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Based on observation, staff interviews, and review of maintenance records between January 9 and January 10, 2018, the facility failed to construct, install and maintain the building systems to ensure life safety to patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0222 Egress Doors
K-0321 Hazardous Areas
K-0324 Cooking Facilities
K-0341 Fire Alarm System - Installation
K-0351 Sprinkler System - Installation
K-0919 Electrical Equipment

Based on observation and interview the facility failed to ensure that the building is maintained to ensure safety of patients in 5 of 8 areas surveyed (Emergency Room, Obstetrics/Surgical floor, Medical Surgical floor, Operating Room and Outpatient Therapy).

Findings include:

On 1/9/18 at 10:00 AM during observation of Obstetrics/Surgical unit dirty utility room door was unlocked and no sign on the door alerting of biohazards being stored in the room.

On 1/9/18 at 10:30 AM during observation of Outpatient Therapy area dirty utility room door was unlocked and no sign on the door alerting of biohazards being stored in the room.

On 1/9/18 at 10:50 AM during observation of Medical/Surgical unit dirty utility room door was unlocked and no sign on the door alerting of biohazards being stored in the room.

On 1/9/18 at 12:00 PM during observation of Emergency Room dirty utility room door was unlocked and no sign on the door alerting of biohazards being stored in the room.

On 1/10/18 at 7:30 AM during observation of Operating Room dirty utility room door was unlocked and no sign on the door alerting of biohazards being stored in the room.

An interview was conducted with Manager of Nursing Services C on 1/9/17 at 4:00 PM who was in agreement that doors should be locked since chemicals and biohazard wastes are stored in the dirty utility rooms.

Based on observation and interview, the facility failed to ensure chairs are maintained without tears to prevent contamination in 2 of 5 patient care areas (Obstetrics/Surgical Inpatient Unit, Surgical/Anesthesia Unit).

Findings include:

Per observation on 1/9/2017 at 10:30 AM, a cloth covered chair at the nurse's station of the obstetrics/surgical inpatient unit was torn with the interior cushion of the seat exposed.

Per observation on 1/10/2017 at 9:00 AM, a cloth covered chair in the anesthesia office within the sterile corridor of the surgical department was torn.

During an interview on 1/10/2018 at 2:10 PM, Nursing Manager C stated there are chairs that "have been at risk, we've been replacing them as we see them but sometimes they slip through."

During an interview on 1/10/2018 at 2:40 PM, Environmental Services Manager S stated there is no policy for ripped cloth on chairs, or a process to notify housekeeping staff when a chair is ripped or torn. Per S, "it's up to the unit managers to let us know the chairs need to be cleaned." When asked how the staff cleans and disinfects the torn chairs, S stated "you really can't [clean them]." Manager S went on to state "the anesthesia area is cleaned by separate EVS [environmental services] staff, I'm not sure what they do there or what their process is."

Based on observation, record review and interview, the facility failed to ensure blanket and fluid warmers maintain recommended temperatures in 1 of 4 warmers observed (Nursing Obstetrics Unit) and failed to monitor refrigerator temperatures in 1 of 1 non-food and non-pharmaceutical refrigerator observed (Breast Milk Refrigerator).

Findings include:

Review of facility policy "Blanket and Fluid Warmers" dated 6/2017 revealed "3. The temperature for warming cabinets for blankets will not exceed 130 degrees Fahrenheit (50 degrees C). 4. The temperature of warming cabinets for fluids will not exceed 104 degrees Fahrenheit (40 degrees C), and for a period no longer than 14 days."

During observation on 1/9/2018 at 10:00 AM, the blanket warmer in the clean room on the obstetrics nursing unit was set at a temperature of 150 degrees Fahrenheit. A sign on the warmer stated "Max Temperature 130 F." Observation of the temperature thermometer on the warmer revealed a temperature of approximately 135-140 degrees Fahrenheit. This finding was confirmed at the time of the observation with Obstetrics Manager T. Manager T observed the thermometer and stated in an interview "it looks like the temperature is about 138 or 140 degrees." Manager T stated the temperature was higher than the maximum temperature of 130 degrees.

In addition to blankets, the blanket warmer contained 3 bottles of sterile water. The label on the sterile water bottles contained storage recommendations for a max temperature of "50 degrees Celsius [122 degrees Fahrenheit]." The sterile water bottles were not dated. During an interview on 1/9/2018 at 10:10 AM, Manager T stated the staff does not label the water bottles and was unable to confirm how long the sterile water had been stored in the warmer.

During an observation of the nursery on 1/9/2018 at 10:15 AM, the nursery contained a refrigerator without a thermometer or any temperature logs for temperature monitoring. Manager T stated at the time of the observation "that refrigerator is used for breast milk storage.

