HospitalInspections.org

Based on observation, interview, review of preventive maintenance records, and review of policies, procedures and manufacturer's instructions, it was determined the CAH failed to ensure that all electrical and patient care equipment had been tracked, inspected and maintained to ensure an acceptable level of safety and quality. Patient care equipment throughout the hospital had not been subject to PM in accordance with manufacturer's recommendations and hospital policies and procedures.

Findings include:

1. On 01/10/2017 at 1428 a WelchAllyn SureTemp thermometer was observed in the ED with no visible inventory number. A purple "Biomedical Engineering" sticker affixed to the thermometer reflected "No PM Required" with a recorded date "11/23."

On 01/11/2017 at 1130 a WelchAllyn SureTemp thermometer was observed inside the Respiratory Therapy Suite. A PM Sticker reflected "Inspection Due 11/2016."

During an interview on 01/13/2017 at 1000 with ADM of Plant Engineering, he/she stated that the hospital does not do any PM on the WelchAllyn Sure Temp thermometers because "there's nothing to PM" on the devices. The ADM of Plant Engineering stated that he/she had reviewed the manual and found no recommended interval for PM for the thermometers.

Review of the 2003 WelchAllyn Service Manual revealed the following: "Preventive Maintenance...The following preventive maintenance is recommended to maximize uninterrupted service with the SureTemp Plus Model 690 and 692 Thermometers...Six-Month Maintenance, Units that are in service on a regular basis should have the following preventive maintenance performed every six months...Perform the Power-On Self Test and Model 6900 or 9600 Plus Calibration Testing procedure found in the Model 9600 or 9600 Plus Operation Manual."

2. During a tour of the Rehabilitation Unit on 01/11/2017 at 1015, a splint warmer was observed to have a PM sticker that reflected, "Electrical Safety Test...Inspection Due 11/2016."

During review of PM records on 01/12/2017 at 1000, with the ADM of Plant Engineering and a Biomed Tech II it was confirmed there was no current PM record for the splint warmer.

3. During a tour of the Rehabilitation Unit on 01/11/2017 at 1015 a thermal therapy unit was observed to have a PM sticker that reflected, "Inspection Due 5-2016."

During review of PM records on 01/12/2017 at 1000 with the ADM of Plant Engineering and a Biomed Tech II, it was confirmed the thermal therapy unit had not had a PM since 05/2015.

4. During a tour of the kitchen on 01/11/2017 at 1600 an ice cream freezer and a cookie oven were observed to have PM stickers that reflected "Electrical Safety Test...Inspection Due 11/2016."

During review of PM records on 01/12/2017 at 1000 with the ADM of Plant Engineering and a Biomed Tech II it was confirmed there were no current PM records for the ice cream freezer or the cookie oven.

5. During a tour of Respiratory Therapy on 01/11/2017 at 1100 a T-7 Telephonic EEG machine was observed to have a PM sticker that reflected "Inspection Due 11/2016."

During review of PM records on 01/12/2017 at 1000, with the ADM of Plant Engineering and a Biomed Tech II it was confirmed that no current PM record could be produced.

6. During a tour of SPD on 01/12/2017at 1200 a packaging sealer was observed to have a PM sticker that reflected, "Inspection Due 12/2016."

During review of PM records on 01/12/2017 at 1000 with the ADM of Plant Engineering and a Biomed Tech II it was confirmed the sealer had been deleted from the system. The Biomed Tech II stated, "They told me it was gone."

7. A review of the hospital's policy, "Medical Equipment Management Plan," dated as last reviewed "10/2016," revealed "The medical equipment management plan defines how medical equipment safety will be managed. It indicates the scope of the program, the roles and responsibilities of the individual and groups involved in using and maintaining medical equipment..." The policy contained no criteria or provision for evaluating and determining whether or not a piece of medical equipment required preventive maintenance. In an email received on 02/08/2017 at 0757 from the hospital's Quality Review Analyst-Risk Management Assistant, it was confirmed that the October 2016 policy was the only Medical Equipment Management Plan.

Based on observation, interview, review of policies and procedures and drug tracking documents, it was determined that the CAH failed to ensure that drugs were stored appropriately. Drugs were observed to be unsecured, outdated and otherwise unusable.

