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Based on observation and staff interview it was determined that surgery/anesthesia (St. Joseph's Campus) failed to ensure that all medications are secured in all operating rooms which are not actively providing patient care. Additionally, there was a failure to ensure that all medication preparation and administration follow basic safety procedures that require all medications which are drawn up in syringes prior to administration are labeled with the name of the medication and the dosage. This deficient practice was observed in one (1) of four (4) operating rooms (Room #7). Failure to secure all drugs can result in medications which can be tampered with or removed by unauthorized personnel. Also, medications that are drawn up in syringes prior to usage which are not labeled with the contents and dosage can lead to medication errors resulting in possible patient injury.

Finding include:

1. During a tour of the Surgical Suite on 1/11/12 at 0800 hours surveyors entered four (4) operating rooms which were not actively engaged in a surgical procedure. On top of an anesthesia cart in operating room #7, were two (2) ten (10) cubic centimeter (cc) syringes which were filled with a white milky solution. Neither syringe had a label that identified the medications and the dosage. Additionally these syringes were not secured from tampering or removal by unauthorized personnel due to being located in an operating room that was not staffed or actively providing patient care.

2. The Director of Per-operative Services was present during the tour on 1/11/12 at 0800 hours and agreed the medications were not secure and labeled with the contents and dosage.

Based on observation, staff interview and documentation review during the survey conducted 01/03/12 to 01/11/12, it was determined the hospital failed to maintain the environment and all equipment to ensure the safety of all patients and staff. This determination was based on life safety code deficiencies identified as tags K0018, K0020, K0038, K0062, K0073, K0077, K0144 and K0147 issued to the hospital for non-compliance with the 2000 edition of the life safety code and a deficiency generated related to maintaining the physical environment identified as tag A0722. Therefore, this Condition is not met.

Based on observation it was determined the hospital failed to maintain the required special design consideration for a safe environment on the behavioral health patient care unit by failing to remove potential looping devices or tie-off points.

Findings include:

1. On 01/04/12 during the time frame of 09:00 a.m. and 10:30 a.m., a tour of the behavioral health patient care unit was conducted. At this time, the following design requirements of American Institute of Architects (AIA) guidelines for Design and Construction of Health Care Facilities in reference to behavioral/psychiatric units were observed not to be met:

a. Ten (10) of ten (10) patient care rooms had the following potential looping devices or tie-off points:

Toilet room doors were observed to have lever-type handle hardware.

Nine (9) of ten (10) handsinks were observed to have lever-type water supply handles. Also, the handsink faucets were observed to have a tie-off point design.

b. The patient corridors/common areas had the following potential looping devices or tie-off points:

Lever-type door handle hardware.

These conditions found in the patient care unit is not giving the required special design consideration to prevent potential patient injury or suicide.

Based on observations and staff interview it was determined the facility failed to ensure the central reprocessing (St. Joseph's Campus) department is clean with intact surfaces for all floor areas, ceiling tiles, cabinets and tables. Failure to keep all areas clean and/or maintained with intact surfaces can result in ineffective cleaning resulting in reservoirs for bacteria growth leading to possible cross contamination of supplies that are being reprocessed/sterilized in this department.

Findings include:

1. During a tour of the Central Sterile Processing Department on 1/11/12 at 0920 hours revealed the following observations:

a. The floor surface though out the clean and decontamination sides had areas that were a dark gray color with black streaks with a visible loss of the floor surface. Thoughout the unit the baseboards were heavily stained with dark/black marks and had a build up of dirt at the floor baseboard junction.

b. The yellow cabinets and lower legs/framing of work tables in the clean and decontamination areas had chipped peeling paint leaving exposed bare metal. This represents a non-intact surface that precludes effective cleaning.

c. There was an open floor drain, with only a mesh covering, in the clean reprocessing area about three (3) feet from the table where cleaned instruments and supplies are assembled and wrapped for reprocessing. This drain presents a place where bacteria can proliferate and contaminate the surroundings and act as a portal for fluids or insects to enter into the clean surroundings.

d. In the back of the decontamination area were two (2) air compressors. One of the compressors, Speedaire, had a large build up of gritty oily dirt that could be scraped off. There was a compressed air dryer between the two (2) compressors that had a bucket under it partially filled with cloudy fluid.

e. The ceiling tiles in the back area of the decontamination area were stained and appeared dirty. The metal drop ceiling grids were rusty.

f. A hopper in the decontamination area had large areas of black/dark gray discoloration where the surface porcelain had been worn away.

2. The Director of per-operative services was present during the entire tour on 1/11/12 at 0920-0945 hours and agreed with the above observations.