HospitalInspections.org

Based on observation and interview, the provider failed to:
*Maintain the ceiling and air supply registers for the computer tomography (CT) room clean.
*Have policy and procedures for the maintenance and operation of the therapy pool.
Findings include:

1. Observation and interview on 1/27/15 at 11:20 a.m. with the environmental services manager in the CT room revealed:
*The air supply registers were covered with a dry crusty black residue.
*The ceiling tiles around the air registers also had a black residue on them.
*She was not aware of the condition of the air register and ceiling tiles.
*She agreed those items were in need of cleaning.
*Those items were not on a preventative maintenance schedule.
*The CT room had its own air handling unit, and she was not aware if the air handling unit had any filters.

2. Interview on 1/27/15 at 1:20 p.m. with the environmental services manager revealed:
*The provider had a therapy pool.
*There were no written policies and procedures or records for the operation and maintenance of the therapy pool.
*It was monitored daily for free chlorine, cyanuric acid, pH and total alkalinity with an Aquachek Test strip. Depending on the result of the test the pool chemicals would be altered.
*The results of the test strip were not documented nor were any adjustments made to the pool chemicals.
*The provider had not been submitting weekly water samples to a laboratory for bacteria testing.
*She was not aware they were to submit weekly water samples for bacteria testing.
*The pool filter was changed when the pressure at the filter reached fifteen pounds. The last time the filter had been changed was unknown.

Based on observation, interview, and policy review, the provider failed to ensure:
*Insulin was dated and was not available for use after the expiration date in one of one pyxis (medication distribution system) at one of one nurses station.
*Medications were secured from unauthorized personnel in one of one medication room.
*A medication safe that contained multiple medications located in one of one medication room was secured, and two vials of expired medications were not available for patient use.
*Security of keys used by anesthesia personal for three of three medication areas (operating room (OR), anesthesia cart, and pharmacy.
*Expired bottles of sterile water had been removed in one of one pharmacy.
Findings include:

1. Observation and interview on 1/28/15 at 9:15 a.m. with registered nurse (RN) K revealed:
*She had been preparing to administer insulin to patient 5.
*She retrieved a vial labeled Humalog insulin from the medication dispensing unit. The vial had been opened and was half full.
*There was no patient name or date marked on the vial.
*She stated the Humalog insulin would have been used on multiple patients. She would not have expected to find a patient name, but there should have been a date.
*She confirmed it was the provider's policy and procedure to date all vials upon opening.
*With no date on the vial she would not have been able to identify the date for expiration. Humalog would have expired in twenty-eight days after opening it.
*She disposed of the vial per the provider's policy and reported the incident to the charge nurse.

Interview on 1/28/15 at 2:55 p.m. with the director of patient services confirmed the Humalog insulin vial should have been dated upon opening it.

Review of the provider's September 2013 Medication Administration policy revealed:
*All multidose vials were discarded:
-"Within 28 days of opening, or upon manufacturer expiration date. The vial is marked with the expiration date."
-"When the vial is empty."
-"The product is deemed otherwise unusable."
*Medications should have been verified for expiration prior to administration.

2. Observation on 1/28/15 at 1:50 p.m. of the medication room revealed patient 1:
*Had been admitted to the hospital on 1/26/15.
*Had a bottle of lorazepam milligram (mg) (controlled medication for anxiety) tablets located inside an unlocked cupboard. There were several white pills inside of the bottle. There had been no accounting system in place for the medication inside of the bottle.
*Had a pill caddy labeled with her name on it sitting on the countertop. There were several unidentifiable medications located inside of the pill caddy.

Interview on 1/28/15 at the time of the observation with the director of patient services confirmed the above medications should have been sent home with the family. If the medications could not have been returned to the family an accounting of the medications should have been done immediately upon admission.

Review of the provider's January 2010 Patient's Own Medications policy revealed:
*"If any medications are classified as scheduled."
*"Family will be encouraged to take them home with them."
*"If the medications are going to be stored in the med-room [medication room], they will be counted upon admission and inventoried each shift change with two RN's."

