HospitalInspections.org

Based on policy review, observations and staff interviews the Critical Access Hospital (CAH) failed to ensure all medications are maintained to safely meet patients' needs in one of one anesthesia cart observed in that expired medications were available for use and the CAH failed to ensure staff (Certified Registered Nurse Anesthetist - CRNA Staff Y) disinfected the injection port of an IV during 4 of 5 observations. These deficient practices placed all patients at risk for receiving ineffective medications and exposure to bacterial contamination.

Findings include:

1. Observation on 9/7/16 at 11:00 a.m. in procedure room revealed one anesthesia cart had a plastic box containing medications that are administered by anesthesia included 6 vials of atropine (emergency medication given for very slow heart rate) and 4 vials of glycopyrrolate (used to reduce oral secretions) that were all outdated.

Surgical coordinator staff RN M and CRNA staff Y observed the outdated medications. Staff RN M stated, "drugs were removed from the Omnicell (automated medication dispensing system) prior to the procedure this a.m."

Interview with Pharmacy Director Staff G revealed that the medications throughout the CAH are checked monthly and those in the plastic boxes on the anesthesia cart were missed. Staff G stated, "Our system is to label everything in the pharmacy and Omnicell with a yellow label with the out date visible on the label."

The outdated medications were removed from the anesthesia cart by Staff RN M and taken to the pharmacy for disposal by Pharmacist staff G on 9/7/17.

- Review on 8/9/16 at 8:00 a.m. of policy, "Outdated & Unusable Drugs-MM.4.81" reveals the statement "...medications will be checked monthly (a minimum of quarterly)...All outdated items or unusable items will be removed from stock and replaced with useable items... "

- Review on 8/9/16 at 8:20 am of policy, "Infection Prevention-Pharmacy-MM.4.25" reveals the statement "...Assure that pharmaceutical preparations are sterile, properly packaged, and not outdated..."

- Review on 8/9/16 at 9:00 am of Centers for Disease Control and Prevention (CDC) Basic Infection Control and Prevention Plan reveals "...Medications should always be discarded according to the manufacturer's expiration date (even if not opened)..."

2. Observation of Patient #18's colonoscopy procedure on 09/07/16 at 8:00 a.m. revealed CRNA Staff Y attaching a syringe to the patient's intravenous (IV) injection port and administering a medication without cleaning the injection port with an alcohol swab prior to attaching the syringe 3 of 3 times during the procedure thus potentially contaminating the medication.

- Review of "Pharmacy and Therapeutics" reveals "...failure to properly disinfect the injection port when accessing needle-free valves on IV sets. Result: The port is exposed to potential contaminants that can be pushed into the patient"s IV line after the port has been accessed by tubing or a syringe..."

3. Observation of Patient #17's procedure for an esophogastroduodenoscope (EGD) on 09/07/2016 between 10:25 a.m. and 10:43 a.m. revealed CRNA Staff Y used an alcohol wipe on the port of an intravenous line prior to injecting medication into the line but failed to wipe the port when he/she administered a second injection.

Based on observation, document review and staff interview the Critical Access Hopsital (CAH) failed to ensure the Hydrotherapy pool was maintained in a safe and sanitary manor and failed to ensure staff (Certified Registered Nurse Anesthetist - CRNA Staff Y) performed appropriate hand hygiene during 2 of 2 procedures observed. Failure to maintain the Hydrotherapy pool in a safe and sanitary manor and failure to perform hand hygiene placed all patients at risk for acquiring infections.

Findings include:

1. Hydrotherapy pool observed on 9/6/2016 at 12:20 PM, pool water was blue in color and cloudy.

Therapy Staff Z interviewed on 9/6/2016 at 1:10 PM acknowledged the cloudy water in the hydrotherapy pool and s/he stated that the Hydrotherapy pool was to be drained every 6 months, the PH (a figure expressing the acidity or alkalinity of a solution), Bromine (a dark red fuming toxic liquid used as a sanitizer in pools) and temperature were checked daily. The alkalinity and calcium levels were checked weekly.

