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Based on observation and interview, it was determined the facility failed to maintain the fire and smoke rated barrier in 7 (above the fire-rated doors: in Medical/Surgical (Med/Surg) area near Room 133, at the entrance to the Rehabilitation Center, at the entrance to the Women's Center, near the waiting area in the Women's center, near the Sterilizer Mechanical Room, at the entrance to Radiology, and between Administration and the public restrooms) of 11 areas observed by protecting penetrations in the barrier with a system or material capable of limiting the transfer of smoke. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:

A. While touring the facility with the Director of Maintenance on 02/08/2017 at 1055, the following areas were not sealed with a system or material capable of limiting the transfer of smoke from one side of the barrier to the other:
1) One unsealed penetration through the smoke barrier above the fire-rated doors in the Med Surg. Area near room 133.
2) Five penetrations in the smoke barrier above the fire-rated doors at the entrance to the Rehabilitation Center.
3) Two unsealed penetrations in the smoke barrier above the fire-rated doors at the entrance to the Women's Center.
4) One penetration in the smoke barrier above the fire-rated doors near the waiting area for the Women's Center.
5) Four penetrations in the smoke barrier above the fire-rated doors near the Sterilizer Mechanical room.
6) Two penetrations in the smoke barrier above the fire-rated doors at the entrance to Radiology.
7) Two penetrations in the smoke barrier above the fire-rated doors between Administration and the public restrooms.
B. During the tour, the Director of Maintenance verified the penetrations were not sealed with a material capable of limiting the transfer of smoke from one side of the barriers to the other.

Referenced code: NFPA 101; 2012 edition, Section 8.4.4.1. See K300.

Based on observation and interview, it was determined the facility failed to insure there was no impediment to closing the fire-rated door at the entrance to radiology. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that the fire-rated door would fully close in the event of a fire and smoke event.

A. While touring the facility on 02/08/2017 at 1020, it was observed one of two fire-rated doors at the entrance to Radiology failed to fully close when tested.
B. During the tour, the Director of Maintenance verified the door did not fully close when tested.

Referenced code: NFPA 101, 2012 edition, Section 8.3.3.3. See K363.

Based on observation and interview, the facility failed to provide positive latching hardware on one (General Storage Room) of three doors to rooms with hazardous or combustible materials within the surgical suite by using a roller latch on the door. The failed practice had the potential to affect all patients, staff and visitors due to the potential spread of fire and smoke due to the potential failure of the roller latches to maintain the doors in the closed position in the event of a fire. This was a continuing deficiency. Findings follow:

A. On a tour of the facility on 02/07/17 at 1310, it was observed the door to the General Storage Room in the surgical suite utilized a roller latch to secure the door.
B. During the tour, the Director of Maintenance verified the use of a roller latch on the door.

Referenced code: 42 CFR Section 482.41(b)(1)(ii). See K363.

Based on observation and interview, it was determined electrical panels in two (Operating Room #2 and electrical room in the Women's Center) of nine areas observed did not have a minimum of 36 inches (3 feet) working space in front of the panels because of equipment stored in front of the electrical panels. The failed practice had the potential to affect all patients, visitors, and staff because rapid access to the panels could not be gained in the event of an emergency. Findings follow:

A. While touring the facility on 02/07/17 at 1300, an infant warmer was observed stored in front of the electrical isolation panel in Operating Room #2.
B. While touring the facility on 02/07/17 at 1355, a ladder was stored leaning against one of five electrical panels observed in the electrical room in the Women's Center.
C. During the tour, it was verified by the Director of Maintenance the electrical panels were blocked.

Referenced Codes: NFPA 99, 2012 edition, Section: 6.3.2.1; NFPA 70, 2011 edition, Section: 110.26. See K911.

