HospitalInspections.org

Based on observation it was determined the Facility failed to maintain the building physical structure, environment and equipment in a state of good repair (chipped paint, cracks in the wall and wall dented and a hole) in three (Operating Room #2, surgical corridor, room #303) of ten areas observed. The failed practice had the potential to affect all patients, staff, and visitors due to the potential for germs to breed. Findings follow:

A. While on tour of the facility on 06/21/2017 at 0915, the following was observed:
1) Paint chipping in the shower wall of room #303 beneath the control lever near the shower floor.
2) Operating Room #2
a. Two cracks in the center support column in the center of the back wall.
b. Crack near the bottom corner of the wall next to the supply cabinet.
3) Corner dented and hole in the support wall near the sterilizer in the surgical corridor.
B. While on the tour the Vice President of Facilities Management verified the deficiencies cited above.

Based on observation, review of manufacturer's information on Succinylcholine and interview, it was determined the facility failed to ensure Succinylcholine had been dated with the manufacturer's recommended expiration date of 14 days once removed from refrigeration in three of three (Trays #1-#3) Anesthesia Trays observed in Surgical Services that contained the medication. The potential existed for medications to be used beyond manufacturer guidelines leading to a decrease in potency of the medications upon administration to patients. The practice had the likelihood to affect all patients who received the medication during surgery. Findings follow:

A. During a tour of Surgical Services on 06/20/17 from 1201 to 1245, observation revealed 3 Anesthesia trays that contained unopened vials of Succinylcholine. Tray #1 had 2 vials dated with expiration dates 09/07/17 and 09/07/17; Tray #2 had 2 vials dated with expiration dates 09/19/17 and 09/13/17; and Tray #3 had 2 vials dated with the expiration dates 08/19/17 and 08/31/17. The Trays were ready to be used for upcoming surgeries.
B. Review of package insert for Succinylcholine stated "The multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency".
C. During an interview on 06/20/17 at 1238, the Director of Pharmacy verified they were putting a 90 day expiration date on the vials, once removed from refrigerated storage the first time.

Based on review of policy, review of Medication Error Incident Reports, review of clinical records and interview, it was determined the facility failed to assure in six of six clinical records, there was evidence medication errors were recorded along with notification to the practitioner. The failed practice did not assure the physician was aware of the medication error so that treatment, if any, could be altered. The failed practice had the likelihood to affect any patient with a medication error. The findings follow:

A. Policy titled Quality Assurance Communication Reporting (QACR) stated "A description of the event including what happened, the patient's condition, physician notification and interventions should be recorded in the patient's chart."
B. Review of Medication Error Incident Reports revealed six medication errors dating from 06/01/16 through 06/01/17.
C. Review of the six Medication Errors in the clinical records revealed there was no evidence of documentation of the medication error and notification to the physician.
D. During an interview on 06/19/17 at 1600, the Associate Director of Nursing verified there was no documentation of the medication error or notification to the physician.

Based on observation and interview, it was determined the facility failed to assure all equipment was clean, sanitary and stored in a manner to prevent contamination in one (Operating Room (OR) #2) of three ORs (#1-#3) and one (#1) of two (#1-#2) Trauma Rooms.
The failed practice did not assure patients would be protected from likely sources of infection. The failed practice was likely to affect all patients who had surgery or was treated in the emergency department. The findings were:

A. Observation of OR #2 on 06/20/17 revealed:
1) OR #2 was identified by the OR Manager as clean and ready for use. The basin of one of one solution warmer was soiled with bits of debris. The soiled solution warmer was verified at 1218 by the Operating Room Manager.
2) Observation of the OR table revealed the table surface was wet beneath the cushions. The OR Manager confirmed the observation at 1221 then removed the cushions and stated "They just finished cleaning this room, it must be Virex". Review of the Virex II 256 manufactures instructions for use, provided by environmental services on 06/23/17, revealed "for use as a one-step clean/disinfectant: Pre-clean heavily soiled areas. Apply use solution to hard, non-porous environmental surfaces. All surfaces must remain wet for 10 minutes. Wipe surfaces and let air dry."
3) Observation of the Anesthesia Cart revealed one of one Yankauer suction packages that was opened and attached to suction tubing. The package was labeled single use and contents sterile until opened. The OR Manager confirmed the opened package at 1223 and stated "they do that to save time."
4) Observation at 1225 revealed CRNA (Certified Registered Nurse Anesthetist) #2 had a back pack in a black vinyl chair in OR #2. The backpack was a canvas type material and not covered in any way. The back pack was removed from OR #2 by CRNA #2 at 1225.

