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Based on record review of policies, observation and interview, it was determined the director of nursing failed to delineate responsibilities for patient care in a policy for skin suturing by a Licensed Practical Nurse (LPN) and Surgical Technician (ST) in the Operating Room for one of one surgery observed and performed at Location B. Failure to have a policy did not assure the Director of Nursing approved the patient care activity and nursing services provided at Location B. The failed practice affected Patient #14 and was likely to affect any surgical patient in which the surgeon did not complete skin suturing. Findings included:

A. Observation of surgical procedure Cesarean Section with Salpingectomy on 03/27/18 for Patient #14 showed infant birth time of 2:29 PM. Surgeon #1 completed suturing except for superficial skin layer and exited Operating Room (OR) #1 at 2:58 PM. Continuous observation from 2:58 PM to 3:20 PM showed that ST #1 performed skin closure by suture with LPN #1. Surgeon #1 was not present in OR #1 during the skin closure by suture performed by ST #1 with LPN #1. Circulator #2 stated by interview on 03/27/18 at 3:10 PM that "everyone that scrubs can do skin closure."
B. On 03/30/18 at 11:50 AM, the Director of Surgical Services stated there was no additional competencies or training documented for LPN #1 or ST #1 and there was no specific policy.
C. On 03/30/18 at 12:50 PM, a facility policy for a LPN or ST staff to perform superficial skin closure was requested from the Director of Risk Management and Compliance for Location A. On 03/30/18 at 12:57 PM the Director of Risk Management and Compliance for Location A stated. "We don't have a policy at the other location and we don't allow that."

Location B:

Based on observation, interview, review of personnel files and training documentation, it was determined the facility failed to ensure two of two (Licensed Practical Nurse (LPN) #1 and Surgical Technician (ST) #1) staff members, who performed superficial skin suturing in the operating room on one of one (#14) patient, had documented continuing competency that included potential complications, adverse reactions, and knowledge to recognize and intervene in the event of adverse reactions. The failed practice did not ensure staff was knowledgeable and clinically competent to perform the specialized activity of skin suturing. The failed practice affected Patient #14 and was likely to affect any surgical patient in which the surgeon did not complete skin suturing. Findings included:

A. Observation of surgical procedure Cesarean Section with Salpingectomy on 03/27/18 for Patient #14 showed infant birth time of 2:29 PM. Surgeon #1 completed suturing except for superficial skin layer and exited Operating Room (OR) #1 at 2:58 PM. Continuous observation from 2:58 PM to 3:20 PM showed that ST #1 performed skin closure by suture with LPN #1. Surgeon #1 was not present in OR #1 during the skin closure by suture performed by ST #1 with LPN #1. Circulator #2 stated by interview on 03/27/18 at 3:10 PM that "everyone that scrubs can do skin closure."
B. Record review of personnel files on 03/29/18 showed that LPN #1 had a form in her file titled "Competency of skin closure technique" dated 12/11/11. Surgical Technician #1 had the same form that was dated 12/15/15. The form listed the following skills: throws three knots; selects and utilizes appropriate sutures; utilizes appropriate technique; assures incision is closed properly and securely; inspects area while closing, and understands to notify surgeon if any patient concerns. A check mark was observed next to each category. There was no evidence of continuing competency of ST #1 or LPN #1 such as potential complications, adverse reactions, or identified interventions in the event complications or adverse reactions occur. Review of 2017 Mandatory annual nursing skills for surgical and clinical staff on 03/29/18 showed no evidence of competency assessment for skin closure technique.
C. On 03/30/18 at 11:50 AM, the Director of Surgical Services stated there was no additional competencies or training documented for LPN #1 or ST #1.

LOCATION A

Based on observation and interview, it was determined one of one (#6) physician had a syringe containing a medication that was not labeled with the name of the drug, the amount, and the date and time the medication was drawn up, in the chest pocket of his scrub top. Failure to ensure the syringe was labeled with the name of the drug, the amount and the date and time did not ensure specific identification of the medication and the beyond use date and time. The failed practice had the potential to effect Patient #17 on 03/27/18. Findings follow:

A. During observation in Surgical Services, Physician #6 was observed to have a syringe in his chest pocket. Physician #6 was asked if the syringe was labeled and when removed from the pocket it was observed to have no label on it. The above findings were verified by Physician #6 at 9:15 AM on 03/27/18.
B. The Director of Risk Management and Compliance stated in an interview at 8:50 AM on 03/29/18 there was no policy and procedure for labeling medication syringes.

