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Based on observation, record review, interview, and policy review, the provider failed to ensure all essential patient care equipment in the facility was maintained in a safe operating condition. Biomedical testing could not be ensured or provided for two of two arthroscopic equipment towers and for the neo-natal warmer unit. Findings include:

1. Observation at 9:30 a.m. on 12/20/11 revealed two arthroscopic equipment towers were available for use in the operating room (OR). Closer observation at that time revealed a bio-medical inspection tag could not be located for those two towers. Interview with the OR manager at the time of the observation confirmed those findings. She stated they had obtained that equipment in the summer of 2011 but was unaware if it was leased or owned by the provider.

Continued interview with the environmental services supervisor (ESS) at 11:00 a.m. on 12/21/11 revealed he had contacted the bio-medical inspector regarding the two towers. The ESS revealed the bio-medical inspector had thought those towers were leased but was unaware they had been purchased by the provider. The ESS stated the inspector had not been told those towers were in need of a bio-medical inspection.

2. Observation at 11:45 a.m. on 12/20/11 revealed a neonatal warmer unit was stored in the storage room outside the emergency department (ER). Closer observation at that time revealed a bio-medical inspection tag could not be located for that unit. Interview with the ESS at the time of the observation confirmed that finding. He stated he would contact the inspector again regarding the neonatal warming unit. After a phone call to the inspector by the ESS it was discovered the inspector had been told the provider did not use the warming unit, therefore he had not tested it.

Interview with the director of nursing at 9:45 a.m. on 12/21/11 revealed they did keep the neonatal warming unit for emergency use.They had not used it since they had moved to the new facility.

Review of the neonatal warmer unit/intensive care center policy dated 11/8/10 revealed the following statements: "Although our facility is not properly equipped to deliver or care for newborns on a routine basis, the ER will provide neonatal warming and medical attention as necessary. Newborn patients of emergency births should be revived, warmed, and attended to until transfer to an appropriate facility is made possible."

Based on observation, interview, and policy review, the provider failed to ensure:
*Outdated and unusable medications were not available for use in three of five observed medication storage areas (nursing station, surgical suite, and central supply room.)
*A policy was established to limit access to controlled substances in the surgical suite.
Findings include:

1. Observation on 12/19/11 at 3:15 p.m. of the nursing station medication room revealed:
*Two opened multiple-dose vials of purified protein derivative (PPD). One was marked with an opening date of 10/11/11 and the other 10/17/11.
*Two opened multiple-dose vials of lidocaine one percent injection. One was marked with an opening date of 10/25/11, and the other was not marked with an opening date.

Interview at the above time with pharmacy technician D revealed it was the duty of the pharmacy technicians to inspect the storage areas and remove unusable medications from use. She also stated she must have missed the above items when she last inspected the area.

Interview on 12/21/11 at 10:30 a.m. with the director of pharmacy revealed:
*There was an expectation that opened multiple-dose vials of injectable medications should have been removed from use after they had been opened for thirty days.
*The pharmacy did not have a specific policy to establish how long medications could have been used after opening or packaged.
*The existing policy for drug storage could have been revised to clarify and establish how long the above medications could have been used.

Review of the provider's pharmacy policy for drug storage dated 8/2/10 revealed:
*Out dated medications should have been removed from the storage area and replaced with in-date medications.
*Refrigerated medication should have been used for a period of one month from the date of opening.
*All vials must have been dated and initialled by the nurse who first used the medication.

Review of a manufacturer's package insert for PPD dated December 2006 revealed:
*Opened multiple-dose vials of PPD should have been removed from use after being opened for 30 days.
*Failure to handle and store the PPD as recommended could have resulted in loss of potency and inaccurate test results.




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2. Observation on 12/20/11 at 9:30 a.m. of the sub-sterile room in the surgical suite revealed:
*Seven 500 milligram (mg)/10 milliliter (ml) vials of Ketamine HCI expired October 2011.
*Seven 50 microgram/ml of sufentanil citrate expired 11/1/11.
*Etomidate 40 mg/20 ml, one vial expired 3/1/11, one vial expired 6/1/11, and eight vials expired 12/1/11.