B. Observation of Trauma Room #1 on 06/20/17 at 0834 revealed:
1) One IV (intravenous) fluid administration set, sterile, single use was attached and open hanging on the IV pole. The Emergency Department Manager confirmed the finding at the time of observation and stated, "Someone must have thought they were going to use it."
2) Observation of Emergency crash cart at 0842, bottom drawer, revealed three different bundles of sterile supplies secured with a rubber band: #3 and #4 Miller blade; #4 and (2) #3 MAC blades, and 9 tracheotomy tubes and 3 milliliter syringe. The rubber band could impair the package integrity and compromise the sterility of the contents. The finding was verified by the Associate Director of Nursing at 0848.
3) Observation at 0853 revealed one of one soap dispenser holder that was broken and secured with tape on the side. The broken soap dispenser was verified by the Associate Director of Nursing at the time of observation.
4) Observation at 0853 revealed one of one EKG (electrocardiogram gram) machine stored in the room next to a sink used for hand hygiene. The EKG machine was not covered and likely exposed to splashes from the sink. The storage of the EKG machine next to the sink was verified by the Associate Director of Nursing at the time of observation.



Based on interview, review of policies, and risk assessment, it was determined the facility failed to assure reference material on the risk assessment was dated, therefore it could not be determined if current guidance was followed related to home laundering of surgical scrubs; failed to provide a specific policy or process for staff home laundering of surgical scrubs and failed to provide evidence of monitoring staff home laundering practices. The failed practice did not assure surgical attire would be free from contaminants and affected all patients admitted to the facility for surgery. The findings were:

A. On 6/20/17 at 1212 a tour of the surgical suite was conducted. The Operating Room Director and the facility Infection Preventionist on 06/20/17 stated staff home laundered their scrubs and that a risk assessment had been completed "system wide" and home laundering of surgical scrubs was determined to pose no increased risk to patients or staff.
B. Review of the risk assessment titled "Home laundered vs hospital laundered scrubs in the OR" on 06/21/17 revealed there was no date on the document. There was not a date the risk assessment was initiated, revised or reviewed. The CDC(Center for Disease Control and Prevention), SHEA (Society of Healthcare Epidemiology of America), and AORN (Association of periOperative Room Nurses)recommendations referenced were not dated. Without a date, it could not be determined if the guidelines referenced were the most current.
C. The system Infection Preventionist and facility Infection Preventionist were interviewed on 06/22/17. The System Infection Preventionist stated the risk assessment was initiated in 2005 and revised in 2007. The system and facility Infection Preventionist stated they were not monitoring staff's home laundering except through reported surgical site infections.
D. Review of the facility policy 6211.0305 "Surgical Services/Operating suite/Sterile Supply Attire in semi-restricted -Restricted areas", provided by the Associate Director of Nursing on 06/20/17 at 1559 revealed: "Privately owned home laundered scrubs (matching professional colors as determined by Baptist Health), may be worn in all patient care areas of the surgical services department."
E. On 06/22/17 at 1218, the Associate Director of Nursing, System Infection Preventionist, and facility Infection Preventionist were asked what procedures staff follow for home laundering of surgical scrubs, such as water temperature, wash time, and the use of bleach. There were no procedures provided by the time of the exit on 06/22/17.



31039

Based on observation, review of policy and interview, the Infection Preventionist failed to identify the likelihood for infection control negative outcomes in that in the Rehabilitation Gym three (#1, #2 and #3) of five (#1-5) walkers had paper tape, stickers and adhesive tape (not able to disinfect). By not maintaining therapy equipment in a way that allowed them to be thoroughly cleaned, the facility could not assure a sanitary environment when patients used the walkers. The failed practice had the likelihood to affect all patients that receive therapy services using the therapy equipment. Findings follow:

A. During a tour of Rehabilitation on 06/21/17 from 1015 through 1045, observation revealed three patient walkers stored in the Rehabilitation gym that had paper tape, stickers and adhesive tape (not able to disinfect) in multiple places on them.
B. Review of policy titled Infection Control Policy for Rehabilitation Therapies stated "All transport equipment and therapy items will be cleaned with approved disinfectant by personnel wearing gloves immediately following each patient use."
C. During an interview on 06/21/17 at 1039, the Occupational Therapist #1 verified the paper tape, stickers and adhesive tape that was on the equipment.

