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A. Based on hospital tour and staff interviews it was determined the Director of Laboratory Services failed to ensure that a patient's urine specimen was not left unattended in a public space in one (1) of one (1) unattended urine specimen left in the laboratory waiting room bathroom (patient #21). This failure has the potential for all urine specimens to be cross-contaminated and/or for visitors to be exposed to infectious diseases.

1. Observation of the laboratory waiting room and bathroom on 08/26/19 at 10:10 a.m. revealed one (1) female patient sitting in the waiting room with the bathroom door open with a filled urine cup sitting on a shelf in the bathroom. The urine cup was labeled with a male patient's name (patient #21). There was no staff in the waiting room.

2. An interview was conducted with the Director of the laboratory during the tour of the laboratory. When asked the expectation for urine being left unattended she stated in part: "I don't know how long this has been sitting here but it should be processed once sample left."

3. An interview was conducted with the hospital Administrator on 08/27/19 at 9:15 a.m. When asked the expectation of urine being left in a public area after it has been collected she stated in part: "The expectation is that it would immediately be removed from the bathroom and processed."

B. Based on observation, policy review and staff interviews it was determined the operating room Nurse Manager failed to ensure cell phones were not taken into the sterile processing area. In one (1) of one (1) cell phones laying on a metal counter top in the sterile processing area.

1. Observation in sterile processing on 08/26/19 at 2:00 p.m. revealed a cell phone plugged into an outlet laying on a metal countertop beside of wrapped sterile equipment.

2. Review of the policy titled Central Sterile Department with a last review date of 11/18 states in part: "Dirty or contaminated items must be received in the dirty receiving area. They are then disassembled and cleaned in order to run through the washer/disinfector."

3. An interview was conducted with the central sterile technician on 08/26/19 at 2:05 p.m. When asked if she had a cell phone in the central sterilizing room she stated in part: "Yes, I am sorry."

4. An interview was conducted with the hospital Administrator on 08/27/19 at 9:15 a.m. When asked the process of having a cell phone in the sterile processing area she stated in part: "They could have them under their uniform in their pocket and if need to answer the phone leave the room and take the phone call outside of the room."

C. Based on observation, policy review and staff interviews it was determined the hospital failed to maintain an aseptic environment when storing endoscope tubing in operating room #2 in one (1) of one (1) tubings contaminated. This failure has the potential for all patients who are scheduled for a endoscopy to be at an increased risk for infection.

1. A tour of the operating room was conducted on 08/26/19 at 2:10 p.m. and revealed video endoscope tubing stored in a cabinet in operating room #2. Approximately six (6) inches of one (1) video endoscope tubing tip was laying on the bottom of the cabinet. The cabinet was unsanitary and had dust laying on the bottom of it.

2. Review of the policy titled Tracking/Cleaning/Processing of Endoscopes with a last review date of 01/19 states in part: "Hang scope up in proper position in endoscope cabinet."

3. An interview was conducted on 08/26/19 at 2:10 p.m. with operating room nurse #1. When asked if the tubing should be touching the floor and why there was dust in the cabinet she stated in part: "It shouldn't be touching the floor and they will do our terminal cleaning tonight."

4. An interview was conducted with the hospital Administrator on 08/27/19 at 9:10 a.m. and she concurred the endoscope should not be touching the floor and no dust should be in the cabinet.

Based on observation and staff interviews it was determined the facility failed to ensure the building was maintained in a manner that ensured safety and well being of patients. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census is five (5).

1. Observation on 08/26/19 at approximately 10:11 a.m. revealed the entry ledge to the lab biological hood was rusty and missing paint.

2. Observation on 08/26/19 at approximately 10:18 a.m. revealed no patient call cord in the Radiology patient/staff restroom.

3. Observation on 08/26/19 at approximately 10:20 a.m. revealed no patient call cord in the Emergency Department patient/staff restroom.

4. Observation on 08/26/19 at approximately 10:50 a.m. revealed exposed drywall and broken floor tile in the Dirty Utility Room 111-A.

5. Observation on 08/26/19 at approximately 10:52 a.m. revealed no call cord in the Chapel patient/visitor restroom.

6. Observation on 08/26/19 at approximately 11:03 a.m. revealed exposed drywall near the paper towel dispenser in the handicapped restroom 218-B.

7. Observation on 08/26/19 at approximately 11:15 a.m. revealed exposed drywall in Med Surge Room 10.

8. Observation on 08/26/19 at approximately 2:14 p.m. revealed dust around the light fixtures and ceiling air registers in Surgery Room 1.

9. Observation on 08/26/19 at approximately 2:16 p.m. revealed dust around the light fixtures and ceiling air registers in Surgery Room 2.

10. Observation on 08/26/19 at approximately 2:27 p.m. revealed no call cord in the Same Day Surgery area restroom 2.

11. Observation on 08/28/19 at approximately 8:50 a.m. revealed peeling paint on the shower floor of the shower room near Room 12.

12. Observation on 08/28/19 at approximately 8:52 a.m. revealed peeling paint on the shower floor of patient Room 8.

13. Observation on 08/28/19 at approximately 8:54 a.m. revealed peeling paint on the shower floor of shower room 122-A near Cardiopulmonary.

14. An interview on 08/28/19 at approximately 8:55 a.m. with the Maintenance Director verified these findings. The findings were also acknowledged by the Director of Nursing at the exit interview on 08/28/19 at approximately 11:30 a.m.

