HospitalInspections.org

Based on record review, interview, and policy review, the provider failed to obtain a physician's order for a Cam boot (boot-like device used to protect foot and ankle injuries) for one of one sampled rehabilitation (rehab) in-patient (6) reviewed with a Cam boot. Findings include:

1. Review of patient 6's medical record revealed:
*He was admitted as a rehab in-patient on 12/26/14.
*He had been admitted to the rehab unit from the acute care hospital following a motor vehicle accident.
*He had multiple left-sided injuries.
*There was no physician's order for a Cam boot to be worn on his left leg.
*No documentation on his admission nursing assessment of a Cam boot.
*A 12/27/14 physician's progress note stated his left lower limb was in a Cam boot.

Interview on 1/7/15 at 10:00 a.m. with the director of rehabilitation nursing and registered nurse A confirmed:
*A physician's order should have been obtained for patient 6's Cam boot.
*The Cam boot should have been documented on his admission nursing assessment.

Review of the provider's October 2011 General Management of the Rehab Patient policy revealed:
*On admission from the acute care hospital admission orders were to have been completed and signed by the physician.
*On admission a registered nurse would perform an initial assessment.

Based on record review, interview, and policy review, the provider failed to identify a potential pressure area on admission and implement a comprehensive care plan for one of one sampled rehabilitation (rehab) in-patients (6) reviewed with a pressure ulcer. Findings include:

1. Review of patient 6's medical record revealed:
*He was admitted as a rehab in-patient on 12/26/14.
*He had been admitted to the rehab unit from the acute care hospital following a motor vehicle accident.
*He had multiple left-sided injuries.

Review of physician's progress notes regarding patient 6 revealed:
*A 12/27/14 note stated his left lower limb was in a Cam boot (boot-like device used to protect foot and ankle injuries).
*A 1/1/15 note stated:
-His Cam boot had been removed to examine his skin.
-He had eschar (dead tissue that falls off from healthy skin) from a remote pressure on the left heel area.
-The eschar had dark old purplish solid tissue around the outside with some softness in the center.
-The Cam boot showed no obvious pressure area.
-"I suspect this is old and greater than one weeks' duration from the exam [examination] today. This apparently was not noted on his admission to rehabilitation."

Review of patient 6's rehabilitation nursing plan of care revealed:
*On 12/26/14:
-Problem 5 alteration in skin integrity (condition) related to left thigh post op (operation) incision with staples, left anterior knee post op incision, left anterior thigh, and left clavicle staples.
-Interventions included "assess skin q [every] shift, skin care flip chart, document skin q shift, encourage good hydration, pressure relief, turn q 2-4 hours, change dressing as order, encourage good nutrition, remove staples as ordered."
-No documentation regarding the Cam boot.
*On 1/2/15:
-Problem 3 safety/risk for injury noted left Cam boot.
-Problem 5 alteration in skin integrity as above on 12/26/14. Interventions continued as above on 12/26/14. Additional note "1/1/15 pressure sore to left lateral heel. Consult for WCT (wound care team) sent. Comfy boot to left foot-cam boot discontinued."

Review of patient 6's incision and wound assessment revealed:
*Documentation on 12/26/14 at 12:40 p.m. and on 12/27/14 at 8:00 a.m. related to his left lower leg post op incision.
*Twice daily documentation from 12/27/14 at 10:37 a.m. through 1/1/15 at midnight related to left lower leg post op incision, left knee and thigh post op incision, left should post op incision, and left anterior upper thigh post op incision.
*On 1/1/15 at 4:43 p.m. pressure ulcer to left lateral heel noted.
-Eschar to outer area and blood blister in the middle.
-Unable to stage due to eschar.
-Cam boot removed and comfy boot applied to left foot.

Review of patient 6's wound care treatment plan revealed:
*On 1/2/15:
-"Staff reports they think the ulcer developed because he was wearing the cam walker in bed."
-"The ulcer was just noted since his rehab admission. In appearance, it looks like a deflated and drying blister."
*On 1/6/15:
-"With assessment, note flat, dry blood-filled blister to the left heel."

