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Based on observations, record review, interviews, and video surveillance, the facility's governing body failed to implement directives that ensured the Emergency Department (ED) entrance had staff available 24 hours per day, to identify any patient that presented to the ED, and assist visitors that enter the facility. The facility also failed to ensure that the New Hope Psychiatric Unit's seclusion room's window had tempered glass and the camera had a protective covering creating a safe setting for patients with high risk psychiatric conditions (possible harm to themselves or others). The facility census was 21.

Findings included:

1. Record review of the procedural document titled, "Availability of Patient Access Services," dated 05/2017, showed that the ED patient access area will be staffed every day, 24 hours per day.

During an interview on 05/17/17 at 3:30 PM, Staff O, Patient Access Manger, stated that he just typed the procedural document titled,"Availability of Patient Access Services," and prior to the date, there were no directives for the staff to attend the ED entrance.

2. Record review of the minutes titled, "Environmental Health and Safety Standing Agenda," dated 08/09/16, showed that the staff had concerns with the patient access representative not being present during the evening and night shifts to assist with the check in process or log in visitors that entered the ED entrance.

During an interview on 05/15/17 at 2:50 PM, Staff G, Patient Access Representative, stated that:
- After 11:00 PM, the ED had only one patient access representative on duty.
- During the times staff have left the front desk, a sign was posted with a phone number notifying anyone that if they needed immediate assistance, to please use the phone and dial 1269. That number would ring in the ED.
- There are times when no staff is available for anyone who walked in needing assistance, and/or patients waiting in the ED waiting room.

During an interview on 05/15/17 at 3:25 PM, Staff DD, Health Information Management (HIM) Clerk, stated that:
- There are times when no staff is available for anyone who walked in needing assistance.
- The HIM clerk is responsible to monitor the security cameras in the ED entrance area.
- The phone number 1269 rings to the desk attended by the HIM.
- During the hours of 4:00 AM through 7:00 AM, there was no HIM clerk to answer the phone and/or monitor the security cameras of the ED entrance.

3. Record review of the summary of an event, dated 11/04/16, showed that:
- A patient presented at the ED entrance on 11/02/16.
- No patient access representatives were attending the front desk.
- The patient reported that she had to wait "awhile" before being assisted.

4. Review of video surveillance, date and time randomly chosen by Staff Y, Security and Facilities Service Manager, showed on 05/09/17 at 4:00 AM:
- The ED entrance was left unattended.
- There was signage and a phone directing visitors to call "1269" for assistance.
- There was no HIM clerk monitoring the security cameras and/or the phones.
- There was one patient in the waiting room.

During an interview on 05/18/17 at 10:30 AM, Staff Y, Security and Facilities Service Manager, stated that after reviewing the video surveillance, there was no use in having badge swipe locks on the other facility doors, if you leave ED doors open and unattended.

During an interview on 05/18/17 at 9:10 AM, Staff C, Executive Director Administrator, stated that she was a part of the governing body, and it was her understanding that the ED entrance had been attended 24 hours per day by having security monitor the ED entrance when the patient access representative left the area.

During an interview on 05/18/17 at 11:15 AM, Staff A, President, stated that the governing body was responsible for the everyday operations of the facility and that staff should have had attended the ED entrance 24 hours per day.

5. Record review of the facility's policy titled, "Environmental Health and Safety and Emergency Management Programs," dated 02/2014, showed the objectives of the Safety Management Plan are as follows:
- Provide a safe environment for patients, visitors and staff;
- Conduct safety surveys to identify, eliminate, or minimize avoidable risks and injuries;
- Comply with safety standards and regulations; and
- Identify opportunities to improve safety.

6. Observation on 06/01/17 of photographs provided by Life Safety Code surveyor taken on 05/2017, in the seclusion room at the New Hope Psychiatric Unit, showed an unprotected camera in the ceiling that had a metal bar. This device could have been used as a ligature (an item used for tying or binding something tightly) point and created an unsafe environment.

During an interview on 06/01/17 at 2:45 PM, Staff Y,Security and Facilities Service Manager, stated that he was not aware that the camera in the New Hope seclusion room was unprotected. He also stated that he performed environmental tours of these areas to look for possible ligature items missed, water leaks or any damaged areas two times per year.

7. Observation on 06/01/17 of photographs provided by Life Safety Code surveyor taken on 05/2017, at the New Hope Psychiatric Unit, showed that the door of the seclusion room had glass that was not tempered (treated to give increased strength and would shatter into pellets instead of glass when broken). This increased the possibility of patients being exposed to glass breakage.

During an interview on 06/01/17 at 2:45 PM, Staff Y, Security and Facilities Service Manager, stated that he was not aware that the window in the New Hope seclusion room was not tempered.











