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Based on observation, interview, and policy review the facility failed to provide patient privacy when a patient was placed in a bed located in the corridor.

Findings include:

Observation on 12/15/15, 12/16/15 and 12/17/15, noted a patient bed at the end of the corridor. The area contained two privacy cloth curtains, televisions, and a bedside table. The space lacked privacy from noise, light, or intrusion by visitors or others ambulating in the corridor. A toilet with a door was adjacent to the area outside the privacy curtains. The toilet could be accessed by others in the corridor.

Interview in the afternoon of 12/15/15, with the Director of Medical-Surgical Nursing indicated the bed in the hallway was for "overflow" patients when the unit was full. The Director indicated the space was private, because it had a curtain.

Review of the facility admission rights and responsibilities included, the right to "expect privacy and dignity...."

Based on observation and interview, the facility failed to ensure the confidentiality of a patient's medical record was maintained.

Findings include:

On 12/16/15 at 10:25 AM, on the Pediatric Unit, a computer screen was observed in an alcove with patient's medical information, which included the resident's name, date of birth, admission date and other admission information visible on the computer screen. The Registered Nurse (RN) identified as the nurse who was using the computer several feet away tending to a patient's intravenous (IV) pump. This observation was verified by a Unit Manager who accompanied this Inspector. The RN acknowledged the computer screen had been left on indicating she stepped away to care for the patient. The RN confirmed the computer should have been signed off before leaving the computer unattended.


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On 12/17/15, in the morning, in the outpatient (pre-admitting) waiting room (first floor) there were clipboards for the laboratory and for the treatment rooms. The clipboards had forms with patients names and date of birth (stickers) listed and adhered to the forms. The laboratory clipboard did have a cover sheet for its clipboard, however both boards were accessible to anyone that wanted to view them.

Based on observation, interview, record review and policy review, the facility failed to ensure restraints were not used in 1 of 30 sampled patient (Patient #7).

Findings include:

Patient #7

Patient #7 was admitted on 12/12/15, with diagnoses including acute cholecystitis, diabetes, dementia, and status post open reduction internal fixation of the right hip.

Observation at approximately 12:00 PM on 12/15/15, revealed Patient #7 in bed with wrist restraints in place and tied to the underside of the bed restricting movement of both hands and arms. The patient was observed pulling at both right and left restraints. Inspection of Patient #7's right wrist revealed a two-inch reddened area in the wrist crease area. Also, the patient's right hand and fingers were swollen. The patient was unable to verbalize answers to questions about the restraints.

Observation at 9:50 AM on 12/16/15, revealed the patient in bed without restraints. Inspection of the patient's right revealed four half-inch reddened areas on the right hand and wrist. Swelling of the patient's right wrist was still present although somewhat diminished.

Interview at approximately 12:00 PM on 12/15/15, with the Director of Medical-Surgical Nursing, Unit Manager and Shift Manager indicated the patient was restrained for fear the patient would dislodge the drain in the right hip area. Additionally, the managers indicated the patient had attempted to dislodge an intravenous catheter as well. Query into whether the staff attempted a less restrictive measure to address the problem revealed the alternate non-restraint method occurred simultaneous with restraint application. And, the managers were unable to explain why or how the patient's right hand was reddened and swollen other than due to pulling at the restraint.

The Director of Medical-Surgical Nursing indicated it was facility policy to attempt less restrictive measures and alternate interventions to address the issue before restraint application. Further, the Director indicated the restraints were released and the patient turned every two hours. The Director added staff were trained in restraint use and included in staff competencies completed at the time of new staff orientation and annually thereafter.

Review of the facility policy titled, Restraints, Management of Patients Requiring Restraint, dated 10/2015, provided, "...use of the least-restrictive physical restraint is utilized after alternative interventions have either been considered or attempted." The policy described alternate interventions as re-orientation/redirection, exercise, ambulate, decrease stimulation, and distraction to name a few. The policy identified the justification for restraints as for non-violent/self-destructive or violent/self-destructive behavior.

Review of the policy titled, Standards of Care, dated 06/2013, provided, when immobile a patient must be repositioned every two hours and as needed.

Review of a document titled, Position Description Competencies/Skills for a Registered Nurse (no date), #81 Restraints provided the nurse would assess/reassess, educate and document appropriately regarding a restrained patient.

Review of the clinical record indicated the restraint was initiated on 12/14/15, at 12:12 PM and continued until 6:30 AM on 12/16/15. The following summarizes the documentation regarding release of the restraints:
12/14/15:
-12:12 PM, applied
-2:00 PM, released
-4:00 PM, released
-6:00 PM, continued
-8:00 PM, continued
-10:00 PM, continued

12/15/15:
-12:00 AM, continued
-2:00 AM, continued
-4:00 AM, continued
-6:00 AM, continued
-8:00 AM, released
-10:00 AM, released
-12:00 PM, released
-2:00 PM, released
-4:00 PM, released
-6:00 PM, released
-8:00 PM, continued
-10:00 PM, released

12/16/15:
-12:00 AM, continued
-2:00 AM, continued
-4:00 AM, continued
-6:30 AM, discontinued

Review of the clinical record regarding positioning and repositioning following the application of restraints (12:12 PM):
On 12/14/15, revealed Patient #7 was turned or repositioned at 2:00 PM and not again until six hours later at 8:00 PM and again at 10:00 PM.
On 12/15/15, the patient was turned or repositioned at 12:00 AM through 4:00 PM and the equivalent of every two hours with one three hour gap from 4:00 PM until 9:00 PM.

Review of the clinical record regarding Patient #7's wound/skin assessments lacked documented evidence the reddened areas on the right wrist were assessed. Further, the record lacked evidence the patient's swollen right hand was assessed.

Based on observations, interview and document review, the facility's governing body failed to ensure sterilization procedures were followed according to the facilities policies on sterilization and ensure all staff were trained accordingly.

