HospitalInspections.org

Based on record review, observations, and interview the hospital failed to ensure medical records were protected from water and fire damage as evidenced by medical records from 2001 until present being stored unprotected on open shelving in the medical records room and 3 metal buildings onsite. The hospital failed to ensure Medical Staff By-laws, and hospital policies and procedures related to physicians with delinquent medical records were implemented as evidenced by not implementing hospital policies and procedures for 2 (S19 and S20) physicians with delinquent medical records. Findings:

1. Observation on 4/1/15 at 1:40 p.m. revealed open frame shelves in the medical records room containing open accordion style pocket folders containing records. One room contained multiple open metal frame shelves on rollers with the same accordion style pocket folders containing records. There were multiple sprinklers throughout the medical records area.

In a face to face interview on 4/1/15 at 1:45 p.m. with S16Medical Records Clerk confirmed the records on the open shelves were not protected from the sprinkler system. S16Medical Records Clerk stated that there were 3 metal buildings behind the hospital that also contained medical records.

Observation on 4/1/15 at 2:00 p.m. revealed 3 metal buildings behind the main hospital approximately 10 feet wide by 30 feet long containing open wood shelves along outer walls and in the middle of the floor. S16Medical Records Clerk verified records dating back to 2001. The records were contained in accordion style pocket folders. S16Medical Records Clerk verified there was no fire or alarm system in the metal buildings to protect the records from destruction.

In a face to face interview on 4/1/15 at 2:10 p.m. with S18 Medical Records Manager confirmed S17RHIA (Registered Health Information Administrator) was located at another facility and spoke to her by phone, but stated that she had not seen her on site since she had taken her current position approximately 2 years ago. S18Medical Records Manager confirmed that S17RHIA was aware of the storage of records at the hospital.

In a telephone interview on 4/1/15 at 2:10 p.m. with S17RHIA confirmed that she was located at another hospital but usually came about every 4 - 5 months onsite. S17RHIA confirmed that she was aware of the storage buildings containing medical records and the open shelving throughout the medical records department. S17RHIA gave no response to how the medical records are protected against damage or destruction or if the sprinkler system is activated.

2. In a face to face interview on 4/1/15 at 1:45 p.m. with S18Medical Records Manager revealed there were only 2 physicians (S19 and S20) with delinquent medical records past 30 days.

Review of the Deficiency Report Statistics by Physician for March 2015 revealed the following physicians had delinquent records over 60 days:

S19 Medical Director- #22 records
S20Hospitalist- #11.

Review of the Medical Staff By-laws 6. Article six: Corrective Actions, 6.6.5 Medical Records, revealed in part: A medical record is considered to be delinquent when it has not been completed for any reason within 30 calendar days following a patient ' s discharge. When a medical staff member or individual with clinical privileges has failed to complete a medical record and the record becomes delinquent, following notification, his/her clinical privileges shall be automatically suspended.

Review of the Rules and Regulations, Article 3. Medical Records, 3.23. Once a month the Director of Medical Records will count all incomplete medical records. A letter will be sent to the responsible physician notifying him of his delinquent status. Admission privileges, consultation privileges, and/or scheduling of elective surgery cases will be suspended when incomplete charts are over 30 days from the date of discharge, after due notice from the Chief of Staff.

In a face to face interview on 4/1/15 at 2:00 p.m. with S18Medical Records Manager revealed that she was not aware of any letters sent to the physicians for delinquent medical records.

In a telephone interview on 4/1/15 at 2:10 p.m. with S17RHIA stated that she was unaware of the any letters sent to the physicians for delinquent records. S17RHIA confirmed she can access the medical record information each month. S17RHIA then submits the information to the S3QA Manager.

In a face to face interview on 4/1/15 at 2:35 p.m. with S1Administrator confirmed that she was aware of the delinquent records. S1Administrator verified that the hospital did not send letters to the physicians when records were past 30 days. S1Administrator verified that there was no one following up with the completion of delinquent records.

