HospitalInspections.org

Based on a review of documentation and an interview with staff, the governing body failed to ensure that contracted services were furnished in accordance with the specifications of their contract.

Findings:

During the review of credentialing files for 7 anesthesia providers (staff #A20 through #A26 ) performing services at the hospital under contract, 3 of the 7 providers (#A21, #A22, #A24) did not possess the certifications required of their contract.

The Professional Service Agreement for West Star Anesthesia Services stated, in part (beginning on page 14):

"3. Description of Duties
...
Q. Skills: Each Contractor's Representative must be able to provide certain technical skills, including but not limited to:
...
v. The management of problems in cardiac and respiratory resuscitation;"

* Staff A21 had received basic life support certification and advanced cardiac life support certification from an online provider, with no documentation of a return demonstration of skills.

* Staff A22 had received advanced cardiac life support certification from an online provider, with no documentation of a return demonstration of skills.

* Staff A24 had received basic life support certification and advanced cardiac life support certification from an online provider, with no documentation of a return demonstration of skills.


Review of the Health & Safety Institute and the National Safety Council website found at http://news.hsi.com/onlineonlycpr reveals that, "No major nationally recognized training program in the United States endorses certification without practice and evaluation of hands-on skills.

According to the Occupational Safety and Health Administration (OSHA) online training alone does not meet OSHA first aid and CPR training requirements." Further guidance can be found at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=28541.


In an interview with staff A27 on 3-21-19 (Chief Medical Officer and Anesthesiologist by training), staff A27 agreed that basic life support and advanced cardiac life support was required by the West Star Anesthesia contract and that the above staff had not provided a return demonstration of skills for their certifications.

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 3-21-19.

Based on review of facility documentation and staff interview, the facility failed to obtain appropriate physicians orders for all episodes of restraint.

Findings:

Facility based policy entitled, "PC 210_ Restraints" stated in part,

"5. Order for Restraint

a. An order for restraint must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release."


Review of the medical record for Patient #A19 at Del Sol, revealed the following:

* This patient was in a behavioral restraint of soft restraints to the right and left upper extremities on 02/05/19 from 1520 until 1620 related to aggressive behavior.

* There was a physician order on 02/05/19 1527 at for a "chemical restraint" for 4 hours with the clinical justification of combative, physical aggression, and destructive. This order did not indicate that the patient was in physical restraints.

* A separate physician order was entered on 02/05/19 at 1525 that stated, "Place soft physical restraint to BUE."

* However, this order did not specify clinical justification for the restraint, the duration of use, and/or the and behavior-based criteria for release.


In an interview on 03/20/19 staff members #A32 and #A33 confirmed the above findings that the above order to implement a behavioral physical restraint of Patient #19 on 02/05/19 did not include all the elements of a complete physician order for restraint per policy and regulations.

According to a physician note dated 02/04/19 involving Patient #A19 at Del Sol, "At 18:10 (6:10 PM), patient found face down on the hallway in front of the initial exam room being held in place by 2 El Paso Police Department officers and for (four) security officers. Patient is finally attempting to escape. Patient is acutely psychotic and aggressive at this time. [Physician] is also on scene evaluating patient with me and recommends the use of IM Benadryl, Haldol, and Ativan."

In an interview on February 20, 2019 with the hospital Director of Quality Utilization (staff 8 D) confirmed that no physician order was obtained for the personal restraint conducted on February 4, 2019 on Patient #A19.

Based on a review of documentation and interview, the facility failed to ensure that the patient who is restrained was monitored by a physician, other licensed independent practitioner, or trained staff at an interval determined by hospital policy.

Findings:

Facility based policy entitled, "PC 210_ Restraints" stated in part,

"7. Monitoring the Patient in Restraints

a. Patients are assessed by an RN immediately after restraints are applied to assure safe application of the restraint.

b. An RN will assess the patient at least every 2 hours. The assessment will include:

1) Signs of injury associated with restraint, including circulation of affected extremities

2) Respiratory and cardiac status

3) Psychological status including level of distress or agitation, mental status and cognitive functioning

4) Needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met

5) Hydration/nutritional needs are being met

6) Hygiene, toileting/elimination needs are being met

7) The patient's rights, dignity, and safety are maintained

8) Patient's understanding of reasons for restraint and criteria for release from restraint

9) Consideration of less restrictive alternatives to restraint"


Review of the medical record for Patient #A17 at Las Palmas revealed, patient was in a behavioral restraint (soft all extremities) on 10/03/18 from 2310 until after 0800 on 10/04/18. Nursing staff documented "safety/rights/dignity maintained verified" every 15 minutes. There was no nursing documentation of assessment including: signs of injury associated with restraint, including circulation of affected extremities, respiratory and cardiac status, psychological status including level of distress or agitation, mental status and cognitive functioning, needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met, hydration/nutritional needs are being met, hygiene, toileting/elimination needs are being met, patient's understanding of reasons for restraint and criteria for release from restraint, and/or consideration of less restrictive alternatives to restraint. The assessment of these element is to be completed by nursing every 2 hours a patient is in restraints.

