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Tag No.: A0405
Based on observation, interview, and record review, the hospital failed to ensure that drugs and biological's were prepared in an aseptic manner and administered to prevent contamination in accordance with accepted standards of practice, as evidenced in 1 of 2 departments. (Surgery)
Findings include:
On 5/22/18 at 1:09 PM during an interview with Infection Preventionist L regarding the standards of practice for infection prevention at this facility, Infection Preventionist L stated CDC (Centers for Disease Control).
Review of Center for Disease Control and Prevention (CDC) frequently asked questions, Safe Practices for Medical Injections: "Safety Steps After the Procedure ... MDVs [multiple-dose vials] should be discarded when ... doses are drawn in a patient treatment area."
Review of policy "Multi-Dose and Single Use Vials" #4094578, last approved 6/2015 under Procedure III. "Any vial assigned to an individual patient or taken into a patient's room is used only for that patient."
On 5/21/2018 at 11:25 AM during an observation of the surgical area with Surgical Director K, observed 4 vials on ledge in surgical medication dispensing area (Lidocaine 1% Epinephrine 1:100,000 50 ml vials X2, Adrenalin (epinephrine) 30 mg/30ml vial, and Adrenalin 30 mg/30 ml vial. All vials were opened and labeled with opened dates.
On 5/21/2018 at 11:30 AM during an interview with Surgical Director K, K stated that they do use multiple dose medication vials which are labeled with opened and expired dates and monitored by Pharmacy. K stated the medications are taken into the procedure rooms when needed, and drawn up there.
On 5/22/2018 at 8:27 AM during interview with Pharmacist V, V stated that they do use multiple dose medication vials in Surgery, which are monitored for out-dates by Pharmacy.
On 5/22/2018 at 8:27 AM during interview with Chief Nursing Officer E, E confirmed multi-dose vials are taken into operating rooms where medication is drawn up, and the vials are brought back to the medication dispensing area in the surgical area for use for other patients.
Tag No.: A0441
Based on observation, record review and interview the facility failed to ensure that protected patient information is secured from access of unauthorized persons in 1 of 2 departments observed (patient care area).
Findings include:
The facility policy titled "Confidentiality, Privacy and Security of Health Information" ID # 4340922 last reviewed 6/2009 was reviewed on 5/21/18 at 3:00 PM. This document revealed under "POLICY: It is the policy of the Wheaton Franciscan system that organizations within the System have in place the organizational safeguards necessary to maintain the confidentiality, privacy and security of any and all Protected Health Information (PHI), including electronic (ePHI), (collectively referred to as PHI, unless otherwise noted), in accordance with applicable state and federal law, specifically the Health Insurance Portability and Accountability Act of 1996 (HIPPA)."
On 5/21/18 at 11:15 AM observed in patient care floor rooms 2101, 2105, 2107 & 2113 stickers containing discharged patient information stuck to the bottom and sides of the patient storage closets. The stickers contained patient name, age, sex, medical record number, date of birth, bar code and date of visit.
The above was confirmed in interview with Nurse Supervisor D at the time of observation in each patient room. Nurse Supervisor D stated "we mark patient belongings with those stickers they must be falling off when in the closets."
Tag No.: A0749
Based on observation, record review, and interview, the facility failed to follow national standards of practice in 2 out of 3 observations of patient care (Patient #5 and Pt #32) and failed to maintain an environment that was free from potential contamination in 2 of 2 Departments (Surgical Department, Nursing inpatient unit).
Findings include:
Surgical Attire
Per interview with Surgical Director K on 5/21/2018 at 10:45 AM regarding standards of practice, Surgical Director K stated, "AORN (Association of peri-Operative Registered Nurses) and ASPAN (American Society of PeriAnesthesia Nurses) were followed for surgery and AAMI (Association for Advancement in Medical Instrumentation) for sterile processing.