Based on observation and interview, the hospital failed to ensure the effective implementation of policies/procedures relative to infection control to include a system for identifying, reporting, investigating, prevention,and controlling infections and communicable diseases of patients and personnel. This was evidenced by the hospital's failure to maintain a sanitary physical environment as evidenced by :
a. 4 soiled rolling computer desks, with a computer on each, (COWs or computer on wheels) with dust and dried spills on them,
b. expired intraosseous (into the bone) needle for an infant in the emergency or "crash" cart (expiration date 6/12),
c. A plastic tray, located in the medication refrigerator in the medication area of the Medical Unit, contained a thick pinkish-brown dried substance.
d. 3 telemetry monitors with attached lead lines, reported to be not yet cleaned, lying on the medication preparation counter,
e. Patient's nutrition refrigerator, located in the nourishment room on the Medical Unit, with a dried white flaky substance on the 2nd shelf. The refrigerator contained food stuffs for patient consumption.
f. 8 stacks of Styrofoam cups directly next to the sink, and a box of clear plastic bags used to transport ice to patients for their consumption, on the other side of the sink (directly next to the sink),
g. reports by staff on the Medical Unit, ICU (Intensive Care Unit), and Surgery units that blood capillary testing glucometers were cleaned with alcohol once or twice a week, instead of being disinfected between each patient.
Findings:

An observation 3/30/15 at 12:30 p.m. .to 1:15 p.m. revealed the following:
a. 4 soiled rolling computer desks, with a computer on each, (COWs or computer on wheels) with dust, dried spills, and soiled individual patient medication trays on them, located in the nursing station of the Medical Patient Care Unit,
b. an expired intraosseous needle, for an infant, in the emergency or "crash" cart (expiration date 6/12),
c. A plastic tray, located in the medication refrigerator in the medication area of the Medical Unit, contained a thick pinkish-brown dried substance.
d. 3 telemetry monitors with attached lead lines, reported to be not yet cleaned, lying on the medication preparation counter,
e. Patient's nutrition refrigerator, located in the nourishment room on the Medical Unit, with a dried white flaky substance on the 2nd shelf. The refrigerator contained food stuffs for patient consumption.
f. 8 stacks of Styrofoam cups directly next to the sink, and a box of clear plastic bags used to transport ice to patients for their consumption, on the other side of the sink (directly next to the sink).
S8RN (Registered Nurse), present during the observations, verified the above noted findings.
S8RN reported that the COWs were wheeled into each patient's room, but reported that they were not disinfected between patient rooms. S8RN reported that housekeeping was responsible for cleaning the COWs, which contained patient medication drawers also. The charge RN reported that pharmacy was responsible for cleaning and defrosting the medication refrigerators. S8RN reported that housekeeping would bring the telemetry monitors out of discharged patient rooms and place them on the medication preparation counter. S8RN reported that no cleaning materials were kept in the nursing station. S8RN reported that staff had to go to a housekeeping closet to obtain cleaning supplies, or get it from the housekeeper. The RN indicated that housekeeping was responsible for cleaning in the patient nourishment room. S8RN agreed that the opened Styrofoam cups and clear plastic bags used for patients' ice were probably contaminated each time someone washed their hands in the sink, and should not be located there. S8RN indicated that there was not enough storage room in the nourishment room. S8RN reported that blood glucose monitors/machines (also called glucometers) were cleaned once or twice a week with alcohol. S8RN agreed that the glucose monitoring machines were not disinfected by using alcohol, and by not disinfecting between each patient use, infectious agents could be introduced to the next patient.

In an interview on 3/30/15 at 1:15 p.m. S10RN Medical Unit Manager verified the above noted findings in the Patient Nourishment Room on the Medical Unit. In addition, S10RN Medical Unit Manager verified dust hanging from ceiling tiles above the ice machine, the sprinkler head, and the vent above the sink. These observations were made during the interview with the unit manager. S10RN Medical Unit Manager reported that maybe they (the hospital staff) should start making environmental rounds again. The unit manager reported they used to make rounds to inspect for cleanliness, but the rounds had been stopped a good while ago.

In an interview on 3/31/15 at 3:00 p.m. S11RN Manager reported that glucometers were cleaned daily and between patients with alcohol wipes. S11RN Manager agreed that cleaning with alcohol did not disinfect the glucometers.