3. Interview on 12/20/11 at 10:15 a.m. with the certified surgical technician/operating room manager revealed:
*She had keys that would access all doors and medication storage areas within the surgical suite.
*Those keys would access both the controlled and legend medications.

Interview on 12/20/11 at 10:25 a.m. with the director of pharmacy revealed:*He was responsible to monitor the controlled medications in the surgical suite for expired medications.
*The pharmacy technicians were responsible to monitor the legend medications in the surgical suite for expired medications.
*There was no policy that addressed who was authorized to access the medications in the surgical suite.


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4. Observation on 12/19/11 at 2:45 p.m. of the central supply room revealed six of six 500 ml bags of 5 percent (%) dextrose and 0.9% sodium chloride with an expiration date of September 2011. Interview with the materials manager at the time of the observaton confirmed that finding. She stated she was surpised there were outdated supplies. She and pharmacy technician D went through the central supply room monthly and checked for outdates.

Based on observation, testing, interview, record review, policy review, and manufacturer's recommendations, the provider failed to ensure good infection control practices were followed throughout the facility. The following was found:
- All Wet Task buckets used throughout the facility were not properly labeled to: identify the product, instruct the consumer for proper use, and educate the consumer of possible hazards.
- Uncleanable surfaces were noted in the sterile supply room and operating room (OR).
- A cart of clean housekeeping supplies was found stored and in-use in the dirty utility room of the acute care suite.
- A cloth hand towel was found in-use to wipe hands at the pharmacy sink.
- The handwashing sink in the pharmacy was used to wash dirty dishes.
- Clean towels were found stored directly under the drain line of the pharmacy sink.
- Care plan failed to include proper infection control precautions for one of one sampled patient (11) with a positive diagnosis of methicillin resistant staphylococcus aureus (MRSA).
- Proper hand hygiene was not performed before, during, and after glove use for two of two observations. .
- Outdated medical supplies were found available for use in the OR suite.
- Clean linens were stored in an uncleanable container directly on the floor in a storage room of the acute care suite.
- Common use medical equipment was not disinfected between patient use.
Findings include:

1. Random observation from 12/19/11 through 12/21/11 revealed the following about the Wet Task buckets that held the disinfectant used throughout the facility:
- A handwritten label that stated "25L disinfectant" or just "25L."
- Three of four Wet Task buckets without labels in-use in the emergency room suite.
- No additional information was given on the Wet Task bucket regarding the proper use and precautionary guidelines for the 25L disinfectant.
- No education or training had been given to the housekeeping staff or other hospital staff who used the product throughout the facility.

Interview with the lead housekeeper at 2:00 p.m. on 12/20/11 revealed she was not sure of the exact contact time needed for a terminal disinfection of the OR and procedure room in the OR suite. She stated she had tried to keep all surfaces wet for as long as possible as she thought the contact time was 10 minutes. The lead housekeeper also stated she would check the Wet Task buckets to see if they needed to be refilled. She said she would just "top off" the solution in the buckets and not empty and refill them with fresh solution. She stated she had no way to check the efficacy of the solution to ensure it maintained its effectiveness.

Interview with the environmental services supervisor (ESS) at 2:15 p.m. on that same day revealed he was not aware what the Wet Task buckets were or how they were used. He stated he had thought the disinfectant came in the Wet Task buckets and therefore the buckets were properly labeled. He was not aware that according to the instructions on the Wet Task buckets, the buckets must be labeled to identify the product that included instructions and guidelines for proper use by the consumer. He also stated he had no guidelines or policy to check the concentration and efficacy of the disinfectant inside those buckets.

Random testing of the Wet Task buckets used throughout the facility revealed the concentration was 400 parts per million which met the guidelines of the 3M product.

