HospitalInspections.org

Based on observation, document review and interview, the facility did not ensure patient environmental safety was maintained. This was evident in the random observations of unsecured storage of Angiocatheters and Phlebotomy supplies found in eight (8) supply carts located in the Emergency Department's patient care areas and hallways.

These lapses in environmental safety place patients and visitors at increased safety risk.

Findings:

Observations in the facility's Emergency Department on 7/16/20, at 12:10PM, identified the following:

-Two (2) supply carts located in corridor C, containing angiocatheters used to puncture the patient skin and phlebotomy needles were observed unlocked and unattended.

-One (1) supply cart in the area CC, containing angiocatheters used to puncture the patient skin and phlebotomy needles were observed unlocked and unattended.

Similar findings of unlocked carts containing angiocatheters and phlebotomy needles were also identified in the B area, the step down area, the crash room, and the trauma bay areas.

These observations were confirmed by Staff C (Director of ED), Staff B (Nurse Manager of ED) and Staff D (Director of Nursing Critical Care).

During interviews of Staff C, B and D at the time of the observations. They acknowledged that that the supply carts should have been locked and reported that the facility was aware that staff was unable to lock eight (8) supply carts since June of last year (2019).

The facility policy and procedure (P&P) titled "Medication Policy: General Rules and Safeguards" last reviewed May 2018, contained the following statements: "Needles and syringes must be stored in a secured area at all times (i.e. automated supply station). They are not to be left on top of the medication cart or unattended at any time.

Based on document reviews and staff interviews, the facility failed to ensure that a contingency plan was developed for the procurement of Essential Supplies Medical/Surgical Supplies and Personal Protective Equipment in the event of a large-scale emergency or regional crisis.

Findings include:

Review of the Hospital's Emergency Management manual on 07/17/2020 revealed that the facility does not have a proper contingency plan for the replenishment of all type of supplies in the event shortfalls are projected during a large scale emergencies.

Review of the section 26.8.3 Resource Monitoring in Emergency Management Manual revealed that in the event that the shortfalls are projected, the facility will implement actions like Procurement from alternate or nontraditional vendors, Procurement from communities outside the affected region, Resource substitution, Resource Sharing arrangements with mutual aid partners etc.

Upon interview of System Vice-President For Supply Chain, Staff J on 07/17/2020 at approximately 11:50 AM, it was revealed that the hospital receives a consignment of 15 day supplies every month and the hospital has stockpile of supplies to last 45 -90 days currently.

However, it was also stated that the hospital has not identified any alternate or non-traditional vendors, or methods of resource substitution, methods/mechanism to communicate and transport supplies outside the affected region and has not identified mutual aid partners,as referenced in the Emergency Management Manual.

Therefore, the current arrangement of procuring, transporting and storing supplies without a back-up emergency plan poses a risk to the facility of going into a crisis mode in the event a large scale emergency hits the region in which it is located.

Based on observations and interviews, the facility failed to implement measures to prevent the transmission of COVID-19 as per current guidance issued by the Center for Disease Control (CDC). Specifically, the facility failed to implement: Screening of all staff for signs of respiratory illness.


Findings:

Review of CDC Infection Control Guidance updated May 18, 2020 " ...As part of routine practice, Health Care Personnel (HCP) should be asked to regularly monitor themselves for fever and symptoms of COVID-19 ...Screen all HCP at the beginning of their shift for fever and symptoms consistent with COVID-19 (chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, loss of taste or smell, sore throat, congestion). If they are ill, have them keep their cloth face covering or facemask on and leave the workplace.

Observations conducted at the facility entrances on 7/16 and 7/17/20 revealed Health Care Personnel are not screened at the beginning of their shift for fevers and signs and symptoms of COVID-19.

During an interview with the Staff A (Vice President of Risk Managemen) on 7/16/20 at 11:04 am she acknowleged that they have not been screening all of their staff.

Interview with the Staff L (Chief Executive Officer) on 7/17/20 at 3:30 pm, he stated that the facility's focus was on obtaining personal protective equipment and maintaining an adequate supply. We know we should have been screening the staff. We will start screening all staff on Monday.

There was no indication the facility has implemented the recent CDC Infection Control Guidance updated May 18, 2020 for monitoring and managing healthcare personnel.