HospitalInspections.org

Based on observation, document review and staff interview, the hospital's administrative staff failed to identify and remove or replace all non-breakaway hardware from all areas in the inpatient adult behavioral health unit including 7 of 7 patient bathrooms in 8 of 12 patient rooms (Room #678, #680, #681, #682, #683, #684, #685, and #686) for 8 of 8 adult psychiatric patients (Patients #1, #2, #3, #4, #5, #6, #7, and #8). Failure to establish and maintain a safe environment including non-breakaway hardware for psychiatric patients could potentially provide a point of attachment for a device used for patient strangulation or hanging and result in patient deaths or other life-threatening conditions. The hospital identified an average daily census of 12 in the Behavioral Health Unit.

Findings include:

1. Review of the policy "Environmental Safety and Security," last revised 09/2019, revealed in part, "The Behavioral Health Services Inpatient Unit is committed to providing a safe, ligature resistant environment for all staff, patients, and visitors."

2. Observations during a tour of the inpatient adult behavioral health unit, on 11/18/19 which began at 2:00 PM, revealed 7 of 7 patient bathrooms (Room #678, #680, #681, #682, #683, #684, #685, and #686) in the main behavioral health unit contained a paper towel dispense. Hospital staff had affixed the paper towel holder to the wall and left a gap between the wall and the paper towel holder. The gap could allow a patient to secure a sheet or other item, which would allow the gap to function as an anchor point for a device the patient could use to strangle themselves (a ligature risk).

3. During an interview on 11/18/19 at 3:30 PM, the Behavioral Health Director confirmed the paper towel holders in 7 of 7 patient bathrooms in the main behavioral health unit (Room #678, Room #680, Room #681, Room #682, Room #683, Room #684, Room #685, and Room #686) contained paper towel holders with a gap between the wall and the paper towel holder, which could potentially allow a patient to use the paper towel holder as a ligature anchor point for a patient attempting to strangle themselves.

Based on document review and staff interview, the hospital's administrative staff failed to ensure a qualified staff member performed a face-to-face evaluation for 2 of 3 patients (Patient #20 and Patient #21) placed in restraints due to violent or self-destructive behavior. Failure to ensure a face-to-face evaluation may result in patients being restrained for medical or behavioral reasons that could be appropriately treated without the use of restraints. The hospital identified a census of 137 on entrance.

Findings include:

1. Review of the policy "Restraints and Seclusion," last approved 09/11/19, revealed in part, "A physician/hospitalist, clinical psychologist, other authorized LIP [Licensed Independent Professional], or other qualified healthcare staff responsible for the care of the patient evaluates the patient face-to-face within one hour of the initiation of restraint ...used for the management of violent or self-destructive behavior."

2. Review of medical records on 11/21/19 at 9:00 AM revealed the following:

a. On 09/23/19 at 2:35 PM, RN R placed Patient #20 in 4 point restraints (all extremities) for management of violent behavior. On 09/23/19 at 4:59 PM, RN S removed Patient #20's 4 point restraints. The medical record lacked any documentation of a face-to-face evaluation by a physician/hospitalist, clinical psychologist, other authorized LIP, or qualified healthcare staff responsible for the care of Patient #20.

b. On 09/23/19 at 1:10 PM, RN T placed Patient #21 in 4 point restraints for management of violent behavior. On 09/23/19 at 4:00 PM, RN U removed Patient #21's 4 point restraints. The medical record lacked any documentation of a face-to-face evaluation by a physician/hospitalist, clinical psychologist, other authorized LIP, or qualified healthcare staff responsible for the care of Patient #21.

3. During an interview at the time of the medical record review, the Inpatient Surgery Director confirmed the medical records did not contain documentation of a face-to-face assessment of Patient #20 or Patient #21 within 1 hour of the behavioral health staff placing the patient into restraints for violent or self-destructive behavior.

Based on review of the Quality Improvement Plan, Quality Improvement meeting minutes, Board of Trustees Bylaws and Meeting Minutes, and staff interview, the Hospital quality improvement staff failed to ensure the evaluation of all patient care services provided were reported to the governing body for 12 of 24 patient care services (Maintenance, Anesthesia, Inpatient Physical Therapy, Inpatient Occupational Therapy, Inpatient Speech Therapy, Cardiac Rehabilitation, Pulmonary Rehabilitation, Sleep Study, Pain Clinic, Wound Clinic, and Echo Lab), 1 of 1 contracted patient care service (Dialysis), and 2 of 2 off site patient care services (Medical Arts Building, Story City Rehab and Wellness). The hospital's administrative staff identified a census of 137 patients at the beginning of the survey. Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care.

