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Based on observation, review of Competency Check Off Form and Unit Specific Competencies, review of SGNA (Society Of Gastroenterology Nurses and Associates, Inc.) position statement, and interviews, the Director of Surgical Services failed to ensure that three of three (Licensed Practical Nurse (LPN) #1, Operating Room Technologist (ORT) #1, ORT #2) staff members had the documented competencies in techniques to perform manipulation of the endoscope during endoscopic procedures. Failure to ensure LPN #1, ORT #1, and ORT #2 had documented training specific to manipulation of endoscopes did not assure endoscopy patients received care in a safe setting and had the likelihood to affect all patients whose endoscopy procedures were performed by LPN #1, ORT #1, and ORT #2. Findings follow:

A. During an observation of an EGD (Esophagogastroduodenoscopy)/Colonoscopy on 09/10/24 at 10:20 AM, MD (Medical Doctor) #1 completed the EGD portion of the procedure. The patient was turned via stretcher so that the patient was facing the wall opposite LPN #1 and MD #1 moved to the end of the stretcher and was seated. LPN #1 was observed picking up the distal portion of the colonoscope, applying lubricant and entering the anus of the patient with the colonoscope. She manipulated the scope throughout the rectum, sigmoid, descending, transverse, and ascending colon to canulate the cecum. Once the cecum was reached, LPN #1 withdrew the colonoscope back through the ascending, transverse, descending, sigmoid, and rectum. MD #1 retroflexed the scope and LPN #1 withdrew the scope from the anus of the patient thus completing the colonoscopy. MD #1 operated the control section of the colonoscope throughout the colonoscopy, but did not manipulate the insertion section of the scope inside of the patient.

B. Review of Competency Check Off Form for LPN #1 dated 12/04/03 showed no documented training specific for techniques in the manipulation of endoscopes.

C. Review of SGNA Position Statement "Manipulation of Endoscopes during Endoscopic Procedures" last updated 2012, showed, "Background-the gastroenterology nurse or Nursing Assistive Personnel (NAP) may be called upon to provide assistance to the endoscopist by manipulating the endoscope; thereby enhancing the diagnostic or therapeutic abilities of the endoscopist. Position-The SGNA supports the position that the gastroenterology nurse or NAP educated and experienced in endoscopy may manipulate the endoscope under direct supervision of the endoscopist when required to facilitate an endoscopic procedure. SGNA also asserts the following: 1. The gastroenterology nurse or NAP who assumes this role must have documented competency in: a. Techniques of endoscope manipulation,"

D. In an interview with LPN #1 on 09/11/24 at 9:25 AM, she stated that she had been trained back in 1995 by two gastroenterologists who no longer work for the facility. She stated there is currently one gastroenterologist who manipulates his own endoscopes during procedures. She stated there are five (MD #1, MD #2, MD #3, MD #4, and MD #5) general surgeons who currently perform endoscopic procedures at the facility, and she manipulates the scopes during those procedures. She stated and confirmed that all of her training was "hands on" and there was no documentation of the training. The Director of Surgical Services was present during this interview and confirmed that the facility could not provide documented evidence of LPN #1's training to manipulate endoscopes for EGD and Colonoscopy. The Director of Surgical Services also confirmed the facility follows SGNA guidelines.

E. In a follow-up interview via email with the Director of Surgical Services on 09/17/24 at 3:23 PM, she stated that there two ORTs (ORT #1 and ORT #2) that manipulate scopes for EGD and Colonoscopy. On 09/18/24 at 8:00 AM, the surveyor requested documentation for training specific to the manipulation of endoscopes for ORT #1, and ORT #2.

F. Review of Unit Specific Competencies dated 10/25/18 for ORT #1 and ORT #2 provided by the Director Of Surgical Services on 09/18/24 at 11:49 AM via email showed, "Procedure Duties-assist MD with Procedure as needed." The Director of Surgical Services confirmed via the email no documented training specific to techniques for manipulation of endoscopes for ORT #1 and ORT #2.

