigerated medications must be in a locked refrigerator..."

1. On 9/6/11 at 11:15 AM during an environmental tour of the Progressive Care Unit, a medication station refrigerator door was found unlocked.

Interview with registered nurse (RN) H at 11:15 AM on 9/6/11 confirmed this finding and revealed that the refrigerator door latching/locking mechanism had not been functioning properly.

2. On 9/7/11 at 2:53 PM while touring the Emergency Department, a medication refrigerator in the medication room was found unlocked. This finding was confirmed at the time of discovery by Nurse Manager E.

Based on observation, staff interview and policy review, it was determined that the hospital failed to maintain environmental surface cleanliness and integrity in a manner to assure patient safety in 14 of 28 (50%) patient care/support areas toured. Findings include:

The hospital policy entitled "Safety Management Plan" stated, "...[hospital] will provide a functionally safe environment of care..."

The hospital policy entitled "Housekeeping" stated, "...All soil and dust should be removed from surfaces...This includes horizontal surfaces...If carpeting is well vacuumed daily...microbial count can be maintained at acceptable levels. Spotting will need to be done frequently to maintain the appearance of the carpet. Shampooing in heavy traffic areas should be done more often, probably every month..."

During tours conducted on 9/6, 9/7, 9/8 and 9/9/11, the following observations of a lack of surface cleanliness in patient care/service areas were made:

A. Main Hospital Campus

9/6/11:
11:25 AM -- Progressive Care Unit (PCU)
- paper signs posted with tape on storage unit containing isolation equipment
11:48 AM -- PCU
- rest room #5029 damaged wall over sink and behind toilet; dusty overhead air vent
12:02 PM -- PCU
- wall mounted, metal, fire alarm system control box mounted just inside the door of a supply closet posed a danger of injury to staff (sharp corner of box was covered with gauze squares and packing tape as "protection")
1:05 PM -- Cardiovascular Step Down (CVSD)
- 7 cracked floor tiles in front of east zone elevators
- 16 signs taped to doors, glass and refrigerators
2:50 PM -- Women's Health
- signs taped to refrigerator door

These findings were confirmed by Director of Facilities A at the time of each observation.

9/7/11:
3:00 PM -- Emergency Department
- base of x-ray table was very dusty
3:12 PM -- Diagnostic Imaging
- stained, dirty carpeting in hallway to magnetic resonance imaging (MRI) and computerized tomography (CT) areas
3:23 PM -- Inpatient Rehabilitation Department
- patient waiting area carpeting stained
- stained ceiling tile
3:38 PM -- Window frame opposite North Zone Elevators
- bubbled, moisture-damaged paint surfaces

These findings were confirmed by registered nurse (RN) Quality Analyst A at the time of each observation.

9/8/11:
1:15 PM -- Diagnostic Imaging
- hole in the floor roughly the size of a quarter by the doorstop in x-ray room #3

This finding was confirmed during interview with Director of Radiology A on 9/8/11 at 1:20 PM.

9/9/11:
9:05 AM -- Vascular Lab 1
- 4 cracked floor tiles
- moisture damaged wall over heating unit
- counter laminate was chipped
9:12 AM -- Vascular Lab 2
- 8 cracked floor tiles
- moisture damaged wall next to heating unit
- damaged laminate at corner of base cabinet
9:16 AM -- Hallway and doorway of room #1224
- threshold plate missing, trip hazard
- broken corners on particle board counter
9:16 AM -- Hallway and doorway of room #1196
- gap at threshold between carpeting and tile
9:26 AM -- CT Room
- damaged laminate at sink edge
- damaged wall surfaces
9:37 AM -- Corridor from West Main Entrance
- carpeting soiled and damaged - Confirmed at time of discovery by Interim Director of Environmental Services A who stated that the carpeting "is so worn it no longer can be cleaned."
9:40 AM -- Cardiac Catheterization Lab
- "sink hole" in flooring in cubicle #1
- tape on refrigerator door in procedure room #1
- dust on medical gas supply boom in procedure room #2
10:15 AM -- Laboratory Express
- approximately 8 inch by 2 inch hole in floor covering in staff work area
- tape on refrigerator
10:24 AM -- Laboratory
- taped paper signs and unclean adhesive residue areas on laboratory equipment including a thaw bath, laboratory hood, platelet agitator and reagent refrigerator
10:55 AM -- Distribution
- 2 code carts were observed, one with a lock indicating it was refilled and ready for reuse, the other without a lock; both carts were dusty and had stickers and adhesive residue

