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Based on observation and interview the facility failed to ensure the biohazard room in the Ear, Nose and Throat Clinic is secure and has a sign that biohazards are stored inside, in 1 of 1 biohazard room observed.

Findings include:

On 11/16/17 at 9:45 AM a room directly next to the lobby had the door open and a bin for biohazards inside. There is no sign on the door that biohazards are in the room. This deficiency was confirmed in interview on 11/16/17 at 9:45 AM with Infection Preventionist P, who agreed the door should have a sign and be secured.

Based on observation and interview the facility failed to ensure crash carts containing medications are secured preventing unauthorized access, in 2 of 2 crash carts observed; and policies are in place for staff preparing medications, in 2 of 2 medications observed (Lidocaine (numbing agent)/Afrin (decongestant) and Boric Acid).

Findings include:

Examples of crash carts:

Per observation on 11/16/17 at 9:15 AM, in the Ear Nose and Throat clinic there was a crash cart with a breakaway seal, and no lock to prevent unauthorized access. This deficiency was confirmed in interview on 11/16/17 at 9:15 AM with Administrator Lead L, who was unaware the cart should be locked.

Per observation on 11/16/17 at 9:58 AM, in the Cancer Center, there was a crash cart with a breakaway seal, and no lock to prevent unauthorized access. This deficiency was confirmed in interview on 11/16/16 at 9:58 AM with Clinic Manager Q, who was unaware the cart should be locked.

Examples of medications:

Per observation on 11/16/17 at 9:15 AM, the medication cupboard at the nursing station in the Ears, Nose and Throat Clinic, contained 4 medication bottles and 4 atomizers labeled "10% Lidocaine Afrin" and 4 atomizers labeled "Boric Acid", all dated 12/9/17. Per interview on 11/16/17 at 9:15 AM with Medical Assistant M, the Lidocaine and Afrin is mixed at the nursing station, by clinic staff, and labeled with an expiration date 60 days later; Medical Assistant M stated the Boric Acid powder is poured from a bulk container into the atomizers by clinic staff.

Per interview with Pharmacist N on 11/16/17 at 9:25 AM, s/he revealed the lidocaine is mixed in the pharmacy and provided to the clinic, and was not able to provide a policy for the staff to follow, adding they are topical medications, do not require a hood to mix, and good for 60 days.

Based on observation, record review and interview the facility failed to ensure staff performed presurgical and surgical procedures utilizing aseptic technique, in 1 of 2 staff observed (Staff J); failed to ensure staff donned surgical attire with covered hair and ears per policy, 2 of 5 staff observed (Staff F and G); failed to ensure staff moved about the Operating Room aseptically, in 1 of 5 staff observed (G); failed to ensure staff prepared cleaning solution per manufacturer's instructions, in 2 of 2 staff observed (G and X); failed to ensure staff cleaned the Operating Room after the case per policy, in 2 of 6 staff observed in the Operating Room (Staff G and H; failed to ensure staff had hair and ears covered per policy in Sterile Processing, in 2 of 3 staff observed (Staff T and U);and the facility failed to ensure staff donned protective equipment when pre-cleaning instruments, in 1 of 2 staff observed (Staff O).

Findings include:

Review of facility policy titled Hand Hygiene, dated 9/1/03, revealed under Policy A. 1. Decontaminate hands prior to entering patient rooms or having direct contact with patients. 2. Decontaminate hands after leaving any patient area or room. 3. Decontaminate hands before donning gloves and after removal of gloves..."

Review of manufacturer's instruction for DuraPrep (skin disinfectant), revealed under Step 2. "Beginning at the incision line and working your way out toward the periphery, paint a single uniform coat of solution on the skin. Use only light pressure. Do not scrub or go back over areas already prepped."

Review of facility policy titled Cleaning the Surgical Suite, dated 3/1/81, revealed under 1. Operating Rooms: "b. All horizontal and countertop surfaces will be wiped with a hospital approved EPA (environmental protection agency) registered disinfectant...all non-critical items such as blood pressure cuffs, pulse oximetry cords...etc. will be wiped down as well."

Review of facility policy titled Surgical Apparel, revised 10/16, revealed under #6. "Long sleeved jackets that are snapped closed would be worn by all non-scrubbed personnel."

Examples in the Surgical Department:

On 11/15/17 between 12:22 PM and 2:00 PM the following was observed:

At 12:28 PM, in the Preoperative area, Registered Nurse J inserted an intravenous line in Patient #1, removed her/his gloves and donned new gloves without the benefit of performing hand hygiene. Nurse J left the room to obtain a denture cup for Patient #1 and returned without performing hand hygiene when leaving or returning to the room.

