HospitalInspections.org

Based on clinical record review, interview and policy and procedure review, it was determined the facility failed to obtain consent for treatment for three (#21, #22 and #25) of five (#21-#25) Emergency Room (ER) patients. Failure to obtain consent for treatment did not allow the patients or their caregivers to make knowledgeable, informed and clear decisions regarding their care. The failed practice affected Patients #21, #22 and #25. Findings follow:

A. Review of the ER clinical records of Patients #21, #22 and #25 revealed no signed consents. During an interview with the Director of Patient Care Units/Pain Management/Post Anesthesia Care Unit (PACU) at 1106 on 04/14/17, she verified the above.

B. Review of the policy and procedure titled "Consent to Medical and Surgical Procedures" received on 04/10/17 revealed the following
under " ...PROCEDURE: General Admission Consent; 1. Upon admission to the hospital, a Conditions of Admission Form will be signed (See Conditions of Admission) by the patient or a person authorized and empowered to give consent on behalf of the patient. This consent Form documents the patient's consent to routine hospital services, diagnostic procedures and medical treatment. The Form shall not be used in place of a Consent For Surgical, Medical, Dental or Diagnostic Procedures Form ...."

Based on policy review and interview, it was determined the facility failed to ensure there was a written policy in place regarding abuse of a patient by a staff member. The failed practice did not allow the facility to be knowledgeable, proactive, and timely in responding to allegations of patient abuse by staff and could affect any patient alleging abuse. Findings follow.

A. An abuse policy was requested upon entering the facility on 04/10/17 at 0830.
B. During an interview on 04/12/17 at 0903, the Director of Quality Services confirmed there was no policy related to abuse of a patient by a staff member.

Based on review of Performance Improvement Plan for 2016, Quality Meeting Minutes for April 2016 through March 2017, and interview, it was determined the facility failed to ensure Quality data was reported up to the Director of Quality Services for 3 (Anesthesia, Nutrition Services, and Respiratory Services) of 12 (Anesthesia, Nutrition Services, Emergency Services, Housekeeping, Infection Control, Laboratory Services, Medical Records, Nursing Services, Pharmacy, Radiology, Respiratory Services, and Surgical Services) departments. The failed practice did not ensure the Governing Body was responsible for all aspects of the facility and created the potential to affect any patients using services from those departments. Findings follow.

A. Review of the Performance Improvement Plan for 2016 stated, "The Performance Improvement Plan will be continuous, and will involve areas directly or indirectly related to the delivery of patient care, including, but not limited to: ...Anesthesia Services, Nutrition Services ...Respiratory Services.
B. Review of Quality meeting minutes and related documents provided revealed no evidence of quality data having been reported for Anesthesia for 2nd, 3rd, and 4th quarters of 2016, Nutrition Services for the past 4 quarters, and Respiratory Services for the past 4 quarters.
C. During an interview on 04/10/17 at 1430, the Director of Quality Services confirmed there was no quality data reported for Anesthesia in 2016. She confirmed there was no quality data reported for Respiratory Services on 04/12/17 at 1307.
D. During an interview on 04/12/17 at 1355, the Foodservice Director confirmed there was no quality data reported to the Quality Services Director.

Based on review of facility staffing assignments and interview, it was determined the facility failed to assure a Registered Nurse (RN) would be immediately available for patient care in that a RN was assigned as the Charge Nurse for the Patient Care Unit (PCU) and had individual patient care assignments, while simultaneously assigned as the Emergency Department (ED) RN for 27 of 56 shifts from 03/13/17 - 04/09/17. The failed practice did not assure a Registered Nurse would be immediately available for nursing care and the ongoing assessment of patient needs for the PCU and ED patients. The failed practice affected any patient who presented to the ED for treatment. The findings were:

A. Review of the facility staffing assignments from 03/13/17 - 04/09/17 revealed one RN was assigned as Charge Nurse per shift. The Charge Nurse also had individual patient care assignments on the following 0700-1900 (day) shifts: 03/13/17; 03/16/17; 03/18/17; 03/20/17; 03/23/17; 03/26/17; 04/03/17; 04/06/17 and 04/07/17. The Charge Nurse had individual patient care assignments on the following 1900-0700 (night) shifts: 03/16/17; 03/14/17; 03/17/17; 03/19/17; 03/21/17; 03/22/17; 03/26/17-03/28/17; 03/30/17-04/02/17; 04/04/17-04/08/17. The staffing assignments as above were reviewed and confirmed with the Director of Patient Care Services on 04/11/17 at 0950.

B. On 04/10/17 at 1309, the Director of Patient Care Services stated in an interview the Charge Nurse was the only one assigned to work in the ED and confirmed the Charge Nurse did have patients at times. The Director of Patient Care Services stated if the Charge Nurse had patients assigned to her, then the Patient Care Unit patients would be passed off to another nurse if a patient presented to the ED.

C. On 04/11/17 at 1447, Charge Nurse #1 was interviewed and stated she left the PCU and went to the ED when there was a patient. If Charge Nurse #1 was assigned patients, then she stated she would get another nurse (RN) to take care of her patients. The RN was not immediately available by working on more than one unit.

Based on clinical record review, policy and procedure review and interview, it was determined the facility failed to assure the nursing care plan identified the nursing care needs for one of one (#6) patient in isolation and one of one (#2) patient with a decreased BMI (body mass index) which identified them at nutritional risk. The failed practice did not assure the nursing needs of Patient #6 would be met related to isolation and the nutritional needs of Patient #2 would be met. The failed practice affected Patient #6 and #2 and was likely to affect any other patient in isolation or at nutritional risk. The findings were:

A. Patient #6 was admitted on 04/07/17 at 1528 in contact isolation. Review of the clinical record on 04/14/17 revealed the patient's nursing care needs for Isolation was not addressed in the Care Plan. This was confirmed by the Clinical Coordinator of the Patient Care Unit on 04/14/17 at 1024.

