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Based on observation and interview, the facility failed to ensure patient medical information was secure and not easily accessible to persons not involved in patient care for one inpatient unit (Med Tele Unit) of four inpatient units observed.

The findings included:

Observation and interview of the Med Tele (medical telemetry) unit with the Clinical Manager of the Medical unit and with the Director of Risk Management on September 28, 2010 from 9:05 a.m., until 10:30 a.m., confirmed the unit was a 30 bed unit designed in a horseshoe or U-shape. Continued observation and interview confirmed the unit had a central nursing station with four substations on the unit. Continued observation and interview confirmed each patient room had a plastic holder attached to the outside wall, next to the door of each patient room, for placement of a binder to hold patient information which included patient name, birth date, admission date, age, medical record number, vital signs, care plan, multidisciplinary flow chart, nursing notes, and nursing assessments. Continued observation and interview confirmed the binders protruded from the plastic chart holders for easy access. Continued observation and interview confirmed the staff were not always in the substations; all of the patient rooms were not visualized by staff at all times; and some patient rooms could not be seen from any nursing station even if staff were present at the nursing station. Continued observation and interview confirmed the patient medical information was easily accessible to anyone walking in the hallways.

Interview with the Director of Risk Management on September 28, 2010 at 11:40 a.m., in the conference room, confirmed patient medical information on the Medical unit was not secured and could be accessed by persons not involved in patient care.

Based on observation, review of water culture logs, review of Hemodialysis machine logs, review of the Quality Assessment Performance Improvement minutes, and interview, the facility failed to ensure the data collected from the hemodialysis unit was monitored for the effectiveness and safety of the service provided.

The findings included:

Observation of the Hemodialysis Unit on September 28, 2010 revealed three Hemodialysis (HD) machines ready for use.

Observation revealed each HD machine contained an RO (reverse osmosis) system. (An RO system uses membranes to remove water solutes for dialysis treatment).

Review of the AAMI (Association for the Advancement of Medical Instrumentation) standards revealed action level is >50 CFU/ml. If the facility reaches this level, action is required (such as repeat cultures and/or disinfection of the system and repeat cultures of several sites, or increase dwell time).

Review of the water culture logs revealed on March 26, 2010 the water colony was >200 CFU/ml (colony forming unit per milliliter) measuring water purity.

Review of the water culture logs with water technician #1 in the HD unit on September 28, 2010 at 9:05 AM, revealed the HD unit increased the dwell time (duration of time of disinfection) in April, May, and July in response to the culture reports. Continued interview revealed the RO membranes were changed in each of the three HD machines in May 2010.

Interview with the water technician #1 in the HD unit on September 28, 2010 at 9:05 AM, revealed the frequency of testing the cultures was increased to a weekly analysis from a monthly analysis in April through September, 2010.

Review of the machine maitenance logs revealed each HD machine contained a filter (which prevents bacteria and endotoxins from coming in contact with the patient) before March 2010. Observation of the HD machines verified the filter was in place on each machine; was checked weekly; was within date of expiration; and was within date to be changed.

Review of the laboratory results from January-September 2010 revealed the Medical Director (Nephrologist) of the contracted service had indicated by signature being made aware of the results and agreed with the interventions in place.

Interview by telephone with the contracted water technician on September 29, 2010 at 10:00 AM, confirmed all three of the HD machines RO had been replaced.

Interview by phone on September 28, 2010 at 9:10 a.m., with the contracted Clinical Manager in charge of the HD unit confirmed the HD machines had elevated readings and the contracted HD nurse or contracted water technician responded after each abnormal reading with a new intervention which was reviewed by the HD Medical Director. Continued interview confirmed the filter on the HD machines was functioning to prevent bacteria or endotoxins from coming in contact with the patients, and "...The patients were not in danger of being harmed...the filter is used to keep the endotoxins from coming in contact with the patients..."

Review of the facility's Quality Assurance meeting minutes revealed the facility identified areas to be monitored on the HD unit but did not include as essential the monitoring of the water quality used in HD.

