HospitalInspections.org

Based on document review and staff interview, the acute care hospital's administrative staff failed to submit their capital budget to the state planning agency. Failure to submit their capital budget to the state planning agency could result in the hospital developing and implementing projects that are not approved by the state planning agency. The hospital identified a census of 29 patients at the beginning of the survey.

Findings include:

1. Review of hospital capital expenditure budgets lacked evidence that hospital staff submitted their capital budgets for review by the the state planning agency.

2. During an interview on 3/1/22 at 11:20 AM, the Vice President of Quality confirmed that the hospital staff did not submit their capital budget to the state planning agency for review.

Based on document review and staff interviews, the hospital's administrative staff failed to follow their grievance policy and provide written notice to patients who filed a grievance of the hospital's follow up that contained steps taken in the investigation, the results of the investigation, a statement of confirmation or non-confirmation, any corrective action to be taken by the facility, the date of completion, and the contact person with the telephone number for 32 of 32 grievances reviewed. Failure to provide written notice that contained the required information could potentially result in hospital staff failing to address identified concerns regarding patient care, potentially resulting in life altering or life threatening situations for the patient. The hospital identified a census of 29 patients at the beginning of the survey.

Findings include:

1. Review of the policy "Grievance Policy (Report of Concern)", approved 2/2021, revealed in part, "...The written response should include the date the grievance was received, a summary statement of the grievance, the steps taken in the investigation, the results, a statement of confirmation or non-confirmation, any corrective action to be taken by the facility and still maintain confidentiality, the date of completion and the contact person with the telephone number..."

2. Review of "Report of Concern" information revealed the hospital lacked evidence that they had provided a follow up letter to the patient for 32 of 32 grievances received between 1/1/21 and 2/28/22.

3. During an interview on 3/3/22 at 4:20 PM, the Vice Presdient of Quality confirmed that the hospital had failed follow up with patients after they filed a grievance with the hospital as required by their policy.

Based on medical record review and staff interview, the acute care hospital's administrative staff failed to ensure a physician renewed the restraint order for the the management of violent or self-destructive behavior every 4 hours for 1 of 1 patients (Patient #1) in the Intensive Care Unit. Failure to renew the restraint order for the management of violent or self-destructive behavior every 4 hours could potentially cause a patient to be restrained longer than required, which could potentially result in injury or death. The hospital identified a census of 29 patients at the beginning of the survey.

Findings include:

1. Review of policy "Restraint/Seclusion/Protective Devices", approved 02/2011, revealed in part: "...The original orders for restraint or seclusion are limited to: 4 hours for adults violent or self-destructive behavior..."


2. Review of Patient #1's medical record revealed:

a. On 6/25/21, RN D documented that at 7:50 PM, Patient #1 had become agitated and spoke about jumping out the window. Patient #1 was re-directed and given Ativan (drug used to treat anxiety). Patient #1 sprang from the bed, ran to the window, pounded and the window twice and said, "I need to jump." Patient #1 was swinging their arms, and pulled out their Foley catheter (used to drain urine from the bladder). Nurses attempted to calm Patient #1 but Patient #1 was overpowering nurses. MD E was called to the room, and 3 behavioral health restraints were placed on Patient #1's limbs, and a soft restraint was placed on left lower extremity below the knee due to left ankle fracture.

b. On 6/25/21 at 8:14 PM, MD E wrote an order for "Restraint (Chemical/Physical)."

c. Patient #1 was in restraints from 6/25/21 at approximately 7:45 PM until 6/26/21 at 10:12 AM, approximately 12 hours without any additional physician orders to continue the restraint.


3. During an interview on 3/7/22 at 8:30 AM, the Vice President of Quality confirmed that the physician did not renew the order every 4 hours for adults displaying violent or self -destructive behavior as required by policy.

Based on document review and staff interview, the acute care hospital's administrative staff failed to inform each patient of their visitation rights, including that patients shall have the right, subject to their consent, to receive the visitors they designate, including but not limited to: a spouse, support person, domestic partner (including a same-sex domestic partner), another family member, or a friend, and the right to withdraw or deny such consent at any time. Failure to inform each patient of their visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment. The hospital identified a census of 29 patients at the beginning of the survey.