B. Patient #2 was admitted on 04/07/17 at 1028. An order for a Nutrition Screen based on the initial nursing assessment was entered on 04/07/17 at 1325. A Nutritional Screening Assessment was completed on 04/09/17 at 1148. The Nutritional Assessment revealed "Patient screened out at nutrition risk due to BMI < (less than) 18.5. Current BMI is 17.18. Weights above or below the healthy BMI range (18.5-24.9) increase the risk of future surgery need. Kcal (kilocalorie) needs per day are 1350-1450 (30-35 kcals/kg(kilogram)/IBW(ideal body weight) IBW=100#. Protein needs per day are 60-70g (grams) (about 25% of kcals) Fluid needs per day are >1350 ml (milliliters) or per MD contingent upon labs." Nutrition Intervention revealed "Recommend Vitamin C 500 mg (milligrams) BID (two times per day), MVI (multi vitamin) daily. Ensure Enlive TID (three times per day). Nutritional education regarding steady weight gain to not only speed wound healing but to increase kcals and protein. Monitor Wt (weight), labs (laboratory tests), and po (by mouth)intake."

1) Clinical Record review on 04/13/17 revealed the Plan of Care did not include that Patient #2 was at nutritional risk. The lack of evidence was confirmed by the Clinical Coordinator of the Patient Care Unit on 04/13/17 at 1405.

C. Review of Policy CL 3.9 "Care Plan" provided by the Chief Nursing Officer revealed "to provide nursing care that is holistic and multidisciplinary to the patient across the continuum of care. The Registered Nurse initiates the care plan within 24 hours of admission by utilizing the nursing admission assessment. Nursing diagnosis are determined, specific problems are identified and the appropriate nursing standard is used. The plan of care will be established by the RN and updated as needed by a licensed care giver. The RN will evaluate the patient's progress meeting goals once per shift and revise the plan based on patient's need."


30634

Based on clinical record review, policy review, and interview, it was determined the facility failed to ensure meal intake was documented for 23 of 23 (#1-#20 and #29-#31) patients who received meals. The failed practice did not allow staff to be knowledgeable of patient's meal intake and nutritional status. The failed practice created the potential to affect any patient in the facility. Findings follow.

A. Review of policy titled "Nutrition Assessment, Intervention, Monitoring, and Evaluation" stated, "The Registered Dietitian estimates energy needs and compares the estimated needs to the nutrient analysis for the diet prescribed by the physician. The Registered Dietitian evaluates the patient's PO (by mouth) intake as documented by nursing and determines if the patient's energy needs are being met. If estimated energy needs are not being met, the Registered Dietitian documents the variation and makes a recommendation for energy supplementation."
B. Review of clinical records revealed no evidence of meal intake documentation for 23 of 23 (#1-#20 and #29-#31) patients.
C. During an interview on 04/13/17 at 1353, the Director of Patient Care stated meal intake was only documented if there was a Physician's Order to do so. She confirmed the lack of meal documentation at this time.

Based on review of policies and procedures, interview, review of the Emergency Room Register and personnel files, it was determined the nursing staff failed to assure one (#2) of four (#1-#4) Registered Nurse (RN) assigned to the Emergency Department possessed the specialized qualification of Pediatric Advanced Life Support (PALS) certification as required by facility policy. The nursing staff could not assure emergency care needs of all age group patients would be met. The failed practice was likely to affect any pediatric patient who presented to the Emergency Department. The findings were:

A. Review of Policy ED 15.0: "ED Staffing Pattern" provided revealed "The ED cares for persons in all age groups; therefore, the ED staff must acquire skills needed for the care and treatment of each age group. The ED RN will be certified in ACLS (Advanced Cardiac Life Support) and PALS." "Minimum staffing will include at least one RN available to the ED on a 24 hour basis."

B. On 04/10/17 at 1309, the Director of Patient Care Services stated the Charge Nurse (from the Patient Care Unit) is the only Registered Nurse assigned to work in the ED and all Charge Nurses have PALS.

C. Review of the Emergency Room Register on 04/11/17 revealed from 01/15/17 - 03/06/17 RN #2 was assigned and treated patients in the Emergency Department 11 times.

D. Review of Personnel files for RN #1 - #4 on 04/11/17 at 0900 revealed RN #2 did not have evidence of PALS training or certification. RN #2 had a hire date of 03/05/14. The lack of PALS training/certification was confirmed by the Director of Patient Care Services on 04/11/17 at 1457.

Based on clinical record review, policy and procedure review, and interview, it was determined Physician #2 failed to completed the progress note for two (#22 and #23) of five (#21-25) Emergency Room (ER) patients within 24 hours as required by policy. Failure to document the note at the time of the visit did not ensure current and accurate documentation was available as needed for the ER visits. The failed practice affected Patient #22 and #23. Findings follow:

A. Review of Patient #22's ER face sheet revealed he presented to the ER at 1202 at 04/07/17. Review of Physician #2's progress note revealed it was timed and dated 2155 on 04/11/17.
B. Review of Patient #23's ER face sheet revealed she presented to the ER at 1144 on 04/06/17. Review of Physician #2's handwritten progress note revealed it was dated 04/11/17.
C. Review of the policy and procedure titled "Medical Record Documentation" received from the Clinical Coordinator of Patient Care Unit at 0836 on 04/14/17 revealed the following under "J. ...d. Emergency room documentation will be completed within twenty four hours of the patient's visit ...."
D. During an interview with the Director of Patient Care Units/Pain Management/Post Anesthesia Care Unit at 1108 on 04/14/17 she verified the findings in A, B and C.

Based on policy and procedure review, clinical record review and interview, it was determined the facility failed to ensure verbal orders were authenticated by the ordering practitioner per its policy and procedure requirement of 96 hours for one (#21) of five (#21-#25) Emergency Room (ER) patients. Failure to authenticate verbal orders within the 96 hour time frame did not allow the facility to be in compliance with its policy and procedure. The failed practice affected Patient #21. Findings follow:

A. Review of Patient #21's clinical record revealed orders for X-rays of the right knee at 1443 on 03/06/17, NWB (non weight bearing) with immobilizer and crutches at 1353 on 03/06/17 and for discharge at 1533 on 03/06/17 authored by the Nurse Practitioner. Review of Patient #21's clinical record revealed the above orders were electronically signed by the Nurse Practitioner at 1026 on 03/27/17.
B. Review of Patient #21's clinical record revealed orders for NWB (non-weight bearing) with immobilizer and crutches at 1353 on 03/06/17 and for discharge at 1533 on 03/06/17 were signed by Physician #1 at 1520 on 03/29/17.
C. Review of the policy and procedure titled "Telephone and Verbal Orders" received from Medical Records #1 at 1455 on 04/13/17 revealed the following under "PROCEDURE: ...The prescribing practitioner must sign the written record of the verbal/telephone order within 96 hours of giving the order ...."
D. The findings in A, B, and C were verified in an interview with the Director of Patient Care Units/Pain Management/Post Anesthesia Care Unit at 1106 on 04/14/17.