Interview by telephone with the Clinical Manager of the Hemodialysis unit on September 28, 2010 at 9:42 a.m., revealed the "raw data" collected regarding the water analysis of the HD machines was faxed to the facility. Continued interview revealed the Clinical Manager does not attend the QAPI meetings and is not included in the QAPI practice committee.
Interview with the Chief Nursing Officer and Infection Prevention Coordinator in the HD unit on September 28, 2010 at 9:50 a.m., revealed the data was received from the Clinical Manager of HD, "But I had no idea what it all meant..."
Interview in the HD unit with the contracted HD nurse, and Chief Nursing Officer on September 28, 2010 at 9:50 a.m., confirmed the facility failed to ensure the data collected from the hemodialysis unit was monitored for the effectiveness and safety of the service provided.

Based on credentialing file review, facility forms review, and interview, the facility failed to ensure physicians met the requirements for privileges in conscious sedation for one physician (#6) of six physicians reviewed who received privileges.

The findings included:

Review of the form entitled "Moderate Sedation Privilege Request" revealed the request included Minimal Sedation (a drug induced state in which the patient responds normally to verbal commands) and Moderate Sedation (a drug induced depression of consciousness in which the patient cannot be easily aroused but can respond "purposefully" to verbal commands). Continued review of the form revealed one of the requirements was "Maintain current certification in airway management ACLS (advanced cardiac life support) or ATLS (advanced trauma life support), PALS (pediatric advanced life support) for pediatric patients."

Review of Physician files revealed Physician #6, a Cardiologist, did not have current certification in ACLS or ATLS as required for privileges in Moderate Sedation.

Interview with the Director of Nursing on September 28, 2010, at 12:45 p.m., in the conference room, confirmed Physician #6 did not complete training in ACLS or ATLS as required by the Moderate Sedation Privilege Request.

Based on medical record review, review of personnel records, observation, and interview, the facility failed to assign nursing staff with the specialized qualifications to one patient (#2) in Intensive Care (ICU) of eight patients in the ICU area reviewed.

The findings included:

Patient #2 was admitted to the facility on September 11, 2010 with diagnoses including Respiratory Failure and Subdural Hematoma (brain injury resulting bleeding into the outermost layer of the brain). Medical record review revealed patient #2 had a Subdural Hematoma Evacuation in August 2010 (at another facility) with persistent Encephalopathy; was transferred to this facility and on September 11, 2010 underwent surgical Evacuation of Subdural Hematoma.

Observation of the ICU on September 27, 2010 at 1:15 p.m., revealed patient #2 was unresponsive and on mechanical ventilation.

Review of the personnel and educational file for RN #2 revealed a hire date of 12 months ago; and no documentation of orientation to work in the intensive care area. Review of the file revealed the RN #2 had worked on a nursing care area in the facility which managed patients with less complex equipment and lower acuity care requirements than the ICU. Review of the file revealed no documentation or training of caring for a patient on mechanical ventilation.

Interview with the Director of Education and Chief Nursing Officer in the conference room on September 28, 2010 at 2:25 p.m., confirmed the facility failed to assign nursing staff with specialized qualifications to care for a patient on mechanical ventilation.

Based on medical record review and interview, the facility failed to obtain vital signs during transfusion of two units of Red Blood Cells for one patient (#2) of five transfusion records reviewed.

The findings included:

Patient #2 was admitted to the facility on September 11, 2010 with diagnoses including Respiratory Failure and Subdural Hematoma.

Medical record review revealed patient #2 received two units of Red Blood Cells (RBC) on September 12, 2010. Medical record review of the Transfusion Record revealed the first unit was started at 8:20 AM and was completed at 11:00 AM; and the vital signs (temperature, pulse, respiratory rate, and blood pressure) were recorded on the transfusion record for only the start and completion times of the transfusion. Review of the medical record revealed no documentation of vital signs until 9:00 AM (forty minutes after the transfusion was started). Medical record review revealed no documentation of vital signs from 9:00 AM until 11:00 AM.

Interview with the Manager of the Intensive Care Unit (ICU) at the nurses' station on September 27, 2010 at 1:37 p.m., verified the facility failed to document vital signs more than one time during the blood transfusion with duration of 2 hours and forty minutes.

Medical record review of the Transfusion Record revealed the second unit was started on September 12, 2010 at 3:00 PM and completed at 5:46 PM; and vital signs were only documented for the start and completion times of the transfusion. Medical record review revealed no documentation of vital signs until 4:00 PM, one hour after the transfusion was started.

