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Based on observation, testing, and interview, the provider failed to maintain the durability and cleanability of wall surfaces in two of two housekeeping closets. Findings include:

1. Observation at 9:25 a.m. and again at 3:00 p.m. on 4/26/11 revealed the walls of the housekeeping closets in the basement and on the first floor were discolored and deteriorated. The shelves above those walls held containers of chemicals. It appeared the containers of chemicals would leak periodically and run down the walls. Closer observation and testing at the time of the above observations revealed a fingernail could scrape away large pieces of the wall where the leaking chemicals had eaten through the plaster (photos 5 and 6).

Interview with the director of plant operations at the time of the observations confirmed the above conditions. He stated he was not aware of the condition of those walls but would have them repaired.

Based on observation, policy review, and interview, the provider failed to ensure medications were stored properly and safely in four of six areas (clinic, nurse's station, radiology, and the stress testing area) where medications were used. Findings include:

1. Random observations on 4/25/11 and on 4/26/11 in the clinic revealed:
*Examination rooms 3, 4, 6, 12 had outdated hydrogen peroxide, rubbing alcohol, povidone iodine, and ethyl chloride spray present for use.
*Procedure room 2 had outdated bupivacaine injection and Exactacain 14% spray. There were also opened multiple-dose vials of lidocaine injection and lidocaine/epinephrine injection with no date of opening marked on the vials.
*The sample room had outdated Asmanex Twisthalers and Vospire ER tablets.
*The medication refrigerator used to store insulin samples did not have a thermometer and was not monitored for temperature control. Measurement on 4/26/11 at 9:30 a.m. of the temperature in the upper area of the refrigerator revealed a temperature of 30.4 degrees Fahrenheit (F). Another measurement on 4/26/11 at 11:30 a.m. after insulin had been removed from that area revealed a temperature of 30.5 degrees F.

Interview on 4/26/11 at 9:30 a.m. with licensed practical nurse (LPN) E revealed insulins would be removed from the upper area of the refrigerator. The LPN said a thermometer would be ordered.

Interview on 4/26/11 at 9:30 a.m. with the director of pharmacy revealed:
*The pharmacy staff had not inspected the clinic for proper storage of medications.
*The clinic had been considered a separate provider not part of the hospital.
*Now that the clinic was included as a hospital department the pharmacy staff would inspect the clinic for proper medication storage.
*The refrigerator used to store sample insulins was not a suitable refrigerator for medication storage.

Interview on 4/26/11 at 1:45 p.m. with the director of pharmacy revealed all multiple-dose vials of medication were to be used only 28 days after opening.

2. Observation on 4/26/11 at 8:45 a.m. of the nurses station revealed four outdated 100 milliliter (ml) containers of dextrose 5 percent (%) solution.

3. Observation on 4/26/11 at 9:15 a.m. of the crash cart in the radiology area revealed one outdated 1000 ml container of sodium chloride solution, one outdated container of lactated ringers solution, and two outdated saline flush syringes.

4. Observation on 4/26/11 at 11:30 a.m. of a warming cabinet in the radiology area revealed it contained three different sized bottles of Isovue contrast media. None of the Isovue in the warmer was marked with a date when it had been placed in the warmer. The warmer did not have a thermometer but had a reading of "normal."

Interview on 4/26/11 at 11:40 a.m. with radiology technician H revealed:
*Radiology staff members monitored the warmer to see that it stayed in the normal range.
*She was not aware of what temperature was considered normal.
*When new Isovue was received it was placed in the warmer.
*The staff did not mark the Isovue with the date it was placed in the warmer, but they tried to use the oldest first.

Interview on 4/26/11 at 3:30 p.m. with medical imaging director B revealed she had called the representative of the company that manufactured the Isovue. The company representative had told her the Isovue could have been stored in the warmer indefinitely. The company representative was going to send information that would outline the storage guidelines for Isovue.

Additional interview on 4/27/11 at 8:15 a.m. with medical imaging director B revealed the provider did not have a policy or procedure for warming the Isovue.

Review of the manufacturer's package insert information for Isovue dated September 2005 revealed:
*It was desirable for the Isovue to be used at body temperature when injected.
*The storage temperature range was 68 degrees F to 77 degrees F.
*There were no directions for warming the solution.

Review of a letter received on 4/27/11 from the manufacturer of Isovue and addressed to medical imaging director B revealed:
*Isovue was stable if stored according to the conditions specified in the package insert (68 degrees F to 77 degrees F).
*Clinical experience indicated it was desirable for Isovue to be at body temperature (98.6 degrees F) when injected.
*Contrast warmer temperatures should not exceed 98.6 degrees F.
*Isovue should not be kept in the warmer for any period of time longer than that reasonably needed to reach body temperature or to ensure warmed Isovue was readily available.
*The company advocated following the above protocol.
*The company had data to support allowing Isovue to remain the the warmer for up to a month when the temperature did not exceed 98.6 degrees F and there was at least 6 months before the product's expiration date was reached.