Based on observation, staff interviews, and review of maintenance records between January 9 and January 10, 2018, the facility failed to construct, install and maintain the building systems to ensure life safety to patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0222 Egress Doors
K-0321 Hazardous Areas
K-0324 Cooking Facilities
K-0341 Fire Alarm System - Installation
K-0351 Sprinkler System - Installation
K-0919 Electrical Equipment

Based on record review and interview the facility failed to ensure 125 of 507 (nursing ) policies and procedures are being updated on an annual basis.

Findings include:

The facility policy titled "Policy and Procedure Review" dated effective 2/16 was reviewed on 01/10/18 at 8:30 AM. Under "POLICY:" number 3. "All clinical department policies will be reviewed utilizing the Policy and Procedure Review Form. This will be done annually by the Department Manager/Supervisor and Medical Staff Advisor with final review by the Policy and Procedure (P&P) Review Committee." And under "PROCEDURE:" bullet point number 2 stated "Clinical Departments will: -Have an assigned annual review date by which all policy and procedures will need to be reviewed."

The facility list of Policy and Procedures, their published date and last review date was reviewed on 1/10/18 at 8:30 AM. The following policies all had a "last review date" greater than 1 year from 1/10/18: Adverse or Allergic Reaction, Alcohol Withdrawal Assessment, American Red Cross Contact, Anti-Embolism Stockings, Apical-Radial Pulse, Body Mechanics, Central Line Guide, Code Status, Crash Cart Check, EMAR, Fall Prevention, Feeding Tube Insertion, Feeding Tube Protocol, Foley Catheter Insertion, Foot Cradles, Gait Belt, Heat Therapy-Compresses, Heimlich Chest Drain Insertion and Use, Hickman Catheter Protocol, High Alert Medication, Intake and Output, Intradermal Injection, IV Therapy, Missed Documentation of Medications, Nasogastric Irrigation, Nasogastric Suction, Neurological Assessment, Nursing Medication Administration, Ostomy Care, Ostomy Teaching Plan, Pain Management, Parental Nutritional Therapy Care and Management, Patient Controlled Analgesia , Patient Valuables, Patient Wills, Pediatric Guidelines, Perioperative Order Management, PT, OT and ST Standing Orders, Restraints Use and Monitoring, Seizure Precautions, Specimens Not Obtained Prior to Discharge, Status Change, Stock Supply Request by Other Organization, TB Skin Test, Teaching Teams, Tissue-Eye-Organ Donation, Traction, Transfer Patient to Long-Term Facility, Transfusion Management of Plasma, Transfusion Management of Platelets, Transfusion Reactions, Urinary Catheter Irrigation, Vital Signs, Weighing Patients, Nursing Services Administrative Report, Nursing Services Assignment of Care, Nursing Services Certification Program, Nursing Services Charge Nurse Cell Phone, Nursing Services Chart Review, Nursing Services Committee, Nursing Services Competence, Nursing Services Continuing Education, Nursing Services Dress Code, Nursing Services Extra Weekend Shifts, Nursing Services Goals and Objectives, Nursing Services ID Badge, Nursing Services OB Staffing, Nursing Services Patient Education, Nursing Services Preceptors, Nursing Services Professional Certification Program, Nursing Services Reporting Hotline, Nursing Services Staffing and Scheduling, Nursing Services Temporary Nursing Personnel, Nursing Services Training Checklist, Access to OB Unit, APGAR Scoring, Bathing of a Newborn, Breast Milk Collection and Handling, Cesarean Section Birth, Circumcision Care, Emergency-Precipitous Delivery, Group B Streptococcus, Isolette Filter Change, Newborn Hearing Screening, OB Charges, OB Patient Room Refrigerators, OB Vacuum Extraction, Oxygen Administration-Isolette, Post Lumbar Puncture Headache/Epidural Blood Patch, Postpartum Hemorrhage Balloon/Complete Tamponade System, Preterm Rupture of Membrane, ROM Plus, Safe Formula Prep, Sterilized Packages, TOLAC, Umbilical Cord Blood Gases, Umbilical Cord Prolapse, Whirlpool Tub Cleaning, OB Blanket Warmer Temperature Log, Perioperative Charting, Perioperative Crash Cart, Perioperative Equipment-Automated Vital Sign Monitoring, Perioperative Equipment-Bairhugger, Perioperative Equipment-Stryker Smart Pump Tourniquet, Perioperative Gown and Drape Material, Perioperative Imaging Use During a Surgical Procedure, Perioperative Incapacitation of Anesthetist, Perioperative Interoperative, Perioperative Post Anesthesia Recovery, Perioperative Protective Eyewear, Perioperative Routine Specimens for Lab, Perioperative Surgery Treatment Records, Perioperative Surgical Implant Verification, Perioperative Surgical Personnel Dress Code, Perioperative Surgical Scrub, Perioperative Surgical Site Preparation-Intraoperative, Perioperative Universal Precautions, Perioperative Ambulatory Surgery Discharge, Perioperative Washer Decontaminator-Cleaning & Descaling, Perioperative Washer Decontaminator-Indicator Monitoring, Concussion Management in ED and Follow-up Care, ED Alarms and Response Guidelines, Med Control BLS and Morgan Lens.