Findings include:

On 12/18/15 in the afternoon, the Infection Control Nurse indicated that she was not aware of the new sterilization process was changed 6 months prior. She further indicated that any new projects/products introduced to the facility were run through a committee that involved infection control management. However, this was not done for the new sterilization process that was implemented.

On 12/18/15 in the afternoon, the Director of Quality Assurance indicated the new sterilization process was not included as part of the Quality Assurance and Performance Improvement process.


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On 12/18/15 in the morning, the Sterile Processing Department (SPD)/Central Service Manager indicated the process for sterilization of surgical instruments was changed 6 months ago. The use of Biological Indicators (BI) was changed from using three hour BI to using one or three hour BI when sterilizing instruments. Also, a new computer program to inform staff regarding the settings for each sterilized item and what type of BI to use (one or three hour) was implemented 6 months ago. The SPD Manager indicated the new process was implemented but the program had not been completely uploaded and completed with all the instrument specifications. The SPD Manager indicated the facility sterilization policy was not updated to reflect the changes that were implemented. The SPD Manager indicated the Quality Assurance Staff were not fully informed on the changes SPD implemented 6 months ago.

Based on interview, record review, and policy review, the facility failed to complete admission assessments in a timely manner for 2 of 30 sampled patients (Patients #6 and #8).

Findings include:

Patient #6

Patient #6 was admitted on 11/26/15, with diagnoses including perforated bowel and sepsis.

Interview in the afternoon of 12/15/15, with the Shift Supervisor confirmed an assessment of the patient should occur "upon admission."

Review of the medical record form titled, CORE Care Checklist, indicated it was "Completed for ALL patients, ALL diagnosis." The form was not signed by the Registered Nurse until 12/13/15 at 9:40 AM.

Review of the facility policy titled, Interdisciplinary Patient Assessment, dated 12/2014, Section 3.1 defined an admission assessment as, "an assessment completed by a Registered Nurse (RN) upon admission. "Section 3.1.1 defined the medical-surgical department specific initial assessment timeframe as," within 8 hours upon admission."

Review of the facility policy titled, CORE Measures Screening (Clinical Opportunities Related to Excellence), dated 9/2015, provided in part under Section 4.2, "CORE measure screening will be implemented upon admission. Under the heading Procedure, Section 5.1, the document indicated CORE measure screening occurs "during the admission process."

Patient #8

Patient #8 was admitted on 12/14/15, with diagnoses including, chest pain, hypertension and gastroesophageal reflux disease (GERD).

Interview in the morning of 12/16/15, with the Shift Supervisor again confirmed the CORE Care Checklist should occur "upon admission." The Supervisor also confirmed the section titled, Completed for ALL patients, ALL diagnosis was blank. And the document lacked a signature by a Registered Nurse.

Policy review applies as above.

Based on observation, interview and document review, the drug storage areas were not administered in accordance with accepted professional principles.

Findings include:

On 12/15/15, the medication room for the medical surgical unit located on 2 east was toured. Medications not located in the automated system were placed in patient bins identified by the room number in which the patient resides. Medication for patients in both room 265 and 269 were found to be in the bin marked 265. There were no medications located in the bin marked 269. The floor manager and shift manager were interviewed. The floor manager indicated that it was the pharmacy department's responsibility to place medications in the bin appropriately and the patient's nurse's responsibility to verify the medication prior to administering. Both the floor manager and shift manager agreed that the medications were placed incorrectly in the bins. The floor manager then placed the medications in the appropriate bins. The pharmacy supervisor was interviewed and indicated that the pharmacy department was responsible for filling the bins appropriately and it was the nurse's responsibility to verify the medication prior to administration.

On 12/16/15, the medication room for the medical surgical unit located on 2 east was toured. Bin number 248 contained medications for both room 248 and 247. The intravenous medication for room 247 had been dispensed on 12/15/15 and indicated that is should be refrigerated. The floor manager and shift manager were interviewed. The floor manager indicated that it was the pharmacy department's responsibility to place medications in the bin appropriately and the patient's nurse's responsibility to verify the medication prior to administering. Both the floor manager and shift manager agreed that the medications were placed incorrectly in the bins and agreed that the intravenous medication had not been stored appropriately. The floor manager then placed the medications in the appropriate bins and placed the intravenous medication in the medication disposal bin.


On 12/16/15, the hospital pharmacy was toured. A bottle of Gabapentin was found to be in the multidose shelved area. This area was not refrigerated. The instructions on the bottle indicated to refrigerate the medication. The pharmacy supervisor and director were interviewed. Both agreed that the medication should have been refrigerated. The pharmacy supervisor indicated that the bottle was still cold and that it probably meant the pharmacy technician had probably removed it from the refrigerator to prepare a dose and then returned it to the improper location. The pharmacy supervisor then removed the medication from the multidose shelf.

The facility policy entitled, "Medication Administration," effective 10/15, was reviewed. Section 2.3 indicated that the "Pharmacist is responsible for the initial review of all ordered medications for appropriateness of the medication, including contraindications, dose, frequency and route of the medications for administration by clinical staff..." Section 2.3.1 stated that "Pharmacy staff, under the direction and review by a Pharmacist, are responsible to prepare and dispense medication to be administered by licensed clinical staff..." Policy 4.1, indicated "All medications used in SRD (St. Rose Dominican) will be provided by the Pharmacy Department, unless specifically exempted." Sections 4.3, 4.4 and 4.5 indicate that licensed clinical staff will verify patient identification using two patient identifiers, for all inpatients, the verification process will include referencing the MAR (Medication Administration Record)...prior to medication administration and that medication administration will be performed utilizing the five patients rights: Right patient, Right medication, Right dose, Right time and Right route."


31270


Observation (inspection) in the afternoon on 12/15/15, of the medication room on the medical-surgical unit revealed aspirin suppository stored in the refrigerator next to oral medication.
Interview in the morning on 12/16/15, with the pharmacist confirmed internal and external medications should be stored separately.

