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Based on observation interview and record review the facility failed to have emergency medications readily available when the pediatric emergency medication box had expired medications available for use and an opened endotracheal tube.

Findings include:

An observation during the tour of the facility operating room on 2/21/17 revealed the following expired pediatric emergency medications.

Dexamethasone 4 mg/ml had expired 12/16
Naloxone 0.4 mg had expired 11/16
4.2% Sodium Bicarb had expired September 2016
Atropine 1 mg/10 ml had expired 6/16

Further observation revealed the anesthesiologist's cart had an opened endotracheal tube available for use; it was not labeled when it had been opened and did not have a new expiration date.

During an interview on 2/21/17 Staff#18, Pharmacy Director stated, "I don't check the expiration dates for the medications in the OR...."

During an interview on 2/21/17 in the facility's operating room, Staff #9, Certified Registered Nurse Anesthesiologist stated, "I don't use that box...the tube is good for 30 days after it is opened..." Staff #9, CRNA confirmed the endotracheal tube was not labeled with an opened date.

Review of the facility provided document, Drugs and Biologicals (dated 4/6/16) reflected "Policy: To assure drugs and biologicals are well controlled and dispensed as ordered ...5. All drugs and biologicals shall be checked monthly by...the designated nursing staff for expiration dates...6. All outdated...drugs will be...disposed of..."

Staff #4, Director of Nursing confirmed the findings.

Based on observation, facility document review and interview, the facility failed to maintain the generator in safe operating condition; the facility failed to perform weekly and monthly generator checks.

Findings included:

Review of facility documentation labeled "Emergency Power Supply System" revealed one generator check on 1/16/17. There was no further documentation for 2016 or 2017.

In an interview with the plant operations manager, he stated, "These are all the logs I have. The person who runs the checks isn't here this week." When asked for a policy, none was provided.

The above was verified with the CEO on the afternoon of 2/21/17.

Based on review of facility documents, review of credentialing files and interview, the governing body failed to ensure the medical staff bylaws were implemented and enforced.

Findings included:

The medical staff bylaws stated in part, "6.6 Reappointment Process.
A. Purpose of Reappointment. The purpose of the Medical Staff reappointment process is the conduct of an appraisal to determine the suitability of continuing the Medical Staff membership and Privileges of each Member, and to determine if the Member's membership of Privileges should be continued, discontinued, revised or otherwise changed. The appraisal includes an evaluation of the Member's qualifications and demonstrated competencies to perform each task or activity within the applicable scope of Privileges."

Review of staff #6 and staff #9 credentialing files revealed no current delineation of privileges. In an interview with the health information manager on the morning of 2/21/17, the missing delineation of privileges was verified.

The above was confirmed in an interview with the CEO on the afternoon of 2/21/17.

Based on interview and record review the facility failed to develop and enforce policies for the cleaning and disinfection of the facility's transvaginal ultrasound.

Findings include:

During an interview on the morning of 2/21/17 in the facility's radiology department when asked how the transvaginal ultrasound probe was cleaned, Staff #26, Radiology Technician stated, "We spray it with Transeptic (a topical low level disinfectant spray)....we don't have a written procedure...."

During an interview on the afternoon of 2/21/17 in the facility's conference room when asked had the facility determined the level of disinfecting required and the procedure for cleaning the facility's transvaginal probe, Staff #27, Director of Radiology stated, "No....we have two contradictory instructions on how to clean the probe.....the ultrasound representative had discussed high level disinfecting ....we haven't written a procedure on the cleaning. ..."

During an interview on the afternoon of 2/21/17 in the facility's conference room when asked at what level should the transvaginal probe should be cleaned and after having read the Ultra Sound manufacturer's instructions manual Staff #4, Infection Control Nurse stated, "I think it should be high level disinfection...." When asked if Staff #4, as the infection control nurse, was involved with the develpment and decision on what level the transvaginal probe should be cleaned at Staff #4 stated, "No...I should be...."

Based on facility document review and interview, the facility failed to ensure adequate surveillance was conducted and data collected to monitor and address post-surgical infections.

Findings included:

"CDC [Centers for Disease Control]/NHSN [National Healthcare Safety Network] Surveillance Definition of Healthcare-Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting" stated in part "A superficial incisional SSI [Surgical Site Infection] must meet the following criterion: Infection occurs within 30 days after the operative procedures ..."

Review of facility infection control logs revealed the following:
· Patient #5 had a surgery date of 10/25/16 with a surveillance date of 11/21/16
· Patient #23 had a surgery date of 10/24/16 with a surveillance date of 11/21/16
· Patient #24 had a surgery date of 10/25/16 with a surveillance date of 11/21/16
· Patient #25 had a surgery date of 8/31/16 with a surveillance date of 9/28/16
· Patient #26 had a surgery date of 5/23/16 with a surveillance date of 6/22/16
· Patient #27 with a surgery date of 5/24/16 with a surveillance date of 6/22/16
· Patient #28 with a surgery date of 4/25/16 with a surveillance date of 5/25/16
These patients were assessed for post-surgical infections before the 30 day recommendation.

In an interview with the infection control director on the afternoon of 2/21/17, she confirmed the above.

Based on facility document review, medical record review and interview, the facility failed to ensure a nursing care plan was kept current and addressed the needs of each patient.

Findings included:

Facility policy titled "Care Plans" stated in part, "Nurses update and revise the care plan throughout the patient's admission."

Review of patient #17's medical record revealed patient #17 was admitted for vomiting and had a medical history of Diabetes. Nursing was monitoring blood glucose several times a day. The only nursing care plan found was "At risk for fluid volume deficit" none was found addressing glucose levels.

Review of patient #18's medical record revealed patient #18 was admitted for fever and was placed on antibiotics. The only nursing care plan was "At risk for fluid volume deficit" none was found addressing infection.

The above was discussed and verified in an interview on the afternoon of 2/17/17 with staff #4.