HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to properly prepare, label, administer, and store medications in two of two surgical areas. Findings include:

1. Observation on 10/4/11 at 8:00 a.m. of the warming unit in the sub-sterile area between operating rooms two and three in the same day surgery area revealed:
*One 3000 milliliter plastic bag of normal saline irrigation had a handwritten medication label on it. That label had two unreadable words on it and the number 2.
*That bag was stored with multiple other solutions at a temperature of 117 degrees Fahrenheit. Refer to A724, finding 1.

Interview on 10/4/11 at 8:05 a.m. with the interim director of surgical services revealed:
*She agreed the medication label on the above bag of solution was not readable and had not met the provider's expectations for medication labeling.
*She agreed the above bag with the unreadable medication label had been improperly stored. Refer to A724, findings 1 and 3.

Review of the provider's undated policy for medication labeling revealed the medication labels should have included the following:
-Name and location of the patient.
-Generic and brand name of the drug.
-Name and volume of the diluent.
-Dosage of the medication added.
-Date the medication was added.
-Date and the time the medication expired.

2. Observation on 10/4/11 at 9:50 a.m. of certified nurse anesthetist (CRNA) A preparing and administering the antibiotic Ancef to patient 1 revealed:
*CRNA A reconstituted a one gram bottle of Ancef with fluid from the patient's intravenous (IV) line using a ten milliliter syringe.
*The contents of the above syringe were then administered in the patient's IV port over approximately 10-15 seconds.

Interview and manual review on 10/4/11 at 2:30 p.m. with the director of pharmacy and the interim director of surgical services revealed:
*According to the medication manual the director of pharmacy used Ancef should had been administered over a 3-5 minute time frame.
*They both agreed CRNA A had administered Ancef to patient 1 too quickly according to the pharmacy's medication manual.

Review of the manufacturer's package insert for Ancef confirmed the recommendations found above by the director of pharmacy.

3. Observation and interview on 10/5/11 at 6:40 a.m. of CRNA B as she was preparing medications for patient 48's surgery revealed:
*She broke the top off a glass ampule of ephedrine and withdrew its contents without using a filter needle/straw.
*When asked by this surveyor why she had not used a filter needle/straw she stated "We don't use filter needles/straw on ampules unless we are using them for spinal injection."

Interview on 10/5/11 at 6:50 a.m. with the interim director of surgical services and CRNA C revealed:
*They both agreed a filter needle/straw should have been used after opening a glass ampule to ensure the patient was not injected with glass fragments.
*Pharmacy provided filter needles/straws and they were on every anesthesia cart.

Interview on 10/5/11 at 10:30 a.m. with the interim director of surgical services revealed:
*No policy was available related to filter needle/straw use.
*She agreed use of a filter needle/straw was a basic nursing skill, and staff should have been aware of when to use them.

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, Mo., 2005, pp. 875 and 876, revealed medication in glass ampules should have been withdrawn with a filter needle.

Based on observation, interview, and policy review, the provider failed to ensure the proper warming of intravenous (IV) fluids and irrigation fluids in two of two surgical areas. Findings include:

1. Observation on 10/4/11 at 8:00 a.m. of the warming unit in the sub-sterile area between operating rooms two and three in the same day surgery area revealed:
*The top area of the warmer had multiple bags and bottles of IV fluids and irrigation fluids.
*The temperature of the warmer was 117 degrees Fahrenheit (F) per the unit's digital thermostat.
*One of the 3000 milliliter bags had a handwritten medication label on it that was not readable. Refer to A404, finding 1.

Interview and manufacturer's warming instructions review on 10/4/11 at 8:05 a.m. with the interim director of surgical services revealed:
*No temperature monitoring logs were kept for any of the warming units being used to warm fluids for patients in the surgical areas.
*The fluids found in that unit were used in surgical procedures.
*She agreed the fluids in that warmer needed to have been taken out of circulation and not re-used, as they had been over-heated as per the manufacturer's instructions.

2. Observation on 10/4/11 at 2:15 p.m. of the warming unit located in the main hospital's post anesthesia care unit (PACU) revealed:
*The top area of the warmer had multiple bags and bottles of IV fluids and irrigation fluids.
*The temperature of that warmer was 104 degrees F per the units digital thermostat.
*No temperature monitoring log was present.
*Multiple bags of IV and irrigation fluids had September and October dates.

