HospitalInspections.org

Based on a observations, hospital policies and procedures, document review, and interviews, it was determined the Governing Body failed to ensure compliance with the Conditions of Participation was maintained and that quality patient care was provided, in a safe environment. These deficient practices had the potential to affect all patients served by this facility.

Findings:

Refer to tags A 085, A 144, A 392, A 454, A 464, A 502, A 505, A 547, A 620, A 700, A 724, and A 749.

Based on a review of Steam Load Release - Multiple Cycles (sterilization logs), hospital contracts, and staff interviews, it was determined the facility failed to ensure a contract or a written agreement was documented with an off-site facility for sterilization of surgical instruments.

This had the potential to negatively affect all patients receiving surgery at this facility.

Findings include:

On 8/23/23 at 11:15 AM a review of the Steam Load Release - Multiple Cycles (sterilization logs) from July to August 2023 was conducted with Employee Identifier (EI) # 13, Surgical Scrub Tech (Technician), and the following was documented on the 8/15/23 sterilization log:

a. ...Contents: C (Cesarean)- Section, Lap (Laparotomy) instruments, D & C (Dilation and Curettage) tray x (times) 2 (two), ... Camera, light cord, scope ... Instruments autoclaved at ... (off-site hospital)."

An interview was conducted during the review with EI # 13 who stated that he/she did not perform the sterilization of the surgical instruments and that he/she had taken the instruments to ... (off-site hospital) to be sterilized. The surveyor asked EI # 13 if the facility had a contract with ... (off-site hospital) to perform sterilization of the surgical instruments and EI # 13 replied, "I don't know."

An interview was conducted on 8/23/23 at 12:01 PM with EI # 11, Registered Nurse, Operating Room Manager. The surveyor asked EI # 11 if the hospital had a contract with ...(off-site hospital) and EI # 11 replied, "No contract, just understood between us to help each other."

A review of hospital contracts was conducted on 8/24/23 at 10:00 AM. There was no documentation of a contract or a written agreement with an off-site facility for sterilization of surgical instruments.

An interview was conducted on 8/24/23 at 1:03 PM with EI # 1, Chief Executive Officer, who confirmed there was no contract or written agreement with ... (off-site hospital) to perform sterilization of surgical instruments.

Based on review of medical records (MR), hospital policy, Medical Staff Rules and Regulations, and interview, it was determined the hospital failed to provide a psychiatric evaluation for patients with suicidal ideations.

This affected two of two MR reviewed of patients with suicidal ideations including Patient Identifier (PI) # 12, PI # 31, and had the potential to affect all patients presenting to this hospital.

Findings include:

Hospital policy: Medical Staff Rules and Regulations

Reviewed: 5/26/22

... Admission and Discharge of Patients

... 16.1-7 For the protection of patients, ... precautions to be taken in the care of the potentially suicidal patient include:

a. any patient known or suspected to be suicidal in intent shall be admitted and psychiatric consultation must be offered and documented;

b. if suitable suicide precautions cannot be taken, the patient shall be referred to another institution where suitable resources are available.

Hospital policy: Suicide Precautions

Policy Number: 9159

Revised date: not provided

... As part of the hospital admissions procedure, patients shall be assessed for suicidal ideation.

When there is a suspicion of suicidal ideation, any member of staff can initiate precautionary measures to ensure close supervision and monitoring.

... Patient shall not be left alone until a risk assessment has been performed and an acuity level has been determined.

... The treatment team shall collaborate to determine the patient's suicide risk and develop a multidisciplinary plan of care that identifies interventions to mitigate risk.

Hospital policy: Psychiatric Evaluation

Policy number: 1015

Revised date: not provided

... Any patient accessing care at this facility who requires psychiatric treatment...shall be managed through referral and transfer to a behavioral health facility and/or management through consultative psychiatric services on a temporary basis, until the patient's clinical condition has stabilized to allow for psychiatric facility transfer...

For patients accessing the hospital through the Emergency Department:

The Emergency Department physician shall evaluate the patient and determine the need for a psychiatric evaluation...

1. PI # 12 was admitted to the hospital on 7/5/23 with diagnoses including Insomnia, Hypertension, and Depression.

Review of the Social Needs Screening Tool dated 7/5/23 at 10:56 PM revealed the nurse documented the Mental Health screening score of six of a possible six indicating PI # 12 may have had a mental health need.

Review of the Patient Progress Notes dated 7/7/23 at 10:56 revealed the nurse documented that PI # 12 stated he/she did not want to go home because he/she was afraid he/she was going to kill himself/herself. The nurse further documented the physician and outpatient mental health therapist was contacted.

Further review of the Patient Progress Notes dated 7/7/23 revealed PI # 12 was discharged to home at 11:55 AM to follow up with the outpatient mental health therapist.

There was no documentation a psychiatric evaluation was performed and no documentation suicide precautions were taken to ensure the patient's safety.

An interview was conducted on 8/24/23 at 11:05 AM with Employee Identifier (EI) # 2, Registered Nurse (RN), Clinical Information Technology (IT), who confirmed the hospital policy for care of patients with suicidal ideations was not followed.

2. PI # 31 presented to the Emergency Department (ED) on 8/8/23 at 10:24 AM with a chief complaint of suicidal ideations.

