HospitalInspections.org

ITEM 1:

Based on interview and observation, the hospital failed to ensure that all clinical equipment was inventoried for preventive maintenance.

Failure to ensure that all clinical equipment is inventoried risks patient injury through use of equipment that has not had regular safety inspections and maintenance.

Findings include:

During a tour of the hospital on 09/12/2012, an portable ultrasound machine was observed in a storage room in the respiratory therapy department. The manager of imaging stated that the machine was not part of the imaging department. The director of engineering stated that the machine was used by physicians in the emergency department and obstetrics department. The machine was not provided with a hospital inventory control number, and no record of the machine's regular preventive maintenance could be provided.

ITEM 2:

Based on interview and review of documentation, the hospital failed to ensure that the medical air system was operating in a safe manner, by failing to calibrate the carbon monoxide detector according to manufacturer's guidelines.

Failure to calibrate the carbon monoxide detector risks carbon monoxide contamination of medical air delivered to patients.

Findings include:

During a tour of the hospital on 09/11/2012, it was found that there were two medical air compressors supplying the hospital, each compressor with a carbon monoxide detector. One compressor had an EnMet brand carbon monoxide detector attached. The operations manual for the EnMet detector stated that the detector should be calibrated quarterly with 20 ppm calibration gas. A 10 ppm canister of calibration gas was observed on a shelf near this detector.

The hospital director of engineering stated that the EnMet carbon monoxide detector was installed in 2007 and had been calibrated only once since then.

ITEM 3:

Based on observation, the hospital failed to provide hot water for handwashing not exceeding 120 degrees F.

Failure to ensure that handwashing water it delivered at maximum 120 degrees F. risks injury to patients, staff and visitors through scalding.

Findings include:

During a tour of the hospital on 09/11/2012, it was observed that the temperature of hot water at the handwashing sink in the public toilet room in the rehab department was 124.1 degrees F. when measured with an electronic thermometer at about 1:45 p.m.. Hospital engineering personnel confirmed the measurement at this sink.

The temperature of hot water at the handwashing sink in patient room #2101 was 123.8 degrees F. at 2:05 p.m.

The hospital director of engineering stated that the monitoring system reported potable hot water temperature of 120 degrees F.

ITEM 4:

Based on observation, the hospital failed to provide backflow prevention to protect patients, staff and the public from back-siphonage of contaminated water into the hospital potable water supply.

Failure to provide appropriate backflow prevention risks injury or illness through ingestion of contaminated water.

Findings include:

During a tour of the hospital on 09/12/2012, it was observed that:

a) 1 of 2 patient shower stalls in the therapy pool men's locker room had a shower wand that was capable of extending to touch the floor of the shower and was not provided with an atmospheric vacuum breaker to prevent back-siphonage of contaminated water

b) A housekeeping closet was found with chemical dispensers lacking approved air gaps to prevent back-siphonage of chemicals into the hospital potable water system. The hospital director of engineering stated that all chemical dispensers in the hospital were similar.
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SEE ATTACHED LIFE SAFETY CODE SURVEY REPORT
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Based on record review and review of policies and procedures the hospital failed to follow its policy and procedure for restraining patients for 1 of 3 patient records reviewed (Patients #6).

Failure to follow established utilization guidelines for restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings:

1. The hospital's policy and procedure entitled "Restraints/Seclusion: Use of" (Revised 10/11/2005) stated that a written order for physical restraints was limited to four hours for adults. The policy state that when an order for restraints expired, a licensed independent practitioner must see and assess the patient before issuing a new order.

2. Review of the records of three patients who had been restrained during their hospitalization revealed the following:

Patient #6 was a 38 year-old patient who was treated in the emergency department (ED) on 11/12/2011 for a drug overdose. The patient was agitated and combative had been placed in four point restraints by ambulance personnel. The ED physician wrote an order for four point restraints that authorized use of the restraints for one hour. Nursing documentation indicated that the patient was in restraints from 1:50 PM until 5:30 PM. There was no order authorizing continued use of the restraints after the first hour.
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Based on observation, interview, and review of hospital policies and procedures, the hospital failed develop and implement policies and procedures that ensured intravenous medications prepared in pre-drawn syringes were labeled according to accepted standards of practice, as demonstrated by 1 of 2 anesthesia providers observed (CRNA #2).

