HospitalInspections.org

Based on observation, staff interview, and document review the hospital failed to ensure patient privacy for seven of twelve patients (Patient #'s 36, 37, and 39-43) observed in the preoperative area. This deficient practice has the potential to violate the patient's right to privacy.

Findings include:

- Preoperative Area observed on 10/31/2017 at 11:15 AM revealed Patient #'s 36, 37, and 39-43 with the curtains to their preoperative bay open to people passing by, allowing the patients to be in full view. Staff posted a sign with the patients' names on a pole mounted to their bed.

Registered Nurse Staff S interviewed on 10/31/2017 at 12:00 PM confirmed the patient information was easily accessible to anyone walking by the bay.


Policy titled "Patient Rights" reviewed on 10/31/2017 at 5:00 PM directed, The (patient has the) right to personal privacy.

Based on observation, staff interview, and document review the hospital failed to keep their medical records in a confidential manner for seven of twelve patients observed (Patient #'s 36, 37, and 39-43) in the preoperative area. This deficient practice has the potential to violate the patient's right to privacy.

Findings include:

- Preoperative Area observed on 10/31/2017 at 11:15 AM revealed Patient #'s 36, 37, and 39-43 with their medical record information laying on a rolling stand outside the curtained bay allowing anyone passing by unauthorized access to the patients' private health information.

Registered Nurse Staff S interviewed on 10/31/2017 at 1:50 PM confirmed the patient information was easily accessible to anyone walking by the bay.

Policy titled "Patient Rights" reviewed on 10/31/2017 at 5:00 PM directed, The (patient has the) right to confidentiality of their medical records.

Based on medical record review and staff interview the hospital failed to ensure all orders were signed and dated as required by the Medical Staff Rules and Regulations for 4 of 36 patient's medical records reviewed (Patient #'s 3, 5, 8, and 10). This deficient practice has the potential to cause patients to receive unauthorized treatments and/or medications.

Findings include:

- Patient #3's medical record reviewed on 10/31/2017 revealed Physician Staff FF placed a verbal order for the patient's discharge on 5/3/2017, which remained unsigned as of the medical record review date (25 weeks and 6 days after discharge).

- Patient # 5's medical record reviewed on 10/31/2017 revealed Physician Staff GG placed an order for 25 milligrams of Diphenhydramine (a medication used to treat allergic reactions) on 5/15/2017 that remained unsigned as of the medical record review date (24 weeks and 6 days later).

- Patient # 8's medical record reviewed on 10/31/2017 revealed Physician Staff HH placed an order for 50 milligrams of Tramadol (a medication used to treat pain), 300 milligrams of Tylenol (a medication used to treat pain and/or fever) on 6/15/2017 that remained unsigned until 8/7/2017 (7 weeks and 3 days later).

- Patient # 10's medical record reviewed on 10/31/2017 revealed Provider Staff II placed verbal orders for 10 milligrams of Lisinopril (a medication used to treat blood pressure), one gram of Cefazolin (a medication used to treat infections), 100 milligrams of Docusate (a medication used to treat constipation), and 40 milligrams of Simvastatin (a medication used to treat high cholesterol) on 6/26/2017. The medical record revealed a co-signature was still pending as of the medical record review date (18 weeks later).

Chief Nursing Officer Staff A interviewed on 10/31/2017 at 9:30 AM confirmed the medical record appeared to be missing the provider signatures. Staff A indicated they could have been completed but not scanned into the record yet.

"Medical Staff Rules and Regulations" reviewed on 11/2/2017 at 2:30 PM directed, All orders for treatment must be in writing or entered into the electronic medical record, dated and timed, and signed by the issuing practitioner ... and ... Verbal/Telephone orders must be signed within 48 hours by the prescribing practitioner or by the attending or covering physician.

Based on observation, interview and document review the hospital failed to ensure all medications were securely stored in two of two inpatient supply rooms and one of one laboratory room refrigerators. This deficient practice has the potential to allow unauthorized access to medications.

Findings include:

- Inpatient Supply Room #1 observed on 10/30/2017 at 11:15 PM revealed the following medications in plastic containers located in the open supply room:
- Three 20 milliliter vials of Lidocaine (a numbing medication)
- One 10 milliliter vial of Lidocaine
- Five 3 milliliter syringes of Heparin (a medication used to reduce blood clotting)
- Five 10 milliliter vials of Sodium Chloride (a medication used to increase fluid in the body)

- Inpatient Supply Room #2 observed on 10/30/2017 at 11:30 PM revealed the following medications in plastic totes located in the unlocked supply room:

- Thirty-Seven - 1,000 milliliter bags of Potassium Chloride (a medication used to increase fluids and electrolytes in the body)
- Thirty - 1,000 milliliter bags of Sodium Chloride (a medication used to increase fluids in the body)


- Unsecured Lab room located in the Pre-Operative area observed 10/30/17 at 2:10 PM revealed 1 open box of Hepatitis B vaccine (virus), containing 4 - 0.5ml unopened vials with located in the refrigerator labeled for laboratory testing slides. Anyone could access the vaccine.

