HospitalInspections.org

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Based on observation and staff interview, the facility failed to ensure humidity levels in 4 of 4 operating rooms and 1 procedure room were maintained at environmentally safe levels. The findings were:

During observation of the 4 operating rooms and 1 procedure room on 9/13/16 at 11 AM, the director of perioperative services stated the maintenance director was responsible for monitoring the temperature and humidity in these areas. Interview on 9/13/16 at 5 PM with the maintenance director revealed to maintain adequate air flow, the humidity level was maintained at levels higher than 60%, usually 70% to 80% consistently during the summer. He further stated the facility did not have a dehumidifying system that supported lowering the humidity level to 60%; therefore, the alarm system had been set to activate when humidity levels were identified as out of range at higher than 80%. He was unable to provide monitoring logs or computer printed reports regarding time frames and frequency of out of range humidity levels. Review of the facility policy and procedure titled "Infection Control in the OR [operating room], 6300-0400-01", approved August 2016, revealed the facility was required to maintain the humidity in the ORs and procedure rooms between 30% and 60%.

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Based on policy review and staff interview, the facility failed to ensure patient care policies were reviewed annually by the required individuals. The findings were:

Review of random patient care policies showed they were reviewed annually by department heads and the CNO and CEO. However, interview on 9/14/16 at 3:45 PM with the CNO and quality director revealed the facility failed to ensure a group that included a physician and one or more mid-level professionals reviewed the facility policies annually.

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Based on observation, review of facility policies and professional standards, and staff interview, the facility failed to ensure staff complied with acceptable infection control standards related to safe injection practices for 1 of 2 sample patients (#24) observed receiving perioperative care, glucometer disinfection for 1 of 1 sample patient (#23) observed receiving blood sugar level testing, and unsanitary vents in 1 of 4 operating rooms (OR #4). In addition, the facility failed to ensure an effective system for disinfecton prior to use for instruments in the emergency room. The findings were:

1. Observation of pre-operative care provided for patient #24 on 9/13/16 at 12:45 PM revealed the following concerns:
a. CRNA #1 did not disinfect intravenous ports prior to administering medications. Continued observation revealed he did not disinfect the septums on medication vials prior to needle insertion when he withdrew medications from the vials.
b. Review of the policy and procedure titled, "Lippincott Procedures - IV Bolus Injection", revised 4/15/16, showed staff were required to perform a vigorous mechanical scrub of the lowest needleless injection port of administration tubing for at least 5 seconds with an antiseptic pad; then allow it to dry completely" prior to administering the medication through the intravenous access.
c. The Association for Professional in Infection Control and Epidemiology (APIC) standards for safe injection practices, published in the American Journal of Infection Control, April 2010, recommends intravenous ports, vial stoppers, and access diaphragms be disinfected prior to each use. According to the Centers for Disease Control and Prevention (CDC) recommendations for Safe Injection Practices, updated 2011, the septum on the medication vial and intravenous ports should be disinfected before piercing.

2. Observation on 9/13/16 at 12:25 PM revealed RN #1 used a glucometer for testing patient #23's blood glucose level. Observation revealed the RN did not disinfect the glucometer after she completed the task. Continuous observation revealed the glucometer remained on the bedside stand while additional staff and family entered the patient area. Interview on 9/13/16 at 3 PM with the director of perioperative services revealed the glucometer was a multi-patient use device and the hospital's standards of practice required disinfection after use.

3. Observation with the director of perioerative services on 9/13/16 at 11 AM, revealed lint and debris on two vents in OR #4. At that time the OR manager stated OR #4 was used for storage. Further observation revealed the anesthesia machine was stored directly in front of one of the vents. Interview on 9/13/16 at 1:30 PM with director of environmental services #1 revealed they had a schedule for cleaning the vents and grills and the ones in OR #4 must have been "overlooked."

4. Observation in the emergency department on 9/13/16 at 1:40 PM showed the emergency airway cart had 4 McGill forceps and 3 laryngoscope blades in a drawer that were available for use. However, the facility failed to package the instruments to ensure they were disinfected prior to use. Interview with the CNO at that time confirmed the items were available for use, but not packaged.

