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Based on observation, staff interview, and policy and procedure review, the facility failed to record the temperature of the medication refrigerator on Two West (2W) for 13 of 19 days in September of 2017. (September 2, 3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13, and 14)


Findings Include:


On 9/18/2017 at 10:30 a.m. observation of the medication refrigerator log in the medication room on 2W revealed no documented evidence the refrigerator temperature had been recorded for September 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14, 2017.

During a staff interview on 09/19/17 at 3:52 p.m. the Chief Nursing Officer (CNO) confirmed there were 13 days in the month of September where the medication refrigerator temperature on 2W had not been recorded.

Review of the facility's "Entering a Patient into the System" Pharmacy Policy number 000, last revised June of 2017 revealed: "I. Storage of Medications: A. Drugs are stored under conditions of sanitation, temperature, light, moisture, ventilation, segregation and security. 1. Temperature-Drugs are stored at controlled room temperature or, if refrigeration is required, they are stored in a refrigerator with the sole purpose of storing medications or in a separate compartment within a refrigerator that is capable of maintaining the necessary temperature. 2. Refrigerators are equipped with thermometers and a log is maintained recording the refrigerator temperatures daily ...".

Based on observation, staff interview, dual enzymatic detergent and presoak manufacturer guideline review, and policy and procedure review, the facility failed to ensure the biohazard container that contained the dual enzymatic detergent and presoak solution used to pre-clean the dirty Emergency Department (ED) equipment, such as, laryngoscope blades, non-disposable airways, and suture trays was properly stored to ensure the safety of patients, staff and visitors on one (1) of three (3) days of survey.

Findings Include:

Observation of the ED on 09/18/17 at 12:15 p.m. revealed the Soiled Utility room door was unlocked and did not have a biohazard label on the outside of the door. Observation in the Soiled Utility Room revealed a biohazard labeled red plastic container had been placed on top of a table. The red plastic container contained one (1) to two (2) inches of blue colored fluid. There was a container labeled " ...Dual Enzymatic Detergent and Presoak Solution" located on the right side of the red plastic container.

During an interview on 09/18/17 at 12:18 p.m. the findings made in the Soiled Utility Room were discussed with the ED Director. She confirmed there was no locking mechanism on the Soiled Utility Room door at this time. She stated that the red plastic container contained a Dual Enzymatic Detergent and Presoak Solution used to pre-clean ED instruments, such as suture kits and laryngoscope blades prior to sterilization (autoclaving). She also stated that the red plastic container was transported inside another plastic container at the end of the day to the dirty instrument room located in the Surgical Services Department and that the Dual Enzymatic Detergent and Presoak Solution were changed each day.

During an interview on 09/20/17 at 9:15 a.m., the ED Director confirmed the Soiled Utility Room had been used for the past two (2) years to house the biohazard container for instruments and the door had never had a locking mechanism.

Review of the manufacturer guidelines for "Dual Enzymatic Detergent & Presoak" revealed: "...Use Precautions: Warning: Causes eye irritation. May cause allergy or asthma symptoms or breathing difficulties if inhales ...Do not breathe mist or spray ...Storage and Disposal: Store in a closed container ... First Aid: In inhales ...If swallowed ...If on skin (or hair) ...If skin irritation or rash occurs: Get medical attention. Call a Poison Control Center or doctor ...".

Review of the facility's "Hospital Infection Prevention and Control/Emergency Department" policy, effective date of June 30, 2017, revealed: " ...Responsibilities: ...The ED Nurse Manager shall: ...Assure proper equipment maintenance and cleaning ..."

Review of the facility's "Hospital Infection Prevention and Control/Medical Equipment User/Maintainer Orientation/Education" policy, effective date: June 30, 2017, revealed: "Policy: All new staff and employees of contract agencies utilized by the hospital shall receive appropriate training during orientation on all medical equipment ...Thorough training shall be provided about ...safety procedures ...maintenance procedures ...Review of any specific instructions related to ...patient safety considerations ...The employee shall be educated/trained in the following areas: ...Protect equipment from contamination whenever possible ...Use engineering control and careful work practices to avoid contaminating the equipment ...In-service education shall include the ...safety procedures, work practice controls to minimize equipment contamination ...".

Based on Organ and Tissue Donation agreement review, Tissue Donation Report review, policy review, and staff interview, the facility failed to ensure the specific organ, tissue, and eye procurement requirements are met.

Findings Include:

Review of the facility's contract "Organ and Tissue Donation Agreement" dated 03/01/14 revealed: "Timely Notification for Organ Donation - a timely referral is one that is made as soon as possible (ideally within one (1) hour and allows MORA (Mississippi Organ Recovery Agency) time to evaluate and determine eligibility for organ donation potential for any severely brain-injured or brain dead patient patient prior to the withdrawal of the ventilator and/or care."

Review of the facility's "Tissue Donation Report" revealed the months January, March, and May 2017 had negative reporting. Review revealed January had one (1) death was not called into MORA, March had one (1) death that was not reported within the one (1) hour timeframe, and May had one (1) death that was not reported within the one (1) hour timeframe.

Review of the facility's "Organ, Tissue, and Eye Procurement" policy, revised 7/2017, revealed: "Policy: To promote compliance with statutory and regulatory requirements for organ, tissue, and eye procurement and to facilitate the tissue donation process ...Procedure within one hour of physician documented time of death and before calling the funeral home, a nursing staff member should call the MORA referral number to report every death."

During an interview on 09/19/17 at 2:00 p.m. the Quality Assurance (QA) Nurse stated, "Our investigation revealed in January the nurse caring for the patient was relatively new to our emergency department. In March the patient was shot and the family members was taking sides. We had to call in law enforcement. The degree of intense action in the emergency department at this time delayed the call to MORA past the allowed timeframe. In May our records show the call was made within our required time frame."