HospitalInspections.org

Based on document review, observation, and interview, it was determined that for the Intensive Care Unit (ICU) and Progressive Care Unit (PCU), the Hospital failed to ensure that a qualified staff member was available to continuously observe the telemetry monitors, potentially affecting the 20 patients on census on the two units.

Findings include:

1. On 2/26/18 at approximately 3:10 PM, the Hospital's policy titled, "Telemetry Monitoring" (revised 1/2018), was reviewed and required, "...Appendix A...Ongoing Monitoring... Tele Tech: a. Notifies Primary RN [registered nurse] of any changes in rate or rhythm for immediate patient assessment."

2. On 2/26/18 between 9:50 AM and 11:20 AM, an observational tour was conducted of the ICU and PCU. Between 9:53 AM and 9:57 AM, no staff member was present by the telemetry monitors at the nurses' station. When brought to the attention of the Charge Nurse (E #7), E #7 requested the Secretary/Patient Care Technician (E #8) to sit by the telemetry monitors and to not leave them unattended. E #7 stated that E #8 has had telemetry training, was qualified to monitor telemetry, and was assigned to monitor the telemetry monitors at the nurses' station.

3. On 2/26/18 at 10:00 AM, an interview was conducted with the Director of Nursing for Critical Care (E #4). E #4 stated that the staff nurses can hear and respond to the alarms while working in patients' rooms. E #4 stated that E #8 or a nurse should have been watching the telemetry monitors at the nurses' station.

Based on document review and interview, it was determined that the Hospital failed to ensure all medical records were completed within 30 days of patient discharge.

Findings include:

1. The Hospital's Medical Staff Bylaws Rules and Regulation (amended 3/07) required, "...Delinquent status indicates that a physician has deficient records 15 days post discharge..."

2. On 2/27/18 at approximately 9:00 AM, The Medical Records Administrative Assistant (E #6) presented a letter of attestation that included, "...the total number of incomplete charts for [Hospital] on February 7, 2018, is 81 charts..."

3. On 2/27/18 at approximately 9:00 AM, during an interview with the Director of Accreditation (E #6), E #6 stated that a medical record is considered delinquent by the Hospital when it remains incomplete 15 days after the patient is discharged.

Based on document review, observation, and interview, it was determined that for 2 of 4 staff members (MD #2 and E #14) providing pain relief services using radiology, the Hospital failed to ensure that staff who were performing treatment using radiology, wore film badges to measure potential radiation exposure.

Findings include:

1. On 2/28/18 at 3:10 PM, the Hospital's policy titled, "Safe Operating Procedures for Radiographic Imaging Sources" (revised 2/2018) was reviewed and required, "...F. Whole body film badges will be worn at chest or waist level. When a protective garment is worn, the badges will be positioned outside of the protective garment, at collar level..."

2. On 2/28/18 at 8:10 AM, an observational tour was conducted in the Pain Clinic. Pt. #30 was a 50 year old female undergoing a caudal epidural steroid injection [pain injection] using radiology. The Physician (MD #2) and a Radiology Technologist (E #14) were not wearing film badges during the procedure, while radiology was in use.

3. On 2/28/18 at approximately 8:25 AM, an interview was conducted with MD #2. MD #2 stated that the Nurse had not provided his film badge today.

4. On 2/28/18 at approximately 8:30 AM, an interview was conducted with E #14. E #14 stated that her film badge was at the other [affiliated] Hospital, and E #14 had not received a film badge for this Hospital.

A. Based on document review, observation, and interview, it was determined that for 13 of 13 food items (2 dry foods and 11 refrigerated foods) observed in the kitchen, the Hosptial failed to ensure that food items were dated as required.

Findings include:

1. The Hospital's policy entitled, "[Hospital] Food Supply and Storage Procedures" (revised 8/17) was reviewed on 2/28/18 and required, "... All food... used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption...Dry Storage: Date and rotate items... Refrigerated Storage: Date and rotate items..."

2. On 2/28/18 between 11:15 AM and 11:50 AM, a tour of the Dietary Department was conducted and the following was observed:

At 11:30 AM, the dry food storage room contained 1 bin of oats and 1 bin of wild rice, both opened and undated.

At 11:35 AM, the food storage refrigerator contained 4 bag of jalapeno peppers, 2 bags of tortillas and 5 bags of parsley, all opened and undated.

3. On 2/28/18 at 11:45 AM, the Chef (E #19 ) was interviewed. E #19 stated, "It is a look to decide when the fresh produce is no longer fresh." E #19 stated that there are no dates on any of the produce. E #19 stated that if the fresh produce doesn't look good, then the Hospital does not use the produce. E #19 stated that the bins of oats and rice should have a date noted on the bins to verify when the the bins were opened.