Review of Association for peri-Operative Registered Nurses, Publish Date: May 30, 2017 "A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn."
Review of 2014 edition of AORN Perioperative Standards and Recommended Practices. "The recommendation for non-scrubbed personnel to wear long-sleeved jackets in the OR (Operating Room) or invasive procedure room is not a new recommendation. It has been a part of the AORN 'Recommended practices for surgical attire' since 1994. Wearing long-sleeved attire helps contain skin squames shed from bare arms."
Review of policy "Surgical Attire" #4055846 last approved 2/2017 revealed under Procedure A. #1 "When in the semi-restricted or restricted areas, all non-scrubbed personnel should wear a freshly laundered or single-use long-sleeved warm-up jacket snapped closed with the cuffs down to the wrists ... 2. Jewelry including earrings ... that cannot be contained or confined within the surgical attire should not be worn. Jewelry that cannot be confined within the surgical attire should be removed before entry into the semi-restricted and restricted areas ... B. "All personnel should cover head and facial hair, including sideburns and the nape of the neck."
During observation in the Operating Room on 5/21/18 between 12:28 PM and 12:55 PM during outpatient procedure on Patient #32 in Operating Room #3, observed Anesthesiologist I wearing a blue disposable surgical bouffant tucked behind the ears, exposing both ears with studded earrings and strands of hair around ears outside bouffant at the neckline bilaterally. Observed RN O with sideburns not covered. Observed Surgical Tech P with beard and sideburns not covered.
During observation in the Operating Room on 5/21/18 between 1:03 PM and 1:22 PM during total hip arthroplasty (replacement) on Patient #5 in Operating Room #1, Registered Nurse R with bottom of ears showing, earrings not covered, Radiology Tech N wearing short sleeved scrub top with hairy arms (not covered), Radiology Tech N with sideburns not covered, Surgical Tech P with sideburns and beard not covered, and Anesthesiologist Q wearing a skull cap with 1 inch of hair from back of cap and sideburns not covered.
On 5/22/18 at 1:09 PM during an interview with Infection Preventionist L, L confirmed earring studs should be covered with surgical hat or not worn. L also confirmed long sleeves should be worn in the operating room and all hair should be covered stating "we recently added those requirements to the Surgical Attire Policy."
Hand Hygiene
Review of policy "Hand Hygiene and Gloving Practice, AW" Policy #3666900 last approved 07/2017, under Policy, B, #2 "hands are to be washed properly, or a hand sanitizer is to be applied before gloves are donned and after they are removed."
During observation in the Operating Room on 5/21/18 between 1:03 PM and 1:22 PM during total hip arthroplasty (replacement) on Patient #5 in Operating Room #1, observed Physicians S & T position Patient #5, take off gloves, and leave Operating Room #1 to scrub for surgical procedure without cleaning hands after glove removal.
On 5/22/18 at 1:09 PM during an interview with Infection Preventionist L, L stated hand-washing after glove removal had been identified in their hand hygiene audits and stated "we have been working on that".
On 5/22/18 at 7:04 AM observed Staff Nurse B remove a dressing from Pateint #32's surgical incision on right knee and applying new clean dressing without changing gloves and performing hand hygiene in between.
The above was confirmed with Nurse Supervisor D in interview at the time of observation who stated "yes, [Nurse B] should have changed gloves and done hygiene between dirty to clean dressing."
An interview was conducted with Nurse Supervisor D at the time of observation who stated "it would be expected that gloves were changed and hand hygiene completed after touching the floor".
Out of Date Supplies
Review of policy "Storage and Rotation of Sterile Supplies" Policy # 4336397, last approved 07/2016 #4 "Check supplies on a regular basis to avoid outdated supplies. Rotating stock appropriately will also assist in expired product and waste."
