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Based on observation, record review, and staff interview, the facility failed to ensure the electrical emergency call system alarmed at the Therapy Desk from two dressing/bathroom rooms in the Therapy suite.


Findings include:


Observations on 1/15/16 at 2:00 p.m., with Director of Therapy L, revealed the emergency call system in both dressing/bathrooms by the therapy pool did not sound or light up at the Therapy desk.


Interview at this time with Director of Therapy L, she said she did not know they were not working. She tried a second time to activate the systems, but they did not work at the desk.


During the exit conference on 1/17/16 at 3:15 p.m., CEO A asked Director of Maintenance D if the Therapy emergency call lights were working. Director of Maintenance D said he was still working on them.

Based on observation, record review, and staff interview, the facility failed to ensure there was proper ventilation in all patient care areas as evidenced by: The negative isolation room did not function to provide negative pressure as required.


Findings include:


Isolation Room


Interview on 1/15/16 at 9:30 a.m. with CNO B, during the initial tour, she was asked if she had isolation rooms. She said they had a negative pressure isolation room with an anti-room for air borne infections. She said there was a red ball that would be sucked into the room when the door was closed to show negative pressure.


Observation on 1/17/16 at 9:20 a.m. with CNO B of the negative pressure isolation room revealed the red ball was in the tube in the hallway. She said the door had to be closed. On closing the door, the red ball did not move, but stayed in the same position. She said the side door from the anti-room may be open. She checked and the door was closed. She also checked to see if there was a switch that needed to be turned on. There was no switch. She opened and closed the room door again, but the ball did not move. She said she was not sure why it was not working, but would check with maintenance. By the time of exit on 1/17/16 at 3:45 p.m., nothing was brought to show how come the negative pressure room was not working.


Interview on 1/17/16 at 11:20 a.m. with Maintenance Director D, he said he had no plan for checking the negative pressure isolation room.


Record review of the facility's P&P (policy and procedure) for Negative Pressure Isolation Room dated 4/2012 and revised on 8/2015 revealed the following: "III. Procedure/Intervention(s):


OPERATION:


1. The airflow ball is located on the upper left side of the patient room door.
2. The red ball rolls in the direction of air flow.
3. The tube tilts down towards the outside of the room for failsafe mode and checking.
4. To check for correct operation open the patient room door and the red ball should go towards the outside of the room.
5. With normal isolation airflow the red ball should go into the room when the door is closed ... "

Based on observation, record review, and staff interview, the critical access hospital (CAH) failed to have a policy and procedure for the storage of drugs and biologicals in accordance with accepted professional principles and failed to date a multi-dose vial when it was opened. (Refer to C-0276 for further details). The CAH failed to have a system in place for preventing, identifying, reporting and investigating infection control issues. (Refer to C-0278 for further details).


The cumulative effect of the hospital's failure to ensure accepted professional principles were followed for storage of drugs and use of multi-dose vials and to have a system in place for preventing, identifying, reporting, and investigating infections placed all patients at risk for receiving ineffective medications and acquiring an infection.

Based on observation, record review and staff interview, the facility failed to ensure rules were available for the storage of drugs and biologicals in a drug storage area in accordance with accepted professional principles and that a multi-dose vial was dated when opened.


Findings include:


Observation on 1/15/16 at 3:30 p.m. of the Medication Room by the nurses' station with CNO B revealed a bottle of Lantus (long acting) insulin was opened, but not dated in the refrigerator. In a cabinet there was a jar of topical balm on the shelf next to oral and inhalation medications. On another shelf there was a bottle of nail polish next to oral medications Gavilax (a laxative), Milk of Magnesia (a laxative), and topical Nitro Bid (treats chest pain).


Interview at this time with CNO B, she said she had no idea why nail polish would be in the same cabinet with medications. She said the topicals needed to be on a separate shelf from the oral medications.


Record review of the facility's P&P for Storage of Medications revised on March 2015 lacked any guidance about how to store topical, oral, ear, eye or IV (intravenous)medications separately.