These findings were verified at the time of discovery, by Interim Director of Environmental Services A and Accredited Infection Preventionist A.

B. Southern Health Campus (Surgery Center)

9/8/11:
10:10 AM -- Operating Room (OR) 1
- damaged, uncleanable wallboard
10:15 AM -- OR 2
- damaged, uncleanable wallboard
10:35 AM -- Nurses' station in restricted area
- damaged laminate on desk/counter

These findings were confirmed by Infection Control Coordinator A, Director of Surgical Services A and On-Site Manager/Outpatient Surgery Center A at the time of each observation.

Based on observation, staff interview and policy review, it was determined that the hospital failed to ensure an acceptable level of safety, quality, cleanliness and condition of patient care equipment and supplies in 16 of 28 (57%) patient care and staff support areas. Findings include:

The hospital policy entitled "Cleaning Patient Care Equipment" stated, "...patient equipment must be adequately cleaned between each patient use...Prevent spread of infection and provide a clean, safe environment...Each Department Manager is responsible to ensure that equipment is well maintained and in clean, useable condition..."

The hospital policy entitled "Housekeeping" stated, "...All soil and dust should be removed from surfaces...All soiled fabric will be cleaned whenever identified or reported as being soiled to Environmental Services..."

The hospital policy entitled "Cleaning of Computer Keyboards" stated, "Computer keyboards will be kept clean by disinfecting regularly to minimize the risk and prevent the spread of disease..."


Environmental tours conducted at the Main Hospital Campus and the Southern Health Campus yielded the following observations:

A. Main Hospital Campus

9/6/11:
11:25 AM -- Progressive Care Unit (PCU)
- dust, adhesive on vital sign measurement device
- 2 workstations on wheels found with curled and dirty adhesive labels attached
- intravenous pumps with adhesive residue
- intravenous pole with 5 rusty casters
- dusty computers
- dusty patient scale
1:10 PM -- Cardiovascular Step Down Unit (CVSD)
- portable fan in room 4007 with dusty blades
- fabric on arms of 3 chairs and 1 love seat soiled

These findings were confirmed by Director of Facilities A at the time of each observation.

9/6/11:
2:35 PM -- 2nd floor & Women's Health
- workstation on wheels adjacent to room 217 with dusty, dirty keyboard
- covered keyboard at nurses station, very dusty
- infant hearing screening device with soiled top surface
- dusty scale

These findings were confirmed by Director of Emergency Department and Outpatient Units A at the time of observation.

9/7/11:
12:04 PM -- Distribution Department
- 4 of 4 adult code carts and 2 of 2 pediatric code carts that had been restocked and were ready to leave the department for reuse, were dirty and sticky with adhesive residue and dust

These findings were confirmed by Director of Materials A and Infection Control Coordinator A at the time of observation.

3:00 PM -- Emergency Department
- base of x-ray table was very dusty
3:08 PM -- Radiology
- 2 damaged chair seats in waiting area
- 3 uncleanable fabric upholstered chairs
3:23 PM -- Inpatient Rehabilitation
- adhesive on Intelect (electrical stimulation machine) cart
- small access panel taped in place on Intelect (therapeutic ultrasound machine)
- torn upholstery on round, rolling stool
- 1 uncleanable fabric upholstered chair in patient treatment area
- adhesive residue on cabinets

These findings were confirmed by registered nurse (RN) Quality Analyst A at the time of each observation.