Based on review of Pharmacy Policy: Procedure for Competency Testing of Pharmacy Employees, review of annual competencies for Pharmacy Technicians (Techs), and interview, the facility failed to ensure three (Pharmacy Techs #1, #2, #3) of five (Pharmacy Techs #1, #2, #3, #4, #5) Pharmacy Techs completed current annual competency test as required by policy so optimum delivery of Pharmaceutical Service could be achieved. The likelihood existed the three Pharmacy Technicians could not provide quality Pharmaceutical Services. Findings follow:

A. On 04/10/17 at 1315, competencies for Pharmacy personnel were reviewed. There was no evidence Pharmacy Techs #1, #2 and #3 had completed current annual competency tests.
B. A review of Pharmacy Policy: Procedure for Competency Testing of Pharmacy Employees was reviewed on 04/11/17 at 1005. The policy stated "All pharmacy employees will be tested annually to verify their competency in performing their job."
C. During an interview on 04/13/17 at 0930, the DOP verified the policy did indicate annual competencies would be done on all Pharmacy personnel to include Pharmacy Techs. It was revealed in the same interview Pharmacy Techs #1, #2, and #3 had not completed a current annual competency test within the past twelve months.

Based on obsservation, review of manufacturer's label, and interview, the facility failed to ensure unusable medications were not available for patient use in that Sterile Water for Irrigation was not used as single use only as required by manufacturer. The Sterile Water for Irrigation was located on one (Patient Care Unit) of six (Pain Management Unit, Emergency Department, Patient Care Unit, Surgery, Pre-Operative Unit, Post-Anesthesia Care Unit) patient care areas. The likelihood existed for the Sterile Water for Irrigation to be contaminated and used for patients. Findings follow:

A. A tour of the facility on 04/11/17 between 1255 and 1545 revealed at 1415, two opened single unit 1000 milliliters (ml) bottles of Sterile Water for Irrigation were observed in the refrigerator on the Patient Care Unit. One bottle was dated 03/13/17 and the other dated 04/06/17.
B. At 1420 on 04/11/17, the manufacturer's label was reviewed on the Sterile Water for Irrigation. It revealed the Sterile Water For Irrigation must be used as single use and the unused portion discarded. The two bottles of Sterile Water for Irrigation were therefore unusable.
C. An interview on 04/11/17 at 1425, the Director of Pharmacy verifed the opened bottles of Sterile Water For Irrigation in the refrigerator on the Patient Care Unit were available for patient use, were not used according to manufacturer's label guidelines, and should have been discarded since sterility could not be ensured.

Based on Nutrition Services policy review, and interview, it was determined the facility failed to ensure policies were updated and specific to the facility's organizational practices for 11 of 11 policies. The failed practice did not ensure the policies and procedures were up to date and reflected the current practices of the facility and had the potential to affect any patient receiving dietary services. Findings follow.

A. Review of policy titled "Annual Review of Policy and Procedure Manual by Food Service" stated, "Each manager/supervisor will review the manual each year and sign and date the review sheet."
B. Review of Nutrition Services policy manual revealed the following:
1) Policy titled "Registered and Licensed Dietitians" stated, "The Clinical Staff will we licensed by the State of _____.....Prior to employment, the Clinical Dietitian will be licensed by the State of____."
2) Policy titled "Food and Drug Interaction Education" stated, "The Food and Nutrition Services Department is alerted to patients receiving anticoagulation therapy via _____ prior to meal service."
3) Policy titled "Intake Analysis and Documentation" stated, "The duration of the intake analysis is ____ day(s) unless specified otherwise. If the patient is NPO (nothing by mouth) for part or all of the ____ day period, the dietitian may extend or suspend the intake analysis; changes will be documented in the medical record."
4) Policy titled "Committee Concerned with Nutrition Care" stated, "The _____ committee is designated as the facility approved committee concerned with nutritional care."
5) Policy titled "Malnutrition and the Hospitalized Patient" stated, "Dietitian ....informs the LIP (Licensed Independent Practitioner) when a patient meets the organization's criteria for malnutrition (DEFINE YOUR PROCESS HERE)."
6) Policy titled "Food and Supply Storage" stated, "Store dry and staple items at least ____ (inches) above the floor and ____ (inches) from walls and ____ (inches) from ceiling, consistent with local food protection codes."
7) Policy titled "Tray Preparation and Delivery" stated, "Trays are delivered to each nursing unit by Food and Nutrition Department so that not more than ____ (14 or 15) hours elapse between the serving of the dinner and the serving of breakfast .....Trays are delivered within ____ minutes of being assembled."
8) Policy titled "Floor Supplies" stated, "Discarding of expired items is the responsibility of _____ and is done according to established guidelines."
9) Policy titled "Food Allergies" stated, "Identify all patients with food allergies. These food allergies are communicated via ____ (outline method of notification)."
10) Policy titled "Disaster and Fire Plans" stated, "Disposable ware needed - Determine the types and quantity on hand. Menu - Outline for the duration of the disaster. Do's and Don'ts of the disaster must be detailed ...List the telephone numbers of various key Food and Nutrition Services Department Personnel to contact during the disaster ...This is a guideline - please spend the time to make it fit to your facility. When a disaster really occurs, you need to be prepared."
11) Also contained within the policy manual were mostly blank pages that stated only "Insert Facility's Workstation Assembly Diagram Here," and "Insert Unit Tray Arrangement Diagram Here," and "Fire Evacuation Plan ...Replace with facility department plan."
C. During an interview on 04/12/17 at 1355, the Foodservice Director confirmed the policies were not complete and specific to the facility.

