HospitalInspections.org

Based on interview and contract review, the provider failed to ensure contracted services were reviewed as part of the quality assurance performance program for all patient care contracted services. Findings include:

1. Interview on 3/6/13 at 1:00 p.m. with the quality director revealed she was not familiar with the provider's list of contracted services. She stated the various contracted services might have completed their own internal quality studies and had not reported the results to the quality assurance committee.

Further interview on 3/6/13 at 2:30 p.m. with the quality director confirmed quality studies had been done by the contracted services for radiologists, food service, pathology, and blood supply.

Review of the provider's contracted services list revealed 186 vendor contracts. There was no determination of which vendors provided direct patient care services and would need to be reviewed as part of the provider's quality assurance performance program.

26180

Based on interview, credentialing file review, and medical staff bylaws review, the provider failed to conduct reappraisals of the qualifications for two of nine practitioners (E and F) who had been granted medical staff privileges at the hospital. Findings include:

1. Review of practitioner E's credentialing file revealed:
*A letter dated 9/13/12 read "In accordance with Article V1, Section 3, of the Medical Staff Bylaws, [practitioner name] is hereby granted the temporary Active Staff privileges beginning 9/10/12 and until her application has been approved by the appropriate Service Committees, Medical Executive Committee and Board of Trustees."
-That letter had been signed by the president/chief executive officer and chief of staff.
*A delineation of privileges had been signed by the practitioner on 8/8/12.
*There were no reappraisals of practitioner E's temporary privileges 60 days from the initial approval date of 9/10/12. Then in 30 days when practitioner E's application for staff privileges had not been finalized.
*Practitioner E had requested additional surgical privileges on 2/11/13.
-Those additional privileges were approved by the physicians on the surgical committee respectively on 2/11/13, 2/15/13 and 2/19/13.
*There were no further reviews of her application in practitioner E's file.

2. Review of practitioner F's credentialing file revealed:
*A practitioner provisional appointment review had been completed on 2/3/11 and had been signed by the governing board on 3/24/11.
*There were no further credentialing reviews found in her file.
*There was no recommendation for reappointment from the medical executive committee, or approval from the governing board for reappointment and clinical privileges for the ensuing two year period.
*The practitioner had been practicing without medical credentialing approval for approximately 10 days.

Interview and policy review on 3/6/13 at 3:35 p.m. with the director of medical health information and credentialing revealed:
*Practitioner F's credentials had expired in February 2013.
*The approved temporary privilege for practitioner E to practice should have been reviewed after 60 days, and then renewed for an additional 30 days.
-That policy had not been followed for practitioner E.
*Practitioner E's initial application had never been processed through the medical executive committee or the governing board.
-She was currently not credentialed.
-She had recently requested additional privileges that had been approved.
*The committee that credentialed practitioners was supposed to meet in February but they had not.
-They had cancelled their meeting, because they had not felt they had enough material to review.
*Approximately 96 days had passed since practitioner E's privilege had lapsed.
*For four months practitioner E had performed surgical procedures without approved delineation of privileges and without completing the initial credentialing process.
-From 12/1/12 through 3/6/13 she had performed 101 surgical procedures.
*Updates to the delineation of privileges for all practitioners was done every two years.

Review of the provider's undated bylaws of the medical staff revealed:
*"Initial appointments and reappointment to the medical staff shall be made by the Board of Trustees.
*Unwarranted delay will be construed to mean more than 90 days from the date when a fully completed application is made and all required documents have been received.
*When the recommendation of the Executive Committee of the Medical staff is to defer the application for further consideration, it must be followed up within 60 days with a subsequent recommendation for provisional appointment with specified clinical privileges or for rejection for staff membership.
*Each peer review service committee shall review all pertinent information available on each physician scheduled for periodic appraisal for the purpose of determining its recommendations for reappointment to the medical staff and for the granting of clinical privileges for the ensuing two year period."

