HospitalInspections.org

Based on review of Brauns E3 IV (intravenous) Container frequently asked questions (FAQ), observation and interview, it was determined the facility failed to follow manufacturer's instructions when warming and storing (IV) fluids in one of one offsite Emergency Department location. Failure to follow manufacturer's instructions did not ensure the integrity of the IV solution and was likely to affect any patient who required warmed fluids for treatment. The findings were:

A. Review of Braun E3 IV container FAQ provided by Pharmacist #1 on 03/14/18 at 2:35 PM showed an IV product exposed to 40 degrees Celsius (104 degrees Fahrenheit) and not used within 28 days must be discarded and not returned to storage.
B. Observation on 03/14/18 at 9:13 AM showed six, 1000 milliliter bags of IV solution stored in a blanket warmer in the offsite location of the Emergency Department. The warmer temperature was 120 degrees Fahrenheit (F). The IV bags were not identified as to when they were to be removed and discarded. During an interview on 03/14/18 at 9:17 AM, the Clinical Lead stated the IV bags could stay until the expiration date and that there was no time limit for how long the IV bags remained in the warmer.
C. Pharmacist #1 was interviewed on 03/14/18 at 2:35 PM and confirmed the Braun IV FAQ and that the IV product was only good for 28 days once in the warmer.



31039

Based on observation, review of policy and interview, it was determined the facility failed to ensure outdated medications were not available for patient use in one of one (Obstetrics) Anesthesia supply cart observed. By not disposing of expired medication, the facility could not assure the safety and efficacy of the medications past the expiration date. The failed practice had the likelihood to affect all patients admitted to Obstetrics. Findings follow:

A. Record review of the facility's policy titled, "Expired/Unusable Drugs," showed direction for the facility to remove expired medications from stock so they are not available for patient use.
B. A tour of the Obstetrics Department on 03/12/18 from 3:40 PM to 4:10 PM showed the following outdated medications on the Anesthesia supply cart:
1) One Fentanyl 2 mcg (micrograms) / ml (milliliter) 200 mls for IV (Intravenous administration) expired 01/26/18;
2) One Succinylcholine 20 mg/ml 10 mls for IV use, removed from refrigeration on 08/15/17 and expired 08/29/17;
3) One Glycopyrrolate 0.2 mg/ml for IV expired 01/31/17; and
4) One Epinephrine 1:1000 1 ml for IV expired 3/1/2018.
C. During an interview on 03/12/18 at 4:10 PM, Anesthesiologist #1 verified the outdated medications stored on the cart.

Based on review of manufacturer's instructions for use, three compartment sink log and interview, it was determined the Dietary Director failed to ensure manufacturer's instructions for testing the concentration of the multi-quat sanitizer were followed when used in the three compartment sink for three of three months (12/2017, 01/2018, and 02/2018) reviewed. Failure to follow the manufacturer's instructions for the temperature range of 65-75 degrees Fahrenheit for the testing solution did not ensure an accurate measurement of sanitizer concentration. The failed practice affected all patients, staff and visitors. The findings were:

A. Review of the Oasis 146 Multi-Quat sanitizer and Hydrion manufactures instructions for use on 03/16/18 showed the solution for sanitation range testing should be between 65-75 degrees Fahrenheit. The purpose of the sanitation range testing was to measure the concentration of quaternary sanitizers in parts per million (PPM) to ensure concentration was as required.
B. The Nutritional Services 3 compartment sink Temperature and PPM log for 12/01/17 - 02/28/18 was reviewed on 03/15/18. The log form showed the third sink temperature must 70-75 degrees. The third sink temperature as documented by staff ranged from 70-126 degrees Fahrenheit and was not within the required temperature range as follows: 12/01/17 - 12/31/17, 92 of 93 times; 01/01/18 - 01/31/18, 50 of 50 times and 02/01/18 - 02/28/18, 56 of 56 times.
C. The Director of Dietary was interviewed on 03/16/18 at 9:16 AM and confirmed the third sink temperatures as documented by staff were not within required range according to manufactures instructions for use.

Based on observation and interview, it was determined the facility failed to maintain the building physical structure, environment and equipment in that there was cracking and chipping in the walls, chipped corner in a wall, rust on the casters and cart in two (Room CCU (Critical Care Unit) #3 and Room CCU #4) of eight areas observed. The failed practice had the potential to affect all patients staff and visitors due to the potential for an infection control issue presented by the observed conditions. Findings follow:

A. During a tour of the facility on 04/26/18 at 1:05 PM, observation showed:
1) Cracking and chipping in the walls just above the trim in room CCU #3.
2) Chipped corner of the wall next to the glass door in CCU #3.
3) Rust on the casters (wheels) of the IV pole in CCU #4.
4) In the Obstetrics Operating Room (OB OR), rust on the cart for the "ElectroSurg Generator"; also rust on the casters.
B. During the tour of the Intensive Care Unit (ICU) (Rooms CCU #3 and CCU #4), the failed practices were verified by the ICU Manager.
C. During the tour of the OB OR, the failed practice was verified by the Nurse Manager of the Women's Center.

