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Based on interview and document review, the facility failed to integrate Total Renal Care (TRC) Incorporated dialysis service into their current Quality Assurance Performance Improvement (QAPI) program.

Findings include:

Interview and QAPI review on 2/6/19, at 10:00 a.m., with the director of quality services (DQS)-J regarding the inpatient dialysis services provided by TRC, in agreement with the facility identified dialysis was not documented as reviewed as part of QAPI. DQS-J stated it was an oversight and should have been incorporated.

Review of the undated Hospital Services Agreement, page 5, section 3.9 (a) and (b), TRC, at the facility's request, would participate in the facility's QAPI program. TRC was to monitor quality and provide regular reports to the designee, in compliance with state and federal regulations. TRC was to establish mutually agreed upon performance improvement (PI) on an annual basis.

Based on observation and interview, the facility failed to ensure biohazard waste and sharps were secured in the containers for 2 of 3 containers.

Findings include:

During an tour of the post anesthesia care unit (PACU) on 2/6/19, at 2:00 p.m. with the assistant nurse manager (ANM)-G it was observed, on the floor next to the automatic medication dispensing system, a wheeled wired rack holding a biohazardous waste black eight gallon container with IV (intravenous) bag of fluid with IV tubing attached over flowing out of the opening of the container. Also, next to the automatic medication dispensing system, was a two gallon red sharps container sitting in an off white base with two syringes and several blunt needles sticking out of the three inch opening. Next to the two gallon red sharp container, on the floor, was a blunt needle on the floor.

During an interview on 2/6/19, at 2:05 p.m. the ANM-G stated the containers were overflowing with waste. The ANM-G stated environmental services (EVS) should change them out when they are full. The ANM-G stated the containers should be able to close and nothing overhanging from the opening on the tops of them. The ANM-G stated there were fill lines on the containers, and the items should not extend above the fill lines.

At 2:09 p.m. the ANM-G stated staff that are in the PACU working should notice the containers are full and call to have them replaced.

During an interview on 2/6/19, at 2:43 p.m. with the nurse manager (NM)-H stated staff should call me, the charge nurse or EVS to have the containers replaced before they are overflowing with biohazardous waste and sharp items. The NM-H stated the containers should not be overflowing with items and both were above the fill line.

At 2:44 p.m. the NM-H stated pharmacy marks on the IV bag of medication if it should be discarded in the biohazardous waste containers, the automatic medication dispensing system indicates which syringes, vials or ampule's of medication need to be discarded in the biohazardous waste containers or the computer system alerts staff which medications need to be discarded into the biohazardous waste containers. The NM-H stated IV bags with medication remaining in them with the IV tubing, syringes with medication left in them, vials of medication with medication left in them all should go into the biohazardous waste container.

During an interview on 2/6/19, at 2:55 p.m. with the director of surgical services (DSS) stated the nurses should call when the biohazardous waste black container and red sharps container are to the fill line.

Although requested, the facility did not provide a policy regarding biohazardous waste and sharps containers.

Based on observation, interview, and document review, the hospital failed to ensure 2 of 2 hydrocollator units utilized to provide moist heat therapy to rehabilitation patients were maintained in a sanitary manner.

Findings include:

During observation and interview on 2/5/19, at 3:00 p.m. two hydrocollator units were observed to be available for patient use within the rehabilitation department. One was located in occupational therapy (OT) and the other within the physical therapy (PT) department. Physical therapist (PT)-A, who was the supervisor for the department stated that the hydrocollators were cleaned and refilled with sterile water on a quarterly basis. The cleanings were documented on a flowsheet kept within the department.

Review of the OT hydrocollator cleaning flowsheet, dated 1/19 indicated the hydrocollator was cleaned on 1/1/19. Review of the PT hydrocollator cleaning flowsheet, dated 1/19 revealed the unit had not been cleaned in 1/19.

During further interview on 2/5/19, at approximately 10:30 a.m. the therapies manager (TM) stated that she would expect staff to utilize the manufacturer's guidance for routine cleaning and sanitation of the hydrocollator.

Review of the manufacturer's guidance for the hydrocollator unit, entitled Instructions for Operation, Master Digital Heating Units, undated indicated the water should be drained from the hydrocollator unit and the unit cleaned every two weeks.