Based on observation, interview, review of policies and manufacturer's instructions, it was determined the Infection Control officer failed to prevent and control likely sources of infection in that manufacturer's instructions were not followed for high level disinfection (Cidex OPA -ortho-Phthalaldehyde Solution) related to minimum effective concentration (MEC) testing, temperature, and control testing in one of one scope reprocessing room. Patients had the likelihood of exposure to pathogenic microorganisms as the ability of the high level disinfectant solution to destroy pathogenic microorganism could not be assured. The failed practice was likely to affect any patient who had an endoscopy procedure. The findings were:

A. Observation on 02/07/17 from 0934-0940 of the endoscopy reprocessing room revealed Olympus brushes (re-usable) were placed in a container of Cidex OPA to be high level disinfected (HLD). The Cidex OPA solution was not tested for the MEC prior to placing the used brushes in the solution. The temperature of the Cidex OPA solution was not checked or monitored prior to use.
B. In an interview on 02/07/17 at 0934, Technician #1 stated "the concentration and temperature of the Cidex is checked one time at the beginning of the day." In an interview with the Surgery Manager on 02/07/17 at 1013 it was confirmed the temperature and MEC of the Cidex OPA were monitored one time per day only and control testing was not done when a new Cidex OPA test strip bottle is opened. The temperature was not monitored continuously or prior to use of the Cidex OPA solution to assure it was at or above the minimum temperature of 68 degrees Fahrenheit required for HLD. The MEC was not monitored prior to each use to determine if the solution was at or above the MEC of 0.3% as determined by the Cidex OPA solution test strips.
C. Policy and procedure review on 02/07/17 and 02/08/17 revealed:
1) Policy #6021, "High-level Disinfection of Endoscopes" revealed "devices are disinfected for the appropriate length of time and at the appropriate temperature as specified by manufacturer's instructions. Always follow the manufacturer's recommendations"
2) Policy #6120-0 NSC-EM-1, "Care and Cleaning of Instruments" revealed "Cleaning brushes will also be cleaned and high level disinfected or sterilized after each use."
3) Policy #6120-0 NSC-QA-5, "Monitoring Procedure for ortho-Phthalaldehyde Solution" revealed "Solution will be tested daily to assure appropriate concentration."
D. Review of the Manufacturer's label directions, Instructions for use and Cidex OPA solution test strip Quality Control Procedure on 02/07/17 revealed:
1) Manufacturer's label directions of Cidex OPA solution revealed : "Use Cidex OPA Solution Test Strips to monitor ortho-Phthalaldehyde concentration before each use to detect the MEC (0.3%)." "High Level Disinfection Manual Processing: High level disinfectant at a minimum of 68 degree Fahrenheit for a minimum of 12 minutes or higher to destroy all pathogenic microorganisms."
2) Cidex OPA solution HLD Instructions for Use revealed: "Manual Processing: High Level Disinfectant at a minimum of 20 degrees Celsius (68 degrees Fahrenheit). Cidex OPA solution is a HLD when used or reused, according to the Directions for Use, at or above its MEC as determined by Cidex OPA Solution test strips, with an immersion time of at least 12 minutes for a reuse period not to exceed 14 days." "Re-usage for Disinfection: The ortho-Phthalaldehyde concentration of Cidex OPA solution during its use-life must be verified by the Cidex OPA solution test strips prior to each use, to determine that the MEC of 3% is present. Cidex OPA Solution may be used and reused within the limitations indicated above for up to a maximum of 14 days. During Reuse, it is recommended that the Cidex OPA solution be tested with Cidex OPA solutions test strips prior to each use. This is to ensure that the Minimum Effective Concentration (MEC) of ortho-Phthalaldehyde is present. During the usage of Cidex OPA solution as a high level disinfectant, it is recommended that a thermometer and timer be utilized to ensure that the optimum conditions are met."
3) Cidex OPA solution Test Strips Quality Control Procedures revealed: "Testing Frequency: it is recommended that the testing of positive and negative controls be performed on each newly opened test strip bottle of Cidex OPA solution test strips. After this initial testing, is recommended that testing of freshly prepared positive and negative controls be performed on a regular basis as established by the facility quality control procedures and program. This testing program will serve to minimize errors between different users, use of outdated materials or product that has been improperly stored or handled."