Review of the facility policy titled, Automated Medication Dispensing Devices (AMDD) Management, Stocking & Maintenance, dated 2/2012, Section 1.2 identified the objective to "ensure AMDD are accurately stocked, maintained and managed to secure access and safe dispensing of medication."

Based on document review and interview, the facility's policy regarding tissue requisitions does not match the current requisitions practice with a computerized system.

Findings include:

Current requisitions practice does not include the use of handwritten requisitions with carbon copies. In the current practice, the requisitions are completed in the laboratory information system and a copy of that requisition is sent to the pathology laboratory with the sealed specimen.

The written policy for tissue receipt and reporting was last revised on 5/2007. The procedure states that the yellow carbon copy of the requisition is retained by the laboratory and that the pathology requisition is placed in the outer pocket of the specimen bag containing the sealed specimen. The Laboratory Manager confirmed that the current practice is not reflected in the policy during an interview on December 17, 2015 at approximately 3:00 PM.

Based on observation, staff interview and document review, the facility failed to ensure the kitchen and nourishment stations were maintained in a clean and sanitary manner.

Findings include:

One section of the kitchen was being remodeled for expansion of the cafeteria. A new soft drink dispenser was in the process of installation which included plumbing and electrical connections. The ceiling tiles had been removed and there was an accumulation of dust and dirt debris in the area on the counter and floor. There was no barrier between this area and the food preparation, food storage and food service sections of the kitchen.

Packages of ground beef were observed being thawed under dripping water, however, the water was not draining because plastic wrap was placed over the drain in the sink. The plastic wrap impeded the water from "freely draining" as required by Administrative/Nutrition Services facility policy "Food Preparation and Handling, dated 11/12."

On 12/15/15 and 12/16/15, the door to the produce refrigerator was not closing and latching completely.

On 12/15/15, one of four "red" buckets that was used for sanitizing solution did not contain the sanitizing chemical, this was confirmed when tested with the facility's sanitizer's (Quaternary) testing strips and failed to change color.

On 12/16/15, one cook placed a towel, intended for cleaning/sanitizing work stations, over their shoulder rather than in the red bucket of sanitizing solution.

On 12/16/15, identified Yoplait Light Yogurt in the cafeteria, nourishment room on the fourth floor tower 4W, Pediatric ICU, and the physician's lounge that were past their expiration date of 12/3 and 12/13.

On 12/15/15, identified a container of soup placed in a cupboard that was storage space for Enteral feeding products. The container was warm to the touch. There was also a sandwich container and one open can of soda in the cupboard with the soup.

Based on staff interview and document review, the facility failed to ensure the Dietitian approved three of three diet manuals.

Findings include:

On 12/15/15, the Food Service Director indicated the Dignity Health - St. Rose Dominican - Diet Manual was the current therapeutic diet manual.

On 12/16/15, a Dietitian indicated the Nutrition Care Manual from the Academy of Nutrition and Dietetics was used for patient nutrition education materials, the American Society of Parenteral and and Enteral Nutrition was used for reference for clinical nutritional criteria, and additionally the Diet Manual from Dignity Health was available in the Chief Clinical Dietitians office for reference if needed.

On 12/16/15, the Food Service Director also indicated the Diet Manual from Dignity Health Diet Manual was a hard copy of the Nutrition Care Manual from the Academy of Nutrition and Dietetics.

Review of the "Institutional Approval Form" from the Academy of Nutrition and Dietetics revealed that four Medical Staff Representatives signed on 5/28/15, 6/3/15 and 6/4/15 that the Nutrition Care Manual by the Academy of Nutrition and Dietetics was reviewed and approved for use in the hospital. The Dietitian did not sign this document.

Review of the Dignity Health - St. Rose Dominican - Diet Manual, revised 2015, was "originally developed in 2009 by a team of nutrition interns working under the supervision of the lead clinical dietitian at Dignity Health - St. Rose Dominican. The collaborative efforts of this group resulted in a simplified manual designed for use by physicians and health care professionals in providing nutrition care to patients." This document indicated the Lead Clinical Specialist, R.D. was the Diet Manual Coordinator, there were no signatures from a dietitian approving this diet manual, nor were there any signatures from the Medical Staff Representatives verifying they reviewed and approved this diet manual and there was no information to verify a licensed dietitian from the facility or the contracted food service vendor reviewed and verified the information contained in the diet manual.

The Dignity Health, St. Rose Dominican Pharmacy and Therapeutic Committee meeting minutes dated 5/26/15, did not include documented evidence that the Dignity Health - St. Rose Dominican - Diet Manual, revised 2015 was reviewed and approved for use in the hospital.

The committee minutes reflected that the Lead Clinical Specialist Dietitian presented a review of the the online Adult Nutrition Care Diet Manual with the Committee and the Pediatric Diet Manual. There was no date of publication, no reference to the current edition and no name of the publisher included in the committee meeting minutes.

These minutes reflected that the committee took the following action, "Recommend approval and forward to MEC (Medical Executive Committee)," without the correct title, publisher or date of current edition.

There was a lack of documentation to verify the Lead Clinical Dietitian and the Medical Staff of the facility reviewed and approved all three diet manuals in use at the hospital.

Based on observation, interview, policy review and record review, the facility failed to:
- disinfect a glucometer before and after blood glucose testing for a patient in the emergency department;
- conduct proper hand hygiene;
- properly cleanse hands between glove changes;
- dispose of used, opened and expired patient care equipment;
- maintain clean crash carts and anesthesia carts;
- properly use trash and dirty linen bins in the operating rooms;
- have a process to identify expired steam chemical strips used for sterilization;
- not properly in-servicing Sterile Processing Department staff, updating computer programs to assist with the sterilization process and updating Infection Control Coordinator on the process changes with sterilization;
- discard outdated food, clean refrigerator; label intravenous container and tubing in 1 of 30 sampled patients (Patient #8); and
- maintain a clean and sanitary environment for self serve food areas (vending).

