HospitalInspections.org

Based upon record review and interview, the governing body failed to ensure the Hospital's Quality Improvement (QI) Program evaluated Hospital Services provided under contract or agreement. This was evidenced by the failure to include in the QI activities the evaluation of contracts related to clinical care to ensure the service was provided in accordance with the contract. Findings:

Review of the QI Program data for 2016 revealed there failed to be documented evidence contracted services were evaluated through the QI Program to ensure the services were provided in accordance with the contract.

Interview on 11/30/16 at 10:35 a.m. with S17QA confirmed the services provided by contract were not reviewed through the QI Program.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the patient's care. This deficient practice is evidenced by failure of the nursing staff to administer patient medications as ordered for 1 (#26) of 5 patients reviewed for medication administration out of a total sample of 30. Findings:Review of Patient #26's medical record revealed she was admitted to the hospital on 11/23/16, with an admitting diagnoses of COPD, Sepsis, & Cocaine abuse. Review of the Physician admit orders revealed an order for the following medications: Cevimeline 30 mg oral capsule tid first dose 11/23/16 10:00 p.m.; Venlafaxine 75 mg ER oral daily first dose 11/24/16 at 9:00 a.m. and Fluticasone-vilanterol 100/25mcg INH daily first dose 11/24/16 at 9:00 a.m.

Review of Patient #26's medication administration record revealed the nurses failed to administer a total of 11 doses (11/23- 11/27) of Cevimeline 30 mg and 3 doses (11/24, 11/25, 11/28) of Venlafaxine 75 mg and 5 doses (11/24- 11/28) of Fluticasone-vilanterol 100/25mcg INH. The MARs indicated the reasons for the medications not being administered included that the "medications were not available, family bringing home meds, and schedule conflict." Further review revealed no documentation to indicate that the Venlafaxine was administered on 11/28/16. Review of the Nurses' Notes revealed no documented evidence that Patient #26's physician was notified of the medications not being available for administration.

In an interview on 11/29/16 at 10:00 a.m., S7RN indicated that Cevimeline 30 mg, Venlafaxine 75 mg, and Fluticasone-vilanterol 100/25mcg INH was the patient's home medication (patient specific) and was not available in the Omincell. She indicated that the patient's family failed to bring the medications for administration and the staff failed to notify the physician that the medication was not available. She provided the explanation that at some point (11/26 & 11/27) Venlafaxine was available and administered and had no explanation for its unavailability for the next schedule dose (9:00 a.m. 11/28). She had no explanation for the reason documented "schedule conflict."

In an interview on 11/29/16 at 10:20 a.m., S5RN confirmed that the medications were not administered (medication error) as ordered by the patient's physician and the staff failed to notify the physician of the unavailability of the medications.

Based on record review, observation and interview, the hospital failed to ensure the infection control officer developed and implemented a system for controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:
1) Failure to ensure the glucometer was properly disinfected between patients for 2 of 2 blood glucose fingersticks observed;
2) Failure to properly prepare (alcohol wipe) a single dose vials for medication withdrawal for 2 of 2 observations of injectable medication preparation; and
3) Failure of staff to follow hospital policy and procedure for hand hygiene practices.
Findings:

1) Failure to ensure the glucometer was properly disinfected between patients for 2 of 2 blood glucose fingersticks observed.

Review of the hospital policy titled "Capillary Blood Glucose", presented by S1CNO as current, indicated that the nursing staff is responsible for cleaning the CBG machine after each patient use with "Super Sani-wipes"(disinfectant)

An observation on 11/28/16 at 12:20 p.m., revealed S6RN performed a capillary blood glucose check on Patient #11 without cleaning/disinfecting the glucometer before or after use.
An observation on 11/28/16 at 12: 30 p.m., revealed S6RN performed a capillary blood glucose check on Patient #13 without/cleaning/disinfecting the glucometer before use. S6RN wiped the glucometer down with a 70% alcohol wipe after use and placed it on top of the work station on wheels.

2) Failure to properly prepare (alcohol wipe) a single dose vial for medication withdrawal.

Review of a document titled, "Skills. Medication Administration: Injection Preparation from Ampules and Vials", provided by S1CNO as the current guide used by hospital staff for the preparation and administration of medications, revealed for preparing Medication from a Vial containing solution (for injection) the steps were: 1) Remove cap covering the top of an unused vial to expose the rubber seal, 2) Firmly and briskly wipe the surface of the rubber seal with an alcohol swab, being sure to apply friction, and allow it to dry, and 3) draw up the medication into the syringe

An observation on 11/28/16 at 12:35 p.m., revealed S6RN prepared an injection of Reglan (single dose vial) IV for Patient #13. She removed the vial from the package, inserted the needle into the rubber stopper withdrawing the medication, without first cleaning the rubber septum with alcohol.

An observation on 11/28/16 at 12:11 p.m. revealed S15RN prepare an IV injection of Solu-Medrol from 2 separate single-use vials, and administer the medication to Patient #6. 15RN was observed to remove the plastic flip tops of the two Solu-Medrol vials, insert the needle, and withdraw the medication without cleaning the rubber stopper with alcohol first. S15RN confirmed she did not clean the rubber stoppers prior to accessing them with a needle.