Based on Refrigerator and Freezer Temperature Log review for 01/01/17 through 03/31/17 and interview, it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that refrigerator temperatures were not documented three times per day for six of six (#1-#6) refrigerators and freezer temperatures were not documented three times per day for two of two freezers (#1 and #2); refrigerator temperatures were not 40 degrees or below 256 out of 995 times documented; and freezer temperatures were not zero degrees or below 188 out of 335 times documented. Failure to document temperatures three times per day created the potential for a refrigerator or freezer malfunction to go unnoticed; failure to maintain refrigerator temperatures below 40 degrees and freezer temperatures below zero degrees created the potential for bacterial growth in refrigerated foods and unwanted thawing in freezer foods; and could affect any patient receiving meals from the kitchen. Findings follow.

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 17.B.12 required temperatures of all refrigerators and freezers in the kitchen to be recorded three times per day. Review of Refrigerator and Freezer Temperature Logs for 01/01/17 through 03/31/17 revealed the following:
1) Refrigerators - out of a possible 540 opportunities, temperatures were documented only two times per day 455 times, one time per day 65 times, and not at all 20 times.
2) Freezers - out of a possible 180 opportunities, temperatures were documented only two times per day 155 times, one time per day 21 times, and not at all 4 times.
B. Review of Table 9 stated Refrigerators must be less than or equal to 40 degrees Fahrenheit and Freezers must be less than or equal to zero degrees Fahrenheit. Review of Refrigerator and Freezer Temperature Logs for 01/01/17 through 03/31/17 revealed the following:
1) Refrigerator temperatures were above 40 degrees 256 out of 995 times documented.
2) Freezer temperatures were above zero degrees 188 out of 335 times documented.
C. During an interview on 04/12/17 at 1355, the Foodservice Director confirmed temperatures were not documented three times per day, refrigerator temperatures were above 40 degrees and freezer temperatures were above zero degrees.

Based on Dishmachine Temperature Log review for 01/01/17 through 03/31/17 and interview, it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that dishmachine water cycle temperatures were not documented at each meal 76 out of 270 times; and final rinse cycle temperature was not documented 93 out of 177 times. Failure to document water temperatures created the potential for a dishmachine malfunction to go unnoticed and created the potential to affect any patient consuming foods on dishes that were washed in the dishmachine. Findings follow.

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 17.B.16 stated dishmachine temperatures shall be recorded with each meal. Review of Dishmachine Temperature Logs for 01/01/17 through 03/31/17 revealed the following:
1) Dishmachine wash cycle water temperatures were not documented for 76 out of a possible 270 meals.
2) Dishmachine final rinse cycle water temperatures were not documented for 93 out of a possible 177 meals.
B. During an interview on 04/12/17 at 1355, the Foodservice Director confirmed the water temperatures were not documented at each meal.

Based on Trayline Temperature Monitoring Form review for 01/01/17 through 03/31/17 and interview, it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that temperatures of foods on the patient trayline were not taken before the meal 94 out of 270 times; and were not taken after meals in which trayline lasted longer than 15 minutes 119 out of 270 times. The failed practice did not allow the kitchen staff to know if hot foods were above 140 degrees Fahrenheit and cold foods were less than 40 degrees Fahrenheit through the duration of the trayline service. The failed practice had the potential to affect anyone receiving food from the kitchen. Findings follow.

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 17.B.18 stated temperatures of hot and cold foods on patient trayline shall be taken at the beginning of each meal and at the end of each meal in which trayline lasts longer than 15 minutes. Review of Trayline Temperature Monitoring Forms for 01/01/17 through 03/31/17 revealed the following:
1) Temperatures of patient trayline foods were not documented before each meal 94 out of 270 times.
2) Temperatures of patient trayline foods were not documented after each meal 119 out of 270 times.
B. During an interview on 04/12/17 at 1355, the Foodservice Director confirmed the temperatures were not documented.

Based on observation, policy review, and interview it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that food items in the kitchen were not labeled and dated on a first in, first out (FIFO) basis. The failed practice did not ensure food items were rotated so that the oldest items were used first and created the potential for patients to receive expired food items. Findings follow.

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 17.C.11 required food items to be handled on a first in, first out basis.
B. Review of policy titled "Food Supply and Storage" stated under Dry Storage, "Date and rotate items; first in, first out (FIFO);" under Refrigerated Storage "Date and rotate items; first in, first out (FIFO). Discard food past the use by or expiration date."
C. During a tour of the kitchen conducted on 04/12/17 from 1330 through 1355, numerous items were observed not dated, examples include:
1) Steel cut oats - eight of eight boxes
2) Old fashioned oats - four of four boxes
3) Yellow cake mix - three of three boxes
4) Pickles - three of three bags
5) Chocolate pudding - four of four cans
6) Tomato juice - eight of eight cans
7) Onion rings - three of three bags
8) Pastrami - five of five packages
9) Danishes - two of two boxes
10) Muffins - two of two boxes
D. During an interview at the time of the tour, the Foodservice Director confirmed the food items were not dated.

Based on observations, interviews and policy and procedure reviews, it was determined the facility failed to maintain an active infection control program in that:

A. Infection Control Policies and Procedures were not followed in that hand hygiene was not performed after completion of one of one procedure observed; hand hygiene was not performed when one of one employee who exited one of one contact isolation room; equipment and furnishings in one of one discharged patient room (306) were not cleaned in the order stipulated by policy and procedure. See A-0749.
B. The Infection Control Officer failed to identify that cloth gait belts utilized by the Physical Therapy department were not cleaned between patient uses; and failed to develop and implement policies and procedures to establish a process for cleaning gait belts used between patients. See A-0749.
C. The Infection Control Officer failed to develop and implement a process for how surgical attire was transported and laundered to minimize the potential risk of contamination in the surgical suite; failed to prevent the Operating Room Coordinator and the Direct Implant Technician from entering Operating Room #6 with exposed hair that should have been covered per policy and procedure; and failed to prevent herself and Surveyor #5 from entering Operating Room #6 to observe a surgical procedure while wearing surgical attire that was worn all over the facility. See A-0749.
D. Failed to monitor the process for cleaning and storage of multi dose medication vials and expired supplies which had the potential for contamination of mediation vials and the decreased efficacy of the expired items. See A-0749.