In an interview on 03/20/19 with staff members #A30 and A31 they confirmed that the every 2 hours assessment components were not reflected in the medical record for this patient who was restrained for over eight hours.

Based on a review of documentation and interview, the facility failed to ensure that when restraint or seclusion is used, there was documentation in the patient's medical record of the 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior.

Findings:

Facility based policy entitled, "PC 210_ Restraints" stated in part,

"9. Face-to-face assessment by a Physician or LIP:

a. A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint/seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. At the time of the face-to-face assessment, the LIP/physician/RN/PA will :

1) Work with staff and patient to identify ways to help the patient regain control

2) Evaluate the patient's immediate situation

3) Evaluate the patient's reaction to the intervention

4) Evaluate the patient's medical and behavioral condition

5) Evaluate the need to continue or terminate the restraint or seclusion

6) Revise the plan of care, treatment and services as needed"


Base on a review of documentation, 3 of 3 patients (Patients #A17 and #A18 at Las Palmas and Patient #A18 at Del Sol) had behavioral restraints implemented that did not have a 1-hour face-to-face medical and behavioral evaluation documented. These 3 patients had physician notes indicating the patient was in a behavior restraint. However, the documentation did not include the patient's reaction to the intervention, assessment of their medical and behavioral condition, and/or the need to continue or terminate the intervention.


In an interview with staff members #A30 and A31 on 03/20/19, they confirmed that the electronic record had a template for the 1 hour face to face evaluation, but that staff were not utilizing it to document all the components of the assessment per the facility policy.

Based on interview and record review, the Del Sol's Pre-operative nurses failed to obtain physician's orders for the placement of Peripheral Intravenous catheters and the administration of lactated ringers for 2 .(Patients #1 and #4) of 4 patients.

Findings:

Review of Patient #1's pre-operative orders, on the morning of 3/19/19, reflected an order for the administration of Vasopressin Injection IV (Intravenous Catheter). Patient # 1C did not have an order for the insertion of the IV.

Review of Patient #4C's pre-operative orders, on the morning of 3/19/19, reflected an order for the administration of Zofran IV, Morphine IV and Lactate Ringers IV. Patient # 4C did not have an order for the insertion of the IV.

The facility did not provide the requested policy for the need to clarify the physician's order for the insertion of the IV.

During an interview on the morning of 3/19/19, on the pre-operative unit Staff #24, RN confirmed the finding.

Based on observation, interview, and record review, the pharmacies at Del Sol and Las Palmas campus failed to store and dispense medications in a safe manner when multi-dose liquid and nonaqueous medications were not identified as to the expiration date for that product.

Findings:

Observations during a tour of the Del Sol pharmacy on the afternoon of 3/19/19 revealed, the following multi-dose medications that had been opened and were not labeled when they were opened or when they would expire:

Dexamethasone 0.5 mg/ 5 ml

Cyprohetatine Chloride Syrup (had medication residue on the outside of the glass bottle)

Promethazine Oral (had medication residue on the outside of the glass bottle)

Propranolol 20mg/5ml oral


During an interview on the morning of 3/19/19, in the Del Sol facility's pharmacy, when asked about the labeling of opened multi-dose medications, Staff #3C, Pharmacy technician stated, " ...We label when they will expire, 14 days, I guess ...."

During an interview on the afternoon of 3/19/19, in the Del Sol facility's pharmacy, Staff #5C, Pharmacy Director stated, " ... We don't label the medications when they are opened; we use the manufacturer's expiration date ...." Staff #5C confirmed the facility did not have a policy for the labeling and dating of opened multi-dose medications.

Observations during a tour of the Las Palmas pharmacy on 3/21/19 at 9:20 a.m. with Staff #11C, Pharmacy Director, the following multi-dose bottles of medicines were observed:

- Diuril 237 ml: opened date of 8/18/18, and no written expiration date.

- Senna Syrup 237 ml: opened date of 5/8/18 and expiration date of 5/1/19.


In an observation on 3/21/19 at 9:50 a.m., an unidentified opened multi-dose bottle of medicine was found without the opened date.

In an interview on 3/21/19 at 9:20 a.m., Staff #11C stated "we don't have facility policy and procedures for drug storage and labeling, but there's a process." He stated facility followed the USP (United States Pharmacopeia) 795 and 800 standards.

In an interview on 3/21/19 at 9:50 a.m., Staff #11C stated, there was an update with the USP 795 and 800 standards and facility will "update the process today." He stated the facility followed the BUD (beyond-use date) and once the multi-dose bottle of medicine was opened, the BUD, or the expiration date was 6 months from opened date. He also stated the unidentified opened multi-dose bottle of medicine will be thrown out immediately since facility did not know when the opened date was.

Review of facility provided copy of "Compounding nonsterile preparations: USP <795> and <800>" with the release date of October 1, 2017, reflected the BUD for nonaqueous formulation as 6 months.