Review of the ED Nursing Note dated 8/8/23 at 11:00 AM revealed PI # 31 stated he/she had a suicide attempt on 8/4/23 by taking a combination of medications but had no plan, just thoughts currently.

Review of the ED Provider Note dated 8/8/23 at 12:57 PM revealed the ED physician documented PI # 31 denied suicide thoughts, was calm and stable, and willing to go anywhere for detox and rehabilitation.

PI # 31 was discharged on 8/8/23 at 1:06 PM to be picked up by an employee of a local hospital to go to their detox program.

There was no documentation suicide precautions were taken to ensure the patient's safety and no documentation a psychiatric evaluation was performed.

An interview was conducted on 8/24/23 at 11:25 AM with EI # 2 who confirmed the hospital policy for care of patients with suicidal ideations was not followed.

Based on review of Medical Records (MR), facility policy and procedure, and interviews with staff it was determined the facility failed to ensure an initial assessment for the need of PRN (as needed) medications and/or a follow up assessment was documented after the PRN medication was administered.

This affected 4 of 22 inpatient MRs reviewed including Patient Identifier (PI) # 10, PI # 19, PI # 16, PI # 11, and had the potential to negatively affect all patients admitted to this facility.

Findings include:

Hospital Policy: Pain Assessment, Reassessment and Management
Reference #: 9017
Department: Medical Surgical Unit
Effective Date: 6/14/11

Policy:

Grove Hill Memorial Hospital shall respect and support the patient's right to optimal pain assessment and management ... The organization will also address the appropriateness and effectiveness of pain management.

Procedure:

It is the responsibility of all clinical staff to screen all patients for the presence or absence of pain.

It the screening assessment reveals pain is present in the patient, it is the responsibility of clinical staff to conduct an in depth clinical assessment of the pain, and periodic reassessments of the patient for determination of pain and relief from pain, including the intensity and quality (..., character, frequency, location and duration of pain), and responses to treatment.

...The patient will undergo reassessment of pain ... after every pain control mechanism employed by patient care providers.

...Any patient care provider ... that has implemented a pain control mechanism will reassess the patient within one-half (1/2) hour to determine amount of pain control or relief achieved.

1. PI # 10 was admitted to the hospital on 8/6/23 with diagnoses including Chest Pain and Shortness of Breath.

Review of a Physician's Order dated 8/6/23 at 1:23 AM revealed Morphine 4 mg/ml (milligrams/milliliter) IVP (Intravenous Push) PRN q6h (every six hours) for pain.

Review of the Medication Record revealed PI # 10 was given Morphine 4 mg/ml IVP on 8/7/23 at 3:06 PM. There was no documentation of a pain assessment or why the PRN Morphine was given, and no follow up documentation of the effectiveness after administration.

An interview was conducted on 8/24/23 at 11:07 AM with Employee Identifier (EI) # 2, Registered Nurse (RN), Clinical Information Technology (IT), who confirmed the staff failed to document a pain assessment, the reason the PRN medication was administered, and the effectiveness, per policy.




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2. PI # 19 was admitted to the hospital on 7/16/23 with the diagnosis of Infected Right Gluteal Decubitus Ulcer.

Review of the physician's order dated 7/16/23 revealed orders for Hydrocodone/APAP (acetaminophen) 7.5/325 mg one every eight hours prn.

Review of the Patient Progress Notes (PPN) dated 7/17/23 at 3:22 AM and 7/23/23 at 1:30 PM revealed the patient received Hydrocodone/APAP (acetaminophen) 7.5/325 mg for pain. There was no documentation of the effectiveness of the medication after administration.

An interview was conducted on 8/24/23 at 11:34 AM with EI # 2, who confirmed the staff failed to document the effectiveness of the medications after administration per policy.

3. PI # 16 was admitted to the hospital on 8/1/23 with diagnosis End Stage Dementia.

Review of the physician's orders dated 8/1/23 revealed orders for Hydrocodone/APAP 5/325 mg every six to eight hours prn and Morphine Sulphate Oral Solution 20 mg/ml give 0.25 ml every two hours prn.

Review of the PPN dated 8/1/23 at 9:25 PM and 10: 01 PM revealed the patient received PRN medications, Hydrocodone/APAP 5/325 mg orally and Morphine Sulfate Oral Solution 20 mg/ml 0.25 ml respectively for pain. There was no documentation of the medications effectiveness after administration.

Review of the PPN dated 8/2/23 at 12:33 PM revealed Morphine Sulfate Oral Solution 20 mg 0.25 mg was given PRN for pain. There was no documentation of the effectiveness of the medication after administration.

Review of the PPN dated 8/3/23 revealed Morphine Sulfate Oral Solution 20 mg 0.25 mg was given PRN for pain at 11:04 AM and again at 2:03 PM. There was no documentation of the effectiveness of the medication after administration.

Review of the PPN dated 8/4/23 at 1:30 PM revealed Morphine Sulfate Oral Solution 20 mg 0.25 mg was given PRN for pain. There was no documentation of the effectiveness of the medication after administration.

Review of the PPN dated 8/5/23 revealed Morphine Sulfate Oral Solution 20 mg 0.25 mg was given PRN for pain at 8:02 AM and again at 11:07 AM. There was no documentation of the effectiveness of the medication after administration.
An interview was conducted on 8/24/23 at 11:40 AM with EI # 2, who confirmed the staff failed to document the effectiveness of the medication after administration per policy.




