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Based on observation and interview, it was determined the facility failed to ensure equipment and supplies commonly used in life saving procedures were readily available for treating emergency cases.

Findings were:

Facility Policy entitled, "Crash Carts", stated in part, "1. The crash carts will be maintained in operational readiness at all times by Nursing, Pharmacy using a break-away lock system. 4. The crash carts will be opened every 30 days by Pharmacy personnel. The equipment, medication, and supplies will be checked, inspected, and new locks applied. a. Beginning the 15th of each month, pharmacy personnel routinely checks the crash cart in each area for contents and expiration dates regardless of the last opening date. Documentation of this can be found in the Pharmacy Department."

On a tour of the facility the morning of 01/31/2017, the following were observed:

Medical Surgical Unit Emergency Crash Cart:
Infusion Set 20 gauge ¾ inch expiration date: 03/2016
Infusion Set 20 gauge ¾ inch expiration date: 10/2014
Satin-Slip Stylet 6 French expiration date: 03/2015
Four Plus Safety IV Catheter expiration date: 03/2015
Five Safety Syringe Insulin ½ ml expiration date: 06/2015
Two IV Catheter 24 G ¾ expiration date: 06/2015
Two IV Catheter 24 G ¾ expiration date: 07/2016
IV Catheter 18 G 1 ¼ expiration date: 08/2013
IV Catheter 18 G 1 ¼ expiration date: 06/2016

Operating Room # 2
Endotracheal tube expiration date: 10/2016

Supply Room
LarySeal Laryngeal mask expiration date: 12/2014

The above findings were confirmed with the Chief Nursing Officer on 01/31/2017.

Based on a tour of the facility, review of facility policies, and staff interview, the facility failed to ensure that drugs were stored in accordance with accepted professional principles, and that outdated, mislabeled, or otherwise unusable drugs were not available for patient use.

Findings were:

"Centers for Disease Control and Prevention Injection Safety-Multi-dose vials", states in part, "Medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopeia (USP) General Chapter 797 recommends the following for multi-dose vials of sterile pharmaceuticals:
If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
· If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer ' s expiration date.
The manufacturer ' s expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The beyond-use-date should never exceed the manufacturer ' s original expiration date."

Facility Policy entitled, "MED-UNIT/DRUG STORAGE INSPECTIONS", stated in part, "The Pharmacy will develop a policy to inspect all nursing care units or other areas of the hospital where medications are dispensed, administered, and stored on a regular basis. The inspection will include, but is not limited to the following areas:
· Outdated or otherwise unusable drugs are identified, and their distribution and administration are prevented.
· Multi-dose vials properly dated.

On a tour of the facility the morning of 01/31/2017, the following were observed:

· Amiodarone HCL 150 mg/3 ml. X3 single use vials expired on 09/2016 were available for use in the emergency crash cart on the Medical/Surgical Unit.

· Multi-dose vial of Intradermal Purified Protein Derivative (tuberculin skin test) opened 12/7/2016, in the medication room refrigerator was available for use.

The above findings were confirmed on 01/31/17 by the Chief Nursing Officer (CNO).

Based on review of facility documents, observation and interview, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Findings included:

"OSHA/Blood Borne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

"AORN [the Association of perioperative Registered Nurses] Guideline essentials 2016" for "Flexible Endoscopes" stated in part
"Storing:
· Place flexible endoscopes in a drying cabinet.
· If a drying cabinet is not available, store endoscopes in a closed cabinet with HEPA-filtered air that provides positive air pressure and allows air circulation around the flexible endoscopes ...
· Store flexible endoscopes with all valves open and with removable parts detached but stored with the endoscope ...
· Clean and disinfect storage cabinets when they are visible soiled and on a regular basis ...
Effective storage of flexible endoscopes protects the endoscope and endoscope accessories from damage and reduces contamination to help ensure devices are safe for patient use."

The following was observed on a tour of the facility on the morning of 1/31/17:
· Physical Therapy Department patient table had tears on the corners of area #3 and #4, making it impossible to clean completely
· In the dirty utility room, spray can of Lysol and a gallon of opened and used paint were found under the sink
· In the decontamination room of the OR [operation room], cleaners were stored under the sink which was leaking and dripping water
· All five endoscopes hanging in an open room with removable parts attached and all lumens not hanging completely vertical
· Four disinfectant bottles in the recovery room unsecured
The above was verified on the tour with the CEO and CNO on the morning of 1/31/17.

