HospitalInspections.org

Based on interview and swing bed services review, the provider failed to have specific policies and procedures for patients who required swing bed services. Findings include:

1. Review of the provider's swing bed services program revealed no specific policies and procedures for activities, social services, and care conferences. There was no specific organized policy and procedure manual for patients who required swing bed services.

Interview on 2/3/16 at 9:40 a.m. with the director of nursing and infection control nurse confirmed there were no specific polices and procedures for patients who required swing bed services.

Based on observation and interview, the provider failed to ensure only authorized personnel had access to one of one medication room. Findings include:

1. Observation and interview on 2/2/16 at 9:20 a.m. in the medication (med) room with registered nurse (RN) A revealed the following medications were on the counter:
*Two vials of Humulin R insulin.
*Three vials of bacteriostatic 0.9 percent sodium chloride.
*One vial of lidocain.
*Two bottles of prednisolone sodium phosphate.
*One bottle of antacid.
*One bottle of sodium polystyrene sulfonate suspension.
*One bottle of liquid children's Tylenol.

Interview at that time with RN A confirmed the following staff members had a key to the med room that included the nurses, the director of nursing (DON), and central supply technician (tech) B.

Interview on 2/2/16 at 10:30 a.m. with the DON confimred central supply tech B was a certified nursing assistant and had been responsible for stocking supplies in the med room.

Interview on 2/2/16 at 2:45 p.m. with central supply tech B revealed:
*She let herself in and out of the med room with her own key.
*She had been in the med room several times by herself.
*Sometimes she would let the nurses know when she went into the med room.

Interview on 2/3/16 at 9:00 a.m. with registered pharmacist (RPh) in the med room revealed:
*The Pyxis system and the med refrigerators were always locked.
*She had not been aware central supply tech B had a key to the med room.
*She agreed the above meds were on the med counter, and she did not know why.

Interview on 2/3/16 at 9:05 a.m. with the DON and RPh in the med room revealed:
*The DON confirmed central supply tech B, maintenance supervisor, housekeeping supervisor, chief finance officer, and chief executive officer all had keys to the med room.
*Both agreed:
-The above meds were on the med counter.
-Not everyone should have had access to the med room.
-Only authorized staff should have had access to the med room.

Interview on 2/3/16 at 9:45 a.m. with the DON confirmed they did not have a policy regarding who was authorized to be in the med room.

Based on observation, interview, and product label review, the provider failed to:
*Follow manufacturer's instruction for disinfecting:-One of one endoscope procedure table.
-One of one endoscope storage table.
*Have a policy in place for disinfecting two of two multi-patient shower areas.
*Have a barrier between a hand sink and patient care linens in one of one whirlpool tub room.
Findings include:

1. Observation, interview, and product label review on 2/2/16 at 8:50 a.m. of the endoscope room being set-up for the next procedure revealed:
*Certified nursing assistant (CNA) C stated the endoscope table was disinfected with a PDI disinfectant wipe before each use.
*Registered nurse (RN) D used a PDI Sani-Cloth HB disinfectant wipe to clean off the patient procedure table.
*When asked what the contact time for the disinfectant was RN D stated she was not sure. She stated they sometimes used disinfectant wipes with a one-minute contact time, and sometimes used the wipes with a ten-minute contact time.
*The instructions on the back of the PDI Sani-Cloth HB package that RN D had used indicated a ten-minute wet contact time was required for disinfection.
*RN D used a bed sheet to fan the procedure table dry.
-The disinfectant remained wet less than three minutes.
-RN D used the bed sheet to cover the table for the next patient.
*At 9:55 a.m. the next patient procedure was completed, and CNA C used the PDI Sani-Cloth HB wipe to clean the endoscope table.
-She placed a barrier on the table before the disinfectant had dried, less than two minutes.
*At the same time RN D used disinfectant wipes from the same container to clean the procedure table.
-When she had finished cleansing the table, she again used the bed sheet to fan the procedure table dry.
-She then covered the table with the bed sheet.

Review of PDI Healthcare Sani-Cloth HB Germicidal Disposable Wipe manufacturer's instructions revealed: "Sani-Cloth HB wipes have an overall contact time of 10 minutes. According to the Centers for Disease Control and Prevention Guidelines for Disinfection and Sterilization in Healthcare Settings, the overall contact time is the time it takes the product to disinfect all the microorganisms on the disinfectant's master label."

Interview on 2/2/16 at 2:00 p.m. with the infection control nurse regarding the above observations revealed:
*The disinfectant should have remained wet on the surfaces for ten minutes.
*Her expectation was no employee should ever fan areas as it could potentially spread dust and germs.

2. Observation and interview on 2/2/16 at 1:20 p.m. with CNA E reviewing procedures for disinfecting the two shower areas between patients revealed both shower areas had two spray bottles:
*Betco Forest 5 cleaner/degreaser/deodorant.
*3M Ready-To-Use HB Quat (quaternary disinfectant).

When asked what bottle she would use to disinfect the showers CNA E stated:
*She was told she could use either bottle to clean the shower area.
*There were no directions in the room specifying how the showers were to have been cleaned.

Interview on 2/2/16 at 2:00 p.m. with the infection control nurse revealed:
*The shower areas were to have been disinfected after each patient use.
*She was unable to locate a policy for cleaning the showers.

3. Observation on tour of the hospital on 2/2/16 at 8:30 a.m. and throughout the survey on 2/2/16 and on 2/3/16 revealed a hand sink located in the whirlpool tub room. Beside the sink were several shelves. A stack of patient gowns sat on the shelf directly beside the sink. One of the patient gowns was in contact with the sink. A stack of towels sat on a shelf above the gowns.

Interview on 2/3/16 at 2:30 p.m. with the infection control nurse revealed she agreed patients' linen should have been covered and kept away from the hand sink to prevent cross-contamination from germs.