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Based on observation, interview and record review, the facility failed to ensure emergency equipment was available for immediate use. Expired supplies were found in the emergency (crash) cart in the Emergency Department.

This deficient practice placed the patients at risk for harm, in the event of an emergency, if the supplies were not immediately available for use.

Findings:

a. On 4/5/17 at 12:57 p.m., during an observation of Emergency Department crash cart, the following expired supplies were observed.

1. 4; Stylet with soft distal tip Endotracheal tubes (sizes 10 & 12) expired on 10/2016.
2. 1; 20 ml syringe, expired on 10/2013
3. 2; 60 ml syringes, expired on 1/2015 and 4/2015
4. 1; 30 ml syringe, expired on 3/2014
5. 1; extension set, expired on 5/2016
6. 1; Resuscitation electrode (pediatric) size 0-8 years, expired 2/28/17.

During a concurrent interview, the registered nurse (RN 3) acknowledged the supplies were expired and stated the crash cart was checked monthly.

A review of the facility's policy and procedure titled, "Crash Cart,"dated 2/1/2016, indicated the purpose is to insure adequate supplies are available and the equipment is in proper working function in the case of a cardiac or respiratory arrest. Nursing staff shall be responsible for checking and documentation of the integrity of all equipment on top of the cart.



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b. In the former operating room-

1. There were two (2) Laryngeal Mask Airway labeled Single Use and with expiration date of June 28, 2016.

2. There was intravenous bag of normal saline with expiration date of February 2017.

Based on observation, interview, and document review, the facility staff failed to ensure two containers of liquid nitrogen were stored safely.

Findings:

On 4/5/17 at 2:25 p.m., there were two 22 liter containers of liquid nitrogen stored on the floor in a corridor alcove.

The alcove had a set of wood bifold doors on a track, enclosing the alcove space from the corridor. The doors were not fire rated and did not latch or lock. There was one sprinkler head at the ceiling protecting the alcove area. There was no mechanical or natural ventilation at the alcove area.

There was a photocopy machine in use next to the two containers of liquid nitrogen, and a paper shredder was located in front of the containers.

During an interview at the same time as the observation, the Facility Manager stated that there was no ventilation in the alcove area and that there was no facility policy or procedure for the storage nor for an accidental spill of liquid nitrogen.

During an interview at the same time as the observation, the Licensed Vocational Nurse (LVN) stated that when needed the liquid nitrogen was ladled out of the containers at the current location and placed in a spray gun.

Review of the Safety Data Sheet for liquid nitrogen, indicated that liquid nitrogen needed to be stored segregated, in a well ventilated place, and if heated pressure increase would occur and the container(s) may burst or explode.

Because the liquid-to-gas expansion ratio of nitrogen is 1:694 at 20 °C (68 °F), a tremendous amount of force can be generated if liquid nitrogen is rapidly vaporized in an enclosed space.

Because of its extremely low temperature, careless handling of liquid nitrogen and any objects cooled by it may result in cold burns.

If the liquid nitrogen pools anywhere, it will burn severely.

As liquid nitrogen evaporates it reduces the oxygen concentration in the air and can act as an asphyxiant, especially in confined spaces. Nitrogen is odorless, colorless, and tasteless and may produce asphyxia without any sensation or prior warning.

Per Occupational Safety and Health Administration (OSHA) document titled Laboratory Safety Cryogens and Dry Ice, dated 10/2011 indicates, Do not use or store LN2 (liquid Nitrogen) in confined areas, walk-in refrigerators, environmental chambers or rooms without ventilation. A leak in such an area could cause an oxygen-deficient atmosphere.

Based on observation and interview, the facility staff failed to maintain the premises clean.

Findings:

1) On 4/4/17 at 2:14 p.m.,there was an accumulation of dust on a sprinkler head located above the stove in the kitchen.

During an interview at the same time as the observation, the kitchen staff stated that patient food is cooked on the stove.

2) On 4/5/17 at 3:26 p.m., there was an accumulation of dust at the air return located above two scrub sinks located between the surgery and emergency room.

During an interview at the same time as the observation, the Facility Manager acknowledged the accumulation of dust at the air return.

Based on observation and interview, the facility failed to ensure clean and dirty supplies were not mixed, no expired, opened and undated medications/supplies in the different area of the critical access hospital. This deficient practice had the potential for contamination that could affect the patients in the facility.

Findings:

1. On April 4, 2017, at 11:20 a.m., during the initial tour in the basement with Clinical Manager, the following were observed:

a. A room which was not labeled was used as the laundry room. The clean and dirty cleaning/janitorial supplies were stored together in the clean area of the room. The clean and dirty exit doors were used interchangeably when bringing clean and dirty supplies in the room.

b. The patients' medical records were stored in the Morgue area.

c. In the Central Supply Area, there were corrugated boxes which came from the outside vendors that contained equipment/supplies which were mixed in with the sterile and clean supplies.