Failure to label pre-drawn syringes of medications risks medication errors and transmission of communicable diseases to patients.

References: "Safe Injection Practices to Prevent Transmission of Infections to Patients" (Centers for Disease Control and Prevention; April 2011); "APIC Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Health Care" (Association for Professionals in Infection Control and Prevention; 2010); ASA Statement on the Labeling of Pharmaceuticals for Use in Anesthesiology (American Society of Anesthesiologists, October 2009)

Findings:

1. On 9/13/2012 at 7:50 AM, Surveyor #1 inspected the anesthesia cart in OR #1. The top drawer of the cart contained a 5 ml syringe of clear fluid labeled "Rocuronium". The label did not include the date and time that the medication had been prepared or the strength of the medication. The drawer also contained an unlabeled 20 ml syringe containing white fluid.

During an interview at the time of the observation, CRNA #2 stated that the unlabeled syringe contained the anesthetic medication propofol The CRNA stated that he had prepared both syringes of medication that morning for a surgical case that had been canceled. The CRNA stated that he planned to use the unlabeled syringe of propofol for another surgical patient and placed the syringe in his pocket.

The surgery nurse manager and the Chief Clinical Officer were present during the interview and instructed the CRNA to discard the medications.

2. Review of the hospital's anesthesia services and pharmacy policies and procedures revealed the hospital did not have a policy and procedure for preparing and labeling pre-drawn syringes of medication.
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ITEM 1 - Hand Hygiene

Based on observation and interview, the hospital failed to ensure that staff members performed hand hygiene in accordance with accepted standards of practice.

Failure to perform hand hygiene after contact with contaminated items risks transmission of communicable diseases to patients and staff members.

Findings:

1. On 9/13/2012 at 7:53 AM, Surveyor #1 observed CRNA #1 during administration of anesthesia to Patient #4 in OR #2. After medication administration, CRNA #1 touched the top of a sharps container while disposing of of the used medication syringe. The CRNA did not perform hand hygiene after touching the top of the sharps container and prior to continuing with patient care. The CRNA repeated this action at 8:25 AM and 8:28 AM.

2. On 9/13/2012 at 8:20 AM, Surveyor #1 observed the RN circulator (Staff Member #3) during surgery in OR #2. The circulator compressed the contents of a waste container without wearing gloves. The circulator did not performing hand hygiene after contact with the items in the waste container and prior to touching clean surfaces and supplies.

3. An interview with the Chief Clinical Officer at the time of these observations confirmed that the staff members had not performed hand hygiene according to accepted standards of practice.


ITEM 2 - Multi-dose Vials in OR

Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure that anesthesia providers followed hospital policy and CDC guidelines for use of multi-dose medication vials.

Failure to implement appropriate and effective infection control measures risks transmission of communicable diseases to patients, staff, and visitors.

Findings:

1. On 9/14/2012 at 8:30 AM, Surveyor #1 observed and interviewed a certified registered nurse anesthetist (CRNA #1) who was providing anesthesia to Patient #4 during a surgical procedure in operating room #2. The CRNA's anesthesia cart contained multi-dose vials of medication, including midazolam, labetalol, furosemide, flumazenil, verapamil, neostigmine, and dopamine. Several of the vials had been opened and dated. One vial was open and not dated. The CRNA confirmed that the multi-dose vials were used for multiple patients.

2. CDC guidelines for safe injection practices dated 2/9/2011 state that if a multi-dose vial enters the immediate patient treatment area, including operating rooms, the vial should be dedicated to that patient only and discarded after use.

