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Based on observation, interview and record review the hospital failed to ensure medications were kept in a locked storage area in the one of one treatment rooms in the emergency department.

Findings include:

Record review of a policy titled " Pharmacy Inspections " dated April 2015 stated " Purpose: To provide a policy and procedure which ensures that all areas in this facility where pharmaceuticals are stored and inspected at least quarterly. Procedure: 3.) These inspections will ensure that all drugs are properly stored according to the United States Pharmacopeia or National Formulary ... "

Observation 6/8/15 at 9:30 a.m. during initial tour revealed a metal wall mounted cabinet in the emergency treatment room with medications inside the cabinet. The cabinet did not have a lock. Medications included: Lidocaine (a numbing medication) 1% / 5ml (millimeter); Epinephrine (Treats severe allergic reactions (including anaphylaxis) in an emergency situation) 1mg (milligram) / 1ml x five ampules; Dexamethasone (corticosteroid that prevents the release of substances in the body that cause inflammation) 1ml ampule x 2; Adrenaline (Treats severe allergic reactions (including anaphylaxis) in an emergency situation)1mg / 1ml; Benadryl 50mg / ml; Naloxone (helps to reverse the effects of certain types of medicines) 1ml ampules x 2; Lasix (a water pill) 4ml x 2 vials; Heparin (helps to prevent blood clots) 1ml vials x 6.

Interview with the Director of Nursing (ID# 1) 6/8/15 at 9:30 a.m. revealed the cabinets had been recently painted and the locks were removed to paint.

Telephone interview 6/9/15 at 9:50 a.m. with the Pharmacist (ID# 20) revealed that the public should not have access to medications in the emergency department.

Based on observation, interview and record review the hospital failed to ensure they had a system for identifying, investigating, and controlling infections and communicable diseases in patients in that: they failed to ensure clean endoscopy scopes were not stored in the decontamination room per their policy for two of two scopes [one endoscope {a device with a light attached that is used to look inside a body cavity or organ] and one colonoscope [flexible, lighted instrument used to view the inside of the colon]); the hospital failed to ensure biological indicators used to monitor the sterilization process had matching lot numbers per the manufacturer's guidelines in one of one autoclave room observed; and the hospital's Physical Therapy department failed to monitor the safety and cleanliness of their equipment in that the Paraffin Terabit (hot wax) and the Hydrocollator (hot packs) had no cleaning logs.


Findings include:

- Record review of a policy titled " Endoscope, cleaning, high level Disinfection, and Storage " dated July 2014 stated " Policy: To prevent cross contamination of patients when using gastroscope ...Storage: Ensure that the endoscope is hung securely with the insertion tube and light cable hanging freely in a vented storage cabinet. "

Observation 6/8/15 at 9:15 a.m. during initial tour of the surgical decontamination room revealed two clean endoscopes hanging on a rack on the wall. (One endoscope and one colon-scope) The scopes were draped with a surgical gown.

Interview with the Director of Nursing (ID# 1) 6/8/15 at 9:15 a.m. revealed the scopes have always been stored in the decontamination room. The Director stated the scopes are re-cleaned prior to a procedure.


- Record review of the Brochure for the Attest Pack stated " The Attest Pack is specifically designed to routinely challenge the steam sterilization process ...Directions for Use: 13.) The positive control indicator should be from the same manufacturing date and lot number as the processed biological indicator ... "

Observation 6/8/15 at 10:15 a.m. during initial tour in the autoclave room revealed two biological indicators incubating. The positive control lot number was " 2015-08DF. " The processed indicator ' s lot number was " 2015-09DF. "

Interview 6/8/15 at 10:15 a.m. with the Director of Nursing (ID# 1) revealed she was not aware the lot numbers of the control and processed indicator had to be from the same lot number.

- Record review of a policy dated April 2015 titled " Cleaning Procedure for Hydrotherapy and Infection Control " stated " Hydrocollator machines will be cleaned monthly with mild soap and water ... " A form titled " Physical Therapy Infection Control Procedures " (no date) stated " Department and Equipment Cleaning: 11.) Water in Hydrocollator is changed as needed to maintain cleanliness. 12.) Paraffin is changed as needed to maintain a clean bath. "

Observation 6/8/15 at 10 a.m. during initial tour in the Physical Therapy department revealed a Paraffin Terabit (hot wax) machine with dark brown sediment in the bottom of the warm wax. The Paraffin Terabit did not have a cleaning log. The Hydrocollator machine with hot packs did not have a cleaning log.

