HospitalInspections.org

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Item #1 Fit Testing

Based on observation, interview, and document review the hospital failed to develop and implement an effective process to ensure staff were fit tested for N95 Masks when the hospital changed models and types of N95 respirators.

Failure to develop and implement an effective process to ensure staff are fit tested for appropriate N95 respirators places patients and staff at risk of illness from exposure to communicable disease.

Findings included:

1. Document review of the hospital's policy titled, "Respiratory Protection Program," no policy number, reviewed 11/2020, showed that after the initial fit tests, fit tests must be completed at least annually, or more frequently if there is a change in status of the wearer or if the employer changes model or type of respirator.

2. On 12/03/20 at 12:07 PM, Investigator #5 observed a used N95 mask (Model #8210) sitting on top of an anesthesia machine. During interview with Investigator #5, a Provider (Staff #506) verified that it was his mask. Staff #506 stated that he reused his mask 4 or 5 times and stores it on top of the anesthesia machine between patients.

3. On 12/04/20 from 12:00 PM to 1:00 PM, Investigator #5 reviewed staff fit testing records. The review showed that Staff #506 was fit tested for a Molnlycke N95 size medium. Staff #506 was not fit tested for the N95 Model #8210.

4. On 12/03/20 at 12:15 PM, during interview with Investigator #5, a provider (Staff #507) stated that she had been fit tested for the 3M 1860 size small.

5. On 12/03/20 at 12:30 PM, Investigator #5 observed a Technician (Staff #510) assist a Provider (Staff #506) during endotracheal tube placement in preparation for surgery. Staff #510 was wearing a 3M 1860 mask.

6. On 12/04/20 from 12:00 PM to 1:00 PM, Investigator #5 reviewed staff fit testing records. The review showed that Staff #510 was fit tested for a Molnlycke N95 size medium/large. Staff #510 was not fit tested for the 3M 1860 N96 respirator mask.

7. On 12/04/20 from 12:00 PM to 1:00 PM, Investigator #5 reviewed staff fit testing records. The review showed that Staff #507 was fit tested for a Molnlycke N95 size medium. Staff #507 was not fit tested for the 3M 1860 size small.

8. On 12/04/20 at 3:20 PM, during inspection of the hospital's Emergency Department, Investigator #5 observed a 3M 1860 N95 respirator mask size small, a KN95 mask, and a surgical mask lying on a disposable incontinence pad on the counter near a contracted Provider (Staff #509). During interview with Investigator #5, the Provider (Staff #509) stated that she would choose which mask to wear depending on her level of confidence that a patient was positive or negative for Covid-19. She stated that the company she worked for would send her about 10 of the KN95 masks to wear.

9. At the time of the finding, the Chief Quality Officer (Staff #501) stated that Staff #509 was not utilizing N95 masks per the hospital policy and that KN95 mask was not approved for use.

10. On 12/04/20 from 12:00 PM to 1:00 PM, Investigator #5 reviewed staff fit testing records. The review showed that Staff #509 was fit tested for the Molnlycke N95 size medium/large. Staff #509 was not fit tested for a 3M 1860 N95 respirator mask.

11. On 12/04/20 at 3:40 PM, during interview with Investigator #5, a Provider (Staff #508) stated that he did not know what type of N95 mask he wore and stated he would just use a size large of what the hospital had.

12. On 12/04/20 from 12:00 PM to 1:00 PM, Investigator #5 reviewed staff fit testing records. The review showed that Staff #508 was fit tested for a Molnlycke N95 size medium/large.

13. On 12/04/20 at 4:15 PM, Investigator #5 observed a Registered Nurse (Staff #513) wearing a 3M 8200 respirator mask. During interview with Investigator #5, Staff #513 stated that she was not fit tested for the mask she was using. She stated she usually wore the "green one" but that the hospital was out of those masks. At this time, Staff #513 pulled a plastic container out of a clothe bag that was filled with different types of N95 respirator masks. Staff #513 stated that the masks had been previously used to care for Covid 19 patients and she had found these masks on the unit and she had not been fit tested to the masks in the plastic container.

14. On 12/04/20 from 12:00 PM to 1:00 PM, Investigator #5 reviewed staff fit testing records. The review showed that Staff #513 was fit tested for a Molnlycke N95 size medium/large. Staff #513 was not fit tested for the 3M 8200 N95 respirator mask.

15. On 12/04/20 from 12:00 PM to 1:00 PM, Investigator #5 reviewed staff fit testing records. The review showed that Staff #511 was not fit tested for any N95, and Staff #512 was fit tested for a 3M half facepiece (HF) size large.