A. Based on record review and interview, the provider failed to ensure appropriate nursing documentation, assessments, and evaluations were completed prior to discharge for two of four same day surgery patients (5 and 33). Findings include:

1. Review of patient 5's medical record revealed:
*He was admitted to the emergency room on the morning of 1/20/13 with severe abdominal pain over the last several days.
*A computed tomography (CT) scan was ordered, and it was reported the patient had acute appendicitis with possible perforation. Also the CT indicated the patient might have had a mild ileus (slowing or stoppage of normal bowel activity).
*He had a significantly elevated white blood cell of 18.1 indicating significant infection.
*He had a blood urea nitrogen of 22 and blood glucose of 167 both indicating significant dehydration.
*He reported he had not been eating or drinking over the last several days.
*He was taken to surgery on 1/20/13 at 11:00 a.m. and a laparoscopic appendectomy was performed. It was found at the time of surgery the patient had multiple areas of infectious drainage in his abdomen. the physician irrigated the abdomen via the laparoscope.
*He had an uncomplicated stay in the post-anesthesia care area and was transferred to the nursing unit at 12:35 p.m. on 1/20/13. Once on the nursing unit he was held until 5:00 p.m. and then discharged.
*He had been taking only sips of water until four minutes before his discharge. His intake and output record confirmed no recordable amounts of oral fluids had been taken.
*No nursing documentation or assessments were present to indicate his bowel was functioning after a bowel procedure prior to discharge (i.e. bowel sounds or flatus).
*No repeat labs were ordered to evaluate his dehydration status.
*No continuous monitoring of the patient's temperature was completed to evaluate the status of his known infection.
*No narrative notes were completed by the nursing staff on the floor related to the patient's care or discharge readiness.
*The physician wrote an order after surgery to discharge the patient home when hospital criteria was met. She also wrote to call her if the patient was unable to transfer home. Nursing staff never called the physician prior to his discharge home. Two of the provider's thirteen discharge criteria had not been met prior to discharge according to nursing discharge documentation. Those two criteria were passing flatus and a post-anesthesia score of ten.
*Anesthesia services never completed a post-anesthesia assessment of the patient prior to his discharge.
*The physician never saw the patient prior to discharge.

Interview on 3/6/13 at 3:27 p.m. with the chief nursing officer and the director of quality assurance regarding resident 5's nursing care and documentation revealed:
*They were unable to explain why the patient had been discharged less than five hours after surgery. Both stated those types of patients would have normally been held overnight.
*They agreed the patient's bowel sounds, fluid intake, and temperature were important nursing assessments to have had prior to discharging the patient. They further agreed it was not possible to completely assess nausea and vomiting until the patient had taken in significant fluid and food orally for over a period of time.
*They agreed taking sips of fluid was not substantial enough fluid intake prior to discharge for a patient who had presented with dehydration
*No repeat labs were taken or requested to evaluate the patient's fluid status or blood glucose prior to discharge.
*They confirmed two of the provider's discharge criteria had not been documented as completed prior to discharge.
*They confirmed the patient had not had a post-anesthesia assessment prior to discharge according to documentation.
*They had no follow-up with the patient after discharge.
*They confirmed the overall nursing documentation and assessments of the patient had not explained or outlined why he had been discharged versus holding him and contacting the physician.

2. Review of patient 33's medical record revealed:
*She had a left knee arthroscope on 3/5/13. After the surgery she was directly admitted to the nursing unit.
*She was coherent and able to answer questions after surgery.
*The physician wrote an order after surgery to discharge the patient when hospital criteria had been met.
*No pain scale documentation was used by the nurse. Instead the terms mild/moderate/severe pain had been used to document her pain.
*No documentation the hospital's discharge criteria had been met prior to discharge was present.
*No documentation the patient had urinated after surgery.
*The patient had reported on 3/6/13 at 10:17 a.m. during a post-surgery (follow-up) telephone call her pain/nausea were not well controlled during her hospital stay. She also stated she had still not eaten but was taking liquids. No follow-up questions were asked related to urination.

Interview on 3/6/13 at 4:00 p.m. with the chief nursing officer and the director of quality assurance regarding resident 33's nursing care and documentation revealed:
*They confirmed the nurse had discharged the patient without documenting she had met the hospital's discharge criteria.
*They stated a pain scale of 0-10 should have been utilized during the patient's stay as she was mentally able to answer that question. They further stated that was the provider's normal standard of care for pain.
*They could not explain why the patient had been discharged prior to having any documented urinary output.

3. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th ED., St. Louis, MO, pg. 477, revealed:
*Complete and appropriate documentation was a vital aspect of nursing practice.
*"Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice."