Location A
Based on observation, review of manufacturer's recommendations and interview, it was determined the facility failed to follow manufacturer's recommendations for temperature in that solutions were being stored at 114-115 degrees Fahrenheit, instead of 104 (per manufacturer) in one of one (Surgical Services) fluid warmer observed. By not following manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that have had procedures in the facility. Findings follow:

A. Review of the manufacturer's recommendations showed both bags and bottles of fluids for injection and irrigation could be warmed at a temperature not to exceed 104 degrees Fahrenheit.
B. During a tour of Surgical Services on 03/26/18 from 2:07 PM to 2:50 PM observation showed the following solutions in a warmer at 114-115 degrees Fahrenheit:
1) One-1000 ml (milliliter) bag of 0.9% Sodium Chloride for injection;
2) Nine-1000 ml bottles of 0.9% Sodium Chloride for irrigation;
3) Fourteen-500 ml bottles of 0.9% Sodium Chloride for irrigation;
4) Five-1000 ml bottles of Sterile Water for irrigation; and
5) Five-500 ml bottles of Sterile Water for irrigation.
6) None of the items observed were dated as to when they were put into the warmer.
C. During an interview on 03/26/18 at 2:48 PM, the Director of Risk Management and Compliance verified the solutions were being stored in the warmer at 114-115 degrees Fahrenheit and the manufacturer's recommendations showed both bags and bottles of fluids for injection and irrigation could be warmed at a temperature not to exceed 104 degrees Fahrenheit.

Location A
Based on observation, review of manufacturer's information on Succinylcholine and interview, it was determined the facility failed to ensure Succinylcholine had been dated with the manufacturer's recommended beyond use date in one of one Anesthesia Carts observed in Surgical Services. The potential existed for the medication to be used beyond manufacturer's guidelines leading to a decrease in potency of the medications upon administration to patients. The practice had the likelihood to affect all patients who received the medication during surgery. Findings follow:

A. Review of manufacturer information on Succinylcholine showed that the vials were stable for up to 14 days at room temperature once removed from the refrigerator.
B. During a tour of Surgical Services on 03/26/18 from 2:07 PM to 2:50 PM, observation showed the Anesthesia Cart had two unopened vials of Succinylcholine that were not dated to indicate when it was removed from refrigeration or when it would expire.
D. During an interview on 03/26/18 at 2:49 PM, Physician #1 verified the Succinylcholine was not dated with information to indicate when it reached the 14 day maximum at room temperature.

All Dietary deficiencies are in relation to Location B.

Based on policy review, personnel file review, and interview, it was determined the facility failed to follow standards of practice in the organization of dietetic services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that the Dietary Director did not meet the minimum qualifications necessary as required by facility policy and job description. Failure to have a qualified Dietary Director did not ensure staff was knowledgeable in regard to patient diets and foodservice standards of practice. The failed practice was likely to affect any patient receiving dietary services. Findings follow.

A. Review of Section 17 required the Director of Foodservices to be at a minimum, a Certified Dietary Manager (CDM).
B. During an interview on 03/26/18 at 2:16 PM, the Dietary Director was asked if he was a CDM. He stated he was not, but was enrolled in the course and was on schedule to complete it in September 2018.
C. Review of the Job Description for the Director of Food and Nutrition, received on 03/27/18 at 9:03 AM, showed the person in this position "Must meet CMS [Centers for Medicare and Medicaid Services] and/or state regulations regarding educational qualification for Food Service Director (e.g. Certified Dietary Manager)."
D. Review of policy titled, "Objectives of the Food and Nutrition Services Department/Dining Services," showed "The person in Charge (PIC) must be a manager certified in food protection (ServSafe, or other as required by state/local regulation)."
E. During an interview on 03/28/18 at 9:00 AM, the Director of Quality and the Director of Nursing confirmed the Dietary Director was not a CDM.

Based on Refrigerator and Freezer Temperature Log review from 01/01/18 through 03/25/18 and interview, it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that refrigerator temperatures were not documented three times per day for four of four (Reach-in cooler, and Walk-in Cooler, Dessert/Salad Cooler, Milk Box) refrigerators and freezer temperatures were not documented three times per day for two of two freezers (Walk-in freezer, Outside freezer). Failure to document temperatures three times per day created the potential for a refrigerator or freezer malfunction to go unnoticed and could affect any patient receiving meals from the kitchen. Findings follow.

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 17.B.12 required temperatures of all refrigerators and freezers in the kitchen to be recorded three times per day. Review of Refrigerator and Freezer Temperature Logs from 01/01/18 through 03/25/18 revealed the following:
1) Reach-in Cooler - temperatures were not documented three times per day for 84 out of 84 days.
2) Walk-in Cooler - temperatures were not documented three times per day for 76 out of 84 days.
3) Dessert/Salad Cooler - temperatures were not documented three times per day for 76 out of 84 days.
4) Milk Box - temperatures were not documented three times per day for 76 out of 84 days
5) Walk-in Freezer - temperatures were not documented three times per day for 76 out of 84 days
6) Outside Freezer - temperatures were not documented three times per day for 75 out of 84 days.
B. During an interview on 03/27/18 at 12:06 PM, the Dietary Director confirmed the temperatures were not documented three times per day.

Based on Refrigerator and Freezer Temperature Log review from 01/01/18 through 03/25/18 and interview, it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions, Section 17.B.13, in that the refrigerator/freezer temperatures were not documented once per day for one (Station #1) of four (Station #1, #2, #3, and Obstetrics) nourishment refrigerators in patient care areas. Failure to document temperatures once per day created the potential for a refrigerator or freezer malfunction to go unnoticed and could affect any patient receiving meals from that refrigerator/freezer. Findings follow.

