HospitalInspections.org

Item #1- Malignant Hyperthermia Procedures

Based on interview and facility policy review, the facility failed to ensure patients in all units would receive safe care during a type of medical emergency known as Malignant Hyperthermia (MH).

Findings:

1. Facility policy titled "MALIGNANT HYPERTHERMIA", approved 2/2014, outlined its "Scope" as focused on areas where patients received or recovered from anesthesia. The policy did not address situations in which MH triggering agents other than anesthesia were used. "Training and Education Requirements" read in part that "Employees that care for patients exposed to anesthesia - includes but is not limited to... ICU [Intensive Care Units], ED [Emergency Department]..." would complete annual educational requirements.

2. During tour of the Tacoma General ED on 3/18/2014 at approximately 10:00 AM the ED Nurse Manager (Staff Member #26) stated that the staff did not receive such training, nor was there a process in place to respond in the event of a MH emergency. S/he stated that one non-anesthesia triggering agent was used in the ED, and that the ED population served included patients who had received anesthesia.

3. During tour of the Tacoma General Cardiovascular ICU on 3/18/2014 at approximately 3:00 PM the ICU Director (Staff member #27) stated that staff in the ICU's did not receive MH training, nor was there a process in place to respond to an MH emergency which could result from other triggering agent(s) used in the ICU's.




33163


Item #2- Emergency Procedure

Based on staff interview and review of hospital's policies and procedures, the hospital failed to ensure all staff members knew how to summon the hospital's emergency response team when a patient experienced cardiopulmonary arrest.

Findings:

1. The hospital's policy and procedure entitled "CODE BLUE - EMERGENCY MEDICAL RESPONSE" (Approved 9/09) read in part as follows: "PROCEDURE: I. Activation of Code Blue: A. Staff Responsibilities: 1. Hospitals and other defined areas - Dial 5555 on the hospital phone system, state "Code Blue" (indicate adult or pediatric) and exact location to operator. . . Appendix A Hospital and Other Defined Areas Activating Code Blue By Dialing "5555" From Hospital Phone System. . . Tacoma General Hospital/Mary Bridge Children's Hospital. . . Day Surgery of Tacoma in Baker Center. . . ".

2. On 3/19/2014 at 1:25 PM, Surveyor #5 observed an obstetrical and gynecological surgical procedure in the outpatient Ambulatory Surgery Unit, operating room (OR) #3 located in the Baker Center. During the procedure, Surveyor #5 asked the Circulating Nurse (Staff Member #16) how s/he would summon the emergency response team if the patient experienced a cardiopulmonary arrest. The nurse stated that s/he would dial "811" for an emergency, which is the incorrect number.

Based on review of staff personnel files, the hospital failed to ensure that all staff received training to include demonstrating competencies involved with physical restraints for 2 of 2 staff hired as a licensed nurse from an outside staffing agency.

Findings:

1. Surveyor #3 reviewed Staff Member #1's personnel file information, s/he was a licensed nurse traveler, recently hired to work in the Critical Care area. Hospital staff, providing access to the file, could not provide evidence that the staff member had received training, and was competent to apply, monitor and assess patients needing physically restraining device(s).

2. Surveyor #3 reviewed Staff Member #2's personnel file information, s/he was a licensed nurse traveler, recently hired to work in the Critical Care area. Hospital staff, providing access to the file, could not provide evidence that the staff member had received training, and was competent to apply, monitor and assess patients needing physically restraining device(s).

Based on observation, interview, and record review, the hospital failed to ensure that a Registered Nurse (RN) supervised and evaluated the nursing care provided to patients by a Licensed Practical Nurse (LPN).

Findings:

1. The hospital's Licensed Practical Nurse (LPN) job description (July 2008) read in part as follows: "GENERAL DESCRIPTION. . .The LPN assists the Registered Nurse in implementing the nursing process. Decisions regarding patient care or services required the review and approval of the Registered Nurse. . .".