The hospital's administrative staff reported the following volume of patient care services:
- Maintenance - average daily census of 106 patients
- Nutrition - average number of patient meals served per month - 12,240
- Anesthesia - average number of 736 patients who received anesthesia per month
- Inpatient Physical Therapy - average number of 868 inpatient physical therapy patient visits per month
- Inpatient Occupational Therapy - average number of 322 inpatient occupational therapy patient visits per month
- Inpatient Speech Therapy - average number of 132 inpatient speech therapy patient visits per month
- Cardiac Rehabilitation - average number of 255 cardiac rehabilitation patient visits per month
- Pulmonary Rehabilitation - average number of 62 pulmonary rehabilitation patient visits per month
- Sleep Study - average number of 48 outpatient sleep study visits per month
- Pain Clinic - average number of 315 pain clinic patient visits per month
- Wound Clinic - average number of 408 wound clinic patient visits per month
- Echo Lab - average number of 173 echo lab patient studies per month
- Dialysis - 44 patients per month
- Medical Arts Building (outpatient Physical Therapy - 615 patients per month, Occupational Therapy - 110 patients per month, and Speech Therapy - 75 patients per month) - 800 patients per month
- Story City Rehab and Wellness - Physical Therapy and Occupational Therapy - 449 patients per month

Findings include:

1. Review of the "Board of Trustees Bylaws," dated 3/2019, revealed in part, "... The Board of Trustees is ultimately responsible for the quality of care provided in the medical center. The Board of Trustees shall require, after considering the recommendations of the Medical Staff and the other health care professional staff providing patient care services at Mary Greeley Medical Center, the conduct of specific review and evaluation activities to assess, preserve, and improve the overall quality and efficiency of patient care in the medical center and to minimize risk to patients...."

Review of the policy "Quality/Performance Improvement Plan," dated 10/23/2018, revealed in part, "...The Quality/Performance Improvement process will encompass all functions of patient care and support services provided by Mary Greeley Medical Center ... The Board of Trustees will receive reports and education on Quality/Performance Improvement information and/or activities monthly ...."

2. Review of the Board of Trustees Meeting minutes from November 26, 2018 through September 23, 2019 lacked evidence that Maintenance, Anesthesia, Inpatient Physical Therapy, Inpatient Occupational Therapy, Inpatient Speech Therapy, Cardiac Rehabilitation, Pulmonary Rehabilitation, Sleep Study, Pain Clinic, Wound Clinic, and Echo Lab monitored, evaluated, and reported quality improvement activities regarding patient care services to the Board of Trustees.

Review of the Quality & Patient Safety Council Meeting minutes from September 28, 2018 through September 18, 2019 lacked evidence that Maintenance, Anesthesia, Inpatient Physical Therapy, Inpatient Occupational Therapy, Inpatient Speech Therapy, Cardiac Rehabilitation, Pulmonary Rehabilitation, Sleep Study, Pain Clinic, Wound Clinic, and Echo Lab monitored, evaluated, and reported quality improvement activities regarding patient care services into the hospital wide quality improvement program.

3. During an interview on 11/21/2019 at 9:35 AM, the Director of Quality Management acknowledged that Maintenance, Anesthesia, Inpatient Physical Therapy, Inpatient Occupational Therapy, Inpatient Speech Therapy, Cardiac Rehabilitation, Pulmonary Rehabilitation, Sleep Study, Pain Clinic, Wound Clinic, and Echo Lab monitored, evaluated, and reported quality improvement activities regarding patient care services to the Quality Council and to the Board of Trustees.

Based on observations, policy review, and staff interview, the Hospital x-ray staff failed to ensure staff secured 1 of 2 radiation exposure cords to not allow staff access into the x-ray room (Room 1) during completion of radiological tests of patients. The CAH x-ray staff reported completing an average of 453 x-rays per month in Room 1. Failure to secure radiation exposure cords could allow staff access to the x-ray room while performing an x-ray procedure and exposing staff to unnecessary radiation.

Findings include:

1. Observations during tour of the radiology department on 11/19/2019 at 3:15 PM, with the Director of Radiology, revealed 1 of 1 unsecured exposure cord in x-ray Room 1, which allowed a staff member to enter approximately 8 feet into the x-ray room and still activate the x-ray machine.

