HospitalInspections.org

Based on credential file review, document review, and interview, for 6 of 6 medical/midlevel providers, the governing body did not ensure that peer review was conducted in order that patients receive care of acceptable quality (Staff #38-43).

Findings include:

Review on 6/23/15 and 6/24/15 of credential files for Staff #38-43 (physicians and mid-level providers) revealed no evidence that peer review was routinely completed.

Review of the Quality Assurance and Risk Management Plan (dated 3/31/15) revealed that on page 5, it stated: "Note: See Medical Staff Bylaws for references for peer review process."

Review on 6/23/15 of the Bylaws of the Medical Staff (dated 3/30/10) revealed the information: "9.4 Function of Departments 9.4-1 General Duties (d.) Each Department shall conduct peer review activities and perform assurance reviews. (e.) Each Department may conduct its peer review and quality assurance activities by a committee and, if so, such committee shall meet as often as necessary to fulfill the function."

Interview on 6/23/15 at 1:00PM with Staff #4 (Assistant Administrator/Quality Assurance) revealed that routine peer review is not completed for all providers, and providers are only reviewed for meeting the standard of care for "incidents", "near misses" and readmissions.

Based on document review and interview, the hospital's Governing Body does not review and determine what number of distinct improvement projects are going to be conducted annually.

Findings include:

Review on 6/24/15 and 6/25/15 of medical staff meeting minutes, board meeting minutes and quality committee meeting minutes for the past 8 months revealed no presentation of consensus of any specific quality projects for any set time span.

This finding was verified on 6/25/15 with Staff #4 (Assistant Administrator/Quality Assurance), who acknowledged that it was not a practice of the Governing Body to review and determine the number of distinct improvement projects to be conducted annually.

Based on observation and interview, the hospital does not maintain all components of the medical gas system, the nurse call system, or all floors in the facility potentially affecting delivery of safe patient care.

Findings include:

During tour of the Newfane Division site on 6/23/15, it was observed that the oxygen LED digital lights on the medical gas electronic panel (for oxygen and vacuum) did not function. The vacuum reading indicated -33.1 PSI (pounds per square inch), which would be extremely unlikely for a vacuum system, as it would not able to be achieved in a medical vacuum system. The analog gauge for vacuum indicated -24.0 PSI, which is typical of a correctly functioning vacuum system. Staff #7 (Maintenance) verified the readings at that time, and stated that the LED reading for vacuum PSI would not be likely.

During tour of the Newfane Division site on 6/23/15, it was observed in the Radiology suite that when the nurse call cord located in the patient restroom was pulled, there was no audible alarm. The control panel that announces the nurse call was in a room that, due to reconfiguration, was no longer staffed. This finding was verified with Staff #7 at the time of the observation.

During the tour of the Lockport Division site on 6/24/15, it was observed in the operating suite that at the threshold to operating room (OR) #1, from the corridor, there was adhesive residue approximately one-half inch wide along the length of the door opening. This created a surface in the sterile core that was not easily cleanable, potentially causing infection control issues. This finding was verified with Staff #7 at the time of the observation.

During tour of the Lockport Division site on 6/25/15, it was observed that at the threshold for the door for the endoscope storage room and endoscope cleaning room, there was area of floor, approximately 2 inches by 12 inches in size, in which the floor tiles were missing. This finding was verified with Staff #22 (OR Director) at the time of the observation.

Based on observation, document review and interview, the hospital failed to protect patients from potential infection risk, as evidenced by identification of lapses in generally acceptable infection control practices, including lack of active surveillance processes related to infection control program, improper surgical attire, lack of staff use of protective equipment to prevent disease transmission, and improper handling of biohazard materials.

See findings in Tags #A748, A749 and A756.

Based on interview, the hospital does not have infection control policies related to construction projects.

Findings include:

Interview on 6/24/15 at 2:00PM with Staff #1 (Infection Control Officer) revealed that the hospital has no infection control policies related to construction, renovation, maintenance, demolition and repair, including the requirement for an infection control risk assessment.