Interview 6/8/15 at 10 a.m. with the Physical Therapist (ID# 19) revealed he changes the wax in the Paraffin Terabit and the water in Hydrocollator when it appears dirty. The Physical Therapist acknowledged he did not keep cleaning logs for these machines.

Based on observation, interview and record review the annual Quality Assurance program evaluation failed:

1) Failed to monitor the safety / cleanliness of Physical Therapy equipment. The Paraffin Therabath (hot wax) and the Hydrocollator (hot packs) had no cleaning logs.

2) Failed to ensure clean endoscopy scopes were not stored in the decontamination room (one endoscope and one colonoscope).

3) Failed to ensure biological indicators used to monitor the sterilization process had matching lot numbers per manufacturer's guidelines.

Findings include:

PHYSICAL THERAPY (PT) Department

Record review of a policy dated April 2015 titled " Cleaning Procedure for Hydrotherapy and Infection Control " stated " Hydrocollator machines will be cleaned monthly with mild soap and water ... " A form titled " Physical Therapy Infection Control Procedures " (no date) stated " Department and Equipment Cleaning: 11.) Water in Hydrocollator is changed as needed to maintain cleanliness. 12.) Paraffin is changed as needed to maintain a clean bath. "

Observation 6/8/15 at 10 a.m. during initial tour in the Physical Therapy department revealed a Paraffin Therabath (hot wax) machine with dark brown sediment in the bottom of the warm wax. The Paraffin Therabath did not have a cleaning log. The Hydrocollator machine with hot packs did not have a cleaning log.

Interview 6/8/15 at 10 a.m. with the Physical Therapist (ID# 19) revealed he changes the wax in the Paraffin Therabath and the water in Hydrocollator when it appears dirty. The Physical Therapist acknowledged he did not keep cleaning logs for these machines.

ENDOSCOPES

- Record review of a policy titled " Endoscope, cleaning, high level Disinfection, and Storage " dated July 2014 stated " Policy: To prevent cross contamination of patients when using gastroscope ...Storage: Ensure that the endoscope is hung securely with the insertion tube and light cable hanging freely in a vented storage cabinet. "

Observation 6/8/15 at 9:15 a.m. during initial tour of the surgical decontamination room revealed two endoscopes hanging on a rack on the wall. (One endoscope and one colon-scope) The scopes were draped with a surgical gown.

Interview with the Director of Nursing (ID# 1) 6/8/15 at 9:15 a.m. revealed the scopes have always been stored in the decontamination room. The Director stated the scopes are re-cleaned prior to a procedure.

STERILIZATION

- Record review of the Brochure for the Attest Pack stated " The Attest Pack is specifically designed to routinely challenge the steam sterilization process ...Directions for Use: 13.) The positive control indicator should be from the same manufacturing date and lot number as the processed biological indicator ... "

Observation 6/8/15 at 10:15 a.m. during initial tour in the autoclave room revealed two biological indicators incubating. The positive control lot number was " 2015-08DF. " The processed indicator ' s lot number was " 2015-09DF. "

Interview 6/8/15 at 10:15 a.m. with the Director of Nursing (ID# 1) revealed she was not aware the lot numbers of the control and processed indicator had to be from the same lot number.


- Record review of a document titled " 2014 Year-End QA Report / Recommendations " stated " 2014 data collection was based on 100% review January through November and partial review of December in the following categories:

A) Crash Cart
B) Warmer Temperature
C) Swing bed
D) Transfer to another Acute Care Facility
E) Emergency Department
F) Surgery / Anesthesia
G) Acute Care

The Plan stated " Recommend the following focus for current topics: 6) Surgeries / Anesthesia: Re-evaluate indicators. "

The Plan failed to identify if established policies were followed regarding cleaning PT equipment, storage of clean endoscopes and sterilization of instruments.