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Based on document review and interview, it was determined for 1 of 2 (Pt#5) patients with wounds on admission, the Hospital failed to ensure wound assessments/wound measurements were conducted per policy. This has the potential to affect all patients receiving care at the Hospital with a current census 80 patients.

Findings include:

1. The policy titled "Skin Wound Assessment and Documentation" (last reviewed by the facility 8/20/2019) was reviewed on 6/1/22. The policy noted on page 2, "Wound assessment and documentation on admission ... Wound measurements are obtained upon identification of wound ... Referral. A referral is considered to the wound/ostomy/resource specialist for consultation for the following: Complex and/or non-healing wounds."

2. Pt #5 Date of Service (DOS): 5/25/22
Diagnosis: AKI (Acute Kidney Injury). On 5/31/2022 at approximately 3:00 PM, the medical was reviewed. The Nursing Admission Assessment dated 5/25/22 noted a right buttock pressure ulcer. The Assessment lacked wound measurements, wound assessment and lacked a referral to the wound nurse.

3. During an interview on 5/31/2022 at approximately 3:30 PM, the Quality Manager (E#7) reviewed Pt#5's record and verbally agreed the record lacked the required wound documentation and referral for a wound care nurse and should have been.

Based on document review and staff interview, it was determined for 1 of 2 (Pt#9) medical records reviewed on the MICU (Medical Intensive Care Unit), the Hospital failed to ensure telephone orders were signed by the physician within 72 hours per policy. This has the potential to affect all patients who receive care by the Hospital with a current census of 80 patients.

Findings include:

1. The policy "Medical Staff Rules and Regulations" (revised January 2022) was reviewed on 6/1/22. The policy noted "Article 1: Clinical Aspects 3.8 Orders- Treatment/Medication: #7 Telephone orders shall be used sparingly and must be signed, dated, and timed by the ordering practitioner or another practitioner who is responsible for the care of the patient within 72 of the order."

2. Pt #9 Date of Service (DOS): 5/18/22
Diagnoses: Hypoxia and Respiratory Failure. On 6/1/2022 at approximately 9:30 AM the medical record of Pt #9 was reviewed. As of 6/1/2022, fourteen (14) days have elapsed, and the following telephone orders lacked the physician signature:

a. telephone order dated 5/19/2022 Amiodarone 150 mg/100 ml (milligrams/milliliters) give over 10 minutes
b. telephone order dated 5/19/2022 Amiodarone 900 mg/500 ml D5W (dextrose 5% in water) 1 mg/minute

3. During an interview on 6/1/2022 at approximately 10:00 AM, the Pharmacy Director (E#4) reviewed Pt #9's record and verbally agreed the physician orders had not been sign within the 72 hour requirement and should have been.

Based on document review, observation and interview it was determined the Hospital failed to ensure medications were stored in a secure manner. This has the potential to affect all patients, staff, and visitors who receive care by the Hospital with a current census of 80 patients.

Findings include:

1. The policy titled "Storage-Medication Management" (last revised by the facility, 12/5/2020) was reviewed on 6/2/2022 at approximately 11:20 AM. The policy noted "III. Procedure... B. All medication and biologicals, including controlled medications, investigational and patient own medications, will be stored securely to prevent diversion and locked, when necessary, in accordance with law and regulation."

2. During a tour on 5/31/22 at 11:50 AM of the surgical suites with the Director of Surgical Services (E#8), in OR #9 (Operating Room) the anesthesia cart drawers were observed to be unlocked and unsecured. The drawers contained one (1) 250 milliliter (ml) bottle of Sevoflurane, USP (an ether inhalation anesthetic agent used for the induction and maintenance of general anesthesia) with approximately 75 ml remaining.

3. During the tour on 5/31/22 at 11:50 AM, E#8 observed the above findings and verbally agreed the Anesthesia cart was not secured and the medication was not appropriately stored and secured and should have been.

Based on observation, document review and interview, it was determined for 1 of 2 (E#11) Operating Room staff who required a dosimeter badge, the Hospital failed to ensure the dosimeter badges were monitored per policy. This has the potential to affect all patients who utilize surgical services with an average of 450 procedures per month.

