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Based on observation, interview, record review, and policy and procedure review, the provider failed to maintain:
*The operating room (OR) floor.
*The Hydrocollator in the physical therapy department.
Findings include:

1. Observation on 3/29/11 at 1:40 p.m. in the OR revealed:
*Gaps between the floor tiles that were random in size but were approximately three inches in length and three sixteenths of an inch wide.
*There were gaps between the tiles approximately every eight inches across the majority of the OR floor.
*The gaps contained a moderate amount of debris.

Interview on 3/29/11 at 1:43 p.m. with the director of nursing who was the OR supervisor revealed:
*She was not aware of the condition of the operating room floor.
*She did not know what had caused the gaps between the floor tiles.

Interview on 3/29/11 at 2:30 p.m. with the maintenance supervisor revealed he was not aware of the condition of the OR floor.

2. Observation on 3/29/11 at 11:00 a.m. in the physical therapy department revealed a Hydrocollator.

Interview on 3/29/11 at 11:22 a.m. with physical therapist B revealed:
*The person who cleaned the Hydrocollator was not available.
*The Hydrocollator was cleaned periodically and a log was maintained.
*The Hydrocollator heat packs were used periodically depending on physician orders.

Review of the Hydrocollator cleaning log revealed it was last cleaned on 10/26/10.

Interview on 3/29/11 at 3:00 p.m. with physical therapist B revealed:
*She had talked to the person who cleaned the Hydrocollator.
*The Hydrocollator was cleaned as needed.
*They did not know where the operator's manual was or if they had one.

Review of the policy and procedure for physical therapy equipment provided to this surveyor by the infection control nurse on 3/29/11 at 3:15 p.m. revealed the equipment should have been cleaned according to manufacturer's recommendations.

Review of the Hydrocollator operator's manual found online on 3/30/11 by this surveyor revealed the Hydrocollator tank should have been drained and cleaned systematically at a minimum of every two weeks.

Based on observation, interview, record review, and policy review, the provider failed to:
*Ensure proper isolation procedures were followed by staff members for one of one sampled patient (28) in isolation.
*Failed to clean the blood draw chair between each patient use.
*Ensure expired medical supplies beyond the manufacturer's expiration date were not available for patient use for one of one operating room (OR).
*Follow the manufacturer's testing requirement and the provider's policy for Cidex OPA disinfectant in one of one OR.
*Ensure outside shipping containers were not used to store supplies in one of one OR.
Findings include:

1. Random observations on 3/29/11 from 8:30 a.m. through 10:00 a.m. of resident 28's room and isolation cart located outside her room revealed:
*The sign on the exterior of the patient's door stated the patient was on contact isolation precautions.
*At 8:30 a.m. the director of patient services came out of the patient's room into the hallway with the isolation gown she had on when she was caring for the patient. She then removed the gown in the hallway with ungloved hands and hung it on a hook attached to the isolation cart. That action would cross-contaminate the exterior of the isolation cart as well as the patient care items located on top of the cart.
*At 8:40 a.m. registered nurse (RN) A put on the same gown the director of patient services had placed on the hook of the isolation cart and then entered the patient's room. RN A shortly thereafter came out of the room gowned and gloved with the glucometer she had brought into the patient's room. She proceeded to open the container of aseptic wipes on top of the isolation cart with her contaminated gloved hands. She cleaned the glucometer and placed it on top of the isolation cart. She then removed her gloves, used hand sanitizer, and then removed her contaminated gown and placed it on the same hook the director of patient services had used.
*The same contaminated gown mentioned above was used three more times for a total of five contacts with patient 28.

Interview on 3/29/11 at 10:30 a.m. with the infection control officer revealed:
*Isolation gowns should not have been shared by staff.
*Isolation gowns should not have been worn outside of the patient's room.
*She agreed cross-contamination of the exterior of the isolation cart and its supplies on the top of it had occurred.
*The provider used the current Center of Disease Control standards for isolation.
*She agreed proper contact isolation procedures had not been followed in the above observations.

Interview on 3/29/11 at 3:00 p.m. with the director of patient services revealed she agreed:
*Proper contact isolation procedures had not been followed in the above observations.
*Cross-contamination of the exterior of the isolation cart and its supplies on the top of it had occurred.



