HospitalInspections.org

Based on observation, interview, record review, and policy review, the provider failed to: *Consistently monitor one of one blanket/fluid warmer in one of one operating room (OR) suite for appropriate storage temperatures for intravenous (IV) and irrigation solutions for patient use during surgery and endoscopy procedures.
*Secure IV medications that had been disposed of after patient use in three of three sharps containers in three of three observed areas.
Findings include:

1. Observation on 2/1/16 at 3:40 p.m. in the OR suite with surgical technician A revealed:
*The following solutions were in the top shelf of the blanket/fluid warmer:
-Multiple plastic containers of sodium chloride 0.9 % and sterile water.
-Four 1000 milliliter (ml) IV bags of lactated ringers solution.
-Two 1000 ml bags of normal saline solution.
*The alarm to the warmer was turned off.
*The current temperature of the warmer was 104 degrees Fahrenheit (F).

Review of the Blanket/Fluid Warmer temperature record from 9/1/15 through 1/29/16 during the above observation revealed:
-Inconsistent documentation of daily temperatures for the Blanket/Fluid warmer.
*There was no documentation for the following dates:
-9/17/15 through 9/27/15. Eleven days.
-10/2/15 through 10/20/15. Nineteen days.
-11/18/15 through 11/24/15. Seven days.
-1/13/16 through 1/21/16. Nine days.
*There were multiple times when there was no recording for two to five days during that time.

Interview with surgical technician A during the above observation and record review revealed:
*The Blanket/Fluid warmer was not monitored consistently.
*The warmer had a history of malfunctioning.
*Staff were not in the OR every day, therefore the temperature of the Blanket/Fluid warmer was not monitored daily.
*She could not confirm the temperature of the Blanket/Fluid warmer stayed at an appropriate temperature to maintain the stability of the solutions stored in the warmer.

Interview on 2/1/16 at 3:40 p.m. with OR coordinator B in regards to the above observation revealed there should have been consistent monitoring of the temperature in the blanket/fluid warmer.

Review of the 0.9% sodium chloride and the lactated ringer's package insert revealed:
*Exposure to pharmaceutical products to heat should be minimized.
*Avoid excessive heat.
*It was recommended the products be stored at room temperature 25 degrees Centigrade (C) that would be 77 degrees F., and brief exposure up to 40 degrees C. would be at 104 degrees F.

Interview on 2/2/16 at 4:00 p.m. with the director of nursing (DON) services in regarding the above observations, interview, and record review for the blanket/fluid warmer revealed:
*The warmer's temperature should have been monitored daily.
*She agreed without consistent monitoring of the temperature it would be difficult to ensure the fluids in the warmer were stable.

Review of the provider's revised December 2015 Warmers for Fluid and Medications revealed:
*The purpose of the policy was to provide guidelines for the storage conditions of IV solutions, irrigation solutions, and certain medications.
*Warmer temperatures should have been monitored and logged daily.

2. Observation on 2/1/16 from 3:05 p.m. through 3:40 p.m. in the OR suite and the gastrointestinal (GI) procedure room revealed:
*There was a large red sharps container placed on the floor in the the OR suite next to the anesthesia medication cart.
*The other was placed in the GI procedure room on the floor next to the anesthesia medication cart.
*The tops of the sharps container were not secured.
*There were multiple vials, ampules, and syringes in the containers.
*There were syringes visible that had clear fluid in them.

Interview with surgical tech A during the above observation revealed:
*The used medications were not secured appropriately.
*The top covers for the sharps containers should have been secured.

Interview on 2/2/16 at 4:00 p.m. with the director of nursing services in regards to the sharps containers revealed those containers should have had the top cover secured over the container to prevent diversion of medications.




32355

3. Observation on 2/2/16 at 2:40 p.m. in the medication room at the nurses' station revealed:
*There was a large red sharps container placed on the floor in the medication room.
*The top of the container had not been secured and could be easily removed.
*The container was full of vials, ampules, IV tubing, empty IV medication bags, and syringes.

Interview on 2/2/16 at the time of the above observation with pharmacist D revealed:
*The medications in the sharps containers were not secured and allowed for easy access from the staff.
*She confirmed the medications could have been easily diverted (stolen).
*The top of the sharps container should have been secured.

4. Interview on 2/3/16 at 10:30 a.m. with the DON regarding the sharps containers revealed:
*She:
-Confirmed the sharps containers cover should have been secured.
-Agreed the medications could have been easily diverted by the staff.

Review of the provider's September 2014 Standard and Transmission Based Precautions policy revealed "Sharps containers should be securely closed and locked."

Based on observation, interview, and policy review, the provider failed to ensure:
*One of one registered nurse (RN) C who had been observed providing care for one of three randomly observed patients (room 247) who was on contact isolation had followed the isolation guidelines.
*Two of three observed rooms (operating and procedure) that contained single-use items were not opened prior to patient use.
Findings include:

1a. Random observation on 2/2/16 at 8:45 a.m. of room 238 revealed:
*The room had been located in a circular area with three other patient rooms close to it.
*There had been two signs taped to the closed door.
*Those signs had:
-Indicated the patient had a highly infectious disease and was on droplet and contact precautions.
-Directed any visitors or staff to put on gloves, mask, and a gown before entering that room.
*A linen cart across from the room sitting next to room 235. The linen cart had no lid on it and contained several yellow cloth gowns.
*An unidentified staff member had exited the room wearing a cloth gown. She walked across the circular area and put the contaminated gown inside of the soiled linen cart.

b. Random observation on 2/2/16 at 8:50 a.m. of room 247 revealed:
*The room had been located in a circular area with three other patient rooms close to it.
*There had been a sign taped to the closed door.
*That sign had:
-Indicated the patient had a highly infectious disease and was on contact precautions.
-Directed any visitors or staff to put on gloves and a gown before entering that room.
*A linen cart across from the room and was located directly underneath a shelf containing clean gloves and facial masks. The linen cart had no lid on it, and several yellow cloth gowns were inside of it.