2. Review of hospital policies revealed the hospital lacked a policy addressing the length of the exposure cord.

3. During an interview on 11/19/2019 at 3:15 PM, the Director of Radiology confirmed the staff failed to secure the radiation exposure cord in a way that would not alllow staff access into the x-ray room during x-ray procedures. The Director of Radiology acknowledged the hospital lacked a policy that addressed securing the exposure cord so that staff could not enter the x-ray room and still activate the x-ray machine.

Based on observations and staff interviews, the Acute Care Hospital administrative staff failed to ensure the hot water temperatures at 1 of 1 Obstetric (OB) unit, 1 of 1 Emergency Department (ED), and 1 of 2 off-site Out Patient Therapy Clinics (Medical Arts Building) remained at safe temperatures between 110 - 120 degrees Fahrenheit. Please refer to A-701.

The cumulative effect of this systemic failures and deficient practices resulted in the facility's inability to ensure patient safety. The acute care hosptial's administrative staff identified 1,090 OB inpatient admissions from 05/2019 to 10/2019, 2333 ED patients visits per month, and 800 rehabilitation patient visits per month at the Medical Arts Building off-site Out Patient Therapy Clinic.

Based on observations, document review, and staff interviews, the Hospital's administrative staff failed to create and implement an effective system to ensure staff detected when hot water temperatures exceeded the Hospital's acceptable range for hot water between 110 and 120 degrees Fahrenheit at 1 of 1 Obstetric (OB) unit, 1 of 1 Emergency Department (ED), and 1 of 2 off-site Out Patient Therapy Clinics (Medical Arts Building) available for patients to wash their hands. Failure to monitor hot water temperatures could potentially cause serious scalding burns to patients. The depth of injury relates directly to the temperature and duration of exposure to the hot water. Exposure to hot water at 133 degrees Fahrenheit can cause a third degree burn (destruction of the outer layer of skin and the entire layer beneath) to occur is 15 seconds, one minute at 127 degrees Fahrenheit, and 3 minutes at 124 degrees Fahrenheit. The facility administrative staff identified 1,090 OB inpatient admissions from 05/2019 to 10/2019, 2333 ED patients visits per month, and 800 rehabilitation patient visits per month at the Medical Arts Building off-site Out Patient Therapy Clinic.

Findings include:

1. Observations on 11/19/2019 at 10:45 AM, during a tour of the Medical Arts Building off-site Out Patient Therapy Clinic, with the Director of Outpatient Services and Director of Rehab and Wellness, revealed 4 sinks available for patients to wash their hands. Hot water temperatures observed during the tour included:

- Therapy Exam Room #7. The hot water temperature in the sink was 138.2 degrees Fahrenheit.
- Therapy Gym Area. The hot water temperature in the sink was 137.9 degrees Fahrenheit.
- Neuro Area. The hot water temperature in the sink was 135.7 degrees Fahrenheit.
- Hand Therapy Room. The hot water temperature in the sink was 135.8 degrees Fahrenheit.

During an interview at the time of the observations, the Director of Rehab and Wellness acknowledged and verified the hot water temperatures at the time of the observations.

2. During further observations on 11/19/19 at 3:15 PM at the Medical Arts Building off-site Out Patient Therapy Clinic, with Maintenance Engineer B, revealed Maintenance Engineer B obtained the following hot water temperatures at the hand washing sinks using a hospital thermometer:

- Therapy Exam Room #7. The hot water temperature in the sink was 132.5 degrees Fahrenheit.
- Therapy Gym Area. The hot water temperature in the sink was 121.5 degrees Fahrenheit.
- Neuro Area. The hot water temperature in the sink was 129.1 degrees Fahrenheit.
- The hand therapy room was unavailable at the time of the additional observations.

During an interview at the time of the observations, Maintenance Engineer B acknowledged the sink hot water temperatures were greater than 120 degrees Fahrenheit at the time of the additional observations.

3. Observations on 11/20/19 starting at 1:51 PM, during a tour of the ED with the Emergency Department Director, revealed Maintenance Engineer B obtained the following hot water temperatures, using a hospital thermometer:

- ED Room #6. The hot water temperature in the sink was 131.4 degrees Fahrenheit.
- ED Room #7. The hot water temperature in the sink was 131.4 degrees Fahrenheit.
- ED North Station Sink. The hot water temperature in the sink was 130.6 degrees Fahrenheit
- ED South Station Sink. The hot water temperature in the sink was 130.3 degrees Fahrenheit.

During an interview at the time of the tour, Maintenance Engineer B acknowledged the sink hot water temperatures were greater than 120 degrees Fahrenheit at the time of the observations.

