HospitalInspections.org

Based on observation, policy review and staff interview, it was determined that for 4 of 8 patients (Patient #'s 1, 41, 45 and 49) observed receiving medications or biologicals (transfusion of red blood cells), hospital staff failed to prepare, administer and/or label the biologicals and medications according to established hospital policies/procedures and standards of practice. Findings included:

On 4/6/17 at 2:30 PM, Infection Control Manager A reported that the hospital followed the Association for Professionals in Infection Control and Epidemiology (APIC) guidelines.

The "APIC Position Paper: Safe Injection, Infusion, and Medication Vial Practices In Health Care (2016)" stated, "...Perform hand hygiene (clean hands with alcohol based hand sanitizer or with soap and water) before accessing supplies, handling vials and IV (intravenous) solutions, preparing or administering medications...Disinfect the rubber stopper of medication vials...with sterile 70% (percent) alcohol before inserting a needle..."

The hospital policy entitled "Intravascular Therapy and Devices" stated, "...IV tubing, IV bags, and bottles are to be labeled with date, time initiated...initials..."

The hospital policy entitled "IV administration set priming" stated, "...Be sure to follow infection prevention techniques, such as...hand hygiene...sterile technique when priming an IV administration set, to reduce the risk of infection....gather equipment...perform hand hygiene to prevent contamination...Be careful not to contaminate the port..."

The hospital policy entitled "Blood and blood product transfusion" stated, "...perform hand hygiene...Put on gloves...Prime the blood administration set...Perform a vigorous mechanical scrub of the vascular access device hub for at least 5 seconds using an antiseptic pad...Start the blood transfusion..."

A. Emergency Department
1. On 4/3/17 between 11:41 AM and 11:47 AM, the following was observed as registered nurse (RN) B provided care to Patient #1:

- removed gloves
- donned gloves
- disinfected IV site
- removed syringe from packaging
- inserted syringe needle into medication vial through the rubber stopper
- withdrew medication from vial into syringe
- injected medication into IV
- discarded syringe
- removed and discarded gloves
- returned to patient

RN B failed to:
- sanitize hands before preparing and administering medications
- disinfect rubber stopper of medication vial, prior to inserting needle into the vial

These findings were confirmed by Patient Care Services Director A on 4/3/17 at 11:48 AM.

B. Clinical Decision Unit 5th Floor
1. On 4/3/17 at 12:55 PM, the following was observed in Patient #45's room:

The label for the infusing IV bag of 2 gram Magnesium Sulfate lacked the following:
- date/time initiated
- nurse initials

This finding was witnessed and confirmed by RN C on 4/3/17 at 1:10 PM.

2. On 4/5/17 between 3:30 PM and 3:55 PM, the following was observed as RN C and RN D prepared and administered a transfusion of packed red blood cells to Patient #49:

RN D:
- touched med cart and IV pump
- clamped IV tubing
- disconnected IV solution and tubing from IV pump
- donned gloves
- hung an IV solution over the IV pump
- prepared the IV solution and tubing
- primed the tubing
- clamped tubing
- touched IV pump
- obtained unit of blood, attached to tubing and primed

RN D failed to:
- sanitize hands before preparing the IV solution and blood

RN C:
- touched cart
- donned gloves
- picked up thermometer and took patient's temperature
- removed gloves
- sanitized hands
- touched computer cart
- donned gloves
- disconnected the patient's IV
- handed the IV tubing to RN D
- took the alcohol prep packet from RN D
- removed alcohol prep pad from packaging
- used the alcohol pad to scrub the end of the transfusion tubing
- attached the transfusion tubing to the patient's peripheral IV

RN C failed to:
- sanitize hands before administering IV solutions and blood
- failed to scrub the IV hub with disinfectant before the blood transfusion was connected

On 4/6/17 between 2:30 and 2:35 PM, Infection Control Manager A confirmed that RN C and RN D had not followed the hospital's infection control practices.