Findings include:

1)

On 12/16/16 at approximately 1:30 PM, a Registered Nurse (RN) was observed performing a fingerstick to determine a patient's blood glucose level. The Emergency Department Director of Marketing also observed the procedure. The RN removed the glucometer from the stand at the nurses station and carried the device into the patient's room. The RN also brought the glucose testing strips container into the patient's room and placed the container on the patient's over the bed table. The RN was not observed to disinfect the glucometer prior to patient use.

The RN completed the blood glucose testing procedure and disposed of the lancet properly. The nurse returned the glucometer to the stand without wiping it down with disinfectant. The nurse placed the testing strips into the carrying case located on the nursing unit. The glucometer was available for use on multiple patient's in the emergency department.

The Emergency Department Marketing Director confirmed the nurse did not disinfect the glucometer following its use on a patient.

Review of the hospital's guidelines entitled, "Point of Care Blood Glucose Testing," provided by the Emergency Department Director of Marketing revealed: "Routine decontamination of the blood glucose meter with a hospital approved disinfectant must be performed between each patient use. The guidelines were undated.


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2)

On 12/17/2015 at approximately 10:00 AM, a collection of a blood specimen by venipuncture was observed in the outpatient phlebotomy area. The phlebotomist did not removed the used gloves and perform hand hygiene prior to pushing the wheelchair bound patient out of the phlebotomy area into the waiting area. During an interview with the laboratory manager on 12/18/2015 at approximately 1:30 PM, the laboratory manager confirmed that the hospital infection policy stated to remove gloves and perform hand hygiene prior to leaving a patient care area.


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3)

On 12/15/15 at approximately 11:00 AM, a dressing change was observed. The registered nurse (RN) removed the old dressings, removed the gloves she was wearing, and threw them in the trash. The RN then put on a clean pair of gloves and proceeded to cleanse the wound, dry the area, and place a clean dressing on the wound.

After the dressing change observation, the Director of the Intensive Care Unit was interviewed and asked what the policy was for removing gloves and putting on clean gloves. The Director reported the nurse should have washed her hands or used alcohol based hand sanitizer.

Review of the facility policy, Hand Hygiene, with an effective date of 9/12, revealed under policy 4.0,

4.1.5 "After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, wound dressings or other potentially infectious material.

4.16 After removing sterile or non-sterile gloves and/or other personal protective equipment."


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4)

On 12/15/15 at approximately 10:00 AM, an inspection of the Pediatric Intensive Care Unit (PICU) storage room revealed the following:

- A sterile tray package was stored on a shelf in a cabinet located above the countertop. The adhesive self-sealed package was observed to be wrinkled and open at the end. A Registered Nurse (RN) confirmed the the sterile tray package was open and damaged. The RN indicated the sterile package was good unless opened or damaged.

- A plastic open top zip lock zipper bag with "Kit Made 7/13" documented on the bag was observed in a procedure cart. The kit identified as a chest tube removal kit included a package of Vaseline Petrolatum Gauze, 3 inch x 9 inch overwrap (gauze dressing) with a used by date of 08/2015. The Pediatric Unit Manager confirmed the petroleum gauze was expired.

On 12/15/15 at approximately 10:25 AM, during a tour of the post-partum unit revealed the following:

5)

Crash Cart
-A neonatal crash cart labeled as cart #2 with a Neopuff Infant T-Piece Resuscitator stored on top of the cart. The resuscitator was observed with patient supply line (clear tubing) connected to the gas outlet with the tubing uncovered and draped across the top of the crash cart. The Post-Partum Unit Manager indicated the tubing should have been covered.

-A suction container on the same neonatal cart was observed with a collection of dust on top of the lid. The Post-Partum Unit Manager indicated the suction container should have been checked with the cart's daily check. The Unit manager verbalized, "They should wipe it down." The Unit Manger explained the Charge Nurse and the Shift Manager were responsible for checking the crash carts daily.

On 12/15/15 at approximately 10:35 AM, during an inspection of a storage room on the post-partum unit revealed a bottle of Iodoform packing strips stored behind several other items on a shelf in the first set of cabinets located above the countertop. The Iodoform strips had a stamped date of "2014-03." The Unit Manager was unable to identify whether the date on the bottle was the manufacturer's package date or expiration date. On 12/16/15 at 1:05 PM, the Unit Manager confirmed the Iodoform packing strips 03/2014 was the expiration date.

On 12/15/15 in the morning, during a tour of the Labor Delivery Unit a cart identified by the Labor Delivery Unit Manager as an "anesthesia cart" was observed in with red spillage noted on the front of the drawers and the top of the cart was visibly dirty with a cloudy like substance with several scattered light red dots. The Unit Manager explained the Anesthesia Department or an Anesthesia Technician was responsible for the cleaning the cart. The Unit Manager acknowledged the cart was dirty and verbalized, "Look like it could use a wiping down."

6)

On 12/17/15 at 9:10 AM, observation of room of an unoccupied patient room on the pediatric unit revealed the following:
-A dirty suction container remained in the wall bracket. The suction container was filled with a cloudy mucus-like liquid with a bulb tip aspirator connected (used for suctioning babies).
-A used nasal cannula was draped on the back of the crib.

The licensed nurse acknowledged the dirty suction container and nasal container remained in the room. The licensed nursed verified the tape observed on seal of the bathroom door indicated the bathroom had been cleaned by housekeeping. The Pediatric Unit Manager indicated the nurses normally pulled the dirty suction containers from the patient's room prior to admitting a new patient.

On 12/18/15 in the morning, a registered nurse explained the nurses were responsible for the disposal of the suction containers, tubing and nasal cannulas once the patient was discharged prior to housekeeping cleaning the room.

Facility policy entitled, Cleaning of Patient Care Areas and Rooms: Five Step Process, effective date: 08/15 indicated the following:
"...Responsibilities ...2.2 Nursing Staff - are responsible for stripping patient beds and the appropriate disposal of medical and pharmaceutical waste, i.e., IV tubing, dressings, etc., Once a patient has been discharged ..."