4. Observations on 11/18/19 starting at 1:52 PM, during a tour of the obstetrical department (OB) with the Director of Maternal and Child Services revealed the following hot water temperatures in sinks available for patient use:

- Room 460. The hot water temperature in the sink was 127.4 degrees Fahrenheit.
- Room 466. The hot water temperature in the sink was 127.4 degrees Fahrenheit.
- Room 471. The hot water temperature in the sink was 127.4 degrees Fahrenheit.

During an interview at the time of the tour, the Director of Maternal and Child Services acknowledged the sink hot water temperatures were greater than 120 degrees Fahrenheit.

5. During further observations on 11/19/19 at 8:30 AM in the OB department, with Maintenance Engineer B, revealed Maintenance Engineer B obtained the following hot water temperatures at the hand washing sinks using a hospital thermometer:

- Room 460. The hot water temperature in the sink was 127.7 degrees Fahrenheit.
- Room 466. The hot water temperature in the sink was 128.4 degrees Fahrenheit.

During an interview at the time of the tour, Maintenance Engineer B acknowledged the sink hot water temperatures were greater than 120 degrees Fahrenheit.

6. During an interview on 11/20/19 at 10:24 AM, the Infrastructure Coordinator revealed that the water supply for the South Tower, where the OB unit was located, had the hot water supply circulate hot water at 140 degrees Fahrenheit. The South Tower had a single point where the hot water mixed with the cold water, and supplied the patient care rooms. The mixing valve was located near the laboratory, so the maintenance staff did not check any hot water temperatures on the OB unit.

7. During an interview on 11/20/19 at 9:25 AM, the Facilities Director revealed the maintenance staff did not check the hot water temperatures in any of the patient rooms, as the staff set all of the hot water mixing valves in the hospital for 120 degrees Fahrenheit. Thus, the hot water temperatures at the patient sinks should not go higher than 120 degrees Fahrenheit. The Facilities Director acknowledged Maintenance Engineer B obtained hot water temperature readings greater than 120 degrees Fahrenheit (the hospital's acceptable upper limit for hot water temperatures). The Facilities Director also acknowledged the hospital lacked a policy specifying the acceptable range for hot water temperatures and directing staff on what actions to take if the hot water temperatures exceeded 120 degrees Fahrenheit.

I. Based on review of Contracted Dialysis Service A's (CDS A) policy and procedure, manufacturer's information, observation, and staff interviews, the hospital administrative staff did not ensure total chlorine testing of water used for dialysis was was performed in accordance with manufacturer's directions and CDS A's policy and procedure. In addition, the hospital administrative staff did not ensure CDS A staff members had the correct knowledge regarding the principles behind the actions or steps of the total chlorine testing procedure.

In the dialysis process, water comes in contact with the patients' blood, and the presence of chlorine in water would be toxic, potentially causing harm to dialysis patients. Failure to follow correct procedure when performing total chlorine tests could lead for failure to obtain accurate test results for the presence of chlorine in the water.

The hospital reported 1 patient undergoing hemodialysis treatment during the survey. Findings for 1 of 1 observation of total chlorine testing include:

1. Review of the manufacturer's information titled, "RPC K100-0118 and K100-0118F* Ultra-Low Total Chlorine Test Strips Instructions for Use," indicated the directions for testing included collecting a fresh 100 ml (milliliter) sample of water in a clean plastic sample cup. The directions also instructed the staff to make sure that the sample cup is known to be free of chlorine, or to rinse the sample cup with the water to be tested, prior to collecting the sample.

2. Review of CDS A's policy and procedure # 7-10-05F, titled "Total Chlorine Test Using RPC Ultra Low Total Chlorine Test Strip," last revised 03/2014, directed the staff to rinse the sample collection cup thoroughly with the water to be tested. Staff needed to fill the sample cup to the line marked 100 ml with the sample water, with the rationale for this noted, "this step rinses out any possible contaminants such as residuals of previous samples and reagents."

3. Review of CDSA's staff training documentation titled "CEC4012 Acute Basic Components and Monitoring of Dialysis Quality Water Treatment Systems Procedural Skills Verification Checklist for Teammates Who Perform Water Monitoring & Testing," indicated that CDS A RN (Registered Nurse) A received training on 3/7/19, which included total chlorine testing.

