HospitalInspections.org

Based on record review, interview, and policy review the facility failed to ensure two of two physicians who performed surgical procedures had privileges to supervise Certified Registered Nurse Anesthetists (CRNA).

Findings included:

1. Review of the facility's Medical Staff Bylaws, dated 05/24/23 showed under the section for Allied Health Professional included CRNA's and was further defined to render medical or surgical care under the supervision of a physician and/or dentist.

2. Record review of credentialing files for physicians showed two physicians #9 and #15 had privileges for surgical procedures. The privileges did not show a privilege for supervision of CRNA's who administered anesthesia.

3. During an interview on 06/14/23 at 11:10 AM, Staff M, Credentialing specialist, stated the privileges for the two physicians #9 and #15 would not have supervision of the CRNA's.

Based on observation, interview and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when staff failed to:
- Perform a sterile dressing change for one patient (#17) for two dressing changes observed and one patient (#18) for one dressing change observed.
- Clean and repair under one cabinet in the endoscope (an instrument introduced into the body to a view of its internal parts) cleaning room.
- Repair the top part of the cracked gastroscope (an optical instrument used for inspecting the interior of the stomach) storage cabinet.
- Repair the one inch gap at the bottom, top and center of the colonoscope (an optical instrument used for inspecting the colon and distal ileum) storage cabinet.
- Repair four holes in the wall and five wall scrapes that exposed the drywall in the Endoscopy procedure room.
- Clean rust (reddish brown bacteria that may contribute to hospital-associated infections) and discolored residue under two cabinets in the Central Sterile dirty room.
- Remove rust from the floor under the blanket warmer next to the operating room (OR) scrub sink.
- Remove rust and repair paint chipping from the exterior OR door.
- Remove rust from two wall vents and two ceiling vents from the inside of the OR.
- Repair three holes in the ceiling, two holes in the wall and discoloration with stains of one ceiling tile in the pre-op and post-op bays.
- Adequately repair one kitchen window .
These failed practices had the potential to expose all patients, visitors and staff to cross- contamination and increased the potential to spread infection. The Medical Surgical Unit (swing bed) census was two.

Findings included:

1. Review of the facility's policy titled, "Hand Hygiene and Hand Antisepsis," dated 10/2022, showed the direction for staff to wash hands when:
- Visibly dirty;
- Contaminated;
- Before eating and after using the restroom;
- Before having contact with patients;
- After contact with a patient's intact, non-intact shin and wound dressings;
- After moving from a contaminated body site to a clean body site;
- After contact with inanimate objects; and
- After removing gloves.

2. Review of Patient #17's wound care orders showed that Staff R, Surgeon, ordered a wound care consult and dressing changes per wound nurse protocol.

Although requested, the facility failed to provide a wound nurse protocol.

Observation on 06/14/23 at 10:50 AM, showed Staff P, Wound Care Nurse, changed Patient #17's two wound dressings. Staff P removed the old dressing from wound #1 and with the same gloves removed the dressing from wound #2 (touching the wound) removed gloves, washed hands, applied new gloves, retrieved supplies (exterior was contaminated) and placed them on the clean table. With the same contaminated gloves, touched wound #2, opened drawer, measured wound #1 (touching with contaminated gloves), touched pen (contaminated object), measured wound #2 (touching with contaminated gloves) and touched pen. Staff P then removed gloves, washed hands, applied new gloves, touched pen (contaminated object), drew line on wound #2 (touching the wound with gloves), opened gauze pack, poured sterile water in gauze pack and cleaned wound #2, retrieved supplies, opened new dressing and supplies, laid new dressing on the outside of package (contaminated object), placed new dressing on wound #1, marked dressing, opened new dressing, placed on wound #2, retrieved supplies and wrapped the wound with the same gloves.

Observation on 06/14/23 at 10:20 AM, showed Staff P, Wound Care Nurse, changed Patient #18's right calf dressing. Staff P washed hands, applied new gloves and removed old dressing, removed gloves, washed hands, applied new gloves, measured the wound, retrieved pen (contaminated object) and with the same gloves cleaned the wound with saline and gauze and applied a clean dressing.

3. During an interview on 06/14/23 at 11:15 AM, Staff P, Wound Care Nurse, stated they did not realize they touched the pen before touching the wound, did not realize they touched wound #1 then wound #2 with the same gloves and also stated there was no wound nurse protocol.

During an interview on 06/14/23 at 1:40 PM, Staff F, Infection Preventionist, stated that Staff P should have changed gloves and washed hands after touching a pen and should have changed gloves and washed hands between wound #1 and wound #2.

4. Review of the facility's policy titled, "Cleaning and Sterilization of the Colonoscope and Gastroscope," dated 04/2023, showed the direction for the colonoscopes and gastroscopes to be cleaned and sterilized immediately after each procedure.