B. Based on document review, observation and interview, it was determined that, for 1 of 3 Chefs (E #19), the Hospital failed to ensure facial hair was covered as required.

Findings include:

1. The Hospital's policy entitled, "[Name of Facility] Uniform Dress Code" (revised 3/11) was reviewed on 2/28/18 and required, "... Long facial hair must be covered with a surgical mask and/or hook..."

2. On 2/28/18 during a tour of the kitchen area between 11:15 AM to 11:45 AM, E#19 had a beard that was not covered with a mask.

3. On 2/28/18 at 11:50 AM, an interview was conducted with the Clinical Nutrition Manager (E#20). E #20 stated that it is the expectation that all staff members in the kitchen cover any exposed hair.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of a sample Validation survey conducted on February 26-28, 2018, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

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

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of Sample Validation survey conducted on February 26-28, 2018, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

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

Based on document review, observation, and interview, it was determined that for 1 of 5 rooms (Room #2900) toured on the 2 Medical Unit and 1 of 3 (Room #U5915), the Hospital failed to ensure patient care supplies were stored appropriately, and opened supplies were not available for use.

Findings Include:

1. The Hospital policy titled, "Storage and Shelf Life of Sterile Supplies" (revised 07/2017) was reviewed on 2/26/18 and required, "...Supplies should be stored...on carts with soli surface bottoms...

2. On 2/26/18 at approximately 10:30 AM, during a unit tour of 2 Medical Unit, the following supplies were observed unsecured and available for use in a patient's room (Room #2900):
-Two unopened packages of intravenous needles were lying on the counter near the door;
- One opened syringe with clear liquid inside was lying on the bedside table.

3. On 2/26/18 at 9:50 AM and again at 2::00 PM, an observational tour was conducted of the Intensive Care Unit. In room U5915, an unused, wrapped syringe was lying on the floor. The syringe was observed at 9:50 AM and at 2:00 PM.

4. On 2/26/18 at approximately 10:35 AM, an interview was conducted with the 2 Medical Unit Manager (E#1). E #1 stated that the opened syringe should have been discarded, and unused supplies should have been locked in the supply drawer in the patient's room.

5. On 2/26/18 at 2:15 PM, an interview was conducted with the Director of Critical Care (E #4). E #4 stated the syringe should not be on the floor.

A. Based on document review, observation and interview, it was determined that for 1 of 1 Food Service Worker (E #2) and 1 of 1 visitor (Pt. #3's daughter) observed in the Progressive Care Unit (PCU), the Hospital failed to ensure adherence to infection control practices regarding Droplet and Contact Isolation Precautions.

Findings include:

1. On 2/26/18 at 3:00 PM, the Hospital's policy titled, "Standard Precautions and Transmission-based Isolation Precautions" (revised 7/2017), was reviewed and required, "[For] Droplet Precautions... Wear a simple procedural mask upon entry into the patient's room... [For] Contact Precautions... Gloves and gown are worn every time you enter the room."

2. On 2/26/18 at 11:00 AM, Pt. #3's clinical record was reviewed. Pt. #3 was a 91 year old female, admitted on 2/25/18 with diagnoses of hypoxemia (low oxygen in the blood) and influenza, with orders dated 2/25/18 for Droplet Isolation Precautions.

3. On 2/26/18 at 11:05 AM, an interview was conducted with a Staff Nurse (E #5) in the PCU. E #5 stated that Pt. #3 was also put on Contact Isolation Precautions upon admission due to an order for a respiratory panel on 2/25/18. E #5 stated that Contact Isolation Precautions will remain in place until the results of the panel are received; if the results are negative, the order for Contact Isolation Precautions will be discontinued in the patient's clinical record. At 11:10 AM, there was no order to discontinue Contact Isolation Precautions in Pt. #3's clinical record.

4. On 2/26/18 between 10:30 AM and 11:20 AM, an observational tour was conducted of the PCU. At 10:35 AM, a Food Service Worker (E #2) and a visitor (Pt. #3's daughter), were observed in Pt. #3's room. E #2 was not wearing gloves, a gown or a mask. Pt. #3's daughter was only wearing a mask. A sign was posted outside the room indicating that "Contact/Droplet Precautions" were in place and to perform hand hygiene, don a gown, gloves, and a simple mask "every time you enter the room."

