HospitalInspections.org

Based on observation, review of humidity logs, and staff interview, the facility failed to ensure that equipment and supplies used in the OR were appropriate for the humidity level in 2 of 2 actively maintained ORs. The findings were:

1. Observation of 2 of 2 ORs on 6/14/16 at 4:15 PM with the OR supervisor revealed the humidity level was less than 20% in both rooms. Interview with the OR supervisor at that time revealed the maintenance director was responsible for monitoring the temperature and humidity of the ORs.

2. Interview on 6/15/16 at 1 PM with the maintenance director revealed he did not have a system for monitoring or maintaining logs of the humidity levels, because the only time they needed to address concerns with humidity was in response to the automatic alarm that activated when the humidity was out of range. He stated the range for the alarm was 20% to 60%; and he was not aware of any additional requirements when humidity levels were maintained below 30%.

3. Interview on 6/15/16 at 3:30 PM with the infection control supervisor revealed the facility had not implemented measures to address potential impact of maintaining humidity levels below 30% in the ORs.

4. According to "Relative Humidity Levels in the Operating Room Joint Communication to Healthcare Delivery Organizations, January 2015" (developed at a multi-organization stakeholder meeting convened by AAMI [Association for the Advancement of Medical Instrumentation], website: <>, accessed 5/23/16), "...relative humidity can impact the shelf life and product integrity of sterile supplies...other consumables for some electrosurgical products also are humidity-sensitive...relative humidity may affect the operation of some electro-medical equipment used in the OR...this equipment may malfunction unexpectedly. Too low humidity levels may also impact calibration...Before establishing or re-establishing the low end design RH [relative humidity] levels below 30% in the OR, healthcare facilities should assess the impact of lower RH on the equipment and supplies being used...Have you determined what the IFUs [instructions for use] say about humidity levels for each item in the HDO's [healthcare delivery organization] existing inventory of supplies and equipment used in the OR?"

Based on review of service contracts/agreements and staff interview, the facility failed to ensure policy and procedures were developed to describe 2 of 6 services (radiology, pharmacy) which were provided by contracts/agreements. The findings were:

Review of contract agreements showed there were 2 services which were provided at the hospital which were not included on the "List of Contracted Services." These services were for radiology and pharmacy consulting services. Review of the policy and procedure manuals showed information for these contracted services were not included. Interview with the director of nursing services on 6/16/16 at 10 AM verified policies and procedures related to these 2 contracted services were lacking.

Based on observation, staff interview and review of sterilization and disinfection logs and policy and procedure, the facility failed to ensure laryngoscope blades and handles were disinfected and packaged according to acceptable standards of infection prevention practices. In addition the facility failed to develop a policy and procedure that included acceptable standards of practice for sterilization and disinfection. The findings were:

1. Observation of the OR on 6/14/16 at 4:15 PM with the OR supervisor revealed unpackaged laryngoscope handles and blades located in the drawers and on top of 2 anesthesia carts and 1 resuscitation cart. At that time the operating room supervisor stated the handles and blades were routinely reprocessed using the cold sterilization method after use and returned to the carts unpackaged. She further stated staff followed the "Sterilization" policies and procedures for reprocessing surgical, supplies, and equipment, like laryngoscope blades and handles, that could not be sterilized in the steam sterilizer.

2. Review of the policy and procedure titled, "Sterilization", revised 11/9/15, showed directions for staff to use a disinfection solution (CIDEX) for sterilizing reprocessed surgical supplies and equipment. Interview on 6/15/16 at 4 PM with the infection control supervisor revealed this policy and procedure needed to be revised because Cidex should not be used for sterilization.

3. Interview on 6/15/16 at 5 PM with the operating room supervisor revealed she had no record or system for verifying when the laryngoscope handles and blades had been disinfected or how long they had been unpackaged in drawers and on the tops of the carts. She further stated she understood the rationale for disinfecting and packaging the blades and handles, but this had not been done. Review of the sterilization and disinfection logs for 1/2/16 to 6/13/16 showed no record of cleaning and disinfecting laryngoscope handles and blades. Further review revealed it was unclear whether Cidex had been used for sterilizing other equipment and supplies that could not be steam sterilized.

