HospitalInspections.org

Based on document review and interview, it was determined for 1 of 1 (Pt #14) patient's records reviewed, which required verbal consent for treatment, the Hospital failed to ensure consents were witnessed in accordance with its policy. This has the potential to affect all inpatients and outpatients serviced by the Hospital, with an approximate daily average of 156 inpatients and 594 outpatients daily.

Findings include:

1. The Hospital Policy Stat ID: 4240339 "Consent for Treatment" (last revised 12/2017) was reviewed on 7/19/18 at approximately 4:30 PM. The policy stated "The registration staff should also witness the consent with their signature and if the signature is not a legible signature their name should be printed under the signature for identification purposes. When verbal consents are obtained, a second witness should be obtained with the signature also identified."

2. Pt #14 Start of Care: 7/12/18 Diagnosis: Iron Deficiency Anemia.
Pt #14's record was reviewed on 7/19/18 at approximately 10:25 AM with E#19 (Registered Nurse, Outpatient Infusion Center) and E#20 (Physician Practice Quality Coordinator). On 7/12/18, on page 1 of the "Consent for Treatment" initial area stated "verbal consent" handwritten in the "Signature captured" area. On page 4, the consent stated "I certify that I have fully read front and back of the Treatment Agreements and Authorizations..." and "verbal consent from pt (patient)" was handwritten in the "Signature captured" area. Both areas lacked the signature, and printed name of two witnesses.

3. An interview was conducted on 7/20/18 at approximately 10:45 AM with the Physician Practice Quality Coordinator (E#20). E#20 stated "I noticed that (verbal consent without a witness's signature and printed name)when I was reading the policy. No, we didn't have that (two witnesses and two signatures) on the record."

Based on observation and interview, it was determined for 1 of 10 (Pt #31) patient observations, the Hospital failed to ensure a patient's personal privacy was maintained. This has the potential to affect all patients serviced by the Hospital with a current census of 175 patients.

Findings include:

1. An observational tour of the 3rd floor Medical Telemetry Unit was conducted on 7/18/18 at approximately 12:00 PM with the Director of Risk Management (E#13). In the hallway of the unit, 4 staff members were transferring Pt #31 from standing at a walker to sitting in a wheelchair. One staff member raised Pt #31's gown exposing Pt #31's buttocks.

2. An interview was conducted with E#13 on 7/18/18 at approximately 12:10 PM. E#13 also observed the event and stated "The patient's gown should have been covering (Pt #31) to prevent exposure. The staff assisting the patient are physical therapy assistants and should have kept (Pt #31) covered."

Based on document review and interview, it was determined in 1 of 1 (Pt #17) patient's records reviewed with non-violent restraints, the Hospital failed to ensure the patient was monitored per policy. This has the potential to affect all patients that are restrained.

Findings include:

1. The policy titled "Restraint/Seclusion- Patient Care Services" (revised 4/18) was reviewed on 7/19/18. The policy required a restrained patient to be assessed and the assessment documented at least every two hours.

2. Pt #17 SOC: 5/24/18
Diagnosis: Dislodged Gastric Tube. The clinical record was reviewed on 7/19/18 at approximately 2:15 PM. The Restraint Flowsheet noted the following assessments were greater than the two hour requirement: 5/29/18 at 2:00 PM to 5/29/18 at 5:00 PM (3 hours between assessments); 5/30/18 at 3:00 AM to 5/30/18 at 6:20 AM (3 hours 20 minutes between assessments); 5/30/18 at 6:20 AM to 5/30/18 at 9:36 AM (3 hours 16 minutes between assessments); and 5/30/18 at 9:36 AM to 5/30/18 at 1:50 PM (4 hours 14 minutes between assessments).

3. During an interview on 7/19/18 at approximately 2:45 PM, E#17 (Registered Nurse) verbally agreed Pt #17 had not been assessed every two hours and should have been.

