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Based on record review and interview, the provider failed to ensure all medical staff submitted copies of their current medical licenses to the credentialing personnel. Six of nine providers (A, B, C, D, E, and F) had not submitted copies of their current medical licenses. Findings include:

1. Review of credential files revealed the following six providers' licenses had expired.:
* Provider A's license expired 03/01/16.
* Provider B's license expired 06/30/15.
* Provider C's license expired 03/01/16.
* Provider D's license expired 03/01/15.
* Provider E's license expired 03/01/16.
* Provider F's license expired 03/01/15.

Interview on 04/13/16 at 2:35 p.m. with the human resources director revealed she tried to remind the providers around March 1 of each year their license was about to expire. But she did not always follow-up to see if she had the most current license. She only checked when it was time for appointment or reappointment to the medical staff.

Interview on 04/14/16 at 11:15 a.m. with the chief executive officer confirmed the findings of the above interview. She also confirmed there was no policy for ensuring licenses were current except during reappointment.

Based on observation, interview, and document review, the provider failed to maintain the following:
*One liter bottles of eyewash buffered solution had expired or were missing from five of five areas:
-Emergency room (ER) hopper room.
-Decontamination room.
-Sterilization room.
-North and south soiled utility rooms.
*Wet Task buckets of cleaning solution were not labeled in ten of ten areas:
-Pharmacy.
-ER:
--Hopper room and examination (exam) room 2.
-Decontamination room.
-Computed Tomography (CT).
-Patient wings:
--Observation room.
--Rehabilitation (rehab) room.
--North soiled utility room.
-One of two housekeeping carts.
-Main physical therapy (PT).
*Cleanliness and efficacy of Nutra-Zinc test strips (fluid test strips used for pregnant patients) in one of one ER exam room (2).
*Three of three sodasorb (used to contain gases on the anesthesiology machine) containers were outdated in surgery.
*Nine of nine drain lines were dry and gave off gases in sterilization, women's locker room, and men's locker room.
Findings include:

1. Observation, interview, and confirmation on 4/13/16 from 9:00 a.m. to 11:20 a.m. with the director of plant operations, maintenance supervisor, housekeeping supervisor, and operating room (OR) manager revealed:

a. Two bottles of eyewash buffered solution had expired April 2015 in the sterilization room. Two bottles were missing from the hopper room of ER and the decontamination room. Two of two bottles were missing from the south soiled utility room. One bottle had expired January 2016 in the north soiled utility room.
Interview with the three above staff revealed they were not aware eye wash solutions had an expiration date. Nor were they aware some of the bottles were missing from the eye wash stations.

No policy or procedure could be located regarding the expiration dates or quantities of bottles at the eye wash stations.

b. The Wet Task plastic cleaning buckets were not labeled to identify the product and avoid misuse in the following areas:
-Pharmacy.
-ER:
--Hopper room and exam room 2.
-Decontamination room.
-Computed Tomography (CT).
-Patient Wings:
--Observation room.
--Rehabilitation (rehab) room.
--North clean utility room.
-One of two housekeeping carts.
-Main physical therapy (PT).
Interview with the three above staff revealed they were aware all chemicals and cleaners must be relabeled when placed in another container.

c. A small brown jar sat on top of the fetal monitor machine in exam room 2 with a small roll of what appeared to be test paper inside. The top of that jar had a label with a handwritten note Nutra-Zinc paper. Interview with the above three staff revealed they were not aware of the use for that test paper. Interview with an unidentified physician assistant student revealed the test paper was used to test fluid of a pregnant patient. He could not verify if the strips had an expiration date. Nor could he verify if the cleanliness and efficacy of the test strips had been compromised when removed from its original packaging and placed in another container that had unknown contents.

d. The sodasorb container on the anesthesiology machine had an expiration date of February 2014. Two more sodasorb containers located in sub-sterile room had expiration dates of February and March 2014. Interview with the OR supervisor revealed she was unaware those sodasorb containers had expired. She stated she did not check expiration dates for anything used on the anesthesia machine. She stated she left that to the anesthesiologist.

Interview on 4/14/16 at 2:30 p.m. with the infection control nurse revealed the OR manager should check for all outdates in the OR area. She revealed there was no policy or procedure for who was in charge of checking for outdates for each area of the hospital.

e. The dry drain lines in the sterilization area gave off sewer gas. Interview with the OR supervisor revealed she would have to pour water down the drains to keep the sewer gas from coming up the lines. She also revealed the women's and men's locker rooms also had dry drains, and she would pour water in those lines too.

Interview with the maintenance supervisor revealed he did not have unused or seldom used drain line checks on his preventive maintenance plan to check for sewer gas.

f. Interview on 4/13/16 at 2:00 p.m. with the central supply supervisor revealed he only checked for outdates in the main supply room. He stated he relied on the staff to check for outdates in their respective work areas.

