HospitalInspections.org

32332

Based on observation, interview, and policy review, the provider failed to ensure medications were stored securely in:
*One of one operating room (OR).
*One of one scope room.
Findings include:

1. Observation on 2/11/20 at 1:45 p.m. of the OR accompanied by registered nurse (RN)/surgical director A revealed an anesthesia cart.
*All drawers of the cart were unsecured. One of the drawers contained the following inhalation medications used for anesthesia:
-One 240 milliliter (ml) container of desflurane.
-Two 250 ml containers of sevoflurane.
-One 100 ml container of isoflurane.

2. Observation on 2/11/20 at 2:00 p.m. of the scope room accompanied by RN A revealed a medication cart. All of the drawers were unsecured. The top drawer contained multiple vials of medications including succinylcholine and Rocuronium.

3. Interview at the above time with RN A regarding the unsecured storage of medications in the OR and scope room revealed:
*Other OR medications were locked away in a refrigerator in the OR.
*The inhalant medications in the OR were never locked up.
*The medication cart in the scope room was never locked up.
*There had been discussion of locking the drawers, but they did not require a lock, because:
-The above rooms were always locked when not in use.
-Only the surgery staff (RN A, licensed practical nurse I, and surgical technicians H and J, and certified registered nurse anesthetist (CRNA) (K) had access to the room.

Surveyor: 25107
Observation on 2/11/2020 at 3:00 p.m. in the operating room suite revealed:
*Two housekeeping staff were preparing to terminally clean the OR.
*The OR was not locked, and the housekeeping staff had unrestricted access.
*There were no other surgical or nursing staff present at the time of the terminal cleaning.

Surveyor: 32332
Observation on 2/12/20 at 10:00 a.m. of the OR revealed:*The OR door was locked.
*The male and female changing room doors located to either side of the OR remained unlocked. Those doors both led to the OR. The OR room was not attended at that time.

Interview on 2/12/20 at 10:15 a.m. with RN A regarding security of the medication stored in the OR and scope room revealed:
*The scope room medication cart was now being locked.
*She confirmed:
-She had discussed the medication security with CRNA K, and she would be securing the OR/scope room medications.
-The housekeepers were not supervised when they cleaned the OR and scope room.
-The surgery staff left those doors open for the housekeepers to clean after the surgery staff had finished in the rooms.
-The medications would not have been stored securely from unauthorized housekeeping staff.

Telephone interview on 2/12/20 at 4:15 p.m. with registered pharmacist F regarding unsecured medications in the OR and scope room revealed she had not known medications had not been secured in those rooms.

Review of the provider's August 2019 Medication and Controlled Substance Storage and Access in the Surgical Environment policy revealed the surgical services department "Shall ensure that all prescribed medications are kept locked when not in use."

Based on interview, policy review, and job description review, the provider failed to ensure:
*Education in infection control (IC) practices had been provided to one of one staff member (registered nurse [RN] A) assigned as the IC preventionist.
*The Infection Prevention and Control Committee met routinely to review IC concerns throughout the building.
Findings include:

1. Interview on 2/12/20 at 2:00 p.m. with RN A regarding the IC program revealed:*She had assumed responsibility for the provider's IC program in December 2018 after having left that job eight years ago.
*She was responsible for surgical services and participated as the RN circulator nurse on surgical cases.
*On days surgery was performed she did not have time to review IC practices or information.
*She was allotted eight hours to complete the IC duties each week.
*She did not feel she had enough hours to complete the IC tasks.
*Areas in the hospital were divided up between the supervisors, and the infection control committee audited their specific areas for IC breeches.
-The returned audits had not included specifics for breeches or which employees were identified.
*The IC committee was expected to meet quarterly. Review of those meetings revealed the most recent meetings had been conducted on:
-January 2016.
-January 2018.
-November 2019.
--The November 2019 minutes were a small paper with only a few scribbled notes.
*She had not received formal IC training since starting her current job in December 2018.

Interview on 2/12/20 at 2:40 p.m. with RN A, chief nursing officer B, assistant chief nursing officer G, chief operating officer C, and quality improvement (QI)/ risk manager D confirmed:
*IC committee meetings had not occurred according to their policy.*RN A had not received formal training since she was hired in December 2018.
*Employees B, C, D, and G stated RN A was offered training opportunities but had not taken the initiative to attend them.
*The provider's management company had presented trainings for IC but had not directly approached RN A to assist her.
*Chief nursing officer B confirmed it was her responsibility to see that the IC coordinator had received training for her role as an IC preventionist.

Review of the provider's November 2019 Infection Control Plan and Guidelines policy revealed:
*The provider's administration: "Shall delegate the oversight and management of the Infection Prevention and Control Plan to the Infection Prevention and Control Committee and infection Preventionist."
*The IC committee members:
-Consisted of staff from administration, nursing, laboratory, quality services, surgery, and medical staff.
-Should have met no less than quarterly to review surveillance that had been conducted.

