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Based on clinical record review, and interview, it was determined the facility failed to provide an Important Message from Medicare within two days of discharge for two (#9 and #10) of three (#7, #9, and #10) discharged Medicare patients. The failed practice did not ensure the Medicare patients were aware of their rights and had the potential to affect any Medicare patient. Findings follow.

A. Review of the clinical record of Patient #9, admitted 12/15/16 through 12/21/16, revealed no evidence of an Important Message from Medicare within two days of discharge. During an interview on 12/29/16 at 1500, Clinical Informaticist #1 confirmed there was no Important Message from Medicare upon discharge.
B. Review of the clinical record of Patient #10, admitted 02/15/16 through 02/21/16, revealed no evidence of an Important Message from Medicare within two days of discharge. During an interview on 12/30/16 at 0917, the Clinical Informatics Educator confirmed there was no Important Message from Medicare upon discharge.

Based on clinical record review, policy review, and interview, it was determined the facility failed to ensure restraint monitoring was conducted every two hours as per policy for one (#9) of two restrained patients (#9 and #10). The failed practice did not ensure the patient's needs were assessed periodically, and created the likelihood the patient would remain in restraints longer than necessary, and had the potential to affect any restrained patient. Findings follow.

A. Review of policy titled "Restraint Usage in Non-Behavioral Health Units" stated, "Patients in restraints must be monitored: Every two (2) hours for Non Violent/Non-Self Destructive Restraints."
B. Review of the clinical record for Patient #9 revealed an order for restraints on 12/18/16 at 2123. The clinical record contained no evidence of restraint monitoring after that time.
C During an interview on 12/29/16 at 1530, Clinical Informaticist #1 confirmed the lack of restraint monitoring.

Based on clinical record review and interview, of the 10 in-patient records reviewed, it was determined a Registered Nurse failed to follow the care plan for two (#3 and #10) of three (#1, #3 and #10) patients in that a weight was not obtained every 24 hours as prescribed by a physician. Failing to obtain a weight every 24 hours as prescribed did not allow the Registered Nurse or Interdisciplinary Team to evaluate the medical and nutritional care provided to the patients. The failed practice had the potential to affect all patients who were ordered to have every 24 hour weights obtained. The findings follow:

A. Review of Patient #3's clinical record on 12/30/16 revealed the patient was admitted to the facility on 12/24/16 and was currently a patient. A physician's order dated 12/25/16 at 0400 revealed to obtain a weight every 24 hours. There was no evidence a weight was obtained on 12/25/16, 12/27/16, 12/28/16 or 12/29/16. The findings were confirmed in an interview with the Nurse Manager of the Intensive Care Unit (ICU)/Emergency Department (ED)/Medical Surgical Unit on 12/30/16 at 1030.
B. Review of Patient #10's clinical record on 12/30/16 revealed the patient was admitted to the facility on 02/15/16 and discharged on 02/21/16. A physician's order dated 02/16/16 at 0400 revealed to obtain a weight every 24 hours. There was no evidence a weight was obtained on 02/16/16 or 02/19/16. The findings were confirmed in an interview with the Market Director of Nursing on 12/30/16 at 1000.

Based on observation, review of policy and interview, it was determined three (Registered Nurse (RN) #2, #3 and #4) of five (RN #1-5) RNs assigned the task of testing the defibrillator was not knowledgeable or competent to perform the task assigned. By not testing the defibrillator correctly, the facility could not assure the defibrillator would be in working order had an emergency arose. The failed practice had the likelihood to affect all patients admitted and under the care of the nurses. Findings follow:

A. During a tour of the facility on 12/27/16 from 1245 through 1430, observation revealed the following:
1) On the Medical/Surgical floor, Surveyor #4 asked whoever was responsible for testing the defibrillator to demonstrate how they tested it. RN #2 stated she was responsible for testing it and demonstrated how they tested the defibrillator. RN #2 did not unplug the defibrillator at the beginning of the demonstration.
2) In the Emergency Department, Surveyor #4 asked whoever was responsible for testing the defibrillator to demonstrate how they tested it. RN #3 stated she was responsible for testing it and demonstrated how they tested the defibrillator. RN #3 did not unplug the defibrillator at the beginning of the demonstration.
3. In the Pre-Operative/Post-Operative Unit, Surveyor #4 asked whoever was responsible for testing the defibrillator to demonstrate how they tested it. RN #4 stated she was responsible for testing it and demonstrated how they tested the defibrillator. RN #4 did not unplug the defibrillator at the beginning of the demonstration.
B. Review of policy titled Maintenance, checking and use of defibrillator stated "1. Unplug the unit from the power source. This is to verify that the battery operation is charged."
C. During an interview at the end of the tour on 12/27/16 at 1430, the Market Director of Nursing verified RNs #2-4 had not unplugged the defibrillator unit prior to testing.

