HospitalInspections.org

Based on observation and interview the hospital failed to ensure the Kansas State food code regulations for an airgap or other similar device was implemented at the food preparation sink. This failed practice potentially placed all patients and visitors at risk for food contamination.

Findings included:

- Observation of the hospital kitchen 10/3/2016 at 12:40 p.m. it was noted that the sink used to prepare fresh food did not have an air gap or device to prevent contamination of the sink and potentially contaminate food in the event of a backflow of sewage, gas or other contaminates.


The assistant dietary manager confirmed the sink was without an air gap.



According to the Kansas State Food Code 2012 regulation 107 5-203.14 Backflow Prevention Device, states, "A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT (includes, but is not limited to: ...cafeterias, public or nonprofit organizations routinely serving food ... ").

Based on observation and policy review the Hospital failed to develop and implement a policy that restricted children under six years of age from visiting without prior approval. This failure denied all patients information regarding visiting restrictions and potentially impacted the quality of their hospital stay.


Findings included:


- Review of the Hospital policy and procedure #:7.080 stated, "Children under the age of 12 may visit, but they must be supervised by an adult (18 years or older) at all times."


The policy did not include the regulatory requirement that children under six years of age shall be admitted as visitors only when the hospital has a special family visiting program or when authorized in writing by the attending physician or the chief executive officer of the hospital, or the professional nurse charged with the responsibility for the care of the patient.

Based on interview and record review the hospital failed to ensure that all medical records of discharged patients were completed within 30 days following discharge. Failure to ensure the processing of all patient records in a timely manner according to applicable policies and procedures resulted in a potential delay retrieving patients' medical information.


Findings included:

Interview with the Medical Records Director (Staff X) on 10/05/2016 at 2:00 p.m. revealed there were approximately 86 delinquent medical records (not completed within 30 days) due to physicians not completing the record.

Staff X stated that physicians with delinquent medical records were notified twice a month. Incomplete medical record information was reported to administration at monthly meetings.

- According to the RULES AND REGULATIONS OF THE MEDICAL STAFF OF MCPHERSON HOSPITAL, INC, medical records are to be completed within thirty days following discharge.

Based on observation, staff interview, and policy review the hospital failed to ensure expired medications were removed from patient use in one of one CAT scan (a type of X-ray device) supply cabinet and one of one Medical/Surgical unit medication refrigerator. The deficient practice had potential to cause harm to all patients and increase medication errors.

Findings include:

- Observation of the CAT scan room supply cabinet on 10/3/2016 at 12:50 PM revealed seven bottles of Gastrografin (a lemon flavored water soluble solution patients drink that help doctors see images of the body more clearly during scans) 50 ml (milliliter) expired February 2016.

Interview with Radiology director staff G on 10/3/2016 at 1:00 PM verified expired Gastrografin.

- Observation of the Medical/Surgical unit medication room refrigerator on 10/4/2016 at 4:00 PM revealed 1 vial of Levemir Insulin (medication injection given to people with diabetes to lower blood sugar) opened with no date written on the discard in 28 days label that was on the vial and 1 bottle of Magnesium Citrate (a medication given by mouth to induce bowel movement) with white build up along the bottle and lid.

Interview with pharmacy tech staff Q and Nurse Manager Staff T on 10/4/2016 at 1:00 PM verified the Levemir was not marked with a discard date, saying if it doesn't have a date it needs to come out of there. Pharmacy tech Q removed the leaking Magnesium Citrate bottle and the undated vial of Levemir from the refrigerator.

- Document titled Unusable and outdated medications reviewed on 10/6/2016 at 11:30 AM directed: ...All storage areas of the hospital will be inspected; Surgery, night medication locker and other patient care unit stock areas if applicable, for outdated drugs, contaminated drugs, improperly stored drugs and containers with worn, illegible or missing labels. The pharmacy staff member conducting the inspection will remove all of these types of drugs from the area ...

- Review of the Centers for Disease Control and Prevention regarding Safe Practices for Medical Injections. Medication vials should always be discarded whenever sterility is compromised or questionable.

In addition, the United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

Based on observation and interview the hospital failed to perform ongoing maintenance and inspection to identify areas in need of repair. This failed practice placed the safety and well-being of all patients and visitors at risk.


Findings included:


- Observation on 10/3/2016 of the kitchen, at 12:40 p.m., the storage area for dry goods revealed a crack in the masonry wall behind the canned goods. The crack appeared to have been caulked in the past because the crack had enlarged and the caulking was separating from the sides of the crack. A second crack in the masonry was observed over the door to the dry storage area.

Interview with the kitchen service staff stated they were aware of the problem.

