HospitalInspections.org

Based on observations and personnel interview, the facility failed to maintain a system to ensure the safety of patients.

The findings included:

During a tour of the Outpatient Chemotherapy Infusion Area on 08/27/20, rooms 2 and 3 had the call light wrapped around the handicap rail in the bathroom. If a patient fell, there was no way to call for assistance.

An interview with Personnel 14 on 08/27/20 confirmed the above findings.

Based on observation, record review, and personnel interview, the facility failed to maintain a clean and sanitary environment.

The findings included:

During tours of the facility on 08/27/20 and 08/28/20, the following was observed:

*Lower Level:
-Multiple stained and cracked ceiling tiles throughout
-Wallpaper and baseboards peeling in the clean laundry area
-Dirty Laundry area contained a bucket of Tri-Star Chlorite which had brown and black flaky particles all over the bottom and approximately 4 inches up the plastic container.

*Post-Op Area:
-Linen cart had no barrier on the bottom shelf. When sweeping and mopping, barriers prevent splatter up to clean linen.
-A review of the Refrigerator Temperature Log stated, "Optimal refrigerator temperature 33-38 [degrees Fahrenheit]. Contact Dietary Supervisor or Plant Ops for temperatures outside this range." A review of the log revealed on 08/18/20 and 08/26/20, the temperatures were documented at 40 degrees Fahrenheit. There was no indication the staff had reported the out-of-range temperatures to the Dietary Supervisor or Plant Ops.
-Three patient ice packs were stored in the freezer where nutritional supplements (popsicles) were kept.

*Outpatient Chemotherapy Infusion Area:
-In the supply room, there was no barrier on the bottom shelf were clean supplies were stored. When sweeping and mopping, barriers prevent splatter up to clean supplies. There were also corrugated boxes mixed with clean supplies.
-A refrigerator with patient nourishment supplies (sodas, juice, water) was noted with no thermometer or documentation of refrigerator temperatures.

*Radiology Department:
-The contrast warmer in the CT room contained 8 bottles of Isovue-370 contrast and 6 normal saline 50 cc bags. There was no date to indicate how long the contrast and normal saline had been in the warmer. There was no working thermometer. When the surveyor asked for a log, Personnel 38 provided a log that indicated the last check was completed on 11/09/18. There were no temperature ranges. When asked for a policy, Personnel 38 stated there was no policy.
-The refrigerator in the CT room contained 5 Barium contrast bottles. When the surveyor asked for a log, Personnel 38 provided a log that indicated the last check was completed on 11/09/18. There were no temperature ranges. When asked for a policy, Personnel 38 stated there was no policy. Observed a large amount of ice build-up.

*Physical Therapy Area:
-A review of the Hydrocollator Log revealed there was no consistent documentation on the cleaning.

A review of the policy titled, "Infection Control Guidelines," revealed, "Equipment will be clean according to manufacturer recommendations."

A review of the manufacturer's recommendations for the "Chattanooga Hydrocollator" revealed it should be cleaned every 2 weeks with vinegar and water.

*Respiratory Area:
-There were 3 boxes of respiratory supplies sitting directly on the floor
-There were corrugated boxes mixed with open clean supplies
The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation (AAMI) state, "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).

The above was confirmed during the tours with Personnel 1, 3 and 12.