Review of the South Dakota Board of Nursing's Administrative Rules, Chapter 20:48, revealed:
*"A licensee is personally responsible for the actions that the licensee performs relating to the nursing care furnished to clients and cannot avoid this responsibility by accepting the orders or directions of another person."
*"The registered nurse is responsible for the nature and quality of nursing care that a client receives under the nurse's direction."

B. Based on interview, record review, and policy review, the provider failed to have a registered nurse supervise and evaluate the care patients received during a cardiac stress test. Findings include:

1. Interview on 3/5/13 at 2:40 p.m. with the supervisor of respiratory care revealed:
*He had oversight of the provider's cardiac stress lab.
*He was a licensed respiratory therapist not a registered nurse (RN).
*He and other respiratory care staff who were not RN's were responsible for the care patients received during cardiac stress tests including intravenous line placement, pre-test evaluation, intra-test monitoring, and post-test evaluation. Refer to A1161, finding 1.
*No nursing staff were assigned to the stress lab during stress tests.
*No nursing assessments were completed on patients by an RN at any time.

Interview and policy review on 3/6/13 at 9:24 a.m. with the director of quality assurance revealed:
*She was not aware RNs were not evaluating, assessing, and monitoring stress test patients. She further stated she thought RNs were performing those tests with the physician.
*She agreed a respiratory therapist did not meet the Centers for Medicare and Medicaid regulation for RN supervision, evaluation, and care.
*She agreed the provider's 12/6/06 cardiac stress testing policy had not outlined who the provider considered qualified personnel to perform cardiac stress tests.




15036

C. Based on record review and interview, the provider failed to ensure a physician's order was obtained for the insertion and reinsertion of a Foley catheter for one of one sampled patient (11) with a Foley catheter. Findings include:

1. Observation on 3/4/13 in the morning revealed surveyor 27457 observed patient 11 had a Foley catheter.

Review of patient 11's medical record revealed:
*The physician's orders from 2/28/13 through 3/4/13 had not revealed a physician's order for a Foley catheter or the reinsertion of a Foley catheter.
*An audit trail dated 3/4/13 at 10:30 a.m. stated "Instructions: continue catheter from Avera on 2-27-13."
*A nursing note dated 3/5/13 stated:
-The Foley catheter had been discontinued.
-The patient had urinated eighteen times in the last two hours, a urine culture had been obtained, and the physician was notified.
-The Foley catheter had been reinserted.
*No documented physician's order for reinsertion of the patient's Foley catheter.

Interview and review on 3/6/13 at 4:10 p.m. of patient 11's medical record with RN C revealed:
*The audit trail was for insertion of a Foley catheter. She had instructed the nurse to enter that order after it had been discovered by the surveyor there was no Foley catheter order.
*The patient had not had a physician's order for a Foley catheter when she was admitted to the unit.
*The patient did not have a physician's order for reinsertion of the Foley catheter on 3/5/13.
*She was not able to locate a current physician's order for a Foley catheter in the patient's medical record.
*A physician's order should have been obtained prior to inserting the patient's Foley catheter.

Based on record review, interview, and policy review, the provider failed to ensure the care plans were individualized and updated for patient care needs for two of two reviewed inpatient's (11 and 30) charts. Findings include:

1. Review and interview on 3/5/13 at 10:00 a.m. with nurse manager D regarding patient 11's care plan revealed the nursing diagnosis of alteration in comfort revealed:
*The patient's comfort goal on a scale of 1 to 10 had not been identified by nursing staff.
*Interventions listed included a patient controlled analgesic pump (PCA).
*The PCA pump should not have been listed as an intervention for the patient. The patient received oral and intravenous pain medications.
*The patient's care plan had not been individualized.

2. Review and interview on 3/5/13 at 10:00 a.m. with registered nurse (RN) B regarding patient 30's care plan revealed:
*A nursing diagnosis of fluid volume excess.
*Interventions included monitor hydration status.
*Monitor for edema.
*Fluid restriction had been identified in the additional interventions. There was no documentation of the amounts of fluids allowed per shift or per department (nursing, dietary, etc.).
*The breakdown of the amounts of fluids allowed per shift or department was identified on the patient Kardex. The patient Kardex was not a permanent part of the patient's record.
*A copy of the patient's Kardex was provided for review and indicated a fluid restriction of 2200 milliliter (mL) per day (dietary 1000 mL, 400 mL days, 400 mL evenings, and 400 mL night).
*The breakdown of the patient's fluid allowance should have been on the patient's care plan.
*The care plan had not included alternative interventions like medication administration with applesauce to preserve allowable fluids for drinking.
*It was the expectation that nursing staff individualize care plans in accordance with patient care needs.