In an interview on 11/28/16 at 3:45 p.m. S1CNO indicated that the procedure for preparing medications for injection was to clean the rubber stopper of a vial (of medication) with alcohol before withdrawing the medication. S1CNO provided a Mosby's skill procedure for preparation of injectable medication, and reported that was what the nursing staff was to use for procedures. The CNO reported that all nurses had access through the electronic "policy manager" for procedure related information.

3) Failure of staff to sanitize/wash hands before/after removing gloves.

Review of a hospital policy and procedure titled, "Hand Hygiene" (original date 02/24/03, last reviewed 05/2016) provided by S5RN as current revealed appropriate times to perform hand hygiene (hand washing or hand sanitizer use) included, in part: upon entering a patient's room, before touching patient or the patient's surroundings, after contact with a patient's intact skin and/or patient surroundings, after removing gloves and other PPE.

An observation on 11/28/16 at 12:35 p.m., revealed S6RN placed a pair of gloves on to check Patient #13's O2. She removed the gloves, replacing the gloves without sanitizing/washing her hands before/after removing gloves.

In an interview on 11/28/16 at 12:45 p.m., S6RN indicated that she just forgot to clean the glucometer between patients (#11 and #13). S6RN indicated that since vial had never been opened it was sterile and there no need to wipe the top with alcohol. She indicated that she changed gloves numerous of times during this encounter and she just got in a hurry.

An observation 11/28/16 from 12:20 p.m. to 12:30 p.m., in the hospital room of Patient #6, revealed S8MD enter the room with a stethoscope hanging around her neck. During this observation, S8MD was observed to listen to Patient #6's chest and abdomen with the stethoscope, with no cleaning of the stethoscope before or after examining the patient. S8MD also palpated Patient #6's abdomen. During the observation, S8MD did not perform hand hygiene upon entering the room , in the room, or when she left the room. S15RN, present during the observation verified she did not observe the physician perform hand hygiene in the patient's room, or when she left the patient's room. S15RN verified S8MD had not cleaned her stethoscope before or after use on the patient.


31206

Based on record review, observation, and interview the hospital failed to ensure the hospital's Surgical Services followed acceptable professional standards of practice and hospital policy and procedure governing surgical services and infection control. This failed practice was evidenced by observations of staff with beards and sideburns uncovered in the OR during a surgical procedure and an observation of a staff walking into an OR with no face mask while a sterile table was open in preparation for a surgery and scrubbed personnel were present.
Findings:


The AORN Guidelines for Perioperative Practice, 2015 edition - Guideline for Surgical Attire:
Recommendation I. revealed in part: All individuals entering the restricted surgical area should wear a surgical mask when scrubbed personnel, sterile supplies, and/or sterile equipment are present. A surgical mask protects the patient from transfer of microorganisms ...
Recommendation III revealed in part: All personnel should cover head and facial hair, beards, including the sideburns, the ears, and the nape of the neck, when in semi-restricted and restricted areas. Human hair can be a site of pathogenic bacteria such as MRSA. Hair acts as a filter when it is uncovered and collects bacteria. A clean, low-lint surgical head covering or hood that confines all hair (including beards) and covers scalp skin and ears should be worn. The head covering or hood should be designed to minimize microbial dispersal.
Recommendation IX revealed in part: Restricted areas in a surgical suite includes the O.R. (operating room) and procedure rooms, the clean core, and the scrub sink areas. People in the restricted areas are required to wear full surgical attire (scrub attire, head coverings, masks, and shoe covers as applicable).

Review of hospital policy and procedure titled " OR Attire " (original date 02/2003), provided by S11RN as current, revealed, in part " ...Procedure ...B. Personnel should cover head and facial hair, including sideburns and necklines, when in semi-restricted and restricted areas of the surgical suite ...D. All persons entering restricted areas of the surgical suite should wear a mask when open sterile items are present."

An observation 11/29/16 at 7:45 a.m. revealed S9CRNA, providing anesthesia care to Patient#22 in OR " a " . S9CRNA was noted to have all of his sideburns exposed, uncovered by his disposable head covering. Further observation revealed S18ST was scrubbed, gowned, and prepared the sterile table of instruments. His beard was observed to be exposed on either side of his surgical mask, and extended to part of his sideburns, also exposed. S14RN, circulating nurse present in the OR for the observations, verified the observations and indicated all staff head and facial hair should be covered.

An observation 11/29/16 at 8:10 a.m. revealed S10CRNA enter OR " b " , with the door closing completely behind him. S10CRNA was noted to be without a surgical mask on. Further observation of OR " b " revealed staff scrubbed and standing by a table with opened sterile items on them. S16RN, present in OR " b " verified S10CRNA had entered the OR without a mask, while scrubbed staff were present and sterile items were open. S16RN confirmed S10CRNA should have had a mask on when he entered the OR.

In an interview 11/29/116 at 8:20 a.m. with S11RN and S13CRNA, S11RN, supervisor of surgical services, reported the hospital's surgical services followed AORN guidelines. S11RN provided a copy of the hospital ' s policy and procedure for surgical attire in the surgical suite. Both S11RN and S13CRNA indicated that staff should have all hair covered, including facial hair and sideburns, and all staff entering an OR with scrubbed personnel and/or opened sterile supplies should have a mask on.