In an interview on 3/31/15 at 3:40 p.m., S14RN reported that glucometers were cleaned with alcohol wipes a couple times a week. S14RN reported this was usually done by night shift staff. S15RN reported that the glucometers were cleaned once a week with Clorox wipes. When asked when the Clorox wipes were provided to the unit, S15RN reported they had received Clorox wipes for the first time yesterday, 3/30/15.

In an interview on 4/1/15 at 1:30 p.m. S4IC (Infection Control) Nurse reported that nurses are responsible for cleaning and disinfecting glucometers. S4IC Nurse stated she assumed the P & P (policy and procedure) should be that the glucometers were cleaned after every patient, but did not know what they should be cleaned with. S4IC Nurse indicated she was not aware alcohol did not kill such pathogens as C difficile, HIV (Human Immunodeficiency Virus), HBV (Hepatitis B Virus), and HCV (Hepatitis C Virus), etc. Observations made concerning environmental infection control breaches were discussed with S4IC Nurse. S4IC Nurse indicated someone else was over housekeeping and she was not familiar with those policies and procedures or with hospital cleaning products. S4IC Nurse indicated that no environmental rounds were performed. S4IC Nurse reported that she was the IC Coordinator, but that others reported to her. The IC Coordinator indicated that she spent most of her time doing "Core measure abstractions".

No policies or procedures were provided.

In an interview on 4/2/15 at 3:30 p.m. S9HR (Human Resource) Director reported she was the supervisor of Environmental Services. She indicated the supervisor of Environmental Services had been gone from the position for several months, and she had taken over the position. S9HR Director indicated that full time environmental employees were training newly hired part-time employees, but all were now working independently. S9HR Director indicated that the old Environmental Services supervisor was making rounds; she reported she (S9HR Director) made rounds, but did not document them or their results. The above noted observations were discussed with S9HR Director, who reported that each housekeeper had a daily check list of what they were expected to have done. S9HR Director indicated that he COWs were a nursing responsibility, and that housekeeping was only allowed to wipe the outside of the refrigerator. S9HR Director had no other comments regarding the above noted observations.

Based on record/policy review, observation and interview, the hospital failed to ensure policies and procedures governing surgical care were designed and implemented to assure the achievement and maintenance of high standards of medical practice and patient care as evidenced by:
1) failure to ensure that surgical services were provided in accordance with acceptable professional standards of practice by failing to ensure that surgical instrument trays were available in a quantity that was commensurate with the hospital's expected daily procedure volume, as evidenced by the hospital's routine use of IUSS (Immediate Use Steam Sterilization, with the old term of 'Flash Sterilization') of surgical instrument trays for surgical procedures, and
2) policies and practices that allow staff to launder surgical scrubs at home, and
allowing the use of skull caps to be worn in the restricted areas, thereby having hair exposed in the OR (Operating Room) and other restricted areas.
Findings:



1) failure to ensure that surgical services were provided in accordance with acceptable professional standards of practice by failing to ensure that surgical instrument trays were available in a quantity that was commensurate with the hospital's expected daily procedure volume, as evidenced by the hospital's routine use of IUSS (Immediate Use Steam Sterilization)(Flash Sterilization) of surgical instrument trays for surgical procedures.

A review of the AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices, 2013 edition - Recommended Practice for Sterilization revealed in part: IUSS should not be used as a substitute for sufficient instrument inventory in order to minimize the patient risk for SSI's (surgical site infections).

A review of a hospital policy titled, "Flash Sterilization Unwrapped Method", no issue date, revised 8/13, approved by OR (operating room) Manager, and provided by S11RN Manager as current, revealed in part, the following:
"Note: Flash Sterilization/Sterilization by the unwrapped method should only be used when the item to be sterilized is needed immediately"

Review of a current sterilization log labeled, "Flash Sterilization Record" revealed the following loads and contents by date:
January 2015:
1/5 -2 loads ( both light cords)
1/8- 2 loads ( dental mirror, dental tray)
1/19- 1 load (light cord)
1/22- 1 load (dental mirror)
February 2015:
2/4- 2 loads (no contents identified for either load)
2/5- 5 loads ( each one identified as an eye tray)
2/16-1 load (light cord)
2/18- 1 load (GB- no explanation)
2/19-3 loads ( all identified as "dental")
March 2015:
3/3- 1 load (GB)
3/4- 3 loads (dental mirror, 3 dental trays)
3/5- 2 loads ( eye tray, Phaco hand piece)
3/11-1 load (GB)
3/18-4 loads (dental mirror, 3 dental trays
3/30-1 load (light cord)

In an interview 4/1/15 at 10:15 a.m. S13Tech (Technician) reported that she was responsible for the sterilization of surgical instruments and supplies. S13Tech indicated that "Flash" Sterilization ( IUSS) was used in the hospital in order to keep up with the surgery schedule.