Findings include:

1. The policy titled "Radiation Dosimetry Badges" (revised by the facility, 6/2/2016) was reviewed on 6/1/22. The policy noted "l.... any employee who may be exposed to radiation will be given a radiation dosimetry badge... Vl. Dosimetry badges are to be worn at all times while in a radiation-restricted area... Vll. The employee is responsible for exchanging the dosimetry badge inserts each month... X. If a badge is lost or damaged, please notify the Radiation Safety Officer immediately. A replacement badge will be issue (d) for the rest of the month."

2. During a tour of the surgical suites on 5/31/22 at approximately 2:00 PM, the registered nurse (E#11) was observed in room #8 with a lead apron donned (required for procedures that utilize radiation) and lacked a dosimetry badge. The Director of Surgical Services (E#8) interviewed E#11 and was told by E#11 "I don't have one." E#8 stated "E#11 lost the dosimeter badge and it had not been replaced yet."

3. The Dosimeter Reports from February to May 2022 were reviewed on 6/1/22 at approximately 8:30 AM. The reports noted E#11's last dosimetry reading was on 4/14/22. The reports noted March 2022, 15 of 18 (83%) dosimetry badges were not turned in; April 2022, 4 of 16 (25%) dosimetry badges were not turned in; and May 2022 4 of 22 (18%) dosimetry badges were not turned in and 3 were reported as unused.

4. During an interview on 6/3/22 at 10:15 AM, the Nuclear Medicine Technician (E#12) reviewed the dosimetry report and stated the "m" mean "minimal exposure to radiation" and "ABSENT" means the badges were not turned in for monitoring.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on July 1, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on June 1, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation and interview, it was determined the Hospital failed to ensure patient equipment was maintained to prevent cross-contamination. This has the potential to affect all patients receiving care in the Hospital with a current census of 80 patient.

Findings include:

1. During a tour on 6/1/2022 between 10:00 AM and 11:00 AM of the Obstetrics (OB) Unit, the Operating Room's Anesthesia Cart was observed to have a 7.0 mm (millimeters) Hi-Lo Oral/Nasal Tracheal tube cuffed with a Stylet inserted into the tracheal tube with a 10 ml (milliliter) syringe, inside the open sterile tracheal package.

2. During an interview on 6/1/2022 at approximately 10:50 AM, the Director of OB (E#6) observed the sterile package and stated "this is against our infection control policy."

B. Based on observation, documentation review and interview, it was determined for 1 of 1 (Pt#10) patients observed receiving a nebulizer treatment, the Hospital failed to ensure equipment was cleaned to prevent cross contamination per policy. This has the potential to affect all patients receiving care at the Hospital with a current census of 80 patients.

Findings include:

1. The policy titled "COVID-19 Prevention Program" was reviewed on 6/2/2022 at approximately 11:00 AM. The policy noted on page 4 "8. Aerosol-Generating Procedures (AGPs) on a Person with Suspected or Confirmed COVID-19. Clean and disinfect the surfaces and equipment in the room or area where the procedure was performed, after the procedure is complete."

2. Pt #10 Date of Service (DOS): 5/29/2022
Diagnosis: Hypoxia and Heart Failure. During a tour of the Medical Intensive Care Unit on 6/1/22 at approximately 1:10 PM, Pt #10 was observed to be on AGP precautions which required PPE (Personal Protective Equipment), the Respiratory Therapist (E#5) was observed to assess Pt #10's lung sounds with E#5's personal stethoscope, prior to and after administrating an Albuterol Nebulizer treatment. E #5 left Pt #10's room (#334) and failed to sanitize the stethoscope. E#5 then entered room #332 and did not sanitize the stethoscope prior to assessing the Pt in room #332.

2. During an interview on 6/1/2022 at approximately 3:40 PM, the Quality Manager (E#7). E#7 verbally agreed the stethoscope had not been disinfected and should have been.

Based on document review, observation, and interview, it was determined the Hospital failed to ensure a clean and sanitary environment to prevent the transmission of infectious diseases. This has the potential to affect all staff, visitors and patients who receive care by the Hospital with a current census of 80 patients.

