HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that for 1 of 1 restrained patients (Patient #30) in the sample, staff failed to conduct a face to-face within 1 hour of restraint initiation. Findings included:

The hospital policy entitled "Restraint Management" stated, "...The physician/LIP (Licensed Independent Practitioner) must see the patient face-to-face and document the need for the restraint within one hour after initiation of the intervention..."

Reviewed of Patient #30's medical record revealed:

1. Admitted 8/20/18 with diagnosis: Alcohol Withdrawal
2. Physician order for "Restraint initiate orders, Restraint/Seclusion - Violent" for restraints on 8/20/18 from:
4:55 AM to 8:54 AM
10:03 AM to 2:02 PM
3. No documentation that a face-to-face was performed at any time on 8/20/18

These findings were confirmed by Nurse Manger A on 8/22/18 at 10:30 AM.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 30 patients (Patient #23) in the sample, the registered nurse failed to supervise and evaluate the nursing care. Findings included:

The hospital policy entitled "Prevention and Treatment of Pressure Ulcers" stated, "...After admission assess skin for impairment...Assess all wounds for location, size (length x [by] width x depth)...Turn and position every 2 hours in bed..."

The hospital policy entitled "Patient Assessment Policy" stated, "...Nursing policies and procedures...define and guide elements of assessment/reassessment and priorities in providing nursing care to patients..."

Review of the electronic health record for Patient #23 (admitted 7/13/18) revealed:

1. Documentation of the following wound assessments:
7/17/18: buttock blister
7/18/18: right buttock 3 cm (centimeter) (length) x 1.5 cm (width), left buttock 1 cm x 1 cm
8/23/18: sacrum 5 cm (length) x 6.5 cm (width) x 1.5 cm (depth)

During an interview on 8/22/18 from 9:10 AM to 9:15 AM, Nurse Manager A confirmed there was no evidence of wound measurements between 7/18/18 and 8/23/18 (more than 4 weeks).

2. No evidence that the patient was repositioned every 2 hours between 8/4/18 at 2:00 PM and 8/20/18 at 1:22 PM.

This finding was confirmed by Clinical Liaison Nursing Informatics A on 8/22/18 at 11:00 AM.

Based on medical record review, policy review and staff interview, it was determined that for 4 of 4 organ and/or tissue donor patients (Patient #'s 21, 28, 32 and 37) in the sample, the medical record failed to contain accurate and/or complete information. Findings included:

The hospital policy entitled "Organ Donation Policy" stated, "...The Nurse Coordinator, the Nurse Manager or an RN (registered nurse) will complete Section I of the 'Certificate of Referral/Request for Anatomical Donation' for all patient deaths...If the patient meets the screening criteria for donation, the Nurse Coordinator, the Nurse Manager, or an RN completes Section II of the referral form and places the form in the Medical Record..."

The hospital policy entitled "Documentation Requirements in the Medical Records" stated, "Medical Record documentation...Accurate and complete recording of patient care and treatment is essential...All entries in the medical record must be complete..."

Review of medical records revealed:

1. Patient #21
a. "Certificate of Referral/Request for Anatomical Donation" form dated 4/13/18 contained the following conflicting documentation:

- Section I, Part D: "Patient does not meet criteria for any donation..."
- Section II, Part A: "Patient Meets Preliminary Criteria for Donation..."

2. Patient #'s 28 (4/1/18) and 32 (2/9/18)
a. "Certificate of Referral/Request for Anatomical Donation" form Section I, Part D "Preliminary Screening for Suitability" was incomplete.

3. Patient #37
a. No evidence of a "Certificate of Referral/Request for Anatomical Donation" form was found in the medical record.

These findings were confirmed by Nursing Director B on 8/21/18 between 2:45 PM and 3:48 PM.

Based on observation and staff interview, it was determined that the hospital failed to maintain the building in a manner to ensure the safety for 58 of 58 inpatients on 8/22/18. The hospital failed to meet the applicable provisions of the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (see the attached CMS-2567s referencing LSC deficiencies).

I. Based on observation, policy review and staff interview, it was determined that the hospital failed to ensure that facilities, supplies and equipment were maintained to ensure an acceptable level of safety, quality, and cleanliness in 10 of 20 patient care/support areas. Findings included:

The hospital policy entitled "Safety Management Plan" stated, "...is designed to ensure the health and safety of all staff, patients, and visitors..."

The hospital policy entitled "Infection Control Program-Plant Operations" stated, "...provide a hygienically clean environment by systematic inspection and preventive maintenance of equipment...Physical environment...All surfaces-floors, walls, and ceiling require inspection and repairs as necessary in order to maintain smooth, dry, clean surfaces...Replace or repair damaged structural surfaces..."

