HospitalInspections.org

Based on policy review and interview, it was determined the facility failed to ensure there was a written policy regarding abuse of a patient by a staff member. The failed practice did not allow the facility to be knowledgeable, proactive, and timely in responding to allegations of patient abuse by staff and could affect any patient alleging abuse. Findings follow.

A. Policies titled "Progressive Discipline," "Sexual and/or Personal Harassment," and "Behavior and Conduct of Employees" were provided. The policies contained no information regarding allegations of patient abuse by staff.
B. During an interview on 10/21/15 at 1030, the Director of Quality confirmed there was no policy regarding patient abuse by staff.

Based on clinical record review, interview and policy and procedure review, it was determined the facility failed to follow its policy and procedure in that a Registered Nurse (RN) failed to assess each shift one of one (#8) newborn. Failure to ensure the newborn was assessed each shift by a RN did not ensure the patient's health status/condition, needs and problems were identified and care planned accordingly. The failed practice affected Patient #8 on 10/17/15 and 10/18/15. Findings follow:

A. Review of the clinical record of Patient #8 revealed no RN assessment for two (10/17/15 and 10/18/15 evening shifts) of five (10/17/15 day and evening, 10/18/15 day and evening and 10/19/15 day shifts). During an interview with the Labor and Delivery Director at 1326 on 10/22/15, she verified the above findings.
B. Review of the policy and procedure titled "Documentation in the Medical Record" received from the Chief Nursing Officer (CNO) at 1500 on 10/19/15 revealed an RN must document his or her observations at least once a shift.

Based on policy and procedure review, clinical record review and interview, it was determined the facility failed to ensure the comprehensive nursing care plan was developed and implemented based on the patient's needs for 9 ( #1-3, #6-8, #12, #15, and #17) of 20 (#1-18, #31 and #32) patients. The failed practice did not ensure patients received optimum care to progress and be discharged. The failed practice affected Patients #1-3, #6-8, #12, #15 and #17 on 10/23/15. Findings follow:

A. Review of the policy and procedure titled "Care Plan (Problem List)" received from the Chief Nursing Officer (CNO) at 1500 on 10/19/15 revealed the following: "OBJECTIVE: The purpose of the care plan (Problem List) is for the patient to have a current individual plan of are, which includes the methods, approaches, goals, and modifications necessary to ensure best results for the patient. The plan of care will include the patient and the family involvement. The care plan is now known as the Problem List for the electronic health record and will be referred to as such.
POLICY:
· Each patient's nursing care is based on identified patient care needs and patient care standards and is consistent with the therapies of other disciplines.
· Each patient will have a multidisciplinary plan of care developed at the completion of admission assessment and documentation in the medical record.
· The patient and significant other(s) will be included in the planning of care, as appropriate.
· The plan of care will be measurable, outcome-based, and developed in collaboration with the medical plan of care. The nurse can add new problems anytime they arise.
· The plan of care will guide staff in providing care to the patient ..."
B. Patient #1 was admitted on 10/13/15 with Diagnosis of Hyponatremia and Shortness of Breath. Review of the Problem List revealed PEG (percutaneous endoscopy gastrostomy) tube, the tracheostomy and care related to weekly chemotherapy were not on the Problem list. During an interview with the Medical Surgical Director at 0910, she verified the findings for Patient #1.
C. Patient #2 was admitted on 10/17/15 with diagnoses of COPD (Chronic Obstructive Pulmonary Disease) with acute on chronic respiratory failure, Atrial Fibrillation, Pneumonia and Hypertension. Review of the Problem List revealed Atrial Fibrillation and Pneumonia were not on the Problem List. During an interview with the Medical Surgical Director at 0850 on 10/23/15, she verified the findings for Patient #2.
D. Patient #3 was admitted on 10/12/15 with Diagnosis of Back Pain post fall and Dementia. Review of the Problem List revealed falls, dementia and a implanted port on the right side were not on the Problem List. During an interview with the Medical Surgical Director at 0900 on 10/23/15, she verified the findings for Patient #3.
E. Patient #6 was admitted on 10/10/15 with diagnoses of Rhabdomyolysis and Dehydration. Review of the clinical record revealed Patient #6 developed a pressure ulcer, Clostridium difficile infection, required insertion of a central line and was started on TPN (Total Parental Nutrition). Review of the Problem List revealed Rhabdomyolysis, the pressure ulcer, Clostridium difficile, the central line, and TPN were not on the Problem List. During an interview with the CNO at 1027 on 10/23/15, she verified the findings Patient #6.
F. Patient #7 was admitted on 10/16/15 with diagnoses of Sepsis, COPD, Hypertension, and Benign Prostatic Hypertrophy. Review of the Problem List revealed Sepsis and Hypertension were not addressed on the Problem List. During an interview with the Medical Surgical Director at 0931 on 10/23/15, she verified the findings for Patient #7.
G. Patient #8 was admitted as a newborn. Review of the clinical record revealed there was no Problem List initiated for Patient #8. During an interview with the LDRP (Labor Delivery, Recovery Postpartum)/Nursery Director at 1326 on 10/22/15, she stated the newborn should have had a care plan.
H. Patient #12 was admitted on 08/02/15 with diagnoses of Acute Respiratory Acidosis, Lower Back Pain after a fall, Diabetes Mellitus and Hypertension. Review of the Problem List revealed Lower Back Pain, fall, Diabetes Mellitus and Hypertension were not on the Problem List. During an interview with the Quality/Risk Management Director at 1340 on 10/23/15, she verified the findings for Patient #12.
I. Patient #15 was admitted on 09/17/15 with diagnosis of Acute Pain. Patient #15 underwent surgery twice, placement of central line, gastrostomy tube, urinary catheter and was started on TPN. Review of the Problem List revealed the central line, gastrostomy tube, urinary catheter, TPN, surgical site care and any daily needs were not on the Problem List. During an interview with the Quality/Risk Management Director at 1340 on 10/23/15, she verified the findings for Patient #15.
J. Patient #17 was admitted on 09/11/15 with a Left Upper Arm Abscess which required surgical intervention and antibiotics. Review of the Problem List revealed MRSA (methicillin resistant staphylococcus aureus) infection and the surgical wound were not addressed on the Problem List. During an interview with the Quality/Risk Management Director at 1340 on 10/23/15, she verified the findings Patient #17.


Based on policy and procedure review, clinical record review and interview, it was determined the facility failed to ensure a comprehensive nursing care plan was developed and implemented based on the patient's needs for two of two (#1 and #2) Swing-Bed patients. The failed practice was likely to affect the nursing care rendered to ensure the patients received optimum care to progress and be discharged. The failed practice affected Patients #1 and #2 on 10/23/15 and had the likelihood to affect any patient admitted to Swing-Bed. Findings follow:

A. During an interview with the Case Manager at 1310 on 10/23/15, she stated the Nursing Care Plan policy and procedure utilized by the Swing Bed Program was the same policy and procedure utilized by the facility's nursing service.
B. Swing-Bed Patient #1 was admitted to the Swing-Bed program on 09/11/15 with primary diagnoses of CVA (cerebral vascular accident), Delirium and IDDM (insulin dependent diabetes mellitus). Review of the Problem List revealed Delirium and IDDM were not on the Problem List. During an interview with the Quality Assurance/Risk Management Director at 1340 on 10/23/15, she verified the above findings for Swing-Bed Patient #1.
C. Swing-Bed Patient #2 was admitted to the Swing Bed program on 10/09/15 with a primary diagnosis of sickle cell anemia. Review of the Problem List revealed Atrial Fibrillation, Wound care, Implanted Port care, Confusion, fall precautions and incontinence were not on the Problem List. During an interview with the Quality Assurance/Risk Management Director at 1340 on 10/23/15, she verified the above findings for Swing-Bed Patient #2.