An interview was conducted with Director of Compliance/Quality B and Manager of Nursing Services C on 1/10/18 at 12:45 PM. Staff C stated "We know that there are some departments that are behind with their updates."

Based on record review and interview, the hospital's pharmacy service failed to ensure that medication administration error reports, written by nursing staff, were correctly and completely documented to ensure their cause could be determined, in 3 of 3 patient medication errors reviewed (Patient #'s 27, 28 & 29).

Findings include:

Record review on 1/11/18 at 10:30 AM of facility policy "Medication and Intravenous Administration Errors, revised 10/17" revealed under "1.d. An Adverse Drug Event Prevention Report form must be completed, then it should be sent to the Medication Safety Committee...".

Record review on 1/10/17 at 3:45 PM to 4:15 PM revealed the following:

1) The 8/17/17 "Adverse Drug Event Prevention Report" form written for administration of 8 mg. (milligrams) of Warfarin (blood thinner) when Patient #27 had a medical order for a 4 mg. dose on 8/16/17, revealed that two nurses administered separate 4 mg. doses at 6:11 PM and at 7:51 PM. The form revealed a "need for increased patient monitoring, but no patient harm." There was no documented evidence that any physician was notified to rule out actual harm to Patient #29, and there was no documented evidence that Patient #27 received "increased monitoring". Under "Involved Associate Response and Evaluation", the 2 questions regarding involvement of underlying systems failures and suggestions to prevent further occurrences were not completed (blank). Under "Supervisor Review of Error", there was no documentation of any signatures to show supervisory or associate (nursing staff making errors) review. Under "Medication Error Prevention Team", there was no documented evaluation of the role that underlying systems played in this error or the steps taken to prevent the re-occurrence.

2) The 7/11/17 "Adverse Drug Event Prevention Report" form written for failure to document partial drug waste of Hydromorphone on 7/10/17 at 10:10 PM for Patient #28 revealed a "capacity to cause error". Under "Involved Associate Response and Evaluation", there was no documented answer to the 2 questions regarding involvement of underlying systems failures and suggestions to prevent further occurrences. Under "Supervisor Review of Error" that evaluated "contributing factors" and "stage of process error occurrence", there was no documentation (blank). Under "Medication Error Prevention Team", there was no documented date of review or signature of the staff person that wrote "Wasted with charge RN (registered nurse), did not click "record waste now" button. Will document when next working with that RN."

3) The 8/31/17 "Adverse Drug Event Prevention Report" form written for failure to document "Fentanyl Citrate" being given to Patient #29 on 8/30/17 at 8:49 PM, revealed a "capacity to cause error". Under "Involved Associate Response and Evaluation", the "underlying systems" revealed "human factor med(ication) was administered but not documented" and under "suggestions to prevent future occurrences", stated "get RN (registered nurse) X off nights". Under "Medication Error Prevention Team", there was no documented written evaluation of the role that underlying systems played in this error or the steps taken to prevent the re-occurrence.

During interview with Nursing Services Director C on 1/10/18 at 4: 15 PM, C stated upon review of these forms "the information is missing".

Based on observation, record review and interview, the hospital failed to provide a sanitary environment for the handling and storage of clean laundry, in 2 of 8 areas containing stored linens (main laundry room and main linen storage room), failed to remove unlabeled or expired foods from 1 of 2 inpatient food areas (Surgical/Obstetric Nourishment); failed to disinfect stethoscope between patient use in 1 of 1 respiratory care observation (Patient #26); failed to perform hand hygiene per policy in 2 of 9 direct patient care observations (Patient #24, Patient #26); and failed to properly store clean patient care device in 1 of 9 patient care observations (Patient #16).

Findings include:

Record review on 1/11/18 at 10 AM of the "Centers for Disease Control (CDC)- Guidelines for Environmental Infection Control in Healthcare Facilities, 2003, last updated 2/15/2017" under "G.4." revealed "...After washing, cleaned and dried textiles, fabrics, and clothing are pressed, folded, and packaged for transport, distribution, and storage by methods that ensure their cleanliness until use."