5. On 2/26/18 at 10:40 AM, an interview was conducted with E #2. E #2 stated that she should've followed the isolation precaution instructions posted on the sign, but she just wanted to run in the room quickly to talk to the patient and did not see the sign before entering.

6. On 2/26/18 at 10:45 AM, an interview was conducted with Pt. #3's daughter. Pt. #3's daughter stated that she was only instructed by the nurse to wash hands and put on a mask before entering the room.

B. Based on document review, observation and interview, it was determined that for 1 of 1 Respiratory Therapist (E #3) observed in the Intensive Care Unit (ICU) and 1 of 1 Reprocessing Technician (E #17) observed in the GI Lab, the Hospital failed to ensure hand hygiene was performed after removing gloves.

Findings include:

1. On 2/26/18 at 2:40 PM, the Hospital's policy titled, "Hand Hygiene" (revised 7/2017), was reviewed and required, "At a minimum, perform hand hygiene... Between handling individual patients or their environment... Before putting on gloves and immediately upon removing them."

2. On 2/26/18 between 9:50 AM and 10:30 AM, an observational tour was conducted of the ICU. At 10:05 AM, after performing oral suctioning of a patient and assisting with repositioning, a Respiratory Therapist (E #3) removed his gloves and left the patient's room without washing his hands.

3. On 2/26/18 at 11:15 AM, an interview was conducted with the Director of Nursing for Critical Care (E #4). E #4 stated that the Respiratory Therapist (E #3) should have washed his hands.

4. On 2/28/18 between 10:50 AM and 11:30 AM, an observational tour was conducted of the Gastrointestinal (GI) Lab. At 11:15 AM, a Reprocessing Tech (E #17) had finished the initial cleaning of an endoscope and placed it in the reprocessor (a machine used for high-level disinfection). E #17 then removed her gloves and did not perform hand hygiene prior to touching documents in the room, then going to close the lid and push the start button on the reprocessing machine.

5. On 2/28/18 at 11:25 AM, an interview was conducted with the Executive Director of Nursing (E #27). E #27 stated that she did not notice whether or not E #17 had performed hand hygiene immediately after removing her gloves.

C. Based on document review, observation and interview, it was determined that for 1 of 1 Scrub Technician (E #13) observed in the Operating Room (OR) and 1 of 1 Staff Nurse (E #16) observed in the Pain Clinic, the Hospital failed to ensure that staff did not extend exposed hands or arms over the sterile field.

Findings include:

1. On 2/28/18 at 2:40 PM, the Hospital's policy titled, "Aseptic Technique and Maintaining a Sterile Field" (revised 11/2017), was reviewed. The policy required, "All items should be delivered to the surgical [sterile] field in a manner that prevents nonsterile objects or people from extending over the sterile field."

2. On 2/28/18 between approximately 9:35 AM and 10:15 AM, an observational tour of OR #4 was conducted. At approximately 9:50 AM, the Surgical Technician (E #13) had both arms over the sterile field while E #13 was opening and placing sterile gloves onto the sterile field.

3. On 2/28/18 at approximately 10:45 AM, the findings were discussed with E #26 (Director of Surgical Services). E #26 stated that E #13 should not have extended her hands over the sterile field.

4. On 2/28/18 between 8:00 AM to 8:50 AM, an observational tour was conducted in the Pain Clinic. Pt. #31 was a 45 year old female, scheduled for an outpatient procedure for a Bilateral Lumbar Transforaminal Epidural with Steroid Injection (injection to lower back for pain). At approximately 8:40 AM, a Staff Nurse (E #16) was assisting with the setup of the sterile field for the procedure. E #16 reached over the sterile field with her ungloved hand to dispense a syringe of saline solution into a tray.

5. On 2/28/18 at 8:50 AM, an interview was conducted with the Executive Director of Nursing (E #27). E #27 stated that she did not have a clear view of the sterile field from where she was standing and did not observe the setup.

D. Based on document review, observation, and interview, it was determined that for 1 of 1 Staff Nurse (E #15) observed in the Pain Clinic, the Hospital failed to ensure that medication vials were disinfected prior to access.

Findings include:

1. On 2/28/18 at 12:00 PM, a policy regarding Medication Preparation was requested from the Hospital. At 12:50 PM, the Director of Accrediting (E #10) stated there was no specific policy that stated the rubber septum of new vials should be wiped.

2. On 2/28/18 at 4:00 PM, the Association for Professionals in Infection Control and Epidemiology (APIC) document titled "APIC Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016)," was reviewed. The paper required, "Medication Vials... Disinfect the rubber septum on all vials prior to each entry, even after initially removing the cap of a new, unused vial."