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2. Interview on 3/29/11 at 11:20 a.m. with the laboratory (lab) manager and clinical lab technician C revealed:
*The blood draw chair was cleaned daily if any blood was spilled and as needed.
*As needed was determined by the symptoms and cleanliness of the patient who sat in the chair.
*The chair was cleaned with a disinfectant and cloth towel.
*The cloth towel was changed daily and was stored with the spray bottle.
*Clinical lab technician C always used a new cloth towel.
*They did not know the chair should have been cleaned between each patient with a clean towel.




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3. Random observation on 3/28/11 from 3:30 p.m. to 4:55 p.m. in the operating room revealed the following listed medical supplies were expired and were available for patient use:
*Sixteen Soda-Lime containers - Six had expired September 2001 and ten had expired August 2003.
*One ACMI right angle cutting loop electrode had expired June 2004.
*Seven Butterfly needles - Two had expired July 2004, three had expired March 2006, and two had expired July 2008.
*Eighteen Safety Glide needles - One had expired April 2007, three had expired April 2009, nine had expired October 2010, and five had expired February 2011.
*One Endoscopy plume away laparoscopic smoke evacuation system had expired December 2007.
*Two foreign body retrieval devices had expired December 2007.
*Two Ambu laryngeal masks - One had expired December 2007 and one had expired April 2009.
*Three Bard T-Tubes - One had expired July 2007 and two had expired November 2009.
*One Endopath curved scissors had expired January 2008.
*Six boxes of Vicryl suture - Two boxes had expired January 2008, one box had expired January 2009, one box had expired January 2010, one box had expired July 2010, and one box had expired January 2011.
*One box of Endopath graspers had expired July 2008.
*One Endopath curved dissector had expired August 2008.
*Four polypectomy snares - One had expired September 2008 and three had expired January 2009.
*Nine Radial Jaws had expired January 2009.
*Two ACMI disposable active cords had expired May 2009.
*One box of Endopaths had expired May 2010.
*Two Endopath endoscopic cutters had expired May 2010.
*One box peritoneal catheters had expired June 2010.
*Two disposable suction irrigators had expired August 2010.
*One box Ioban 2 had expired December 2010.
*One box of Whitcare needles had expired January 2011.
*One Fogarty Biliary Balloon had expired January 2011.
*Spinal needles 25 gauge three had expired January 2011.
*Two Bugbee fulgurating electrode tips had expired January 2011.

Interview on 3/29/11 during the time of the observation with surgical technician (ST) E confirmed the above listed supplies were expired and were commingled with supplies that had not expired. There was no set schedule for checking outdated supplies. ST E revealed she checked the supplies for par levels but did not specifically look at the expiration date. ST E confirmed expired supplies should not have been available for patient use. At the time of the above observation the expired supplies were removed from the shelves.

Review of the provider's 1/19/11 inventory and/or removal of dated medical supplies policy revealed:
*The purpose of the policy was to ensure outdated medical supplies were removed from the unit inventory prior to the expiration date.
*The central supply personnel or designee was responsible for checking all supplies for expiration dates.
*Medical supplies that were expired should have been removed from the inventory.
*Monitoring compliance included a spot check for outdated supplies and results should have been reported to the department directors.

4. Observation on 3/30/11 at 8:30 a.m. in the central sterilization room revealed a blue tub of solution. Interview with ST E at the time of the observation revealed that tube contained Cidex OPA, a disinfectant for colonoscopy scopes. ST E revealed the disinfectant was used for 14 days and then discarded. She tested the disinfectant each time a new bottle was activated, but she did not test the disinfectant prior to each use. ST E revealed she was not aware Cidex OPA disinfectant should have been tested prior to each use. There were days when more than one colonoscopy scope was disinfected.

Interview and review on 3/30/11 at 8:30 a.m. with ST E regarding the Cidex Solution Log Sheet revealed:
*The log sheet was used to document test results. A plus sign (+) documented meant the solution passed testing. A negative sign (-) meant the solution should not be used, and a new batch of Cidex solution should then be mixed.
*The Cidex OPA solution passed testing on the days listed below but had only been tested once each day:
*2/18/11 - Two colonoscopies performed and one esophagogastroduodenoscopy (EGD).
*3/2/11 - Two colonoscopies performed and one EGD.
*3/4/11 - Two colonoscopies performed and one EGD.
*3/7/11 - Three colonoscopies performed.
*3/11/11 - Two colonoscopies performed.
*3/14/11 - Two colonoscopies performed.
*3/18/11 - Two colonoscopies performed.
*3/25/11 - Two colonoscopies performed.

