HospitalInspections.org

Based on observation, interviews, and record reviews, the facility failed to maintain an effective infection prevention and control program when, facility stored medical supply carts in a soiled utility room.

Findings included:

In an observation of 2nd Floor Mother and Baby Unit (post-partum) on 1/28/20, at 9:45 a.m., the surveyor observed 2 medical supply carts stored in a soiled utility room. The supplies included Foley catheters, in & out catheters, sterile gloves, non-sterile gloves, and suctioning equipment.

In an interview on 1/28/20, at 9:50 a.m., Staff #6 stated the 2 supply carts found in a soiled utility room should not be stored there.

In an interview on 1/28/20, at 10:00 a.m., Staff #9 stated, "there was a patient last Saturday (1/25/20) who was allergic to latex and so latex free Foley catheter was needed." She stated supply carts were brought up by central supply department and initially stationed next to a patient's room who needed it. She stated she did not know who and when the carts were placed in a soiled utility room.

In an interview on 1/28/20, at 10:30 a.m., Staff #8 stated she did not know who placed the carts in a soiled utility room, but they should not be stored there.

Review of policy titled Latex Sensitivity/Allergy, with reviewed dated of 8/2019, reflected under procedure: " ... 4. Notify Central Supply/or AOD after hours to deliver a Latex Allergy Precaution Supply Cart and/or supplies. (Cart includes: latex free foley catheter, sterile gloves, etc.) ..." There was no information related to storage/return of carts after patient care.

Review of policy titled Disinfections, Cleaning and Reuse of Patient Care Items, with reviewed date of 09/15, reflected the following:
- Definitions: "Critical items involve high risk of infection and are objects that enter sterile tissues ... 1. Examples of items include ... urinary catheters ..."
- Procedure: "Storage of patient care supplies ... a. Patient care supplies are to be stored and rotated in a clean utility area ..."

Based on interview and record review, the facility failed to provide appropriate and organized emergency services, when nursing staff failed to take Patient #1's vital signs before discharge.

Findings included:

Review of Patient #1's ED (Emergency Department) Patient Depart Summary indicated she was discharged on 6/1/19, at 00:15.

Review of Patient #1's Flowsheet for vital signs reflected the last vital signs were taken on 5/31/19, at 18:11 (approximately 6 hours before discharge).

In an interview on 1/28/20, at 3:00 p.m., Staff #3 confirmed the above findings.

In an interview on 1/28/20, at 4:05 p.m., Staff #15 stated she expects vital signs to be taken within an hour before discharge.

Review of ED policy titled Discharge of Patients, with revised date of 8/15, reflected "Procedure ... 3. Discharge vital signs will be obtained. Blood pressure, pulse and respirations will be taken on patients with a length of stay in the department of > 1 hour."

Review of ED policy titled Admission/Transfer/Discharge Criteria, with revised date of 8/15, reflected under Procedure Steps: Transfer/Discharge Criteria: "1. The discharge ... will be initiated after the decision is reached by the patient's admitting or ED physician. This decision will be based on ... b. The blood pressure, pulse, respirations and temperature are within normal limits for that patient."