HospitalInspections.org

.Based on observation and document review, the hospital failed to ensure that contracted hemodialysis staff members followed the manufacturer's instructions for use when performing chemical tests on the water used in the hemodialysis machine.

Failure to follow instructions for use when performing chemical tests on water used in hemodialysis puts patients at risk of poor outcomes during the procedure.

Findings:

On 9/7/2016 at 10:45 AM, Surveyor #2 observed a contracted registered nurse (Staff Member #14) as s/he used a chemical test strip to assess the pH of water used for the hemodialysis procedure. The manufacturer's instructions for use indicated the wait time for reading the colorimetric scale on the strip was 15 seconds. The surveyor observed that the staff member read the strip immediately after submerging it in the water sample.

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Item #1- Surgical Attire
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Based on observation and review of hospital policy and procedures, the hospital failed to ensure that staff members followed policy for surgical attire to reduce the risk of microbial contamination within the surgical environment.
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Failure follow hospital policy for surgical attire puts patients at an increased risk of infection during surgical procedures.
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Findings:
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1. The hospital policy and procedure titled "Operating Room Attire" (Revised March 2015) under the section "Masks" read in part: "1. Disposable masks are to be worn at all times in each OR suite whenever sterile supplies are open."
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2. On 9/7/2016 at 10:00 AM in the outpatient surgery center, Surveyor #1 observed a surgical technician (Staff Member #3) as s/he opened the door to an operating room and partially entered the surgical suite in order to retrieve their cover jacket. At the time of the observation, sterile supplies and instruments were open and exposed, and the staff member was not wearing a surgical mask.
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Item #2- Environmental Cleaning

Based on observation and review of hospital policies and procedures, the hospital failed to provide a sanitary environment that meets the standards of national guidelines and hospital policies.

Failure to maintain appropriate sanitation standards and equipment maintenance increases the risk of transmitting infections to patients, staff, and visitors.

Findings:

1. The hospital standard process description titled, "Discharge Cleaning" (version 7/2016), under "Task Description," steps 7, 8, 9, and 10 read in part: "(7) Wash walls and high dust including shower... (8) and (9) ...inspect mattress for tears and report to supervisor if mattress compromised. (10) Clean ... sink." "Required Supplies: "Virex, Clorox RTU Bleach ..."

The hospital policy titled, "Environmental Infection Prevention" (approved 3/15/2016), steps 1, 2, 5, 6, and 7 read in part: (1) ... ensure effective environmental cleaning and disinfection ... appropriate cleaning schedule for environmental surfaces and equipment is established ... (2)(a) ...schedules must identify ... equipment to be cleaned ... (5)(d)(i) ...Mattresses and pillow covers with tears ... that cannot be ... repaired will be discarded. (6)(a) all medical equipment will be cleaned and disinfected ... (7)(c) Any item that falls on the floor shall be considered contaminated...)."

2. On 9/6/2016 between 2:15 PM and 3:20 PM, during the discharge cleaning of patient room #962 by a housekeeper (Staff Member #4), Surveyor #3 observed the following:

a. While donning gloves, Staff Member #4 dropped a clean glove on the floor. S/he retrieved and donned the glove that was now contaminated.

b. While cleaning the hand sink with a wiping cloth that had been soaked in disinfectant solution, Staff Member #4 rinsed the cloth with running water and wrung it out. S/he continued wiping the sink, faucet handles, and exposed plumbing with the same cloth.

c. Staff member #4 was unable to adjust the patient bed. S/he reported the problem to the Environmental Services Director (Staff Member #5), who called for service. Staff Member #4 retrieved clean bed linens from the clean linen supply and began making the bed in its reclined position. After Staff Member #5 directed Staff Member #4 to stop making the bed, s/he re-folded the bed linens that were now contaminated and started to return them to the clean linen supply. Staff Member #5 directed her/him to take the linens to the soiled linen storage area. S/he then placed the linens in the drawer of the patient bedside table. Staff Member #5 then directed staff member #4 to place the linens on a cart for removal to the soiled linen storage area.

d. When Staff Member #4 completed the discharge cleaning, the surveyor observed that the cleaning had not included the shower, nor had the staff member completed high dusting as indicated in the hospital policy.

e. Staff Member #4 did not report a tear in the mattress on the shift report, or verbally to Staff Member #5 as directed by procedure.

f. Staff Member #4 did not report the cracked plastic face of the wall-mounted sphygmomanometer on the shift report, or verbally to Staff Member #5 as directed by procedure.


Item #3- Hand Hygiene
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Based on hospital policies and procedures, the hospital failed to ensure that staff followed hospital procedures for hand hygiene.
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Failure to perform hand hygiene creates risk for transmission of infectious organisms and development of infectious disease.