2. On 3/17/2014 at 12:55 PM, Surveyor #5 observed an LPN (Staff Member #17) who was providing nursing care to an infant (Patient #2) in the newborn observation unit. Patient #2 had been admitted on 3/12/2014 at 8:58 PM to the unit and had been placed on child protective services observation. Assessments for this infant consist of observing for drug withdrawal, including (but not limited to) observing for seizures, projectile vomiting, and regurgitation. On the day of the surveyor's observation, Staff Member #17 was assigned to care for this patient with a RN "in charge" of supervising care.

3. Review of Patient #2's medical record revealed that a full physical assessment of the infant had been performed and documented by Staff Member #17 including vital signs, weight, pain assessment, neurological, cardiovascular, respiratory, genitourinary, integumentary, physical findings, interventions and feeding assessment. The record did not include evidence that the supervising RN had reviewed and concurred with the LPN's assessed findings.

4. An interview with the Unit Manager (Staff Member #22) on 3/17/2014 at 12:15 PM revealed the Mother-Baby Unit consists of RN and LPN "teams". The LPN will deliver care and perform assessments on maternal patients and infants. The RN on the team oversees and supervises the LPN and documents this in the electronic medical record.

5. Review of two patient records on 3/20/2014 revealed the following:

a. Patient #3 was a 36-year-old patient who had been admitted on 1/31/2014 to the birthing center for a repeat cesarean section. The patient was transferred to the mother-baby unit on 2/1/2014 at 5:00 AM, after recovering from the surgical procedure. Record review revealed that on 2/2/2014 at 7:45 AM and 2/3/2014 at 8:30 AM, an LPN performed nursing care and post-surgical assessments. The record lacked evidence that an RN had reviewed and concurred with the LPN's assessment findings and care provided.

b. Patient #4 was a 34-year-old patient who had been admitted on 12/31/2013 to the birthing center in active labor The patient was transferred to the mother-baby unit on 1/1/2014 at 11:00 AM, after recovering from the delivery. Record review revealed that on 1/1/2014 at 4:30 PM, an LPN completed a pain assessment and recorded a three out of ten pain scores. The LPN gave both a narcotic and non-narcotic pain reliever to the patient. The record lacked evidence that an RN had reviewed and concurred with the LPN's assessment findings and care provided.

6. During an interview on 3/22/2014 at 9:45 AM, the Chief Nursing Executive (Staff Member #18) confirmed the lack of RN oversight of patient care given by LPN's.

Based on review of staff personnel files, the hospital failed to document competency verification for non-employee licensed nurses for 2 of 2 staff hired from an outside staffing agency.

Findings:

1. Surveyor #3 reviewed Staff Member #1's personnel file information, he/she was a licensed nurse traveler, recently hired to work in the Critical Care area. Hospital staff, providing access to the file, could not provide evidence that the staff member's competency had been verified to meet the hospital's established criteria for staff working in critical care areas.

2. Surveyor #3 reviewed Staff Member #2's personnel file information, he/she was a licensed nurse traveler, recently hired to work in the Critical Care area. Hospital staff, providing access to the file, could not provide evidence that the staff member's competency had been verified to meet the hospital's established criteria for staff working in critical care areas.

Based on interview and record review, the facility failed to administer certain drugs according to practitioner orders.

Findings:

1. Between 1:30-3:30 PM on 3/20/2014 Surveyor #6 reviewed several Tacoma General medical records with a Nurse Analyst (Staff Member #33). Two of these records documented the care received by patients undergoing withdrawal from alcohol.

2. Patient #8 was a 51 year old admitted on 3/12/2014. His/her physician orders included the use of the CIWA Scale, a validated assessment tool which gives a score to guide the dose of medication to be given to manage symptoms of alcohol withdrawal. The medication prescribed was Lorazepam, a sedative/tranquilizer, and is meant to be given promptly after doing the assessment, since patient condition can change rapidly. This was confirmed by the Pharmacy Manager (Staff Member #34).