3. The hospital's policy entitled "Multiple Dose Medication, Syringes - Use and Storage" (Reviewed 4/14/2009) read as follows: "2. Anesthesia policy is to use single-dose, methyl paraffin free (MPF) drugs for injection in all anesthetics."


ITEM 3 - Cross-contamination During Medication Administration

Based on observation and interview, the hospital failed to ensure that medications and supplies delivered to patients were not subject to cross contamination from unclean surfaces for 1 of 1 staff member observed (Staff Member #4).

Failure to prevent cross-contamination of medications and supplies risks transmission of infectious disease to patients during medication administration.

Findings:

a. One 9/11/2012 at 12:00 PM, Surveyor #1 observed Staff Member #4 deliver medications to Patient #5 in room 2202. While transporting the medications to the patient's room, Staff Member #4 dropped a vial of medication and a 100 ml bag of intravenous fluid on the floor, then picked up the items and placed them into the patient's medication drawer. The staff member did not clean and disinfect the surface of these items prior to placing them in a clean area.

b. The hospital's Chief Clinical Officer witnessed the observation above and confirmed that the staff member had not delivered the medications and supplies according to acceptable standards of practice.


ITEM 4
Based on observation, interview and review of hospital policies, the hospital failed to implement policies to prevent cross-contamination of ultrasound equipment in the imaging department.

Failure to prevent cross-contamination of clinical equipment risks transmission of infectious disease to patients undergoing ultrasound procedures.

Findings include:

During a tour of the hospital imaging department on 09/12/2012, it was observed that a disinfecting station was located on the wall of the ultrasound room. This station is referred to as the "GUS unit" according to the imaging department manager. The following discrepancies were found in the use of the GUS unit to disinfect transvaginal and transrectal ultrasound probes:

a) The station consisted of a canister labeled "Initial Rinse" and a canister labeled "High Level Disinfectant", which implied that the rinse is to be used prior to the disinfection.

b) Review of hospital policy "Wall-mounted vapor control system for transvaginal and transrectal ultrasound probes", dated 05/2011, found that the policy stated the procedure for disinfecting the probes as follows:

"Disinfection: 1. Disconnect transducer cable from the ultrasound machine...2. Remove any sheath or condom, wipe off gel, and wash probe with enzymatic cleaner prior to disinfection. Allow to dry for 2 minutes. 3. Place the probe gently into the soak container...4. Soak probe in disinfectant for 20 minutes...Rinsing: 1. Place the probe in the rinse container inside the GUS unit...for one minute. 2. Remove probe from the GUS unit and wipe with a paper towel. Then rinse in the sink under cold running water for ate least 30 seconds. Probe is now available for use."

c) In an interview at the same time as the policy review, the ultrasound technologist stated that she wipes the probes with a Sani-wipe, then places the soiled probes into the rinse container, then into the disinfectant container, then back into the rinse container again, before placing the probe back on the machine for use.

The process described by the ultrasound technologist recontaminated the probes by placing them into the rinse solution both before and after the disinfection process. The process also did not include the enzymatic cleaner or final rinse under cold running water referred to in the policy. The labeling on the GUS unit referred only to an initial rinse, not a final rinse in the rinse container.
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Based on review of facility policies and procedures and interview, the hospital failed to ensure that all hospital policies and procedures were reviewed on an annual basis.

Failure to systematically review policies and procedures risk delivery of inappropriate or ineffective patient care.

REPEAT CITATION - CITED APRIL 2009

Findings:

1. The hospital's policies and procedures for care of long-term care ("Swing Bed") patients included a signature sheet that indicated the policies had been last reviewed in August 2009. The hospital's policies and procedures for anesthesia services included a signature sheet that indicated the policies had been last reviewed in April 2009..

2. An interview with the hospital's Chief Clinical Officer (CCO) on 9/12/2012 at 9:30 AM revealed that it was facility policy for all hospital policies and procedures to be reviewed on an annual basis. The CCO stated that the swing bed policies and procedures had been reviewed within the past year but confirmed there was no documentation of this review.