41623

5. PI # 11 was admitted to the hospital on 7/31/23 with diagnoses including Tachycardia, Anemia, and Metastatic Colon Cancer.

Review of the physician's orders dated 7/31/23 revealed orders for Percocet 5/325 mg (Oxycodone/APAP) tablet one every six hours as needed.

Review of the Medication Record revealed Percocet was given on 8/2/23 at 3:25 AM. There was no documentation of an assessment of the pain and no documentation of a follow up assessment of the effectiveness of the medication.

An interview was conducted on 8/24/23 at 10:55 AM with EI # 2 who confirmed the assessment of pain before and after administration of the prn was not performed per hospital policy.

Based on review of medical records (MR), Article XVI, Medical Staff Rules and Regulations, and interview, it was determined the hospital failed to ensure physician's orders were signed and dated per medical staff rules and regulations.

This deficient practice affected three of five outpatient surgical records reviewed, including Patient Identifier (PI) # 26, PI # 23, and PI # 24, and had the potential to affect all patients receiving outpatient surgery at this hospital.

Findings include:

Hospital Policy: Medical Staff Rules and Regulations
Approved Date: 5/26/22

Article XVI
Medical Staff Rules and Regulations

...16.2 Medical Records

...16.2-9

All clinical entries in the patient's medical record shall be accurately dates (dated) and signed.

1. PI # 26 was admitted to the facility on 6/1/23 for an Outpatient Suburethral Sling.

Review of the MR revealed "Post-Op (Operative) Orders." There was no documentation of the date the physician signed the post-op orders as directed per the medical staff rules and regulations.

An interview was conducted on 8/24/23 at 11:24 AM with Employee Identifier (EI) # 2, Registered Nurse (RN), Clinical Information Technology (IT), who confirmed the physician failed to document the date he/she signed the post-op orders.

2. PI # 23 was admitted to the facility on 8/3/23 for an Outpatient Hysteroscopy and Dilation and Curettage.

Review of the MR revealed "Post-Op Orders." There was no documentation of the date the physician signed the post-op orders as directed per the medical staff rules and regulations.

An interview was conducted on 8/24/23 at 11:24 AM with EI # 2, who confirmed the physician failed to document the date he/she signed the post-op orders.

3. PI # 24 was admitted to the facility on 6/6/23 for an Outpatient Diagnostic Laparoscopy With Rule Out Ectopic Pregnancy and Any Other Deemed Procedures.

Review of the MR revealed "Post-Op Orders." There was no documentation of the date the physician signed the post-op orders as directed per the medical staff rules and regulations.

An interview was conducted on 8/24/23 at 11:24 AM with EI # 2, who confirmed the physician failed to document the date he/she signed the post-op orders.

Based on review of medical records (MR), Medical Staff Rules and Regulations, and interviews, it was determined the hospital failed to ensure consultations were completed as requested.

This deficient practice affected one of twenty-two inpatient records reviewed including Patient Identifier (PI) # 12, and had the potential to affect all patients admitted to this hospital.

Findings include:

Hospital Policy: Medical Staff Rules and Regulations

Policy number: not provided

Approved: 5/26/22

... 16.1-7 ...any patient known or suspected to be suicidal in intent shall be admitted and psychiatric consultation must be offered and documented...

16.2-7 Consultation shall show evidence of a review of the patient's records by the consultant, pertinent findings on examination of the patient, the consultant's opinion and recommendation. This report shall be made part of the patient's record...

1. PI # 12 was admitted to the hospital on 7/5/23 with diagnoses including Insomnia, Hypertension, and Depression.

Review of the physician's order dated 7/5/23 at 9:26 PM revealed an order for consult for Employee Identifier (EI) # 22, Nurse Practitioner, Psychiatric Mental Health Nurse.

Review of the History and Physical dated 7/6/23 at 7:29 AM revealed the physician documented PI # 12 had mental health issues and would consult EI # 22.

PI # 12 was discharged on 7/7/23 at 11:55 AM. There was no documentation the consultation by EI # 22 was performed.

An interview was conducted on 8/24/23 at 11:05 AM with EI # 2, Registered Nurse, Clinical Information Technician, who confirmed the psychiatric consult was not completed as ordered.

Based on observation, hospital policy, and interview, it was determined the facility failed to ensure:

1. Medications within the labor and delivery unit patient rooms were stored securely and not accessible to patients and visitors.

2. Anesthesia medications were stored in the anesthesia cart per hospital policy.

This did affect one of one surgical observations conducted, including Patient Identifier (PI) # 34, and had the potential to negatively affect all patients and visitors served by this hospital.

Hospital Policy: Security of Staff and Medications
Policy Number: 20-01
Department: Pharmacy
Reviewed Date: 6/11/14

Requirement for Lockable Storage:

Lockable storage units or lockable medication carts, if necessary, shall be provided for medication storage areas throughout the facility. Medications shall be kept in locked storage or be inaccessible to patients, visitors, and unauthorized staff.

1. A tour of the hospital's Labor and Delivery Unit was conducted on 8/22/23 at 12:42 PM with Employee Identifier (EI) # 34, Utilization Review.