At 12:52 PM, in the Operating Room, Certified Registered Nurse Anesthetist F and Surgical Technician G had exposed hair and ears.

At 1:00 PM, Registered Nurse J applied Duraprep (disinfecting solution) to Patient #1's right hand designated for Carpal Tunnel Release. Nurse J began at the incision site (inside the right wrist), and proceeded to paint the solution away from the wrist lifting and returning with the Duraprep sponge,ending with the fingers that were above the wrist allowing the solution to drip down over the surgical site.

At 1:05 PM Surgical Technician G, in sterile gown, walked behind Physician I, front of his/her gown to the Physician's back, placed the cautery pouch on the drape to Physician I's right and returned to his/her left.

At 1:35 PM Surgical Technician G removed gloves after the surgery, did not perform hand hygiene, picked up the telephone receiver and replaced it, left the room and returned with out performing hand hygiene.

At 1:40 PM Surgical Technician G prepared a disinfectant solution Virex II for cleaning the Operating Room. Technician G stated s/he squirt 1/2 pump of the Virex II into a basin and add 1/2 gallon of water. Technician G did not measure the water which was nearly to the top of the basin. At 2:00 PM Register Nurse X prepared another mixture of Virex II for cleaning the Operating Room, Nurse X stated s/he used "1 solid squirt (Virex) to 1 gallon of water". The solution was half the amount in the same size basin that Technician G used.

Instructions from the Virex 256 label revealed "To Prepare Use Solution: Add the product at 1/2 oz. (ounce) per gallon of water (1:256)." Per interview with Director of Nursing on 11/15/17 at 1:40 PM, 1/2 pump (on the container) is 1/2 oz.

Between 1:40 PM and 2:10 PM Technician G, with exposed arms, used one wash cloth dipped in the Virex solution to clean the lights, anesthesia cart, starting at the top working to the bottom of the lights, then at the top of anesthesia cart working to bottom. Technician G dipped the same cloth in the Virex solution and proceeded to clean an intravenous pole. During this same observation, Technician H, with exposed arms, used one cloth to clean the linen bag holders, mayo stand (to hold instruments), an intravenous pole (did not clean the hooks at top of pole), the visible surfaces of the desk, without lifting items to clean entire surface, and did not clean the shelf above the desk. Technician H dipped the same cloth in the Virex solution between cleaning of equipment. The cloth velcro straps that secured Patient #1's arm during the procedure were not cleaned or exchanged out with a clean set after the procedure.

Per interview with Operation Room Manager E on 11/16/17 at 8:30 AM, s/he stated "Staff should know to use one cloth for each piece of equipment."

Examples in Sterile Processing:

Per observation on 11/16/17 between 2:15 PM and 2:45 PM Sterile Processing Technicians S and T had hair and ears exposed.

Examples in Ears, Nose and Throat Clinic:

Per observation on 11/16/17 at 9:34 AM Registered Nurse O cleaned an exam room (no number) removed gloves, donned new gloves, did not perform hand hygiene, pre-cleaned a nasal and ear speculum, holding the instruments above the water line and did not have on personal protective equipment (gown and shield) to prevent contamination of her/his scrubs and protect her/his eyes from potential splatter.

The above deficiencies were discussed in interview with Infection Preventionist P on 11/16/17 at 3:15 PM, who confirmed staff should have ears and hair covered, wear long sleeved jacket on the Operating Room, have continuous contact with the skin while applying Duraprep, and not have it drip over the incision site; staff in sterile gowns should move back to back, not front to back; staff should use a new wash cloth rather than dip a used one in disinfectant solution, clean items top to bottom and not go to another piece of equipment with the same cloth, and staff should wear a gown and shield when pre-cleaning instruments.

Based on record review and interview, the facility failed to ensure there were informed consents signed by the patient for anesthesia received during procedures, in 3 of 5 medical records with anesthesia (#2, 3 and 4). This deficiency directly affects Patients #2, 3 and 4.

Findings include:

Review of facility Rules and Regulations of Medical Staff dated January 2012, revealed under 17. "Written, signed, informed, surgical and anesthesia consents shall be obtained by the physician prior to the operative procedure..."

Review of facility policy titled Informed Consent, revised 10/15, revealed under I. A. "The physician should inform the patient of the nature of the procedure, the risks involved,...the possibility of complications..."

Patient #2's medical record review on 11/16/17 at 12:15 PM, revealed Patient #2 had cataract surgery on 9/28/17. There was no documentation by anesthesia staff that risks were discussed prior to signing the informed consent for anesthesia. The signed consent was signed by a witness but with no credentials to ensure it was an anesthesiologist, and does not indicate type of anesthesia to be provided during the surgery in the medical record. This deficiency was confirmed on 11/16/17 at 12:15 PM with Assistant Manager V, who agreed there should be a consent form.

