HospitalInspections.org

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Based on record review, interview and policy review the facility failed to ensure performance improvement and sustainability in the area of sterile processing and ensure data collected from all hospital departments was used in the identification of opportunities for improvement and changes that will lead to improvements in care provided by the hospital. Findings:

Record review on 8/3-6/2020 revealed:

The Joint Commission Survey (the accrediting organization that conducts surveys for safety and performance improvement), conducted 8/14-17/18, final report dated 12/6/18, revealed the facility had deficiencies in sterilization processing (of instruments used during dental procedures at the clinics) at 1 of the sub-regional clinics (SRC).

The Quality Assurance Performance Improvement presentation, dated 6/26/20, revealed 3 of the 6 SRC had documentation errors with sterilization.

Review of the sterilization records from 6/20/20 revealed the SRCs continued to have documentation issues to ensure sterilization of the instruments.

During an interview on 8/4/20 at 8:30 am, when asked if all the sterile processing is done in the hospital, the Sterile Processing Department (SPD) Manager stated the processing for the hospital was done here. The processing for instruments in the SRCs, where dental procedures were performed, had not been consistent with sterilizations standards. In addition, staff had been writing on the outside of the package after sterilization, causing it to bleed through the package. During the interview the SPD Manager stated, due to the pandemic, he/she had been unable to conduct onsite performance activities within the past few months.

During an interview on 8/6/20 starting at 8:40 am, the Performance Improvement Administrator stated the facility had been working to improve instrument sterilization in the SRCs.
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Based on record review, interview, and policy review of the hospital's quality program, the hospital failed to ensure that aggregated data regarding patient medical errors was investigated and incorporated into the facilities quality program. Failure to systematically collect, measure, and assess data regarding potential medical errors limited the hospital's ability to improve patient outcomes. Findings:

Record review, on 8/5/20, of the past 12 months of the electronic reporting system, "Quantros", with the Performance Improvement Administrator (PIA), revealed the electronic reporting system was used by the facility to track unusual occurrences and events. Further review revealed, 439 of the reports were open and 150 reports were overdue.

Review of a report, due to be completed 7/28/20, revealed Patient #3 had received ibuprofen when it was a listed allergy. Further review revealed a nurse manager had signed off the report, but the pharmacy review was pending. There was no information on the investigation explaining how the event had occurred or any follow up conducted by the facility.

During an interview on 8/6/20 beginning at 8:40 am, the PIA stated when a Quantros report is submitted it sends an email to the assigned managers for that department and Risk Management.

During the review the PIA shared a submission from 2/2000. In the Quantros report the Reporter had expressed multiple concerns, which included a shortage of oxygen supplies in the emergency department. To PIA stated the reporter subsequently filed a grievance with the facility's accrediting organization due to the delay in response.

During the interview the PIA stated during last year, after the new facility opened, the department did not receive any reports.

When asked if a Quantros' report had been filed regarding the potential cross contamination of COVID-19 in the emergency department 7/22/20, that had been reported to both surveyors by emergency room staff. The PAI reviewed the cases and stated there was no record of anything related to cross contamination in the emergency room.

During a telephone interview on 8/6/20 at 9:30 am, the facility's Risk Manager (RM) was asked about the Quantros reporting system. The RM stated he/she assigned different profiles to staff who are most appropriate to do the investigation of the incident. The RM stated every incident should have been investigated and he/she would follow up on all of the incidents as well. The RM further stated the staff who are assigned to the incident have 2 weeks to complete the investigation and during this time they will get an email from the system every 2 days reminding them the event needed to be completed. In addition, the RM stated the Quantros incident reporting system began on 5/15/19 and the facility is in the process of revamping the system of how they assign a person to do the root cause analysis. The RM stated he/she was unaware of the overdue cases.

Review of the facility's policies revealed:

1. "Quantros Safety Event Reporting", dated 5/1/19, revealed "It is the policy of the Yukon-Kuskokwim Health Corporation (YKHC) to document and address all safety events, unusual occurrences, and near misses that occur on all corporate owned and leased property and wherever care and services are provided as a YKHC operation."

2. "On Quantros Safety Event Reporting", dated 5/1/19, revealed "Complete the Manager's General Investigation Follow Up and address any outstanding issues...

3. If no action is required or intervention was appropriate, note this in the Managers Investigation Follow Up section and sign the form. All Safety Events should be addressed and acknowledged by the manager before forwarding on to the next level. If there are no other managers required to review the Safety Event, forward it to Risk Management...

