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Based on observations, interviews, and record review, the facility failed to ensure the infection control policies were implemented in the surgical services and central processing departments by the persons designated to enforce infection control.

1. The facility failed to implement its policy on expired medication and supplies as evidenced by several expired medications and supplies and undated opened medications found during the inspection of the surgery services department and central processing department. This failure had the potential to cause infections if the expired supplies and medications were used on patients.

2. The facility failed to provide a sanitary environment to avoid sources and transmission of infection and communicable disease.

3. For Patient 32, the IV site was not initialed, dated, or timed by the staff member who started the IV line in accordance with the facility's policy and procedure. This deficient practice had the potential to result in infection due to the prolonged use of the same heparin lock.

4. The facility failed to ensure Employee 5 received infection control training annually, as per policy.

Findings:

1. During the tour of Operating Room 1 with the registered nurse (RN) supervisor of Surgical Services and Central Processing, Employee 1, on November 12, 2013 at 10 a.m., the following expired medications and supplies were found:

a. In the medication supply cabinet:
i. Cetacaine Topical Anesthetic Spray, expired on December 2012,
ii. A one pint of Strong Iodine Solution, expired on September 2011,
iii. A 12-fluid (fl) ounce (oz) of Purell Hand Sanitizer, expired on November 2012,
iv. Gelfoam, expired on March 2009,
v. Gelfoam, expired on July 2012,
vi. Gelfoam, expired on December 2011,
vii. Gelfoam, expired on June 2013,
viii. Three (3) Gelfoams, expired on May 2011,
ix. Gelfoam, expired on November 2011.

b. In the hallway, the suture cabinet:
i. Thirty-two (32) of the 1 - 4 Metric Polysorb Braided Lactomer 9-1 30 inch Violet sutures, expired on February 2012,
ii. Twenty-four (24) of the 1-Polysorb 5 x 18 inch Violet sutures, expired on September 1994.

During the concurrent interview with Employee 1, she read the expiration dates of the items mentioned above and stated, "Yeah, it's expired." Employee 1 removed the expired items from the cabinets for disposal.

The facility policy and procedure titled "Expired and Unusable Medication" dated March 1, 2004 indicted "all expired and unusable medication must be retrieved and returned to the pharmacy."

A review of another facility's policy and procedure titled "Central Services Infection Control Policies," dated November 2013, indicated "Supplies stored in Central Services, surgery or in nursing units are rotated to assure first in, first out and to prevent expiration of patient care items. Items that has expired or may expire prior to use are to be removed by Central Service staff and returned to Purchasing to be deleted form hospital inventory."


2. The personnel file for Employee 5 was reviewed on November 12, 2013 at 3:20 p.m. Employee 5 was hired by the facility on June 1, 1996. The latest infection control training in Employee 5's file was on June 12, 2012 which was found in a document titled "Anniversary Update Test Scores". The Anniversary Updated Home test indicated the test consisted of 60 questions including questions regarding "Infection Control".

During the interview on November 13, 2013 at 11:12 a.m., Employee 9, the Supervisor of Surgery and Central Processing Services, stated the last time Employee 5 was scheduled to work was on September 12, 2013 but he gave away that shift. Employee 9 stated, "Since that time, he knew he was delinquent with influenza (flu) vaccine acceptance or declination, TB (tuberculosis) screen, and infection control training."

At 1:35 p.m., during an interview, Employee 9 stated she found out from Employee 5 that he wanted to continue his employment in the facility, so Employee 9 informed him to comply with the facility's requirements which include the completion of the flu vaccination, TB screen and infection control review.

According to the facility's policy and procedure titled "Employee Anniversary Update" dated April 1, 2004, an Anniversary Update Home Study Inservice and Tests was created to refresh and reorientate hospital personnel to general safety and security, infection control, body mechanics, fire and electrical safety, hazardous materials, and other matters of importance with which employees must remain familiar and knowledgeable. Hospital employees at their anniversary date of hire are required to pass the Anniversary Update Home Study tests with at least a 90% passing grade.