Based on Patient Meal Service Report review, policy review, and interview, it was determined the facility failed to document the time duration of patient trayline, therefore it could not be determined if temperature documentation was needed at the end of meal service for a trayline lasting longer than 15 minutes as stated in facility policy for all meals from 03/01/17 through 05/31/17. The failed practice created the potential for temperature decreases in hot trayline foods to go unnoticed and could affect any patient consuming foods from the trayline. Findings follow.

A. Review of policy titled "Food Production and Service" stated, "Food temperatures are taken at least at the beginning and end of meal service that continues for more than 15 minutes. If meal service lasts for 15 minutes or less, food temperatures are taken at the beginning of service."
B. Review of policy titled, "Patient Meal Service" stated, "At the beginning and end of each meal, the temperature of all hot and potentially hazardous cold foods will be recorded on the Patient Meal Service Report. If any food item that does NOT meet temperature standards, the CSL (Customer Service Leader) will take appropriate action. For facilities that hold foods for 15 minutes or less on trayline, only beginning temperatures are required."
C. Review of Patient Meal Service Reports from 03/01/17 through 05/31/17 revealed no documentation as to whether the trayline lasted longer than 15 minutes and revealed no documentation of food temperatures at the end of the meal.
D. During an interview on 06/21/17 at 1015, the Foodservice Director stated sometimes a trayline lasts longer than 15 minutes and sometimes it doesn't, it just depends on the census. She confirmed the lack of an end of meal temperature at the time of the interview.

Based on clinical record review and interview, it was determined the facility failed to ensure that Registered Nurse #1 administered three of three doses of Morphine for Patient #2, in accordance with written orders. By not adhering to the written orders, the facility could not assure the safety of the patient who received the medication. The failed practice had the likelihood the affect all patients in the facility. Findings follow:

A. During clinical record review on 06/21/17, the following were revealed:
1) Patient #2 had an order for Morphine Syringe 4 mg (milligram) may be given every 3 hours as needed for moderate pain, signed by Physician #1 on 06/18/17 at 2317;
2) RN #1 assessed Patient #2 at 0006 on 06/19/17 to have no pain;
3) RN #1 gave Patient #2 Morphine 4 mg at 0006;
4) RN #1 re-assessed Patient #2 at 0026 to have no pain;
5) RN #1 assessed Patient #2 at 0307 on 06/19/17 to have no pain;
6) RN #1 gave Patient #2 Morphine 4 mg at 0307;
7) RN #1 re-assessed Patient #2 at 0400 to have no pain;
8) RN #1 assessed Patient #2 at 2205 on 06/19/17 to have no pain;
9) RN #1 gave Patient #2 Morphine 4 mg at 2205; and
10) RN #1 re-assessed Patient #2 at 2239 to have no pain.
B. During an interview on 06/21/17 at 1500, Medical Surgical Nurse Manager verified the order for Morphine was for moderate pain and each does given, Patient #2 was assessed to have no pain. The Medical Surgical Nurse Manager stated the medications were given due to increased Respirations, not pain. Therefore the medication was not given in accordance of the order that was written.

Based on policy review, medical staff review, and interview, it was determined the facility failed to have evidence of a contractual agreement with a dentist. The failed practice did not ensure a dentist would be available to provide routine and/or emergency dental services for patients. The failed practice had the potential to affect any patient admitted to a Swing-bed. Findings follow:

A. Review of Physician list revealed no evidence of a Dentist on staff at the facility.
B. Review of Swing-Bed policies and documentation revealed no evidence of a contract with a Dentist.
C. During an interview on 06/20/17 at 0935, the Clinical Quality Facilitator and Regional Swing Bed Manager confirmed the facility did not have a contract with a Dentist.