HospitalInspections.org

On 9/2/15 at 1030 during a tour of the facility, found in the endoscope reprocessing room floor storage of patient care supplies, filters for the endoscope reprocessing machine. Staff N confirmed these findings and said they have a lack of shelf storage space.

On 9/2/15 at 1035 found five reprocessed endoscopes located in procedure room #1 hanging without benefit of storage in an enclosed cabinet to protect from contaminates. Staff N confirmed these findings and indicated that there were no funds for purchasing a proper storage cabinet.


29774

Based on observation, interview and document review, the facility failed to ensure: staff followed infection control policies for hand hygiene, equipment is cleaned between patients, patient care supplies/equipment were not stored on the floor and refrigerators/ freezers used to store specimens, breast milk and medications are maintained and monitored resulting in the missed opportunity to reduce the risk of transmission of infectious agents among all patients served by the facility. Findings include:

On 8/31/15 between 1250 and 1410 a tour of the facility revealed the following:

Floor storage of patient care supplies in the equipment storage room on 2 East and cleaned patient-ready commodes hanging on the wall over the trash bin, in the soiled utility room with the sanitized bucket left drying on a towel next to the double sink. Staff H confirmed these findings, stated, "storage space is a problem." The specimen refrigerator in the soiled utility room had ice accumulated to about 2 inches. Staff H was asked who is responsible for monitoring the specimen refrigerators to which she replied, "I am not sure, we rarely use that refrigerator."

Floor storage of two boxes of patient information pamphlets was found in the Labor and Delivery clean supply room preventing the ability to sweep and mop the floor. Staff G confirmed these findings.
A refrigerator labeled for "breast milk" in the storage area of the obstetrical unit was found that lacked temperature monitoring for appropriate range in which to store breast milk. Staff G was asked who is responsible to monitor the appropriate temperature range for this breast milk storage refrigerator, to which she replied, "We check the other (food) refrigerator, we should probably check this one at the same time."

In the Critical Care Unit (CCU) found storage under the hand hygiene sink at the nurses station and found two inches of accumulated ice in the medication refrigerator/freezer. Staff E stated that shouldn't be there and removed the items from under the sink. When asked who monitors and defrosts the refrigerator, staff E stated, "I'm not sure."

On 8/31/15 at 1305 observed staff F preparing to conduct blood glucose testing in the CCU area. Staff F placed the supplies needed to do the test in her pocket. She proceeded to Room #3 to conduct the test, placing the glucometer on the bed while retrieving supplies from her pocket and obtaining a drop of blood. Staff F then left the room, sanitized her hands changed her gloves and took the glucometer into room #1 without sanitizing the glucometer. She reached into her pocket and retrieved the remaining testing supplies, placed the glucometer on the overbed table and proceeded with collecting the blood for the test for the patient in room #1. Staff F did not sanitize the glucometer after exiting room #1. Staff E was asked if storage of patient care supplies in a caregivers pocket was acceptable to which he replied, "No." Staff E was asked what the policy is for sanitizing the glucometer between patients to which he replied, "She should have wiped it (glucometer) down between patients."

On 9/2/15 at 1100 a review of policy titled, "Use of the Nova StatStrip Bedside Glucose Meter" with no revised/approved date revealed "Clean the meter between patients and /or prior to docking by following the Cleaning Procedure Below....Cleaning Procedure 1. The meter must be cleaned between patients and prior to docking using a hospital approved disinfectant."

On 8/31/15 at 1410 observations revealed staff Q, nursing assistant, left room 244 after providing incontinence care, removed her gloves crossed the nurse's station, put on another pair of gloves and retrieved the meal tray for a patient in protective isolation, put on a yellow gown and mask and went into the room to deliver a meal tray. Staff Q failed to sanitize her hands after removing gloves from room 244 and after removing gloves after delivering a food tray in room 212. Staff H was asked whether this staff missed hand hygiene opportunities after removing her gloves to which she replied, "Yes she did."

On 9/2/15 at 1130 a review of undated facility policy titled, "Handwashing" stated, "...hands should be washed before entering a patient room and upon exiting, before having direct contact with patients, before performing donning gloves or partaking in procedures ...... after removing gloves..."

On 9/1/15 between 0700 and 1100, during observations in the OR (operating room) revealed the anesthesiologist, staff S came into the OR twice at 0800 to evaluate the patient and again at 0830 to evaluate the patient. Both times staff S failed to sanitize hand either before entry or after exit. Interview with staff N on 9/1/15 at 1100 regarding requirements for hand hygiene in the OR she stated, "..he should have sanitized his hands after touching the patient and before exiting the OR."

On 9/1/15 at 1230 during observations of injectable medication pass revealed staff R, registered nurse completed the medication pass, and failed to remove her gloves and sanitize her hands before documenting on the computer on wheels and replacing items back into the patients medication drawer. On 9/1/15 at 1240 interview with staff E confirmed that staff R should have removed her gloves and sanitized her hands before typing on the computer and returning items to the patients medication drawer.