Observation and interview on 12/21/11 at 9:45 a.m. of the OR manager and director of nursing (DON) revealed the surfaces in the operating room had been cleaned with 3M 25L wipes stored in a Wet Task bucket. They used those wipes to disinfect all equipment and tables between two surgical cases. The surfaces were observed to dry within 90 seconds. They were not aware of how long the surfaces should have stayed wet for the product to be effective.

Review of the manufacturer's label revealed a wet contact time of 10 minutes was needed to disinfect surfaces.

Review of the provider's revised August 2011 environmental cleaning in the surgical practice setting policy revealed:
*No directions on how long the contact time of the 3M 25 L disinfectant should have been left on the surface.
*Nursing personnel would ensure that appropriate cleaning methods of procedures were achieved and had knowledge of the required sanitation requirements.

2. Observation from 9:15 a.m. to 9:45 a.m. on 12/20/11 of the OR suite revealed:
a. A plastic cart with sterile supplies was stored in the sterile supply room. The handle of that cart had layers of silk tape wound around one corner of the handle (photo 2). Interview with the OR manager at the time of the observation confirmed that finding. She revealed that cart was used to transport sterile supplies and instruments into the OR. She stated she was aware that corner had been wrapped with tape, and that tape created an infection control issue.
b. An oxygen bottle key laid on top of the anesthesia cart on the OR room. That oxygen key had been wrapped with layers of Coban tape (photo 3). Interview with the OR manager at the time of the observation confirmed that finding. She stated she was not aware that key had been taped but agreed it created an infection control issue.
c. Two pieces of silk tape under the OR table. The one piece of tape was approximately four inches long and was found on the side of the OR table. The other piece of tape was approximately five inches long and had instruction for the use of the tilt wheel on the OR table.Interview with the OR manager at the time of the observation confirmed that finding. She stated she was not aware there were pieces of tape left on the OR table. She stated the OR room had already been terminally cleaned by the housekeeping staff, and they should have noticed the tape. The OR manager agreed tape created an infection control issue.

3. Observation at 1:50 p.m. on 12/20/11 revealed a housekeeping storage cart was stored in the dirty utility room of the acute care suite. That housekeeping storage cart contained clean supplies including toilet paper, paper towels, facial tissue, and clean mop bucket heads. Interview with the ESS at the time of the observation confirmed that finding. He stated he did not know why that clean supply cart had been stored in the dirty utility room.He had a housekeeper move the cart at that time.

4. Observation at 2:30 p.m. on 12/20/11 revealed a cloth hand towel was hung on the cabinet door under the handwashing sink in pharmacy. Interview with pharmacy technician D at the time of the observation confirmed that finding. She stated she had used that towel to wipe her hands after she had done her dishes in that handwashing sink. Continued observation at that time revealed eight to ten clean towels were stored directly under the drainline of that handwashing sink. Pharmacy technician D revealed she used those clean towels to dust and clean the pharmacy. She stated she was aware clean patient items could not be stored under drainlines but was not aware clean linens could not be stored under the drainline.



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5. Review of patient 11's closed acute care record revealed:
*He had been admitted on 9/10/11 with diagnoses that included pneumonia.
*He had a positive nasal swab on 9/12/11 for MRSA.
*He had a physician's order for muprion ointment to both nostrils twice daily for five days and Hibiclens shower daily for seven days.
*He was discharged to swing bed status on 9/13/11.
*A 9/10/11 radiology report of a chest Xray revealed he had a clinical history that included a "wet cough."
*His Kardex listed a MRSA screen on 9/10/11 and recheck of a MRSA screen scheduled for 9/21/11.
*His care plan dated 9/10/11 had not indicated his positive MRSA status.
*His Kardex had not indicated any infection control precautions that should have been followed.