RN Staff J acknowledged the medication and stated no medications are to be stored in the lab room.


Policy titled "Pharmaceutical Storage" directed, all drugs and biological will be kept in a secured storage area. The Director of Nursing, Consultant Pharmacist, Associate Director of Nursing, and designated RN's will have access to the secured area... ...Drugs requiring refrigeration will be stored in the drug refrigerator only.

Based on observation, document review, and staff interview the hospital failed to ensure preventative maintenance was performed on all patient care equipment for five of five observed life care patient controlled analgesia (PCA) pumps (a device used to allow a patient to self-administer a predetermined amount of pain medication), nine of nine observed mistral air machines (a device used to deliver warm or cooled air to a patient), two medication fluid pumps (Room #129 and #130), four of five observed VenaFlow elite machines (a machine used to deliver intravenous medications), the Sterrad Sterilizer (used to sterilize surgical instruments) in the Central Sterile Room, three of three temporal thermometers at the nurses' station and two of two observed centrifuges (a device used to spin blood specimens for laboratory studies) (nurses' station and laboratory). This deficient practice has the potential to cause patients to receive care with ineffective equipment, which could lead to harm or death. The facility failed to ensure a remote safety stop station was available for their generator. This failure has the potential to cause injury or death to patients or staff.

Findings include:

- Inpatient care Equipment Room #1 observed on 10/30/2017 at 11:20 AM revealed five of five life care PCA pumps with inspections stickers indicating the next scheduled preventative maintenance (PM) was due on 3/2016, four of eight mistral air machines with inspection stickers indicating the next scheduled PM was due on 10/2016 and four of eight mistral air machines without any inspection stickers.

- Inpatient Room #'s 129 and 130 observed on 10/30/2017 at 11:30 AM revealed two medication fluid pumps with inspection stickers indicating the next inspection was due 10/2015.

- In-Patient Equipment Room #2 observed on 10/30/2017 revealed the following equipment with outdated inspection stickers: four of five VenaFlow elite machines (a machine used to deliver intravenous medications) with outdated inspection stickers, three were dated 2/2014, and one was dated 12/2015

- Central Sterile Room observed on 11/1/2017 at 3:30 PM revealed the Sterrad Sterilizer with an inspection sticker from 2016.

BioMedical Staff JJ interviewed on 11/1/2017 at 1:30 PM revealed the Sterrad Sterilizer had been inspected and the manufacturer conducted PM's. Staff JJ provided documentation but agreed the information should have been placed on the machine.

- Pre-operative bay #4 observed on 10/31/2017 at 10:25 AM revealed a mistral air machine without inspection stickers.

- Inpatient Nursing Station observed on 10/30/2017 at 10:00 AM revealed the following items without inspection stickers: Three temporal thermometers and one centrifuge (a device used to spin blood specimens for laboratory studies).

- Laboratory observed on 10/30/2017 at 2:10 PM revealed one centrifuge without an inspection sticker.
BioMedical Staff JJ interviewed on 11/1/2017 at 1:00 PM confirmed the stickers should indicate when the PM's are due. Staff JJ indicated they do not have a log for those items currently and cannot verify if the items without stickers or out of date stickers have had routine maintenance. Staff JJ revealed they had to buy new stickers because the cleaning chemical use when cleaning the machines cause the writing to come off of the older BioMed stickers.
The facility failed to provide their policy directing staff to ensure their Preventive Maintenance program tracked all patient care devices to ensure the routine maintenance is preformed according to manufactures guidelines and at least annually.


- Facility tour on 11/1/2017 at 1:15 PM revealed the facility lacked an emergency remote manual stop) button used to turn off the generator in case of a malfunction).

BioMedical Staff JJ interviewed on 11/1/2017 at 1:25 PM confirmed they could not find a generator safety stop.