Based on document review and interview, it was determined for 1 of 2 (Pt #14) patient's records reviewed who had received a blood transfusion, the Hospital failed to ensure medications were administered as ordered by the physician. This has the potential to affect all patients who receive blood transfusion services at the Hospital with an approximate average of 120 transfusions per month.

Findings include:

1. Pt #14 Start of Care: 7/12/18
Diagnosis: Iron Deficiency Anemia. Pt #14's record was reviewed on 7/19/18 at approximately 10:25 AM with E#19 (Registered Nurse, Outpatient Infusion Center) and E#20 (Physician Practice Quality Coordinator). A physician order dated 7/11/18 noted that Pt #14 was to receive two units of packed red blood cells, with instructions to; "Give 1st unit followed by 20 mg (milligrams) Lasix then give unit 2." Nursing documentation stated the Lasix was given after the 2nd unit instead of between the 1st and 2nd unit of blood transfusions.

2. An interview was conducted with E#19 and E#20 during the record review. Both verbally agreed the Lasix was not given between the transfusion of the 1st and 2nd units of packed red blood cells and should have been.

Based on document review and interview, it was determined in 1 of 1 (Pt #17) patient's records reviewed for accurate documentation of intake, the Hospital failed to ensure documentation was accurate and complete. This has the potential to affect all inpatients who receive services by the Hospital with a current census of 175 patients.

Findings include:

1. The policy titled "Medical Record Documentation" (revised 5/18) was reviewed on 7/19/18. The policy stated "All physicians treating a patient shall be responsible for completing appropriate sections of the episodes records.... Documentation and findings of assessments... Relevant observations... The response to care, treatment, and services provided... Patient-generated information..."

2. Pt #17 SOC: 5/24/18
Diagnosis: Dislodged Gastric Tube. The clinical record of Pt #17 was reviewed on 7/19/18 at approximately 2:15 PM. A Physician's order dated 5/25/18 at 12:59 AM required Pt #17's intake and output to be monitored every 2 hours and more frequently as needed, until the order was discontinued on 6/1/18 at 5:35 PM. The Comprehensive Intake/Output Flowsheet dated 5/28/18 at 7:00 AM to 5/29/18 at 7:01 AM (24 hours) noted Pt #17's 24 hour intake as 4211 ml (milliliters). However, the Comprehensive Intake/Output Flowsheet lacked documentation in the "IV (Intravenous) Piggyback" section of the flowsheet of IV antibiotic administration of Vancomycin 250 ml, Keppra 100 ml and Zosyn 200 ml. The "IV" section of the flowsheet noted 1744 ml was infused. However, the order and documented rate of IV infusion solution was 50 ml/hour (hr) which equals 1200 ml/24 hrs. The "NG/GT (Nasogastric/Gastrostomy Tube)" section of the flowsheet noted that 2267 ml of tube feeding was administered. However, the order and documented rate of tube feeding infusion was 75 ml/hr which equals 1800 ml/24hrs. The Comprehensive intake/Output flowsheet dated 5/29/19 7:00 AM to 5/30/18 at 7:01 AM (24 hours) noted in the "IV Piggyback" section 0 mls were infused. However, 1000 mls of IV piggyback antibiotics were administered during this time frame. The Comprehensive Intake/Output Flowsheet dated 5/30/18 7:00 AM to 5/31/18 7:01 AM (24 hours) lacked documentation of any intake, although tube feeding was administered at 75 ml/hr, IV solution infused at 50 ml/hr, and 300 ml of IV piggyback antibiotics were administered during this timeframe.

3. During an interview on 7/20/18 at approximately 10:00 AM, E#17 (Registered Nurse) stated "We tried to figure out how the intakes are imported into the Comprehensive Flowsheets and the Physician's Progress Notes but they just don't add up. I think it's an.... (Electronic Health Record software interface problem)." E#17 verbally agreed the Intake and Output monitoring of all patients was not accurate and should have been.

Based on document review and interview, it was determined in 2 of 2 (Pt's #14 and #15) patient's records reviewed whom had received blood transfusions, the Hospital failed to ensure blood transfusion consents were completed in accordance with its policy. This has the potential to affect all patients who receive a blood transfusion by the Hospital with an approximate average of 120 transfusions per month.