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3. On November 12, 2013, between 9 to 11 a.m., during the initial tour of the facility, the following were observed:

a. In the Operating Room 2,
- There was a packet of Con Med 6 inch needle with an expiration date of February 2006.
- There were two (2) packets of Con Med Electrosurgical Handpiece with an expiration date of February 2012.

b. In The Supply Room,
-There were Esteem Sterile Polyisoprene Powder Free Surgical Gloves:
a packet of Size 8 with an expiration date of December 2011,
two (2) packets of size 6 1/2 with an expiration date of January 2012, and
a packet of size 7 1/2 with an expiration date of October 2011.

- There were Neutralon Brown Latex Surgical Gloves:
two (2) packets of size 6 1/2 with an expiration dates of September 2006 and November 2007, and
a packet of size 8 1/2 with an expiration date of May 2004.

- There was an open box of Biogel Box Surgical Gloves that contained size 8 gloves mixed in with different other sizes. The box had 12 packets of gloves with an expiration date of June 2010 while the rest of the packets were current.

c. In the Central Supplies,
- There was a packet of Bladed/Shielded Surgical Trocar with Universal Converter with an expiration date of November 2011.
- There were three (3) packets of Kendall TED Anti-Embolism Stockings with an expiration date of September 2012 and April 2011.
- There were four (4) packets of Bard Male External Catheter with an expiration date of January 2013.

d. In the Recovery Room,
- There was a packet of Soft PVC Nasopharyngeal Airway with an expiration date of December 2012.
- There was a tube of Lubricating Jelly opened and undated.


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4. On November 13, 2013 at 1:55 p.m., Patient 32 was observed sitting up in bed. The patient was alert and able to make her needs known. A heparin lock, a method of intravenous (IV) medication administration, was observed in the patient's right forearm. The heparin lock's dressing was intact. However, there was no label to indicate which staff member had started the IV (heparin lock), nor the date or time it was started.

A review of Patient 32's clinical record, conducted on November 13, 2013 at 2:15 p.m., indicated the patient was admitted to the facility on November 11, 2013 with diagnoses of severe hyponatremia (abnormally low sodium level in blood), history of hypothyroidism (low thyroid level), and history of anxiety.

A review of the Nursing Admission Assessment document, dated November 11, 2013, indicated the patient had periods of forgetfulness and was able to function independently.

A review of the physician order, dated November 11, 2013 and timed at 2:10 p.m., indicated for IV infusion of normal saline at keep vein open (KVO) rate and for 3% Saline solution to infuse at 40 cubic centimeters (cc) per hour for 10 hours.

Another order dated November 12, 2013, indicated to discontinue the IV solution and convert IV line to a heparin lock (a catheter that was left in place for IV access, but the solution and tubing were discontinued).

On November 12, 2013 at 2:05 p.m., during an interview with Employee 17, he stated the IV site should have been initialed, dated, and timed by the staff member who started the IV line, in order to prevent the possibility of infection.

According to the facility's policy and procedure titled "Intermittent Infusion Lock", revised March 20, 2012, the IV dressing was to be labeled with date, time, and initials following insertion of the IV line.



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5. During the initial tour in Operating Room (OR) 1 on November 12, 2013 at 9:10 a.m., an opened tube of bacitracin ointment, an antibiotic, which expired on March 2012 and ventolin metered dose inhaler were found inside the first drawer of the anesthesia cart. In the second drawer of the same cart, an opened Lubrifresh eye ointment container was found. In another cart, 16 of the opened five ml (milliliters) vials of sterile water were found. The opened medication containers were not labeled with a date as to when they were opened.

At 9:45 a.m., during an initial tour in Operating Room 2, a vial of Neostigmine 10 mg/1 ml which expired on October 30, 2013 and Diphenhydramine 50 mg/1 ml which expired on March 2012 were found inside the first drawer of the anesthesia cart. In the second drawer of the cart, there was an opened tube of Lidocaine HCL 2% which did not have a date as to when the medication tube was opened.