A. During an environmental tour on 8/21/18, the following observations were made and confirmed by Plant Maintenance Director A at the time of the finding:

10:43 AM: Patient Restrooms in Hallway by Wound Care Unit
- rusted vents on the door of men and women's restroom

10:50 AM - 10:59 AM: Dietary Services Area Kitchen
- eighteen (18) rusted ceiling vents
- one (1) ceiling tile missing above the spice racks
- small hole in the wall

11:03 AM - 11:17 AM: Emergency Department

1. Patient Restroom:
- rusted bariatric support
- chipped paint and bubbling paint on the side wall near the glass sliding door

2. Exam Room:
- rusted pipe underneath the sink

11:20 AM - 11:35 AM: Radiology Unit

1. Room F:
- rusted sink cabinets

2. Interventional Room:
- chipped wall paint

3. Room B:
- rusted casters on a moveable IV (intravenous) pole

12:56 PM - 1:09 PM: 6th North and 6th South Unit

1. Patient Rooms:
- unsecured toilet/plumbing access panel in patient room #'s 602, 636 and 638

2. Patient Restrooms:
- rusted bariatric toilet support in patient room #'s 617 - 619, 623, 626 and 628

1:30 PM - 1:55 PM: Labor and Delivery/Maternity Unit

1. Patient Rooms:
- chipped wall paint in patient room #'s 455 - 457

2. Special Nursery Room:
- chipped wall paint
- base wall molding detaching from the wall

3. Caesarean section (C-Section) Room #1:
- two (2) moveable IV poles with rusted casters
- two (2) moveable carts with rusted casters
- chipped wall paint

4. C-section Room #2:
- one (1) stool with rusted casters
- three (3) moveable carts with rusted casters

1:56 PM - 2:50 PM: Operating Rooms (ORs)

1. OR #4:
- rusted casters on a moveable cart
- four (4) rusted oxygen canisters

2. OR #6:
- one (1) rusted oxygen canister

3. OR #7:
- one (1) rusted oxygen canister
- one (1) rusted compressed air canister
- rusted casters on a moveable cart
- rusted Electrosurgical Generator & Monitor (Force FX [Trademark] Valleylab)

4. OR #11:
- moveable cart with rusted casters
- stool with rusted casters

5. OR #10:
- rusted stool seat
- rusted casters on two (2) movable carts
- supply boxes stored on carts

B. During an environmental tour of off-campus designated provider-based entities on 8/22/18, the following observations were made and confirmed by Director of Radiology A at the time of the finding:

9:34 AM - 9:43 AM: North Wilmington Women's Center
- two (2) broken ceiling tiles in the janitorial closet

10:05 AM - 10:20 AM: The Women's Place

1. Radiology Area Patient Restroom:
- chipped wall paint
- small holes in the wall

2. Patient Waiting Area:
- small hole in the wall

C. During an environmental tour on 8/23/18, the following observations were made and confirmed by Quality Assurance Nurse A at the time of the finding:

9:52 AM - 9:55 AM: Inpatient Dialysis Unit
- base wall molding detaching from the wall
- rusted air vents
- chipped wall paint
- light brownish color stains on the back wall near the window

II. Based on observation, policy review and staff interview, it was determined that for 6 of 6 patients in the 6th North patient care area on 8/21/18, the facility failed to ensure that emergency supplies were readily available. Findings included:

The hospital policy entitled "Code Response Policy/Emergency Equipment Maintenance" stated, "...Materials Management will be accountable for maintaining the stock and expiration dates of the remaining medical supply and equipment drawers..."

Review of the 6 North crash cart contents on 8/21/18 at 11:47 AM revealed a Portex® Cricothyroidotomy Emergency Airway Kit that expired in 6/2017.

This finding was confirmed by Nurse Manager A on 8/21/18 at 11:47 AM.

I. Based on observation, job description review, policy review and staff interview, it was determined that for 8 of 22 patient care observations (Patient #'s 4, 7, 8, 20, 23, 30, 35 and 36), the infection control officer failed to ensure that staff adhered to infection control measures. Findings included:

The hospital's job specification entitled "Infection Control Practitioner" stated, "...Position Summary...Conducts organization-wide Infection Control Surveillance, analyzes data...provides education to staff...develops and implements prevention activities and maintains relevant policies..."

