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Based on observation, policy review, and interview the provider failed to ensure a quality assurance process was fully implemented and monitored to protect the central supply from being contaminated during construction.
Findings include:

1. Observation and interview on 3/28/12 at 9:00 a.m. in central supply storage with the materials management person revealed:
*The central supply storage was located in a construction zone. All items coming and going from the central supply room would pass through a construction zone.
*All shelves, containers, and supplies within the central storage room had dust on them. None of them were covered (photos 4, 5, 6, and 7).
*Construction had been started in late December 2011. As construction progressed to the central supply area the supplies were moved into the old emergency room. The old emergency room was located in the construction zone on the lower level.
*Plastic barriers were erected to contain the construction dust.
*When the abatement team was doing construction they brought in an air handling system and dust was not an issue.
*When the abatement team left they took their air handling system with them.
*When the next phase of construction began no air handling system was brought in. That was when the dust had started to contaminate the temporary central supply area.
*She had notified the director of materials management, maintenance supervisor, and chief nursing officer of the dust entering the storage. She brought in a fan to blow the dust out but it was not able to control the dust.
*The central supply had been moved back into the central storage room just a week ago.
*The room had not been completed and was missing the suspended ceiling.

Phone interview on 3/28/12 at 9:23 a.m. with the director of material management revealed:
*Prior to construction he had attempted to have central supply moved out of the construction zone. It was an administrative decision to leave central supply in the construction zone.
*He had not seen the contamination personally but had been made aware of the situation by the materials management person.
*He agreed the supplies for central storage should have been stored to prevent contamination from dust at all times.

Interview on 3/28/12 at 10:10 a.m. with the chief nursing officer (CNO) and RN C revealed:
*The administration had made the decision to keep the central supply in the construction zone. The hospital had completed a risk assessment with the central supply and after considering multiple control measures the provider felt they could protect the supplies from contamination during construction.
*The CNO had been notified by the materials management person that dust had been entering into the temporary central supply.
*Neither were aware that all of the central supplies had been contaminated by construction dust.
*The central supply contained supplies for the entire hospital and attached clinic.
*Both agreed that contaminated supplies were an infection control risk.
*Both agreed more should have been done during construction to have prevented the supplies from being contaminated.
*RN C was suppose to participate in the monthly construction meetings.
*RN C was notified of the date when the last construction meeting was to occur but not the time of the meeting. She was to be paged when the meeting started, so she could attend, but she had not been paged.

Random interviews during the survey and record review with the maintenance person revealed:
*The contamination of central supply had been brought to his attention by the materials management person.
*He had addressed the contamination concern in the February construction meeting. Review of the meeting minutes confirmed contamination from dust had been an issue. He was not sure why RN C had not been notified of the meeting.
*He confirmed the contamination had started after the abatement team had left on January 13, 2012 and construction had begun.
*He confirmed no air handling equipment was brought in to remove dust when the construction phase began. They were using the plastic barriers to contain the dust.
*He attended weekly and monthly meetings with the construction crews. Only the monthly meetings were documented. He had addressed concerns with the construction crews at the weekly meetings but it had not been documented.
*He had monitored the construction but had not documented his findings.

Review of the provider's February 2012 safe storage of medical and surgical supplies policy revealed:
*"Clean or sterile medical and surgical supplies will be handled separately from potential sources of contamination.
*Medical and surgical supplies will be stored in a manner that provides protection against conditions that might compromise sterility and packaging.
*To prevent damage or contamination, supplies will be stored in a manner that prevents package compromise and provides protection against dust, moisture, insects, and temperature and humidity extremes. This applies to storage in the central storeroom, designated bulk storage areas and in patient care ares.
*Closed or covered cabinets and open shelving or carts used for sterile storage should be maintained in a clean and dry conditions."