3. Observation on 1/28/15 at 2:15 p.m. of the medication room revealed a small safe bolted to the wall. The safe had a numbered dial and key opening area on the door. The door was unlocked and easily opened by the surveyor. Inside of the safe revealed:
*Two clear plastic caddies containing several vials of medication. The following medications were located inside each of the plastic caddies:
-Six vials of Fentanyl citrate (controlled pain medication).
-Seven vials of midazolam (medication for sedation).
-Four vials of ketamine hydrochloride (controlled substance causing loss of consciousness).
-Four vials of ephedrine sulfate (used for shortness of breath and chest pains). Two of the vials had an expiration date of December 2014.

Interview on 1/28/15 at the time of the observation with the director of patient services revealed the safe was used to store the anesthetist's medications used for surgical procedures. It should have been locked. The anesthetist and pharmacist were the only staff members who had access to that safe. She confirmed the ephedrine sulfate was expired and should have been discarded.

Review of the provider's November 2013 controlled Substances policy revealed:
*"The purchase, storage, distribution and accounting of controlled substances will be done in accordance with all federal and state laws and standards of professional practice."
*"A transaction record for all controlled substance in schedules II, III, and IV."



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4. Observation and interview in the anesthetist's office on 1/28/15 at 9:00 a.m. with certified registered nurse anesthetist (CRNA) G revealed:
*He kept the key to the operating room and the locked anesthesia cart on a key ring in his office when he was off duty.
*The keys were kept in an unlocked desk drawer.
*The door to his office was not always locked.
*The key ring also had a key to the pharmacy.
*He confirmed the ring of keys was accessible to unauthorized staff.

Review of the provider's undated Storage of Keys policy revealed:
*The keys to the anesthesia cart would be stored in the locked office of the CRNA.
*Anesthesia staff could check those out the morning of surgery and return them to the locked office upon leaving the building.



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5. Observation and interview on 1/27/15 at 2:00 p.m. in the pharmacy with pharmacy director J revealed there were sixty 100 milliliter bottles of sterile water with an expiration date on each bottle of 2/1/14. Pharmacy director J confirmed the sterile water had expired and should have been discarded.

Review of the provider's revised September 2012 Pharmacy policy revealed "Pharmacy will be responsible for checking all in house medications for outdates."

Based on observation, interview, and policy review, the provider failed to ensure an environment free from potential cross-contamination (spreading bacteria from one surface to another) had been maintained:
*For one of one medication administration through a feeding tube (tube in the stomach for feeding and nutrition) for one of one sampled patient (5).
*During personal care for one of one sampled patient (4) by two of two observed patient care technicians (PCT) (L and M) on one of one medical floor area.
*For two of two observed intravenous (IV) insertions for two of two sampled patients (38 and 44).
*Foam positioning wedges used on multiple patients were cleanable for three of four imaging departments (radiology, computed tomography [CT], and a provider based clinic radiology clinic.
Findings include:

1. Observation on 1/28/15 at 9:10 a.m. of registered nurse (RN) K administering medication to patient 5 through a feeding tube revealed she:
*Retrieved all of his medications from a medication dispensing unit. All of the medications were individually packaged.
*Placed all of those medications in a cup on her movable table. The table contained a laptop for documentation and a scanner to scan all medications for billing purposes.
*Entered the patient's room with her table, sanitized her hands, and put on a clean pair of gloves.
*With those gloved hands she:
-Moved the patient's covers and gown to reveal his feeding tube.
-Retrieved one of the medications from the cup and the scanner. She scanned the medication prior to opening the package.
-Opened the package and put the medication inside of a small plastic bag.
-Grabbed the handle of the medication pill crusher, crushed the medication, and placed it in a cup for administration.
-Opened the patient's feeding tube and administered the medication.
-Charted on the laptop after administering the medication.
-Retrieved another pill from the cup and opened the package. The pill and the package fell on the floor.
-Picked up the package from the floor and continued to administer the rest of his medications through the feeding tube using the same process as above.
-Had not removed her gloves and sanitized her hands after picking up the pill package that had fallen on the floor.

