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Based on observations, interviews, and record reviews, it was determined the facility staff failed to ensure a working call-device to notify emergency department staff of someone needing assistance at the emergency department ambulance entrance.

The findings include:

The facility's call-device to notify emergency department staff of someone needing assistance or entrance from the emergency department ambulance entrance was noted to not be functioning during emergency department (ED) observations on the afternoon of November 5, 2014.

On November 5, 2014 at approximately 1:00 p.m., the facility's ED nurse manager was interviewed related to the aforementioned broken call-device; the survey team was informed that the call-device was tested monthly but the monthly test were not documented. The survey team was provided with a copy of a work order, dated November 5, 2014 at 1:25 p.m., with the following description of the problem: "Back door call bell for EMS not working. Urgent request placed".

On November 6, 2014 the survey team was told the call-device was now working and that the ambulance entrance call device had been added to the ED checklist. The survey team was provided a copy of the ED checklist which now included guidance to "check (ambulance) entrance intercom." The survey team returned to the ED with Staff #49. Upon testing the call-device it was noted that the call-device was not alarming/sounding to notify ED staff of a need at the ED's ambulance entrance.

On the afternoon of November 6, 2014 a facility staff member Staff #34 informed the survey team that the company of the call-device in question was contacted and has someone on the way to work on the call-device.

When asked about a facility policy that speaks to the call-device, the survey team was provided with a policy entitled, 'Electrical Safety Policy.' This policy did not speak directly to the aforementioned call-device but it did include the following information: "Through the regular inspections of environment of care rounds, hazardous surveillance rounds and biomedical environmental sweeps, all non-clinical electrical equipment will be verified as being in an appropriate condition and rating (UL) or equivalent to ensure ongoing safe operations."

Based on document review and interview the facility's nursing staff failed to monitor patient's vital signs as ordered during a blood transfusion for one of four patients (Patient #23).

The findings included:

Four patients' medical records who had received a blood transfusion were reviewed on November 7, 2014 at approximately 10:00 am (Patient #21, #23, #37, and #45). The review revealed the following information pertaining to Patient #23.

Packed red blood cells identified as unit #W 2012 in the medical record of Patient #23 were administered on 10/22/2014 beginning at 6:38 am and completed at 10:50 am. No required documentation of baseline vital signs fifteen minutes prior to the infusion beginning were found in the medical record of Patient #23.

Packed red blood cells identified as unit #W 2027 in the medical record of Patient #23 were administered on 10/22/2014 beginning at 8:04 p.m. and completed at 11:05 p.m.. No required documentation of baseline vital signs fifteen minutes prior to the infusion beginning were found in the medical record of Patient #23.

Packed red blood cells identified as unit #W 2029 in the medical record of Patient #23 were administered on 10/29/2014 beginning at 11:44 am and completed at 2:32 p.m.. No documentation of a baseline temperature being taken fifteen minutes prior to the beginning of the blood transfusion found in the medical record of Patient #23. Documentation of Patient #23's temperature is recorded for 12:00 p.m. and 2:31 p.m.. No documentation of one hour post transfusion temperature found in the medical record of Patient #23.

The facility's policy titled Policy for Transfusion of Blood Products was requested and received at approximately 12:30 p.m. on 11/07/2014. A review of the policy was conducted on 11/07/2014 and 11/10/2014. The policy states under the title of Baseline Vital Signs "take patient's vital signs, including temperature, pulse, blood pressure, and respirations within 15 minutes prior to starting the blood." The policy states under the title of Vital Signs Follow-up "take vital signs in the following intervals from the start of the transfusion; within 15 minutes prior to starting the blood, then 15 minutes after starting the blood. Repeat vital signs 30, 60, 120, 180 minutes after starting the infusion. Take vital signs 1 hour post transfusion and record on the Blood Administration Flow Sheet."

Staff #34 was present during the electronic medical record reviews on November 7, 2014. Staff #34 confirmed the findings pertaining to the blood transfusion documentation on Patient #23. Staff #34 stated the facility's policy requires documentation of baseline vital signs fifteen minutes prior to the start of a blood transfusion.

Based on document review and interview the facility's utilization review (UR) committee failed to have two physicians as part of the committee.

The findings included:

An interview was conducted on November 10, 2014 from 11:16 a.m. through 1:00 p.m., with Staff #22 and Staff #23 during the review of the facility's utilization review plan. Staff #23 requested that Staff #14 join the interview. Staff #14 reported that the facility's utilization review committee was "Fairly young" and just getting started. Staff #22, Staff #23 and Staff #14 reviewed the UR committee meeting minutes. Staff #14 reported that Staff #64 "chaired the committee."

Review of the UR committee meeting minutes for the following dates: June 27, 2013; August 1, 2013; September 12, 2013; October 10, 2013; May 6, 2014; June 12, 2014; and August 14, 2014 only listed one physician as part of the UR committee.

An interview was conducted on November 10, 2014 at 12:50 p.m., with Staff #14. Staff #14 verified that only one physician was part of the facility's UR committee. Staff #14 reported others physicians may if the committee requests attend to clarify a specific case under review.

