HospitalInspections.org

Based on record review an interview the facility failed to notify animal control of a patient with a dog bite as required by local laws.

Findings included:

Review of the City of Lamesa city code reflected ...
"Sec. 2.03.003 Reports of rabies
(a) Duty to report. Any person having knowledge of an animal bite or scratch to an individual that the person could reasonably foresee as capable of transmitting rabies or of an animal that the person suspects is rabid shall report the incident to the animal control officer. The report shall include the name and address of any victim and of the owner of the animal, if known, and any other data which may aid in the locating of the victim or animal.
(b) Submission of animal for quarantine. The owner of an animal that is reported to be rabid or to have exposed an individual or that the owner knows or suspects to be rabid or to have exposed an individual shall submit the animal for quarantine to the animal control officer.
(c) Investigation. The animal control officer shall investigate all reports filed under this section ..."

Patient #2 was treated in the ED for a dog bite on 1/9/22. Review of the ED record did not reflect the notification of animal control or other local authority.

Review of the facility policy titled "Notification of Police" last updated 8/19/19 reflected "The Police are to be notified of all car accidents, gunshot wounds, knife wounds, fights, attempted suicides, assaults and any other type of incident of a violent nature
PROCEDURE:
1. The Emergency Room Nurse should contact the Police Department 872-2121 and
give a verbal report of the incident involved.
2. The police department should dispatch an officer to the Emergency Room to get a
complete report from the victim, if possible.
3. The Emergency Room nurse document notified of the Lamesa Police Department on
the Emergency Room Record."

Staff #2 verified these findings.

Based on review of medical records and interview, the facility failed to ensure that each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient was renewed as authorized by hospital policy.

Finding included:

Facility based policy "Restraint" stated in part,
"Procedure:
Use of a physical or mechanical device to involuntarily restrain the movement of the whole or part of the body for protection from injury.
A. Types of restraints ...
3. Other types of restraints
a. Soft restraints - linen, dressing, (Stockinette, or Kling) ...

B. Orders for Restraints
1. A physician's order is required for mechanically restraining a patient
2. The physician's order must include
a. the device to be used
b. the reason for device
c. time limit for restraint to be used
3. In emergency situations (violent, aggressive, confused/disoriented)
a. the patient may be restrained without the order
b. the order must be obtained by notifying the physician as soon as
possible (preferably within the hour)
c. the order should be signed within 24 hours"

Review of the facility restraint log revealed 1 patient (Patient #10) that was restrained for 2021 and 2022.

Review of Patient #10's record revealed the following:
Only one physician order was present for the use of restraints was on 08/24/21 ordered at 2237 to start at 0600 on 08/24/21. The order stated in part, "soft restraints, loose, re-evaluate 2 hours, recertify q 24 hr".

Patient # 10 was in soft wrist restraints from 08/24/21 at 0600 until 08/26/21 at approximately 1130. Per policy and written order this restraint should have been recertified/re-ordered by the physician every 24 hours.

The above findings were verified with staff member #10 on 04/19/22.

Based on review of medical records and interview, the facility failed to ensure the condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner
or trained staff at an interval determined by hospital policy.

Findings included:

Facility based policy "Restraint" stated in part,
"Procedure:
Use of a physical or mechanical device to involuntarily restrain the movement of the whole or part of the body for protection from injury.
A. Types of restraints ...
3. Other types of restraints
a. Soft restraints - linen, dressing, (Stockinette, or Kling) ...

C. Use of Restraints

General Nursing
1. Restraints will be released at least every two (2) hours(more often if necessary)
2. Extremities restrained should be checked at a maximum of every two (2) hours to prevent compromise in circulation
3. The need shall be reassessed every two (2) hours"
Review of the facility restraint log revealed 1 patient (Patient #10) that was restrained for 2021 and 2022.

Review of Patient #10's record revealed the following:
Only one physician order was present for the use of restraints was on 08/24/21 ordered at 2237 to start at 0600 on 08/24/21. The order stated in part, "soft restraints, loose, re-evaluate 2 hours, recertify q 24 hr".

Review of the medical record revealed that nursing staff only documented on this patient on the following dates and times:
08/24/21 at 0600, 1200, 1800, 1900, 2100, and 2300.
08/25/21 at 0100, 0300, 0500, 0700, 0900, 1100, 1259, 1600, 1956, and 2200.
08/26/21 at 0005, 0207, 0400, 0700

Patient # 10 was in soft wrist restraints from 08/24/21 at 0600 until 08/26/21 at approximately 1130. Per policy and written order this restraint should have been re-evaluated every 2 hours per documentation/ medical record review, there were gaps in assessing this restrained patient every 2 hours.

The above findings were verified with staff member #10 on 04/19/22.

Based on observation and interview the facility failed to ensure that outdated drugs were not available for patient use.

Findings included:

1.) Observation of the CT Scan room revealed a toolbox with emergency medications. The toolbox was caked in dust. Upon opening the toolbox the following expired medications were found:
Lidocaine HCL 100mg/5ml expired 2/2021
Lidocaine HCL 100mg/5ml expired 3/2022
Atropine Sulfate 0.1mg/ml (1mg/10ml) expired 4/2021
Diphenhydramine 50mg/ml expired 5/2021

2.) Observations of the medication storage room of the emergency department revealed the following expired medications:
Promethazine 12.5mg suppositories (4) expired 12/2021
Bisacodyl 10mg suppositories (4) expired 12/2021

During an interview with staff #2 she verified these findings.