Interview on 1/28/15 at the time of the above observation with RN K confirmed she had soiled her gloves after picking up the pill package from the floor. She should have removed those gloves and sanitized her hands prior to administering the rest of his medications. She agreed the process had created an environment for cross-contamination.

Review of the provider's December 2014 Tube Feeding policy revealed no procedure to follow for proper hand hygiene and glove use during the administration of medications.

2. Observation on 1/27/15 at 3:55 p.m. of PCT L and M revealed:
*They entered patient 4's room to assist her with personal care. With gloved hands they:
-Pulled down her bed covers and removed her urine soiled incontinent brief.
-Assisted her to sit on the edge of the bed.
-PCT M retrieved a gaitbelt from a shelf and placed it around the patient's waist.
-Assisted her to sit on a bedside commode.
*PCT M removed her soiled gloves, sanitized her hands, and put on a clean pair of gloves.
*PCT L continued to leave her gloves on and straightened the patient's bed covers, bed pad, and adjusted the siderail on the bed.
*They assisted the patient to stand.
*PCT M cleansed the patient's perineal (bottom) area, grabbed a tube of ointment from the bedside table, opened the tube, and placed some of the ointment in her hand. She then rubbed the ointment onto the patient's perineal area.
*PCT M placed the soiled tube of ointment on the bedside table by the patient's phone.
*PCT L and M assisted the patient with putting on a clean incontinent brief and laid her back down to rest on her bed.
*PCT L left her soiled gloves on, and she pulled up the bed covers and gave the patient her call light.
*At that time they both removed their soiled gloves and sanitized their hands.
*PCT L had not removed her gloves or sanitized her hands during the entire process of assisting the patient with personal care.

Interview on 1/27/15 at the time of the above observation with PCT M revealed:
*She had not recognized the above process as an unsanitary practice until being interviewed.
*She agreed their technique had not been sanitary and placed the patient at risk for cross-contamination.

Interview on 1/28/15 at 3:15 p.m. with the director of patient services confirmed the above process had been unsanitary.



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3. Observation on 1/28/15 from 8:15 a.m. through 9:25 a.m. revealed:
*Registered nurse (RN) A entered patient 44's room to administer her medications.
*During the above time RN A discovered her intravenous (IV) site had blood around it and determined the IV needed to be changed.
*RN A:
-Gathered the supplies from the IV supply case that had been brought into the room.
-Without creating any clean barrier the new IV supplies were laid in their packages on the bedding of the patient's bed.
-Removed the IV from the patient's right hand and laid the soiled bandages on the bed until it was discarded in the Sharps container. At that time gloves were changed and hand hygiene was performed.
-Removed the new IV supplies from their package, and laid the empty packaging on the bed next to the other supplies.
-Disinfected with an alcohol wipe the area on the patient's hand where the IV was to be inserted and laid it on the bed.
-Also removed the billing sticker from the packages and stuck each one of them to the patient's bedside table.
-Laid some of the empty packaging on the window sill.
-Was unable to get the IV started during the first attempt.
-Discarded the IV supplies in the Sharps container and changed gloves after performing hand hygiene.
-Gathered a new set of IV supplies and laid them on the patient's bed without preparing a clean barrier. The empty packages from the first attempt were also still there.
-Identified another area to re-insert the IV.
-Repeated the cleaning of the site on the patient's hand with the alcohol wipe and laid it on the bed.
-Repeated the disposing of the packages after supplies were removed from them on the patient's bed, and stuck the billing stickers from the packages on the patient's bedside table.
-Inserted the IV on the second attempt.
-Gathered all the empty packages from the bed and disposed of them.
-Removed the stickers from the bedside table.
-Had not sanitized the bedside table after removing the stickers from it.
*Gathered the remaining empty packages from the window sill, and threw them in the garbage before leaving the room.