Review of the provider's 2/17/10 Cidex OPA solution for manual processing at 20 degrees Celsius policy revealed the Cidex OPA solution should have been tested prior to each use with Cidex OPA solution test strips.

Review of the Cidex OPA manufacturer's monitoring parameters revealed to ensure the disinfectant was above the minimum effective concentration level the Cidex OPA solution should have been tested prior to each use.

5. Random observation on 3/28/11 between 3:30 p.m. and 4:45 p.m. in the operating room revealed several cardboard boxes on the storage shelves. Review of the labeling on the cardboard boxes revealed the supplies had been stored in the original outside shipping containers. Interview with ST E at the time of the observation revealed she was not aware outside shipping containers should not have been used to store supplies in the operating room.

Review of Association of periOperative Registered Nurses Perioperative Standards and Recommended Practices, 2010 Edition, Denver CO., page 103, revealed "Supplies and equipment should be removed from external shipping containers and web-edged or corrugated cardboard boxes in the unrestricted area before transfer into the surgical suite. External shipping containers and web-edged cardboard boxes may collect dust, debris, and insects during shipment and may carry contaminants into the surgical suite."

Review of the provider's receiving of hospital supplies, equipment, and service policy dated 12/14/09 had not addressed delivery of supplies to the operating room.

Based on observation, record review, and interview, the provider failed to ensure:
*Self-administration of medication had been approved by the physician and the interdisciplinary team had determined it was a safe practice for two of two patients (2 and 4) who self-administered medications after set-up by the nurse.
*The patient's rights to refuse medications was granted for one of five patients (5) observed during medication administration.
*Medications were administered in a sanitary manner for one of five patients (5) during medication administration.
*The medication administration record (MAR) was not signed prior to patients taking their medications for two of five sampled patients (2 and 4).
*The MAR was signed at the time the nurse actually administered medications for one of five sampled patients (5).
Findings include:

1. Observation and interview with medication aide (MA) D on 3/29/11 during her medication pass revealed:
a. At 7:55 a.m. she entered patient 2's room and placed the patient's medications on the overbed table. Patient 2 confirmed she wanted her medications left on the overbed table, so she could take them when she ate breakfast. MA D returned to the medication cart and placed her initials on the MAR to indicate the medications had been administered. Interview at the time of the above observation with MA D revealed the patient was alert and oriented, and therefore they could leave the medications at the bedside.

b. At 8:00 a.m. she entered patient 4's room and placed the patient's medication on the overbed table. Patient 4 confirmed she wanted her medication left on the overbed table to take with her breakfast. MA D returned to the medication cart and placed her initials on the MAR to indicate the medications had been administered. Interview at the time of the observation with MA D revealed the patient was alert and oriented, and therefore they could leave the medications at the bedside.

c. Interview on 3/29/11 at 9:25 a.m. with MA D revealed:
*She was not sure if patients 2 and 4 had been approved for self-administration of medication.
*She would ask one of the nurses if either patient could self-administer their own medications.
*She had been taught during medication administration training both patients' medications could be left at the bedside for them to self-administer.
*She had placed her initials on each patient's MAR that indicated the medications had been administered.
*The patients would let her know when they had taken their medications.

d. Interview on 3/30/11 at 2:55 p.m. with the director of patient care services (DPCS) revealed:
*Patients 2 and 4 had not been approved for self-administration of medications. Their care plans had not addressed self-administration of medications.
*Patients if able were allowed to self-administer their own medications.
*A physician's order was required for patients to self-administer medication, and their care plans should address self-administration of medications.
*The provider did not have a system in place to evaluate patients for self-administration of medications.

e. Review of the provider's 10/7/09 self-administration of medication policy revealed:
*"An individual may self-administer medications if ordered by the physician/nurse practitioner/physician's assistant and if the interdisciplinary team determines that this is a safe practice for the individual."
*Appropriate notations for self-administration of medication determinations should have been documented on the patient's care plan and/or nurse's notes.

