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Based on observation, interview, and record review, the hospital's 1 of 2 outpatient clinics (Specialty Clinic) on 4/26/16 did not keep the drugs in a secure area and the refrigerator that stored the drugs was not locked.

Findings included:

During a tour of the outpatient "Specialty Clinic" on 4/26/16 at 10:30 AM with Personnel #5 the following was observed:

A small refrigerator was observed in an anteroom. The refrigerator had a padlock that was open. The anteroom had no doors and was located in front of the patient rooms. The refrigerator contained the following drugs: 13 single doses of influenza vaccines, 5 single doses of pneumoccocal vaccines, 3 mL pens of "Lantus Solostar 100 units/mL," and an open Tuberculin 5 units/1 mL. Personnel #17 was asked why the refrigerator which contained multiple vaccines was unsecured. Personnel #17 replied she did not know. She stated Personnel #16 was in-charge of all drugs including vaccines.

In an interview on 4/27/16 at approximately 10:00 AM, Personnel #7 was informed of the above findings. She stated that all medications must be secured and the refrigerator in the outpatient clinic should have been locked.

Medication Management Policy # 3.0.13 "Inventory Control" reviewed 2/2015 required "III...H. Medications stored in a refrigerator will be secured..."

Based on observation, interview, and record review the hospital failed to ensure the dietary department requirements were in compliance in that the following was observed during the survey on 4/25/16:
1) 1 of 8 dietary staff (Personnel #46) did not wear an effective hair restraint;
2) The floor inside the only dry pantry had cracked, peeling and discolored tiles with rusty stains. Areas of the baseboard were missing or pulling away from the wall;
3) 2 of 2 opened steak sauces and 4 of 4 opened cans of icing did not have an opened date written on the containers; and
4) Sixteen of approximately 24 plastic drinking glasses were stored wet and were stacked upon one another.

Findings included:

During a tour of the facility's only kitchen at 10:30 AM on 04/25/16 the following was observed. Personnel #45 was present and confirmed the findings below:

1) Personnel #46 did not have on a hair restraint. The surveyor asked Personnel #46 why he wasn't wearing a hair restraint and he said he couldn't find one.

2) The dry pantry's linoleum floors had tiles that were peeling with rust stains and discoloration. Areas of the baseboard were missing or pulling away from the wall. On a column in the center of the room the baseboard was completely missing exposing dry, yellow glue. On 2 areas of the baseboard peeling tape was observed holding the baseboards together at 2 of the wall's corners.

3) In the dry pantry 2 opened steak sauces and 4 opened cans of icing did not have an opened date written on the containers.

4) Sixteen plastic drinking glasses were stored wet and stacked upon one another on a counter top next to the coffee maker.

During an interview on 04/25/16 at 10:50 AM with Personnel #45 she confirmed the above findings.

A review of the hospital's Dress Code policy with a revised date of 12/14/15 reflected, "...Hair net or covering must be worn when working in the kitchen or cafeteria unless head is shaved..."

A review of the hospital's Food Labeling and Dating policy with a reviewed date of 02/08/16 reflected, "...All stored foods shall be labeled to indicate type of product and date prepared or date the product is to be discarded... Items such as Salad Dressing, Mustard, Soy Sauce, etc. are dated with the date they were opened and discarded according to manufacturer's shelf life or a month from open date, whichever comes first..."

Based on observation and interview, the hospital did not maintain supplies and equipment in that:

A. 2 of 2 opened bottles of hydrogen peroxide found in the outpatient "Specialty Clinic" expired and/or were not dated and initialed when initially opened.

B. In operating room (OR) #5, 1 of 4 glass panes in a cabinet was broken and held in place with tape.

Findings included:

A. During a tour of the outpatient "Specialty Clinic" on 4/26/16 at 10:30 AM with Personnel #5 the following was observed:

In patient room #1 was an open bottle of 4 fluid ounces of hydrogen peroxide 3% available for patient use. Personnel #17 was asked what the process was when opening a multidose bottle of hydrogen peroxide. Personnel #17 replied the bottle was opened yesterday and forgot to put the date and employee's initials.

In an anteroom of the clinic across from patients' rooms, an open bottle of 16 fluid ounces of hydrogen peroxide 3%, expired on 6/2013 was found. No date and employee initials were found on the bottle. Personnel #17 stated they have been using the hydrogen peroxide and have been left in the anteroom. Personnel #17 did not know the hydrogen peroxide was expired.