Review of the policy entitled North Memorial Health PT/OT/ST Infection Prevention in Therapy policy, dated 2/6/19 indicated that hydroculator [sic] cleaning would be performed using a hospital-approved disinfectant quarterly.

Based on observation, interview, and document review, the facility failed to follow infection control best practices during 1 of 1 dialysis observations. In addition, the facility failed to properly disinfect a glucometer for 1 of 3 patients (P1) observed during glucometer checks.

Findings include:

Observation and interview on 2/5/19 at 8:25 a.m. with the hospital services administrator for dialysis registered nurse (RN)-K, in the dialysis unit identified there were 4 dialysis stations, 2 on each side. A curtain separated stations 1 and 2 and again between 3 and 4 with a wall in the middle. One patient was currently dialyzing in station 4, closest to the window on the right side of the room. RN-K stated staff brought P2 from observation to the dialysis unit to dialyze as she was being discharged from the facility directly after her dialysis treatment. RN-K stated normally patients in observation would be dialyzed in observation, in their room, but P2 was instead brought to the unit. P2 was identified as being hepatitis B positive (Hep B+), a highly infectious viral disease causing liver inflammation that can potentially lead to death. There was no current patient dialyzing in station 3, which was adjacent to station 4, separated by only a curtain. Environmental services (ES) staff were responsible for terminal cleaning environmental surfaces throughout the hospital, no matter where a patient received treatment. Those surfaces included the hospital bed, overbed table, and floors. RN-K was unsure how or with what products environmental staff when cleaning the stations for terminal cleaning, but stated they were to use appropriate products that would be effective at killing the Hep B+ virus. There was no width of 1 station in between stations 3 and 4, nor a physical non-permeable barrier like a wall. Staff would use that station after the terminal cleaning performed by staff for other patient.. Stations were only cleaned after each use. Station 3 would not be routinely terminally cleaned after P2 dialyzing next to it in station 4, as it remained empty at the time.

Interview and product review on 2/5/19, at 9:20 a.m., with ES lead (ESL)-K indicated only 2 products were used by ES. 1 was Ecolab Oxycide. That product was used on all surfaces except floors. That products manufacturer's label identified it was effective at killing Hep B+ as it was a bacterial and viralcidal product, effective at killing the Hep B+ virus. The other product was Ecolab High Performance Neutral Cleaner. The manufacture's label listed the chemical as a cleaner, not a disinfectant, and it would not be effective at killing Hep B+. ES Lead was unaware the chemical was not appropriate. ES staff had no way of knowing what chemicals were needed with each patient. Only if a patient was on special precautions, droplet, contact, or otherwise would the Oxycide be used. P2 had no such signage at her station or in her observation room she had been at that morning.

Observation and interview on 2/5/19 at 10:00 a.m., of medication pass for P4 identified she was to receive the IV medication Protonix, 40 mg reconstituted in 10 cubic centimeters (CC) of normal saline (NS) over 2 minutes. RN-O proceeded to pop the dust cover off the medication vial. RN-O failed to wipe the top of the vial with an alcohol wipe prior to reconstituting and administering the medication. RN-O was unaware the cap was only a dust cover and had assumed it was sterile.

Observation and interview on 2/5/19 at 10:15 a.m. with RN-P while she performed medication administration on P5 identified P5 was in isolation precautions. RN-P was wearing a gown and gloves, but failed to tie her gown. During the administration of the medication, RN-P's gown repeatedly slipped off her shoulders requiring she touch her gown and uniform with her contaminated gloves. After the administration, RN-P reported P5 was infected with extended spectrum beta-lactamase (ESBL) and staff were required to wear gown and gloves when in contact with P5 for any reason. RN-P agreed she had not put on her personal protective equipment gown (PPE) appropriately as it should have been tied in the back and had contaminated her clothing when she repeatedly pulled up the gown after it had slipped off her shoulder.

