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Based on observation, pharmaceutical standards of practice, and staff interview, this facility failed to
indicate when medications were opened in 1 of 1 anesthesia cart, failed to properly identify medications in 1 of 1 anesthesia cart, and used 1 of 1 anesthesia cart for storage of personal medications. Failure to date, identify, and properly store medications has the potential to affect all surgical patients at this facility including the 6 patients scheduled for procedures on the date of the survey.

Findings include:

Per the United States Pharmacopeial, 2008, "SINGLE-DOSE AND MULTIPLE-DOSE CONTAINERS
+ Beyond-use date 28 days, unless specified otherwise by the manufacturer, for closure sealed multiple-dose containers after initial opening or entry."

A tour of the surgical suite was conducted on 5/14/2012 at 10:25 a.m. accompanied by DON A. Pharmacist M was contacted to open anesthesia carts for inspection.

Cart 1 had the following open, undated multi-dose vials used for the purposes of anesthesia in the drawer: Rocuronium Bromide 50 milligrams (mg) per 5 milliliters (ml), Succinylcholine 200 mg, 20 mg/ml-3 vials; Sodium Chloride, and Dexamethasone 4 mg/ml.

Per Pharmacist M, the protocol at this facility is to date vials that are opened, and these vials should have a date on them and do not.

According to the Pharmacist for the State of Wisconsin, Succinylcholine is only good for 14 days once the vial is opened, while the remainder of the listed medications should be used within 28-30 days of opening.

Cart 2 contained a Ventolin inhaler (used for breathing problems) which was not labeled for a patient. Neither Pharmacist M or DON A could identify if the inhaler was for patient use or the CRNA's own use. Pharmacist M did say that if the inhaler does belong to the CRNA it should not be in the anesthesia cart.

Cart 3 contained an opened vial of Succinylcholine which was not dated and also held more fluid than a vial that was unopened from the manufacturer. Neither Pharmacist M or DON A could state why this vial would have more than the normal amount of fluid in it.

Cart 3 also contained a medication container with numerous medications in it with a CRNA's name on the container. Pharmacist M stated that these were the CRNA's personal medications and agreed they should not be in the anesthesia cart.

A phone interview was conducted with ICP I on 5/14/2012 at 11:30 a.m. Surveyor #26711 inquired if anesthesia carts were being monitored and ICP I stated that a couple of facility rounds were made over the past few weeks but anesthesia is an area ICP I has had difficulty getting to.

Based on observations, staff interviews, policy review, and nationally recognized guidelines from the Centers for Disease Control (CDC), this facility failed to safe guard patients and visitors from harmful chemicals kept in soiled utility rooms in 3 of 6 departments (Med/Surg, Intensive Care Unit-ICU, and OB); failed to ensure measures were taken to control and prevent infections and avoid cross contamination of patients during cares in 1 of 1 Surgery observation (Pt. #17); and failed to obtain an adequate amount of equipment for surgical cases to avoid rapid cycle sterilization. Failure to follow infection control practices affected all 10 patients in the facility during the time of the survey, and the 6 patients scheduled for procedures in the surgical suite.

Findings include:

The facility policy titled, "Hand Hygiene," dated 3/18/2011, was reviewed at the previous survey on 11/17/2011 at 10:55 a.m., stated on Page 1 of the policy, under the section "When to Practice Hand Hygiene: Whenever hands are visibly dirty or contaminated; Before: having contact with patients, putting on gloves, inserting an invasive device, manipulating and invasive device; After: having contact with patient's skin, having contact with bodily fluids or secretions, non-intact skin, wound dressings, contaminated items, having contact with inanimate objects near a patient, removing gloves."

Regarding flash sterilization, the CDC states in its Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008: Do not use flash sterilization for convenience, as an alternative to purchasing additional instrument sets, or to save time. Category II. 817, 962.

A tour of the facility was conducted between 10:56 a.m. and 11:40 a.m. accompanied by DON A. It was noted that the doors to the soiled utility rooms on Med/Surg, ICU, and OB continue to be unlocked and continue to have sani-cloths (a germicidal cleaning wipe which states to keep out of reach of children) in areas that could be reached by children if they were to enter these rooms.

In addition to the wipes the OB department also had Enzymatic detergent pre-soak for soaking of surgical instruments, and Vesta-syde instrument decontamination system packets, both which state to keep out of reach of children, in the soiled utility room.

DON A agreed that these chemicals should not be within access of patients/visitors.

Surgery
An observation of the pre-surgical process (prep of the patient) for Pt. #17 was conducted on 5/14/2012 at 11:40 a.m. accompanied by DON A.

CRNA L was observed to have dropped something, possibly a needle cap, on the floor and go to L's hands and knees under the surgical table to find it. CRNA L did not wash hands after getting up from the floor and proceeded to touch the anesthesia cart and equipment as well as Pt. #17's intravenous tubing with L's hands.

DON A stated A did not see CRNA on the floor, but agreed that if that was the case, hands should be washed when getting up.

Sterilizer
In an interview with surgery staff, RN E, on 5/14/2012 at 10:25 a.m., RN E stated that the rapid cycle sterilizer (also known as flash sterilizer) continues to be used due to not having enough equipment. Examples of this would be in the rare event that the facility would do three cesarean sections (c-section) in a row, they only have 2 c-section sets.

RN E also stated that the facility continues to have 3 sets of eye trays (surgical instruments for eye surgeries). RN E stated that on days that eye surgery is scheduled the facility can do 7-14 cases per day with an average of 10. The instruments are being flash sterilized between cases due to not having enough equipment.

DON A was present during this interview. These findings were also discussed with CEO B on 5/14/2012 at 3:00 p.m.

Based on observation, interview, and recognized dietary practices, the hospital failed to ensure dietary staff practice proper hand hygiene after removal of gloves in 1 of 1 observation (Staff G). These practices affected all 10 patients in the facility at the time of the survey.

Findings include:

A fact sheet titled, "Using Disposable Gloves," from the Wisconsin Food Code, was provided to Surveyor #26711 on 5/14/2012 at 12:53 p.m. by Dietary Mgr. H.
The fact sheet states in part, "Hands must be carefully washed with soap and warm water, then dried before and after gloves are worn."

An observation of kitchen staff G was conducted on 5/14/2012 at 12:35 p.m. accompanied by DON A and Dietary Mgr. H. Staff G was observed putting on a pair of gloves to serve a customer food in the cafeteria line, then remove the gloves and did not wash hands after.

In an interview with Dietary Mgr. H at 12:45 p.m. on 5/14/2012, H stated that because staff G did not touch anything soiled (was in the cafeteria line with gloves on to serve food, then served the food and then removed the gloves) Staff G would not have to wash G's hands.

After the observation at 1:00 p.m., DON A confirmed that this is not following hospital policy or the Wisconsin Food Code as stated on the fact sheet.