C. Tunnell Cancer Center
1. On 4/3/17 between 11:41 AM and 11:58 AM, the following was observed as RN G prepared and administered IV medications for Patient #41:

- sanitized hands
- removed cap from medication vial #1
- inserted syringe #1 with needle into rubber septum and withdrew medication
- removed cap from medication vial #2
- inserted syringe #2 with needle into rubber septum and withdrew medication
- removed cap from medication vial #3
- inserted syringe #3 with needle into rubber septum and withdrew medication
- removed cap from medication vial #4
- inserted syringe #3 with needle into rubber septum and withdrew medication
- removed cap from medication vial #5
- inserted syringe #4 with needle into rubber septum and withdrew medication
- sanitized IV port on bag of IV solution
- diluted each medication syringe with IV solution
- removed needle from end of syringe #1
- sanitized IV port and administered medication from syringe #1
- removed needle from syringe #2
- administered medication from syringe #2 via IV port
- removed needle from syringe #3
- administered medication from syringe #3 via IV port
- removed needle from syringe #4
- administered medication from syringe #4 via IV port

RN G failed to:
- sanitize the rubber septum after removing cap and prior to withdrawing each medication

These findings were confirmed by RN F on 4/3/17 at 12:08 PM.

Based on observation, policy review and staff interview, it was determined that for 1 of 1 inpatient pharmacy and 1 of 3 outpatient drug storage areas, the hospital failed to follow accepted standards of practice for pharmaceutical services. Findings included:

The hospital policy entitled "Unusable and Outdated Drugs" stated, "...All drug storage areas of the hospital will be inspected monthly, including satellite pharmacies...for outdated drugs...improperly stored drugs...The Pharmacy staff member conducting the inspection will remove these products...Should nursing staff discover any of the above items in their areas, the pharmacy will be notified to pick up the times or they will be returned to the pharmacy noting the problem with the returned items..."

A. Observations in the inpatient hospital pharmacy on 4/3/17 at 10:30 AM and 1:30 PM revealed the following expired medications:
- Ten (10) TPA (tissue plasminogen activator) frozen syringes (expired: 3/28/17)
- Three (3) Gabapentin syringes (expired: 1/27/17)
- One (1) Amoxicillin Suspension 100 milliliters container (expired: 4/1/17)

B. Observations in the Beebe Outpatient Surgery Center drug storage area on 4/4/17 between 10:30 AM and 11:30 AM revealed the following:
- Eight (8) 1 liter bags of the intravenous solution "D5 (Dextrose 5%) Lactated Ringers" (expired: 3/31/17)

During an interview on 4/4/17 at 3:00 PM, Director of Pharmacy A:
- confirmed these findings
- reported that these medications should have been identified as expired and removed

Based on observation and staff interview, it was determined that the hospital failed to maintain the building in a manner to ensure the safety for 169 of 169 inpatients on 4/3/17. The hospital failed to meet the applicable provisions of the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (see the attached CMS-2567s referencing LSC deficiencies).

Based on review of documents, policy review and staff interview, it was determined that for 1 of 1 nutritional services area that provided food services, staff failed to perform twice daily equipment temperature checks to ensure the safety and well-being of patients. Findings included:

The hospital policy entitled "Equipment Temperature" stated, "...The AM (morning) and PM (evening) staff record the temperature of all refrigerators and freezers in the department upon opening and closing the department...team members are responsible for monitoring the temperature of the equipment at least twice daily and document..."

Review of Nutritional Services "Equipment Temperatures" logs dated between January 2016 and March 2017 revealed equipment temperatures were not checked at least twice daily in accordance with hospital policy.

Interview with Accreditation Specialist A at 12:22 PM on 4/7/17 confirmed this finding.

Based on observation and staff interview, it was determined that the hospital failed to meet the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association (see the attached CMS-2567s referencing LSC deficiencies).

Based on observation, policy review and staff interview, it was determined that the hospital failed to ensure that facilities, supplies and equipment were maintained to ensure an acceptable level of safety, quality and cleanliness in 15 of 19 patient care/support areas. Findings included:

The hospital policy entitled "Safety Management Plan" stated, "...will provide a functionally safe environment of care and manage staff activities to reduce the risk of injuries...Safe working conditions and practices are established by using knowledge of safety principles..."

The hospital policy entitled "Outdating Disposable Sterile Supplies" stated, "To establish guidelines for inspection and removal of outdated disposable sterile supplies..."