NFPA 110, 5.6.5.6 regulation reviewed on 11/1/2017 at 2:45 PM stated, All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. An appendix item at A-5.6.5.6 suggests: For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based on observation, staff interview, and policy review, the hospital failed to remove and replace outdated medical supplies from the inpatient medication room and the outpatient therapy room. The deficient practice of failing to dispose of outdated supplies by the facility places all patients at risk for receiving ineffective, unsafe supplies resulting in harmful treatment.

Findings include:

- Inpatient medication room observed on 10/30/2017 at 1:00 PM revealed the following outdated supplies:

4-18 gauge, 1 1/4:" IV needles, expiration 7/2015

Inpatient Manager Staff B confirmed the outdated supplies and removed them from the medication room.

- Outpatient therapy room observed on 11/1/2017 at 3:23 PM revealed one bottle of ultrasound gel (helps to efficiently transmit signals between the probe and the skin surface) with an expiration date of 7/2016.

Physical Therapy Staff BB interviewed on 11/1/2017 at 3:23 PM confirmed the bottle was expired and stated they refill their bottles from a larger bottle. When asked where the larger bottle was, they were unclear of the location.

Policy titled "Materials Management Services" reviewed on 11/2/2017 at 11:30 AM directed "...The other departments have a designated individual from their department to requisition, rotate and stock supplies for their area..."

Based on observations, interviews, and documents review, the hospital failed to ensure alcohol-based rubs were appropriately located in one of one pre-operative area; failed to demonstrate proper handling of multi-use vials in one of two observations; and failed to ensure the hospital had an airborne isolation room. The facility also failed to ensure therapy equipment surfaces were cleanable in one of one therapy equipment storage area and one of one outpatient therapy gym; failed to ensure the hydrocollator (used to warm up heat packs in hot water) was clean and sanitary in one of one outpatient therapy gym; and ensure fabric gait belts were appropriately cleaned during one of one terminal room cleaning (room 115). The facility also failed to ensure one of two central sterilization instrument processing rooms (south end of the building) was free of oscillating fans, and failed to ensure staff maintained proper personal protective equipment (PPE) when drying instruments. The facility failed to ensure their recycling of biohazard materials were properly stored and the container remained closed during one of two surgical procedure observations. The facility also failed to ensure staff followed safe injection practices involving the recapping of needles in three of three injection medication administration observations, and failed to ensure the glucometer was properly cleaned after use for one of two blood-glucose monitoring observations. The facility failed to confirm housekeeping staff followed acceptable practices of environmental surface disinfection when performing terminal cleaning of the surgical suites in two of two observations (OR suite #5 and #2), and the facility failed to provide documentation of temperature, humidity, and air exchanges for all areas of the surgical suite. The facility failed to ensure staff performed appropriate hand hygiene in all patient-care functions in one of one observation (Staff T). The facility failed to educate staff regarding the risks of exposure to formalin (a preservative used for certain laboratory specimens) and failed to provide appropriate personal protective equipment (PPE) when handling formalin, failed to store only lab specimens in one of one refrigerators, and failed to restrict food in the lab area. Failure by laboratory staff to wear PPE put them at risk of exposure to inhalation pneumonia and if ingested, death. The facility also failed to store medical supplies as directed and packaged by manufacturer's in 2 of 2 surgical suites (Surgical Suite 4 and 5) and one of two in-patient nursing units. The facility failed to ensure all food products were labeled with outdates and destroyed when outdates were elapsed in two of two kitchen refrigerators and failed to clean and prepare fresh produce in a clean area of the kitchen.

The cumulative effect of the systemic failure to follow infection control guidelines has the potential to expose patients, staff and guests to bacteria, viruses and other pathogens that could result in harm, severe illness, poor health outcomes, or death.

Findings include:

See evidence at A-0749

Based on observations, interviews, and documents review, the hospital failed to ensure alcohol-based rubs were appropriately located in one of one pre-operative area; failed to demonstrate proper handling of multi-use vials in one of two observations; and failed to ensure the hospital had an airborne isolation room. The facility also failed to ensure therapy equipment surfaces were cleanable in one of one therapy equipment storage area and one of one outpatient therapy gym; failed to ensure the hydrocollator (used to warm up heat packs in hot water) was clean and sanitary in one of one outpatient therapy gym; and ensure fabric gait belts were appropriately cleaned during one of one terminal room cleaning (room 115). The facility also failed to ensure one of two central sterilization instrument processing rooms (south end of the building) was free of oscillating fans, and failed to ensure staff maintained proper personal protective equipment (PPE) when drying instruments. The facility failed to ensure their recycling of biohazard materials were properly stored and the container remained closed during one of two surgical procedure observations. The facility also failed to ensure staff followed safe injection practices involving the recapping of needles in three of three injection medication administration observations, and failed to ensure the glucometer was properly cleaned after use for one of two blood-glucose monitoring observations. The facility failed to confirm housekeeping staff followed acceptable practices of environmental surface disinfection when performing terminal cleaning of the surgical suites in two of two observations (OR suite #5 and #2), and the facility failed to provide documentation of temperature, humidity, and air exchanges for all areas of the surgical suite. The facility failed to ensure staff performed appropriate hand hygiene in all patient-care functions in one of one observation (Staff T). The facility failed to educate staff regarding the risks of exposure to formalin (a preservative used for certain laboratory specimens) and failed to provide appropriate personal protective equipment (PPE) when handling formalin, failed to store only lab specimens in one of one refrigerators, and failed to restrict food in the lab area. Failure by laboratory staff to wear PPE put them at risk of exposure to inhalation pneumonia and if ingested, death. The facility also failed to store medical supplies as directed and packaged by manufacturer's in 2 of 2 surgical suites (Surgical Suite 4 and 5) and one of two in-patient nursing units. The facility failed to ensure all food products were labeled with outdates and destroyed when outdates were elapsed in two of two kitchen refrigerators and failed to clean and prepare fresh produce in a clean area of the kitchen. These deficient practices have the potential to expose patients, staff and guests to bacteria, viruses and other pathogens that could result in harm, severe illness, poor health outcomes, or death.

Findings include:

- Pre-operative nursing care area observed on 10/31/2017 at 10:14 AM revealed 12 curtained bays for patient care. Locations for alcohol based hand rub (hand sanitizer stations) observed to be one on the unit itself on the far back wall, near the entrance to the unit, and one by the nurses station adjacent to management offices. No alcohol based rub stations were observed near patient care areas, entrances to rooms or staff workstations or other appropriate locations.

Chief Nursing Officer (CNO) Staff A interviewed on 10/31/2017 at 11:30 AM confirmed that in the pre-operative areas, alcohol based hand rub is not located in appropriate areas and reports, "we had it in there [curtained patient bays], but the fire marshal had us move them."

On 11/2/2017, the facility failed to provide a policy regarding the placement of alcohol based hand rubs.

- Pre-operative nursing care area observed on 10/31/2017 at 10:14 AM revealed the staff nurse BB drawing up medication from a multi-use vial (MUV) near the patient care bay #7. The vial was then set on the bedside table for future use for subsequent cases. Entry into a patient care area renders the multi-use vial dedicated to single patient use, and therefore should have been discarded.

- Document titled "Infection Management Program" reviewed on 11/3/2017 directed, parenteral medications are considered to be sterile, and are maintained in a manner that prevents the introduction and growth of microorganisms in the multi-dose vial and open one multi-dose vial at a time, mark the vial with the date and time when opened. Multi-dose medications should follow pharmacy recommendations for discarding.

CNO Staff A interviewed on 10/31/2017 at 11:30 AM reported the hospital does not contain a negative air pressure room to protect patients and staff from airborne contagious respiratory diseases.

The American Institute of Architects Guidelines for Design and Construction of Hospital and Health Care Facilities 1996-97, 7.2.CI. "At least one airborne infection isolation room shall be provided. These rooms may be located within individual nursing units and used for normal acute care when not required for isolation cases, or they may be grouped as a separate isolation unit."

According to the Centers for Disease Control and Prevention (CDC) "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis (TB) in Health-Care Settings, 2005", Secondary environmental controls consist of controlling the airflow to prevent contamination of air in areas adjacent to the source (Airborne Infection Isolation rooms) and cleaning the air by using high efficiency particulate air (HEPA) filtration or UVGI (ultraviolet germicidal irradiation - a method of disinfection to kill or inactivate microorganisms by destroying their ability to perform vital cellular functions with short-wave ultraviolet light).

- On 11/2/2017, the facility failed to provide a policy regarding negative pressure rooms.

- Physical Therapy Equipment Storage Area observation on 10/31/2017 at 2:20 PM revealed three sets of crutches with cracked, damaged padding on the underarm portion and handgrips; one of which had visibly soiled cloth tape to hold the underarm pad onto the crutch, rendering the padding un-cleanable.

Physical Therapy Director Staff EE interviewed on 10/31/2017 at 2:20 PM confirmed the padding of three sets of crutches are in disrepair and are un-cleanable. Staff EE reports they will take these items out of use and order new sets.