Review of the provider's November 2018 Surgical Services and Infection Control Team Leader job description revealed responsibilities included but were not limited to:
*Coordination of nursing care given to pediatric, adolescent, adult, and geriatric patients within the surgical suite in accordance with nursing principles.
*Oversight of safety measures to prevent accidents, harm, or injury to the patient, staff, or equipment.
*Initiating the collection of cultures and isolation precautions, and staff education on infection prevention and control.
*Assisting the surgeons in operation through provision of qualified staff, prepared and maintained schedules that ensured staff availability for all procedures, and call schedule to ensure twenty-four hour operating room coverage.
*"Develops and implements a system for identifying, investigating, reporting, maintaining records, and preventing, the spread of nosocomial infections among patients of all ages and healthcare personnel. Confers with medical and nursing staff to determine occurrence of nosocomial infections and appropriate implementation of isolation precautions."
*Developing and maintaining applicable policies and procedures for the OR and IC areas in accordance with the South Dakota Department of Health.
*Monitor use of germicides, cleaning products, antiseptics, and disinfectants in-use throughout the facility.
*Monitors methods of asepsis, sterilization, and disinfection employed throughout the hospital.
*Chair the IC committee, prepared statistics and other pertinent data, and conducted quarterly meetings.
*Stayed informed on changing IC practices and presented plans for compliance.
*Developed and implemented departmental quality assessment plan and process improvement.

Based on observation, interview, tub bath operation manual review, and policy review, the provider failed to ensure infection control practices were maintained for:
*The disinfection of one of one bath tub in the acute care unit.
*One of one storage cabinet with missing laminate in the acute care tub room.
*One cloth chair in one of one operating room (OR).
*One of one soiled linen collection cart with heavily rusted areas in the acute care tub room.
*Three of three cloth chairs located inside the central sterilization room (CSR).
Findings include:

1. Observation on 2/11/20 at 10:15 a.m. of the acute care unit accompanied by chief executive officer (CEO) C revealed a whirlpool tub. When this surveyor questioned nursing assistant (NA) E how the tub was disinfected she stated she:*Closed the tub drain.
*Opened a container of whirlpool cleaner and poured "about two ounces" of the disinfectant into the foot well of the tub.
*Filled the foot well with water up to the seat area that was approximately nine inches above the foot well.
*Used that disinfectant mixture to scrub the tub and seat.
*Allowed the disinfected areas to remain wet for ten minutes.
*Rinsed the tub with clean water.

Interview with NA E at the above time revealed when asked why she had not used the disinfectant button on the tub to dispense the appropriate disinfectant solution she replied the disinfectant button had not been functioning for a long time, so the NA's poured the disinfectant out of the container, and then added water to the disinfectant.

Review of the provider's Cascade Sit-Bath System 6900 Safe Operation and Daily Maintenance Instructions for disinfecting the above tub revealed: "For Aqua-Aire Tubs, press and hold the disinfect button located on the left side of the tub. As the button is held down, the properly mixed cleaning solution is running through the aire injection system and out of all the aire jets. Release the button after you see solution coming out of all the aire jets and you have 1 to 1 1/2 gallons of disinfectant solution of disinfectant solution in the foot well of the tub."

Review of the Penner Whirlpool Disinfectant solution directions at the above time with CEO C revealed:
*The disinfectant protocol was required by the environmental protection agency (EPA) at a dilution of 1:64 (two ounces per gallon water).
*CEO C confirmed the foot well held several gallons of water, and the disinfectant was too diluted with water for appropriate disinfection.

2. Observation of the acute care tub room on 2/11/20 at 10:15 a.m. with the administrator revealed:
*A storage cabinet that held patient care towels and personal cleaning supplies.
-Two shelves in that cabinet had areas of laminate missing with particle board exposed.
-The bottom shelf had water damage where the particle board had expanded.
*A soiled linen collection cart with a heavily rusted base.

Interview at the above time with CEO C confirmed the exposed particle board shelving and the rusted linen collection cart were not cleanable surfaces.

3. Observation on 2/12/20 at the following times revealed:*At 10:00 a.m. a cloth covered chair was observed in the OR.
*At 10:15 a.m. three cloth covered chairs were observed in the CSR in the sterilization area.

Interview on 2/12/20 at 10:15 p.m. with RN A confirmed the above cloth covered chairs were not cleanable and should not have been used in the operating and sterilization areas.

4. Review of the provider's November 2019 Infection Control Plan and Guidelines policy revealed:*Administrative controls for infection control included:-Providing equipment and supplies to support infection prevention and control activities.
-Directing, encouraging, and monitoring staff adherence to recommended infection prevention and control practices.