Based on observations, interviews, and record reviews, Las Palmas facility failed to ensure that the specific food and dietetic services organization requirements were met when:

(A) facility's dietary department failed to provide services in a clean and sanitary environment.

(B) staff did not properly cover their hair or mustache for acceptable hygiene practices.

Findings:

(A) The following observations on the morning of 3/18/19, in the Las Palmas kitchen, revealed:

-The inner lid of the ice machine had a black sticky residue under the lid.

- A wet mop was sitting on the floor.

- Dried food debris was noted on the food mixer, can opener blade and gears, under the cabinets, on an opened bag of disposable spoons, on a bulk sugar container and copious amounts of food on the sides of the tilt sauté pan.

- Old dried food grease was splattered and dripping down the wall behind the grill.

- The tile in front of the tilt sauté pan was missing large amounts of grout, making the floor not cleanable.

- The floor drains were dirty with dark material and old food debris.


During an interview on the afternoon of 3/18/19, in the facility's kitchen, Staff #12C, Registered Dietitian confirmed the findings.


(B) In an observation in the kitchen service area (Las Palmas) on 3/18/19 at 1:24 p.m., Staff #14C, Cook, had a mustache and was working without a beard restraint.

In an interview on 3/18/19 at 1:24 p.m. with Staff #16C, Kitchen Director, regarding the requirement for beard restraints, she stated "it's not a full beard, so it's okay."

In an observation in kitchen service area (Las Palmas) on 3/18/19 at 1:52 p.m., an unidentified female staff was observed wearing a hairnet without covering her bangs.

In an observation in kitchen service area (Del Sol) on 3/19/19 at 9:40 a.m., 3 unidentified male staff with beard and/or mustache were observed with no beard restraints.


In an interview on 3/19/19 at 9:58 a.m. with Staff #15C, Kitchen Director, he stated even mustaches must be covered in the kitchen service areas, and also "it's the state law and must follow the TFER (Texas Food Establishment Rule) rule."


Review of facility provided policy from the Food & Nutrition Services Department "Personal Hygiene" with most recent approval date of 5/30/17 revealed in part:

- Purpose: "To prevent the spread of food borne illness"

- Policy: "Employees will practice good personal hygiene habits at all times while on duty"

- Procedure: 1.b. "Hair nets and/or caps worn at all times"

There was no information in the policy related to covering of beards/mustaches.


Review of TFER, last revised October 2015, under rule 228.43(a) stated in part " ...food employees shall wear hair restraints such as hats, hair covering or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food ..."

Based on humidity and temperature documentation records, and staff interview, the facility failed to ensure they followed their plan of correction to ensure that the temperature and humidity levels were maintained in an acceptable range in the operating rooms and procedure rooms.

The facility maintenance and engineering staff did not frequently monitor the humidity and temperature readings throughout the day while procedures were being performed in the rooms as per their approved plan of correction. Documentation on the temperature and humidity logs only had documentation of the temperature and humidity at the beginning of a treatment day and had no documentation of the effects of adjustments when they were made by environmental services.


Cross refer to tag A0726

Based on review of documentation, tour of the facility, and interview, it was determined that the hospital failed to monitor the temperature and humidity in areas of the hospital that requires temperature and humidity control. Failure to ensure humidity levels are maintained in the operating rooms and all procedure rooms place all patient's safety at risk during the procedure. Low humidity levels can increase the risk of electrostatic shock in the surgical room and procedure rooms.

Findings:

According to an article entitled "Relative Humidity Levels in the Operating Room Joint Communication to Healthcare Delivery Organizations 2015" it was stated in part:

"Relative humidity may affect the operation of some electro-medical equipment used in the OR, particularly with older model electro-medical equipment. This equipment may malfunction unexpectedly. Too low humidity levels may also impact calibration. Larger electrostatic discharge (ESD) pulses may create a risk of destruction of parts, premature failure, and erratic behavior of software that is "confusion" from ESD pulses. And, in an environment where humidity is low, a person can more easily become "charged" and receive an electrostatic shock when coming in contact with medical equipment."


Facility policy entitled "Temperature and Relative Humidity Monitoring Policy and Log" stated in part "Temperature and humidity levels are continuously monitored using an (automated system and/or local monitors.) The Las Palmas Del Sol Healthcare System will maintain Humidity and Temperature in accordance with Title 25 Texas Administrative Code Chapter 133-subchapter 133.169©. NFPA 99 2012 and the Association of Surgical Technologist (AST) a 20% RH as the lower limit for anesthetizing locations. Las Palmas Del Sol will take corrective action to maintain 30-60% RH, but will not intervene to stop procedures until the RH is below 20% at the Physician's discretion ...

PROCEDURE:

HUMIDITY:

The relative humidity of air supplied to all required areas requiring monitoring will be done daily prior to the start of the first case by either the Facilities Engineering Department, if automated systems are provided or the department staff for local monitors. When possible, central adjustments will be made to maintain relative humidity within 30%-60%.