Interview on 10/4/11 at 2:20 p.m. with the interim director of surgical services revealed:
*She could not tell this surveyor for sure whether or not the dates found on the fluids in the PACU warming unit indicated the date they had to be removed from the warming unit or if the dates indicated the date they had been placed into the unit. She had been instructing staff to write the date the warmed fluids needed to be removed from the warmer instead of the date they were placed in the warmer. However no formal policy related to that process had been developed.
*She agreed the fluids in the PACU warming unit labeled with a date prior to the 10/4/11 might have been expired and should have been removed from the warmer.

3. Observation and interview on 10/4/11 at 3:10 p.m. with the interim director of surgical services in the main hospital's operating room 3 revealed:
*Only two operating rooms were being used as the others were under construction. Both of those operating rooms had older warming units in them. She stated those units were not being used to put fluids in as their temperatures were not able to be controlled well.
*No temperature monitoring log was present.
*Inside the warming unit in operating room 3 were two 1000 milliliter pour bottles of saline dated 9/30/11. The temperature of that warming unit was 119 degrees F.
*She was not aware staff had started to use that warming unit again.
*She agreed the fluids in that warmer needed to have been taken out of circulation as it could not be verified the warmer had not exceeded the manufacturer's recommended warming temperature.

Review of the provider's April 2011 warming IV solutions and irrigation solutions policy revealed:
*It did not require monitoring of the temperatures of the warming units.
*It did not standardize how the fluids would be marked as warmed to ensure fluids were not re-warmed once they had been removed from a warming unit.
*It did not outline the manufacturer's requirements for arthromatic and uromatic irrigation solutions in plastic bags. Both of those were warmed by the provider.
*It had not been updated to require warmed fluids be labeled with the date they needed to be removed from the warmer as indicated by the interim director of surgical services.

Review of the Association of periOperative Registered Nurses 2010 Perioperative Standards and Recommended Practices, 2010 Edition, Denver, CO., pp. 224 and pp. 225, revealed:
*A warming units temperature was checked at regular intervals according to the provider's policy and documented on a temperature log or recorded electronically.
*Setting, maintaining, and monitoring a warmer should have been assigned to specific personnel.
*Warming units with fluids in them should have been labeled with the safe temperatures of operation as per the manufacturer's instructions
*Fluids and blankets maintained in the warmer were used on a first-in, first-out basis.
*Fluids kept in a warming device would be maintained according to the manufacturer's recommendations.
*Solutions warmed to a temperature above normal body temperature should not exceed 98.6 degrees F at the time they were placed inside the body. That temperature should have been verified per sterile thermometer.

Based on observation, interview, and policy review, the provider failed to ensure:
*Two of three observed physicians (D and E) performed appropriate hand hygiene prior to and after delivery of care for one patient (1).
*Two of two sterile processing department ceilings were maintained in a hygenic manner.
Findings include:

1a. Observation on 10/4/11 at 8:50 a.m. of physician D in the same day surgery preoperative area revealed the physician entered patient 1's room and preformed a physical examination of the patient. He did not perform any hand hygiene prior to or after the patient's examination. After leaving the room he went on to see two additional unidentified patients in the preoperative area prior to going back to the operative area. Physician D was not noted performing hand hygiene during the course of any of the additional observations.

b. Observation on 10/4/11 at 10:15 a.m. of physician E after performing surgery on patient 1 revealed the physician removed his surgical gloves and then proceeded to the post-operative area where he sat at the nurses stations and handled multiple objects cross-contaminating them. Shortly after that observation the physician left the same day surgery area. The physician was never observed performing hand hygiene after performing surgery.

c. Interview and policy review on 10/5/11 at 1:10 p.m. with the infection control officer revealed:
*She agreed proper hand hygiene had not been performed by the above two physicians.
*She agreed the above physicians had not followed the provider's revised August 2011 general standard precautions policy that outlined hand hygiene.

2. Observation on 10/4/11 from 12:15 p.m. through 2:15 p.m. of the sterile processing department areas in the same day surgery area and at the main hospital location revealed:
*The ceilings in both clean sterilization areas had a large amount of brown dust accumulated on and around both the ventilation intake and output vents.
*The hanging ceiling braces in the main hospital clean sterilization area had multiple areas of rust and damage on them.