Review of the provider's 8/1/02 policy and procedure for nursing care plans revealed:
*The care plan was to document, implement, and coordinate the patient's plan of care utilizing nursing diagnoses based on assessed needs.
*The care plan would be completed based on the nursing assessment and was a permanent part of the patient's medical record.
*"Each nursing care plan includes expected outcome and nursing orders/interventions, specific to the nursing diagnoses. The RN will individualize each care plan by evaluating each expected outcome and nursing order/intervention. The nurse will draw a single line through inapplicable statement(s), and place date and initials after each deletion."
*"The nursing orders/interventions are reviewed and revised as the needs of the patient change."

B. Based on observation and interview, the provider failed to ensure medication verification was completed for one of two sampled patients (28) prior to conducting an intravenous (IV) flush. Findings include:

1. Observation on 3/4/13 at 3:15 p.m. of patient 28's IV flush by registered nurse (RN) A revealed the normal saline syringe was not scanned for verification by RN A prior to flushing the patient's IV.

Interview on 3/4/13 at 3:20 p.m. with RN A confirmed she should have scanned the normal saline syringe barcode to verify the normal saline solution prior to administration.

Interview on 3/5/13 at 8:45 a.m. with nurse manager D confirmed staff should have scanned the saline solution barcode prior to flushing the patient's IV. Nurse manager D revealed bar code scanning by the computer was part of medication administration verification for patients.





27457

A. Based on observation, interview, and policy review, the provider failed to ensure drawn-up medication syringes and multiple-dose vials of medication were properly labeled in the nuclear medicine department and one of one observed surgery patient (33). Findings include:

1. Observation on 3/5/13 at 9:33 a.m. of patient 33's surgery revealed a fifty milliliter syringe of an unknown substance was on the anesthesia cart when the patient entered the operating room. After the patient was positioned on the operating table and had received preliminary sedation certified registered nurse anesthetist (CRNA) Q took the unlabeled syringe and used it to attempt to enter the patient's left knee. Upon not being able to enter the knee in the right position the physician was contacted by the circulating nurse. When the physician entered the room the CRNA handed off the unlabeled syringe to the physician.

2. Observation and interview on 3/5/13 at 2:55 p.m. of the nuclear medicine medication preparation room revealed:
*No patients were present in the department.
*One opened and partially used multiple-dose vial of saline was on the back counter. The vial had no date or time as to when the vial had been opened.
*Next to the above vial was an unlabeled five milliliter syringe of an unknown fluid.
*Nuclear medicine technician O stated the above syringe was saline from the above un-dated and un-timed vial of saline.
*Nuclear medicine technician O agreed both the above syringe and multiple-dose vial were not properly labeled.

3. Interview on 3/5/13 at 3:30 p.m. with the chief nursing officer revealed:
*She agreed CRNA Q had not properly labeled the above syringe of medication prior to his use or prior to handing the medication off to the physician.
*She confirmed proper medication and syringe labeling had not occurred in the nuclear medicine department.

Review of the provider's 7/1/12 medication handling for nurses policy revealed:
*Multiple-dose vials should have been dated and discarded after twenty-eight days. Any vials opened without a date should have been discarded.
*Medications drawn-up and not immediately used should have been labeled with its contents and date and time of preparation.
*Any product drawn-up should have been administered within an hour.

Based on record review and interview, the provider failed to ensure initial and on-going competencies for intravenous (IV) starts had been performed and documented for nine of nine sampledradiologic technologists (G, H, I, J, K, L, M, N, and O). Findings include:

1. Review of the provider's 4/15/08 radiologic technologists multi-level competency policy revealed the nine radiologic technologists G, H, I, J, K, L, M, N, and O had been approved by the diagnostic imaging director and radiologist to perform IV access.

Review of the provider's 6/11/12 radiologic technologist job description revealed IV starts had not been listed as a job responsibility.

Interview on 3/15/13 at 3:55 p.m. with the diagnostic imaging director revealed:
*Radiologic technologists started IVs for magnetic resonance imaging and computed tomography imaging.
*Radiologic technologists received on-the-job training for starting IVs.
*Initial and on-going competencies for starting IVs had not been documented.