Based on observation, interview, and policy review, the provider failed to ensure all infection prevention and control practices were implemented for:
*Cleanliness and sanitary condition of clean patient use items.
*Sterilization of surgical and procedure equipment.
*Disinfection of patient rooms with contact precautions.
*Co-mingled patient laundry.
*Storage of clean laundry.
Findings include:

1. Random observation from 4:15 p.m. through 4:45 p.m. on 4/25/11 of the clinic examination/procedure rooms 1, 2, 3, 4, 7, 9, 11, and 12 revealed the following items were stored beneath the hand sink drain lines:
*Clean instruments.
*An unopened bottle of hydrogen peroxide.
*Clean wash cloths, towels, underpads, pillow cases, and drapes.
*Clean dressings and bandages.
*Single-use packages of first aide ointment.
*Clean emesis bags and basins.
*Clean rolls of exam table paper.
(Photos 1 - 4.)

Interview at 9:15 a.m. on 4/26/11 with the maintenance supervisor and the director of plant operations (DPO) confirmed the above findings. They stated the clinic staff had been told they were not to store any items under the hand sink drain lines.

2. Observation at 5:00 p.m. on 4/25/11 in the clinic revealed an opened one gallon container of Cidex under the drain line of the hand sink in procedure room one. Closer observation of that one gallon container revealed it had not been identified with the date it had been opened. Review of the manufacturer's label at that time revealed the container must be labeled with an open date and must be discarded after 75 days. Interview with licensed practical nurses (LPN) E and I at the time of the observation confirmed that finding. They stated they were aware the container must be labeled but had forgotten to write the date on the container.

Continued interview with LPN E at that same time revealed she used the Cidex to disinfect and sterilize specific suture removal instruments for the clinic. She revealed the clinic had no policy or procedure for disinfection and sterilization of instruments. She had been given verbal training on how to use the Cidex. She stated she and LPN I used procedure room one for cleaning, disinfecting, sterilization, and storage of patient use instruments. She said she tried to keep specific areas for dirty and clean, but it was hard. LPN E said she would pull a divider curtain between the areas of dirty and clean when working on instruments. But she realized it was not complete separation when cleaning, disinfecting, and sterilizing larger equipment such as the scope.

Additional observation at that same time revealed a container of Metrizyme enzymatic detergent was stored next to the container of Cidex. The expiration date on that enzymatic detergent was "2/10." Interview with LPN E at the time of the observation confirmed that finding. She stated they had not used that product for some time, but apparently had not disposed of the container after the expiration date.

Interview with LPN I at 2:00 p.m. on 4/26/11 revealed she disinfected the flexible sigmoidoscope for the clinic. She stated they had no policy or procedure for disinfection of patient use equipment. But she kept some instructions on a note card for the scope. Those instructions read: "1) Run Cidex through machine, 2) Rinse with clear water, 3) Soak parts in Cidex, 4) Air dry."

Interview at 2:30 p.m. on 4/26/11 with the director of nursing for the hospital revealed the hospital and clinic were to mostly use single-use sterile instruments. Other instruments were to be sent to their parent company for reprocessing and sterilization.

Review of the hospital April 2011 policy titled Sterilization and Disinfection revealed the following statement under guidelines: "Custer Regional Hospital does not sterilize items on premises. All items that require sterilization are sent to RCRH SPD/CS. CRH utilizes disposable sterile items as much as possible."

3. Interview at 5:00 p.m. on 4/26/11 with housekeeper J revealed she used the quaternary disinfectant for all patient rooms. She stated the quaternary disinfectant killed everything. She stated she was not aware of any other product they would use for isolation rooms. However she said she would gown up, use gloves, and a mask when the nurses identified a patient room with precautionary signage.

Continued interview at 10:30 a.m. on 4/27/11 with the housekeeping supervisor revealed she was aware they must use a bleach solution for certain isolation rooms with contact precautions. She stated she had just taken over the supervisor position and had not had time to conduct training or create checklist forms for the housekeepers to use on their carts.

Review of the August 2008 policy titled Concurrent and Terminal Cleaning of Isolation Rooms revealed a hand written note "1/2 cup bleach to 1 gallon water" by the concurrent and terminal cleaning guidelines. The housekeeping supervisor stated she had not written that note. She also stated she was not aware that hand written note was not the correct procedure and direction per the Centers for Disease Control and Prevention (CDC) guidelines. CDC procedures and directions were one cup of bleach to one gallon of water for the infection control of specific diseases.