The hospital policy entitled "Hand Hygiene" stated, "...Hand...Decontamination...hand wash...Alcohol-based Antiseptic Agent...is indicated before having direct contact with patients...Before inserting urinary catheters, peripheral vascular catheters or other invasive devices that do not require a surgical procedure...After contact with a patient's intact skin...non intact skin...wound dressings...if moving from a contaminate (sic) body site to a clean body site...After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient...After removing gloves...Other aspects of Hand Hygiene:...Gloves..."

The hospital policy entitled "Standard Precautions and PPE (personal protective equipment)" stated, "...Masks and Protective Eyewear...Proper hand washing or hand hygiene must be practiced after contact with infectious materials, even if gloves have been worn..."

On 8/22/18 at 2:50 PM, Nursing Director B reported that the hospital followed Lippincott Procedures "IV (intravenous) solution preparation, adding medications to the container" as the standard of practice for infection control which stated, "...For medication from a vial...Remove the vial's lid. Perform a vigorous mechanical scrub of the vial stopper using an alcohol pad. Allow it to dry completely...withdraw the medication..."

The hospital policy entitled "Cleaning and Disinfection of Workstations on Wheels" stated, "...Keyboards and mice (sic) on the Workstation on Wheels should be wiped down after using with a patient on isolation...The Workstation on wheels should NOT be taken into any isolation room..."

The hospital protocol entitled "Anesthesia Provider Checklist Protocol for Hand Hygiene" stated, "...spinals and epidurals...wash hands...or use alcohol-based cleanser prior to putting on sterile gloves..."

The hospital policy entitled "Nursing IV Medication Administration Guidelines" stated, "...Additional References...APIC (Association for Professionals in Infection Control and Epidemiology) position paper entitled "Position Paper: Safe Injection, Infusion, And Medication Vial Practices In Health Care (2016)". This APIC paper stated, "...Disinfect the rubber septum on all vials prior to each entry, even after initially removing the cap of a new, unused vial..."

The hospital policy entitled "Dialysis Procedures and Checklists" stated, "Contractor for Dialysis...will use the policy...agreed to...Once treatment is complete, the patient must completely vacate the dialysis station before the dialysis machine can be cleaned, disinfected, allowed to dry and set up for the next treatment...clean areas should be clearly designated for the preparation and handling and storage of medications and unused supplies and equipment...Clean areas should be clearly separated from dirty areas where used supplies, equipment or blood samples are handled or stored..."

A. On 8/21/18 between 11:58 AM and 12:08 PM, the following was observed in the Emergency Department (ED) as registered nurse (RN) A provided care to Patient #4:

- touched tray and supplies with ungloved hands
- donned gloves
- touched ED room door and door handle
- disinfected patient's arm
- inserted IV into arm
- removed gloves
- sanitized hands

RN A failed to sanitize hands:
- before donning gloves
- after touching inanimate objects
- before direct patient contact
- before insertion of an IV catheter

These findings were observed and confirmed by Nursing Director A on 8/21/18 at 12:08 PM.

B. On 8/21/18 between 2:42 PM and 3:04 PM, the following was observed in the Labor and Delivery Department as Physician A provided care to Patient #20:

- washed hands
- placed mask on face
- touched cart
- removed epidural kit
- touched light
- gathered other supplies and removed items from kit
- cleaned patient spine with betadine
- donned sterile gloves
- inserted epidural
- placed sharps in sharps disposal
- taped and secured epidural
- placed all sharps in sharps disposal
- placed trash in trash can
- removed sterile gloves
- washed hands

Physician A failed to sanitize hands:
- after touching inanimate objects
- before direct patient contact
- before donning sterile gloves

These findings were observed and confirmed by Quality Assurance Nurse A on 8/21/18 at 3:04 PM.

C. On 8/21/18 between 12:30 PM and 1:00 PM, the following was observed as RN F prepared medication to administer to Patient #35:

- donned gloves
- scanned vial
- touched computer mouse
- opened medication drawer and removed normal saline prefilled syringe and needle
- opened medication vial
- inserted syringe into medication vial and withdrew medication (Tordol)
- wiped medication administration port with alcohol

RN F failed to:
- sanitize hands after touching inanimate objects
- sanitize hands before direct patient contact
- disinfect rubber septum before inserting needle

These findings were confirmed with RN F on 8/21/18 at 1:00 PM.

D. On 8/22/18 between 8:40 AM and 9:15 AM, the following was observed as RN D provided wound care to Patient #23:

- sanitized hands
- gowned, gloved and entered room
- gathered supplies
- turned patient
- removed old dressing and discarded
- removed/discarded gloves
- donned gloves
- cleansed wound, dried with gauze, discarded used supplies
- removed/discarded gloves
- donned gloves
- applied topical ointment to wound and covered with dressing
- removed/discarded gloves
- removed/discarded gown and gloves
- washed hands
- exited room

RN D failed to sanitize hands after:
- removing gloves

These findings were confirmed with RN D on 8/22/18 at 9:15 AM.