4. During observations of the total chlorine testing on 11/18/19 at 3:45 PM, CDS A RN A entered the water room, opened the primary sample port and let the water run for approximately 10 seconds, and then collected sample water using a 120 ml (milliliter) sample cup. CDS A RN A verbalized they needed 100 ml of sample water, however, the actual amount of water collected as observed in the sample cup was 110 ml, and which was pointed out to CDS A RN A by the surveyor. CDS A RN A verified that the amount of sample was 110 ml, and stated that it was hard to see the 100 ml mark/indicator in the cup. CDS A RN A did not reduce the amount of water in the cup, but went ahead and tested the 110 ml water sample. When asked if the amount of water was critical for the total chlorine test, CDS A RN A replied that it did not matter, and further stated that a 30 ml water can also be used for testing and the result will not be affected at all.

5. During a phone interview on 11/19/19 at 1:57 PM, CDS A RN A acknowledged that when she did the total chlorine test on 11/18/19, she did not rinse the sample cup, because CDS A RN A did not have anywhere to dump the water used to rinse out the cup. CDS A RN A also revealed that, because she opened the sample port and let the water run for 5-10 seconds to purge any unwanted water in the pipeline, she did not need to rinse the cup. CDS A RN A further revealed that rinsing the sample cup is "not in policy" and that the staff only make sure the sample cup was covered.

6. On 11/19/19 at 2:15 PM, the CDS A Biomedical Staff reviewed the total chlorine testing procedure including rinsing the sample cup 2 times with water from the sample port and then filling the cup to a 100 ml for testing. The CDS A Biomedical Staff revealed that rinsing the sample cup and collecting the correct amount of water are critical steps for getting accurate test results.

7. On 11/19/19 at 2:30 PM, the hospital Director for Rehabilitation (Liaison Officer for CDS A) acknowledged the importance of following the total chlorine testing procedure as provided by the manufacturer's information and the CDS A's policy and procedure.


42027




II. Based on observation, document review, and staff interviews, the Hospital's administrative staff failed to ensure 1 of 2 off-site Out Patient Therapy Clinics' (Medical Arts Building) staff laundered the fabric hydrocollator (heating unit for moist heat therapy) pack wraps after patient use. Failure to launder the pack wraps after use could potentially result in the transmission of germs to patients, which could potentially cause skin irritation or infection. The hospital's administrative staff identified an average of 35 out patients per month treated with moist heat therapy at the off-site Patient Therapy Clinic.

1. Observations during a tour of the Medical Arts Building off-site Out Patient Therapy Clinic, on 11/19/2019 at 10:45 AM with the Director of Rehab/Wellness and the Director of Outpatient Services, revealed 4 dark tan discolored hydrocollator pack wraps hanging on horizontal rungs near the hydrocollator heating unit and 1 dark tan hydrocollator pack wrap lying on a nearby shelf.

2. During an interview at the time of the tour, the Director of Rehab and Wellness revealed that the physical therapy staff hung the wet hydrocollator pack wraps up to dry after the staff use the packs on patients, unless the pack appeared soiled.

3. Review of the document "Hot Packs," effective 03/14/2018, revealed in part, "... Clean up ... Take pack off. Put pack back into machine. Put padding and wraps in laundry ...."

4. During an interview on 11/19/2019 at 12:55 PM, the Director of Rehab and Wellness and the Director of Outpatient Services acknowledged the physical therapy staff failed to launder the hydrocollator packs after each patient use, as required by the hospital's policy.



42028


III. Based on observation and staff interviews, the hospital's administrative staff failed to ensure the ED staff removed outdated supplies from the Emergency Department (ED). Failure to remove outdated patient supplies from the ED supplies, resulted in expired supplies remaining available for use in patient care, potentially resulting in staff using the expired items for patient care after the manufacturers' expiration date (the date after which the manufacturer will no longer guarantee the safety and quality of the supply). The Hospital identified an average of approximately 2,359 patient visits per month in the ED.

Findings include:

1. Observations during a tour of the ED on 11/20/2019 at 2:30 PM, revealed the following expired supplies:

ED Medication Room
Suture Cupboard
a. 3 packages 4-0 Plain gut suture #1824, expired 01/2019.
b. 2 packages 3-0 Silk suture #K-832 expired 07/2017 and 1 package expired 07/2019
c. 1 package 6-0 Monocryl suture #Y489 expired 01/2018, and 2 packages expired 07/2018
d. 8 packages 6-0 Vicryl suture # J833 expired 08/2018
e. 1 package #2 Ethibond suture #406 expired 01/2017, 1 package expired 07/2017, and 1 package expired 07/2018
f. 4 packages 4-0 Prolene suture #8831 expired 1/2017
g. 1 package 5-0 Prolene suture #8720 expired 01/2018
h. 3 packages #1 Prolene suture # 8425 expired 01/2019, and 1 package expired 07/2019
I. 2 packages 3-0 Ethilon #627 expired 07/2016

2. During an interview at the time of the tour, ED Director revealed the nursing staff should check the ED supplies every month and remove any expired supplies. The ED Director acknowledged the nursing staff had failed to remove the expired supplies, potentially allowing the nursing staff to use the supplies for patient care.