3. The record showed that on 3/13/2014 at 9:46 AM the patient's CIWA score was 10, requiring a 2 mg dose; however that dose was not given until 10:52 AM, over an hour later. On 3/14/2014 at 2:50 AM the patient's score was 14, requiring a 2 mg dose. However the dosage documented as given was 4 mg, twice as much as ordered. On 3/14/2014 at 4:20 AM the patient's score was 18, requiring a 4 mg dose. However, the dosage documented as given was 2 mg, half the dose which was ordered. No notations or new orders were found which would explain why the medications were not given as ordered.

4. Patient #9 was a 66 year old admitted on 3/12/2014 with multiple diagnoses, including alcohol withdrawal. Surveyor #6 found a similar variation between Lorazepam orders per the CIWA scale, and the dosage given to the patient, without documentation as to why the variation occurred.

Based on interview and record review, the facility failed to maintain a promptly completed medical record for 1 of 3 Tacoma General Emergency Department patients who were reviewed for safe discharge (Patient #7).

Findings:

Between 2:45 PM and 3:20 PM on 3/19/2014 Surveyor #6 reviewed Emergency Department (ED) records with a Clinical Analyst (Staff Member #32). Patient #7 had been evaluated in the ED on 3/15/2014 for alcohol intoxication, agitation, and reported seizures. The physician's note indicated that Social Work had been notified and evaluated the patient to plan for safe discharge. However, the surveyor found no documentation by the Social Worker in the patient's record. At 3:50 PM on 3/19/2014, the Director of Clinical Informatics (Staff Member #33) confirmed this lack of documentation.

.
Item #1- Unlabeled Medication Syringes

Based on observation, interview, and review of hospital's policies and procedures the hospital failed to ensure that syringes of medication and solutions were labeled according to hospital policy and procedure.

Findings:

1. The hospital's policy and procedure entitled "LABELING MEDICATIONS AND SOLUTIONS IN PERIOPERATIVE, PROCEDURAL AND OTHER CLINICAL SETTINGS" (Revised 11/13, Approved 1/14) read in part as follows: . . . III. Labeling Occurs At The Time Any Medication Or Solution Is Transferred From The Original Packaging To Another Container And Is Not Used Immediately. . . A. . .The label will be prepared and applied at the time the medication or solution is prepared. . . " Page 3 under " Immediate Use: " " . . . Immediate use DOES NOT include medications removed from the original container to be: 1. Used over the course of a procedure. . . ".

2. On 1/20/2014 at 1:30 PM, Surveyor #5 observed Patient #5 during an outpatient spinal injection procedure. Prior to the injection, the Neurologist (Staff Member #19) withdrew fluid from three vials into three unlabeled syringes. Each unlabeled syringe of fluid was placed on the sterile field. The contents of one syringe was injected into the patient's neck after the patient's neck was x-rayed using a portable fluoroscope, the contents of the other two syringes were injected at different times during the procedure.

3. After the procedure was completed, Surveyor #5 interviewed Staff Member #19 and asked how s/he identified what was in the unlabeled syringes. The staff member stated that the "10 cc" syringe contained "the dye"; one of the "5 cc" syringes contained the "cloudy" solution which was the pain medication; and the third syringe contained the skin anesthetizing medication.

4. An interview on 3/22/2014 at 8:45 AM with the Pharmacy Clinical Manager (Staff Member #20) confirmed that not labeling pre-drawn syringes of medications and solutions was against hospital policy.


Item #2 - No Preoperative Orders for Intravenous Access and Solutions

Based on observation and interview, the hospital failed to ensure that nursing staff members obtained physician orders for insertion of intravenous (IV) accesses and the types of solutions to be infused.

Findings:

1. On 3/19/2014 at 12:45 PM in the Ambulatory Surgical Center, Surveyor #5 observed Patient #1, a 33 year-old, receiving care in the Pre-Operative Unit prior to a surgical procedure. A solution of fluid was infusing into the patient's arm. Review of the patient's medical record revealed the record did not include physician's orders for insertion of an IV access and the type of solution to be infused.