Based on admission documentation review, interview, and policy review, the provider failed to ensure all patients were screened for nutritional needs upon admission. Findings include:

1. Review of the provider's patient admission documentation revealed patients provided information related to:
*Height and weight.
*History of cardiac disorders and surgeries.
*History of gastrointestinal disorders, surgeries, and dysphagia.
*History of endocrine disorders and surgeries.
*History of skin problems.
*Gastrointestinal symptoms.

Interview on 3/5/13 at 2:00 p.m. with the registered dietitian (RD) revealed:
*The above areas were addressed at the time of the patient's admission.
*Nurses completed the above areas with the patient.
*Nurses notified her when they thought a patient was at potential for nutritional risk.
*There were no specific nutrition at risk criteria encompassed in the admission documentation.
*She had been working on a specific nutrition at risk screening tool, but it had not been implemented.
*She worked Monday through Friday and between the hospital and the nursing home.

Review on 3/5/13 at 4:30 p.m. with the RD of the provider's Nutritional Screening/Assessment policy reviewed April 2007 revealed it was in the process of being revised. The policy provided nutritional screening criteria for patients at high risk, moderate risk, or low/no risk. The policy was a work in progress.

26180

Based on observation, interview, and policy review, the provider failed to maintain equipment in a manner that ensured safety for three of three blanket warmers in one medical unit and one emergency department (ED). Findings include:

1. Observation on 3/4/13 at 2:14 p.m. of an Olympic blanket warmer in the medical unit nurse's station revealed the device was set to 150 degrees Fahrenheit (F).

Interview at that time with registered nurse (RN) A revealed:
*The blanket warmer was to have been set at 150 degrees F.
*The temperatures of the blanket warmers were monitored daily by the nurses and recorded on the log.
-The monitoring was done by scanning a blanket in the warmer.
*A scan of the blanket at that time revealed it was 145 degrees F.
*She was unaware if there was a policy regarding blanket warmers.

Review of the medical unit blanket warmer temperature logs revealed:
*For December 2012 the blanket temperature per scan ranged from 100 degrees F to 134.5 degrees F. The temperature was over 130 degrees F four times.
*For January 2013 the blanket temperature per scan ranged from 105 degrees F to 140 degrees F. The temperature was over 130 degrees F six times.
*For February 2013 the blanket temperature per scan ranged from 96 degrees F to 145 degrees F. The temperature was over 130 degrees F seven times.
*Through March 4, 2013 the temperature had been over 130 degrees F once.
*A typed note on the top of each log read "Blanket warmer set to 150 degrees F."

2. Review of the ED Amsco blanket warmer temperature log near the nursing station revealed:
*For December 2012 the blanket temperature per scan ranged from 135 degrees F to 153 degrees F.
-The temperature was over 130 degrees F thirty-one times.
-The bottom shelf temperature per the internal thermometer ranged from 145 degrees F to 150 degrees F.
*For January 2013 the blanket temperature per scan ranged from 75 degrees F to 154 degrees F. The temperature was over 130 degrees F twenty-nine times. One day the temperature had not been recorded.
*For February 2013 the blanket temperature per scan ranged from 140 degrees F to 156 degrees F. The temperature was over 130 degrees F twenty-seven times. One day the temperature had not been recorded.
*The temperature on display for the above three months ranged from 148 to 150 degrees F.

Review of a second ED Amsco blanket warmer temperature logs revealed:
*For December 2012 the blanket temperature per scan ranged from 136 degrees F to 151 degrees F. The temperature was over 130 degrees F twenty-nine times. Two days the temperature had not been recorded.
*For January 2013 the blanket temperature per scan ranged from 146 degrees F to 153 degrees F. The temperature was over 130 degrees F twenty-seven times. Three days the temperature had not been recorded.
*For February 2013 the blanket temperature per scan ranged from 144 degrees F to 153 degrees F. The temperature was over 130 degrees F twenty-six times. Two days the temperature had not been recorded.
*The temperature on display (where the temperature was set) during the above three months was 150 degrees F.