Based on clinical record review and interview, it was determined the facility failed to ensure physician ordered daily weights were followed for 4 (#2-#4 and #12) of 6 (#2-#5, #12 and #31) patients with daily weight orders. The failed practice did not ensure patient's needs were met and created the potential for a weight loss or gain to go unnoticed and could affect any patient with daily weight orders. Findings follow.

A. Review of clinical records revealed the following:
1) Patient #2-daily weights ordered on 10/17/15. Review of the Graphic I (intake) & O (output) from 10/17/15 to 10/22/15 revealed a weight was not documented on two of five possible days.
2) Patient #3- daily weights ordered on 10/12/15. Review of the Graphic I & O from 10/15/15 to 10/20/15 revealed a weight was not documented on one of five possible days.
3). Patient #4-daily weights ordered on 10/16/15. Review of the Graphic I & O from 10/16/15 to 10/21/15 revealed a weight was not documented on one of five possible days.
4) Patient #12-daily weights ordered on 08/08/15. Review of the Graphic I & O from 08/08/15 to 08/10/15 revealed a weight was not documented on one of two possible days.
B. During an interview on 10/23/5 at 0830, the Director of Quality confirmed the weights were not documented for Patient #2, #3, #3 and #12.

Based on observation, review of manufacturer recommendations and interview, it was determined the facility failed to follow manufacturer's recommendations in that the expiration date written on one of one vial Succinylcholine exceeded 14 days located in one (#1) of two (#1-#2) anesthesia carts. The failed practice did not assure the safety or efficacy of the medication. The failed practice had the likelihood to affect all patients that have had procedures using the medication. Findings follow:

A. During a tour of the facility on 10/20/15 from 1330 to 1535 revealed Anesthesia Cart #1 had an open vial of Succinylcholine and was dated: opened 10/6, expired 11/3 [initials]. The label had a 28 day expiration date on it.
B. Review of manufacturer's recommendation for storage of Succinylcholine Chloride revealed the "multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency." The facility did not have a process to assure the Succinylcholine Chloride was not in use beyond the 14 days, once removed from refrigerated storage.
C. During an interview on 10/20/15 at 1444, Certified Registered Nurse Anesthetist #1 verified she was following the Hospital's 28 day expiration policy on Multiple Dose Vials.

Based on clinical record review and interview, it was determined the facility failed to ensure meal consumption was documented for four (#2, #4, #5, and #12) of 13 (#1-#12, and #31) inpatients requiring therapeutic diets. The failed practice did not allow medical personnel to assess the patient's diet tolerance and had the potential to affect any patient on a therapeutic diet. Findings follow.

A. Review of clinical records revealed the following:
1) Patient #2 had an order for a cardiac diet beginning on 10/19/15 at 1148. Review of the Graphic I (intake) & O (output) revealed three of eight meals were not documented from 10/17-22/15.
2) Patient #4 had an order for a cardiac diet beginning on 10/16/15 at 1816. Review of the Graphic I & O revealed 5 of 12 meals were not documented from 10/16-21/15.
3) Patient #5 had an order for a cardiac, low cholesterol diet beginning on 10/16/15 at 1846. Review of the Graphic I & O from 10/16-20/15 revealed 10 of 12 meals were not documented.
4) Patient #12 had an order for an 1800 calorie diabetic diet beginning on 08/02/15 at 2001. Review of the Graphic I & O revealed 15 of 20 meals were not documented 08/02-10/15.
B. During an interview on 10/23/15 at 1340, the Director of Quality confirmed the missing meal documentation for Patient #2, #4, #5 and #12.

Based on observation, and interview, it was determined the facility did not meet Life Safety Code requirements related to smoke barrier maintenance, maintenance of the self-closing doors for two of six stairwells and in one of five of the smoke compartments' doors, and required testing of three of three Line Isolation Monitors. Failure to maintain the smoke resistance of the fire walls had the potential to all building occupants because the spaces have the potential to allow smoke to enter adjacent smoke compartments during a smoke and fire event. Failure to maintain the ability of the fire doors to fully self-close had the potential to affect all building occupants because the partially open doors would allow smoke and fire to pass from one smoke compartment to another and it would also allow smoke and fire to pass into and trough the vertical opening of the stairwells. Failure to perform annual testing on the line isolation monitors had the potential to affect patients and staff in the Trauma 1 and both operating rooms because the facility could not be assured that the equipment used in those rooms would not inflict an electrical shock during use. The failed practice had the potential to affect all patients, staff, and visitors. The facility had a census of 16 on 10/19/15. See K21, K25, K27, and K130.