Findings include:

1. The Hospital Policy Stat ID: 4780330 "Blood and Component Administration" (last revised 04/2018) was reviewed on 7/19/18 at approximately 4:00 PM. The policy stated on pages 1 and 2 "Consent for Blood and Blood Products: 1. A signed "Consent for Blood and Blood Products" is required for all non-emergent transfusions. Refer to Policy Consent for Treatment (Operative and Invasive Procedures). 2. The Physician is responsible to initiate a discussion with the patient prior to the patient signing the consent. The discussion is to include..."

2. The Hospital Policy Stat ID: 4958096 "Consent for Treatment (Operative and Invasive Procedures)" (last revised 05/2018) was reviewed on 7/19/18 at approximately 4:00 PM. On page 1, the policy stated "C. Authorization for the Consent for Blood/Blood Products This form will be completed for a patient receiving whole blood, autologous blood... including patients who are going to surgery and have been typed and screened/crossmatched for blood... will be signed by the appropriate person and witnessed by a RN/LPN (Registered Nurse/Licensed Practical Nurse)."

3. Pt #14 SOC: 7/12/18
Diagnosis: Iron Deficiency Anemia. Pt #14's record was reviewed on 7/19/18 at approximately 10:25 AM with E#19 (Registered Nurse, Outpatient Infusion Center) and E#20 (Physician Practice Quality Coordinator). A physician's order dated 7/11/18 noted Pt #14 was to receive two units of packed red blood cells. On 7/12/18, the "2/Consent for Blood & (and) Blood Products" stated "I have discussed the above with patient and/or family/legal representative" followed by a signature line titled "Physician signature". The consent lacked a physician signature.

4. Pt #15 SOC: 5/7/18
Diagnosis: Coronary Artery Disease. Pt #15's record was reviewed on 7/19/18 at approximately 11:10 AM with E#19 and E#20. On 5/7/18, Pt #15 underwent a coronary artery bypass surgery. Pt #15's "2/Consent for Blood & (and) Blood Products" lacked a physician signature.

5. An interview was conducted with E#19 and E#20 during the record reviews and both verbally agreed the physician signatures were lacking.

Based on interview and document review, it was determined the Hospital failed to ensure Pharmaceutical Services established, implemented and maintained an ongoing competency evaluation process in compliance with current USP (United States Pharmaceuticals) <797> regulations. This has the potential to affect all inpatients and outpatients who receive Pharmaceutical Services from the Hospital.

Findings include:

1. The USP <797> Clean Room Guidelines and Standards require for "Personnel who prepare compounded sterile products must be provided with appropriate training from expert personnel, audio-video instructional sources, or professional sources before beginning to prepare products. Personnel shall perform didactic review, written testing, media fill testing.... at least annually."

2. The personnel files were reviewed on 7/19/18 at approximately 10:30 AM. The following Pharmacy Technician's personnel files lacked documentation of didactic training and written testing for compounding:
a) E#26, Date of Hire (DOH) 8/26/02
b) E#27, DOH 11/6/1995
c) E#28, DOH 3/8/04
d) E#29, DOH 6/4/07

3. During an interview on 7/19/18 at approximately 10:00 AM, E#29 (Pharmacist) stated didactic review and written testing for compounding had not been implemented. E#29 stated "I know we need to work on getting some audio-visuals for education. We do the media fill test twice a year but not any written competency."

Based on observation, document review and interview, it was determined the Hospital failed to ensure medications were stored in a secure manner. This has the potential to affect all patients serviced by the Hospital with a current census of 175 patients.

Findings include

1. An observational tour of the Radiology department was conducted on 7/17/18 at approximately 1:55 PM with the Radiology Manager (E#5) and the Director of Imaging (E#6). One open bottle of Disk Barium Sulfate 700 milligram tablets and one open box of Gas II Effervescent Granules were sitting on top of the personal protective equipment box on the wall of the radiology room which is an unsecured area that is accessible to patients in the room. E#5 and E#6 both observed the above.