Findings include:

1. The Environmental Services Department policy titled "Surgery Cleaning" (issued 2/1/2022) was reviewed on 6/2/22 at approximately 9:45 AM. The policy noted "Daily Terminal Cleaning (AORN (Association of peri-operative Registered Nurses)Environmental Cleaning Recommendation IV.) 2. Clean and disinfect surgical lights and high equipment/surfaces... Surgery Suites: 3. Wash Walls, doors, door frames, electrical outlets, rubber hoses, fixtures attached to walls, including wheels on Rolling Equipment, and outside surface of cabinets or shelves with germicidal solution."

2. During tours conducted on 5/31/22 through 6/2/22, the following was observed:

Surgical Services:
a) On 5/31/22 at approximately 2:15 PM, in the Recovery Room, 2 monitors were observed to have large amounts of dust on top;
b) On 5/31/22 at approximately 2:45 PM, OR #1 (Operating Room) the Davinci Surgical Robot and Davinci Computer Support Cabinets had large amounts of dust on top;
c) On 6/1/22 at approximately 9:45 AM, staff were observed to turnover/clean OR #5 for the next case. EVS staff failed to mop the floor where surveyors were standing, and staff failed to dispose of full, open top trash receptacle before the next case and the Phaco machine was not cleaned;
d) On 6/1/22 at approximately 10:00 AM prior to entering a procedure room to observe a surgery, the Director of Surgical Service (E#8) requested we donn a new surgical mask. the Nurse Educator (E#13 ) donned a new mask although wore the old mask around her/his neck throughout the rest of the tour at approximately 10:55 AM.

During an interview on 6/1/22 at approximately 10:25 AM, E #8 verbally agreed that staff should be cleaning all surfaces and emptying trash/ soiled linens between cases and at the end of the day. E #8 stated "I will talk with them about it."

3. During tours conducted on 5/31/22 through 6/2/22, the following was observed:
Cardiac Catheter (Cath) Lab:
a) On 6/1/22 at approximately 11:00 AM, the clean supply/equipment room was observed to have a Datascope CS300 Automated Counterpulsation Machine with dried blood on the wheel and wheel housing;
b) On 6/1/22 at approximately 11:10 AM, Cath Lab #2 was observed to have one 500 milliliter (ml) bag of 1000 unit Heparin Sodium (with approximately 20 ml remaining) sitting in the sink, trash on the floor and under cabinets, ETCO2 (Endo (endoscopic) Tracheal Carbon Dioxide) pigtail taped to procedure table without caps on and end connection open, one 250 ml bag of Normal Saline taped to procedure table, a clean restraint tied to the bed was resting on the floor, a single use bottle from the previous patient was observed in the injector and a new sterile bottle was observed on the countertop;
c) On 6/1/22 at approximately 11:20 AM, Cath Lab #1 was observed to have an ETCO2 (Endo Tracheal Carbon Dioxide) pigtail laying on the procedure table without caps on and end connection open, and suction tubing stored in a wall basket, opened without packaging.
d) On 6/1/22 at approximately 11:25 AM, the Monitor Room's data cabinet was observed to have a dusty package labeled "Blue Sensor Pouch" with an expiration date of 6/2018.

During the tour on 6/1/22, between 11:00 AM and 11:30 AM, the Manager of the Cath Lab (E#10) observed the above findings and verbally agreed the equipment and rooms were not appropriately cleaned and supplies were not appropriately stored and should have been. E#10 stated "We leave it (single use bottle in the injector) until the next patient comes in, then we change it. i don't know why we don't change it when we turnover. It's just the way it's always been done."

4. During tours conducted on 5/31/22 through 6/2/22, the following was observed:

Emergency Department:
a) On 6/1/22 at approximately 1:30 PM, the supply room closet was observed to have the following expired items:
- 1 box of Tubifast 2 way stretch tubular bandage, expired 3/2020;
- 1 box of Curos Disinfecting Caps, expired 4/6/2022;
- 1 box of Merocel Surgical Sponge Product, expired 5/15/2022.

During the tour on 6/1/22 at approximately 1:30 PM, the Emergency Department Manager (E#14) verbally agreed the products in the storage closet were expired and should have been disposed of. E#14 stated "I think the whole closet need to be gone through."