5. Observation on 06/13/23 at 2:35 PM, in the endoscope cleaning room, showed unclean and cracks under one cabinet.

Observation on 06/13/23 at 2:40 PM, in the gastroscope cabinet, showed the top part cracked and open at the top with particle shedding that exposed the sterilized gastroscopes to the outside environment.

Observation on 06/13/23 at 2:45 PM, in the colonoscope cabinet, showed an approximate one inch gap at the bottom, the top and center that exposed the sterilized colonoscopes to the outside environment.

Observation on 06/13/23 at 2:50 PM, in the endoscopy procedure room, showed to the right of the door, four holes (particle shedding) in the wall and five wall areas with scrapes that exposed drywall (particle shedding).

6. Review of the facility's policy titled, "Cleaning Operating Room Suite, Terminal Clean," dated 04/2023, showed the direction to ensure aseptic environment for surgical procedures to include filters and vents to be checked routinely by the Maintenance Department every six months.

7. Observation on 06/13/23 at 2:30 PM, in the Central Sterile dirty room, showed dirt and rust under cabinet #1 and rust and particle board (particle shedding material) under cabinet #2.

Observation on 06/13/23 at 3:00 PM, next to the scrub sink and under the blanket warmer, a large amount of rust on the floor.

Observation on 06/13/23 at 3:00 PM, at the entrance of the OR suite, showed the exterior door with rust and paint chipping (particle shedding).

Observation on 06/13/23 at 3:10 PM, in the OR suite, showed two wall vents and two ceiling vents with rust.

Observation on 06/13/23 at 3:25 PM, in the pre-op and post-op bays, bay #1 with two holes in the ceiling tiles, bay #3 one hole in the ceiling tile and two holes in the wall and bay #4 one stained ceiling tile.

Observation on 06/12/23 at 3:30 PM of the rear window of the kitchen showed the window had been repaired using clear packing tape and a fabric strip. The window was directly above cans of food and the tape on one corner of the window had over a dozen deceased insects on the sticky side of the tape. The tape and fabric strip could not have been adequately cleaned.

8. During an interview on 06/14/23 at 1:40 PM, Staff F, Infection Preventionist, stated they had a yearly log that showed the environmental checklist and the maintenance department should have repaired the holes, scrapes, rust, replace cabinets and replace the kitchen window..

9. Review of the environmental inspection, showed the last inspection was performed on 08/11/22.

Based on policy, record review and interview, the facility failed to:
- Complete a comprehensive quality of life activities assessment, which identified specific individualized, activity interest for two of two current Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients (#4 and #5) and for two of two discharged Swing Bed patients reviewed (#14 and #16).
- Provide specific, individualized activity interests that stimulated the patient's physical and mental well-being for two of two current Swing Bed patients (#4 and #5) and for two of two discharged Swing Bed patients reviewed (#14 and #16).
- Develop a comprehensive activity care plan, which included activity interests and interventions for two of two current Swing Bed patients (#4 and #5) and for two of two discharged Swing Bed patients reviewed (#14 and #16).
These failed practices had the potential to affect all Swing Bed patients by failing to stimulate their minds, body and social interests. The facility census was two Swing Bed patients.

Findings included:

1. Review of the facility's policy titled, "Swing Bed Comprehensive Assessments," dated 12/2022, showed no staff directives related to performing an activity assessment of patients admitted to the facility's Swing Bed program and the policy also failed to address the need to include activities into the patient's Swing Bed care plan.

2. Review of Patient #4's Electronic Medical Health Record (EMHR) showed the patient was admitted to the facility's Swing Bed program on 06/08/23, with complaints of left shoulder and pelvis fracture.

Review of Patient #5's EMHR showed the patient was admitted to the facility's Swing Bed program on 06/09/23, with complaints of urinary elimination impaired.

Review of Patient #14's EMHR showed the patient was admitted to the facility's Swing Bed program on 06/02/23, with complaints of weakness and gait strengthening.

Review of Patient #16's EMHR showed the patient was admitted to the facility's Swing Bed program on 04/10/23 with complaints of right hip fracture.

Review of Patient #4's, #5's, #14's and #16's EMHR showed staff failed to conduct a comprehensive quality of live activity assessment of the patients to assist in identifying the patients' activity interests and staff failed to develop a comprehensive activity care plan for the patients during the patients stay in the facility's Swing Bed program.

3. During an interview on 06/13/23 at 2:16 PM, Staff F, Registered Nurse (RN), Infection Preventionist, Utilization Review, stated the facility's Swing Bed program currently does not perform an activity assessment of patients admitted to the Swing Bed program and the facility does not include the activity component in Swing Bed patient's care plan. Staff F stated the facility's system stopped populating the activity component in the Swing Bed care plan in 2021. Staff F stated in 2021, the facility received notice the facility no longer was required to have an Activity Director over the Swing Bed program and the activity component was removed from the facility's electronic system for care plans.

During an interview on 06/14/23 at 1:51 PM, Staff L, RN, Nurse Manager, acknowledged neither current nor discharged Swing Bed patients' EMHR contained an activity assessment or care plan that addressed activities.