36473

Based on observation, interview and record review, the facility failed to ensure that staff followed their policies and the infection prevention standards for The United States Pharmacopeia (USP) for compound sterile processing when they failed to:
- Clean the hood after each Chemotherapy (Chemo) sterile compound preparation;
- Wear protective eye glasses when preparing Chemo sterile compound preparations;
- Remove paper (a particle shedding item) temperature logs from the inside of the door of the Chemo room and the sterile compound room;
- Remove eye makeup prior to entering the sterile compound room;
- Secure hair hanging out of a hair scrub cap prior to entering the sterile compound room;
- Remove earrings prior to entering the Chemo room; and
- Remove name tags prior to garbing and entering the Chemo room and the sterile compound room.
These deficient practices had the potential to increase the risk of cross contamination and placed all patients that received Chemo and Sterile compounded medications, at risk for infection. The facility census was 21.

Findings included:

1. Record review of the facility policy titled, "Sterile Admixture," revised 02/2017, showed that all compounded medications mixed in the pharmacy, are compounded using the professional principles stated in the United States Pharmacopeia (USP), Chapter 797.

2. Record review of the USP, Chapter 797, dated 2013, showed that before entering the buffer area, all outer garments to include makeup, jewelry and earrings were to be removed; hair should be up in a scrub cap, unnecessary items removed and all paper products were to be removed from the room. Chapter 797 also showed that when preparing Chemo sterile compound preparations, protective eye wear should be worn and the hood should be cleaned in between each chemo.

3. Observation on 05/16/17 at 9:00 AM, in the Chemo room (buffer area), showed a paper temperature log attached to the inside of the Chemo room door. Observation showed Staff FF, Pharmacy Technician in the buffer area and she:
- Wore earrings and a nametag under her garb;
- Did not wear a protective eye shield; and
- Did not clean the hood between Chemo admixtures.

During an interview on 05/17/17 at 3:30 PM, Staff FF stated that she didn't realize she had left her earrings on and was unaware that the nametag could not be left on. She also stated that she misunderstood the term batch (a group of like items mixed at the same time) in the USP, Chapter 797, as far as cleaning in between the admixtures. She stated that she thought she didn't need to clean after each one, but that she cleaned every 30 minutes.

During an interview on 05/17/17 at 3:40 PM, Staff W, Director of Pharmacy, stated that he was unaware of the need for an eye shield in the Chemo room. At a later time, he stated that they were needed and on order and also stated that Staff FF should not have had earrings and a nametag on and the paper logs should not be on the inside of the rooms.

4. Observation on 05/16/17 at 10:10 AM, in the sterile admixture room on the left of the Ante room, showed
a paper temperature log attached to the inside of the door of the room. Observation showed Staff JJ, Pharmacy Technician in the ante room and she:
- Had hair not covered by her scrub cap;
- Wore her nametag under her garb; and
- Wore eye makeup.

During an interview on 05/17/17, at 10:32 AM, Staff JJ stated that she was unaware that her hair was not covered by her hat; that she couldn't wear eye makeup or her nametag and that the temperature log wasn't supposed to be in the room.

During an interview on 05/17/17 at 10:15 AM, Staff W, Director of Pharmacy, stated that Staff JJ should not have had make up on and should have had her hair under the scrub cap. He also stated that he didn't realize she had a nametag on and she shouldn't have any paper in the sterile room.

Based on observation, interview and policy review, the facility failed to ensure that staff followed infection control policies and infection prevention standards when they failed to:
- Maintain a sterile environment in isolation rooms (rooms used to help stop the spread of germs from one person to another) when staff contaminated their gloves and then contaminated supplies used for one patient (#7) of one patient observed.
- Prevent transmission of disease by returning a potentially contaminated unused medication from an isolation room for one patient (#7) of one patient observed to the pharmacy for redistribution.
- Ensure that the Central Sterile Processing (the area of the hospital where medical/surgical supplies and equipment were cleaned, prepared, processed, stored and issued for surgery and patient care) work areas were terminally cleaned daily to prevent breaching aseptic technique (method designed to prevent contamination of the sterile process).
- Remove all particle shedding objects (box with envelopes of processed items) from the Central Sterile Processing area.
- Clean the inside trap of the Sterris Washer (washer that cleans and sterilizes instruments prior to sending to Central Sterile clean room) in the Central Sterile dirty room, which increased the potential of contamination.
- Remove six expired laryngoscope blades (instruments used to obtain a view of the vocal folds to place a breathing tube in patients) from the surgical supply room.
- Label the intravenous catheter (small plastic tube placed in a vein for delivery of fluids and medications) site dressing with date, time of insertion, and initials for three patients (#2, #3, and #4) of six patients observed.
- Record daily temperatures on one cabinet fluid warmer of one observed to validate and preserve the integrity of the intravenous solution (fluids that will be injected into the body).
These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The facility census was 21.