C. Risk Management

1. The Risk Manager reviews the Safety Events and contacts managers if additional information is necessary. The Safety Event should be a "snapshot" of the event which provides valuable information down the line that may no longer be available or would result in reliance on memory to determine the facts. The Risk Manager will assure the most complete information is documented on the Safety Event...

2. Additional information or supporting documentation should be attached to the Safety Event and marked 'Privileged & Confidential'.

3. Follow up information should be completed as soon as possible following an event and can be negotiated with the Risk Manager as needed.

4. Safety Events are tracked and kept in Quantros for reporting and analyzing purposes. The Risk Manager may prepare reports for various committees, work teams, investigations, trending and analysis.

5. The Risk Manager is available as a resource and may be consulted anytime regarding unusual occurrences or near misses."

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Based on observation, interview, and policy review the facility failed to employ methods for the prevention and control of transmissions of infections in the areas of 1) sharps disposal containers; 2) Legionella (pathogenic bacteria that can cause pneumonia)--water management plan; 3) cleaning medical equipment; 4) sterilization; 5) COVID-19 surveillance and mitigation; 6) cross contamination; and 7) environment. These failed practices created a risk of exposure and transmission of health-care-acquired infections in patients. Findings:

1) Sharps Disposal Containers

Based on observation and interview, the facility failed to ensure sharps and partially used narcotics and medications were disposed of in a manner to prevent potential diversion and/or sharps injury.

Observation in the Obstetrics Surgery Room on 8/4/20 at 8:30 am, revealed two 5-gallon sharps containers located on the floor. The tops were open, and the funnel valve used to prevent access was missing, leaving needles, a used drill bit, and partially used medications vials visible and accessible through the top. One needle container was more than ½ full and the other was more than ¼ full.

Observations of the used vials and syringes revealed they contained residue and had the labels: "Diprivan" used for sedation during general anesthesia for surgery or other medical procedures; "Succinylcholine" used to cause short-term paralysis as part of general anesthesia; "Ofirmev" (acetaminophen) injection; and "Atropine" injection- used to reduce saliva and secretions in the airway.

During an interview on 8/5/20 at 8:00 am, the Environmental Services (EVS) Manager stated EVS was responsible for replacing the sharp boxes in the facility. When asked about the sharps disposal containers missing the funnel valve and having an opening big enough to reach into, the EVS Manager stated sharps and medications should not be accessible once inside of a sharps disposal container.

During a telephone interview on 8/5/20 at 2:41pm, the EVS Manager stated Materials had ordered a different type of sharps container. The available funnel valve did not fit into the top of the new sharp containers.

During an interview on 8/5/20 at 4:50 pm, when asked about the sharps container in the Obstetrics Surgery Room, the Infection Control Preventionist (ICP) stated the using the open sharps containers was not acceptable.

2) Legionella Water Management Plan

Review of the facility's Legionella Water Management Plan, untitled and undated, revealed the "YKHC [Yukon Kuskokwim Health Corporation] Hospital Water Flow Diagram", was based on the old hospital diagram and did not list the emergency department and ancillary departments that were located in the old building and attached to the new 3-story building. The risk for stagnant water between the 2 buildings was not addressed.

Review of the multidisciplinary team, designated for the water management plan, revealed 4 of the 8 listed staff no longer worked at the facility.

The diagram did not include the behavior health, wellness center, optometry, pharmacy, and outpatient center departments, all located in the new building.

Observations during the survey on 8/4-5/20 revealed the outpatient department, the wellness department, the dental department, and inpatient had several rooms and units that had been decommissioned on the 1, 2, and 3rd floors.

Interview with the Interim Facilities Manager (IFM) on 8/5/20 at 9:00 am, when asked about the outdated diagram and water source identified in the facility's water management plan, the IFM stated the new water management plan was still a draft form. The IFM stated 4 of the staff of the multidisciplinary team no longer worked at the facility. The IFM stated the wells were no longer used as the hospital had been piped into the city's domestic water line.

The plan listed 8 ice machines that were to be emptied and disinfected monthly and shower heads and hoses were to have been emptied of stagnant water.

During the interview, when asked what types of tasks were performed related to the Legionella Water Plan, the IFM stated environmental services (EVS) runs the sinks in the unused rooms and facilities staff monitors the water temperatures and cleans the ice machines.

Review of the ice machine maintenance records, provided by the facility on 8/5/20, revealed work orders for the maintenance of 3 ice machines, 1 of the ice machine's work order was not completed, and the work order for 1 ice machine was completed 8/5/20.

