HospitalInspections.org

Based on review of quality assurance information and staff interview the Hospital failed to evaluate services provided by agreement or by arrangement as part of the overall quality improvement program. This had the potential to affect all patients receiving care from the hospital.

The findings include: The Hospital did not routinely evaluate all patient care services. The Quality Assurance (QA) Manager was interviewed on 12/16/10 at 9:00 a.m. He confirmed that not all contracted services had been evaluated as a part of the hospital's quality assurance program.

Quality of contracted services was not routinely evaluated with results reported to the governing body. QA was lacking for contracted services including: pest control, waste /recycling management-including hazardous waste removal, blood services, organ procurement, and Health East transportation.

Based on interview and record review, the Hospital failed to ensure that the governing body received reports evaluating provision of care for services provided by arrangement or agreement. This had the potential to affect all patients receiving care from the hospital.

The findings include: The Hospital failed to ensure that all services affecting patient care were evaluated with findings reported to the governing body. The Quality Assurance (QA) Manager was interviewed on 12/16/10 at 9:00 a.m. He confirmed that contracted services had not all been evaluated as a part of the hospital's quality assurance program.

Quality of contracted services was not routinely evaluated for all contracted services directly affecting patient care. QA was lacking for contracted services including: pest control, waste /recycling management-including hazardous waste removal, blood services, organ procurement, and Health East transportation.

Based on record review, policy review and staff interview, the hospital failed to document the status of the alcohol-based skin preparation prior to initiation of surgical procedures for 6 of 8 surgical patients whose records were reviewed (S1, S2, S3, S4, S5 and S6).

Findings include: The status (dryness) of the alcohol based skin preparations utilized for surgical procedures had not been documented in six (6) surgical records (S1, S2, S3, S4, S5 and S6) reviewed.

It was noted during record review on 12/14/10 that the alcohol-based skin preparations Duraprep and Chloraprep had been routinely used for surgical procedures. Documentation was lacking in records S1, S2, S3, S4, S5 and S6 to verify these alcohol-based skin preps had been dry prior to initiating the identified surgical procedures:

S1 had chloraprep solution documented as the operating room (OR) skin prep for the parathyroidectomy performed on 12/9/10.

S2 had Duraprep solution used for the appendicitis performed on 12/9/10.

S3 had a sigmoid resection performed on 12/9/10 with the utilization of the skin prep solution Duraprep.

S4, had a splenectomy performed on 12/10/10 and the prep solution utilized had been Chloraprep.

S5, who had coronary bypass surgery on 12/10/10 had Duraprep used as the alcohol based skin preparation solution.

S6, had Chloraprep used as the alcohol based skin preparation solution for a temporal craniotomy performed on 12/10/10.

Upon interview with the Quality/Safety/Compliance Manager for surgery at 10:30 a.m. on 12/14/10, she verified the required documentation was missing in the identified records. She indicated the OR (operating room) documentation in the electronic record had a section under "preparation" for staff to identify '"yes/no" when alcohol based skin preps had been used and should have included the following: "(1) Manufacturer instructions for use were followed: y/n;(2) Patient hair and linen are free of alcohol based skin preparations: y/n; (3) Alcohol based skin prep was completely dry prior to draping: y/n; (4) all of the above steps have been verified prior to initiating surgical procedures: y/n; and (5) Area prepped." The Quality/Safety/Compliance Manager further indicated it had been a standard of practice to document the status of the prep prior to initiation of the surgical procedure and stated she was puzzled by the lack of such documentation in the records identified (S1, S2, S3, S4, S5 and S6). Upon further investigation by this Manager it was stated on 12/15/10 at 4:30 p.m. that the electronic documentation system 'Epic' had been "upgraded" recently and the required documentation had erroneously disappeared. It was indicated the hospital OR averaged 50 surgical procedures daily. The missing documentation had not been reported and/or communicated to management and they had been unaware of the problem until it had been identified by the surveyor.

It was noted during record review at the Same Day Surgery (SDS) unit that the required documentation was evident during record review and not missing. Interview with the SDS nurse manager at 9:30 a.m. on 12/16/10 confirmed the upgrade had not affected the electronic 'Epic' system at the SDS. It was indicated they performed an average of 30-40 procedures daily at the SDS.