Outpatient Therapy observed on 11/1/2017 at 3:23 PM revealed stair-training equipment with hand rails on either side constructed of raw porous wood without a protective sealant or coating, rendering the surface of the item un-cleanable.

- Physical Therapy Staff AA interviewed on 11/1/2017 at 3:23 PM confirmed the surface of the stair-training item is un-cleanable.

- Housekeeping Staff DD observed during cleaning of inpatient room 115 on 11/1/2017 at 9:29 AM revealed staff DD wiping down a fabric gait belt (used to help patients stand up or walk) that had significant fraying along the edge.

Housekeeping Staff DD interviewed on 11/1/2017 at 9:29 AM acknowledged the disrepair of the fabric gait belt, sharing that most of the gait belts are nylon or plastic and are furnished by therapy, stating, "they must have kept this one for emergencies" and proceeded to place the gait belt back into the patient drawer.

CNO Staff A interviewed on 11/2/2017 at 10:00 AM reported to clean the fabric gait belts, they are to be soaked in cleaning solution and hung to dry, not just wiped down.

On 11/2/2017, the facility failed to provide a policy regarding un-cleanable surfaces, wood surfaces or fabric gait belts.


- Outpatient Therapy Unit observed on 11/1/2017 at 3:23 PM revealed a hydrocollator (moist hot pack machine) containing rust-colored water with areas of a white film floating on top. Review of the last four months of temperature and cleaning logs reveal the hydrocollator had not been cleaned.

- Physical Therapy Staff AA interviewed on 11/1/2017 at 3:23 PM stated they rarely use the moist heat packs. When asked about cleaning routines, stated the hydrocollator may have been cleaned in January, and believes it should be cleaned once a year.

Policy reviewed on 11/1/2017 titled, "Moist Hot Packs" directed, Therapy staff will follow appropriate practice in the application of moist hot packs and proper care, monitoring, and cleaning of the hydrocollator tank ... Unit should be drained and cleaned at least yearly, more often if deemed necessary.

Document titled "Instructions for Operation and Care of Stationary 4 Pack Thermalator" (name brand for the hydrocollator) reviewed on 11/1/2017 directed, Monthly maintenance: See care and cleaning. Clean wire rack and insert using mild soap. Rinse thoroughly with clean tap water. Dry with soft cloth.

- Central Sterilizing Instrument Processing Room on the south end of the building observed on 11/1/2017 at 3:30 PM reveals an oscillating fan installed on the wall near the top of the ceiling, blowing air over the table where instruments were being packaged for sterilization, and throughout the room.

Surgical Manager Staff G interviewed on 11/2/2017 at 12:45 PM acknowledged the presence of the fan in the processing room.

On 11/2/2017, the facility failed to provide a policy on the use of oscillating fans in the central sterilizing room.

Association of periOperative Nurses (AORN) Guidelines as of 2017 directed, IVv. Free-standing fans, portable HEPA filtering devices, humidifiers, air conditioners, and dehumidifiers should not be used in restricted areas or sterile processing areas .... Free-standing fans can disrupt airflow patterns, resulting in contamination of the sterile field.

- Central Sterilizing Instrument Processing Room on the south end of the building observed on 11/1/2017 at 3:30 PM revealed processing staff using pneumatic medical air (similar to using a hose from an air compressor) to dry instruments coming from the washer to prepare them for sterilization. Observation revealed staffs were not wearing any Personal Protective Equipment (PPE), including eye protection, to protect from the aerosol (water droplets in the air) particles from the instruments.

Central Processing Supervisor CC interviewed on 11/1/2017 at 3:30 PM acknowledged the staff were not wearing PPE, and reports it is not required by the Association for the Advancement of Medical Instrumentation (AAMI).

Document titled, "Sterilization in Healthcare Facilities" from the AAMI guidelines as of 2011 reviewed on 11/2/2017 directed, Fluid resistant face masks protect personnel who are cleaning contaminated items from splash or spatter that could contain pathogens ...Liquid splashes and aerosols can contact the eyes from any direction, including settling out of the air from above. Liquids act as vehicles for the transfer of microorganisms from soiled materials and from the skin of personnel; therefore wet surgical attire should be considered contaminated.

- Patient #39 observed on 10/31/2017 at 3:10 PM revealed an advantage reprocessing container with used surgical equipment in it and the lid open and a lead apron (a shield used to protect the wearer from radiation exposure during x-rays) lying over the top of it.

Registered Nurse (RN) Staff Y interviewed on 10/31/2017 at 3:10 PM indicated the reprocessing containers are in all fourteen operating rooms. Staff Y indicated they feel storing the used surgical items in those containers still poses an infection control risk.