According to "The Handbook on Storing & Securing Medications" Second Edition Edited by Thomas E. Kirschling, Pharm.D., M.S. Joint Commission Resources
Forward An Important Obligation Page 7: "Assuring the safe storage and security of medications is a fundamental pharmaceutical care process that serves as a foundation for any hospital pharmacy safety program. Examples of proper storage and security of medications include...that external products are stored separately from medications administered internally;..."


Record review of the facility's Policy and Procedure (P&P) Medication administration form multi dose vials revised on December 2015 revealed the following:
" III. Procedure/Intervention(s): ...The healthcare provider shall write the expiration date on the vial, when it is opened ...For multiple dose vials, the expiration will occur 28 days after the vial has been opened/punctured, ... "

Based on observation, record review, and staff interview, the facility failed to ensure there was a system for preventing, identifying, reporting and investigating infections in the facility as evidenced by:

- Multiple areas in the facility had thick layers of dust and grime., ED (Emergency Department) Kitchen, Therapy Department and Laboratory.

- Equipment used in the OR (Operating Room) had rust and peeling paint.

- Central Processing did not follow manufacturer's recommendations when using the enzymatic cleaner (used to remove foreign material (organic material, tissue, blood) from instruments. Thorough cleaning is required before high-level disinfection and sterilization can occur.) and presoak.

- Non-disposable laryngoscope blades (metal instruments used to help place a breathing tube) were not disinfected between patient use.

- Temperature and Humidity levels were out of range without facility staff following their policy and procedures for identifying and fixing the problem.

- Air flow rates were not being monitored in the OR Suite


The facility's failure to have a system in place for preventing, identifying, reporting and investigating infections placed all patients receiving services at risk for acquiring an infection.


Findings include:


Environment

Observations on 1/15/16 at 9:30 a.m., during the initial tour, with CNO (Chief Nursing Officer B revealed the following:

1. The patients' snack area ice machine had a build-up of scale and grime in the overflow tray and in the two clear plastic dispensing cones.


Record review of the facility's Policy & Procedure (P&P) for Nutrition Room dated 7/16/15 revealed the following: " III. Procedure/Intervention(s): Clean every day: ...
c. Wipe front of ice machine and coffee maker ... " The P&P lacked guidance about cleaning the clear plastic dispensing cones.


Interview with CNO B at this time revealed she did not know who was responsible for ensuring the ice machine was cleaned routinely.



2. The stretcher mattress in ER (Emergency Room) 1 had tears in the plastic covering. There was a layer of dust accumulation on the shelf under the stretcher.


Interview with CNO B revealed she had a request to replace the mattress and it was on order. She said the nurses clean the touch areas after every patient and housekeeping should clean under the stretchers daily.


3. ER 1 had a layer of dust on the monitor and support arm, on the legs on the COW (Computer on Wheels) and on the arm of the over bed light.


4. ER 2 had a thick layer of dust on top of the emesis bag dispenser and on the COW legs.


5. The portable x-ray machine in the hall by ED (Emergency Department) had a thick layer of dust.


Record review of the facility's P&P (policy and procedure) for Emergency Rooms Housekeeping revised on 9/2012 revealed ER tables were to be wiped daily. The P&P lacked any guidance about wiping high and low places such as monitors and equipment legs.



Kitchen

Observations on 1/14/16 at 1:20 p.m. of the facility kitchen with Dietary Manager (DM) J revealed the following:

1. The ice machine had some whitish scale buildup at the lip of the opening under the door. There was a pinkish substance on the white shield inside the ice machine where the ice cubes collected. Further observation revealed a layer of dust on the air vents on the side of the machine.


Interview at this time with DM J, she said the machine was wiped down weekly.


2. The shelf under the steamer had a thick accumulation of dust and grime to sight and touch.


3. The griddle had a thick accumulation of black/brown burnt on grease and grime around the edges.


4. The shelf over the stove and griddle had a layer of grease to touch.


5. A three tiered cart next to the stove had a thick accumulation of dirt and grime by sight and touch that covered the shelves and the foil and plastic wrap dispensers.


