HospitalInspections.org

Based on document review and interview, the governing board failed to ensure the hospital's Quality Assurance Performance Improvement (QAPI) program included 5 of 45 services provided by all hospital departments and contracted services for calendar year 2014.

Findings:

1. Review of the medical staff bylaws, approved 12-1-14, indicated in a section entitled Ongoing Professional and Practice Evaluation, criteria to be evaluated may include review of procedures performed and clinical outcomes; patterns of blood and pharmaceutical usage; requests for tests and procedures; length of stay patterns; morbidity and mortality data; and Practitioner's use of consultants.

2. Review of the hospital's QAPI program indicated the services of Anesthesia (contract), Cardiac-Thoracic Surgery, Endoscopy, and Reconstructive Surgery were not included as part of the hospital's QAPI program because there was no documentation of practitioners who provided these services of having been evaluated as stated above.

3. In interview, on 8-4-2015 at 9:45 am, employee #A6, Physician Credentialing, confirmed there was no documentation of practitioner evaluation as stated above, and no other documentation was provided prior to exit.

4. Review of the hospital's QAPI program indicated there was no documentation for 1 of 2 contracted laundries.

5. In interview, on 8-4-2015 at 12;10 pm, employee #A9, Director of Supply Chain & Linen, confirmed one of the contracted laundries was not part of the hospital's QAPI program and no other documentation was provided prior to exit.

Based on document review, observations, and interview, the infection control officer(s) failed to ensure that systems for controlling infections and communicable diseases of patients and personnel were implemented in regard to: TB (tuberculosis) testing for new hires for 1 of 1 RNs (registered nurses) hired in 2015 (staff member P1); 3 staff, in 5 observations, with surgical masks down around the neck (staff members #67, #70, and #71); the lack of disinfection of patient floors during terminal cleaning after patient discharge; failing to monitor the standards and appropriate techniques for laundering EVS (environmental services) mop heads and cleaning cloths; failing to ensure that staff cleaned/disinfected the glucometer after use on a patient, for two of two observations (pt. #6 and #7 and staff #63 and #66); failed to develop a system related to hand hygiene practices, appropriate use of gloves, and cleaning of patient care equipment to reduce the risk of transmission of pathogenic microorganisms for 2 of 2 (63 and 64) operating room (OR) nursing staff and 1 of 2 (D2) anesthesiologists and 1 of 1 (67) guest care partners observed; and maintaining the quality of air in the OR suites related to temperature to decrease risk of infection for 2 of 2 (3 and 4) OR suites toured.

Findings:
1. Review of the policy "Tuberculosis Control Plan FY 2015", policy number 979507, last approved on 07/2014, indicated on page 5, under "Surveillance for TB Transmission": "...B. Two-step TST (tuberculin skin test) will be performed upon associate/team member hire and followed by annual TST. 1. TST placement and interpretation will be completed by OAHP (Office for Associate Health Promotion)...or by a trained associate/team member...".

2. Review of the policy "Health Requirements for Employment", policy number 297715, approved 12/2012 and expiring 12/2015, indicated on page 3: '"..4. Tuberculin Test - As a condition of employment, all candidates will be given a two-step Mantoux Tuberculin Skin Test (TST) in the manner recommended by the Center for Disease Control (CDC)...".

3. Review of the health record for RN P1, who was hired 4/13/15, indicated a first step TB test was given 3/17/15 and read on 3/19/15, but lacked documentation of a second TB, of the two steps, being given to this newly hired employee.

4. Interview with staff member #72, human resources staff, at 10:30 AM on 8/4/15 indicated:
a. A letter was sent from OAHP to RN P1 dated 4/22/15 that indicated the second of a two step skin test needed to be performed.
b. No further follow up for staff RN P1 can be found, or was documented.
c. Facility policy was not followed in regards to the policy, as listed in 1. and 2. above, requirement for a two step TB test at the time of hire.

5. Review of the policy "Uniform, Dress Code and Appearance Policy", policy number 1214322, approved 02/2015, indicated on page 4 under "Surgery": "...d. Surgical masks...Prior to leaving the operating room masks must be removed and discarded...i. Contaminated personal protective equipment (PPE) shall not be worn outside the surgical area."

6. Review of the policy "Uniform, Dress code and Appearance Policy", policy number 1214322, approved 02/2015, indicated on page 4 under "Supply Chain": "...d. If known in advance that a Supply Chain Team Member will be working in a Process Area with a specific dress code for an extended period of time, the Team Member will be so advised in order to comply with those requirements."

7. At 9:45 AM and 12:50 PM on 8/3/15, and 3:25 PM on 8/4/15, staff member #67, a materials/supply chain staff member, was observed to be in the hallway outside the administration offices with a surgical mask down around the neck.

8. At 9:45 AM on 8/4/15, it was observed that a "hybrid surgery" RN (staff RN #70) was in the hallway of patient rooms on the second floor (2A hallway) with their surgical mask down around the neck.