Materials Manager Staff D interviewed on 11/2/2017 at 10:30 AM indicated the reprocessing containers are approved for biohazard material and if they are closed, pose no more risk than a sharps container.

The facility failed to provide a policy directing staff to ensure recycling containers remain closed at all times.

Document titled "Infection Management Program" reviewed on 11/3/2017 directed, infectious waste will be disposed of in a consistent and safe manner and in compliance with federal regulations. Regulated medical waste includes the following ...human pathological waste, microbiological waste, all sharps and items that are contaminated with blood or body fluids. All hazardous waste is segregated at the point of origin in appropriate labeled/color coded biohazard bags or boxes. Packaging will be suitable to maintain the integrity of the contents during transportation and storage. Temporary storage will be maintained in a low traffic area prior to transportation for off-site disposal.


- Pre-operative (Op) Staff BB observed on 10/31/2017 revealed staff BB administered sub-cutaneous Lidocaine (a numbing medication) using a syringe and needle in preparation to place an IV. After administering the medication, staff BB took the cap in one hand and the syringe with the used needle in the other and recapped it before placing it in the sharps container, posing risk for needle-stick injury.

- Pre-operative Registered Nurse Staff S observed on 10/31/2017 at 12:00 PM preparing to start an IV. Staff S opened a vial of Lidocaine and punctured the septum without wiping it with alcohol. Staff S recapped the needle before continuing to prepare their IV supplies. Staff S then applied gloves without performing hand hygiene and inserted the IV. Staff removed their gloves and continued providing care to Patient # 39 without performing hand hygiene.

RN Staff S interviewed on 10/31/2017 at 12:05 PM stated, "I know I shouldn't have recapped the needle the way I did but it's easier, so ding me".

- Pre Op RN Staff T observed 10/31/2017 at 10:30 AM preparing Patient #36 for surgery injected subdermal lidocaine (numbing agent under the skin) prior to IV needle insertion. Immediately after injecting the lidocaine, RN Staff T recapped the lidocaine needle and then dropped it into the sharps container.

RN Staff T confirmed s/he recapped the needle and "I know we are not supposed to do that but the sharps container is at the head of the bed and sometimes too difficult to reach for immediate access."

On 11/2/2017, the facility failed to provide a policy regarding safe injection practices.

According to the Centers for Disease Control (CDC) "In practice, actions to implement universal precautions include ... avoiding needle recapping; especially two-handed needle recapping."

- Preoperative area observed on 10/31/2017 at 12:50 PM revealed Registered Nurse (RN) Staff V performing a blood sugar check on the unidentified patient in bay #3. At 1:50 PM RN Staff Z picked up the glucometer (a device used to test blood sugar levels) and placed it into its container located at the nurse's station without cleaning it.

Chief Nursing Officer interviewed on 11/1/2017 at 3:30 PM confirmed staff should all be aware they are required to clean the glucometer before and after each use.

Policy titled "Blood Glucose Monitoring/Treatment Protocol" reviewed on 10/31/2017 at 5:30 PM directed, Clean the PXP meters with a Germicidal Disposable Wipe before and after each patient testing.


- Housekeeping Staff N and O observed 10/31/2017 at 1:45 PM in surgical suite 2 wearing surgical scrubs performed hand hygiene prior to entering the room. Neither staff member wore surgical masks or protective eyewear. Wearing gloves and using sani cloth cleaning wipes, both were observed wiping the surgical stools, mayo stands, surgical instrument cart, part of the anesthesia drug cart surface, and the surgery bed. Gloves were not changed during the procedure except when exiting and re-entering the surgical suite. After cleaning one of the stools, Housekeeping Staff N moved a blanket warmer mechanical unit from the floor and set it on top of a previously disinfected stool. She then disinfected the top surface of the equipment leaving the feet, cord, and stool unwiped. When cleaning the surgical bed, Housekeeping Staff N was observed disinfecting the top of each removable cushion, part of the side surfaces, and then turned it over and placed the disinfected surface down onto an unwiped cushion to disinfect the bottom surface. The base of the surgical bed was not disinfected. The anesthesia cart was not disinfected, including the keyboard. None of the surgical equipment was moved away from the wall. Housekeeping Staff N disinfected the surgical suite walls randomly with no pattern to establish a complete coverage of all wall surfaces. Paper previously placed behind a wall meter was unmoved along with a box labeled sponge counter bags. The lower walls were not disinfected. Housekeeping Staff O mopped the surgical suite floor with no established pattern and equipment was not moved during the process. At no time was the ceiling mopped.