6. A shelf under one of the prep tables had an accumulation of grease and grime to touch.


7. The covered meat slicer had food particles on it and the shelf it was on had an accumulation of grease and food particles to touch and sight.


8. The "Big Dipper" grease catcher on the floor under the slicer and the one under the back prep sink had a thick accumulation of black/brown grime in the grooves and crevices.


Interview at this time with DM J, she said maintenance took care of the grease catchers and told them not to do anything with them.


9. The back prep table drawers had accumulation of grime on the edges and inside the drawers. Utensils were being stored in cardboard boxes.


Interview at this time with DM J, she asked if that was okay to use the cardboard boxes. When she was asked if she could wash and clean them, she said she understood.


10. There was a wire corner rack by the back prep sink with a thick accumulation of food particles on the floor. There was a thick accumulation of grime under the back side prep table.


Interview at this time with DM J, she said when she came to the facility she made up cleaning schedules.


Record review of the facility's Cleaning Schedule for Sunday, December 27, 2015 to Friday, January 15, 2016 revealed each staff person had a specific job to do each day from cleaning work tables, shelves, small appliances, refrigerators, freezers and ovens. There was nothing noted about cleaning drawers, carts, floors, griddle or the grease catcher.



Record review of the facility's P&Ps for Dietary revealed the following:


1. Cleaning of All Cupboards, Drawers and Shelves dated 5/4/05 and revised on 1/21/13. The policy stated the areas would be cleaned weekly.


2. Cleaning Carts, Small Utility and Large Carts dated 12/14/09 and revised on 1/21/13. The policy stated the carts would be cleaned daily.


3. Stainless Steel Shelving, Counters & Drawers date 3/24/09. The policy stated the areas were to be cleaned daily.


4. Cleaning Floors dated 6/2005 and revised on 1/21/13. The Procedure was to dry mop floors to remove loose soils and then Housekeeping would wash the floor daily in the morning.


5. Kitchen Grease Removal---Big Dipper dated 10/23/13. The policy stated the daily maintenance was to empty the clear plastic/oil container. The internal strainer basket was to be emptied and washed inside and out. The weekly maintenance was to check the collection trough and wiper blades for any solids build-up. The blades were to be wiped off and the timer was to be checked. The policy lacked any guidance about cleaning the outside of the units.



Physical and Occupational Therapy Department

Observations on 1/1516 at 2:00 p.m. with Therapy Director L revealed the following:


1. A three tiered cart with a thick accumulation of dust on the bottom shelf.


2. A bed in a patient treatment room had a layer of dust under the bed.


3. In curtain cubicle 4 there was a three tiered cart with a layer of dust on the 2nd and 3rd shelves.


4. In curtain cubicle 3 there was a three tiered cart with a layer of dust on the 2nd and 3rd shelf and under the bed on the frame.


5. In curtain cubicle 2 there was a layer of dust under the bed on the frame.


6. A blue cart by the desk had a unit to soak splinting material and there was a thick layer of dust on both shelves.


7. There was a silver metal three tiered cart with a thick layer of dust on the 3rd shelf.


8. The top of the refrigerator had a thick layer of dust.


Interview at this time with Therapy Director L, she said housekeeping was responsible for doing the general cleaning in the unit. She said she guessed the modality carts should be the concern of the staff.



Record review of the facility's P&P for Physical and Occupational Therapy housekeeping revealed no guidance about cleaning equipment carts or beds.


Laboratory

Observations on 1/15/16 at 2:30 p.m. with Lab Director M revealed the following:

1. Two phlebotomist's carts with accumulation of dust.

2. Inside the blood bank refrigerator was a thick accumulation of dust and debris.

3. The top of the refrigerator had a thick layer of dust.


Interview at this time with Lab Director M, she said housekeeping was responsible for cleaning the lab. Approximately 30 minutes later, Lab Director M said she was incorrect saying it was housekeeping's job to clean the area, but was the lab staff's job to clean the area.