Based on observation in the Respiratory Therapy Department, review of the MetriCide OPA Plus Solution Log, review of policies and procedures and interview, it was determined the Infection Control Officer failed to control infection in that the facility failed to follow manufacturer's guidelines for use to ensure the MetriCide OPA Plus (a high level disinfectant for reprocessing heat-sensitive respiratory equipment) was maintained at the minimum temperature of 68 degrees Fahrenheit, and failed to test the MRC (minimum recommended concentration) of the MetriCide OPA Plus prior to each use for high level disinfection (HLD) of reusable respiratory equipment. Failure to follow manufactures guidelines for use did not assure the efficacy of the solution in use for high level disinfection and therefore the effectiveness of disinfection and prevention of infection. The failed practice affected all patients in which reusable respiratory equipment was used, from 05/29/15 through 10/21/15 as evidenced by the MetriCide OPA Plus Solution Log. The findings were:

A. Observation of the Respiratory Therapy Department on 10/21/15 at 1025 revealed a solution identified by the Respiratory Therapy Director as MetriCide OPA Plus used to high-level disinfect reusable respiratory therapy equipment. Review of the log identified by the Respiratory Therapy Director as the MetriCide OPA Plus solution log, but labeled "Omnicide OPA Check" revealed no documentation of the solution temperature. Review of the "Control Run" from 05/29/15 through 10/21/15 revealed there was no evidence when the solution was used more than one time per day to determine if a test was performed for MRC.
B. In an interview at the time of observation on 10/21/15 the Respiratory Therapy Director, in the presence of the Infection Control Director, confirmed the temperature of the solution was not checked and that the MRC was not checked prior to each use as required per manufacture's guidelines and evident on the log provided.
C. Review of the manufacturer's guidelines at the time of observation revealed: "MetriCide OPA Plus Solution is a high level disinfectant for reprocessing heat sensitive semi-critical medical devices for which sterilization is not suitable and when used according to the directions for use. MetriCide OPA Plus may be used or reused at or above it's MRC of 0.3% as determined by MetriCide OPA Plus Solution Test Strips, in manual reprocessing with an immersion time of at least 12 minutes at a minimum of 68 degrees Fahrenheit." "Always use MetriCide OPA Plus Solution Test Strips to monitor the concentration of orth-phthalaldehyde before each use. Immerse device completely in MetriCide OPA Plus Solution for a minimum of 12 minutes at 68 degrees Fahrenheit or higher to destroy all pathogenic microorganisms."
D. Review of the policy OS1010 revealed "Manufacturer's written instructions shall be followed when preparing disinfectant solutions, calculating expiration dates, and labeling solution soaking containers. The HLD solution shall be tested daily prior to use and documented in log book. The solution shall be discarded if the test strip indicated the solution is below the minimum effective concentration."


Based on observation of staff in a contact isolation room, clinical record review, interview and review of policies and procedures it was determined the Infection Control Officer failed to control infection in that Registered Nurse (RN) #3 and Licensed Practical Nurse (LPN)#1 failed to follow contact isolation precautions for one of one patient (#6) in contact isolation while in the patients room and providing care in that neither gloves nor gowns were worn. It could not be assured other patients and staff exposed to RN #3 and LPN #1 would be protected from likely sources of infection. The failed practice was likely to affect the census of nine patients. The findings were:

A. Observation on 10/20/15 at 1455, in the company of the Infection control Director, revealed RN #3 and LPN #1 were in the room of Patient #6 with the door partially opened. RN #3 and LPN #1 were observed interacting with the patient touching the patient, bed and bed linen and intravenous tubing. RN #3 and LPN #1 did not have on gloves or a gown at the time of observation. RN #3 had on a long sleeve fleece type jacket that was observed rubbing against the patient ' s upper side rail of the bed.
B. Review of Patient #6 clinical record 10/20/15 revealed the patient was on contact isolation for a history of Clostridium difficile. As of 10/19/15, the toxin was negative and the antigen was positive. The Infection Control Director confirmed on 10/20/15 at 1520 the patient was on contact precautions.
C. Observation on 10/20/15 at 1455 revealed LPN #1 exited the room of Patient #6 and by interview, confirmed she was not following isolation precautions and stated "No, I didn't have on anything. I know better. I should have had on a gown and gloves." Observation on 10/20/15 at 1515 revealed RN #3 exited the room of Patient #6 and by interview, confirmed she did not have on gloves or a gown while providing care to Patient #6. The Infection Control Director requested she remove her fleece type jacket and placed it in a plastic bag at the time of interview.
D. Review of the policy IC 1402 revealed "Contact Precautions: Designed to reduce the risk of transmission of epidemiological important microorganisms by direct or indirect contact. Direct-contact transmissions involved skin to skin contact and physical transfer of microorganisms ... Indirect-contact transmission involved contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the patient's environment." The specific precautions included private room, hand washing required, wear gown if soiling is likely, wear gloves, limit transport of patient to essential purposes only, limit use of non-critical care equipment to single patient use ..."


Based on observation, interview and review of policies and procedures it was determined the Infection Control Officer failed to control infection in that Registered Respiratory Therapist (RRT)#1 failed to disinfect a handheld pulse oximeter (device used to measure the oxygen saturation in the blood), a stethoscope (instrument used to listen to the lung sounds during respiration) and clipboard between use for two of two (#4 and #7) patients who received a respiratory updraft treatment. Patient #4 and #7 were not protected from likely sources of infection from equipment that was not disinfected prior to reuse. The failed practice was likely to affect any patient who had respiratory updraft orders. The findings were:

A. Observation on 10/19/15 at 1415 revea1ed RRT #1 provided an updraft treatment to Patient #7. After performing hand hygiene, RRT #1 donned gloves which remained on throughout the respiratory treatment and assessment. The respiratory assessment included using a handheld pulse oximeter, stethoscope and a clipboard. A handheld pulse oximeter finger probe was placed on the right index finger of Patient #7 and the device was placed on the patient's bed. Patient #7 rested his hand on top of the handheld pulse oximeter. RRT #1 removed a stethoscope from around her neck and used it to assess the lung sounds of Patient #7 then replaced the stethoscope around her neck. A clipboard was placed on the bedside table by RRT #1 and retrieved several times for documentation and to remove the medication for updraft from a zip top bag secured to the clipboard. Upon completion of the updraft treatment for Patient #7, RRT #1 removed her gloves and performed hand hygiene. RRT #1 retained possession of the clipboard, stethoscope and handheld pulse oximeter and exited the room.
B. Observation on 10/19/15 at 1435 revealed RRT #1 provided an updraft treatment to Patient #4. After performing hand hygiene, RRT #1 donned gloves which remained on throughout the respiratory treatment and assessment. The respiratory assessment included using a handheld pulse oximeter, stethoscope and a clipboard. A handheld pulse oximeter finger probe was placed on the left index finger of Patient #4 and the device was placed on the patient's bed. RRT #1 removed a stethoscope from around her neck and used it to assess the lung sounds of Patient #4 then replaced the stethoscope around her neck. A clipboard was placed on the bedside table by RRT #1 and retrieved several times for documentation and to retrieve the medication for updraft from a zip top bag secured to the clipboard. Upon completion of the updraft treatment for Patient #4, RRT #1 removed her gloves and performed hand hygiene. RRT #1 retained possession of the clipboard, stethoscope and handheld pulse oximeter and exited the room.
C. Continuous observation of RRT #1 from Patient #7 through the respiratory treatment for Patient #4 revealed the handheld pulse oximeter, stethoscope and clipboard were not disinfected between the patients on 10/19/15. In an interview with RRT #1 on 10/19/15 at 1450 she stated "Sometimes I use alcohol foam on my stethoscope, but not always" and confirmed she did not disinfect the handheld pulse oximeter, stethoscope or clipboard between patients.
D. Review of policy #1752, "Pulse-Oximetry Policy" revealed (infection control) "If the device probe is intended for multiple patient use, the probe should be cleaned between patient applications with the disinfectant provided or ETOH. Probes only need to be wiped off, do not soak probes in disinfectant. The external part of the monitor should be wiped down after use whenever the device remains in a patient ' s room for prolonged periods, when soiled, or when it has come in contact with potentially transmittable organisms."