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 17.B.13 required temperatures of all refrigerators and freezers in patient care areas to be documented once per day. Review of Refrigerator and Freezer Temperature Logs for 01/01/18 through 03/25/18 showed the following:
1) Station #1 Freezer-temperatures were not documented for 20 out of 28 days in February 2018.
2) Station #1 Refrigerator-temperatures were not documented for 20 out of 28 days in February 2018.
B. During an interview on 03/27/18 at 12:06 PM, the Dietary Director confirmed the temperatures were not documented.

Based on Dishmachine Temperature Log review for 01/01/18 through 03/25/18 and interview, it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that the dishmachine water cycle and final rinse cycle temperatures were not documented for the dinner meal for 84 out of 84 days. Failure to document temperatures created the potential for a dishmachine malfunction to go unnoticed and had the likelihood to affect any patient consuming foods on dishes that were washed in the dishmachine. Findings follow.

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 17.B.16 stated dishmachine temperatures shall be recorded with each meal. Review of Dishmachine Temperature Logs from 01/01/18 through 03/25/18 revealed the following:
1) Dishmachine wash cycle water temperatures were not documented for 84 out of 84 dinner meals.
2) Dishmachine final rinse cycle water temperatures were not documented for 84 out of 84 dinner meals.
B. During an interview on 03/27/18 at 12:06 PM, the Dietary Director confirmed the water temperatures were not documented at each meal.

Based on Trayline Temperature Monitoring Form review for 01/01/18 through 03/25/18 and interview, it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that temperatures of foods on the patient trayline were not documented before the meal 8 out of 252 times; and temperatures were not documented after meals 242 out of 252 times. The failed practice did not allow the kitchen staff to know if hot foods were above 140 degrees Fahrenheit and cold foods were less than 40 degrees Fahrenheit through the duration of the trayline service. The failed practice had the potential to affect anyone receiving food from the kitchen. Findings follow.

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 17.B.18 stated temperatures of hot and cold foods on patient trayline shall be taken at the beginning of each meal and at the end of each meal in which trayline lasts longer than 15 minutes. Review of Trayline Temperature Monitoring Forms for 01/01/18 through 03/25/18 revealed the following:
1) There was no documentation as to how long trayline lasted at each meal. Therefore, it was unknown as to whether or not food temperatures should be taken at the end of trayline.
2) Temperatures of patient trayline foods were not documented before each meal 8 out of 252 times.
3) Temperatures of patient trayline foods were not documented after each meal 242 out of 252 times.
B. During an interview on 03/27/18 at 12:06 PM, the Dietary Director confirmed the temperatures were not documented.

Based on observation, policy review, and interview it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that food items in one of one walk in freezer were not labeled and dated on a first in, first out (FIFO) basis. The failed practice did not ensure food items were rotated so that the oldest items were used first and created the likelihood for patients to receive expired food items. Findings follow.

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions Section 17.C.11 required food items to be handled on a first in, first out basis.
B. Review of policy titled "Food Supply and Storage" showed, "Date and rotate items; first in, first out (FIFO). Discard food past the use by or expiration date."
C. During a tour of the kitchen conducted on 03/26/18 at 1:35 PM, numerous items in the walk in freezer were observed not dated, examples include:
1) Broccoli - 7 of 7 bags
2) Green Beans - 8 of 8 bags
3) Corn - 12 of 12 bags
4) Cauliflower - 9 of 9 bags
5) Italian Vegetable Blend - 23 of 23 bags
6) Pork Pattie Fritters - 3 of 3 boxes
D. During an interview at the time of the tour, the Dietary Director confirmed the food items were not dated.

Based on Nutrition Services policy review, and interview, it was determined the facility failed to ensure organization in that policies were not updated and specific to the facility. The failed practice did not ensure the policies and procedures were up to date and reflected the current practices of the facility and had the potential to affect any patient receiving dietary services. Findings follow.

A. Review of Nutrition Services policy manual revealed the following:
1) Policy titled, "Scope of Services," showed "INSERT YOUR DEPARTMENT'S SCOPE OF SERVICES (PROVIDED FROM YOUR QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PROCESS)." No scope of services was listed.
2) Review of a policy page showed, "ORGANIZATIONAL CHART OF FACILITY/COMMUNITY ADMINISTRATION (Please insert)." No organizational chart was inserted.
3) Review of a policy page showed, "ORGANIZATIONAL CHART OF DEPARTMENT (Please insert)." No chart was inserted.
4) Review of a policy page showed, "HOURS OF OPERATION." No hours of operation were listed.
5) Review of a policy page showed, "ORGANIZATIONAL CHART OF COMPANY REGIONAL TEAM (Please insert)." No chart was inserted.
6) Review of a policy page showed, "ASSEMBLY LINE DIAGRAM SAMPLE." No diagram was attached.
7) Review of a policy page showed, "INSERT UNIT TRAY ARRANGEMENT DIAGRAM HERE." No diagram was attached.
8) Review of policy titled, "Tray Identification/Delivery/Pick-Up," showed "Trays are delivered within ____ minutes of being assembled on trayline."
9) Review of policy titled, "Repairs," showed "Repairs to essential equipment are initiated by the Maintenance Department within ____hours."
10) Review of a policy page showed, "FIRE EVACUATION PLAN Replace with facility/community department plan." No plan was attached.
11) Review of a policy page showed, "FACILITY/COMMUNITY WIDE DISASTER PLAN (Insert Facility's/Community's Policies and Procedures)." No policies and procedures were inserted.
B. During an interview on 03/28/18 at 10:32 AM, the Dietary Director confirmed the policies were not complete.

