HospitalInspections.org

15036

A. Based on observation, interview, and policy review, the provider failed to ensure:
*Nursing staff documented medication administration after the medications had been administered for three of three sampled patients (2, 3, 39).
*The intravenous (IV) port had been disinfected with an alcohol wipe prior to administering medications or infusing an IV for two of two samples patients (2 and 39) Findings include:

1. Observation on 8/11/15 at 8:20 a.m. of patient 3's medication administration revealed registered nurse (RN) B:
*Entered the patient's room and scanned the Zofran (medication to prevent nausea) information into the computer.
*Documented in the computer the medication had been administered.
*Scanned the patient's identification band.
*Administered the medication to the patient.
*Exited the patient's room.

Interview with RN B immediately after exiting the room revealed no further documentation was required for the medications administered to patient 3.

2. Observation on 8/11/15 at 8:30 a.m. of patient 39's medication administration revealed RN M:
*Entered the patient's room and verified the patient identification band.
*Signed the IV medication as given in the computer.
*Had not disinfected the IV port.
*Started the infusion of patient 39's IV antibiotic.
*Exited the patient's room.

3. Observation on 8/11/15 at 8:35 a.m. of patient 2's medication administration revealed RN M: *Checked the patient's medication administration record.
*Signed off the medications had been given.
*Administered the patient the medications (Aspirin and docusate [stool softener]).
*Exited the patient's room.

4. Observation on 8/11/15 at 8:45 a.m. of patient 2's medication administration revealed RN M:
*Signed the medication as given.
*Had not used alcohol to disinfect the IV port.
*Started the infusion of patient 2's IV antibiotic.
*Exited the patient's room.

5. Interview on 8/13/15 at 4:00 p.m. with nurse manager N revealed:
*The nursing staff should have documented after the medication had been given not before.
*The IV ports should have been disinfected with an alcohol wipe prior to medication administration.

Review of the provider's November 2014 Intravenous Admixture policy revealed IV ports should have been disinfected with an alcohol wipe prior to accessing for medication administration.

B. Based on record review, interview, and policy review, the provider failed to ensure:
*The surgical team evaluated and clarified the patient's allergic response to contrast dye prior to using betadine prep and irrigation during the surgical procedure for one of one sampled patient (7) with a contrast dye allergy.
*A complete list of the patient allergies was listed on all surgical documents for one of one sampled patient (7) with a contrast dye allergy.
Findings include:

1. Review of patient 7's medical record revealed:
*The patient was admitted on 8/10/15 for a right total knee revision.
*The 8/3/15 preoperative history and physical report documented she was allergic to "Ct [contrast] Dyes [Diagnostic X-Ray Materials]" and nickel.
*The Pre-Procedure Assessment report dated 8/10/15 and the Pre-Procedure Checklist dated 8/10/15 documented "Contrast Dye SEVERITY: Mild REACTION: Hives TYPE: Drug Allergy SENSITIVITY: Allergy."
*The surgery schedule for 8/10/15 had not listed the patient's allergy to contrast dye.
*The anesthesia review and plan dated 8/10/15 documented the contrast dye and nickel allergy.
*The intraoperative OR (operating room) documentation dated 8/10/15:
-Listed the patient's nickel allergy.
-There was no documentation of the contrast dye allergy.
-Listed the patient's surgical site had been cleansed with betadine, and betadine 30 milliliters in 1000 liters of normal saline had been used for irrigation of the surgical site.
-There was no documentation the patient had been questioned regarding her allergy to contrast dye.
-There was no documentation the surgical team had assessed the patient's response to contrast dye and ruled out allergic responses.
-The plan of care had a statement "Allergy(s) and reactions(s) verified and documented."

Interview on 8/13/15 at 2:18 p.m. with the surgery manager revealed:
*Patient's allergies were verified preoperatively during the preoperative phone call and again on the day of their surgical procedure.
*OR staff did not check for allergies. Checking for allergies was part of the preoperative process.
*For patients that listed contrast dye as an allergy betadine based products should not have been used during the surgical procedure.

