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1 MEDICAL CENTER DRIVE

LEBANON, NH 03756

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on observation and interview, it was determined that the hospital failed to maintain the surgical suites environment in a manner to fully protect vulnerable patients with appropriate security.

Findings include:

Observation on 12/11/17 of the hospital's surgical suites, revealed two doors entering the main core that were not secured to prevent unauthorized access and could be directly accessed by the public. The two doors were labeled as (423L-M) "Main Entry", and (427Q01) "Same Day Surgery".


While touring with Staff H (Facility's Maintenance) on 12/14/17 at 11:30 a.m. we walked through the double doors which opened by motion sensors into the surgical area and passed the security window which was unattended at the time to try and locate Staff I (Registered Nurse).

Interview on 12/14/17 with Staff H and Staff I revealed that these doors were locked down during the evening hours and staff must use their security card to enter the area. During the day, the doors were unlocked and could be accessed by any person outside the surgical suites.

SECURE STORAGE

Tag No.: A0502

Observation on 12/11/17 at approximately noon during tour of the intensive care nursery revealed a partially filled sharps container was observed sitting on a window counter sill, and it was not attached to prevent it from falling over or being stolen. This unattached sharps container was pointed out to Staff B (Registered Nurse) who related that they don't have a lot of wall space.



13504

Based on observation and interview, it was determined that the hospital failed to secure drugs and biologicals from unauthorized individuals and to potentially prevent tampering, accidents or diversion.

Findings include:

Observation on 12/12/17 and 12/14/17 during tour of the emergency department revealed that several vials of medication were discarded in a holding container that was opened and accessible to any unauthorized staff or patients in the area.

Interview on 12/12/17 and 12/14/17 with Staff F (Registered Nurse) and Staff G (Registered Nurse) revealed that multiple vials of medication were discarded into the above container. Both Staff F and Staff G revealed that some of the medications that were discarded into the container was Dilaudid, Fentanyl, and Propofol.

Interview 12/14/17 with Staff M (Medical Supply) confirmed that these containers that the medication vials were being discarded into are only to be used for IV bags and solutions and not medication vials.

Observation on 12/12/17 during tour in the emergency department revealed that several sharps containers were not attached or secured and could be removed by unauthorized staff or patients.


27714

Observation on 12/12/17 at approximately 11:00 a.m. on tour of the second floor revealed an alcove where sharps containers were stored for disposal. The sharps containers were behind an accordion style fence. There was approximately one and half feet of space between the top of the fence and the ceiling. Staff C (Quality Assurance and Safety) observed that a person was able to reach into holes in the fence and hand a sharp container over the fence. The sharps container had needles and vials inside. There were greater than 200 sharps containers of multiple sizes stored in the alcove, approximately 20 were accessible by reach.






26364

Observation on 12/12/17 at 11:45 a.m. of the Short Stay Unit revealed an unlocked medication refrigerator in the locked medication room. The unlocked refrigerator contained the following medications: Neurontin (anticonvulsant, migraine prophylaxis), insulin, Ativan (anxiety) and flu vaccines.

Interview on 12/12/17 at 11:55 a.m. with Staff J (Registered Nurse-Unit Manager) confirmed the medication refrigerator was unlocked. Staff J revealed that registered nurses, licensed nurses aides and the stocking clerk had access to the above medication room with the unlocked refrigerator.

MONITORING RADIATION EXPOSURE

Tag No.: A0538

Based on interview and record review, the hospital failed to ensure that radiation workers are checked periodically for amount of radiation exposure in the outpatient surgical center (OSC).

Findings include:

Interview on 12/14/17 at approximately 10:15 a.m. with Staff E (OSC Manager) revealed that use of dosimeter badges at the OSC was "optional". Interview also revealed that were 2 mini fluoroscopes, 2 full sized fluoroscopes, and 1 portable fluoroscope in use at the OSC.

Interview on 12/14/17 at approximately 2:00 p.m. with Staff D (Quality Assurance and Safety) revealed there were approximately 75 employees who worked in the OSC that could have potential exposure from the fluoroscopes in use in the operating rooms.