2. Observation on 3/29/11 at 8:08 a.m. of MA D's medication administration to patient 3 revealed:
*While wearing clean gloves she removed the medications from the medication drawers, placed a small ink dot on the MAR beside the medications she was preparing to administer, dropped two of the pills on top of the medication cart, picked the pills up with her gloved hands, and placed them in the medication cup.
*Prior to entering the patient's room MA D stated the patient was refusing to take his medications. When asked if the patient was ill she said his dementia was getting worse.
*Upon entering the patient's room MA D asked the patient if he would take his medications. The patient responded he did not want the medications.
*She explained to the patient taking his medication might make him better. The patient still stated "No" to taking the medications.
*She then said let me help you with taking your medications, opened the patient's mouth, and put five pills (Calcium 600 with Vitamin D, enteric coated Aspirin, Tamsulosin, Senna S, and Seroquel) in the patient's mouth. The patient promptly spit all the pills out, several went into the water glass, and the remaining went in a Kleenex MA D held up to his mouth.

Interview on 3/29/11 at 9:35 a.m. with MA D regarding patient 3 revealed:
*There were times when the patient refused to take his medications.
*Maybe she should have offered the above listed medications at a later time and not have insisted he take them.
*Sometimes with encouragement he would take his medications after refusals.

Interview on 3/30/11 at 2:55 p.m. with the DPCS revealed patient 3 had at times refused to take his medications. She had instructed staff passing medications to approach him at a later time and offer the medications.

Review of patient 3's care plan updated 3/29/11 revealed medication refusals had not been addressed as a problem. Alteration in psychological status due to a history of dementia had been addressed but had not included interventions for medication administration.

Review of Pamela J. Carter and Amy J. Stegen, Lippincott's Advanced Skills for Nursing Assistants, A Humanistic Approach to Caregiving, 2005, Philadelphia, PA, page 310, revealed when administering medications, tell the nurse immediately if:
*"The person is experiencing problems that make you question whether you should administer the medication.
*The person refuses to take the medication."

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, MO., 2005, page 843, revealed in accordance with The Patient Care Partnership and because of the potential risk related to medication administration, a client had the right to refuse a medication regardless of the consequences.

3. Observation on 3/29/11 at 8:08 a.m. of patient 5's medication administration revealed MA D after putting on clean gloves:
*Signed the patient's MAR for his nasal spray and skin ointment. Interview at that time with MA D revealed she had administered the nasal spray and put the skin ointment on around 6:30 a.m. She had forgotten to sign the MAR and was now doing so.
*Without changing gloves she entered the dining room. The patient was seated in his wheelchair at the table. Using her gloved hands to remove pills from the medication cup she placed them in the patient's mouth.

Interview on 3/29/11 at 9:25 a.m. with MA D revealed she should not have touched the patient's medications with her contaminated gloves. She should have placed the medications in his mouth with a spoon.

Based on medical record review, interview, and policy review, the provider failed to ensure current history and physical reports were in the medical records for two of five surgical patients (7 and 8) prior to their surgical procedures. Findings include:

1. Review of the medical records for patients 7 and 8 revealed there were no current history and physical reports. Review of the medical records revealed:
*Patient 7: Had been admitted on 2/18/11 for a colonoscopy procedure.
*Patient 8: Had been admitted on 3/25/11 for a colonoscopy procedure. An encounter nurse interview note-w/plan (with plan) completed by a certified physician assistant dated 11/18/10 that contained history and physical information was found in the medical record. There was no documentation from the physician updating that history and physical report.

Interview on 3/29/11 at 2:55 p.m. with the director of patient care services (DPCS) confirmed patients 7 and 8 did not have current history and physical reports in their medical records. The DPCS revealed normally for colonoscopy patients the clinic note or an encounter note would be in the patient's chart and was used as the history and physical.

Review of the provider's October 2010 Rules and Regulations of the Medical and Dental Staff revealed:
*The physician was responsible for ensuring the patient's medical record was complete and legible. The content should have included a history of present illness and a physical examination report.
*"When the history and physical examination are not recorded before an operation or any potentially hazardous diagnostic procedure, the procedure shall be cancelled, unless the attending practitioner states in writing that such delay would be detrimental to the patient."