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Based on interview, review of documentation of 6 of 6 employees requiring certification and review of policy and procedures, it was determined the CAH failed to fully implement its policy and procedures for food handler's certification and BLS certification. Staff that required certifications for food handlers and BLS were not current as required by the CAH policy.

Findings include

A review of a policy and procedure titled "Job Title: Cook" dated approved/revised "02/2007" was reviewed. It stipulated that "...Must possess Oregon Food handler's card within 30 days of appointment...Must possess CPR within 180 days of appointment."

A review on 04/25/2017 at 1515 of staff who required certification reflected 6 staff members obtained current food handler's certifications on 04/25/2017.

During an interview on 04/6/2017 at 1300 the Dietary department supervisor confirmed 5 employees had expired food handler's certifications and 1 employee had not obtained a certification. He/she confirmed 2 employees had expired BLS certifications.

Based on observation and interviews, it was determined the CAH failed to develop and implement policies and procedures to ensure that a manual jet ventilator available for emergency use had been identified, inventoried, and maintained.

Findings include:

1. During a tour of the surgical services department on 04/26/2017 at 1000 a manual jet ventilator observed did not have an inventory tag, a preventive maintenance sticker, or any other identifying information. The ventilator was also missing the cover for the pressure gauge.

* During interview with the DPC at the time of the observation he/she stated, "I don't think that [manual jet ventilator] has ever been used."

* During interview with the CEO on 04/26/2017 at 1630 he/she stated "We don't have a policy or procedure for [use of] the manual jet ventilator."

Based on observation, interview, review of PM documentation and policies and procedures, it was determined that the CAH failed to develop and implement written policies and procedures to ensure that all facility and patient care equipment had been maintained to ensure an acceptable level of safety and quality: All patient care equipment was not incorporated into the CAH inventory and there was a lack of PM documentation.

Findings include, but not limited to:
1. There were no written facility and equipment PM plans or policies and procedures.

2. On 04/25/2017 at 1140 observations in the Rehabilitation Department revealed the following:
* A TENS unit loaned out to patients had no identifiable inventory/property # and no evidence of PMs;
* All fitness equipment had no identifiable inventory/property #.

3. On 04/26/2017 at 0830 observations in the Sleep Lab revealed the following:
* Two Norco Desensitizers had no identifiable inventory/property # and no evidence of PMs;
* A treatment chair had no identifiable inventory/property # and no evidence of PMs.

4. On 04/26/2017 at 1040 observations in the Infusion Clinic revealed the following:
* Two treatment chairs had no identifiable inventory/property # and no evidence of PMs.

5. On 04/25/2017 at 1525 observations in Respiratory Therapy revealed the following:
* Two Spirometers had no identifiable inventory/property # and no evidence of PMs;
* A home nebulizer machine had no identifiable inventory/property # and no evidence of PMs;
* An ECG machine had no identifiable inventory/property # and no evidence of PMs; and
* A hospital bed had no identifiable inventory/property # and no evidence of PMs

6. On 04/26/2017 at 1115 observations in SPD revealed the following:
*A Steris Warming Cabinet had no identifiable inventory/property # and no evidence of PMs
*A Steris SteamSterilizer had no identifiable inventory/property # and no evidence of PMs
*A Heat Sealer had no identifiable inventory/property # and no evidence of PMs

7. During an interview with the Facilities Manager on 04/27/2017 at 1315, he/she confirmed that the hospital's biomed equipment PM is completed semiannually by St Charles Medical Center and that the above equipment, devices and the hospital's durable medical equipment such as hospital beds and treatment chairs were not incorporated into the "Active Equipment List for HDH" and there were no records of PM. In regards to if the hospital maintained a hospital-wide inventory list for all facility and medical equipment essential to the operation of the CAH, he/she stated "I'm not quite sure if there is even a list."

Based on observations, interviews, review of policies and procedures, and review of other documentation it was determined the CAH failed to fully develop and implement policies and procedures in the following areas:
* Grievance Process

1. A policy and procedure titled "Grievance Process" dated approved/revised 11/30/2007, was reviewed. It stipulated that "The Administrator, or his designee, shall contact the complainant within three (3) working days of receipt of the grievance...The Administrator shall issue a written decision regarding the validity of the grievance no later than thirty (30) days after its filing. Harney District shall maintain the files and records of grievance, the investigation, and the written decision."