Findings included:

1. Record review of facility policy titled, "Contact precautions" (process and items- gown, gloves- used to prevent the spread of infections), dated 07/2016, showed the following:
- Perform hand hygiene and change gloves before and after any contact with patient or their environment;
- Items in the patient environment likely to have been contaminated must be handled in a manner to prevent transmission of infectious agents;
- Utilize contact precautions with patients with known infections or patients suspected of being infected with germs that are easily transmitted through direct or indirect contact;
- Minimize exposure to diseases transmitted by both direct and indirect contact with patients or their environment.

2. Record review of Patient #7's, History and Physical (H & P, section of the medical record where the physician documented the reason for admission), showed that the patient had a lung infection from Methicillin Resistant Staph Aureus (MRSA, an infection caused by a type of bacteria that has become resistant to many of the antibiotics previously used to treat those infections.)

3. Observation of Patient #7 on 05/16/17 at 9:00 AM showed Staff R, Registered Nurse (RN), put on an isolation (protective) gown and gloves and carried two medications and supplies into the room. Staff R placed medications on the over bed table without cleaning the table. Staff R then adjusted Patient #7's gown and bed linens, asked the patient her name and date of birth while she held the patient's wrist and checked the band to identify the patient. Staff R then carried medications back to the computer on wheels which was located at the doorway of the room. Staff R touched the computer screen with gloved hands to display the medications she was about to administer and used the hand held scanner on the computer table to scan the medications. She then carried the medications back to the over bed table. Staff R opened a package of intravenous (IV- small tube that is inserted under the skin into a vein) tubing (tube used to carry medication from the bag to the IV site), inserted the tube into an access point of the bag of medication, placed the tubing into a pump, programmed the pump by touching the screen on the front of the pump and then reached under the isolation gown to get a pen to write the date on a label and attached the label to the tube. Staff R then reached back under her gown to replace the pen into her pocket. Staff R did not change gloves, isolation gown or clean hands at any time during this process.

Staff R advised Patient #7 that she also had a medication that would be administered by an injection in the stomach area. Patient #7 refused the medication. The medication was a pre filled syringe in a sealed manufacturer's package. The RN carried the medication package, now contaminated from being placed on the over bed table and the RN's soiled gloves, and placed it on the computer on wheels table at the entry door. After care on Patient #7, Staff R carried the medication package down the hall and placed the medication into the return to pharmacy drawer of the medication dispensing machine.

During an interview on 05/16/17 at 10:30 AM, Staff T, Assistant Nurse Manager, who had been present at this observation, stated that she did not realize the extent of the potential contamination that had just occurred.

During an interview on 05/16/17 at 1:30 PM, Staff R stated that she had heard about her infection control breaches and was very embarrassed. Staff R stated that she realized some of the issues while she cared for Patient #7 and stated that she was nervous about being observed. She stated that in retrospect she understood the concerns and learned from this experience.

During an interview on 05/17/17 at 12:45 PM, Staff MM, Infection Prevention Specialist, stated that she had heard about this situation and realized it was not something that she had previously identified as an issue. Staff MM stated that they have recognized the potential seriousness of this situation and are working toward a correction.

4. Record review of the procedure for cleaning of sterile processing rooms from the Association of Operating Room Nurses (AORN) and the Association for the Advancement of Medical Instrumentation (AAMI), showed they recommend that they are terminally cleaned (usually includes removing all detachable objects in the room, cleaning lighting and air duct surfaces in the ceiling, and cleaning everything downward to the floor. Items removed from the room are disinfected or sanitized before being returned to the room) daily the same as the operating, delivery and invasive procedure rooms.

5. Record review of the facility's policy titled, "Infection Control Policy and Procedure," dated 10/2016, showed that the terminal cleaning of the sterile processing room is performed by housekeeping.

6. Observation on 05/16/17 at 10:49 AM, in the Central Sterile processing room, showed:
- A box of envelopes (particle shedding products that can cause contamination) on the same counter used for processing and packaging sterile instruments;
- A table and chairs (without being terminally cleaned these are additional contamination objects);
- A computer;
- A tape dispenser: and
- Two sheets of paper on the table.

During an interview on 05/18/17 at 9:45 AM, Staff LL, Sterile Processing Technician, stated that the box had the stack of code sheets in envelopes of previously processed instruments.

During an interview on 05/18/17 at 10:17 AM, Staff V, Manager of Surgical Services, stated housekeeping should have been terminally cleaning the sterile processing rooms, the same as the operating rooms.

During an interview on 05/18/17 at 10:10 AM, Staff KK, Housekeeping Manager, stated that they have never terminally cleaned the sterile processing room and that they do not have a policy that speaks to that.