2. On 3/20/2014, Surveyor #5 reviewed the medical records of Patient #7, a 27year-old with a diagnosis of pelvic pain. The patient had been admitted on 3/18/2014 to the Outpatient Surgical Center for a surgical procedure. Pre-operative orders in the patient's medical record did not include a physician's order for insertion of an IV access and the type of solution to be infused. The medical record revealed that an IV was started with a solution of fluid infusing in the patient in the pre-operative unit.

3. On 3/20/2014 at 11:15 AM, an interview with the Director of Ambulatory Surgical Center (Staff Member #21) confirmed that these pre-operative orders were missing.

Based on observations and review of pharmaceutical literature, the hospital failed to ensure that intravenous and irrigation fluids were stored appropriately and were not available for patient use after the maximum storage time.

Findings:

1. Per review of hospital policy and procedure titled "Warmers", last revised 9/2013, it states in paragraph 2 that fluids are to be kept in the warmer for a maximum of 14 days. It also states that the bags should be labeled with the expiration date.

2. During observations in the "Core" area of the Tacoma General Surgery Department, on 3/18/2014, the intravenous/irrigation fluid warmer was viewed. The warmer contained three (3) plastic containers of 3000 ml Sorbitol-Mannitol irrigation fluid that had a "remove and do not use" date of 2/28/2014.

3. An additional fluid warmer was viewed outside operating room #5, on 3/18/2014. The warmer contained nine (9) bottles of irrigation fluids that had a "remove and do not use" date of 3/17/2014.

4. On 3/18/2014 at approximately 10:10 AM Surveyor #6 observed approximately 6 one-liter over-wrapped flexible bags of intravenous fluids (IV) in the Emergency Department (ED) warming cabinet. The cabinet temperature was set at 110 degrees Fahrenheit (F.). The ED Clinical Director (Staff Member #25) stated that an Accrediting Agency Surveyor told them that the cabinet temperature "must" be set at that temperature. Staff Member #25 stated that the bags were stored in the cabinet at that temperature for 14 days. When asked for confirmation of permissible parameters from the fluid supplier, documentation indicated that the appropriate storage temperature for the IV bags should be 104 degrees F. for no longer than 14 days.

Based on observation, interview, and review of manufacturer's instructions, the facility failed to maintain patient care supplies to ensure an acceptable level of quality.

Findings:

1. During observations in the operating room areas on 3/18/2014, a "Pediatric Anesthesia Turnover Cart" was noted in the hallway, by Surveyor #3 . The cart contained a large plastic bin of heart monitoring electrodes. All of the electrodes were out of their manufacturer's package and did not have an available expiration date.

2. During observations in the surgery recovery areas on 3/18/2014, Surveyor #3 observed a cart containing approximately thirty (30) heart monitoring electrodes. All of the electrodes were out of their manufacturer's package and did not have an available expiration date.

3. During tour of the Tacoma General Emergency Department (ED) on 3/18/2014 Surveyor #6 observed an open packet of electrodes used with equipment which monitored heart rhythm. The package was open but no opening date was documented. The manufacturer's package instructions indicated that quality of the electrodes could not be ensured after 30 days of being opened, due to potential adhesive deterioration. This package was found in ED room #2 at approximately 9:00 AM. At approximately 9:05 AM a similar open, undated package was found in ED room #31. The ED Nurse Manager (Staff Member #26) stated that tracking the package open dates was not a practice followed in the ED.

Based on observation, the facility failed to ensure proper temperature controls in the food service area of Tacoma General's Dietary Department.

Findings:

1. On 3/19/2014 at 3:00 PM, Surveyor #1 used a thin-stem thermometer to determine the following items kept on ice on the service line in the Tacoma General Cafeteria were not in compliance with the Washington State Retail Food Code which states that potentially hazardous food must be maintained at 41 degrees Fahrenheit or less, except during active preparation for up to two hours, cooking or cooling:

a. Chopped lettuce: 59 degrees Fahrenheit
b. Sliced tomatoes: 56 degrees Fahrenheit

The kitchen supervisor (Staff Member #3) confirmed these findings at the time of the survey.