The hospital policy entitled "CODES - Emergency, Disaster Codes, Resuscitation Cart, and Equipment" stated, "...We have a responsibility to enhance safe, quality patient care by maintaining uniformity of all resuscitation carts and contents and to assure the safety to those performing defibrillation...Resuscitation carts are to remain locked at all times..."

The hospital policy entitled "Sanitation and Safety, and Environment of Care Inspection" stated, "...Department, safety and sanitation inspections will be conducted at least once a month by a designated team member, to detect any electrical, safety, sanitation, and fire hazard, and maintain cleanliness standards...To maintain a safe work environment for the team members and customers..."

The hospital policy entitled "Temperature Stability: Refrigerators and Freezers" stated, "...Temperature documentation, food/beverage rotation, and refrigerator cleanliness is the responsibility of the Patient Care Team Members..."

The hospital policy entitled "Cleaning of all Equipment" stated, "Staff at Tunnell Cancer Center will adhere to the Infection Control Manual policy for Cleaning Patient Care Equipment...Infusion Area: Beds/Chairs - Minimal Frequency to Clean - After each use..."

The hospital document entitled "Disposable Items" stated, "...it's the responsibility of the receiving unit to carefully check the package items for integrity and expiration dates prior to use..."

The hospital document entitled "2017 EOC (Environment of Care) Environmental Tours" stated, "...The organization conducts Environmental Tours to identify environmental deficiencies, hazards and unsafe practices...Any deficiencies found needs to be corrected by director/manager. Are all medication secured...med cart/cabinets locked...Area is free of tape residue...free of dust...free of cracked caulking...free of dirty, stained or chipped ceiling tiles..."

A. During a tour of the Emergency Department (ED) on 4/3/17 at 11:36 AM, the following was observed:

1. Obstetrics and Gynecology Cart
- 35 expired Amnihooks (amniotic fluid hooks)
- 1 female catheter kit "Use By" date: 12/2014
- 1 unsecured 20 gauge intravenous (IV) catheter with needle attached

These findings were witnessed and confirmed by Patient Care Director A on 4/3/17 at 11:36 AM.

B. During a tour of the Beebe Surgical Center on 4/3/17 between 1:00 PM and 2:15 PM, the following was observed:

1. Neonate/Pediatric Crash Cart - lock broken
2. Adult Crash Cart - oxygen tank not full, reading 1500 - 1800 psi (pounds per square inch)

Interview with Respiratory Director A on 4/7/17 at 12:02 PM revealed that if an oxygen tank was not at 2000 psi, it needed to be replaced with a full tank.

These findings were confirmed by Nurse Manager D on 4/7/17 between 1:09 PM and 2:15 PM.

C. During a tour of the Dietary Services Area on 4/3/17 between 11:40 AM and 11:48 AM with Director of Support Services A and RN (registered nurse) F, the following observations were made and confirmed at the time of discovery:

1. Food Storage Area/Pantry storage racks:
- debris under two metal storage racks
- cobwebs on bottom of one storage rack
- soiled towel

2. Walk in Refrigerator #2:
- brown sediment on left wall from ceiling to half way down the wall behind the metal storage rack of food

3. Kitchen:
- debris on floor under steamer
- rusty metal bracket on pipe

D. During a tour of the Tunnell Cancer Center on 4/3/17 between 11:48 AM and 12:21 PM, the following was observed:

1. Hallway by Medical Oncology Unit:
- dead bugs in the ceiling light

2. Pharmacy:
- chipped paint on the back wall

3. Infusion Patient Bedroom A:
- dusty stretcher base

These findings were confirmed by Physical Rehabilitation Services Director A on 4/3/17 between 11:48 AM and 12:21 PM.

E. During a tour of the Beebe Outpatient Surgery Center on 4/3/17 between 11:54 AM and 2:37 PM, the following was observed:

1. OR (operating room) #2:
- chipped wall paint

2. OR #4:
- chipped wall paint

3. Storage equipment room:
- business card taped on the Medtronic Fusion ENT (ears, nose and throat) and Coblator II Arthrocare ENT systems

4. OR #3:
- rust all around the bottom of the stool
- chipped wall paint

5. Storage Room #123:
- chipped wall paint
- plastic base wall molding was torn off from the wall

These findings were confirmed by Sterile Processing Technician A and Physical Rehabilitation Services Director A on 4/3/17 between 2:17 PM and 12:29 PM.