Location B

Based on observation, interview, review of policy and manufacturer's instructions for use, it was determined the facility failed to ensure acceptable level of safety and quality in that did not follow their policy and the manufacturer's instructions for labeling the control solutions for the point of care blood glucose testing devices in three (Emergency Department, Medical Surgical and New Life) of four (Emergency Department, Medical Surgical, New Life, and Senior Care) areas observed. The accuracy and quality of control results could not be assured without a date label three months of opening (Emergency Department, Medical Surgical) and failure to assure expired control solutions were not available for use (New Life) did not ensure the accuracy of the control results. The failed practice was likely to affect all patients who required point of care blood glucose testing in the Emergency Department, medical Surgical and New Life units of the facility. Findings included:

A. Record review of the facility's policy titled, "570.0000 Inform II Policy Procedure," dated 11/2015, showed Accu-chek Inform II control solutions expire on the date printed on the vial label or three months from opening, whichever came first. When an operator opened a vial of controls they must handwrite the expiration date on the vial, which would be three months from opening or the printed vial label. Review of manufacturer's instructions showed that accurately testing known levels of glucose (controls) ensured the system and the individual technique used in testing provided accurate results.
B. On 03/28/18 at 11:15 AM observation showed Accu-chek Inform II control solutions, Level I and II on the Medical Surgical unit were not dated to show the three month expiration date after opening. The finding was verified by Registered Nurse (RN) #2 at the time of observation.
C. Observation on 03/28/18 at 11:31 AM showed Accu-chek Inform II control solutions, Level I and II in the Emergency Department were not dated to show the three month expiration date after opening. The finding was verified by RN #1 at the time of observation.
D. Observation of the New Life unit on 03/28/18 at 11:29 AM showed that the Accu-chek Inform II control solutions, Level I and Level II were labeled as opened on 11/17/17. The control solutions were observed available for use after the expiration date of 02/18/18. The findings were verified by RN #3 at the time of observation.
E. The Laboratory Director for Location B was interviewed on 03/28/18 at 11:35 AM and verified the control solutions were to be dated with the expiration date of three months of opening.

Based on the review of policy, review of Center for Disease Control (CDC) Guidelines, review of physician files, and interview, Location B failed to ensure three (#2, #3, #7) of eight (#1-#8) physicians had received Hepatitis B Immunization or had been offered and declined the immunization. The failed practice did not ensure the transmission of Hepatitis B between the physicians and patients would be prohibited if there was exposure to blood or bodily fluids. Findings follow:

A. Review of policy titled, "Associate Hepatitis B Program," on 03/29/18 at 8:30 AM showed CDC Guidelines would be followed.
B. Review of the CDC Guidelines on 03/29/18 at 9:30 AM showed healthcare workers, to include physicians, with the potential for exposure to blood or bodily fluids should be offered Hepatitis B Immunization.
C. Review of physician files on 03/29/18 at 10:00 AM showed there was no evidence Physician #2, #3, and #7 received the Hepatitis B Immunization or had been offered and declined the immunization.
D. An interview with the Location A Director of Risk Management and Compliance on 03/30/18 at 10:00 AM, she verified there was no evidence of Physicians #2, #3, and #7 had received Hepatitis B Immunization or having been offered and declined the immunization.


27453

Location B

Based on record review of policies, employee files and interview, it was determined the Infection Prevention Nurse at Location B failed to control infections in that annual screening and respirator fit testing was not performed for 12 (Registered Nurse (RN) #1, #4-#10, Licensed Practical Nurse (LPN) #1 - #4) of 14 (RN #1, #4-#11, LPN #1-#4 and Operating Room Technician #1) employees. The facility did not assure staff did not have conditions that would prevent them from safely wearing a respirator and that the respirator fit in order to decrease the risk of airborne infection to employees. The failed practice affected RN #1, #4- #10, LPN #1 - #4 and was likely to affect all other clinical staff.

A. Record review of the policy titled, "Respiratory Protection for Airborne Precautions," revised 10/2017, showed respirator fit test screening was to be performed for all staff (associates) annually during their month of hire and as indicated. The purpose of fit testing was to decrease employee risk of infection from an organism that could be transmitted through the airborne route during contact with the patient and/or the patient environment while performing job duties.
B. Record review of employee files on 03/29/18 showed RN #1, #4-#10 and LPN #1-#4 did not have evidence of annual screening and respirator fit testing. There were no evidence of previous screening or respirator fit testing results provided for review.
C. The Infection Prevention Nurse for Location B was interviewed on 03/29/18 at 11:13 AM and stated employee screening and respirator fit testing had not been performed annually as required by policy, that previous fit testing results were not available and only "a few" employees had been fit tested. The Infection Prevention Nurse confirmed the findings in A and B at the time of the interview.