Observation and interview on 3/4/13 from 4:15 p.m. until 4:30 p.m. with nurse manager D regarding the blanket warmers revealed:
*The Amsco blanket warmer in the ED was set at 150 degrees F.
*An internal removable thermometer read 210 degrees F. That thermometer had been in there for a long time, was not accurate, and should have been replaced.
*They completed daily temperature scans on that warmer.
*Staff scanned each blanket as it was removed from the warmer.
*Staff followed the blanket warmers manufacturer's recommendations for setting the blanket warmers temperature at 150 degrees F.
*She was unaware that 150 degrees was too warm.

3. Interview on 3/5/13 at 8:00 a.m. with nurse manager D revealed:
*She had looked into the blanket warmer policy, and the Olympic warmer should have been set at 120 degrees F.
*The nurses were to have adjusted the temperature of the Olympic warmer if the scanned temperature exceeded 120 degrees F.
-She had assumed staff had done that.
*Their temperature logs did not show any temperature adjustments had ever been made for the Amsco or Olympic blanket warmers.

Review of the provider's 10/29/12 warming cabinet operation maintenance/monitoring policy revealed:
*"Warming cabinet operating instructions:
-1. Cabinet designed to heat liquids in vented and non-vented containers, metal objects, and muslin, cotton, or wool blankets. Settings are not to exceed warmer factory recommendations (120 degrees on the smaller Olympic Warmette, and 150 degrees on larger Amsco unit."
*It had not addressed what they were to do if the temperature of the blankets exceeded a safe temperature.
*It had not addressed what a safe temperature should have been for blankets warmed for patient use.

Review of the Association of periOperative Registered Nurses, Standards and Recommended Practices for Inpatient and Ambulatory Settings, Denver, CO, 2012 Ed., p. 222, revealed "Blanket-warming cabinet temperatures should not exceed 130 degrees F (54 degrees Celsius)."

A. Based on observation, interview, and manufacturer's instruction review, the provider failed to ensure:
*Intravenous supplies were stored and handled in a hygenic manner on one of four nursing units.
*Proper aseptic technique was used for one of one patient's (33) observed intra-articular joint injection (left knee injection).
*Proper aseptic technique was used for the preparation of administration of intravenous medications for one of one observed surgical patient (33).
*Manufacturer's suggested preoperative surgical skin preparation (prep) drying time was followed for one of one observed surgical patient (33).
*Contaminated waste was properly handled after one of one observed surgical case.
Findings include:

1. Observations on 3/5/13 from 8:29 a.m. through 12:10 a.m. of the care of patient 33 in the pre, intra, and post-operative phases of surgical care revealed:
*Registered nurse (RN) R in the nursing care unit brought in a plastic zip-lock bag that contained multiple intravenous (IV) catheters and other associated medical supplies into the patient's room and set it on her bed. After starting the IV RN R then put back into the bag the tourniquet she had used as well as left over supplies she had removed and placed on the patient's bed. RN did the above while still wearing the gloves she had worn when starting the IV. After removing her gloves RN R proceeded to take the zip-lock bag back to the nurses station where she stored it with other supplies. No handwashing occurred after that IV insertion.
*In the operating room certified registered nurse anesthetist (CRNA) Q began the procedure for a left knee injection. He put on gloves without hand hygiene then proceeded to use an alcohol swab on the outside of the patient's left knee. The area he swabbed with alcohol was roughly the size of a quarter. He then proceeded to palpate (feel) the patient's knee with non-sterile gloves over the area he had just cleansed. He then proceeded with the sterile needle inserting it into the patients un-cleansed skin. CRNA Q preformed that procedure a total of five times using the same technique and only changed the needle once. After the fifth attempt the physician was called to introduce the needle into the patient's knee. The physician was handed the contaminated needle and without prepping the knee the needle was inserted into the intra-article space of the knee. At that time the physician handed off the syringe to CRNA Q to inject its contents into the patient's knee.
*Throughout the case CRNA Q was noted to not alcohol swab the patient's IV ports prior to entering them with a syringe.
*Throughout the case CRNA Q was noted to not alcohol swab the tops of medication bottles prior to entering them.
*The patient's left knee was cleansed with a Prevail topical patient preoperative skin prep by the circulating nurse. Immediately following the prep the physician immediately began to drape the patient's leg for surgery. The prep solution was visibly wet at the time draping began.
*The circulating nurse placed a biohazard bag containing two saturated gauze pads into the regular garbage. Also the saturated section of the drape was placed in the regular garbage.

