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Based on observation and interview, it was determined the facility failed to ensure the condition of the hospital environment was maintained in a manner that provided a level of safety and well-being of patients, staff and visitors in that one of one fire barrier wall was not sealed with fire-proof sealant located in the corridor adjacent to the X-ray Room. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

Observations on 07/30/19 at 01:50 PM of the corridor fire barrier wall adjacent to the X-ray Room showed two non-sealed holes of one-inch diameters present which were not fire-proof sealed per NFPA 1: 12.9.6.2 to prevent the migration of fire and smoke. One of the holes had a piece of white plastic inserted surrounding electrical cables, the other hole was completely hollow. This finding was verified by the Director of Maintenance at the time of the observation.

Based on observation, review of manufacturer's recommendations and interview it was determined the facility failed to ensure its safety and quality of one of one point of care blood glucose testing device by not documenting the open dates for two of two glucose control solution bottles. The failed practice had had the potential to affect any patient in the facility requiring blood glucose testing. Findings follow:

A. Review of the manufacturer's recommendation for the Accu-Check Inform II control solutions showed to "Write the date the bottle was opened on the bottle label. The control solution is stable for three months from that date ...".
B. During tour of the Medical Unit on 07/29/19 at 1:40 PM, two of two Accu-Check Inform II control solutions were found without the date of opening or discard date written on the bottles.
C. Findings in A and B were verified by the Director of Nursing on 07/29/19 at 1:45 PM

Based on observation and interview, the facility failed to provide an orderly environment for patients, staff, and visitors in that one of one portable EKG (electrocardiogram) machine was stored in the corridor blocking 18 inches of the path of egress. The failed practice had the likelihood to affect all patients and staff as it would prevent them from having full instant use of the means of egress in the event of a fire or other emergency. Findings were:

Observations on 07/29/19 at 1:50 PM. of the corridor outside the Emergency Room showed one portable EKG machine was sitting outside the Emergency Room doorway and plugged in to a nearby outlet, blocking 18 inches of the path of egress. This finding in was verified by the Director of Nursing at the time of observation.

Based on observation and interview, it was determined the facility failed to meet the provisions of the Life Safety Code in that medical gas tanks were being stored without proper signage, fastening, and segregation in two of two storage locations. The failed practice had the potential to affect all patients and staff in that the oxygen tanks were not arranged for quick access in the event of an emergency, and were prone to falling and/or scraping which could result in ignition. The lack of signage also presents the potential for an ignition source to be used in the vicinity of the tanks which could result in ignition. Findings were:

A. Observation on 07/29/19 at 02:15 PM. showed 3 portable oxygen cylinders were stored in the closet of the Emergency Room without any signage required by NFPA 99:5.1.3.1.9 present on the closet door's exterior. This finding was verified by the Director of Maintenance at the time of observation.
B. Observation on 07/29/19 at 2:28 PM. showed 26 portable oxygen cylinders were being stored in Medical Gas Storage without any signage required per NFPA 99:5.1.3.1.9 present on the entry door. This finding was verified by the Director of Maintenance at the time of observation.
C. Observation on 07/29/19 at 2:28 PM showed 26 portable oxygen cylinders were stored without segregation of full/empty tanks as required per NFPA 99:5.3.13.4.2. This finding was verified by the Director of Maintenance at the time of observation.
D. Observation on 07/29/19 at 2:28 PM showed 12 of 26 portable oxygen cylinders were stored in Medical Gas Storage without any fastenings to secure them from falling as required by NFPA 99:5.1.3.3.2. This finding was verified by the Director of Maintenance at the time of observation.

Based observation and interview, it was determined the facility failed to follow standards of practice of maintaining a sanitary environment in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions for Table 9 in that laundry water temperature was found to be below 120 degrees Fahrenheit (F) in all washing machine use for laundering patient textiles. The failed practice did not ensure textiles and fabrics were free from contaminants and had the potential to affect all patients and staff. Findings follow:

A. Review of the Arkansas Rules and Regulations for Hospitals and Related Institutions, Table 9, showed the water for laundry was to have nothing under 120 degrees F.
B. Water temperatures were tested during tour of the Laundry on 07/30/19 at 10:37 AM and found to be 82 degrees F. A second water temperature test was performed with the Maintenance Director on 07/30/19 at 12:13 PM and water in the Laundry was found to be below 115 degrees F.
C. During interview with the Maintenance Director on 07/30/19 at 10:40 AM, he stated that there was no documentation or monitoring of the laundry water.
D. The above findings in B were verified with the Ancillary Officer on 07/30/19 at 12:25 PM.