No p/p could be located regarding the labeling and identification of containers used for cleaners and chemicals.







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Based on random observation, testing, interview, policy review, and record review, the provider failed to ensure:
*A coffee pot, brewer, creamer, sugar, and cups were not available for use in the clean linen side of one of one laundry room.
*Patient care supplies were not stored under drain lines in two of two (hopper room of emergency room [ER] and north clean utility of patient wing) areas.
*One of one gallon container of iodine scrub solution in examination (exam) room 2 was not outdated.
*Staff followed testing guidelines for one of three disinfectants (Activate) used in the hospital.
*Proper disinfection procedures were followed for one of one patient whirlpool.
*Styrofoam cups were stored to prevent contamination at two of two (coffee and water) drink stations in the hospital lobby.
*A policy and guideline were in place for reprocessing of four of four stored scopes.
*One of one certified nursing assistant (G) did not double glove during patient (28) care.
Findings include:

1. Random observation and interview on 4/13/16 from 9:00 a.m. to 4:00 p.m. with the director of plant operations, maintenance supervisor, housekeeping supervisor, and operating room (OR) manager revealed:

a. A coffee pot, brewer, creamer, sugar, and cups were noted in the clean side of the laundry room between the two machines. The housekeeping supervisor confirmed the finding and revealed staff should not have drinks or snacks in the laundry area.

No policy or procedure policy or procedure could be located regarding drinks in the laundry room.

b. A variety of patient and staff supplies were stored under drain lines in the ER hopper room and in the north clean utility room. Including:
*Dispenser rolls of paper towels.
*Twist 'N Fill cleaners and chemicals used by housekeeping.
*Blue paper patient capes.
The maintenance supervisor confirmed the above findings and revealed staff were aware patient and staff clean supplies could not be stored under drain lines.

No policy or procedure could be located regarding storage of clean patient and staff supplies under drain lines.

c. A one gallon container of iodine scrub was stored beneath the sink in ER exam room 3. That iodine had expired November 2012. Interview with an unidentified ER registered nurse revealed she was not aware of that container of iodine, nor that it had expired. It was removed from use.

d. A spray bottle of Activate was noted in the x-ray room and in the laboratory (lab). Interview with an unidentified radiologic technologist and the medical lab technician H confirmed they used that product. They were not aware if it had an expiration date or when it was first activated with water. Interview with the housekeeping supervisor and plant operations director revealed they were not familiar with the product. It had been ordered by different departments for use in the hospital.

Review of the package insert with the Activate bottles revealed:
*It did not require an expiration date.
*The product should have been tested initially after installation of the bleach cartridge with the water spray bottle to ensure the solution was at least 5000 parts per million (ppm).
*Periodically testing the solution to ensure it was still 5000 ppm.

No policy or procedure could be located regarding the use of Activate in the hospital.

e. Patient room 112 had a whirlpool tub. A one gallon container of BETCO Quat Stat disinfectant sat beside the tub. The BETCO product was being used as the disinfectant for the tub's internal disinfection process. Interview with the housekeeping supervisor revealed she was not aware if that was the correct disinfectant for the tub. Interview with certified nurse assistant I revealed he used the disinfectant by the tub and followed the procedures posted in the room.

Review of the manufacturer's guidelines for the Invacare whirlpool tub revealed:
*Read and understand all information on the Invacare brand disinfectant before use.
*The disinfectant dispensing system had been factory tested and calibrated for use with Invacare disinfectant.
*The use of any disinfectant with a dilution ratio or viscosity (thickness) level different then that of Invacare disinfectant would result in an improper mixture of disinfectant and water.

Review of the 7/6/10 dated bathtub cleaning policy revealed "4. whirlpools shall be cleaned after patient use according to manufacturer's instructions."

f. Stacks of singe-use coffee cups were unprotected and sat on the counter by the coffee pot and brewer in the hospital lobby. Additional stacks of unprotected single-use coffee cups sat on top of the five gallon water bottle at the Culligan water dispenser.

Observation revealed two unidentified guests picked those coffee cups off the floor and placed them back on the coffee station counter or on top of the water bottle at the water dispenser. The director of plant operations and the maintenance supervisor confirmed they had also seen guests place soiled coffee cups back in-use.

g. Four different scope models hung in the scope cabinet in the sterilization area. Interview with the OR manager revealed she would write the serial number in her record book each time a certain scope was used for a procedure. She stated she did not keep track of how long the different scopes would hang without additional reprocessing. She was unaware certain manufacturers required additional reprocessing after their scope had hung for five or more days.

