HospitalInspections.org

Based on record review, medical staff bylaws review, and interview, the provider failed to ensure specific privileges had been approved for one of one physician assistant (PA) (E) and one of one certified nurse practitioner (CNP) (F). Findings include:

1. Review of PA E's credentialing file revealed:
*He had been reappointed to the medical staff on 10/26/18.
*His delineation of medical privileges desired had:
-A handwritten note of "As per PA-C SD Guidelines."
-No boxes had been selected for specific privileges.
*His 10/20/16 PA practice agreement delegation of tasks stated he could:
-"Function in the hospital setting by obtaining medical histories and performing physical examinations, making patient rounds, recording patient progress notes and other appropriate medical services, and issuing, transmitting and executing patient care orders as delegated by the supervising physician."
-Have patient admission and discharge.

2. Review of CNP F's credentialing file revealed:
*She had been reappointed to the medical staff on 11/1/18.
*Her delineation of medical privileges desired had:
-A handwritten note of "As per CNP SD Guidelines."
-No boxes had been selected for specific privileges.
*The CNP collaborative agreement had not listed any procedures she could have performed.

3. Review of the provider's May 2017 Medical Staff Bylaws revealed every medical professional was entitled to exercise specific clinical privileges granted by the governing board.

Interview on 7/10/19 at 11:12 a.m. with credentialing and human resources director G revealed:
*The PA practice agreement's delegation of tasks dictated PA E's privileges.
*The CNP collaborative agreement's delegation of tasks dictated CNP F's privileges.
*She agreed the CNP and PA delegation of tasks were general and not specific.
*The department staff would not have been aware what those privileges were.

Based on observation, interview, and policy review, the provider failed to ensure medications (med) had been properly monitored and secured to prevent unauthorized access to them in the following areas:
*One of one randomly observed soiled utility room located on the medical unit.
*Randomly observed sharps containers holding partially used meds in one of two emergency room (ER) bays (1 and 2), one of one procedure room, one of one outpatient nurses' station, and one of one outside storage area were handled by unauthorized staff (housekeeping and maintenance) when they were full.
Findings include:

1a. Observation and testing on 7/9/19 at 9:30 a.m. in the soiled utility room on the medical unit revealed:
*The room was unlocked and contained several cupboards and patient use items.
*In the back of the room was a standing weight scale with a large cardboard box on top of it.
-That box was opened, lined with a red biohazard garbage bag, and contained eight sharps containers.
-Those containers were filled with used needles, syringes, and med vials.

b. Observation on 7/9/19 at 9:35 a.m. of ER bays 1 and 2 revealed:
*Both of the rooms had:
-Large biohazard sharps containers sitting unsecured on top of a small red cart with wheels on it.
-Been opened to visitors, patients, and staff to wander in and out of them.
-Been located approximately 15 to 20 feet from the ER entrance and exit area.
*The sharps containers:
-Were approximately five gallons in size.
-Had large white lids attached to the top of them with a large opening on one end.
--Testing revealed a hand would slide through that opening.
-Had used needles, syringes, vials of meds, blood soiled bandages, and intravenous (IV) tubing in them.
*There had been two, 30 milliliter (ml) med vials inside of the sharps container in ER bay 1 with medication residual inside of them.

c. Observation on 7/9/19 at 9:50 a.m. of the procedure room revealed:
*The room was unlocked and contained several cupboards and multiple patient use items for procedures.
*On one of the shelves was an unsecured biohazard sharps container.
-The container had been partially filled with used needles, syringes, and med vials.

d. Observation and interview on 7/9/19 at 9:53 a.m. with registered nurses (A and B) at the nurse's station in the outpatient care area revealed:
*There had been a small sink located outside of the patient rooms.
*Underneath that sink was a large biohazard sharps container sitting unsecured on top of a small red cart with wheels on it.
*The sharps container:
-Was approximately five gallons in size.
-Was full of used syringes, needles, bandages, and med vials.
-Had a large lid on top of it with a large opening on one end of it.
--The back of the lid was unsecured and testing revealed a hand could slide through that opening.
*They:
-Confirmed the contents inside the sharps containers in the procedure room and outpatient area.
-Agreed they were unsecured and allowed easy access by visitors, staff, and patients.
-Confirmed there were sedating medications used for some of the procedures.
--Those vials were to have been disposed of in a special waste disposal unit located in the med room.
*Once the sharps containers were full the housekeeping staff and maintenance department were responsible for the removal of them.
*They were not sure what the housekeeping staff or maintenance department would have done with those containers.

