HospitalInspections.org

Based on observation and interview, the hospital failed to ensure all medical records were properly stored in secure locations where they were protected from water damage in the event that the sprinkler system was activated.

Findings:

Observation on 07/26/17 at 10:00 a.m. of the medical records storage room revealed several sliding racks of closed paper medical records with 2 sprinkler heads directly above the racks, one on each end. Further observation revealed that when the sliding racks were condensed together, a space of about 2 inches remained open between the top of each rack and one end was left completely open with charts uncovered underneath the sprinklers in the ceiling.

On 07/26/17 at 10:00 a.m., an interview with S5Medical Records Clerk revealed that the records had not been scanned into the electronic medical records system. She further confirmed that some of the records were less than 5 years old. When asked if the paper medical records would be protected from destruction or water damage if the sprinkler system was activated, she stated no.

Based on observation and interview, the hospital failed to ensure that there was a protocol developed and implemented for the use of normal saline flushes during CT procedures involving intravenous contrast.
Findings:

On 07/24/17 at 3:25 p.m., observation of the CT procedure room in the radiology department revealed a 500mL bag of normal saline hanging on an IV pole. Further observations revealed that the bag was spiked and the end of the tubing was wrapped in an empty alcohol swab packet. The bag contained approximately 100mL and was not dated.

Interview with S4RT on 07/24/17 at 3:30 p.m. revealed that the staff pulls normal saline flushes from the 500mL bag to use on the patients during CT procedures involving intravenous contrast. She further stated that approximately 40-50mL is used per patient and the bag is usually used for 9-10 different patients. When asked if the same bag is used over several days until it is empty, she stated yes. She was unable to state when the bag was first punctured.

On 07/26/17 at 1:00 p.m., interview with S2DOCS revealed that there was no protocol that had been developed for the use of normal saline flushes during CT procedures involving intravenous contrast. She further confirmed that the above normal saline bag should not have been used over several days on multiple patients.

Based on observation and interview, the hospital failed to develop a system for identifying and controlling infections and communicable diseases of patients as evidenced by failing to maintain a sanitary hospital environment.
Findings:

On 07/24/17 at 10:00 a.m., observations on the second floor revealed a blood pressure machine which included EKG leads. Further observations of the wiring from the leads revealed that they were very sticky and coated with a black substance.

On 07/24/17 at 10:10 a.m., observations of the second floor revealed another blood pressure machine that contained an oxygen saturation monitor. Observations of the monitor revealed that the wiring contained a sticky substance on it and was coated with a black substance.

On 07/26/17 at 9:55 a.m., observations in the Respiratory/Cardiopulmonary office revealed an EKG machine. Observations of the wiring connected to the EKG leads revealed they were coated with a black sticky substance. Interview with S4RT at that time confirmed that the EKG had not been properly cleaned and disinfected.

On 07/26/17 at 10:50 a.m., interview with S1DON confirmed the above items were not properly cleaned/disinfected and posed an infection control risk to the patients of the hospital.

On 07/24/17 at 10:00 a.m., observation revealed second floor patient room a, which had a notice on the door stating the room had been cleaned, had one white pillow and one beige pillow on the unmade bed. The pillows had tears and holes in the plastic coverings which exposed the cotton batting on the inside of the pillows. There was a vertical tear several inches long in the covering of the recliner located in the area where the head rests.

On 7/26/17 at 2:00 p.m., an interview with S1DON confirmed the pillows and the recliner would not be able to be cleaned and disinfected properly.


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Based on observation and interview, the hospital failed to ensure that all respiratory services were delivered in accordance with medical staff directives as evidenced by having multiple expired respiratory medications that were available to be used on patients in the hospital.
Findings:

On 07/26/17 at 9:40 a.m., observation of the Respiratory/Cardiopulmonary office revealed a cabinet that contained respiratory medications that were used on the patients in the hospital. Observation of these medications revealed multiple expired inhalation medications. These included:

(22) Ipratropium Bromide inhalation solution unit doses, expired February 2016
(2) Sodium Chloride inhalation solution 3mL unit doses, expired January 2017
(1) Sodium Chloride inhalation solution 3mL unit dose, expired 09/30/15
(8) Budesonide inhalation suspension 0.25mg/2mL unit doses, expired February 2017
(40) Ipratropium Bromide inhalation solution unit doses, expired February 2017

At this time, interview with S4RT revealed that all respiratory medications/inhalations used for the patients in the hospital are stored in the above cabinet. She further confirmed that the above medications were expired and were available to be used on the patients.