Record review of the facility's P&P for Laboratory/Lab Office housekeeping revised on 9/2010 lacked guidance about cleaning the blood bank refrigerator or carts. The top of the refrigerator was to be cleaned monthly.


Surgical Department


Observations on 1/15/16 at 10:20 a.m. in the Surgery Suite with CNO B and LPN (Licensed Practical Nurse) I revealed the following:

1. Two white rolling metal linen hampers had chipped paint with rust on the legs and wheels.

2. In the main operating room a malignant hyperthermia ( a rare life-threatening complication of general anesthesia) sign was taped to the wall with plastic tape.

3. There was pitting rust on the blue electric cautery ( machine use to help control bleeding during a surgery) stand and shelf.

4. There was a leak under the sink in the procedure room with a discolored liquid in a plastic tray and a dried brownish liquid stain underneath the tray.



Central Processing


Observation on 1/15/16 at 9:30 a.m. with CNO B of the ED trauma room revealed multiple zip lock bags of different sized non-disposable laryngoscope blades (metal instrument used to assist in placement of a breathing tube) in the emergency cart.


Interview at this time with CNO B, she said she did not know how the blades were processed after patient use. She said LPN I took care of processing instruments.


Interview on 1/15/16 at 3:15 p.m. with LPN I, she said she only cleaned the non-disposable laryngoscope blades. She said she did not do any kind of disinfection on the blades.


Observation on 1/15/16 at 10:30 a.m. of the endoscopy (a nonsurgical procedure used to examine a person's digestive tract. Using an endoscope, a flexible tube with a light and camera attached to it, your doctor can view pictures of your digestive tract on a color TV monitor) cleaning sink revealed a black mark in the sink.

Interview with LPN I at this time revealed she did not know how many gallons the black mark represented in the sink. She showed the 2-ounce plastic measuring cup she used and said she put two 2 ounce cups in the sink filled to the black mark.


Review of the label on the bottle of enzymatic detergent and presoak revealed the following: For instrument holding solution, endoscopic channel flush or manual scope cleaning use ½ oz (ounce) to 1 oz of concentration solution per gallon of water. For difficult or dried on soil use 2 oz of concentration solution per gallon of water.


Observation on 1/15/16 at 3:00 p.m. with LPN I of the Sterile Processing Department revealed the sink in the decontamination room did not have a mark to note how many gallons of water to use. The same enzymatic detergent and presoak was being used.


Interview at this time with LPN I, she said she did not know how many gallons it held and just put in 2 oz like when cleaning the endoscopes.


Record review of the facility's Policy and Procedure for Reprocessing of Colonoscope (is a long, thin, flexible tube with a camera and a light on the end that is used to examine the inside of the large intestine) dated 11/1996 and revised on 10/28/13 revealed the following:

"III. Procedure/Intervention(s): ... B. Remove scope to washroom .... Add 2 ounces cleaning solution to 4 gallons warm distilled water in washroom sink .... "


Interview on 1/17/16 at 2:30 p.m. with CNO B, she said the 2 oz to 4 gallons in the P&P was based on the manufacturer's recommendation of ½ oz per gallon.



Temperature/Humidity/Air Flow rate in the OR Suite


Observation on 1/15/16 at 10:20 a.m. with CNO B and LPNI of the Operating Room revealed a wall monitor for temperature and humidity.


During an interview at this time with LPN I, she was asked how they documented temperature and humidity. She said the temperature and humidity was monitored by a computer system that was monitored by Director of Maintenance D. She said his numbers were more accurate that the ones on the wall monitor. When she was asked about air flow rates, she said she did not know anything about that.


During an interview on 1/15/16 at 11:00 a.m. with RN E, Director of the OR (Operating Room), she was asked about the temperature, humidity and air flow. She said Director of Maintenance D recorded all of that, but she monitored it by the wall mounted unit.


