HospitalInspections.org

Based on record review and interview, the facility's medical records were not accurately written in that:
A. 2 of 6 inpatients (Patient #8 and #9) who received blood and/or blood product transfusions had incomplete "Transfusion Tag" record documentation. The staff did not document the date and time of the delivery of blood and/or did not appropriately acknowledge, verify, and certify the transfusion information;
B. 1 of 1 patient (Patient #21) on 02/20/14 had an AV (arteriovenous) fistula placed. The facility short form which included surgery documentation for history and physical, and a post-op note did not include a time for the post operative note; and
C. 1 of 1 patient (Patient #31) who received a hemodialysis treatment on 03/05/14 had no documentation as to why the order for the blood flow rate was not followed.

Findings included:

A. Patient #9 received blood and/or blood product transfusions on 02/27/14. The RNs did not check the indicated boxes to acknowledge, verify, and certify the following information in the "Transfusion Tag" record: "[ ] Physician order is verified; [ ] Consent form is signed; [ ] Baseline vitals are done; [ ] Blood tag is verified blood tag...[ ] Blood tag is verified with armband..."

Patient #8 received blood and/or blood product transfusions on 03/06/14. The delivery of the blood/ blood product was not dated and timed as required. The RNs did not check the indicated boxes to acknowledge, verify, and certify the following information: "[ ] Physician order is verified; [ ] Consent form is signed; [ ] Baseline vitals are done; [ ] Blood tag is verified blood tag...[ ] Blood tag is verified with armband..."

In an interview on 03/11/14 at approximately 9:40 AM, the Director of Nursing (Personnel #3) was informed of the above findings and she confirmed the findings.

B. Patient #21 had an AV fistula placed on 02/20/14. The physician did not time the entry for the post operative report. The history and physical part of the form and the history and physical update at the bottom of the form were both timed at 10:00 AM.

C. Patient #31 had orders for a blood flow rate of 400 mL/min. On 03/05/14 the patient received a dialysis treatment with a blood flow rate of 300 mL/min. There was no documentation as to why the blood flow rates were different.

In an interview on 03/12/14 at approximately 10:00 AM, the Director of Nursing (Personnel #3) was informed of the above findings and confirmed the findings for items B and C.

Based on observations, interviews and record reviews the hospital failed to ensure the Director of Dietary Services supervised and maintained the dietary department in a responsible manner in that the following was observed during the survey:
1) 4 of 4 trash receptacles were uncovered in the kitchen area. 2) 1 of 4 dietary staff (Personnel #22) did not wear an effective hair restraint. 3) The floor inside the only dry pantry and the flooring in front of 1 of 2 freezers had cracked, peeling and discolored tiles with rusty stains. The floor under one 1 of 1 hot box was dusty and dirty with small pieces of paper. 4) Six of approximately 12 buffet pans were stored and wet and were stacked upon one another.

Findings included:

During a tour of the facility's only kitchen on the afternoon of 3/11/14 the following was observed. Personnel #16 was present and confirmed the findings below:

1) Four trash receptacles in the kitchen area that contained food scraps and/or soiled papers were uncovered.

2) Personnel #2's hair restraint did not restrain approximately 2 inches of his hair between the lower edge of his hair restraint and the lower edge of his hair at his neck.

3) The pantry's linoleum floors had tiles that were peeling with rust stains and discoloration. The tile in front of the freezer was cracked with missing pieces of tile and was discolored. An accumulation of dust, dirt and small pieces of paper were observed on the floor under the hot box.

4) Six buffet pans were stored wet and stacked upon one another.

During an interview on 3/12/14 at 9:30 AM with Personnel #27 he confirmed the trash receptacles in the kitchen did not have required lids.

Review of the contracted dietary service's Cleaning and Sanitation policy and procedures dated 2/18/13 revealed, "...Maintain good housekeeping, general cleanliness, and sanitation of the entire location... Air-dry all equipment and utensils after sanitizing them using either a manual or mechanical process. Provide ample space to facilitate self-draining of equipment so that it can air-dry properly... Store clean and sanitized equipment and utensils in a way that protects them from contamination..."