2. The Hospital Policy Stat ID: 5171594 "Medication Administration" (last reviewed 7/2018) was reviewed on 7/20/18 at approximately 11:25 AM. On page 2, the policy stated "Medication Security: Medication carts, drawers... Medications are never to be left unattended on carts, AMDC (Automated Medication Dispensing Cabinet) or counters."

3. An interview was conducted with E#5 and E#6 on 7/17/18 at approximately 2:15 PM. E#6 stated that the radiology technicians removed the medications from a cabinet and placed them in the radiology room for use during the day. Both verbally agreed the medications were accessible to patients and should not be in an unsecured area.

Based on observation, document review and interview, it was determined the Hospital failed to ensure that all foods were appropriately labeled per policy. This has the potential to affect all patients, staff and visitors who utilize dietary services.

Findings include:

1. On 7/18/18 a tour was conducted of the Nursing units between 1:00 PM and 3:00 PM. During the tour, the following was noted in the patient's refrigerators:
a) 2nd floor Medical Surgical Unit- undated sandwich, undated/unlabeled ice cream bar, and undated milkshake
b) 2nd floor Pediatric Psychiatric Unit- opened and undated two 64 oz (ounce) bottles of Orange Juice
c) 5th floor Observation Unit- undated container of jello
d) 5th floor Intensive Care Unit- undated/unlabeled bowl of soup, cornbread, and a large bowl of salad

2. During a tour of the Dietary Department on 7/17/18 at approximately 1:30 PM with E#3 (Chef), the following was noted:
a) 1 container of lemon pepper seasoning celery salt, opened and dated 3/24/17
b) 1 container black sesame seeds opened and dated 7/6/16
c) 1 container whole black pepper opened and undated
d) 1 box of cream of wheat opened and undated

3. The policy titled "Food Storage on Patient Care Units" (approved 6/2017) was reviewed on 7/19/18 at approximately 3:00 PM. The policy stated "All food items.... will be properly labeled and dated. All perishable foods will be covered, dated and properly refrigerated...."

4. The policy titled "Food Supply and Storage" (revised 1/18) was reviewed on 7/17/18 at approximately 3:30 PM. The policy required "Procedures...Date and rotate items... Dry storage life of foods... if there is no expiration date on the package, add the time listed here to the date the food is received... spices and herbs... room temperature storage...+ 1 year."

5. During an interview on 7/18/18, E#1 (Chief Nursing Officer) observed the above and stated that the food items should have been labeled and dated or discarded.

6. During an interview on 7/17/18 at approximately 1:35 PM, E#3 verbally agreed the undated items in the dietary department should have been discarded.


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Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Sample Validation survey conducted on July 17 through July 19, 2018, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Sample Validation survey conducted on July 17 through July 19, 2018, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation, document review and interview, it was determined the Hospital failed to ensure mechanical and electrical equipment available for patient use was inspected and had routine maintenance. This has the potential to affect all patients receiving care at the Hospital with a current census of 175 patients.

Findings include:

1. A tour of the Orthopedic/Neurological Unit on 5 East was conducted on 7/17/18 between 1:30 PM and 2:30 PM with the Unit Manager (E#13) and the Chief Nursing Officer (E#1). In the storage room, 2 blanket Warmers lacked a preventive maintenance sticker or an inspection tag.

2. The policy titled "Preventive Maintenance System" (approved 1/2018) was reviewed on 7/19/18 at approximately 10:00 AM. The policy indicated "New equipment is added to the equipment inventory according to procedures in Biomed Policy and Procedure manual. A PM (Preventive Maintenance) schedule will be established according to the manufacturer requirements listed in the service/operators manual."

3. During an interview on 7/18/18 at approximately 10:00 AM, E#1 stated that maintenance was unable to provide documentation of receipt of the warmers or documentation that the warmers were put into the PM cycle.