Observation, interviews, and document review on 2/5/19 at 10:52 a.m., in P3's room with the medical floor nursing director (RN)-M and RN-N identified upon entrance, there was no dialysis nurse present in the room while P3 was dialyzing or immediately outside the room within line of sight. RN-K went to find RN-N 1 minute later, RN-N arrived. When asked why there was no nurse present in the room, RN-N replied she had stepped away for only a moment. P3's dialysis access site was visible, however there was no constant line of sight while the RN-N was not in the area. RN-N stated if she had to go on break or use the restroom, she would tell the floor nurses so they could monitor the patient. RN-N proceeded to take P3's temperature without putting on gloves. RN-N failed to use hand sanitizer after performing that task. RN-N wore a gown that was untied in the back at the waist, exposing the back side of her uniform. RN-N also wore her mask underneath her nose while performing discontinuation of dialysis access on P3's central line access. At 11:17 a.m., RN-N was observed to touch the dialysis machine with her gloved hand and immediately turn to P3 and connected P3's flush for her access site, suing those same gloves. At 11:19, RN-N once again touched the machine, without changing gloves, and immediately returned to P3's access and began flushing the line. RN-N only wiped the access site with an alcohol wipe for 3 seconds prior to attaching the flush. After she finished flushing and applying a dressing over the access lines, RN-N removed her gloves, performed hand hygiene and began cleaning the machine. RN-N wiped down the machine with a disinfectant wipe and let it dry. At 11:21 a.m., 2 minutes later the machine had dried. RN-N had returned the used clamp from P3 back onto the dialysis machine. RN-N identified she used Alcavis bleach wipes to disinfect her machine. RN-N verified the back of the container specified in order to achieve appropriate disinfection, the chemical must have a wet contact time of 5 minutes. RN-N was unaware of that required contact time. RN-N stated she placed the disposable clamp back on the machine to be disinfected at another location as it was used again for other patients after it was to be disinfected. RN-N agreed placing the clamp back on the machine would contaminate the machine had it been appropriately disinfected. RN-N had not replaced the curtain after dialysis.

Interview on 2/5/19 at 11:30 a.m. with RN-K about the breeches in infection control and lack of supervision identified she agreed RN-N should have been present in the room at all times while P3 was dialyzing. RN-N should have removed her gloves and sanitized her hands after every task. RN-N had not worn her gown or mask correctly. RN-K agreed the machine had not been disinfected appropriately after use.

Interview on 2/6/19 at 11:45 a.m. with the infection control epidemiologist (ICE) related to the breeches in infection control seen throughout the facility identified she agreed, housekeeping was not using the appropriate cleaning product for dialysis station floor cleaning for patients who were Hep B+. it was her expectation staff used the appropriate product depending on its kill identifiers listed on the manufacturer's label. Regarding the inappropriate PPE usage, her expectation was staff were to appropriately wear PPE as required to prevent spread of infection, and discard gloves, and perform hand hygiene after tasks. Dust covers on medication vials were not a substitute for cleansing with an alcohol wipe before needle insertion. ICE agreed it was a dust cover only and needed to be disinfected prior to use. Per the dialysis policy, the curtains used in dialysis treatment were part of the station, and should have been taken down and washed/disinfected. ICE was unaware but agreed that was a necessary part of treatment to disinfect the station.

Review of the 11/28/18, Infection Prevention: Cleaning of Patient Equipment and Environment policy identified cleaning and disinfecting were to be performed daily on floors and included removal of gross contamination, followed by the disinfection of the surface.

Review of the 7/30/18, Medication Administration policy made no mention of how staff were to appropriately prepare medications, drawn up with a syringe to ensure staff were appropriately disinfecting the vial before accessing it.

Review of the 7/3/01, Infection Control in the Hospital Dialysis Setting identified non-disposable items and clamps were to wiped down with a 1:100 bleach solution after every treatment. There was no mention of following manufactures guidelines on the use of wet-contact time. Appropriate PPE was to be worn whenever there is potential for contact with blood, contaminated equipment, and environmental services. Staff were to change gloves when going from a dirty to clean task, and after touching one patient or their dialysis machine.







38693

P1 was admitted to the hospital on 2/4/19.

P1's provider orders dated 2/5/19, at 8:35 a.m. directed blood glucose meter testing 4 times daily-before meals and at bedtime.

On 2/5/19, at 11:18 a.m. nursing assistant (NA-A) was observed using a glucometer to check a blood glucose level on P1. NA-A completed the blood glucose check and walked out of P1's room with gloves still on. NA-A set the glucometer on a counter outside of P1's room, removed her gloves, applied new gloves and then began to wipe down glucometer with a "PDI screen wipe." NA-A stated she used this wipe to clean the glucometer in between patient use. NA-A explained she used the screen wipe to wipe down the whole glucometer, and then it was ready to use when it was dry. NA-A stated the glucometer did not have to be wet a certain length of time and the glucometer dried fast.