The tour included observation of LDR (Labor, Delivery and Recovery) rooms 123 and 124, which are accessible to OB (Obstetric) patients and visitors.

LDR room 123 had a large cabinet next to the sink with a padlock hanging on one side of a hinge/hardware that was disconnected from the wooden cabinet. Inside the cabinet were multiple non-controlled medications, IVF's (Intravenous Fluids), syringes and supplies available for use with OB patients.

LDR room 124 also had a large cabinet next to the sink with hardware securely connected to accommodate the use of a padlock. There was no padlock attached to the hardware to secure the cabinet. Inside the cabinet were multiple non-controlled medications, IVF's, syringes and supplies available for use with OB patients.

The facility failed to store the medications securely.

An interview was conducted on 8/22/23 at 3:37 PM with EI # 9, Registered Nurse (RN) Charge Nurse, who confirmed the medications were not stored securely to be inaccessible to patients, visitors, and unauthorized staff.




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2. PI # 34 was admitted to the facility on 8/23/23 for an Outpatient Esophagogastroduodenoscopy (EGD) with Possible Biopsies and Colonoscopy, Possible Biopsy.

During observations of care conducted on 8/23/23 from 6:36 AM to 8:13 AM, the surveyor observed the following:

At 7:00 AM the surveyor entered the Procedure Room and observed EI # 7, Certified Registered Nurse Anesthetist (CRNA) preparing IV medications for PI # 34. EI # 7, retrieved two prepared IV medication syringes and placed the two syringes in his/her front shirt pocket. The surveyor asked EI # 7, what was in the two IV syringes that he/she had placed in /her pocket. EI # 7 stated, "Lidocaine and Robinul". EI # 3 then proceeded to leave the Procedure Room with the two prepared IV medication syringes in his/her front shirt pocket.

EI # 7 failed to store the two IV medication syringes in the locked anesthesia cart per facility policy.

An interview was conducted on 8/23/23 at 12:01 PM with EI # 11, Registered Nurse, Operating Room Manager, who confirmed the staff failed to store anesthesia medications in the anesthesia cart per facility policy.

Based on observations, hospital policies and procedures, Centers for Disease Control and Prevention (CDC) Injection Safety recommendations, and interview, it was determined the facility failed to ensure:

1. Opened medication vials were labeled with the date opened.

2. Single use vials were not opened, stored and available for future use.

3. Expired medications and solutions were not available for patient use.

This deficient practice had the potential to affect all patients receiving care at this hospital.

Findings include:

Hospital Policy: Unusable Medications and Devices
Policy No: 18-09
Department: Pharmacy
Reviewed Date: 6/2/14

Policy

Unusable medications and devices shall be handled and disposed of in accordance with this policy.

Definition of Unusable Medications and Devices

Unusable medications and devices include those that are:

Expired (outdated)...

Pharmacy Storage of Unusable Medications and Devices

The pharmacy shall store unusable medications and devices in specially designated areas (old bathroom closet)...

Hospital Policy: Expiration Dates
Policy No: 7013
Department: Pharmacy
Reviewed Date: 6/2/14

Policy

Length of Use of Multiple-Use Sterile Medications

Multiple-use containers of sterile medications shall be dated and initialed or signed when first opened or entered.

Hospital Policy: Use of Multiple Dose Vials (MDVs)
Reference #: 7058
Department: Medical Surgical Unit
Effective Date: 6/8/10

Policy:

...The healthcare provider shall write the expiration date on the vials, when opened.

...Opened single-dose ampuls shall not be stored for any period of time.

Hospital Policy: Storage of Medications and Solutions in Patient Care Areas
Reference#: 7013
Department: Medical Surgical Unit
Effective Date: 6/14/11

Procedure:

...Drugs shall be kept in locked storage when unattended...

Record open and discard dates on solution bottles.

Hospital Policy: Medication and Solution Administration - Invasive Procedures
Reference #: 7042
Department: Medical Surgical Unit
Effective Date: 6/14/11

Policy

...The following medications and solutions must be labeled when removed from their original containers:

Medications:

...Vaccines...

Solutions

Hospital Procedure: Infection Control
Reference #: 5003
Department: Anesthesia
Effective Date: Not Documented

Procedure:

... At the completion of the procedure, all medications will be discarded.

CDC Injection Safety

Questions about Single-dose/Single-use Vials

...A single-dose or single-use vial is a vial of liquid medication intended for parenteral administration (injections or infusion) that is meant for use in a single patient for a single case, procedure, injection.

...Single-dose or single-use vials are labeled as such by the manufacturer and typically lack an antimicrobial preservative...Vials that are labeled as single-dose or single-use should be used for only a single patient as part of a single case, procedure, injection...

If a single-dose or single-use vial has been opened or accessed (e.g., needle-punctured) the vial should be discarded... It should not be stored for future use.

1. A tour of the Emergency Department (ED) was conducted on 8/22/23 at 9:00 AM with Employee Identifier (EI) # 16, Registered Nurse (RN), ED Nurse Manager.

a. In the Procedure Room the following out of date supplies were observed:

Normal Saline 500 ml (milliliter) solution was opened and not labeled with a date.

b. In the Trauma Room, the following medications were observed in the Disaster Box and available for patient use:

Epinephrine 0.1 mg (milligram)/ml 10 ml x three syringes with an expiration date of 9/22.

