HospitalInspections.org

UNLOCKED CHEMICALS AND UNSECURED OXYGEN TANK

1. Based on observation, facility policy, and staff interview, the Critical Access Hospital (CAH) failed to maintain an environment free of accident hazards on 3 of 3 days of survey (May 30 - June 1, 2017). Failure to securely store chemicals utilized by housekeeping and other staff placed cognitively impaired patients who display confusion and wandering behaviors, as well as children, at risk for accidents due to accessibility to hazardous chemicals. Failure to securely store oxygen tanks placed patients, staff, and the public at risk for injury should the tank become disengaged or damaged.

Findings include:

Review of the CAH policy, "Materials Management," states, ". . . Storage areas: In order to provide a . . . safe environment for customers and employees . . . areas are kept in a clean and orderly fashion. . . . Safety and security shall be of utmost importance. . . . Oxygen tanks are to be stored in upright, secured holders located on the floor or in metal wall racks. MSDS [material safety data sheet - information regarding the chemicals in a commercial product] are available and accessible."

Observation of the respiratory department on the morning of 05/31/17 identified an unsecured oxygen tank under the sink on the floor, laying horizontally on the floor.

Observation of the environment occurred on the afternoon of 05/31/17 with a environmental services manager (#7) and identified the following chemicals with hazard warning labels and not stored in a secure location:
* present in an alcove (no door), identified as the dirty utility room in the obstetric (OB) wing, a spray bottle of Clorox Bleach Germicidal Cleaner, labeled to keep out of reach of children, and a bottle of Dawn antibacterial hand soap, labeled for external use only and keep out of reach of children
* present in a clean utility room in the OB wing, an unlocked cabinet with several chemicals on an upper shelf; the chemicals included Clorox Bleach spray bottle and an iodine prep solution bottle with a warning label of for external use only
* an unlocked janitor closet in the OB wing with a cleaning cart which contained a gallon of Clorox bleach, spray bottle of Clorox, a spray bottle of Virex germicidal labeled to avoid contact with skin, eyes and clothing, and several other spray disinfectants and cleaners
* an unlocked tub room between the OB unit and nurses' station with a gallon jug of Clorox bleach and Clorox spray in a cabinet sitting of the floor
* an unlocked soiled utility room on the medical/surgical nursing unit which contained a spray bottle of Clorox, and a bottle of Isosorb with a label for industrial use only and to keep out of reach of children
* an unlocked employee lounge room with a gallon jug of Clorox bleach in a cabinet under the sink
* an unlocked storage room on the nursing unit with two gallon jugs of Clorox bleach, two Bleach Germicidal Cleaners bottles, two bottles of Isosorb, and a bottle of betadine scrub

During the tour of the above areas, a supervisory staff member (#7) confirmed each of the areas as unlocked.

During interview on 05/31/17 at 11:00 a.m., a respiratory therapy staff members (#9) confirmed the CAH staff failed to store the oxygen in a secure manner.

LAUNDRY MAINTENANCE AND CONDITION

2. Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure proper maintenance and cleanliness of the clean and dirty areas of 1 of 1 laundry department. Failure to properly maintain all areas of the hospital limits the CAH's ability to ensure a safe and clean environment for patients.

Findings include:

Observation of the CAH's laundry department occurred on the afternoon of 05/31/17 with an environmental services staff member (#7). The area utilized identified:
* all the cabinets/cupboards in the clean area with chipped surfaces and rough edges. Observation showed the laminated counter-top under these cabinets with two quarter size cut outs/holes punched out of them. The counter included two separate pieces joined together and the edges where joined as rough and gaping
* the upper outer lip of a large clothing bin used for clean laundry cracked and taped over with a wide strip (estimated width of two inches) of clear tape
* the entire base/platform where staff weigh dirty laundry coated with a heavy rust buildup and indentations (as if hammered out) on the platform which limits the ability to make the surface cleanable

On the morning of 06/01/17, two unidentified laundry staff members weighed linen bags of dirty laundry onto the scale and then threw the bags across a threshold into the laundry room near the washing machines. A laundry staff member (#11) stated staff wipe down the scale once a week.

