HospitalInspections.org

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Based on review of humidity logs, staff interview, and review of facility policies, the facility failed to ensure equipment and supplies were stored in areas with adequate humidity in accordance with manufacturer's instructions in 4 of 4 anesthetizing surgical areas (operating rooms #1, #2, #3, and #4). The findings were:

1. Review of humidity logs showed humidity levels were monitored in the operating rooms (OR)18 days from 10/22/18 to 11/27/18. This review showed humidity levels were below 30%: 2 times in OR #1, 1 time in OR #2, 6 times in OR #3, and 4 times in OR #4.

2. Interview on 11/29/18 at 2 PM with the director of quality and surgical services director revealed their system for monitoring humidity levels did not include measures for how to respond when the levels were below 30%. They further stated they did not know the impact lower humidity levels had on equipment and supplies in the 4 OR's.

3. Review of the facility's policy "Relative Humidity", reviewed 2018, showed "A relative humidity to be maintained at between 30%-60% in anesthetizing areas, both flammable and non-flammable. The humidity rating shall be recorded every day anesthetizing agents are used." ..."Applicable forms will be filled out by the Operating Room and Delivery Room personnel. The date, time and relative humidity will be recorded by the charge nurse whenever their areas are used."

4. Review of "Humidity Levels in Surgical Settings: Understanding the Standards and Managing the Risk," Gallagher Healthcare Practice, April 2015, showed "...low humidity level can adversely impact equipment, supplies and shelf life. As a starting point, it is essential that the OR staff and suppliers are familiar with the manufacturer's Instructions for Use (IFU)...As assessment of the UFI's for equipment and supplies used in the OR (electrodes, shelf life, etc) will determine the required humidity requirements for using or storing the equipment..."

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Based on observation, staff interview, and review of policies and procedures, the facility failed to ensure multi-dose medications were labeled to identify the expiration date. In addition the facility failed to ensure single-dose medications were not available for use for multiple patients. This failure was identified in 2 patient care units in the hospital and 2 patient care areas at 1 of the 2 off-campus locations. The findings were:

1. The following concerns were identified during observations of medication storage areas in the hospital:
a. Observation on 11/27/18 from 5:15 PM to 5:40 PM showed an opened multi-dose vial of labetalol (anti-hypertension) was stored in the anesthesia cart in operating room #1; and an opened single-dose vial of bupivacaine (local anesthetic) was stored in the anesthesia cart in operating room #4. Further observation showed the vials were half full and not labeled with the date opened or a beyond-use date (BUD). At that time, the surgical services director stated the multi-dose vial should have labeled with the date it was opened; and the single dose vial should have been discarded after use.
b. Observation on 11/28/18 at 3:25 PM in the wound care and hyperbaric treatment area revealed 2 multi-dose vials of xylocaine (local anesthetic) were stored and available for continued use. Further observation showed the vials were not labeled with the date opened or BUD. At that time, the hyperbaric assistant stated all opened medications should be labeled with the opened date.

2. The following concerns were identified during observations of the medication storage area at the off-campus clinic building:
a. Observation on 11/28/18 at 11:10 AM in the pediatric clinic medication storage area showed a multi-dose vial of xylocaine (local anesthetic) was opened, not dated, and available for use.
b. Observation on 11/28/18 at 12:30 PM in the orthopedic medication storage area showed a multidose vial of bupivacaine (local anesthetic) was opened, not dated, and available for use. Interview at that time with the clinic nurse revealed the use of multi-dose vials was a common practice, but the lack of dates was an oversight.

3. Review of the policies and procedures, titled "Pharmacy: Sterile Compounds (Preparation and Usage)," reviewed 2018, showed, "Multiple dose vials used outside of the pharmacy may only be used one vial per patient, and must be disposed of at the end of the day and have a BUD (beyond-use-date) clearly written on the multiple use vial."

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Based on observation, staff interview, and review of policies and procedures, the facility failed to ensure staff followed acceptable standards of infection prevention practices during pre-procedure anesthesia care. This failure was observed during observations of 1 of 2 patients (#32) receiving pre-procedure anesthesia care.
The findings were:

1. On 11/27/18 at 11:55 AM registered nurse (RN) #1 was observed assisting certified nurse anesthetist (CRNA) #1 with endotracheal intubation for patient #32. Continuous observation revealed RN #1 did not wear gloves or perform hand hygiene during the following tasks: The RN opened packages, and handed instruments and supplies to the CRNA, who wore gloves. The CRNA completed the intubation procedure and gave the used items to the RN. The RN placed the used reuseable instruments in the bin for items to be sterilized, and discarded the single use items. He returned to the patient and began to touch the patient, drapes, equipment and other surfaces. During the observation, the operating room supervisor stated all staff had been trained to wear gloves when assisting with anesthesia administration, and did not know why RN #1 had not done that.

2. Review of the policies and procedures titled, "Surgical Services, Attire in the Operating Room and CSR [Central Sterile Process]," reviewed 2018, showed "Sterile gloves should be worn when performing sterile procedures, and unsterile gloves should be used for other tasks that require contact with potentially hazardous or infectious material. Gloves should be changed when soiled. Hands should be washed with soap and water or the use of a facility recommended alcohol based liquid after removal of gloves and between patients."