On 5/21/18 between 10:45 and 11:25 AM, during tour of surgical area with Surgical Director K, observed hypothermia cart with expired supplies: Y type blood sets List #12434-01 X4 with expiration date of 01/07 X1, TUR (transurethral resection) Y set with expiration date 10/05 X1, 3 peripheral catheter safety needles 20 gauge with expiration date 2/2016 X 2 , 2/2017 X1, 3 peripheral catheter safety needles 18 gauge, expiration date 12/2016 X1 and 3/2017 X2, and one package of "Clear trace" electrodes for adult electrocardiograms with expiration date 2/2017.
On 5/21/18 at 12:10 PM during tour of surgical area with Surgical Director K, observed one 20 french 5 cc ribbed Foley catheter in the surgical supply area with expiration date 01/2017.
On 5/21/18 at 2:45 PM during tour of Same Day Surgery with Surgical Director K, observed in crash cart, 2 BD (Becton Dickinson) Insyte Autoguard intravenous catheters with expiration date of 3/2018 X2.
On 5/22/18 between 10:45 AM and 1:09 PM on facility tour during an interview with Surgical Director K, K stated that outdated supplies are looked for and pulled during stocking of supplies, K stated these "must have been missed".
Refrigeration temperatures
Review of policy "Refrigerators and Freezers: Maintaining Proper Temperatures" policy #4917825 last approved 5/2018, under II. Storage of Nutritionals: A. "Temperatures of refrigerators and freezers on inpatient units are checked and documented daily by nursing staff."
On 5/21/18 at 12:38 PM during tour of Same Day Surgery with Surgical Director K, observed "Food Refrigerator and Freezer Temperature Log" for April 2018. "Initials" column was blank for April 1, and 26 - 30. Requested May 2018 log, unable to locate at this time.
On 5/21/18 at 12:38 during an interview with Surgical Director K while touring Same Day Surgery , K stated refrigeration check responsibilities are assigned to department staff on a quarterly basis, K was unaware of who was responsible for refrigeration checks this quarter.
On 5/22/18 at 9:45 AM during an interview with Personal Care Attendant (PCA) U, U provided "Food Refrigerator and Freezer Temperature Log" which revealed May written in after Month/Year (no year). The "Initials" column for May 17 & 18 were blank. U stated when they did their checks they are to initial under the date that the check was completed and they would notify maintenance with temperature readings outside of the "desired range". When questioned why the "Initials" column was blank on some of the days, U stated "it must not have been checked those days". U stated "All staff help to make sure it gets done, I'm not sure who checks it when I'm off". U also confirmed the staff did not check the freezer temperatures.
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Cleaning of equipment
The facility policy titled "Infection Prevention and Equipment/Environment" ID #4852193 was reviewed on 5/22/18 at 11:00 AM. This document on page 4 under "Equipment Cleaning" revealed "Computers - Clean immediately when visibly soiled and at least once a day."
On 5/22/18 at 7:36 AM observed Staff Nurse C roll mobile computer work station into room 2113. In preparing to administered insulin Staff Nurse C performed hand hygiene and applied gloves, picked up insulin syringe in package off the computer workstation and dropped packaged syringe onto floor. Staff Nurse C picked packaged syringe up off the floor and laid back onto computer workstation table top. Nurse Supervisor D left patient room to retrieve a new packaged syringe, returned with and handed to Staff Nurse C. Staff Nurse C opened, drew up insulin and administered to patient without changing gloves and performing hand hygiene after picking up package off the floor.
An interview was conducted with Nurse Supervisor D on 5/21/18 at 11:45 AM in regards to portable computer workstation, how they are used and when they are cleaned. Nurse Supervisor D stated "staff take the computer all the way into the patient rooms. I think they clean the [portable computer station] daily." When asked about portable computer work stations being "parked" in hallways where they can be touched by all staff and visitors then being taken into the patient room without being cleaned Nurse Supervisor D stated "I see what you mean."