Findings include:

1. During a tour of the ICU on 01/11/2017 at 1413 a "Rapid Response Kit" was observed hanging from the wall. A blue break-away lock numbered 0481062 was attached to the kit. A document titled "Code Cart Lock Log" reflected the date the kit was last opened and a new lock attached. Review of that document revealed the current attached lock number did not match the last lock number, 1200022, identified on the log as having been attached to the kit on 11/20/2016. The kit was opened by staff at the time of the tour and was observed to contain a bottle of bacteriostatic saline for injection that had expired on 12/31/2016. During an interview with the ICU Manager at that time, he/she stated "The pharmacy is in charge of keeping that kit stocked."

2. During a tour of the CT exam room with the CT tech on 01/11/2017 at 1500 a "Hypersensitivity Response Kit" was observed on the counter. A blue break-away lock numbered 1200071 was attached to the kit. An untitled log attached to the kit handle identified the last entry was dated 06/01/2016 and reflected that a different lock number had been attached at that time. There was no documentation to reflect the circumstances or date lock number 120071 had been placed.

3. During a tour of OR 2 on 01/12/2017 at 1143 a bottle of Sevoflurane Inhalation Anesthetic and an unopened vial of Succinylcholine 200 mg/20 mg/ml, were observed in the unlocked anesthesia cart. During an interview at that time the OR Manager stated "the anesthesia carts are all supposed to be locked." A break-away tab observed on the top of the Sevoflurane bottle was broken but still attached to the bottle and the OR Manager confirmed that it was unclear if the bottle had been used or not.

4. A policy titled "Samaritan Health Services, Emergency Medications-System Policy" last revised 02/19/2016 reflected "Pharmacy is responsible for the medications stored in carts and kits...Each time the seal is broken, the drugs are inventoried and replenished if needed."







37917

Based on observations, interviews, 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 of ultrasound transducers was conducted in patient exam rooms;
*Patient care supplies were outdated or otherwise unusable;
*Unlabeled IV tubing was observed on infusing IV's;
*Damaged and uncleanable environmental and equipment surfaces were observed;
*Soiled patient care equipment was observed;
*Outdated and unlabeled food was stored in patient nourishment refrigerators and;
*Inappropriate storage of linens, equipment, and housekeeping supplies was observed.

Findings include:

1. During a tour of the Imaging Department with the Imaging Manager on 01/11/2017 at 1500, the "back-up" ultrasound exam room was observed to contain an ultrasound machine, a wall mounted Trophon ultrasound transducer disinfection machine and a wall mount that held five ultrasound transducers. During interview at that time the Imaging Manager stated that the transducers on the wallmount were no longer used due to incompatibility with the Trophon.

* During further tour of the imaging department with the manager and the Ultrasound Tech on 01/12/2017 at 1315, the main ultrasound exam room was observed to contain a patient bathroom. In the bathroom was a toilet, a hand-washing sink, an IV pole and an instrument tray on wheels. During interview with the tech at that time he/she reported that after an ultrasound exam was completed in the main exam room the transducer was wiped off, transported into the bathroom, washed in the hand-washing sink then transported through the department to the "back-up" ultrasound exam room for completion of the disinfection process in the Trophon. The tech further reported that after a procedure was conducted in the "back-up" exam room the transducer was wiped off, transported through the department to the bathroom in the main exam room to be washed in the hand-washing sink, then transported back through the department to the "back-up" exam room for completion of the disinfection process in the Trophon.

2. During a tour of the Imaging Department with the Imaging Manager on 01/12/2017 at 1414 the following observations were made:

* Multiple "Veni-gard IV catheter dressings" with expiration dates of "03/2015" were observed in the CT IV start kit available for patient use. In an interview with the CT tech at that time, he/she stated "we don't really use those, we use the IV start kit that comes packaged all together."

* In a hallway nook outside the Imaging Department there were two portable x-ray machines covered with a layer of dust and debris.

3. During a tour of the ED with the ED Manager on 01/10/2017 beginning at 1355 the following observations were made:

* An outdated Proctol Parasitology System stool culture kit with an expiration date of "May-2016" was observed available for patient use.

* An open bottle of hydrogen peroxide was observed on a wound cart. The bottle did not reflect when it had been opened. During an interview with the ED Manager at that time, he/she stated "open items are to be dated and timed, or thrown away."

* Multiple wall mounted suction containers observed in the ED had hand-held suction wands attached to suction tubing in open packages and a layer of dust covered the top of each suction container. It was unclear if the hand-held suction wands were clean and unused.

