HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure one of one radiant warmer for newborns was accessible and in working condition. Findings include:

1. Observation on 11/30/15 at 3:00 p.m. revealed a storage closet next to emergency department room three. In that closet the radiant warmer was stored against the back wall. In front of the radiant warmer was equipment that included:
*Two carts that contained personal protective equipment.
*One sit-to-stand lift.
*One wheelchair.
*Eight oxygen tanks.
*Numerous other patient care items.

Interview on 12/2/15 at 9:30 a.m. with the director of nursing confirmed the radiant warmer was not readily accessible for use if a birth occurred. There had been an emergency birth on 10/26/15 and she was not sure if the radiant warmer had been used. She also stated the radiant warmer had not been working for approximately three to four weeks from the above date. Continued interview on 12/2/15 at 11:00 a.m. revealed she had found out it had just been repaired.

Review of the provider's revised October 2013 Emergent Delivery of Newborn; Stabilization and Treatment policy revealed after the newborn was delivered "Thoroughly dry and warm neonate with blankets [do not leave the blankets on neonate], return to mother's side if at all possible. Place infant in radiant warmer."

A. Based on observation, testing, and interview, the provider failed to maintain:
*A functioning nurse call system in:
-The bathrooms of the:
--Blood draw room.
--Bone density room.
--Ultrasound room.
--X-ray area.
Findings include:

1. Observation on 11/30/15 at 2:45 p.m. revealed an older nurse call system in the bathroom of the ultrasound room. Testing of that call system revealed it had not activated the small light or button of the unit. It was not answered by a technician or any other staff. Interview with an unidentified staff person revealed she was not aware the call light did not work. She did not know if a signal went to the nurses station or not. Review of the call light panel at that time at the nurses station revealed there was no call light activated.

Testing of the other call systems within the older part of the hospital revealed they would not illuminate at the panel at the nurses station.

Interview at the time of the observation and testing with the maintenance supervisor revealed they had installed a new nurse call system in the hospital this fall. He had thought they installed the system through out the entire building. He was not aware they had only installed the system in the newer part of the hospital and not the older part of the hospital. Nor was he aware they had disconnected the old system from the older part of the hospital.

No policy was provided for nurse call systems at the time of the survey.

B. Based on observation and interview, the provider failed to:
*Attach pertinent information to identify the contents and manufacturer's directions for two of two cloth wipe buckets.
*Maintain the cleanliness of one of one housekeeping cart.
Findings include:

1. Observation on 11/30/15 at 1:30 p.m. revealed a housekeeping closet in the physical therapy building. A white bucket with cloth wipes sat in that room. There was no label to identify the solution contents of that bucket or how to use the solution in that bucket. Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated he was unsure what the solution was inside that bucket.

Continued observation on that same day at 4:00 p.m. revealed a housekeeping cart in the corridor of the hospital. That cart had the same white bucket with solution and no label. Interview with the housekeeping supervisor at the time of the observation confirmed that finding. She stated she was not aware those buckets must be labeled to identify the product and directions for its use.

2. Observation on 11/30/15 at 4:00 p.m. revealed a housekeeping cart in the corridor of the hospital. That cart appeared as though it had been smeared with mud on the bottom levels where the mop bucket and broom were located. Interview with the housekeeping supervisor at the time of the observation confirmed that finding. She stated she had not noticed how dirty the cart was.

No policy was provided for labeling of unidentified cleaning products or cleanliness of housekeeping carts at the time of the survey.

32572

Based on observation, interview, policy review, and manufacturer's review, the provider failed to ensure:
*Eight outdated vacutainer vials (tubes for collecting blood) were not available for use in the emergency room (ER) bays (separate areas to maintain privacy) 1, 2, 3, and 4 because of expiration dates.
*Intravenous (IV) fluids had been correctly dated when placed in the warming cabinet.
*The warming cabinet temperature followed manufacturer's recommendations.
*Opened vials of medication were stored and dated according to policy.
Findings include:

1. Random observations on 11/30/15 and 12/1/15 of ER bays 1, 2, 3, and 4 revealed:
*Bays 1 and 2:
-Two green topped tubes had expired July 2015.
-Two yellow topped tubes had expired February 2015 and August 2015.
-Two blue topped tubes had expired April 2015 and 1October 2015.
*Bay 3 one blue topped tube had expired May 2015.
*Bay 4 two yellow topped tubes had expired May 2015 and October 2015

Surveyor: 26632
Interview on 12/1/15 at 4:00 p.m. with the director of nursing (DON) revealed she had asked the inventory coordinator and the ER bay storage cabinets were to have been checked on a monthly basis for outdated supplies. She stated the inventory coordinator had missed looking at the vacutainers. She also stated they had no policy regarding outdated supplies.