Staff DD interviewed on 9/9/2016 at 10:15 AM, s/he said that when the bromine level is too high they can turn it off and recheck the levels at a later time. S/he said that if the pH is too high or low chemicals can be added to raise or lower the pH and they follow the instructions on the chemical containers. The CAH provided no documentation to show that pH and bromine levels were adjusted or rechecked.

- Documents titled Daily Pool Testing Records for September 2015, July, August and September of 2016 reviewed on 9/9/2016 at 10:00 AM revealed the pool was completely drained on 9/1/2015, partially drained on 4/26/2016 and two-thirds drained on 6/24/2016. PH ranges were to be 7.2 - 7.4, 48 of 48 days reviewed were out of range. Bromine range of 3.0 - 5.0 reviewed and revealed levels over 5.0 and up to 20+ on 35 of 48 days reviewed. There was no documentation that the pool was completely drained and cleaned in the past six months.

- Policy titled Hydrotherapy reviewed on 9/9/2016 at 10:00 AM directed ...Pool is to be drained and cleaned a minimum of every 4 - 6 months or as indicated.

- According to the HydroWorx Operating and Maintenance Manual reviewed on 9/9/2016 ...The standard pH level is 7.5, below 7.4, the water is too acidic and causes corrosion and eye irritation. Above 7.6, it is too alkaline and causes eye irritation plus water cloudiness, scaling, stains, and reduced sanitizer efficiency ...

- Observation of Patient #18's colonoscopy (scope of the intestinal tract) procedure on 09/07/16 at 8:00 a.m. in OR (operating room) procedure room #1 revealed CRNA Staff Y wearing gloves while administering medications during the procedure. Following the procedure, CRNA Staff Y assisted in moving the patient from the procedure room to the recovery area while wearing the same gloves he/she had on during the procedure. Following the move, CRNA Staff Y charted in the medical record, and then removed the gloves, thus potentially contaminating the medical record and causing the potential for cross contamination.

- Observation of CRNA Staff Y during the EGD (Esophagogastroduodenoscope) procedure for Patient #17 revealed the CRNA inconsistently used alcohol based hand rub between glove changes. The alcohol based hand rub was placed in an area where the CRNA had to leave the patient's bedside to get to the hand rub and obtain fresh gloves.

- Policy review on 9/10/16 at 10:10 am of policy titled, "Hand Hygiene" revealed "...Wear gloves when contact with blood or other potentially infectious materials, mucous, membranes, and non-intact skin could occur. Change gloves during patient care if moving from a contaminated body site to a clean body site. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients. Remember that the use of gloves is not a substitute for hand hygiene..."

- Review of the "CDC Guidelines for Hand Hygiene and Gloves reveals" "...wearing gloves is not a substitute for hand hygiene. Dirty gloves can soil hands. Always clean your hands after removing gloves...Put on gloves before touching a patient's non-intact skin, open wounds or mucous membranes, such as the mouth, nose, and eyes, Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face), Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination, Failure to remove gloves after caring for a patient may lead to the spread of potentially deadly germs from one patient to another.."

Based on policy review, observations and staff interviews the Critical Access Hospital (CAH) failed to ensure nursing staff (Certified Registered Nurse Anesthetist - CRNA Staff Y) handled medications according to the CAH's policy. This deficient practice placed all patients at risk for receiving incorrect or ineffective medications.

Findings include:

- Observation on 9/7/16 at 7:30 am in Pre-Operative Room One revealed Patient #18's pre - op assessment performed by CRNA Staff Y. During the assessment Staff Y had a single syringe visible in breast pocket of scrub top.

Interview with Staff Y at that time revealed pre-drawn medication propofol (short-acting medication that results in a decreased level of consciousness and lack of memory used for certain surgical procedures). The medication was labeled with the drug name, date, amount of medication, and initials of Staff Y. Staff Y stated "I always draw up the propofol before starting procedures so it is ready for use." The procedure was scheduled to begin at 8:00 am and actual start time was 8:10 am.

- Review on 9/10/16 at 11:00 am of policy, "Medication Administration-MM.5.10 " revealed "...Medications will be prepared immediately prior to administration, particularly medications prepared for parenteral administration..."



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