Staff #14 and the surveyor reviewed the required number of physician as specified in the regulations. Staff #14 stated, "We do not have two physicians assigned to our committee."

Based on the Life Safety Code Validation survey, conducted between October 17, 2014 and October 27, 2014, the Condition of Physical Environment is not met. Those deficient practices and the associated regulations can be found in the respective Life Safety Code survey (FNWG21).

Based on observations, interviews, and document review the infection control officer failed to monitor, identify and ensure:

1. Staff practices during the cleaning of instruments were performed in a manner to reduce the spread of infectious agents for one (1) of two (2) observations.

2. Staff performed hand hygiene between glove changes for one (1) of nine (9) observations.

3. Non-disposable items were disinfected between patients for four (4) of four (4) pads observed in the radiology unit.

4. Dietary staff prepared food in a manner to reduce the potential of contamination.

5. Anesthesia staff did not prepare medications from a multidose vial in the immediate patient area for one (1) of one (1) interview.

The findings included:

1. Observation and interview was conducted on November 4, 2014 at 2:56 p.m., with Staff #5 and Staff #10. Staff #10 removed four closed containers utilized during surgery from a cart. Each container had multiple trays, within which contained surgical instruments and other items (hoses for electrical connectors) from the containers. Staff #10 visually inspected the clamps, tools, and other items with lumens. Staff #10 did not place the items in the sink in order to pre-wash them before putting them in the automatic washer. Staff #10 removed the fourth container from the cart; Staff #10 explained that the instruments had been utilized during a "hip arthoplasty (hip replacement) surgery." The tray contained awl-like instruments with lumens, which Staff #10 visually inspected, placed back on the tray without attempting to clean any biological debris from the lumens, and proceeded to place the tray in the automatic washer. The surveyor asked Staff #10 whether instruments with lumens were pre-washed or cleaned with a disposable pipe cleaning-tool. Staff #10 reported he/she visually looks and if there was blood visible he/she would "wash it." Staff #10 reported he/she used the pipe cleaner-tool after the items came out of the automatic washers.

An interview was conducted 3:56 p.m. on November 4, 2014 during the end of the day meeting. The facility staff was informed of the findings and a policy/procedure was requested.

Review of the facility's policy titled "Processing Instrumentation in De-Contam In House [Sic]" read in part "4. ...Wash all instrumentation that can go though the washer first ..."

An interview was conducted on November 6, 2014 at 2:10 p.m., with Staff #5 and Staff #57. Staff #57 reported Staff #10 should have placed all instrumentation in the sink and pre-washed each item prior to placing them in the automatic washer. Staff #57 explained minute pieces of tissue and bone would not be seen by visually inspecting the instruments. Staff #57 reported all clamps, scissors should be opened inspected and brushed under water prior to placing them in the automatic washer. Staff #57 reported all instruments with a lumen (a cavity) and cannula (flexible tubing) should have been cleaned with a "disposable pipe-cleaner" prior to being placed in the automatic washer.


2. Observation and interview was conducted on November 4, 2014 from approximately 1:59 p.m. through 2:40 p.m., with Staff #5 and Staff #9. Staff #9 demonstrated his/her job task of performing high level disinfection of endoscopes (a flexible tube utilized to look inside a body cavity which may have a light and other attachments). Staff #9 was observed to change his/her gloves seven times during the processing of two bronchoscopes (an endoscope used to visualize the airway and lungs) from post procedure to automated disinfection. Staff #9 connected the first bronchoscope to a connector then to an air outlet and submerged the bronchoscope in water/enzymatic solution in one sink. Staff #9 removed his/her gloves put on a new pair of gloves to perform the same task on the second bronchoscope. While waiting for the air leak test to complete Staff #9 removed his/her gloves put on a new pair of gloves without performing hand hygiene. Staff #9 reported the procedure had two bronchoscopes because the physician performed a biopsy. Staff #9 continued the processing changing gloves and moving between the two bronchoscopes. Staff #9 changed gloves and without performing hand hygiene tested the chemical level within each high level disinfect chamber of the automated unit. At 2:40 p.m. the surveyor asked Staff #9 why he/she did not perform hand hygiene between glove changes. Staff #9 responded "I was going from dirty to dirty."

An interview was conducted 3:56 p.m. on November 4, 2014 during the end of the day meeting. The facility staff was informed of the findings and a policy/procedure was requested.

Review of the facility's policy titled "Hand Hygiene", which read in part "Policy: Hand hygiene measures are the single most important strategy for preventing Healthcare Acquired Infections (HAI) because skin of patients and personnel serve as a reservoir of infectious agents. All staff will adhere to this policy to reduce the transmission of microorganisms to patients and personnel [name of the facility] ... 11. Perform hand hygiene after removing gloves ..."

An interview was conducted on November 5, 2014 at approximately 3:30 p.m., with Staff #5. Staff #5 was informed of the findings. Staff #5 acknowledged recognizing during the observation on November 4, 2014 that Staff #9 "should have performed hand hygiene before putting on new gloves."


