HospitalInspections.org

Based on observation and staff interview, the hospital failed to store medical records for 1 of the 5 physician practices reviewed, in a manner that ensures that they are protected from potential water damage. The findings include:

During tour of the Physician Practices located in the Gannett Building, on the morning of 10/21/15, medical records for patients of the Orthopedic Physician Practice were stored in a room in the basement area on open faced shelving and located directly under an open ceiling with exposed piping and sprinklers, creating opportunity for potential water damage.

The observation was confirmed by the VP of Physician Practices who was present at the time of tour, and who also acknowledged the potential for water damage.

Based on observation and staff interview, the hospital failed to store medical records in a secure manner that ensured that unauthorized individuals cannot gain access for 2 of 5 physician practices. Findings include:

During tour of outpatient physician practices, on the morning of 10/21/15, the following observations were made:

a. medical records were stored in unsecured opened shelving units in the front office area of a general surgery practice

b. medical records were stored directly on the counter within the front office space of an orthopedic practice, as well as in boxes on the floor of the same office space.

The individual Practice Managers, and the Director of Operations for Physician Practices, all of whom were present at the time of tour, confirmed the observations and acknowledged that housekeeping personnel perform cleaning services after hours with no staff present, creating opportunity for unauthorized access to the records.

Based on observation and staff interview, there was a failure of plant services to conduct routine preventative maintenance for the cleaning of outflow vents in all 3 of the hospital's Operating Rooms to ensure the safety and well being of patients. The findings are as follows:

During a tour of the Perioperative Service area accompanied by the Nurse Manager on 10/19/15 at 1:55 PM the internal wall grates of the 2 outflow vents located near the floor on opposite ends in OR 2 were observed to be coated with dust. The Nurse Manager confirmed the observation and further acknowledged on the morning of 10/21/15 both OR 1 and OR 3 internal grates of the outflow vents were also coated with dust. Per interview on 10/21/15 at 12:15 PM the Director of Plant Services confirmed the cleaning of the internal wall grates had been excluded from the Preventative Maintenance schedule for routine cleaning.

Based on observation and interview, the Hospital's Infection Control program failed to assure staff consistently maintained infection control standards of practices in all areas of the hospital. Findings are as follows:

1. Per observation on 10/2015 at 8:55 AM an Anesthesia Technician was observed disinfecting an anesthesia cart. Opened multi-dose medication vials to include Propofol ( used to induce or maintain anesthesia), Midazolam (used for anesthesia, procedural sedation) and other unidentified medications were left on the cart. When asked if the multi-dose medication vials would be disposed prior to the cart being brought into an OR for another surgical case, the Anesthesia Technician stated the multi-dose medication vials will remain with the cart and will be used within the operating room by Anesthesia staff for the next surgical patient during induction of anesthesia. The CDC (Center for Disease Control and Prevention) states: "Mult-dose vials should be dedicated to a single patient whenever possible. If multi-dose vials must be used for more then 1 patient, they should not be kept or accessed in the immediate patient treatment area (to include operating rooms)."

Per interview on 10/21/15 at 1:18 PM, the Chief of Anesthesia confirmed the practice of multi-dose medications vials being brought into patient treatment areas, to include operating rooms, and may have been used for more then 1 patient. The Chief Medical Officer also confirmed on 10/21/15 at 1:30 PM, an immediate change in policy had been implemented requiring all multi-dose medication vials are to be used for a single patient only. In addition, the present practice by Anesthesia staff using multi-dose medication vials in patient treatment areas will no longer continue.

2. During a tour of the Radiology Department on 10/20/15 beginning at 9:55 AM, 02 (oxygen) tubing was observed unpackaged and wound loosely over the wall connectors in 2 of the x-ray rooms and 1 CT room. When asked how staff assure that the tubing had not been used, the Lead Radiology Technician (RT) reported that staff expect that the tubing was replaced by the previous staff member after it was used; however, in the DR(digital radiology) x-ray room, RT #2 stated that in this room, the 02 extension tubing was not changed between patients, only the tubing connected to the nasal cannula or mask was replaced for each patient. RT #2 confirmed that the manufacturer's instruction on an unopened package in the room stated that the tubing was for "single patient use." In the bone density test room, an open cell foam positioner was observed. RT#1 reported that newer positioners purchased by the department were vinyl clad to ensure the ability to sanitize the outside surface between patients. The RT confirmed that there was an infection control risk with the use of the foam positioner as a thorough disinfection of the foam surface could not be assured.
3. During an observation of a venipuncture (blood draw) in the out-patient lab, the following infection control issues were observed: a. Following the venipuncture, without removing contaminated gloves, the phlebotomist opened a new multi-use roll of Coflex bandage tape to secure a dressing to the patient's arm (Coflex bandage = an elastic wrap used to secure a small dressing without the use of tape); the roll was then put on the counter to be used for other patients. The phlebotomist also handled lab paperwork and outer packaging containing the blood tube while still wearing the same gloves worn during the venipuncture. b. During the venipuncture procedure, the patient's bare skin was in direct contact with a vinyl arm support (without a protective barrier in place). Following the procedure, the vinyl surface was not sanitized. The phlebotomist reported that the arm supports were disinfected at the start of each day or if blood spills or skin problems were identified during the venipuncture. c. The phlebotomist failed to sanitize his/her hands after removing his/her gloves and using the lab computer. The above findings were confirmed by the Lab Services Director at the time of the observation and s/he confirmed that infection control practices had not been followed for gloving, handwashing and disinfection of reusable equipment.
On 10/21/15 at 10:30 AM, the hospital's Infection Control Nurse (ICN) confirmed that the above observations in the radiology and laboratory departments were infection control issues and that standard precautions related to handwashing and gloving had not been followed as per hospital policy. Per review of the policy labeled Venipuncture Procedures, (effective: 5/19/99, Revision: 4; review date 11/5/13), following a blood draw, staff are directed to "Remove gloves, wash your hands" as soon as possible. The policy titled, Equipment Cleaning/Disinfection Procedure (last reviewed 4/2015) for noncritical equipment (items that contact only intact skin, which includes furniture) states that 1. Most noncritical reusable items may be decontaminated where they are used. 2. These items could potentially contribute to secondary transmission by contaminating hands of healthcare workers or by contact with medical equipment that will subsequently come in contact with other patients. 3. Items must be cleaned using an appropriate disinfectant. The ICN confirmed that the arm support used during venipuncture procedures should have been cleaned following the procedures for sanitizing noncritical equipment.