Review of the providers February 2012 safety, infection control and interim life safety during repair, renovation, construction and demolition activities policy revealed:
*"3.1.5.1. Contractors will participate in the assessment, implementation, monitoring, and enforcement of the plans.
*3.1.5.2 Participation may include project worker training, supplying specialized equipment to create and maintain safe conditions, monitoring staff behavior and compliance with safe practices, and maintained necessary records and documentation.
*3.1.6 Documentation of the risk assessment, plans developed to manage the impact of construction, updates to the assessment, and implementation of the plans shall be maintained and readily available within the construction services office.
*3.1.6.1 Risk assessments will be communicated regularly and as needed to the environments services manager.
*3.1.7 Monitoring of compliance will be documented by safety, infection control, facilities management staff, and construction representatives.
*3.2.3 Construction activities will be performed in a manner that minimizes contamination of the environment.
*Construction activity type C, risk group 3-4 (store room), specific requirements for reducing the risk of contamination.
-1. Obtain infection control permit from SMC construction supervisor before construction begins.
-2. Isolate HVAC system in area where work is being done to prevent contamination of duct sytem.
-3. Complete all critical barriers from deck-to-deck or implement control cube method before construction begins.
-4. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.
-5. Seal holes., pipes, conduits, and punctures appropriately.
-6. Construct ante room and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving the work site or they can wear cloth or paper coveralls that are removed each time they leave the work site.
-7. All personnel entering the work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area.
-8. Do not remove barriers from work area until completed project is inspected by SMC construction supervisor, infection control department, and thoroughly cleaned.
-9. Vacuum work ares with Hepa filtered vacuums. wet mop area with disinfectant.
-10. Place dust mat at entrance and exit of work area and keep moist. Clean and replace dust mats as needed.
-11. Monitor for and vacuum of mop dust accumulation in area adjacent to the construction activities.
-12. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.
-13. Contain and cover construction waste before transporting in tightly covered containers.
-14. Remove isolation of HVAC system in areas where work is being performed.
*The general contractor is responsible for maintaining dust-free containment of construction areas to prevent patients, employees, and workers from being exposed to internal and external construction dust. Filters must be installed on any return duct and inspected regularly. Negative air machines must be utilized when necessary to maintain a negative air pressure.
*Ventilation: Must be maintained at all times from dirty area to clean area, this must be monitored."

Interview on 3/28/12 at 3:36 p.m. with RN C, chief nursing officer, and the maintenance supervisor revealed:
*RN C had read the safety, infection control and interim life safety during repair, renovation, construction, and demolition activities policy. She was not aware of the specific requirements for reducing the risk of contamination for the construction that was being done.
*The CNO and maintenance supervisor were not aware of the specific requirements for reducing the risk of contamination.
*The maintenance supervisor had not read the document and was not aware that it existed.
*Items 2, 3, 9, 10, 11, 12, and 13 of the specific requirements for reducing the risk of contamination were being completed.
*Items 1, 4, 6, 7, and 8 of the specific requirements for reducing the risk of contamination had not been completed.
*Item 5 had partially been completed, but negative air pressure had not been maintained.

The pre-construction risk assessment was not available for review by this surveyor at the time of the survey.

Based on record review, interview, and policy review, the provider failed to ensure the proper privileging for one of one surgeon (A). Findings include:

1. Review of the provider's surgical log revealed surgeon A had performed carpal tunnel release procedures on 12/2/10 and 7/21/11.

Review of physician A's clinical privileges from 11/20/09 and 7/13/11 revealed he had not been granted any privileges by the provider to perform carpal tunnel procedures.

Interview on 3/29/12 at 11:00 a.m. with the chief nursing officer and the business office manager revealed:
*Physician A was a general surgeon.
*They had no documentation of physician A's training or continued competence in performing carpal tunnel procedures until this surveyor requested that documentation.
*They agreed physician A had not been privileged by the medical staff to perform carpal tunnel procedures.
*A list of physician A's privileges was not kept in the operating room suite to ensure operating room staff had access to his privileges as per Centers for Medicare and Medicaid regulation.
*They agreed proper privileging procedures had not occurred for physician A.
*They confirmed physician A should not have been allowed to perform carpal tunnel procedures in the facility until he had been properly privileged.
*No specific policy related to privileging was available at that time.

Based on observation, interview, and policy review, the provider failed to not have unexpired medications in the following areas:
*Emergency room.
*Second floor crash cart.
*Anesthesia kit.
Findings include:

1. Observation on 3/28/12 at 10:30 a.m.of the anesthesia kit in the pharmacy revealed:
*The anesthesia kit was stored in the pharmacy when surgeries were not scheduled.
*The pharmacist was responsible to update the medications in the kit.
*Five vials of ephedrine sulfate 50 milligrams (mg) outdated February 2012.

Interview at that time with the pharmacy director confirmed the ephedrine was outdated. He further confirmed he was responsible to change the outdated medications in the kit but had not had time to complete the task.