Review of the provider's August 2015 Patient Admission policy revealed "The admission nurse introduces self and greets patient and family. At this time the patients I.D band is verified with chart information, including date of birth, allergies are verified with the patient and also the H&P [history and physical] at this time. A red allergy band is placed on the patient. The reconciled allergy list will be documented in the patient profile in the Clinical Care Station application."

Review of the Association of perioOperative Registered Nurses Perioperative Standards and Recommended Practices, 2012 Edition, CO, p. 266, revealed the perioperative (OR) nurse should have obtained patient medication allergies and reactions and clearly document them in the patient's medical record.

15036

A. Based on observation and interview, the provider failed to ensure:
*Clean linen, clean patient supplies, equipment, and surface interiors were maintained in a sanitary and serviceable condition in eight of eight patient care areas (pre-operative patient rooms, patient rooms, operating room [OR], clean supply storage area, pediatric post-anesthesia care unit, adult post-anesthesia care unit, four closets outside the surgical suite, and anesthesia workroom), and in one of one OR janitorial area.
*Excess equipment and supplies were not stored in one of one pain clinic procedure room.
Findings include:

1. Observation and interview on 8/10/15 at 1:45 p.m. with the quality coordinator on the preoperative area revealed:
*The pre-operative rooms had numerous unwrapped tongue blades in a drawer.
*The tongues blades were used during the examination of a patient's mouth.
*There was a potential for the tongue blades to become contaminated.
*An uncovered three tiered cart with patient clean supplies. The cart had a layer of dust on it and needed cleaning.
*Blankets provided to patients were stored unprotected on a cart.

2. Observation on 8/10/15 at 2:00 p.m. on the third floor with the quality coordinator of an empty patient room revealed a closet full of supplies and linen. Interview at the time of the observation confirmed the closet was set-up the same way in all patient rooms. The supplies and linen stayed in the closet during the patient's admission and unused supplies and linen were not discarded after the patient was discharged unless the patient had been on isolation precautions. The quality coordinator revealed there was a potential for the supplies and linen to become contaminated during a patient's admission.

Observation on 8/10/15 at 3:15 p.m. revealed patient 38 entered the pain clinic procedure room for an epidural injection (medication injected into the back to relieve pain). The procedure room was used to store:
*Numerous sterile supplies on an open wire rack unit.
*Several opened plastic bins with sterile supplies for specific physicians' procedures in the future.
*Numerous opened plastic bins with sterile supplies for the next day's surgical procedures.
*Two stretchers made up with a sheet and pillow.
*Two wheelchairs.
*A medium sized linen transport cart used to transport linens from a contracted business.
*A large wooden desk used by staff for charting.

Interview on 8/10/15 at 3:50 p.m. with RN H revealed:
*All supplies were in individual sterile packages and could be stored in the procedure room.
*The plastic bins of supplies were used for patient procedures the next day. There were bins that contained sterile supplies for specific physician cases in the future.
*The storage of sterile supplies on the wire racks were used daily and access to them was convenient.
*The pain clinic was short on supply storage space.
*If a patient became dizzy after their procedure the stretchers and wheelchairs were only a short distance away.

3. Observation on 8/11/15 at 11:50 a.m. in the central supply clean storage room revealed:
*The entrance into the central supply clean storage area had:
-A large area of severely torn wallpaper and plastic base board material creating an uncleanable surface.
-A small room off the entrance had a box of equipment, an outside shipping container, and a piece of equipment that had been stored on the floor.
*Behind the implant freezer door were three large gouges in the wall that created an uncleanable surface.
*The bottom shelving of the wire racks had a clear Plexiglas covering. Dust was visible on that Plexiglas and touching of the surface left fingers dusty.
*On the bottom shelf of one wire rack was a black case and the exterior of that case had a layer of visible dust. Touching the case surface left fingers dusty.