Findings include:

1. Review of the policy "Visitation," dated 2/2021, revealed that the policy failed to address that patients shall have the right, subject to their consent, to receive the visitors they designate, including but not limited to: a spouse, support person, domestic partner (including a same-sex domestic partner), another family member, or a friend, and the right to withdraw or deny such consent at any time.

2. Review of the undated patient handout "Patient Rights and Responsibilities," revealed the patient handout lacked information to inform patients of their right to receive the visitors they designate, including but not limited to: a spouse, support person, domestic partner (including a same-sex domestic partner), another family member, or a friend, and the right to withdraw or deny such consent at any time.

3. During an interview on 3/2/22 at 2:00 PM, the VP of Quality verified the Visitation Policy and the Patient Rights and Responsibilities patient handout lacked information to inform patients of their right to receive the visitors they designate, including but not limited to: a spouse, support person, domestic partner (including a same-sex domestic partner), another family member, or a friend, and the right to withdraw or deny such consent at any time.

Based on document review and staff interview, the acute care hospital's administrative staff failed to have a policy that required each patient be informed of their visitation rights, including that patients shall have the right, subject to their consent, to receive the visitors they designate, including but not limited to: a spouse, support person, domestic partner (including a same-sex domestic partner), another family member, or a friend, and the right to withdraw or deny such consent at any time. Failure to have a policy that fully informed each patient of their visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment. The hospital identified a census of 29 patients at the beginning of the survey.

Findings include:

1. Review of the policy "Visitation," dated 2/2021, revealed that the policy failed to address that patients shall have the right, subject to their consent, to receive the visitors they designate, including but not limited to: a spouse, support person, domestic partner (including a same-sex domestic partner), another family member, or a friend, and the right to withdraw or deny such consent at any time.

2. During an interview on 3/2/22 at 2:00 PM, the VP of Quality verified the Visitation Policy lacked information to inform patients of their right to receive the visitors they designate, including but not limited to: a spouse, support person, domestic partner (including a same-sex domestic partner), another family member, or a friend, and the right to withdraw or deny such consent at any time.

I. Based on observation, document review, and staff interviews, the Hospital administrative staff failed to ensure the hospital staff kept patient medical information secure from unauthorized access in 1 of 1 Health Information Management (HIM) Department. The Director of HIM identified approximately 12,000 patient medical records stored unsecured in the HIM department. Failure to keep patient medical information confidential could potentially result in theft of a patient's information and potentially result in identity theft or unauthorized release of a patient's private medical information.

Findings include:

1. Review of an undated Hospital policy "Corporate Integrity Program," revealed in part, "... Medical Records are strictly confidential, which means that they may not be released except with the consent of the patient ... no employee is permitted access to the medical record of any patient without a legitimate, job-related reason for do doing ...".

The Vice President of Quality provided an untitled report to show fob entrance into the HIM Department in February. Review of the report showed 1 EVS employee entered the department on 2/3/2022 at 4:35 PM, 6:21 PM, 6:23 PM and 6:32 PM, which is after the identified hours the department is normally staffed.


2. Observation of the HIM Department, on 3/1/22 at approximately 9:50 AM, with the Executive Lead Meditech Expanse, revealed a large work room with work stations for 5 employees and had shelving and desks which held patient's medical information. A large room adjacent to the work room, divided by an unlocked door, had a large, multiple row, open shelving unit which contained hundreds of patient medical records. The HIM department has 2 doors to the hallway, which can be secured by a key lock and a 3rd door to the hallway, secured by a key fob mechanism.

3. During an interview at the time of the observations, HIM Tech A reported the department is generally staffed on weekdays between 6:00 AM to 4:00 PM, and the area is locked when unstaffed. The Executive Lead Meditech Expanse reported HIM employees, Maintenance and the Administrative Staff have access to the HIM department. HIM Tech A reported housekeeping generally come in around 2:30 PM but may come in after staff are gone, or on a weekend, to vacuum or complete duties that may be disruptive to their work. HIM Tech A, HIM Tech B and HIM Records Clerk C reported the patient medical records received by their department included records from the Behavioral Medical Unit and Obstetrics, Lab and Radiology reports, therapies, patient face sheets, and a variety of other paper records. The HIM staff reported they have areas to secure patient medical records, prior to leaving for the day, but acknowledged they do not and the records are left unsecured on desks and other shelving. HIM Tech A reported the door between the 2 rooms is left unlocked and Executive Lead Meditech Expanse acknowledged staff entering the department would have access to patient medical records in both rooms whether they entered by a key or key fob.

