HospitalInspections.org

Based on document review and interview the facility failed to provide the patients with the correct phone number for lodging a grievance/complaint with the State agency, resulting in the potential for patients to lack the knowledge to file a complaint or grievance with the State agency. Findings include:

On 8-2-2011 at approximately 1345 during review of the document titled "Patient Rights and Responsibilities" it was revealed that the incorrect phone number was listed to file a complaint with the State agency.

On 8-3-2011 at approximately 0915 during an interview with staff AA it was confirmed that the phone number was incorrect in the document.

Based on observation and interview, the facility failed to ensure the security of patients medical information in 9 out of 17 units plus the Out Patient Express Unit (3E, 4T 4S, 4W, 5S, 6NW, 6SE, 7S and the Emergency Department), resulting in the potential for a violation of patient privacy. Findings include:

On 8-1-2011 at approximately 1030 during a tour of 3E it was observed that medical records were not secured, and could not be visualized from the nurses station.

On 8-1-2011 at approximately 1040 during an interview with staff B it was stated "Usually, someone is in the hallway and can see all the charts." The surveyor then questioned if staff were always present on the night shift, and could ensure no unauthorized persons were accessing patient information. Staff B stated "I think so, but I'm not sure."

On 8-1-2011 at approximately 1500 during a tour of 4T it was observed that medical records were not secured, and could not be visualized from the nurses station.

On 8-1-2011 at approximately 1500 during an interview with staff JJ it was stated "Usually, at least one staff member is in the hallway, so if someone were to access a chart that was not supposed to then they would see them."


27781

On 08/02/11 between 2:00 p.m. and 2:30 p.m. observations were made on unit 5 South and 7 South of the medical record storage units. Nurse manager (C) reported that the medical records were stored in wallaroo wall mounted workstations and that they were always kept unlocked. Based on the location of the nurse station it was impossible to have full view of all of the wallaroos on the unit by staff sitting at the nurses station.

On 08/03/11 at 0945 a laptop computer was observed in the hallway of 6 Northwest which was open and had private patient information displayed on the screen.
On 1030 a.m. on 08/03/11, another laptop computer was observed in the hallway of 6 Southeast which was also open and had private patient information displayed on the screen and was visible for any onlooker to read. Nurse manager (LL) was made aware of the observations and verified the findings.



29313

During the initial tour of 4S and 4W on 08/02/11 between 1030 and 1130 it was observed that the patient medical records were stored in wallaroos, (wall mounted workstations) and that they were always kept unlocked. Based on the location of the nurse station it was impossible to have full view of all of the wallaroos on the unit by staff sitting at the nurses station, which made patient information unprotected and accessible to unauthorized persons.

These findings were confirmed by the Director of Womens and Childrens Services (MM).

During the initial tour of the Emergency Department (ED) on 8-2-11 between 1125 and 1300 it was observed that patient information was accessible to unauthorized persons throughout the ED via computers and paper charts, which made patient information unprotected. Portable computers [unattended] were observed in numerous locations throughout the department. When in standby mode, the screens were blank, but when a keystroke or mouse movement was initiated, the screen reactivated showing patient information [names, locations, etc.]. Paper charts were observed unattended at workstations near patient rooms. Most covers were blank, but contained pages of patient specific information. Three folders contained a patient name recorded on a gummed note; one of which had below the name "voluntary admission".

These findings were confirmed by the Director of Emergency Services (OO).

During the initial tour of the outpatient Express Care on 8-3-11 at approximately 1130 it was observed that patient information was accessible to unauthorized persons via the computer, which made patient information unprotected.

These findings were confirmed by the Business Operations Manager (NN).


29774

On 8/1/11 at approximately 1045 during tour of 6 SE found the wall storage units for medical records unlocked. When interviewing staff G regarding the provision of security for medical records in these unlocked wall units she stated " we have never had a problem in the past with not locking these units". When asked regarding the ability to visualize all the wall storage units from the nurses station she stated that " you cannot visualize all of the storage units from the nurses station".

On 8/1/11 at approximately 1200 during tour of 6 NW found the wall storage units for medical records unlocked. When interviewing staff J regarding the provision of security for medical records in these unlocked units and the ability to visualize all the wall storage units from the nurses station she stated that "this is a busy unit and there is always someone in the corridor that monitor these unlocked (units)".