Based on observations, interview and policies and procedures review, it was determined the Infection Control Officer failed to identify hand hygiene was not performed in accordance with policies and procedures in that one of one (#1) Anesthesiologist failed to wash his hands after performing a spinal procedure. One of one Patient Ambassador (#1) failed to remove gloves and perform hand hygiene prior to leaving one of one Contact Isolation Room. Failure to perform hand hygiene after potential contact with blood or body fluids had the potential for cross contamination for patients, staff and visitors. The failed practice had the potential to affect all patients, staff and objects both staff members may have had physical contact with. Findings follow:

A. During observation of Patient #31's epidural placement, Anesthesiologist #1 was observed to finish the procedure, go to the nursing station and retrieve Patient #31's clinical record, document on the clinical record and then go to the sink and wash his hands. The above was verified in an interview with the Pre-Operative/Pre-Testing Coordinator at 0955 on 04/11/17.
B. During hand hygiene observations made on the 300 Patient Care Unit at 0845 on 04/13/17, Patient Ambassador #1 was observed to come out of Contact Isolation Room #303 without removing his gloves or performing hand hygiene. Patient Ambassador #1 went to the Nursing Station, returned to the 300 Patient Care Unit where he was stopped by Surveyor #5. Surveyor #5 asked Patient Ambassador #1 if he removed his gloves and performed hand hygiene after leaving Contact Isolation Room #303 and he stated he did not. The above was verified by the Director of Ancillary Services at 0855 on 04/13/17.
C. Review of the policy and procedure titled "Infection Control - Anesthesia Services" received from the Infection Control Nurse at 1005 on 04/13/17 revealed the following under "POLICY: ...D. Hand washing and /or disinfecting with approved material shall be done before and after each patient exposure ...."
D. Review of the policy and procedure titled "Isolation Precautions" received at 1220 on 04/10/17 revealed the following under "III. Contact Precautions: ...C. Gloves and Hand Hygiene, Remove gloves before leaving the patient's room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. After glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of micro-organisms to other patients or environments."


Based on observation, interview and policy and procedure review, it was determined the Infection Control Officer failed to have a process in place to monitor the process for cleaning a discharged patient room. In one of one (#306) discharged room observed revealed one of one (#1) Housekeeper did not clean from clean to dirty to prevent contamination of equipment in the order per policy and procedure. Failure to have a process in place to monitor, identify and correct the technique used in the cleaning of a discharged room did not to ensure the policy and procedure was being followed to prevent surface and hand contamination. Failure to clean the discharged room per policy and procedure had the potential for the next patient to have hands and objects contaminated by touch. Findings follow:

A. During observation of the cleaning of a discharged room at 1305 on 04/10/17, the following was observed:
1) Housekeeper #1 cleaned the top of the overbed table (cleanest), down the leg and the base (dirtiest) then back to the inside of the drawers located immediately under the top of the overbed table (cleanest).
2) In the bathroom, Housekeeper #1 cleaned the bedside commode located in the shower, then went to the second bedside commode where she cleaned the arms, seat, lid, back brace, feet and legs, then moved to the regular toilet where she cleaned the plumbing including the flush handle, the seat and bowl all with the same cloth. The above was verified in an interview with the Director of Environmental Services at 1350 on 04/10/17.
B. Review of the policy and procedure titled "Patient Room Discharges/Transfers" received from the Director of Environmental Services at 1415 on 04/10/17 revealed the following under "PROCEDURE: ...7. Thoroughly clean all the patient contact items with the second cloth (in the following order): Overbed table inside and out, under the tabletop, including leg and base. ... 13. The fifth cloth should be used to wipe down the flush valve, pipes, toilet seat, followed by the exterior of the bowl."


Based on observation, interview and policy and procedure review, it was determined the Infection Control Officer failed to identify that eight of eight cloth gait belts utilized by the Physical Therapy department were not sanitized between patient use. Failure to identify, develop and implement a policy and procedure to ensure gait belts were cleaned between patients had the potential to allow cross contamination of infections between patients. The failed practice affected all patients whose care involved the use of gait belts. Findings follow:

A. Observation made at 0855 on 04/13/17 revealed eight cloth gait belts hanging on hooks in an alcove on the 300 Patient Care Unit.
B. The Director of Physical Therapy (PT) stated in an interview at 0900 on 04/13/17 the gait belts were taken to Central Sterile and autoclaved weekly and a gait belt with visible blood or body fluids was placed into a biohazard bag for cleaning. The Director of PT stated the gait belts were not routinely cleaned between patients.
C. Review of the policy and procedure titled "Gait Belt Cleaning" received from the Director of Patient Care Units/Pain Management/Post Anesthesia Care Unit at 0940 on 04/13/17 revealed the following: " ....PROCEDURE:
1) All gait belts will be taken weekly to Central Sterile for cleaning.
2) Any patient who has been placed on infection control precautions will have a belt placed in their room for individual use. Upon discharge, the belt will be placed in a biohazard bag until it is cleaned.
3) Any belt soiled with bodily fluids is placed in a biohazard bag until it is cleaned.
4) Belts are hung to dry following processing through the washer-sterilizer."


Based on observations and interviews, it was determined the Infection Control Officer failed to have a process in place to identify outdated supplies (Hydrogen Peroxide, Betadine and Alcohol) which were available for patient care use in three of three (Pre-Operative, Procedure Room #1 and Procedure Room #2) patient care areas. The likelihood existed for the expired Hydrogen Peroxide, Betadine and Alcohol not to effectively clean the patient care equipment. Findings follow:

A. During a tour of the Pre-Operative Area at 0730 on 04/011/17, the following outdated supplies were observed and available to clean patient care equipment in the Pre-Operative Area: Hydrogen Peroxide 70% Spray one 16 ounce partial bottle expired 02/17 and one 16 ounce partial bottle expired 11/16;
B. During an interview with the Coordinator of PreOp/Pretesting at 0745 on 04/11/17, she verified the findings in A.
C. A tour of the Pain Management Unit on 04/11/7 between 1255 and 1340 revealed the following outdated supplies were available for use in Procedure Room #1 and Procedure Room #2:
1) Procedure Room #1: One partial 16 ounce bottle of Betadine expired 07/15.
2) Procedure Room #2:
a) One partial 16 ounce bottle of Betadine expired 07/15: and
b) One partial 16 ounce bottle of Isopropyl Alcohol expired 10/16.
D. During an interview with the Clinical Coordinator of Pain Management at 1310 on 04/11/17, she verified the Betadine in Procedure Rooms #1 and #2 and the Isopropyl Alcohol in Procedure Room #2 was outdated and available for patient use.