Observations of the main laundry room and main linen storage room on 1/10/18 from 2:45 PM through 3:30 PM revealed the following:

1) The main laundry room containing the commercial washers and dryers did not have a washable ceiling. The ceiling was observed to have exposed pipes with gray dust and debris on their surfaces.

To the left of the commercial dryer, there was a cart containing partially exposed (uncovered) "clean" folded linens that were not covered from the ceiling dust debris. In the linen folding area, to the right of the commercial dryers were two carts, situated against the wall, containing partially exposed "clean" linens that were not protected from dust debris.

The linen folding area contained 2 wooden folding tables. Both table top surfaces had areas where the varnish had worn off exposing porous wood surfaces which could not be effectively disinfected. Both table top surfaces had nicks and gouges on their surfaces exposing porous wood which could not be effectively disinfected.

The linen folding area contained 1 large wooden sorting bin table on wheels. The wooden sorting bin table had a varnished surface that was "bubbled" on it's bottom surface, with areas between bubbles had exposed porous wood that could not be effectively disinfected. The sides of the wooden sorting bin table contained wooden support dowels, on it's four corners, that contained un-varnished porous wood and rusty exposed nails.

2) The main linen storage room did not have a washable ceiling. The ceiling was observed to have exposed pipes with gray dust and debris on their surfaces.

The main storage room was observed to have wooden shelves along the concrete walls, containing exposed (uncovered) "clean" linens. The top of wooden shelves were covered in a layer of gray dust debris. The wood shelf tiers were made of painted (white) wood, that had gouges and nicks on it's surfaces, exposing porous wood that could not be effectively disinfected.

During interview with Supervisor K on 1/10/2018 at 3:30 PM, Staff K verified the conditions of the dusty ceiling surfaces, the exposed linens on the carts, the conditions of the folding tables and the sorting bin, and the conditions of the storage room shelving. Staff K stated "I did not realize that these areas were not clean storage rooms".


34337


Inpatient Nourishment Area

Review of facility policy "Date Marking" (undated) revealed "All food items will be date marked. E. Any food item found without a date or with a use-by date that has passed will be discarded."

During observation of the Surgical/Obstetric inpatient nourishment room on 1/9/2018 at 9:50 AM, the patient food refrigerator contained 3 cartons of milk with a use-by date of 1/7/2018, unlabeled and undated pudding and an unlabeled, undated milk shake.

During an interview on 1/9/2018 at 10:00 AM, Dietary Aide W stated the refrigerator is stocked "every day and the PM shift is supposed to throw away outdated supplies."

Patient Care Equipment Cleaning

Review of policy "Medical Equipment Cleaning" dated 6/2017 revealed "All non-critical medical equipment is cleaned thoroughly with hospital-approved disinfectant after patient use (i.e. BP cuffs, stethoscopes...)."

On 1/10/2018 at 10:55 AM, Respiratory Therapist N entered Patient #26's room with a stethoscope and performed a lung assessment without first disinfecting the stethoscope. After Patient #26's respiratory treatment, Respiratory Therapist N used the stethoscope to assess Patient #26's lungs and exited the room with the stethoscope and without performing stethoscope disinfection.

This observation was shared with Nursing Manager C on 1/10/2018 at 3:00 PM. C stated staff are expected to "disinfect [stethoscopes] in between patients."

On 1/9/18 at 12:00 PM observed Certified Nurses Aide G perform a fingerstick blood glucose on patient on Medical/Surgical floor room 216. After cleaning glucometer with "Cavi" wipes in patient room prior to leaving the room Staff G put the cleaned glucometer into left lower pocket in scrub top.

An interview was conducted with Manager of Nursing Services C on 1/9/18 at 1:50 PM. When asked if putting a clean glucometer into a uniform pocket was an accepted practice Staff C replied "No, [Staff G] should not have put it in her pocket after it was cleaned."

Hand Hygiene

Review of facility policy "Hand Hygiene Guideline" dated 6/2016 revealed "1. Hand hygiene must be used: ...- before and after patient contact/care. ...-before and after glove use..."

During intravenous insertion on 1/10/2018 at 7:10 AM, Registered Nurse R donned gloves to palpate insertion site on Patient #24's arm. R then removed gloves and pulled a pen from pocket without performing hand hygiene, labeled the intravenous dressing and donned another pair of gloves without performing hand hygiene. Registered Nurse R then proceeded to prep Patient #24's skin for intravenous insertion.