Housekeeping Staff N interviewed 10/31/2017 at 2:00 PM remarked, "we always clean the ceiling at the end".

- Housekeeping Staff P observed 10/31/2017 at 2:20 PM in surgical suite 5 wearing surgical scrubs performed without mask or eye protection. Wearing gloves and using sani wipes, Staff P moved between each piece of equipment and was observed cleaning all surfaces including all keyboards and bases. Tubing connected to the anesthesia machine was not disconnected. All equipment was moved away from the wall and the wall was cleaned in a systematic fashion covering all wall surfaces. The ceiling was not disinfected. All equipment was moved away from the wall prior to floor mopping and then all equipment was moved back against the wall following mopping the center of the room. Housekeeping Staff P moved around the edges first then moved from the center to the door.

Housekeeping Staff P interviewed 10/31/2017 at 2:40 PM stated s/he had been instructed to never remove any tubing connected to any equipment which makes it difficult to clean around especially if anesthesia does not clean up their equipment after a case.

Policy titled "Terminal Cleaning for Operating Rooms" reviewed on 10/31/2017 at 3:00 PM directed, Housekeeping personnel assigned to the operating suites will follow the established guidelines when performing terminal cleaning... ...Appropriate PPE must be worn when cleaning the surgical suites e.g. gloves, protective clothing, masks, protective eyewear... ...(Clean from top to bottom, and start furthest from door and work towards doorway) as follows: walls and ceilings, vents, operating room lights, chairs, lamps sinks, tabletops, and counters, instrument tables and other flat surfaces... ...operating room bed. Clean all surfaces of mattress pad, tabletop, sides, base, legs, and any accessories. Remove gloves, sanitize hands and put on a clean pair gloves.

- Review on 11/1/2017 at 10:30 AM of QAPI (quality) report documentation for the each quarter starting January, 2017 revealed the following:
-October through December, 2016, No alarms reported for temperature or air exchanges by the monitoring company
-October through December, 2016, No humidity reports presented by the monitoring company
-January through March, 2017, No alarms reported by the monitoring company
-March through June, 2017, No reports presented by the monitoring company
-July through September, 2017, No reports presented by the monitoring company

Material Manager Staff D interviewed 10/31/2017 at 11:00 am confirmed the reports were incomplete and the Facility had recently changed company used to monitor the temperatures, humidity, and air exchanges after it was discovered the previous company was not accurately monitoring and reporting.

The Association of periOperative Registered Nurses (AORN) website on May 25, 2016 stated, The recommended temperature range in an operating room is between 68 [degrees] F [Fahrenheit] and 75 [degrees] F . . . The recommended humidity range in an operating room is between 20% [percent] to 60% based on addendum d to ANSI (American National Standards Institute)/ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers)/ASHE (American Society for Healthcare Engineering) Standard 170-2008.

- Pre Op RN Staff T observed 10/31/2017 at 10:30 AM preparing Patient #36 for surgery performed direct patient care including obtaining vital signs, preparing medications, glove changes, performing two IV starts, moving handrails of bed, and moving patient care equipment without performing hand hygiene. Ten opportunities to perform hand hygiene were missed during the observation. No hand sanitizer was available in the patient cubicle. The closest hand sanitizer or hand washing facilities were located at the nursing station, approximately 15 feet from the patient care area.

Pre Op RN Staff T interviewed on 10/31/2017 at 11:00 AM acknowledged the missed opportunities for performing hand hygiene.

Policy "Hand Hygiene" reviewed on 11/2/2017 at 4:00 PM directed, Hand hygiene measures are the single most important prevention strategy for avoiding healthcare associated infections (HAI). The hands of personnel serve as a critical reservoir of infectious agents.

- The laboratory room observed 10/30/2017 at 2:10 PM revealed a gallon box labeled Formalin Fixative 10% neutral. No PPE was observed in the lab. Observation also revealed one box of Hepatitis B vaccine containing 4 unopened vials were stored in the refrigerator with lab specimen discs for the Istat (bedside lab testing equipment) machine. One cookie and multiple packages of candy were located in two drawers in the lab room.

SAFETY: Work in well ventilated area, wear goggles, gloves, and lab coat. Formaldehyde: severe eye and skin irritant. Sensitizer by skin and respiratory contact. Toxic by ingestion and inhalation. Target organ effects on
respiratory system. Corrosive. Carcinogen. Label with FORMALDEHYDE WARNING label.