Facility policy entitled, "Isolation Precaution Practices," Policy #IC-I-2035, Effective: 08/15 indicated:
"...5.10 All supplies and items inside an isolation room that cannot be cleaned and disinfected will be discarded at end of patient stay..."


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7)

On 12/16/15 in the morning, a surgical procedure was observed in operating room #6. The operating room had two trash bins and one dirty linen bin lined against cabinets, which stored surgical supplies and equipment. The bins had flat plastic covers approximately 2 feet by 2 feet that covered the opening of the bins. The trash and dirty linen bins had a foot pedal to open the bin covers.

During the procedure the operating room staff and two supply vendors were using the tops of the trash and dirty linen bins as a table to:

-Place medical equipment and supplies being taken out from the medical supply storage cabinets that were beside the bins.
-Place packaged medical supplies that were obtained from outside of the operating room and opening the packages while on top of the bin covers.
-Open and don sterile surgical gloves for the procedure.
-Place wrapped sterilized surgical trays used for the procedure.
-Place paper work and used as a writing table during the procedure.
-Place trash picked up from the floor and setting it on top of the trash bin possibly not able to open the top due to several clean items such as supplies and papers that were also stacked on the bin cover.
-Use as an arm rest while waiting for the surgeon or surgical staff for any request to obtain more supplies or just waiting for the procedure to be completed.

During the procedure all three bin tops were stacked with medical supplies, equipment and paper work. When staff attempted to use the bins to place trash or dirty linen in them, the staff had to open the tops using their upper extremity (hand, forearm, elbow and upper arm) to secure the items stacked on top. While opening the bin top with one extremity the other hand was used to slip the trash or dirty linen through the small opening, thus having the hand holding the items brush against the inside of the bin cover and the inside of the dirty bin.

Some staff were opening the bin covers either with their bare hands or with soiled gloves. The staff were not using the foot pedal to open the bins due to having to secure the items stacked on top of the bins with their hands so they would not fall off.

On 12/16/15 at 9:45 AM, the Operating Room Manager indicated it was not acceptable for the staff to use the tops of the trash bins and dirty linen bins as a table and the bin covers should be opened by using the foot pedals and not their bare hands or soiled gloves.

8)

On 12/17/15 at 2:45 PM, a pediatric emergency crash cart was stored in the Sterile Processing Department (SPD). The SPD Manager indicated a pediatric crash cart located in the SPD was already cleaned, inspected, re-stocked and ready to go up to the unit. After breaking the seal and examining the inside drawers of the cart, there was:

-An endotracheal tube packaged with an expiration date of 10/2006.
-An endotracheal tube package that was fully opened with the old packaging noted to be torn and dirty.
-A surgilube container with an expiration date of 2014.

Hanging on the outside of the same pediatric emergency crash cart were AMBU (Air, Mask, Bag, Unit) bags that were stored in plastic bags. The plastic bags were old, dirty, shredded and ripped with parts of the AMBU bag protruding from the holes located on the bottom and sides of the bag.

On 12/17/15 in the afternoon, the SPD Manager indicated the pediatric cart that was ready to go to the unit was not acceptable and needed to be checked, cleaned and re-stocked again. The SPD Manager indicated the expired and open items such as the 2006 expired endotracheal tube should have been discarded. The SPD Manager indicated the AMBU bags, hanging on the outside of the cart in an unacceptable plastic bag, may have had parts missing due to the holes in the bag.

9)

On 2/17/15 in the afternoon, SPD staff had work stations to organize and prepare cleaned surgical items for the sterilization process. Located at each station were containers with unpackaged steam chemical strips used for the sterilization process for each load. The staff indicated the containers were replenished with new strips when it ran low. There was no identified expiration date on the individual strips or container at the work station. The chemical strips were obtained from a manufacturer bag of strips located in a storage cabinet in the SPD. The bag had an expiration date for the strips, but when the containers located at the work stations were replenished and mixed with older strips there was no process in identifying which strips were possibly expired.

On 2/17/15 in the afternoon, the SPD Manager indicated the process needed to be changed to identify expired steam chemical strips being stored in containers at the work station.

10)

On 12/17/15 in the afternoon, the SPD Manager indicated one (1) hour or three (3) hour Biological Indicators (BI) were used during the sterilization process of surgical instruments.

On 12/17/15 in the afternoon, the Inspector asked how would the staff know what type of BI would be used for each surgical instrument to be sterilized.

On 12/17/15 in the afternoon, the SPD Manager indicated there was a new process for sterilizing instruments initiated 6 months ago. The SPD Manager indicated a new program initiated 6 months ago informed the technician what setting to use for sterilization for each item/package (load). The program also informed the technician what type of BI to use for the load, either a 1 or a 3 hour BI.

On 12/17/15 in the afternoon, the Inspector randomly chose an instrument to go through the sterilization process. A surgical drill that was recently sterilized was chosen to go through the process. The SPD Manager attempted to look up the surgical drill in the new program. There was no information on the specifications for sterilization or what type of BI (1 or 3 hour) to use in the program. The Inspector requested to have the SPD Manager locate a different brand name surgical drill from the program the facility used frequently. The SPD Manager located a list of over 20 different surgical drills in the new program. None of the drills had information regarding the specifications for sterilizing the items especially what type of BI to use, either 1 or 3 hour indicator.

On 12/17/15 in the afternoon, the SPD Manager indicated data was not completely loaded in the new program to inform the staff the specifications for sterilization for a specific item and what BI to use for each load.

On 12/17/15 in the afternoon, the Senior Director of Perioperative Services indicated there was another program (database A) the staff had access, to inform them on the sterilization specifications for each item to be sterilized.

On 12/17/15 in the afternoon, the SPD Manager had difficulty logging into the second program (Sure Point) with other SPD staff not knowing the password or program that was available to them. After the password was confirmed by the SPD Manager, navigating through the system was slow and time consuming. The program informed the staff what sterilizing settings were needed for an item, but the program did not inform the user on what type of BI to use for the load.