4. During an interview on 3/1/22, at 10:15 AM, the Director of Materials Management/Environmental Services (EVS) confirmed housekeeping staff have a master key and fob access to the HIM Department, and are assigned to complete their assigned duties between 2:00 PM to 5:00 PM and are instructed to clean the area while staff are present.

5. During an interview on 3/2/22, at 9:10 AM, the Director of HIM reported she is also the Privacy Officer and acknowledged housekeeping staff would be a group of employees who would not need access to patient medical records as part of their position and should not have access to the records within the HIM department. She confirmed housekeeping staff should not have access to the information and should not be in the department when staff are not present.

6. During an interview on 3/2/22 at 9:25 AM, the Director of Materials Management/EVS confirmed EVS staff have access to the HIM Department with a master key and a fob and have the ability to enter the department during unstaffed hours and access by key would potentially go undetected. The Director of Materials Management/EVS identified 20 EVS employees with key and/or fob access to the HIM Department.


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II. Based on observation, review of policies/procedures, and staff interviews, the Hospital and Clinic staff failed to protect all confidential patient information from unauthorized access to faxes sent to unsecured fax machines with patient information in the Therapy room (Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), in Respiratory Therapy (RT), Radiology, and in 3 of 4 Clinics. Failure to keep patient medical information confidential could potentially result in unauthorized access of a patient's personal/medical information and potentially result in unauthorized release of personal information. The Vice President of Quality identified approximately 40 faxes per day in non-twenty four hour staffed hospital departments. The clinic Director of Clinic Services identified approximately 60 faxes per day throughout 4 clinics.


Findings include:

1. Observation on 3/2/2022, during a tour of the radiology department with the Director of Radiology, revealed 1 of 1 FAX machines located in an unlocked area.

2. During an interview on 3/2/2022 at 9:00 AM, the Director of Radiology revealed the Radiology Department areas are locked when the departments are closed, however, housekeeping staff have access to the locked departments and to clean after hours when the department does not have staff present.

3. Observation on 3/3/2022 during a tour of Physical Therapy, Occupational Therapy, Speech Therapy, Respiratory Therapy revealed 2 of 2 FAX machines in an unlocked area.

4. During an interview on 3/3/2022 at 9:35 AM, the Lead Receptionist of PT, OT, ST indicated housekeeping staff have access to the PT, OT, ST department when the department does not have staff present.

5. During an interview on 3/3/2022 at 10:35 AM, the Director of Respiratory Therapy indicated housekeeping staff have access to the Respiratory Therapy department when the department does not have staff present.

6. Observation on 3/3/2022, during a tour of the Carroll medical clinic revealed 1 of 1 FAX machines located in an unlocked area.

7. During an interview on 3/3/2022 at 11:00 AM, the Director of Clinical Services indicated housekeeping staff have access to the medical clinic when the department does not have staff present.

8. Observation on 3/7/2022 during a tour of Manning, Westside, and Coon Rapids medical clinics revealed 3 of 3 FAX machines located in an unlocked area at each clinic location.

9. During an interview on 3/7/2022 at 11:30 AM, the Director of Clinical Services indicated housekeeping staff have access to each medical clinic when the department does not have staff present.

Based on observation, document review, and staff interview, the Hospital's administrative staff failed to ensure the clinic staff removed outdated medication from 1 of 4 sample medication cupboards and 1 of 5 medication cupboards. Failure to remove outdated medications from the Hospital's supplies, available for patient use, could potentially result in the staff using expired medication for patient use after the manufacturer's expiration date, potentially resulting in the staff using medication on a patient after the date which the manufacturer guaranteed the sterility and efficacy of the medication. The Director of Clinic Services reported an average of 1150 patients per month.