16. On 12/04/20 at 2:45 PM, Investigator #5 and the Chief Quality Officer (Staff #501) reviewed the hospital's list of N95 mask inventory. The review showed that the hospital did not have any Molnlycke N95 respirator masks or any 3M HF mask in their inventory.

17. At the time of the review, Staff #501 verified the finding. She stated that the hospital had contracted with an outside company to perform initial staff fit testing, but that the hospital was in the process of bringing fit testing back into the hospital and had begun the process a couple days prior.

Item #2 Operating Room Cleaning

Based on observation, interview, and document review, the hospital failed to ensure the staff used effective infection control measures when cleaning the Operating Room (OR).

Failure to ensure the staff used effective infection control measures when cleaning the (OR) puts patients, staff, and visitors at risk of illness from communicable diseases.

References: Association of Perioperative Registered Nurses (AORN) Guidelines for Perioperative Practice: Environmental Cleaning, 2020, Recommendation 2. Cleaning; 2.8.1 Consider items that contact the floor for any amount of time to be contaminated.

Findings included:

1. Document review of Capital Medical Center Infection Control Plan, policy #IC 1.0, updated 08/20, showed that the Association of perioperative Registered Nurses (AORN) is used as a guideline when developing and implementing infection prevention and control

2. On 12/03/20 between 1:20 PM and 3:30 PM, Investigator #8 observed the cleaning of OR #2. An Environmental Services (EVS) staff member (Staff #801) used a disinfectant soaked cloth to disinfect stainless-steel tables and chairs while wiping the lower portions of the equipment, Staff #801 allowed the cloth to contact the floor several times. Following contact with the floor, Staff used the now contaminated cloth to wipe other equipment.

3. At the time of the observation, Investigator #8 interviewed Staff #801 about the OR cleaning procedures. Staff #801 acknowledged that the disinfectant cloth had been in contact with the floor during the cleaning.

Item #3 Hand Hygiene

Based on observation and document review, the hospital failed to perform hand hygiene in the central sterile room.

Failure to ensure the staff perform hand hygiene puts patients, staff, and visitors at risk of illness from communicable diseases.

Findings included:

1. Document review of the hospital's policy titled, " Hand Hygiene" Policy No IC 4.0, revised 04/19, showed that staff are to change gloves when in contact with potentially contaminated surfaces.

2. On 12/04/20, between 9:30 AM and 10:40 AM, Surveyor #1, observed a Central Sterile Technician (Staff #101) knock over signage that was attached to the central sterile cart, Staff #101 picked up the signage from the floor and continued to touch sterile surfaces without performing hand-hygiene.
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Based on interview, and document review, and review of the Medical Staff Bylaws, the hospital failed to ensure staff recorded a complete history and physical (H&P) in the patient's medical record prior to an invasive operative procedure requiring anesthesia for 4 of 6 patients reviewed (Patients #502, #505, #506, and #903).

Failure to ensure that information required for clinical decision-making was readily accessible to all providers caring for the patient risks poor health outcomes due to unknown or known co-morbid conditions.

Findings included:

1. Document review of the hospital's document titled, "Medical Staff Bylaws," revised 11/2013, showed that the patient's physician must document the history and physical in the medical record before an operative or other high-risk procedure is performed. The minimum content for history and physicals included:

a. Chief Complaint.

b. History of Present Illness.

c. Relevant Past Medical and Surgical History.

d. Current Medications.

e. Allergies or Adverse Drug Reactions.

f. Psychological History.

g. Assessment of Body Systems including the lungs.

2. On 12/03/20 at 10:35 AM, Investigator #5, Investigator #7, the Chief Quality Officer (Staff #501), and the Manager of Peri-Operative and Post-Operative Services (Staff #502) reviewed the medical record for Patient #502. The document review showed the provider (Staff #503) failed to document a complete history and physical that included the patient's current medications as directed by hospital policy.

3. At the time of the observation, Staff #501 and #502 verified the finding and stated that the provider should have assessed and documented the patient's current medication as part of a complete history and physical prior to surgery.

4. On 12/03/20 at 11:00 AM, Investigator #5, Investigator #9, and Staff #901 reviewed the post-operative chart for patient (Patient #903). The patient's chart contained an abbreviated short form H&P that contained a list of medications including ciprofloxacin (an antibiotic), dexamethasone (a corticosteroid that prevents the release of substances in the body that cause inflammation), ibuprofen (an anti-inflammatory medication) and penicillin. A line was drawn through all medications. There was no documentation regarding the crossed off medications, who had crossed the medications off, or why the medications where crossed off. There was no further documentation of patient medications on the history and physical document. Document review of the patient's discharge medication list showed the patient's current medications included albuterol and ibuprofen.

