HospitalInspections.org

Based on observation, interview, and review of facility policy, the facility failed to maintain a sanitary environment in one of one x-ray room; failed to ensure expired Pediatric defibrillator pads were not available for patient use for one of three crash carts; and failed to follow facility policy for hand hygiene for one of three injection observations.

The findings included:

Observation on 9/14/15 at 11:05 AM, in the X-ray room, revealed one x-ray led apron with the straps and bottom portion of the apron touching the dirty floor.

Interview with the Radiology Technician (RT) on 9/14/15 at 11:05 AM, in the x-ray room, revealed "...looks like the metal bar may be broken from the weight of the apron..." Further interview revealed the aprons were used by the staff during x-ray procedures and confirmed the aprons straps and bottom portion of the apron were touching the dirty floor.

Observation on 9/14/15 at 11:15 AM, in the x-ray room, revealed one unopened pre-packaged Pediatric Defibrillator pad on top of the crash cart with an expiration date of January, 2015.

Interview with Registered Nurse (RN) #1 on 9/14/15 at 11:15 AM, in the x-ray room, confirmed the Pediatric Defibrillator pads were expired and were available for patient use.

Observation on 9/16/15 at 10:30 AM, in the Emergency Department (ED) Cardiac Room, revealed RN #2 preparing an intravenous injection for a patient in the ED. Further observation revealed the RN donned gloves after preparing the medications for administration. Continued observation revealed prior to giving the injection the RN picked up dirty trash from the floor, threw the trash in the trash can, and continued to administer the medications without changing the contaminated gloves or sanitizing the hands.

Interview with RN #2 on 9/16/15 at 10:30 AM, in the ED hallway, confirmed the nurse failed to change the contaminated gloves or sanitize the hands after picking up the trash on the floor and prior to administering the medications to the patient.

Review of facility policy "Bloodborne Pathogens Exposure Control Plan" last revised 5/15, revealed "...Gloves are single use...replace gloves if torn, punctured, contaminated or if their ability to function as a barrier is compromised..."

Interview with the Infection Control Nurse on 9/16/15 at 1:30 PM, in the conference room confirmed the nurse failed to follow the facility's policy regarding the changing of contaminated gloves and medication administration.

Based on medical record review and interview, the facility failed to complete a discharge summary for one patient (#22) of twenty-three medical records reviewed.

The findings included:

Medical record review revealed Patient #22 was admitted to the facility on 1/22/15 with diagnoses including Community Acquired Pneumonia, Hypertension, Congestive Heart Failure, Atrial Fibrillation and Physical Deconditioning.

Medical record review of an admission History and Physical dated 1/22/15 at 7:56 PM, revealed "...Swing bed status for deconditioning...continue monitoring INR [lab test for blood thinners] heart rate BNP [blood test which indicates congestive heart failure] and Potassium..." Further review revealed "...1/24/15...will complete 10 days of abx [antibiotics] for pneumonia..."

Medical record review revealed the patient was discharged home on 1/30/15. Further review revealed no discharge summary was in the patient's medical record.

Interview with Registered Nurse #3 on 9/16/15 at 2:20 PM, in the conference room, confirmed there was no discharge summary in the patient's medical record.

Interview with the Clinical Director of Inpatient Services on 9/16/15 at 2:45 PM, in the conference room, confirmed there was no discharge summary in the patient's medical record.