2. Review of the provider's undated Warming Cabinets policy revealed:
*"Warm according to the device manufacturer's recommendations and consistent with the IV solutions manufacturer's recommendations."
*"The warming cabinet for IV solutions may be set and warmed at a temperature no greater than 42 degrees C [Celsius, 107.6 degrees F.]"
*"IV solutions will be labeled when they are placed in the warming cabinet and will remain no longer than 14 days in the warming cabinet."
*"The IV solutions that are removed at 14 days will be identified as 'previously warmed', they should not be returned to the warmer but can be used up to the labeled expiration date (provided they have not been warmed more than once)."

Random observations on 11/30/15 and 12/1/15 of a warming cabinet outside of the nurses station revealed:
*It contained nine bags of 0.9% (percent) sodium chloride (NaCl) IV fluid 1000 milliliters (ml) bags with the overpouches intact. Those bags had the following 2015 dated labels placed on them:
-One bag 12/23.
-Four bags 12/26.
-Two bags 12/28.
-Two bags 12/29.
*It had a digital temperature readout on the front of the cabinet. That temperature read 107 degrees Fahrenheit (F).
*Testing of the warming cabinet on 11/30/15 at 2:20 p.m. revealed a temperature of 106.8 degrees F.

Interview on 11/30/15 at 1:00 p.m. with registered nurse (RN) B revealed the IV fluids could be in the warmer for thirty days. If the IV fluid passed the date on the label the fluid would be removed from the warmer, and placed on the shelf for two weeks. It would be labeled dated when it needed to be removed from the shelf. Those IV bags were dated for 2015.

Interview on 12/1/15 at 11:00 a.m. with RN B revealed:
*The nursing staff dated the IV fluids when placed in the warming cabinet.
*The night nurses were to monitor the temperature of the warming cabinet.
*She was unable to find any monitoring documentation.

Interview on 12/1/15 at 1:20 p.m. with the DON revealed:
*The IV fluids placed in the warming cabinet were to be dated for two weeks.
*The night nurses were to monitor the temperature of the warming cabinet.
*The documentation form did not include the temperature of the warming cabinet.

Review of the IV fluids manufacturer's recommendations revealed "IV solutions of volumes 150 ml or greater can be warmed in their plastic overpouches to temperatures not exceeding 40 degrees C (104 degrees F), and for a period no longer than 14 days."

Surveyor: 26632
3. Observation on 11/3015 at 1:30 p.m. revealed opened vials of medication in the physicians documentation room. Those medication vials included:
*Single-dose vial of bupivacaine HCl 0.5 percent (%) and 1% lidocaine with no open date.
*Multiple-dose vial of 2% lidocaine and 1% lidocaine with epinephrine with no open date.

Interview on 11/30/15 at 2:00 p.m. with the DON confirmed the open vials of medication listed above. She believed one of the physicians had probably used them and left them in the physicians documentation room. She agreed the vials of medication should have been dated when opened. She also stated all medication vials, even if listed as multiple-dose, were to only have been used as a single-dose and then discarded.

Review of the provider's revised May 2011 Use of Single-Dose and Multiple-Dose Containers of Sterile Injectable Medications policy revealed:
*Single-dose vials should have been discarded after use and not returned to stock on clinical units.
*Once a multiple-dose vial was punctured it should have been assigned a beyond-use date. *The beyond-use date for an opened or entered multiple-dose vial was twenty-eight days unless otherwise specified by the manufacturer.

26632

A. Based on observation, interview and policy review, the provider failed to ensure contaminated enzymatic cleaner was disposed of so as not to contaminate the laboratorys (lab) handwashing sink. Findings include:

1. Interview and observation on 12/2/15 at 8:00 a.m. with licensed practical nurse A and the director of the clinic revealed:
*Contaminated soiled instruments were cleaned in the lab room.
*After the instruments were cleaned with the enzymatic cleaner the contaminated fluid was disposed of in the handwashing sink.
*They both agreed contaminated liquids could splash to surrounding clean items, and that sink was not a dedicated (for a specific task) sink.

