HospitalInspections.org

Based on observation and interview it was determined the Facility failed to ensure patients received care in a safe setting by not assuring used sharps were not easily accessible in 2 of 2 (Trauma 1 and Trauma 2) ERs (Emergency Rooms). By not assuring used sharps were not easily accessible to patients and visitors, the Facility could not assure patients would be free from environmental safety risks and pathogens. Findings follow:
A. During a tour of the ER on 11/16/21 at 2:55 PM, 5-gallon plastic sharps containers (with an opening large enough for an adult to put their hand in) were observed mounted to the wall in 2 of 2 (Trauma 1 and 2) Rooms. The circular opening of the containers were approximately 5 inches in diameter. This Surveyor easily placed their hand in the opening of an empty container.
B. During a tour of the ER on 11/16/21 at 2:57 PM, the 5-gallon plastic sharps container mounted to the wall in ER Trauma Room #1 was observed to be overfilled with sharps protruding from the top of the container.
C. The findings in A and B were confirmed at the time of observation by the (Director Of Nursing) DON and ER Manager.

Based on review of policy, observation, and interview, it was determined the facility failed to follow accepted professional principles in that an emergency cart was not secured with a break away seal on one of one Emergency Malignant Hyperthermia cart observed. By not securing the cart with a breakaway seal, the facility could not assure the contents of the cart would be available for an emergency. The failed practice had the likelihood to affect all patients who needed Emergency Malignant Hyperthermia medications. Finding follow:

A. Record review of policy titled, "Emergency Medication Distribution," revised 10/2019, showed emergency medications will be secured with tamper evident locks. Tamper evident locks are locks that break away, and when they break away, it is evidence someone had been in the cart and it will not be ready for an emergency.
B. During a tour of Surgical Services on 11/16/21 from 1:44 PM until 2:38 PM; observation showed the Malignant Hyperthermia emergency cart was unlocked and it was not secured with a breakaway seal.
C. During an interview on 11/16/21 at 2:23 PM, the Surgery Supervisor verified the emergency Malignant Hyperthermia medications were being stored in a cart that was not secured with a breakaway seal.

Based on review of manufacturer's recommendations, observation and interview, it was determined the facility failed to adhere to accepted professional standards in that they did not follow manufacturer's recommendations for length of storage for IV (Intravenous) and Irrigation solutions, and temperature in one of one fluid warmer. By not following manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that have had procedures in the facility that required IV and Irrigation fluids. Findings follow:
A. Review of Manufacturer's storage recommendations for Baxter IV and irrigation solutions showed that the IV solutions could be warmed to temperatures not exceeding 104 degrees Fahrenheit, and for a period of no longer than 14 days.
B. During a tour of the facility on 11/16/21 from 1:44 PM to 2:38 PM, observation showed the following solutions in a warmer that was set at 138 degrees Fahrenheit:
1) #2 Baxter Sodium Chloride 1000 ml (milliliter) IV solutions;
2) #2 Baxter lactated Ringer's 1000 ml IV solutions; and
3) #1 Baxter Sodium Chloride 1000 ml Irrigation solutions.
None of the products were dated to assure they didn't exceed the Manufacturer's recommendation of length of stay in a warmer. The warmer was set at 138 degrees Fahrenheit, and Manufacturer's recommendation was 104 degrees Fahrenheit.
C. During an interview on 11/16/21 at 2:01 PM, the Surgery Supervisor verified the findings at B.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition and NFPA 13 Standard for Installation of Sprinkler Systems 2010 Edition, it was determined supplies in the Postanesthesia Care Unit (PACU) Storage Closet were not stored 18 inches below the sprinkler deflector as required by NFPA 13:8.8.6, 2010 edition and were in the path of the sprinkler spray pattern. The failed practice had the likelihood to affect all patients and staff in that a potential fire in the PACU Storage Closet would not be immediately extinguished and could spread to other nearby areas due to the spray pattern of the activated sprinkler being obstructed. Findings follow:

A. Review of NFPA 101 2012 Edition: 9.7.1.1 showed automatic sprinkler systems shall be in accordance with NFPA 13.
B. Review of NFPA 13 2010 Edition: 8.8.6 showed the top of storage must be at least 18 inches below the deflector of the sprinkler.
C. Observation on 11/16/2021 at 1415 of the Storage Closet near the PACU showed three 11-inch-tall paper towel rolls adjacently stacked on a shelf 8 inches below the sprinkler deflector. This finding was verified by the Director of Plant Services at the time of observation.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition and NFPA 80 Standard for Fire Doors and Other Opening Protectives 2010 Edition, the facility failed to maintain four of four fire-rated door assemblies (Kitchen/Serving Doorway, Kitchen Dry Storage, Surgery Waiting Room, Materials Management Office) as required by NFPA 101 2012 Edition in that all four of the fire-rated door assemblies were wedged in the open position. The failed practices had the likelihood for the fire-rated doors to be left open in the event of a fire, allowing smoke and fire to rapidly transfer into the adjacent spaces. The failed practices had the likelihood to affect all patients, staff, and visitors. Findings were as follows:

A. Review of NFPA 101 2012 edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80. Review of NFPA 80 2010 edition: 5.2.13.3 showed blocking or wedging of doors in the open position shall be prohibited.
B. Review of NFPA 101 2012 Edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80. Review of NFPA 80 2010 Edition: 5.1.3.2 showed fire-rated doors shall be kept closed and latched or arranged for automatic closing
C. Observation of the Kitchen on 11/16/2021 at 1500 showed the doorway connecting the Kitchen and Serving Area was comprised of a fire-rated door assembly which was held open by a door-stopper wedged under the door leaf. This finding was verified with the Director of Plant Services on 11/17/2021 at 0930.
D. Observation of the Kitchen Dry Storage on 11/16/2021 at 1515 showed the entryway was comprised of a fire-rated door assembly which was held open by a door-stopper wedged under the door leaf. This finding was verified with the Director of Plant Services on 11/17/2021 at 0930.
E. Observation of the Materials Management Office on 11/17/2021 at 1000 showed the entryway was comprised of a fire-rated double-door assembly which was held open by two door-stoppers wedged under each door leaf. This finding was verified with the Director of Plant Services at the time of observation.
F. Observation of the Surgery Waiting Room on 11/16/2021 at 1030 showed the entryway was comprised of a fire-rated door assembly which was held open by a door-stopper wedged under the door leaf. This finding was verified with the Director of Plant Services at the time of observation.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 99 Health Care Facilities Code 2012 Edition and NFPA 70 National Electric Code 2011 Edition, it was determined that two of two electrical panels in the Operating Room 1 (OR 1) Storage Room did not have a minimum of 36 inches (three feet) working space in front of the panels because of equipment stored in front of the panels. The failed practice had the potential to affect all patients, visitors, and staff because rapid access to the panels could not be gained in the event of an emergency. Findings follow:

A. Review of NPFA 99 2012 Edition:15.5.1.2 showed that electrical equipment shall be in accordance with NFPA 70.
B. Review of NFPA 70 2011 Edition:110.26 showed that access and working space of at least 36 inches (3 feet) shall be maintained for electrical equipment operating at 600 volts, nominal, or less to ground and working spaces shall not be used for storage.
C. While touring the Storage Room near Operating Room 1 on 11/16/2021 at 1345, it was observed that a storage cart and wheeled monitor were stored directly in front of two electrical panels just inside the door to the storage room. This finding was verified with the Director of Plant Services at the time of observation.

Based on interview and review of the Rules for Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to ensure Operating Room 1 (OR 1) and Operating Room 2 (OR 2) were maintained at the required temperature range of 68-73 degrees Fahrenheit for the 11 months leading up to the date of the survey (January 2021, February 2021, March 2021, April 2021, May 2021, June 2021, July 2021, August 2021, September 2021, October 2021, November 2021). The failed practice had the likelihood to affect all patients undergoing procedures in these spaces during this timeframe in that an elevated risk of infection was present because there was no practice in place to ensure a temperature conducive to a sterile environment was provided.
Findings follow:

A. Review of the Rules for Hospitals and Related Institutions in Arkansas 2021 showed operating rooms and endoscopy rooms shall be provided with a dry bulb temperature of 68-73 degrees Fahrenheit.
B. Review on 11/17/2021 at 0830 of the facility's Temperature Record for OR 1 showed the operating room was kept at a temperature outside of the required range of 68-73 degrees Fahrenheit for 196 days of the 212 days recorded.
C. Review on 11/17/2021 at 0845 of the facility's Temperature Record for OR 2 showed the operating room was kept at a temperature outside of the required range of 68-73 degrees Fahrenheit for 182 days of the 212 days recorded.
D. The above findings were verified with the Director of Plant Services on 11/17/2021 at 1330.

