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Based on observation and staff interview, the facility failed to ensure the formalin hood located in the operating room's (OR) endoscope cleaning room was set up for use to properly ventilate formalin fumes.

Findings include:

Observation on 5/31/17 in the endoscope cleaning room with Staff F (OR Tech) at approximately 12:30 p.m. revealed the formalin container pour spout was hanging over the edge of the workbench and outside of the formalin hood. The formalin hood was crowded with supplies and there was no room for the formalin container to be completely inside the hood and the formalin container was not raised above the surface of the workbench inside the hood for proper use of the pour spout, which was located flush with the bottom of the formalin container.

Interview on 5/31/17 with Staff F at approximately 12:30 p.m. confirmed the pour spout of the formalin container was outside the hood hanging over the edge of the workbench. Staff F explained that when staff dispense formalin from the formalin container they push it back into the hood and tip it back.

Staff F demonstrated Staff F's above explanation. Observation on 5/31/17 of Staff F's demonstration at approximately 12:30 p.m. revealed there was no room behind the formalin container to push it back without pushing back the supplies stored behind the container.

Based on observation, interview and review of Hospital logs and policy and procedures it was determined that the Critical Access Hospital failed to ensure medications were not outdated and failed to ensure that carts containing medications are secured and not accessible to unauthorized individuals.

Findings include:

Observation on 5/30/17 in the Emergency Department at approximately 9:50 a.m. with Staff A (Registered Nurse) revealed an emergency pediatric crash cart with individual secure tie drawers. Each of these drawers contained medications, needles and syringes that were able to be freely opened without breaking the secure tie on each of the individual drawers.

Observation during this Emergency Room tour with Staff A also revealed a black portable hand held unsecured tray containing multiple 10 cc prefilled syringes and supplies for placement of IV (intravenous) line infusions (catheters, etc) on the side of the Trauma Room 4 crash cart. Staff A confirmed at the time of the above observations that this tray and the above listed pediatric crash cart were not secure and were accessible to unauthorized individuals.


27714

Observation in the Pharmacy on 5/30/17 at approximately 3:00 p.m. revealed 12 tablets of Niacin CR (continuous relief), 500 MG (milligrams) on the stock shelves that expired on 3/24/17.

Interview with Staff E (Pharmacist) on 5/30/17 at approximately 3:00 p.m. confirmed the above finding.

Review of the Pharmacy's procedure titled "Sterile Product Compounding, Barrier Isolation Operation" (not dated) revealed it is the procedure to perform an initial wipe down of the barrier isolator hood: "At the beginning of each compounding activity the internal surfaces, sleeves and gloves of the main chamber are first cleansed and sanitized with sterile 70% isopropyl alcohol. Wiping is accomplished with a non-linting wipe." and a terminal wipe down: "Following completion of work, decontamination of the interior surfaces is repeated after removal of all materials (utilize same procedure as an initial wipe down)."

Review on 6/1/17 of compounding logs in the pharmacy revealed two different logs. The Pharmacy Sterile Prep Room Cleaning Log from 4/5/17 to 5/10/17 recorded the products used for cleaning. The Pharmacy Sterile Compounding Product Record recorded the pre-preparation cleaning of the hood but no the terminal wipe down.

Interview with Staff E on 6/1/17 at approximately 11:00 a.m. confirmed the pharmacy follows the above procedure for cleaning and disinfecting the barrier isolator hood and that there was missing documentation of that cleaning and disinfecting.


35333

Observation on 5/31/17 of the flash room located between operating rooms (OR) with Staff B (Registered Nurse) at approximately 12:00 p.m. revealed two lavender top blood collection tubes with and expiration date of 4/30/2017 and three blue top blood collection tubes with an expiration date of 5/9/2017.

Review of "OR Inventory Assignment Log" revealed the flash room's inventory had been checked earlier this day on 5/31/17.

Interview on 5/31/17 with Staff B at approximately 12:00 p.m. revealed the inventory check of the flash room failed to identify the expired blood collection tubes and removed them from stock.

Observation on 5/31/17 of an intravenous (IV) cart located in post anesthesia care unit (PACU) with Staff B at approximately 12:45 p.m. revealed one cleansing swab for venipuncture with and expiration date of 11/30/2016 available for use on the cart.

Based on observation, record review and interview, the Critical Access Hospital (CAH) failed to follow infection control policies and procedures and maintain equipment integrity for infection control practices in three departments of the hospital.

Findings include:

Review of the Pharmacy's procedure titled "Sterile Product Compounding, Barrier Isolation Operation" (not dated) revealed it was the procedure to perform an initial wipe down of the barrier isolator hood: "At the beginning of each compounding activity the internal surfaces, sleeves and gloves of the main chamber are first cleansed and sanitized with sterile 70% isopropyl alcohol. Wiping is accomplished with a non-linting wipe." Further review of the "Sterile Product Compounding, Barrier Isolation Operation" procedure revealed, for a terminal wipe down: "Following completion of work, decontamination of the interior surfaces is repeated after removal of all materials (utilize same procedure as an initial wipe down)."

Review on 6/1/17 of compounding logs in the pharmacy revealed two different logs. The Pharmacy Sterile Prep Room Cleaning Log from 4/5/17 to 5/10/17 recorded the products used for cleaning. The Pharmacy Sterile Compounding Product Record recorded the pre-preparation cleaning of the hood but not the terminal wipe down.

Interview with Staff E (Pharmacist) on 6/1/17 at approximately 11:00 a.m. confirmed the pharmacy followed the above procedure for cleaning and disinfecting the barrier isolator hood and that there was missing documentation of the terminal wipe down following completion of work.


35333

Observation on 5/31/17 in the Inpatient Rehabilitation Department at approximately 8:50 a.m. with Staff D (Physical Therapist) revealed a tear, 1-2 inches in length on the seat of the recumbant stepper equipment, and worn corners exposing fabric smaller than a dime in size on the mat table.

Interview on 5/31/17 with Staff D at approximately 8:50 a.m. revealed the equipment was cleaned and disinfected after each patient use, during this cleaning the equipment was inspected for wear and tears. Staff D confirmed the wear and tear found by the surveyor had not been noticed and had not been reported for repair during the last inspection and cleaning of equipment.

Observation on 5/31/17 in the Outpatient Rehabilitation Department at approximately 9:45 a.m. with Staff C (Director of Rehabilitation Services) revealed a hole smaller than a dime in the bed located in room T-1. Two support cushions were observed to have worn corners; five worn corners on one block cushion, 6 worn corners on the second block cushion. Tears and worn corners in the equipment exposed porous materials, which is unable to be cleaned and disinfected between patient use. The facility failed to ensure equipment in contact with patients could be cleaned and disinfected.

Interview on 5/31/17 with Staff C at approximately 9:45 a.m. revealed the equipment was cleaned and disinfected after each patient use and during this cleaning the equipment was inspected for wear and tears. Staff C confirmed the wear and tear found by the surveyor had not been noticed and had not been reported for repair during the last inspection and cleaning of equipment.


18010

Observation on 5/31/17 in Operating Room 2 at approximately 11:30 a.m. with Staff B (Registered Nurse) revealed opened wall shelving with multiple individual sterile instrument containers being stored on these shelves. Staff B confirmed at the time of this observation that these instrument containers with sterile instruments inside are stored in Operating Room 2 during operative procedures. The facility failed to maintain a sanitary environment to avoid cross contamination and avoid sources and transmission of infections by storing these sterile instruments in the open wall shelving during individual operative procedures.