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Based on observation, review of policies and procedures, and staff interviews, the facility failed to ensure expired medications were discarded and opened medications were labeled with the date opened in 2 of 3 storage areas. The findings were:

According to the policy and procedure entitled "Multi-Dose Vials", approved 8/5/10, medication vials should be labeled with the date opened and the date of expiration (28 days after opening), and all vials should be discarded at the expiration date. The facility's failure to follow this policy was noted during the following observations:

On 3/11/14 at 8:45 AM opened and expired vials of folic acid, Oxytocin, and Pneumovac medications were observed in the nursing unit medication room. Further observation revealed an opened vial of lidocaine without a date open label. Interview with RN #1 at that time confirmed the medications were available for use and the medications should have been discarded. Later that day, on 3/11/14 at 2 PM, opened and expired vials of Xylocaine and Kenalog were observed in the exam room 1 anteroom.

Based on observation and staff interview, the facility failed to develop and implement a process for determining whether eye medication compounds from another state were approved for use and in compliance with Wyoming Pharmacy Act, Rules and Regulations. In addition, the facility failed to ensure medications were administered by qualified staff. The findings were:

1. On 3/12/14 at 8:35 AM and again at 9:20 AM ophthalmology technician #1 was observed administering the following medications to patients: Eye drops from an eye medication container labeled PTC and a 2 milligram Valium pill.

2. During an interview on 3/12/14 at 8 AM and at 10:50 AM ophthalmology technician #1 stated she was a member of the physician's staff who traveled from another state to provide eye surgeries at the facility. She stated the PTC eye medication was a compound that was mixed in large quantities in another state and poured into smaller eye drop medication containers for use in Wyoming. (Compounding" means and includes the preparation, mixing, or assembling of a drug or device, and the packaging and labeling incident thereto for sale or dispensing.) She further stated she routinely administered a Valium pill to the patients pre-operatively as prescribed by the physician.

3. Interview with the director of ambulatory and surgical services on 3/13/14 at 8:38 AM revealed the following information:
a. The facility did not determine whether administering the compound eye medication was in compliance with the Wyoming Pharmacy Act, Rules and Regulations.
b. The facility did not have evidence a pharmacist inspected and approved all components of the medication, drug product containers, closures, in-process materials, and labeling; nor was there evidence compounding records were reviewed to assure that no errors had occurred in the compounding process.
c. The facility had not implemented a process for determining whether the ophthalmology technician was qualified to administer medications.
d. The facility did not have a system for evaluating staff competencies for the eye surgery staff.

Based on observation, review of policy and procedures and staff interviews, the facility failed to ensure staff performed hand hygiene during random observations of care. The findings were:

1. Observation on 3/10/14 at 3:02 PM revealed respiratory therapist #1 moved a used laryngoscope blade from the emergency cart to a table surface with ungloved hands. Further observation revealed she continued to handle other items on the emergency cart, then wheeled the cart to another area of the facility without performing hand hygiene.

2. Observation on 3/12/14 at 10 AM revealed CNA #1 removed the bagged trash from the operating room and placed it outside of the room with ungloved hands. Further observation revealed the surgery technician placed the clean linen on the operating room without performing hand hygiene between tasks.

3. During an interview on 3/13/14 at 8:38 AM the surgical services manager stated the respiratory therapist and CNA failed to perform acceptable standards of practice for hand hygiene.

4. According to the "Handwashing" policy, approved 8/5/10, staff were directed to perform hand hygiene after contact with objects (including equipment) located in the patients' environment.

Based on observation, review of facility policies and procedures, review of manufacturer's instructions, and staff interview, the facility failed to ensure semicritical medical items received at least high level disinfection prior to reuse and were stored in a sanitary manner. In addition, the facility failed to ensure horizontal surfaces in the operating room (OR), the recovery room, and the procedure room were maintained in a sanitary manner. The cumulative effect of these systemic failures resulted in a determination the facility failed to meet the requirements for the Condition of Participation for Surgical Services. The findings were:

1. According to "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, by CDC, "...semicritical items contact mucous membranes or nonintact skin. This category includes...laryngoscope blades...Semicritical items minimally require high-level disinfection..." Review of the manufacturer's instructions for the Welch Allyn laryngoscope blade (used in the facility), provided by the CEO on 3/13/14 at noon, revealed minimum high level disinfection was required, and the blades were compatible with the Steris System 1 for processing. According to the facility's policy "Rules & Regulations" for the anesthesia department (reviewed December 2013), "...All laryngoscope blades shall undergo mechanical cleaning with brush and soapy water, followed by immersion in Steris Processor after each use, to achieve high-level disinfection and rinsed thoroughly before reuse." The following concerns were identified related to the disinfection and storage of laryngoscope blades:
a. During a tour of sterile processing areas and interview on 3/12/13 at 2:10 PM, CNA #1 stated the laryngoscope blades were put in the "washer" (Steris Reliance 333 washer), but did not receive high level disinfection or sterilization. She stated "as far as I know, we don't have to sterilize [the blades]." According to the manufacturer's instructions for the Steris Reliance 333 washer/disinfector, the washer "...is intended for automated cleaning, low level disinfection...Steris does not intend, recommend nor represent in any way that this Reliance 333 washer/disinfector be used for the terminal disinfection or sterilization of any regulated medical device.."
b. During an interview on 3/13/14 at 8:25 AM, the director of ambulatory and surgical services stated used laryngoscope blades should be cleaned in the washer, and then put in the Steris System 1 for high level disinfection. She further stated it was possible staff were missing a step, and were not putting the blades in the Steris System 1. She stated the facility did not have a log of items put into the Steris System 1, therefore she could not provide documentation to show the blades received high level disinfection. She stated data was entered into the Steris System 1, which would show on the ticker tape (data printed on rolls of paper). She stated the code "RT" was used for the blades; however, the facility did not have a written policy which showed the blades were the only device using that code. The facility had no surveillance process to monitor the reuse of the laryngoscope.
c. On 3/13/14 at 11:04 AM, the CEO stated the code "RT" on the ticker tape of the Steris System 1 could be used to show the blades were disinfected. However, at 11:14 AM the CEO stated she would be unable to show all blades were put in the Steris System 1, because sometimes another code besides "RT" would be used with the blades. When asked what documentation the facility had to prove the blades received high level disinfection, the CEO stated she would look at the ticker tapes and get back to the surveyor. At the time of the exit conference with facility staff on 3/13/14 at 1:05 PM, no documentation was provided. As of 3/25/14, no additional information was provided.
d. Observation on 3/10/14 at 2:55 PM revealed the emergency room physician removed an uncovered laryngoscope blade from the emergency room cart drawer and used it during the provision of patient care. Observation with CRNA #1 on 3/12/13 from 1:35 PM to 1:48 PM revealed uncovered larygoscope blades were available for use in the drawers of the obstetric and anesthesia carts. At that time the CRNA stated the larygoscope blades were usually stored in this manner. During an interview on 3/13/14 at 8:25 AM, the director of ambulatory and surgical services stated the storage of the laryngoscope blades "was an issue." She stated the facility needed to come up with a process for storing the blades, because "throwing them in the cart is not appropriate anymore."

2. The following concerns were identified related to cleaning of the OR, recovery room, and procedure room:
a. Observation of the OR on 3/12/14 at 7:45 AM revealed an adjoining area (part of the OR, as there was no door) which contained an autoclave. Upon the request of the surveyors, OR tech #1 used a cloth to wipe across the top surface of the cabinet located in that room. Dirt and dust was visible on the cloth. According to the facility's policy "Operating room Cleaning and Sanitation" (December 2013), ..."Housekeeping will terminally clean the OR on days that the department is used...Terminal Cleaning: All surfaces wiped down." During an interview on 3/12/13 at 4:55 PM environmental services staff #1 stated the tops of the cabinets in the autoclave room "occasionally had a mop run over it...with the air flow, don't get a lot of dust in there."
b. Observation of the recovery room (room where medical procedures were also performed) on 3/12/13 at 7:50 AM revealed 4 free standing cabinets which contained sterilized medical instruments and supplies. OR tech #1 used a cloth to wipe across the top surface of the cabinets. Dirt and dust was visible on the cloth. OR tech #1 stated the surface was rough wood.
c. Observation on 3/12/14 at 1:05 PM revealed environmental services staff #1 and #2 terminally cleaned the procedure room (endoscopy suite). The top of the cabinet located in the room was not cleaned. Interview with environmental services staff #1 at that time revealed the top of the cabinet was "dusted monthly." Review of the facility's policy "Cleaning [Endoscopy] Suite in between patients" (December 2013) revealed "The environmental services department will clean all surface areas...at the end of each day the room is used."

Based on review of policies and procedures and staff interview, the facility failed to have written policies in place to address visitation rights of patients, including any restrictions or limitations. The findings were:

During an interview on 3/11/14 at 11:10 AM, case manager #1 provided the surveyor with the facility's policy on patient rights. Review of the policy "Patient Rights" (revised November 2009) revealed the policy did not address visitation rights of patients. On 3/11/14 at 2:03 PM the CEO provided the surveyor with a policy entitled "Patient Visitation Rights" (dated March 2013), which included the required elements. However, review of the policy showed no evidence it was approved by the governing body or medical staff, nor was currently in effect in the facility. On 3/11/14 at 2:20 PM, the CEO stated she was not sure the policy had ever been approved because she was unable to find any documentation.

Based on medical record review, staff interview, and review of the patient/family handbook, the facility failed to inform patients of their visitation rights for 17 of 17 sample patients (#1, #2, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20). The findings were:


During an interview on 3/11/14 at 11:10 AM, case manager #1 stated patients were informed of their rights on admission, and were told that every room contained a patient/family handbook, which described their rights. Review of the medical records for sample residents #1, #2, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #19, and #20 revealed the patient or family signed a form on admission which stated they were aware there was a patient/family handbook in every room. However, review of the patient/family handbook showed the handbook only listed the visiting hours in regards to visitation. The handbook did not include the visitation rights of patients, including any restrictions or limitations. In addition, the handbook failed to inform the patient of his/her right to receive any visitors whom s/he designated.

Based on review of policies and procedures, staff interview, and review of the patient/family handbook, the facility failed to have written policies to ensure visitation privileges were not limited or restricted based on race, color, national origin, religion, sex, gender identity, sexual orientation or disability. In addition, policies were not in place to ensure that all visitors enjoyed full and equal visitation privileges. The findings were:

On 3/11/14 at 2:03 PM the CEO provided the surveyor with a policy entitled "Patient Visitation Rights" (dated March 2013), which included the required elements regarding visitation rights. However, review of the policy showed no evidence it was approved by the governing body or medical staff, nor was currently in effect in the facility. On 3/11/14 at 2:20 PM, the CEO stated she was not sure the policy had ever been approved because she was unable to find any documentation. Review of the patient/family handbook showed the patient visitation rights information was not included.