Based on interview and record review the facility failed to implement interventions to prevent prolonged pressure to 1 (#10) of 5 sampled residents with pressure sores from a total sample of 52 patients resulting in the development of facility acquired pressure sores. Findings include:

On 8/01/10 at 11:30 a.m., record review revealed that patient #10 was admitted into the facility on 06/08/11 with complaints of abdominal pain, nausea and vomiting, confusion and weakness. The patient also had a history of renal cell carcinoma.

The patient's initial skin assessment dated 06/08/11 revealed that the patient's skin assessment was WNL (within normal limits), no wounds present, skin turgor was good and the skin condition was pink, warm and dry.

The Braden Scale for predicting pressure sore risk dated 06/08/11 revealed a score of 21. A total score of 18 or less represented a risk for pressure sore development.

Review of the Flow Sheet documentation revealed the the development of pressure sores:
On 06/28/11 Stage one pressure sores were identified, one located on the buttocks and the others on the patients bilateral thighs.
On 06/29/11 the patients Braden Score was measured at 13 and the pressure sore on the buttocks had a yellow base with serosanguinous drainage, the sores on the bilateral thighs were reddened with serosanguinous drainage.
On 06/30/11 the pressure sore on the buttocks increased to a stage 2 pressure ulcer.

Review of the Patient Management Plan for Impaired Skin/Tissue Integrity included: Inspect and document skin assessment particularly bony prominences every shift, offer toilet every 2 hours, every two hour and as needed turning schedule regardless of type of pressure relieving mattress.

Further review of the flow sheet revealed documentation of turning and repositioning of the patient on the following dates and times prior to the development of the pressure sores:
On 06/26/11 at 1700 (turned on left side) nearly 4 hours later at 2056 (patient turned),
on 06/27/11 at 0530 (log rolled) nearly 5 hours later at 10 a.m. (family turned patient),
on 06/28/11 at midnight (turned) four and one half hours later at 0430 (turned) no activity of turning or repositioning patient again until 1025 when a bath was given six hours later. No further turning or repositioning activity until 1747 when the patients brief and linens were changed (7 hours later);
on 06/29/11 at 1230 patient was turned to right side, at 2309 patient was turned to the left side (over 11 hours later)

The flow sheet documentation revealed that patient #10 was discharged from the hospital to a nursing home on 6/30/11. A nurses note written at 14:14 revealed, "Patient going to nursing home, called report to nurse, told of wounds on coccyx..."

The patient was readmitted into the facility the day after her discharge on 07/01/11 with complaints of shortness of breath and progressive weakness. Review of the Interim History and Physical dated 07/01/2011 revealed "Significant for excoriations and ulceration in the perianal and perineal areas."

On 08/02/11 review of photos of the patients skin revealed significant ulcerations in the coccyx area with skin breakdown.

Based on medical record review and interview the facility failed to maintain completed medical records on 2 out of 2 (#43, #44) outpatient surgery center patients. Findings include:

During medical record review on 8-3-11 at approximately 1200 it was found in patient #43 medical record that the patient received no discharge instructions and no proof of such instructions were given could be produced.

During medical record review on 8-3-11 at approximately 1210 it was found in patient #44 medical record that the patient had discharge instructions in the medical record, but had not signed that he/she understood and received a copy.

These findings were confirmed by the Director of Surgical Services (T).

Based on medical record review and interview the facility failed to maintain completed records for 6 of 33 patients reviewed (#1, #2, #3, #27, #33, #34), resulting in the potential for error in medical treatment. Findings include:

On 8/1/2011 and 8/2/2011 during medical record review it was determined that patients #1, #2, #3, #27, #33, #34 did not have orders noted/verified by the nurse. Staff were unable to show evidence of consistent order processing.

On 8/2/2011 at approximately 1430 during an interview with staff A it was stated "We don't have a consistent system with noting orders, we either need to note them in the chart or note them in the computer, not one or the other or neither."