Location B

Based on observation and interview, it was determined the Infection Prevention Nurse for Location B failed to have a system in place to prevent and control likely sources of infection in that there was an accumulation of dust, soiled equipment, rips in vinyl coverings and expired supplies in two (Emergency Department, Senior Care) of five (Emergency Department, Senior Care, Surgical Services, New Life, and Medical Surgical) areas observed. The failed practices did not assure patients would be protected from likely sources of infection. The failed practice was likely to affect the Senior Care census of eight on 03/07/18 and all patients treated at the Emergency Department. Findings included:

A. Observation of the Emergency Department on 03/28/18 at 2:30 PM showed:
1) The Wash Down room had an accumulation of dust and debris on the surface of floor and on wheelchair parts, a fan and a cushion stored in the area. The findings were verified by the Medical Service Director on 03/28/18 at 2:31 PM.
2) Two of two computer on wheels for nursing staff use had an accumulation of dust on the surface. The finding was verified by the Medical Service Director on 03/28/18 at 2:37 PM.
3) The Trauma Room had an expired blood spill kit from 05/11/12; sterilized surgical basin, expired 03/23/18; Single use stylet, two of two, size small expired 09/14/17. The findings were verified by the Medical Service Director on 03/28/18 at 2:48 PM.
4) An accumulation of dust was observed on high touch surfaces in Rooms #4 -#9. Two bedside commodes were stored under an open cabinet outside Room #5-#9. Observation showed one of the two bedside commodes, identified as clean and ready for use by Registered Nurse (RN) #1, contained a small amount of a yellow liquid inside the pail portion of the commode. The finding was verified by RN #1 on 03/28/18 at 3:21 PM.
B. Observation of the Senior Care Department on 03/27/18 at 8:55 AM showed:
1) One of one patient in the hallway was observed in a reclining geriatric chair with the vinyl surface ripped and stuffing material exposed on one of the two arm surfaces of the chair. Rips in the smooth vinyl covering with stuffing material exposed does not allow the disinfection of the equipment between patients.
2) The Director of Senior Care stated items in the storage room should be clean and ready for use on 03/27/18 at 9:19 AM. The storage room included one of three reclining geriatric chairs with the vinyl surface ripped and stuffing material exposed on two arm surfaces of the chair; two of three wheelchairs with vinyl arm surfaces ripped and stuffing material exposed; one of one lap cushion with multiple rips in the vinyl type covering and under stuffing exposed. A total of 23 chair cushions and pads were observed dusty and soiled stored on an open cabinet or in wheelchairs in the storage room. A computer on wheels and a vital sign monitor was observed with dust covering the surface.
3) The findings in B. 1 and 2 were verified by the Director of Senior Care on 03/27/18 at 9:26 AM.




29485

LOCATION A

Based on observation, interview, policy and procedure review, it was determined the Infection Prevention Nurse failed to control infections in that:
1. Two of two (Certified Registered Nurse Anesthetist (CRNA) #4 and Physician #5) members of the surgical team with facial hair, did not cover all head hair during a surgical procedure, all surgical staff were allowed to wear home laundered scrubs from home into the surgical suite.
2. One of one disposable oxygen mask was not discarded or cleaned after being dropped on the floor, prior to use on a patient.
Failure to ensure all head hair was covered had the potential to allow the dispersal of microorganisms from staff hair, failure to ensure staff did not wear surgical scrubs from home to the operating suite did not allow the facility to be assured the surgical scrubs were clean and free from microorganisms and failure to ensure only clean equipment was used in patient care had the potential to allow contamination of a surgical wound. The failed practices had the potential to affect any patient that underwent surgery in the facility and Patient #17 on 03/28/18. Findings follow:

A. Review of the policy and procedure titled "Surgical Suite Dress Code and Traffic Control," received from the Charge Nurse at 10:15 on 03/27/18 showed all hair was to be covered. The above policy and procedure also showed the following under Semi-restricted Areas; " ...Freshly laundered scrub suits may be worn from home. Street clothes are NEVER worn beyond the semi-restricted and restricted areas ..." and under Restricted Areas: "1. Fresh laundered scrub suits. Shirt/pants and socks/stockings ..." Review of the above policy and procedure referenced "AORN Recommended Practices 2001, ..." Review of the current AORN Guidelines for Perioperative Practice, 2015, showed all individuals who enter the semi-restricted and restricted areas should wear scrub attire that has been laundered at a health care-accredited laundry facility or disposable scrub attire provided by the facility and intended for use within the perioperative setting.
B. Observation of Physician #5 from 9:30-11:30 AM on 03/27/18 showed he was performing a thyroidectomy on Patient #17 while wearing a regular surgical mask. Facial hair was visible from the edges of the surgical mask to the edges of his face as well as below the bottom of the mask.
C. Observation of CRNA #4 from 9:30-10:54 AM on 03/27/18 showed he was delivering anesthesia to Patient #17 while wearing a regular surgical mask. Facial hair was visible from the edges of the surgical mask to the edges of his face as well as up the temples and the nape of the neck.
D. The Charge Nurse stated in an interview at 9:55 AM on 03/27/18 that the facility adhered to AORN (Association for periOperative Nursing) and CMS (Centers for Medicare/Medicaid Services) and stated surgical staff wore their scrubs from home into the building every day. Surveyor #1 requested the dress code policy and procedure.
E. During an interview in Operating Room #4, at 11:25 AM on 03/27/18 with Surgical Technicians #1 and #2, both stated they wore their scrubs from home into the building every day.
F. During an interview with the Operating Room (OR) Director at 11:55 AM on 03/27/18, she stated that surgeons, anesthesia staff and surgical staff wear their scrub uniforms from home into the building.
G. Observation of Patient #17's surgical procedure showed the disposable oxygen mask was dropped on the floor to the right of the operating room table at 11:22 AM on 03/27/18. The disposable mask was picked up and placed on the pillow on the right side of the patient's head. Physician #6 picked up the disposable oxygen mask, attached it to the anesthesia circuit and ventilated Patient #17 with the mask.
H. During an interview with the Charge Nurse at 11:22 AM on 03/27/18, the findings in A, B and F were verified.


Based on observations, interview, policy and procedure review and AORN (Association of periOperative Nurses) guidelines, it was determined the Infection Prevention Nurse failed to control infections in that semi-critical equipment (laryngoscope blades) was not packaged to prevent recontamination in two (Operating Room (OR) #4 and Nursery) of three (Operating Room, Nursery and Emergency Department) areas. Failure to ensure the equipment was packaged after cleaning to prevent recontamination had the potential to allow dirty equipment to be used in patient care. The failed practice had the likelihood to affect any patient whose care required the use of the laryngoscope blades in the Nursery and Operating Room (OR) #4. Findings follow:

A. Review of the policy and procedure titled "Cleaning of Resuscitation Equipment" received from the Cardiopulmonary Director on 03/26/18 showed the blades were to be washed, soaked for 20 minutes in glutaraldehyde solution and then dried and taken to the appropriate crash cart.
B. Review of the 2015 AORN Guidelines for Perioperative Practice showed laryngoscope blades should be stored in individual packages to minimize the potential for contaminating blades and was a CDC (Centers for Disease Control) recommendation.
C. Observation in the Nursery at 1:55 PM on 03/26/18 showed 13 unpackaged laryngoscope blades lying loosely in an open box in a cabinet. The above findings were verified by Registered Nurse (RN) #1 at 2:00 PM on 03/26/18.
D. Observation in OR #4 at 2:30 PM on 03/26/18 showed 14 unpackaged laryngoscope blades were lying loosely in the second drawer of the Anesthesia Cart. The above findings were verified by the Charge Nurse at 2:35 PM on 03/26/18.
E. The Charge Nurse stated during an interview at 9:55 AM on 03/27/18 that the facility adhered to AORN and CMS (Centers for Medicare/Medicaid Services) guidelines.


Based on observations and interview it was determined the Infection Control Nurse failed to ensure that only clean equipment was utilized in patient care in that one of one stethoscope observed made contact with the floor and was not cleaned prior to use on a patient and was not cleaned prior to hanging it around a Certified Respiratory Therapist (CRT) #1's neck. Failure to clean equipment after contact with contaminated items had the potential to allow cross contamination. The failed practice affected Patient #19 on 03/29/18. Findings follow:

Observation of an updraft treatment administered to Patient #19 by CRT #1 at 10:35 AM on 03/29/18 showed CRT #1 placed the stethoscope in the wire basket on the base of the wheeled workstation. The diaphragm fell through the wire basket on to the floor. CRT #1 moved the wheeled workstation, stepping on the diaphragm initially, and continued to drag the stethoscope on the floor for four feet. After administering the updraft treatment, CRT #1 retrieved the stethoscope, without cleaning it first, and listened to Patient #19's lungs. After listening to the lungs, CRT #1 placed the stethoscope around her neck, resting the diaphragm on her uniform thereby contaminating her uniform as well. During an interview with CRT #1 at 10:55 AM on 03/29/18 the above findings were verified.