Interview on 9/21/11 at 8:30 a.m. with the infection control (IC) nurse revealed:
*She had been aware patient 11 had a positive nasal swab for MRSA.
*She stated she had contacted resident 11's physician on 9/12/11, and patient 11 had been placed on muprion ointment to both nostrils twice daily for five days and Hibiclens shower daily for seven days per protocol.
*She stated he had not been placed on any type of infection control precautions.
*She agreed he had an active respiratory infection and a positive MRSA screen. She stated infection control precautions should have been initiated and documented.
*She agreed there was no documentation other departments that had provided services had been notified of patient 11's MRSA postive status.

Review of the provider's revised 10/28/10 pneumonia-community acquired policy revealed:
*In order to protect health care workers and prevent transmission of a contagious agent staff were to adhere to respiratory and body substance precautions until the contagious agent was identified.
*In the event the agent was identified as contagious respiratory isolation was to be continued.
*Precautions to be taken included gloves and mask.

Review of the provider's revised 7/6/10 posting and notification to indicate a patient was on isolation policy included directions to:
*Have placed the instructions for the precaution in the Kardex.
*Notify dietary, housekeeping, and the rehabilitation departments.

6. Observation on 12/20/11 from 5:05 p.m. through 5:20 p.m. of registered nurse (RN) A and patient 1 during a gastrostomy tube (G-tube) feeding revealed:
*RN A entered the room with the tube feeding supplies.
*She used an alcohol based hand sanitizer (ABHS) as she entered the room.
*She placed the supplies on patient 1's overbed table.
*She put on gloves and then turned the water faucet on with her left hand to fill a container with water.
*She then opened the end of the G-tube and checked for placement of the G-tube with a 60 cubic centimeter (cc) catheter tip syringe.
*She then opened a new enteral feeding bag, took a pen out of her pocket, wrote on the label, and replaced the pen in her pocket.
*She removed her gloves and without washing her hands or using ABHS she put on new gloves.
*She mixed 60 cc of water with one teaspoon of Metamucil in a cup and drew it up into the syringe.
*She touched patient 1's right hand and wrist as she checked the patient's identification band.
*She then administered the Metamucil through patient 1's G-tube and flushed it with 30 cc of water.
*Water leaked onto patient 1's abdomen, and RN A wiped that up with a paper towel.
*She removed her gloves and without washing her hands or using ABHS she put on new gloves.
*She poured the enteral feeding formula into the feeding bag and attached it to the end of patient 1's G-tube.
*She secured it with tape from her pocket and placed the tape back into her pocket.
*She rinsed the water container and removed her gloves and washed her hands.

Interview with RN A after the above observation revealed she was not aware of what the policy was for handwashing or using ABHS between glove changes.

Review of the provider's revised 7/6/10 hand hygiene policy revealed all employees should have washed hands after removing gloves.

7. Observation on 12/20/11 at 9:45 a.m. of the surgical suite revealed:
*Three BD E-Z scrub 205 povidone/iodine surgical scrub brushes with an expiration date of November 2011.
*One box of Filtron surgical masks with an expiration date of February 2009.

Interview at the above time with the certified OR manager revealed she was responsible for monitoring expiration dates for the surgical supplies.

8. Observation on 12/19/11 at 3:05 p.m. of the nursing care unit linen room revealed an opened cardboard box filled with towels. That box was placed directly on the floor. There was another smaller cardboard box with towels placed on top of the larger cardboard box (photo 1).

Interview on 12/19/11 at 3:30 p.m. with the DON revealed:*Those linens were old and stained.
*He agreed they were still available for use for patient care.
*He agreed they were stored in an uncleanable container.

Interview on 12/21/11 at 8:40 a.m. with the IC nurse agreed the above linens had been stored in an uncleanable container.