During an interview on 8/5/20 at 3:30 pm, the ICP stated the Water Management Plan had not been revised since the facility moved to the new building over a year ago.

Reference: Guidelines for Preventing Health-Care--Associated Pneumonia, 2003. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR March 26, 2004 / 53(RR03); 1-36 ..."Maintain a high index of suspicion for the diagnosis of health-care associated Legionnaires disease and perform laboratory diagnostic tests (both culture of appropriate respiratory specimen and the urine antigen test) for Legionellosis on suspected cases, especially in patients who are at high risk of acquiring the disease (e.g., patients who are immunosuppressed, including HSCT or solid-organ-transplant recipients; patients receiving systemic steroids; patients aged >65 years; or patients who have chronic underlying disease such as diabetes mellitus, congestive heart failure, and COPD..."

3. Medical Equipment

During an observation on 8/4/20 at 4:30 pm, Staff #7 removed a stereoscope from his/her neck and used it listen to Patient #2's chest, while he/she placed a portable pulse oximeter (device that measures oxygen levels) on the Patient's finger. Staff #7 then placed the stethoscope back around his/her neck, documented the results in the computer, and after performing hand hygiene, collected the pulse oximeter and left Patient #2's room. Staff # 2 did not clean the stethoscope or pulse oximeter before or after exiting the room.

Review of the CDC Infection Control Recommendations for COVID-19 and YKHC Infection Preparedness Checklist", undated, revealed "All non-dedicated, non-disposable medical care equipment used for patient care should cleaned and disinfected..."

4. Sterilization

On 8/4/20 at 7:30 am, observation of the clean supply room, near the obstetrics surgery suite revealed several shelving units that contained sterilized instruments and clean supplies, used in surgical procedures.

Spot check of the instruments revealed 2 sealed pouches contained hemostats without a class 3, 4, or 5 sterilization indicator (tape or strips that indicate steam sterilization was adequate) and 4 sets of hemostats that were processed with the jaws closed (where the steam would not reach).

Observation of the sterilization processing revealed the department was currently housed in the former morgue of the hospital. During the observation, Sterile Processing Department (SPD) Staff #1 applied an ice vest (a vest packed with ice) to work in the instrument wash room, as the room was extremely hot without ventilation.

During an interview on 8/4/20 at 9:30 am, SPD Manager stated since he/she had completed training for sterile processing, he/she put a class 5 indicator in all of the sterilized pouches. The SPD Manager stated equipment should be processed in the open position so the steam can reach all parts of the instrument. The SPS Manager stated the instruments would need to be reprocessed.

The SPD Manager stated sterile processing being conducted in the former morgue was not optimal, as the instrument washing room did not have a pass through for instruments from the dirty to clean side and the washing room was so hot staff had to wear an ice vest.

When asked if all the sterile processing is done in the hospital, the SDP Manager stated the processing for the hospital was done there. The processing for instruments in the SRC (Sub-Regional Clinic), where dental procedures were performed, had not been consistent with sterilizations standards and staff were writing on the outside of the package after sterilization, causing it to bleed through the package.


5. COVID-19 (infections pandemic causing virus) Surveillance and Mitigation


During an observation on 8/4/20 at 9:30 am, on the unit Licensed Nurse (LN) #1 exited from behind the nurse's station walked down the hall towards room 2119 without a face mask on. When the LN observed the surveyor on the unit, he/she put his/her face mask and proceeded down the hall.

During an observation and interview on 8/4/20 at beginning at 4:30 pm, the Interim Facility Director (IFD) entered the conference room wearing a face mask with the top two ties tied and secured at the back of his/her head and the bottom two ties below his/her chin area missing. When asked about the missing bottom ties on the mask, used to properly secure the mask, the IFD disclosed he/she always has a drink in his/her hand and took a sip of the drink.

When asked about screening of staff and patients entering the facility, the IFD stated: 1) patients have to answer the screening questions and have their temperature checked; 2) staff who enter though the main facility door should have the screening questions and temperature check. The IFD further stated he/she purchased laser type thermometers for use all over the facility which cost a large amount of money.

The IFD stated with the construction of the new emergency department being completed staff entrances changed. Currently staff come in the main entrance, side door or back doors. He/she further stated he/she comes in a back door he/she has keys to and doesn't get screened. The IFD continued with he/she does not agree the situation (COVID 19 pandemic) is as bad as it's made out to be.

During a continuous observation on 8/5/20 from 6:50 am to 8:05 am, in the main lobby of the facility revealed:

At 7:25 am Staff #2 entered the facility with his/her face mask below his/her nose.