40282

Based on observation and review of manufacture's recommendations, it was determined the Infection Control Nurse failed to identify and control infections in that 11 of 11 adult laryngoscope blades and 1 of 1 pediatric laryngoscope blade was found unwrapped in the crash cart in one of one Emergency Room. The failed practice did not assure the equipment had been cleaned or sterilized and stored to ensure protection from damage or contamination. The failed practice had the potential to affect all patients who needed the use of a laryngoscope for intubation. See C-0278 for details

Based on review of policy, manufacturer guidelines, review of equipment temperature logs for the hot pack machine (stores and heats hot packs) and interview, it was determined the facility failed to clean the hot pack machine every two weeks (per manufacturer's instructions) for one of one hot pack machine in the outpatient rehabilitation gym toured. By not cleaning the hot pack machine per policy, the facility could not assure the hot packs when patients used these items. The failed practice had the likelihood to affect all rehabilitation patients who received hot pack therapy. Findings were:

A. Record review of the facility's policy titled, "Governing Rules for the Rehabilitation Clinic," showed the cleaning procedures for the hot pack machine would be done per the manufacturer's instructions.
B. Record review of the manufacturer's instructions for maintenance showed the tank should be drained, cleaned and inspected at a minimum of every two weeks.
C. Record review of equipment temperature logs (which were used to document cleaning dates also) showed the hot pack machine was cleaned twice in the past 12 months, 04/16/19 and 10/25/18.
D. During an interview on 07/30/19 at 8:56 AM, the Director of Rehabilitation Services verified the hot pack machine had only been cleaned twice in the last year.

Based observation and interview, it was determined the facility failed to follow standards of practice of maintaining a sanitary environment in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions for Table 9 in that laundry water temperature was found to be 82 degrees Fahrenheit (F). The failed practice did not ensure textiles and fabrics were free from contaminants and had the potential to affect all patients and staff. Findings follow:

A. Review of the Arkansas Rules and Regulations for Hospitals and Related Institutions, Table 9, showed the water for laundry was to have nothing under 120 degrees F.
B. Water temperature was tested during tour of the Laundry on 07/30/19 at 10:37 AM and found to be 82 degrees F. A second water temperature test was performed with the Maintenance Director on 07/30/19 at 12:13 PM and water in the Laundry was found to be below 115 degrees F.
B. During interview with the Maintenance Director on 07/30/19 at 10:40 AM, he stated that there was no documentation or monitoring of the laundry water.
C. The above findings in B were verified with the Ancillary Officer on 07/30/19 at 12:25 PM.


40282


Based on observation and review of manufacture's recommendations, it was determined the Infection Control Nurse failed to identify and control infections in that 11 of 11 adult laryngoscope blades and 1 of 1 pediatric laryngoscope blade was found unwrapped in the crash cart in one of one Emergency Room. The failed practice did not assure the equipment had been cleaned or sterilized and stored to ensure protection from damage or contamination. The failed practice had the potential to affect all patients who needed the use of a laryngoscope for intubation. Findings follow:

A. During tour of Emergency Room # 1 on 07/29/19 at 2:10 PM, 11 of 11 unwrapped laryngoscope blades were found in the top drawer of the crash cart unwrapped.
B. During tour of Emergency Room #1 on 07/29/19 at 2:10 PM, 1 of 1 unwrapped laryngoscope blade was found in the bottom drawer of the pediatric cart.
C. The findings in A and B were verified by the Infection Control Nurse and the Director of Nursing DON 2:15 PM on 07/29/19.

Based on manufactures directions for use and interview, it was determined the facility failed to prevent and control the spread of infection in that the effectiveness of the McKesson Multi-Enzymatic Cleanser was not being performed by checking the solution temperature prior to each use. Failure to perform temperature checks of the solution prior to each use did not assure its accuracy. The failed practice had the potential to affect all patients whose care required high level disinfected equipment. Findings follow:

A. Review of the manufacturer's direction for use received on 07/30/19 showed the McKesson Multi-Enzymatic Cleanser had an optimum efficiency when used at 95 degrees and it should be used between the temperatures of 68-122 degrees F.
B. During an interview on 07/30/19 at 9:15 AM with the Infection Control Nurse, Surveyor #1 requested a log of solution temperature checks. The Infection Control Nurse stated that she had not been checking the temperature prior to using the solution.

Based on observations and interview, it was determined the facility failed to assure that patient care rooms had areas of visible dirt were clean and tidy in three of three rooms (Medical Unit Rooms # 7 and #11 and Emergency Room (ER) #1) in that the rooms had areas of visible dirt, stains on furniture, soiled tape (harbors bacteria and cannot be cleaned and disinfected), rust (cannot be cleaned or disinfected due to the porous nature), and dead bugs. The failed practice did not ensure the rooms were sanitary, clean, and ready for patient care to prevent the spread of infection. The failed practice had the potential to affect any patient whose care was rendered and received in the ER and the Medical Unit. Findings follow:

A. Observation on 07/29/19 in the Medical Unit Room # 7 at 1:30 PM showed the following:
1) Bathroom sink stained with several light gray eroded stains.
2) In the bottom of the back wall cabinet (for patient use) on the right side, were two bug glue strip traps with multiple dead bugs on both strips.
B. Findings in A were verified by the DON at 1:45 PM on 07/29/19.
C. Observation on 07/29/19 in the Medical Unit Room #11 at 1:45 PM showed the following:
1) Beside the bathroom toilet was an old bed pan washing system attached to the wall and held together with wide strips of old soiled tape and a rubber tubing coming from the wall approximately 2 feet long which was capable of touching the toilet and floor when moved.
2) One of one bed side cloth chair soiled with multiple stains.
D. Findings in C were verified by the DON at 2:00 PM on 07/29/19.
E. Observation on 7/29/19 in ER Room #1 at 2:10 PM showed the following:
1) Several dead bugs along the side back wall floor and several dead bugs in the pediatric cart bottom drawer which also had patient care items (several syringes and 4 x 4's).
2) A vent in the bottom center of the side back wall with rusted areas over 50% of vent cover.
3) Visible dirt on the floor and a yellow stain approximately 6 inches x 4 inches by bed number 2.
4) One of one bedside commode with rusted legs.
5) One of one empty lined plastic container labeled rejected linen with several dead bugs in the container.
6) A clean supply storage area located in ER #1 had two of two equipment pieces (one Intravenous Ultrasound System and one Glidescope) ready for use but were unmarked and uncovered with no way of knowing if the equipment was clean and ready for use.
7) On the medication cart monitor was a note approximately 3 inches x 3 inches stating "Do not remove off ever" attached to the monitor with soiled adhesive tape.
8) The door entering into ER # 1 had a note stating "Emergency Department Limit Two Guests per Patent" attached to the door with solid adhesive tape.
F. Findings in E (1-6) were verified by the Infection Control Nurse and the DON at 2:25 PM on 07/29/19
G. Findings in E (7&8) were verified by the Infection Control Nurse at 9:15 AM on 07/30/19.



31039

Based on observation, review of APIC (Association for Professionals in Infection Control and Epidemiology) position paper and interview, it was determined the facility failed to mitigate risks of healthcare related infections by not identifying the practice of storing MDVs (Multiple Dose Vial) once opened, in immediate patient treatment areas in one of one Emergency Departments trauma room that had two beds present. By not identifying the risk of this practice carries, the facility could not assure their patients safety. This failed practice has the likelihood to affect all patients receiving emergency treatment in the facility. Findings were:

A. Review of APIC position paper titled, "Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016)," showed MDV should never enter the immediate patient care area, they must be dedicated for single patient use and discarded immediately after use.
B. During a tour of the facility on 07/29/19 from 1:36 PM to 2:42 PM, observation showed the following in a cabinet in the trauma room:
1) One MDV of Xylocaine 1% 20 milliliters, opened and dated 07/07/19; and
2) One MDV of Xylocaine 1% with Epinephrine 20 milliliters, opened and dated 07/24/19.
C. During an interview on 07/29/19 at 9:09 AM, the Director of Pharmacy verified the opened and dated MDVs observed in B.

Based on observation, review of Arkansas Department of Health, Rules and Regulations for Critical Access Hospitals 2016, Section 61: Physical Facilities, Health Information Unit and interview, it was determined the facility failed to store medical records in that the paper medical records were stored in one of one building that was not protected from fire by either a one-hour fire rated enclosure or protected by a sprinkler system; and failed to have a smoke detection system. By not storing medical records properly, the facility could not assure the integrity of the records. The failed practice had the likelihood to affect all patients' records stored by the facility. The findings follow:
A. Review of Arkansas Department of Health, Rules and Regulations for Critical Access Hospitals 2016, Section 61: Physical Facilities, Health Information Unit showed medical records stored by a facility shall be protected from fire by either a one hour fire rated enclosure or protected by a sprinkler system, and have a smoke detection system.
B. During a tour of Medical Records on 07/30/19 at 1:15 PM, observation showed 83 cases of paper medical records stored in an unused resident room in a separate building. The room was not a one-hour fire rated enclosures or protected by sprinklers, and it did not have a smoke detection system.
C. During an interview on 07/30/19 at 1:23 PM, the Supervisor of Medical Records verified the paper medical records stored were not protected from fire.

Based on observation and interview, the facility failed to provide battery-powered emergency lighting for one of one emergency generator as required by NFPA 101, 2000 edition. The failed practice had the likelihood to affect all patients and staff in that in the event of a power outage emergency there would be no lighting available to illuminate the work area around the generator, which would delay or prevent the maintenance required to keep the generator functioning. The findings were:

Observation on 07/30/19 at 10:45 AM of the generator showed that the overhead lighting present was powered solely by the main electrical system, and no battery-powered lighting was present. This finding in was verified by the Director of Maintenance at the time of observation.