2. Observation on 3/29/12 at 9:00 a.m. with staff nurse B of the second floor crash cart revealed four prefilled syringes of epinephrine 1 mg had an outdate of February 2012.

Interview at that time with staff nurse B confirmed the epinephrine syringes were outdated. She further confirmed it was the nurses' responsibility to check the crash cart every month and inform the pharmacist what medications needed to be replaced due to outdating.

Review of the outdate/replacement document revealed the pharmacist had been notified of the outdated epinephrine on 2/28/12 by the nursing staff.

Interview on 3/29/12 at 9:30 a.m. with the chief nursing officer confirmed there was a system for the nursing staff to check monthly for outdated medications. However they had to keep reminding the pharmacist to reorder medications to replace them in the crash cart.

Review of the pharmacy policy dated April 2010 revealed:
*"There is a system in place for nursing to check out dates of emergency room and other nursing areas. Nurses check for outdates monthly of emergency packs and medications."
*"The pharmacy director is responsible for the purchase of all medications."




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2. Observation on 3/27/12 at 11:16 a.m. of the emergency room refrigerator and medication cabinet revealed:
*Three vials of tetanus and diphtheria toxoids absorbed in the refrigerator had expired on 2/6/12.
*Four vials of A-Methapred had expired on 3/1/12.
*Five tablets of Captopril had expired in January 2012.
*Three luer-jet syringes of epinephrine 1:10,000 had expired in February 2012.
*Two vials of Phenytoin had expired in February 2012.
*Two vials of Tubutaline had expired in September 2011.
*Four vials of Procainamide had expired on 1/9/11.

Interview on 3/27/12 at 1:00 p.m. with RN C revealed she agreed the medications were expired and should have been removed from circulation.

Review of the nursing departments outdate checklist revealed the emergency room medications and supplies had last been checked for outdates/expiration on 2/27/12, 2/28/12, and 2/29/12.

Review of the pharmacy outdate replacement check list for February and March 2012 revealed:
*Several of the medications noted above had been identified on that list on 2/29/12 by nursing personnel.
*The pharmacist had not noted the medications as reordered until 3/26/12.
*None of the noted medications had been signed off as delivered.

Interview on 3/28/12 at 10:14 a.m. with the director of pharmacy revealed:
*He was on-site from Tuesday through Friday for one to four hours and then on call after that.
*He relied mainly on nursing staff for the hospital department medication audits.
*He stated he reordered medications regularly but was not good at documenting those reorders or documenting the delivery of those medications to the units. When asked why he had poor documentation of the replacement of emergency medications he had no comment.
*When asked why it took almost thirty days for the reorder of the the emergency medications noted above on the outdate replacement check list he stated most of the time he had it in stock and did not document it.
*When asked why the specific expired emergency medications for the emergency room had not been replaced he had no explanation.

Review of the provider's reviewed October 2011 emergency medication/equipment policy revealed:
*The expiration dates of emergency room medications were to have been regularly checked and replaced if expired.
*Non-expired emergency medications were to have been available for the treatment of emergency cases.

Based on observation, manufacturer's direction review, policy review, and interview, the provider failed to:
*Protect the central supply storage area from contamination.
*Follow the manufacturer's directions for rinsing medical equipment after high level disinfection with Metricide OPA.
*Follow the provider's policy in regards to labeling high level disinfectant containers.
*Follow manufacturer's directions for the operation of one of one ultra sonic cleaner.
*Maintain cleanable surfaces in the central supply reprocessing (CSR) area.
*Protect the paper towel supply for two of two hand sinks in the emergency room (ER).
Findings include:
1. Observation, policy review, and interview on 3/28/12 revealed the provider failed to protect the central supply storage area from contamination. Refer to Tag C220.

2. Observation and interview on 3/27/12 at 3:45 p.m. in CSR with registered nurse (RN) C revealed:
*Two clear plastic containers with blue lids were placed in a portable ventilation hood.
*One container was water and the other container was Metricide OPA.
*The water was labeled and dated when activated. The Metricide OPA was not labeled but was dated with the activation date.
*The Metricide OPA was used for high level disinfection of laryngoscopes and endoscopes. The water was used for rinsing items after having been high level disinfected.
*Both containers would have been drained after having been used for fourteen days.
*After being high level disinfected equipment would be thoroughly rinsed one time in the water tub.
*She disinfected laryngoscopes using Metricide OPA and than rinsed them once with the water.

