HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure only authorized personnel had access to medications in sharps containers in:
*All patient care areas.
*A medical waste holding area awaiting destruction.
Findings include:

1. Observation on 2/8/17 at 8:50 a.m. in operating room (OR) 7 revealed a sharps container secured to the anesthesia cart. Interview with certified registered nurse anesthetist (CRNA) F at that time regarding removal and storage of full sharps containers revealed:
*The sharps containers contained used syringes and medication vials used during the surgeries.
*The medication vials contained any left-over medication not used during the procedures.
*When the sharps containers were full they were removed by the CRNA or more often removed from the carts by the surgical technicians (techs) as they were cleaning up after the procedures.
*Those containers were taken to the garbage bay for pick-up by the medical waste contractor.
*The surgical techs should not have had access to those unused medications in the sharps containers.

2. Observation and interviews on 2/8/17 at 11:15 a.m. of the biohazard room with registered nurse (RN) E, surgical director A, and maintenance director B revealed:
*All medical waste including sharps containers were stored in the biohazard room until the medical waste company picked them up on Mondays and Thursdays.
*That room was located off the receiving area.
*Sharps containers from all areas of the hospital were transported through the unsecured garbage room and through another unsecured door into the biohazard room.
*That room had an exit door that led to the outdoor garbage docks.
*That exit door was unlocked and unalarmed during the daytime and was alarmed by the recovery care center (RCC) nurses for the night around 10:00 p.m. each day.
*Housekeepers, maintenance workers, and surgical techs transported the sharps containers to the biohazard room.
*The biohazard room did not have access to enter from the outside.
*The receiving area did have access to enter from the outside and was located adjacent to the garbage/biohazard area. Those outside doors were unlocked and unalarmed during the daytime. They were locked and alarmed by the RCC nurses around 10:00 p.m. each day.
*They agreed medications in the sharps containers were not secured.
*They agreed the housekeepers, maintenance workers, and surgical techs should not have had authority to access those unused medications.
*There was no system in place to tell how many sharps containers had been placed in the biohazard room or if any of the containers had been removed.

3. Observation on 2/9/17 at 11:15 a.m. during a walk-through tour of the hospital with RN E revealed in the Block Room (used for anesthesia) had the following:*One over-sized unsecured sharps container on wheels.
*Three unsecured sharps containers in baskets on the walls.
*Two unsecured sharps containers placed on two line cart work stations.
Interview with RN E at that time revealed the above containers should have been secured to prevent them from being carried away.

Review of the provider's July 2015 Pharmacy Security policy revealed:
*"The security of the pharmacy and every place where medications are stored will be maintained."
*The policy had not included security of medications in the sharps containers, how biohazard waste was to have been secured, or who was to have access to the pharmaceutical waste awaiting destruction/removal.

Interview on 2/9/17 at 9:30 a.m. with RN E revealed he was unable to locate another policy specific to security of sharps/biohazard containers.

32332

Based on observation, interview, and policy review, the provider failed to have a preventative maintenance program that identified and repaired environmental issues and a process for storage of clean/dirty supplies for:
*Missing paint and exposed areas of drywall above the instrument washer for one of one clean sterilization room.
*Two uncleanable rusted cautery trays, and one uncleanable rusted equipment basket in the operating room (OR) suite.
*Missing laminate and exposed wood for one storage shelf in the OR hallway.
*Two areas of flooring separating from the wall in the OR suite.
*Multiple OR doors with paint chips and dents.
*One OR door with three areas of exposed wood.
*Missing laminate for two walls in the OR hall beside the storage shelves.
*Cleaning multi-patient equipment between patient use for one of one sampled patient (39).
*Storage of patient-use equipment under a sink in a patient room for one of one sampled room (18).
*Storage of patient-use equipment at the bedside of a room (18) ready to receive a new patient.
*Storage of a portable suction machine and suction canisters in a sanitary environment.
*An uncovered ice scoop placed beside cleaning products used for disinfection in the recovery care center (RCC) clean utility room.
*Paper products stored in the RCC 1 and RCC 2 soiled utility room.
*Patient care products placed directly on the floor of the supply closet in the RCC area.
*Clean patient care urinals and graduate pitchers in the post-anesthesia soiled utility room.
Findings include:

1. Observation and interview on 2/7/17 at 2:00 p.m. with central supply room (CSR) director J in the sterilization room revealed four areas of missing paint and exposed drywall approximately six by eight inches in diameter above the two instrument washers. Interview at that time revealed she:
*Did not know how long those exposed areas had been present.
*Did not know if those areas had been repaired in the past.
*Stated the paint had peeled away, because the washer doors had been opened too early causing the steam to damage the walls.
*Agreed the exposed drywall was not cleanable.

2. Observation and interview on 2/9/17 at 12:00 noon during a tour of the OR suite with surgery director A revealed:
*Two cautery carts (2 and 15) with areas of rust to the top and side edges of each cart.
*One Microscope 2 screen cart with a wire basket attached to hold equipment had all four horizontal wires covered in rust.
*The OR hallway supply area cupboard SHLD CP6 had one shelf with a two-by-three inch area of missing laminate exposing raw wood.
*A four-inch gap between the wall and wall border beside the OR hallway supply area.
*An equipment storage area between OR 9 and 10 revealed a four-inch gap between the wall and wall border.
*Multiple paint chips and dents in OR doors.
*The OR 3 door had paint chips and three, three-inch areas of exposed wood.
*The OR hallway supply area revealed two approximately two foot areas of missing laminate from the each side of the cupboards.