Interview with the Chief Nursing Officer and the Manager of the Intensive Care Unit at the nurses' station of the ICU on September 27, 2010 at 1:25 p.m., and review of the facility's policy titled 'Blood Tranfusion', revealed the policy directed the nurse to obtain vital signs fifteen minutes after the transfusion started; and "Monitor the vital signs hourly or more frequently if indicated and record..."

Interview with the Chief Nursing Officer at the nurses' station of the ICU on September 27, 2010 at 1:30 p.m., and review of the facility's blood tranfusion documentation record, revealed the vital signs are to be documented fifteen minutes after initiation of transfusion and each hour until transfusion is completed. Continued interview confirmed the facility failed to obtain vital signs as required on the facility's blood transfusion record during two transfusions for patient #2.

Interview with the Manager of the Intensive Care Unit at the nurses' station on September 27, 2010 at 1:39 p.m., verified the facility failed to document vital signs more than one time during the blood transfusion with duration of 2 hours and forty-six minutes.

Based on medical record review, review of facility policy, and interview, the facility failed to obtain an informed consent for transfusion of two units of Red Blood Cells for one patient (#2) of five transfusion records reviewed.

The findings included:

Patient #2 was admitted to the facility on September 11, 2010 with diagnoses including Respiratory Failure and Subdural Hematoma.
Medical record review revealed patient #2 received two units of Red Blood Cells (RBC) on September 12, 2010.

Review of the facility policy titled, Blood Transfusion, revealed the instruction for a completed informed consent for Blood or Blood Products prior to initiation of the transfusion.

Medical record review revealed no documentation of the completed informed consent.

Interview with the Chief Nursing Officer and Manager of the Intensive Care Unit (ICU) at the nurses' station on September 27, 2010 at 1:37 p.m., confirmed the facility failed to obtain a completed consent prior to the blood transfusion.

Based on observation and interview, the facility failed to ensure outdated intravenous fluids and sterile irrigation fluids were not available for patient use in the Women's Center Cesarean Section (C-Section) Operating Room (OR).

The findings included:

Observation with the Director of the Women's Center and the Acute Clinical Care Director of the C-Section OR (operating room) fluid warmer on September 27, 2010, at 2:45 p.m., revealed the warmer containing the following outdated or not dated fluids available for patient use: one 1000 ml (milliliter) bag of Lactated Ringer (for use in intravenous infusion) dated to be removed or used by September 17, 2010; two 1000 ml bottles of Sterile Water (to be used for irrigation) with no date on the bottles; and two 1000 ml bottles of Sodium Chloride (to be used for irrigation) with no date on the bottles.

Interview outside the C-Section OR with the Director of the Women's Center and the Acute Clinical Care Director on September 27, 2010, at 2:45 p.m., confirmed the intravenous fluids and sterile irrigation fluids kept in the warmer were to be dated as to when they are to be removed from the warmer if not used; removed if not used by the date indicated; and the outdated and unlabeled sterile intravenous and irrigation fluids were available for patient use.

Based on medical record review and interview, the facility failed to ensure safety precautions for female patients of child bearing age in the Emergency Department (ED) receiving an x-ray for one (#16) of six ED medical records reviewed.

The findings included:

Patient #16 was admitted to the ED on September 28, 2010 for complaints of Vomiting, Diarrhea, and Abdominal Pain. Medical record review revealed the patient was a 29 year old female. Continued medical record review of the Physician's Orders, dated September 28, 2010 at 9:31 a.m., revealed "...HCG (test for pregnancy)...KUB (x-ray of the abdomen)..." Continued medical record review of the Nurse's Notes, dated September 28, 2010 at 9:52 a.m., revealed "...to x-ray..." Continued medical record review of the laboratory (lab) reports, dated September 28, 2010 at 9:55 a.m., revealed "...HCG...Negative..."

Interview at the ED Nurses' Station with the Registered Nurse #1 on September 28, 2010 at 10:10 a.m., confirmed the HCG lab results arrive via fax to the ED and are placed in the medical record. Continued interview revealed the patient went to the Radiology Department for an x-ray prior to the lab results for the HCG arriving in the ED. Continued interview revealed the Radiology Department would check the lab result on the computer of the HCG's for females of child bearing age prior to administering the x-ray.

