HospitalInspections.org

Based on observation, review of personnel files, policies, log books and medical records and staff interview, it was determined the governing body failed to ensure policies were developed and implemented to promote the delivery of quality health care. This directly impacted 3 of 7 patients (#9, #12, and #13) whose surgical records were reviewed and 2 of 2 patients (#15 and #18) whose care was observed. This failure had the potential to result in a staff member performing tasks outside of the scope of practice, emergency equipment not being monitored for patient safety, and patients and staff exposed to potential cross contamination of infections. Findings include:

1. The personnel file was reviewed for the STFA. There was only one employee with this title. His personnel file contained a job description titled "Operating Room Technician." It did not include the duties the individual was approved to perform when serving as first assist to the surgeon. The file did not contain evidence the STFA had been privileged or credentialed to assist the surgeon.

The credentialing file of a PA, who was also noted to be a first assist, was reviewed. His file contained documentation the PA was credentialed and privileged to perform specific tasks during orthopedic surgeries. His file contained documentation of supervisory oversight by a board certified orthopedic surgeon. Similar information was not found for the STFA.

Patient #9 was a 55 year old male admitted to the facility on 1/07/13 for removal of lesions on his right temple and left forearm. His medical record contained an "INTRAOPERATIVE NURSING RECORD" form that indicated the surgeon was assisted by the STFA.

The Surgical Services Nurse Manager was interviewed on 3/25/13 at 12:50 PM. He explained the STFA's role during surgery included assisting the surgeon with positioning the patient or instruments, dressing the surgery site at the completion of surgery, and possibly suturing the incision if the surgeon requested assistance. He confirmed the exact scope of practice for the STFA was not clear. The Surgical Services Nurse Manager confirmed the STFA was not privileged or credentialed to perform those activities during surgery. He stated that he was not aware of the issue being addressed by the Medical Staff.

The governing body failed to ensure processes were developed and implemented for defining the duties and oversight of the STFA.

2. According to the "Adult and Pediatric Crash Cart-Check" policy, dated 4/08/11, the crash cart in "PACU will be checked on days when there are patients being cared for" on the unit. Among other items, nursing staff were to ensure the crash cart seal was intact, the defibrillator was plugged into the wall and the batteries were charged, and the defibrillator passed the "charge test."

The log for documenting crash cart assessments (such as checking to ensure machinery worked and supplies were current) was reviewed from 1/02/13 through 3/14/13. This log was compared to the OR log to ensure that the crash cart was checked each day that surgeries were performed. During the month of February it was noted that on 6 of 20 surgery days, 2/06/13, 2/13/13, 2/14/13, 2/18/13, 2/20/13, and 2/25/13, there was no documentation the crash cart had been checked.

Medical records for 4 patients who had surgery in February of 2013 were reviewed. Patient #12 was cared for in PACU on 2/14/13 and Patient #13 was cared for in PACU on 2/20/13. Patient #12 and #13 were cared for in the PACU on days when the crash cart was not checked in accordance with the CAH's policy.

The Surgical Services Nurse Manager was interviewed on 3/25/13 at 12:50 PM. He stated he was not aware that the crash cart had not been assessed on each day when surgical procedures were performed. He confirmed staff were expected to complete this task on days when surgeries were performed and was not sure why this was not accomplished.

The governing body failed to ensure the CAH's policy was consistently implemented to ensure the resuscitation equipment in the PACU was checked daily.

3. The CAH's "Handwashing Policy," dated 7/01/05 and revised 9/30/06, contained instructions for hand hygiene using soap and water and alcohol based hand rub. According to the policy, "If hands are not visibly soiled, or after having contact with inanimate objects or patient's intact skin, use an alcohol-based hand rub for routinely decontaminating hands. Decontaminate hands by handwashing or alcohol-based rub: ...before and after each patient contact, after removing gloves or protective equipment."

According to the CDC "Guidelines for Hand Hygiene in Health-Care Settings," dated 10/25/02, "Personnel should be informed that gloves do not provide complete protection against hand contamination. Bacterial flora colonizing patients may be recovered from the hands of [equal to or greater than] 30% of HCWs [Health Care Workers] who wear gloves during patient contact. Further, wearing gloves does not provide complete protection against acquisition of infections caused by hepatitis B virus and herpes simplex virus. In such instances, pathogens presumably gain access to the caregiver's hands via small defects in gloves or by contamination of the hands during glove removal."

The "Textbook of Basic Nursing, 9e [edition]," published by Lippincott, Williams, & Wilkins in 2008, explained the process of administering medication using IV ports. Instructions include wiping the port with alcohol wipes prior to access for medication administration.

Infection control policies and standards of practice were not followed. Examples include:

a. Patient #15 was a 36 year old female admitted to the facility on 3/20/13 for surgery on her right shoulder. Her care was observed from 9:10 AM until 11:45 AM. Infection control breaches were observed as follows:

- At 9:45 AM the Pre-operative RN placed an IV in Patient #15's right hand. He placed the tourniquet and tape he had used back on the portable tray that held IV start supplies without wiping them down. The tray was placed on a cart in the hallway.

- At 9:59 AM, the CRNA was observed to administer medication to Patient #15 using the IV on two occasions without wiping the port with alcohol prior to administration. In addition, hand hygiene was not performed prior to the medication administration.