Based on observation, document review and interview, the hospital has not developed an effective infection control system: 1) the hospital does not ensure that personnel adhere to policy regarding surgical attire and infection control policy and procedures; 2) the hospital does not maintain cleaning of all environmental surfaces and textiles; 3) the hospital does not ensure appropriate use of equipment to ensure control of infectious agents; and 4) the infection control officer does not obtain data from all potential surgical site infections sources.

Findings pertinent to (1) above include:

Review of the Infection Control Manual policy "Surgical Attire" (revised 5/2015) revealed: "POLICY This policy identifies appropriate surgical attire for all personnel entering the semi-restricted and restricted areas of the Operating Room. . . PROCEDURE . . . 5. All individuals must wear a disposable mask when entering a restricted area and/or opening sterile supplies. . . 6. Non-scrubbed personnel can (w)ear jewelry if it is contained or confined within the surgical attire. . . Scrubbed personnel cannot wear jewelry include: necklaces, watches, rings and bracelets. If earrings are worn, they must be small and covered. If earrings are not covered, they must be removed."

Observation at the Lockport Division site on 6/24/15 at 1:38PM in the cystoscopy room, which is located in the restricted area of the surgical suite, revealed Staff #26 (Director of Anesthesia) performed an epidural procedure on Patient #18 while not utilizing a mask. Staff #26 was wearing a watch and bracelet that were not covered by scrub attire. No handwashing was noted at the completion of the procedure. This observation was witnessed by Staff #1 (Infection Control Officer), who stated that the staff member should be wearing a mask and not wearing jewelry.

Observation at the Lockport Division site on 6/24/15 at 4:15PM of operating room (OR) #2 revealed Staff #29 (OR Registered Nurse) and Staff #30 (Surgical Technician) setting up the sterile field for surgery. Both staff members were noted to have bouffant head coverings tucked behind their ears with earrings exposed and over the sterile field. This observation was also witnessed by Staff #1, who confirmed it was not appropriate surgical attire.

Review on 6/23/15 of the Infection Control Manual (last revised 5/2015) revealed: "SECTION III INFECTION CONTROL MEASURES, SECTION 3.1 EPIDEMIOLOGY OF INFECTION, 3. CONTACT PRECAUTIONS/ISOLATION, Specifications For Contact Precautions/Isolation . . . c) Gowns and gloves must be worn when entering the patient room. . . e) Handwashing before and after each patient contact. . . Diseases/Symptoms Requiring Contact Precautions/Isolation . . . b) Staphylococcus aureus resistant to Methicillin/Nafcillin/Oxacillin (MRSA)."

Observation at the Lockport Division site on 6/23/15 at 2:55PM in the intensive care unit revealed a placard on the door for Patient #27 stating "Transmissible Microorganism". (Investigation revealed the patient had MRSA - Methicillin-resistant Staphylococcus aureus). Staff #17 (Patient Care Technician) entered the room without donning a gown to empty the patient's urinal. In addition, Staff #17 did not perform hand hygiene upon exiting the patient's room.

These observations were witnessed by Staff #1 (Infection Control Officer) at the time of the tours. Staff #1 also stated that staff are encouraged to wear gowns when handling any body fluids.


Findings pertinent to (2) above include:

During tour at the Lockport Division site on 6/25/15 at 10:00AM of the endoscopy suite, it was revealed that towels placed on the bottom of the endoscope storage rack were not changed at intervals frequent enough to prevent microbial growth and maintain cleanliness. It was observed that on one of the towels there were many small white particles. The towels had damp spots on them from the processed scopes.

During interview on 6/25/15 at the time of observation, Staff #22 (OR Director) verified this finding and stated that the towels were changed weekly.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 9/30/11.


Findings pertinent to (3) above include:

Review on 6/23/15 of policy "SHARPS: DISPOSABLE OF" (revised 5/21/15) revealed: "4. Disposal and Destruction of Syringes, Needles and Sharps: D. All sharps containers should either be secured in a wall enclosure, wall bracket, countertop holder or floor cart to ensure stability., E. Sharps containers must be sealed for removal and disposal when 3/4 filled."