F. During a tour of the Beebe Endoscopy Center on 4/4/17 between 8:56 AM and 9:43 AM, the following was observed:

1. Endoscopy Unit patient bathroom:
- chipped wall paint

2. Patient Room #4:
- damaged dry wall and chipped paint
- holes in the dry wall

3. Patient Room #1:
- stain on walls

4. Patient waiting area bathroom:
- rusted ceiling grid
- damaged and cracked dry wall
- paint stain on wall
- brownish stain around the toilet base
- caulk pulled away from sink

5. Patient waiting area:
- chipped wall paint
- unsealed open space around incoming water fountain pipe

These findings were confirmed by Physical Rehabilitation Services Director A on 4/4/17 between 8:56 AM and 9:43 AM.

G. During tours of the Beebe Main campus on 4/4 - 4/6/17, the following was observed:

1. Surgical Services: 4/4/17 between 11:17 AM and 12:16 PM
a. OR #7
- chipped wall paint

b. OR #8
- rust on the wheels of 3 carts
- rust on the base of kick bucket
- chipped wall paint
- rust on the wheel of stool
- business card taped on cabinet

c. OR Clean Supply Room
- expired Stryker Interventional Spine Inflator
- 10 packs of expired Cardiotomy Reservoir Cell Salvage
- 19 packs of expired Reservoir "Y" adapters

These findings were confirmed by OR Director A and Physical Rehabilitation Services Director A on 4/4/17 between 11:17 AM and 11:40 AM.

d. OR Sterile Process Clean Room
- rusted air vent

e. OR Sterile Process Dirty Room
- rusted air vent

These findings were confirmed by Sterile Processing Manager A and Physical Rehabilitation Services Director A on 4/4/17 between 12:14 PM and 12:18 PM.

2. Women's Health: 4/4/17 at 1:42 PM
a. Clean Storage
- 3 open packs of Kendall 40103 Foam Neonatal Electrodes without an open date label
- chipped wall paint in soiled utility Room #2122
- no caulking around visitor's restroom toilet

These findings were confirmed by Physical Rehabilitation Services Director A on 4/4/17 between 1:42 PM and 1:47 PM.

3. Nutritional Services: 4/4/17 at 2:45 PM
- rusted ceiling grid
- ice buildup in ice cream freezer
- rust on the refrigerator door
- rusted ceiling air vent

These findings were confirmed on 4/4/17 by Physical Rehabilitation Services Director A between 2:45 PM and 2:57 PM and Accreditation Specialist A between 3:12 PM and 3:40 PM.

4. Physical Rehabilitation Services: 4/4/17 at 3:01 PM
- dusty air vent in patient bathroom
- paint scraped off in the back room
- small holes in the wall closet
- chipped wall paint in the waiting area

These findings were confirmed by Lead Mechanic A and Physical Rehabilitation Services Director A on 4/4/17 between 3:01 PM and 3:06 PM.

5. Cardiac Testing: 4/4/17 at 3:16 PM
- small holes in the floor of supply room
- small holes in the wall in patient room
- chipped wall paint in Room #1282
- rusted bariatric support in patient bathroom
- small holes in patient bathroom
- dirty and dusty air vent in Room #1294
- broken ceiling tile in hallway

These findings were confirmed by Lead Mechanic A and Physical Rehabilitation Services Director A on 4/4/17 between 3:16 PM and 3:27 PM.

6. Emergency Department: 4/5/17 at 8:54 AM
- dusty air vent in restroom #1148A
- rusted bariatric supports in 2 bathrooms
- wall penetrations in waiting area
- rusty air vent at vestibule entrance
- sticky and yellowish color floor stain in Room #5

These findings were confirmed by Accreditation Specialist A and Lead Mechanic A on 4/5/17 between 8:54 AM and 9:23 AM.

7. 5th floor Nursing Unit: 4/5/17 at 9:29 AM
- rusted air vent in the hallway in front of Room #5071
- rusted water fountain drain

These findings were confirmed by Accreditation Specialist A and Lead Mechanic A on 4/5/17 between 9:29 AM and 9:40 AM.