Review of the dosimetry report for the OSC for October 2017 revealed results of 3 personnel being monitored by dosimeter badges. A control badge was also assigned to each fluoroscope.

FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE

Tag No.: A0724

Based on observation, interview, and review of manufacturer's instruction, it was found that hospital failed to maintain glucose meters control process as required by manufacturer's instructions, to ensure aceptable safety and qulity.

Findings include:

Review of manufacturer's instructions for the hospital's glucose meters control solution revealed the following directions

"Do not use if the expiration date has passed. Discard any unused control solution 90 days after first opening or after the expiration date."

Observations during survey revealed that several hospital based departments and outpatient clinics were using controls solutions greater than 90 days after opening or past the manufacturer's expiration date. Expired control solutions were discarded at the time of findings and new bottles opened.

INFECTION PREVENTION CONTROL ABX STEWARDSHIP

Tag No.: A0747

Based on observation, interview, and record review, the hospital failed to adhere to accepted standards of infection control practice for maintaining patient care equipment, proper storage of scope equipment, hand hygiene, and cleaning of environmental surfaces in multiple areas.

(Cross refer to tag A 749)

INFECTION CONTROL PROGRAM

Tag No.: A0749

Observation during tour of the Dialysis Unit on 12/13/17 at approximately 1:20 p.m. revealed Patient #65 undergoing a dialysis treatment. During this observation time Staff L(Registered Nurse) was observed providing care to Patient #65 and after removing gloves no handwashing or use of hand sanitizer was utilized. Staff L (Registered Nurse) was observed exiting and entering the treatment area without utilizing hand sanitizer or completing hand washing.

Review of the "Hand Hygiene" policy and procedure dated "20-MAR-2013" revealed the following:
" Purpose
The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination.

Responsibility All staff, patients, patient care givers, including physicians and non-physician practioners, social workers, dietitians and any other indirect patient care staff follow the same requirements for hand hygiene.

Policy: Hand Hygiene
Hand hygiene includes washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub with 60-90% alcohol content. Drying effects of alcohol can be counteracted by addition of emollient or humectants, e.g. 1-3% glycerol.

The table below identifies when hands shall be washed specifically with soap and water or when alcohol based hand rubs can be used...

Hands Will Be ...

Decontaminated using alcohol based hand rub or
by washing hands with antimicrobial soap and water

When ...
. Before and after contact with patients
. Entering and leaving the treatment area
. Before performing any invasive procedure such as
vascular access cannulation or administration of parenteral
medications
. Immediately after removing gloves
. After contact with body fluids or excretions , mucous membranes, non-intact skin , and wound dressings if hands are not visibly soiled
. After contact with inanimate objects near the patient
. When moving from a contaminated body site to a clean body site of the same patient ..." .

Interview on 12/14/17 at approximately 1:15 p.m. with the hospital Infection Control program staff to include, the Hospital Epidemiologist, the Regional Hospital Epidemiologist, the Quality Assurance and Safety Manager and the hospital Infection Preventionists revealed that the hospital infection control program failed to have active surveillance rounds to include all inpatients and outpatients off-site services.
















13504

Based on observation, interview, and record review, the hospital failed to adhere to professional standards for controlling infections and communicable diseases in the areas of maintaining patient care equipment,availability of personal protective equipment, proper storage of scope equipment, hand hygiene, and cleaning of environmental surfaces in multiple areas.

Findings include:

Observation on 12/11/17-12/14/17 during tour of the outpatient clinics revealed that several exam tables had tears on the surface. Breaches in the integrity of the exam tables can prevent proper cleaning and acceptable method for disinfection.

The findings are as follows:

Endocrinology exam room #23 tear in exam table, Infectious Disease exam room #2 tear in exam table, Rheumatology exam room #2 tear in exam table, Hematology oncology exam rooms #12 and #20 tears in exam tables, and Cardiology exam room #2(479) tear in exam table.