* During review of a grievance on 04/26/2017 at 1000 the DON reported documentation of the grievance reflected a patient's spouse reported an incident to a physician that his/her spouse was evaluated at the hospital on 08/12/2016 for onset of lumps bilateral arms. The hospital was unable to perform the ultrasound to rule out DVT due to ultrasound technicians are not available in the evenings. The patient returned the next day and ultrasound results were obtained. The DON confirmed the patient was contacted by the CEO. He/she confirmed documentation did not state the date patient was contacted. He/she confirmed there was no evidence of a resolution letter provided to the patient.

* During review of a grievance on 04/26/2017 at 1000, the DON reported documentation of patient involved in a trauma auto accident. The patient phoned in on 02/28/2017 with a complaint of inadequate pain relief prior to transfer to another hospital. The DON confirmed there was no evidence of an investigation and no evidence of correspondence to the patient.

* During review of a grievance on 04/26/2017 at 1000, the DON reported documentation of a grievance received by a patient on 09/14/2016 admitted to labor and delivery. The patient attached and submitted a complaint to a hospital survey. The patient reported the staff treated her differently after complaining of discomfort when the nurse pushed on her fundus too hard. The DON confirmed the hospital placed a phone call to the patient on 10/14/2016 and during the call the hospital confirmed with the patient that she had received a resolution letter. During review of the complaint, the hospital was unable to provide evidence of that letter mailed to the patient.





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37917

Based on observations, interviews, and review of policy and procedures, it was determined the CAH failed to ensure that medications were stored, handled, and labeled appropriately and outdated or otherwise unusable drugs are not available for patient use.

Findings include:

1. During observation of a surgical procedure with the DPC on 04/26/2017 beginning at 1000, one unlabeled 20cc syringe containing 15cc's of white fluid, and one empty 3cc syringe labeled "Midazolam" were observed lying on the anesthesia cart immediately after the case concluded. The syringes were not dated, timed, or authenticated.

2. During tour of the surgical services department on 04/26/2017 beginning at 0845 a cart containing intubation equipment and medications was observed. It contained approximately 80 vials of various local anesthetics, including 8 vials of Lidocaine with Epinephrine in an unlocked, toolbox-like cart. The key to the lock was observed laying inside the unlocked box.

* During further tour of the surgical services department at the same time a Cellsaver was observed with a one liter bag of 0.9% Sodium Chloride hanging from the IV pole attached to the unit. The bag of Sodium Chloride had a orange sticker affixed to the front of the bag with the following handwriting on it "0650 [time], 01/3/17 [date], 30,000 units heparin" the sticker was initialed by the OR manager. The bag was connected to IV tubing and attached to the machine available for patient use. This rendered this piece of emergency equipment not ready for emergency use.

3. During an interview with the OR manager on 04/27/2017 beginning at 0815 he/she stated "That bag of Heparin that is attached to the CellSaver was for a training. It shouldn't be there. It should have been thrown away."

4. During tour of the sterile processing department on 04/26/2017 at 1130, a blue plastic storage bin observed located on the bottom shelf of a clean supply unit, contained one bottle of Kenalog 40mg/ml an injectable steroid, two bottles of Bupivacaine 2.5mg/ml injectable local anesthetic, and one bottle of Sodium Bicarbonate 50 mEq. for injection.

5. During a tour of the ED on 04/25/2017 beginning at 0920, the infant/child emergency response kit was observed. The kit contained two containers of Lidocaine Hydrochloride Oral Topical Solution that had expiration dates of "02/17."

6. Review of a policy titled "Storage, Labeling, and Discarding Requirements for Drug Products," dated "10-01," stated "Drugs must be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security."

7. Review of an additional policy titled "High Alert Medications" dated 06/06/2016 reflected "High Alert Medications are drugs that bear a higher risk of causing significant patient harm..." "...medications appropriate for inclusion in this High Alert Medication policy...Lidocaine with epinephrine..." Further, "If High Alert Medications must be kept in patient care areas, locked storage areas shall be used..."

8. During an interview with the OR manager on 04/27/2017 beginning at 0800, he/she stated, "all drugs are supposed to be locked up and narcotics are double locked."

Based on observation, interview, and review of policies and procedures it was determined the CAH failed to fully develop and implement policies and procedures for infection prevention in the following areas:
* Disinfection and cleaning supplies were not dated when poured into secondary containers;
* Patient care supplies were outdated or otherwise unusable;
* Outdated and unlabeled food was stored in patient nourishment refrigerators;
* Hand hygiene practices;
* Labeling of IV tubing.