OR/Procedural Areas:

Escalation of out-of-range readings will be done using the following escalation process:

A. Level 1: Readings are obtained by the individual responsible for monitoring the room prior to a procedure or during daily checks in supply areas and recorded on the Room Temperature and Humidity Log. Any relative humidity reading found unacceptable/out of range will initially require adjustment of the thermostat in the individual room. Temperature and humidity will be re-checked within an hour. Corrective action should be documented on the Room Temperature and Humidity Log. If the parameters are within range, no further action is required. If the parameter continues to be out of range, and the temperature is set to the design specification in Table B, Facilities Engineering is to be notified by phone.

B. Level 2: Alerts received by Facilities Engineering from the system or from the individual room for out of range relative humidity levels exceeding 1 hour will require the validation of the temperature setting. If the relative humidity is out of range and the temperature setting is within the range as described in Table B, Facilities Engineering staff will respond to that room and/or the supply air handling unit for possible further corrective actions. Actions taken should be documented on the Room Temperature and Humidity Log. Departmental Leadership should also be made aware of potential issue.

C. Level 3: In the event Facilities Engineering is unable to bring relative humidity back to an acceptable range, the temperature setting is within the described range in Table B, a risk assessment should be performed by the Proceduralist/Surgeon, OR Staff/Supervisor, Anesthesia Staff to determine if the out of range levels could negatively affect patient care. If the temperature setting in the room is out of the design range as described in Table B, a decision to continue and any actions taken should be documented on the Room Temperature and Humidity Log. Procedures in progress can be completed.

D. Level 4: For continued out of range relative humidity levels, when the temperature setting is within the described range in Table B or moisture accumulation on the walls or horizontal surfaces, the room should be closed until the issue is corrected. Any actions taken should be documented on the Room Temperature and Humidity Log. ...

TEMPERATURE:

OR/Procedure Areas

If the temperature is found to be out of range in an OR/procedural area, the physician should be notified to determine if the levels could negatively affect patient care. If the physician opts to proceed with the case, this should be documented on the Room Temperature and Humidity Log."


Facility Document entitled "Del Sol Medical Center-PROACTIVE RISK ASSESSMENT 2018" dated 12/05/2018 stated:

"Describe the Issue: Humidity issues in OR, L&D OR and Cath Lab seen when physician requesting lower temperatures see increase above acceptable range based on ASHRAE 170-2008. Humidity issues also evident during cold weather months' decrease in humidity levels <30%. At present running low temperatures to increase humidity levels but unsuccessful and decreasing temperatures from approved range.

Arguments in support of the issue-why things should remain the same: None-everyone is in agreement that we must do what is needed to maintain relative humidity levels between 30 and 60%. If RH level goes below 30% you increase risk of fire due to dry air and some older equipment may not function appropriately, due to age of some equipment. Not sure if issues will be seen.

Arguments against the Issue-why things should change: The problem is low humidity can impact surgical equipment and increase fire risk for patients and staff. Ventilation requirements under Title 25 Texas Administrative Code 133 are that the humidity must be between 30% and 60%. Based on ASHRAE 170-2008 risk would be minimal to none. RH% below 30% is not in compliance with Title 25 Texas Administrative Code Chapter 133.

Mitigation: What could you do to decrease risk? Portable humidifiers are being considered for use to lower (sic-raise) the humidity. Installation of permanent humidifiers has been approved for funding and looking to make corrections starting around March 2019. If humidity levels are at or below 30% the engineering staff will notify the charge nurse on duty and steps will be taken to adjust temperature to correct issue.

Conclusion: Installation of permanent humidifiers targeted for start of March 2019, we are changing the monitors in these areas to ones that can be calibrated and installation of building automated system that monitors temperature, humidity and pressure relationships for each invasive procedure room.

Monitoring: Engineering staff will monitor temperature and humidity three times per day and adjustments to temperature will be made."

Review of Temperature and Humidity Log for the Cardiac Catheter Lab at Las Palmas Hospital for the month of February 2019 revealed the following:

The log stated:

"Temperature (Optimum Range 68-75 F)

Humidity (30-60%). This was scratched out and hand written in: (20-60%)

If temperature/humidity out of range appropriate action must be taken and documented."


The temperature for the entire month ranged from 56-66 F. Under Actions Required, it was noted daily: "Dr. Ok with Room Temp. Engineering called."


Humidity for the entire month ranged from 20--59%. Handwritten on the bottom of the log was "Humidity change per engineering." No documentation was provided to the survey team to explain the rationale behind the change in humidity parameters. Temperatures and humidity levels were only documented at the beginning of the day.

In an interview with the Clinical Coordinator of the Las Palmas Cardiac Catheter Lab on 3/19/19, the out of range humidity/temperatures for the catheter lab were confirmed.

Review of Temperature and Humidity Logs for Cardiac Catheter Labs 1 and 3 for the months of February through March 20, 2019 revealed the following:

Catheter Lab #1 for the month of February 2019 had humidity ranging from 5% to 39%. When humidity was out of range, it was noted that "Facilities notified" and temperature was adjusted. No follow up documentation was noted after temperature was adjusted.