Interview with Infection Control Coordinator A and Accredited Infection Preventionist A on 9/8/11 at 2:55 PM revealed that each department manager was expected to ensure that equipment was maintained and in clean useable condition.

9/8/11:
9:03 AM -- Vascular Lab #1
- dusty shelf under stretcher
- diagnostic ultrasound machine dusty
9:14 AM --Vascular Lab #2
- dusty, dirty computer keyboard
- damaged computer keyboard tray
- dusty shelf under stretcher
9:20 AM -- Radiology -- Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI)
- 5 chairs and 1 love seat with damaged arms
- 2 uncleanable fabric upholstered chairs
9:42 AM -- Cardiac Catheterization Lab (Preparation and Recovery area)
- old sticker residue and remnants on top of code cart
9:50 AM -- Cardiac Catheterization Lab (Procedure Room #1)
- top of code cart was dusty, dirty adhesive residue was present
9:52 AM -- Cardiac Catheterization Lab (Procedure Room #2)
- top of code cart soiled with adhesive residue and dust
9:53 AM -- Cardiac Rehabilitation
- 2 exercise bicycles with dirty adhesive residue and tape pieces
- 4 upper body ergometers (exercise machines) with adhesive tape pieces and tape residue
- 2 recumbent exercise bicycles with many pieces of tape
- sticker remains and adhesive residue on top surface of code cart
- treadmill power cord partially affixed to floor with multiple pieces of dirty, crumpled, packing tape
10:15 AM -- Lab Express (blood draw area)
- adhesive foam tape remains on laboratory technician work table
- soiled tape holding sign to top surface of work table

B. Southern Health Campus (Surgery Center)

9/8/11:
10:10 AM -- Operating Room (OR) #1
- damaged OR table pad covering
- stickers and adhesive residue on prep table
10:15 AM -- OR #2
- damaged OR table pad covering
- stickers and adhesive residue on prep table
- curled labels on electrocautery unit
10:42 AM -- Post Anesthesia Care Unit
- tape, sticker and adhesive residue on top surface of code cart

These findings were confirmed by Infection Control Coordinator A, Director of Surgical Services A and On-Site Manager/Outpatient Surgery Center A at the time of each observation.

Interview with Infection Control Coordinator A and Accredited Infection Preventionist A on 9/8/11 at 2:55 PM revealed that each department manager was responsible to ensure that equipment was maintained and in clean useable condition.

Based on closed medical record review, policy review and staff interview, it was determined that for 1 of 4 (25%) patients (Patient #34) in the sample that had expired in the hospital, staff failed to notify the Organ Procurement Organization (OPO). Findings include:

The hospital policy entitled "Organ, Tissue and Body Donation" stated, "...At or near the time of every patient death, Beebe Medical Center shall contact Gift of Life Donor Program (GLDP) to determine a patient's suitability for anatomical donation..."

The hospital policy entitled "Care of the Patient at Death" stated, "...Confirm Organ, Tissue and Body Donation policy has been followed, and Gift of Life has been contacted..."

Review of Patient #34's closed medical record revealed the following:

11/26/10
- Review of the 9:10 AM "PA (Physician's Assistant) Progress Notes" documentation included a plan to extubate (remove artificial airway) when family arrived - family did not want re-intubation.

- Review of the 10:15 AM "Progress Notes" documentation included a plan to extubate after conversation with the power of attorney - comfort measures.

- Review of the 10:22 AM "Progress Notes" documentation - Catholic priest contacted

11/27/10
- Review of the 4:25 PM "Progress Notes" documentation revealed that the physician was called to pronounce Patient #34 at 3:50 PM.

Review of the medical record revealed no documentation to support that the Gift of Life Donor Program was contacted by staff when Patient #34's death was imminent or at the time of Patient #34's death.

Interview with Nurse Manager A on 9/6/11 at 10:35 AM confirmed this finding. Nurse Manager A reported that the hospital had identified and addressed the missed opportunity through education and process changes.

