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Based on observation, interview, and documentation review the facility failed to ensure: the fire rated construction around vertical openings were maintained (K-20); the fire rated construction of smoke barriers (K-25); proper door openings in smoke barriers (K-27); exit components had proper fire resistance ratings (K-33); the proper width of aisles (K-39); proper maintenance of emergency lighting (K-46); fire drills were conducted as required (K-50); proper use of portable heating devices (K-70); occupancy separations were maintained with at least a one hour fire resistance rating (K-114); maintenance of all components of offsite or onsite business occupancies such as sprinkler systems. fire alarm systems, etc. (K-130).
This has the potential to affect all patients, staff, and visitors to the facility. The cumulative effects of these systemic practices resulted in the facility's inability to ensure the safety of the patients (A-710). The facility's census at the time of the survey was 271.

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients, visitors, and staff to the facility.
1. Please see K20 for findings related to the facility failing to maintain the fire rating around chases and shafts.
2. Please see K25 for findings related to the facility failing to maintain the rating on smoke barriers.
3. Please see K27 for the findings related to the facility failing to maintain the proper rating on doors in fire rated walls.
4. Please see K33 for the findings related to the facility failed to maintain the fire rating around exit stairwells.
5. Please see K39 for the findings related to the facility failing to maintain the corridors width.
6. Please see K46 for the findings related to the facility failing to test battery powered emergency lighting 30 seconds monthly, and 90 minutes annually.
7. Please see K50 for the findings related to the facility failing to perform fire drills in the medical office building at least annually.
8. Please seek K70 for the findings related to use of portable heating devices.
9. Please see K114 for the findings related to maintaining at least a one hour fire rating on occupancy separations.
10. Please see K130 for the findings related to on and offsite business occupancies failing to keep sprinkler heads free from debris as in accordance with NFPA 25; failing to keep spare sprinkler heads and a wrench in the ambulatory surgery center; failed to have the alarm system in the medical office building tested as in accordance with NFPA 72.

Based on observation, staff interview, review of infection control policies and review of manufacture instructions, the facility failed to ensure disinfection followed manufacturer instructions for glucose testing (Patient #35) and failed to follow hand hygiene and changing gloves for a peripherally inserted intravenous catheter of a patient in contact precautions (Patient #34). This affected two of 36 sampled patients. This has the potential to affect all patients in the hospital. The active census at the time of the survey was 271.

Findings include:

1. On 12/17/14 at 7:40 AM, Staff E was observed performing a blood glucose test using an Accu-check blood glucose monitor on Patient #35. After the blood glucose test was completed, Staff E was observed cleaning the Accu-chek monitor with a packaged swab stored in the monitor holder. Staff E indicated he/she had used an alcohol swab to disinfect the blood sugar monitor. Staff F, manager of the unit, also confirmed alcohol swabs are used for disinfection of the blood glucose monitor between patients.

Review of the facility policy on Point of Care Testing Glucose, approved on 10/28/14, revealed to not use any cleaning and disinfecting product other than that which is recommended by the manufacturer and the facility's infection control policy.

Review of the Accu-chek monitor manufacturer's instructions for cleaning and disinfecting indicated to use a Clorox Germicidal Wipe or Super Sani-Cloth Germicidal Disposable Wipe between each patient.







21893

On 12/17/14 at 11:00 AM, Staff D was observed to insert a Peripherally Inserted Central Catheter (PICC) into the right upper arm of Patient 34. Patient 34 was in Contact Isolation for ESBL (a multi drug resistant bacteria) drainage from a wound. Staff D was observed to put on personal protective equipment (PPE) prior to entering the patient's room, including gown and gloves. Staff D assisted the patient back into bed, assessed the patient, and began to set up for the procedure. Staff D cleared the bedside table and elevated the bed to an appropriate height for the procedure. Staff D placed a towel on the bedside table and positioned Patient 34's arm on the bedside table. Staff D then reached into the basket on the SiteRite cart (mobile cart with an ultrasound and EKG machine) without changing gloves. Staff D pulled out a roll of tape and attempted to tape the patient's arm to the table to help ensure the patient did not move the arm during the procedure. The tape ripped, so Staff D then reached back into the basket for a different roll of tape and secured the arm to the table by taping above and below the wrist. The roll of tape was returned to the basket. Staff D also reached into the same basket for a disposable marker, a measuring tape and a surgical hair cover, all with the same pair of gloves. Staff D was observed to remove gloves and put on new gloves several times during the procedure with hand hygiene only performed a couple of times and not every time. Staff D was observed at the end of the procedure to remove gloves, perform hand hygiene, and then reach into a pocket under the PPE gown without gloves for a pen. Staff D was then observed to write the date and time on a sticker and place the sticker on the PICC line dressing, all without wearing gloves. This was confirmed with Staff C at the time of observation.