Based on review of facility policy, review of Medication Refrigerator Temperature Logs and interview, it was determined that nurses failed to follow facility policy in that medication refrigerator temperatures were not being checked and documented daily, per policy, in two (Intensive Care Unit (ICU) and Emergency Services) of five (Emergency Services, 2 North East, ICU, Labor & Delivery, and Surgical Services) departments toured. By not monitoring the temperature daily, the facility could not assure medications and biologicals were stored in proper conditions and could not assure their safety or efficacy. The failed practice had the likelihood to affect all patients receiving refrigerated medications in the facility. Findings follow:

A) Record review of the facility's policy titled, "Refrigeration & Freezing," showed medication refrigerator and freezer temperatures in patient care areas shall be monitored and recorded, daily.
B) During a tour of the facility on 09/09/24 from 12:30 to 4:00 PM, review of the Medication Refrigerator Temperature Logs showed the following:
1) ICU -
Refrigerator #1 was missing evidence (initials) the medication refrigerator was monitored two (9/1, and 9/2) out of nine (9/1-9/9) days.
Refrigerator #2 was missing evidence (initials) the medication refrigerator was monitored two (9/1, and 9/2) out of nine (9/1-9/9) days.
2) Emergency Services -
The medication refrigerator was missing evidence (initials) the medication refrigerator was monitored four (9/1, 9/6, 9/7 and 9/8) out of nine (9/1-9/9) days.
C) The findings were verified at the time of discovery, by the Manager of Informatics.

Based on observation, review of policy and interview, it was determined the facility failed to ensure floor stock was properly controlled in one of one Emergency Services toured in that a prescription medication was observed in a Rapid Response backpack that was not secured. The prescription medication was unsecured and accessible to unlicensed personnel. By not controlling floor stock, the facility could not assure the safety, integrity or efficacy of the uncontrolled medications. The failed practice had the likelihood to affect all patients that were treated at this facility. Findings follow:

A. Record review of the facility's policy titled, "Emergency Drugs," showed all emergency room stock shall be stored securely. The security system may include seals or other devices to detect unauthorized entry into a container or the removal of a package from the storage area.
B. During a tour of the facility on 09/09/2024 from 12:30 PM to 4:00 PM, observation showed a red Rapid Response backpack in Emergency Services that had a vial of Adrenalin 30 milligrams/ 30 milliliters in it. The medication was not secured in any fashion. This Rapid Response backpack is for emergency use, and should be treated like a crash cart, or emergency kit, sealed with a breakaway seal and checked every shift.
C. During an interview on 09/09/2024 at 12:49 PM, the Manager of Informatics verified the findings at B.

Based on observation of the Emergency Department, Dietary, Medical Records and Medical Surgical Nursing Unit and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of infection and/or placed the patients at risk of fire. The failed practice had the likelihood to affect all patients, staff and visitors. Findings follow:

A. Observation of the Emergency Department on 09/09/24 showed the following:
1) At 12:34 PM, Ceiling tiles in Emergengy Room (ER) 1 had water stains
2) At 12:35 PM, ER 1 had rust and mold under unlocked sink
3) At 12:35 PM, All ER rooms 1-4 need Coverings for exposed nurse call reciprocals
4) At 12:37 PM, Exposed sprinkler head in ER 5
5) At 12:38 PM, Restroom between ER 3-4 pull cords were longer than six inches from the floor.
6) At 12:40 PM, ER 1-6 needed to have scratched and damaged doors repaired and sealed
7) At, 12:41 PM, ER 1 needed missing electrical socket needed reciprocal cover replaced
8) At 12:45 PM, all damaged and stained tiles need to be replaced throughout the ED
9) At, 12:46 PM, The utility room labled as clean was being used as a dirty utility room.
10) At, 1:00 PM, wall penetrations in the sheet rock above door of the isolation room.
11) At 1:05 PM, Isolation room base boards were missing
12) At 1:12 PM Decontamination room had unidentified objects insides, wall penetrations, dirty vents, and dirty floor

B. The findings in A were verified by the Director of Maintenance on 09/09/24 at the time of observation.

C. Observation of the Medical Records Department on 09/09/24 showed at 1:31 PM, Medical records room was not sprinkled according to NFPA 101.

D. The findings in C were verified by the Director of Maintenance on 09/09/24 at the time of observations.

E. Observation of Dietary Department on 09/09/24 showed the following:
1) At 1:58 PM, Dead roach in the pantry
2) At 1:58 PM, build up of dust and grime around the baseboards of the pantry
3) At 2:21 PM, Medical gas (C02) not secured in room located directly behind dietary

F. The findings of E were verified with the Director of Maintenance on 09/09/24 at the time of observation.

G. Observation of the Medical Surgical Unit on 09/09/24 at 11:11 AM showed:
1) Tape missing from air vent, wrong tape being using around window the tape should be able to be cleaned without dissolving, and hose disconnected on air purification system in isolation room.