B. Based on observation, document review and interview, it was determined the Hospital failed to ensure patient care equipment available for use was maintained in a safe working condition. This has the potential to affect all patients serviced by the Emergency Department (ED) and all patients who potentially could receive an anesthesia block.

Findings include:

1. During a tour of the ED on 7/17/18 at approximately 1:30 PM, an Adult Difficult Airway cart had a black unlocked case in the bottom drawer which contained a Fiberoptic LF-1 Intubation Fiberscope with no preventive maintenance tag and no documentation as to when the item was last cleaned.

2. A document titled "Tech Ready document" was reviewed on 7/19/18 at approximately 2:00 PM. The document contained two links that stated the following:
(1) The "(Name brand) LF-1 Intubation Fiberscope Discontinuation Letter"dated 5/5/04 stated it was a response to an inquiry concerning the length of time (company) would provide repair parts and services. The letter stated "... we will continue to manufacture replacement parts and service items for a minimum of eight (8) years after the product has been last sold, officially designated discontinued and/or replaced by the next generation product... The (name brand) LF-1 Intubation Fiberscope, last manufactured and sold in 1995, has been replaced by the (Company name) LF-GP...The unique repair parts for the LF-1 were discontinued in March 2003..."
(2) The "(Name brand) LF-1 Tracheal Intubation Fiberscope" instructions listed a "Cleaning, Disinfection and Sterilization Procedures" chart to follow for the Fiberscope.

3. During an interview on 7/17/18 at approximately 1:30 PM, E#8 stated "This (scope) is used for difficult airways. I don't remember the last time it was used and would not be able to say when it was cleaned. If it's in the box, it was cleaned before it was put there."

4. During an interview on 7/19/18 at approximately 4:10 PM, E#9 (Director of Perioperative Services) stated "I was told by (E#16- the Central Sterilizing Technician) the scope was found in the ED and this had been turned over to (E#9) for follow up. We have no documentation as to when it was used last, no documentation of the last PM (preventive maintenance) and no documentation as to when it was last cleaned."

5. During a tour of the Outpatient Surgery Department on 7/18/18 at approximately 9:15 AM, one (Name brand) Dig RC with the metallic gray tag numbered 09695 was on a cart. The Nurse Manager Outpatient Surgery (E#10) was present and stated the equipment "was used by anesthesia when they do blocks". There was no documentation as to when the (name brand) Dig RC was last used/inspected and no policy or procedure as to how it was to be used and/or monitored to assure it was functioning correctly.

6. The "(Name brand) Dig RC" manufacturer Technical Service Manual and the User Manual were reviewed on 7/19/18 at approximately 12:30 PM.
(1) The Technical Service Manual stated on page 3, "The Function Tests should be conducted before each use." and referred to page 6 of the User Manual.
(1) The User Manual stated on page 6, "Function Test ..." and listed the steps to include in the test on pages 6 thru 10.

7. An interview was conducted with E#9 on 7/19/18 at approximately 4:10 PM. E#9 stated "This hasn't been used for at least the last three years and we do not have any policy or guideline for a safety check when it is used."



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C. Based on observation, document review and interview, it was determined the Hospital failed to ensure emergency carts were checked and equipment was monitored per policy. This has the potential to affect all patients who receive care by the Hospital with a current census of 175 patients.

Findings include:

1. During a tour of the Telemetry Unit and Intensive Care Unit on 7/18/18 from approximately 1:00 PM to 3:00 PM with E#1 (Chief Nursing Officer) and E#12 (Director of Nursing), the following emergency cart logs lacked documentation of the required daily checks:
a) 3rd floor Telemetry Unit crash cart on 6/25/18.
b) Intensive Care Unit crash cart on 6/3/18.

2. During a tour of the Obstetrical Unit on 7/19/18 at approximately 9:00 AM with E#1 (Chief Nursing Officer) and E#18 (Registered Nurse), the following logs lacked documentation of the required daily checks:
a) OB (Obstetrics) Post Partum Unit crash cart on 6/29/18.
b) Labor and Delivery Unit Medication Audit of the Epidural Cart on June 2018, 7 of 31 days in May 2018 and 9 of 30 days in April 2018.