Interview on 1/28/15 at 2:45 p.m. with RN A confirmed he should have created a clean barrier for the supplies when changing the IV for patient 44. He agreed the bedside table should have been cleaned after removing the discarded supplies.

Interview on 1/28/15 at 3:45 p.m. with the director of patient care services agreed a clean barrier should have been created when an IV was being started.



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4. Observation and interview on 1/27/15 from 10:15 a.m. through 10:50 a.m. in patient 38's room with RN B and RN H revealed:
*RN H was training new employee RN B.
*RN B placed gloves on her hands without performing hand hygiene, reached into her pockets with those gloved hands, and obtained an alcohol prep package to cleanse the patient's left forearm and hand.
*RN B placed IV supplies on the bedside table without creating a clean field to place the supplies on.
*RN B then inserted the IV into the patient's left hand.
*At 10:25 a.m. RN B changed her gloves. She then took off the gloves, took pieces of tape and wrote the date on them, and placed the tape on the IV tubing. She had not performed any hand hygiene.
*RN B then discarded the used IV supplies into the garbage and removed her gloves without performing hand hygiene.
*RN B then put on a new pair of gloves.
*At 10:35 a.m. RN B administered medication by IV injection.
*At 10:40 a.m. with the same pair of gloves on RN B administered a nebulizer treatment to the patient.
*At 10:50 a.m. RN B removed her gloves and did not perform any hand hygiene.
*RN H had not directed RN B to perform any hand hygiene during the above procedures.

Interview on 1/27/15 at 10:52 a.m. with infection control nurse I confirmed RN B should have used hand gel between each glove change.

Interview on 1/27/15 at 11:35 a.m. with the director of patient care revealed:
*RN B should have used hand gel to disinfect her hands between glove change.
*Her expectations were to do hand hygiene in between glove changes.

Review of the provider's revised March 2013 Peripheral IV Assessment, Remove, and Maintenance policy stated for IV catheter insertion to wash hands and follow standard precautions before starting the procedure.

Review of the provider's February 2014 Hand Hygiene policy revealed:
*Purpose "Hand hygiene is the single most important procedure for the control of infection. It is a critical component of patient and employee safety."
*Hand sanitizing should occur:
-Before each patient contact and after patient contact.
-After glove removal.



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5. Observation on 1/27/15 at 1:15 p.m. in the ambulance entrance/garage revealed:
*There were eight boxes of 1000 milliliter (ml) IV solution stored on the floor. One of the IV boxes had been opened, and there were IV bags of solution missing from the box.
*There was one box of IV 100 ml solution bags that also had been opened and was stored on the floor.
*There were two large boxes of male urinals stored on the floor.

Interview on 1/27/15 at 1:30 p.m. with environmental services manager D regarding the above findings revealed:
*The central supply personnel were responsible for putting those supplies away.
*The supplies should not have been stored on the floor.
*She confirmed some of the boxes had been opened, and those supplies had been removed from the boxes.
*She stated the central supply room (CSR) manager was in surgery, and was not available for an interview.

Interview on 1/28/15 at 8:25 a.m. with chief finance officer C regarding the observation of the supply boxes stored on the floor revealed:
*The CSR manager was not available, because she was in surgery.
*There should not have been any supplies stored on the floor in the ambulance/garage.
*The normal process would have been once the supplies were received the staff would place a yellow sticker on those supplies. They would then be placed into the CSR supply area.
*If the staff would not have time to put those supplies away then those supplies should have been placed on pallets to keep them off direct contact with the floor.
*She confirmed there was no policy or procedure for the storage of patient supplies.



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6. Observations on 1/27/15 at 2:10 p.m. of the radiology and CT rooms and on 1/28/15 at 4:15 p.m. of the radiology room at an off-site clinic revealed a total of twenty-seven foam positioning wedges without cleanable surfaces or covers.

Interview on 1/27/15 at 2:10 p.m. with radiologic technologist E revealed:
*She agreed the positioning wedges were not cleanable and could have been an infection control risk.
*The positioning wedges were covered with a pillowcase for use but had not been cleaned between patients.