Interview on 8/11/15 at the time of the above observations with staff member J confirmed the above observations. Staff member J revealed he had not performed any cleaning tasks in that area. He was not sure if there was a cleaning schedule for the central supply clean storage area. Staff member J revealed he had not completed a work order to repair the entrance walls and the wall behind the freezer. He was not sure if there had been a work order submitted to fix the interior walls. Staff member J confirmed the alcove had equipment stored in a bin on the floor, a piece of equipment was stored directly on the floor, and an outside shipping container was stored in that area. He was not sure why the equipment had been stored on the floor, some of the equipment was no longer used, and he was not aware the outside shipping container should not have been stored with clean supplies.

4. Observation on 8/11/15 at 11:20 a.m. of four closets outside the surgical suite used to store OR equipment revealed:
*Closet one had patient litho (stirrups) positioning devices stored on the floor.
*Closet two had employee coffee cups stored on the top shelf, a bin of positioning devices/pads, and black endoscope scope cases stored in a box on the floor.
*Closet three had outside Olympus shipping containers stored on the floor.
*Closet four had two large bags of used equipment wrapping papers stored on the floor. Jackets and pants were stored in the closet and had a layer of visible dust on them.

Interview on 8/13/15 at 11:35 a.m. with OR lead staff O regarding the OR closets revealed patient care items should not have been stored on the floor. He was not aware why the other items were in that closet. The closets were also used to hang employee coats in the winter.

5. Observation on 8/11/15 at 2:20 p.m. in the adult post-anesthesia care unit with the quality coordinator and department manager revealed a large accumulation of blankets and pillows in an uncovered storage bin. These items were unprotected from dust and potential contaminates.

Interview on 8/11/15 at the time of the above observations with the quality manager and department manager revealed the patient blankets and pillows should have been stored in a manner to prevent contamination.

6. Observation on 8/11/15 at 3:10 p.m. in the clean equipment storage area revealed:
*A black pad with cracked corners and a tear that had been repaired with a clear adhesive covering. The edges of that covering had started to peel exposing the tear. The cracked edges and tear created an uncleanable surface.
*A positioning device with a foam pad that had a large crack. The crack had been covered with tape used to secure a patient's dressing.
*A green positioning device with a tear had been repaired with a clear adhesive dressing.
*A gel pad with a tear had been repaired with a clear adhesive dressing. That adhesive dressing was peeling and exposed the sticky gel inside of the gel pad.
*An arthroscopy pump (device used to circulate water) base had a large amount of rust which created an uncleanable surface.

7. Observation on 8/11/15 at 3:20 p.m. of the janitor's closet in the clean equipment storage area revealed:
*The walls of the janitor's closet were discolored with spots of brownish to black smudges.
*The floor was severely discolored brown, was moist along the baseboard, and had a small amount of debris on it.
*A plastic bin with a blue towel was on the floor. The bin contained two jugs of cleaning solutions. The bin and blue towel had large amounts of green spillage and dust.
*A roll of paper towels for handwashing was on the shelf next to the cleaning supplies. The cleaning supplies on the shelf were dusty.
*The janitor's closet was not an enclosed area. The mop bucket was stored touching a stand used to store clean patient equipment.

8. Observation and interview with the quality coordinator on 8/11/15 at 3:55 p.m. revealed:
*In OR room 14:
-A housekeeping staff member was terminally cleaning the floor in that room.
-The black base of the microscope stored in that room had a layer of visible dust on it.
-Interview with housekeeper J revealed at the end of the day he was only responsible for cleaning the OR floor and spot cleaning the walls if needed. The OR staff at the end of the day was responsible for cleaning the equipment.
*In OR room 11 (eleven) - the Valleylab cautery device (used to cut and stop bleeding) had a layer of dust on the bottom shelf.
*The emergency chest tube and tracheotomy closet had a layer of dust and small amounts of debris on the floor. Shelving dividers were stored on the closet floor.

Interview at the time of the above observations with the quality coordinator confirmed the above findings.

9. Interview on 8/12/15 at 1:40 p.m. with the director of environmental services revealed:
*Housekeeping staff were responsible for cleaning flat surfaces, OR lights, substerile rooms (small room between two ORs), and window sills each day.
*Housekeeping staff were not responsible for equipment disinfection.
*He communicated with housekeeping staff daily, and any cleaning issues were taken care of right away.
*It was common knowledge areas in the OR required repair. Areas were repaired one month and needed the same repair the next month.
*There was a planning process in place to add additional storage space. That would help eliminate damaged walls and equipment.
*He looked at the facility daily but had not always documented areas that needed repair.
*Environmental rounds were documented that were sent to department managers.