9. At 12:30 PM on 8/5/15, staff member #71, a perfusionist, was noted to be in the administrative hallway with their surgical mask down around the neck.

10. Staff member #52, a CNS (clinical nurse specialist), was present for all of the observations listed in 7., 8., and 9., except the 9:45 AM observation of #67 on 8/3/15, and stated that surgical masks are not to be worn in hallways down around the neck.

11. Interview with staff member #51, the infection preventionist, at 3:10 PM on 8/4/15 indicated:
a. The current dress code policy does not address that cath lab (hybrid surgery) personnel are to remove their surgical masks before leaving the department, but that the policy is in review and will indicate this in the future.
b. It is the expectation that staff will not wear surgical masks down around the neck throughout, and in the hallways of, the facility.

12. Review of the policy "Discharge Cleaning", policy number 168655, last approved 7/2012, and expiring 7/2015, indicated on page 2 in section M.: "Place Wet Floor Sign and perform microfiber mop process in the patient room with GP Forward using standard S-Stroke procedure."

13. Review of the policy "Bloodborne Pathogen Exposure Control Plan FY 2015", policy number 979525, last approved on 07/2014, indicated on page 4. under "E. Housekeeping": "...3. Equipment and working surfaces are cleaned and decontaminated after contact with blood or OPIM. (Other Potentially Infection Material)

14. At 10:45 AM on 8/4/15, while in the company of staff member #51, the infection preventionist, it was observed that a room terminal clean (of a non isolation patient--room 340) by EVS staff #P7, was performed with "Stride" general cleaning solution used on the floor surface.

15. At 11:40 AM on 8/3/15, interview with staff members #57, #58, and #59 (EVS managers, supervisors and process leaders) indicated that in the case of a terminal room cleaning of a patient who was not in isolation, the general cleaning product "Stride" was to be used, and not a disinfectant.

16. At 4:15 PM on 8/3/15 and 2:45 PM on 8/5/15, interview with staff member #51, the infection preventionist, indicated:
a. Even though nursing staff are to call EVS staff for any blood and body fluid spills, it cannot be determined that, at the time of a patient discharge, the EVS staff can be totally assured that all spills were appropriately disinfected and thus may be putting future patients at risk when no disinfectant is used on the patient room flooring with the current terminal cleaning processes.
c. Current policies indicate a GP Forward general cleaner is used, but policies going to committee for approval later this month, will indicate the "Stride" general cleaner now being utilized.

17. At 12:15 PM on 8/3/15, interview with staff member #60, the EVS process leader, indicated that:
a. A separate contracted laundry company is utilized for cleaning microfiber mop heads and cleaning cloths used by EVS staff, not the hospital's contracted laundry service.
b. The EVS company is not monitoring the laundry techniques to assure appropriate cleaning of the mop heads and cleaning cloths.

18. At 1:30 PM on 8/3/15, interview with staff member #51, the infection preventionist, indicated that the infection control committee is not monitoring the effectiveness and appropriateness of the laundering of EVS utilized mop heads and cleaning cloths.

19. Review of the policy "Point of Care Testing: Regulatory Requirements and Quality Assurance", policy number 998482, last approved 09/2014, failed to indicate that the glucometer should be cleaned/disinfected after each patient use.

20. Review of the policy "Point of Care General Testing", policy number 1370973, last approved 02/2015, failed to indicate that the glucometer should be cleaned/disinfected after each patient use.

21. Review of the manufacturer's manual for the Accu-Chek inform II, indicated that Clorox Germicidal wipes and Super Sani-Cloth Germicidal Disposable Wipes were both "acceptable" for cleaning and disinfecting the device.

22. At 12:30 PM on 8/3/15 in the company of staff member #52, a clinical nurse specialist, staff member #63, a guest care partner, was observed doing a glucometer (blood sugar) check on pt. #7 and failed to clean the device after performing the test by placing it back in the carrier and returning it to the nursing station without performing a disinfection.

23. At 2:30 PM on 8/3/15, in the company of staff member #52, a clinical nurse specialist, staff member #66, a guest care partner, was observed doing a glucometer check on pt. #6 and cleaned the device, after performing the blood check, with an alcohol wipe.

24. Interview with staff member #52 at 12:35 PM and 2:35 PM on 8/3/15 indicated that both staff members #63 and #66 failed to clean the glucometer, as per facility expectations, after performing blood sugar checks.

25. Interview with staff member #51, the infection preventionist, at 11:45 AM on 8/4/15, indicated glucometers are to be cleaned with PDI/Cavicide wipes or Clorox wipes and not alcohol swabs.

26. At 9:00 AM on 8/4/15, in the company of staff member #52, a clinical nurse specialist, it was observed that nurse #73, prior to administering Insulin (for coverage) subcutaneously to the patient in room 208 (pt. N4), performed the duty of drawing up the medication on the counter top beside, and within 3 feet of, the handwashing sink.