Findings include:
1. Observations on 3/3/2022, at 11:10 AM, during a tour of the Clinic, revealed the following:

a. 2 of 2 sample bottle of Bystolic 20 mg tablet, 7 tablets in each bottle, expired 2/2022

b. 4 of 4 sample box Myrbetriq Extended Release tablets, 7 tablets each box, expired 12/2021

c. 5 of 5 sample box Ubrelvy 100 mg tablet, 1 tablet per box, expired 1/2022

d. 11 of 11 sample box Ubrelvy 50 mg tablet, 1 tablet per box, expired 2/2022


2. Review of Medication Samples policy, last revised 10/2016, revealed in part " ...maintaining records associated with the acquisition, dispensing, ... entered into a log upon receipt which includes medication name, manufacturer, lot number, expiration date, ..."

3. Review of Clinic Expiration Log revealed Clinic Emergency, Office/Stock, Sample and Clinic supplies were checked on 2/11/2022 and signed by clinic RN.

3. During an interview on 3/3/2022 at the time of the observation, the Director of Clinical Services acknowledged the sample medication was outdated and clinic staff failed to remove the outdated medication from the sample and medication cupboard.

4. Observation on 3/3/2022, at 11:20 AM, during a tour of the Clinic, revealed 6 of 6 Ceftriaxone 250 mg single dose vial, expired 12/2021

5. During an interview on 3/3/2022, at the time of the observation, the Vice President of Quality acknowledged the medication was outdated and clinic staff failed to remove the outdated medication from the cupboard. The Vice President of Quality revealed the Clinic lacked a policy for checking clinic medications for outdates.

Based on observation, policy review, and staff interview, the Hospital x-ray staff failed to ensure staff secured 1 of 8 radiation cords (Fluoroscopy/x-ray room) to not allow staff access into the x-ray room during completion of radiological tests of patients. The Hospital x-ray staff reported completing an average of 65 exams per day for the hospital. Failure to secure radiation exposure cords could allow staff access to the x-ray room while performing and x-ray procedure and exposing staff to unnecessary radiation.

Findings include:

1. Observations during tour of the radiology department on 3/2/2022 at 9:00 AM, with the Director of Radiology, revealed 1 of 1 unsecured exposure cord in the fluoroscopy/x-ray room for the Radiology Department which allowed a staff member to enter approximately 3 feet into the fluoroscopy room and still activate the x-ray machine.

2. Review of the Hospital policy "Radiation Safety for Staff and Patients," dated last revised September 2021, revealed in part, "To provide a diagnostic or therapeutic procedure utilizing ionizing radiation following generally accepted procedures to maintain the dose "as low as reasonably achievable" (ALARA).

3. During an interview on 3/2/2022 at 9:15 AM, the Director of Radiology confirmed the staff failed to secure the radiation exposure cord and could allow to access into the fluoroscopy room for the Hospital during the fluoroscopy procedure.

Based on observation, document review, and staff interview, the Hospital's administrative staff failed to ensure the hospital had a preventative maintenance program to ensure all equipment is tested for performance and safety before initial use and to ensure all equipment is inspected, tested, and maintained to ensure their safety, availability, and reliability. Failure to have an effective preventative maintenance program could result in equipment failure or unsafe electrical equipment used by staff on patients and potentially culminate in patient harm and/or death. The Hospital administrative staff identified an inpatient census of 29 patients on entrance to the facility.

Findings include:

1. Medical Surgical Department (Med Surg) 46 of 46 hospital beds (41 of 41 VersaCare Beds, 4 of 4 Progressa Beds, 1 of 1 Stryker Epic 2 Beds).

a. Review of "Service Manual, Progressa Bed," revised 10/2021, revealed in part, "The Progressa Bed requires an effective maintenance program ...annual preventive maintenance (PM) and testing."

b. Review of "Service Manual, VersaCare Bed," revised 2/2012, revealed in part, "It is necessary for the VersaCare Bed ...recommend annual preventive maintenance (PM) and testing ..."

c. Review of "Service Manual, Stryker Epic-2 Bed" revision date unavailable, revealed in part, "Preventative maintenance should be performed at a minimum of annually ...more frequently based on ..."

d. Review of policy "Equipment Master Inventory" last revised 11/2005, revealed in part, "Equipment included in the master inventory will be inspected for all ...as set forth in the performance specifications of the manufacturer's service or installation manual ..."

e. Observation on 2/28/2022 at 11:00 AM revealed the Progressa, VersaCare, and Stryker Epic-2 Beds on the medical surgical and intensive care units lacked a maintenance or biomedical equipment sticker to indicate the beds had preventive maintenance performed.

f. During an interview on 3/1/2022 at 8:00 AM, the Vice President of Quality Management confirmed that preventative maintenance had not been completed on any patient beds in the medical surgical or intensive care units.

g. During an interview on 3/1/2022 at 8:35 AM, the Facilities Manager reported the patient beds are not covered under their bio-med contract. Facility maintenance staff conduct an electrical check when beds are put into use and would check again if a problem with the cord, etc. The Facilities Manager reported they are not trained on the Hill-ROM beds so do not conduct any checks of the electronic bed scale component.