Interview on 1/7/15 at 10:00 a.m. with the director of rehabilitation nursing and registered nurse A regarding patient 6 revealed:
*Nursing charting was done by exception. If nothing had been observed there would be nothing documented.
*An initial nursing assessment of his skin had been completed on his admission, and no area on his left heel had been documented.
*His Cam boot had been ordered on 12/19/14 during his acute hospital stay.
*His Cam boot should have been documented on his initial nursing assessment.
*His Cam boot should have been addressed on his initial rehabilitation nursing plan of care.
*His left heel pressure ulcer might have been acquired during his hospital stay.
*There was no determination if the pressure ulcer would have been avoidable or not.

Review of the provider's October 2011 Interdisciplinary Plan of Care policy revealed charting on the patient's medical record would be comprehensive, precise, legible, and reflect an accurate account of the patient's condition. Care data would be documented in the development of an interdisciplinary plan of care.

A. Based on observation, interview, and policy review, the provider failed to ensure:
*Outside shipping containers were not used to store supplies in the clean supply storage room.
*Infection control practices were implemented to prevent potential cross-contamination of patient endoscopic equipment as evidenced by:
-Staff members after precleaning contaminated colonoscopes carried the scopes in their gloved hands dripping water on the floor from the soiled utility room to the Medivator (automated endoscope disinfection device) in the clean utility area for high-level disinfection (HLD).
-After HLD of colonoscopes staff members recontaminated the scopes by placing a First-step precleaning package and valves packaged from the manufacture on top of the colonoscope for use on scheduled procedures.
-Endoscopy technician (ET) D used his bare hands to place a high-level disinfected scope designated for a patient endoscopy procedure in an Oasis scope transport container.
-At the end of patient 63's colonoscopy procedure to prevent cross-contamination of environmental surfaces physician E did not perform hand hygiene prior to making a phone call in procedure room three.
-ET D and ET E did not perform hand hygiene with soap and water after completing precleaning of contaminated colonoscopy scopes.
-ET D did not perform hand hygiene after removal of his contaminated personnel protective equipment (PPE) and proceeded to complete clean tasks in the scope processing room.
Findings include:

1. Observation on 1/6/15 at 9:40 a.m. in the endoscopy clean supply room revealed two outside shipping containers with sterile supplies. Interview with the department manager at the time of the observation revealed normally shipping containers were not brought into or stored in the clean supply room. The department manager revealed outside shipping containers should have been removed in central supply. The department manager agreed the outside shipping container was a source of contamination by pests or other bacterial contaminants.

2. Observation on 1/6/15 at 10:57 a.m. in endoscopy room three revealed physician F finished patient 63's colonoscopy procedure, removed his contaminated gown and gloves, did not perform hand hygiene, and made a phone call. He then used soap and water for handwashing prior to exiting the room.

3. Observation on 1/6/15 at 11:00 a.m. in the endoscopic reprocessing area revealed ET D:
*Removed high-level disinfected colonoscopes from the Medivator and placed them in Oasis scope transport containers.
*He removed a First-Step precleaning package from a bin on the counter and a package of valves from the cabinet and placed both items on top of the high-level disinfected colonoscopes.

Interview with ET D at the time of the above observation revealed that was the normal process used to prepare scopes for patient use throughout the day.

Interview on 1/7/15 at 10:55 a.m. with the infection control coordinator revealed she was not aware staff members recontaminated high-level disinfected endoscopes prior to patient use by placing a First-Step and valve package on top of the scopes prior to use. She stated placing those items on the HLD scopes caused contamination of the high-level disinfected scopes.

Interview on 1/8/15 at 8:05 a.m. with the endoscopy department manager confirmed the above process recontaminated endoscopy scopes that had been high-level disinfected. He stated staff should not have used bare hands to handle high-level disinfected endoscopy scopes.