Based on personnel record review, job description review and staff interview, it was determined that for 1 of 2 (50%) emergency department (ED) personnel files (Employee #23) reviewed, the hospital failed to ensure that the employee maintained phlebotomy certification as required. Findings include:

The hospital job description and performance review for "Patient Care Tech" stated, "Licensure/Certification/Registration: Must become certified in phlebotomy within one year of hire..."

Review of the personnel file for Employee #23 revealed that Phlebotomy certification was obtained from the American Society of Phlebotomy Technicians on 12/3/09 and was valid through 12/31/10.

Interview with Vice President of Human Resources A on 9/9/11 at 1:50 PM revealed that it was the expectation that Employee #23 maintained phlebotomy certification. Vice President of Human Resources A confirmed that Employee #23 had been performing phlebotomy since 1/1/11 without the required certification.

Based on observation, policy review and staff interview, it was determined that for 1 of 2 (50%) observed respiratory treatments, respiratory therapist (RT) A failed to follow the hospital policy approved by the medical staff. Findings include:

The Respiratory Care Department Policy and Procedure entitled "Endotracheal/Tracheostomy Suctioning" stated, "...Wash hands and observe universal precautions...open suction cath kit, apply [sterile] gloves and connect suction catheter to suction tubing with non sterile hand...Insert catheter...If secretions are tenacious...repeat suctioning procedure..."

Patient #13

On 9/6/11 at 12:30 PM, Surveyor D observed respiratory therapist (RT) A suction Patient #13's tracheotomy (a breathing tube inserted into the patient's trachea via the front neck). During the observation, RT A:

- Performed hand hygiene; donned non-sterile gloves
- Opened and reached into the sterile suctioning kit with gloves
- Touched kit's sterile contents (sterile wrapped gloves, suction catheter, bottle of normal saline solution) with gloves

- With same gloves
- Removed sterile gloves from the kit and laid them in their wrapper on the table
- Held and uncapped the bottle of sterile saline solution
- Opened the paper wrapper and donned sterile gloves, placing them over the non-sterile gloves
- Connected the suction catheter (no longer sterile) to the patient's suction tubing
- Suctioned the patient
- Cleared secretions from the catheter by dipping it into the saline bottle
- Suctioned the patient
- Removed gloves (both sets)
- Performed hand hygiene

RT A:

- Donned sterile gloves over contaminated gloves
- Touched sterile kit contents with contaminated gloves
- Failed to use sterile technique when suctioning the patient

RN Quality Analyst A, present at the time of the observation, confirmed this finding. Interview with RN Quality Analyst A and Nurse Manager A on 9/6/11 at 1:00 PM confirmed that the expectation of the hospital was that sterile technique be used for tracheotomy suctioning.

Based on personnel record review, policy review, competency review documentation and staff interview, it was determined that for 1 of 1 (100%) respiratory therapy personnel records (Employee #16) reviewed for competency documentation, the skills were not rated or graded. Findings include:

The hospital policy entitled "Team Member Competency" stated, "...All Directors/Managers are responsible for validating the competency of team members...Successful completion of required competencies will be documented through use of skill checklist and/or written confirmation of cognitive testing. Checklists must be completely filled out..."

Review of Employee #16's "Competency Assessment" checklists dated 6/13/11, included documented demonstration of skills for:
- NeoBar (airway tube holder)
- Nasal Prongs
- Portable home ventilator
- Laerdal (manufacturer)/Crash Cart Compact Suction Unit
- LTV (type of ventilator)

The "Competency Assessment" contained a section identified as "Quality of Performance (circle appropriate number)". This section was left blank by the evaluator for all 5 checklist skills. During an interview on 9/12/11 at 9:10 AM, the Director of Respiratory Therapy A confirmed that it was unclear from the documentation if Employee #16's competencies had been evaluated. In addition, the Director of Respiratory Therapy A stated that the expectation was that the competency form be completed in full.