1. During a tour of the ED on 04/25/2017 beginning at 0920 with the DPC the following observations were made:
* A bottle of Gastrocult developer with an expiration date of "02/2017" and two Gastrocult slides, both with expiration dates of "03-17;"
* Three 8F and one 12F Foley catheters all with the expiration date of "23-12-2016;"
* Three 14g IV cannulas with an expiration date of "2016-01;"
* Two 16g IV cannulas with expiration dates of "2015-06;"
* One 16g IV cannula with an expiration date of "2016-03;"
* Two IV blood infusion tubing packages with expiration dates of "2016/03;"
* An infant/child intubation tray had red tape across the top that read "Expired Blades 03/16." Additionally, a list of contents dated 11/28/2015 was taped to the top of the tray and contained a note that read "Expired blades until new ones arrive;"
* A capnography CO2 detection device had an expiration date of "2015-12;"
* A GlideScope Cobalt/Ranger GVL 1 Stat device had an expiration date of "2014-10-06;"
* A 15g IO needle set with an expiration date of "04/2016;"
* A 15g IO needle set with an expiration date of "06/2014;"
* An EZ-Connect fluid transfer set with a female luer lock with an expiration date of "04-2011;"
* An EZ-Connect fluid transfer set with female luer lock with an expiration date of "08-2015;"
* Two 7F Percutaneous Sheath Introducer Kits were observed in a cabinet under the ED nursing area sink with expiration dates of "2015-03;"
*Multiple wall mounted suction containers observed in the ED had hand-held suction wands attached to suction tubing in open packages. It was unclear if the hand-held suction wands were clean or unused.
* Review of the ED infant/child emergency kit at the time of tour revealed it contained outdated care items. The findings included two 20g IV cannulas with expiration dates "2011-06" and "2011-08," two 22g IV cannulas with expiration dates "2011-03" and "2011-07," and one 24g IV cannula with an expiration date of "2013-12." One 12F Foley catheter with an expiration date of "2013-11."
* Review of the ED difficulty airway cart at time of tour revealed an open Combitube intubation tube with writing on the package that stated, "Not Sterile Was Opened (New Has Been Ordered)." The Combitube was in the emergency airway cart and available for patient use.
* Similar findings related to outdated supplies were identified throughout the ED supply area.

* A clear plastic bottle with "Bleach" written on it and an illegible chemical safety sticker affixed to the front was observed under the sink in ED trauma treatment bay. There was no date, time, or initials on the bottle to reflect when it was transferred to the secondary container. There was also no discard date. Similar findings were present in the surgical services undersink storage area.
*A clear plastic bottle with clear fluid inside had written on the side "Ice Machine Sanitizer." The bottle did not include the date, time, or initials of the person who transferred the cleanser into the secondary container.

Review of the policy titled "Event Related Sterility of Packages," dated "7/31/15" reflected "All packaging will be inspected prior to arrival at point of use...[for] compromised sterility." "Any item with indications of package compromise must be returned to decontamination area."

During an interview with the DPC at the time of observations, he/she stated "we need to do a better job checking for outdates."

During an interview with the DPC at the time of observation, he/she stated "are they supposed to date and time it?"

During an interview with the CFO on 04/25/2016 at 1545, he/she stated "We don't have a policy related to [transferring chemicals into] secondary containers." Further, in an email communication received from the CFO on 05/01/2017, it reflected a draft policy titled "Chemical Labeling for Secondary Containers" dated, 05/01/2017. The draft policy indicated "...Labeling is required of secondary containers used for cleaning, decontamination and disinfection that are to be stored for later use...Affix a label...identifying the following: Chemical name...Date Mixed...Replace After...Initials...Other Comments..."

2. During a tour of the Infusion Clinic on 04/26/2017 at 1040 with the Infusion RN, a patient was observed receiving an infusion with unlabeled IV tubing.

A procedure titled "Lippincott Procedures - IV administration set (tubing) change" was reviewed. It stipulated, "...Label the administration set and solution container with the date of initiation or the date when change is necessary, as directed by your facility..."

During an interview with the CFO on 04/27/2017 at 1530, he/she stated the hospital was unable to provide a policy regarding IV tubing changes and that the hospital uses the Lippincott procedure for IV tubing changes.

During an interview with the Infusion RN at that time he/she stated that "we do not always mark IV lines, often there is just a single line running."

3. During a tour of the surgical services area on 04/26/2017 beginning at 0900 a malignant hyperthermia cart was observed to have contained the following outdated items:
* Two IV start kits with expiration dates of "6/16" and "07/16;"
* A 22g IV cannula with the expiration date of "2016-06;"
* A 20g IV cannula with the expiration date of "2016-07;"
* Three 18g IV cannulas, one with the expiration date of "2016-05" and two with the date of "2016-06;"
* One GE Healthcare HMEF 1000/S, Disposable HME with intergrated bacterial viral filter with sampling port. The expiration date listed on the package was "2015-11."