2. On 3/19/2014 at 3:30 PM, Surveyor #2 observed the thermometer located inside a reach-in cooler for "grab and go" sandwiches read 50 degrees Fahrenheit. Equipment must be maintained to ensure that pre-packaged potentially hazardous foods remain at 41 degrees Fahrenheit or less during cold holding. Surveyor #2 proceeded to use a thin stem thermometer to evaluate the temperature of the following items:

a. "New Yorker" Sandwich: 45 degrees Fahrenheit
b. BBQ Chicken Sandwich: 56 degrees Fahrenheit

The dietary manager (Staff Member #4) confirmed these findings, and as s/he could not determine how long the items had been out of temperature, all potentially hazardous food items in the unit were discarded.

3. On 3/19/2014 at 3:10 PM, Surveyor #1 used a thin-stem thermometer to measure the temperature of rice noodles on the serving line. The item temperature was 77 degrees Fahrenheit (F). Surveyor #1 interviewed a production cook (Staff Member #9) about the preparation of the cooked rice noodles. Staff Member #9 indicated that the noodles are only held for the duration of the lunch service, and then discarded. Surveyor #1 observed no time marking on the containers of rice noodles to indicate how long they were maintained out of temperature.

Reference: 2009 FDA Food Code 3-501.16

4. On 3/19/2014, at 3:44 PM, Surveyors #1 and #2 observed vacuum-packed containers of gravy stored in a walk-in cooler. Surveyor #1 interviewed the Tacoma General Chef (Staff member #8) about the preparation process for the cooked and packaged gravy. S/he indicated the gravy was cooked, chilled and then sealed. Facility staff could provide no Hazard Analysis Critical Control Point Plan (HACCP) for this item or its process.

Reference: The Washington Administrative Code (WAC) 246-215 (Adopted from the 2009 FDA Food Code) 03540 (2).

Based on observation and interview, the facility failed to follow certain systems for infection prevention.

Findings:

ITEM #1 - CROSS CONTAMINATION

1. During tour of the Tacoma General Critical Care Unit on 3/18/2014 at approximately 11:00 AM Surveyor #6 observed that clean patient care items were placed immediately adjacent to the hand washing sink at the station. This subjected them to potential contamination from splashing of liquids during hand washing.
.
2. During tour of the Tacoma General Radiation Oncology Unit on 3/18/2014 at approximately 3:40 PM a stack of toys was observed in the Pediatrics Waiting Room. Some of the toys included board games, which contained paper items which could not be readily disinfected. Asked about sanitizing procedures for these items between children, the Manager (Staff member #31) stated s/he did not know of any processes, and that s/he would be the one to have put them into place.
.
3. Touring the Tacoma General Radiation Oncology Unit at approximately 3:50 PM on 3/18/2014, Surveyor #6 observed that clean patient items were placed immediately adjacent to a hand washing sink, potentially exposing them to contamination from splash.
.


29784


Item #2- Clean Equipment

Based on review of policy and procedure, observation and staff interview, the facility failed to assure clean equipment between use for patient care in the Allenmore Hospital Heart Lung Center and Emergency Department.
.
Findings:
.
1. In review of policy and procedure titled "CLEANING, DISINFECTION AND STERILIZATION", it contained information about cleaning procedures. Page 6 of 16 contained information about cleaning non-critical patient care items. Item #1 stated "All non-disposable patient care equipment shall be cleaned and disinfected between patients ...".
.
2. On 3/19/2014 at 9:45 AM Surveyor #4 observed equipment in the Allenmore Heart Lung Center. The treadmill machine had one blood pressure cuff for use with multiple patients. The outside of the cuff was a soft woven fabric material and not cleanable/washable between patient care episodes.
.
a. On the same day at 1:00 PM, Surveyor #4 observed blood pressure equipment used for care in the Emergency Department triage room. An electronic automatic cuff was located on the desk. Several inches of the blood pressure cuff extension cord were placed/rested on the floor in a location within a few inches of the triage patient chair.
.
3. At the same date/time as item 2a. the respiratory therapist (Staff Member #41) was interviewed. S/he stated that only the interior surface of the blood pressure cuff was cleaned after each patient use. Later that day, s/he identified that the manufacturer provided disposable blood pressure cuffs for the cardiac treadmill machine and that the department would purchase them for patient use.
.
a. At the same date/time as item 2b., a nurse (Staff Member #37) in the Emergency Department was interviewed about the blood pressure extension tubing placed/rested on the floor. S/he stated that it was typically cleaned between patient use and then relocated to the floor.
.