Review of the Isolation Precautions policy revealed hand hygiene was to be performed immediately after gloves were removed to prevent cross contamination. For contact isolation, gloves and gown should be worn when entering the patient room, while performing patient care, and when potential contact with contaminated surfaces may occur. Supplies were to be dedicated to a single patient and equipment used for multiple patients adequately cleaned and disinfected prior to use on another patient.

Based on observation, staff interview, review of infection control policies and review of manufacture instructions, the facility failed to ensure disinfection followed manufacturer instructions for glucose testing (Patient #35) and failed to follow hand hygiene and changing gloves for a peripherally inserted intravenous catheter of a patient in contact precautions (Patient #34). This affected two of 36 sampled patients. This has the potential to affect all patients in the hospital. The active census at the time of the survey was 271.

Findings include:

1. On 12/17/14 at 7:40 AM, Staff E was observed performing a blood glucose test using an Accu-check blood glucose monitor on Patient #35. After the blood glucose test was completed, Staff E was observed cleaning the Accu-chek monitor with a packaged swab stored in the monitor holder. Staff E indicated he/she had used an alcohol swab to disinfect the blood sugar monitor. Staff F, manager of the unit, also confirmed alcohol swabs are used for disinfection of the blood glucose monitor between patients.

Review of the facility policy on Point of Care Testing Glucose, approved on 10/28/14, revealed to not use any cleaning and disinfecting product other than that which is recommended by the manufacturer and the facility's infection control policy.

Review of the Accu-chek monitor manufacturer's instructions for cleaning and disinfecting indicated to use a Clorox Germicidal Wipe or Super Sani-Cloth Germicidal Disposable Wipe between each patient.







21893

On 12/17/14 at 11:00 AM, Staff D was observed to insert a Peripherally Inserted Central Catheter (PICC) into the right upper arm of Patient 34. Patient 34 was in Contact Isolation for ESBL (a multi drug resistant bacteria) drainage from a wound. Staff D was observed to put on personal protective equipment (PPE) prior to entering the patient's room, including gown and gloves. Staff D assisted the patient back into bed, assessed the patient, and began to set up for the procedure. Staff D cleared the bedside table and elevated the bed to an appropriate height for the procedure. Staff D placed a towel on the bedside table and positioned Patient 34's arm on the bedside table. Staff D then reached into the basket on the SiteRite cart (mobile cart with an ultrasound and EKG machine) without changing gloves. Staff D pulled out a roll of tape and attempted to tape the patient's arm to the table to help ensure the patient did not move the arm during the procedure. The tape ripped, so Staff D then reached back into the basket for a different roll of tape and secured the arm to the table by taping above and below the wrist. The roll of tape was returned to the basket. Staff D also reached into the same basket for a disposable marker, a measuring tape and a surgical hair cover, all with the same pair of gloves. Staff D was observed to remove gloves and put on new gloves several times during the procedure with hand hygiene only performed a couple of times and not every time. Staff D was observed at the end of the procedure to remove gloves, perform hand hygiene, and then reach into a pocket under the PPE gown without gloves for a pen. Staff D was then observed to write the date and time on a sticker and place the sticker on the PICC line dressing, all without wearing gloves. This was confirmed with Staff C at the time of observation.

Review of the Isolation Precautions policy revealed hand hygiene was to be performed immediately after gloves were removed to prevent cross contamination. For contact isolation, gloves and gown should be worn when entering the patient room, while performing patient care, and when potential contact with contaminated surfaces may occur. Supplies were to be dedicated to a single patient and equipment used for multiple patients adequately cleaned and disinfected prior to use on another patient.