HospitalInspections.org

Based on observation, interview, and competency review, the provider failed to ensure safety checks were performed daily on four of four defibrillators (life sustaining equipment). Findings include:

1. Observation on 1/12/16 at 1:30 p.m. of the emergency department revealed:
*There had been two separate areas to allow treatment for two patients.
*Both of those areas each had a defibrillator.

Interview on 1/13/16 at 9:30 a.m. with registered nurse (RN) B revealed:
*The provider had four defibrillators on the main floor.
*The nursing staff should have performed manual safety checks daily on all four of the defibrillators.
*In November 2015 the nursing staff had competency training on how to perform those safety checks.

Review of the RN Competency safety check schedule on 1/13/16 revealed:
*The documentation for safety checks started on 11/13/15 and ended on 1/6/16.
*There was no documentation to support the safety checks had been performed prior to 11/13/15.
*In November there were five days documented that safety checks had been completed. Those dates had been 11/13/15, 11/16/15, 11/17/15, 11/22/15, and 11/30/15.
*There was no documentation to support the staff had performed safety checks on the defibrillators for the other twenty-five calendar days in November.
*In December there were three days documented that safety checks had been completed. Those dates had been 12/05/15, 12/14/15, and 12/22/15.
*There was no documentation to support the staff had performed safety checks on the defibrillators for the other twenty-eight calendar days in December.
*In January there were two days documented, 1/4/16 and 1/6/16 that safety checks had been completed.
*There was no documentation to support the staff had performed safety checks on 1/1/16, 1/2/16, 1/3/16, and 1/5/16.

Continued interview on 1/13/16 at 9:40 a.m. with RN B and certified nurse practitioner E regarding the above documentation revealed:
*They agreed there was no documentation to support:
-The safety checks for the defibrillators had been started prior to 11/13/15.
-They had been performed daily.

Review of the provider's undated RN Competency form revealed safety checks were to have been completed daily.

The provider had no policy and procedure in place for defibrillator safety checks.

A. Based on interview, record review, policy review, and review of manufactures instructions for use, the provider failed to follow the manufactures instruction for discarding Cidex OPA high-level disinfectant after fourteen days in use. Findings include:

1. Interview on 1/13/16 at 10:10 a.m. with employee D and the director of radiology revealed:
*The provider was using Cidex OPA to high-level disinfect the trans vaginal probe.
*The in use solution was tested each use.

Review of the testing log sheet revealed:
*Warning: Do not use solution beyond its stated use and reuse life.
*Solution was put in use on 7/29/15 and was dated as expiring on 8/29/15. That solution should have been discarded on 8/11/15, fourteen days from being placed in use.
-That solution was tested, passed, and used on 8/14/15.
*Solution was put in use on 9/2/15 and was dated as expiring on 10/2/15. That solution should have been discarded on 9/15/15, fourteen days from being placed in use.
-That solution was tested, passed, and used on 9/16/15, 9/30/15, and 10/9/15.
*Solution was put in use on 10/15/15 and was dated as expiring on 11/15/15. That solution should have been discarded on 10/28/15, fourteen days from being placed in use.
-That solution was tested, passed, and used on 11/4/15.
Solution was put in use on 12/1/15 and was dated as expiring on 1/1/16. That solution should have been discarded on 12/14/15, fourteen days from being placed in use.
-That solution was tested, passed, and used on 12/23/15.
*Solution was put in use on 1/13/16 and was dated as expiring on 2/13/16.

Review of the CIDEX OPA instructions for use revealed: "Reuse Period for Disinfection: Cidex OPA solution has demonstrated disinfection efficacy in the presence of 5% organic soil contamination and microbiological burden during reuse. CIDEX OPA Solution may be reused for up to a maximum of 14 days provided the required conditions of ortho-phthalaldehyde concentration and temperature exist based upon monitoring described in the Directions for Use. DO NOT rely solely on days in use. Concentration of this product during its reuse life must be verified by the CIDEX OPA Solution Test Strip prior to each use to determine that the concentration of ortho-phthalaldehyde is above the MEC (minimum effective concentration) of 0.3%. The product must be discarded after 14 days, even if the CIDEX OPA Solution Test Strip indicates a concentration above the MEC."

Further interview on 1/13/16 at 10:15 a.m. with employee D and the director of radiology revealed:
*They agreed they should have been discarding the Cidex OPA solution after 14 day of use.
*They were not for sure how they got off track from the instructions from use.

