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Based on observation, interview and policy review, the facility failed to ensure staff checked emergency code carts and failed to ensure the integrity of the breakaway locks on emergency carts not in constant surveillance. This had the potential to affect all patients receiving emergency treatment. The hospital census was nine.

Findings include:

1. The facility's Emergency Department including a triage room, trauma bay, 11 treatment rooms, and four observation rooms, was toured on 07/23/24 at 12:50 PM. An emergency cart was observed in the two-bed trauma room. A red breakaway lock was threaded through only the first hole within the locking handle and then through itself. The breakaway lock was not threaded through the second hole which allowed the nine drawers of the emergency cart to be opened leaving emergency medication and equipment unsecured. Drawers one and two contained advanced cardiac life support drugs. Drawers three to eight contained basic airway equipment including bag valve masks, nasal cannulas, and oxygen masks. Drawer nine, a gray color, contained a tackle box with a label that read "Code Drugs." Drawer nine also contained Diazepam 2.5 mg rectal gel (emergency medication used to stop cluster seizures).

Staff B, present during the tour, confirmed that the breakaway lock should've been threaded through both holes of the locking handle in order for the drawers to remain locked, thereby securing emergency medication and equipment.

Review of the policy titled "Standardized Medications on Crash Carts", approved on 02/11/15, stated during a code the plastic lock is broken on the crash cart to make medication available. After the code, the nurse will remove medication trays and exchange them at the pharmacy for new trays. Nursing will then replace the plastic lock on the cart.


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2. Environmental tour conducted on 07/23/24 between 2:29 PM and 3:10 PM revealed the facility's crash cart located in the main hallway between the medical surgery patient area and the ICU unit failed to document the daily monitoring of the crash cart as follows:

Review of the months of April, May, June and July to date of 07/25/24 there were no daily crash cart checks as follows:
Between 04/12/24 and 04/20/24 elapsed time of 8 days
Between 04/21/24 /and 4/23/24 elapsed time of 2 days
Between 04/26/24 and 4/30/24 elapsed time of 4 days
Between 04/30/24 and 05/03/24 elapsed time of 2 days
Between 05/03/10 and 05/10/24 elapsed time of 7 days
Between 05/13/23 and 05/18/24 elapsed time of 5 days
Between 05/23/24 and 05/25/24 elapsed time of 2 days
Between 05/28/24 and 06/01/24 elapsed time of 4 days
Between 06/06/24 and 06/09/24 elapsed time of 2 days
Between 06/12/24 and 06/15/24 elapsed time of 2 days
Between 06/17/24 and 06/22/24 elapsed time of 4 days
Between 06/23/24 and 06/29/24 elapsed time of 5 days
Between 07/03/24 and 07/09/24 elapse time of 5 days
Between 07/09/24 and 07/13/24 elapsed time of 3 days
Between 07/14/24 and 07/17/24 elapsed time of 2 days
Between 07/20/24 and 07/22/24 elapsed time of 1 day

During an interview on 07/25/24 at 3:23 PM, Staff A confirmed it was the expectation that facility nurses checked the emergency crash carts daily. Staff A stated it was usually night shift but it should be done and documented on the Crash Cart Check sheet daily. Nursing leadership collected the sheets at the end of the month.

During an interview on 07/25/24 at 4:01 PM, Staff B stated the facility had inpatients during the times the facility failed to monitor the medical surgical unit crash carts.

3. During an observation on 07/23/24 at 1:47 PM, the emergency department (ED) front crash cart did not have the red plastic lock securely latched to the cart leaving the contents of the cart unsecured. The cart contained commonly used code medications such as first and second level Advanced Cardiac Life Support (ACLS) medications, endotracheal tubes used during insertion of breathing tubes, syringes, needles, and other commonly used supplies utilized during codes.

Staff B was present during the observation and confirmed the findings.