Epinephrine 0.1 mg/ml 10 ml x three syringes with an expiration date of 7/23.

Lidocaine 100 mg/5 ml x two syringes with an expiration date 11/22.

Atropine 1 mg syringe with an expiration date of 5/23.

Adenosine 6 mg/2 ml x three vials with an expiration date of 5/23.

Ondansetron 4 mg/2 ml x two vials with an expiration date of 7/23.

Dexamethasone 4 mg/ml x four vials with an expiration date of 5/23.

Diphenhydramine 50 mg/ml x four vials with an expiration date of 5/23.

Furosemide 20 mg/ml x five vials with an expiration date of 7/23.

Amiodarone 50 mg/ml x four vials with an expiration date of 11/22.

50 % Dextrose 25 mg/50 ml x two syringes with an expiration date of 7/22.

Nitroglycerin 0.4 mg tablets x one bottle with an expiration date of 7/24.

GlucaGen 1 mg injection with an expiration date of 9/22.

Naloxone 0.4 mg/ml x five vials with an expiration date of 3/23.

Furosemide 40 mg/ 4 ml x five vials with an expiration date of 1/23.

0.9 % Sodium Chloride 100 ml infusion x two bags with an expiration date of 1/23.

Dopamine 400 mg/250 ml infusion bag with an expiration date of 3/22.

0.9 % Sodium Chloride 1000 ml infusion x two bags with an expiration date of 3/23.

c. In the refrigerator in the medicine room the following out of date medications were observed and available for patient use:

Ativan 1 mg/ml 10 ml vial was opened and not labeled with a date of expiration.

Humulin R insulin 10 ml vial opened and labeled with the date 6/23/23.

Lantus insulin 10 ml vial opened and not labeled with a date of expiration.

An interview was conducted on 8/22/23 at 10:00 AM with EI # 16, who confirmed the medications were expired and available for patient use.

2. During a tour of the pharmacy on 8/22/23 at 10:00 AM with EI # 20, Pharmacy Manager, the following drugs (or items) were identified:

a. 1 MDV Tuberculin Purified Protein Derivative (PPD) opened without a date.

b. 1 bottle of Ferric Subsulfate (Monsel's Solution) 500 ml was opened without a date, expired 7/2020, and stored for future use.

An interview was conducted during the tour with EI # 20, who confirmed the MDV of PPD should have been labeled when opened and the Monsel's Solution should have been stored in the pharmacy bathroom closet and not available for patient use, per hospital policy.

3. During a tour of Operating Room (OR) 1 (One) in the Surgical Services Department on 8/22/23 at 11:00 AM with EI # 7, Certified Registered Nurse Anesthetist (CRNA), the following drugs were identified in the anesthesia cart:

a. Esmolol HCL (Hydrochloride) injection 100 mg/ml single use vial opened and available for patient use.

b. Bupivacaine 0.5 % 150 mg/30ml single use vial opened and available for patient use.

c. Lidocaine 1 % 500 mg/50 ml MDV opened without a date.

An interview was conducted during the tour with EI # 7, who confirmed the MDV was not labeled per hospital policy and the single use vials were opened and available for patient use and failed to meet CDC recommendations and hospital procedure.

4. During a tour of the Surgical Services Department on 8/22/23 at 11:22 AM with EI # 11, OR Manager, the following medications were observed as expired and available for patient use in the malignant hyperthermia medication cart:

a. (Six) Procainamide HCL injection 1000 mg/2 ml MDV's with expiration date 4/2023.

b. (One) Lidocaine 2 % injection 100 mg/5 ml MDV with expiration date 4/2023.

c. (Two) Heparin Sodium injection 5000 units/1ml SDV's with expiration date 6/1/23.

d. (Two) Ryanodex (Dantrolene Sodium) 250 mg strength vials with expiration date March 2023.

An interview was conducted during the tour with EI # 11 who confirmed the medications were expired, and available for patient use.




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41624

Based on review of radiology staff personnel files, job description for the Manager of Imaging, and interview, it was determined the hospital failed to ensure:

1. The manager of the radiology department had the minimum qualifications required per job description.

2. The manager was registered with ARRT (American Registry of Radiologic Technologists) per job description minimum qualifications.

This deficient practice affected Employee Identifier (EI) # 15, Radiology Manager, and had the potential to negatively affect all patients receiving imaging services at this hospital.

Findings include:

Hospital Job Description:

Title: Manager Imaging
Job Code: 810301
Revised: 5/15/15

Position Purpose and Scope of Responsibility:

Manages overall operation of multi modality imaging department including but not limited to areas such as CT (Computerized Tomography)...US (Ultrasound), Breast Imaging...Diagnostic Radiography...

Principal Accountabilities:

...Job Accountability # 2 - Selects, orients, trains, evaluates...departmental staff...

Minimum Qualifications:

Knowledge/Education:

- Graduate of an accredited School of Radiologic Technology or equivalent.
- B.S. (Bachelor of Science) in applicable field or equivalent working knowledge.
- Considerable clinical knowledge of the area's scope of care/practice.
- Working knowledge of management practices and techniques.

Licensure, Registration, Certification:

- Registry with ARRT

1. A review of select personnel files was conducted on 8/24/23 which included a review of EI # 15's personnel file.

The review revealed there was no documentation of education, current registration with ARRT, and no evaluation of a skills competency in the file.