Based on record review and staff interviews it was determined the facility failed to make adequate provisions to ensure the availability and reliability of equipment needed for its operations and services. This deficient practice could affect all patients, staff and visitors in the areas referenced. Facility census five (5).

1. Record review on 08/27/19 at approximately 10:12 a.m. revealed no specific equipment maintenance inventories for all essential mechanical, electrical and patient-care equipment was provided during survey.

2. Record review on 08/27/19 at approximately 10:18 a.m. revealed the equipment maintenance program was not based off of manufacturer recommendations or other generally accepted standards of practice for an alternate maintenance schedule.

3. An interview on 08/27/19 at approximately 10:19 a.m. with the Maintenance Director verified these findings. The findings were also acknowledged by the Director of Nursing at the exit interview on 08/28/19 at approximately 11:30 a.m.

Based on record review and staff interviews it was determined the facility failed to ensure proper ventilation in patient care areas. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census is five (5).

1. Record review on 08/27/19 at approximately 10:22 a.m. revealed no documentation of the testing of proper air pressure relationships for the Lab was provided during survey.

2. Record review on 08/27/19 at approximately 10:24 a.m. revealed no documentation of the testing of proper air pressure relationships for the Pharmacy was provided during survey.

3. Record review on 08/27/19 at approximately 10:26 a.m. revealed no documentation of the testing of proper air pressure relationships for the Surgery Decontamination Room was provided during survey.

4. Record review on 08/27/19 at approximately 10:28 a.m. revealed no documentation of the testing of proper air pressure relationships for the Surgery Sterile Storage areas was provided during survey.

5. An interview on 08/27/19 at approximately 10:30 a.m. with the Maintenance Director verified these findings. The findings were also acknowledged by the Director of Nursing at the exit interview on 08/28/19 at approximately 11:30 a.m.

Based on observation, record review and staff interviews the facility failed to provide safety from fire and meet the provisions applicable to Existing Healthcare Occupancies of the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) 101. This deficient practice could affect all residents, staff and visitors in the areas referenced. Facility census five (5).

Findings include:

1. In reference to Federal Life Safety Code citation K291 the facility failed to ensure the appropriate testing of emergency lighting.

2. In reference to Federal Life Safety Code citation K324 the facility failed to ensure the appropriate testing of the kitchen cooking equipment.

3. In reference to Federal Life Safety Code citation K351 the facility failed to ensure the proper maintenance of the sprinkler system.

4. In reference to Federal Life Safety Code citation K521 the facility failed to ensure the appropriate installation and testing of fire dampers.

5. In reference to Federal Life Safety Code citation K914 the facility failed to ensure appropriate maintenance and testing of electrical receptacles at patient bed locations.

6. In reference to Federal Life Safety Code citation K918 the facility failed to ensure essential electric system maintenance and testing of the emergency generator and related equipment.

7. An interview on 08/28/19 at approximately 10:45 a.m. with the Maintenance Director verified these findings. The findings were also acknowledged by the Director of Nursing at the exit interview on 08/28/19 at approximately 11:30 a.m.

Based on observation, document review and interviews it was revealed the facility failed to ensure laboratory equipment was used safely and according to manufacturer's directions for use. This failure to use equipment that is not disinfected properly before using in the laboratory setting has the potential to negatively impact all patients if the equipment is not properly used or is not disinfected between patients.

Findings include:

1. A physical tour of the laboratory was conducted on 8/27/19 at about 10:35 a.m. This surveyor observed the phlebotomist complete a venipuncture on a patient who had come in for lab work. The phlebotomist removed the blue tourniquet from the patient's arm and put it directly back onto her workstation. The patient left immediately and I asked the phlebotomist if she cleans this tourniquet or if she reused it. She stated she doesn't clean it and that sometimes she does reuse it.

2. In an interview with the Director of Clinical Diagnostic Services on 8/27/19 at about 11:00 a.m. the above finding was discussed. She stated she was unsure of the manufacturer's directions for use but would look them up. She brought the box of the tourniquets out and it said they were disposable. She agreed the staff should have disposed of the tourniquet after using it on the patient. It was not documented the blue tourniquet could be safely reused.

Based on observation, document review and interviews it was revealed the facility failed to provide security measures for all medical records that safeguard them from unauthorized disclosure and use by unauthorized persons. This failure to ensure all medical records at the facility are not available to possible public access has the potential to negatively impact all patients at the facility if medical records are not kept secure.

Findings include:

1. A tour of the hospital departments was conducted on 8/26/19 at about 10:10 a.m. At the door to the medical records department it was noted across the hall an office had shelves of manila folders with numbers that looked like medical records. When the resident of the office was asked if they were patient records, the reply was, "Yes." The resident of the office was asked if she left the office through the day and she replied, "Yes." She was asked if she leaves the door open or unlocked and she replied, "Yes, sometimes."

2. The facility policy entitled Confidentiality and Security of Protected Health Information, last reviewed/revised 5/16, stated in part: "It is the hospital's responsibility to establish and implement security measures that safeguard both the medical record and its informational content, whether in hard copy, video, film, or in the computerized form, against loss, defacement, tampering, unauthorized disclosure and use by unauthorized persons."

3. The Medical Director was asked at the time of the tour on 8/26/19 at about 10:10 a.m. if the medical records in the office across the hall were left unsecured at times and she stated, "Yes. We will fix this."