Based on policy review, observations and staff interviews the hospital failed to ensure all supplies are maintained to safely meet patients' needs for both day-to-day operations in two of three Emergency Department (ED) Emergency crash carts, one of one Operating room emergency crash cart, in one of one Laboratory department supply tote, one of one Operating room anesthesia workroom, one of one Obstetrical supply room, one of one Neonatal respiratory tool box, one of one Neonatal crash cart, one of one Adult airway tool box and one of one Adult crash cart, one of one Anesthesia procedure cart, one of one Medication cart in the obstetrical operating room, one of two Rehabilitation center supply closet, one of one CAT scan room, one of two Nursery supply drawers, and one of one 3rd Floor clean utility room. This deficient practice or failure of the facility not to dispose of expired supplies placed all patients at risk for receiving ineffective supplies/treatments. Additionally, the hospital failed to ensure the Rehabilitation Center monitored and documented the temperature of the Hydrocollator (water tank for storing moist hot packs) and failed to document that monthly cleaning was completed. Failure to ensure Hydrocollator temperatures were monitored put all patients at risk for burns or ineffective treatment and potential for transmission of infection.

Findings include:



- Emergency Crash Cart # 1 observed on 10/3/2016 at 1:00 PM revealed the following outdated supply:

1) One King LTSD Kit/Trousse/Kit (disposable, simple to use alternative airway device that provides superior patient ventilation) Size 3 with expiration date of 9/30/2016.

ED Manager Staff N interviewed on 10/3/2016 at 1:10 PM acknowledged the kit was expired. Staff N stated our Respiratory Department takes care of our Emergency Crash Carts.

- Emergency Crash Cart # 2 observed on 10/3/2016 at 1:30 PM revealed the following outdated supplies:

1) One IV safety Needle (a catheter placed in a vein to give fluids and/or medications) 18g x 1 ½ gauge with expiration date of 6/2016.

2) One King LTSD Kit/Trousse/Kit Size 4 with expiration date of 8/2016.

3) One Intubating stylet (helps reduce friction between stylet and endotracheal tube for easy endotracheal tube insertion and removal) 10 French with expiration date of 5/2016.

4) One Nasopharyngeal Airway (a tube that is designed to be inserted into the nasal passageway to secure an open airway) 18 French with expiration date of 1/2015.

ED Manager Staff N interviewed on 10/3/2016 at 1:40 PM acknowledged the supplies were expired and should have been replaced.

- Operating Room Emergency Crash Cart observed on 10/5/2016 at 10:08 AM revealed the following outdated supplies:

1) One Oral/Nasal Tracheal Tube (catheter that is inserted into the trachea, windpipe, for establishing and maintaining a airway) 4.0mm with expiration date of 7/2016

2) One Oral/Nasal Tracheal Tube 6.5mm with expiration date of 12/2012.


ED Manager Staff N interviewed on 10/5/2016 at 10:10 AM acknowledged the supplies where expired and should have been replaced.

- Lab Technician's supply tote container observed on 10/3/2016 at 3:15 PM revealed seven Blood Culture Vials (used to collect blood from a person to find and identify any infectious organisms) with expiration dates of 5/30/2016, 6/30/2016 and 7/31/2016.

Director of Laboratory Staff F interviewed on 10/3/2016 at 3:30 PM acknowledged the blood culture vials where expired and should have been disposed of.

Technical Supervisor Staff M interviewed on 10/3/2016 at 3:30 PM acknowledged the blood culture vials were expired. Staff M mentioned they do not use that supply tote that much anymore.

- Operating Room Anesthesia Workroom wall cabinet observed on 10/5/2016 at 10:30 AM revealed the following outdated supply:

1) One Insyte 20gauge 1.0 inch (a catheter placed in a vein for fluids and/or medications) with expiration date of 6/2016.

Surgery Manager Staff L interviewed on 10/5/2016 at 10:30 AM acknowledged the expired supply in the Anesthesia Workroom should have been disposed.

- Observation of Obstetrical supply storage room on 10/4/2016 at 11:20 PM revealed two 3.5 mm (millimeter) endotracheal tubes (a tube placed in the windpipe to help with breathing) with an expiration date of 6/2016.

Interview with Obstetrical unit manager Staff P on 10/4/2016 at 11:25 AM verified expired endotracheal tubes.

- Observation of neonatal respiratory tool box in the obstetrical unit on 10/4/2016 at 11:30 AM revealed three 3.5 mm (millimeter) endotracheal tubes (a tube placed in the windpipe to help with breathing) with an expiration date of 6/2016 and one Delee mucous trap (a device used for suctioning) with an expiration date of 11/2015.

- Observation of neonatal crash cart in the obstetrical unit on 10/4/2016 at 11:35 AM revealed one 20 gauge intravenous needle expired 9/2016 and 3 expired packets of Red Dot ECG (electrocardiogram) electrodes used for monitoring the heart.

- Observation of Adult Airway Toolbox in the obstetrical unit on 10/4/2016 at 11:45 AM revealed one tube of Lidocaine (a topical numbing gel) 2% expired 7/2016, one CO2 (carbon dioxide) detector expired 8/2016, one ABG (arterial blood gas) kit with use by date of 7/2016 and one Satin Slip Stylet with use by date of 3/2014.

- Observation of Adult crash cart in the obstetrical unit on 10/4/2016 at 11:50 AM revealed two packets of Prevantics (a skin antiseptic solutions that helps reduce preventable infections) expired on 5/2015.

Interview with Obstetrical Manager Staff P on 10/4/2106 at 12:00 PM verified expired supplies in the neonatal respiratory tool box, neonatal crash cart, adult airway toolbox, and adult crash cart.