Interview on 1/17/16 at 11:20 a.m. with Maintenance Director D, he said he did not know if there was anything that happened in the way of an alarm if the temperature or humidity were off. He said he did not have a plan for documenting air exchanges for the OR nor sterile processing.


Observation of the computerized temperature and humidity of the OR and Sterile processing areas revealed the humidity was 14 and the temperature was 65.7 in the Sterile processing area. The reading for the OR said the unit was off. He said the humidity had been as low as 20 before but never 14. He said he did not know why the units showed they were off. He said he only recorded the temperature and humidity once a day and documented it on a log.


Record review of the log revealed the following:


Humidity in the OR, decontamination room, instrument room and storage room from January 1 to 16, 2016 were below 30% 12 of 16 days. The temperature was below 68 degrees Farenheit on 8 of 16 days.


Observation at this time with CNO B and Maintenance Director D of the Operating room and procedure rooms humidifiers revealed they were on. Maintenance Director D said the problem was probably the cartridges that cleaned the water lines. He said he had ordered new ones, but had not put them in yet. Observation of the wall monitor in the Operating Room revealed the temperature was 65 degrees Fahrenheit (F) and the humidity was 21%. There was no wall monitor for the procedure room. The wall monitor in the sterile supply storage room was not working and the one in the decontamination room showed the humidity was at 21%.


During the exit conference on 1/17/16 at 3:10 p.m. CEO (Chief Executive Officer) A asked OR Director E if Director of Maintenance D ever told her about the temperature and humidity being out of range. She said he had not told her.


During an interview on 1/17/16 at 3:00 p.m. with CNO B, she said the facility did not have a Policy and Procedure for Air Exchanges in the OR and Sterile Processing.


Record review of the AORN (Association of periOperative Registered Nurses) Journal dated June 2009 given by CNO B revealed the following recommendations:
" Humidity, temperature, and air exchanges in the OR ... A relative humidity level that is too low can result in excessive bacteria-carrying dust in the surgical environment or static electricity ...Log should be maintained on humidity, temperature, and air exchanges. " The recommended settings were in a table and were as follows for the American Institute of Architects (AIA): Temperature OR, decontamination: 68 - 73 degrees F Preparation and packaging: 75 degrees F Humidity in all areas: 30 to 60%
Air Exchanges per hour: OR 15; Decontamination 10; Prep and packaging 4.


Record review of the facility's Policy and Procedure for Temperature and Humidity in the Surgery Areas dated Jan 2015 revealed the following:


" II. Policy: Appropriate temperature and humidity levels will be maintained for patient safety. III. Procedure/Intervention(s):
A. Room temperature and humidity levels are continually monitored by OR Staff and Plant Ops (operations)

B. Expected Ranges:
Temperature/Humidity Ranges for Perioperative Areas
O.R. 68-75 degrees/30-60%...
ENDOSCOPY 70-75 degrees/30-60%
CENTRAL STERILE 72-78 degrees (No humidity was noted); CENTRAL PROCESSING 68-73 degrees/30-60%

C. If the temperature or humidity level is not within range:
1. O.R. notifies Plant Ops or Plant Ops notifies O.R. if reading is out of range.
2. Plant Ops staff will take further corrective actions as needed.
3. If the temperature or humidity level is out of range, a risk assessment should be performed by O.R. staff, surgeon and anesthesia staff to determine if the levels will negatively affect patient care ....

5. Infection Control will be notified if levels fall and remain out of range during a procedure. "



Interview on 1/16/16 at 10:10 a.m. with Director of Lab M, she said she was the facility's Infection Control Preventionist. She said she had a strong background in bacteria and causes of infection, but was not a nurse. While looking over the facility's Infection Control Plan with Director of Lab M for monitoring hand hygiene there was no monitoring noted in the kitchen, surgery or the laundry. When Director of Lab M was asked about that, she said she had not thought to include them. She said she would add them to her list.