5. At the time of the review, Staff #901 verified the finding and further reviewed the medical record. She was unable to find supplemental documentation of who revised the medical record. Staff #901 reported that documenting the patient's current medications is required as part of the history and physical prior to receiving surgical services.

6. On 12/03/20 at 4:15 PM, Investigator #5 and the Chief Quality Officer (Staff #501) reviewed the medical record for Patient #505. The review showed the provider failed to document a completed history and physical that included a review of the patient's airway/lungs.

7. At the time of the observation, Staff #501 verified the findings and stated that an airway assessment is required as part of a complete history and physical.

8. On 12/03/20 at 4:30 PM, Investigator #5 and the Chief Quality Officer (Staff #501) reviewed the medical record for Patient #506. The review showed the provider failed to document a completed history and physical that included the patient's current medications as directed by hospital policy.

9. At the time of the observation, Staff #501 verified the finding, further reviewed the medical record and was unable to locate evidence of the patients' current medication list.

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Based on interview, document review, and review of the hospital's Medical Staff Bylaws, the hospital failed to ensure that the post-operative surgical notes were completed, and including all required elements as directed by the Medical Staff Bylaws in 4 of the 6 patient charts reviewed (Patient #505, #506, #901, and #904).

Failure to ensure that information required for clinical decision-making was readily accessible to all providers caring for the patient's postoperatively risks patient safety and clinical care following surgery.

Findings included:

1. Document review of the hospital's document titled, "Medical Staff Bylaws," revised 11/2013, showed:

a. Immediately upon completion of the operative or other high-risk procedure, and before the patient is transferred to the next level of care, the patient's physician must complete a brief operative procedural note or a full operative report in the medical record.

b. The brief operative report must include ...estimated blood loss.

c. If a brief operative report is documented, then the full post-operative report must be completed in the medical record within 24 hours after the procedure.

2. On 12/03/20 at 10:10 AM, Investigator #9 and the Manager of Pre-Operative and Post-Operative Care (Staff #901) reviewed post-operative medical record for patient (Patient #901). The review showed the surgeon failed to document a post-operative note prior to the transfer to the next level of care.

3. At the time of the review, Staff #901 verified the missing documentation and stated that the hospital's policy is that the brief post-operative note should be in the patient's chart immediately following the procedure, and the full operative report should be in the patient's chart within 24 hours.

4. On 12/03/20 at 4:15 PM, Investigator #9 and Progressive Care (PCU) Nurse (Staff #902) reviewed a current inpatient post-operative medical record for patient (Patient #904). The patient underwent a surgical procedure on 12/02/20. Investigator #9 found no evidence the surgeon (Staff #505) competed a full post-operative note.

5. At the time of the review, Staff #902 verified that the full post-operative note was not in the patient's chart and stated that the post-operative note should be completed and placed in the patient's medical record within 24 hours post-surgery.

6. On 12/03/20 at 4:15 PM, Investigator #5 and the Chief Quality Officer (Staff #501) reviewed the current in-patient medical record for Patient #505. The patient underwent a surgical procedure on 12/02/20. An anesthesia post procedure note showed that anesthesia performed a post-operative assessment on 12/02/20 at 1:21 PM. Investigator #5 found no evidence the surgeon (Staff #505) completed and documented a full post-operative note within 24 hours post-surgery.

7. At the time of the observation, Staff #501 verified the findings and stated that the document might be in transcription.

8. On 12/04/20 at 10:00 AM, Staff #501 provided a copy of the full post-operative notes for Patient #904 and Patient #505. The documents showed that the provider documented the post-operative note for patient #904 on 12/03/20 at 5:41 PM, and documented the full post-operative report for Patient #505 on 12/03/20 at 6:06 PM. Staff #505 verified that the post-operative notes were documented after the investigator findings and stated that the provider was new to the organization and that she would follow up with the provider regarding post-operative note requirements.

9. On 12/03/20 at 4:30 PM, Investigator #5 and the Chief Quality Officer (Staff #501) reviewed the medical record for Patient #506. The review showed the surgeon (Staff #504) failed to document a complete brief post-operative note that included estimated loss.

10. At the time of the observation, Staff #501 verified the finding, and stated that a post-operative note should include estimated blood loss.
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