Based on observation, interview and review of policies and procedures, it was determined the Infection Control Officer failed to control infection in that Registered Nurse (RN) #1 failed to assure a multi-dose medication vial (1% Xylocaine with epinephrine) used on Patient #31 was dated when opened and failed to disinfect the rubber septum with alcohol after removing the protective cap for two of two (Methylene Blue and Bacitracin) medication vials prior to accessing with a needle. Failure to date the multi-dose vial when opened did not assure the medication would be discarded within 28 days after opening and did not assure the integrity of the medication. Failure to disinfect the rubber septum with alcohol on previously unopened vials of medication did not assure Patient #31 would be protected from infection. The failed practice was likely to affect any patient who received care by RN #1. The findings were:

A. Observation on 10/20/15 at 0935 revealed an opened 20 milliliter multi-dose vial of 1% Xylocaine with epinephrine on the side table of Operating Room #1. The opened multi-dose vial did not have a date when opened or a discard date. On 10/20/15 at 1009 RN #1 retrieved the multi-dose vial of Xylocaine from the side table and presented it to the RN #2 (Scrub Nurse) who withdrew the medication with a syringe and needle and proceeded to use the medication on Patient #31. RN #1 confirmed on 10/20/15 at 1030 the multi-dose vial of Xylocaine did not have a date when opened, a use-by or discard date and stated "I opened it the first case today."
B. Observation on 10/20/15 at 1010 revealed the protective cap was removed from a vial of Methylene Blue by RN #1. The rubber septum was not disinfected with alcohol after removal of the protective cap nor prior to puncture by RN #2. Observation on 10/20/15 at 1018 revealed the protective cap was removed from a vial of Bacitracin 50,000 units by RN #1. The rubber septum was not disinfected with alcohol after removal of the protective cap nor prior to puncture by RN #2.
C. In an interview with RN #1, and in the company of the Infection Control Director, on 10/21/15 at 1600 she confirmed the rubber septum of the vials of Methylene Blue and Bacitracin were not disinfected with alcohol after removal of the protective cap nor prior to use.
D. Review of policy #PH 1304 revealed "Multi-dose vials: Date vial with a permanent marker upon first use write the date vial is first used, count 28 days and write EXP and the date. It is the responsibility of the first used to write the first use date and the expiration date." "The stopper is swabbed with alcohol before each puncture. If contamination is suspected, a new vial is to be used." Single Dose vials: "clean with alcohol and remove the contents aseptically."


Based on observation, review of policy and procedures and interview, it was determined the Infection Control Officer failed to control infection in that Registered Nurse (RN) #1 (circulating RN) failed to perform hand hygiene after removing gloves in Operating Room (OR) #1 for one of one (Patient #31) surgical case observed. Failure to perform hand hygiene before contact with a patient, after contact with the patient, after contact with blood, body fluids or contaminated surface, and after removing gloves did not prevent the likely spread of infection. The failed practice affected Patient #31 and had the likelihood of affecting all patients who had surgery in the facility. The findings were:

A. Observation on 10/20/15 at 0950 revealed RN #1, acting as the circulating nurse for the procedure, donned a pair of non-sterile gloves and removed the soiled dressing. RN #1 then reapplied another pair of gloves without performing hand hygiene, then proceeded to perform a betadine scrub on Patient #31. RN #1 changed gloves after the scrub and a minimum of four times from 0950 to 1045 and did not perform hand hygiene. RN #1 was observed accessing sterile supplies, the sterile suture supply cart and the computer keyboard during the surgical procedure.
B. There was no alcohol hand sanitizer observed in OR #1 or OR #2 on 10/20/15. In an interview on 10/21/15 at 1615 with RN #1, in the company of the Infection Control Director, RN #1 confirmed she did not perform hand hygiene after removal of the soiled dressing, before performing the surgical scrub or between any glove change and confirmed there was no alcohol hand sanitizer available in OR #1 or OR #2.