During tour of the above areas in addition to several inpatient areas it was observed that several pieces of patient care equipment and surfaces such as IV poles, counter tops, ultra sound machines and blood pressure machines had tape on them which prevents proper cleaning and disinfection. Also observation in the outpatient oral surgery department in exam room #1 revealed two of two chairs had duct tape wrapped around the arm rests. This type of tape frays and exposes adhesive which prevents proper cleaning and disinfection of the contact surfaces.

The following two observations were made pertaining to properly cleaning and disinfecting patient treatment exam tables in between patients use on 12/12/17.


Observation on 12/12/17 during tour of Rheumatology with Staff A (Registered Nurse) at approximately 1:30 p.m. revealed an exam room that was just used by a patient failed to have the exam table cleaned and disinfected, during a room turnover by Staff K (Medical Assistant).

Observation on 12/12/17 at approximately 2:15 p.m. during tour of Cardiology with Staff A revealed again after a room was used by a patient that staff failed to clean and disinfect the exam table during a room turnover. In both observations the protective paper sheets were placed over the exam tables which had not been cleaned.

Observation on 12/12/17 during tour of the Emergency Department revealed that the floor throughout the area had several cracks and splits. The engineering department provided documentation from outside vendors that the floor was cracking due to the shifting of the subfloor. Colored tape was being used throughout the unit on the floors to cover the cracks/splits in the floors membrane. Tape is porous and can prevent proper cleaning and infection control processes.

Observation during tour of the outpatient departments identified instances where several instruments that were used for procedures were waiting to be transported to central sterile supply in biohazard containers. When these observations were made, clinical staff from each department explained the processes for the cleaning of these instruments prior to transport. Clinical staff stated at times the instruments would need to be "cleaned" with a brush and rinsed off with water prior to being sprayed and placed in the containers to remove any visible materials. Each staff member was asked by surveyor to show what is worn for PPE (Personal Protective Equipment, gloves, mask, eye protection and gowns) in case of splatter or spray during the gross cleaning of these instruments. When staff showed surveyors where the PPE was located for the gross cleaning of the equipment the availability of the PPE was very inconsistent throughout the departments and many failed to have the proper PPE needed for this cleaning procedure. Some areas only had eye protection and gloves, others areas had gowns and gloves. All interview and observation were confirmed with Staff A (Registered Nurse outpatient manager) who was present for each finding while touring these out patient clinics.

Observation during tour with Staff A (Registered Nurse) on 12/12/17 and 12/13/17 revealed that three outpatient clinic glucometers had dark type substance that looked like smeared blood on the glucose meter surface where the test strips are inserted into the machine for patient blood sugar testing. These glucometers were on docking stations available for patient use. When these findings were identified staff were interviewed and questioned by surveyor on what type of cleaning solution should be used for the cleaning of the glucometers. All staff confirmed the "Purple top sani wipes" were used between patient use and when reviewing the label of the product it stated it was a "Bactericidal, Tuberculocidal, and Virucidal."In each instance the clinical staff knew the appropriate process and product but could not explain how the above mentioned glucose meters had not been cleaned.

In one instance interview with Staff E (Outpatient Surgical Center Manager) revealed that it was the OSC's practice to clean the glucometer after each use so that it was ready for use in the docking station.

Observation during tour of the urology department on 12/12/17 revealed that several cysto-nephro videoscopes were in a non temperature/humidity controlled cabinet, hanging from hooks with the distal ends of the scopes coiled up due to their lengths and resting on the bottom of the cabinet where two chucks (Protective sheets made from paper and vinyl) were placed. There was no documented evidence of temperature or humidity monitoring.

Review of the manufacturer's instruction under "Storage of the endoscope" (sections 5 & 6) revealed the following: "Hang the endoscope in the storage cabinet with the distal end hanging freely. Make sure that the insertion tube hangs vertically and as straight as possible." and "Store the instruments (including the endoscope) in a clean and dry condition at 10 - 40 C, 30 - 85% humidity."