HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of nine patients with 31 clinical records reviewed. Based on policy review, clinical record review and staff interview nursing staff failed to follow hospital policy for blood administration for one of five sampled patients that received blood (#27).

Findings include:

- The CAH's policy for Blood/Blood Component Transfusion reviewed on 4/18/12 at 4:30pm, directed "...begin transfusion at 75ml (milliliter)/hr (hour) ...rate can be increased by 25ml/hr every 15 minutes not to exceed 200ml/hr..."

- Patient #27's clinical record reviewed on 4/18/12 at 9:00amm revealed an admission date of 11/2/11 with diagnosis of Anemia. The patient had low hemoglobin and the physician ordered a transfusion of four units of packed red blood cells. Patient #27's clinical record review revealed nursing documentation of the first unit of packed red blood cell began on 11/3/11 at 10:50am. The clinical record lacked documentation of the rate of administration for the first unit of packed red blood cells. Nursing documentation for the second unit of packed red blood cells indicated a start time of 11/3/11 at 2:35pm. The clinical record lacked documentation of the rate of administration for the second unit of packed red blood cells. Nursing documentation for the third unit of packed red blood cells indicated a start time of 11/4/11 at 11:45am at a rate of 100ml/hr. Fifteen minutes later the Registered Nurse (RN) increased the rate of infused to 125ml/hr. The clinical record lacked documentation of the rate of administration for the third unit of packed red blood cells after 12:00pm. Nursing documentation for the fourth unit of packed red blood cells indicated a start time of 11/4/11 at 3:20pm. The clinical record lacked documentation of the rate of administration for the fourth unit of packed red blood cells. The clinical record lacked evidence the RN followed the hospital's policy for the rate of infusion of the blood.

Administrative staff A and staff D interviewed on 4/18/12 at 10:35am acknowledged patient #27's clinical record lacked evidence of the rate of infusion for three units of packed red blood cells and unit number three began at a rate of 100ml/hr not the CAH's policy of 75ml/hr. Staff A indicated the RN failed to followed the hospital's policy for the rate of infusion of the blood.

The Critical Access Hospital (CAH) reported a census of nine patients. Based on observation, staff interview and documents review, the infection control officer failed to develop an active infection control system to identify, monitor, and implement infection control practices. The deficient practice affected one daily patient room cleaning, two of three glucometer uses (patient # ' s 13 and 30, one of six medication passes (patient #30), one of one wound dressing changes (patient #12) and one patient with oxygen extension tubing (patient #12).



Findings include:


- Observation of staff E cleaning room #119 on 4/17/12 between 10:15am and 10:30am revealed the following breaches in infection control practices regarding hand hygiene and preventing potential transmission of organisms for one patient room to another patient room. For example:

Staff E with gloved hands placed a cleaning caddy with supplies directly on the floor of room 119. Staff E cleaned the bedside table and counters of the room, picked up trash, picked up the supply caddy and left the room. Staff E sat the contaminated supply caddy on a cleaning cart in the hallway and carried the trash down the hall to the soiled utility room. Staff E returned to the cleaning cart and placed the contaminated caddy into the cleaning cart. Staff E entered room
#120 with the same pair of gloves then left the room without gloves, carrying trash in their unprotected hands. Staff E returned to the cleaning cart applied clean gloves and entered room #119 to sweep the floor. Staff E failed to perform hand hygiene and change gloves each time they enter or exited patient rooms. Staff E failed to clean the cleaning supply caddy that sat on the floor in the patient room.

Staff E, interviewed on 4/17/12 at 10:30am acknowledged they failed to perform hand hygiene each time they entered and exited patient rooms. Staff E acknowledged they sat the cleaning supply caddy on the floor of room 119 and failed to clean the caddy before placing the caddy in the cleaning cart. Staff E confirmed they would use the cleaning caddy in other patient rooms.

- Staff D, observed on 4/17/12 at 11:40am, entered patient #30 ' s room, a patient in contact isolation, to administer medications and performed an accucheck (a bedside test to check a patient's blood sugar level). Staff D entered the room, performed hand hygiene, put on a gown and gloves. Staff D assisted the patient with repositioning then started preparations to perform the accucheck. Staff D reached under their gown with their contaminated hand and pulled out their name badge to scan the badge with the glucometer. Staff D pulled their isolation gown back and reached into the pocket of their scrubs with their contaminated gloves for a paper and pen, replaced the paper and pen back into their pocket. Staff D laid the glucometer on the patient 30 ' s bedside table and obtains a blood sample for testing. Staff D placed the glucometer on their computer, pulled their isolation gown back and reached into the pocket of their scrubs for the paper and pencil with their contaminated hand and wrote something down, then placed the paper and pen back into their scrub pocket.