Catheter Lab 1 for the month of March 1st through 20, 2019 had humidity ranging from 5% to 34% (10 out of 20 days < 20%). Again "Facilities notified" and temperature was adjusted. No follow up documentation was noted after temperature was adjusted.

Catheter Lab #3 for the month of February 2019 and March 1st thru 20th 2019 had appropriate humidity and temperature levels. These levels were only documented in the morning, once a day; contrary to the plan described in the Proactive Risk Assessment, 2018.


The following Operating Room Temperature and Humidity logs at Del Sol Hospital for the month of February 2019 were reviewed:

OR "Main" had humidity ranging from 22 % to 40%. (20 of 28 days the humidity level was < 30%). Only 3 days of the month had "Actions Required" listed as "work order." This OR had no listed parameters for temperature and only had a maximum level of humidity (60%).

OR # 1 had humidity levels ranging from 17% to 56%. (16 of 28 days' humidity was < 30%). Temperature range was appropriate between 68-75 F.

OR # 2 had humidity levels ranging between 14% to 40%. (20 of 28 days' humidity was < 30%). Temperature levels (recommended at 68-75 F) ranged from 50 degrees to 68 F. It was noted multiple times "Humidifier left in room."

OR # 3 had humidity levels ranging between 13% and 53%. (18 of 28 days' humidity was < 30%). Temperature levels ranged between 55 degrees to 68 F. It was noted multiple times "Humidifier left in room."

OR # 4 had humidity levels ranging between 15% and 50%. (18 of 28 days' humidity was < 30%). Temperature levels ranged between 55 degrees to 68 F. It was noted multiple times "Humidifier left in room."

Trauma Room # 5 had humidity levels ranging between 10% and 32%. (22 of 28 days' humidity was < 30%). Temperature levels were appropriate. It was noted multiple times "Humidifier left in room."

OR # 6 had humidity levels ranging between 12% and 50%. (18 of 28 days' humidity was < 30%). Temperature levels were appropriate. It was noted multiple times "Humidifier left in room."

Room # 7 (no indication of type of room was provided) had humidity levels ranging between 16% and 44%. (16 of 28 days' humidity was < 30%). Temperature levels ranged between 60 degrees to 70 F. It was noted multiple times "Humidifier left in room."

OR # 8 had humidity levels ranging between 14% and 50%. (19 of 28 days' humidity was < 30%). Temperature levels ranged between 60 degrees to 73 F. It was noted multiple times "Humidifier left in room" and "Maintenance notified."

OR # 9 had humidity levels ranging between 15% and 44%. (14 of 28 days' humidity was < 30%). Temperature levels ranged between 58 degrees to 73 F. It was noted multiple times "Humidifier left in room."

OR # 10 had humidity levels ranging between 13% and 45%. (17 of 28 days' humidity was < 30%). Temperature levels ranged between 60 degrees to 71 F. It was noted multiple times "Humidifier left in room."

CT Room # 1 had humidity levels ranging between 21% and 40%. (20 of 28 days' humidity was < 30%; 2 days were not checked for temperature or humidity). Temperature levels ranged between 66 degrees to 75 F. Twice it was noted that a work order was placed to correct humidity.

Radiology Room had humidity levels ranging between 14% and 32%. (22 of 28 days' humidity was < 30%). Temperature levels ranged between 55 degrees to 68 F. It was noted multiple times "Called engineering for humidity."

Ultra Sound # 1 had humidity levels ranging between 21% and 43%. (2 of 28 days' humidity was < 30%). Temperature levels ranged between 55 degrees to 68 F. Temperature was within range.

Ultra Sound # 2 had humidity levels ranging between 23% and 45%. (3 of 28 days' humidity was < 30%). Temperature levels were appropriate. It was noted multiple times "Called @ temp."

Anesthesia Work Room had humidity levels ranging between 22% and 59%. (19 of 28 days' humidity was < 30%). Temperature levels ranged between 40 degrees to 72 F (log had no designated range.) Temperature not recorded February 1st thru 4th. Humidity not recorded February 1st thru 3rd. It was noted several times "Work order called."

Ortho Supply Room had humidity levels ranging between 15% and 55%. (20 of 28 days' humidity was < 30%). Temperature Log had no designated range. It was noted multiple times "Humidifier left in room" and "work order called."

OR Supply Room had humidity levels ranging between 23% and 50%. (18 of 28 days' humidity was < 30%). Temperature log had no designated range. It was noted multiple times "Humidifier left in room" and "work order."

OR Sterile Care had humidity levels ranging between 15% and 33%. (27 of 28 days' humidity was < 30%). Temperature log had no designated range. It was noted multiple times "work order called."

OR Sterile Neuro Room had humidity levels ranging between 16% and 42%. (21 of 28 days' humidity was < 30%). Temperature log had no designated range. It was noted multiple times "work order called."