I. Based on document review, observation, and staff interview, the hospital's administrative staff failed to ensure the surgical staff followed the manufacturer's instructions for cleaning surgical instruments for 2 of 2 ultrasonic cleaners located in the Sterile Processing Department. Failure to follow the manufacturer's instructions for use while cleaning instruments could potentially result in the cleaning process failing to remove all of the bacteria and debris, which could then potentially infect a different patient since the staff members believed the instrument was safe to use on another patient. The hospital performed 9,563 surgical procedures the past fiscal year.


Findings include:

1. Observations on 11/19/19 at 1:30 PM, during a tour of the Sterile Processing Department, revealed the surgical staff used Prolystica 2X Concentrate Enzymatic Presoak and Cleaner in 2 of 2 ultrasonic cleaners used to clean surgical instruments

2. Review of the manufacturer's instructions for Prolystica 2X Concentrate Enzymatic Presoak and Cleaner revealed in part, "[cleaning a]ctivity increases as the water temperature increases. Clean for a minimum of 1-5 minutes. Cleaning times may be longer with dried on proteinaceous materials. If lower temperatures are used, a longer cleaning time may be necessary. Do not exceed 130 degree Fahrenheit."

3. During an interview at the time of the tour, the Clinical Coordinator, Sterile Processing Department, acknowledged the manufacturer's requirement to monitor the water temperature when using Prolystica 2X Concentrate Enzymatic Presoak and Cleaner in the ultrasonic cleaners, and confirmed that staff did not monitor the temperature of the water in the ultrasonic cleaners.



42028


II. Based on observation, document review, and staff interviews, the Hospital surgical staff failed to ensure surgical staff sanitized their hands before donning gloves for aseptic tasks and after glove use during 1 of 1 observed surgical procedure (Patient #17). Failure to ensure surgical staff followed approved infection control standards of practice in accordance with the Centers for Disease Control (CDC) recommendations could potentially result in the surgical staff failing to remove bacteria which contaminated their hands during a procedure and potentially transmit the bacteria to another patient, potentially causing a life-threatening infection. The Hospital's administrative staff identified the surgical staff performed 9,563 surgical procedures for the past fiscal year.

Findings include:

1. Review of the "Hand Hygiene Policy," revised 06/2019, revealed in part. "Hand hygiene is a general term used by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to refer to hand washing, antiseptic hand washing, antiseptic hand rubbing and surgical hand asepsis .... Hand hygiene ... is the most important procedure in preventing infection. To protect a patient from health care-associated infection, hand hygiene must be performed routinely and thoroughly. (sic)."

2. Review of the policy "Hand Hygiene in Healthcare Settings -- Healthcare Providers", reviewed 04/29/19, revealed in part ... "Clinical indications for hand hygiene: soap and water or alcohol-based hand sanitizer are: ... if the task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves..."

3. Observations on 11/19/2019, beginning at 9:30 AM during Patient #17 Laporascopic Ovarian Cystectomy (removal of an ovarian cyst through an abdominal incision with a scope), revealed the following:

--10:12 AM Medical Doctor (MD) C removed their non-sterile gloves and failed to perform hand hygiene.

--10:17 AM MD H, Registered Nurse (RN) F, and RN G removed their non-sterile gloves and failed to perform hand hygiene.

--10:18 AM RN D failed to perform hand hygiene prior to donning sterile gloves prior to applying the disinfectant solution and scrubbing Patient #17's abdomen.

--10:22 AM RN F failed to perform hand hygiene prior to donning sterile gloves, prior to performing the facial disinfectant scrub on Patient #17. After performing the facial disinfectant scrub, RN F removed their sterile gloves and failed to perform hand hygiene.

--10:25 AM RN F removed their sterile gloves and failed to perform hand hygiene.

--10:53 AM RN D removed their non-sterile gloves, proceeded to touch the suction machine, and failed to perform hand hygiene.

--12:04 PM RN D removed their non-sterile gloves and failed to perform hand hygiene.

--12:12 PM RN D and RN L removed their non-sterile gloves and failed to perform hand hygiene.