According to hospital policy RH-SP-SS02-60 dated June 2010, ChloraPrep: a solution of 2% chlorhexidine gluconate (CHG) and 70% isopropyl alcohol and DuraPrep: a solution of 0.7% Iodophor and 74% isopropyl alcohol can be used as an antiseptic skin cleanser preoperatively. Policy further stated "Surgical prep solutions will be allowed to dry completely and dissipate prior to draping the patient or utilizing the laser or electrosurgical device; and the skin condition of the surgical site will be assessed before the preoperative skin prep and documented in the patient's medical record." The procedure (H) Fire Risk Reduction Measures for Alcohol-Based Preparations identified the following: (a.) The use of an alcohol-based skin preparation in anesthetizing locations is not considered safe, unless appropriate fire risk-reduction measure are taken. Prep solutions containing alcohol give off flammable vapors. (b.) Follow the appropriate risk-reduction measures listed below: read and follow manufacturer's written instructions for use, Use appropriate-sized skin preparation solutions packaged to ensure controlled delivery to the patient in unit dose applicators, Ensure alcohol based skin prep solution does not soak into the patient's hair or linen. Sterile towels should be placed to absorb drips and runs during application and should be removed prior to draping, Verify that all of the above has occurred prior to initiating the surgical procedure (c.) Flammable skin prep solutions should not be heated.

Interview with the Quality/Safety/Compliance Manager and the SDS Nurse Manager at 11:30 a.m. on 12/16/10, confirmed the required OR documentation had been restored in the 'Epic' system however, they also indicated they should have been able to identify loss of such information in a more timely manner by communication with staff.

Based on observation, and interview, the hospital failed to maintain freezer equipment in the kitchen in proper working condition. This had the potential to affect any patients receiving meal service from the kitchen. Findings included:

The hospital's main walk in freezer had ice build up around the door and in the back by the cooling unit, in addition, a free standing freezer (#28) was noted to have excessive ice build up.

The tour of the kitchen was conducted at 9:00 a.m. on 12/14/10. During the tour it was observed that the main freezer was noted to have ice build up around the plastic curtain as you entered the freezer. In the back of the large freezer there was condensate on the ceiling around the cooling unit, ice build up on the piping coming off the unit, and icicles hanging down from the unit onto boxes of hamburger buns. A free standing freezer (#28) which contained baking products, had excessive ice build up around the door seal and icicles hanging down on boxes of food in the back of the freezer.

When interviewed during the tour, the Director of Food Service agreed there was a problem with the freezers.

Based on observation, interview, and record review, the hospital failed to ensure infection control policies were developed, and practices implemented, to promote sanitary conditions for 1 of 1 patient observed during wound care (P1), to ensure sanitary conditions were maintained for patients who used shared equipment, and to ensure a sanitary dietary environment. In addition, these practices had the potential to affect all patients who required blood glucose testing with a glucometer and any patient who received their meals from the kitchen. Findings include:

Appropriate infection control precautions were not followed related to glove changing and handwashing, cleaning of shared blood gluose testing equipment, and maintenance of sanitary conditions in the dietary department.

:


20012

Appropriate infection control practices related to glove changing and handwashing were not implemented during care for patient (P1).

P1 had been admitted to the hospital on 12/13/10 with diagnoses that included: chest pain and open areas on the buttocks.

At 9:05 a.m. on 12/14/10, RN (registered nurse)-A was observed to assess a wound and to provide incontinence care for P1. RN-A washed her hands and put on gloves prior to assiting P1 to her right side. RN-A opened P1's incontinence brief and tucked it under P1's right hip. RN-A then pressed her gloved fingers around an open areas on P1 buttocks. RN-A indicated at that time that P1's incontinence brief was wet and should be changed. Without changing her gloves, RN-A went across the room, opened a plastic bag of briefs, picked up a package of wipes, and returned to the bedside with the items. RN-A then went to P1's bedside stand and picked up a spray bottle of peri-wash and a tube of cream and brought them to the bedside. RN-A completed peri-cares for the patient who had been incontinent of urine and applied a new incontinence brief before covering P1 with a sheet. RN-A wore the same gloves during the assessment of the wound and provision of incontinence care. She touched several items in the patient's environment with the soiled gloves on.

At 9:17 a.m. on 12/14/10, RN-A was interviewed and verified she should have changed her gloves prior to handling the incontinence supplies.

On 12/15/10 at 2:00 p.m. the Director of Nursing for the Medical-Surgical Unit was interviewed and indicated that it would have been expected that RN-A change her soiled gloves before proceeding with incontinence care.

On 12/15/10 at approximately 2:45 p.m. an infection control manager (RN-C) verified staff should wash or use sanitizer gel between glove use.

The hospital failed to ensure that multi-use glucometers were effectively disinfected between patient use.

During a tour of the hospital's cardiac rehab offsite location at 11:15 a.m. on 12/14/10, a glucometer (portable glucose testing device) was observed on the counter of the desk. RN-H was interviewed at that time and stated that the glucometer was used to test patients' blood sugars before and after their exercise as directed by their physicians. The RN stated that they had two machines available and checked blood sugars approxiamately 10 times a day. When questioned about the disinfection of the machine, the RN stated she wiped the glucometer off with an alcohol wipe between residents.


19200

On 12/15/10 at 8:10 a.m. RN-E was observed administering medications and performing a glucometer check for P4. RN-E utilized the universal glucometer from their unit. She took the glucometer into the patient's room, wiped it down with alcohol swabs, obtained the blood sample and placed the glucometer on the patient's bed. After leaving the patient's room, the glucometer was again wiped down with alcohol prior to putting it back into the base unit for use for other patients. The RN-E stated the PCA (personal care attendants) are the people who usually do the blood sugars so they would normally be responsible for the cleaning of the units.