H. The findings of G were verified with the Director of Maintenance on 09/09/24 at the time of observation.

Based on observation and interview it was determined the facility failed to ensure the equipment in three (Emergency Department (ED), Computed Tomography (CT), and Surgical Intensive Care Unit (SICU)) of seven (ED, Radiology, Nuclear Medicine, 2 North East (NE), SICU, CT and Magnetic Resonance Imaging (MRI)) units toured. The facility failed to ensure that all equipment was functional and safe for patient and staff use. By not ensuring all equipment was functional and safe for use there was an increased risk for harm. The failed practice had the likelihood to affect all patients receiving treatment in these areas. Findings follow:

A. Observation of ED on 9/9/24 at 12:56 PM showed a LifePak20 Defibrillator on a Urology cart across from nurses' station. There was no evidence of a defibrillator daily check log showing the defibrillator had been checked, was in good working order and ready for emergency use. During an interview with the ED Manager on 9/9/24 at 12:58PM, she stated this was an "extra defibrillator" and that daily checks were not being performed, however, there was a possibility the difibrilator may be used if needed in an emergency. The findings were confirmed in an interview with the ED Manager and Manager of Informatics on 9/9/24 at 12:58 PM.

B. Observation of ED Radiology Room on 9/9/24 at 1:03PM, showed a closet containing clean linens and supplies had broken shelf brackets causing shelves to lay on one another along with the shelf's contents. The findings were confirmed in an interview with the Clinical Staff Educator on 9/9/24 at 1:09 PM.

C. Observation of SICU on 9/9/24 at 2:20 PM, showed that crash cart #2 had bare exposed wire on lead wire that attaches to patient during defibrillation process. Review of crash cart log showed that daily check on 9/9/24 had been performed and all items were indicated to be in good working order. The findings were confirmed in an interview with the Clinical Staff Educator on 9/9/24 at 2:21 PM.

D. Observation of CT on 9/11/24 at 10:03 AM, showed four 100 milliliter bottles and four 200 milliliter bottles of "IsoVue" radiopaque diagnostic intravenous solution were stored at 40 degrees Celsius (ºC) or 104 degrees Fahrenheit (ºF). A sign on the warming device stated that solution should be maintained at 37 ºC or 98.6 ºF. Manufacturer's Instructions stated store between 20-25 ºC or 68-77ºF and recommended that solution may be warmed to body temperature prior to injection. The findings were confirmed in an interview with the Director of Radiolgy on 9/11/24 at 10:05 AM.

Based on observation, and interview, it was determined the facility failed to maintain a clean and sanitary environment in that they failed to keep hand washing sinks and sink areas clean, in three (2 North East, Intensive Care Unit (ICU) and Labor & Delivery) of five (Emergency Room, 2 North East, ICU, Labor & Delivery, and Surgical Services) departments toured. By not keeping the hand washing sinks and sink areas clean, the facility could not assure employees hands were clean to perform tasks like medication preparation, medication administration and patient care, to prevent the spread of infection. This failed practice had the likelihood to affect all patients receiving medications and patient care in these three areas. Findings follow:

A. During a tour of the facility on 09/09/24 from 12:30 to 4:00 PM, observation showed the following:
1) 2 North East
Handwashing sink #1 was visibly dirty, with a dark grimy substance accumulated around the sink's edges and the backsplash where it attached to the counter. Where the backsplash met the counter, a brown thick liquid substance accumulated between the back of the sink and the backsplash. The faucet was leaking, and there was build up around the faucet base. There was trash in the drain.
Handwashing sink #2 was visibly dirty, with a dark grimy substance accumulated around the sink's edges and the backsplash where it attached to the counter. There was a grime like substance accumulating in the drain.
2) ICU
Handwashing sink #1 was visibly dirty, with a dark grimy substance accumulated around the sink's edges and the backsplash where it attached to the counter. There was a buildup of green/black grime around the faucet.
Handwashing sink #2 was visibly dirty, with a dark grimy substance accumulated around the sink's edges and the backsplash where it attached to the counter. There was a brown/black buildup in both drains. There was also black dirt on the counter, next to the sink.
3) Labor & Delivery
Handwashing sink was visibly dirty, with a dark grimy substance accumulated around the sink's edges and the backsplash where it attached to the counter. Some of the caulking was missing where the counter and the backsplash meet, and there was water and grime accumulated there.
B. The findings were verified at the time of observation with the Manager of Clinical Informatics.