Review of Medical Executive Committee Meeting Minutes for the month of December 2018 revealed no mention of awareness of temperature/humidity issues in the surgical areas. In interviews with executive staff on 3/21/19, it was admitted that while the issue was discovered in December and a plan was made to mitigate the problem, the plan was not followed and low humidity continued to put patients and staff at risk.


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Interview with Environmental Services at Del Sol, in the conference room on 3/20/19, revealed, there was no documentation that the environmental staff monitored the humidity and temperature controls multiple times during the day when the humidity and temperature was out of range as per their plan developed on 12/5/18. They further acknowledged the temperature and humidity levels were only documented at the beginning of the day in the operating rooms and procedure rooms and there was no documentation the environmental staff monitored the temperature and humidity throughout the days while patient surgeries and procedures were occurring.



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Review of the OR Temperature and Humidity Logs (#1-10) at Las Palmas for February 2019 revealed the following readings. This form indicated the Optimum temperature range was 68-75 degree Fahrenheit and Humidity was 20-60%. In an interview on 03/20/19, engineering staff member #35 verified the facility standard is 30-60% and the form being used for that month was an old version that did not reflect the actual standard for humidity.

OR #1 had humidity levels ranging from 17 % to 47 % (16 of 28 days' humidity was < 30%). Temperature range was appropriate between 58.1 to 70.4 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. There was only one action note that engineering was contacted regarding the readings (on 02/18/19). Multiple dates (18 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on 6 of those dates, indicating there was no necessity to adjust the temperature.

OR # 2 had humidity levels ranging from 25 % to 56 % (1 of 28 days' the humidity was < 30%). Temperature range was appropriate between 65.5 to 69 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (18 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on 17 of those dates, indicating there was no necessity to adjust the temperature.

OR # 3 had humidity levels ranging from 33 % to 59 % (No days had humidity < 30%). Temperature range was appropriate between 59.5 to 86.5 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. There was only one action note that engineering was contacted regarding the readings (on 02/16/19). Multiple dates (18 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on all 18 of those dates, indicating there was no necessity to adjust the temperature.

OR # 4 had humidity levels ranging from 31 % to 57 % (No days had humidity < 30%). Temperature range was appropriate between 65.5 to 69 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (12 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on all 12 of those dates, indicating there was no necessity to adjust the temperature.

OR # 5 had humidity levels ranging from 30 % to 54.1 % (No days had humidity < 30%). Temperature range was appropriate between 65 to 71.5 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (16 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on all 16 of those dates, indicating there was no necessity to adjust the temperature.

OR # 6 had humidity levels ranging from 30 % to 49 % (No days had humidity < 30%). Temperature range was appropriate between 65.7 to 69 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (17 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on all 17 of those dates, indicating there was no necessity to adjust the temperature.

OR# 7 had humidity levels ranging from 21 % to 49 % (2 dates had humidity < 30%). Temperature range was appropriate between 62.5 to 69 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (20 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on 19 of those dates, indicating there was no necessity to adjust the temperature.

OR # 8 had humidity levels ranging from 19 % to 44 % (8 dates had humidity < 30%). Temperature range was appropriate between 65.8 to 68.3 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (15 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on 11 of those dates, indicating there was no necessity to adjust the temperature. On 02/22/19 the humidity of 20 % and the 02/25/19 the humidity of 20 % had no actions noted.

OR # 9 had humidity levels ranging from 20 % to 44 % (10 dates had humidity < 30%). Temperature range was appropriate between 59.9 to 68.2 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (15 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on 9 of those dates, indicating there was no necessity to adjust the temperature.

OR # 10 had had humidity levels ranging from 25 % to 49 % (3 dates had humidity < 30%) for 02/01/19 to 02/08/19. OR #10 was closed for construction on 02/08/19. Temperature range was appropriate between 58.6 to 64.5 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (8 of 8 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on all 5 of those dates, indicating there was no necessity to adjust the temperature.


In an interview on 03/20/19, staff member #A35 confirmed for the Las Palmas the humidity values are 30-60% and the OR staff was using the wrong form that had the value of 20-60 % indicated. For March 2019 the OR #1-10 log reflected the correct humidity values of 30-60 %. Staff member #A35 also verified that the temperature did not need to be adjusted if the humidity reading is within normal limits. Review of the March 2019 Temperature and Humidity logs revealed that the appropriate humidity values of 30-60 % were obtained.

In an interview on 03/20/19, staff member #A36 Interim Administrative Director of Surgical Services and #A37 Director of Surgical Services confirmed that the staff in OR #1-10 were not properly completing the Temperature and Humidity Logs per facility policy in February 2019. Per staff member #A36 starting to record the temperature and humidity from the readings obtained in the engineering department starting the week of 02/18/19, so the temperature reading would be more accurate and consistent.

On 03/20/19, staff members A#35 , A36, and A37 confirmed the above findings regarding the temperature and humidity logs for ORs #1-10 at Las Palmas.

Based on observation and interview, the facility failed to ensure a sanitary environmental practices to avoid sources and transmission of infectious and communicable diseases.

