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Based on observation, interview, and policy review, the facility failed to ensure that staff followed infection control policies and infection prevention standards when they failed to:
- Ensure an opened multi-dose vial of insulin (a medication that regulates the amount of sugar in the blood) had the date opened or the beyond use date (BUD) marked on the bottle for one patient (#2) of three patient's medications checked.
- Perform hand hygiene (by using soap and water or a waterless hand sanitizer or foam) before they entered the patient's room for two patients (#10 and #11) of three patients observed.
- Perform hand hygiene after staff touched inanimate objects (non-living objects, such as keyboards, tables, etc.), then administered medications to two patients (#10 and #11) of three patients observed.
- Ensure the cleanliness of the Workstation on Wheels (WOWs, computer and supplies on wheels) when they were used during the care provided to two patients (#10 and #11) of three patients observed..
-Ensure the cleanliness of the crash cart (a container on wheels carrying medicine and equipment for use in emergency resuscitations) in the Emergency Department (ED).
- These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The facility census was six.

Findings included:

1. Review of the facility's policy titled, "Multi-dose Vials," dated 04/2018, showed that upon opening a multi-dose vial, the date must be written on the vial as to when the vial was opened. Multi-dose vials expire 28 days after opening.

Observation on 02/25/19 at 4:50 PM in the Northwest Wing medication room, showed that Patient #2 had a multi-dose vial of insulin that was open and without an opened date or a BUD date written on the vial.

During an interview on 02/25/19 at 4:55 PM, Staff B, Director of Nursing (DON) and Infection Control Nurse, stated that she expected all multi-dose vials labeled with the date they were opened and a BUD.

During an interview on 02/26/19 at 11:40 AM, Staff Q, Pharmacist, stated that once a multi-dose vial was opened, the date opened and the BUD should have been filled out on the vial by the staff member who opened it.

2. Review of the facility's policy titled, "Handwashing," dated 03/2018, showed the directive for staff to perform hand hygiene:
- Before having direct contact with patients;
- After touching inanimate objects; and
- After removing gloves.

3. Review of the facility's policy titled, "Workstation on Wheels (WOW) Cleaning," dated 04/2018, showed the directive for staff to disinfect the WOW once a shift and if known contamination occurs or when it was visibly dirty; WOWs may be pulled into the doorway of the patient rooms.

Observation on 02/26/19 at 10:05 AM showed Staff P, Registered Nurse (RN), failed to:
- Clean the WOW before she pushed it into the patient's room.
- Perform hand hygiene before she entered Patient #10's room.
- Perform hand hygiene after she touched inanimate objects, including the WOW, and before she prepared and administered nebulizer (a device that turns liquid medication into a mist for inhalation into the lungs) medications.
- Clean the WOW after she left Patient #10's room, and used the keyboard on the dirty WOW to document after she had performed hand hygiene.

During an interview on 02/26/19 at 10:20 AM, Staff P, RN, stated that:
- She did not perform hand hygiene before she entered Patient #10's room, but her normal practice was to use hand sanitizer before she entered a patient's room, when she left a patient's room, and while in a patient's room.
- She should have cleaned the WOW right after she left the patient's room and before she used the dirty keyboard with clean hands.
- The facility's normal practice was to clean the WOWs at the start of each shift, which was equivalent to twice a day, but not between patients.

Observation on 02/26/19 at 3:45 PM, Staff R, RN, failed to:
- Clean the WOW before she pushed it into Patient #11's room.
- Perform hand hygiene before she entered the patient's room.
- Perform hand hygiene after touched the WOW and before she prepared and administered an oral medication to Patient #11.

During an interview on 02/26/19 at 3:50 PM, Staff R, RN, stated that she always performed hand hygiene before she entered and after she exited a patient's room; before she prepared and administered medications if her hands were not clean.

During an interview on 02/26/19 at 4:00 PM, Staff B, DON and Infection Control Nurse, stated that:
- Staff were expected to perform hand hygiene only before direct patient contact.
- Staff were expected to perform hand hygiene if hands were visibly soiled.
- Staff were not expected to perform hand hygiene before they entered a patient's room.
- WOWs should be cleaned at the start of each shift and if they were dirty.

4. Even though requested the facility failed to provide a policy for cleaning the crash cart.

Review of the facility's policy titled, "Cleaning, Sterilization, and Disinfection of Patient Care Equipment," dated 03/2018 showed that Class II, Semi-Critical items, are those items that come into contact with intact mucous membranes (a tissue that lines many body cavities and organs) but do not penetrate body surfaces, such as endoscopes (a scope introduced into the body to view internal parts), endotracheal tubes (a small tube inserted through the mouth or nose that extends into the lungs, to maintain an open passageway for oxygen), oropharyngeal tube stylets (used to provide free passage of air to an unconscious person), anesthesia (gases or drugs administered to block pain during a surgical operation) masks, artificial manual breathing unit (ambu, a self inflating bag that when squeezed, provides air into a persons lungs who cannot breathe on their own) masks, and laryngoscopes (an instrument for examining the inside of the throat) blades. Meticulous physical cleaning followed by an appropriate high level disinfection treatment would give a reasonable degree of assurance that the items are free of pathogens (bacteria or virus that can cause disease). Class III, Non-Critical items, are those items that do not touch the patient or that touch only intact skin, such as blood pressure cuffs and stethoscopes. Routine cleaning with soap and water is sufficient for these items.

Observation on 02/25/19 at 3:30 PM in the ED hallway, showed a crash cart that was visibly dirty, rusty, and with clumps of dust on the bottom shelf floor and in the corners. Patient Care Equipment was stored on this crash cart.

During an interview on 02/25/19 at 3:30 PM, Staff C, RN, stated, "It probably wouldn't hurt to clean it."