Interviews on 10/4/11 from12:15 p.m. through 2:15 p.m. with the interim director of surgical services and the supervisor of the sterile processing revealed:
*Housekeeping was to clean the ceiling of both of the areas every month.
*They were not aware of any records kept related to the cleaning of those ceilings.
*They both agreed the dust on the ceilings in both areas could contaminate surgical instruments if it fell off.
*They agreed the hanging ceiling braces in the main hospital clean sterilization area were rusty and in need of maintenance.

Interview on 10/5/11 at 1:15 p.m. with the infection control officer revealed she agreed the dust located on the ceilings of both clean sterile processing areas noted above should have been kept clean to ensure instruments were not contaminated with any falling dust.

Based on record review, interview, policy review, and contract review, the provider failed to ensure the timely referral of death was made to the contracted organ procurement organization (OPO) for two of three sampled patients' death records (51 and 52). Findings include:

1. Review of patient 51's record revealed:
*The patient had an endotracheal tube (breathing tube) and had been on a ventilator.
*A physician's order for extubation (removal of the endotracheal tube and ventilator) when the family was ready had been written on 7/21/11 at 9:57 a.m.
*Extubation had occurred on 7/21/11 at 10:10 a.m.
*At 10:42 a.m. no heart tones or respirations had been auscultated (heard by stethoscope) for one minute, and the patient had been declared expired by the physician.
*The OPO had not been notified of patient 51's death until 11:50 a.m. that day, more than one hour after the time of cardiac death.
*No nursing documentation was found in the patient's record of the reason for the delay in notifying the OPO or if the OPO had been notified prior to the removal of life support.

2. Review of patient 52's record revealed the patient had been born on 9/14/11 at 6:15 a.m. at 21 weeks gestation and had expired four minutes later at 6:19 a.m. The OPO had not been called until 9:43 a.m. that same day, over three hours after the time of death. No nursing documentation was found in the patient's record of the reason for the delay in notifying the OPO.

3. Interview on 10/5/11 at 10:30 a.m. and again at 2:00 p.m. with the director of the emergency department/OPO coordinator revealed:
*The staff tried to call the OPO within one hour of any patient's death.
*She was unsure why the OPO had not been notified within one hour of the deaths of patients 51 and 52.
*If the staff had been unable to notify the OPO of a patient's death within one hour the reason should have been documented in the patient's record.
*The staff should have notified the OPO in the cases of imminent death and before the removal of life-sustaining treatment.
*The provider had the capability of maintaining patients on life support until the OPO team arrived.
*The staff had not received any competency training in the OPO policies and procedures since she had been hired by the provider two years ago.
*Hospital competencies were completed once a year for all the staff, but they had not covered OPO policies and procedures every year in those competencies.

4. Interview on 10/5/11 at 2:25 p.m. with the director of obstetrical services revealed she had not received any training in the OPO policies and procedures since she had started at the facility six months ago.

Review of the provider's organ and/or tissue donation policy and procedure reviewed and revised July 2008 revealed:
*Referral of all deaths, regardless of age (20 weeks gestation and older), or medical history to the OPO was required.
*Timely referral of all deaths (within one hour) was essential for the procurement of potentially transplantable tissues/eyes.
*The definition of cardiac death was the cessation of cardiac/respiratory function.
*Notification to the OPO was required to be made prior to the withdrawal of any life-sustaining therapies.
*Timely notification meant notification to the OPO within one hour of a cardiac death.

Review of the perinatal loss policy revised June 2011 revealed live births greater than 20 weeks gestation who subsequently had died required the notification of the OPO.

Review of the 2009 amendment agreement of the provider's contract with the OPO revealed the provider should have:
*Notified the OPO as soon as possible after the death of any individual including a patient with the potential for organ donation after cardiac death.
*Worked cooperatively with the OPO to identify and maintain patients with the potential for organ donation after cardiac death and to refer those patients to the OPO prior to the withdrawal of life-sustaining therapies.
*Worked cooperatively with the OPO in the education of all of the appropriate hospital staff on donation issues.