A subsequent interview with the CCO on 9/13/2012 at 11:00 AM confirmed that the anesthesia services policies and procedures had not been reviewed annually according to hospital policy.

3. Review of the hospital's policy and procedure entitled "Policy Development, Revision, Deletion, and Implementation" (Effective 2/21/2012) confirmed that it was facility policy for all hospital policies and procedures to be reviewed on an annual basis.
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Based on record review and interview, the hospital failed to ensure that discharge instructions for wound care were given to the receiving skilled nursing facility for 2 of 2 patients reviewed (Patients #7, #8)

Failure to provide instructions for wound care inadequate treatment and possible adverse outcomes following discharge.

Findings:

Patient #7 was an 88 year-old patient who had been admitted on 5/9/2012 for treatment of left hip cellulitis. The patient also had decubitus ulcers on both heels. Review of the discharge instructions sent to the skilled nursing facility revealed the instructions did not have physician orders or nursing care instructions for care of the wounds on the patient's hip and heels.

Similar findings were found in the records of Patient #8.
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Based on record review, review of policies and procedures, and interview, the facility failed to ensure that staff members developed and implemented an activity program for 3 of 3 long-term care patients reviewed (Patients #1, #2, #3).

Failure to develop and implement an activities plan for long-term care patients risks impairment of physical, mental, and psychosocial well-being.

Findings:

1. Review of the medical records of three long-term care ("swing bed") patients revealed that 3 of 3 records lacked documentation of a comprehensive activities assessment and development of an activities plan.

On 9/14/2012 at 9:00 AM, an interview with the facility's Chief Clinical Officer, a hospital case manager (Staff Member #1) and a social worker (Staff Member #2) confirmed that it was facility policy for swing bed patients to be assessed for activity interests, and that an activities plan was to be developed for these patients.

2. Review of hospital's policies and procedures for swing bed patients at the time of the interview revealed there was no written policy and procedure regarding the facility's activities program.
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Based on interview and review of the hospital's patient rights information, the Critical Access Hospital failed to develop a policy and procedure for informing patient's of their visitation rights when admitted to the hospital according to 42 CFR 485.635(f).

Failure to inform patients of their rights and to incorporate those rights into visitation policies and procedures limits the patient's ability to exercise those rights.

Findings:

1. On 9/11/2012 at 1:405 AM, an interview with the Chief Clinical Officer and a patient admissions clerk (Staff Member #1) revealed that patients were given a brochure to read entitled "Patient Rights and Responsibilities" when admitted to the hospital for inpatient care and outpatient care.

Review of the contents of this handout revealed it did not include the patient's visitation rights identified under 42 CFR 485.635(f)(1) and (f)(2).

2. Review of the hospital's policy and procedure entitled "Visitors" (Effective 11/11/2010) revealed that the policy did not identify the patient's visitation rights identified under 42 CFR 485.635(f)(1) and (f)(2).
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Based on interview and review of the hospital's patient rights information, the Critical Access Hospital failed to develop a policy and procedure for informing patient's of their visitation rights when admitted to the hospital according to 42 CFR 485.635(f).

Failure to inform patients of their rights and to incorporate those rights into visitation policies and procedures limits the patient's ability to exercise those rights.

Findings:

1. On 9/11/2012 at 1:405 AM, an interview with the Chief Clinical Officer and a patient admissions clerk (Staff Member #1) revealed that patients were given a brochure to read entitled "Patient Rights and Responsibilities" when admitted to the hospital for inpatient care and outpatient care.

Review of the contents of this handout revealed it did not include the patient's visitation rights identified under 42 CFR 485.635(f)(3) and (4).

2. Review of the hospital's policy and procedure entitled "Visitors" (Effective 11/11/2010) revealed that the policy did not identify the patient's visitation rights identified under 42 CFR 485.635(f)(3) and (4).
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