At 7:42 am Staff #5, with face mask off, walked from the information area vending machine location in the main lobby to registration door #4.

When the Staff entered door #4 he/she put his/her mask on as he/she walked to the exit door at the side of the facility and exited the building.

At 7:50 am, Patient #1 entered the facility through the main door, walked past the screening desk toward the information desk. As the person passed the area he was stopped by security and asked to put a face mask on.

At 7:57 am, Staff #3 entered the facility at the main entrance unmasked. He/she walked around the screening station past the screening staff remained unmasked to the hospital elevators where he/she entered the elevator unmasked to another level of the facility.

At 7:58 am, Staff #1 entered the facility at the side entrance with his/her face mask below his/her nose. The staff proceeded to the time clock area, past registration doors, and continued past the pharmacy toward the Emergency Department hall. During the observation Staff #1 did not move the top of his/her face mask over his/her nose.

During a continuous observation on 8/5/20 from 6:40 am to 8:30 am, in the main facility lobby, revealed all incoming staffs and patients (a total of 31 persons) had not received a temperature check. Thermometers were observed on/in the screening station carts.

During an this observation a total of 29 of these persons did not conduct any hand hygiene when entering the faciltiy. A hand sanitizer dispenser was located at the screening station which was not observed to be used by people entering the facility.

During the continuous observation on 8/5/20 from 6:40 am to 8:30 am, there was a touch registration device for patients to check in with. Throughout the observations, 5 patients used this device without being cleaned in between. The times of these observations occurred at 7:52 am; 7:57 am; 8:05 am; 8:23 am; and 8:28 am. The device was cleaned by a staff member at 8:30 am.

During an interview on 8/5/20 at 7:05 am, Certified Nurse Assistant (CNA) #1 was asked about staff screening to enter the facility. The CNA stated staff do not have their temperatures checked. He/she further stated the Security Staff (SS) might come over and ask questions about symptoms, but not on a consistent basis.

During an interview on 8/5/20 at 10:50 am, Staff #3 stated, he/she comes to work through the main door of the facility. The Staff stated SS asked screening questions but he/she never had his/her temperature checked. Staff #3 stated the temperature check might be for patients coming to the facility to be seen.


During an interview on 8/5/20 at 4:20 pm, Staff Screener #1, when asked about screening, stated he/she would ask questions if person has any symptoms, hand out masks, check every staff and patients temperature. When asked about the check in device, the Staff Screener stated he/she would clean the registration device after every patient, and used line marks on paper to keep track of how many people entered through there station. He/she further stated temperature checks started 3 weeks ago when they got the new thermometers. Staff Screener #1 stated he/she had training on the screening.

During an interview on 8/5/20 at 5:00 pm, the ICP stated temperatures should be taken for incoming persons and high touch areas should be cleaned.

"YKHC Standard Work Form", dated 4/9/20, "YKHC will require employees to wear face coverings or masks upon entry to the workplace." "Key Points...Members of the public are also requested to provide their own face covering for use when at a YKHC facility...Depending on availability, they will be given a mask to wear for the entire duration of their stay."

6. Cross Contamination

During a facility tour of the Emergency Department (ED) on 8/3/20 at 4:45 pm, the ED Manager stated during the tour of the unit, there had been a COVID 19 positive patient in a room. When the patient was moved to another facility the room was closed for a few days before it was cleaned, medications not used were disposed of in the units' regular medication room, and an emergency cart was brought into the room also being exposed to the virus.

During an interview on 8/5/20 at 5:00 pm, the ICP stated the room where the COVID 19 patient was seen in the ED was closed for 72 hours due to the EVS staff not knowing how to clean the area. The emergency carts and ventilator were stored in an adjacent area then cleaned. He/she further stated the staff didn't have terminal cleaning (deep cleaning needed for highly contaminated areas) experience.

Review on 8/6/20 of the facility policy "SCR Terminal Cleaning of Isolation Rooms During COVID-19 Outbreak", dated 4/3/20, revealed "If you can, dedicate medical equipment to patients with known or suspected COVID-19. b. When a patient is discharged or before using the medical equipment on another patient, you must disinfect using a hospital grade disinfectant...After discharge terminal cleaning may be performed by ESWs [environmental services workers]. They should delay entry into the room for...All other clinic rooms: 3.5 hours. b. ESWs should wear a gown and gloves while performing terminal cleaning. i. a facemask and eye protection should be added if splashes and sprays during cleaning and disinfection activities are anticipated or required..."
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