Interview on 7/9/19 at 11:00 a.m. with the pharmacist regarding the unsecured biohazard sharps containers revealed:
*Meds should not have been disposed of in the red sharps containers.
-All vials containing meds should have been put into the designated med disposal containers she had available for them to use.
*She stated:
-"I'm only in charge of the black boxes not the red ones."
-"To be honest I don't know what they use those other containers for or what you are even talking about."
-"All narcotics should be wasted per protocol and technically those vials are considered empty anyway and could be just put in the garbage."
-"All the med vials should be put in the black boxes and just sharps in the others."
-"Maintenance is in charge of the other boxes not me."
-"I have no idea what they do with them."
*She confirmed:
-She was responsible for all the pharmaceuticals in the facility.
-The medical staff had access and the capability of using potassium, calcium, magnesium, Versed, epinephrine, and naloxone in all of those areas above.
-Those above medications were considered high risk meds with side effects that when not used properly could have created a negative outcome.
*She stated "I was not aware there were vials in those containers, there should not be."
*She stated:-The nurses were placing med vials in the red sharps containers, because they were expected to walk to the medication room to place them in the proper pharmaceutical boxes.
-It would have taken longer to place them in the pharmaceutical waste containers.

e. Observation and interview on 7/9/19 at 12:30 p.m. with the environmental services director revealed:
*When sharps containers were full they were placed in an opened cardboard box in the unsecured soiled utility room.
*When that cardboard box was full of sharps containers the housekeepers brought it to the outside shed.
*The environmental services director sealed the cardboard box with tape.
*There was a small storage shed located outside and in back of the facility.
*The shed had a garage type door on the front of it that was unlocked, was easily pushed up, and allowed access into the building.
-That door was locked only during the night.
*There was a designated staff smoking area located by the shed.
-Three staff members including the environmental service director had been outside smoking at the time of the above observation.
*There were six cardboard boxes taped shut and were ready for the biohazardous waste vendor to pick them up.
-Those boxes were full of biohazard sharps containers collected from multiple areas of the hospital.
-The housekeeping and maintenance staff had been responsible for collecting those containers.
*All staff had access to the shed and storage area for the sharps containers.
*He was not sure if there had been meds in those containers but confirmed they were not authorized personnel to handle meds.

f. Interview on 7/9/19 at 1:11 p.m. with the administrator regarding the above observations and interviews revealed she:
*Was unaware of the process they used for the security and access of the biohazard sharps containers.
*Agreed access to meds should have been limited to authorized staff only.
-Housekeeping and maintenance were not considered authorized staff.




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Review of the provider's July 2015 Pharmaceutical Waste policy revealed:
*"All departments where medications are prepared, dispensed, and administered must dispose of the pharmaceutical waste in the proper black box."
*Red sharps containers were to have been used for hazardous medical waste. -"Do not use for ANY pharmaceutical waste."
*All departments were to have managed pharmaceutical waste by disposing it in the appropriate color coded containers.
*"Items such as partial tablets and vials that do not have 'reasonable expectation for credit' will be disposed of in the proper receptacle."
*"Dispose of compatible pharmaceuticals and non-regulated pharmaceutical waste in specifically labeled black waste containers."*"The Pharmacy Director will establish mechanisms for identifying and characterizing medications that require special handling for disposal, as well as developing mechanisms to ensure proper disposal of these medications by staff. The mechanisms may include reminders on labels, medication administration records, and listing on 'trash' receptacles as to what should be discarded in it."

Based on interview and policy review, the provider failed to ensure infection control procedures had been followed for:
*Disinfecting the procedure room floor after colonoscopy procedures.
*Using personal protective equipment (head covers and masks) during colonoscopy procedures.
Findings include:

1. Interview on 7/9/19 at 2:00 p.m. with registered nurse (RN) A revealed colonoscopy procedures were performed in the procedure room twice weekly.

Interview with housekeeper C regarding disinfection of the procedure room after each colonoscopy revealed:
*The nurses:
-Removed and cleaned all the machines and utensils.
-Removed linens and sent them to the laundry.
-Disinfected the procedure table.
*The housekeeper entered the procedure room once daily at the end of the day to clean the floor.
*The nurse could call the housekeeper to disinfect the floor if she wanted to.
*Most of the time it was done just at the end of the day.

Interview on 7/10/19 at 1:50 p.m. with the director of nursing regarding the colonoscopy procedures revealed:
*The procedure room floor should have been disinfected after each patient procedure.
*Nurses personal protection equipment (PPE) during the colonoscopy procedure had included gowns, gloves, and shoe protectors.
-The staff had not been using head coverings or masks.
-The staff could use the head and mask PPE if it was necessary.