Referenced Code: 42 CFR Section: 482.41(a)

Based on observation and interview, it was determined that the infection control officer did not identify and control infections in that Vascular Access Nurse #1 failed to maintain a sterile environment by placing contaminated items on her sterile field while inserting a Peripherally Inserted Central Catheter (PICC) in one of one (#33) contact isolation patient. The failed practice did not assure Vascular Access Nurse #1 mitigated the risks of healthcare-associated infections by maintaining aseptic technique while placing a PICC line. The failed practice had the potential to affect all patients requiring PICC line insertion. Findings follow:

A. On 03/13/18 at 2:00 PM, Vascular Access Nurse #1 donned a contact isolation gown and gloves and entered Patient #33's room. Once Vascular Access Nurse #1 was inside the contact isolation room she removed her isolation gown and gloves for 5 minutes while she prepared her PICC line drape and supplies. Vascular Access Nurse #1 then began to prep Patient #33's arm with betadine swabs. Vascular Access Nurse #1 proceeded to don her sterile gown, gloves and mask. During the procedure, Vascular Access Nurse #1 used the same syringe and needle to inject Lidocaine in 4 separate locations and placed it back on the sterile field. Vascular Access Nurse #1 then used the introducer and guidewire on two separate attempts to access Patient #33's vein and placed it back on the sterile field.
B. On 03/13/18 at 2:45 PM, the above findings in A were verified with the Infection Control Officer.


Based on observation, review of manufacturer's recommendation and interview, it was determined the Infection Control Officer failed to prevent and control infections in that oxygen extension tubing was not being changed after each patient in two of two (#1 and #2) Gastrointestinal (GI) Rooms. Failure to change the oxygen extension tubing after each patient use did not ensure the oxygen tubing was free of airborne contaminants. The failed practice had the potential to affect all patients receiving Endoscopy procedures. Findings follow:

A. During tour of GI Room #1 and GI Room #2 on 03/13/18 at 10:30 AM, showed oxygen extension tubing hanging from the wall ready for the next patients use. The use of oxygen extension tubing on multiple patients was verified by the Durector of Surgery.
B. Review of the manufacturer's packaging of the oxygen extension tubing showed that it was for single patient use.
C. The above findings in A and B were verified with the Director of Surgery on 03/13/18 at 10:30 AM.


Based on review of facility policies and procedures, review of employee's files and interview, it was determined the Infection Control Officer failed to control infections in that 317 of 367 employees did not have an annual FIT Testing of their respirator. The failed practice did not ensure employees would be protected against Tuberculosis (TB) while caring for patients with confirmed TB. The failed practice had the potential to affect all employees and patients of the facility. Findings follow:

A. Review of the facility's policy and procedure on 03/13/18 at 9:45 AM titled, "Tuberculosis Control Program," showed the FIT testing was repeated on an annual basis and when a worker developed any condition which may affect a change in the way their respirator fit the face.
B. Review of the list of employees for FIT testing, received from the Infection Control Officer on 03/13/18 at 10:10 AM, showed 317 of 367 employees did not have annual Fit test performed.
C. During interview with the Infection Control Officer on 03/13/18 at 11:00 AM, she stated that annual FIT testing had not been performed and that their goal was to have these completed by April 2018.
D. The above findings in A, B, C, and D were verified with the Infection Control Officer on 03/13/18 at 11:05 AM.


Based on observation and interview, it was determined the infection control nurse failed to ensure a sanitary environment in that the cabinet below the sink in the decontamination room had a large area of rust and peeling paint on it. The failed practice did not ensure the environmental surfaces were clean and free on contaminants. The failed practice had the potential to affect all surgical patients requiring the use of surgical instruments. Findings follow:

A. During tour of Surgery and Central Sterile areas on 03/13/18 at 1:00 PM, showed in the decontamination room the cabinet below the sink had a large area of rust and peeling paint.
B. During interview with the Chief Nursing Officer, she stated this area had been scheduled for remodeling sometime in 2018 and a new cabinet quote had been obtained 07/03/17.
C. The above findings in A and B were verified with the Infection Control Officer on 03/13/18 at 1:30 PM.

Based on clinical record review, policy and procedure review and interview, it was determined in 5 of 5 (#1, #8, #12, #13, and #27) surgery patients the Post Anesthesia Evaluations were completed at exactly 60 seconds from the time these patients left the Operating Room. Failure to sufficiently recover patients prior to completing the post anesthesia evaluation did not ensure the patient was free of complications and safe to discharge from the recovery area. The failed practice had the potential to affect all surgical patients receiving anesthesia services. Finding follow:

A. Review of the Post Anesthesia Evaluations showed:
1) The anesthesia stop time for Patient #1 was 1:49 PM and the post anesthesia evaluation was completed at 1:50 PM.
2) The anesthesia stop time for Patient #8 was 11:55 AM and the post anesthesia evaluation was completed at 11:56 AM.
3) The anesthesia stop time for Patient #12 was 3:47 PM and the post anesthesia evaluation was completed at 3:48 PM.
4) The anesthesia stop time for Patient #13 was 5:57 PM and the post anesthesia evaluation was completed at 5:58 PM.
5) The anesthesia stop time for Patient #27 was 4:53 PM and the post anesthesia evaluation was completed at 4:54 PM.
B. Review of the policy and procedure titled, "Anesthesia Policy and Procedure," showed the post anesthesia evaluation may take place as soon as the patient was awake enough to participate meaningfully in the physical examination.
C. The above findings in A were verified with the Applications Manager on 03/16/18 at 9:15 AM.