4. On 04/26/2017 beginning at 1000, during an observation of a surgical procedure on a patient in contact isolation with a known MRSA history, the CRNA touched the patient's face, hands, and head without gloves, then touched the roller clamp on the patient's IV.

Review of a policy titled "Standard Precautions," dated 04/08/2013 reflects "Gloves are to be worn when touching...contaminated items...Gloves shall be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms."

During an interview with the OR manager on 04/27/2017 beginning at 0800 he/she stated, "Standard precautions are that everyone should be wearing gloves with isolation patients."

5. During a tour of the ICU department on 04/25/2017 at 1030 the following outdated patient supplies were observed:
* Six tegaderm dressings with an expiration date of "02/2012;"
* One container of Sanicloths with an expiratioan date of "03/2017."

6. During a tour of the Labor and Delivery department patient supply room on 04/25/2017 at 0915 the following outdated patient supplies were observed:
* One box of tegaderm with an expiratioan date of 2014;
* One box of Sure klens ampoules with an expiration date of 2012;
* One container of Chemstrips with an expiration date of 2016.

7. During a tour of the Med/Surg department patient supply room on 04/25/2017 at 0950 the following outdated patient supplies were observed:
* One box of G.I test strip with an expiration date of 03/2017;
* Two tegaderm dressings with an expiration date of 2014.

8. During a tour of the Dietary Department on 04/25/2017 at 1415 the following supplies were observed:
* One opened box of Minute Rice on a supply shelf
* One opened box of Cornmeal on a supply shelf

During an interview with the dietary supervisor at the time of the observations, he/she reported "we don't have a policy for putting the contents of an open box in a closed container, we use those supplies up fast so they're not sitting on the shelf very long."


37237

Based on documentation for 3 of 3 blood transfusions in 3 of 3 medical records reviewed (Patients 3, 4 and 5), review of the document "Blood Product Issue Log," and review of policies and procedures, it was determined that the CAH failed to ensure that the "Transfusion Record," the "Blood Product Issue Log," and a Physician's Order were accurately documented.

Findings include:

1. Review of medical record of Patient 3 contained the document "Transfusion Record." The Transfusion Record reflected the Patient 3 received a blood transfusion that was started on 11/20/2016 at 0200 and was stopped on 11/20/2016 at 0300. The Transfusion Record reflected that the "15 Minutes After Start" section used to record vital signs was blank.

Patient 3 received a second blood transfusion that was started on 11/20/2016 at 0315 and was stopped on 11/20/2016 at 0400. The Transfusion Record reflected that the "15 Minutes After Start" section used to record vital signs was blank.

Patient 3 received a third blood transfusion that was started on 11/20/2016 at 1025. The Transfusion Record reflected that the Stop Date and Time were blank.

The Transfusion Record reflected Patient 3 received a fifth blood transfusion that was started on 11/21/2016 at 0030 and stopped on 11/21/2016 at 0100. The document "Blood Product Issue Log" was reviewed and reflected that the time the unit was issued from the lab was blank.

2. Review of medical record of Patient 4 contained the document "Transfusion Record." The Transfusion Record reflected Patient 4 received a blood transfusion that was started on 04/07/2017 at 1435 and was stopped on 04/07/2017 at 1715. The Transfusion Record reflected a time of 1505 in the "15 Minutes After Start" section to record vital signs. Vital signs were not recorded until 30 minutes after the transfusion started.

The Transfusion Record for Patient 4 reflected he/she received a second transfusion. The Start Date and Time were blank. The transfusion was stopped on 04/08/2017 at 0050.

3. Review of medical record of Patient 5 contained the document "Transfusion Record." The Transfusion Record reflected Patient 5 received a blood transfusion that was started on 01/20/2017 at 2235. The Transfusion Record reflected that the Stop Date and Time were blank.

The medical record of Patient 5 reflected an authenticated hand-written Physician Order for two units PRBCs. The Physician Order was not dated or timed.

The policy titled "Transfusion of Blood Products." date effective "11/2008" was reviewed. It stipulated that: "The Lippincott procedure for Blood and Blood Product Transfusion shall be followed for administration." It further stipulated "...Documentation: The Transfusion Record form will be utilized to...Record start time and vital signs as listed..."

Review of the Lippincott Procedure "Blood and blood product transfusion," date revised 08/12/2016, reflected "On the transfusion record, document: the date and time the transfusion was started and completed...the patient's vital signs before, during and after the transfusion..."