In an interview 3/31/15 at 2:45 p.m. S11RN Manager reported that IUSS of dental instruments was used because, "we were told these only had to be high-level disinfected, so we flash them before they are taken back to the dental office." With regards to eye instruments listed in the IUSS log, S11RN Manager stated, "the doctor brings his (instruments) and we have ours, but not enough for the number of cases on the schedule."



2) policies and practices that allow staff to launder surgical scrubs at home, and
allowing the use of skull caps to be worn in the restricted areas, thereby having hair exposed in the OR (Operating Room) and other restricted areas

Review of Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings (Association of periOperative Registered Nurses [AORN], 2013 Edition) revealed, in part, the following:
"...AORN recommended practices for perioperative nursing practice...are based on principles of nursing science, microbiology, research, review of the scientific literature, and the opinions of knowledgeable experts...
Recommended Practices for Surgical Attire: ...
Recommendation II. Clean surgical attire, including shoes, head coverings, masks, jackets, and identification badges should be worn in the semi restricted and restricted areas of the surgical or invasive procedure setting... IIa. Facility-approved, clean, and freshly laundered or disposable surgical attire should be donned daily in designated dressing areas before entry or reentry into the semi restricted and restricted areas.
Recommendation III. All individuals who enter the semi restricted and restricted areas should wear freshly laundered surgical attire that is laundered at a health care-accredited laundry facility or disposable surgical attire provided by the facility and intended for use within the perioperative setting.
Recommendation IV: All personnel should cover head and facial hair, including side burns and the nape of the neck, when in semi restricted and restricted areas... IV.a. A clean, low-lint surgical head cover or hood that confines all hair and covers scalp skin should be worn...IVa.2. Reusable head coverings should be laundered in a health care-accredited laundry facility after each daily use.
Recommendation V: Surgical attire should be laundered in a health care-accredited laundry facility... Health care-accredited laundry facilities are preferred because they follow industry standards... An accredited health care facility laundering process includes monitoring correct measurement of chemical, sufficient water, correct temperature, mechanical action, and the duration of the washing cycle...Home laundering is not monitored for quality, consistency, or safety... V.a. Laundered surgical attire should be protected during transport to the practice setting to prevent contamination...
Recommendation IX: The health care organization's quality management program should evaluate compliance with surgical attire policies and identify and respond to opportunities for improvement..."

Review of hospital policy titled, " Surgical Suite", issued 5/20/88, last revised 1/15, and approved by OR Manager , provided by S11RN (Registered Nurse) Manager as current, revealed , in part the following: ..."II. Attire, A. Those entering the restricted area of the surgical suite shall wear scrub clothes provided and laundered by the hospital contract service.
Review of a hospital policy titled, "Home-Laundered Surgical Scrubs", issued 3/23/10, no review or revision date, and approved by CNO (Chief Nursing Officer), IC (Infection Control) Officer, and Quality Manager, and provided by S11RN Manager as current, revealed the criteria for Home Laundering of surgical attire. Further review revealed no procedure for documentation or assurance of the criteria being followed for the home laundering.
An observation 4/1/15 from 10:00 a.m. revealed hospital surgical staff wore different style scrubs of various colors.
In an interview 3/31/15 at 2:10 p.m. S11RN Manager reported staff in surgical area wore scrubs bought and laundered by individual personnel. S11RN Manager indicated that each personnel laundered their own scrubs at home, but could not provide any evidence of compliance with laundering standards for linens used in hospitals. S11RN Manager reported that some staff did wear disposable OR skull caps for head coverings. S11RN Manager agreed that the skull caps did not cover all hair (nape of neck, side burns, etc).