Review of the contracted dietary service's Food Safety Training Associate Hygiene-Hair Restraints and Jewelry dated 10/19/11 revealed, "...Hair restraints must be worn by associates, including one or a combination of: -Clean hat or baseball cap-Clean visor with hairnet-Approved hairnet-Facial hair restraint for facial hair longer than 1/4 inch..."

Based on observation, interview, and record review, the facility's designated infection control officer failed to implement policies governing control of infections in that:
A. 2 of 3 registered nurses (RNs) (Personnel #7 and #8) did not perform appropriate hand hygiene after removal of soiled gloves in the day surgery unit;
B. 4 of 4 physician and/or personnel (Physician #11, Personnel #24, Personnel #25, and Personnel #26) wore surgical masks outside the restrictive area of the day surgery unit.
C. 3 of 5 personnel (Personnel #25, #28 and #29) failed to wear effective hair restraints in the Operating Room (OR) during a sterile surgical procedure.
D. 5 of 9 scissors instruments were sterilized with their tips in the closed position.

Findings included:

A. On 03/10/14 at 12:35 PM a tracer patient (Patient #1) was followed by a surveyor in the preoperative area of the day surgery unit. After an unsuccessful attempt to start an intravenous access to Patient #1, Personnel #8 removed his soiled gloves and stepped out of the patient's room. He then proceeded to the clean utility. He did not wash or sanitize his hands as required. At approximately 12:37 PM Personnel #7 donned a pair of clean gloves and conducted an assessment of Patient #1 preoperatively. After completion of the assessment, Personnel #7 removed the soiled gloves. She then proceeded to document in the patient's medical record and entered data into the computer. She did not wash or sanitize her hands as required.

B. On 03/10/14 at 2:33 PM, while waiting for the second tracer patient, Patient #2 to come out from the restrictive/ intraoperative area to the postoperative area (post-op) following a surgical procedure, Personnel #25 was observed coming out from the restrictive area to the post-op area wearing a surgical mask. At 2:49 PM, Physician #11 and Personnel #24 were observed pushing Patient #2's gurney to the post-op area. Both Physician #11 and Personnel #24 were wearing their used surgical masks hanging down around their necks. At 3:09 PM, Personnel #26 was observed coming out from the intraoperative area to the clean supply room located in the postoperative area.

In an interview on 03/11/14 at 10:25 AM, Personnel #14 (Certified Infection Control Preventionist) was informed of the above findings. Personnel #14 confirmed the above findings in the presence of the Director of Nursing (Personnel #3).

Policy: "Hand Hygiene Protocol" last reviewed on 04/2013 page 2 required "Indications for Handwashing and Hand Decontamination...10. Decontaminate hands after removing gloves."

Policy: "Surgical Attire" last reviewed 11/2013 page 2 required "4...c. Masks should not be worn hanging down from the neck. d. Surgical masks should be discarded after each procedure..."

C. During Patient #2's surgical procedure on the afternoon of 03/10/14 Personnel #25 was observed with long strands of hair hanging out of her bouffant hat. Personnel #28 was observed with his bouffant hat placed on his head to allow the lower portion of his hair to remain uncovered and unrestrained. Personnel #29 wore a surgical cap that allowed the bottom half of his hair to remain unrestrained. Personnel #21 was with the surveyor and confirmed the observation.

The facility's Surgical Attire policy dated 11/2013 reflected, "...A facility approved clean, low-lint, surgical head cover or hood that confines all hair and covers scalp skin should be worn..."

D. During a tour of the sterile supply room on the afternoon of 3/10/14, the surveyor observed 5 scissors had been sterilized with their tips in the closed position. Personnel #21 confirmed the observation. The arrangement of these instruments had not allowed the point of the greatest bio-burden, to be directly exposed to the sterilizing agent, as their tips were in the closed position. These instruments were stored in bins.

The facility's "Packaging, Preparation, and Sterilization policy dated 11/2013 reflected, "...Instruments to be sterilized will be arranged according to the following guidelines... All jointed instruments should be in the open or unlocked position with ratchets not engaged..."




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