Observation, interview, and manufacturer's direction review, on 3/28/12 at 1:20 p.m. in CSR with RN C and the surgery outreach manager from Canby hospital revealed:
*The endoscopes were brought to the facility from the Canby hospital. They would be transported in a case. The cases would not be considered clean, so the scopes would be reprocessed with a high level disinfection prior to the procedure.
*When the scope(s) were processed they would be cleaned, soaked in high level disinfectant for twenty minutes, and then thoroughly rinsed in the water container.
*The surgery outreach manager was not aware the water was being used for fourteen days. She was not aware the provider was using Metricide OPA.
*Both agreed the containers were not labeled according to the provider's policy.
*Neither person was aware of the manufacturer's directions for rinsing. Both thought one rinse was adequate.
*The manufacturer's directions stated "Following removal from Metricide OPA Plus Solution, thoroughly rinse the semi-critical medical device by immersing it completely in a large volume (e.g., 9 liters) of water. Use sterile water unless potable water is acceptable.
-Keep the device totally immersed for a minimum of 1 minute in duration, unless a longer time is specified by the reusable device manufacturer.
-Manually flush all lumens with large volumes (not less than 100 ml) of rinse water unless otherwise noted by the device manufacturer.
-Remove the device and discard the rinse water. Always use fresh volumes of water for each rinse. Do not reuse the water for rinsing or any other purpose.
-Repeat the procedure TWO (2) additional times, for a total of THREE (3) RINSES, with large volumes of fresh water, at least 9 liters each rinse, to remove Metricide OPA Plus Solution residues. Residues may cause serious side effects. SEE WARNINGS. THREE (3) SEPARATE, LARGE VOLUME WATER IMMERSION RINSES ARE REQUIRED. THE VOLUME OF WATER USED IN EACH RINSE CYCLE SHOULD BE AT LEAST 9 LITERS."

Review of the provider's February 2012 high level disinfection policy revealed:
*"When high level disinfectant is poured into a container for use the container will be labeled with the solution name, date, time, concentration, amount of solution, and the name of the person who prepared the solution."
*Care of instruments after .55 percent OPA soak
-"Thoroughly rinse the device by immersing it completely in a large volume (e.g. 2 gallons) of water. Use sterile water unless potable water is acceptable."
-Immerse device completely for a minimum of one minute, unless a longer time was specified by the device manufacturer.
-Manually flush all lumens with large volumes (at least 100 mL (milliliters)) of rinse water unless otherwise noted by the device manufacturer.
-Discard the rinse water after each use. Fresh volumes of water are necessary for each rinse. Do not reuse the water for rinsing or any other purpose.
-Repeat the rinse a minimum of two (2) additional times, for a total of at least three (3) rinses, with large volumes of fresh water to remove OPA solution residues. Residues may cause serious side effects."

3. Observation, interview, and manufacturer's direction review on 3/27/12 at 4:00 p.m. in CSR with RN C revealed:
*The provider had an ultrasonic cleaner. The cleaner was filled with a liquid and and a gray residue lining the bottom of the tank (photo 2).
*The items being cleaned were washed to remove the gross contamination then placed in the ultrasonic cleaner tank to be cleaned. The items were not suspended by wires or any trays; they were placed directly in the tank.
*Manufacturer's direction stated caution do not place parts or containers directly on the bottom of the cleaning tank; use a tray or wire to suspend items.
*She agreed the manufacturer's direction for the operation of the ultrasonic cleaner had not been followed.

4. Observation and interview on 3/27/12 at 4:00 p.m. in the CSR with RN C revealed:
*A painted plywood board approximately two feet wide by three feet long had been placed over the rim flush sink. The edges were not painted and had exposed wood and would not have been cleanable (photo 3).
*The board was used to store soiled equipment.
*She agreed the board with the exposed wooden edge would not have been cleanable.

5. Observation and interview on 3/27/12 at 2:00 p.m. with RN C in the emergency room revealed:
*The paper towel supplies for two of two hand sinks were not protected. The dispensers were open on the sides and the top and did not protect the paper towel supply from contamination from splash or soiled hands (photo 1).
*She agreed the paper towel supply would not be protected and could have become contaminated.