Based on interview and policy review, the facility failed to ensure that all patient medical records were completed with in 30 days of discharge of the patient. Findings include:

On 08/03/11 at approximately 1111 during an interview with the Manager of Health Information, it was determined that there were 159 closed medical records that were not completed within 30 of the patient discharge.
On 08/03/11 at approximately 1115 the Manager of Health Information confirmed these findings.
On 08/03/11 at approximately 1135 during review of the " Medical Staff Rules and Regulations " it was noted on page 13 under the heading of " Completion of Medical Records " it states that the " records of discharged patient shall be completed within a period of time that will in no event exceed thirty (30) days following discharge.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based on observation and interview, the facility failed to maintain condition of the hospital in a manner to assure the safety and well being of patients. Findings include:

During the facility tour on August 1, 2011 it was observed that there was water leaking through the ceiling tiles in the resident activity room and the resident craft room within the Psychiatric Unit located on the 5th floor.
During the facility tour on August 2, 2011 it was observed that the sealant on the floor in the laundry was worn off exposing concrete. There were also chipped floor tiles in the laundry clean linen storage area. Based on the size of the floor tiles, these tiles were assumed to contain asbestos. Since these floor tiles are chipped, the integrity of the tile is damaged which could expose staff and patients (by contaminating the clean linen) to asbestos.
During the facility tour on August 2, 2011 it was observed that the facility had installed spitter on after the atmospheric vacuum breaker on the water supply serving the portable R.O. (reverse osmoses) in the dialysis unit on 6th floor. This can expose the atmospheric vacuum breaker to be under constant pressure which can cause it to fail. It can also cause the hot water to leach into the cold water supply and could potentially cause scalding.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See K-tags on the CMS-2567 dated August 3, 2011 for Life Safety Code.

Based on observation and interview the facility failed to promptly remove accumulated trash and soiled linens from soiled utility rooms resulting in the potential risk for exposure to infectious agents, injury to healthcare workers and vermin appeal. Findings include:

On 8/1/11 at approximately 1050 during facility tour of 6 S found in the soiled utility room:
a) two large clear bags with trash (one was leaking a clear fluid) on the floor
b) an over flowing soiled linen hamper
c) floor storage of three pillow cases stuffed with soiled linen. Accumulation of the trash and soiled linens limited the entry door swing and physical entry into the room.

On 8/1/11 at approximately 1205 during facility tour of 6 E found in the soiled utility room:
a) three large clear bags with trash on the floor
b) an over flowing soiled linen hamper
c) floor storage of five pillow cases stuffed with soiled linen. Accumulation of the trash and soiled linens limited the entry door swing and physical entry into the room.

Interview with staff G confirms that the rooms were cluttered with accumulated trash and soiled linen.

On 8/1/11 at approximately 1210 during facility tour of 6 N found in the soiled utility room:
a) two large clear bags with trash on the floor
b) an over flowing soiled linen hamper
c) floor storage of three pillow cases stuffed with soiled linen. Accumulation of the trash and soiled linens limited the entry door swing and physical entry into the room.

On 8/1/11 at approximately 1225 during facility tour of 6 W found in the soiled utility room:
a) one large clear bag with trash stored on the floor
b) floor storage of four pillow cases stuffed with soiled linen. Accumulation of the trash and soiled linens limited the entry door swing and physical entry into the room.

Interview with staff J confirms that the rooms were cluttered with accumulated trash and soiled linen.

Based on observation and interview the facility failed to maintain an acceptable level of safety and quality of the supplies provided for patient use. Findings include:

On 08/01/11 at approximately 1200 during observation in clean supply room on 7 west it was observed that there was a " Thoracostomy Tray " that was labeled "expired 03/10. Inside, the kit contained a 36FR Thoracic Catheter that outdated on 06/11, and a 40FR Thoracic Catheter that outdated on 10/10.

On 08/01/11 at approximately 1201 during an interview, the Director of Surgical Services confirmed these findings.



29313

During observational tour on 8-1-11 at approximately 1500 it was found on 5E in the procedure room that 85 pink topped blood draw tubes were found with an expiration date of 7/11.

These findings were confirmed by the Director of Womens and Childrens Services (MM).

During observational tour on 8-1-11 at approximately 1530 it was found on 7E in the supply cart, at the nurses station that one culture swab expired 5-11 and one culture swab expired 7-11.

These findings were confirmed by Clinical Nurse Manager (C).



29774

On 8/1/11 at approximately 01120 during facility tour of 6 SE found in the clean storage room a "CAPD Tubing Change Kit" with an expiration date of 5/11.