The surveyor then requested the job description for the manager of radiology which revealed minimum qualifications were required. The surveyor requested documentation of the qualifications required for EI # 15 as radiology manager, and none were provided.

An interview was conducted on 8/24/23 at 1:09 PM with EI # 17, Administrative Assistant, who confirmed there was no documentation of education, ARRT certification, or evaluation of skills competency per job description requirements.

Based on observations, review of hospital policies and procedures, and interviews with staff, it was determined the hospital failed to ensure the dietary service equipment and work area were inspected for safe use, clean and kept free of encrusted grease deposits and/or accumulated soil.

This had the potential to affect all patients admitted to this hospital.

Findings include:

Hospital Policy:
Subject: Infection Prevention and Control Oversight
Department: Nutritional Services
Revised: No Date

Purpose:

To prevent and control contamination and the spread of infection within the department and the hospital.

Policy:

Nutritional Services staff shall follow all appropriate infection prevention and control measures for all food service.

Responsilibilites:

...Ensure clean, sanitary work areas,..and equipment for handling of supplies...
...Provides continuing preventive maintenance of equipment...
Control of the System: Preventive and corrective maintenance shall be documented.

1. A tour of the dietary department was conducted on 8/22/23 at 9:07 AM with Employee Identifier (EI) # 6 Dietary Manager (DM). The following deficient practices were observed:

Observation of a three (3) compartment sink revealed the first sink (wash bin) leaking water onto the floor.

EI # 6 stated, "the sink had been leaking for about one week, had been reported to the maintenance personnel and a part had been ordered to fix it." The surveyor requested documentation for the requisition repair, no documentation was provided.

There was encrusted grease deposits and/or accumulated soil build up on the floor between the gas stove and the fryer. EI # 6 reported, he/she was unable to reach under and between the stove and fryer area to clean.

The following icemaker had no preventative maintenance (PM) documentation:

There were two industrial refrigerators and two industrial upright freezers with PM stickers indicating a due date of 3/2/2019.

An interview was conducted on 8/24/23 at 8:50 AM, who confirmed the staff failed to ensure the dietary department work areas were kept cleaned and free of encrusted grease deposits and/or accumulated soil, preventive maintenance of equipment performed and documented per the hospital's policy.

Based on observations during facility tour with hospital staff by the Life Safety surveyor and staff interviews, it was determined the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations, and A 724 for findings.

Based on observations and interviews, it was determined the staff failed to ensure expired supplies were not available for patient use.

This deficient practice had the potential to affect all patients receiving care at this hospital.

Findings include:

1. A tour of Operating Room (OR) 1 (one) was conducted on 8/22/23 at 11:00 AM with Employee Identifier (EI) # 7, Certified Registered Nurse Anesthetist (CRNA). The following items were expired and available for patient use on the anesthesia cart:

a. Six 22 gauge (G) 3.5 " (inch) Spinal Needles with an expiration date of 1/31/23 and available for patient use.

b. One 20 G 1.00" IV (Intravenous) catheter with an expiration date of 1/1/23 and available for patient use.

c. One 18 G 1.16" Insyte Autoguard with an expiration date of 3/31/23 and available for patient use.

An interview was conducted during the tour with EI # 7, who confirmed the supplies were expired and available for patient use.



41623

2. A tour of the Emergency Department (ED) was conducted on 8/22/23 at 9:00 AM with EI # 16, ED Nurse Manager.

a. In the Procedure Room the following out of date supplies were observed:

Iodaform one half inch single use gauze packing, opened and available for use.

Iodaform one quarter inch single use gauze packing opened and available for use.

Iodaform one inch single use gauze packing opened and available for use.

An interview was conducted on 8/22/23 at 10:00 AM with EI # 16, who confirmed the supplies were expired and available for patient use.

Based on observations, hospital policies and procedures, the Center for Disease Control and Prevention (CDC) Injection Safety recommendations, the CDC and Prevention Guidelines for Hand Hygiene in Health-Care Setting, Instructions For Use: Pentax Tri-Bristled Cleansing Brush for Endoscopic Channel, Steam Load Release - Multiple Cycles (sterilization logs), Attest Results (biological indicator of the steam sterilizer), and staff interviews, it was determined the facility failed to ensure infection control practices were followed for hand hygiene, medication preparation, use of single use supplies, and documentation of surgical instrument sterilization procedures.
These deficient practices had the potential to affect all patients served by this facility.

Findings:

Refer to A 749.

Based on observations, hospital policies and procedures, the Center for Disease Control and Prevention (CDC) Injection Safety recommendations, the CDC and Prevention Guidelines for Hand Hygiene in Health-Care Setting, Instructions For Use: Pentax Tri-Bristled Cleansing Brush for Endoscopic Channel, Steam Load Release - Multiple Cycles (sterilization logs), Attest Results (biological indicator of the steam sterilizer), and staff interviews, it was determined the facility failed to ensure the staff:

a. Performed hand hygiene per hospital policy.

b. Cleaned the septum (rubber top of a medication vial) on all medication vials with alcohol before piercing with the syringe needle per CDC recommendations.

c. Never used single - use brushes on more than one endoscope as directed per the Instructions For Use for Pentax Tri-Bristled Cleansing Brush when performing high level disinfection of an Endoscope.

d. Maintained documentation of all sterilization of surgical instruments and ensured surgical instruments met exposure time and temperature and biological indicator monitoring for the steam sterilizer per facility policy.