- At 10:00 AM, the CRNA was observed to pick up a 30 ml syringe that had fallen to the floor. The syringe was to be used to do a shoulder nerve block. The syringe was placed back on the bedside table and used during the block procedure.

- At 10:02 AM the CRNA picked up a trash can and relocated it closer to his work area. Hand hygiene was not performed after handling the trash can.

- In the OR, at 11:21 AM, the CRNA was observed to lift up the IV port of Patient #15's IV tubing that was resting on the operating table and administer medication. The port was not wiped with alcohol prior to administration.

- At 11:28 AM a sensor on Patient #15's forehead was changed. The cable that attached to the sensor fell to the floor. The CRNA picked up the cable and connected the cable to the sensor without wiping the cable with disinfectant, and without changing his gloves.

- At 11:41 AM, the Circulating RN, who had been assisting with patient positioning while wearing gloves, was observed to apply sterile gloves over the gloves that were already worn. She then proceeded to apply the skin prep to Patient #15's arm and shoulder prior to surgery.

- At 11:43 AM, the Surgical Services Nurse Manager who was assisting in the OR, was observed positioning the patient and cleaning up the OR environment. He removed the gloves he was wearing and donned sterile gloves to assist the Circulating RN in completing the skin prep. Hand hygiene was not observed after the removal of one pair of gloves and prior to donning the sterile gloves.

- At 11:47 AM, the Circulating RN was observed to remove her sterile gloves and dispose of them. She then proceeded to assist with equipment set up, including adjusting cords and pedals on the floor. Following this she was observed to document information in the computer and then exited the OR to get additional supplies. Hand hygiene was not performed after removing gloves or after touching the floor.

b. Patient #18 was a 65 year old male admitted to the ED 3/19/13 with abdominal pain. His care was observed by two surveyors from 1:25 PM to 2:00 PM. Infection control breaches were noted as follows:

- At 1:30 PM the RN was observed to start Patient #18's IV. Once the IV was in place, she removed the gloves she was wearing, reached into a supply cabinet to obtain a syringe pre-filled with normal saline, and administered a portion of the saline into the IV. She was not observed to complete hand hygiene after removing gloves and before moving to the next task.

- At 1:55 PM the RN left Patient #18's room after placing a nasal cannula on Patient #18 and administering medication. She walked across the hall to a locked medication room. She operated the button lock on the door and went into the room. The RN unlocked a medication cabinet, placed a syringe into the cabinet, locked the cabinet and returned to Patient #18's room. Once in the room she handled the IV tubing and set up an IV pump for the infusion of fluids then charted on the computer. No hand hygiene was performed during that time.

The Surgical Services Nurse Manager, who was also the Infection Control Officer, was interviewed on 3/21/13 at 3:30 PM. He confirmed that IV ports should be wiped with alcohol prior to access for medication administration. He confirmed it was his expectation that hand hygiene be completed in accordance with facility policy and standards of practice. He confirmed that picking up items off of the floor and using them for patient care was not appropriate infection prevention.

The governing body failed to ensure its infection control policy was consistently implemented to promote the delivery of quality health care.

Based on record review, review of facility policies and interview, it was determined the CAH failed to ensure staff administered medications to patients in accordance with facility policies. Failure to follow policy and standards directly impacted 1 of 1 ED patients (#4), who received intravenous antibiotics and whose records were reviewed. The failure to follow facility policies and standards of practice had the potential to result in adverse patient outcome. Findings include:

1. Patient #4 was a 52 year old male admitted to the ED on 3/17/13 for care related to diabetic foot ulcers. Patient #4's "Emergency Department Record", dated 3/17/13, included diagnoses of coronary atherosclerosis, COPD, and a history of kidney failure and documented an IV was started in Patient #4's left forearm at 3:16 PM. The RN who cared for Patient #4 documented the administration of Vancomycin 1.5 gm in 300 ml Normal Saline from 4:28 PM until 5:22 PM, an administration time of 54 minutes. In addition, Meropenem 2 gm in 100 ml of Normal Saline was administered from 4:28 until 5:13 PM. This indicated both medications were infusing simultaneously through the same IV. Patient #4 was discharged to home at 5:35, which was 13 minutes after the antibiotics were completed.

According to "Nursing 2013 DRUG HANDBOOK," Vancomycin in dosage greater than 1 gram must be infused over 90 minutes. The handbook advised caution for patients with impaired kidney function. The drug handbook listed Meropenem as incompatible with other intravenous drugs and should be used with caution for patients with impaired renal function which could also cause seizures or adverse CNS reactions. Patient #4's "Emergency Department Record", dated 3/17/13, documented Patient #4 had a history of kidney failure.

The facility's policy "Medication Administration Policy and Procedure," dated 9/15/99 and reviewed 3/24/11, included "The nurse will monitor the patient's response to the first dose of a new medication."

During an interview on 3/21/13 beginning at 8:55 AM, the Pharmacy Director stated the recommendation for Vancomycin and Meropenem would be to administer first one then the other, and not both together. He stated the first dose of an antibiotic the patient should be monitored for at least 20 minutes after infusion was complete. He was unable to provide a policy related to patient monitoring after antibiotics.

The CAH failed to ensure that the policy for administration of medications was followed.