* Numerous wall surfaces were observed with gouges and areas of peeling paint. The wooden countertop between the triage area and the patient care area of the ED had multiple chips, scrapes, and holes rendering the surface uncleanable.

* The bare concrete floor in the decontamination shower room was cracked and in disrepair rendering the floor uncleanable.

* A gurney observed in the ED was observed to have dirt and grime covering the wheel and brake. During an interview with the ED Manager at that time, the gurney was identified as "ready for a patient."

* A Welch-Allyn thermometer wall mount in the triage area was observed to have dirt and grime covering it. In addition, a dirty piece of clear tape was affixed to the wall plate.

* Two rolling stools observed in the ED outside of patient exam room 4 had cracked vinyl seat cushions which had been covered with dark blue tape.

* The patient nourishment refrigerator was observed to contain two containers of Jell-o with expiration dates of "29 DEC 2016."

* The janitor's closet contained a mop bucket filled with dirty water and multiple wet, dirty mop heads were piled in the floor sink.

* The ED decontamination shower room contained an unzipped and open clean linen cart with linens, and various other patient care equipment such as walkers, folded chairs, and a folding cot. Maintenance supplies, multiple black duffle bags, and various other items were also stored in the room. It was unclear whether the linen and equipment were clean or dirty. Those items stored in the decontamination shower room rendered the room unusable.

4. During a tour of the ICU unit on 01/11/2017 beginning at 1100 with the ICU Manager the following observations were made:

* A dirty, unlabeled cup containing unidentified liquid was observed in the patient nourishment refrigerator.

* The Rapid Response Kit contained outdated supplies:
A Medchoice IV Start Kit had an expiration date of "04/14."
Two 22g IV cannulas had expiration dates of "06/2016."
Two 18g IV cannulas had expiration dates of "06/2016."
Two 20g IV cannulas had expiration dates of "05/2015."
An IV extension set tubing expired "06/2012."
An arterial Blood Gas Kit expired on "07/2015."
A suction extension tubing expired "10/2014."

5. During a tour of the pre-op area of surgical services on 01/12/2017 beginning at 0944 with the OR Manager, four 18g IV cannulas were observed with expiration dates of "06/2016." Those findings were confirmed with the OR manager at that time.

6. During tour of the PACU on 01/12/2017 at 1008 the following observations were made:

* Multiple suction containers were mounted on the walls behind each bed with hand-held suction wands attached to suction tubing in open packages. A layer of dust covered the top of each suction container. It was unclear if the hand-held suction wands were clean and unused.

* Two yogurt containers were observed in the patient nourishment refrigerator with expiration dates of 01/06/2016. During an interview with the OR manager at that time, he/she stated "the volunteers stock that refrigerator, we need to remind them to check the dates."

7. During a tour of the Med/Surg unit with the Med/Surg Manager at 1137 on 01/11/2017 a clean supply room door was observed to have white gauze and clear tape covering the latch mechanism of the door. This rendered the surface of the door uncleanable.

8. A policy and procedure titled "Samaritan Health Services, IV administration set (tubing) change" dated 04/09/2014 was reviewed. It stipulated, "...Label the administration set and solution container with the date of initiation or the date when change is necessary..." The policy was not implemented in the following areas:

* Observations on 01/11/2017 at 1417 in ICU 2 revealed an actively infusing IV connected to a patient. The IV tubing was not labeled. During an interview with the ICU Manager at that time he/she confirmed that "all IV tubing should be labeled."

* Observations on 01/12/2017 at 1400 in the Ambulatory Infusion Clinic revealed two actively infusing IVs connected to a patient. Neither of the IV tubing lines were labeled.



37237













37917

Based on interview and review of documentation in 1 of 2 open surgical records (Patient 18), it was determined that the CAH failed to ensure the accuracy and completeness of the medical record.

Findings include:

1. Review of the medical record of Patient 18 reflected the patient underwent an outpatient endoscopy procedure on 01/12/2017 at 1000.

The pre-anesthesia assessment recorded by the CRNA on 01/12/2017 at 0915 reflected the patient was assessed as an ASA III. The patient's pre-op assessment recorded by the surgeon on 01/12/2017 at 0930 reflected the patient was assessed as an ASA I. There was no documentation to reflect that the discrepancy in ASA assessments had been identified.

In an interview with the OR Manager on 01/12/2017 at 1538 he/she stated "the ASA levels should not be different."