Interview, manufacturer's instruction review, and policy review on 3/6/13 at 10:31 a.m. with the infection control nurse revealed:
*All the above observations were breaches in basic infection control standards.
*She confirmed the above observations were in violation of the provider's policies related to IVs, aseptic technique, handwashing, and handling of contaminated waste.
*The surgical prep should have been allowed to dry for three to five minutes according to the manufacturer's directions.



25107

B. Based on observation, interview, and document review, the provider failed to disinfect reusable equipment between uses by patients for two of two air masks used in the sleep laboratory. Findings include:

1. Observation and interview on 3/4/13 at 3:00 p.m. in the sleep lab with the respritory therapy supervisor revealed:
*Respiratory air masks were laid on the counter and appeared to have been washed.
*The provider washed the air masks with enzymatic detergent and ivory soap in-between patients.
*The products used to clean the equipment did not make any claim to disinfect.

Review of the cleaning instructions for the air masks revealed:
*The method used by the provider to clean the masks was approved by the manufacturer for single patient equipment.
*The equipment manufacturer had approved the equipment for multiple patient use and reuse.
*They also provided a list of appropriate disinfectants to use along with a cleaning and disinfection guide.

Interview on 3/5/13 at 10:00 a.m. with the respritory therapy supervisor revealed:
*The air masks and tubing were washed between patients as indicated above.
*Those items were currently not being disinfected between patients.
*Those items should have been disinfected between patients.

Interview on 3/5/13 at 4:25 p.m. with the clinical quality specialist revealed the air masks and tubing should have been disinfected between patients.

Review of the provider's July 2004 nursing department general infection control measures policy revealed "All reusable equipment shall be cleaned on a scheduled basis and with a disinfectant between patients."



15036

C. Based on observation, interview, and policy review, the provider failed to ensure nursing staff:
*Disinfected a Carpuject injection device after each use for one of one sampled patient (30).
*Completed appropriate hand hygiene prior to flushing the intravenous (IV) Heplock needle for one of two sampled patient's (30).
*Established a clean surface prior to opening IV start kit supplies for one of one sampled patient (28).
Findings include:

1. Observation on 3/4/13 at 2:58 p.m. of registered nurse (RN) A administering Ativan 2 milligrams (mg) to patient 30 revealed:
*She obtained a prefilled syringe with Ativan 2 mg from the medication storage unit.
*She placed the prefilled syringe into a Carpuject injection device obtained from her pants pocket.
*She performed hand hygiene using a hand sanitizer.
*She entered the patient's room and lowered the patient's bed siderail.
*She scanned the Ativan prefilled syringe and saline flush syringe for computer verification.
*She without wearing gloves opened an alcohol wipe, cleaned the insertion port for a couple of seconds, flushed the Heplock with sterile saline, and then administered Ativan 2 mg.
*She discarded the empty prefilled syringe, did not disinfect the Carpuject injection device, and placed the device in her pants pocket.

Interview on 3/4/13 immediately after the above observation with RN A revealed she had not disinfected the Carpuject injection device after use. She had not disinfected it on a regular basis nor after each use. She kept the Carpuject device in her pants pocket, because it belonged to her.

2. Observation on 3/4/13 at 3:15 p.m. of RN A performing an IV start for patient 28 revealed:
*She gathered the IV start supplies required, opened the supplies on the uncleaned overbed table, placed her clean gloves on the overbed table, and placed a paper drape under the patient's arm.
*Without performing hand hygiene she put on the clean gloves, applied the tourniquet, cleansed the IV site, inserted the IV needle, and attempted to flush the needle with the saline flush syringe.
*The IV would not flush. She stated the hospital policy was one attempt per staff, and she would call the nursing supervisor to restart the patient's IV.
*The used IV needle was removed and the open guaze from the uncleaned overbed table was placed on the IV site.

Interview on 3/5/13 at 8:25 a.m. with RN D revealed:
*To prevent contamination of IV sites staff wore gloves to clean the IV ports prior to medication administration.
*Hand hygiene should have been performed after touching contaminated surfaces.
*Staff should have disinfected the Tubex and Carpuject device before and after each patient use.

Review of the provider's infection control plan dated 7/22/04 revealed hands must be washed:
*Before and after patient contact.
*After contact with sources that might have been contaminated.
*After removing gloves.

