HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 1 Medical Records Department, the Hospital failed to ensure the completion of medical records within 14 days of discharge, as required by the Hospital.

Findings include:

1. The Hospital's "Medical Staff Bylaws, Rules and Regulations" (revised November 2018) was reviewed on 4/24/19 and included, "...The records of discharged patients shall be completed within a period of time that will in no event exceed fourteen (14) days following discharge..."

2. On 4/24/19 at approximately 3:15 PM, the Director of Medical Records (E #3) presented the surveyor with a letter of attestation, dated and signed by E #3 on 4/24/19, which included, "...Delinquent charts ( > 30 [greater than or equal to] days post discharge) for the month ending March, 2019...340..."

3. On 4/24/19 at approximately 2:15 PM, an interview was conducted with E #3. E #3 stated that the Hospital's Bylaws, Rules and Regulations were revised and now includes that a medical record is considered delinquent 14 days after discharge. Medical records were previously delinquent 30 days after discharge. E #3 stated that the current computer system has no ability to run a report on 14 day delinquent records, only 30 day. E #3 stated that a new computer system is being put into place to run these reports, but E #3 could only provide a report of 30 day delinquent records for the previous month (March 2019), as the report is generated monthly and is not complete yet for April 2019.

Based on document review, observation and interview, it was determined that for 1 of 3 food storage coolers (cooler #1), the Hospital failed to ensure opened food was dated and disposed of, upon the expiration (use by) date. This potentially affected the 499 patients on census receiving food trays on census 4/25/19.

Findings include:

1. The Hospital's policy titled, "Systemwide Food and Nutrition Services Food Safety and Sanitation Standards of Operation", (reviewed by the Hospital on 7/26/18) was reviewed on 4/24/19 and included, "Food and Nutrition's food safety program will adhere to the regulations and guidelines mandated by the latest of the FDA (Food and Drug Administration) Food Code."

2. The Food Code, United Public Health Service, 2017 was reviewed on 4/24/19. The code included, "...Time/Temperature control for safety food prepared and held in a Food Establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold or discarded."

3. During a tour of the kitchen area on 4/24/19 from 10:50 AM to 11:30 AM the following was observed:
In cooler #1 - A bag of tilapia filets (fish) was opened and not labeled with date (not on menue for the day), a 14 by 9 inch pan of yellow squash was labeled with a use by date of 4/23/19 (one day over), and a 6 by 4 inch tray of cut tomatoes was labeled with a use by date of 4/23/19 (one day over).

4. During an interview on 4/24/19 at approximately 11:20 AM, the Chief Chef (E#2) stated, "All food should be labeled when opened and should be discarded when the use by date has passed, to be sure the food is safe to consume."

Based on observations during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on April 23 - 25, 2019, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on April 23 - 25, 2019, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on document review, observation and interview, it was determined that for 2 of 3 staff (E#4 and E#5) observed in the OR (Operating Room), the Hospital failed to ensure that hand hygiene was performed appropriately.

Findings include:

1. The Hospital's policy titled, "Hand Hygiene" (undated), was reviewed on 4/24/19 and required, "... Use soap and water OR alcohol-based hand rub... After removing gloves..."

2. An observational tour of the Main OR (Operating Room) was conducted on 4/24/19, between 9:45 AM and 11:30 AM. At approximately 10:10 AM, OR suite #19 was observed being prepared for a surgical procedure. An Anesthesia Technician (E#4) was observed wiping down the medication and anesthesia carts with disinfectant. E#4 then removed a bag of trash from the OR suite. E#4 removed her gloves and returned to the OR suite to setup clean supplies on the medication cart without performing hand hygiene. At 10:29 AM, the Circulating Nurse (E#5) dropped a package of paired gloves on the floor. E#5 then, picked up the package from the floor and continued to gather and open supplies for the sterile field without performing hand hygiene.

3. An interview was conducted with the Vice President of Surgical Services (E#6) on 4/24/19, at approximately 11:47 AM. E#6 stated, "She (E#4) should have 'foamed' her hands (the use of alcohol-based hand rub) after she took out the trash and removed her gloves...it is (alcohol-based hand rub dispenser) right outside the door." E#6 stated that after picking anything off the floor, staff should wash their hands.

A. Based on document review, observation, and interview, it was determined that for 1 of 1 Circulating Nurse (E #5), the Hospital failed to ensure the sterility of the surgical field was maintained by staff. This could potentially allow for contamination of the sterile supplies for the case scheduled in Operating Room #19.

Findings include:

1. The AORN (Association of Perioperative Registered Nurses) guidelines, with a Copyright date of 2012-2019, were reviewed on 4/25/19 and required, "...Sterile items that are introduced to the sterile field should be opened, dispensed, and transferred by methods that maintain the sterility and integrity of the item and the sterile field... Medications and sterile solutions should be... transferred in a slow, controlled manner..."

2. An observational tour of the Main OR (Operating Room) was conducted on 4/24/19, between 9:45 AM and 11:30 AM. At approximately 10:10 AM, OR suite #19 was being prepared for a surgical procedure. At 10:29 AM, the Circulating Nurse (E#5) dropped a package of sterile paired gloves on the floor. E#5 picked up the package from the floor and proceeded to open the package over the sterile field, potentially contaminating the sterile field. At 10:39 AM, E#5 was observed pouring a medication solution into a container on the sterile field. E#5 was holding the bottle with her bare hand and was shaking the bottle to dispense the solution, potentially contaminating the sterile field.

3. An interview was conducted with the Vice President of Surgical Services (E#6) on 4/24/19, at approximately 11:47 AM. E#6 stated that items dropped on the floor should be discarded and that staff should never shake items over the sterile field. E #6 stated on 4/25/19 at 9:12 AM, that the Hospital follows AORN (Association of Perioperative Registered Nurses) guidelines for infection prevention.

B. Based on document review, observation, and interview, it was determined that for 1 of 1 Circulating Nurse (E#5) observed, the Hospital failed to ensure staff adherence to the surgical dress code.

Findings include:

1. The Hospital's policy titled, "Dress Code for Associates" (effective 6/26/18), was reviewed on 4/24/19 and required, "... Attire for Restricted and Semi-Restricted Areas... Hair Covering: All possible head and facial hair must be covered with clean protective headwear adequate in size to extend beyond the hairline..."

2. An observational tour of the Main OR (Operating Room) was conducted on 4/24/19, between approximately 9:45 AM and 11:30 AM. At approximately 10:10 AM, OR suite #19 was being prepared for a surgical procedure. At 10:26 AM, setup of the sterile field began while the Circulating Nurse (E#5) had approximately 3 inches of hair exposed from her surgical cap on both sides of her neck.

3. An interview was conducted with the Vice President of Surgical Services (E#6) on 4/24/19, at approximately 11:47 AM. E#6 stated that the expectation is for all hair to be covered when staff are in the operating room area.