- Observation of the anesthesia procedure cart in the Obstetrical unit on 10/5/2016 at 9:05 AM revealed one expired Combined Spinal and Epidural Anesthesia kit, one size 4 Laryngeal mask airway (a medical device used to keep the airway open) expired 8/2014 and one size 3 Laryngeal mask airway expired 12/2015.

- Observation of the medication cart in the obstetrical operating room on 10/5/2016 at 9:15 AM revealed two endotracheal tubes that were sterile opened and available for patient use.

Interview with CRNA Staff U on 10/5/2016 at 9:30 AM verified expired and opened supplies in the anesthesia procedure cart and obstetrical operating room.

- Observation of Rehab Center supply closet on 10/3/2016 at 2:10 PM revealed Nineteen packets of Iodine swabs expired in 2009, eleven Promogran matrix (a wound dressings) expired 3/2013, four expired culture swabs and many expired wound VAC ( a negative pressure wound therapy technique using a vacuum to promote wound healing) dressing supplies.

Interview with physical therapist manager Staff I on 10/3/2016 at 2:20 PM verified expired supplies in the Rehab Center supply cabinets.

- Observation of CAT scan room supply cabinet on 10/3/2016 at 12:50 PM revealed 2 Vacutainer needles (needles used to draw blood) with expiration dates of 7/2013 and 8/2015 and three tubes of water soluble lubricant with various expiration dates.

Interview with Radiology director Staff G on 10/3/2016 at 1:00 PM verified expired vacutainer needles and water soluble lubricant.

- Observation of the Obstetrical Unit Nursery on 10/4/2016 at 11:15 AM revealed a large bag of sterile packaged safety pins, 2 safety pins per package, with a use by date of 2/2016 and one packet of Prevantics swabs (a skin antiseptic solutions that helps reduce preventable infections) expired 5/2015.

Interview with Obstetrical Unit manager Staff P on 10/4/2016 at 11:15 AM verified use by date of 2/2016 for the sterile safety pins and the expired Prevantics swabs.

- Observation of the 3rd Floor clean utility room, conducted on 10/04/2016 at 1:30 PM., revealed the following expired supplies; Steri-strips (09/2016).

Interview with Materials Management Staff W stated material management routinely conducted inventory reviews for expired supplies throughout the hospital every 6 to 7 months. Staff W stated it had been 8 months since the last inventory review.

- Policy reviewed on 10/4/2016 at 4:00 PM revealed the hospital failed to develop a policy to ensure the hospital disposed all expired supplies.




- Observation of Hydrocollator on 10/3/2016 at 2:00 PM revealed cloudy discolored water. No evidence of documented temperatures or cleaning.

Interview with physical therapist manager Staff I on 10/3/2016 at 2:05 PM, s/he said that they try to maintain the Hydrocollator temperature between 155-168 degrees but they do not keep a temperature log. The Hydrocollator is cleaned about every 30 days or when the water is cloudy or discolored. They do not document when the Hydrocollator is cleaned.

Document titled Department of Rehabilitation Services Continuous Quality Improvement Section IIIA reviewed on 10/4/2016 at 10:20 AM directed ...Quality control documents will be maintained for the following areas: Temperature control of Hydrocollator tanks on a weekly basis

- Temperature will be maintained at 158-167 degrees F (70-75 C)

- Biomedical will be notified immediately if any variance is noted ...

Document titled Department of Rehabilitation Services Infection Control Plan Section XB reviewed on 10/4/2016 at 10:20 AM directed ...-Hydrocollator machines will be thoroughly rinsed, scrubbed and disinfected on a monthly basis unless otherwise need according to established cleaning procedures ...

Based on observation and staff interview the hospital failed to monitor temperature and humidity in 3 of 3 operating rooms (OR). Failure to monitor temperature and humidity in the operating rooms puts all patients at risk for discomfort, potential malfunction of equipment and infection from the deterioration in products.

Findings include:

- Observation of the obstetrical (OB) unit on 10/4/2016 at 11:00 AM revealed two labor and delivery rooms, five postpartum (following childbirth) rooms, one nursery and one operating room (OR).

Interview with OB manager staff P on 10/4/2016 at 12:00 PM, s/he was asked about temperature and humidity logs for the OB OR. S/he said that OR staff from down stairs come up when there is a cesarean section and that they may have a temperature and humidity log. S/he reported that the only thing OB staff do in the OB OR is receive the baby.

- Observation of the OB OR on 10/5/2016 at 9:30 AM revealed no temperature or humidity logs.

- Review of AORN Guideline and Clinical Resources: The recommended temperature range in an operating room is between 68°F and 75°F. Collaborate with infection prevention, and facility engineers when determining temperature ranges. Each facility should determine acceptable ranges for temperature in accordance with regulatory and accrediting agencies. Guideline for a safe environment of care, part 2. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

The recommended humidity range in an operating room is 20% to 60% based upon addendum d to ANSI/ASHRAE/ASHE Standard 170-2008. Each facility should determine acceptable ranges for humidity in accordance with regulatory and accrediting agencies and local regulations.