27. At 9:25 AM on 8/4/15, in the company of staff member #52, a clinical nurse specialist, it was observed that nurse #74, prior to administering Lovenox subcutaneously to the patient in room 210, pt. N8, performed the duty of drawing up the medication on the counter top beside, and within 3 feet of, the handwashing sink.

28. At 10:00 AM on 8/4/15, interview with staff members #52 and #51, the infection preventionist, indicated every patient room in the facility had the medication counter adjacent to the handwashing sink in the room, making this medication preparation area within 3 feet of the sink.


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29. Policy #279379, titled "Hand Hygiene Antisepsis", revised/reapproved 8/12, was reviewed on 8/5/15 at approximately 1500 hours, indicated on pg. 3, under Gloves section, point A., "Gloves are required when the possibility exists of exposure to a guest's mucous membranes, broken skin, or blood or other body fluids, secretions, or excretions (i.e., Standard Precautions) and/or as indicated per isolation protocol."

30. Policy #1214322, titled "Uniform, Dress Code and Appearance Policy", revised/reapproved 2/15, was reviewed on 8/5/15 at approximately 1505 hours, indicated on pg. 4, under Surgery section, point h., "Gloves and eye protection must be worn when inserting invasive lines, intubating or extubating guests, and when touching items contaminated with blood or body fluids."

31. Policy #398146, titled "Practice Guidelines for Anesthesia Team Members", revised/reapproved 3/13, was reviewed on 8/5/15 at approximately 1510 hours, indicated on pg. 1, under Procedure section, point E., "Dress Code: Refer to the [facility] dress code policy."

32. Policy #1678419, titled "Surgery Environment Sanitation", revised/reapproved 7/15, was reviewed on 8/5/15 at approximately 1515 hours, indicated on pg:
A. 1, under Procedure section, point G., "All items that come in contact with the guest during a procedure are considered contaminated and are cleaned with the appropriate germicidal cleaning solution or discarded."
B. 2, under Procedure section, point M.4., "After each procedure, the OR suite and control room in the hybrid OR will be cleaned. This includes...wiping down of all monitor cords in contact with the guest."

33. Policy #1397573, titled "Air Handling and Control in Surgery", revised/reapproved 7/15, was reviewed on 8/5/15 at approximately 1520 hours, indicated on pg. 1, under Procedure section, point A.1.d., "Temperature control of 68-73 degrees F (Fahrenheit) is recommended except when a guest condition warrants temperatures outside of this range."

34. OR temperature logs for 8/3/15 and 8/4/15 were reviewed on 8/5/15 at approximately 1525 hours, and indicated OR temperatures were 59-63 degrees F on 8/3/15 and 61-63 degrees F on 8/4/15.

35. 2015 Infection Prevention Risk Assessment was reviewed on 8/5/15 at approximately 1535 hours, and indicated under the Internal Controls section, "Intentional Hypothermia OR Guests = Room Temp 62-68 degrees F."

36. While in the OR (3) on 8/4/15 at approximately 1226 hours, accompanied by staff 55 (Process Leader OR and Short Stay):
A. staff D2 (anesthesiologist) was observed wearing gloves while inserting a Quad Lumen Central Line, then removed gloves and placed a tray that was soiled with patient's blood into a large red biohazard container without gloves.
B. staff 63 (OR Nurse) and 64 (OR Nurse) were observed several times stuffing wrappers and other garbage, without gloves on, into the same large red biohazard container that staff D2 had just placed the contaminated tray in. Neither of them performed hand hygiene after each time they stuffed garbage into this container.

37. While in the OR (4) on 8/5/15 at approximately 1202 hours between surgical cases, accompanied by staff 51 (Infection Control Preventionist), staff 67 (Guest Care Partner) was observed mopping the OR floor and touched patient care equipment leads that were hanging from the equipment and touching the floor. Staff 67 then proceeded to wrap up these leads and hang them on the equipment without wiping them off.

38. Staff 51 was interviewed on 8/5/15 at approximately 1217 and 1445 hours, and confirmed all staff are to follow hand hygiene, use gloves appropriately, and follow the dress code when in the OR suite as required per facility policy and procedure. Cleaning of the OR suites is to be done according to policy and procedure and was not as described above.

39. Staff 60 (Process Leader Clinical Engineer) and staff 51 were interviewed on 8/4/15 at approximately 1110 hours and 8/5/15 at approximately 1445 hours, respectively, and confirmed OR suite temperature readings were outside the temperature range as defined by policy. The Infection Prevention Risk Assessment ranges for OR room temperature were outside the defined temperature range defined in the Air Handling and Control in Surgery policy. Also, the patient's condition is not documented in the medical record to determine whether or not temperatures outside the range were warranted during the surgical procedure when temperatures are not within the policy defined ranges.