2. Obstetrical Department (OB) called "The Birth Place" 10 of 10 OB Beds, (8 of 8 Hill-ROM Affinity Three Birthing Beds and 2 of 2 Hill-ROM VersaCare beds)

a. Review of "Service Manual, Affinity Three Birthing Bed and Affinity Four Birthing Bed from Hill-ROM" dated 2007, revealed in part, "The Affinity Three Birthing Bed...require an effective maintenance program...recommend that you perform semi-annual preventive maintenance (PM) along with quarterly battery check...'

b. Observation on 3/1/2022 at 1:10 PM revealed the Hill-ROM Affinity Three Birthing Beds in patient rooms 362 and 366 lacked a maintenance or biomedical equipment sticker to indicate the beds had preventive maintenance performed.

c. During an interview on 3/1/2022, at the time of the observation, the Obstetrical (OB) Director acknowledged the beds in patient rooms 362 and 366 had not been marked in any way to indicate preventive maintenance had been completed. The OB Director verified that none of the 10 beds in the OB department, "The Birth Place", (8 of 8 Hill-ROM Affinity Three Birthing Beds and 2 of 2 Hill-ROM VersaCare beds) had preventative maintenance stickers attached nor had preventative maintenance completed on them.

d. During an interview on 3/3/2022 at 8:09 AM, the Vice President of Quality Management confirmed that preventative maintenance had not been completed on any of the patient beds in "The Birth Place".

I. Based on observation, document review, and staff interview, the Hospital's administrative staff failed to ensure the staff removed outdated medication and supplies from the Medical Surgical and Emergency areas, including patient rooms, utility closets, nurse's stations, and crash carts. Failure to remove outdated medications and supplies from the Hospital's supplies, available for patient use, could potentially result in the staff using expired medications and/or supplies for patient use after the manufacturer's expiration date, potentially resulting in the staff using medication on a patient after the date which the manufacturer guaranteed the sterility and efficacy of the medication and supplies. The Hospital administrative staff identified the census on entrance was 29 patients.

Findings included:
1. Observation during a tour of the Medical Surgical Department on 2/28/2022 at 11:15 AM revealed the following outdated supplies:
a. In Medical Surgical Room 342
2 of 3 ChloraPrep One Step applicator, expired on 9/2021
8 of 8 Cotton Tipped Applicators, expired 6/2021
5 of 5 Adult Tongue Depressors, expired 10/2020
2 of 9 Surgical Lubricant 3 gm packet, expired 9/30/2021
1 of 1 Lubricating Jelly 3 gm packet, expired 10/2018
7 of 7 Adult Tongue Depressors, expired 10/2020
6 of 6 Adult Tongue Depressors, expired 11/2020

b. In Medical Surgical Room 343
4 of 4 Cotton Tipped Applicators, expired 3/2021
2 of 6 Surgical Lubricant 3 gm packets, expired 3/2021
2 of 2 Lubricating Jelly 3 gm packets, expired 5/2019
3 of 3 Iodine Prep Pad, expired 11/2019
4 of 9 Cotton Tipped Applicators, expired 5/2020
15 of 15 Adult Tongue Depressors, expired 11/2020
1 of 1 Adult Tongue Depressors, expired 10/2021
2 of 2 Adult Tongue Depressors, expired 6/2020
3 of 3 Iodine Prep Pad, expired 8/2021
1 of 1 Lubricating Jelly 3 gm packet, expired 5/2019
2 of 2 Surgical Lubricant 3 gm packet, expired 9/20/2021
1 of 1 Surgical Lubricant 3 gm packet, expired 9/30/2021
1 of 1 Surgical Lubricant 3 gm packet, expired 9/2019