37145

Based on observation, and interview, it was determined the facility failed to provide measures to prevent and control the spread of infection and maintain a clean and sanitary environment in that the countertops and cabinet areas where clean and sterile supplies were stored in the Emergency Department (ED) had red and brown splatters. The failed practice promoted the spread of infection. This failed practice had the likelihood to affect all patients receiving care, and all staff and visitors to the ED . Findings follow:

A. During a tour of the Emergency Department on 09/09/24 from 12:30 to 1:30 PM, observation showed the following:
1) The countertop adjacent to rooms 18 and 19 had a dried splattered red and brown colored substance.
2). The overflow supply cabinet adjacent to rooms 18 and 19 had a splattered red and brown colored substance and inside the cabinet a container of 20 ml (milliliter) syringes had a red and brown colored dried substance to the top of the packaging.
B. The findings in A were verified at the time of observation with the Infection Control Nurse.


47891

Based on observation and interview it was determined that the facility failed to ensure the cleanliness of treatment equipment in the Emergency Department. Failure to maintain the cleanliness of the equipment promoted the spread of infection. The failed practice had the likelihood to affect all patients treated in the Emergency Department. Findings follow:

A. Observation of the Emergency Department cast supplies room showed there were two equipment boxes sitting on the floor. One was marked as a cast kit and the other a toolbox labeled Dr. (Named).
B. Observation of the hall by the Emergency Department nurses station showed there were blood splatters on one of five mobile computer stations.
C. Observation of the hall by the Emergency Department nurses station showed there was tape and tape residue on four of five mobile computer stations.
D. Observation of outside of Emergency Department room 22 showed in the hallway there was blood splattered on the lid of a dirty linen cart. Above the linen cart there were red splatters on the air vent in the ceiling.
E. Observation of the ambulance entryway showed there were cobwebs, dead insects, dirt, and debris in the ceiling corners and floor.
F. The findings in A, B, C, D, and E were confirmed in an interview with Infection Control Nurse on 9/9/2024 at 1:10 PM.



Based on observation and interview it was determined that the facility failed to maintain a clean and sanitary environment in that the facility failed to maintain doors on patient care units in a manner that allowed disinfection on one (2 North East) of 3 (2 North East, 2 North West, and Intensive Care Unit) units toured. The failed practice promoted the spread of infection. The failed practice had the likelihood to affect all patients receiving care in the facility. Findings follow:

A. The doors on unit 2 North East to rooms 13, 14, 15, 17, 19, 22, 23, and 24 were worn to bare porous wood making it a surface that could not be disinfected.
B. The findings in A were confirmed with the Infection Control Nurse on 9/9/2024 at 1:20 pm.


Based on observation and interview it was determined that the facility failed to ensure that equipment was maintained in a clean manner in that the mobile computers on 2 North East had tape and tape residue on 4 of 5 of them. The failed practice had the likelihood to affect all patients treated in that unit. Findings follow:

A. Observation of the 2 North East unit on 9/9/2024 at 1:15 PM showed that 4 of 5 mobile computer stations had tape and tape residue on them.
B. The findings in A were confirmed with the Infection Control Nurse 9/9/2024 at 1:20 pm.


Based on observation and interview it was determined that the facility failed to maintain emergency equipment in that the airway box in the intensive care unit had 2 pair of Magill Forceps were uncovered and 2 Shiley inner cannulas packaging was compromised by liquid. Failing to maintain this equipment could not ensure the cleanliness of these items. The failed practice had the likelihood to affect all patients in the intensive care unit. Findings follow:

A. Observation of the intensive care unit showed that in the airway box there was:
1. 2 pairs of Magill forceps were not in a package and sitting open in the bottom of the airway box.
2. 2 Shiley inner cannulas were found to have compromised packaging in that one had water stains and the other had ink on the paper packaging.
B. The findings in A were confirmed with Infection Control Nurse on 9/9/2024 at 1:30 pm.

Based on observation and interview it was determined the facility failed to maintain equipment in a clean and sanitary condition in that 2 of 2 recliner chairs found in a storage room on the intensive care unit were cracked and torn. The failed practice did not allow the chairs to be cleaned and disinfected and promoted the spread of infection. The failed practice had the likelihood to affect all patients cared for in the intensive care unit. Findings follow:

A. Observation of the intensive care unit on 9/9/2024 at 1:30 PM showed that in a storage room there were 2 chairs with torn and frayed covering exposing porous threads and material.
B. The findings in A were confirmed with the Infection Control Nurse on 9/9/2024 at 1:35 pm.


