HospitalInspections.org

Based on Medical record review, staff interview and document review the hospital failed to assure all clinic records contained a discharge summary including the outcome of the hospitalization, disposition of care and any follow up care planned in 1 of 30 records reviewed (Patient #23). This deficient practice had the potential for ineffective discharge planning.

Findings include:

- Patient #23's medical record review on 1/10/2017 revealed an admission date of 9/27/2016 with discharge date of 9/28/2016 lacked evidence of a discharge summary in the medical record.

Physician Staff A interviewed on 1/11/2017 at 9:50 AM acknowledged that Patient #23's medical record did not have a discharge summary.

Untitled document reviewed on 1/11/2017 at 12:30 dictated: "...4. DISCHARGE NOTE, A discharge summary containing at a minimum the outcome of the hospitalization, disposition of the care, and provisions for follow-up care must be dictated for hospital stays longer than 48 hours (hrs). For inpatient hospital stays shorter than 48 hrs a written discharge not containing the outcome of hospitalization, disposition of the case and provisions for follow-up care is placed in the medical record by the discharging physician ..."

Administrative Staff C interviewed on 1/11/2017 at 1:00 PM acknowledged the untitled document was obtained from the Medical Staff Rules and Regulations.

Based on observation, staff interview, and policy review the facility failed to ensure all expired and non-useable medications were removed from patient care areas and unavailable for patient use. This failure had the potential to expose patients to ineffective medications that could cause a worsening of condition.

Findings include:

- Malignant Hyperthermia Cart observed on 1/9/2017 at 4:00 PM revealed the following expired medications:

1. One vial Furosemide (a medication used to treat fluid buildup within the body) 20milligrams with an expiration date of 12/1/2016.
2. One vial Lidocaine (a medication used to numb the skin) 20 milligrams with an expiration date of 9/1/2016.

Pharmacy Staff I interviewed on 1/9/2016 at 4:00 PM confirmed the expired medications and indicated they will have to educate staff on the importance of keeping all medications to the drawer they are assigned to. Staff I stated, "Those medications should not have been in the second and third drawers. All medications should have been in the top drawer."

- Medical Surgical Unit nurses station Omni cell supply drawers observed on 1/9/2017 at 12:00 PM revealed one 1,000 milliliter bag of Sodium Chloride (a medication used to replace fluid in the body) with an expiration date of 9/1/2016.

Pharmacy Staff I interviewed on 1/9/2016 at 12:05 PM indicated the Omni Cell machine requires them to put the expiration dates into the system when they are replacing inventory and they are unaware why the system did not identify the Sodium Chloride as expired. Staff I reported they run a monthly inventory report.

- Emergency Supply Cart located on the Medical Surgical unit observed on 1/9/2016 at 11:20 AM revealed two bags of Sodium Chloride (a medication used to replace fluid in the body) 250 milliliters (ml) with an expiration date of 12/2016.

Policy titled Disposal of Expired, damaged, contaminated and recalled drugs reviewed on 1/11/2016 at 11:15 AM directed "... Expired, damaged, recalled and contaminated medications are considered unusable and must be removed from circulation ..."

Based on staff interview and policy review the hospital failed to develop policies and procedures directing hospital staff on the appropriate actions to take when they have been notified of receiving potentially infectious blood and blood components. The deficient practice to develop policies and procedures for potentially infectious Blood and Blood components placed all patients at risk for inadequate notification and care following post exposure to potentially infectious blood or blood products.

Findings include:

Physician Staff A interviewed on 1/11/2017 at 12:15 acknowledged the hospital would follow procedures that are in place for any incident if there was a potentially infectious blood transfusion. Lab Corp who provides the blood and blood products would be responsible. The facility did not produce a policy/procedure addressing Potentially Infectious Blood and Blood Components prior to the survey exit.

Blood banking policies, transfusion policies and Infection Prevention and Control Plan 2016 reviewed on 1/11/2017 at 4:30 PM failed to address potentially infectious blood and blood products.

Minimally Invasive Surgery Center and Lab Corp agreement reviewed on 1/11/2017 and states Lab Corp would "... lab agrees to notify the hospital, according to FDA requirements in the event that a blood donor subsequently tests repeatedly reactive for infectious agents..."