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9. Observation of physician C and RN A's wound care rounds on 12/20/11 from 9:20 a.m. through 9:40 a.m. revealed:
*Physician C entered patient 3's room and put on clean gloves without washing or sanitizing his hands.
*He asked for RN A's flashlight that was in her left scrub top pocket.
*He touched patient 3's unclothed buttock with his left gloved hand and held the flashlight in his right gloved hand.
*After viewing the wound physician C placed the flashlight into his contaminated left gloved hand and handed it back to RN A.
*RN A held the flashlight in her right gloved hand, placed it into her left ungloved hand, and without cleaning it put it back into her left scrub pocket.
*Physician C then listened to patient 3's lung sounds with his stethoscope placed on the patient's unclothed back.
*Without cleaning the bell of the stethoscope physician C placed the stethoscope back around his neck.
*Physician C and RN A then removed their gloves, washed their hands, and left patient 3's room.
*After entering patient 4's room physician C and RN A put on clean gloves.
*Physician C listened to patient 4's heart and lung sounds through the patient's gown with the stethoscope from around his neck. He then listened to her bowel sounds with the bell of the stethoscope on her unclothed abdomen and placed it back around his neck.
*RN A placed a wound measuring sheet on patient 4's tray table and set the flashlight from her pocket on top of that sheet.
*After cleansing and measuring the depth of the wound RN A moved the flashlight off of the measuring sheet and measured the wound. She then removed the backing from the measurement sheet and attached it to the patient's wound care documentation sheet.
*Prior to leaving patient 4's room physician C and RN A washed their hands with soap and water at the handwashing sink. Sitting on that sink was a set of clean linen including sheets and a bedspread that could have been splashed and contaminated during handwashing.
*RN A's flashlight remained on patient 4's tray table after RN A had left the room.
*Physician C left patient 4's room and at no time had been observed by the surveyor cleaning the bell of the stethoscope around his neck.

10. Observation of RN A on 12/20/11 from 9:45 a.m. through 10:00 a.m. in patient 4's room revealed:
*The flashlight was still on patient 4's tray table.
*RN A completed a dressing on patient 4's abdominal wound, removed her gloves, and washed her hands at the sink. She then picked up the contaminated flashlight from the tray table. Without cleaning the flashlight she placed it back in her left scrub top pocket and her unused dressing supplies into her right pocket. She also moved some clean linen from a chair in the room, so a visitor in the room could sit down.
*Prior to leaving patient 4's room RN A again washed her hands with soap and water at the handwashing sink.
*The clean bed linens remained on that handwashing sink each time RN A washed her hands.
*At no time was RN A observed cleaning the flashlight.

11. Observation of RN A on 12/20/11 at 10:20 a.m. during patient 1's peg tube dressing change revealed RN A had removed her gloves. She had applied clean gloves twice without washing her hands in between glove changes.

12. Interview on 12/20/11 at 3:30 p.m. with the DON confirmed:
*Physician C's stethoscope should have been cleaned between and after use on each patient.
*The flashlight should have been cleaned before it had been touched by RN A's ungloved hand and placed in her pocket.
*The flashlight should have been cleaned before and after use in each patient's room.
*The nursing policies and procedures had not included the cleaning of medical equipment or flashlights between use on each patient.

Interview on 12/21/11 at 8:00 a.m. with the IC nurse confirmed:
*Physician C should have washed his hands or used ABHS on his hands prior to entering patient 3's room.
*Physician C should have cleaned his stethoscope between and after use on each patient.
*RN A should have cleaned her flashlight after it had become contaminated and before it had been taken to another patient's room.
*Clean bed linens should not have been placed on patient 4's handwashing sink, because they could have been contaminated during handwashing.

Based on observation, interview, and policy review, the provider failed to ensure:
*The medication administration record (MAR) was not signed prior to a patient taking their medication for one of two sampled patients (4).
*Narcotic medication was disposed of in the proper receptacle for one of one
sampled patient (5) receiving a new Fentanyl patch.
Findings include:

1. Observation on 12/20/11 at 8:30 a.m. of registered nurse (RN) A revealed she had given patient 4 two Percocet tablets for pain.

Interview at that time with RN A revealed she had already signed patient 4's MAR even though the two Percocet tablets had not yet been given to the patient.Further interview revealed:
*She knew the MAR should not have been signed before patient 4 had taken the medication.
*She had signed the MAR first, because she knew patient 4 would have taken the medication since she had been in pain.
*The emergency room nurse had sometimes helped with medication pass on the floor. She had signed the MAR first, so the ER nurse would know the medications had been given.
*If patient 4 had not taken or refused the medication RN A would have circled her initials on the MAR to indicate they had not been taken.