Interview on 1/28/15 at 4:15 p.m. with radiologic technologist F revealed she agreed the foam positioning wedges were not cleanable.

Based on observation, interview, and admission packet review, the provider failed to ensure patient privacy and confidentiality were maintained for one of one sampled patient (38) who had been in the emergency department (ED) and admitted to the medical area, and one of one randomly observed an unidentified patient in the ED. Findings include:

1. Observation on 1/27/15 at 9:55 a.m. in the ED revealed patient 38 was sitting in a wheelchair. She had on an open backed hospital gown that exposed the bare skin on the left side of her back and an incontinent brief she was wearing. There was a housecoat draped across the back of the wheelchair. At the above time registered nurse (RN) B and H transported her in the wheelchair to her assigned patient room. They had not covered her back. Patient 38 had not been offered a lap robe or the
housecoat that had been placed on the back of her wheelchair prior to her being transported.

On 1/27/15 at 10:00 a.m. outside of patient 38's assigned room RNs B and H assisted her with transferring from the wheelchair to the stand-up scale located in the hallway outside her room. During that time she used a walker and stood with assistance from RNs B and H. The backside of her hospital gown was open and exposed her bare back and incontinent brief.

Observation on 1/27/15 from 10:05 a.m. through 10:50 a.m. in patient 38's room revealed:
*The door to the room was open.
*She was lying on the bed and could be seen from the doorway.
*During the above time:
-RN B inserted an IV into the patient.
-Several hospital staff members entered and exited her room conversing with RNs B and H.
-Other hospital staff were in the hallway conversing with RNs B and H through the open door.

Interview on 1/27/15 at 11:35 a.m. with the director of patient care regarding the above observations with patient 38's care confirmed:
*The patient should have been weighed in her room.
*She should not have had her back side exposed.
*It was a breach of privacy and confidentiality.

2. Observation on 1/28/15 at 8:15 a.m. in the ED room revealed an unidentified patient lying on a bed. The door to the room was open, and the curtain had not been pulled around the patient. There was a staff member in the ED room assisting the patient. The patient had a cervical collar on. There was a lot of red tinged drainage on the pillow case. Visitors and other staff were walking by that opened ED room.

Interview on 1/28/15 at 8:25 a.m. with infection control nurse I confirmed:
*The area outside the ED room was a waiting room and several people passed through that area during the day.
*The door and/or curtain in the ED room should have been closed or pulled when a patient was in it to provide privacy and confidentiality.

Review of the provider's Patient Bill of Rights Responsibilities handbook revealed:
*"The patient has the right to every consideration on his/her privacy concerning his/her own medical care and confidential information."
*"The patient has the right to considerate and respectful care."
*"The patient has the right to expect that all communications and records pertaining to his care should be treated as confidential."

Based on observation, interview, record review, policy review, and manufacture's review, the provider failed to ensure:
*The medication route had been verified for one of one sampled patient (5) who received medications through a nasogastric tube ([NG] a tube that was placed through the patients nostril into the stomach for administering medications and nutrition).
*Intravenous (IV) medication was administered according to the drug reference handbook used by the nursing staff for one of two sampled patients (38) who had received IV medications.
Findings include:

1. Observation and interview on 1/28/15 at 9:20 a.m. of registered nurse (RN) K revealed:
*She had been preparing to administer medications to patient 5. The patient had a feeding tube and required all of his medications to be administered through the feeding tube.
*When she had confirmed the medications with his current physician's orders the route stated orally on all of his medications.
*RN K confirmed the route had been ordered incorrectly for the patient. The physician's orders should have indicated all of his medications were to have been administered through the feeding tube.
*All nurses were responsible to ensure the physician's orders indicated the correct route for medication administration on all patients.
*The physician should have been contacted and the route clarified upon admission. The patient had been admitted on 1/15/15.

Interview on 1/28/15 at 3:15 p.m. with the director of patient services confirmed the above order for patient 5 had indicated the wrong route. It was the staffs responsibility upon admission to ensure the physician's orders had been clarified for the correct route.

