HospitalInspections.org

Based on staff interview, policy and procedures review the facility failed to maintain current certification for staff.

Findings include:

The employees educational in-services were reviewed on 10/17/14 at 8:15 A.M. The review revealed some of the licensed staff had expired Pediatric Advanced Life Support (PALS) certification. Their PALS certification expired on 9/30/14. The four licensed staff were scheduled to work during the week of October 1-18, 2014.

The "Policy No.: 600-120-4 Pediatric Advanced Life Support (PALS) Training" effective September 15, 2014 was reviewed. Under II. Policy: D = it stated, "Required staff is responsible for maintaining a current PALS certification at all times, with renewal requirement every 2 years. Clinical staff with an expired certificate will not be allowed to work leave without pay (LWOP)."

An interview was conducted with the Inservice Education Manager on 10/17/14 at 8:20 A.M. She acknowledged that the four licensed staff had expired certification and were scheduled to work. She mentioned that there was someone coming to do the certification.

Based on observations and staff interviews the facility failed to ensure that expired supplies kept in the intensive care unit (ICU), and on the Med-Surg crash cart were replaced.

Findings include:

On 10/15/2014 at 9:15 AM, reviewed the ICU crash cart and supplies with LN#1. According to LN#1 the supplies kept on the ICU unit are checked monthly and she showed the log book to validate that supplies are monitored monthly. The supplies log book noted that the supplies were last checked in 8/14 with dates highlighted in yellow or pink, for items that were soon to expire. Inquired how staff would know that items with expiration dates highlighted were removed. To show that the expired items were removed LN#1 went to the blue supply cupboard and looked at a yellow highlighted date of 8/14 for 25/23g butterfly cath. The bin for the butterfly cath was located and there were 6 packaged butterfly catheters bound together with a rubberband and a yellow sticky note on top with the expiration date of 8/14. The ICU department manager, (LN#2) came to introduce self and stated, "Yes they, (packages of butterfly cath) are expired, and should have been removed, but that's why a yellow sticky was placed on the items." According to LN#2, the supplies log book was not really used and that's why staff didn't write in the log book after the date of 8/14. She further stated that the ICU staff just know that supplies are to be checked monthly, and that she knows to check supplies and makes sure that nothing expired. The LN#2 removed the packages of expired butterfly cath and the supplies log book.
The West Kauai Medical Center (KVMH) Policy No. 510-109-1; Revision No. 4; Policy and Procedure Dept: Intensive Care; Effective Date: March 12, 2014; Supersedes Policy: #3 - 11/23/10; and Reviewed by LN#2 on 7/13/11. This P & P provides under, II. Policy: C. All ICU personnel are responsible in checking expirations of medications and supplies.
On 10/15/2014 at 10 AM, looked at the Crash cart on the MS unit with LN#6, and found two packages of 3M Red Dot monitoring electrodes expired on 9/2014. The LN#6 removed the two packages and informed the MS charge nurse.
The West Kauai Med Center (KVMH) Policy No. 220-109-32; 500-109-1; Revision No. 7; Effective date: July 14, 2011; Supersedes Policy: #6 - 7/22/10; Subject: Crash Carts (Emergency drug carts); Policy and Attachments reviewed on 2/25/14 with no changes documents on page 2 of 6; II. Policy: A. All medications, supplies and equipment of the crash carts shall be stocked, maintained, readily available and secured.

Based on observations and staff interviews, the facility failed to ensure that the surgical circulating nurses followed the hand hygiene policy.

Findings include:

On 10/15/14 at 10:50 AM, observed patient (Pt#7), undergoing an outpatient surgery to remove a pterygium from his/her right eye. Those present included the Ophthalmologist (MD), head surgical nurse (LN#3), and two surgical circulating nurses.
After the time-out period, one of the circulating nurses (LN#4), removed her gloves and went to pour liquid from a plastic bottle into a stainless steel bowl that was on the stainless steel table that the surgical nurse worked from. The LN#4 then came to ask my name and wrote my name down with a pen and paper pad, and placed them into her pocket, and went to the side of the surgical table as the MD performed the surgical procedure.
The other surgical circulating nurse, (LN#5) also removed her gloves after the time-out period and continued to assist by dropping items onto the stainless steel table and held a container for the surgical nurse to aspirate contents from into a syringe. The LN#5 was then observed writing into a composition book at a side desk, and without sanitizing hands went to assist the MD to finish up the surgical procedure. The LN#5 assisted the MD by placing eye drops into Pt#7's eyes and handed the MD an ointment tube and tape. The MD placed the sterile gauze with ointment onto the patient's eye and taped around the gauze. The procedure ended at 11:19 AM.
On 10/17/14 at 7:45 AM, interviewed LN#3, and she stated that the circulating nurses used hand sanitizer after they removed their gloves. Informed LN#3 that both circulating nurses used a pen and paper tablet to write into and did not sanitize hands before continued to provide assistance to surgeon and surgical nurse. The LN#3 stated that she plans to sit down with surgical nurses and look at hand hygiene protocols.
The KVMH Policy No. 570-125-1; Revision No. 6; Policy and Procedure Dept: Operating Room/Recovery Room; Issued by: Operating Room/Recovery Room Department Nursing; Effective Date: November 20, 2001; Supersedes Policy: #5- 8/00; Subject: Infection Control; Approved by Eileen Nakaahiki; Page 1 of 12; and, Reviewed by: Hospital Performance Improvement Committee on 8/29/00. This P & P under, III. Procedure: C. Orientation and Instruction of Personnel; Handwashing and Personal Hygiene: ...Hands shall be washed before handling any clean medical equipment, etc., after handling anything soiled or contaminated, ...