3. Observations were conducted on November 5, 2014 from 12:48 p.m. through approximately 2:00 p.m., with Staff #5, Staff #59 and Staff #60. Observations conducted in the two available fluoroscope rooms revealed a blue pad was used on the examination table to provide patient comfort. Staff #59 reported the pads were disinfected between patients and monitored daily for tears. Staff #59 stated, "I can't believe that there is a tear I just told the surveyor we inspect the pads daily." The observation revealed both blue pads used on the examination table had tears in the surface on the bottom corner. Staff #5, Staff #59, Staff #60, and the surveyor conducted an observation in the two available imaging examination rooms. The blue pad in both rooms had a tear in the surface of a lower corner.

Staff #59 and Staff #60 both acknowledged the surface of the blue pads should not be disinfected between patients if the surface was not intact.

4. Observations and interviews were conducted on November 10, 2014 from 9:04 a.m. through 10:49 a.m. with Staff #61, Staff #62 and Staff #63. During the tour of the dietary department at 9:35 a.m. the observation revealed the back wall of the main exhaust hood over the stove was covered in a gray fluffy substance. The surveyor asked how often the exhaust hood was cleaned; Staff #62 reported "every six months" but then changed the answer to "every month." The surveyor inquired if the exhaust hood was cleaned by an outside entity or by staff, Staff #62 stated "An outside company comes in to clean the hood every month." Staff #61 reported that the weekend staff for dietary was assigned to clean the hood in between the cleaning by the outside vendor. The surveyor asked Staff #61 and Staff #62 to make an observation of the back wall inside the exhaust hood that was positioned over the cooking area. Staff #61 stated, "That's dust someone must have missed cleaning it this weekend." Staff #61 was able to acknowledge the amount of "dust" on the inside back wall of the exhaust hood was "probably more than a week's worth of dust." Staff #61 verified the "dust" or gray substance could fall into food being prepared on the stove and was a potential contaminate. The surveyor requested to review the cleaning assignment for staff and the contract with the outside vendor responsible for cleaning the exhaust hood.

An interview was conducted on November 10, 2014 at approximately 1:30 p.m., with Staff #62. Staff #62 presented the contractual agreement with the outside vendor and reported the exhaust hood was not being cleaned monthly but every six months. Staff #62 presented a document titled "Weekend Cleaning Checklist" with the handwritten dates "11/8 & (and) 11/9." Staff #62 stated "We have modified our form to include the weekend cleaning of the exhaust hood." Staff #62 reported the previous "Weekend Cleaning Checklist" did not include the cleaning of the exhaust hood; therefore no one had been assigned to clean the exhaust hood. Staff #62 stated, "I think we all just look at the area in the front of the hoods and the vents. I don't think we ever just turn around and look at the (inside) back wall."


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5. During the tour of surgical services (pre-operative care area, operating room, and post-operative care area) and observation of a surgical procedure from 9:45 a.m. to 1:00 p.m. on 11/05/2015 revealed Staff #58 storing multi-dose medication vials in the anesthesia cart used for more than one patient in an immediate patient treatment area.

An interview was conducted on 11/05/2014 at approximately 10:55 a.m., with Staff #58 prior to a surgical procedure in the operating room. Staff #58 confirmed he/she does have two (2) multi-dose medication vials stored in the anesthesia cart. "If I had to use the two (2) multi-dose vials which includes rocuronium and neostigmine for a procedure, I would first wipe the rubber septum with alcohol, draw the medication up with one needle and syringe for each vial and dispose of the rocuronium because this is only used for one patient even though it is a multi-dose vial. After I draw up the neostigmine, the multi-dose vial is dated and initialed when first opened and stored in the emergency drawer on the anesthesia cart and used for the next patient unless the medication has expired or the 28 days has passed." Staff #58 acknowledged that medications are drawn up in the operating room on the anesthesia cart within the immediate vicinity of the patient. Staff #58 reported not being aware of the proper method of using multi-dose vials (not preparing medications from a multidose vial in the immediate vicinity of a patient) or any changes in the facility's policy for multi-dose vial use. Staff #58 acknowledged he/she thought as long as the multi-dose vial was cleaned with alcohol before and after use, only one (1) needle and syringe were used, multi-dose vials could be used on multiple patients.

Review of the facility's policy titled "Multi-dose Vial Use" read in part "Procedure: Multi-dose vials are dated and initialed when first opened. The expiration date (28 days unless the manufacturer recommends a shorter date) is written on the vial immediately when opened. Vials which have reached their expiration date will be properly discarded and a replacement vial will be requested from the pharmacy."

According to drugs. com, rocuronium is used for relaxing muscles during surgery and mechanical breathing. Rocuronium is a nondepolarizing neuromuscular blocker and works by blocking nerve impulses to the muscles, resulting in temporary muscle paralysis. Neostigmine is used for the prevention and treatment of postoperative distention and urinary retention after mechanical obstruction has been excluded. Neostigmine is a reversal of effects of non-depolarizing neuromuscular blocking agents after surgery.