c. In Medical Surgical Room 345
1 of 1 Surgical Lubricant 3 gm packet, expired 8/2020
1 of 1 Surgical Lubricant 3 gm packet, expired 3/2020
3 of 8 Adult Tongue Depressors, expired 11/2020
2 of 4 ChloraPrep One Step packet, expired 9/2021
1 of 18 Adult Tongue Depressors, expired 5/2020
1 of 18 Adult Tongue Depressors, expired 6/2020
1 of 12 Cotton Tipped Applicators, expired 8/2021
1 of 1 Surgical Lubricant 3 gm packet, expired 2/2019
1 of 1 Surgical Lubricant 3 gm packet, expired 9/30/2021
1 of 1 ChloraPrep single Swabstick, expired 9/2020
3 of 6 ChloraPrep One Step packet, expired 9/2021
1 of 9 Cotton Tipped Applicator, expired 4/2014
1 of 13 Adult Tongue Depressor, expired 5/2018

d. In Medical Surgical Room 357
1 of 13 Adult Tongue Depressor, expired 6/2020
6 of 13 Adult Tongue Depressor, expired 11/2020
2 of 2 Providine Iodine Prep pad, expired 3/2021
1 of 1 Providine Iodine Swabs x 3, expired 3/2021

e. In Medical Surgical Clean Storage Room
2 of 24 29Gx1/2" Insulin Syringe, expired 6/30/2021
4 of 24 29Gx1/2" Insulin Syringe, expired 12/31/2021
4 of 24 29Gx1/2" Insulin Syringe, expired 5/31/2021
4 of 24 29Gx1/2" Insulin Syringe, expired 11/30/2021
1 of 1 22Gx1" Insyte Autoguard Syringe, expired 10/31/2020
1 of 1 24Gx3/4" BD Insyte Autoguard syringe, expired 1/31/2021
1 of 60 Adult Tongue Depressors, expired 6/2020
1 of 60 Adult Tongue Depressors, expired 10/2020
2 of 2 20Gx1" Kendall Monojet Safety Needle, expired 11/2017
1 of 6 19Gx1 ½" Magellan Needle, expired 2/2020
11 of 11 20Gx1: Magellan Safety Needle, expired 2/2020
1 of 1 PullUp Probe Cover Kit 5"x48", expired 10/24/2021

f. In Nurse's Station Cupboard
2 of 7 29Gx1/2" Magellan Insulin syringe, expired 11/30/2021
1 of 7 29Gx1/2" Magellan Insulin syringe, expired 5/31/2021

g. In Medical Surgical Clean Storage
2 of 7 Extension Set 15", expired 4/1/2021

h. In Intensive Care Unit National Institute of Health Stroke Scale Cart
2 of 4 Duoderm 6x7 Triangle, expired 720/21
1 of 1 Brava Moldable Ring Coloplast, expired 2/23/2017
1 of 4 Marathon NoSting Cyanoacrylate Skin Protectant, expired 2/28/2021
1 of 4 Marathon NoSting Cyanoacrylate Skin Protectant, expired 9/2016
9 of 9 BBL Culture Swab Plus, expired 12/31/2021
2 of 3 Mineral Oil Enema, expired 6/2019
1 of 1 Pedialax Enema, expired 12/2021

i. In Crash Cart on Medical Surgical floor
1 of 2 OneStep Red Resuscitation Electrode, expired 5/4/2021

2. Observations during a tour of the Emergency Department (ED) on 3/1/2022 at 9:00 AM revealed the following outdated supplies:
a. In Emergency Department Red Crash Cart
3 of 3 BD Insyte-N Autoguard 24Gx6", expired 9/30/2021

b. In Emergency Department 2nd Crash Cart
1 of 4 8.5 ET tube, expired 1/16/2022
1 of 3 Vicryl Suture, expired 7/31/2021
1 of 2 0.9% NaCL 1000 ml, expired 10/2021
2 of 2 Lactated Ringers 1000 ml, expired 9/1/2021
1 of 1 Gammex Sz 7 Sterile Gloves, expired 1/1/2022
1 of 3 Gammex Sz 7.5 Sterile Gloves, expired 4/1/2021
2 of 2 Gammex Sz 6.5 Sterile Gloves, expired 7/1/2021
1 of 3 22Gx1" BD Insyte Autoguard syringe, expired 10/31/2021
1 of 3 22Gx1" BD Insyte Autoguard syringe, expired 7/31/2021
1 of 2 BD Insyte 14Gx1.75" Autoguard syringe, expired 7/31/2021
3 of 3 BD Insyte Autoguard 16Gx1.16" syringe, expired 9/30/2031