-- 12:14 PM MD H removed their sterile gloves, proceeded to the monitor tower to retrieve pictures taken during the procedure, proceeded to the desk, touched the computer, picked up personal cell phone, and failed to perform hand hygiene.

--12:15 PM RN G removed their sterile gloves, removed their facial mask, and failed to perform hand hygiene.

--12:17 PM RN D removed their non-sterile gloves and failed to perform hand hygiene.

--12:20 PM RN G removed their non-sterile gloves, proceeded to desk, picked up personal cell phone, and failed to perform hand hygiene.

--12:22 PM Surgical Services Terminal (end of day) cleaning team failed to perform hand hygiene prior to using cleaning detergents during cleaning process.

--12:26 PM RN E removed their non-sterile gloves, touched the computer, and failed to perform hand hygiene.

4. During an interview on 11/21/2019 at 8:30 AM, Surgical Services Director, RN I, and RN J agreed they expected the surgical staff to perform hand hygiene according to the hospital Handwashing policy.

5. During an interview on 11/21/ 2019 at 9:40 AM, Infection Prevention Coordinator M discussed the hand hygiene policy. They clarified the hospital staff used the CDC guidelines for hand hygiene and glove usage. They educate the hospital staff using World Health Organization format, i.e. before touching a patient, before clean/aseptic procedures, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. They agreed the surgical staff should perform hand hygiene according to the hospital's Handwashing policy.




III. Based on observation, document review, and staff interviews, the Hospital Cardiac Catheterization Lab (a special hospital room where minimally invasive tests and procedures to diagnose and treat cardiovascular (heart) diseases are performed) staff failed to ensure cardiac cath staff sanitized their hands before donning gloves for aseptic tasks and after glove use during 1 of 1 observed cardiac cath procedures (Patient #18). Failure to ensure cardiac cath staff followed approved infection control standards of practice in accordance with the Centers for Disease Control (CDC) recommendations could potentially result in the cardiac cath staff failing to remove bacteria which contaminated their hands during a procedure and potentially transmit the bacteria to another patient, potentially causing a life-threatening infection. The Hospital's administrative staff identified the cardiac cath staff performed 1,476 cardiac catheterization procedures for the past fiscal year.

Findings include:

1. Review of the "Hand Hygiene Policy," revised 06/2019, revealed in part, "Hand hygiene is a general term used by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to refer to hand washing, antiseptic hand washing, antiseptic hand rubbing and surgical hand asepsis....Hand hygiene ... is the most important procedure in preventing infection. To protect a patient from health care-associated infection, hand hygiene must be performed routinely and thoroughly. (sic)."

2. Review of the policy "Hand Hygiene in Healthcare Settings -- Healthcare Providers", reviewed 04/29/2019, revealed in part ... "Clinical indications for hand hygiene: soap and water or alcohol-based hand sanitizer are: ... if the task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves..."

3. Observations on 11/20/2019, beginning at 8:45 AM during Patient #18's Cardiac Catheterization Ablation (a procedure to treat abnormal heart rhythms when medicines are not effective), revealed the following:

--9:02 AM RN (Registered Nurse) N removed their non-sterile gloves and failed to perform hand hygiene prior to opening sterile items to the sterile field.

--9:10 AM RN O removed their non-sterile gloves and failed to perform hand hygiene.

--9:11 AM RN P removed their non-sterile gloves and failed to perform hand hygiene prior to applying heart electrode pads to Patient #18.

--9:20 AM Medical Doctor (MD) V failed to perform hand hygiene prior to donning sterile gloves to perform the cardiac cath procedure on Patient #18.

--9:30 AM the PM/CVT (Paramedic/Cardio Vascular Technician) removed their non-sterile gloves and failed to perform hand hygiene.

--9:38 AM the PM/CVT removed their non-sterile gloves and failed to perform hand hygiene.

--10:45 AM the PM/CVT removed Patient #18's face mask and failed to perform hand hygiene before performing additional tasks.

--10:55 AM MD V removed their sterile gloves, proceeded to pick up their personal cell phone, and failed to perform hand hygiene.

--11:00 AM RN N and RN P failed to perform hand hygiene prior to donning sterile gloves and before applying pressure to catheter placement sites in Patient #18's groin.


4. During an interview on 11/21/2019 at 8:30 AM, the Cardiac Cath Lab Supervisor agreed they expected the cardiac cath lab staff to perform hand hygiene according to the hospital Handwashing policy.

