HospitalInspections.org

Based on observation, interview and record review, the facility failed to develop and maintain a safe environment increasing the likelihood of injury for two-thirds of the female patients in due to lack of call lights in two (2) of three (3) restroom stalls for one (1) of eight (8) off site patient care locations.

Findings include:

Observation on 12/3/14 at 11:00 a.m. of the off campus therapy unit revealed that there are separate restrooms for males and one for females. Continued observation of the female restroom revealed three (3) separate stalls, however only one (1) of the three (3) stalls contained an emergency pull cord for patient use in the event of an emergency.

Interview 12/3/14 at 11:00 a.m. the Director of Outpatient Services confirmed the above findings.

On 12/4/14 at 11:00 a.m. the Administrative Assistant confirmed that there
was no evidence of a policy addressing the emergency call light system.

Based on observation, interview, and record review, the facility failed to maintain safe emergency supplies, increasing the likelihood of a delayed response and/or patient death for all patients receiving care in the Particle Accelerator building on the main campus and the Diagnostic Imaging off-site location.

Findings include:

1. Observation on 12/2/14 at 12:30 p.m. of the Particle Accelerator building revealed the Crash cart (a cart of supplies used for the treatment of emergencies) contained have the following expired supplies:

Three (3) red top blood tubes expired 6/2014
Two (2) purple top blood tubes expired 8/2014
Two (2) green top tubes expired 06/2014
Two (2) blue top tubes expired 3/2014
One (1) CO 2 detector expired 8/2014
Two (2) ABG packs expired 9/2014
One (1) pack of electrodes expired 11/25/14

Interview with the touring technician confirmed the above.

2. Observation on 12/3/14 at 1:15 p.m. of the Diagnostic Imaging off-site facility in a nearby town, revealed that the Crash Cart contained have the following expired supplies:

2 purple top vacutainers expired 10/14
2 blue top vacutainers expired 1/14
2 red top vacutainers expired 10/14
2 green top vacutainers expired 11/14
2 x 20 Gauge IV catheters expired 2/14
4 x 20 Gauge IV catheters expired 3/14
5 x 16 Gauge IV catheters expired 11/13
4 x 18 Gauge IV catheters 12/12
1 luer tubing for IV use expired 6/14
1 x patient ABG sampling kit expired 5/14
1 x 5.5 mm x 7.5 mmx19mm endotracheal tube expired 8/14
2 x 6.0 mm x 8.2 mm x 16 mm endotracheal tube expired 11/14
1 x 7.0 mm x 8.2 mm x 9.6 mm x 26 mm x 26 mm endotracheal tube expired 4/14


The Director of Radiology confirmed the above findings.

Review of Policy 8.01 (rev. May 2, 2014) and titled "Crash Cart Security and Defibrillator Checks" revealed "It is the responsibility of the individual checking the cart to correct any discrepancies found prior to signing the check sheet...Pharmacy will restock the drugs, apply a numbered lock to the drug drawer, then send the cart to Materials Management for restocking supplies in the cart."

Based on record review and interview, the facility failed to clean and sanitize a single patient use device in one (1) of eight (8) off-site locations increasing the likelihood of blood borne pathogen cross-contamination from patient to patient, failed to follow manufactures recommendations, and failed to follow the facility's policy on single use patient use devices.

Findings include:

Observation on 12/3/14 at 1:35 p.m. of the off campus "Outpatient Imaging Center" in nearby city, revealed a blood glucose monitoring device.

Review of the manufacture booklet revealed that the blood glucose monitor was to be used as a single patient device. Per the manufacture instructions the single patient device is to be cleaned with "household bleach" weekly.

Interview at the time of the observation with the Director of Radiology revealed the device was "new" and this is confirmed due to the manufacture instructions were still contained in a plastic covering, which was opened during the observation. Continued interview revealed that blood glucose monitoring was "rarely" completed at the location. The Director stated that usage maybe once every six months, and that if needed the clinic located at the same location would come and complete a venipuncture for blood glucose monitoring. The Director stated that be blood glucose monitoring device when used was cleaned with "Cavi-wipes" (Cavi-wipes is an alcohol based cleaning product) between patient use rather than bleach, thus the glucose monitoring machine is disinfectant-infected however, not sterilized.

Review of Policy 3.68 (rev. February 2012) titled "Blood Glucose (Nova StatStrip)" revealed no evidence of instructions for the particular blood glucose monitoring device in this off-site location.