10. Observation and interview with the quality coordinator on 8/13/15 at 8:30 a.m. in the anesthesia workroom revealed:
*Clean anesthesia supplies (hoses, masks, and Coban bandages) were stored in bins on the floor. The area behind those bins had an accumulation of dust.
*Underneath the handwashing sink stored in a box were numerous clips for the warming devices used for patients.
*Medium sized piece of laminate was missing from a cabinet door. Another cabinet door was misaligned and had not closed properly.

11. Observation and interview on 8/13/15 at 9:10 a.m. with the quality coordinator and OR manager regarding the unsanitary conditions and disrepair found in the operating rooms outlined in findings 3, 4, 6, 7, 8, and 9 revealed:
*He agreed the cleaning and disinfection process for the OR environment was not effective in maintaining a clean and sanitary environment.
*The director of housekeeping was responsible for conducting monthly rounds for environmental issues, but he had not received feedback regarding those rounds.
*The OR decontamination staff were responsible for cleaning and disinfecting the OR. He had not received feedback from the staff regarding the status of the cleaning. There was no documentation of that cleaning process when completed.
*He made daily rounds in the OR but had not documented environmental and cleaning issues when noted.



25107

12. Observation and interview on 8/10/15 at 3:00 p.m. with the director of environmental services revealed:
*The paper towel dispenser located at the third floor recovery care nurses station provided no protection from the top to prevent drips from hands from contaminating the rest of the supply.
*The paper towel dispenser located at the first floor stepdown unit was the same type.
*He agreed the paper towel supply for hand washing sinks should have been protected from contamination.

13. Observation and interview on 8/12/15 at 8:35 a.m. with registered nurse A and the director of environmental services in the pediatric post anesthesia care unit revealed:
*A small stack of white wash cloths was stored on the edge of the hand sink.
*The wash cloths were used for cleaning patients' faces.
*They agreed those wash cloths should not have been stored next to the hand sink where splash from handwashing could contaminate them.

15036

Based on observation, interview, and policy review, the provider failed to ensure:
*The drain removal and dressing change for one of one sampled patient (36) was completed in a sanitary manner by two of two staff members (B and C) to prevent contamination of the surgical wound.
*Hand hygiene was completed by two of two staff members (D and E) at the conclusion of two of two sampled patients' (37 and 38) surgical procedure.
*Prior to withdrawal of medications from a vial the septum (rubber stopper) or intravenous (IV) port was not disinfected with an alcohol wipe for two of two sampled patients (37 and 38), by three of three staff members (F, G, and H), and in two of two patient care areas (pain clinic and operating room).
*The staff disinfected one of two digital thermometers had been disinfected after patient use in one of one pediatric postanesthesia care unit.
*Sterile suction tubing set-ups were not contaminated prior to patient use in one of one adult post-anesthesia care unit.
*Patient care supplies was protected to prevent potential contamination in one of one adult postanesthesia care unit.
Findings include:

1. Observation on 8/10/15 at 3:15 p.m. of patient 38's urology surgical procedure revealed:
-Medication vials (Ominpaque, Xlyocaine 1% [percent], betamethasone, and bupivacaine) were opened by RN H. She had not disinfected the rubber stopper of the vials prior to staff member D withdrawing the medication from each vial.
-At the end of patient 38's epidural injection physician D removed his contaminated gloves and had not performed hand hygiene prior to charting on the patient's record at the nurses' computer tower.
-At the end of patient 38's epidural injection RN H returned the plastic bin used for supplies back on the wire rack of sterile supplies without disinfecting the bin. Interview with RN H immediately after the procedure revealed the plastic bin should have been disinfected after each use.

2. Observation on 8/11/15 at 8:30 a.m. of patient 39's IV antibiotic administration revealed RN M had not disinfected the IV port with an alcohol pad prior to hanging the patient's antibiotic medication.