3. "The Birth Center" Obstetrical (OB) department Universe 355 deliveries in 2021

Observations on 3/1/2022 at approximately 1:10 PM, revealed the following expired items:

OB Room 362 supply drawer
5 of 5 medium sterile nitrile single exam gloves expired 8-2021

OB Crash Cart
1 of 1 Ambu CO 2 detector-adult expired 1-21-22


4. During an interview at the time of the observations, the OB Director acknowledged the items were outdated and should have been noted and replaced during the monthly outdate checks.

5. During an interview on 3/2/2022 at 8:55 AM, the Vice President of Quality Management acknowledged several outdates in both the Medical Surgical and Emergency Department, and stated the Hospital does not have a formal policy for checking outdated supplies.

6. During an interview on 3/1/2022 at 10:30 AM, the Director of Emergency Department, Cornary Care Unit, Pulmonary/Cardiac Rehab, Respiratory Therapy acknowledged several outdates in the Emergency Department and stated staff have assigned areas to check for outdates monthly but there is not a policy for checking outdates.




II. Based on observation, document review, and staff interview, the Hospital's administrative staff failed to ensure the hospital and 2 of 4 medical clinics ensured water temperatures in patient areas did not exceed 120 degrees Fahrenheit. Failure to routinely monitor water temperatures in patient access areas could potentially culminate in patient harm and/or death. The hospital administration identified an inpatient census of 28 patients on entrance.

Findings include:

1. Observation on 2/28/2022 on tour of medical surgical unit, room 318 patient sink water temperature125.2 degrees.

2. Observation on 2/28/2022 on tour of medical surgical unit, room 313 patient sink water temperature 127.5 degrees.

3. Observation on 2/28/2022 on tour medical surgical unit, room 305 patient sink water temperature 129.0 degrees.

4. Observation on 2/28/2022 on tour medical surgical unit, room 333 patient sink water temperature 133.6 degrees.

5. Observation on 3/1/2022 in medical surgical room 342 patient sink water temperature 135.6 degrees.

6. Observation on 3/1/2022 in medical surgical room 356 patient sink water temperature 132.4 degrees.

7. Observation on 3/7/2022 at Coon Rapids medical clinic, patient/visitor restroom sink water temperature 126.6 degrees.

8. Observation on 3/7/2022 at Coon Rapids medical clinic, patient room #1 sink water temperature 130.8 degrees.

9. Observation on 3/7/2022 Manning medical clinic, main patient exam room sink water temperature 129.7 degrees.


10. During an interview on 3/1/2022 at 8:35 AM, the Facilities Manager reported maintenance staff do not routinely check hot water temperatures. The Facilities Manager reported new electronic hot water temperature controls were installed and the set point was at 117 degrees Fahrenheit. The Facilities Manager reported that the control was decreased to 115 degrees Fahrenheit on 2/28/2022, after water temperature greater than 120 degrees Fahrenheit was noted on the medical surgical unit on survey entrance. The Facilities Manager reported his staff was performing some hot water temperature testing during a period when the old regulation system was faulting and before the new system was installed, but the water temperatures were not documented. The Facilities Manager reported that once the new water temperature controls were installed the staff no longer conducted water temperature testing.

Based on document review and staff interview, the acute care hospital's administrative staff failed to ensure the Governing Board appointed the Infection Preventionist professional who was responsible for the infection prevention and control program. Failure of administrative staff to ensure the Governing Board appointed the Infection Preventionist may result in an individual leading the program who does not have the appropriate credentials which could potentially negatively impact patient care. The hospital identified a census of 29 patients at the beginning of the survey.

Finding include:

1. Review of the Infection Control Committee meeting minutes from 5/21/21 to date revealed a new Infection Preventionist was leading the meeting on 2/9/22.

2. Review of the Governing Board meeting minutes from January 2021 to date revealed the Governing Board had not appointed a new Infection Preventionist.

3. During an interview on 3/2/22 at 2:00 PM, the Vice President of Quality confirmed that the Governing Board had not appointed the current Infection Preventionist.