3. On 2/28/18 between 8:00 AM to 8:50 AM, an observational tour was conducted in the Pain Clinic. At 8:40 AM, a Staff Nurse (E #15) drew up two medications without cleansing the rubber septum of either vial before accessing with a needle.

4. On 2/28/18 at 8:50 AM, an interview was conducted with the Executive Director of Nursing (E #27). E #27 stated that she was unaware if medications that were new and capped needed to be disinfected.

5. On 2/28/18 at 1:00 PM, an interview was conducted with the Infection Control Officer (E #32). E #32 stated that she was qualified to perform duties as an Infection Control Officer based on her certification and training from APIC.

E. Based on document review, observation, and interview, it was determined that for 1 of 1 Staff Nurse (E #18) observed in the Gastrointestinal (GI) Lab, the Hospital failed to ensure that Intravenous (IV) sites were thoroughly disinfected and allowed to dry prior to insertion.

Findings include:

1. On 2/28/18 at 3:00 PM, the Hospital's policy titled, "Peripheral IV [PIV] Access, Establishment and Maintenance" (revised 12/2017), was reviewed. "Addendum A [Guidelines for PIV Access]" of the policy required, "k. Cleanse insertion site with antiseptic solution and allow to dry completely... The insertion area should be thoroughly wiped with alcohol and allowed to dry." The policy failed to specify a time frame for how long the site should be scrubbed with alcohol.

2. On 2/28/18 between 10:50 AM and 11:30 AM, an observational tour was conducted in the Gastrointestinal (GI) Lab. At approximately 10:55 AM, a Staff Nurse (E #18) was preparing to start a PIV on a patient. E #18 donned clean gloves, wiped the intended site of insertion for approximately 5 seconds, then immediately took a piece of gauze to wipe the cleansed area.

3. On 2/28/18 at 11:05 AM, an interview was conducted with the Executive Director of Nursing (E #27). E #27 stated that she did not see E #18 wiping the alcohol off but did observe her using the gauze to palpate the site after cleansing.

F. Based on interview and observation, it was determined for 2 of 4 disinfecting solutions at an Outpatient Imaging Center, the Hospital failed to ensure that expired disinfecting solutions were not available for use at the Outpatient Imaging Center, potentially affecting the approximately 900 patients seen every month.

Findings include:

1. On 2/27/18 at 2:00 PM, the Hospital's policy regarding Expired Cleaning Supplies was requested. At 2:40 PM, the Director of Accrediting (E #10) stated they did not have a policy for Expired Cleaning Supplies.

2. On 2/27/18 between 8:30 AM and 9:00 AM, an observational tour was conducted at the Outpatient Imaging Center. At approximately 8:45 AM, the following was observed:

- A bottle of CaviCide (disinfectant spray), with an expiration date of 12/2012, was found in the supply cabinet in the Mammography Room.

- A bottle of CaviCide (disinfectant spray), with an expiration date of 1/2016, was found on the desk in the MRI (Magnetic Resonance Imaging) Control Room.

3. On 2/27/18 at 8:55 AM, an interview was conducted with the Director of Imaging (E #9). E #9 stated that she would dispose of the two expired bottles.

Based on observation, document review, and interview, it was determined that for 3 of 3 Registered Nurses (RNs) (E #28, E #29, and E #30), 1 of 1 CRNA (Certified Registered Nurse Anesthetist/E #31) in OR (operating room) #9, and 3 of 5 (MD #1, E #11, and E #13) staff members in OR #4, the Hospital failed to ensure adherence to the dress code while in the operating room.

Findings include:

1. On 2/28/18 between 9:40 AM and 10:45 AM, an observational tour of OR #9 was conducted. At approximately 10:20 AM, where a sterile field was opened, E #28, E #29, E #30, and E #31's hair was exposed on the sides of their faces and backs of their necks.

2. On 2/28/18 between 9:35 AM and 10:15 AM, during observation of OR #44, it was noted that the Surgeon (MD #1), the Physician Assistant (E #11) & the Surgical Technician (E #13) had hair that was not confined in the surgical head covering.

3. On 2/28/18 at approximately 11:30 AM, the Hospital's policy titled, "Surgical Attire" (revised 12/17) was reviewed and required, "... I. All personnel will cover head and facial hair, including side burns and the nape of the neck, when in the semi-restricted and restricted areas...A clean, low-lint surgical head cover or hood that confines all hair and covers scalp hair will be worn..."

4. On 2/28/18 at approximately 10:45 AM, findings were discussed with E #26 (Director of Surgical Services). E #26 stated that the hair should be contained and not exposed.