During an interview with the Operating Room Supervisor, Employee 9, on November 12, 2013 at 9:25 a.m., she stated the bacitracin, Ventolin, Lubrifresh eye ointment, and Lidocaine were for multiple patient use and these medications did not come in direct contact with the patients. She stated that the expired medication should be removed from the carts and the opened medication should have been labeled with an open date and expiration date handwritten on the medication container.



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6. On November 12, 2013 at 9:30 a.m., during an inspection of the Operating Room (OR) 2 in the presence of Employee 1, an operating room technician (ORT), three (3) of the Poole Suction Instrument with an expiration date of November 2010 were found inside a cabinet. The suction instruments expired three years ago.

During a concurrent interview, Employee 1 stated the staff was supposed to check the expiration dates of the surgical supplies and remove them from the cabinet.

At 10 a.m., during an inspection of the supply room with Employee 1, three (3) convertors laparoscopy packs were found inside a cabinet. Two of the packs had an expiration date of September 2012 and one pack had an expiration date of October 2012. These supplies expired one year ago. The expired supplies were mixed with the supplies that were to expire on 2015 thru 2017.

During a concurrent interview, Employee 1 stated the supplies in the cabinet should be arranged according to their expiration dates and the supplies that were about to expire should be used first.

According to the facility's policy and procedure titled "Central Services Infection Control Policies," dated November 2013, supplies shall be checked for expiration dates. Supplies stored in Central Services, surgery or in nursing units are rotated to assure first in, first out and to prevent expiration of patient care items. Items that had expired or may expire prior to use are to be removed by Central Services staff and returned to Purchasing to be deleted form hospital inventory.

Based on interview and record review, the facility failed to ensure the signed informed consent was dated and timed before the surgery was performed for two of 32 sampled patients (23 and 25). Patient 23's informed consent for total abdominal hysterectomy with bilateral salpingo oophorectomy (a surgical procedure to remove the uterus, fallopian tubes, and ovaries) was signed and dated by the patient; however, there was no time indicated as to when the informed consent was signed. Patient 25 also signed the informed consent for a total abdominal hysterectomy with bilateral salpingo oophorectomy; however, the informed consent was not dated. This deficient practice had the potential to result in a surgery without the patient's consent.

Findings:

On November 14, 2013 at 1:30 p.m., during a closed record review, the following were noted:

1. According to the Admission Face sheet, Patient 23 was admitted to the facility on October 9, 2013, with diagnosis of pelvic pain. On the day of admission, the patient had a total abdominal hysterectomy with bilateral salpingo oophorectomy. The patient was discharged on October 11, 2013.

A review of the Authorization For and Consent for Hysterectomy indicated the patient signed the consent form on October 7, 2013; however, the time the patient signed the consent form was not indicated.

2. According to the Admission Face sheet, Patient 25 was admitted to the hospital on July 1, 2013, with diagnosis of painful abdomen. On this day, the patient had a total abdominal hysterectomy with bilateral salpingo oophorectomy. The patient was discharged July 3, 2013.

A review of the Hysterectomy -Informed Consent indicated the patient's signature; however, there was no date to ascertain when the patient signed the consent.

On November 15, 2013 at 2 p.m., during an interview, Employee 14 (director of nursing) stated the informed consent should be timed and dated.

Based on interview and record review, the facility failed to ensure the operative reports for 3 of 32 sampled patients (Patient 1, 2, and 18) were signed by the surgeon as stated in the facility's policy and procedure.

Findings:

1. The clinical record for Patient 1 was reviewed on November 14, 2013 at 1:45 p.m. Patient 1 was admitted to the facility on October 16, 2013 for exploration and release of tissue and tendon repair of the left lacerated middle finger surgery.

A review of the Operative Report dated October 16, 2013 indicated the report was not signed by the surgeon who performed the surgery. The patient was discharged from the facility on the same day.