Based on observation and interview, it was determined the Infection Control Coordinator failed to identify, investigate and control infections in that a sanitary environment was not maintained as follows:

1. Seven (2-Room #301, 1- Room #313, 1-Room #329, 1-Trauma Room #1, 1-Emergency Room (ER) Exam Room #4 and 1-Intensive Care Unit (ICU) Supply Closet) of 14 (2-Room #301, 2- Room #313, 2-Room #329, 2-Room #330, 3-Trauma Room #1, 2-ER Exam Room #4 and 1-ICU Supply Closet) air vents had a thick buildup of dust.
2. One (Room #301) of two (Room #301 and Room #302) blue fall mats had white powdery residue on the edge of the mat.
3. Two (Room #301 and ICU #4) of seven (Room #301, Room #313, Room #329, Room #330, Trauma Room #1, ER Exam Room #4 and ICU #4) beds had a thick buildup of dust or red splatters on the frames.
4. Two of two (Room #329 and ICU #4) standing fans had a buildup of dust on the fan blades.
5. One (Room #330) of four (Room #301, Room #313, Room #329 and Room #330) shower chairs had a brown residue.
6. One (Post Anesthesia Care Unit (PACU) Bay #13) of five (Room #301, Room #313, Room #329, Room #330, PACU Bay #13) over-the-bed table had a dried brown residue inside the table.
7. One of one (Gastroenterology Equipment Room) Electrocardiography (EKG) machine had a buildup of tape residue.
8. Two of two (Operating Room (OR) #1 and #3) OR beds had a buildup of tape residue.
9. One (OR Room #1) of two (OR Room #1 and #3) Anesthesia carts had a buildup of tape residue . The failed practice promoted the spread of infection from cross contamination. The failed practice had the potential to affect all patients admitted to the facility or on which the equipment was used. The findings follow:

Observation on 12/27/16 revealed the following:
A. At 1250, Room #301 revealed:
1) The air vent in the restroom had a thick buildup of dust;
2) The air vent over the patient bed had a thick buildup of dust;
3) The frame at the head of the bed had a thick buildup of dust.
4) The blue fall mat leaning against the wall had a white powder residue on the edge of the mat.
5) The findings were confirmed in an interview with the Nurse Manager of ICU/Emergency Department (ED)/Medical Surgical Unit on 12/27/16 at 1250.
B. At 1255, Room #313 revealed:
1) The air vent in the restroom had a thick buildup of dust.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1255.
C. At 1305, Room #329 revealed:
1) The vent in the restroom had a thick buildup of dust.
2) The standing fan had a buildup of dust on the fan blades.
3) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1305.
D. At 1309, Room #330 revealed:
1) The shower chair had a brown residue on the frame under the seat.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1309.
E. At 1315, Trauma Room #1 revealed:
1) One of three air vents had a thick buildup of dust.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1315.
F. At 1325, ER Exam Room #4 revealed:
1) One of two air vents had a thick buildup of dust.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1325.
G. At 1330, ICU Room #4 revealed:
1) The standing fan had a buildup of dust on the fan blades.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1330.
H. At 1335, the ICU Supply Closet revealed:
1) The air vent had a thick buildup of dust.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1330.
I. At 1340, PACU Bay #13 revealed:
1) The over-the-bed table had a dried brown residue inside the table.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1340.
J. At 1345 the Gastroenterology Equipment Room revealed:
1) The EKG machine had a buildup of tape residue.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1345.
K. At 1400, OR Room #3 revealed:
1) The bed had a buildup of tape residue.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1400.
L. At 1410, OR Room #1 revealed:
1) The bed had a buildup of tape residue.
2) The Anesthesia cart had a buildup of tape residue.
3) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1410.