Based on interview, it was determined the Infection Control Officer failed to control infection in that the facility failed to have a policy or procedure that addressed steps to take in the event discrepancies occurred between a device manufacturer's instructions and equipment used for sterilization or high level disinfection. Failure to have policies or procedures for staff in the event of discrepancy did not assure the process for sterilization or high level disinfection used by staff was effective in preventing infection. The failed practice was likely to affect all patients treated at the facility who required the used of sterilized or high level disinfected equipment. The findings were:

A. The Infection Control Director was asked to provide any policy or procedure the hospital had in place to address the steps to take when there was a discrepancy between manufacture ' s guidelines and the equipment used for sterilization or high-level disinfection on 10/21/15 at 1600. At the time of interview, the Infection Control Director stated to Surveyor #1 and #2 she was not aware of a policy but would look.
B. On 10/22/15 at 1615, the Infection Control Director reported to Surveyor #2 and #3 that the facility does not have a policy in place at this time to address steps to take in the event of discrepancy between device manufacturer's instructions and equipment used for high level disinfection or sterilization.


Based on observation of the Laundry Department and interview, the Infection Control Officer failed to control infection and did not assure the seperation of clean from dirty in that freshly laundered linen was processed in the same area where soiled floor cleaners, including dust mops, floor cleaners, dust pans and sweepers were stored in a bin. The failed practice did not assure contamination of clean laundry would not occur. The failed practice affected all patients who receive care in the hospital. The findings were:

A. Observation on 10/21/15 at 0927 revealed 13 soiled floor cleaning (dust mops, floor cleaners, dust pans and sweepers) items were stored in a bin in the laundry washer room, beside the door leading to the dryer room. Laundry bins that contain clean linen must be transported through the doorway beside the soiled floor cleaning items and into the dryer room.
B. The Environmental Services Director and Plant Operations Director confirmed that the items stored in the laundry washer room were soiled items and that the flow of laundered linen was through the door adjacent to the soiled items on 10/21/15 at 0930.


29485

Based on observations and interview it was determined the facility failed to ensure only currently dated supplies were available for patient use in three (Emergency Room (ER), Operating Room (OR), and in Labor and Delivery (L & D) of six ( ER, OR, L & D, Medical Surgical Unit, Intensive Care and Central Sterile) areas observed. Failure to ensure only currently dated supplies were available for patient use had the potential to compromise any treatment rendered using expired supplies. The failed practice affected any patient whose care required the use of the expired supplies. Findings follow:

A. During the tour of the ER at 1335 on 10/20/15, two of two 16 French Foley 5 cc (centimeter) were found expired on 08/15 and 09/15 respectively in the clean supply room. During an interview with the ER Director at 1400 on 10/20/15, she verified the above findings.
B. During the tour of the OR at 1430 on 10/20/15, three of three bottles of Thin Prep were found to have expired 06/25/15 in the flash sterilization room between OR #1 and #2. During an interview with the Quality/Risk Manager at 1430 on 10/20/15, she verified the above findings.
C. During the tour of the L & D unit at 1500 on 10/20/15, one of one D5W 500 milliliters was found to have expired 06/15. During an interview with the L & D Director at 1500, she verified the above findings.


30634

Based on observation, policy review, and interview, it was determined the facility failed to ensure the cleaner being used in the Radiology Department was on the list of cleaners approved by the facility. Failure to use an approved cleaner did not ensure the Infection Control Committee had approved the effectiveness of the cleaner being used and had the potential to affect any patient needing radiology services. Findings follow.