Based on observation, review of professional literature, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff monitored the temperature and humidity of 1 of 1 sterile storage area in the surgical department. This failure limited the CAH's ability to ensure the temperature and humidity remained within the recommended ranges to inhibit the growth of microorganisms, bacteria and mold.

Findings include:

The Centers for Disease Control and Prevention (CDC) document, "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008," updated 02/15/17, pages 72-92, stated, ". . . Sterilizing Practices . . . Physical Facilities. . . . The sterile storage area should be a limited access area with a controlled temperature (may be as high as 75 [degrees] F [Fahrenheit]) and relative humidity (30-60% in all works [sic] areas except sterile storage, where the relative humidity should not exceed 70%). . . . Recommendations for Disinfection and Sterilization in Healthcare Facilities . . . C. Recommendations . . . 18. Storage of Sterile Items. a. Ensure the sterile storage area is a well-ventilated area that provides protection against . . . temperature and humidity extremes. . . ."

Observation of the surgical department occurred on the afternoon of 05/31/17 with an administrative surgical nurse (#4) and a surgical/central supply staff member (#5). The nurse stated the CAH performed surgical cases mostly every day of the week and included general, podiatry, ophthalmology, obstetric/gynecologic, orthopedic (upper extremity), and gastrointestinal procedures. Observation showed a large room the staff member's identified as the sterile storage area, which contained all the processed surgical packages and trays.

During an interview at this time, the staff members (#4 and #5) confirmed the CAH did not monitor the temperature and humidity of the sterile supply room.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed standard infection control practices for 2 of 2 active patients (Patient #1 and #5) observed during blood glucose testing. Failure to perform hand hygiene or handwashing after blood glucose testing and removal of gloves has the potential to spread microorganisms to other patients, staff, and visitors, increasing the risk for infection.

Findings include:

Review of the policy "Blood Glucose Monitoring with Precision PCx Testing System" occurred on 05/31/17. This policy, dated 05/05/15, stated, ". . . INFECTION CONTROL: 1. Hospital policy requires the use of gloves when performing blood glucose testing. . . ."

Review of the policy "Standard Precautions" occurred on 05/31/17. This policy, dated 08/07/13, stated, "Policy and Procedure: Standard Precautions represents a system of barrier precautions to be used by all personnel for contact with blood . . . of ALL patients, regardless of the patient's diagnosis. These precautions are the 'standard of care.' . . . Standard Precautions focuses on reducing the risk of transmission of microorganisms. . . . The purpose is to reduce transmission of infectious agents between patients, caregivers, and others in the medical center environment, and to reduce the incidence of HCA [health care acquired] infections among patients. . . . Standard Precautions will be followed by all personnel and will be based on the degree of anticipated exposure to body substances. . . . II. Handwashing: A. Because HCA infections are most frequently spread by contact and the most common form of contact is through hands. HANDWASHING is the most important and most effective means of preventing HCA transmission of organisms. Employees have a responsibility for maintaining hand hygiene by adhering to specific infection control practices. . . . B. Handwashing Products . . . 4. Alcohol based agents are an acceptable alternative to soap and water unless organic material is suspected on the employees hands . . . Then soap and water are required. C. Procedure . . . 4. Wash hands: before and after patient contact . . . after removing gloves . . . III. Personal Protective Equipment (PPE): A. Gloves . . . 1. Gloves must be worn for: anticipated contact with . . . body substances . . . 4. Remove and discard gloves after each individual task involving body substance contact, before leaving the bedside. . . . 5. Wash hands as soon as possible after glove removal . . ."

Observation on 05/31/17 at 10:45 a.m. showed a nurse (#6) performed blood glucose testing on Patient #5. After completion of the test, the nurse (#6) removed her gloves and left the patient's room with the blood glucose monitor. She took the monitor to the clean utility room, cleansed the monitor with a disinfectant wipe and placed the monitor on the docking station. The nurse (#6) realized another patient required testing, so she took the monitor to Patient #1's room, placed gloves, and performed blood glucose testing. After completion of the test, the nurse (#6) removed her gloves, left the patient's room with the blood glucose monitor, took the monitor to the clean utility room, and cleansed the monitor with a disinfectant wipe. She placed the monitor on the docking station, left the clean utility room, walked to the hallway outside the nurse station, and charted on a computer.