Review of the provider's September 2013 Medication Administration policy revealed:
*"The right route of medication will be verified prior to administration."
*"Right route-no medication for which there is more than one possible route of administration may be given unless the intended route is specified by the prescribing practitioner."



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2. Observation and interview on 1/27/15 at 10:35 a.m. in patient 38's room revealed RN B administered furosemide (medication used to decrease excess fluid) 40 milligrams (mg) IV push (administered directly through the IV line) within thirty seconds.

Interview at the above time with RN B confirmed the medication should have been administered slowly over one to two minutes IV.

Review of patient 38's medical record revealed a 1/27/15 physician's order for furosemide 40 mg IV push once only.

Interview on 1/27/15 at 11:35 a.m. with director of patient care confirmed:
*Furosemide should have been administered IV over one to two minutes.
*The provider used the Nursing 2015 Drug handbook as their medication resource book.

Interview on 1/27/15 at 2:00 p.m. with pharmacy director J revealed he:
*Was unsure how long to administer furosemide IV push.
*Would need to look up recommendations for the administration of furosemide 40 mg IV push.

Review of Nursing 2015 Drug Handbook, page 664, revealed to administer furosemide "40 mg IV injected slowly over one to two minutes."

Based on observation, interview, and policy review, the provider failed to ensure in one of one surgical suite:
*An environment free from cross-contamination (spreading of bacteria from one surface to another) had been maintained during the storage of three of three endoscopes (lighted tubes to look inside the body) set-up on over-the-bed tables prior to being used for three scheduled endoscopy procedures.
*Three of three endoscopes were in a secured storage cabinet in the operating room office after they had been disinfected.
*Outside shipping boxes were not stored in two of two surgical areas (endoscope processing room and in the surgical office/clean supply area) used for storage.
*Multiple (multi) use patient equipment (blood pressure cuff, electrocardiogram machine [EKG], and the pulse oximeter) were disinfected between surgical procedures.
*Pre-cleaned colonoscope was transported in a container for processing to prevent environmental contamination.
*Handwashing was consistently done to prevent cross-contamination of the surgical area during one observed pre-surgical set-up by three of three employees (N, O, and P).
Findings include:

1. Observation on 1/27/15 from 10:00 a.m. to 10:30 a.m. in the surgical office/clean supply storage area revealed:
*Three over-the-bed tables were covered with a white towel.
*On each of the tables was a plastic bottle of sterile water, a tweezers, and an endoscope.
*A cupboard was directly above two of the tables that contained clean linen.
*Two unidentified maintenance men came into the surgical office in street clothes.
*A patient was wheeled into the surgical suite on a bed adjacent to the over-the-bed tables.
*There was not consistent surgical staff in the office to monitor the endoscopes for potential contamination.
*There was an unlocked cabinet where the endoscopes were stored after they had been disinfected at the end of the day.

Interview on 1/27/15 at 10:40 a.m. with surgical technician N revealed:
*They always set-up the over-the-bed tables ahead of all surgical procedures for the day early in the morning.
*The tables saved time during the day by being pre-set when the physicians were ready to start each surgical procedure.
*The cupboard above the over-the-bed tables was often opened for linen and was a potential cross-contamination issue.
*She confirmed they were unsure who entered the office when none of the surgical staff were in that area.
*There was potential for cross-contamination of the endoscopes prior to them being used.
*They did not lock the cabinet where the endoscopes were stored after they had been high-level disinfected.
*There was potential for cross-contamination of the endoscopes when they were stored in the unlocked cabinet when no surgical staff were in the office to monitor unauthorized access to the cabinet.

2. Observation on 1/27/15 at 10:45 a.m. of the surgical office/clean supply storage area and the endoscope processing room revealed:
*Four Revitalox outside shipping boxes were sitting on the floor in the surgical office/clean supply area.
*Five Olympus outside shipping boxes were sitting on the floor in the endoscope processing room.