On 12/15/10 at 8:15 a.m., PCA-F and PCA-G were interviewed about the disinfecting of glucometers between patients. PCA-F stated the glucometers were wiped down with cavi wipes in between patients. However, PCA-G stated cavi wipes destroy the machine so they should be wiping down the machines with alcohol swabs.

During interview at 3:10 p.m. on 12/15/10, RN-C (infection control nurse) was interviewed about the use of glucometers. RN-C stated staff were to supposed to use Cavi- Wipes (a disinfectant wipe) to disinfect the glucometers between patient use. RN-C further indicated that she had spoken to the manufacturer of their glucometers and that Cavi-Wipes were the recommended product.

The facility's Accu-Check Inform Glucose Meter Procedure last revised 3/01/10, directed staff to "...Clean meter with one alcohol wipe between each patient test and when placed in the docking station."

The PCU Enviromental Disinfection Checklist dated 2010, directed staff to disinfect the Accu-checks with a damp Cavi-wipe when shared between patients.

During review of employee files on 12/16/10 in the morning, a competency checklist for fingerstick blood glucose testing was found in several employees' files. It was determined from the employee reviews, that as recently as 6/10/10, staff were being competency evaluated in the following procedure: ..."Wipe Accuchek Inform (glucometer) meter with 1 alcohol wipe between each patient test and when placed in the docking station."

The hospital failed to maintain infection control standards in the dietary department.

The kitchen tour was conducted on 12/15/10 at 9:00 a.m. and the following issues were identified: There were no thermometers in refrigerator #3 and #5. There were also no thermometers in the baked goods refrigerator, in the walk-in produce refrigerator or in the box lunch refrigerator.

The hospital policy and procedure for Food Storage and Temperature Control, last reviewed 9/08, included: "Thermometers are placed in all refrigerators and freezers where they can be easily seen for checking and documenting on the Temperature Control Log. Temperatures are documented daily." Temperature logs were requested at the time of the tour, but were not available.

At 9:15 a.m. on 12/15/10 during the dietary tour, seven large mixing bowls were observed to have been stored wet. The bottoms of the bowls were wet, with up to an inch of standing water in the bottom. Utensil bins and baking pans were observed to be stained with a white substance on the bottom. The Director of Food and Nutrition services, present during the tour, stated these were hard water stains. It was further stated the pans had obviously been put away wet as the white substance was hard on the bottom of the pans. The Director of Food and Nutrition verified that the practice of storing pans wet was unacceptable.

The following food storage/preparation areas were observed to be unclean with dried on food stains and/or debris:
Eighteen (18) muffin tins that had been used just that morning were heavily stained with thick black debris and were very rusted; the mixing bowl rack and utensil drawers were soiled; the shelves on the carts in the walk-in freezer, in #26 refrigerator, and in #28 small freezer; the shelves in the food prep area were soiled with food debris and black grease stains; two grills were heavily soiled in the front and around the knobs; six Vulcan ovens were very heavily soiled throughout the inside with a build up of black grease;

Meat was not observed to be stored/thawed in an appropriate manner.

Eighty (80) lbs of hamburger, in 5 lb packages, was observed to be stored on a shelf in the cooler on one inch deep trays. Below the hamburger were 3 boxes (one opened) of ready to eat barbecued pork. There was visible bloody juices under the hamburger and there were some droplets of bloody appearing juices on the floor in front of the cart. There was no visible bloody juices on the boxes of pork. At the time of the observation, the Director of Food Services stated the pork should not have been placed under the thawing hamburger.

The hospital's dietary department policy, Cleaning Schedules last reviewed 9/08, included, "...Surfaces of equipment must be thoroughly cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris...All assigned cleaning will be reviewed by a supervisor upon completion to determine if requirements are met...."

The hospital policy for Infection Control, Sanitation, Food borne Illness, Temperatures, revised 5/08, included: ..."Quality assurance duties covering specific instructions on hand washing, equipment maintenance, sanitation and food handling are enforced at all times...All carts will be sanitized with quaternary ammonium compound once a day or more often if there are spills...Food carts, cabinet and counter areas, equipment surfaces, and table tops are sanitized with quaternary solution...."

Cleaning schedules were requested during the tour, any of the daily and weekly assignments had not been completed as they should have been and some cleaning schedules had not even been established. There was no indication the schedules had been reviewed by the supervisors.

During interview with the Director of Food and Nutrition services on 12/15/10 at 10:30 a.m., the director agreed with the above observed findings, and acknowledged the cleaning schedules had not been completed as they should have been. In addition, the director said the supervisors had identified many of these areas as needing improvement when they did their ongoing audits.