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4. During an observation on 07/24/24 at 2:30 PM, the Radiology and Nuclear Medicine departments were toured. A crash cart in the Stress Lab was unlocked and unattended by staff.

Staff G was present during the observation and confirmed the findings.

Review of the policy titled "Standardized Medications on Crash Carts", approved on 02/11/15, stated during a code the plastic lock is broken on the crash cart to make medication available. After the code, the nurse will remove medication trays and exchange them at the pharmacy for new trays. Nursing will then replace the plastic lock on the cart.

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Based on record review, observation, interview and policy review, the facility failed to ensure expired medications and supplies were disposed of and failed to meet the requirements for NFPA 101-2012 Edition, Chapter 19 Existing Healthcare. This has the potential to affect all patients receiving services in this facility.

See A922 and K345, K353, K372, K374, K761 and K918.

Based on observation and interview, the facility failed to ensure expired medications and medications were disposed of. This had the potential to affect all patients receiving care in the facility. The hospital census was nine.

Findings include:

1. During an observation of 07/24/24 at 10:30 AM, the storage closet in Room 1 of the Sleep Lab contained a bottle of Gebauer Ethyl Chloride Topical Spray (topical medication used to prevent pain caused by injections and minor surgical procedures) with an expiration date of 02/23.

The storage closet in Room 2 of the Sleep Lab contained two Nu prep Skin Prep Gel (lowers skin impedance to enhance performance of a monitoring electrode) with an expiration date of 01/01/24.

The cabinet above sink in the respiratory department had a box containing 40 plastic vials of 0.9% Sodium Chloride inhalation solution (used to moisten airways and to loosen mucus or phlegm to help improve lung function) with an expiration date of 07/22.

Staff F was present during the observation and confirmed the findings.

2. During an observation of the pharmacy on 07/24/24 at 1:40 PM, the storage shelf contained a bottle of Doxycycline for Patient #32 that had no expiration date.

During an interview on 07/24/24 at 1:45 PM, Staff J stated he was uncertain of an expiration date for the medication and the medication should've been disposed of.

3. During an observation on 07/24/24 at 3:05 PM, the storage closet in infusion department contained two bags Lactated Ringer's Electrolyte Injection Solution (replaces electrolyte loss in patients with low blood volume or low blood pressure) with an expiration date of 06/24
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Staff K was present during the observation and confirmed the findings.

The freezer in the infusion department contained two frozen meals, one with an expiration date of 07/22 and the other 09/23.

Staff A was present during the observation and confirmed the findings.

See Life Safety Code Report

Based on observation, interview and policy review, the facility failed to ensure medical records were protected from unauthorized access, fire or water damage. This had the potential to effect any patient whose paper charts were stored in the facility's on site barn storage area. The current census was nine.

Findings include:

During an observation on 07/25/24 at 10:25 AM, the pole barn on the facility property housed vehicles, tractors, and environmental grounds machinery, equipment and supplies used in property management. The facility maintenance man unlocked the barn entry door, as well as a separate door that opened to a generalized storage area that contained a caged area which contained medical records. These locked areas were all unlocked by the facility maintenance staff. There were greater than six large metal shelving units filled with unboxed medical records and stored by medical record number dated between 2016 and 2022. There were no protective coverings of these medical records. There were were no sprinklers observed in the storage area of the barn.

During an interview on 07/25/24 at 10:05 AM, Medical Record Staff N stated the facility medical records were primarily electronic since fall of 2020 however there were some hard paper medical records that the facility stored on site in the barn located behind the main hospital. Staff N stated she did not have keys to the barn but the facility's maintenance department did. Staff N stated there were probably thousands of medical records in the barn that had recently been removed from a secured storage facility and placed in the barn on the hospital property. Staff N stated she estimated only three to five percent of the medical records stored in the barn had been scanned into the facility's electronic medical record system. Staff N stated the building was not equipped with a sprinkler system in the event of fire nor were the records safe from non-authorized staff. Staff N confirmed the medical records contained protected health information.