Findings:

1. The hospital policy and procedure titled, "Infection Prevention and Control Policy for Hand Hygiene" (Approved March 2015) read in part, "... C. Healthcare workers are required to perform hand hygiene for specific tasks and situations: Before applying clean exam gloves . . . Immediately after removing clean exam or sterile gloves . . . Between dirty to clean tasks on the same patient... "

2. On 9/6/2016 at 3:30 PM, Surveyor #2 observed a member of the environmental services staff (Staff Member #13) as s/he completed a terminal cleaning of an operating room. The staff member exited the room after performing a terminal cleaning, and began to restock the room with clean items, without first discarding his/her gloves, performing hand hygiene and donning new gloves.

3. On 9/7/2016 between 9:30 and 10:00 AM during a spinal injection in the Pain Clinic, Surveyor #4 observed a registered nurse (Staff Member #7) and a provider (Staff Member
#8) as they removed and changed exam gloves twice, without performing hand hygiene prior to putting on clean exam gloves.

4. On 9/7/2016 at 10:30 AM in the Dialysis Unit,Surveyor #4 observed two transporter staff members (Staff Members #9 and #10) put on clean gloves without performing hand hygiene as they prepared to transfer Patient #3 into an isolation room.
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5. On 9/7/2016 at 11:45 AM, Surveyor #4 observed a sterile procedure performed on Patient #4. A staff member (Staff Member #11) assisting with the procedure moved a trash receptacle closer to the patient's bed. The staff member removed his/her gloves but did not perform hand hygiene prior to putting on clean gloves.
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Item #4- Personal Protective Equipment

Based on observation and review of hospital policies and procedures, the hospital staff members failed to comply with the hospital's personal protective equipment (PPE) procedures when implementing barrier and transmission precautions for patients in Contact isolation.
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Failure to use PPE correctly can lead to the transmission of potentially pathogenic microorganisms to other patients and healthcare workers.
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1. The hospital used the U.S. Centers for Disease Control and Prevention (CDC) placard #CS250673-E, "How to Safely Remove Personal Protective Equipment (PPE) Example #1 stated in part, "Remove PPE in the following sequence 1.Gloves. . . 2. Gowns. . ." Example #2 for procedure to remove PPE stated in part, "1. Gowns and Gloves: Gown front and sleeves and the outside of gloves are contaminated. . . Grasp the gown in the front and pull away from your body so that ties break, touching the outside of the gown with only gloved hands. While removing the gown, fold or roll the gown inside out into a bundle. As you are removing the gown, peel off the gloves at the same time, only touching the inside of the gloves and gown with your bare hands. . ."


2. On 9/6/2016 at 11:45 AM in the urology and neuroscience unit, Surveyor #1 observed a registered nurse (Staff Member #2) as s/he administered medications to Patient #2, who was in contact isolation. After touching the computer workstation, the bedside table, and the patient's arm, the nurse reached under their protective gown and into their uniform pocket to retrieve a syringe with normal saline in order to flush the intravenous port of the saline lock.

3. On 9/6/2016 at 12:00 PM, Surveyor #4 observed a registered nurse (Staff Member #12) as s/he prepared to leave the room of Patient #4 who was in Contact isolation. During PPE removal, the staff member first removed his/her gloves and then reached to the front of the gown to untie the waist tie touching the outside of the gown with bare hands.


4. On 9/7/2016 at 10:30 AM, Surveyor #4 observed transporters (Staff Members #9 and #10) as they removed their gowns first and then their gloves when preparing to leave the room of a patient in Contact Enteric isolation.

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Based on record review, interview, and review of hospital policy and procedures, hospital staff members failed to complete a pre-operative medical history and physical (H&P) within 30 days of surgery for 1 of 6 patient records reviewed (Patient #1).
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Failure to complete a history and physical exam prior to surgery places patients at risk for poor outcomes due to changes in unknown or known co-morbid conditions.
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Findings:
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1. The hospital policy and procedure titled "History and Physical Assessment Requirements for Procedures Requiring Anesthesia Service or Procedural Sedation" (Approved 4/12/2011) read in part, "All patients undergoing surgical procedures requiring the assistance of the anesthesia service or undergoing sedation for diagnostic or therapeutic procedures must have a history and physical assessment performed within 30 days of the date of the procedure. . .H&P's older than 30 days must be repeated. In doing so, a provider may refer to an H&P older than 30 days but must review all 8 elements listed above and note where each item is the same or detail how it is different. Both the update and the previous history and physical must be available at the time of the surgery."
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2. On 9/7/2016 at 3:30 PM in the post anesthesia care unit, Surveyor #1 reviewed three surgical medical records. Patient #1's history and physical was completed on 6/17/2016. Patient #1 underwent a surgical procedure on 9/7/2016.
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3. In an interview immediately following the medical record review, a Director of surgical services (Staff Member #1) confirmed the history and physical for Patient #1 was completed outside of the required 30-day period. S/he verified that staff did not perform the required review and update prior to the procedure.
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