2. The clinical record for Patient 2 was reviewed on November 14, 2013, at 2:20 p.m. Patient 2 was admitted to the facility on October 2, 2013 for the several types of bilateral functional endoscopic sinus surgery (a minimally invasive procedure in which the sinus air cells are opened for surgical process by direct visualization) procedures.

A review of the Operative Report dated October 2, 2013 indicated the report was not signed by the surgeon who performed the surgery. The patient was discharged from the facility on the same day.

During the interview with the director of nursing (DON) on November 15, 2013 at 2:10 p.m., she stated both Operative Reports for Patient 1 and 2 were not signed by the surgeons who performed the patients' respective surgeries. The DON stated the operative reports should have been signed within 14 days of patient's discharge.

During the interview with Employee 17, the health information clerk, on November 15, 2013 at 2:18 p.m., she stated after the health information department received the dictated Operative Reports, the health information staff would leave the patients' charts in the Surgery Department the day before the surgeon's next scheduled surgery in order for the surgeon to sign the Operative Reports inside each patient's chart . If the surgeon did not sign the Operative Report, the surgeon would be given one more chance on another scheduled surgery day. If the surgeon still did not sign the report and the patient had been discharged for more than 14 days, the surgeon would then be placed on a suspension list until the Operative Report is signed.

According to the facility's policy and procedure titled "Medical Staff Rules and Regulations," approved by the Committee of the Whole-Executive Session on December 4, 2008 and by the Governing Board dated January 8, 2009, the operative or high risk procedure progress note is entered in to the medical record immediately after surgery to provide pertinent information for any individual required to attend to the patient. The full operative or other high-risk procedure report must be written or dictated within fourteen (14) days of the date of the operation of high-risk procedure. All charts shall be considered delinquent after fourteen (14) days following discharge. Physicians will be notified regularly of their incomplete charts.



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3. A review of Patient 18's clinical record indicated the patient was admitted to the facility on September 30, 2013 for gastrointestinal (GI) bleeding.

According to the consultation report dated October 1, 2013, the surgeon recommended an upper GI endoscopy, a procedure that uses a lighted, flexible endoscope (a medical device consisting of a long, thin, flexible or rigid tube which has a light and a video camera) to see inside the upper GI tract (the first part of the small intestine - the esophagus, stomach, and duodenum).

A review of the Operative Report dated October 1, 2013 indicated Patient 18 had undergone an esophagogastroduodenoscopy (EGD, a test to examine the lining of the esophagus (the tube that connects your throat to your stomach), stomach, and first part of the small intestine using a small camera (flexible endoscope) that is inserted down the throat). The Operative Report was not signed by the surgeon.

A review of the clinical record indicated the patient was discharged on October 3, 2013.

On November 15, 2013 at 2:10 p.m., during an interview, the director of nursing (DON) stated the operative report should have been signed within 14 days of the patient's discharge.

At 2:18 p.m., during an interview, the health information clerk, Employee 17, stated the health information department usually received the dictated Operative Report after the patient's discharge. Once the Operative Report was received, Employee 17 explained the patient's chart would be left in the Surgery Department the day before the surgeon's next scheduled surgery in order for the surgeon to sign the Operative Report. If the surgeon did not sign the report, Employee 17 stated the surgeon would be given another chance to sign the report on another scheduled surgery day. After multiple chances and the surgeon still did not sign the report for more than 14 days from the date the patient was discharged, Employee 17 stated the surgeon's name would be placed on a suspension list and the surgeon would not be able to perform any surgery until the patient's Operative Report was signed.

According to the facility's policy and procedure titled "Medical Staff Rules and Regulations," approved by the Committee of the Whole-Executive Session on December 4, 2008 and by the Governing Board dated January 8, 2009, the operative or high risk procedure progress note is entered in to the medical record immediately after surgery to provide pertinent information for any individual required to attend to the patient. The full operative or other high-risk procedure report must be written or dictated within fourteen (14) days of the date of the operation of high-risk procedure. All charts shall be considered delinquent after fourteen (14) days following discharge. Physicians will be notified regularly of their incomplete charts.