Review of the policy titled "Health Insurance portability Act (HIPPA)", reviewed 05/02/23, listed the established minimum level of protection for patient information and administrative steps for compliance. The minimum necessary and the least amount of information necessary to accomplish the permitted task. The policy directed that protected health information included information on patients' past, present and future physical and mental condition; provision of payment; identifying information including name, address, medical record number, telephone number, birthday, admission and discharge dates.

Review of the policy titled "Retention of Secondary Records", reviewed 03/23/22, directed that secondary records were those records that contained patient information or specific information regarding the operation of a department and were not maintained in a medical record. These records were kept separate from medical records and were secured in a secure location.

Based on observation, interview, policy review and manufacturer's recommendations review, the facility failed to ensure staff properly reprocessed cystoscopy equipment. This had the potential to affect any patient who underwent cystoscopy at the facility. The facility performed eight cystoscopic procedures during the month of July 2024. The census was nine.

Findings include:

During an observation on 07/25/24 at 9:20 AM, the cystoscopy (equipment and procedure that allows the visualization the lining of the bladder and the ureter) area of the hospital had one cystoscopy procedure room as well as an associated high level disinfection re-processing room on the lower level of the facility. The facility employed two medical assistants (Staff L and Staff M) who reprocessed used cystoscopes. Observation of the reprocessing room revealed a room equipped with a twin compartment stainless steel sink. There was a one-gallon pump jug of Proslystica 2X Concentrate Enzymatic Presoak and Cleaner. There were no fill marks observed on the sink to indicate any liter or gallon fill points.

During an interview on 07/25/24 at 8:35 AM, both Staff L and Staff M stated the scope reprocessing steps were to bring a used scope placed in a sealed container to the reprocessing room, prepare the left side of the sink (dirty side) with a solution of two pumps of Prolystica cleaner and to add warm water enough to cover the scope; remove the used cystoscope and place in the solution and proceed to clean the entire scope top to bottom, then rinse in clean water in the second compartment, and then place in the electronic cleaner for additional processing. Staff L and Staff M stated they were instructed to use two pumps of the enzymatic cleaner in the left side of the two-compartment sink and add warm water. Neither Staff L nor M could state the amount of water needed to reach the manufacturer's dilution factor. Both stated they had been instructed on how to prepare the solution, but this was many years ago and had not been supervised, observed or competency checked since.

Review of the personnel for Staff L revealed a hire date of 08/14/06 and Staff M had a date of hire of 09/04/11. The job description for both staff was Clinical Medical Office Assistant. The job descriptions failed to include duties outlined for the responsibility for high level disinfection of equipment. Neither personnel file contained documentation that Staff L or Staff M were trained, or competency checked to perform high level disinfection of cystoscope equipment.

During an interview on 07/25/24 at 2:53 PM, Staff I confirmed neither staff's personnel file contained any documentation they were educated or competency checked for high level disinfection of cystoscope equipment. Staff I stated there had been no infections associated with cystoscopy procedures in the preceding two quarters of 2024.

Review of the policy titled "Surgery, Infection Prevention Surgery" reviewed 04/11/24, stated the policy was to provide guidelines for cleaning and disinfecting all endoscopes and prevent the spread of infections. The policy further directed that all endoscopes must be thoroughly cleaned and disinfected after each use following recommended manufacturer's guidelines. High level disinfection of the endoscope and all channels must be performed after each use according to manufacturer instructions. The procedure directed staff to completely immerse all submersible parts of the scope in water and enzymatic detergent following manufacturer's recommendations for dilution of the detergent.

Review of the manufacturer's directives for the Steris Prostylica 2X Enzymatic Presoak and Cleaner directed the dilution factor was 1-4 milliliters (mL) cleaner per liter of water. The directions further instructed staff to use the pump to deliver 15 mL of detergent per 5-8 liters of warm water.