Based on observation, interview and policy and procedure review, it was determined the Infection Control Officer failed to have a process in place to monitor and ensure multi-dose vials were dated when opened in one of one Pre-Operative Unit; and one of one medical vial the diaghragm was cleaned prior to entering the vial in Operating Room (#6). Failure to date multi-dose vials when opened did not ensure the facility knew when to discard the medication vial; failure to clean the diaphragm of the medication vial prior to entering the vial did not assure a contaminant had not been introduced into the vial. The failed practice affected any patient whose treatment required the use of the multi-dose vial in the Pre-Operative Unit and affected Patient #31 on 04/11/17. Findings follow:

A. During a tour of the Pre-Operative Unit at 0730 on 04/11/17, a partial vial of Lidocaine HCL 200 mg (milligram)/20 ml (milliliter) was observed to be opened and un-dated. The above was verified during an interview with the Coordinator of Pre-Operative/Pretesting at 0745 on 04/11/17.
B. During observation of Patient #31's surgical procedure, the Certified Registered Nurse Anesthetist (CRNA) #1 was observed to open the top of three medication vials containing 2% (percent) Lidocaine 20 ml vial, Fentanyl 2 ml vial and Ropibacaine 30 ml vial respectively. CRNA #1 then did not cleanse the diaphragm before withdrawing the medications into separate syringes. The above was verified with the Director of Perioperative Services, Central Sterile and Testing during an interview at 1230 on 04/11/17.
C. Review of policies and procedures revealed the following:
1) "Dating of Sterile Containers" received from the Infection Control Officer at 1050 on 04/11/17 revealed the following under "POLICY: ... Multiple Dose Vials (with preservative) Discard 28 days after opening. (Must be labeled with date, time and initials of person opening.) ..."
2) "Dating of Opened Sterile Containers" received from the Infection Control Officer at 1050 on 04/11/17 revealed the following under "POLICY: ...Multiple Dose Vials (with preservative) These vials must be labeled with the expiration date of 28 days after initial puncture. The label must contain the date, time and initials of the person that opened the vial."
3) "Labeling of Medications" received on 04/10/17 revealed the following: " ...17. All multi-dose vials must be labeled with the strength if not apparent, expiration date of 28 days from initial puncture, and initials of professional entering the vial ..."
D. Review of the policy and procedure titled "Medication Administration" received from the Infection Control Officer at 1050 on 04/11/17 revealed the following under "Guidelines; ...7 ...d. Cleanse the rubber diaphragm with alcohol before using a sterile access device each time the multi-dose vial is accessed." " ...9. If a stoppered vial is used, the top will be disinfected with 70% alcohol prior to withdrawal of medication."


Based on observation, interview and policy and procedure review, it was determined the Infection Control Officer failed to have a process in place to identify and prevent two (Operating Room (OR) Coordinator and Direct Implant Technician) of six (Certified Registered Nurse Anesthesist, Circulator, Director of Perioperative Services/Central Sterile/Testing, OR Coordinator, Direct Implant Technician, and Infection Control Nurse) employees from entering the OR (during a surgical procedure) with exposed facial and nape of neck hair. Failure to ensure facial and head hair was completely covered had the potential for contamination of the sterile field. The failed practice affected Patient #31 on 04/11/17. Findings follow:

A. During observation of Patient #31's surgical procedure, the OR Coordinator was observed to wear a mask that did not cover the facial hair from the edge of the mask to his ears and the Direct Implant Technician's hair from ear to ear at the base of the scalp was not covered. The above was verified during an interview with the Director of Perioperative Services/Central Sterile/Testing at 1325 on 04/11/17.
B. Review of the policy and procedure titled "SURGERY ATTIRE" received from the Director of Quality at 1330 on 04/12/17 revealed the following under "PROCEDURE: ...10. Head and facial shall be covered, when in the semi-restricted and restricted areas of the surgical suite. ..."


Based on observation, interview and policy and procedure review, it was determined the Infection Control Officer failed to develop and implement a process for how surgical attire would be transported and laundered to minimize the potential risk of surgical suite contamination; failed to provide evidence of which nationally recognized infection control guidelines were used to prevent and control infections in the surgical suite; and failed to protect the integrity of the surgical suite by allowing herself and Surveyor #5 to enter the surgical suite in scrub attire that was worn all over the facility before entering the surgical suite to observe a surgical procedure. Failure to develop a process for transporting and laundering surgical attire did not allow the Infection Control Officer and the facility to be sure of the cleanliness of surgical attire worn by all surgical staff; failure to identify which nationally recognized infection control guidelines were adopted did not allow staff, physicians or regulatory bodies to be knowledgeable of and adhere to standards; and failure to ensure staff attire was clean before entering the surgical suite had the potential to contaminate and cause infection. The failed practice affected Patient #31 on 04/11/17. Findings follow:

A. Observations made during the surgical procedure of Patient #31 at 1300 on 04/11/17 revealed the Infection Control Officer allowed herself and Surveyor #5 to enter the restricted area (Operating Room #6) while wearing scrub attire that both had worn all over the facility.
B. During an interview with the Infection Control Nurse at 1330 on 04/11/17, she stated the Surgical Services employees laundered their scrubs and cloth caps at home.
C. During an interview with the Director of Environmental Services at 1045 on 04/13/17, he stated the only scrubs sent out to the contracted commercial laundry service were scrubs for visitors (students, sales/vendor representatives, etc.) and all employees laundered their scrubs at home.
D. During an interview with the Director of Perioperative Services/Central Sterile/Testing, the Operating Room (OR) Coordinator and the Infection Control Officer at 1440 on 04/11/17, the Director of Perioperative Services/Central Sterile/Testing stated each employee was given five sets of scrubs which the employees wore home, laundered and wore back to the facility.
E. During an interview with the Director of Perioperative Services/Central Sterile/Testing, the Infection Control Officer and the Director of Ancillary Services at 1550 on 04/12/17 they were asked "What guidelines does the facility follow per its policy and procedure titled "Surgery Attire." Surveyor #5 did not receive a clear cut answer in this interview.
F. Review of the policy and procedure titled "Surgical Scope of Service" received from the CCO at 1230 on 04/13/17 revealed the following under "OBJECTIVES: ...3. Provide quality individualized nursing care based on the nursing process and adherence to established standards of care provided through organizations such as AORN (Association of Perioperative Nurses), APIC (Association for Professionals in Infection Control and Epidemiology), and ASPN (American Society for PeriAnesthesia Nurses)." There was no evidence which nationally recognized infection control standards were used to prevent and control infections in the surgical suite.
G. During an interview with the Chief Clinical Officer (CCO) at 1245 on 04/13/17, she stated the facility "operated under AORN - with exceptions - but the policies and procedures did not reflect any exceptions from established standards of practice the facility operated under."


03485

Based on observation and interview, the facility failed to have a program for identifying and ensuring multiple dose vials (MDV) of medications located in two of two (Procedure Room #1, Procedure Room #2) patient care areas in the Pain Management Unit were treated as single use medications and discarded after opened for patient use. Due to the MDV of medications being located in a patient care area, the likelihood existed for the medications to be exposed to contamination and administered to other pain management patients. Findings follow:

A. On 04/11/17 between 1255 and 1340, a tour was conducted of the Pain Management Unit. The following opened MDV of medications (not being treated as single use) were observed in Procedure Room #1 and Procedure Room #2 and were available for use in the immediate patient care area in which the likelihood of contamination existed:

1) Procedure Room #1
a) Three Betamethasone 30 milligrams (mg)/5 milliliters (ml); and
b) One Xylocaine 1% 20ml.
2) Procedure Room #2-One Betamethasone 30mg/5ml.
B. An interview was conducted with the Chief Clinical Officer (CCO) at 1325 on 04/11/17 regarding the opened MDV of medication in Procedure Room #2. It was verified one opened MDV of Betamethasone 30mg/5ml was in the immediate patient care area, not being treated as single use and available for administration to other pain management patients. A second interview was held with the CCO at 1340 on 04/11/17 regarding the opened MDV of medications in Procedure Room #1. It was verified the three opened MDV of Betamethasone 30mg/5ml and one opened MDV of Xylocaine 1% were in the immediate patient care area, not being treated as single use, and available for administration to other pain management patients.


27453

Based on observation and interview, it was determined the Infection Control Officer failed to have system in place to identify and control infections in that there were soiled furnishings, tape residue, expired supplies, torn equipment coverings, dust, and opened sterile packages in four (Operating Room #1, Pain Management Unit, Patient Care Unit and the Emergency Department) of six (Operating Room #1, Pain Management Unit, Patient Care Unit and the Emergency Department, Pre-op, and Post Anesthesia Care Unit) areas observed. The failed practices did not assure patients would be protected form likely sources of infection. The failed practice was likely to affect the census of 13 patients on 04/10/17 and all patients admitted to the facility. The findings were:

A. Observation of Operating Room (OR) #1, identified by the OR Clinical Coordinator as ready for patient use, on 04/11/17 between 1453 and 1519 revealed:
1) Two of two step stools with an accumulation of dried material on the top surface. The OR Clinical Coordinator stated "That is probably bone wax and is hard to remove." The residue did not allow the stools to be disinfected between cases.
2) Tape residue on the desk surface in OR #1. The residue did not allow the desk surface to be cleaned/sanitized.
3) A paper magazine in the second drawer of the anesthesia cart. The paper composition of the magazine could not be cleaned/sanitized between patients.
4) Episicon Spinal Epidural Anesthesia, one of one in drawer three of the anesthesia cart available for use that expired 02/2017. Sterility could not be assured if used past the expiration date.
5) Cervical traction bar with cloth type cord attached that was visibly discolored. The material of the cord was porous and could not be sanitized between patients.
6) A heating pad with a ripped cloth exterior was observed plugged into the Anesthesia Cart and draped over the side of the cart. The ripped cloth exterior could not be cleaned/sanitized between each patient.
7) Two of two laryngoscope blades were unprotected and attached to the handles which were stored upright on the surface of the anesthesia cart. The blades were not protected from likely sources of infection or contamination after sterilization or high level disinfection until use.
8) One of one Yankauer suction package was opened on one end and attached to tubing. The sterile package of the Yankauer suction was opened prior to use and therefore sterility could not be assured.
The findings in A.1 - 8 were confirmed on 04/11/17 by the OR Clinical Coordinator and Director of Surgical Services at the time of observation.

B. Observation of the Pain Management Unit which included Procedure Room #1 and #2 on 04/11/17 between 1255 and 1340 revealed:
1) Procedure Room #1 had a black cart identified by the Clinical Coordinator of Pain Management Services as a "Procedure Cart." Observation of the top drawer of the cart revealed a container of mints that had been opened in the top drawer along with sterile supplies and syringes. Food items stored with sterile supplies did not assure the integrity of the sterile items would be assured. Tape residue was observed along the top edges of the Procedure Cart. The tape residue did not allow the surface of the Procedure Cart to be cleaned/sanitized.
2) Procedure Room #2 had in the top drawer of the Procedure Cart 15, 5 milliliter (ml) syringes and 3, 3 ml syringes, open with the needle and needle cover attached. The 18 syringes and needles had been removed from their original sterile, single use packaging in advance of use and placed in the drawer; therefore sterility could not be assured.
3) The room located between Procedure Room #1 and #2, identified as a "clean room" by the Clinical Coordinator of Pain Management Services, revealed:
a. One of one box style fan stored on the floor. The fan on the floor did assure it was clean and was included in the same storage area as sterile supplies.
b. Two large cardboard boxes stacked one on top of the other on the cabinet surface with paper documents stored within. The boxes with paper records and documents could not be cleaned/sanitized and were in the same storage area as sterile supplies.
c. Three of three wrapped surgical packages, identified as "large probes". There was no label that identified when the item was sterilized or that the contents were sterile.
d. The Clinical Coordinator of Pain Management Services stated the label probably "fell off" and that the sterile packs without a dust cover were sterile for 30 days.
The findings in B. 1 - 3 were confirmed on 04/11/17 at the time of observation by the Clinical Coordinator of Pain Management Services.