4. Observation at 10:30 a.m. on 4/26/11 revealed a washer and dryer in the basement of the rehabilitation building. Interview with certified nurse assistant/physical therapy aide A at the time of the observation confirmed the rehabilitation building did their own laundry. She stated the towels were all sent to the parent company. But they laundered the patients' athletic shorts that were worn during their therapy. She stated they used only detergent and did not add any disinfectant to the wash cycle. She said if the patient would have an accident they would wash out the shorts in the laundry sink before adding them to the other patient's shorts. Continued interview with certified nurse assistant/physical therapy aide A revealed she was not aware a disinfecting process must be used for co-mingled laundry. She said they used hot water. Testing of the hot water at that time revealed the temperature was at 118 degrees Fahrenheit (F) and not the required 160 F. for disinfection of co-mingled laundry.

5. Observation at 4:10 p.m. on 4/26/11 revealed three large mesh bags of clean linen stored directly on the floor of the clean linen closet by the director of nursing's office. Interview with the DPO at the time of the observation confirmed that finding. He stated staff were aware clean linen must be kept off the floor.

Based on policy review, observation, and interview, the provider failed to ensure patients' records were secured at all times. Findings include:

1. Observation in the physical therapy building revealed unlocked doors to the basement where some medical records were stored. Observation at 10:20 a.m.on 4/26/11 revealed the door that lead to the basement stairwell was unlocked. Also at that time the door that lead into the room at the bottom of the stairs where the records were stored was propped open by a concrete block.

Interview on 4/26/11 at 1:42 p.m. with the medical records director revealed all areas where patients' records were stored were kept locked when personnel were not present. She also stated only medical records, maintenance departments,and the nurses station have keys to the records area.

Review of Medical Records policy MR-7181-025 Security of Medical Records revealed it was the department's responsibility to maintain confidentiality and security of the original medical record. The policy also stated "Access to medical records is restricted to authorized personnel/medical staff and shall be readily accessible at all times." Under the procedure section of the policy number five stated "Medical Records Department is responsible for safeguarding both the record and its informational content against loss, defacement, and tampering." They were also responsible to safeguard the medical records against use by unauthorized individuals. Review of Medical Records policy MR-7181-024 Safeguard of Health Information revealed under procedure #1 "The medical record department will strive to ensure that medical records will be maintained in secure and restricted areas with access/usage limited to Custer Community Hospital staff members who have a need to know based on patient care needs."

Based on record review and interview, the provider failed to ensure a performance improvement plan was implemented for 24 of 24 quality improvement study entries for the first quarter of 2011 in which the the result was below the established target. Findings include:

1. Review of the performance improvement meeting minutes revealed no improvement plan had been implemented for quality improvement study entries when the result had been below the targeted result. The perfornance improvement worksheets failed to show evaluations of corrective actions had been done.

Interview on 4/27/11at 9:30 a.m. with the performance improvement coordinator confirmed no performance improvement plan had be done for those twenty four studies.

Interview at 10:45 a.m. on that same day with laboratory director revealed improvment plans had been done for the labratory studies during the first quarter of 2011. However the plans had not always been reported to the performance improvement committee or included on the performance improvement worksheet.

Interview on 4/27/11 at 10:45 a.m. with the medical imaging director revealed she had done a performance improvement plan for the studies she had submitted to the performance improvement committee for the first quarter of 2011. She stated she had not documented the improvement plan anywhere. She also stated it had not been included it in the first quarter 2011 performance improvement report she had submitted to the performance improvement committee.

Based on record review, interview, and policy review, the provider failed to ensure the swing-bed activities program for eight of eight patient's (1, 2, 3, 4, 5, 6, 7, and 8) was directed by a qualified professional. Findings include:

1. Review of eight of eight (1, 2, 3, 4, 5, 6, 7, and 8) swing-bed patients' records revealed the activities assessments for those patients had been completed by certified nursing assistant/physical therapy aide (CNA/PTA) A. There had been no activities documentation in any of those records written by an occupational therapist or any other qualified activities professional.

Interview on 4/27/11 at 11:50 a.m. with CNA/PTA A revealed:
*She had worked with the activities director at the nursing home prior to becoming the activities coordinator at the hospital.
*Her experience with activities at the nursing home had been mostly observation.
*She had no "official" training in activities coordination.
*She thought occupational therapist K had done quarterly reviews of the swing-bed patient activities in the past.

Interview on 4/27/11 at 1:30 p.m. with the director of nursing revealed there was no consultant assigned to oversee the swing bed activities program. He stated CNA/PTA A completed all the activities assessments and provided activities for the swing bed patients. He was not aware a qualified activities coordinator, occupational therapist, or a qualified recreation specialist was to oversee the activities program. He also stated there was no policy that addressed those requirements for swing bed patients.