Based on observation, interview, and record review the facility failed to ensure that the facility, supplies, and equipment were maintained to ensure an acceptable level of safety and quality.

Findings included:

In an article published by Spectrum Health in July, 2014 it was stated "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."

According to APIC: "Supplies must be: Removed from shipping cartons or cardboard boxes before storage to prevent contamination with soil/debris that may be on cartons ...Do not leave outer shipping boxes in clinical areas (due to risk of environmental contamination)." Preventing Infection in Ambulatory Care, Winter 2011/2012; available: http://apic.org/Resource_/TinyMceFileManager/Education/Preventing-Inf-in-Amb-Care-Winter2012-FINAL.PDF.

During a tour of the laboratory area on 04/18/22 in the afternoon the following infection control issues were noted:
* Red duct tape was observed on the floor of lab, the tape was peeling off the floor with visible dirt and debris stuck to the adhesive, as tape cannot not be effectively disinfected this provided a risk for cross contamination.
* 3 large external shipping boxes were observed stored on a sink in the laboratory area. Storage of supplies in this manner could potentially allow for dirt, debris, and or pests from the outside shipping containers to contaminate supplies stored nearby.
* One standing oscillating fan was noted in the corner of the room. Staff member #15 verified this fan was used in the "summer". This fan presents a risk of blowing dirt and debris around the laboratory potentially effecting the equipment and/or contaminating supplies in that area.

On 04/18/22 staff member #15 (the lab) manager verified the above findings.

A tour of the radiology department on 04/18/22 in the afternoon revealed the following infection control issues:
* Dust was observed on high horizontal areas of the CT scanner room and the stress test room.
* In the CT room 4 external shipping boxes were observed stored with the clean supplies. Storage of supplies in this manner could potentially allow for dirt, debris, and or pests from the outside shipping containers to contaminate clean supplies stored nearby.


The above findings were verified on 04/19/22 by staff members #2 and 17.

A tour of the emergency department on 04/18/22 in the afternoon revealed the following infection control issues:
* Dust was observed on high horizontal areas of the trauma room.
* Tape was observed on multiple surfaces including carts and EKG machines. The tape was dirty, lifting, and unable to be cleaned.
* Dust was observed on the crash cart and the suction machine across from the nurses station.
* A unknown red substance was observed on top of the crash cart in the trauma room.

The above findings were verified on 4/18/22 by staff member #2.

During the tour of the Emergency Department (ED) on the afternoon of 4/18/22 the Life Pac 15 monitor and defibrillator was observed on the crash cart. The Life Pac 15 had no sticker reflecting that it had an annual inspection.

During an interview with staff #2 she reported that the equipment is checked annually by an outside provider and she did not know why this was not checked.

Further interview with staff #2 on the morning of 4/19/22 she reported that the facility has two Life Pac 15 monitors and the other one was checked but this one was in the maintenance department and was missed.


31690

Based on review of job descriptions, personnel files and interview, the facility failed to ensure that individuals qualified through education, training, experience, or certification in infection prevention and control, were appointed by the governing body as the infection preventionist(s)/infection control professional(s).

Findings included:

Facility job description entitled "Employee Health, Infection Control Director" stated in part,
"Job Qualifications: ...
D. Experience: ...
2. Technical Training: Current CPR [Cardiopulmonary Resuscitation] Certification. ACLS [Advanced Cardiac Life Support] preferred. During the course of Employment receive beneficial education/certifications in areas of Infection Control."

Review of the personnel files for staff members #10 and 11, Both of whom were identified as the Infection Control Directors, revealed that neither employee had any documented education or certification in infection control. In interview on 04/19/22, staff member #10 verified that both of the infection control directors [including themselves] had not "officially had any infection control training". Staff member #10 [one of the the 2 Infection Control Directors] also verified the 2 Infection Control Directors had a been in their roles since 2020.

In an interview on 04/19/22, staff member #17 (Human Resources) verified the 2 staff members listed (who were identified by the facility as being the Infection Control Directors) had no documented education, certification, or training in infection control as required by regulations.

Based on observation, record review, and interview the facility failed to ensure that staff adhere to infection and prevention and control policies and procedures when disinfecting an Accucheck Inform II glucometer.

Findings included:

Review of the undated "Accu-Check Inform II Meter" directions sheet reflected the following:
"... Cleaning the Accu-Check meter: Use super sani-cloth germicidal disposable wipes only. The part of the meter that can be cleaned and disinfected is the area around the test strip port, the meter display(touchscreen) and the meter housing(entire meter surface). The proper technique to cleaning the meter is by gently wiping the outside of the meter 3 times horizontally and 3 times vertically and carefully wipe around test strip port area. Allow the surface of the meter to remain damp until 2 minutes. Dry the meter thoroughly with a dry cloth or gauze."

During an interview with staff #10 related to the disinfecting of the glucometer she reported that the minimum contact time was 30 seconds to one minute.

Review of the Super Sani-Cloths instructions for use reflected that the surface must be wet for at least two minutes.
Staff #2 confirmed these findings.