The facility policy titled, Biological Testing of Sterilizers, with an effective date of 11/2014, documented:

"...Pre-vacuum or Vacuum-Assisted Steam Sterilizers..."
"...A BI test pack will be included on the first regular load of the day and every load with implantable materials in it..."
"...Incubate both the processed and the non-processed control spore test ampules and read results in (3) three hours of incubation..."

On 12/17/15 in the afternoon, the SPD Manager indicated the facility policy regarding the use of BI did not reflect on how the SPD was using BI for sterilizing items. The SPD Manager indicated the facility had been using 3 hour indicators for all the loads, but was recently changed 6 months ago. Now the facility used 1 or 3 hour BI (depending on the sterilization setting on an item) to release some instruments back to surgery quicker.

On 12/17/15 in the afternoon, the SPD Manager indicated the staff needed to be in-serviced on how to access and navigate through the database A program since the other new program, implemented 6 months ago, was not fully updated on sterilization specifications.

On 12/18/15 in the morning, the SPD Manager indicated the facility policy regarding the use of BI was not always followed. The SPD Manager indicated the first load of the day may contain a 1 hour or 3 hour BI, depending on what the sterilization settings required for the first item placed in the machine. The SPD Manager indicated the policy required a 3 hour BI for the first regular load of the day. The SPD Manager indicated the Policy needed to be updated.

On 12/18/15, in the morning, the SPD Manager indicated the new program, implemented 6 months ago informing staff on the sterilization settings and which BI to use for a load, was only 50% updated. The SPD Manager indicated the Infection Control Director and the Quality Assurance Director were not fully updated on the changes made with the use of a new program and using 1 and 3 hour BI in the sterilizing process.


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On 12/18/15, in the afternoon the Infection Control Nurse indicated that she was not aware of the new sterilization process was changed 6 months prior. She further indicated that any new projects/products introduced to the facility are run through a committee that involves infection control management. However, this was not done for the new sterlization process that was implemented.


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11)

Observation in the afternoon on 12/15/15, and the morning on 12/16/15, of two refrigerators, one in the patient nourishment room and the other in the nurse ' s station were visibly soiled. The patient nourishment room refrigerator contains various items for patient consumption. The refrigerator at the nurse ' s station contained items for immune-compromised patients.

Interview in the afternoon of 12/15/15, with the dietary worker confirmed the patient nourishment refrigerator was soiled.

An interview on the morning of 12/16/15, with the shift supervisor confirmed the refrigerator in the nurse ' s station was soiled.

Review of the facility policy titled, Sanitary Conditions & Infection Prevention in Food Management, dated 11/2012, Section 1.2 identified the objective was to "maintain strict sanitary conditions in order to prevent the growth of disease producing organisms and the production of bacterial toxins and to eliminate food contaminates." And Section 5.15 provides refrigerators "must be kept clean at all times," and Section 5.15.2 "spills must be wiped up immediately."

12)

Observation in the afternoon of 12/15/15, of the patient nourishment room refrigerator revealed a container with a half of a sandwich. The container was dated 12/11/15.

Interview with the dietary worker indicated the label on the container was not a dietary label, rather put on the container by nursing. Regardless, the worker explained, the policy was to discard the food within three days of the date on the container.

Review of facility policy titled, Food & Non-Food Purchasing & Storage, dated 11/2012, identified the policy objective as "to provide a process for safely receiving and storing food and non-food items for use for patients."

13)

Patient #8

Patient #8 was admitted to the facility on 12/14/15, with diagnoses including chest pain, gastroesophageal reflex disease (GERD), and hypertension. The patient was receiving intravenous fluids.

Observation on the morning of 12/16/15, of Patient #8 receiving intravenous (IV) medication administration revealed a bag of Normal Saline (NS) and a secondary empty bag labeled Athecrenic Acid used to treat patient's GERD, which were connected to IV tubing. Neither the NS, empty bag of medication or tubing were labeled indicating a day or time the tubing or medication was hung or the staff person responsible for setting up and administering the medication.

Interview with the nurse on the morning of 12/16/15, with the nurse indicated the facility policy was to label the IV tubing and solution.

Review of the facility policy titled, Adult Vascular Access Devices (VAD), Insertion & Maintenance, dated 6/2015, Section 4.9 provided, "all IV tubing, including secondary sets, will be labeled with time, date and clinical staff ' s initials to identify when the tubing was hung."


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14)

In morning of 12/17/15, the venting area located next to the public dining area and 1 West Unit was examined for cleanliness and sanitation. The microwave was found to be filthy with cooked-on food substances on all internal surfaces of the device. This issue was brought to the dietary department's attention and the dietary staff indicated that this was an environmental (housekeeping) responsibility. The Dietary Manager indicated that they have cleaned the microwave in the past when it was brought to their attention. The environmental staff soon arrived and discussion about getting the microwave clean was conducted.

15)

In the afternoon of 12/16/15, on the dirty side of the sterilization processing suite, the facility was doing construction activities. The construction activities were properly barrier-off from the sterilization activity, however the construction personnel had removed two (2'x2') exhaust duct grills outside of the construction zone. The overhead openings of these two exhaust ducts were filthy with a large accumulation dirt. Construction personnel indicated that the vent grills had been removed for several days. The facility staff did not intervene at any time to have cleaning conducted and/or barrier protection for the vent openings.

Based on observation and interview, the facility failed to ensure the confidentiality of a patient's medical record was maintained.

Findings include:

On 12/16/15 at 10:25 AM, on the Pediatric Unit, a computer screen was observed in an alcove with patient's medical information, which included the resident's name, date of birth, admission date and other admission information visible on the computer screen. The Registered Nurse (RN) identified as the nurse who was using the computer several feet away tending to a patient's intravenous (IV) pump. This observation was verified by a Unit Manager who accompanied this Inspector. The RN acknowledged the computer screen had been left on indicating she stepped away to care for the patient. The RN confirmed the computer should have been signed off before leaving the computer unattended.