B. During a tour of the OR suite on the morning of 04/26/16 the following was observed and confirmed by Personnel #40.

A glass pane in a cabinet in operating room (OR) #5 was broken and held in place with tape.


27128

Based on observation, interview, and record review, the facility's infection control officer did not ensure the following infection control issues were addressed:

A. 1 of 3 sharp containers found in the outpatient Specialty Clinic was not changed and the container was in the fill line;

B. 1 of 1 two-tier cart in the laboratory area of the outpatient Specialty Clinic had clean supplies. The bottom shelf of the cart that had clean supplies was observed to have multiple scattered white circular spots about 3/4" and black sticky matter that measured approximately 3" x 4;"

C. 3 of 6 staff members (Personnel #36, #39, and #42) did not wear effective hair restraints during surgery in the operating room (OR);

D. 1 (Personnel #42) of 2 vendors who were wearing cleanroom suits during surgery in the OR had a tear in his suit;

E. 1of 1 staff member (Personnel #43) that was observed inserting an IV (intravenous line) did not sanitize her hands after removing her gloves;

F. 2 of 3 personnel (Personnel #38 and #44) were observed in the pre-op area with face masks in their pockets. Personnel #38 had 2 medication filled syringes in her pocket;

G. 6 of 6 clean supplies (3 Bicarbonate jugs, 2 packages of bloodlines, and 1 acid concentrate jug) were stored on a cart inside the dialysis restroom right beside the toilet bowl;

H. 1 of 1 personnel (Personnel #10) was observed in the hemodialysis unit with a face mask below her nose while she drew blood from the patient's blood lines;

I. 1 of 1 personnel (Personnel #10) chewed gum while she drew blood from the patient's blood lines and discontinuance of the patient's dialysis treatment; and

J. 1 of 1 personnel (Personnel #10) removed 2 arteriovenous fistula (AVF) needles from patient #1's vascular access and placed the used AVF needles where the patient's left arm rested while personnel #10 held the patient's vascular site.

Findings included:

During a tour of the outpatient clinics of the hospital on 4/26/16 at 10:30 AM with Personnel #5 the following was observed in the Specialty Clinic:

A. In patient room #1 a sharp container was found to be full up to the fill line. Personnel #17 was asked if she agreed with the surveyor that the sharps container was full. She replied that it had been full for about 2 weeks and could not change it until the order for sharp containers arrived. She stated she ordered it about 2 weeks ago. Personnel #5 was asked to check the sharps container order. At approximately 1:40 PM on 4/26/16 a computerized document was provided to the surveyor regarding the sharps container order. According to the computerized document, the sharps container was delivered on 4/7/16.

B. In the laboratory area, the surveyor observed a two-tier cart that stores clean supplies. On the middle portion of the bottom shelf, multiple scattered white circular spots about 3/4" and black sticky matter that measured approximately 3" x 4" were observed. In the presence of Personnel #5, Personnel #17 was asked when the cart was last cleaned. She replied she did not know. She stated she had been employed in the clinic for a year and the cart had been "like that."

In an interview on 4/26/16 at approximately 1:50 PM, Personnel #4 was informed of the above findings. She confirmed that the sharps container should have been changed when it became full and the cart should have been cleaned.

C. On 4/26/16 at approximately 10:15 AM 3 (Personnel #36, #39, and #42) personnel were observed wearing skull caps during surgery in OR #1. Their hair was not contained at the nape of the neck and the surrounding area around their ears.

D. On 4/26/16 at approximately 10:20 AM Personnel #42 was observed wearing a cleanroom suit during surgery in OR 1. The suit had a tear at the area over his right back pants pocket. Personnel #42 came out of the OR and Personnel #40 asked him to change his cleanroom suit because it had a tear. Personnel #42 said he tore the suit on purpose so he could reach his back pocket easily.

E. On 4/26/16 at 10:55 AM Personnel #43 was observed inserting an IV (intravenous line) into Patient #28's left arm. She did not sanitize her hands after removing her gloves.

F. On 4/26/16 at 11:15 AM Personnel #38 was observed in the pre-op area with a face mask in her pocket and 2 medication filled syringes in another pocket. Personnel #44 was in the pre-op area with 2 face masks in her pocket.

During an interview with Personnel #40 on 4/26/16 at approximately 11:40 AM she confirmed staff shouldn't carry their masks or syringes in their pockets, and staff should sanitize their hands after removing their gloves. She said the hospital followed AORN (Association of periOperative Registered Nurses) standards and recommendations.