Based on observation, policy and procedure review, and interview it was determined the facility failed to prevent and control hospital acquired infections in the Preop Holding area for one of one patient (Patient #37) in that no hand hygiene was performed during the care of Patient #37 while in this area. Failure to perform hand hygiene during the care of Patient #37 did not assure Patient #37 was free from possible transmission of infectious organisms from healthcare personnel. The failed practice had the potential to affect all patients receiving care in the Preop Holding Area. Findings follow:
A. Observation of staff in the Preop Holding Area on 11/17/21 from 07:00 AM to 07:45 AM showed, Patient #37 observed brought to the Preop Holding Area via bed by RN #1 with gloves on and received by LPN #1. RN #1 removed his gloves and left the Preop Holding area without performing hand hygiene. LPN #1 placed monitors on Patient #37 and lifted Patient #37's blanket to assess if SCDs (Sequential Compression Devices) had been applied. No hand hygiene performed. At 07:10 AM RN #2 came to bedside from OR (Operating Room) and verified Patient #37's name and DOB (Date of Birth) with the identification bracelet, procedure to be performed, and allergies while touching the siderails of the bed, no hand hygiene performed. At 07:20 AM, RN #3 placed gloves on her hands and hung IV fluids and antibiotics and connected the IV tubing to the IV catheter. RN #3 removed gloves; no hand hygiene performed. At 07:25 AM the CRNA came to bedside and interviewed Patient #37, placing her clipboard on the siderail of the bed and picking it back up. No hand hygiene prior to coming to or leaving the bedside.
B. Review of Policy and Procedure titled "Guidelines for Hand Hygiene in Healthcare Settings" showed, "Handwashing Guidelines Indications for hand washing and hand antisepsis: before having direct contact with patients and or between patients, after contact with a patient's intact skin, (taking pulse, blood pressure and lifting a patient), after removing gloves."
C. On 11/17/21 at 07:25 AM, there were 3 hand sanitizer dispenser units observed available for use in or near the Preop Holding area.
D. The findings in A, B, and C were confirmed with the ADON at the time of the observations.



Based on observation and interview, it was determined the facility failed to maintain a sanitary environment and prevent transmission of infection in one of one patient nourishment room in that there was no regularly scheduled cleaning of the microwave. Failure to clean the microwave did not assure patient food heated in the microwave would be free from pathogens. Failure to clean the microwave had the potential to affect all patients having food warmed in the microwave. Findings follow:
A. During a tour of the Medical/Surgical Unit Patient Nourishment Room on 11/16/21 at 3:05 PM, the microwave oven used for heating patient food was noted to be entirely covered on the inside with burnt on food particles and rust.
B. In an interview with the Medical/Surgical Unit Manager at the time of the observation she confirmed the microwave was used for warming patient food and that there was no cleaning schedule for the microwave.

Based on observation and interview, it was determined the facility failed maintain a sanitary environment in one of one medication rooms in that there was no regularly scheduled cleaning. Failure to clean the medication room did not assure medications prepared for patients would not be sources and transmission of infections. The failed practice had the potential to affect all patients on the Medical/Surgical Unit receiving medications. Findings follow:
A. During a tour of the Medical/Surgical Unit Medication Room on 11/16/21 at 3:10 PM, there was a bin of Dextrose 5% Lactated Ringers (D5LR) 1000 millimeter (ml) bags located directly under the RX Destroyer Container with medication waste noted covering the outside of the container and running down the wall.
B. In an interview with the Medical/Surgical Unit Manager at the time of the observation she confirmed the RX Destroyer container was covered with waste and waste was running down the wall. She stated that the container needed to be changed and that it had a really bad smell. She confirmed the clean bags of IV (intravenous) fluid located directly beneath the RX Destroyer.

Based on observation and interview, it was determined the facility failed to maintain a sanitary environment for one of one inpatient Hospice Rooms (room 327) by not assuring cloth furniture was not available for patient/visitor use. By not assuring only furniture that could be sanitized between use was available, the facility could not assure pathogens were not present on inanimate objects in the patient care area. The findings had the potential to affect any patient receiving care in room 327. Findings follow:
A. During a tour of the Medical/Surgical Unit on 11/16/21 at 3:15 PM, a cloth loveseat was observed in one of one Hospice Room (327) available for use.
B. In an interview during the tour of the Medical/Surgical Unit on 11/16/21 at 3:15 PM, the DON and Medical/Surg Manager confirmed the presence of the cloth loveseat (which cannot be sanitized) in room 327. They stated that the room had recently been remodeled and the cloth love seat placed in the room at that time. They confirmed no way to sanitize cloth loveseat or monitor the spread of pathogens from inanimate objects.