4.a. Observation on 1/6/15 at 12:20 p.m. in the endoscopy soiled utility room revealed ET D after pre-cleaning contaminated colonoscopy scopes in the soiled utility he exited that area, removed his PPE (contaminated gown and gloves) walked into the clean area of the scope processing room and began to lay clean towels on the counter. ET D did not perform hand hygiene prior to performing that task.

b. Observation on 1/7/15 at 8:30 a.m. of ET D revealed he entered the scope processing room carrying an Oasis scope transport container labeled soiled, entered the soiled utility room, left the contaminated scope to be processed, exited the soiled utility room, did not remove his contaminated PPE (gown and gloves), opened the door, and exited the scope processing area wearing his contaminated PPE.

c. Observation on 1/7/15 at 8:46 a.m. revealed ET D entered the scope processing room with a contaminated endoscope used to examine the esophagus and stomach for processing, used hand gel to complete hand hygiene, used his bare hands to place a high-level disinfected scope into an Oasis transport container, and exited the scope processing area. ET D was asked by the surveyor why he was not wearing gloves to handle the scope. ET D replied "What was the difference of putting the scopes in the clean Oasis transport tray and my use of hands. These are clean procedures."

d. Observations on 1/6/15 from 11:15 a.m to 12:20 p.m. and on 1/7/15 from 8:20 a.m. to 9:00 a.m. in the endoscopy processing room revealed ET D and ET E used hand sanitizer to complete hand hygiene after precleaning contaminated colonoscopes. ET D and E was not observed using soap and water to complete hand hygiene during the above timeframes.

5. Interview on 1/7/15 at 10:55 a.m. with the infection control coordinator revealed:
*To prevent cross-contamination of environmental areas staff working in the soiled scope processing room should have removed contaminated PPE prior to exiting the processing area.
*To prevent recontamination of endoscopes that were high-level disinfected staff should not have recontaminated by placing clean accessory items on top of the scopes.
*To prevent recontamination of high-level disinfected endoscopes staff should not have been handling scopes with their bare hands.
*She was not aware the Association of periOperative Registered Nurses (AORN) and the Society of Gastroenterology Nurses and Associates (SGNA) recommended staff should wash with soap and water after cleaning contaminated endoscopes.

Interview on 1/8/15 at 8:05 a.m. with the endoscopy department manager revealed:
*To prevent cross-contamination of environmental surfaces staff should have removed contaminated PPE prior to exiting the scope processing area.
*Staff should have performed hand hygiene after removal of contaminated PPE.
*Staff were taught to use hand gel upon entering and exiting the scope processing area. He was not aware AORN and SGNA recommended staff use soap and water for hand hygiene in the scope processing area.
*Staff should not have handled high-level disinfected scopes with bare hands.

Review of the provider's March 2014 Endoscope Reprocessing policy revealed:
*Endoscopic reprocessing followed SGNA and Olympus guidelines for scope reprocessing and AORN 2010 Perioperative Standards and Recommended Practices.
*The policy did not address:
-Avoidance of recontaminating endoscopes after high-level disinfection.
-Removal of contaminated PPE prior to exiting scope reprocessing area.
-Using soap and water to complete hand hygiene in the scope reprocessing area.

Review of the provider's October 2014 Hand Hygiene policy revealed:
*"When hands are dirty or contaminated with body substances, you should wash with soap and water."
*"If your hands are not visibly soiled, use an alcohol-based hand rub for routine cleaning of hands."
*"Clean hands after removing gloves."

Review of the Association of periOperative Registered Nurses, Perioperative Standards and Recommended Practices, 2014 Edition, Denver, CO, Cleaning and Processing Endoscopes, page 536, revealed "Hands must be washed after removing PPE. Perforations can occur in gloves, and hands can become contaminated when removing PPE."