Interview with staff G confirms that the assembled kit has exceeded the written expiration date. Staff G indicated that they have a dedicated person from her unit whose responsibility is to, among other things, monitor the supplies in the room and return any expired supplies.

On 8/2/11 at approximately 1000 during record review reveals policy titled "Dated Supplies" states, "If outdated supplies are found, they will be replaced with fresh supplies....Outdated supplies are to be given to the Warehouse/Distribution Manager or Inventory Control Clerk for disposition."

Based on interview and observation, the facility failed to provide adequate space equipment for the inpatient dialysis service. Findings include:

During the facility tour on August 2, 2011 at approximately 2:45 PM it was observed that the 4 station inpatient dialysis unit did not provide adequate space to serve four patients. The facility had converted two rooms that were previously used as semi-private medical/surgical inpatient rooms. Each patient station had approximately an 8 foot by 8 foot area to house the patient bed and dialysis machine. This takes up a majority of the space leaving little room for the staff to circulate around the patient. The space also lacked adequate storage. Supplies were stored in the old wardrobes. When storing dialyzers and IV solutions in the wardrobes they were too long so that the wardrobe doors could not be closed all the way. Also the bathroom was used to store clean linen, acid and bi-carb as well as housed a portable R.O. (reverse osmoses) unit.
During interview with the dialysis manager during the facility tour it was reviled that the space is often over crowded. This facility treats several inmates which requires one or two correctional officers to accompany the inmate during treatment. The dialysis manager stated that during the morning run, they had 4 patients, one of which was an inmate that was accompanied by two correctional officers. Another patient had a few family members with them. The room was so full it make it difficult to access the patient. It was also mentioned that when a patient is coding and there is not enough room for the code team to all enter the room and are usually lined up in the hallway. It was also stated that the unit has a central R.O. system but has been running on two portable R.O. systems for about 2 years. Using the portable R.O. systems take up additional space in the bathrooms and have caused frequent water leaks/spills over the last two years.

Based on record review and interview, the facility failed to provide adequate humidity levels in the C-Section operating room (1 of 1). Findings include:

Based on record review, the humidity in the C-Section Operating Room was high on August 2 at 8:09 AM and 2:30 PM (76% and 77% respectively). The facility was not able to produce any readings from previous days because of their computer system that records this data was down.
During interview with the director of plant engineering on August 2, 2011 at approximately 2:30 PM it was agreed that the humidity was high in the C-Section Operating Room.

Based on observation and interview, the facility failed to maintain a sanitary environment. Findings include:

During the facility tour on August 1, 2011:

-Approximately 8:30 AM-11:00 AM: It was noticed that all of the soiled utility rooms serving the inpatient rooms on the main patient tower were filled with soiled linen making it difficult to even enter the room. Interview with the laundry supervisor on August 2, 2011 at approximately 9:00 AM it was indicated that laundry only ran Monday through Friday however staff were available to collect and sort laundry on the weekends. The soiled linen holding area was observed full on Tuesday August 2, 2011 which may be why not all the soiled linen was collected from the soiled utility rooms on the inpatient floors.
-Approximately 10:30 AM: It was observed that clean linen and supplies were being stored in a common shower room on 5th Floor North.
-Approximately 11:00 AM: It was observed that an IV bag was being drained into the hand wash sink across from station 5 in the Pre-Operation area. This practice ties up the hand wash sink so that staff are unable to use the sink for handwashing.
-Approximately 1:30 PM: It was observed that some of the new filters for the air handling units were being stored on the floor of the CUB mechanical room. This practice increases the chance of the filters could become wet and contaminated.
-Approximately 3:30 PM: It was observed that the clean linen room located outside of the Psychiatric Unit located on the 5th floor (across from the elevators) had several bed linens that appeared to be dirty piled up on the floor. The hand wash sink in this clean linen room did not have a soap or towel dispenser.

During the facility tour on August 2, 2011 at approximately 10:30 AM it was observed that the facility did not have a smooth, scrubbable ceiling tile throughout the central sterile processing area. Interview with the maintenance manager during the tour revealed that the facility had recently replaced some ceiling tiles and the facility plans to replace the remaining ceiling tiles in the next couple months.