On 9/2/15 at 1030 during a tour of the facility, found in the endoscope reprocessing room floor storage of patient care supplies, filters for the endoscope reprocessing machine. Staff N confirmed these findings and said they have a lack of shelf storage space.

On 9/2/15 at 1035 found five reprocessed endoscopes located in procedure room #1 hanging without benefit of storage in an enclosed cabinet to protect from contaminates. Staff N confirmed these findings and indicated that there were no funds for purchasing a proper storage cabinet.


29774

Based on observation, interview and document review, the facility failed to ensure: staff followed infection control policies for hand hygiene, equipment is cleaned between patients, patient care supplies/equipment were not stored on the floor and refrigerators/ freezers used to store specimens, breast milk and medications are maintained and monitored resulting in the missed opportunity to reduce the risk of transmission of infectious agents among all patients served by the facility. Findings include:

On 8/31/15 between 1250 and 1410 a tour of the facility revealed the following:

Floor storage of patient care supplies in the equipment storage room on 2 East and cleaned patient-ready commodes hanging on the wall over the trash bin, in the soiled utility room with the sanitized bucket left drying on a towel next to the double sink. Staff H confirmed these findings, stated, "storage space is a problem." The specimen refrigerator in the soiled utility room had ice accumulated to about 2 inches. Staff H was asked who is responsible for monitoring the specimen refrigerators to which she replied, "I am not sure, we rarely use that refrigerator."

Floor storage of two boxes of patient information pamphlets was found in the Labor and Delivery clean supply room preventing the ability to sweep and mop the floor. Staff G confirmed these findings.
A refrigerator labeled for "breast milk" in the storage area of the obstetrical unit was found that lacked temperature monitoring for appropriate range in which to store breast milk. Staff G was asked who is responsible to monitor the appropriate temperature range for this breast milk storage refrigerator, to which she replied, "We check the other (food) refrigerator, we should probably check this one at the same time."

In the Critical Care Unit (CCU) found storage under the hand hygiene sink at the nurses station and found two inches of accumulated ice in the medication refrigerator/freezer. Staff E stated that shouldn't be there and removed the items from under the sink. When asked who monitors and defrosts the refrigerator, staff E stated, "I'm not sure."

On 8/31/15 at 1305 observed staff F preparing to conduct blood glucose testing in the CCU area. Staff F placed the supplies needed to do the test in her pocket. She proceeded to Room #3 to conduct the test, placing the glucometer on the bed while retrieving supplies from her pocket and obtaining a drop of blood. Staff F then left the room, sanitized her hands changed her gloves and took the glucometer into room #1 without sanitizing the glucometer. She reached into her pocket and retrieved the remaining testing supplies, placed the glucometer on the overbed table and proceeded with collecting the blood for the test for the patient in room #1. Staff F did not sanitize the glucometer after exiting room #1. Staff E was asked if storage of patient care supplies in a caregivers pocket was acceptable to which he replied, "No." Staff E was asked what the policy is for sanitizing the glucometer between patients to which he replied, "She should have wiped it (glucometer) down between patients."

On 9/2/15 at 1100 a review of policy titled, "Use of the Nova StatStrip Bedside Glucose Meter" with no revised/approved date revealed "Clean the meter between patients and /or prior to docking by following the Cleaning Procedure Below....Cleaning Procedure 1. The meter must be cleaned between patients and prior to docking using a hospital approved disinfectant."

On 8/31/15 at 1410 observations revealed staff Q, nursing assistant, left room 244 after providing incontinence care, removed her gloves crossed the nurse's station, put on another pair of gloves and retrieved the meal tray for a patient in protective isolation, put on a yellow gown and mask and went into the room to deliver a meal tray. Staff Q failed to sanitize her hands after removing gloves from room 244 and after removing gloves after delivering a food tray in room 212. Staff H was asked whether this staff missed hand hygiene opportunities after removing her gloves to which she replied, "Yes she did."

On 9/2/15 at 1130 a review of undated facility policy titled, "Handwashing" stated, "...hands should be washed before entering a patient room and upon exiting, before having direct contact with patients, before performing donning gloves or partaking in procedures ...... after removing gloves..."

On 9/1/15 between 0700 and 1100, during observations in the OR (operating room) revealed the anesthesiologist, staff S came into the OR twice at 0800 to evaluate the patient and again at 0830 to evaluate the patient. Both times staff S failed to sanitize hand either before entry or after exit. Interview with staff N on 9/1/15 at 1100 regarding requirements for hand hygiene in the OR she stated, "..he should have sanitized his hands after touching the patient and before exiting the OR."

On 9/1/15 at 1230 during observations of injectable medication pass revealed staff R, registered nurse completed the medication pass, and failed to remove her gloves and sanitize her hands before documenting on the computer on wheels and replacing items back into the patients medication drawer. On 9/1/15 at 1240 interview with staff E confirmed that staff R should have removed her gloves and sanitized her hands before typing on the computer and returning items to the patients medication drawer.