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1) Cross Refer to K-233- Based on observations and testing, the facility failed to properly maintain door openings in smoke barrier walls in accordance NFPA 101 section 19.2.2.3. These condition deficiency practices affect the entire Main Hospital building of the facility.

Findings Include:

On October 30, 2018 at 1:20 p.m. observation revealed all the smoke barrier doors in the Main Hospital section of the facility did not properly close upon activation of the fire alarm system.

Observation also revealed the smoke barrier doors in the Intensive Care Unit (ICU) North of the facility did not closed upon activation of the fire alarm system. The smoke barrier doors in the ICU North of the facility were held in the open position by sensor.

2) Cross Refer to Tag K-372- Based on observations, the facility failed to properly maintain smoke barrier walls for the purpose of providing one (1) half hour fire resistance as directed by NFPA 101 section 8.5.6. These condition deficiency practices effect the entire Main Hospital and Ambulatory Surgery Center (ASC) buildings of the facility.


On October 29 and 30, 2018 observation revealed unsealed penetrations in the smoke barrier walls in the following areas of the facility:

1) The smoke barrier walls on the 3rd and 4th floors of the Main Hospital terminated at the underside of a solid ceiling. The solid ceilings contain numerous unsealed penetrations on the 3rd and 4th floors of the Main Hospital.
2) The smoke barrier walls on 2nd floor of the Main Hospital contain unsealed penetrations.
3) The smoke barrier walls on all 5 floors of the ASC Building contain unsealed and improperly sealed penetrations.

*The 2nd, 3rd, and 4th floors of the Main Hospital each contain four (4) smoke compartments.

**Each of the 5 floors of the Ambulatory Surgery Center (ASC) building contains 1 smoke barrier wall.

Based on observation, review of the high-level disinfectant solution test log(s), review of the directions for use for the high-level disinfectant solution and solution test strips, staff interview, and policy and procedure review, the facility failed to ensure ultrasound staff performed the high-level disinfectant solution test strip according to the directions for use and document the results of the test strip each time the high-level disinfectant solution was used to clean ultrasound probe(s) to avoid sources and transmission of infections and communicable diseases on two (2) of three (3) days of survey.

Findings Include:

Observation of Ultrasound (US) Room #1 in the Radiology Department on 10/30/18 from 11:50 a.m. to 12:00 noon revealed a white box that was locked and had a biohazard sticker on the outside of the box. When US Technician #1 was asked what was in the white box, she stated it was high-level disinfectant 14 day solution used to process vaginal probes. When asked if the facility maintained documentation of the usage of the high-level disinfectant solution, she confirmed that the facility did. Review of the " ...High-Level Disinfectant Solution Test Log" showed that the solution test strip result was documented on 10/30/18 as a "Pass". The "..High-Level Disinfectant Solution Test Log" was documented daily from 10/1/18 - 10/30/18 with a solution test strip result of "Pass" documented each day. When Technician #1 was asked if the high-level disinfectant solution was tested with the recommended solution test strip prior to each use (cleaning of a vaginal probe), she said, "No, we check (test with a solution test strip) the solution (high-level disinfectant) daily and record it (result)". The Radiology Director was present during the observation timeframe and confirmed all observations and statemens. He also stated that the same high-level disinfectant process was used in the US areas in the Emergency Room (ER) and Imaging Services Departments to test and clean the US probes.

Observation of the US department in the Imaging area on 10/30/18 at 12:49 p.m. revealed the high-level disinfectant solution process was documented and conducted the same as it was in the hospital US Room #1.

Observation of the US area in the ER on 10/30/18 at 12:55 p.m. revealed the high-level disinfectant solution process was documented and conducted the same as it was in the hospital US Room #1.

During an interview on 10/30/18 at 12:40 p.m. the Radiology Director confirmed that the staff in the hospital US Department, ER and Imaging Services areas recorded a solution test strip on each day the high-level disinfectant 14 day solution was used to clean patient equipment.

During an interview on 10/31/18 at 9:40 a.m. the Infection Control Nurse confirmed that patient care equipment should be cleaned according to manufacturer guidelines.

Review of the " ...High-Level Disinfectant Solution Test Log" documentation from September 1, 2018 to October 31, 2018 revealed the US Technicians in the hospital US and ER departments and the Imaging Center used the solution test strips to test the high-level disinfectant solution prior to usage at the beginning of the day and recorded the solution test strip result.

Review of the "Directions For Use" for the high-level disinfectant 14 day solution revealed: " ...Directions for Use ...Use ...solution test strips to monitor ortho-phthalaldehyde concentration before each use to detect the MEC (Minimum Effective Concentration) (0.3%). Follow the directions for use provided with the ...solution test strips ...".

Review of the " ...High-Level Disinfectant Solution Test Strip" container revealed: " ...Solution Test Strips monitor the minimum effective concentration (MEC) of the ...high-level disinfectant Solution during its use life ...Directions For Use - When To Test: Test solution before each usage to guard against dilution, which may lower the ortho-phthalaldehyde level of the solution below its (MEC). Test solution before immersing instruments ...".