Review of the provider's November 2018 Colonoscopy policy revealed:*The procedure was attended by two nurses and one colonoscopy tech.
*The policy had not specified:
-What PPE was to have been used.
-How the room was to have been cleaned after the procedure.

Review of the provider's June 2018 Housekeeping/Environmental Services policy revealed:
*The purpose was to maintain a clean environment for patients and minimize the risk of patient and healthcare personnel exposure to potentially infection microorganisms.
*For cleaning procedure rooms the housekeeper was to have followed the hospital terminal cleaning process in between patients with the exception of the pain clinic.
*The hospital terminal room cleaning included:
-Moving from the door of the room and systematically cleaning the room.
-Ending the terminal cleaning of the room by washing the floor.

Review of Amber Wood et. al, Guidelines for Perioperative Practice, 2019 Ed., AORN, Denver, CO., revealed in regard to flexible endoscopes:
*Page 209:
-II.d.: "Clean surgical attire and head coverings should be worn in the processing room and procedure rooms of the endoscopy suite. Surgical attire is worn to provide a high level of cleanliness and hygiene within the endoscopy environment and to promote patient and worker safety."
-II.e.: "Personnel working in the endoscopy suite must wear PPE. It is a regulatory requirement that PPE be worn whenever splashes, spray, spatter, or droplets of blood, body fluids, or other potentially infectious materials may be generated and eye, nose or mouth contamination can be reasonably anticipated."
-II.e1: Personal protective equipment should be worn in accordance with the AORN Guideline for Prevention of Transmissible infections, the AORN Guideline for Surgical Attire, and the AORN Guideline for Cleaning and Care of Surgical Instruments."

Based on record review, interview, and policy review, the provider failed to ensure the medical records were complete to ensure:
*Interventions for discharge planning had been put in place for 3 of 15 patients' (16, 18, and 19) care plans.
*Concerns of chronic pain management and a history of clostridium difficile (C. Diff) for 1 of 1 sampled patient's (4) care plan.
Findings include:

1a. Review of patients 16, 18, and 19's care plans revealed:
*A focus area for discharge plan of care had been identified for all three of them.
*There had been three interventions underneath of that focus area:
-"All admission outcomes and interventions."
-"Identify discharge needs."
-"Specify and order needed equipment."
*All of the above interventions had been documented as met upon discharge from the facility.
*There was no documentation to support what individualized interventions each of those three patients had required:
-To work on during their stay at the facility.
-To have in place prior to discharge from the facility.
-To ensure a successful and safe discharge from the facility had occurred.

Interview on 7/10/19 at 4:00 p.m. with the director of nursing regarding the above patients' medical record reviews revealed she:
*Confirmed the discharge planning should have:
-Supported individualized interventions for all three of those patients.
-Had documented interventions in place to ensure a successful and safe discharge from the facility had occurred.




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b. Interview on 7/8/19 at 4:15 p.m. with patient 4 revealed she:*Was admitted on 7/8/19 after a fall.
*Had a urinary tract infection (UTI).
*Had started IV antibiotics for the UTI.
*Worried she would get a C. diff (clostridium difficile) infection.
*Had a history of getting C. diff after receiving IV antibiotics.
*Had chronic back and neck pain and required frequent pain medication to relieve the pain.

Interview on 7/9/19 at 10:00 a.m. with registered nurse (RN) D confirmed patient 4 had a history of:
*C. diff.
*Chronic back pain.

Review of patient 4's 7/8/19 care plan revealed:
*Three problem areas:-Discharge Plan of Care.
-Risk of injury related to her fall.
-Risk of infection related to her UTI.
*Pain had not been identified as a problem.
*Her history of C. diff had not been identified as a concern.

Interview on 7/10/19 at 4:20 p.m. with the quality control coordinator regarding patient 4's care plan confirmed the care plan should have addressed her pain and history of C. diff.

Review of the provider's revised April 2019 Care Plans policy revealed:
*Care plans were to have been initiated on admission after a nursing assessment was completed and discussion with the patient.*"A minimum of two care plans in addition to the discharge care plan will be initiated upon admission of all acute, observation, and swing bed patients by admitting nurse."
*All care plans were to have been reviewed each shift and documentation was to have been completed.
*"Review all care plans including outcomes and interventions."
*Care plans were to have been developed, implemented, and revised to meet the patient's psychological and medical needs.
*"Interventions will need to be addressed as done or not done."
*If an intervention had not been done the nurse was to have selected not done and given the reason it was not done.
*"Care plans will be completed when patient is able to meet all outcomes and all interventions are done or at time of discharge."