33163


4. On 3/17/2014 at 12:30 PM while inspecting the medication room on the Mother-Baby Unit, Surveyor #5 observed a plastic basket, on the counter, that contained blood sample collection supplies. The supplies included blood collection tubes, needles and gauze. Dust was noted on the bottom of the basket.
.
During an interview on 3/17/2014 at 12:35 PM, the manager of the unit (Staff Member #22) stated blood samples are drawn from patients' using supplies from this basket. The manager stated that the basket was carried into a patient's room, taken out and carried into another patient's room and was not cleaned between use. Staff Member #22 stated the night shift nurses clean and stock the basket, but that there was no process to document this process. The hospital was unable to locate a policy or procedure for sanitizing the basket between patients.
.
5. On 3/19/2014 at 2:30 PM, Surveyor #5 inspected the medication room on the fifth floor medical/surgical unit. A plastic basket containing arterial blood collection supplies was located on the top shelf of the medication room. Dust was noted throughout the entire basket.
.
6. During an interview on 3/19/2014 at 2:35 PM, the 5th floor Medical/Surgical Unit Manager (Staff Member #23) stated the basket was taken from one patient's room to another patient's room and was not cleaned between use. The manager confirmed this risked cross-contamination and hospital acquired infections.
.
The basket was removed by Staff Member #23 after the interview and was no longer available for patient use.
.
7. On 3/19/2014 at approximately 9:45 AM, Surveyor #6 inspected the procedure room in the Regional Cancer Center. The surveyor observed a plastic basket sitting on a counter which contained patient care supplies. The basket had a light coating of dust, and there were pieces of debris mingled with the items in the basket. The basket was the single example observed of patient care supplies stored on the counter-top (all other supplies were stored in drawers and cabinets). The Radiation Services Nurse Manager (Staff Member #31) stated that the basket was always stored there.
.



33674

Item #3- Equipment Cleaning and Disinfection
.
Based on observation, interview and record review the facility failed to implement certain systems and procedures for controlling/preventing infections.
.
Findings:
.
1 . Reference: "Olympus Endoscope Cleaning Guide EVIS 40/140/240 160-Series (2003) 08/03/PWC-10008" Steps 8, 12, and 13 State in part: "Immerse in freshly prepared detergent solution. Aspirate detergent solution into suction channel; Attach injection tube and channel plug. Flush detergent solution into air, water and suction channels".
.
a. On 3/19/2014 at 11:00 AM, Surveyor #1 interviewed a peri-operative service tech (Staff member #12) on the process of disinfecting an endoscope, S/he stated in part the s/he would use an enzymatic sponge to clean the scope; then leak test it; then submerge the scope in water without the use of detergent.
.
2. On 3/17/2014 at 1:20 PM Surveyor #1 observed a bottle of chemical indicator test strips in the Respiratory Therapy department, marked with an expiration date that exceeded the manufacturer's expiration date on the bottle. This finding was confirmed by Respiratory Therapy Manager (Staff member #11).
.
3. Reference: Centers for Disease Control and Prevention "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008": "Flash sterilization should not be used for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time. Because of the potential for serious infections, flash sterilization is not recommended for implantable devices (i.e., devices placed into a surgically or naturally formed cavity of the human body)".
.
a. On 3/19/2014 at 12:10 PM, Surveyor #1 reviewed logs kept to document the contents of the immediate use ("flash") sterilizer loads at the Covington Medical Center. The review revealed that from February 12, 2014 to March 19, 2014, at least eight (8) immediate use ("flash") sterilizer loads contained implantable surgical items. This finding was confirmed by Assistant Nurse Manager (Staff Member #13).
.
4. On 3/20/2014 at 3:30pm Surveyor #1 observed a peri-operative staff technician (Staff Member #15) wipe down cables from a portable monitor with a disinfecting solution. While wiping down the cables the peri-operative technician allowed the cables to touch the floor then placed them back on its designated hook.
.