Tag No.: A1000
Based on record review and interview anesthesia services failed to complete a pre-operative anesthesia physical assessment prior to surgery in 4 of 32 surgical patients reviewed (Pt # 11, 16, 24 and 29) and failed to
ensure that patients who had anesthesia were fully recovered prior to documenting the post-anesthesia evaluation in 19 of 32 patients who received anesthesia services (Patient #2, 4, 6, 7, 10, 11, 12, 13, 14, 15, 16, 17, 20, 24, 27, 28, 29, 30, 32).
Findings include:
Anesthesia services failed to document a pre-anesthesia physical exam in 4 of 32 patient records reviewed (See tag 1003).
Anesthesia services failed to document a post-anesthesia evaluation after the patient was recovered from anesthesia in 19 of 32 patient records reviewed (See tag 1005).
The cumulative effect of these deficiencies potentially affect all patients receiving Anesthesia Services at this facility.
Tag No.: A1003
Based on record review and interview anesthesia services failed to complete a pre-operative anesthesia physical assessment prior to surgery in 4 of 32 surgical patients reviewed (Pt # 11, 16, 24 and 29).
Findings include:
Facility policy titled "Provision of Anesthesia Services" dated 4/2013 was reviewed on 5/22/18 at 9:10 AM. This document states "Pre-Anesthesia Evaluation ... the pre-anesthesia evaluation of the patient should include at the minimum ...interview and examination of the patient."
Patient #11's medical record was reviewed on 5/22/18 at 9:30 AM. Patient #11 received general anesthesia on 1/30/18. There was no pre-anesthesia physical exam documented.
Patient #16's medical record was reviewed on 5/22/18 at 10:00 AM. Patient #16 received general anesthesia on 5/1/18. There was no pre-anesthesia physical exam documented.
Patient #24's medical record was reviewed on 5/22/18 at 10:25 AM. Patient #24 received general anesthesia on 4/6/18. There was no pre-anesthesia physical exam documented.
Patient #29's medical record was reviewed on 5.22.18 at 10:45 AM. Patient #29 received general anesthesia on 5/3/18. There was no pre-anesthesia physical exam documented.
An interview was conducted with Anesthesiologist I on 5/22/18 at 12:00 PM. Anesthesiologist I stated Anesthesiology staff are forgetting to click boxes on the physical exam link. Anesthesiologist I confirmed the above patient records did not have a physical exam documented prior to the patients receiving anesthesia.
Tag No.: A1005
Based on record review and interview, anesthesia staff failed to ensure that patients who had anesthesia were fully recovered prior to documenting the post-anesthesia evaluation in 22 of 32 patients who received anesthesia services (Patient #2, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 17, 20, 21, 22, 24, 27, 28, 29, 30, 32).
Findings include:
Reviewed facility policy titled "Provision of Anesthesia Services on 5/22/18 at 9:10 AM. This document reads "Post Anesthesia Evaluation ... The evaluation may not begin until the patient is sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation, (e.g., answer questions appropriately, perform simple tasks, etc.)."
Patient #2's medical record was reviewed on 5/22/18 at 11:05 AM. Patient #2's anesthesia stop time was 9:43 AM and the post anesthesia evaluation was documented two minutes earlier at 9:41 AM.
Patient #4's medical record was reviewed on 5/22/18 at 11:45 AM. Patient #4's anesthesia stop time was 9:39 AM and the post anesthesia evaluation was documented five minutes earlier at 9:34 AM.
Patient #5's medical record was reviewed on 5/22/18 at 10:32 AM. Patient #5's anesthesia stop time was 4:32 PM and the post anesthesia evaluation was documented at 4:34 PM.
Patient #6's medical record was reviewed on 5/22/18 at 11:55 AM. Patient #6's anesthesia stop time was 4:58 PM and the post anesthesia evaluation was documented one minute earlier at 4:57 PM.
Patient #7's medical record was reviewed on 5/21/18 at 1:07 PM. Patient #7's anesthesia stop time was 12:19 PM and the post anesthesia evaluation was documented one minute later at 12:20 PM.