Interview by phone with the Director of Radiology on September 28, 2010 at 10:18 a.m., confirmed the Radiology Department's policy requires any female of child bearing age not recieve an x-ray until the status of an HCG determined the patient was not pregnant. Continued interview confirmed the Radiology Department does not check the lab results of ED patient's on the computer for the results of the HCG's for females of child bearing age prior to the x-ray. Continued interview revealed when the Radiology Department is notified to get an ED patient for x-ray it is assumed the results for the HCG were negative and the patient has been cleared for x-ray.

Interview at the ED Nurses' Station with the ED Director and the Acute Clinical Care Director on September 28, 2010 at 10:20 a.m., confirmed there was no established process to assure a female of child bearing age does not receive an x-ray without the results of the HCG to protect an unborn fetus.

Based on observation and interview, the facility failed to ensure proper storage of foods in the dietary department; and based on observation, interview and review of facility personnel files, the facility failed to ensure competency of the dietary staff responsible for maintaining the correct temperature of food on the warming table of the food service line for one of one food service staff.
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The findings included:

Observation with the Director of the Dietary Department of the walk in cooler on September 27, 2010 at 11:30 a.m., revealed three stacked cardboard trays, each containing 2 1/2 dozen exposed eggs, situated next to and in direct contact with raw meat wrapped in plastic and containing bloody fluids from the meat.

Interview with the Director of the Dietary Department in the walk in cooler on September 27, 2010 at 11:30 a.m., confirmed the eggs are not to be stored in contact with the raw meat as the practice of eggs being in contact with raw meat was not a sanitary or safe practice.

Interview with dietary staff #1 by the warming table of the food service line in the dietary department on September 27, 2010 at 11:55 a.m., revealed dietary staff #1 reported taking the temperature of the food on the warming table and recording the temperature in the food temperature log. Continued interview revealed dietary staff #1 was unable to describe the process for checking the calibration of the thermometer used to check the food temperatures.

Observation of the calibration of the thermometer used to check the temperature of the food on the warming table of the food service line revealed the thermometer registered 31.5 (normal 32 degrees) degrees with placement in a glass of ice water.

Review of the job description within the personnel file of dietary staff #1, dated October 8, 2008 revealed "...takes and monitors food temperatures throughout the patient tray assembly..." Continued review of the personnel file revealed there was no documentation specific to training on calibrating temperature of thermometers before checking food temperatures.

Interview in dietary department with the manager of the dietary department on September 27, 2010 at 12:10 p.m., confirmed the staff responsible for checking the food temperatures on the warming table of the food service line was to be able to calibrate the thermometer used for taking the food temperature to assure the correct temperature was maintained. The Dietary Department Manger confirmed the staff's job description required the staff be able to perform the duty of checking the temperature of the foods to be served and the thermometer would need to be calibrated prior to checking the temperature. Continued interview confirmed there was no documentation the staff was trained to calibrate the thermometer used to monitor food temperatures.

Based on observation, review of manufacturer's recommendations, and interview, the facility failed to ensure outdated supplies were not available in the Women's Center; the Newborn Nursery, the Cesarean Section (C-Section) Operating Room (OR), the Emergency Department (ED), Same Day Surgery, the Medical-telemetry Unit, and Progressive Care Unit.

The findings included:

Observation in the Nurses' Work Station of the Women's Center with the Director of the Women's Center and the Acute Clinical Care Director on September 28, 2010 at 1:20 p.m., revealed the Level 1 and Level 2 quality controls (for the testing of the high and low calibration of the Glucometer used to test blood glucose levels) were dated to be discarded August 11, 2010.

Interview in the Nurses' Work Station of the Women's Center with the Director of the Women's Center and the Acute Clinical Care Director on September 28, 2010 at 1:20 p.m., confirmed the Level 1 and Level 2 controls were available for use to test the accuracy of the Glucometer readings and the Level 1 and Level 2 controls had expired.

Observation with the Director of the Women's Center and the Acute Clinical Care Director in the Newborn Nursery on September 27, 2010 at 2:20 p.m., revealed a cabinet containing 25 blood culture collection tubes with an expiration date of March 31, 2010; and a cabinet containing 4 ready to use baby bottles containing sterile water to be used for consumption by a newborn with an expiration date of February 2009.

Interview in the Newborn Nursery with the Director of the Women's Center and the Acute Clinical Care Director on September 27, 2010, at 2:20 p.m., confirmed the blood culture collection tubes and baby bottles of sterile water were available for patient use and had expired.