3. The policy titled "Crash Cart, Respiratory Box, and Defibrillator Checks" (approved 4/2018) was reviewed on 7/20/18. The policy required "1. Routine Checks: A. Crash carts will be checked daily... On units where there are defibrillators, the RN (Registered Nurse) check marks that the defibrillator passed the "test ok" procedure. The RN indicates on the CRASH CART/DEFIBRILLATOR CHECK FORM that both the crash cart and the defibrillator has been checked, "

4. During the tours on 7/18/18 and 7/19/18, E#1 reviewed the logs and verbally agreed the daily checks had not been completed per policy and should have been.

A. Based on observation, document review and interview, it was determined the Hospital failed to ensure staff maintained and enforced Contact Precautions as required. This has the potential to affect all patients, staff and visitors at the Hospital.

Findings include:

1. A tour of the 3rd floor Medical Telemetry Unit was conducted on 7/18/18 at approximately 10:30 AM through 12:00 PM with the Director of Nursing (E#12) and the Nurse Manager (E#15). Room #320 had a Contact Isolation sign posted on the door and PPE (Personal Protective Equipment) was at the door. The following breaches in infection control were observed:
a. The Hospitalist (E#14) was in the isolation room and then opened the door and summoned a visitor from inside the room to the door. The visitor lacked PPE. The same visitor left room #320 at 11:05 AM without performing hand hygiene.
b. At 11:10 AM, a Dietician entered room #320 without wearing gloves.
c. At 11:15 AM, the visitor (mentioned above) re-entered room #320 without donning PPE.

2. The policy titled "Contact Isolation" (revised 4/2017) was reviewed on 7/19/18 at approximately 10:30 AM. It indicated "C. Gloves 1. Wear gloves (clean, non-sterile gloves are adequate) when entering the room even if the patient is not in the room.... 3. Remove gloves before leaving the patient area. 4. After glove removal and hand washing ensure... D. 1. In addition to wearing gloves, wear a gown (a clean, non-sterile gown is adequate) when entering the room. 2. Remove the gown before leaving the patient's environment."

3. During an interview on 7/18/18 at approximately 11:25 AM, E#12 stated "I saw what you saw." (Incidents mentioned above)

B. Based on observation, interview and document review, it was determined the Hospital failed to ensure an open bottle of blood glucose machine control solution was labeled with the expiration date to ensure the product was not outdated and available for use. This has the potential to affect all patients serviced by the Hospital with a current census of 175 patients.

Findings include:

1. An observational tour of the Emergency Department was conducted on 7/17/18 between approximately 1:00 PM and 1:50 PM with the Emergency Department Director (E#7). An opened bottle of blood glucose machine control solution was note labeled with an expiration date.

2. The Hospital Policy Stat ID: 5068666 "(Brand name) Glucose System" (last revised 7/2018) was reviewed on 7/19/18 at approximately 3:30 PM. On page 3, the policy stated "NOTE:..(brand name) glucose monitoring machine control and linearity solutions expire on the date printed on the vial label, or three months from opening, whichever comes first. Whenever an operator opens a vial of controls or linearity solution, he/she must handwrite the expiration date and his/her initials on the vial. That date will be either three months from opening or the date printed on the vial label, whichever comes first."

3. An interview was conducted with E#7 on 7/17/18 at approximately 1:30 PM. E#7 stated the control solution was to be dated when opened and is only good for 90 days after opening.

C. Based on observation and interview, it was determined the facility failed to ensure a single use item was disposed of properly to avoid the potential for cross contamination. This has the potential to affect all patients serviced by the Hospital with a current census of 175 patients.

Findings include:

1. An observational tour of the Emergency Department was conducted on 7/17/18 between approximately 1:00 PM and 1:50 PM with the Emergency Department Director (E#7). One open two ounce bottle of Wound Cleanser was in the cabinet in Triage Room #1, which lacked the date as to when it was opened. E#7 also observed the open bottle.