Review of Society of Gastroenterology Nurses and Associates, Inc., Guideline for use of High Level Disinfectants & Sterilants for Reprocessing Flexible Gastrointestinal Endoscopes, 2013, Chicago, Ill, revealed "To avoid cross-contamination, change gloves and wash hands whenever moving from a dirty to clean task or environment."



20031

B. Based on observation, interview, testing, and policy review, the provider failed to ensure:
*Two of two emergency department (ED) wooden tower form holders were maintained cleanable and in good condition to prevent a possible injury.
*One of one ED bathroom used for urine collection was maintained:
-To prevent possible cross-contamination of specimens.
-To prevent possible contamination between patients.
*Three of three clean linen carts in the ED were completely covered to prevent possible contamination of the clean linen.
*Three of three patient positioning frames in the operating suite were kept in a cleanable, durable condition.
Findings include:

1. Observation on 1/6/15 from 1:30 p.m. to 3:00 p.m. of the ED revealed:
a. Two shelved wooden towers by the nurses' station and physician's charting area were used to hold ED forms. Those towers were the size of a large high school locker and held paper forms for use in the ED. The laminate on those wooden towers was cracked and broken. Large pieces of laminate the size of footballs was missing and exposed the wood. The cracked and broken laminate created sharp edges to the touch that could cause injury to the upper or lower limbs, hands, or patient's feet in a wheelchair. Interview with the vice president (VP) of professional services at the time of the observation confirmed that finding. He stated staff used those towers in case the electronic charting on the computers failed. He stated he was not aware of the condition of the towers but would have them repaired or replaced.
b. The public/patient/staff use bathroom by the nurses' station had stacks of urine specimen containers and cleansing towelettes. The shelf above the handsink held a cracked and broken small plastic container that held two by two and four by four unprotected gauze pads. Interview with patient care technician (PCT) C at the time of the observation confirmed those findings. He stated that particular bathroom was used for urine collection from patients. The gauze pads were used to "dry their private areas after using the cleansing towelettes." He stated that bathroom had been set up in that manner for over five years since he had worked in the ED. PCT C revealed no one was aware of what type of disease a patient might have in their urine. He stated "A patient may have MRSA [methicillin resistant staphylococcus aureus] [infectious disease] or E. coli [Escherichia coli] [infectious disease] and spread it around the bathroom, and no one would know." Interview with the VP of professional services at the time of the observation confirmed those findings in the bathroom. He stated he would talk with the director of ED to correct the problem.

Review of the provider's October 2014 Specimen Collection policy revealed:
"A.4. Use appropriate technique (avoid contaminating specimen) and appropriate collection devices, sterile container, and media must be used."

c. Three metal wheeled tables held clean linen for the ED. Those metal tables were partially covered with a sheet or towel. Interview with the VP of professional services at the time of the observation confirmed those findings. He stated he was aware clean linen must be completely covered to protect it from possible contamination.

2. Observation on 1/7/15 at 10:45 a.m. revealed three padded patient positioning frames on the floor in the corridor of the operating room suite. All three of those padded frames had cracks, rips, and tears in the vinyl pads that exposed the underlying foam rubber. Interview with registered nurse B at the time of the observation confirmed that finding. He stated he was not aware why those positioning frames were stored in the hallway. He was also unaware the pads on those frames were ripped and torn. He stated he would order new pads.

Based on observation, interview, record review, and policy review, the provider failed to complete one of seven sampled patient's (14) surgical permits according to the provider policy. Findings include:

1. Review of patient 14's medical record revealed
The patient had been admitted on 1/6/15 for a surgical procedure.

The informed Consent for Surgery and Procedure record revealed:
*Abbreviations used were "R" with a circle around it which had been clarified as right and also "MPT" for metatarsophalangeal joint (a joint of the foot).
-The definitions for right had been written under the abbreviation and initialed.
-The definition for MPT had been written off to the left side of the page and initialed.
-No date was written as to when the written definitions had been placed on the document.
*The consent had been signed by the patient on 1/5/15 at 10:07 a.m.
-The consent had been signed by the witness on 1/6/15 at 10:07 a.m.
-The consent had been signed by the physician on 1/6/15 at 10:33 a.m.