Observation with the Director of the Women's Center and the Acute Clinical Care Director in the C-Section OR (operating room) on September 27, 2010, at 2:45 p.m., revealed a cabinet containing the following expired sutures: 2 ½ dozen Chromic Gut 3-0 sutures without an expiration date; ½ dozen Chromic Gut 3-0 sutures with an expiration date of July 2010; 1 dozen PDS II sutures with an expiration date of July 2010; and 1 dozen Vicryl sutures with an expiration date of July 2007. Continued observation of the C-Section OR revealed a cabinet containing the following expired items: 2 Viral Culture Swabs with an expiration date of January 11, 2008; and 1 Culture Swab with an expiration date of August 2008.

Interview outside the C-Section OR with the Director of the Women's Center and the Acute Clinical Care Director on September 27, 2010, at 2:45 p.m., confirmed the sutures and culture swabs were available for patient use and had expired.

Observation with the Director of the ED and the Acute Clinical Care Director in the ED Orthopedic Room on September 28, 2010, at 8:45 a.m., revealed the following sutures without an expiration date: two 5-0 Silk Black Braid sutures; eight 4-0 Silk Black Braid sutures; six 3-0 Silk Black Braid sutures; one 00 Plain suture; and eighteen 00 Prolene Blue Filament sutures.

Interview in the ED Orthopedic room with the ED Director and the Acute Clinical Care Director on September 28, 2010, at 8:45 a.m., confirmed the sutures were available for patient use and had no date to indicate when the sutures expired as did all similar sutures available.



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Observation at the nursing station in Same Day Surgery on September 27, 2010 at 1:00 p.m., revealed approximately 50 blue top laboratory blood collection vials with an expiration date of August, 2010.

Interview with the Director of Surgical Services on September 27, 2010 at 1:00 p.m., at the Same Day Surgery nursing station, confirmed the blood collection vials were available for patient use beyond the expiration date.

Observation of the glucometer (machine used for checking patient blood sugar) located at the nursing station in Same Day Surgery on September 27, 2010 at 1:05 p.m., revealed the manufacturer's label on the Level 1 and Level 2 quality controls indicated "Discard 3 months after opening..." and were marked "Date opened 6/10/10 Discard 9/10/10."

Interview with the Manager of Same Day Surgery on September 27, 2010 at 1:05 p.m., at the nursing station, confirmed the Level 1 and Level 2 quality controls were completed every day, had been completed the morning of September 27, 2010, and the quality control fluids had expired.

Observation of a glucometer located at a nursing substation on the Med Tele unit on September 28, 2010 at 9:10 a.m., revealed the manufacturer's label on the Level 1 and Level 2 quality controls indicated "Discard 3 months after opening..." Continued observation revealed the quality controls were not dated when opened.

Interview with the Clinical Manager of the Med Tele unit on September 28, 2010 at 9:10 a.m., at the nursing substation on the Medical unit, confirmed the quality controls had not been dated when opened and were to be dated to determine expiration.

Observation of a patient nutrition refrigerator on the Med Tele unit on September 28, 2010 at 9:20 a.m., revealed one eight ounce container of PediaSure (nutritional drink for children) with an expiration date of June 1, 2010, and one eight ounce can of TwoCal HN (nutritional supplement or liquid nutritional meal) with an expiration date of March 1, 2010.

Interview with the Clinical Manager of the Med Tele unit on September 28, 2010 at 9:20 a.m., at the patient nutrition refrigerator, confirmed the PediaSure and TwoCal were available to be distributed to patients and consumed by patients and the nutritional items were expired.


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Observation of the Progressive Care Unit (PCU) medication room on September 28, 2010 at 2:35 p.m., revealed the glucometer and supplies in the closed glucometer case ready for use.

Observation of the Level I and Level 2 control bottles revealed the manufacturer's label indicated "Discard 3 months after opening..." and revealed the hand written notation the bottles were opened on June 6, 2010 and noted "Discard" on September 6, 2010.

Review of the manufacturer's recommendations revealed, "Check the expiration date on the glucose control solution bottles. A bottle is good for three months after opening or until the expiration dated printed on the label, whichever comes first."

Interview with the manager of PCU in the medication room on September 28, 2010 at 2:38 p.m. confirmed the facility failed to discard the solution as per manufacturer's recommendations.