There were two (2) packets of Urethral Catherization with expiration date of February 2017 and ten (10) bottles of 100 ml of 0.9% Sodium Chloride with expiration date of 1 April 2017.

There were boxes on the floor. The metal rack contained supplies that were close to the ceiling.

d. In the Physical Therapy Room, there was a Parallel Bar which had a broken handle and had black plastic wrapped around the handle.

e. In the Tub/Shower Room, there were large equipment being stored. The shower is currently being used. The material of the call cord in the shower room is not cleanable.

f. In The Laboratory Room, the following were found:

Three (3) Hema Controls Level 1, 2 and 3 with expiration date of July 3, 2016.

Two (2) Bio Rad level 1 and 2 used for Urinalysis with expiration date of March 31, 2017.

A container of Siemens Urine Dipstick was opened and undated.

Twelve (12) vials of Lipase Re - Agent Solution with expiration date of January 2017.

Twenty four (24) vials of Micro Test-M4 with expiration November 10, 2015.

Two (2) vials of Immuno-Assay Control Solution Levels 1 and 2 were opened and undated.

Two (2) Lypocheck Assay Chemistry Control Solution levels 1 and 2 opened and undated.


2. On April 5, 2017, at 8:50 a.m., during the initial tour of the rural health clinic with Clinical Manager, the following were observed:

a. In Room 5 , the following were noted:

1. Two (2) bottles of Hydrogen Peroxide opened and undated.

2. Two (2) bottles of Provident Alcohol with expiration date of January 2015 and August 2016.

3. Two (2) bottles Packing Strip opened and undated. The label in the the bottle indicated "sterile until opened". It was single use.

4. A bottle of Fecal occult Developer opened and undated.

b. There was an aerator in the faucet in the handwash sink in Room 1, Room 2, hallway area and Room 4. The faucet in Room 4 was leaking.

c. There was an opening in the ceiling in Room 2.

d. The Restroom in the patients' area had no call light.

e. There was a vial of medication "Mupirocin Ointment (antibiotic ointment) opened and undated in Room 3.

During an interview with Clinical Manager, at the time of observation, stated that he saw the concerns and stated will be acted upon.

f. Radiology Department-

1. There was a bottle of Hydrogen Peroxide 3% USP with expiration date of June 2016.
2. There were two (2) boxes of Barium Redicat on the floor.
3. There were 10 pieces of weight bearing platform on the floor.

g. The Mobile Unit -

1. There was a container of foam sanitizer (All Care Plus) with expiration date of October 2015 in C-Scan area.
2. There were four (4) full body apron that did not have a tag or a label to identify the individual apron for preventive maintenance.
3. The vent for air intake had rust and thick dust. This was checked by the staff member at the time of observation.
4. There were two (2) bottles of 0.9% normal saline injection, USP with expiration date of 1 May 2016.

Based on record review and interview, the facility failed to ensure the services were furnished in accordance with the facility policies and procedures. There were no policies and procedures in place for yearly employee competency evaluation, Outpatient and therapeutic services, Acupuncture services, Consent for outpatient therapies, Hepatitis B and Flu vaccination status for Medical Staff.

Findings:

1. A review of Patient 26's medical record indicated Patient 26 had 12 outpatient visits for acupuncture performed by PT1 between 12/6/16 and 4/5/17. There were no consents signed for the acupuncture treatments. There were no physician orders for acupuncture or follow-up evaluations by a physician.

A review of Patient 27's medical record indicated Patient 27 had 25 outpatient visits for acupuncture performed by PT1 between 11/12/16 and 4/4/17. There were no consents signed for the acupuncture treatments, there were no physician orders for acupuncture or follow-up evaluations by a physician.

A review of PT1 Employee file did not document any competency evaluations for acupuncture.

On 4/6/17 at 2 PM, during an interview with the chief nursing officer (CNO) and director of human resources (DHR), there were no policy and procedure in place for yearly competency. DHR indicated Employees were not completing yearly competencies. CNO indicated there were no Policy and procedure for Acupuncture outpatient services, or for consent before treatment for outpatient services.

2. During an interview with the Medical Staff credential supervisor, on 4/5/17 at 1:30 PM when asked for the policy for medical staff evaluation, TB status, Hepatitis B status and yearly Flu vaccination, she indicated, the facility currently did have a policy for yearly PPD testing. Medical Staff credential supervisor indicated the facility did not have a policy for Hepatitis B status screening and yearly flu vaccination requirements for the medical staff.

Based on observation, interview and review of standards of practice, the facility failed to provide a sanitary environment.
(1) Cardboard shipping boxes were used to store medical supplies, in the central supply room. (2) Emergency pull cords in a restroom and shower / tube room, were made out of cloth, unable to be disinfected. (3) Dirty towels and a dirty mop head were found on the floor of the laundry room, crossing over to the clean area.

This deficient practice had the potential to place patients at risk for cross-contamination and infection.