On 1/10/2018 at 10:55 AM, Respiratory Therapist N wore gloves to assess Patient #26, removed gloves and proceeded to chart on the bedside computer without performing hand hygiene.

These observations were shared with Nursing Manager C on 1/10/2018 at 3:00 PM. C stated staff are expected to perform hand hygiene per policy.








37420

Based on observation, record review and interview, the facility failed to document criteria for safe discharge from the Operating Room to Recovery in 2 of 3 patients discharged to Phase 2 Recovery (Patient #22, Patient #24) and failed to use skin prepping agents per manufacturer recommendations in 1 of 1 surgical patient observed (Patient #24).

Findings include:

Anesthesia Skin Preparation

Review of the American Association of Nurse Anesthetists [AANA] guidelines for Dural Puncture Epidural procedure, received from the facility for review on 1/10/2018 at 4:15 PM, revealed "Neuraxial Insertion Preparation: ...The skin is prepped prior to the procedure following the facility policy and manufacturer's recommendations for the proper use of the skin prep agent, including contact and drying times. If contact time has been reached, wipe residual agent, and place the sterile drape around insertion site to prevent infection and contamination..."

On 1/10/2018 at 8:32 AM, Nurse Anesthetist Q prepped Patient #24's skin for spinal anesthesia using betadine solution. Staff Q scrubbed Patient #24's skin then immediately wiped the injection site with sterile gauze and began the injection procedure. No time elapsed to allow for antimicrobial contact time or dry time.

During an interview on 1/10/2018 at 3:15 PM, Anesthesia Manager P stated the facility does not have a policy guiding the use of skin prep agents for spinal anesthesia but follows the guidelines provided by the AANA. When asked about the manufacturer recommendations for contact and dry time of the betadine skin prep agent used, Manager P stated "It's okay for us to wipe [the excess betadine] to make sure it doesn't get into the meninges." When asked how the facility ensures prepping agents are being used to maximize antimicrobial effectiveness, P stated "we can't let it dry." When asked, Manager P did not provide manufacturer's recommendation for betadine skin prep.

Anesthesia Discharge to Recovery

Review of facility policy "Anesthesia Phase 1 and Phase 2 Recovery" dated 11/2017 revealed "A person requiring anesthesia services will be evaluated after the anesthetic is completed in the OR [Operating Room] as to whether the patient will be taken to a Phase 1 recovery area or a Phase 2 unit for recovery. This determination will be made by the anesthetist..."

Review of facility policy "Phase II Recovery P & P" dated 2/2017 revealed "1. Patient will be accepted onto the unit from surgery following Phase 1 Recovery or directly from OR if the patient has met the Modified Aldrete Score as directed by anesthesia."

During an interview on 1/10/2018 at 9:50 AM, Surgical Services Manager O stated that surgical patients that receive general anesthesia are "usually transferred to the PACU" (post-anesthesia care unit) and spinal anesthesia patients "are transferred to the inpatient medical-surgical unit if they are an inpatient" and surgical outpatients are transferred to the ambulatory care area for recovery. Per Staff O, the PACU was considered Phase 1 recovery and inpatient/ambulatory care was considered Phase 2 recovery.

During an interview on 1/10/2018 at 10:45 AM, Anesthesia Manager P stated "it's okay for patient's to be discharged to the med-surg floor with an aldrete score of 9 or more." Per Staff P, "I think that's in our standing orders."

Per medical record review, Patient #22 underwent spinal anesthesia for a right total hip arthroplasty on 12/18/2017. Patient #22's anesthesia stop time was documented as 10:38 AM and out of surgical room time documented as 10:47 AM. There was no documentation of an aldrete score, assessment or note prior to discharge to Phase 2 recovery. Patient #22 was discharged from the OR directly to the inpatient medical-surgical unit. Patient #22's first post-operative aldrete score was documented on the medical-surgical unit as "8" out of 10 at 11:30 AM, 44 minutes after discharge from the OR.

Per medical record review, Patient #24 underwent spinal anesthesia for a left knee arthroscopy on 1/10/2018. Patient #24's anesthesia stop time was documented as 9:35 AM and out of surgical room time documented as 9:29 AM. There was no documentation of an aldrete score, assessment or note to discharge to Phase 2 recovery. Patient #24 was discharged from the OR directly to the ambulatory care unit. Patient #24's first post-operative aldrete score was documented in the ambulatory care unit as "9" out of 10 at 9:47 AM, 18 minutes after discharge from the OR.

During an interview on 1/10/2018 at 3:00 PM, Surgical Services Manager O stated "the CRNA [Certified Registered Nurse Anesthetist] look at the patient and review the aldrete score [prior to discharge from the OR], but don't document it."