Based on observation, interview, and review of facility policy, the facility failed to maintain separation of clean and dirty in the Women's Center and Nursery; failed to store patient supplies and equipment to maintain the supplies in a clean and/or sterile manner in the Women's Center, Nursery, ED (Emergency Department) and OR (Operating Room); failed to provide clean nutrition areas and ice dispensers in the ED and Medical Telemetry unit; failed to ensure staff removed gloves and performed hand hygiene in the ED; failed to ensure staff food items were not stored with patient items in patient care areas and not stored with patient nutrition in the OR and Same Day Surgery; and failed to ensure disinfection of IV (Intravenous) ports prior to accessing in the OR.

The findings included:

Observation in the Women's Center Nurses' Work Station with the Director of the Women's Center and the Acute Clinical Care Director on September 27, 2010 between 1:10 p.m. and 1:25 p.m., revealed a drawer containing blood pressure cuffs, oxygen wall socket mechanisms, patient gait belts, three screw drivers and instruction manuals. Continued observation revealed a cabinet with three 3 ounce bottles of Betadine scrub solution, one 3 ounce bottle of Chlorhexidine Gluconate 3%, and ten 17 ounce cans of foam hand sanitizer located on the shelf above batteries of various sizes. Continued observation revealed a used patient heating pad located in the under sink cabinet.

Interview in the Women's Center Nurses' Work Station with the Director of the Women's Center and the Acute Clinical Care Director on September 27, 2010 at 1:10 p.m., confirmed the drawer contained clean and dirty supplies and clean supplies are to be separated from dirty supplies; chemicals are not to be stored above non-chemical supplies; and the used patient heating pad was not to be stored in the under sink cabinet.

Observation in the Women's Center Locker Room with the Director of the Women's Center and the Acute Clinical Care Director on September 27, 2010 at 1:40 p.m., revealed the entry to the Women's Center Locker Room could only be accessed by going through the soiled utility room containing soiled linen and trash. Continued observation revealed the room had a scrub gown hanging on a hook on the wall, 14 pairs of shoes, a bag containing clothing, and lockers.

Interview in the Women's Center Locker Room with the Director of the Women's Center and the Acute Clinical Care Director on September 27, 2010 at 1:40 p.m., confirmed the only entry and exit for the locker room was to pass through the soiled utility room. Continued interview confirmed there had been no identified hospital acquired infection related to the Women's Center, Nursery, or Cesarean Section Operating Room. Continued interview confirmed the practice of passing through the soiled utility room to enter or exit the Locker Room was a breech of infection control practices.

Interview at the Women's Center Nurses' Station with the Registered Nurse Charge Nurse for Women's Center Day Shift on September 28, 2010 at 7:55 a.m., confirmed the Women's Center Staff who wear scrubs in the Cesarean Section (C-Section) Operating Room (OR) must enter and exit the Women's Center Locker Room by passing through the soiled utility room. Continued interview confirmed by passing through the soiled utility room in scrubs being used in the C-Section OR was a breech in infection control practices.

Observation of the Newborn Nursery with the Director of the Women's Center and the Acute Clinical Care Director on September 27, 2010 between 2:30 p.m. and 2:45 p.m., revealed a cabinet containing an uncovered Pulse Oximeter (device to measure the amount of oxygen in the blood), numerous bags of intravenous fluids and numerous intravenous start kits (supplies to initiate a venous access). Continued observation revealed a cabinet containing two 16 ounce bottles of alcohol on the same shelf as sterile wrapped Circumcision trays, sterile gloves and circumcision instruments.

Interview in the Newborn Nursery with the Director of the Women's Center and the Acute Clinical Care Director on September 27, 2010 between 2:30 p.m. and 2:45 p.m., confirmed the Pulse Oximeter was not clean and was stored with clean items; and the bottles of alcohol were not to be stored on the shelf with the sterile supplies.

Observation of the Emergency Department (ED) with the Director of the ED and the Acute Clinical Care Director on September 28, 2010 between 8:30 a.m. and 9:30 a.m., revealed the ice machine available for patient use in the Triage area had a buildup of pink brown substance at the shoot area of the ice dispenser. Continued observation revealed Environmental Service staff #1 exited ED room #6 with gloved hands and walk down the corridor touching the hand rail and enter ED room #8 without removing the gloves. Interview in ED room #8 with Environmental Services staff #1 revealed the gloves had been worn to clean ED room #6. Continued observation revealed three 16 ounce bottles of alcohol located on a shelf above medical supplies in a cabinet in the medication room. Continued observation revealed a rolling cart containing an uncovered (named) cautery machine (used to burn tissue - usually to stop bleeding) with a heavy buildup of dust covering the cart and the cautery machine.