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On 12/17/15, in the morning, in the outpatient (pre-admitting) waiting room (first floor) there were clipboards for the laboratory and for the treatment rooms. The clipboards had forms with patients names and date of birth (stickers) listed and adhered to the forms. The laboratory clipboard did have a cover sheet for its clipboard, however both boards were accessible to anyone that wanted to view them.

Based on observations, interview and document review, the facility's governing body failed to ensure sterilization procedures were followed according to the facilities policies on sterilization and ensure all staff were trained accordingly.

Findings include:

On 12/18/15 in the afternoon, the Infection Control Nurse indicated that she was not aware of the new sterilization process was changed 6 months prior. She further indicated that any new projects/products introduced to the facility were run through a committee that involved infection control management. However, this was not done for the new sterilization process that was implemented.

On 12/18/15 in the afternoon, the Director of Quality Assurance indicated the new sterilization process was not included as part of the Quality Assurance and Performance Improvement process.


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On 12/18/15 in the morning, the Sterile Processing Department (SPD)/Central Service Manager indicated the process for sterilization of surgical instruments was changed 6 months ago. The use of Biological Indicators (BI) was changed from using three hour BI to using one or three hour BI when sterilizing instruments. Also, a new computer program to inform staff regarding the settings for each sterilized item and what type of BI to use (one or three hour) was implemented 6 months ago. The SPD Manager indicated the new process was implemented but the program had not been completely uploaded and completed with all the instrument specifications. The SPD Manager indicated the facility sterilization policy was not updated to reflect the changes that were implemented. The SPD Manager indicated the Quality Assurance Staff were not fully informed on the changes SPD implemented 6 months ago.

Based on observation, interview and document review, the drug storage areas were not administered in accordance with accepted professional principles.

Findings include:

On 12/15/15, the medication room for the medical surgical unit located on 2 east was toured. Medications not located in the automated system were placed in patient bins identified by the room number in which the patient resides. Medication for patients in both room 265 and 269 were found to be in the bin marked 265. There were no medications located in the bin marked 269. The floor manager and shift manager were interviewed. The floor manager indicated that it was the pharmacy department's responsibility to place medications in the bin appropriately and the patient's nurse's responsibility to verify the medication prior to administering. Both the floor manager and shift manager agreed that the medications were placed incorrectly in the bins. The floor manager then placed the medications in the appropriate bins. The pharmacy supervisor was interviewed and indicated that the pharmacy department was responsible for filling the bins appropriately and it was the nurse's responsibility to verify the medication prior to administration.

On 12/16/15, the medication room for the medical surgical unit located on 2 east was toured. Bin number 248 contained medications for both room 248 and 247. The intravenous medication for room 247 had been dispensed on 12/15/15 and indicated that is should be refrigerated. The floor manager and shift manager were interviewed. The floor manager indicated that it was the pharmacy department's responsibility to place medications in the bin appropriately and the patient's nurse's responsibility to verify the medication prior to administering. Both the floor manager and shift manager agreed that the medications were placed incorrectly in the bins and agreed that the intravenous medication had not been stored appropriately. The floor manager then placed the medications in the appropriate bins and placed the intravenous medication in the medication disposal bin.


On 12/16/15, the hospital pharmacy was toured. A bottle of Gabapentin was found to be in the multidose shelved area. This area was not refrigerated. The instructions on the bottle indicated to refrigerate the medication. The pharmacy supervisor and director were interviewed. Both agreed that the medication should have been refrigerated. The pharmacy supervisor indicated that the bottle was still cold and that it probably meant the pharmacy technician had probably removed it from the refrigerator to prepare a dose and then returned it to the improper location. The pharmacy supervisor then removed the medication from the multidose shelf.

The facility policy entitled, "Medication Administration," effective 10/15, was reviewed. Section 2.3 indicated that the "Pharmacist is responsible for the initial review of all ordered medications for appropriateness of the medication, including contraindications, dose, frequency and route of the medications for administration by clinical staff..." Section 2.3.1 stated that "Pharmacy staff, under the direction and review by a Pharmacist, are responsible to prepare and dispense medication to be administered by licensed clinical staff..." Policy 4.1, indicated "All medications used in SRD (St. Rose Dominican) will be provided by the Pharmacy Department, unless specifically exempted." Sections 4.3, 4.4 and 4.5 indicate that licensed clinical staff will verify patient identification using two patient identifiers, for all inpatients, the verification process will include referencing the MAR (Medication Administration Record)...prior to medication administration and that medication administration will be performed utilizing the five patients rights: Right patient, Right medication, Right dose, Right time and Right route."


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Observation (inspection) in the afternoon on 12/15/15, of the medication room on the medical-surgical unit revealed aspirin suppository stored in the refrigerator next to oral medication.
Interview in the morning on 12/16/15, with the pharmacist confirmed internal and external medications should be stored separately.

Review of the facility policy titled, Automated Medication Dispensing Devices (AMDD) Management, Stocking & Maintenance, dated 2/2012, Section 1.2 identified the objective to "ensure AMDD are accurately stocked, maintained and managed to secure access and safe dispensing of medication."

Based on observation, interview, policy review and record review, the facility failed to:
- disinfect a glucometer before and after blood glucose testing for a patient in the emergency department;
- conduct proper hand hygiene;
- properly cleanse hands between glove changes;
- dispose of used, opened and expired patient care equipment;
- maintain clean crash carts and anesthesia carts;
- properly use trash and dirty linen bins in the operating rooms;
- have a process to identify expired steam chemical strips used for sterilization;
- not properly in-servicing Sterile Processing Department staff, updating computer programs to assist with the sterilization process and updating Infection Control Coordinator on the process changes with sterilization;
- discard outdated food, clean refrigerator; label intravenous container and tubing in 1 of 30 sampled patients (Patient #8); and
- maintain a clean and sanitary environment for self serve food areas (vending).