Interview on 12/20/11 at 2:50 p.m. with the director of nursing (DON) confirmed the provider's policy was to sign the MAR after medications had been given and not prior to administration.

Review of the provider's medications administration standards policy reviewed in August 2011 revealed for administration and documentation "Record immediately on the MAR your initials (Never chart a medication before administering it)."

2. Observation on 12/20/11 at 10:30 a.m. of licensed practical nurse (LPN) B revealed he had removed a 75 microgram Fentanyl (narcotic) patch from patient 5's back prior to application of a new patch. After removal of the patch LPN B removed his gloves and with the Fentanyl patch still inside one of the gloves he threw both gloves in patient 5's garbage can.

Interview at that time with LPN B revealed he had always disposed of Fentanyl patches in the garbage can but had made sure they had been inside the glove prior to disposal.

Interview on 12/20/11 at 2:50 p.m. with the DON revealed:
*Fentanyl patches should have been discarded in the sharps container and not a garbage can where someone could have had access to them.
*The provider had no policy and procedure for the disposal of used Fentanyl narcotic patches, but they should have one developed.

Interview on 12/21/11 at 10:00 a.m. with the director of pharmacy confirmed:
*Fentanyl narcotic patches should have been disposed of in the sharps container in the patients' rooms.
*The provider had no policy and procedure for the disposal of Fentanyl patches.

Based on record review, interview, and policy review, the provider failed to ensure a nursing care plan was initiated or completed for 5 of 13 closed record acute care sampled patients (1, 12, 13, 14, and 36). Findings include:

1. Review of patient 1's closed acute care medical record revealed she had been admitted on 12/16/11. She had been discharged to swing bed status on 12/19/11. Review of her acute care Kardex revealed the care plan section had not been filled out.

2. Review of patient 12's closed acute care medical record revealed she had been admitted on 10/11/11 and discharged to home on 10/12/11. Review of her admission nursing assessment initial patient planning/discharge planning section revealed the plan of care had been initiated on 10/11/11 at 9:40 p.m. Review of patient 12's acute care Kardex revealed the care plan section had not been filled out.

3. Review of patient 13's closed acute care medical record revealed she had been admitted on 10/2611 and discharged to home on 10/29/11. Review of her admission nursing assessment initial patient planning/discharge planning section revealed the plan of care had been initiated on 10/26/11 at 6:45 a.m. Review of patient 13's acute care Kardex revealed the care plan section had not been filled out.

4. Review of patient 14's closed acute care medical record revealed she had been admitted on 11/17/11 and discharged to another nursing facility on 11/21/11. Review of her admission nursing assessment initial patient planning/discharge planning section revealed the plan of care had been initiated on 11/17/11 with no time indicated. Review of patient 14's acute care Kardex revealed the care plan section had not been filled out.

5. Review of patient 36's closed acute care medical record revealed he had been admitted on 11/17/11 and transferred to another nursing facility on 11/18/11. Review of his admission nursing assessment initial patient planning/discharge planning section revealed the plan of care had been initiated on 11/17/11 at 9:00 a.m. Review of patient 36's acute care Kardex revealed the care plan section had not been filled out.

Interview on 12/20/11 at 3:55 p.m. with the director of nursing revealed:
*He expected the care plan would have been completed within eight hours after admission.
*The night charge nurse was responsible for the completion of a chart review on all charts that included the care plan.

Review of the provider's revised 2/2/11 acute patient care plan policy revealed within eight hours of admission all patients would have had an initial plan of care generated by the registered nurse.

Review of the provider's revised 11/12/10 standards of practice policy for the plan of care revealed the nursing department would utilize the American Nurses Association's standards of practice for the plan of care. That implementation would have included assessment, planning, implementation, and evaluation.