Observation at the Lockport Division site during a walking tour of all medical units on 6/22/15 from 10:00AM through 11:00AM revealed all "Computers on Wheels (CoW's)" had unsecured sharps containers located in the back recessed area of the apparatus.

Explanation provided by Staff #4 (Assistant Administrator/Quality Assurance) and Staff #5 (Nurse Manager 2N/2C) during the tour was that the containers were not for use of sharps disposal and were used to dispose of biohazard medication per pharmacy recommendation.

Inspection of sharps containers during the tour revealed that more than 10 of the containers showed contents of visible sharps, with the containers filled beyond the fill capacity line and with sharps protruding out of the opening at the top of the containers.


Findings pertinent to (4) above include:

Review on 6/24/15 of "surgical site infection" data provided by Staff #1 revealed the data is derived from only culture reports performed by the Eastern Niagara Health System. No attempt is made to actively collect other data for other identifiable surgical site infections for cases that are not cultured, or for cases in which the cultures are performed elsewhere outside of the hospital's lab system.

This finding was verified by Staff #1 on 6/24/15.

Based on interview, the infection control officer does not ensure staff are in compliance with job specific tasks related to infection prevention policies and procedures, to ensure staff use safe techniques to protect patients from infection risks.

Findings include:

During interview on 6/24/15, Staff #1 (Infection Control Officer) stated that no staff member has performed any significant audits assessing staff competence related to infection prevention (such as handwashing, aseptic technique or invasive equipment audits).

Based on observation, document review and interview, anesthesia services has not implemented safety practices and security of medication in the operating suites, leading to potential for loss of medications that include controlled substances.

Findings include:

Review on 6/24/15 at 4:00PM of anesthesia policy "Handling Medication" (last reviewed 3/2009) revealed: " POLICY It will be the policy of the anesthesia department to adhere to all drug control regulations in the operating room area . . . Controlled drugs will be handled in compliance with state and federal regulations. . . PROCEDURE 1.) All drugs must be labeled with the concentration written on the syringe."

During tour at the Lockport Division site of operating room (OR) #1 on 6/24/15 at 10:55AM, observation revealed an open, unlocked and unattended anesthesia cart. Lying on top of the cart were 3 full unlabeled syringes that were stuck through the rubber stopper on the medication vials of Propofol (hypnotic/amnestic agent used for induction/maintenance of anesthesia), 2% Lidocaine (local anesthetic) and Rocuronium (neuromuscular blocker used with general anesthesia to induce temporary paralysis). Unlicensed Staff #28 (Housekeeping Attendant) was in the room cleaning it in preparation for the next surgical case. Staff #23 (Certified Registered Nurse Anesthetist) entered the OR; Staff #23 explained that the medication was for the next surgical case and he was just on his way to lock up the medication after being gone for just a minute. Contained in the unlocked and previously unattended anesthesia cart were the following medications:

- Succinylcholine (used to induce muscle relaxation and short-term paralysis)
- Amidate (short-acting anesthetic agent used for induction of general anesthesia and
sedation for short procedures)
- Ketorolac (management of moderately severe acute pain)
- Propofol
- Lidocaine
- Naloxone
- Xylocaine
- Glycopyrrolate
- Sterile water
- Epinephrine
- Cefazolin
- Sodium Chloride
- Pitressin
- Heparin
- Pitocin
- Ephedrine Sulfate
- Ondansetron
- Dexamethasone Sodium Phosphate
- Diphenhydramine
- Metoclopramide
- Flumazenil
- Phenylephrine Hydrochloride
- Solumedrol
This observation was witnessed by Staff #1 (Infection Control Officer) at the time of tour. Staff #1 verified that all anesthesia carts are to be locked when unattended.

During tour of OR #3 on 6/24/15 at 1:10PM, observation revealed an open, unlocked and unattended anesthesia cart that contained the same 23 medications listed above in the previous observation. This observation was witnessed at the time of tour by Staff #1 who again confirmed that all anesthesia carts must be locked when unattended.