Review of the provider's December 2014 Prepare and Transport Items - Decontamination policy revealed there was no mention of where to dispose of the contaminated enzymatic cleaner.

Review of the provider's April 2014 Sterilization and Disinfection policy revealed:
*The policy statement was "Sterilization and disinfection procedures will prevent the transmission of infectious disease."
*There was no mention of where to dispose of the contaminated enzymatic cleaner.


32572

B. Based on observation, product information review, and interview, the provider failed to ensure:
*Five of five positioning Styrofoam devices used in therapy had a cleanable surface.
*Paper towels and a single-service paper towel dispenser were in place for one of one computerized axial topography (CAT) scan room.
*Clean towels, Styrofoam coffee cups, a roll of paper towels, and patient ice bags were stored from possible contamination under three randomly observed drain lines (blood draw, nurses ante, and water and ice machine).
*One of one housekeeper (C) and the housekeeping supervisor were aware of the contact time for the disinfectant used throughout the hospital.
*An employee use room (sleep room two) was not used as a dual-purpose room for a patient stress test treatment room.
Findings include:

1. Observation on 11/30/15 at 1:15 p.m. revealed five Styrofoam devices in a plastic tote in the therapy gym. Interview with an unidentified therapist in the gym at that time revealed those devices were used as positioning devices for patients. She stated they used a disinfectant and wiped them clean after each use. She was not aware those items were porous and were not cleanable.

Interview on 12/2/15 at 10:45 with the director of therapy revealed he was not aware those Styrofoam devices were uncleanable and could not be used.

No policy was provided for the cleanliness of patient use items in therapy at the time of the survey.

2. Observation on 11/30/15 at 2:15 p.m. revealed no paper towels and no paper towel dispenser in the CAT scan room. Interview with the maintenance supervisor (MS) at the time of the observation confirmed that finding. He stated they had changed suppliers a couple months ago for paper towels. Apparently they had missed that room when they removed the old dispensers.

No policy was provided for items needed at a handwashing sink at the time of the .

3. Observation on 11/30/15 from 1:15 p.m. to 2:45 p.m. revealed the following:
*A stack of clean cotton towels were stored under the drain line of the handwashing sink in the blood draw room.
*Clean rolls of paper towels were stored under the drain line of the handwashing sink in the nurses ante room.
*Stacks of Styrofoam cups and clean ice bags for patients were stored under the drain line of the water and ice machine in the front lobby.

Interview with the MS at the time of the above observations confirmed those findings. He stated staff were aware no clean patient use items could be stored under any drain line.

No policy was provided for storage of clean patient use items under drain lines at the time of the survey.

4. Interview on 12/1/15 at 10:45 a.m. with housekeeper C revealed she used the disinfectant in the white bucket throughout the entire hospital. She stated the contact time for that particular disinfectant was one minute.

Review of the product information for Oxivir Five 16, the product in the bucket, revealed it had a five minute contact time.

Interview with the housekeeping supervisor at 2:00 p.m. on that same day revealed she had done training on that product about two months ago when they had changed companies. She had informed all staff the contact time for the disinfectant was one minute. She was not aware the other product used in the hospital Oxivir TB Wipes had a one minute contact time, but her product had a five minute contact time.

No policy was provided for the training of housekeeping staff or how to follow manufacturer's guidelines at the time of the survey.

5. Observation on 11/30/15 at 2:00 p.m. revealed a gurney with bedding was stored in sleep room one. Two tread mills were also stored in that room. Interview with the MS at the time of the observation confirmed that finding. He stated he was not aware why that patient-use gurney or two tread mills were in that room. He stated that sleep room was used for on-call staff.

Interview on 12/2/15 at 10:55 a.m. with the director of nursing revealed that room was used as a treatment room for patient stress tests. The patients walked on the tread mills and then would lay down on the gurney for tests. She stated she had not contacted the South Dakota Department of Health when she made the sleep room a dual purpose room. She also revealed she had not considered the possibility of contamination of the equipment when staff slept in the room.

No policy was provided for notification for change of use of a room at the time of the survey.