During an interview on 02/25/19 at 3:30 PM with Staff A, Administrator, stated that she agreed the crash cart needed to be cleaned.

During an interview on 02/27/19 at 1:30 PM with Staff B, DON and Infection Control Nurse, stated that the crash carts should be cleaned periodically and when visibly dirty.






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Based on interview and record review, the facility failed to routinely inspect and properly maintain radiation (the use of energy waves to diagnose or treat disease) shielding (blocking) devices, which included lead (a protective measure against the harmful effects of radiation exposure) apron shields, glove shields, mitten shields, and thyroid (a large gland in the neck that secretes hormones that regulate growth and development) shields. This deficient practice had the potential for use of shielding devices that no longer maintained functional integrity (soundness, whole) and subsequent unintentional radiation exposure to patients and staff. The facility census was six.

Findings included:

1. Although requested, the facility did not provide a policy or procedure that directed staff how to routinely test shielding devices.

Review of the facility's radiation shielding devices test log on 02/26/19 at 9:12 AM, showed that integrity tests were last conducted on 04/23/13, for lead aprons sequentially numbered 1, 2, 4-12 (it was noted that apron 3 was offsite and, therefore, not included in the test), lead aprons lettered A-G, thyroid shields labeled T1-T8, one set of gloves, and one mitten.

During an interview on 02/26/19 at 9:12 AM, Staff D, Radiology Manager, stated the following:
- Shielding devices should be tested at least annually;
- Shielding devices currently used were last tested on 04/23/13;
- The Radiology Department averaged between 450-550 procedures per month; and
- The facility did not have a policy or procedure in place that directed staff to routinely test shielding devices.

Based on observation, interview and record review, the facility failed to ensure an order for wound care treatment was written in a manner that was complete, before nurses provided wound care to one current patient (#12), of two current patients with surgical wounds reviewed. This failure had the potential to affect the care and outcomes of all patients with wounds. The facility census was six.

Findings included:

1. Even though requested, the facility failed to provide a policy related to transcription of orders from the Patient Transfer Form upon admission.

Review of the Patient #12's medical record showed a Transfer Form (from the hospital the patient was transferred from)order, dated 02/20/19, for "Daily dressing change to right knee, cleanse with Betadine (a mild medical cleanser), cover with dry dressing, secure with X-Span (a tubular cover to secure dressings)." The patient's current dressing treatment order in the Electronic Medical Record (EMR), originally dated 02/22/19, showed "Change dressing daily." The current order did not specify the treatment to be used during the dressing change.

Observation on 02/27/19 at 9:50 AM, showed Staff U, Registered Nurse (RN), proceeded to gather supplies for Patient #12's dressing change, which included a mild antiseptic (cleanser that prevents the growth of germs), dry dressing, and a tubular (tube-like) cover to secure the dressing.

During an interview on 02/27/19 at 10:00 AM Staff U, RN stated that she was present on 02/22/19 when Patient #12 was admitted, and she remembered the treatment orders that were on the Patient Transfer Form at the time of admission. She also stated that the current treatment order in the EMR should have stated the full and correct treatment order. She stated that Staff T, Nurse Practitioner (NP), had written the orders at the time of admission.

During an interview on 02/27/19 at 12:00 PM Staff T, NP stated that she wrote the admission orders from the faxed discharge (D/C) packet that was received from the transferring hospital. She stated that those orders were not as complete as the D/C packet that arrived with the patient, which had the complete treatment order written on the transfer form. Staff T stated that the nursing staff could have called her to clarify and write the complete treatment order, but it was ultimately her responsibility to ensure the order was complete.

During an interview on 02/27/19 at 1:30 PM Staff B, RN, Director of Nursing (DON) stated that there was no policy on order transcription from the D/C summary of the transferring hospital. She stated that the process was for the physician or NP to transcribe the admission orders from the D/C orders that came from the transferring hospital, or the nurse could have called the physician or NP to get the transferring order approved, and then written the order. She stated that even though there was no policy, the nursing staff all knew the procedure.

Review of Patient #12's EMR, showed that the dressing changes were completed on 02/22/19, 02/23/19, 02/24/19, 02/25/19 and 02/26/19, without the full and correct treatment order.

Based on observation, interview and policy review, the facility failed to ensure patients' paper medical records were protected against unauthorized access (by individuals who were not providing care for those patients) in six areas of six areas observed for unauthorized medical records access in the facility. This deficient practice had the potential to permit unauthorized individuals to access, review, and/or possibly alter documented health information in patients' medical records located in those areas. The facility census was six.

Findings included:

1. Review of the facility's policy, "Medical Records Departments," reviewed 02/2019, showed:
- The Director of Medical Records was responsible for the security and confidentiality of the medical records;
- The Director of Medical Records would ensure medical records were safeguarded against loss, destruction, or unauthorized use; and,
- The Director of Medical Records would ensure proper storage areas had access control maintained.

Observation on 02/26/19 at 10:55 AM showed a typed list of all medical record storage locations displayed in the Medical Records Department. The locations listed included Rooms #1, #2, #3, #4, the area between Rooms #2 and #3, and the back room of the Medical Records Department.

Observation and concurrent interview on 02/26/19 at 11:15 AM showed five designated rooms outside of the Medical Records Department that stored patients' paper medical records. Numerous patient records were stored in each of the rooms. Staff K, Medical Records Director, stated the following facility staff had keys that accessed these medical record storage areas:
- Every Medical Records Department staff member (five full-time staff, which included the department director);
- The Maintenance Department; and
- Patient care staff, for use after business hours.

During an interview on 02/26/19 at 3:15 PM, Staff B, Director of Nursing (DON), stated that the keys to all medical record storage areas were on a key ring, which was kept on a shelf in the medication room located on the Northwest Wing patient care area.


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