The nurse (#6) failed to perform hand hygiene or handwashing after completion of blood glucose testing and removal of gloves, prior to moving on to the next patient and other tasks, during two consecutive observations as mentioned above.

During an interview on the afternoon of 05/31/17, an infection control nurse (#2) stated staff must perform handwashing or hand hygiene after blood glucose testing and after the removal of gloves. She stated staff must perform this as soon as possible after the task is completed, prior to leaving the patient's room and moving onto other tasks and patients.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to provide safeguards against loss, destruction, or unauthorized use of medical records for 3 of 3 unlocked medical record storage areas (clinic, respiratory therapy, and stress lab) observed. Failure to store records in a secure manner limited the CAH's ability to prevent loss or destruction of records and to ensure the maintenance of patient confidentiality.

Findings include:

Review of the policy "Content and Security of the Medical Record" occurred on 05/31/17. This policy, dated January 1990, stated, ". . . All clinic records are locked after hours within the HIM [Health Information Management] Department. . . ."

Review of the policy "Security and Protection of Records" occurred on 05/31/17. This policy, dated April 1996, stated, ". . . All patient health information is considered confidential . . ." The policy failed to address the security of medical records stored outside of the Health Information Management Department.

Review of the policy "Access to Medical Records" occurred on 05/31/17. This policy, dated 12/17/03, stated, "West River Health Services recognizes the importance of securing and protecting the confidentiality of health information. . . ." The policy failed to address the security of medical records stored outside of the Health Information Management Department.

- Observation on 05/31/17 at 8:50 a.m. identified medical records (patient electrocardiogram test strips and reports) stored in and on top of six unlocked file cabinets in an unlocked storage room in the clinic.

During an interview on 05/31/17 at 8:50 a.m., an administrative staff member (#10) confirmed the CAH did not ensure the security of the patient electrocardiogram tests and reports stored in the unlocked storage room in the clinic.


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- Observation on 05/31/17 at 11:00 a.m. identified a binder with patient names in a room utilized by respiratory therapy.

During an interview on 05/31/17 at 11:00 a.m., a staff member (#9) stated staff use the binder to track patients who have received pulmonary function tests. The staff member stated staff do not always lock the door to the department.

- Observation on 05/31/17 at 11:45 a.m. identified five file cabinets in the stress lab with identifiable patient information. A staff member (#8) stated the files hold stress tests and holter monitor records. The staff member stated she may leave the room unlocked for five minutes after a procedure while she walks with a patient back to the nuclear X-ray department.

The CAH failed to ensure patient confidentiality in both the respiratory therapy department and the stress lab by leaving the doors unlocked and no staff present.

Based on policy review, record review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the Quality Improvement (QI) program evaluated all patient care services and other services affecting patient health and safety for 4 of 4 quarters reviewed (August 2016, November 2016, February 2017, and May 2017). Failure to ensure departments perform QI monitoring limited the CAH's ability to identify risk factors affecting patient care and implement corrective action if necessary.

Findings include:

Review of the policy titled "Quality Improvement/Risk Management Plan-2016" occurred on 06/01/17. This policy, revised 02/15/16, stated,
". . . Scope
The Quality Improvement/Risk Management program shall apply to all departments, services, and practitioners whose activities within the institution have a direct or indirect influence on the quality of patient care. . . ."

Reviewed on 06/01/17, the CAH's 2016 and 2017 QI Master List (reporting schedule) failed to include the Central Supply Reprocessing (CSR) department.

Reviewed on 06/01/17, the August 2016-May 2017 QI Committee's quarterly meeting minutes lacked evidence CSR submitted reports.

Reviewed on 06/01/17, the August 2016-May 2017 QI monitors submitted to the QI Committee failed to include reports from CSR.

During interview on 06/01/17 at 9:15 a.m., a quality improvement staff member (#3) confirmed CSR had not submitted reports to the QI Committee during the past year and CSR should participate in QI monitoring.