Review of the providers June 2014 High Level Disinfection for Intercavitary Ultrasound Probes policy revealed: Discard disinfectant solution after 14 days.




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B. Based on observation, interview, and policy review, the provider failed to ensure sanitary conditions were maintained for:
*One of one oxygen cylinder storage areas.
*Two of two emergency room examining areas containing single-use suction (removal of secretions in the mouth) equipment remained sealed until needed.
*Six of six patient rooms (102, 106, 107, 403, 408, and 409) that had single use personal care products.
Findings include:

1. Observation on 1/12/16 at 1:30 p.m. of the ambulance entrance area revealed:
*A large metal cage with multiple open holes in it. Inside the metal cage were several ready-to-use patient oxygen cylinders.
*The metal cupboard had been located next to the decontamination area (cleansing area for patients with an infectious disease).
*The decontamination area had been open with no solid barrier to separate it from the oxygen cylinder holding cage.

Interview on 1/13/16 at 2:45 p.m. with certified nurse practitioner (CNP) E revealed:
*She had confirmed the oxygen cylinders were used for patients.
*She agreed:
-The oxygen cylinder holding area should not have been placed directly next to the decontamination area.
-The oxygen cylinders were at risk of being exposed to any infectious disease that required the use of the decontamination area.
-There was the potential for cross-contamination and the spreading of an infectious disease from one patient to another.

2. Observation on 1/12/16 at 1:40 p.m. of the emergency room revealed:
*Two patient examination areas.
*Each of the examination areas had been set-up for suctioning.
*The first examination area had an opened package next to the suction waste container. When this surveyor picked up the package a yanker (device to remove secretions from the mouth during suctioning) fell out and hit the wall. The yanker was attached to plastic tubing that had stopped it from dropping to the floor.
*The second examination area revealed an unpackaged yanker attached to plastic tubing and touching the wall.

Interview on 1/13/16 at 3:00 p.m. with CNP E regarding the above observations revealed:
*She was aware the single-use suction equipment had been opened and set-up for quick access.
*She stated "We have a practitioner who prefers this equipment to be set-up and ready to use."
*She agreed:
-That had not been a good practice, and all supplies should have remained sealed in their original packages until they were used.
-Equipment in an unsealed package should have been considered contaminated.
-There was the potential for cross-contamination and the spreading of bacteria from one patient to another.

3. Random observations on 1/12/16 from 9:30 a.m. through 10:50 a.m. of empty patient rooms revealed:
*Each patient room contained a cupboard with a large drawer underneath the counter.
*Inside of the drawers were multiple patient use care items. Those items had been:
-Packages of alcohol wipes.
-Toothettes used to cleanse the patient's mouth.
-Several rolls of used tape.
-Pens and pencils.
-Unpackaged cotton balls.
-Unpackaged small 2 x (by) 2 square gauzes.

Interview on 1/12/16 at 11:00 a.m. with registered nurse A regarding the above observation revealed:
*She confirmed the above supplies would have remained in the drawers after a patient had been discharged.
*The supplies would not have been removed and replaced with new ones.
*She could not guarantee the patient or their visitors would not have opened the drawer and touched any of the supplies.
*She agreed:
-The supplies should have been replaced after each patient was discharged.
-There was the potential for cross-contamination from one patient to another.

Interview on 1/13/16 at 1:15 p.m. with CNP E revealed:
*She had confirmed the supplies should have been removed and replaced with clean supplies after each patient discharge.
*She agreed that had not been a good practice, and there was potential for cross-contamination of bacteria from one patient to another.

4. Interview on 1/13/16 at 2:30 p.m. with the infection control nurse revealed:
*She had not been aware of all the above areas of concern.
*She confirmed:
-The oxygen cylinders should not have been stored next to the decontamination area.
-All packages should remain closed until the equipment or supplies were ready to be used.
-Their process for leaving patient supplies in the rooms after each discharged patient was not good practice.
*She completed rounds in the facility with the quality assurance nurse each quarter.
*The above areas of concern had not been a part of their checklist.

Review of the provider's September 2006 Single Use Items policy revealed no procedure in place for the staff to follow for opening packages before they were ready to be used.

Review of the provider's September 2006 Cleaning of Patient Rooms policy revealed disposable supplies should have been removed upon a patient's discharge or transfer.