This did affect one of one surgical observation conducted, including Patient Identifier (PI) # 34, one of one patient room terminal cleaning, two of two observations conducted for administration of parenteral (Intravenous) medications, including PI # 1, and one of one observation of wound care to an unsampled patient.
This had the potential to affect all patients receiving care at this hospital.

Findings include:

Hospital Policy: Handwashing
Reference #: 3006
Department: Infection Control
Effective Date: Not Documented

Policy:

Hospital personnel shall wash their hands to prevent the spread of infections:

... Before applying and after removing gloves.

CDC and Prevention Guidelines for Hand Hygiene in Health-Care Setting
Last Updated June 25, 2018

When to Perform Hand Hygiene:

Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed)

After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings.

After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

After glove removal.

Hospital Policy: Use of Multiple Dose Vials (MDVs)
Reference #: 7058
Department: Medical Surgical Unit
Effective Date: 6/8/10

... Procedure:

The healthcare provider will perform hand hygiene before handling the MDV.

Hospital Policy: IV (Intravenous) Admixture Preparation
Reference #: 7041
Department: Medical Surgical Unit
Effective Date: 6/8/10

Procedure:

...Break and remove seal(s) from vial of medication...and wipe rubber stoppers with alcohol swab..

CDC Injection Safety

...Medication Preparation Questions

...2. How should I draw up medications?

Parenteral (intravenous) medications should be accessed in an aseptic manner. This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it.

Instructions For Use:
Pentax Tri-Bristled Cleansing Brush for Endoscopic Channel
CS6021T

1. Intended Use

Note: Single - use brushes are non - sterile for single use. Never use brushes on more than one endoscope. Re-using single - use cleaning brush results in partial or unsuccessful cleaning and increases risk of cross contamination.

Hospital Policy: Sterilization
Reference #: 5039
Department: Sterile Processing
Effective Date: Not Documented

Policy:

Every sterilized item shall have a load control identification that indicates the sterilizer used, the cycle or load and the date of sterilization.

Procedure:

Performance records for all sterilizers shall be maintained for each cycle and retained in the department.

...Time-temperature recording device and temperature and pressure gauges shall be monitored by the sterilizer operator at the beginning and end of each sterilizer cycle to verify function.

...Time temperature recording device indicating the load number shall be maintained...

Information recorded from a sterilization cycle shall include the following:

...Load number

...Exposure time and temperature, if not provided on chart

...Name of operator

...Results of biological monitor, where applicable.

Hospital Policy: Attest Biological Indicator Use
Reference #: 5046
Department: Sterile Processing Surgical Services
Effective Date: Not Documented

Purpose:

To test steam sterilizer to ensure proper functioning.

Procedure:

...A test pack will be used for each steam load to be run.

Responsibility:

Central Sterilization personnel are responsible for the proper use, interpretation and documentation of the Attest Biological Indicators with each steam cycle.

1. An observation of patient room terminal cleaning was conducted on 8/22/23 at 11:55 AM with Employee Identifier (EI) # 8, Environmental Services.

EI # 8 performed hand hygiene, removed gloves from the box, then dropped one glove onto the floor. EI # 8 picked up the glove from the floor and applied the dirty glove to the left hand. EI # 8 failed to perform hand hygiene after contacting the dirty surface.

EI # 8 then sprayed the bed with disinfectant, removed the gloves and applied new gloves. EI # 8 failed to perform hand hygiene after removing gloves.

After wiping all surfaces, EI # 8 removed the gloves and applied clean sheets to the bed. EI # 8 failed to perform hand hygiene after removing the gloves.

An interview was conducted on 8/24/23 at 11:30 AM with EI # 2, Registered Nurse, Clinical Informatics Technician, who confirmed the staff failed to follow the hospital policy for hand hygiene.

2. PI # 34 was admitted to the facility on 8/23/23 for an Outpatient Esophagogastroduodenoscopy (EGD) with Possible Biopsies and Colonoscopy, Possible Biopsy.

During observations of care conducted on 8/23/23 from 6:36 AM to 8:13 AM, the surveyor observed the following:

At 6:36 AM EI # 18, Registered Nurse (RN) OR, escorted PI # 34 to Pre-Operative (Op) Room 1 (one). EI # 18 applied gloves, obtained PI # 34's vital signs and removed his/her gloves without performing hand hygiene.

At 6:42 AM EI # 18 started an IV on PI # 34 and removed his/her gloves without performing hand hygiene.

At 7:00 AM the surveyor entered the Procedure Room (PR) and observed EI # 7, Certified Registered Nurse Anesthetist (CRNA) preparing IV medications for PI # 34. EI # 7 opened four MDVs of Propofol and withdrew the solution from each vial into a syringe without cleansing the septum of each vial with alcohol per CDC recommendations.

At 7:07 AM PI # 34 was taken to the PR and EI # 7 applied gloves and connected PI # 34 to the monitor. EI # 7 then removed his/her gloves without performing hand hygiene.