Based on observation, interview and policy review the hospital failed to ensure outdated sterile medical supplies were removed from patient use in 1 of 3 Emergency Crash carts, 1 of 1 Medical Surgical nurse's station and 1 of 1 Malignant Hyperthermia (a life threatening condition triggered by exposure to certain drugs used for general anesthesia) supply cart. This deficient practice or failure of the facility not to dispose expired sterile supplies placed all patients at risk for receiving ineffective supplies.

Findings include:

- Emergency Crash cart observed on 1/9/2017 at 11:20 PM revealed two Suction Connection tubes with expiration dates of 6/2007 and 11/2007 and four Tongue Depressors with an expiration date of 9/2007.

Administrative Staff C interviewed on 1/9/2017 at 11:30 acknowledged the expired Suction Connection tubes and Tongue Depressors.

- Medical Surgical Area nurse's station observed on 1/9/2017 at 12:00 PM revealed six roll on anti-perspiration bottles with an expiration date of 9/2017.

Administrative Staff C interviewed on 1/9/2017 at 12:00 PM acknowledged the expired anti-perspiration bottles.

- Malignant Hyperthermia supply cart observed on 1/9/2017 at 4:00 PM revealed one Foley Catheter trey (a medical device used to remove urine from the bladder) with an expiration date of 4/2014.

Policy titled Management of Sterile Supplies reviewed on 1/11/2016 at 11:10 AM directed: "...d. Any damaged, opened, wet/moist, or non-sterile (indicator color change) supplies are removed and disposed ..." and "...7. Sterile equipment/supplies will be rotated whenever restocking takes place. To assure the supplies are used in a timely manner, rotation should be first in, first out ..."

Based on observation, staff interview, and document review the facility failed to ensure staff cleaned the rubber septum of medication vials prior to piercing them with a needle to withdraw medication during two of two observations (Staff D) and failed to ensure staff wore their surgical mask properly during four random observations (Staff A, E, and F) . The facility failed to ensure single use sterile items were not available for patient use in four of eight patient rooms (Room #'s 103, 104 and ICU Rooms 1 and 2), failed to ensure sharps containers were replaced when items reached the Full Line at two of two nurses stations. The facility failed to maintain a sanitary environment by failing to require housekeeping staff to use acceptable practices for disinfecting environmental surfaces in one of one observed terminal cleaning in the procedure room (Housekeeping Staff N) and failed to ensure all surfaces were cleanable in one of one procedure rooms and one of two Operating Rooms (OR # 2). These deficient practices have the potential to expose patients to bacteria and/or infectious diseases.

Findings include:

- Certified Registered Nurse Anesthetist Staff D observed on 1/10/2017 between 12:30 PM and 1:30 PM revealed Staff D failed to wipe the rubber septum of two observed medication vials prior to puncturing each and withdrawing medications.

- Certified Registered Nurse Anesthetist Staff D observed on 1/10/2017 between 3:15 PM and 4:00 PM revealed Staff D failed to wipe the rubber septum of five medication vials prior to puncturing each and withdrawing medications.

Physician Staff A interviewed on 1/11/2017 at 9:45 AM confirmed staff are expected to wipe the rubber septum prior to puncturing and withdrawing medications and revealed it is in the facility's policy.

Policy titled Medication Administration reviewed on 1/11/2017 at 11:15 AM directed "...All medication vial tops, puncture/access tops are disinfected prior to access. Alcohol prep swabs are sufficient ..."

- Unidentified Staff F observed on 1/9/2017 at 10:30 AM walking through the Hospital waiting area with a mask dangling around their neck.

- Physician Staff A observed on 1/10/2017 at 11:10 AM revealed Staff A in the pre-operative area with a surgical mask dangling around their neck.

- Physician Staff A observed on 1/10/2017 at 11:30 AM in the lobby of the hospital with their surgical mask hanging around their neck under the chin talking to family members.

- Surgical Tech Staff E observed on 1/10/2017 at 4:30 PM with their surgical mask hanging around their neck under the chin as they walked between the hall and sterilization room in the surgical area and raised the same mask to cover their nose and mouth when opening the surgical suite door.

Physician Staff A interviewed on 1/11/2017 at 9:45 AM confirmed staff are required to remove facemasks completely and change between patients.