Based on record review, interview, and policy review, the provider failed to ensure 1 of 13 acute stay patients (23) received nursing care that assessed and met her pain control needs. Findings include:

1. Review of patient 23's medical record revealed:
*She had been admitted on the afternoon of 11/27/12 to an acute bed from the emergency room.
*She had been diagnosed with fractures to both of her upper arms.
*She was being held at the hospital until 11/28/12 until she could have orthopedic surgery at another facility.
*She had been noted by nursing and the physician to have been mentally challenged.
*The physician had ordered morphine two mg every half an hour and Tylenol 500 milligram (mg) three times a day to help control her pain. Tylenol had also been ordered as needed every four to six hours for a total dose not to exceed four grams. She had received a total of nine doses of morphine, eighteen mg and two doses of Tylenol one thousand mg during her stay (11/27/12 through 11/28/12).
*She had received morphine two mg for arm pain evaluated as a ten (on a scale of one through ten with ten being the worst) in the emergency room at 12:45 p.m. on 12/27/12.
*Her pain had not documented as re-evaluated until 4:19 p.m. on 11/27/12 in the acute patient area when she had been given another dose of two mg of morphine for level ten pain. Two prior doses had been given at 2:00 p.m. and 3:40 p.m., however no pain assessment had been completed for those times.
*Multiple nursing pain follow-up assessments had not been documented and those that had been completed frequently showed the patient's pain level to have been between six and ten.
*Review of the patient's vital signs taken during the course of her stay did not reflect any reason not to administer pain medication.

Interview, record review, and policy review on 3/28/12 at 10:30 a.m. with registered nurse (RN) D regarding the nursing care and assessments she and two other nurses had given patient 23 on 11/27/12 and 11/28/12 revealed:
*She had admitted the patient to the acute stay floor on 11/27/12 and had been her nurse that evening shift.
*She confirmed the patient's vital signs had been stable during the course of her shift as well as during the other shifts.
*She agreed no documentation indicated the patient should had not received more doses of morphine and Tylenol.
*She confirmed nursing pain assessments had not been completed frequently enough, especially to evaluate pain medication effectiveness.
*She could not explain why patient 23 had not received more pain medication when her pain levels had been assessed at higher levels throughout her stay.
*She confirmed the provider's revised October 2011 acute and chronic pain policy had not been followed.

Interview, record review, and policy review on 3/29/12 at 8:30 a.m. with RN C regarding patient 23's pain and nursing interventions revealed:
*She confirmed the statements of RN D.
*The 11/27/12 and 11/28/12 nursing care plan had not addressed the patient's pain or mental handicap. She confirmed it would have been important to care plan both of those as they had direct impact on the patient's care.
*She confirmed nursing assessments for pain had not been frequent enough and adequate for the patient's condition.
*She confirmed the provider's reviewed July 2007 standard of nursing practice policy, the revised 11/12/10 nursing care plan policy, and the revised October 2011 acute and chronic pain policy had not been followed.

Interview on 3/29/12 at 10:30 a.m. with the chief nursing officer regarding patient 23's pain and nursing interventions revealed she confirmed:
*The patient pain management/assessment had not been properly handled.
*Proper care planing had not occurred for the patient.

Based on record review and interview, the provider failed to ensure two of two sampled emergency room patients (24 and 29) who received oxygen therapy had documented physician's orders for that intervention. Findings include:

1. Record review and interview on 3/28/12 at 2:00 p.m. with registered nurse (RN) E revealed:
*Patient 24 had been admitted to the emergency room on 11/18/11 for the treatment of a left hip fracture. During the course of his emergency room visit he had been treated with oxygen and that oxygen was noted as having been adjusted/titrated. No physician's order existed for any oxygen therapy for that patient.
*Patient 29 had been admitted to the emergency room on 1/25/12 for the treatment of chest pain. During the course of his emergency room visit he had been treated with oxygen. No physician's order existed for any oxygen therapy for that patient.
*She confirmed oxygen required a physician's order per the provider's policies and nursing standards of practice.
*She confirmed nursing staff should have sought a verbal or written order from the physician for the oxygen that had been applied and titrated.

Interview on 3/29/12 at 10:40 a.m. with the chief nursing officer revealed she agreed with the statements of RN E.

Based on record review, interview, and care plan review, the provider failed to ensure 1 of 13 sampled acute stay patients (23) had a comprehensive nursing plan of care. Findings include:

1. Review of patient 23's 11/27/11 and 11/28/11 care plan revealed she had no care planing that had addressed her pain needs or her mental handicap after having sustained fractures of both arms. Refer to C295, finding 1.