Patient #10's medical record was reviewed on 5/21/18 at 2:00 PM. Patient #10's anesthesia stop time was 4:40 PM and the post anesthesia evaluation was documented at the same time 4:40 PM.
Patient #11's medical record was reviewed on 5/22/18 at 9:30 AM. Patient #11's anesthesia stop time was 3:32 PM and the post anesthesia evaluation was documented at the same time of 3:32 PM.
Patient #12's medical record was reviewed on 5/22/18 at 9:45 AM. Patient #12's anesthesia stop time was 1:33 PM and the post anesthesia evaluation was documented at the same time of 1:33 PM.
Patient #13's medical record was reviewed on 5/22/18 at 10:02 AM. Patient #13's anesthesia stop time was 11:34 AM and the post anesthesia evaluation was documented one minute prior to the stop time at 11:33 AM.
Patient #14's medical record was reviewed on 5/22/18 at 10:20 AM. Patient #14's anesthesia stop time was 4:59 PM and the post anesthesia evaluation was documented one minute prior to the stop time at 4:58 PM.
Patient #15's medical record was reviewed on 5/22/18 at 10:22 AM. Patient #15's anesthesia stop time was 3:46 PM and the post anesthesia evaluation was documented one minute prior to the stop time at 3:45 PM.
Patient #16's medical record was reviewed on 5/22/18 at 10:00 AM. Patient #16's anesthesia stop time was 11:39 AM and the post anesthesia evaluation was documented at the same time 11:39 AM.
Patient #17's medical record was reviewed on 5/22/18 at 11:00 AM. Patient #17's anesthesia stop time was 11:44 AM and the post anesthesia evaluation was documented at the same time of 11:44:AM.
Patient #20's medical record was reviewed on 5/22/18 at 11:20 AM. Patient #20's anesthesia stop time was 10:49 AM and the post anesthesia evaluation was documented at the same time of 1:33 AM.
Patient #21's medical record was reviewed on 5/22/18 at 11:22 AM. Patient #21's anesthesia stop time was 2:33 PM and the post anesthesia evaluation was documented at 2:33 PM.
Patient #22's medical record was reviewed on 5/22/18 at 11:50 AM. Patient #22's anesthesia stop time was 8:02 AM and the post anesthesia evaluation was documented at 8:03 AM.
Patient #24's medical record was reviewed on 5/22/18 at 10:25 AM. Patient #24's anesthesia stop time was 11:24 AM and the post anesthesia evaluation was documented at the same time of 11:24 AM.
Patient #27's medical record was reviewed on 5/22/18 at 11:38 AM. Patient #27's anesthesia stop time was 9:12 AM and the post anesthesia evaluation was documented at the same time of 9:12 AM.
Patient #28's medical record was reviewed on 5/22/18 at 11:45 AM. Patient #28's anesthesia stop time was 10:11 AM and the post anesthesia evaluation was documented at the same time of 10:11 AM.
Patient #29's medical record was reviewed on 5/22/18 at 10:45 AM. Patient #29's anesthesia stop time was 8:04 AM and the post anesthesia evaluation was documented at the same time of 8:04 AM.
Patient #30's medical record was reviewed on 5/22/18 at 12:21 PM. Patient #30's anesthesia stop time was 9:03 AM and the post anesthesia evaluation was documented four minutes earlier at 4:57 AM.
Patient #32's medical record was reviewed on 5/22/18 at 11:55 AM. Patient #32's anesthesia stop time was 11:37 AM and the post anesthesia evaluation was documented one minute earlier at 11:36 AM.
An interview was conducted with Anesthesiologist I on 5/22/18 at 12:00 PM. Anesthesiologist I stated Anesthesiology staff may be checking on the patients again at a later time and stated "maybe didn't document that. Probably got busy and forgot."
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