Staff D reached into a drawer of their computer with their contaminated gloves and obtained medications for patient #30. Staff D administered the medications then removed patient #30 ' s telemetry (a portable unit to monitor the heart) and placed the telemetry on the computer. Staff D then removed their gown and gloves performed hand hygiene, put on a clean pair of gloves, pick up the glucometer and the telemetry and left patient 30 ' s room without cleaning both machines.

Staff C, interviewed on 4/17/12 at 12:00pm acknowledged they reached under their protective gown with contaminated gloves and failed to clean soiled equipment before leaving patient
#30 ' s room.


- Patient #13 ' s clinical record reviewed on 4/17/12 at 9:00am revealed an admission date of 3/27/12 with diagnoses of hip replacement, diabetes and an infection with patient isolation. Staff K, entered patient #13 ' s room on 4/16/12 at 11:40am, and applied gloves and a gown. Staff K performed blood glucose monitoring for patient #13. Staff K obtained additional supplies from the clean supply cabinet in the room with the soiled gloves on their hands.

Staff I, interviewed on 4/17/12 at 3:30pm acknowledged the supply cabinet is a clean area and should not be touched with contaminated gloves.

- Patient #12 ' s clinical record, reviewed on 4/16/12 at 2:30pm, revealed a swing bed admission date of 4/3/12 with diagnoses including respiratory failure, infection, pneumonia and skin wounds. Staff F and G, observed on 4/17/12 at 9:30am entering patient #12 ' s room, a patient in droplet isolation, and prepared to change three wound dressings. Staff F and G put on protective gloves, gowns and facemasks. Staff F moved a box of protective gloves from the clean supply area in the patient ' s room and placed the box of gloves on the bedside stand, near the patient ' s head of bed. Staff F removed the dressing to the right lower leg, removed the gloves and put on another pair of gloves. Staff F cleaned the wound, removed the gloves and applied another pair of gloves. Staff F removed their gloves, put on another pair of gloves, took photos, measured the wound and applied a clean dressing. Staff F removed their gloves and did not perform hand hygiene.

Staff F then put on gloves and removed the dressing on the patient ' s left buttock. Staff F removed the gloves and applied another pair of gloves, without performing hand hygiene. Staff F cleaned the wound, applied wound gel to the wound and applied the dressing to the wound without changing gloves. Staff F remove the gloves and failed to perform hand hygiene.

Staff F applied another pair of gloves, removed the dressing to the left buttock, took a photo and measured the patient ' s wound. Staff F applied a clean dressing to the wound, then removed the gloves and failed to perform hand hygiene. Staff F put on another pair of gloves and placed the wound care supplies in a manila envelope. Staff F failed to perform hand hygiene after removing protective gloves eight times during the patient ' s dressing changes.

Staff G assisted staff F with the dressing changes, removing gloves four times without performing hand hygiene before applying another pair of gloves.

The CAH ' s policy titled "Handwashing", reviewed on 4/17/12 at 4:00pm, revealed, " It is necessary to perform hand hygiene immediately after gloves are removed " .

Staff J, the infection control officer, interviewed on 4/17/12 at 1:30pm, confirmed staff are to perform hand hygiene when protective gloves are removed.

- Staff F and G assisted patient #12 to the physical therapy (PT) treatment area on 4/17/12 at 10:00am. Upon arrival in the PT treatment area, staff G removed a 25-foot long oxygen tubing hanging from the wall oxygen outlet. The tubing attached to the patient ' s oxygen mask oxygen to deliver supplement to the patient. The tubing lay on the floor during the patient ' s PT treatment.

Staff J, PT director, interviewed on 4/17/12 at 10:00am, acknowledged the oxygen extension tubing is used by at least two inpatients while they are in the PT treatment area. Staff J acknowledged the two patients who are using the tubing are in isolation for respiratory infections.

Staff I, the infection control officer, interviewed on 4/17/12 at 11:35am confirmed the oxygen extension tubing is a single patient use item and must be discarded every 30 days.

- The information insert including in the oxygen extension tubing, reviewed on 4/17/12 at 11:35am, indicates the tubing is for single patient use only.

The CAH failed to develop an active infection control system to identify, monitor, and implement infection control practices.