3. Observation on 8/11/15 at 8:40 a.m. of patient 36's dressing change revealed:
*Registered nurse (RN) B gathered the necessary supplies and placed the supplies on the patient's overbed table.
*The overbed table had not been disinfected to establish a clean work space.
*The overbed table had a container of juice, hand gel, TV channel changer, snacks, water, and papers on it.
*RN B while wearing clean gloves:
-Tore a sterile gauze package in half contaminating the dressing.
-Removed the gauze pad from the package touching the edges and middle of gauze pad contaminating the dressing.
-While holding the dressing in her hand she unhooked the patient's drain from his gown further contaminating the dressing.
-Handed the contaminated dressing to physician assistant-certified (PA-C) C who wiped drainage that leaked from the wound after the drain had been removed.
-Tore a sterile gauze package in half contaminating the sterile dressing and handed the dressing to PA-C C who then placed it over the wound.

4. Observation on 8/11/15 at 8:45 a.m. of patient 2's medication administration revealed RN M had not disinfected the IV port with an alcohol pad prior to hanging the patient's antibiotic medication.

5. Observation on 8/11/15 at 10:09 a.m. of patient 37's epidural surgical procedure revealed:
-The certified registered nurse anesthetist F and anesthesiologist G administered medications to the patient through his IV line. The rubber ports used to administer medications had not been disinfected with an alcohol wipe prior to medication administration.
-At the end of patient 37's surgical procedure physician 38 removed his x-ray apron, contaminated gloves, and exited the operating room (OR) without performing hand hygiene.

6. Observation and interview with the quality coordinator on 8/11/15 at 2:10 p.m. in the pediatric post-anesthesia care unit revealed:
*There were no further patients to be recovered for that day, the staff should have completed disinfection of the area, and the staff had been released to go home.
*Digital temple thermometers were used to take the patients temperature in that area.
*The probe design of the digital thermometer included small openings surrounded by flexible rubber-like material.
*The the quality coordinator revealed the temple thermometers did not have disposable covers and should have been disinfected with an alcohol pad after each patient's use.
*The quality coordinator stated ATP (adenosine triphosphate) monitoring was used to determine the cleanliness of certain items in the environment. A reading of 45 or less with the ATP monitor indicated the item tested had been properly disinfected.
*The surface that touched the patient's skin was tested by facility staff with the ATP monitor. The level of contamination readout revealed 114, which was 69 points above the allowable level of contamination.
*The quality coordinator confirmed a reading of 114 would have indicated the digital thermometer probe had not been properly disinfected after use on a patient(s).

Review of the manufacturer's cleaning and care instructions for the digital temple thermometer revealed the staff should have wiped the tip and probe with an alcohol swab or cotton swab moistened with 70% alcohol before and after each use.

7. Observation on 8/11/15 at 2:10 p.m. in the operating room suite revealed an unattended cart that held IV fluids, three of the IV bags had the outer pouches (wrapper) removed, and one of the IV bags had IV tubing connected.

Interview at the time of the above observation with the quality manager revealed IV bags should not have been taken out of the protective wrapper until the fluids were ready for use. This was at the end of the day and there were no further OR cases scheduled. The quality manager revealed there was a potential for the IVs to become contaminated when out of the wrappers, when IV tubings were connected, and the solutions were not immediately used.

Interview on 8/13/15 at 9:05 a.m. in the operating room with the quality manager, surgery manager, and anesthesia technician K revealed:
*The IV bags were removed from the outer wrapper,connected to IV tubing, and returned to the warmer.
*The potential for contamination was possible when the IV bags had IV tubing attached and stored for later use.
*Because the OR got busy that process was completed to ensure warm fluids were ready to go when needed.
*Normally at the end of the day there would not have been IV bags left over.
*The anesthesia technician was responsible for IV bags and ensuring fluids were available for patient use.