Observation on 2/2/16 from 10:05 a.m. through 10:30 a.m. with registered nurse (RN) C revealed:
*He had:
-Gathered several supplies to assist the patient in room 247 to empty his bladder.
-Stated the patient had a history of Methicillin-resistant Staphylococcus aureas (MRSA [highly infectious disease]) and was on contact precautions.
-Put on a gown and clean gloves prior to entering the patient's room.
-Performed the above procedure and left the room.
-Not removed his gown and disposed of it until after he left the patient's room.
-Put the contaminated gown inside of the soiled linen cart located underneath the clean gloves and facial masks.

Interview on 2/2/16 at the time of the above observation with RN C revealed:
*He confirmed the soiled linen carts were always placed outside of any patient's room who would have been on isolation precautions.
*He agreed:
-That was not a good practice, and the soiled linen carts should have been placed inside of the patients' rooms.
-There was a potential for cross-contamination of bacteria from one patient to another.

c. Interview on 2/3/16 at 10:15 a.m. with the DON confirmed:
*The patient in room 247 had a history of MRSA in his urine.
*The best practice would have been to leave the soiled linen cart inside of the patient's room to ensure no spreading of bacteria from one patient to another had occurred.

Interview on 2/3/16 at 10:25 a.m. with the infection control nurse revealed the disposal of any personal protective equipment (PPE [gowns, gloves, and masks]) should have been done prior to leaving or directly outside of the patient's room.

Review of the provider's undated procedure for Removing PPE revealed "Before leaving room remove gown and gloves."




30170

2. Observation on 2/1/16 from 3:05 p.m. through 3:40 p.m. of the operating room (OR) suite and the gastrointestinal (GI) procedure room revealed:
*The OR suite had the following one-time patient use items opened from the package:
-Endotracheal (ET) tube (used for intubation of patient prior to surgery) was lying on the anesthesia medication cart under a blue towel.
-A syringe.
-An anesthesia mask that would have been used to administer gasses to a patient was out of the package and lying directly on the floor of the OR.
-Suction tubing was strung from the suction on the wall across the back of the OR suite wall to the side of the OR suite and was hanging on the wall.
-A Yankauer suction tip was on the anesthesia cart completely out of the package.
*The GI procedure room had the following one-time patient use items opened from the package:
-ET tube and syringe was placed on the anesthesia medication cart and was covered with a blue towel.
-An anesthesia mask that would have been used to administer gases to the patient was lying on the anesthesia cart.
-A Yankauer suction tip and suction tubing.

Interview with surgical technician A during the above observations revealed:
*She was unsure how long the observed supplies had been opened.
*The extended suction tubing that had been strung across the OR wall had been set-up for newborns in case of an emergency.
*She agreed the one-time patient use supplies should not have been opened prior to patient use.

Interview on 2/2/16 at 4:00 p.m. with the director of nursing services in regards to the one-time patient use items revealed those items should not have been open prior to patient use.

Review of the provider's September 2014 Safe Storage of Medical and Surgical Supplies policy revealed "Medical and surgical supplies will be stored in a manner that provides protection against conditions that might compromise sterility and packaging."

Based on interview, record review, and policy review, the provider failed to ensure:
*Initial activity history and assessment had been completed for three of five swing bed patients (20, 22, and 23) .
*One of one activity coordinator reviewed the activity plan for two of five swing bed patients (4 and 20 according to the provider's policy.
Findings include:

1. Review of patients 20, 22, and 23's electronic medical record revealed:
*Patient 20 had been admitted to swing bed services on 8/1/15 and discharged on 8/31/15.
*Patient 22 had been admitted to swing bed services on 9/22/15 and discharged on 9/30/15.
*Patient 23 had been admitted to swing bed services on 11/16/15 and discharged on 11/24/15.
*There was no documentation to support an activity history and assessment had been completed within three days of their admission to swing bed services.

2. Review of patients 4 and 20's electronic medical records revealed:
*Patient 4 had been admitted to swing bed services on 1/5/16 and discharged on 2/3/16.
*Patient 20 had been admitted to swing bed services on 8/1/15 and discharged on 8/31/15.
*There was no documentation to support their activity plan was reviewed and updated every two weeks.

3. Interview on 2/3/16 at 10:15 a.m. with the activity coordinator revealed:
*She was the occupational therapist and activity coordinator.
*There had been care conference meetings every week on all of the patients.
*She would have attended those meetings.
*She would not have reviewed the patient's activity plan during those meetings.
*She confirmed the initial activity history and assessment had not been completed on all swing bed patients.
*She would not have reviewed the activity plan on any patient who received swing bed services.

Interview on 2/3/16 at 10:30 a.m. with the director of nursing revealed:
*She confirmed the activity coordinator:
-Would not have completed initial history assessments on all of the patients who received swing bed services.
-Attended all care conferences and that the patient's activity plan would not have been reviewed.

Review of the provider's April 2015 Swing Bed Patient Activity Program policy revealed:
*"The activity coordinator or her designee shall complete the activity history and assessment of the swing bed patient within 3 working days of admit."
*"At least every 2 weeks for the first month, then monthly, the activity plan will be reviewed and updated; a progress note documented and any changes conveyed to the nursing staff."