Policy titled Dress Code, Restricted area reviewed on 1/11/2017 at 11:15 AM directed "...A mask is to be worn only in the operating room that has opened sterile supplies and during a sterile procedure. The mask is removed when not in the OR and/or procedure ..."

- AORN 2012 at VI.b. Reads: "A fresh clean surgical mask should be worn for every procedure."

- AORN 2012 at VI.b.1 Reads: "Masks should not be worn hanging down from the neck. The filter portion of a surgical mask harbors bacteria collected from the nasopharyngeal airway. The contaminated mask may cross-contaminate the surgical attire top."

- AORN 2012 at VI.c. Reads: "Surgical masks should be discarded after each procedure."


- Room #103 observed on 1/9/2017 at 11:05 AM revealed an open Yankauer suction tip (a device used to remove secretions from the mouth) connected to suction tubing.

- Room #104 observed on 1/9/2017 at 11:00 AM revealed and open Yankauer suction tip (a device used to remove secretions from the mouth) connected to suction tubing.

- Intensive Care Unit Room #1 observed on 1/9/2017 at 11:55 AM revealed and open Yankauer suction tip (a device used to remove secretions from the mouth) connected to suction tubing.

- Intensive Care Unit Room #2 observed on 1/9/2017 at 11:50 AM revealed and open Yankauer suction tip (a device used to remove secretions from the mouth) connected to suction tubing.

Physician Staff B interviewed on 1/11/2017 at 9:15 AM indicated staff keep the Yankauer suction tips open and connected so if there is an emergent need they do not need to spend time opening the packaging.


Policy titled "Management of Sterile Supplies "reviewed on 1/11/2016 at 11:15 AM directed "...Any damaged, opened, wet/moist, or non-sterile (indicator color change) supplies are removed and disposed or reprocessed ..."


- Medical Surgical Unit nurse's station observed on 1/9/2017 at 11:35 AM revealed a sharps container with items above the "Full" line.

- Pre-operative Unit nurse's station observed on 1/10/2017 at 10:25 AM revealed a sharps container with items above the "Full" line.

Director of Nursing Staff G Observed on 1/10/2017 at 11:00 AM instructing Registered Nurse Staff H how to replace the sharps container. Staff G stated, "It's important to make sure to check them and get them changed out if they are at the full line"

Physician Staff A interviewed on 1/11/2016 at 9:45 AM confirmed sharps containers must be replaced when they are at the Full line. Staff A indicated they have several staff members assigned to this task.

Policy titled Sharps, exposure control reviewed on 1/10/2017 at 11:15 AM directed " ...Consideration for sharps box removal should start when it is ¾ full below the full marked line. When line is reached they must be removed and replaced with a new empty sharps box ..."


- Terminal cleaning observed on 1/11/2017 at 12:00 PM revealed Staff N performing a terminal cleaning in the procedure room. Staff mopped the floor with a single mop head reintroducing the mop into the bucket of cleaning solution multiple times.

Director of Nursing Staff G interviewed on 1/11/2017 at 3:35 PM revealed they were not aware the mop heads must not be reintroduced into the cleaning solution.

According to the 2015 Edition of Guidelines for Perioperative Practice, Association of Perioperative Registered Nurses: "I.e.3. Used cleaning materials (e.g., mop heads, cloths) should not be returned to the cleaning solutions container. Used cleaning materials are considered contaminated and returning them to the cleaning solution container contaminates the solution. VI.b.2. Cleaning should progress from top to bottom areas. During cleaning of top areas, dust, debris, and contaminated cleaning solutions may contaminate bottom areas. If bottom areas are cleaned first, these areas could potentially be re-contaminated with debris from the top areas."

- Procedure room observed on 1/11/2017 at 12:00 PM revealed the operating table contained a pad with a tear at the head of the pad with tape covering it and one rolling chair had a tear in the seat cushion leaving these surfaces non-cleanable.
- Operating Room #1 observed on 1/10/2017 at 1:30 PM revealed a piece of paper taped to the wall leaving the surface non-cleanable.

Physician Staff B interviewed on 1/11/2017 at 9:45 AM revealed they were not aware of the paper taped to the wall and indicated they require papers mounted in the OR to be in plastic.