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Based on observation, staff interview and review of maintenance logs, the facility failed to ensure sanitary conditions in 1 of 1 kitchens and for 2 of 2 ice machines. The resident census was 10. The findings were:

1. Issues identified related to ice machines:
a. Observation on 9/13/16 at 4:45 PM showed the ice machine located on the 3rd floor medical unit was noted to have rust colored debris on the interior of the lid and the edge of the ice bin.
b. Observation on 9/13/16 at 4:22 PM of the ice maker/dispenser unit located in the cafeteria showed it appeared clean on the outside surface. When asked about sanitation, the dietary supervisor verified the dietary staff did not perform this function and she would try to locate information.
c. Interview with the dietary supervisor on 9/13/16 at 4:45 PM revealed the 3rd floor machine was old and required frequent repairs by maintenance. The maintenance department was also responsible for the sanitation of the machine.
d. Review of the scheduled work order log showed the ice machine on the 3rd floor medical unit had a completed date for each month with the most current being 8/30/16. However the information as to what was done was not included. Additionally, interview with the quality director on 9/14/16 at 9:15 AM verified there was no policy and procedure related to sanitation of ice machines, and the one located in the cafeteria was not included on the maintenance log.

2. Observation in the kitchen on 9/13/16 at 4:22 PM showed the following sanitation issues related to cleanliness and poor condition of equipment:
a. Three plastic pitchers were stored on a clean shelf. The pitchers had cracks and fissures throughout.
b. Thirteen cutting boards which were stored on a rack for use. These cutting boards were in poor condition with scores and stains.
c. The 2 ceiling vents located above the back food preparation table had an accumulation of black dust and grease on and around the vents.
d. The wall behind the steamer had paint which was peeling away in large sections.

3. Interview with the dietary supervisor on 9/13/16 at 4:45 PM verified the equipment items were not in good condition and needed to be replaced. She also verified the vents and wall behind the steamer needed to be addressed and maintenance would need to be made aware.

According to Food Code 2013, U.S. Public Health Service: 4-601.11 "(A) Equipment food-contact surfaces and utensils shall be clean to sight and touch...(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris."

According to Food Code 2013, U.S. Public Health Service: 4-201.11 "EQUIPMENT and UTENSILS shall be designed and constructed to be durable and to retain their characteristic qualities under normal use conditions.

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Based on service agreements review and staff interview, the facility failed to ensure a list of 6 of 6 services (radiology, otolaryngology, neurology, oncology, ophthalmology, infectious disease) under arrangement or agreement was maintained. The findings were:

Review of agreements between the facility and outside entities showed agreements were in place for radiology (tele-radiology reading), otolaryngology, neurology, oncology, ophthalmology, and infectious disease. Interview with the CNO and quality director on 9/14/16 at 3:45 PM revealed the facility failed to maintain a list of the services furnished under arrangements/agreements. Further, they were not aware the list was required to describe the nature and scope of the services provided.

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Based on medical record review, staff interview, and policy review, the facility failed to ensure informed consents were properly completed for 3 of 6 sample patients (#4, #12, #20) who required informed consents. The findings were:

Medical record review included 3 obstetric patients who received epidurals (spinal anesthetic) during labor. The following issue with informed consent were identified:
a. Medical record review showed patient #4 was admitted to the facility on 9/11/16 in labor and received an epidural at that time. The review confirmed the patient had a consent for the epidural anesthesia titled, "Patient Informed Consent for Anesthesia." However, the following areas were incomplete on the form: The area for who was authorized to administer anesthesia was blank, the area for exceptions was blank, the date the patient signed was 9/2/16 (9 days before epidural) and had no time documented as required, and the "Anesthesia Provider Signature" was blank for signature, date, and time.
b. Medical record review showed patient #12 was admitted to the facility on 9/12/16 in labor and received an epidural at that time. The review confirmed the patient had a consent for the epidural anesthesia titled, "Patient Informed Consent for Anesthesia." However, the following areas were incomplete on the form: The area for patient name related to authorization was left blank, the area for who was authorized to administer anesthesia was blank, and the area for exceptions was blank.
c. Medical record review showed patient #20 was admitted to the facility on 6/9/16 in labor and received an epidural at that time. The review confirmed the patient had a consent for the epidural anesthesia titled, "Patient Informed Consent for Anesthesia." However, the following areas were incomplete on the form: With the exception of the patient's signature for risks and benefits, the entire form was left blank including the date and time the patient signed.
d. Interview with CRNA #2 on 9/14/16 at 1:30 PM confirmed the 3 sample obstetric patients had incomplete informed consents for epidural anesthesia, and the expectation was for the informed consents to be complete in all areas.
e. Review of facility policy titled, "Consents, 3500-0600-01" last approved 12/2016 showed under "Express Consent", ..."At the time of admission, the consent for medical and/or surgical treatment is signed by the patient or authorized representative. This signature will be witnessed by a hospital staff member and the date and time noted. All blank spaces MUST be filled in before the consent is signed."