Findings:

During a tour of the 3rd floor at Del Sol facility the morning of 3/19/2019, the follow was observed,

Patient room 312A was missing the veneer around the rim of the bedside table with visible exposed raw wood.

Patient room 319A had worn varnish on the surface area and corners of the bedside table with visible exposed raw wood.

Patient room 322B had worn varnish on the surface area and corners of the bedside table with visible exposed raw wood.

Patient room 335A had 6 exposed screws on the right entry wall.

Patient room 433 bathroom sink had exposed gray/black residue and sealant protruding around the perimeter of the sink.

Baseboards were visibly soiled with black marks throughout the 3rd floor

This was confirmed in an interview with Staff #5, Roster B.

Based on observation, interview, and record review, the facility failed to provide patient care in a sanitary environment in that,

a.) The sterile processing department was routinely using IUSS (Immediate Use Steam Sterilization) due to a lack of sufficient equipment and had erroneously reported the numbers of equipment that had been IUSS.

b.) The staffs were taking equipment into patient's room, that were on contact isolation, did not thoroughly clean them before transporting the equipment to other areas of the hospital, possibly spreading drug-resistant organisms throughout the hospital.

c.) Contaminated biohazard tubs were stored outside where patients/public could gain access

Findings:

a.) Review of Del Sol Hospital's IUSS records reflected on 9/19/18, 12/7/18,12/8/18, 10/22/18, 10/15/08 (2 times), and 10/1/18, the Stryker 8 drill was required to be flashed sterilized due to "all items in use" on 12/7/18 and on 12/5/18 the Dental Extraction instruments were flashed sterilized due to "all items in use".

During an interview in the morning of 3/20/18 in the Del Sol Hospital's sterile processing department Staff #23C, OR director, stated, "All the surgeons want to use the Stryker 8 drill, I have others but they want the newest model .... We try to order more items if we see a need." When asked if the instrument needs are taken to the Quality, Infection Control or Governing Body for approval. Staff #23C stated, "No, Staff #7, Sterile Processor Supervisor tells me if we need more ...."

The facility did not have a central log for the items that were IUSS; the surveyor was required to look for items in two large books of records, making it difficult to locate IUSS items. Additionally, the facility had externally reported (5) IUSS items for the month of 12/2018 the facility records reflected (8) IUSS items.
Review of the facility provided policy Cleaning, Disinfection, and Sterilization (dated 11/27/18) reflected," ...11. Flash Sterilization ... b. ... Flash sterilization should never be used for convenience, to save time, or as an alternative to purchasing additional instrument sets ...."

Review of the Del Sol facility provided American Journal of Infection Control 41 article (2013) reflected "AORN recommended practices ... The AORN guidelines remind us that IUSS should be kept to a minimum, used only in specific situations, and done in a controlled manner. IUSS should not be used because of scheduling or lack of sufficient instrumentation. IUSS may be associated with increased risk of infections because of time pressure put on staff because of time restrictions ...."

During an interview on the morning of 3/20/19 in the Del Sol Hospital's administrative offices Staff #2C, Assistant CNO, stated the facility utilizes the AORN for the infection control guidelines.


b.) An observation, during a tour on the afternoon of 3/19/19, in the Del Sol Intensive Care Unit revealed a Radiology technician taking a portable x-ray machine into a contact isolation room. The technician was observed donning personal protective gown and gloves. The technician completed the x-ray and rolled the machine out of the room, hitting items in the room while attempting to back the machine out. Staff #1C, and was observed wiping off parts of the x-ray machine; Staff #1C did not wipe the entire machine down. Further observation revealed an approximate 24 x .25 inch streaking of a dark red substance left on the machine's cloth cable cord. The dark red substance did not appear to have come from the current patient. Additionally, a large stack of exposed plastic sheets, used to cover the x-ray machine's cassettes, were being stored on the machine and were left on the machine.

During an interview on the ICU, on 3/19/19, Staff #1C, when asked how the equipment is cleaned after removal from an isolation room and what the plastic sheets were used for Staff #1C stated," I clean the machine after each patient. I have to wait three minutes before I can use it. I clean the push buttons, handles and the cassettes .... The plastic sheets are to cover the cassettes." When asked if the Staff member was going to use the plastic covers, Staff #1C asked, "So I can't take the covers into other rooms.?"

During an interview on the ICU, on 3/19/19, Staff #2C, ICU Director confirmed the finding.

An observation on the morning of 3/20/19, on the Del Sol inpatient unit revealed Staff #21C, RN taking her rolling medication cart into a contact isolation room. The cart had multiple drawers containing single use normal saline syringes. The patient was on contact isolation for MRSA, (methicillin-resistant Staphylococcus aureus bacteria).

During an interview on the Del Sol medical surgical unit, on 3/20/19, when asked about the cleaning of the cart and the items in the drawers, Staff #21C, RN stated, "I wipe off the keyboard, drawers, computer screen and table top with the wipes .... I can reuse the items in the drawers as long as I didn't open them ...." The wheels and casters, electrical cords, and back of the cart were not mentioned as having been cleaned.