During the facility tour on August 2, 2011 at approximately 2:45 PM the inpatient dialysis unit lacked adequate storage. Supplies were stored in the old wardrobes. When storing dialyzers and IV solutions in the wardrobes they were too long so that the wardrobe doors could not be closed all the way. The wardrobe that they were being stored in was adjacent to a patient station and was close enough that the dialyzers and IV solutions could be splattered with blood particularly when the patient is starting or finishing treatment. The bathroom in the dialysis unit was used to store clean linen, acid and bi-carb as well as housed a portable R.O. (reverse osmoses) unit. This is not a proper location to store clean linen as it has a increased chance of becoming contaminated. During interview with the dialysis manager during the facility tour it was mentioned that the facility's central R.O. system had not been used in about 2 years. Instead of using the R.O. ports in the wall, the facility is using a portable R.O. system that hooks up to the hand wash sink and then runs hoses across the floor to the dialysis machine. It was stated that the portable machines frequently have leaks. Also, the hand wash sink is not available to staff since the portable R.O. system is attached to the sink during treatment.


29313

During observational tour on 8-1-11 at approximately 1030 on 4S and 4W it was observed in a soiled utility room the storage of reusable vases. During the same tour it was observed in the nutrition room that they were storing towels and vases under the sink, that was actively leaking at the time of observation.
During observational tour on 8-1-11 at approximately 1500 on 5E it was observed in a soiled utility room the storage of reusable baskets and vases on shelves.

These findings were confirmed by the Director for Womens and Childrens Services (MM).



29774

Based on observation, interview and document review the facility failed control transmission of infectious agents by
a). failing to ensure use of personal protective equipment in patient care isolation rooms
b). adequately cleaning pill crushers that are used for more than one patient
c). storing clean equipment in soiled utility rooms and under sinks
resulting in the potential for transmission of infectious agents among the units' bed capacity of 42 patients. Findings include:

On 8/1/11 at approximately 1145 during facility tour, found staff M entered room 654 (patient #41) to speak at bedside with the patient. Room 654, a private room, is labeled with an isolation sign that indicates a requirement for application of gown and gloves before entering room. Interview with staff M reveals that she "may enter the room without gown or gloves if staying inside the pink box" (pink colored floor tile located in the ante room that ends before entry into the room's bed space). It was pointed out that staff M stepped far outside the pink boxed area and was at the bedside, to which she replied " I didn't touch anything and I washed my hands". Additionally the patient in room 654 had visitors who were not wearing gowns nor gloves. Interview with the nurse who cared for the patient, staff M reveals that when asked whether the visitors were instructed regarding the need to use gown and gloves while visiting the patient reveals that there was no documentation of education for either the patient nor the visitors regarding the need to use gown and gloves and perform hand hygiene before leaving the room.

On 8/3/11 at approximately 0825 during document review of facility policy titled "Isolation Precautions" it is revealed that the policy states "Contact Precautions....wear gown and gloves when entering the room...remove gloves and gown upon exiting the room and perform hand hygiene...". The policy fails to specify anything regarding a "pink box" nor exclusion from applying the gown and gloves. The policy goes on to specify that for visitors; "..nurses to explain need for isolation precautions...proper use of personal protective equipment....Contact Precautions: gown, gloves and handwashing recommended for visitors...Education sheets are available in the Document Center.".

On 8/1/11 at approximately 1155 during facility tour, found in room 635 that staff Y had entered the room without application of a gown and gloves, which was labeled with an isolation sign indicating the need to don a gown, gloves upon entry. Interview with staff Y regarding failure to apply gown and gloves she replied that I only had to speak with her for a second. Additionally the family member visiting in the room was not wearing gown or gloves. Interview with staff Y confirms that "the visitor is the patient's daughter, who has been educated about contact precautions, cares for her mom at home and chooses not to wear the PPE". A review of the record for patient #39 confirms that under safety teaching the patient, the family and the significant other has been educated regarding fall risk, fall prevention. When asked for documentation for education for MRSA isolation, on 8/2/11, received patient records with MRSA Education documented on 8/1/11 at approximately 1243.

Interview with staff G regarding education for patients and visitors in isolation rooms reveals that visitors and patients are given a CDC handout on FAQ's MRSA , which may or may not be documented in the patient record. The Document Center was out of FAQ's MRSA sheets.