Item #1: Skin Antisepsis
.
Based on observation, review of policy and procedure and staff interview, the facility failed to apply skin antisepsis prior to surgery in adherence with the manufacturer's directions.
.
Findings:
.
1. On 3/18/2014 at 1:20 PM skin preparation for a surgical incision was observed by Surveyor #4 at the Gig Harbor Ambulatory Surgery Center. The patient (Patient #11) had surgery on her/his right finger that day. The circulating nurse (Staff Member #38) applied an antiseptic skin solution (Chloraprep) in preparation for the surgical incision.
.
2. The flow of the antiseptic application to areas was as follows: front of wrist, palm and end of fingers/fingernail area, back of lower arm, back of hand, palm and between fingers/fingernails, back of the fingers/fingernails and front of fingers/fingernails. The surgical area did not have 30 seconds of back and forth stroke contact with the antiseptic solution and some of the antiseptic solution reached the surgical site subsequent to contact with the fingernail area and the periphery of the surgical site.
.
3. Surveyor #4 reviewed facility policy titled "PREOPERATIVE SKIN ASSESSMENT" and on page 2, section A. 1. and in the section about Chloraprep it stated "follow the manufacturer's guidelines for application."
.
4. On 3/18/2014 at 1:45 PM the manufacturer's instructions for Chloraprep application with Tint (26 ml applicator) was reviewed during an interview with the Manager of the surgery center (Staff Member #39). The package instructions stated for "dry surgical sites use gentle back and forth strokes for 30 seconds." The Manager stated that the nurses in that area also followed AORN, "Perioperative Standards and Recommended Practices".
.
5. Subsequently Surveyor #4 reviewed those AORN Guidelines (2012) , specifically "Recommendation V" under "Patient Skin Antisepsis". That section stated "The skin around the surgical site should be free of. . .debris. . .transient organisms to minimize contamination of the surgical wound before application of the antiseptic skin preparation. Before Section V.a. it further stated, "Some anatomic areas contain more debris that others (e. g ...under fingernails ...). Cleaning these areas separate from the surgical prep prevents distribution of microorganisms from these areas to the surgical site."
.
6. During another discussion with a RN (Staff Member #40) on 3/19/2014 at 10:00 AM, who provided care to patients having endoscopy procedures (for percutaneous endoscopic gastrostomy tubes), s/he stated that s/he applied Chloraprep antiseptic solution (5.25 ml applicator) from the center point of the surgical area with a continuous outward circular motion to the periphery. This technique would not assure 30 seconds back and forth antiseptic and skin contact at the surgical site.
.


33163


Item #2: Surgical Attire

Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure operating room staff members wore head attire that completely covered their hair during a surgical case in the Ambulatory Surgery Center (ASC).
.
Findings:
.
1. The hospital's policy and procedure entitled "SCRUB ATTIRE, MANAGEMENT OF AND CLEANING TIME" (Revised 6/11/ Approved 8/11) read in part as follows: "Scope: this policy applies to all persons entering the semi-restricted or restricted areas at all MultiCare Health System (MHS) facilities. . .G. All head and facial hair, including sideburns and neckline, will be covered. . .1. The surgical hat or hood should be clean, free of lint, and should confine all hair. ".
.
2. On 3/19/2014 at 1:25 PM, Surveyor #5 observed an obstetrical and gynecological surgical procedure in the outpatient ambulatory surgery center, located in the Baker center. In operating room (OR) #3 after the sterile instruments were opened, the surgical nurse (Staff Member #24) was observed wearing two different surgical hats. The nurse's hair was exposed at the side of the head and back of the head. The surveyor reported this to the unit manager. The manager advised the surgical nurse to step out of the surgical suite and adjust the surgical hat to contain all of his/her hair.
.