HospitalInspections.org

Based on observation, record review and interview, the hospital failed to ensure crash carts were prepared for use for one (Trauma Room 1 adult crash cart) of three crash carts.

This failed practice has the likelihood to place patients with a life-threatening, emergent condition at risk of delay in care.

Review of policy titled "Adult/Pediatric Crash Carts" read in part, "Crash carts will be checked daily ...Adult: ...Check if cart is locked"

During a tour of the ED on 08/18/21 at 11:05 AM, an adult crash cart was observed in Trauma Room 1 with no locking mechanism or deterrent in place for drawers #2 and #3. The drawers were able to be opened and contained medication and supplies.

On 08/18/21 at 11:05 AM, Staff A observed the unlocked drawers and stated they have always been unlocked.

Based on record review and interview, the hospital failed to ensure a set of bylaws were in effect for one (Fairview Regional Medical Center governing body) of one governing bodies.

This failed practice has the likelihood to create a lack of clear instruction for governing body members and medical staff members responsible for the delivery of quality patient care.

Surveyors were presented with two sets of governing body bylaws.

Review of one set of bylaws showed a title of "Fairview Hospital Board of Control Bylaws, Rules and Regulations June 2008." The document bore signatures and an approval date of June 26, 2008.

Review of the other set of bylaws showed a title of "Fairview Regional Medical Center Authority Bylaws, Rules and Regulations September 2014." The document bore no signatures and no approval date. The document differed from the June 2008 bylaws with changes to several articles and the addition of a new article.

On 08/19/21 at 3:20 PM, Staff C reviewed both sets of governing body bylaws and stated the following:
1. The 2014 bylaws were sent to City Council to ratify in 2014 and they never received a signed copy back.
2. Governing body bylaws were reviewed every two years.
3. The 2014 bylaws were used to onboard new members.

Based on record review and interview, the hospital failed to ensure evaluation of a clinical contracted service for one (Staff H) of 159 contracted services.

This failed practice has the likelihood to place patients at risk of receiving services or care that lead to poor patient outcomes.

Review of policy titled "Contract Management" read in part, "Purpose: To describe the process for [sic] insuring all contracts are entered into appropriately and reviewed annually to evaluate if they are meeting the needs of Fairview Regional Medical Center ....Contract Tracking: 1. Once a contract has been approved by all parties the contract will be routed to the HR/Community Relations Director who will enter it into the SQSS contract database."

Review of the hospital's list of contracted services showed a dietary department service contract for Staff H. Review of SQSS showed no entry of a contract with Staff H and no evaluation of the service provided.

On 08/19/21 at 2:57 PM, Staff B reviewed the list of contracted services and SQSS and stated the following:
1. Contract evaluations were completed in SQSS.
2. There was no contract entered and no evaluation of service for Staff H in SQSS and there should have been.
3. Inability to show the competence of the service provider was a risk to patients.

Based on observation, record review and interview, the hospital failed to ensure a clean operating room for one of one operating rooms.

This failed practice has the likelihood to place patients at risk of surgical site infection.

Review of policy titled "Terminal Cleaning HK-011" read in part, "Damp-clean all furniture ...and any other flat surfaces ....Purpose: ...To reduce the potential for nosocomial infections."

The OR was toured on Wednesday, 08/18/21 at 12:05 PM and had been terminally cleaned the day before. A greasy, yellow substance and a sticky, brown substance were observed and palpated on the outside of a door of a white metal cabinet hung on a wall opposite of the OR entry door. Also observed in the OR was an open box of Kleenex on the bottom shelf of a table to the right of the OR entry door upon entry.

On 08/18/21 from 12:05 PM to 12:55 PM, Staff A observed the substances on the white metal cabinet and the Kleenex in the OR and stated the following:
1. All surgeries and procedures take place on Mondays only.
2. Housekeeping terminally cleans the OR.
3. The OR had been terminally cleaned on Tuesday, 08/17/21.
4. The substances should not have been present after a terminal clean.
5. The substances could cause patient infection.

On 08/19/21 from 1:50 PM to 1:57 PM, Staff F stated the following:
1. The open box of Kleenex should have been thrown away as it was porous could not be terminally cleaned.
2. Housekeeping staff received no training specific to terminal cleaning of an OR aside from on-the-job training.
3. The risk of an ineffective terminal clean was surgical site infections.