HospitalInspections.org

Based on observation, record review and interview, the facility failed to ensure hand sanitizers are available for staff in the medication room, and expired supplies will not be available for use in 1 of 6 areas observed (Medical/Surgical); the facility failed to ensure staff used aseptic technique during blood draws in 1 of 1 staff observed performing blood draws (G); the facility failed to ensure staff have all hair and ears covered during procedures in surgery in 4 of 5 staff observed (H, I, J and LL).

Findings include:

Per review of facility policy titled, "Hand Hygiene," dated IP [infection prevention] 3101, dated 3/2014, it states "Perform Hand Hygiene a the following times: A. WHO [World Health Organization] 5 Moments for Hand Hygiene...B. Before and after glove use."

Per review of facility policy titled Invasive Procedures, #IP3312 revised 3/14, states under E. "1. A head covering/hood must be worn by all personnel to confine all hair at all times in restricted OR (operating room) area...F. Surgical Masks...4. Must NOT be worn around the neck or placed in one's pocket...G. Protective Eyewear/Faceshields 1. Must be worn in addition to surgical masks when splattering and spraying of blood/body substances is likely..."

Per the Association of periOperative Registered Nurses, 2016 edition, states under Aseptic Practice: Surgical Attire Recommendation I states "Clean surgical attire should be worn in the semi-restricted and restricted areas of the perioperative setting...(under figure 2. Surgical Attire) Surgical head covering confines hair and completely covers ears, scalp skin, sideburns and napes of the neck. Surgical mask with eye protection is worn whenever contact with blood, body fluids, or other potentially infectious material is anticipated."

Example of findings:

Per during tour of the Medical/Surgical area with Manager D on 6/1/16 between 8:30 AM and 8:55 AM the following was observed:

The medication room had new counters placed which compromised the wall integrity including holes in the wall from removal of the hand soap dispenser; and had no hand sanitizer in the room while the sink is being replaced.

The clean supply room had 10 culture swabs that expired 5/21/16.

The above findings were confirmed during observation with Manager D who added hand gel would be placed in the med room and the culture swabs would be removed.

Example of blood draw:

On 6/1/16 at 9:05 AM Medical Technician G was observed performing a lab draw on Patient #11 in the Emergency Department. Tech G noted the contact precaution sign on the door and donned a gown, did not wash and did not don gloves. Tech G entered the room and proceeded to examine and palpate Patient #11's arm to find a site. Once the site was located, Tech G donned gloves, placed 5 lab tubes on Patient #11's bed, drew the blood into the tubes, placing two back on the bed. When all the tubes were filled, Tech G, while wearing the same gloves, handled the hand held I-stat (devices used to receive orders and print labels) entered data for the tube labels and proceeded to handle the blood tubes applying the labels. Tech G removed the gloves, removed gown and left the room. Tech G washed and proceeded to Patient #12's room in the Emergency Department. Tech G noted a contact precaution sign on Patient #12's door, donned a gown, washed, did not don gloves, picked up the I-stat and entered data, and entered Patient #12's room without the benefit of hand hygiene or gloves.

The above findings were discussed in interview on 6/1/16 at 9:30 AM with Emergency Department Manager D who acknowledged Tech G should have washed and worn gloves entering rooms with contact precautions.

Per interview with Lab Manager QQ on 6/1/16 at 2:50 PM staff are expected to cover the i-stat with a plastic bag when working with patients on contact precautions.

Example in outpatient surgery:

The following was observed on 6/1/16 between 10:55 AM and 12:00 PM in the outpatient surgery department:

At 10:55 AM Anesthesiologist H entered Patient #13's room with a mask hanging around his/her neck.

At 11:33 AM Operating Room, where Patient #13 was scheduled for a colonoscopy, Nurse J and Certified Registered Nurse Anesthetist LL do not have ears and/or sideburns covered with their bonnet.

At 11:30 AM Physician I entered the procedure room and did not have ears, sideburns and beard covered. Physician I did not have eye protection or a mask on during a colonoscopy procedure.

At 11:50 AM Anesthesiologist H entered the procedure room, did not have ears covered and had a mask hanging around his/her neck.

Per interview on 6/1/16 at 12:00 PM with Operating Room Manager E, Manager E acknowledged hair needed to be covered masks need to be removed between procedures. Manager E stated the facility follows the Association of periOperative Registered Nurses.

Based on record review and interview, the facility failed to ensure staff that administer anesthesia are given privileges to perform those duties, in 32 of 32 Certified Registered Nurse Anesthetist credentialed for the facility (K through PP).

Findings include:

Per the facility's Medical Staff Bylaws, Rules and Regulations of the Medical Staff dated October 2013, it states under 5 Appointment and Reappointment 5.5-6 "...As soon as practicable, the Credentials Committee shall transmit to the Executive Committee a written report and its recommendations as to appointment and, if appointment is recommended, as to...Clinical Privileges to be granted...Article 6 Clinical Privileges 6.2-1 "Each application for appointment and reappointment to the Medical Staff...must contain a request for the specific Clinical Privileges desired by the applicant...6.2-2 Requests for Clinical Privileges shall be evaluated...6.4-1 Each department shall develop an application/request form delineating the Privileges for which an applicant my apply...."

In interview with Administrator A on 6/1/16 at 9:40 AM, Administrator A provided a signed 2/26/16, document stating "...certified registered nurse anesthetists (CRNAs) are authorized to administer anesthesia to (the facility's) patients...I grant temporary approval to the following CRNAs to provide professional nurses anesthetist services to hospital patients for a period not to exceed 90 days from the date below.(2/26/16)"

Per interview on 6/1/16 at 9:45 AM with Credentialing Supervisor C, when asked to provide evidence of the privileges granted to the CRNAs working at the facility, Supervisor C stated "There are no privileges in the credential files." The CRNAs involved are K through PP.

Per telephone conference call on 6/1/16 at 1:15 PM with Medical Doctor F, Administrator A, and House Attorney RR, during discussion of the requirement to give CRNAs credentials, Attorney RR stated "I have no argument with that".

Based on record review and interview, the facility failed to ensure a post-anesthesia note is completed after a patient has recovered from anesthesia, in 1 of 4 surgical records reviewed (3).

Findings include:

Per interview with Medical Doctor F on 6/1/16 at 1:00 PM, when asked if there are any guidelines for Anesthesiologist to follow for post anesthesia notes, Doctor F stated we have a policy, and up to personal judgement.

Per review of facility policy titled Anesthesia Procedure and Clinical Documentation #ANES 2.3, reviewed 1/16, it states under Postoperative Documentation and Procedures it states 1. "The Anesthesiologist will be responsible for the recovery room care given each patient and will evaluate each patient prior to discharge."

Patient #3's medical record review on 6/1/16 at 1:05 PM revealed Patient #3 had a kidney stone extraction on 5/9/16. Patient #3 entered the Phase I Post Anesthesia Care Unit (PACU) post surgery at 11:26 AM. The post-anesthesia note is completed at 11:29 AM, 3 minutes out of surgery. Patient #3 was transferred to Phase II PACU at 12:00 PM and continued to stay in Phase II until discharge at 5:15 PM. This is confirmed in interview, during record, on 6/1/16 at 1:05 PM with Operating Room Manager E, who added "They (anesthesia) usually states 'until meet discharge criteria'." Manager E confirmed there are no other notes by an anesthesiologist regarding recovery from anesthesia, and would expect another note.