5. During an interview on 11/21/ 2019 at 9:40 AM, Infection Prevention Coordinator M discussed the hand hygiene policy. They clarified the hospital staff used the CDC guidelines for hand hygiene and glove usage. They educate the hospital staff using World Health Organization format, i.e. before touching a patient, before clean/aseptic procedures, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. They agreed the surgical staff should perform hand hygiene according to the hospital's Handwashing policy.




IV. Based on document review, observation, and staff interview, the Hospital failed to ensure 1 of 1 observed Anesthesiologist (Anesthesiologist C) cleansed the IV tubing hub site on 3 of 3 medication administration of 1 of 1 observed surgical procedures (Patient #17) and 1 of 1 observed PM/CVT (Paramedic/Cardio Vascular Technician) cleansed the IV tubing hub site on 3 of 3 medication administration of 1 of 1 observed cardiac catheterization ablation procedure (Patient #18) . Failure to cleanse the IV tubing hub site could potentially result in the Anesthesiologist C and PM/CVT (Paramedic/Cardio Vascular Technician) introducing bacteria, viruses, or fungi into the IV tubing, could potentially result in the patient developing a life threatening infection. The Hospital's administrative staff identified the surgical staff performed 9,563 surgical procedures and 1,476 cardiac catheterization procedures for the past fiscal year.

Findings include:

1. Observations on 11/19/19 at 10:08 AM, during Patient #17's Laporascopic Ovarian Cystectomy (removal of ovarian cyst through an abdominal incision with a scope), revealed Anesthesiologist C failed to cleanse the IV tubing hub site with 70% isopropyl alcohol prior to administering 3 doses of medication to Patient #17 on 3 separate occasions.

2. Observations on 11/20/2019 at 9:34 AM and 10:50 AM during Patient #18's cardiac catheterization ablation procedure (a procedure to treat abnormal heart rhythms when medicines are not effective) revealed PM/CVT failed to cleanse the IV tubing hub site with 70% isopropyl alcohol prior to adminstering 3 doses of medication to Patient #18 on 3 separate occasions.

3. Review of the policy "IV Therapy (Peripheral) (MGMC) Critical Notes," reviewed 02/2018, revealed in part "Injection and Needleless Connectors ... Aseptically clean ports with appropriate antiseptic solution prior to use."

4. During an interview on 11/21/2019 at 8:30 AM, Surgical Service Director and Cardiac Cath Lab Supervisor agreed they expected the surgical services staff and cardiac cath lab staff use 70% isopropyl alcohol prior to administering medication to patients through the IV tubing.

Based on document review and staff interview, the hospital's administrative staff failed to ensure post-anesthesia evaluations were performed in a timeframe sufficient for the patient to recover from general anesthesia for 2 of 5 reviewed patients (Patient #17 and Patient #19) who received general anesthesia for their surgical procedure. Failure to ensure the evaluations were performed in a timeframe sufficient for the patient to recover from general anesthesia may result in patient's developing adverse symptoms related to their anesthesia that are not identified and treated by a person qualified to administer anesthesia. The hospital performed 9,563 surgical procedures the past fiscal year.

Findings include:

1. Review of the Medical Staff Rules and Regulations, revealed in part, "A post-anesthesia evaluation must be documented ... and must be documented in the medical record ... The patient must be sufficiently recovered so as to participate in the evaluation, e.g. answer questions, perform simple tasks, etc."

2. Review of medical records on 11/21/19 at 9:45 AM, revealed the following:

a. On 11/21/19, Patient #17 received general anesthesia (medication used to put patients into a very deep sleep prior to performing surgery) to remove a cyst and possibly an ovary. The surgical staff transferred Patient #17 to the recovery room (an area used to monitor patients who underwent surgery) at 11:21 AM. Anesthesiologist K documented they performed the post-anesthesia recovery assessment at 11:28 AM (7 minutes after the surgical staff transferred Patient #17 to the recovery room).

b. On 08/16/19, Patient #19 received general anesthesia for back surgery. The surgical staff transferred Patient #17 to the recovery room at 11:57 AM. Anesthesiologist K documented they performed the post-anesthesia recovery assessment at 12:01 PM (4 mintues after the surgical staff transferred Patient #19 to the recovery room).


3. During an interview at the time of the medical record review, the Director of Surgical Services acknowledged that when Anesthesiologist K assessed the patients 4-7 minutes after the surgical staff transferred the patient to the recovery room, the patient would not have sufficiently recovered from the general anesthesia to participate in the post-anesthesia assessment as required by the Medical Staff Rules and Regulations.