Interview in the ED with the Director of the ED and the Acute Clinical Care Director on September 28, 2010 between 8:30 a.m. and 9:30 a.m., confirmed the ice machine in the triage area had a buildup of pink brown substance at the shoot area of the ice dispenser; gloves were to be removed and hands washed before exiting a patient care area; and the cautery machine and cart were not clean and free of dust buildup.



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Observation of Operating Room (OR) #1 on September 27, 2010 at 12:15 p.m., revealed an arm board (padded board which attaches to the operating room table for placement of patient arm during surgery) was stored on top of a biohazard sharps box.

Interview with the Director of Surgery on September 27, 2010 at 12:15 p.m., in OR #1 confirmed patient supplies were not to be stored on biohazardous containers.

Observation of an anesthesia cart outside OR #1 on September 27, 2010 at 12:30 p.m., and inside OR #5 on September 28, 2010 at 9:00 a.m., revealed the bottom drawer contained half a bag of Lifesavers stored with numerous LMAs (Laryngeal Mask Airways - placed in patients' mouth/throat for mechanical assistance in breathing during surgery) and multiple containers of anesthesia gases.

Interview with CRNA (Certified Registered Nurse Anesthetist) #1 on September 28, 2010 at 9:00 a.m., in OR #5, and with the Infection Control Practitioner on September 28, 2010 at 1:15 p.m., in the conference room, confirmed staff food items were not to be stored or consumed in patient care areas.

Observation of the patient nutrition room in Same Day Surgery on September 27, 2010 at 1:15 p.m., revealed the patient refrigerator had sticky, colored substances and debris on the shelves and bottom of the refrigerator. Continued observation of the refrigerator revealed two 20 ounce soft drinks, opened, partially consumed, and not dated, located in a door bin with patient drinks. Observation of the cabinets revealed all the cabinets had various dirt and food debris and food spills in the cabinets. Observation of the ice machine revealed ice shoots had pink-brown slime coating the inside of the dispensers.

Interview with the Same Day Surgery Manager on September 27, 2010 at 1:15 p.m., in the patient nutrition room confirmed the 20 ounce soft drinks belonged to staff members and were not to be stored with patient nutrition; and confirmed the refrigerator, cabinets, and ice machine were in need of cleaning.

Patient #18 was admitted to the facility on September 28, 2010 for a Laparoscopic Cholecystectomy (removal of gallbladder).

Observation on September 28, 2010 at 8:45 a.m., revealed patient #18 was brought to OR #5 with an IV (intravenous catheter for medication administration) in place and IV fluids running through the IV. Continued observation revealed CRNA #1 accessed a port (valve located on the IV tubing for administration of medications) with five different syringes of medication, without disinfecting the port prior to accessing.

Review of the facility's policy Infection Prevention Strategies for Intravascular Catheters Infections revised February 7, 2008 revealed, "...wipe access port with an appropriate antiseptic and access the port only with sterile devices..."

Interview with CRNA #1 on September 28, 2010 at 9:00 a.m., in OR #5, confirmed the CRNA did not disinfect IV ports before accessing them because the patient "...just came from Same Day Surgery..."

Interview with the Infection Control Practitioner on September 28, 2010 at 1:15 p.m., in the conference room, confirmed the facility's policy was all IV ports were to be disinfected by wiping with an alcohol or chloraprep pad prior to each access for medication administration.

Based on medical record review and interview, the facility failed to ensure the patient condition assessment and anesthetic plan was approved by the supervising practitioner for one (#17) of six surgical records reviewed. Tennessee does not have exemption to this regulation from the State's Boards of Medicine and Nursing.

The findings included:

Medical record review revealed patient #17 was admitted to the facility on September 20, 2010 with diagnoses including Cellulitis. Medical record review revealed patient #17 received general anesthesia for one hour and 20 minutes (2110-2230) on September 21, 2010 for the surgical procedure of Incision and Drainage of the Left Antecubital area and for Central Line Placement.