Pre Op Manager RN Staff K interviewed on 10/31/2017 at 2:20 PM acknowledged the hepatitis vaccine and food products and removed them from the lab. RN Staff K confirmed no PPE was located in the lab.

- The anesthesia carts observed on 10/31/2017 at 3:00 PM had the following open supplies in the carts:
Surgical Suite 4:
1-Plastic airway valve
1-Cuffed Nasotracheal (tube placed in airway to keep flow of oxygen) Tube
1-10 ml syringe
1-suction catheter
Surgical Suite 5:
1-Endotracheal (tube placed in airway to keep flow of oxygen) tube

Operating room (OR) RN Staff X interviewed on 10/31/2017 at 3:00 PM confirmed the open supplies and disposed of them in medical waste.

In Patient Nursing Unit observed 10/30/2017 at 11:45 AM had the following open supplies:
59 - Tuberculin syringes out of original packing stored in basket in nursing station drawer

RN Staff F interviewed on 10/31/2017 at 11:55 AM acknowledged the open syringes stating, "We do that so we can use them a little more quickly when we need them". RN Staff F removed them from the patient care area.

Outpatient Therapy Gym observed on 11/1/2017 at 3:23 PM revealed a package of steri-strips (thin strip-like bandages used to keep the edges of cuts and wounds together) opened on the bookcase near the back of the room. Packaging on the steri-strips reads, "do not use of package is opened or damaged."

Physical Therapy Staff EE interviewed on 11/1/2017 at 3:23 PM acknowledged the package is open, and discarded it in the trash. Staff EE shared that they mostly treat knee replacements and sometimes have to call nursing to come and replace steri-strips during treatment.

Policy titled "Materials Management Services" reviewed on 11/2/2017 at 3:30 PM directed, "The Materials Management Department order, stocks, rotates and reviews (quality, quantity, and expiration).

- Kitchen refrigerator observed 10/30/2017 at 1:00PM revealed the following food items transferred from bulk containers to serving containers and were unlabeled with expiration dates:
1-container of cubed cheese, unlabeled with content and expiration date
1-container of pickles, unlabeled with content and expiration date
1-container of peaches, unlabeled with content and expiration date
1-container of sour cream, outdated 10/19/2017
1-container of beef paste, outdated 10/29/2017

- Document titled "Kitchen Sanitation Inspection" reviewed 10/31/2017 at 9:00 AM was performed by the dietician on 9/28/2017 directed, staff to put year on all date labels, use full label with expiration date, and label all dry storage with expiration date.

Kitchen Staff I interviewed on 10/30/2017 at 1:20 PM confirmed the outdated and unlabeled food items and removed the products from refrigeration.

- Kitchen area observed on 10/30/2017 at 1:00 PM revealed a window next to the dishwasher where dirty dishes are received, rinsed, and loaded into racks to go through the dishwashing process. Across from the dishwasher within 3 ft. are 3 sinks labeled with fill lines. A handwashing sink was located next to the three sinks. No other sinks were located in the kitchen.

Kitchen Staff I interviewed on 10/30/2017 at 1:00 PM stated the sinks are used to wash the dishes if the dishwasher is not working. The sinks are also used for fresh produce washing and prep. S/he further stated if produce is to be prepped the sinks are thoroughly cleaned with a product intended to disinfect the surfaces.

Kitchen Manager Staff E interviewed 10/31/2017 at 9:00 AM confirmed the sinks were used for produce prep and rarely used for dishwashing unless the dishwasher is not functioning. S/he stated, "we have never had anywhere else to prep our produce. This area is so small."

Based on medical record review, interview and document review, the facility failed to ensure the post-operative report was signed by the physician and was a complete medical record within the 30-day requirement for one of twenty seven records reviewed (Patient #26). This deficient practice has the potential to place all surgical patients at risk for incomplete medical records and continuity of care.

Findings include:

- Patient #26's medical record reviewed on 11/1/2017 revealed Patient #26 was admitted on 2/3/2017 for an outpatient surgery with a diagnosis of a right 5th phalanx fracture (finger fracture), and was dismissed later that day after recovery. Medical record review revealed the operative report was signed on 3/15/2017, 40 days after discharge; exceeding the 30-day requirement.

CNO (Chief Nursing Officer) Staff A interviewed on 11/2/2017 at 11:30 AM acknowledged the signature on the operative report was past the 30-day requirement.

Document titled, "Medical Staff Rules and Regulations" reviewed on 11/2/2107 directed, The attending physician is responsible for the timely preparation and completion of the patient medical record. Medical record entries must be authenticated within thirty-days following the patient's discharge.