Interview with surgery director A revealed she agreed:
*The areas of exposed wood were not cleanable surfaces.
*The equipment with rust was not cleanable.
*The areas of wall/flooring gaps caused an infection control risk.
*The areas of missing wall laminate posed an infection control risk as those areas were not smooth.
*The provider was in initial planning for updating the OR area.
*There were no dates as to when the updating would be completed.

3. Observation on 2/8/17 at 7:40 a.m. of registered nurse (RN) G cleaning a blood-pressure cuff, electronic thermometer, and pulse oximeter after obtaining vital signs for patient 39 revealed she:
*Removed a disinfectant wipe from its container.
*Began disinfecting the above equipment with the wipe.
*Dropped the wipe on the floor.
*Picked up the wipe from the floor and continued cleaning the equipment.
*Disposed of the wipe and returned the equipment to the storage area.

Interview on 2/9/17 at 12:30 p.m. with PreOp 1 supervisor E regarding the above observation revealed:
*He agreed the nurse had not used clean technique to disinfect the equipment.
*His expectation was the nurse would have discarded the wipe and obtained a clean disinfectant wipe to finish cleaning the equipment.

Surveyor: 18559
4. Observation and interview on 2/9/17 at 11:20 a.m. of patient room 18 with nurse manager D revealed:
*Toothpaste, tooth brushes, bed pans, and graduate pitchers were being stored under the sink.
*He was not sure why the clean supplies were being stored under the sink.
*Those supplies should have been stored in the clean storage area.

Review of the Centers for Disease Control (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, https://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf, page 75, accessed on 2/13/17, revealed medical supplies should not have been stored under sinks where they might have become wet.

Surveyor: 32332
5. Observation and interview on 2/9/17 at 11:20 a.m. of patient room 18 with nurse manager D revealed:
*A drawer at the bedside of a room not being used contained:
-Approximately twenty emesis bags.
-Approximately ten blue cloths.
-Incontinent pads and briefs.
*None of the above patient care items had been sealed.
*Nurse manager D stated the patient care items were not removed from patient rooms between discharges and new admissions unless the patient who had been discharged from that room had been on isolation precautions.
*He would not have known if the previous patient had contact with those items.

Review of Patricia A Potter et. all, Fundamentals of Nursing, 9th Ed., St. Louis, Mo., 2017, p. 456, revealed items that came in contact with intact skin were to have been disinfected. Those type of items had included blood pressure cuffs, linens, and bedside trays.

6. Observation and interview on 2/9/17 at 11:30 a.m. during a tour of the patient care areas with RCC nurse manager D, RN manager E, maintenance director B, environmental services director C revealed in the RCC areas:
*An uncovered ice scoop placed beside cleaning products used for disinfection in the clean utility room.
*The RCC 2 soiled utility room contained:
-A box containing toilet tissue on the sink area.
-A metal open-shelving unit containing patient pamphlets approximately one foot away from a hopper used for cleaning soiled linens.
*The RCC 1 soiled utility room contained:
-Paper products including toilet tissue, facial tissues, and paper towels.
-A hopper.
*A bag of patient briefs and a stack of clean patient bath basins sat directly on the floor of the RCC hallway supply closet.

Observation of the post-anesthesia area soiled utility room revealed clean patient urinals and graduate pitchers were stored in there also.

Interview at that time with RNs B and E revealed:
*Clean patient items should not have been stored in soiled utility rooms.
*Ice scoops were to have been covered and stored away from cleaning supplies.
*They did not believe the hoppers were being used.

Review of APIC Text of Infection Control and Epidemiology, 3rd Ed., Washington, DC, 2009, p.105-4, revealed sinks and hoppers posed health risks:
*Because of contamination of sink drains.
*From splashing contaminated water onto supplies and equipment.

Review of Patricia A. Potter et. al, Fundamentals of nursing, 9th Ed., St. Louis, Mo, 2017, page 460, revealed:
*Standard precautions were the primary strategies for prevention of infection transmission and included contact with equipment and surfaces contaminated with potentially infectious materials.
*The nurse in acute care settings was to follow standard precautions in all standards of care.

Surveyor: 18559
7. Observation and interview on 2/9/17 at 12:35 p.m. with the director of materials and safety in the basement storage area revealed:
*The paint on the brick wall had bubbled, flaked, had a white powdery substance on it.
*A portable suction machine and an opened box with suction canisters were next to that wall.
*He stated that wall had been that way since it had rained in the fall.
*He had just started to do environmental safety rounds in March 2016.
*Environmental safety rounds would be done twice per year.

Interview on 2/9/17 at 1:40 p.m. with the quality assurance RN K revealed environmental safety rounds were done twice a year. She thought the last time the environmental safety rounds were performed was last summer. She was not aware of the condition of the wall in the storage area.

8. Review of the provider's February 2017 Management of Clean Equipment/Supplies policy revealed:
*Clean equipment and supplies should have been stored in clean areas or rooms.
*Clean supplies should have been stored separated from contaminated equipment or supplies.
*Only a limited amount of clean supplies could have been stored under a sink. Included in that was: bath basins, graduate cylinders, and urinals.
*Policy had not addressed what should have been done with unprotected clean supplies after a patient was discharged.