E. On 8/22/18 between 2:50 PM and 3:00 PM, the following was observed as RN H inserted an IV access for Patient #36:

- sanitized hands
- elevated bed with bed controls
- donned gloves
- gathered and prepared supplies
- applied tourniquet to patient's arm
- wiped IV site with alcohol
- picked up IV needle/catheter and removed cap
- inserted needle/catheter and connected IV fluid
- removed tourniquet
- discarded trash
- removed gloves
- performed hand hygiene

RN H failed to sanitize hands:
- after touching inanimate objects
- before insertion of an IV catheter

These findings were confirmed by Nurse Manager A on 8/22/18 at 3:00 PM.

F. On 8/21/18 between 12:35 PM and 12:44 PM, the following was observed in the Intensive Care Unit (ICU) as RN G provided care to Patient #30:

- sanitized hands
- donned gloves
- opened packaging
- uncapped medication vial
- inserted needle into medication vial's rubber septum
- withdrew medication with needled syringe
- instilled medication into IV port

RN G failed to disinfect the medication vial's rubber septum prior to accessing with a needle

This finding was confirmed by RN G on 8/21/18 at 12:45 PM.

G. On 8/21/18 between 3:00 PM and 3:19 PM, the following was observed in the inpatient dialysis center as RN B provided care to Patient #7:

- sanitized hands
- donned gloves
- clamped dialysis tubing
- touched saline bag hanging on dialysis machine
- disconnected bloodlines
- removed gloves
- donned gloves
- untaped needle and removed needle #1
- applied gauze and tape to needle site
- untaped needle and removed needle #2
- applied gauze and tape to needle site

RN B failed to sanitize hands:
- after touching inanimate objects
- after removing gloves

This finding was confirmed by RN B and Nursing Director C on 8/21/18 at 3:45 PM.

H. On 8/21/18 between 3:20 PM and 3:40 PM, the following was observed in the dialysis center as RN B provided care to Patient #7:

- mixed bleach water for cleaning machine in a basin marked "dirty"
- obtained cloths and placed them in the bleach water
- cleaned dialysis machine with bleach cloths while the patient was still present in the station
- placed 2 used blue clamps and a wand into the basin marked "dirty"

RN B failed to:
- keep clean and dirty separated
- wait for the patient to exit the station prior to cleaning the station

These findings were confirmed by RN B and Nursing Director C on 8/21/18 at 3:45 PM.

I. On 8/22/18 between 11:27 AM and 11:33 AM, the following was observed as RN E exited Patient #8's room who was on contact isolation:
- removed gown and gloves at doorway
- sanitized hands
- workstation on wheels (WOW) removed from room and placed in hallway

RN E failed to follow contact isolation precautions:
- brought WOW into isolation room
- failed to clean WOW before removing from isolation room

These findings were confirmed by Nursing Director D on 8/22/18 at 11:33 AM.

II. Based on policy and document review and staff interview, it was determined that for 67 of 67 inpatients on 8/24/18, the hospital's infection control officer failed to ensure that water management policies included specific testing protocols and acceptable ranges for control measures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Findings included:

A. The hospital policy entitled "Infection Control - Maintenance, Testing, and Treatment of Cooling Towers and Domestic Water Systems" stated, "...Test hot water system monthly for...Free chlorine levels..."

The policy failed to include specific testing protocols and acceptable ranges for control measures.

B. During an interview on 8/24/18 between 2:00 PM and 3:35 PM, Infection Control Practitioner A reported that:
- per the document entitled "Legionella, low flow fixtures and Chlorine dissipation" dated 11/9/15, "...Chlorine...must be above 0.5 parts per million (ppm) of free chlorine in order to be effective against Legionella bacteria and other organisms in the water supply..."
- the testing level for chlorine should not drop below 0.5 ppm

C. Review of testing logs for the hot water system revealed areas where the chlorine levels were below the 0.5 ppm levels and no documented action was taken:
11/7/17: 3 areas (0.43, 0.35 and 0.45 ppm)
11/22/17: 1 area (0.4 ppm)
3/8/18: 1 area (0.48 ppm)
3/28/18: 1 area (0.44 ppm)
5/9/18: 1 area (0.17 ppm)

During an interview on 8/24/18 between 2:00 PM and 3:50 PM, Plant Maintenance Director A confirmed these findings.