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Based on medical record review, staff interview, and policy review, the facility failed to complete a post-anesthesia evaluation for 1 of 6 sample patients (#12) who received anesthesia. The findings were:

Medical record review showed patient #12 was admitted to the facility on 9/12/16 in labor and received epidural anesthesia at that time. Review of the record showed the patient was discharged on 9/14/16 without any complications. The following issues were identified:
a. Review of the record showed the time of discontinuance of the epidural anesthesia for patient #12 was not documented, and the facility failed to document a post-anesthesia evaluation.
b. Interview with the quality director on 9/14/16 at 2:30 PM confirmed the facility failed to ensure the patient had a post-anesthesia evaluation, and the expectation was for all patients who receive epidural anesthesia to have a post-anesthesia evaluation.
c. Review of facility policy titled, "Nursing Management of Patient-Controlled Analgesia and Patient-Controlled Epidural Analgesia (PCEA), 6100-0363-05 last approved 8/2016 showed under "Removal" staff were to..."Notify provider of abnormal findings. Document procedure completion, condition of the catheter tip, patient response, and any variances."

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Based on review of patient admission information, and staff interview, the facility failed to ensure swing bed patients were fully informed of all required rights. The swing bed patient census was 1. The findings were:

Review of the swing bed patient admission information showed written information was provided which included patient rights. There was also an acknowledgement form to show the patient received a copy of the "Patient Bill of Rights and Responsibilities." Review of the listed "Patient Rights" failed to show information related to work, mail, access and visitation, personal property, and married couples. Interview with the quality director on 9/14/16 at 9 AM verified the information provided to swing bed patients did not include these areas of rights.

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Based on staff interview and review of policy and procedures, the facility failed to ensure a program of ongoing activities was available for swing bed patients. The swing bed patient census was 1. The findings were:

Interview with the social worker, the director of inpatient nursing, and the quality director on 9/13/16 at 2 PM verified there was no activities program or any activity professional. The interview further verified the current swing bed resident (#1) spent much of his/her time in therapy and initiated their own activities. Review of a "Swing Bed -Admission 6150-0386-02" policy approved 12/2015 showed services which were available included "Activities as appropriate based on evaluations by physical therapy and occupational therapy."

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Based on medical record review and staff interview, the facility failed to ensure a comprehensive assessment was completed for 3 of 3 sample swing bed patients (#5, #11, #14) who required a comprehensive assessment. The findings were:

1. Review of the medical record showed patient #5 was admitted to swing bed status on 2/28/16. Review of the 14 day initial comprehensive assessment showed it was dated 3/11/16. The assessment was a collection of data related to a variety of areas. There was no summary or analysis of the data to determine if care planning was needed. In addition, the review showed the required areas of customary routine, communication, cognitive patterns, activity pursuit, medications, and psychosocial well being were not addressed/completed. Further, there was no documentation of the residents participation in the assessment.

2. Review of the medical record showed patient #11 was admitted to swing bed status on 3/8/16. Review of the 14 day initial comprehensive assessment showed it was dated 3/27/16 (day 19). The assessment was a collection of data related to a variety of areas. There was no summary or analysis of the data to determine if care planning was needed. In addition, the review showed the required areas of customary routine, communication, cognitive patterns, activity pursuit, medications, and psychosocial well being were not addressed/completed. Further, there was no documentation of the residents participation in the assessment.

3. Review of the medical record showed patient #14 was a long term swing bed patient and was admitted to swing bed status on May 18, 1994 and was discharged when s/he expired on 7/22/16. Review of the record showed the 2016 required annual comprehensive assessment was not completed. Review of the most recent comprehensive annual assessment showed it was dated 4/1/15. The assessment was a collection of data related to a variety of areas. There was no summary or analysis of the data to determine if care planning was needed. In addition, the review showed the required areas of customary routine, communication, cognitive patterns, activity pursuit, medications, and psychosocial well being were not addressed/completed. Further, there was no documentation of the residents participation in the assessment.

4. Interview with clinical analyst #1 on 9/13/16 at 3:25 PM verified the electronic comprehensive swing bed assessment was not always being fully completed, and did not capture all of the required areas.