Patient #3's medical record review on 11/16/17 at 12:40 PM revealed Patient #3 had a tonsillectomy and septoplasty (correction to the nasal septum) on 10/9/17. There was no documentation by anesthesia staff that risks were discussed prior to signing the informed consent for anesthesia. The signed consent was not signed by the anesthesiologist, and does not indicate type of anesthesia to be provided during the surgery in the medical record. This deficiency was confirmed in interview on 11/16/17 at 12:40 PM with Registered Nurse W, who agreed there should be a consent form.

Patient #4's medical record review on 11/16/17 revealed Patient #4 had shoulder surgery on 8/24/17. There was no documentation by anesthesia staff that risks were discussed prior to signing the informed consent for anesthesia. The signed consent was not signed by the anesthesiologist, and does not indicate type of anesthesia to be provided during the surgery in the medical record. This deficiency was confirmed on 11/16/17 at 12:52 PM with Registered Nurse W, who agreed there should be a consent form.

Based on record review and interview, the facility failed to ensure there were post anesthesia notes that were timed when completed and/or comprehensive including Cardiopulmonary Status, Level of Consciousness, Follow up or observations, level of activity, color and sensation, in 4 of 5 medical anesthesia records reviewed (#1, 2, 3 and 4).

Findings include:

Per interview with Anesthesiologist R on 11/16/17 at 8:11 AM, s/he stated the Postanesthesia note should include Cardiopulmonary Status (Respirations, Blood Pressure, Heart Rate, Oxygen Saturation), Level of Consciousness, Follow up or observations, Level of activity, Color and sensation after blocks or epidurals.

Patient #1's medical record review on 11/16/17 at 11:10 AM revealed Patient #1 had Carpal Tunnel surgery (widening of an opening in the wrist releasing pressure on nerves) with a bier block (anesthetic injected in the surgical area to prevent any feeling) on 11/15/17. Per the Anesthesia Record dated 11/15/17 it revealed Patient #1 was out of surgery at 1:39 PM. The Postanesthesia Note dated 11/15/17 was not timed and had a checked box in front of the statement "Vital Signs Stable, No complications, No Follow-up Needed." A check mark was in the box in front of the statement "Awake and Alert". The note did not include documented vital signs, level of activity, color and if sensation returned after the block used for surgery. This deficiency was confirmed in interview on 11/16/17 at 11:10 AM with Assistant Manager V, who agreed the documentation was incomplete.

Patient #2's medical record review on 11/16/17 at 12:15 PM, revealed Patient #2 had cataract surgery on 9/28/17. Per the Anesthesia Record dated 9/28/17 it revealed Patient #1 was out of surgery at 9:12 AM. The Postanesthesia Note dated 9/28/17 timed 9:12 AM, immediately out of the Operating Room, and had a checked box in front of the statement "Vital Signs Stable, No complications, No Follow-up Needed." A check mark was in the box in front of the statement "Awake and Alert". The note did not include documented vital signs, level of activity, color and if sensation returned after the block used for surgery. This deficiency was confirmed in interview on 11/16/17 at 12:15 PM with Assistant Manager V, who agreed the documentation was incomplete.

Patient #3's medical record review on 11/16/17 at 12:40 PM revealed Patient #3 had a tonsillectomy and septoplasty (correction to the nasal septum) on 10/9/17. Per the Anesthesia Record dated 10/19/17 it revealed Patient #3 was out of surgery at 10:42 PM. The Postanesthesia Note dated 10/19/17 was not timed and had a checked box in front of the statement "Vital Signs Stable, No complications, No Follow-up Needed." A check mark was in the box in front of the statement "Awake and Alert". The note did not include documented vital signs, level of activity, color and if sensation returned after the block used for surgery. This deficiency was confirmed in interview on 11/16/17 at 12:40 PM with Registered Nurse W, who agreed the documentation was incomplete.

Patient #4's medical record review on 11/16/17 revealed Patient #4 had shoulder surgery on 8/24/17. Per the Anesthesia Record dated 8/24/17 it revealed Patient #4 was out of surgery at 2:03 PM. The Postanesthesia Note dated 8/24/17 was timed 2:04 PM, 1 minute out of the Operating Room, and had a checked box in front of the statement "Vital Signs Stable, No complications, No Follow-up Needed." A check mark was in the box in front of the statement "Awake and Alert". The note did not include documented vital signs, level of activity, color and if sensation returned after the block used for surgery. There was no informed consent for anesthesia provided during the surgery in the medical record. This deficiency was confirmed in interview on 11/16/17 at 12:52 PM with Registered Nurse W, who agreed the documentation was incomplete.