Based on review of the Society for Gastrointestinal Nurse Association Guidelines, review of the manufacturer's instructions for reprocessing, observation, and interview, it was determined the facility failed to maintain a sanitary environment by not assuring cross-contamination did not occur in transporting one of one gastroscope from the Gastrointestinal (GI) Lab to the Scope Reprocessing Room in a waterproof, covered, container or package. Failure to assure cross-contamination did not occur during the transport of the dirty gastroscope had the potential to spread bioburden onto all staff and working surfaces in the Procedure and Reprocessing Room and had the potential to spread bioburden to all patients having GI procedures. Findings follow:
A. Review of SGNA's ( Society of Gastrointestional Nurses Association) Standards of Infection Prevention in Reprocessing of Flexible Gastrointestinal Endoscopes 2011, the soiled endoscope should be transported to the reprocessing area in a closed container that prevents exposing staff, patients, or the environment to potentially infectious organisms. The transport container must be labeled to indicated biohazardous contents.
B. Review of the OLYMPUS BF 190 Series Reprocessing Manual provided by the Facility, once the endoscope has been detached from the light source and pre-cleaned at the bedside, the endoscope should be transported in a covered container.
C. On 11/17/21 at 10:15 AM, at the conclusion of an esophagogastroduodenoscopy (EGD), LPN ( Lisenced Practical Nurse) #2 handed the used endoscope to RN (Regisyered Nurse) #4 who walked with the endoscope uncontained into the Scope Reprocessing Room.
D. On 11/19/21 at 10:00 AM the ADON verified the findings in A, B, and C and confirmed the Facility follows SGNA guidelines in the GI Lab.

Based on observation, review of manufacturer's instructions for use, policy and procedure review, and interview, it was determined the facility failed to prevent and control infections by not assuring one of one Aldechek ALDAHOL 1.8 Glutaraldehyde Indicator Strip bottle was dated once opened. Failure to assure a date of opening was assigned to indicator strips did not assure outdated test strips were not used when testing the efficacy of endoscope disinfection solutions. The failed practice had the potential to affect all patients undergoing GI procedures in the facility. Findings follow:
A. Observation on 11/17/21 at 10:30 AM, at the conclusion of an EGD, in the Scope Reprocessing Room, showed the Aldechek test strip container was opened with no date written on the container. RN #4 verified no date was written on the Aldechek container and stated the date was usually written on the bottle.
B. Review of Aldechek ALDAHOL 1.8 Glutaraldehyde Instructions for use showed, "Do not use any remaining strips 90 days after opening the bottle."
C. Review of Policy/Procedure: Use of ALDAHOL showed, "Use ALDAHOL 1.8 only according to its directions for use. Monitor the glutaraldehyde concentration of ALDAHOL 1.8 with Aldechek ALDAHOL 1.8 Glutaraldahyde Indicators before each use."
D. Findings in A, B, and C were verified with the ADON on 11/17/21 at the time of the observation.

Based on review of Association of Perioperative Registered Nurses (AORN) Guidelines 2012-2021, policy and procedure review, and observation, it was determined the CRNA (Certified Registered Nurse Anesthetist) failed to assure the achievement and maintenance of high standards of medical practice and patient care by not verifying the procedure and site for one of one patient (Patient #37) in OR (Operating Room) #1 prior to the placement of a spinal anesthesia block by not performing at "time-out". Failure to perform a "time-out" prior to the procedure did not assure Patient #37 would be free from potential harm from incorrect/unnecessary procedures and had the potential to affect all patients having surgical/invasive procedures. Findings follow:
A. Review of AORN Guidelines for Perioperative Practice: Team Communication 5. Time Out showed, 5.1 "The perioperative team must perform a time out before an operative or invasive procedure begins."
B. Review of policy and procedure: "Time-Out" Before Invasive or Surgical Procedure showed, ""Time-Out" will be called by the RN (Registered Nurse) or Radiology Technician (RT) in charge immediately prior to any and all surgical or invasive procedures. All staff present shall participate in a final verification of the procedure and site (using active not passive communication): verify the correct patient, state the procedure, identify the site, check site marking on the patient. Once all staff is in agreement, the procedure will progress."
C. During observation on 11/17/21 at 07:54 AM in OR#1, Patient #37 was positioned, monitors were placed, the back was prepped for sterility and spinal anesthesia was administered by the CRNA without a "Time-Out" being performed.
D. Findings in A, B, and C were verified with the Assistant Director of Nursing ADON on 11/19/21 at 10:00 AM, she and the DON also confirmed the facility follows AORN Guidelines.

Based on review of Speech Therapist Job description, review of the Arkansas Rules and Regulations for Hospitals 2021, Section 23, review of Speech Language Pathologist's (SLP) personnel file and interview, it was determined one (#1) of two (#1 and #2) SLP did not have evidence of current CPR (Cardio-Pulmonary Resuscitation) certification. By not having evidence of this qualification, the facility could not assure services provided to patients would be given by a qualified therapist. The failed practice had the likelihood to affect all patients that receive Speech Language Rehabilitation Services. Findings follow:
A. Record review of the Speech Therapist Job description, dated 07/01/19, showed the SLP was required to comply with the State of Arkansas's regulations.
A. Record review of the Arkansas Rules and Regulations for Hospitals 2021, Section 23, showed all SLPs shall maintain competency in life support measures.
C. Review of SLP #1's personnel file showed no evidence of a current CPR certification.
D. During an interview on 11/18/21 at 12:10 PM, the Risk and Regulatory Compliance Officer verified that SLP #1 was not CPR certified.