4. Interview with the CNO on 6/16/16 at 10:45 AM revealed the emergency cart in the emergency department and on the nursing care units also contained unpackaged laryngoscope handles and blades.

5. According to the Association of Perioperative Registered Nurses 2015 Edition of Guidelines for Perioperative Practice, the standards and recommendations for sterilization and disinfection include: Laryngoscope blades are semi-critical devices that require at a minimum high-level disinfection and "high-level disinfection devices that cannot be place in appropriate barrier material are prone to recontamination when stored".

Based on review of service agreements, staff interview, and review of the services list, the facility failed to ensure 2 of 6 contracted services (pharmacy and radiology) were included in the list. In addition, the list failed to include descriptions of the services furnished under agreements including the nature and the scope of the services provided. The findings were:

1. Review of the "List of Contracted Services" showed there were 4 services: Occupational Therapy, Physical Therapy, Speech Therapy, and certified registered nurse anesthetist (CRNAs). The list failed to show a description of the services provided and the scope and frequency.

2. Review of contract agreements showed there were 2 services which were provided at the hospital which were not included on the list. These services were for radiology and pharmacy consulting services.

3. Interview with the director of nursing services on 6/16/16 at 10 AM verified the list was not complete and did not provide details related to the services provided under contracts or agreements.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure the physician signed 4 of 20 sample patient records (#3, #4, #12, #14) who had history and physicals completed by non-physician practitioners. The findings were:

1. Review of the medical record showed patient #4 was admitted to swing bed status on 5/16/16 for diagnoses which included abscess and uncontrolled diabetes. The history and physical was completed by a Physician Assistant - Certified. The medical record did not include a physician co-signed signature for the history and physical.

2. Review of the medical record showed patient #14 was admitted to inpatient status on 3/28/16 for diagnoses which included congestive heart failure. The history and physical was completed by a Family Nurse Practitioner. The medical record did not include a physician co-signed signature for the history and physical.

3. Review of the medical record showed patient #3 was admitted to swing bed status on 1/18/16 for diagnoses which included chronic systolic heart failure and hypoxia. The history and physical was completed by a Physician Assistant - Certified. The medical record did not include a physician co-signed signature for the history and physical.

4. Review of the medical record showed patient #12 was admitted to inpatient status on 3/22/16 for diagnoses which included and chronic obstructive pulmonary disease. The history and physical was completed by a Family Nurse Practitioner. The medical record did not include a physician co-signed signature for the history and physical.

5. Review of policy and procedure for "Physician Assistance Guidelines", revised 12/30/15, showed, "...Histories, physical examinations and other chart entries must be reviewed and countersigned by the responsible physician(s)."

6. Interview with the medical records health information director on 6/15/16 at 4:30 PM verified the lack of the physician's required signature and further stated a policy and procedure had not been developed that specifically addressed physician responsibility for co-signing history and physicals completed by all allied professionals.

Based on medical record review and staff interview, the facility failed to ensure comprehensive assessments were completed for 3 of 3 sample swing bed patients (#1, #2, #4). The findings were:

1. Review of the medical record showed patient #1 was admitted to swing bed status on 5/9/16. Review of the 14 day assessment showed it was dated 5/23/16. The assessment was a collection of data related to a variety of areas. There was no summary or analysis of the data to determine if care planning was needed. In addition, the review showed the required areas of vision and dental had no data/information.

2. Review of the medical record showed patient #2 was admitted to swing bed status on 5/23/16. Review of the 14 day assessment showed it was dated 6/6/16. The assessment was a collection of data related to a variety of areas. There was no summary or analysis of the data to determine if care planning was needed.

3. Review of the medical record showed patient #4 was admitted to swing bed status on 5/16/16. Review of the 14 day assessment showed it was dated 5/30/16. The assessment was a collection of data related to a variety of areas. There was no summary or analysis of the data to determine if care planning was needed. In addition, the review showed the required areas of vision, physical functioning, and dental had no data/information.

4. Interview with the director of nursing services on 6/15/16 at 9 AM revealed the assessment forms had been revised recently and a section for summary or analysis of the data was not included. She verified the data needed to be analyzed to develop care plans.