Based on observation and interview it was determined that the facility failed to maintain the patient care environment in a clean and sanitary manner in intensive care unit room 2335 in that the air blower air intake and exhaust contained dirt and debris. By failing to maintain the air blower the facility did not ensure that patients in this room were protected from potentially infectious material. The failed practice had the likelihood to affect all patients admitted to the intensive care unit room 2335. Findings follow:

A. Observation of the intensive care unit room 2335 on 9/9/2024 at 2:00 AM/PM showed a blue air blower on a stand and was connected to a window with collapsable tubing. The air intake and exhaust were caked with dirt and debris. The collapsable tubing was torn at the connection to the window allowing air to flow back inside. The aluminum tape holding the tubing to the window was peeled back exposing adhesive which had collected dust and debris.
B. The findings in A were confirmed with the Infection Control Nurse on 9/9/2024 at 2:10 pm.



51070

Based on review of policy, observation and interview it was determined that the facility failed to maintain a clean and sanitary environment in four (Emergency Department (ED), Radiology Department, Nuclear Medicine, Computed Tomography (CT)) of seven (ED, Radiology, Nuclear Medicine, 2 North East (NE), Surgical Intensive Care (SICU), CT and Magnetic Resonance Imaging (MRI)) units toured. Failure to ensure a clean and sanitary environment increased the risk for transmission of infectious organisms and spread of communicable disease. The failed practice had the likelihood of affecting all patients receiving care in these units. Findings follow:

A. Review of Policy "Seven Step Cleaning" on 9/16/24, showed that step 3 "Damp Wipe" was to "wipe everything" with a damp rag using approved disinfectant and that surface should be allowed to air dry for allotted time as determined by the manufacturer label.

B. Observation of the ED on 9/9/24 between 12:35 PM and 1:15 PM, showed the following:

1. The countertop in the hallway on the back side of nurses station on 9/9/24 at 12:38 PM, had blood splatter next to lab tubes and other supplies. The finding was verified in an interview with the Infection Control Nurse on 9/9/24 at 12:40 PM.

2. Two ED technicians cleaned room ED 22 on 9/9/24 at 12:48 PM. The mattress was sprayed with disinfectant and clean linen was immediately applied without allowing mattress to air dry or be wiped after allotted time stated on disinfectant label. An open AMBU (Artificial Manual Breathing Unit) bag was left hanging on the wall suction flowmeter. The findings were verified in an interview with the Manager of Informatics on 9/9/2024 at 12:50 PM.

3. The ED Radiology Room on 9/9/24 at 1:03 PM, showed the following:
a) Food condiments, used gloves turned inside out, and a sticky syrup-like substance on a rolling table.
b) Wall scraped down to drywall behind portable x-ray machine.
c) Supply/Linen closet with signs taped to inside of doors.
d) Used gloves turned inside out on control room counter.
e) The findings in 3 were confirmed in an interview with the Clinical Staff Educator on 9/9/24 1:03 PM.

C. Observation of Radiology Department on 9/10/24 at 1:45 PM, Showed the door in X-Ray room 1 had a small area of unfinished wood with four unfilled holes where old hardware had been removed. The finding verified in an interview with the Director of Radiology on 9/10/24 at 1:45PM.

D. Observation of Nuclear Medicine on 9/10/24 from 1:50 PM to 2:05 PM showed the following:
1. Personal items (coats, essential oils, etc..) were stored with clean linen in closet next to control counter.
2. Sink in "hot" supply room was found to have greenish blue stains with corrosion around hot and cold-water handles.
3. Under the sink in "hot" supply room cabinet door was warped and had cracked paint and flecks of wood along with several metal supplies.
4. The findings in D were verified in an interview with the Director of Radiology on 9/10/24 at 2:05 PM.

E. Observation of CT on 9/10/24 at 2:10 PM and again on 9/11/24 at 10:04 AM, showed the following:
1. IV (intravenwous) start tray stored in the clean linen cart in both room CT 1 and CT 2.
2. The CT machine in room CT 2 had chipped paint and deep gouges making it difficult to disinfect.
3. The findings in E were verified in an interview with the Director of Radiology on 9/11/24 at 10:04 AM.