Interview on 1/27/15 at 10:48 a.m. with nurse manager I regarding the above revealed:
*The outside shipping boxes should not have been in the surgical area.
*There was a potential for cross-contamination not knowing where the boxes had been prior to being put in the surgical area.

3. Observation on 1/27/15 at 11:30 a.m. in the operating room revealed:
*Registered nurses K and O and surgical technician N were cleaning the OR and equipment after a colonoscopy procedure had been performed on patient 45.
*They were using a cloth and a bucket that contained Virex disinfecting solution.
*They did not clean off the EKG machine, the blood pressure cuff, or the pulse oximeter.

Interview on 1/28/15 at 9:05 a.m. with the certified registered nurse anesthetist regarding the above revealed:
*He thought the operating room staff disinfected the above equipment after each surgical procedure.
*He did not have the time to disinfect any equipment between surgical procedures.
*He confirmed the above equipment was used by multiple patients and should have been disinfected between each patient's surgical procedure.

4. Observation and interview on 1/27/15 at 12:30 p.m. of surgical technician N revealed she:
*Placed the colonoscope that had been used for a procedure in a blue tub of water in the OR room.
*Took the tub to the dirty utility room to clean the endoscope.
*Hand carried the colonoscope to the endoscope processing room for high-level disinfection in the automated endoscope reprocessor.
*The endoscope was dripping water onto the floor while being transported to the endoscope room.
*Should not have transported the endoscope to the processing room in that manner.

5. Observation on 1/27/15 from 11:10 a.m. through 12:30 p.m. of the surgical area revealed:
*Physician P completed colonoscopy procedures on patients 13 and 45. Both times he washed his hands in a sink in the dirty utility room for approximately thirty seconds. He used a paper towel to dry his hands and then proceeded to turn off the faucet with his bare hands.
*RN O coughed into her gloved hand and then touched patient 13. She did not change gloves or wash her hands prior to touching the patient.
*Surgical technician N:
-Took soiled equipment after a surgical procedure on patient 45 to the dirty utility room. She took off her gown and gloves and prior to putting on new gloves had not washed her hands.
-Took off her gloves after she had cleaned the operating room after a surgical procedure on patient 45. She proceeded to bring in the over-the-bed table that contained the endoscope into the operating room for patient 13 without washing her hands.

Interview on 1/27/15 at 3:00 p.m. with nurse manager I regarding handwashing revealed:
*Handwashing should have always been done when removing soiled gloves and before putting on new gloves.
*A paper towel should have been used to turn off the handles on the faucets after handwashing.

Review of the provider's 4/1/09 Infection Control Procedures policy revealed:
*All employees were to follow proper protocols for handwashing.
*Traffic controls within the work area were maintained in accordance with infection control guidelines.
*Employees had received training in the prevention of cross-contamination.
*Cleaning techniques were appropriate for each item decontaminated.



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Based on record review and interview, the provider failed to ensure nursing staff documented the level of sedation for three of three sampled surgery patients (7, 9, and 11) that received conscious sedation. Findings include:

1. Review and interview of the intraoperative documentation for patients 7, 9, and 11's surgical procedure with the director of patient care services revealed:
*Patient 7 had an esophagogastroduoduodenoscopy (EGD) (tube with camera to view the throat, stomach, and upper colon) procedure and colonoscopy (tube with camera to view the lower colon) procedure on 9/24/14.
*Patient 9 had a colonoscopy procedure on 1/13/15.
*Patient 11 had a colonoscopy procedure on 12/29/14.
*Patients 7, 9, and 11 surgical procedures were performed under conscious sedation.
*Versed and Propofol were the sedating agents.
*The patient's sedation level throughout their procedure had not been documented.
*The sedation level should have been documented as follows:
-Zero (0) equaled no sedation.
-One (1) equaled mild sedation.
-Two (2) equaled moderate sedation.
-Three (3) equaled severe sedation.
*The DPCS confirmed the nursing staff should have documented the level of sedation for each of the above listed patients.

Review of the provider's 2011 Nurse-Administered Propofol Sedation policy revealed there was no guidelines for checking and documenting the patient sedation level.