Review of the provider's August 2011 "Temperature Management of Warmers and Coolers (Fridges)" policy revealed:
*IV solutions could be warmed in their plastic outer wrapper for no longer than fourteen days.
*Once the solutions had been removed from the warmer, they could not be returned to the warmer.
*The policy had not addressed potential infection control issues with prematurely spiking the IV solutions prior to patient use.

8. Observation on 8/11/15 at 2:20 p.m. in the adult postanesthesia care unit with the quality coordinator and department manager revealed:
*Each recovery bay had the suction tube connected to wall suction, the suction tip was attached to the other end and stuck in the manufacturer's package.
*The following items were stored at the handwashing sink: a covered bin with ice, a bin to hold the ice scoop, drinking cups in plastic wrap, a box of paper wrapped straws, a box of unwrapped plastic spoons, and a stack of clean white towels.

Interview on 8/11/15 at the time of the above observations with the quality manager and department manager revealed:
*The suction tubing was stored in that manner for easier access.
*If the suction tubing and tip stored at any bay was not used during patient care that tubing and tip were not discarded. It would have been available and used for the next patient.
*They both agreed the suction tubing and tip had the potential to be exposed to different patients multiple times throughout the day if not used.

9. Interview on 8/13/15 at 4:28 p.m. with the infection control coordinator (ICC) confirmed:
*To prevent cross-contamination of the environment physicians D and E should have performed hand hygiene after removing their contaminated gloves.
*To prevent potential medication contamination it was the hospital's policy to disinfect the rubber stopper of vials prior to withdrawal of medications.
*When completing a dressing change:
-Staff members B and C should have established a clean work area. The overbed table used during the dressing change should have been disinfected prior to and after use.
-Staff member B should not have torn open the sterile gauze package. The gauze package was designed to peel open to prevent contamination of the dressing.
-Staff member B should not have contaminated the dressing with her gloved hands. The gloves were clean not sterile.

Review of the provider's November 2014 Handwashing policy revealed:
*"Hand hygiene is the single most important strategy to reduce the risks of transmitting organisms from one person to another or from one site to another on the same patient."
*"Cleaning hands promptly and thoroughly between patient contact and after contact with blood, body fluids, secretions, excretions, equipment and potentially contaminated surfaces is an important strategy for preventing healthcare-associated infections."
*Staff members should have cleaned "Hands before and after routine patient care activities and after hand contaminating activities."
*Hand hygiene should have been performed before and after patient contact, including dry skin contact, and before leaving the unit.

Review of the provider's August 2014 Medication Administration policy revealed the policy had not addressed disinfection of vial rubber stoppers.

Review of the provider's November 2014 Intravenous Admixture policy revealed staff should have disinfected IV ports using friction and 70% alcohol prior to administering medications.

B. Based on observation and interview, the provider failed to ensure the hot and cold water was turned on for one of one handwashing sink in the central processing room. Findings include:

1. Observation on 8/11/15 at 3:55 p.m. in the central sterile processing room revealed an instrument set had been placed in the handwashing sink. Removal of the instrument set and turning the water handles to the on position revealed no water came out of the faucet.

Interview at the time of the above observation with the central sterilization reprocessing (CSR) lead person revealed the water to that sink had been turned off. She had been informed by her maintenance staff the sink was not required in the sterile processing area. The CSR lead revealed the staff used hand gel throughout the day for hand hygiene and if needed they exited sterile processing and entered the decontamination room to wash their hands.



25107

C. Based on interview, and policy review, the provider failed to have a process for recalling sterilized instruments should a biological indicator show a failure of the autoclave. Findings include:

1. Interview on 8/13/15 at 12:10 p.m. with the operating room department manager and the CSR lead in regards to recalling sterilized instruments revealed:
*The sterilized instruments were only tracked with the autoclave number and load number while those instruments were in CSR.
*A biological indicator that required a twenty four hour incubation period was run with every load.
*Instruments left the CSR before the biological indicator could incubate for twenty four hours.
*They had no process for recalling those sterilized instruments should a biological indicator show a failure of the autoclave.

Review of the provider's Sterilization and Autoclave Qualifications and Testing after Positive Biological Test policies revealed neither policy addressed what procedure to follow for instruments that had been processed in the failed autoclave.