Review of the facility's " ...High-Level Disinfectant Solution" policy, revision date of 06/5/18" revealed: " ...Purpose or Scope: To provide guidelines for staff using high-level disinfectants, identify employee safety practices when working with high-level disinfectants, and to utilize the high-level disinfectants in an efficient manner ...Procedure: ...Instruments must be fully immersed in solution and all lumens should be filled with solution and placed in a covered container for 12 minutes ...solution maintains its effectiveness for a period of 14 days To ensure effectiveness , test strips must be used prior to immersion of instruments ....Results must be documented on Solution Log Sheet ....Discard used ...Solution after 14 days ...".

Review of the facility's " ...High-Level Disinfectant Solution Test Strips" policy, revision date of 06/5/18, revealed: "Policy: It is the policy ...that test strips will be utilized prior to each use to verify the Minimum Effective Concentration (MEC) of ...Solution ...Procedure: MEC Testing ...Solution will be tested for the MEC prior to performing high level disinfection of items ...The indicating pad will be completely purple to indicate that the MEC is present. If any blue color is present on the indicating pad, the solution is below the MEC and must be discarded. Discard poured ...solution after 14 days ...Record all results in the ...log sheet ...".

Review of the facility's "Isolation Precautions (Standard a & Transmission-Based)" policy, revision date of 8/23/18, revealed: "Standard precautions are the foundation of all precautions to prevent transmission of infectious agents ...Infectious agents may be present in blood, body fluids, and ....mucous membranes ...Level I Standard Precautions - Standard Precautions apply to all patients ...regardless of known/unknown diagnosis or infection status ...Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals ...E. Patient-Care Equipment - Handle used patient-care equipment soiled with blood and body fluids, secretions and excretions in a manner that prevents ...transfer of microorganisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately ...".

During exit conference on 10/31/18 at 1:35 p.m. these findings were discussed with facility staff. No further documentation was submitted for review.

Based on observation, review of the high-level disinfectant solution test log(s), review of the directions for use for the high-level disinfectant solution and solution test strips, staff interview and policy and procedure review, the facility failed to ensure ultrasound staff performed the high-level disinfectant solution test strip according to the directions for use and document the results of the test strip each time the high-level disinfectant solution was used to clean ultrasound probe(s) on two (2) of three (3) days of survey.

Findings Include:

Cross Refer to A-0747 for the facilities failure to ensure ultrasound staff performed the high-level disinfectant solution test strip according to the directions for use and document the results of the test strip each time the high-level disinfectant solution was used to clean ultrasound probe(s) to avoid sources and transmission of infections and communicable diseases.

Based on record review, staff interview, and Policy and Procedure review, the facility failed to notify the Organ Procurement Organization (OPO) in a timely manner of individuals whose death was imminent or who had died in the hospital, for eight (8) out of two hundred and twenty one (221) patient deaths during the last twelve (12) months. One (1) patient in January, 1 patient in March and three (3) patients in April of 2018 were not called in. Two (2) patients in April and 1 patient in July of 2018 were called in late.

Findings Include:

Review of the facility's "Donation Referral Compliance and Conversion Rates" report for 2018 revealed there was 1 patient in January, 1 patient in March and three (3) patients in April of 2018 who were not called in and 2 patients in April and 1 patient in July of 2018 who were called in late.

During an interview on October 31, 2018 at 12:35 p.m. the Director of Quality confirmed the facility had not called in 1 patient in January, 1 patient in March and 3 patients in April of 2018, and 2 patients in April and 1 patient in July of 2018 were called in late.

Review of the facility's "Organ/Tissue Donation/Routine Referral" Policy and Procedure revealed: " ...Purpose or Scope: It is the policy of Rush Foundation Hospital to provide the option of donation and facilitate the recovery of organs, tissues, and eyes for transplantation, education or research. Families of potential donors determined to be medically suitable will routinely be afforded the opportunity to authorize to donation. Upon verification by MORA that one or more medically suitable donation options exist, the hospital shall be responsible for facilitating communication between MORA and potential donor's legal next of kin to ensure that the donation option can be provided ...Definitions: ...G. Timely Notification for Organ Donation: A timely referral is one that is made as soon as possible or within one hour and allows MORA (Mississippi Organ Recovery Agency) to evaluate and determine eligibility for organ donation potential for any imminent or eligible death prior to the withdrawal of ventilator and/or care. H. Timely Notification for Tissue Donation: For individuals who have died a cardiac death, notification is timely if the referral is made to MORA within one hour of the cardiac death ...E. Procedures Following Pronouncement of Death: ...3. Notification of MORA - The organ/Tissue Donation Data form must be completed on ALL deaths and patients with a neurological insult with a Glasgow Coma scale of 5 or less by the assigned patient care nurse (see attached). A. The nurse will telephone (1-800-362-6169) on all deaths to see if patient qualifies for organ/tissue/eye donation. The call must be within 60 minutes after death ..."

Based on record review, staff interview and Policy and Procedure review, the facility failed to notify the Organ Procurement Organization (OPO) in a timely manner of individuals whose death was imminent or who had died in the hospital, for eight (8) out of two hundred and twenty one (221) patient deaths during the last 12 months (September 2017 through August 2018).

Findings include:

Cross Refer to A-0884 for the facility's failure to notify, in a timely manner, the OPO of eight (8) individuals whose death was imminent or who had died in the hospital during the last 12 months (September 2017 through August 2018).