Findings include:

1)

On 12/16/16 at approximately 1:30 PM, a Registered Nurse (RN) was observed performing a fingerstick to determine a patient's blood glucose level. The Emergency Department Director of Marketing also observed the procedure. The RN removed the glucometer from the stand at the nurses station and carried the device into the patient's room. The RN also brought the glucose testing strips container into the patient's room and placed the container on the patient's over the bed table. The RN was not observed to disinfect the glucometer prior to patient use.

The RN completed the blood glucose testing procedure and disposed of the lancet properly. The nurse returned the glucometer to the stand without wiping it down with disinfectant. The nurse placed the testing strips into the carrying case located on the nursing unit. The glucometer was available for use on multiple patient's in the emergency department.

The Emergency Department Marketing Director confirmed the nurse did not disinfect the glucometer following its use on a patient.

Review of the hospital's guidelines entitled, "Point of Care Blood Glucose Testing," provided by the Emergency Department Director of Marketing revealed: "Routine decontamination of the blood glucose meter with a hospital approved disinfectant must be performed between each patient use. The guidelines were undated.


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2)

On 12/17/2015 at approximately 10:00 AM, a collection of a blood specimen by venipuncture was observed in the outpatient phlebotomy area. The phlebotomist did not removed the used gloves and perform hand hygiene prior to pushing the wheelchair bound patient out of the phlebotomy area into the waiting area. During an interview with the laboratory manager on 12/18/2015 at approximately 1:30 PM, the laboratory manager confirmed that the hospital infection policy stated to remove gloves and perform hand hygiene prior to leaving a patient care area.


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3)

On 12/15/15 at approximately 11:00 AM, a dressing change was observed. The registered nurse (RN) removed the old dressings, removed the gloves she was wearing, and threw them in the trash. The RN then put on a clean pair of gloves and proceeded to cleanse the wound, dry the area, and place a clean dressing on the wound.

After the dressing change observation, the Director of the Intensive Care Unit was interviewed and asked what the policy was for removing gloves and putting on clean gloves. The Director reported the nurse should have washed her hands or used alcohol based hand sanitizer.

Review of the facility policy, Hand Hygiene, with an effective date of 9/12, revealed under policy 4.0,

4.1.5 "After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, wound dressings or other potentially infectious material.

4.16 After removing sterile or non-sterile gloves and/or other personal protective equipment."


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4)

On 12/15/15 at approximately 10:00 AM, an inspection of the Pediatric Intensive Care Unit (PICU) storage room revealed the following:

- A sterile tray package was stored on a shelf in a cabinet located above the countertop. The adhesive self-sealed package was observed to be wrinkled and open at the end. A Registered Nurse (RN) confirmed the the sterile tray package was open and damaged. The RN indicated the sterile package was good unless opened or damaged.

- A plastic open top zip lock zipper bag with "Kit Made 7/13" documented on the bag was observed in a procedure cart. The kit identified as a chest tube removal kit included a package of Vaseline Petrolatum Gauze, 3 inch x 9 inch overwrap (gauze dressing) with a used by date of 08/2015. The Pediatric Unit Manager confirmed the petroleum gauze was expired.

On 12/15/15 at approximately 10:25 AM, during a tour of the post-partum unit revealed the following:

5)

Crash Cart
-A neonatal crash cart labeled as cart #2 with a Neopuff Infant T-Piece Resuscitator stored on top of the cart. The resuscitator was observed with patient supply line (clear tubing) connected to the gas outlet with the tubing uncovered and draped across the top of the crash cart. The Post-Partum Unit Manager indicated the tubing should have been covered.

-A suction container on the same neonatal cart was observed with a collection of dust on top of the lid. The Post-Partum Unit Manager indicated the suction container should have been checked with the cart's daily check. The Unit manager verbalized, "They should wipe it down." The Unit Manger explained the Charge Nurse and the Shift Manager were responsible for checking the crash carts daily.

On 12/15/15 at approximately 10:35 AM, during an inspection of a storage room on the post-partum unit revealed a bottle of Iodoform packing strips stored behind several other items on a shelf in the first set of cabinets located above the countertop. The Iodoform strips had a stamped date of "2014-03." The Unit Manager was unable to identify whether the date on the bottle was the manufacturer's package date or expiration date. On 12/16/15 at 1:05 PM, the Unit Manager confirmed the Iodoform packing strips 03/2014 was the expiration date.

On 12/15/15 in the morning, during a tour of the Labor Delivery Unit a cart identified by the Labor Delivery Unit Manager as an "anesthesia cart" was observed in with red spillage noted on the front of the drawers and the top of the cart was visibly dirty with a cloudy like substance with several scattered light red dots. The Unit Manager explained the Anesthesia Department or an Anesthesia Technician was responsible for the cleaning the cart. The Unit Manager acknowledged the cart was dirty and verbalized, "Look like it could use a wiping down."

6)

On 12/17/15 at 9:10 AM, observation of room of an unoccupied patient room on the pediatric unit revealed the following:
-A dirty suction container remained in the wall bracket. The suction container was filled with a cloudy mucus-like liquid with a bulb tip aspirator connected (used for suctioning babies).
-A used nasal cannula was draped on the back of the crib.

The licensed nurse acknowledged the dirty suction container and nasal container remained in the room. The licensed nursed verified the tape observed on seal of the bathroom door indicated the bathroom had been cleaned by housekeeping. The Pediatric Unit Manager indicated the nurses normally pulled the dirty suction containers from the patient's room prior to admitting a new patient.

On 12/18/15 in the morning, a registered nurse explained the nurses were responsible for the disposal of the suction containers, tubing and nasal cannulas once the patient was discharged prior to housekeeping cleaning the room.

Facility policy entitled, Cleaning of Patient Care Areas and Rooms: Five Step Process, effective date: 08/15 indicated the following:
"...Responsibilities ...2.2 Nursing Staff - are responsible for stripping patient beds and the appropriate disposal of medical and pharmaceutical waste, i.e., IV tubing, dressings, etc., Once a patient has been discharged ..."

Facility policy entitled, "Isolation Precaution Practices," Policy #IC-I-2035, Effective: 08/15 indicated:
"...5