8. 4th floor Nursing Unit: 4/5/17 at 9:50 AM
- dirty ceiling light above ice machine
- stained floor underneath patient toilet in Room #410
- caulking pulled away from restroom sink
- dusty vent in Room #3002

These findings were confirmed by Accreditation Specialist A and Lead Mechanic A on 4/5/17 between 9:50 AM and 10:52 AM.

9. Orthopedic Unit: 4/5/17 at 10:50 AM
- rusty wheels on supply room cart

These findings were confirmed by Accreditation Specialist A and Lead Mechanic A on 4/5/17 between 9:50 AM and 11:05 AM.

10. West Main Entrance Restroom: 4/6/17 at 9:50 AM
- rusted bariatric support in bathroom

This finding was confirmed by Lead Mechanic A on 4/6/17 between 9:51 AM and 11:05 AM.

Based on observation, job description review, policy review and staff interview, it was determined that for 4 of 12 patient care observations (Patient #'s 1, 11, 25 and 42), the infection control officer failed to ensure that staff adhered to infection control measures. Findings included:

The hospital job description entitled "Manager Infection Prevention" stated, "...Responsible for...compliance with all relevant policies/procedures and regulations...Responsible for oversight of the area of Infection Prevention, control, surveillance..."

On 4/6/17 at 2:30 PM, Infection Control Manager A reported that the hospital followed the Association for Professionals in Infection Control and Epidemiology (APIC) guidelines.

The "APIC Position Paper: Safe Injection, Infusion, and Medication Vial Practices In Health Care (2016)" stated, "...Perform hand hygiene (clean hands with alcohol based hand sanitizer or with soap and water) before accessing supplies, handling vials and IV (intravenous) solutions, preparing or administering medications...Disinfect the rubber stopper of medication vials...with sterile 70% (percent) alcohol before inserting a needle..."

The hospital policy entitled "Hand Hygiene Practices for the Prevention of Infection" stated, "...Decontaminate hands before having direct contact with patients...Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient...Decontaminate hands after removing gloves...Patients in isolation...wash hands prior to entry into patient's room..."

A. On 4/3/17 between 11:41 AM and 11:47 AM, the following was observed in the Emergency Department as registered nurse (RN) B provided care to Patient #1:

- removed gloves
- donned gloves
- disinfected IV site
- removed syringe from packaging
- inserted syringe needle into medication vial through vial's rubber stopper
- withdrew medication from vial into syringe
- injected medication into IV
- discarded syringe
- removed and discarded gloves
- returned to patient

RN B failed to:
- sanitize hands before preparing and administering medications
- sanitize hands after removing gloves
- disinfect rubber stopper of medication vial, prior to inserting needle into the vial

These findings were observed and confirmed by Patient Care Services Director A on 4/3/17 at 11:48 AM.

B. On 4/3/17 between 2:40 PM and 2:58 PM, the following was observed at Beebe Outpatient Surgery Center as RN H provided care to Patient #42:

- donned gloves
- prepared IV medication bottle and tubing
- placed label on IV bottle
- hung medication bottle on IV pole and fed tubing through pump
- wiped IV port and connected tubing
- touched IV pump
- disconnected tubing from patient
- cleared the air from the tubing
- disinfected the IV port
- reconnected the tubing to the IV port
- started infusion

RN H failed to perform hand hygiene:
- prior to donning gloves

This finding was observed and confirmed by RN F on 4/3/17 at 3:00 PM.

C. On 4/4/17 between 10:40 AM and 11:00 AM, the following was observed on the 3rd Floor Orthopedic Unit as certified nursing assistant (CNA) #1 provided care to Patient #11:

- moved bedside table from ante room to patient isolation room
- gowned and gloved prior to entering isolation room

CNA #1 failed to perform hand hygiene:
- after touching inanimate object
- before entering the patient's isolation room

These findings were confirmed by CNA #1 and Nurse Manager B on 4/4/17 at 11:00 AM.

D. On 4/4/17 between 2:05 PM and 2:10 PM, the following was observed on the 5th Floor Clinical Decision Unit as RN A provided care to Patient #25:

- touched medication cart
- prepared IV medication bag
- labeled IV medication bag
- disconnected old IV bag
- administered IV medication

RN A failed to perform hand hygiene:
- after touching inanimate object
- before administering medication

These findings were observed and confirmed by Nurse Manager C on 4/417 at 2:10 PM.