Based on observation, and interview of Respiratory Therapy staff and review of manufacturer's label, it was determined the Infection Control officer failed to prevent and control likely sources of infection in that manufacturer's instructions for single use Sterile Water for irrigation was not followed. Failure to discard the sterile water after a single use did not follow manufacturer's instructions and did not assure patients would be protected from likely sources of infection. The failed process affected one of one (#4) patient observed and was likely to affect any patient who had respiratory therapy updraft treatment. The findings were:

A. Observation on 02/08/17 at 1430 revealed Respiratory Therapist #1 performed an updraft treatment for Patient #4 then proceeded to rinse the updraft nebulizer from a bottle labeled as "Sterile Water for irrigation". The label stated the sterile water was for single use and did not contain a bacteriostatic. At the time of observation, Respiratory Therapist #1 was asked how long the sterile water for irrigation was used and replied "It is used once open for 24 hours. I will throw this one away tomorrow at this time."
B. Review of the Equipment Cleaning Policy from the Director of Respiratory Therapy revealed "Updraft nebulizers are rinsed with sterile water, or tap water followed by alcohol if rinsing is needed and left to air dry between uses on the same patient".
C. In an interview with the Director of Respiratory on 02/08/17 at 1457 he confirmed the findings in A.


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Based on observation, review of sterile package labeling and interview, it was determined the Infection Control Nurse failed to prevent and control infections by not assuring sterile supplies (suction tubing) were not open and available for patient care in three of three (#2, #3 and #4) Operating Rooms (OR) toured. Failure to prevent the use of opened supplies for patient care did not assure the supplies remained clean and patients were not exposed to contaminants. The failed practice was likely to affect all patients admitted to the facility for surgery. Findings follow:

A. During a tour of Surgical Services on 02/07/17 from 1320-1355 with the Surgery Nurse Manager the following were observed:
1) In OR #2, an opened package of sterile suction tubing was observed connected to a suction liner. Review of package label revealed "Do not use if package is opened or damaged."
2) In OR #3, an opened package of sterile suction tubing was observed connected to a suction liner. Review of package label revealed "Do not use if package is opened or damaged."
3) In OR #4, three opened packages of suction tubing were observed connected to suction liners. Review of package label revealed "Do not use if package is opened or damaged."
B. During an interview with the Surgery Manager Nurse on 02/07/17 at 1348, she confirmed the findings in A and confirmed the suction tubing was connected by the staff to be used the following morning.

Based on clinical record review and interview, it was determined the facility failed to assure one of one (Patient #9) obstetric record reviewed had a history and physical examination performed within 24 hours or no more than 30 days prior to admission. Failure to have a history and physical assessment in the clinical record did not allow staff to have knowledge of health conditions that may cause additional risk to the patient prior to delivery or anesthesia. The failed practice affected Patient #9 and was likely to affect all obstetric patients in the facility. The findings were:

A. The clinical record review for Patient #9 on 02/08/17 at 1340 revealed Patient #9 was admitted to the facility on 02/5/17 at 1652. There was no evidence a history and physical examination was performed.
B. Registered Nurse #1 confirmed the clinical record did not have a history and physical examination documented on 02/08/17 at 1340 and stated "Medical Records said the history and physical had been sent to the physician's office for completion."

Based on clinical record review and interview, it was determined the facility failed to assure the time of the surgery was documented on the operative report for 2 (#4 and #5) of 12 (#4, #5 and #21-#30) surgical clinical records. Failure to document the time of the surgical procedure did not allow the facility to establish a time line of events and procedures that occurred during the patient's hospital stay. The failed practice affected Patient #4 and #5 and was likely to affect other surgical patients. The findings were:

A. Review of the operative report for Patient #4 and #5 on 02/09/17 revealed no time of surgery.
B. On 02/09/17 at 1015 in an interview with Registered Nurse #1 the findings in A. were confirmed.

Based on review of Anesthesia Policy and Procedure Manuals, clinical record review and interview, it was determined the facility failed to assure a post anesthesia evaluation was completed within 48 hours after surgery for 4 (#22, #23, #24 and #29) of 12 (#4-#5 and #21-#30) patient's with surgical procedures . Failure to complete the post anesthesia evaluation did not assure patients had been assessed for the absence or presence of anesthesia related complications and was likely to affect all patients admitted to the facility for surgery. Findings follow:

A. Review of surgical records for Patient #22, #23, #24 and #29 revealed no evidence of a post anesthesia evaluation within 48 hours.
B. Review of Anesthesia Policy and Procedures on 02/09/17 at 1002 revealed "At least one post-anesthetic visit will be recorded no longer than 48 hours post-anesthesia, describing the presence or absence of anesthesia related complications."
C. Findings in A were confirmed by interview with the Surgery Nurse Manager during clinical record review on 02/08/17 from 1245-1515.