Review of the provider's nursing department general infection control measures policy dated 7/22/04 revealed:
*Hands should have been washed before, after, and between patient contact; before contact with medications, clean medical equipment, and supplies.
*All resuable equipment shall be cleaned on a scheduled basis and with a disinfectant between patients.

Based on record review, interview, and policy review, the provider failed to ensure three of five sampled surgical patients (4, 5, and 33) had a fully documented pre-anesthesia evaluation. Findings include:

1. Review of patients 4, 5, and 33's pre-anesthesia documentation revealed:
*The provider had a standardized form for the anesthesia personnel to utilize to appropriately document their assessments.
*All three patients had multiple areas left blank on their forms related to vital signs at the time of the assessment, previous anesthesia history including complications, indications that risks and complications were explained to the patients, history of substance abuse, history of tobacco use, laboratory values, and diagnostic studies performed on the patient.

Interview and policy review on 3/5/13 at 1:36 p.m. with the director of anesthesia regarding the above findings revealed:
*He confirmed the pre-anesthesia forms had not been appropriately completed by the anesthesia providers. He had been aware of the problems with pre-anesthesia documentation but had not been able to get it resolved.
*He confirmed the provider's 7/10/12 pre-anesthesia evaluation procedure had not been followed.

Interview on 3/5/13 at 3:30 p.m. with the chief nursing officer revealed she confirmed the above statements and findings.

Based on record review, interview, and policy review, the provider failed to ensure three of five surgical patients (4, 5, and 33) had documented post-anesthesia evaluations prior to discharge. Findings include:

1. Review of patients 4, 5, and 33's post-anesthesia records revealed they had no documentation of a post- operative visit and evaluation from an anesthesia provider prior to discharge home.

Interview and policy review on 3/5/13 at 3:30 p.m. with the chief nursing officer revealed the anesthesia providers had not followed their 11/30/12 post-anesthesia evaluation policy for any of the above patients.

Based on record review and interview, the provider failed to ensure initial and on-going competencies for intravenous (IV) starts had been performed and documented for two of two sampled nuclear medicine technologists (O and P). Findings include:

1. Review of the 1/14/10 nuclear medicine technologists job description revealed:
*A nuclear medicine technologist measures, injects, and starts an IV for injection of doses.
*Competencies were required in all aspects of clinical nuclear medicine.

Interview on 3/5/13 at 3:55 p.m. with the diagnostic imaging director and nuclear medicine technologist revealed:
*Nuclear medicine technologists started IVs for nuclear medicine studies.
*Nuclear medicine technologists received on-the-job training for starting IVs.
*Initial and on-going competencies for starting IVs had not been documented.

Based on interview and policy review, the provider failed to ensure cardiac stress testing services rendered by respiratory therapy had policies for the appropriate supervision, qualifications, and standards of practice. Findings include:

1. Interview on 3/5/13 at 2:40 p.m. with the supervisor of respiratory care revealed:
*He also had oversight of the provider's cardiac stress laboratory (lab).
*He was a licensed respiratory therapist not a registered nurse.
*He and other respiratory care staff who were not registered nurses were responsible for all the care patients received during cardiac stress tests. That care included intravenous line placement, pre-test evaluation, intra-test monitoring, and post-test evaluation.
*No nursing staff were assigned to the stress lab during stress tests.
*No nursing assessments were completed on patients by a registered nurse at any time.
*No code cart (emergency cart) was immediately available to the physician at the time of the testing. If an emergency arose a code blue would have been called, and the emergency room team would have had to respond.
*He and his staff of therapists had no documented training related to cardiac stress tests or intravenous line placement.
*Not all of his staff that performed cardiac stress tests were trained in advanced cardiac life support.
*He had no policies for the appropriate supervision, qualifications, and standards of practice for cardiac stress testing.
*The cardiac stress testing area was not involved in the provider's quality assurance program.

Interview and policy review on 3/6/13 at 9:24 a.m. with the director of quality assurance revealed:
*She was not aware registered nurses were not evaluating, assessing, and monitoring stress test patients. She further stated she thought registered nurses were performing those tests with the physician.
*She agreed the provider's 12/6/06 cardiac stress testing policy had not outlined who the provider considered qualified personnel to perform cardiac stress tests.

Interview on 3/6/13 at 1:30 p.m. with the chief nursing officer revealed she confirmed respiratory care did not have the proper policies for the appropriate supervision, qualifications, and standards of practice for cardiac stress testing.