During a tour of the facility's hemodialysis unit on 4/25/16, the surveyor observed the following:

~ At 10:50 AM:
G. 6 of 6 clean supplies (3 Bicarbonate jugs, 2 packages of bloodlines, and 1 acid concentrate jug) were stored on a cart inside the dialysis restroom right beside the toilet bowl;

This finding was confirmed in an interview with personnel #10 on 4/25/16 at 10:55 AM.

~ At 1:30 PM:
H. Personnel #10 drew blood from the patient's dialysis access with her glasses on and with the face mask below her nose, with her nose exposed.

I. Personnel #10 was observed drawing blood from the patient's access and discontinued the patient's dialysis treatment, chewing during drawing blood and discontinuance of the dialysis treatment.

This finding was confirmed in an interview with personnel #10 on 4/25/16 at 1:40 PM.
When personnel #10 was asked what was she chewing while she drew blood and/or discontinuance of the dialysis treatment, she replied, "I'm nervous, that's my thing, I chew gum."

~ At 1:45 PM:
J. 1 of 1 personnel (Personnel #10) removed 2 arteriovenous fistula (AVF) needles from patient #1's vascular access and placed the used AVF needles on top of the bed where the patient's left arm rested while personnel #10 held the patient's vascular site. Personnel #10 picked up the two used AVF needles and walked approximately 6 steps to the sharps container that hung on the wall.

This finding was confirmed in an interview with personnel #10 on 4/25/16 at 1:55 PM.

"Infection Prevention and Control Policy...Cleaning, Disinfection..." page 7 revised 2/2015 required "a. Clean housekeeping surfaces...on a regular basis...and when these surfaces are visibly soiled."

The AORN (Association of periOperative Registered Nurses) 2014 Edition Recommendation IV, page 53 reflected "...All personnel should cover head and facial hair, including side-burns and the nape of the neck, when in the semirestricted and restricted areas...IV.a ...Head coverings designed to contain hair and scalp skin will minimize microbial dispersal. Skull caps may fail to contain the side hair above and in front of the ears and hair at the nape of the neck..."

The Dialysis Policy dated 2/10/07 included "...IV. Procedure...1. Infection Control...e. Staff members will wear gowns...and face shields or goggles and masks to protect themselves...when performing procedures during which spurting...of blood might occur...staff members will not eat...in the dialysis treatment area...6. Environmental practices...C. Equipment...iii. Needles and sharps...b). Disposable needles and...must be discarded in puncture proof..."







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31016

Based on observation, interview, and record review, the hospital's 1 of 2 outpatient clinics (Specialty Clinic) on 4/26/16 did not have appropriate professional employee and discharge instructions. The clinic had 2 full time certified medical assistants (CMAs) that conducted patient assessments.

Findings included:

During a tour of the outpatient "Specialty Clinic" on 4/26/16 at 10:30 AM with Personnel #5 the surveyor reviewed 2 patient medical records (Patient #4 and #5) that were seen by physicians earlier that morning. Patient #4's and #5's assessments were recorded in preprinted forms called "DMC Senior Healthcare Center Assessment." The forms contained Patient #4's and Patient #5's allergies, weight, vital signs, chief complaint, and history of present illness. The forms also contained "ROS (review of systems) that was all negative; High risk for skin breakdown: No; High risk for falls: not checked; Signs and Symptoms of Possible Abuse Victim: No...Reviewed patient's diagnosis/conditions...adverse allergic reactions and medications: No changes. Both assessments were signed by Personnel #16 in the "RN Signature (registered nurse)" line. Personnel #16 and #17 were non-professionals that could not conduct nursing assessments. Both Patient #4 and #5 did not have discharge instructions/teaching before they were discharged from the clinic.

In an interview on 4/26/16 at 10:40 AM in the presence of Personnel #5, Personnel #17 was asked who conducted Patient #4's and Patient #5's assessments and showed Personnel #17 the documentation. Personnel #17 replied "Personnel #16." Personnel #17 was asked if Personnel #16 was a registered nurse (RN). Personnel #17 replied she was not and stated "Personnel #16 was a CMA just like me." Personnel #17 was asked if there was a RN working in the clinic. Personnel #17 replied there was none. Personnel #17 stated "its me and Personnel #16" who worked in the clinic.

In an interview on 4/26/16 at approximately 1:40 PM, Personnel #2 was informed of the above findings. Personnel #2 confirmed the findings.

Policy 5.100 "Discharge from the Hospital" reviewed 2/2016 required "II...Discharge instructions will be provided by a registered nurse and documented on appropriate instruction sheet."