Review of the nursing progress notes revealed an entry on 1/6/15 at 11:05 a.m. that stated "Dr. _____ (name) in to write out procedure on surgical permit rather than use initials."
-There was no documentation if the form was updated in the presence of the patient.
-The consent did not indicate the time it had been changed.

Review of the provider's revised May 2005 Informed Consent for Invasive Procedures policy revealed:
*"Surgical or other Consent: Entries must be legible, written without abbreviation..."
*"Errors: If the consent form contains an error, a new consent form will be completed and signed prior to the procedure."

Interview on 1/8/15 at 9:10 a.m. with the surgery supervisor confirmed he would have expected a new consent form to have been completed.

A. Based on observation, interview, and policy review, the provider failed to ensure:
*Outside shipping containers were not used to store supplies in the clean supply storage room.
*Infection control practices were implemented to prevent potential cross-contamination of patient endoscopic equipment as evidenced by:
-Staff members after precleaning contaminated colonoscopes carried the scopes in their gloved hands dripping water on the floor from the soiled utility room to the Medivator (automated endoscope disinfection device) in the clean utility area for high-level disinfection (HLD).
-After HLD of colonoscopes staff members recontaminated the scopes by placing a First-step precleaning package and valves packaged from the manufacture on top of the colonoscope for use on scheduled procedures.
-Endoscopy technician (ET) D used his bare hands to place a high-level disinfected scope designated for a patient endoscopy procedure in an Oasis scope transport container.
-At the end of patient 63's colonoscopy procedure to prevent cross-contamination of environmental surfaces physician E did not perform hand hygiene prior to making a phone call in procedure room three.
-ET D and ET E did not perform hand hygiene with soap and water after completing precleaning of contaminated colonoscopy scopes.
-ET D did not perform hand hygiene after removal of his contaminated personnel protective equipment (PPE) and proceeded to complete clean tasks in the scope processing room.
Findings include:

1. Observation on 1/6/15 at 9:40 a.m. in the endoscopy clean supply room revealed two outside shipping containers with sterile supplies. Interview with the department manager at the time of the observation revealed normally shipping containers were not brought into or stored in the clean supply room. The department manager revealed outside shipping containers should have been removed in central supply. The department manager agreed the outside shipping container was a source of contamination by pests or other bacterial contaminants.

2. Observation on 1/6/15 at 10:57 a.m. in endoscopy room three revealed physician F finished patient 63's colonoscopy procedure, removed his contaminated gown and gloves, did not perform hand hygiene, and made a phone call. He then used soap and water for handwashing prior to exiting the room.

3. Observation on 1/6/15 at 11:00 a.m. in the endoscopic reprocessing area revealed ET D:
*Removed high-level disinfected colonoscopes from the Medivator and placed them in Oasis scope transport containers.
*He removed a First-Step precleaning package from a bin on the counter and a package of valves from the cabinet and placed both items on top of the high-level disinfected colonoscopes.

Interview with ET D at the time of the above observation revealed that was the normal process used to prepare scopes for patient use throughout the day.

Interview on 1/7/15 at 10:55 a.m. with the infection control coordinator revealed she was not aware staff members recontaminated high-level disinfected endoscopes prior to patient use by placing a First-Step and valve package on top of the scopes prior to use. She stated placing those items on the HLD scopes caused contamination of the high-level disinfected scopes.

Interview on 1/8/15 at 8:05 a.m. with the endoscopy department manager confirmed the above process recontaminated endoscopy scopes that had been high-level disinfected. He stated staff should not have used bare hands to handle high-level disinfected endoscopy scopes.