30634

Based on observation, policy review, and interview, it was determined the infection control officer failed to ensure expired foods were not available for patient use, and failed to ensure foods requiring refrigeration were refrigerated. The failed practice created the potential for patients to experience a foodborne illness due to receiving expired foods and/or rancid foods due to lack of refrigeration and could affect any patient receiving those food items. Findings follow.

A. A tour of the kitchen was conducted on 12/29/16 from 0900 through 0920. The following items were observed:
1) Chocolate Ensure pudding-23 of 29 cups, expired 12/01/16
2) Vanilla Ensure pudding-24 of 40 cups, expired 12/01/16
3) Soy sauce-one of one gallon, opened, not refrigerated. Label on bottle stated "refrigerate after opening."
4) Teriyaki sauce-one of one gallon, opened, not refrigerated. Label on bottle stated "refrigerate after opening."
B. During an interview at the time of the tour, the Dietary General Manager confirmed the expired items and the unrefrigerated items.


36533

Based on review of manufacturer's instructions for use, review of Rapicide ortho-phthalaldehyde (OPA)/28 Solution logs and interview, it was determined the facility failed to prevent and control infections as follows:
1. Assure Rapicide OPA/28 Solution was tested for the Minimum Recommended Concentration (MRC) before each use for the dates of 12/05/16-12/27/16.
2. Establish Quality Control procedures for Rapicide OPA/28 Test Strips for the testing of a positive and negative control solution as recommended by the manufacturer.
3. Document the testing of positive and negative controls on Rapicide OPA/28 Test Strips as recommended by the manufacturer for one of one Rapicide OPA/28 Test Strips bottle in current use for the dates of 12/05/16-12/27/16.
Failure to follow manufacturer's instructions did not assure patients were protected from infection and had the likelihood to affect all patients receiving procedures utilizing semi-critical equipment requiring high level disinfection. Findings follow:

A. Review of the Rapicide OPA/28 log on 12/27/16 at 1500 revealed no documentation of the MRC validation prior to each use or positive and negative control testing of Rapicide OPA/28 Test Strips for the dates of 12/05/16-12/27/16.
B. Review of Rapicide OPA/28 Solution manufacturer's instructions for use on 12/28/16 at 1200 revealed "Rapicide OPA/28 may be reused according to the directions for use for up to 28 days provided that prior to each use the concentration of OPA in the solution is verified using Rapicide OPA/28 Test Strips to be above the MRC of 0.35%. The test strips must be used prior to each use."
C. Review of Rapicide OPA/28 Test Strips manufacturer's instructions for use revealed "Implementing routine use of control solutions will increase user proficiency, minimize procedural errors and protect against the inadvertent use of outdated product or product that is deteriorated due to improper storage or handling. Each facility should establish its own Quality Control procedures. Perform quality control testing by following directions for use and testing a positive and negative control solution. If the results from the control solutions are not as expected, do not use the remaining strips for testing disinfectant solutions. Retain the bottle of test strips and contact MEDIVATORS at 1-800-444-4729 to request technical support."
D. Review of policies and procedures revealed no evidence of a policy for Quality Control procedures of the use of Rapicide OPA/28 Test Strips.
E. During interview with the Supervisor of Perioperative Services on 12/28/16 at 0907, he confirmed Rapicide OPA/28 was used for high level disinfection of semi-critical equipment and stated the MRC was not checked before each use and no positive and negative controls for Rapicide OPA/28 Test Strips were documented.

Based on clinical record review and interview, it was determined the facility failed to assure Operative Reports included the date and time of surgery in 1 (#6) of 12 (#6, #10-#20) surgical records and the time of surgery in 8 ( #10-#15, #17 and #20) of 12 (#6, #10-#20) surgical records. Failure to document the date and time a surgical procedure took place did not establish a time-line of surgical events in the course of a patient's admission to the facility. The failed practice was likely to affect all surgical patients admitted to the facility. Findings follow:

A. Clinical record review was conducted on 12/29/16 from 1300-1530 and 12/30/16 from 0900-1230 and revealed the following:
1) Operative Report for Patient #6 revealed no evidence of the date and time of the surgical procedure.
2) Operative Report dated 02/18/16 for Patient #10 revealed no evidence of the time of the surgical procedure.
3) Operative Report dated 12/09/16 for Patient #11 revealed no evidence of the time of the surgical procedure.
4) Operative Report dated 12/23/16 for Patient #12 revealed no evidence of the time of the surgical procedure.
5) Operative Report dated 11/01/16 for Patient #13 revealed no evidence of the time of the surgical procedure.
6) Operative Report dated 12/13/16 for Patient #14 revealed no evidence of the time of the surgical procedure.
7) Operative Report dated 12/20/16 for Patient #15 revealed no evidence of the time of the surgical procedure.
8) Operative Report dated 12/14/16 for Patient #17 revealed no evidence of the time of the surgical procedure.
9) Operative Report dated 12/23/16 for Patient #20 revealed no evidence of the time of the surgical procedure.
B. Findings in A were confirmed at the time of clinical record review by Registered Nurse (RN) #6 for Patient #6, #11-#15, #17 and #20 and the Market Director of Nursing for Patient #10.

Based on clinical record review and interview, it was determined the facility failed to assure Operative Reports included the type of anesthesia administered in 4 (#11-#13 and #15) of 5 (#11-#15) Endoscopy surgical records. Failure to document the type of anesthesia administered did not assure post-operative assessment and monitoring had been performed. The failed practice was likely to affect all patients undergoing Endoscopy surgical procedures. Findings follow:

A. Clinical record review was conducted on 12/29/16 from 1300-1530 and revealed the following:
1) Operative Report dated 12/09/16 for Patient #11 revealed no evidence of the type of anesthesia administered.
2) Operative Report dated 12/23/16 for Patient #12 revealed no evidence of the type of anesthesia administered.
3) Operative Report dated 11/01/16 for Patient #13 revealed no evidence of the type of anesthesia administered.
4) Operative Report dated 12/20/16 for Patient #15 revealed no evidence of the type of anesthesia administered.
B. Findings in A were confirmed at the time of clinical record review by RN #6.

Based on observation and interview, it was determined the Infection Control Coordinator failed to identify, investigate and control infections in that a sanitary environment was not maintained as follows:

1. Seven (2-Room #301, 1- Room #313, 1-Room #329, 1-Trauma Room #1, 1-Emergency Room (ER) Exam Room #4 and 1-Intensive Care Unit (ICU) Supply Closet) of 14 (2-Room #301, 2- Room #313, 2-Room #329, 2-Room #330, 3-Trauma Room #1, 2-ER Exam Room #4 and 1-ICU Supply Closet) air vents had a thick buildup of dust.
2. One (Room #301) of two (Room #301 and Room #302) blue fall mats had white powdery residue on the edge of the mat.
3. Two (Room #301 and ICU #4) of seven (Room #301, Room #313, Room #329, Room #330, Trauma Room #1, ER Exam Room #4 and ICU #4) beds had a thick buildup of dust or red splatters on the frames.
4. Two of two (Room #329 and ICU #4) standing fans had a buildup of dust on the fan blades.
5. One (Room #330) of four (Room #301, Room #313, Room #329 and Room #330) shower chairs had a brown residue.
6. One (Post Anesthesia Care Unit (PACU) Bay #13) of five (Room #301, Room #313, Room #329, Room #330, PACU Bay #13) over-the-bed table had a dried brown residue inside the table.
7. One of one (Gastroenterology Equipment Room) Electrocardiography (EKG) machine had a buildup of tape residue.
8. Two of two (Operating Room (OR) #1 and #3) OR beds had a buildup of tape residue.
9. One (OR Room #1) of two (OR Room #1 and #3) Anesthesia carts had a buildup of tape residue . The failed practice promoted the spread of infection from cross contamination. The failed practice had the potential to affect all patients admitted to the facility or on which the equipment was used. The findings follow:

Observation on 12/27/16 revealed the following:
A. At 1250, Room #301 revealed:
1) The air vent in the restroom had a thick buildup of dust;
2) The air vent over the patient bed had a thick buildup of dust;
3) The frame at the head of the bed had a thick buildup of dust.
4) The blue fall mat leaning against the wall had a white powder residue on the edge of the mat.
5) The findings were confirmed in an interview with the Nurse Manager of ICU/Emergency Department (ED)/Medical Surgical Unit on 12/27/16 at 1250.
B. At 1255, Room #313 revealed:
1) The air vent in the restroom had a thick buildup of dust.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1255.
C. At 1305, Room #329 revealed:
1) The vent in the restroom had a thick buildup of dust.
2) The standing fan had a buildup of dust on the fan blades.
3) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1305.
D. At 1309, Room #330 revealed:
1) The shower chair had a brown residue on the frame under the seat.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1309.
E. At 1315, Trauma Room #1 revealed:
1) One of three air vents had a thick buildup of dust.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1315.
F. At 1325, ER Exam Room #4 revealed:
1) One of two air vents had a thick buildup of dust.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1325.
G. At 1330, ICU Room #4 revealed:
1) The standing fan had a buildup of dust on the fan blades.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1330.
H. At 1335, the ICU Supply Closet revealed:
1) The air vent had a thick buildup of dust.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1330.
I. At 1340, PACU Bay #13 revealed:
1) The over-the-bed table had a dried brown residue inside the table.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1340.
J. At 1345 the Gastroenterology Equipment Room revealed:
1) The EKG machine had a buildup of tape residue.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1345.
K. At 1400, OR Room #3 revealed:
1) The bed had a buildup of tape residue.
2) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1400.
L. At 1410, OR Room #1 revealed:
1) The bed had a buildup of tape residue.
2) The Anesthesia cart had a buildup of tape residue.
3) The findings were confirmed in an interview with the Nurse Manager of ICU/ED/Medical Surgical Unit on 12/27/16 at 1410.


30634

Based on observation, policy review, and interview, it was determined the infection control officer failed to ensure expired foods were not available for patient use, and failed to ensure foods requiring refrigeration were refrigerated. The failed practice created the potential for patients to experience a foodborne illness due to receiving expired foods and/or rancid foods due to lack of refrigeration and could affect any patient receiving those food items. Findings follow.

A. A tour of the kitchen was conducted on 12/29/16 from 0900 through 0920. The following items were observed:
1) Chocolate Ensure pudding-23 of 29 cups, expired 12/01/16
2) Vanilla Ensure pudding-24 of 40 cups, expired 12/01/16
3) Soy sauce-one of one gallon, opened, not refrigerated. Label on bottle stated "refrigerate after opening."
4) Teriyaki sauce-one of one gallon, opened, not refrigerated. Label on bottle stated "refrigerate after opening."
B. During an interview at the time of the tour, the Dietary General Manager confirmed the expired items and the unrefrigerated items.


36533

Based on review of manufacturer's instructions for use, review of Rapicide ortho-phthalaldehyde (OPA)/28 Solution logs and interview, it was determined the facility failed to prevent and control infections as follows:
1. Assure Rapicide OPA/28 Solution was tested for the Minimum Recommended Concentration (MRC) before each use for the dates of 12/05/16-12/27/16.
2. Establish Quality Control procedures for Rapicide OPA/28 Test Strips for the testing of a positive and negative control solution as recommended by the manufacturer.
3. Document the testing of positive and negative controls on Rapicide OPA/28 Test Strips as recommended by the manufacturer for one of one Rapicide OPA/28 Test Strips bottle in current use for the dates of 12/05/16-12/27/16.
Failure to follow manufacturer's instructions did not assure patients were protected from infection and had the likelihood to affect all patients receiving procedures utilizing semi-critical equipment requiring high level disinfection. Findings follow:

A. Review of the Rapicide OPA/28 log on 12/27/16 at 1500 revealed no documentation of the MRC validation prior to each use or positive and negative control testing of Rapicide OPA/28 Test Strips for the dates of 12/05/16-12/27/16.
B. Review of Rapicide OPA/28 Solution manufacturer's instructions for use on 12/28/16 at 1200 revealed "Rapicide OPA/28 may be reused according to the directions for use for up to 28 days provided that prior to each use the concentration of OPA in the solution is verified using Rapicide OPA/28 Test Strips to be above the MRC of 0.35%. The test strips must be used prior to each use."
C. Review of Rapicide OPA/28 Test Strips manufacturer's instructions for use revealed "Implementing routine use of control solutions will increase user proficiency, minimize procedural errors and protect against the inadvertent use of outdated product or product that is deteriorated due to improper storage or handling. Each facility should establish its own Quality Control procedures. Perform quality control testing by following directions for use and testing a positive and negative control solution. If the results from the control solutions are not as expected, do not use the remaining strips for testing disinfectant solutions. Retain the bottle of test strips and contact MEDIVATORS