Facility based policy entitled, "Flexible Scope - testing for detection for blood" stated in part,
"Policy: It is the policy in the surgery department at Ward Memorial, to practice the principle of detection for blood after initial cleansing of flexible scopes.
Procedure: Testing for detection of blood residue inside the biopsy channel of a scope is performed after each scope is initially cleansed with the Endo-Flush EFP 250."

Review of facility documentation of endoscope cleaning revealed the following dates cleaning was completed with no documentation of the pass/fail testing for detection of blood residue:
· 4/18/16 Scope #1 at 9:00 AM
· 4/18/16 Scope #2 at 10:02 AM
· 4/18/16 Scope #3 at 10:45 AM
· 5/16/16 Scope #1 at 8:30 AM
· 5/16/16 Scope #2 at 10:37 AM
· 5/16/16 Scope #3 at 12:25 PM
· 5/17/16 Scope #3 at 11:01 AM
· 6/20/16 Scope #1 at 10:37 AM
· 6/20/16 Scope #2 at 10:52 AM
· 6/20/16 Scope #1 at 4:15 PM
· 6/20/16 Scope #2 at 5:05 PM
· 6/20/16 Scope #1 at 5:50 PM
· 7/18/16 Scope #1 at 9:30 AM
· 7/18/16 Scope #2 at 10:15 AM
· 7/18/16 Scope #4 at 11:00 AM
· 8/22/16 Scope #1 at 9:20 AM
· 8/22/16 Scope #2 at 10:15 AM
· 8/22/16 Scope #3 at 11:12 AM
· 9/19/16 Scope #1 at 8:56 AM
· 9/19/16 Scope #2 at 9:40 AM
· 9/20/16 Scope #1 at 12:06 PM
· 9/20/16 Scope #2 at 1:11 PM
· 9/20/16 Scope #1 at 2:07 PM
· 9/20/16 Scope #2 at 11:29 AM
· 9/20/16 Scope #4 at 12:05 PM
In an interview with the Chief Nursing Officer and staff #12 on the afternoon of 1/31/17, the above was confirmed and verified the documentation was missing.

Amsco Eagle Series 3000 Gravity and Vacamatic Sterilizers Manual stated in part, "Routine Maintenance ... The following procedures should be performed at regular intervals, as indicated. This frequency is the minimum and should be increased if usage of the sterilizer demands ...
4.1 Daily ...
1. Clean chamber as follows:
a. Wash inside of chamber and loading equipment ...
b. Rinse with tap water ...
c. Remove chamber drain strainer ...
d. Place strainer back in chamber drain ...
4.2 Weekly
1. Flush chamber drain as follows ...
2. Check controls and status signals as follows ...
3. Flush steam generator ...
4.3 Monthly
1. Place a few drops of heavy machine oil ...
4.4 Quarterly
1. Grease door post as follows ...
2. Inspect door gasket ..."

In an interview with staff #12, when asked for preventive maintenance records, staff #12 stated they contract that and someone comes annually. When asked for a policy regarding preventive maintenance and the sterilizer manual, none was provided.

Review of personnel files for staff #4 revealed no documentation of education and training of sterilization.

Review of personnel files for staff #4 and staff #12 revealed no documentation of continuing education, orientation or on-the-job training.

Review of performance records revealed incomplete records for the third and fourth quarters of 2016.

The above was verified with the Chief Nursing Officer and staff #12 in an interview on the afternoon of 1/31/17.

Based on record review and interview, the facility failed to ensure medical records had dated signatures of the doctors of medicine or other health care professionals.

Findings included:

Facility rules and regulations of the medical staff stated in part, "Section B: Medical Records ...
1) Specific physician responsibility in completing a medical record are:
...f) Discharge summary dictated or hand written and signed within 14 days of discharge ...
...j) Detailed operative reports dictated or hand written immediately following the procedure and signed within 14 days."

Review of patient #1's medical record on 1/31/17 revealed a surgery date of 12/14/16 with operation and discharge notes dated 12/14/16 without a signature.

Review of patient #2's medical record on 1/31/17 revealed a surgery date of 12/13/16 with operation and discharge notes dated 12/13/16 without a signature.

Review of patient #3's medical record on 1/31/17 revealed a surgery date of 11/15/16 with operation and discharge notes dated 11/15/16 without a signature.

Three of three surgery records reviewed had no dated signatures well over the 14 days required by the rules and regulations of the medical staff.

The above was verified in an interview with the Chief Nursing Officer on the afternoon of 1/31/17.