Based on observation, review of manufacturer guidelines and interview, it was determined the Infection Prevention Nurse failed to control infections in that the temperature of two of two (Outpatient Center and White County Surgery Center (WCSC) scope cleaning rooms was not monitored to ensure the temperature remained in the range of 59 to 86 degrees Fahrenheit per manufacturer's guidelines. Failure to monitor the temperatures of the scope cleaning rooms did not assure the efficacy of the scope cleaning solution. The failed practice had the potential to affect any patient whose care required the use of scopes processed in the two scope cleaning rooms. Findings follow:

A. Observation of the scope cleaning room at the WCSC at 10:45 AM on 03/28/18 showed the temperature of the room was not monitored.
B. Observation of the scope cleaning room at the Outpatient Center at 12:45 PM on 03/28/18 showed the temperature of the room was not monitored.
C. Review of the Metricide OPA Plus manufacturer's guidelines showed the Metricide OPA Plus was to be stored in the temperature range of 59 to 86 degrees Fahrenheit.
D. During an interview with the Assistant Vice President for Surgical Services at 1:00 PM on 03/28/18, she verified the findings in A, B, and C.


Based on observation and interview, it was determined the Infection Prevention Nurse failed to control infections in that a discharged room was not cleaned from a clean to dirty order. Failure to clean in a clean to dirty order had the potential to allow cross contamination among patients, visitors and staff. Findings follow:

A. Observation of the cleaning of discharged patient Room #2327 at 3:37 PM on 03/27/18 showed the following:
1) Housekeeper #1 cleaned the over-bed table from the table top to the base, then using the same cloth cleaned the couch seat, back cushion, the couch ends and the back of the couch, then using the same cloth cleaned two pillows front and back, the seat of a straight back chair, the back, and then the legs top to bottom; the heating/cooling unit was then wiped down, the window sills were wiped, then the left side, the seat, the back and the right side of a chair were cleaned. Housekeeper #1 then moved to the foot of the bed and cleaned the foot board and the foot of the mattress at which point the initial rag was dropped to the floor.
2) Housekeeper #1 then disposed of rag #1 and retrieved rag #2. Housekeeper #1 cleaned the mattress, the bed rack, the bottom bed frame, the wall-mounted sphygmomanometer including the face and the cord, the left upper side rail, the face of the IV (intravenous) pump, then the face of the PCA (patient controlled analgesia) including the cord and button, the IV pole and base, then the telephone, the nightstand top, first drawer and the inside of the bottom cabinet. Housekeeper #1 then moved to the bathroom and raised the toilet seat and cleaned the underneath of the toilet seat, then cleaned the toilet bowl rim then lowered the toilet seat and cleaned the seat.
3) Housekeeper #1 then disposed of rag #2 and retrieved rag #3. Housekeeper #1 cleaned the base of the flush connecting pipe attached to the back of the commode base, then up to the top of the pipe and then the handle. Housekeeper #1 then cleaned the toilet bowl base.
B. The Director of Environmental Services (EVS) stated during an interview at 3:50 PM on 03/27/18 that the housekeepers were not taught top to bottom, clean to dirty and there was nothing in the policy and procedure specifying top to bottom or cleanest to dirtiest order.


31039

Location A
Based on review of Physician's Tuberculosis(TB) records, policy and interview, the Infection Prevention Nurse failed to control infections in that two (#2 and #5) of five (#1-#5) Physicians for TB ) were not annually screened for TB. By not assuring the Physicians were screened annually, the facility couldn't assure they were controlling infections and communicable diseases of patients and personnel. The failed practice had the likelihood to affect all of the employees and patients in the facility. Findings follow:

A. Record review of the facility's policy titled, "Associate TB Skin Testing," dated 01/2016, showed that all associates will be screened for TB upon hire and annually.
B. Review of the Physician's Tuberculosis records showed Physicians #2 and #5 had no evidence of an annual TB screening.
C. During an interview on 03/27/18 at 4:01 PM, the Chief Nursing Officer verified the findings at A and B.


38994

Location A

Based on observation, review of package insert and interview, it was determined the Infection Prevention Nurse failed to control infections in that one of one single use 1000 ml (milliliter) bag of 0.9% Sodium Chloride was used for multiple patients in the CT (Computerized Tomography) Scan auto injector. The failed practice did not ensure the Sodium Chloride solution was free of contaminates and had the potential to affect all patients requiring CT Scans with Sodium Chloride injection. Findings follow:

A. Review of the package insert for Sodium Chloride Injection showed the solution contained no bacteriostatic, antimicrobial agent or added buffer and each was intended only as a single-dose injection. When smaller doses were required, the unused portion should be discarded.
B. Tour of the Radiology Department's CT Scanning room on 03/28/18 at 9:15 AM showed a single use 1000 ml bag of 0.9% Sodium Chloride solution hanging from the CT Scanner with 600 ml left to count dated 03/28/18.
C. During interview with the Director of Radiology on 03/28/18 at 9:15 AM, she stated the current practice was to use one 1000 ml bag of 0.9% Sodium Chloride for all patients requiring a CT Scan in a 24-hour period.
D. The above findings in A, B, and C were verified with the Director of Risk Management and Compliance on 03/28/18 at 9:20 AM.