During an interview on the Del Sol Medical Surgical unit on 3/20/19, Staff #2C stated the drawers can lock and can be used to hold the different patient's medications. Staff #2C confirmed the findings.

Review of the facility provided policy Management of Clean and Dirty Patient Equipment (dated 8/19/18) reflected, " ...D. ANY equipment enter an isolation room must be wiped down before being used for another patient .... A. Remove obvious soiling with damp cloth. C. Wipe down item to be cleaned D. Do not rinse; allow to air dry at least five (5) minutes. ..."


c.) In a tour of the Del Sol Environmental Services department and outside of the facility (near commercial trash bin and biohazard storage container located near the road), on 3/19/19 at 10:04 a.m., approximately 20 biohazard tubs were found stored outside of the biohazard storage container adjacent to the road. Several biohazard tubs had dark unknown liquid inside, along with debris and various foreign matters such as paper and disposable gloves.

In an interview on 3/19/19 at 10:04 a.m. with Staff #17C, Director of Environmental Services (EVS), she stated that approximately 20 biohazard tubs found outside were already cleaned and stored at that area. She stated she did not know the exact cleaning process and "not sure whether sterilized, cleaned with water, or contents just dumped" because they were cleaned by Stericycle (contracted service). She further stated these biohazard tubs were only used in the EVS areas, and not in any other units.

In a tour of the Del Sol Emergency Department (ED) on 3/19/19 at 10:22 a.m., the same type of biohazard tub was found and in-use in the soiled utility room.

In an interview on 3/19/19 at 10:40 a.m. with Staff #18C, Director of Facility Management, he confirmed that biohazard tub found in the ED were the same biohazard tubs used by EVS. He further stated EVS serviced these biohazard tubs when they become full.

Review of undated facility provided policy of Stericycle's "Procedures for Cleaning Small and Medium Size Reusable Containers Utilizing the Automated Tub Washer" stated in part under Cleaning of the tubs:

1. "Empty container, verify no loose debris remains in container, place upside down on conveyor belt to tub washer."

3. "Visually verify the container was washed and deodorized."

4. "Recheck the inside of the container to verify that no water or foreign matter exists."

Based on interview and record review, the facility failed to provide surgical services in a sanitary environment when the Del Sol Facility's Endoscope Processing system and Surgical Instrument Washer's routine maintenance were not being performed according to the Manufacturer's recommendation.

Findings:

An observation during a tour of the Del Sol Facility's Sterile Processing Department, on the morning of 3/19/19, revealed a yellow and white substance along the door and at the base of the facility's surgical instrument washer.

During an interview on the morning of 3/19/19, in the facility's sterile processing department, when asked for the routine preventative maintenance of the surgical instrument washer and the Endoscope Processing System, Staff #7C, Sterile Processing Supervisor verified the parts of the washer that were being cleaned but failed to provide documentation that the preventative maintenance was being performed as scheduled. Staff #7C stated, the Steris Manufacturer conducts the routine maintenance on the Endoscope Washer, " ...We call them out if we need something ..."

Review of the facility provided Reliance EPS Endoscope Processing System routine maintenance manual reflected,

" ...3.1 Verify debris screen in chamber is clean and in good condition .... 1x/day

3.2 Perform a D-SHORT cycle every 54 hours

3.3 Clean chamber rotary spray arm assembly 1x/week ...

3.5 Clean plastic surfaces and processor exterior panels 1x/week

3.6 Clean steel surfaces 1x/day ...

5.1 Clean endoscope processing support rotary spray arm assembly 1x/week

5.2 Clean three draining holes at bottom of control handle boots using a thin wire or compressed air 1x/week

5.3 Clean draining holes in bottom of Reliance CDS Chemical Delivery System using a thin wire or compressed air 1x/week

5.4 Clean venting orifice of two Allen hex screws from Reliance CDS using compressed air 1x/week ...

5.8 Verify flexible silicone tubing of Flow Units is in good condition (not brittle, discolored, cracked, yellowish). Verify Flow Unit adapters and ports are in good condition 1x/week


Review of the facility provided Steris Washer Manufacturer's cleaning instructions reflected, " ...5.4 Clean washer/disinfector exterior (see Section 6.6) Once a Week.

Based on interview and record review, the facility failed to provide surgical services in a safe manner when the anesthesiologist documented a patient's operative information before the patient had arrived into the operating room.

Findings:

Review of a Del Sol Hospital Surgical Patient#1C's operative report, dated 3/19/19 at 12:30 pm, reflected, " ...Ventilation controlled, Position Supine, Pressure points checked and padded, and eyes taped ...." had been documented as having been completed. Patient #1C was still in the pre-operative unit and the items had not been completed.

The facility failed to provide a requested policy for the appropriate documenting of surgical procedures.

During an interview on the morning of 3/19/19, in the Pre-operative surgical unit, Staff #2C confirmed the findings.