Review of the Pre-Anesthetic Evaluation form dated September 21, 2010 revealed the Certified Registered Nurse Anesthetist (CRNA #2) performed the assessment and documented an anesthetic plan. Medical record review revealed the CRNA determined patient #17 was classified as ASA III E, a patient with a severe systemic disease having an emergent surgery. Medical record review of the Intraoperative Anesthesia Record dated September 21, 2010 revealed patient #17 received general anesthesia from 2110-2230 (1 hour and 20 minutes). Medical record review revealed no documentation the assessment or anesthetic plan was approved by another practitioner (Anesthesiologist or Surgeon).

Medical record review of the Pre-Anesthetic Evaluation form dated September 25, 2010 revealed the CRNA determined patient #17 was classified as ASA II E, a patient with a mild systemic disease having an emergent surgery. Review revealed the anesthetic evaluation and plan was performed and signed by CRNA #2. Medical record review of the Intraoperative Anesthesia Record dated September 25, 2010 revealed patient #17 received sedating anesthesia from 1643-1735 (52 minutes).

Interview in the conference room with the Manager of Surgical Services on September 28, 2010, at 11:45 a.m., verified the facility has approved via bylaws a CRNA may perform assessment, develop anesthetic plan, and administer anesthesia under supervision of the Surgeon in the absence of the Anesthesiologist. Continued interview confirmed the facility failed to assure the patient condition assessment and anesthetic plan was approved by the required supervising practitioner.

Based on medical record review and interview, the facility failed to ensure a Post-Anesthesia evaluation was completed for one (#17) of six surgical records reviewed.

The findings included:

Medical record review revealed patient #17 was admitted to the facility on September 20, 2010 with diagnoses including Cellulitis. Medical record review revealed patient #17 received general anesthesia for one hour and 20 minutes (2110-2230) on September 21, 2010 for the surgical procedure of Incision and Drainage of the Left Antecubital area and for Central Line Placement.

Review of the medical record revealed no documentation of the Post-Anesthesia evaluation seven days post surgery.

Interview in the conference room with the Manager of Surgical Services on September 28, 2010, at 11:45 a.m., confirmed the facility failed to assure a Post-Anesthesia evaluation was completed timely.

Based on medical record review and interview, the facility failed to ensure the Emergency Department (ED) integrated services with the Radiology Department to ensure precautions for female patients of child bearing age in the ED receiving an x-ray for one of six ED medical records reviewed.

The findings included:

Patient #16 was admitted to the ED on September 28, 2010 for complaints of Vomiting, Diarrhea, and Abdominal Pain. Medical record review revealed the patient was a 29 year old female. Continued medical record review of the Physician's Orders, dated September 28, 2010 at 9:31 a.m., revealed "...HCG (test for pregnancy)...KUB (x-ray of the abdomen)..." Continued medical record review of the Nurse's Notes, dated September 28, 2010 at 9:52 a.m., revealed "...to x-ray..." Continued medical record review of the laboratory (lab) reports, dated September 28, 2010 at 9:55 a.m., revealed "...HCG...Negative..."

Interview at the ED Nurses' Station with the Registered Nurse #1 on September 28, 2010 at 10:10 a.m., confirmed the HCG lab results arrive via fax to the ED and are placed in the medical record. Continued interview revealed the patient went to x-ray prior to the lab results for the HCG arriving in the ED. Continued interview revealed the Radiology Department would check the lab result on the computer of the HCG's for females of child bearing age prior to administering the x-ray.

Interview by phone with the Director of Radiology on September 28, 2010 at 10:18 a.m., confirmed the Radiology Department's policy requires any female of child bearing age not recieve and x-ray until the status of an HCG has determined the patient was not pregnant. Continued interview confirmed the Radiology Department does not check the lab results of ED patient's on the computer for the results of the HCG's for females of child bearing age prior to the x-ray. Continued interview revealed when the Radiology Department is notified to get an ED patient for x-ray it is assumed the results for the HCG were negative and the patient has been cleared for x-ray.

Interview at the ED Nurses' Station with the ED Director and the Acute Care Clinical Director on September 28, 2010 at 10:20 a.m., confirmed there was no established process to integrate services between the x-ray department and the ED to assure a female of child bearing age does not receive an x-ray without the results of the HCG to protect an unborn fetus.