On 8/1/11 at approximately 1220 found in semi-private room storage cabinet a pill crusher that had visible soiling with whitish and yellowish powdery material inside and brownish material on the outside of the equipment. Interview with staff J regarding use of this equipment confirms that it is used between patients and should be cleaned between uses. Staff J confirms that this pill crusher was soiled. Interview with staff N and X confirms that the Infection Control committee and Pharmacy are looking into getting individually assigned pill crushers that can be sent home with the patient at discharge.

On 8/2/11 at approximately 0930 during document review of facility policy titled "Equipment Cleaning: Non-critical, reusable patient care equipment" reveals that "patient care equipment must be clean and appropriately disinfected before reuse with another patient or before being placed in storage".

Based on record review and interview, the facility failed to ensure a post anesthesia evaluation had been documented within 48 hours after surgery for 4 of 10 records reviewed (patient ' s # 23, #24, # 25, and #26). Findings include:

On 08/02/11 at approximately 1410 during record review for patient ' s # 23, #24, # 25, and #26 it was noted that the 48 hour post anesthesia evaluation had not been completed. According to the document titled " Preoperative Anesthesia Evaluation " the section at the bottom of the page titled " Postoperative Anesthesia Note " was found incomplete.

On 08/02/11 at approximately 1300 during an interview with the Director of Surgical Services, it was determined that no other documentation could be found that could confirm that a post op evaluation was completed.

Based on observation, interview and record review the facility failed to implement safe measures for use of multidose inhalers (MDI) among more than one patient without the approval of
a) Medical Staff
b) Infection Control Committee
c) Manufacturers' recommendation for
1. use among more than one patient
2. cleaning between patients
resulting in risk for transmission of infectious agents among 238 admitted patients using multidose inhalers. Findings include:

On 8/1/11 it was determined that respiratory therapy were using multi-dose inhalers for more than one patient. Interview with staff N on 8/2/11 at approximately 1415 reveals that "they have been doing this since the early to mid-1990's".. Canada and Europe have been doing this since the early 1990's". " I have studies on file that demonstrate that you can use a single inhaler among many patients without risk of transmission..". Staff N was asked for scientific evidence and manufacturers insert or a letter from the manufacturers that allows the use of their product for more than one patient. Staff N "googled" the topic and provided three studies. In addition the results of a Canadian Health Technology Inquiry Service was provided. Letters from any of the manufacturers was never provided.

On 8/3/11 at approximately 1100 interview with staff U and Z regarding duration of this practice and approval for this practice reveals that " it was done so long ago, it was before we started working here". Staff U states "its a fairly common practice". Staff U and Z were asked for evidence that the use of multidose inhalers for more than one patient was approved by the facility's Infection Control Committee, Medical Staff or the various drug manufacturers. None of these documents could be provided. Staff U and Z indicated that training for use of the valved holding chamber and cleaning of the MDI occurs for respiratory therapist on orientation with documentation of competency for "MDI/DPI".

On 8/3/11 at approximately 0955 during Infection Control Committee interview reveals that the Infection Control Committee had not approved this practice and that this practice precedes any member's tenure on the committee.

On 8/3/11 at approximately 1030 during record review of package inserts for; Symbicort, Advair, Ventolin and Flovent fails to specify for single patient use however instructions are written in the first person.

On 8/3/11 at approximately 1045 during document review of facility policy titled "Metered Dose and Dry Powder Inhaler Therapy Number 460" reveals under "Common Use Inhalers; ...Patient utilizing common use inhalers will be issued a valved holding chamber to prevent cross-contamination of the inhaler. Inhalers will be disinfected with an alcohol wipe in between patients...". Interview with staff U regarding who handles the chamber and the inhaler, confirms that "both the Therapist and sometimes the patient will handle the chamber and the inhaler".



29314

On 8-1-2011 at approximately 1030 during a tour of 3E it was observed that inhalers were being used for all patients that had an order for respiratory inhalers on that unit. The respiratory cart contained in one drawer a mix of Advair, Flovent, Symbicort and Ventolin that were being used for multiple patients.

On 8-1-2011 at approximately 1030 during an interview it was confirmed with staff B and staff U that the inhalers were used for multiple patients. Staff B stated "They all have their own spacers, we just use the inhalers between patients and we wipe them down with alcohol between patients. We do this throughout the whole hospital, unless someone is in isolation, then they get their own."