Findings:

On 4/4/17 at 11:25 a.m., during the initial tour of the facility with the Medical Group Office Manager (MGOM), the following was observed:

1. Numerous cardboard boxes were observed in the central supply room, containing medical supplies and stationary items. Boxes were placed on shelves along side patient supplies. Some boxes contained bags of 0.9 sodium chloride solution (Normal saline, a solution used for intravenous therapy).

2. The emergency pull cord in the tub/shower room, was made out of cloth fabric. The emergency pull cord, in the patient restroom of the emergency department, was also made out of cloth fabric.

3. A dirty mop head and multiple dirty towels were observed on the floor of the laundry room, crossing over the room's clean area.

During a concurrent interview, the MGOM, stated he was not aware that supplies could not be stored in cardboard boxes. The MGOM agreed the emergency pull cords were unable to be cleaned. The MGOM further stated, dirty linen should not be in the clean linen area.


According to the Association for Professionals in Infection Control and Epidemiology (APIC) newsletter, Winter 2011/2012 edition, titled, "Preventing Infection in Ambulatory Care" (http://apic.org/Resource/TinyMceFileManager/Education/Preventing-Inf-in-Amb-Care-Winter2012-FINAL.PDF): "Healthcare supplies must be removed from shipping cartons and cardboard boxes before storage to prevent contamination from soil/debris that may be on cartons...Do not leave shipping boxes in clinical areas due to risk of environmental contamination."

Based on observation, interview and record review, the facility failed to:
1. Provide radiologic services in a safe manner.
2. Assure all radiology technicians wore a badge to monitor radiation exposure.

Findings:

During a tour of the Facility Radiology Department, on 4/6/17 at 8:25 am. Radiology Tech#1(RT#1) did not have a radiation monitor badge. When asked he stated he was new and would get a badge soon. When asked how the facility aprons were checked, RT#1 provided a facility document titled, "Pacific Medical Physics [Facility Name]" dated 8/13/15.

On 4/6/17 at 12:30 PM, during an interview with the chief nursing officer (CNO), she indicated she was the radiation supervisor. CNO was asked for radiology meeting minutes and appointment of a qualified employee to oversee radiology services by the Governing body. There were no radiology meetings minutes or radiology in services available for review. There were no yearly competencies for the radiology technicians for review.

Based on interview and record review, the facility failed to ensure one (1) direct patient care staff had a current competency evaluation on file.

Findings:

On 4/6/17 at 11:22 a.m., the review of the personnel files indicated registered nurse (RN 1) was hired on 9/10/14. RN 1's job description indicated she worked in the hospital. RN 1's last appraisal or competency evaluation was conducted on 1/22/15. No current competency evaluation or appraisal was found in the file.

During a concurrent interview, the director of human resources (DHR) stated that competencies are conducted upon hire and annually but stated that the file was incomplete.

On 4/6/17 at 11:32 a.m., during an interview, the chief nursing officer (CNO) stated there was no policy for yearly competencies.

Based on record review and staff interview, the facility failed to ensure 3 of 28 sampled patients had the right to formulate an advance directive prior to a performance of a procedure.

Findings:

During review of the patient's clinical record on April 6, 2018, indicated the following:

1. Patient 8, a four (4) year old, was admitted to the facility on April 5, 2017 for a well-baby clinic. The consent for medical treatment, release of information and consent for provider access to your prescription history was reviewed and indicated the patient signed the consent.

2. Patient 4 was admitted to the facility on January 26, 2017 due to hypertension. The clinical record failed to show written documentation for an advance directive.

3. Patient 5 was admitted to the facility on April 5, 2017 due to complaint of skin rash. The clinical record failed to show written documentation for an advance directive.

During an interview with Clinical Manager while reviewing the clinical record, the advance directive was not in the clinical record.

Based on record review and interview, the governing body failed to implement a quality assurance and performance improvement (QAPI) program that assured employees had competency yearly and physicians wrote orders and consents were obtained prior to treatment, and physicians oversee and monitor outpatient services. This failure resulted in Patients receiving care in an unsafe environment,

Findings:

A review of Patient 26's medical record indicated Patient 26 had 12 outpatient visits for acupuncture performed by PT1 between 12/6/16 and 4/5/17. There were no consents signed for the acupuncture treatments, there were no physician orders for acupuncture or follow-up evaluations by a physician.

A review of Patient 27's medical record indicated Patient 27 had 25 outpatient visits for acupuncture performed by PT1 between 11/12/16 and 4/4/17. There were no consents signed for the acupuncture treatments, there were no physician orders for acupuncture or follow-up evaluations by a physician.

A review of PT1 Employee file did not document any competency evaluations for acupuncture.

On 4/6/17 at 2 PM, during an interview with the chief nursing officer (CNO) and director of human resources (DHR), there were no policy and procedure in place for yearly competency. DHR indicated employees were not completing yearly competencies. CNO indicated there were no policy and procedure for Acupuncture outpatient services, or for consent before treatment for outpatient services.