C. Observation of the Patient Care Unit on 04/11/17 between 1413 and 1445 revealed:
1) One of one crash cart had an accumulation of dust on the top surface. The Director of Quality confirmed the findings of dust on 04/11/17 at 1445.
2) Patient Room 116 was identified as clean and ready for patient occupancy on 04/11/17 at the time of observation. The computer keyboard in the room had an accumulation of dust on the keyboard surface. The presence of dust on the keyboard was confirmed at the time of observation by the Director of Patient Care Services.

D. Observation of the Emergency Department on 04/11/17 between 1346 and 1412 revealed:
1) One of one stretcher, identified as ready for patient occupancy at the time of observation by the Director of Ancillary Services, had three drops of a reddish brown material on the edge.
2) In an adjacent room to the Emergency Department, five stretchers were stored and identified as ready for patient occupancy by the Director of Ancillary Services. Five of five stretchers had an accumulation of dust and two of five stretchers had drops of reddish brown substance.
The findings in D. 1-2 were confirmed by the Director of Ancillary Services at the time of observation.

Review of the Operating Room Log, policy and procedure review and interview, it was determined the facility failed to include 2 (Pre-operative and Post-operative diagnoses) of the 14 required elements (patient's name, hospital number, date of the operation, inclusive or total time of the operation, name of the surgeon and any assistant(s), name of nursing personnel (scrub and circulating), type of anesthesia used and name of person administering it, operation performed, Pre and post-op diagnosis, and age of patient) on the Operating Room Log.
Failure to include the required elements did not allow the facility to identify, track and trend potential problems. Findings follow:

A. Review of the Operating Room Log received from the Director of Perioperative Services/Central Sterile/Testing at 1300 on 04/11/17 revealed the log did not contain preoperative and postoperative diagnoses. The above was verified by the Director of Perioperative Services/ Central Sterile/Testing during an interview at 1550 on 04/12/17.
B. Review of the policy and procedure titled "Operating Log" received from the Director of Quality at 1330 on 04/12/17 revealed preoperative and postoperative diagnoses were not on the list of elements required by the policy and procedure.

Based on clinical record review and interview, it was determined the facility ailed to assure the time of the surgery was documented in 24 of 24 (#1, #3-#5, #7-#20, #26-#31) operative reports. Failure to document the time of the surgical procedure did not allow the facility to establish a time line of events and procedures that occurred during the patient's hospital stay. The failed practice affected Patient #1, #3-#5, #7-#20, #26-#31 and was likely to affect all surgical patients. The findings were:

A. The following Operative Reports were reviewed and lacked the time of the surgical procedure. The findings were confirmed by the Clinical Coordinator of the Patient Care Unit on:
Patient #1, 04/13/17 at 1255
Patient #3, 04/13/17 at 1410
Patient #4, 04/13/17 at 1530
Patient #5, 04/14/17 at 0937
Patient #7, 04/14/17 at 1046
Patient #8, 04/14/17 at 1110
Patient #9, 04/14/17 at 1113
B. The findings were confirmed by the Clinical Coordinator on:
Patient #10, 04/13/17 at 1507
Patient #11, 04/13/17 at 1324
Patient #12, 04/13/17 at 1406
Patient #13, 04/13/17 at 1431
Patient #14, 04/13/17 at 1511
Patient #15, 04/13/17 at 1526
Patient #16, 04/13/17 at 1535
Patient #17, 04/14/17 at 0851
Patient #18, 04/14/17 at 0914
Patient #19, 04/14/17 at 0928
Patient #20, 04/14/17 at 0945
Patient #26, 04/14/17 at 1000
Patient #27, 04/14/17 at 1013
Patient #28, 04/14/17 at 1009
C. The findings were confirmed by the Director of Patient Care Services on:
Patient #29, 04/14/17 at 1036
Patient #30, 04/14/17 at 0935
Patient #31, 04/14/17 at 0903

Based on review of policies and procedures, Patient Care Unit assignments, review of personnel files and interview, it was determined the facility failed to assure one (#2) of four (#2-#4) RN Charges Nurses assigned to the Emergency Department was certified in Pediatric Advanced Life Support (PALS) as required by facility policy. The facility could not assure emergency care needs of pediatric patients would be met. The failed practice was likely to affect any pediatric patient who presented to the Emergency Department. The findings were:

A. Review of Policy ED 15.0: "ED Staffing Pattern" provided revealed "The ED cares for persons in all age groups; therefore, the ED staff must acquire skills needed for the care and treatment of each age group. The ED RN will be certified in ACLS (Advanced Cardiac Life Support) and PALS." "Minimum staffing will include at least one RN available to the ED on a 24 hour basis."

B. On 04/10/17 at 1309, the Director of Patient Care Services stated the Charge Nurse (from the Patient Care Unit) was the only Registered Nurse assigned to work in the ED and all Charge Nurses have PALS.

C. Review of the Patient Care Assignments revealed RN #2 was assigned as Charge Nurse and to cover the ED per shift. RN #2 was assigned as Charge Nurse, 8 (03/14/17-03/16/17; 03-23/17, 03/24/17; 03/28/17; 03/31/17 and 04/02/17) of 28 day (0700-1900) shifts from 03/13/17 - 04/09/17. The staffing assignments as above were reviewed and confirmed with the Director of Patient Care Services on 04/11/17 at 0950.

D. Review of Personnel files on 04/11/17 at 0900 revealed RN #2 did not have evidence of PALS training or certification. RN #2 had a hire date of 03/05/14. The lack of PALS training/certification was confirmed by the Director of Patient Care Services on 04/11/17 at 1457.