Location A
Based on observation and interview, it was determined the Infection Prevention Nurse failed to control infections in that open packages and unpackaged patient use items (9 of 9 bioclusive dressings and 8 of 8 Yanker suction catheters) were found in the pre and post-operative areas in the Surgery Center. Failure to ensure package integrity at time of use did not ensure these items were free from contamination prior to use. The failed practice had the potential to affect all patients having surgery in the Surgery Center. Findings follow:

A. During tour of the Surgery Center on 03/25/18 at 10:35 AM, showed nine unpackaged bioclusive dressings were found in the drawer at the pre-operative desk.
B. During tour of the post-operative area of the Surgery Center on 03/28/18 at 10:45 AM, showed eight open Yanker suction catheters in Post-operative Bays #1-6, #9 and on the crash cart. Two open oxygen masks were found in the drawer of post-operative bays # 3 and # 5.
C. During interview with the Surgery Center Director on 03/28/18 at 10:45 AM, she stated current practice was to have open and ready equipment in each post-operative bay.
D. The above findings in A, B, and C were verified with the Chief Nursing Officer on 03/28/18 at 10:50 AM.

Location A
Based on review of credential files of Certified Registered Nurse Anesthetists (CRNAs), review of Anesthesia Services Contract, review of Arkansas Department of Health Rules and Regulations for Hospitals (2016) and interview, Anesthesia Services failed to ensure two (#1 and #4) of four (#1-#4) CRNAs had current Life Support Certification. By not assuring all certifications are current and up to date, Anesthesia Services could not assure CRNAs #1 and #4 would be competent in an emergency situation. The failed practice had the likelihood to affect all patients admitted into the Surgery Center for procedures. Findings follow:

A. Record review of Anesthesia Services Contract showed CRNAs were to comply with the Arkansas Department of Health Rules and Regulations for Hospitals.
B. Record review of the Arkansas Department of Health Rules and Regulations for Hospitals, Section 11.B.6. showed that all licensed nursing personnel shall be competent in life support measures.
C. Review of CRNAs credential files on 03/27/18 showed that CRNA #1 and #4 did not have evidence of current competencies in life support measures.
D. During an interview on 03/28/18 12:01 PM, the Chief Nursing Officer verified the findings at C.

Location A
Based on observation, review of policy and interview, it was determined Anesthesia Services failed to have 18 vials of Dantrolene in the Ambulatory Surgery Center (ASC) to treat a Malignant Hyperthermia (MH) Emergency. By not stocking 18 vials of Dantrolene, Anesthesia Services could not assure they were prepared for a Malignant Hyperthermia Emergency. The failed practice had the potential to affect all patients admitted for surgical procedures. Findings follow:

A. Record review of the policy titled, "Malignant Hyperthermia," dated 10/2015, showed the ASC should have stocked 18 vials of Dantrolene. Six were stored in the MH cart, and twelve were supposed to be stored in Post-Acute Care Unit (PACU)
B. A tour of the ASC on 03/28/18 from 10:30 AM to 11:10 AM showed the facility did not have 12 of the 18 vials required for Dantrolene.
C. During an interview on 03/28/18 at 10:58 AM, the Director of the Ambulatory Surgery Center verified they did not have the full 18 vials of Dantrolene, as the policy stated they would.

Location A
Based on review of Centers for Disease Control and Prevention (CDC) Infection Control Guidelines, observation and interview, it was determined Anesthesia Services failed to take proper precautions to prevent potential infections in that Multiple Dose Vials (MDV) were used, stored and available for patient use in one of one (Room #4) Operating Room toured (immediate patient treatment area). By not adhering to CDC Guidelines for safe injection practices, Anesthesia Services could not assure they wouldn't cross contaminate a MDV and use on other patients. The failed practice had the likelihood to affect all patients requiring Anesthesia Services. Findings Follow:

A. Review of CDC's 2007 (last updated 10/2017) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, IV.H. Safe Injection Practices, showed MDVs were not to be kept and accessed in immediate treatment areas, for multiple patients.
B. During a tour of Surgical Services on 03/26/18 from 2:07 PM to 2:50 PM, observation showed two open vials of Atropine 8 milligram/20 milliliter MDV. One was labeled with an expiration date of 04/21/18 and one was labeled with an expiration date of 04/05/18.
C. During an interview on 03/26/18 at 2:36 PM, Physician #1 verified, the open vials of Atropine were accessed in the immediate patient treatment area and the MDVs were used on more than one patient.

Based on review of physical therapy policy, review of physical therapy personnel files, and interview, Location B failed to ensure one (Physical Therapy Assistant #1) of two (Physical Therapy Assistant #1, Physical Therapist #1) physical therapy personnel were currently trained and certified in basic life support technique. The lack of current training and certification had the likelihood to affect all patients in the Physical Therapy Department at Location B requiring basic life support measures. Findings follow:

A. Review of policy titled, "CPR[cardiopulmonary resuscitation] Certification/BLS [basic life support]," on 03/28/18 at 9:45 AM showed all department staff that participate in patient care would be trained and certified in basic life support techniques.
B. Review of physical therapy personnel files on 03/28/18 at 10:15 AM showed Physical Therapist Assistant #1 had certification in basic life support that expired on 08/04/17.
C. During an interview with Physical Therapist #1 on 03/28/18 at 10:30 AM, it was verified the training/certification in basic life support had expired.