2. An interview was conducted with E#7 on 7/17/18 at approximately 3:30 PM. E#7 stated the Wound Cleanser was found to be a one time item and should have been disposed of after it was used.


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D. Based on observation, document review and interview, it was determined the Hospital failed to ensure that patient care items were safe and sanitary to avoid the potential for cross contamination. This has the potential to affect all patients who receive services at the Hospital with a current census of 175 patients.

Findings include:

1. During a tour of the Rehabilitation Therapy Gym on 7/18/18 at approximately 11:15 AM, the treatment table had approximately a 2 inches long rip in the covering.

2. During an interview on 7/18/18 at approximately 11:25 AM, E#21 (Rehabilitation Unit Manager) verbally agreed the table could not be adequately disinfected with the rip in the covering and stated "That rip is something we do need to have repaired."

3. During a tour of the Inpatient Rehabilitation Unit on 7/18/18 at approximately 1:45 PM, there were 7 Medline Equagel Pressure Redistribution cushions in the supply room, and each had a "Sanitized" label. The care tag sewn onto the inside of the cover stated "Care Instructions: "*Cover -Cover may be washed in low heat water with normal detergent -Hang dry or tumble dry WITHOUT heat to avoid shrinking *Gel Component -Gel Component may be hand washed in warm water with dish soap and hang dried -Do not wash/dry in hot machine settings".

4. During an interview on 7/18/18 at approximately 1:45 PM, E#24 (Director of Inpatient Rehabilitation) stated "I think the process is the outer stretch cover is sent to laundry when the patient is discharged. The gel cushion is cleaned with the Sani-wipes and stored on the right side of the shelf until the cover comes back from laundry then the cover is placed on the cushion. A "Sanitized" strip is put on top (of the cushion) and put on this (left) side of the shelf for the next patient."

5. During an interview on 7/18/18 at approximately 1:50 PM, E#25 (Team Leader Inpatient Rehabilitation) stated "We don't do that. We just wipe the gel pad and the outer cover off with the wipes (Sani-wipes). I guess I could send it (stretch cover) to laundry if it was visibly dirty."

6. During an interview on 7/19/18 at approximately 10:00 AM, E#1 verbally agreed the Sani-wipes were not an approved disinfectant for the gel cushion and the covers had not been adequately disinfected between patient use. E#1 verbally agreed it was unable to be determined if the gel cushions were intended for multiple patient use due to the low level of disinfection and possible cross contamination.

7. During a tour on 7/18/18 at approximately 2:00 PM of the Intensive Care Unit, an open package of primary Intravenous (IV) tubing was in the stock cabinet outside of room #4.

8. During an interview on 7/18/18 at approximately 2:05 PM, E#23 (Intensive Care Unit Manager) stated the IV tubing should not have been left opened and should have been discarded.


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E. Based on observation and interview, it was determined for 1 of 1 pill crusher on the Observation Unit and 1 of 1 (Name brand) Activated Clotting Time (ACT) machine on the Intensive Care Unit, the Hospital failed to ensure the equipment was cleaned after use to avoid exposure. This has the potential to affect all patients who utilize this equipment.

Findings include:

1. During a tour on 07/18/18 at approximately 12:30 PM with E#1 and E#22 (Nurse Manager of the Observation Unit), a pill crusher in the cabinet of the medication preparation area had a white powder substance on it. E #1 stated, during a concurrent interview, that the pill crusher should have been cleaned after use and had not been.

3. During a tour on 07/18/18 at approximately 1:35 PM with E#22 (ICU Manager), the ACT machine in the medication room had a visible red substance near the area where the blood sample is obtained. E#22 stated, during a concurrent interview, that the ACT machine is used for blood collection at the bedside and is cleaned by the nurse after use prior to being returned to the medication room. E #22 nodded "yes" when asked if the red substance could be blood and immediately requested a nearby nurse clean the machine.




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