4.a. Observation on 1/6/15 at 12:20 p.m. in the endoscopy soiled utility room revealed ET D after pre-cleaning contaminated colonoscopy scopes in the soiled utility he exited that area, removed his PPE (contaminated gown and gloves) walked into the clean area of the scope processing room and began to lay clean towels on the counter. ET D did not perform hand hygiene prior to performing that task.

b. Observation on 1/7/15 at 8:30 a.m. of ET D revealed he entered the scope processing room carrying an Oasis scope transport container labeled soiled, entered the soiled utility room, left the contaminated scope to be processed, exited the soiled utility room, did not remove his contaminated PPE (gown and gloves), opened the door, and exited the scope processing area wearing his contaminated PPE.

c. Observation on 1/7/15 at 8:46 a.m. revealed ET D entered the scope processing room with a contaminated endoscope used to examine the esophagus and stomach for processing, used hand gel to complete hand hygiene, used his bare hands to place a high-level disinfected scope into an Oasis transport container, and exited the scope processing area. ET D was asked by the surveyor why he was not wearing gloves to handle the scope. ET D replied "What was the difference of putting the scopes in the clean Oasis transport tray and my use of hands. These are clean procedures."

d. Observations on 1/6/15 from 11:15 a.m to 12:20 p.m. and on 1/7/15 from 8:20 a.m. to 9:00 a.m. in the endoscopy processing room revealed ET D and ET E used hand sanitizer to complete hand hygiene after precleaning contaminated colonoscopes. ET D and E was not observed using soap and water to complete hand hygiene during the above timeframes.

5. Interview on 1/7/15 at 10:55 a.m. with the infection control coordinator revealed:
*To prevent cross-contamination of environmental areas staff working in the soiled scope processing room should have removed contaminated PPE prior to exiting the processing area.
*To prevent recontamination of endoscopes that were high-level disinfected staff should not have recontaminated by placing clean accessory items on top of the scopes.
*To prevent recontamination of high-level disinfected endoscopes staff should not have been handling scopes with their bare hands.
*She was not aware the Association of periOperative Registered Nurses (AORN) and the Society of Gastroenterology Nurses and Associates (SGNA) recommended staff should wash with soap and water after cleaning contaminated endoscopes.

Interview on 1/8/15 at 8:05 a.m. with the endoscopy department manager revealed:
*To prevent cross-contamination of environmental surfaces staff should have removed contaminated PPE prior to exiting the scope processing area.
*Staff should have performed hand hygiene after removal of contaminated PPE.
*Staff were taught to use hand gel upon entering and exiting the scope processing area. He was not aware AORN and SGNA recommended staff use soap and water for hand hygiene in the scope processing area.
*Staff should not have handled high-level disinfected scopes with bare hands.

Review of the provider's March 2014 Endoscope Reprocessing policy revealed:
*Endoscopic reprocessing followed SGNA and Olympus guidelines for scope reprocessing and AORN 2010 Perioperative Standards and Recommended Practices.
*The policy did not address:
-Avoidance of recontaminating endoscopes after high-level disinfection.
-Removal of contaminated PPE prior to exiting scope reprocessing area.
-Using soap and water to complete hand hygiene in the scope reprocessing area.

Review of the provider's October 2014 Hand Hygiene policy revealed:
*"When hands are dirty or contaminated with body substances, you should wash with soap and water."
*"If your hands are not visibly soiled, use an alcohol-based hand rub for routine cleaning of hands."
*"Clean hands after removing gloves."

Review of the Association of periOperative Registered Nurses, Perioperative Standards and Recommended Practices, 2014 Edition, Denver, CO, Cleaning and Processing Endoscopes, page 536, revealed "Hands must be washed after removing PPE. Perforations can occur in gloves, and hands can become contaminated when removing PPE."

Review of Society of Gastroenterology Nurses and Associates, Inc., Guideline for use of High Level Disinfectants & Sterilants for Reprocessing Flexible Gastrointestinal Endoscopes, 2013, Chicago, Ill, revealed "To avoid cross-contamination, change gloves and wash hands whenever moving from a dirty to clean task or environment."



20031

B. Based on observation, interview, testing, and policy review, the provider failed to ensure:
*