At 7:32 AM the EDG procedure was completed on PI # 34 and EI # 7, EI # 11, OR Nurse Manager (NM), EI # 12, Surgical Scrub Technician (Scrub Tech), and EI # 19, Medical Doctor (MD), General Surgeon, removed his/her gloves without performing hand hygiene.

At 7:35 AM EI # 7 retrieved one bag of IV fluids and three MDVs of Propofol from the anesthesia cart without performing hand hygiene per hosptial policy. EI # 7 then withdrew the solution from each vial of Propofol into a syringe without cleansing the septum of each vial with alcohol per CDC recommendations.

At 7:37 AM EI # 7 and EI # 19 applied gloves without performing hand hygiene and at 7:39 AM started Colonoscopy procedure on PI # 34.

At 7:44 AM EI # 7 removed his/her gloves without performing hand hygiene and retrieved one vial of NeoSynephrine and a syringe. EI # 7 withdrew the solution into the syringe without cleansing the vial septum with alcohol per CDC recommendations.

At 8:13 AM the Colonoscopy procedure was completed on PI # 34 and EI # 7 removed his/her gloves without performing hand hygiene.

An interview was conducted on 8/23/23 at 12:01 PM with EI # 11 who confirmed the staff failed to perform hand hygiene per hospital policy and clean the rubber septum of medication vials with alcohol per CDC recommendations.

3. An observation was conducted on 8/23/23 at 8:18 AM with EI # 12 to perform high level disinfection of the Endoscope. EI # 12 obtained a cleansing brush lying on the counter and stated, "We open it (brush) in the morning and use it (brush) on each scope until we are through at the end of the day and then dispose of it". The surveyor asked EI # 12, "Are you saying that you use the same brush on all of your scopes until the end of the day?" EI # 12, replied, "Yes."

The facility failed to ensure the staff never used single - use brushes on more than one endoscope as directed per the Instructions For Use for Pentax Tri-Bristled Cleansing Brush when performing high level disinfection of the Endoscope.

After completion of high level disinfection of the Endoscope EI # 12 removed his/her gloves without performing hand hygiene.

An interview was conducted on 8/23/23 at 8:45 AM with EI # 11 who verified the staff was using a single - use brush on multiple Endoscopes and confirmed the staff failed to follow the Instructions For Use for Pentax Tri-Bristled Cleansing Brush when performing high level disinfection of the Endoscope.

4. An observation of medication administration by EI # 9, RN, was conducted on 8/23/23 at 9:00 AM to administer IV Pepcid to PI # 1.

While preparing the medication for administration, EI # 9 removed the plastic cap covering the septum of the Pepcid vial, punctured the septum with a needle, and withdrew the solution into the syringe without cleansing the vial septum with alcohol per policy and CDC recommendations.

An interview was conducted on 8/24/23 at 3:00 PM with EI # 4, Infection Preventionist, who confirmed staff failed to follow hospital policy to cleanse the vial septum with alcohol before withdrawing the medication.

5. An observation was conducted in Central Sterile on 8/23/23 at 10:39 AM with EI # 13, Scrub Tech, to perform cleaning and disinfection of surgical instruments. EI # 13 applied gloves, performed cleaning and disinfection of the surgical instruments and removed his/her gloves without performing hand hygiene.

An interview was conducted on 8/23/23 at 12:01 PM with EI # 11 who confirmed the staff failed to perform hand hygiene per hospital policy.

6. A review of the Steam Load Release - Multiple Cycles (sterilization logs) from July to August 2023 and Attest Results (biological indicator of the steam sterilizer) was conducted on 8/23/23 at 11:15 AM with EI # 13 and the following was identified on the 8/15/23 sterilization log:

a. Load No (Number): There was none documented.

b. See Enclosed Record Card (Exposure time and temperature): There was none documented.

c. Initial: EI # 13 with documentation which read, Contents: C (Cesarean)- Section, Lap (Laparotomy) instruments, D & C (Dilation and Curettage) tray x (times) 2 (two), ... Camera, light cord, scope ... Instruments autoclaved at ... (off-site hospital)".

d. Attest Results (biological indicator of the steam sterilizer): There was none documented.

An interview was conducted during the review with EI # 13 who stated that he/she did not perform the sterilization of the surgical instruments and that he/she had taken the instruments to ... (off-site hospital) to be sterilized. EI # 13 further stated that he/she failed to obtain the sterilization documentation from ... (off-site hospital) when he/she picked up the instruments on 8/16/23.

An interview was conducted on 8/23/23 at 12:01 PM with EI # 11 who verified the staff failed to ensure surgical instruments met exposure time and temperature and biological indicator monitoring of the steam sterilizer and staff failed to maintained documentation of all sterilization of surgical instruments per hospital policy.

7. An observation of wound care to an unsampled patient by EI # 9 was conducted on 8/24/23 at 12:00 PM.

EI # 9 performed hand hygiene, applied gloves, opened and laid out supplies needed for care. EI # 9 then removed his/her gloves and applied new gloves without performing hand hygiene.

After cleaning the wound, EI # 9 removed the glove to his/her right hand, and applied a new glove without performing hand hygiene.

After completing wound care, EI # 9 removed his/her gloves, applied new gloves without performing hand hygiene and gathered dirty linens to place in the hamper.

An interview conducted on 8/24/23 at 3:00 PM with EI # 4 confirmed staff did not perform hand hygiene per hospital policy.




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