On 2/6/19, at 8:45 a.m. the infection prevention manager (IPM) stated the expectation for cleaning glucometers was to disinfect glucometers after each patient use. IPM stated staff should use the "Super Sani-Cloth" for disinfecting glucometers according to the manufacturer's instructions for wet time. IPM explained that these wipes were an Environmental Protection Agency registered disinfectant for patient use equipment. IPM explained that the "PDI screen wipe" only a disinfectant for nonmedical equipment and was not appropriate to use to disinfect glucometers.
Manufacturer for StatStrip Glucose Hospital Meter instructions page 6-4, indicated to clean glucometer with a 10% solution of household bleach or 70% isopropyl (rubbing) alcohol.

A facility policy titled Whole Blood Glucose-Nova Stat Strip Meter effective date of 4/4/18, was reviewed. The policy directed the glucometer must be disinfected between each customer use with a 0.5% solution of sodium hypochlorite or 10% solution of household bleach.

Based on observation, interview, and document review, the hospital failed to ensure the safe use of an electrocautery device, resulting in a risk for fire in the operating room (OR) and/or risk for patient burns for 1 of 5 patients (P6) observed during a surgical procedure where the surgeon and/or surgical staff failed to operate the electrocautery device as directed by hospital policy and manufacturer recommendations.

Findings include:

P6 was observed on 2/6/19, at 1:14 p.m. during a tonsillectomy surgical procedure (removal of the tonsils). P6 was observed to utilize oxygen during the surgical procedure. During the procedure, it was noted the use of a Electrocautery Generator (a cautery pencil device) was utilized by medical doctor (MD)-A. At 1:15 p.m. after utilizing the cautery pencil, MD-A handed the pencil to surgical tech (ST)-A. ST-A was observed to wipe the tip of the pencil off with a drape and then place it on a draped mayo table (used to place surgical instruments) that was located over the patients upper chest. The cautery pencil tip rested on the draped table for 2 minutes before ST-A picked it up at 1:17 p.m. and handed it to MD-A. At 1:18 p.m., after utilizing the cautery pencil, MD-A handed the pencil to ST-A. ST-A again was observed to wipe the tip of the the pencil off with a drape and proceeded to place it on the draped table located over P6's chest area. The cautery pencil tip rested on the draped table for 1 minute before ST-A picked it up at 1:19 p.m., and handed it to MD-A. ST-A failed to place the electrocautery device in the holster.

Interview on 2/6/19, at 1:40 p.m. circulating registered nurse (RN)-D indicated she did not observe the cautery pencil resting on the draped mayo table during the above times. RN-D further included it was the responsibility of the ST, MD and RN to make sure the cautery pencil was holstered after each use as facility policy directed.

Interview with ST-A on 2/6/19, at 2:00 p.m. confirmed the cautery pencil had been placed on the draped table after cleaning the tip of the pencil. ST-A indicated he must have gotten busy and forgot to place it in the holster as the facility policy directed.

Interview on 2/6/19, at 2:30 p.m. OR nurse manager (NM)-A indicated ST-A should have placed the cautery pencil in the holster when not in use due to the potential for fire. NM-A further included all OR staff had been trained on the safety/use of the cautery pencil.

A review of the hospital's incident/accident reports for the past year revealed no incidents of fire/injury had occurred related to the use of electrocautery devices.

Review of the hospital's policy, Fire Prevention and Plan for Surgical Services dated 1/5/17, included fire risk assessment precautions for surgical cases. The policy directed any heat generating device (electrocautery) when not in use to holster.

Review of the manufactures instructions for Valley Lab Cautery pencil included; Warning: Fire hazard: Do not place active accessories near or in contact with flammable materials (such as gauze or surgical drapes), flammable gases, or high levels of oxygen. Electros accessories that are activated or hot from use can cause a fire. When not using active accessories, place them in a holster or in a clean dry, nonconductive, and highly visible area not in contact with the patient. Inadvertent contact with the patient may result in burns.