A. During a tour of the Radiology Department on 10/20/15 from 1335 to 1400, when asked what various surfaces were cleaned with (x-ray table, CT table, etc) the Director of Radiology stated, "409."
B. During an interview with the Director of Radiology on 10/22/15 at 0820, she stated the 409 is used to clean "sticky stuff" and then the area is cleaned with an approved wipe product.
C. Review of the Material Safety Data Sheet revealed 409 is classified as a "multi-purpose spray cleaner and disinfectant."
D. Review of policy titled "Disinfectants and Antiseptics" revealed 409 was not on the list.
E. Review of Radiology policies revealed no evidence of a specific cleaner to be used in the department.
F. During an interview on 10/22/15 at 0820, the Infection Control Nurse confirmed 409 was not on the list of approved cleaners.


Based on observation and interview, it was determined the facility failed to ensure expired biopsy needles were not available for patient use in the CT room. Failure to ensure expired biopsy needles were not available for patient use did not prevent unsterile needles to be introduced into the body which increased the risk of infection. The failed practice had the potential to affect any patient needing a biopsy. Findings follow.

A. During a tour of the Radiology Department on 10/20/15 from 1335 to 1400, the following was observed:
1) Turner biopsy needle, three of three size 22-15.0-two expired 08/11 and one expired 07/11.
2) Turner biopsy needle, seven of seven size 20-15.0-six expired 06/15 and one expired 07/11.
B. During an interview at the time of the tour, the Director of Radiology confirmed the biopsy needles were expired.


31039

Based on observation and interview, the facility failed to maintain five (#1-5) of eight (#1-8) In-patient walkers located in Rehabilitation Services to prevent a thorough cleaning between patients in that they had duct tape and/or worn stickers on them which cannot be cleaned or disinfected. The facility could not assure a sanitary environment when patients used these items. The failed practice had the likelihood to affect all patients that receive therapy services using the walkers. Findings follow:

A. During a tour of In-patient Rehabilitation Services on 10/20/15 at 0850, observation revealed eight walkers stored in a storage closet. Five of the walkers had worn stickers and/or duct tape on them.
B. During an interview on 10/20/15 at 0850, the Director of Rehabilitation verified the five walkers had tape and/or worn stickers on them that prevented a thorough cleaning between patients.

Based on clinical record review and interview, it was determined the facility failed to ensure the time of the operation was included in the operative report for 8 (#1, #9, #11, #13, #14, and #16-#18) of 9 (#1, #9, #11, and #13-#18) surgical patients. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow.

A. Review of operative reports revealed the time of surgery was not documented for Patients #1, #9, #11, #13, #14, and #16-#18.
B. During an interview on 10/23/15 at 0830 and 1340, the Director of Quality confirmed there was no time of surgery on the Operative Report.

Based on review of the Swing Bed Policy and Procedure Manual and interview it was determined the facility failed to develop and implement written policies and procedures to prohibit mistreatment, neglect and abuse of residents. The failed practice did not allow the facility to have in place an effective system to prevent mistreatment, neglect and abuse of residents and manage employees who have been accused of such. The failed practice had the likelihood to affect any patient admitted to Swing-Bed. Findings follow:

A. Review of the Swing Bed Policy Manual provided by the Case Manager at 1415 on 10/19/15 revealed there were no written policies and procedures to prohibit and manage mistreatment, neglect and abuse of residents and misappropriation of resident property.
B. The findings in "A" were verified by the Case Manager at 1300 on 10/20/15.

Based on interview, it was determined the facility did not employ a qualified professional to direct the Swing Bed Activities program. Failure to employ a qualified professional did not ensure the Swing Bed patients were receiving activities designed to meet the interests, physical, mental and psychosocial well-being of each patient. The failed practice affected Swing Bed Patient #1 and #2 and any patient admitted to Swing-Bed. Findings follow:

During an interview with the Case Manager at 1050 on 10/20/15, she stated the facility did not have a qualified person to direct the Swing Bed Activities program.