7. Record review of the facility's policy titled, "Decontamination Area Procedures," dated 10/2016, showed the directive for staff to inspect all instruments and equipment to assure their adequacy for re-use following decontamination.

8. Record review of the Sterris washer cleaning log showed that cleaning was performed weekly and Sterris field service report showed that the washer had been serviced yearly.

9. Observation on 05/16/17 at 10:45 AM, in the Central Sterile decontamination room, showed the inside of the Sterris washer trap, to be unclean with debris and a piece of paper in the bottom.

During an interview on 05/16/17 at 11:10 AM, Staff V, Manager of Surgical Services, stated that she thought that there were emergency operating room (OR) cases over the weekend and this was why it had not been cleaned.

10. Observation and concurrent interview on 05/16/17 at 11:00 AM, in the surgical supply room, showed six expired laryngoscope blades dated 04/22/17. Staff V, Manager of Surgical Services stated that she assigns the OR staff to go through the supply room one time per month to look for expired supplies and sometimes they miss items.

11. Record review of the facility's policy titled, "IV Line Care," revised 02/2017, showed after the IV insertion, a sterile dressing should be applied and labeled with the date and time of insertion, and initials.

12. Observation on 05/15/17 at 4:00 PM and 4:10 PM, in the Emergency Room (ER), showed no date, time, or initials on the right antecubital (AC, the depression area in front of the elbow) dressing that covered the IV site of Patient #2 and showed no date, time, or initials on one left AC dressing that covered an IV site for Patient #3.

During an interview on 05/15/17 at 4:05 PM and 4:15 PM, Staff I, RN, stated that the IV dressings were not labeled but should have been as directed in the policy.

13. Observation on 05/15/17 at 4:20 PM, in the ER, of Patient #4, showed no date, time, or initials on the right AC dressing that covered an IV site.

During an interview on 05/15/17 at 4:25 PM, Staff J, RN, stated that the IV dressing was not labeled and the IV dressing should have been labeled.

During an interview on 05/15/17 at 4:30 PM, Staff F, Clinical Nurse Manager of the ED, stated that all nurses should have labeled their IV's with date, time, and initials.

14. Observation on 05/15/17 at 4:50 PM in the ER room #2, showed a contrast media warming unit with five IV fluid bags inside, ready for patient use. The unit had a temperature indicator (a gauge to monitor temperature) to measure the temperature of the inside of unit.

15. Record review of the facility's document titled, "Daily Charge Nurse Checks," dated 05/2017, showed that no staff had recorded the temperatures on the contrast media warming unit from 05/01/17 through 05/15/17.

During an interview on 05/15/17 at 4:55 PM, Staff F, Clinical Nurse Manager of the ED, stated that after review of the ER daily nurse checks record, no staff had recorded daily temperatures on the contrast media warming unit, and that the staff should have recorded the temperatures daily.

During an interview on 05/18/17 at 8:45 AM, Staff EE, Clinical Engineering Manager, stated that the manufacture requirements on the contrast media warming unit in the ER, was that the temperatures were recorded daily.

During an interview on 05/18/17 at 12:45 PM, Staff MM, Manager of Infection Prevention, stated that nurses should have adhered to the facility policies and directives for prevention of the spread of infection.





36473




29511

Based on observation, record review, and interview the facility failed to ensure that stored foods were dated when opened. This deficient practice placed all patients at risk for unsanitary food service and cross contamination of food. The facility census was 21.

Findings included:

1. Record review of facility policy B003, titled, "Food Storage," dated 01/2017 showed that staff should:
- Store food in a manner that prevented contamination and maintained the safety and wholesomeness of food for human consumption.
- Label and date unused portions and opened packages with the date opened, and the date to be discarded.
- Dispose of the product at the close of business on the discard date on the label.

2. Record review of the United States Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2013 Food Code, Chapter 3-302.12, "Food Storage," showed direction for facility dietary staff to label food with the dated opened.

3. Observation on 05/17/17 at 11:00 AM, in the kitchen dry storage room and freezer, showed the following opened food packages that were not labeled with the date opened or date to be disposed:
- In dry storage an open bag of red gelatin powder (about four ounces), an open container of cocoa powder (about three ounces), and an open bottle of corn syrup (about five ounces;
- In the freezer an open bag of sweet potatoes (about 10 ounces),and an open bag of corn (about eight ounces).

During an interview on 05/17/17 at 11:15 AM, Staff II, Dietary Manager, stated that all opened items should be marked with the date the food was opened and the date to be discarded. Staff II stated that we could not be sure how long the food would remain safe if products are not dated when opened or when to discard. Staff II stated that all staff are supposed to date items they open and this process was not being monitored at this time.