Interview with the infection control nurse revealed they used the Association of Professionals in Infection Control (APIC) guidelines for sterilization and scope processing. She confirmed the scopes were to be reprocessed after they hung for five or more days.

Review of the 2015 APIC guidelines revealed no guideline could be located regarding the reprocessing of scopes.

Review of the January 2016 dated Endoscope Cleaning and Maintenance policy revealed no guidelines for reprocessing of scopes.


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h. Observation on 4/13/16 from 9:50 a.m. through 10:10 a.m. revealed CNA G assisted the wound care nurse with a dressing change for patient 28. At the end of the dressing change CNA G took off her gloves. It was noted she had another pair of gloves on under the first pair. She assisted patient 28 to reposition in bed then removed her second pair of gloves and washed her hands.

Interview on 4/13/16 at 10:15 a.m. with the wound care nurse (who also served as the infection control nurse) stated "CNA G always does that, that way if she had to remove her gloves during care she would not have to wash or sanitize her hands until after she had finished."

Review of the provider's reviewed 1/1/16 Hand Hygiene policy revealed all employees would wash their hands after removing gloves. Gloves would have been changed after each patient encounter.

Based on document review and interview, the provider failed to ensure the following contracted services had been reviewed by the quality assurance performance improvement (QAPI) committee. Those contracted services included:
*Registered dietitian/licensed nutritionist (RD/LN).
*Therapy services that included physical, occupational, and speech therapy.
*Ultrasound technologist.
*Medical review services.
*Consultant dentist.
*Physician assistant and certified nurse practitioner services from the Veteran's clinic.
Findings include:

1. Review of the provider's QAPI committee meeting minutes from March 2015 through March 2016 revealed none of the above contracted services had been reviewed.

Interview on 4/14/16 at 9:00 a.m. with the QA coordinator revealed:
*Contracted services were not reviewed on an annual basis.
*She was unaware all the contracted services must be reviewed that involved patient care or services.
*She agreed those services should have been included in the QAPI.

Based on interview, record review, and policy review, the provider failed to ensure an initial activity history and assessment had been completed for five of nine swing bed patients (2, 3, 4, 8, and 38). Findings include:

1. Review of patients 2, 3, 4, 8, and 38's electronic medical records revealed:
*Patient 2 had been admitted to swing bed services on 4/11/16 and was still a patient.
*Patient 3 had been admitted to swing bed services on 3/22/16 and was still a patient.
*Patient 4 had been admitted to swing bed services on 4/8/16 and was still a patient.
*Patient 8 had been admitted to swing bed services on 3/16/16 and discharged on 3/24/16.
*Patient 38 had been admitted to swing bed services on 3/24/16 and was still a patient.
*There was no documentation to support an activity history and assessment had been completed within three days of their admission to swing bed services.
*There was no documentation any activity history and assessment had been completed at all.

Interview on 4/14/16 at 10:00 a.m. with the swing bed coordinator revealed:
*The occupational therapist (OT) had discovered on 4/11/16 the initial activity assessments were not being completed by the activity coordinator.
*No activity assessments had been completed for the prior three weeks.
*There had been a miscommunication between the OT and the certified occupational therapy assistant (COTA) with the activity coordinator. The activity coordinator had thought the OT and COTA had been completing the activity assessments.

Review of the provider's 3/29/10 Activities policy revealed:*The activity director would report to the hospital director of nursing and would use the OT as a consultant in the facility.
*The activity department would maintain an accurate record of daily patient attendance/participation in activities.

Review of the provider's reviewed 1/1/16 Swing Bed Program policy revealed activities would be provided to the patient daily by the nursing staff and the activity department.

Based on record review and interview, the provider failed to ensure one of nine sampled swing bed patients (1) was monitored and interventions were in place to prevent constipation. Findings include:

1. Review of patient 1's electronic medical record revealed:
*She had been admitted to swing bed services on 3/11/16 and was discharged to the nursing home during the survey on 4/13/16.
*She had diagnoses of a fractured left femur and right rib fractures.
*She had received narcotic pain medications, had limited activity, and decreased fluid intake during her recovery.
*During her stay she had seventeen bowel movements (BM) that had been described as hard, and five BMs that had been described as normal.
*She had received milk of magnesia five times and two bisacodyl suppositories.
*An order for Colace 100 milligram twice daily had been started on 4/11/16.

Interview on 4/13/16 at 4:00 p.m. with the director of nurses and the swing bed coordinator revealed:
*There was no bowel protocol to follow for the management of constipation.
*It had been addressed in a morning interdisciplinary meeting, but they were not sure of that date.
*On 4/5/16 patient 1 had requested three prunes every morning.
*They agreed patient 1 was at risk for constipation due to her diagnosis, narcotic pain medication use, decreased activity, and decreased fluid intake.