HospitalInspections.org

Based on policy review, observation and interview, the hospital failed to ensure safe handling and preparation of medications for 1 of 3 (11/28/16) days of observation during the validation survey.

The findings included:

1. Review of the hospital's "[Hospital's initials] Pharmacy IV [intravenous] Room Standard Operating Procedures" policy revealed, "...Vials shall have a clear beyond use date/time written on the vial after opening/puncture...Multi-dose vials are good for 28 days once opened unless otherwise stated in the product literature...Vials not meeting this criteria should be discarded..."

Review of the hospital's "Storage of Medications" policy revealed, "...Proper medication storage is needed...to ensure medication stability per manufacturer's recommendations, and to maintain the integrity of dispensing regulations in accordance with State and Federal law...On each nursing unit, medications will be stored in [name of medication dispensing machine] or in the unit's secured medication room...If the medication retrieved is not administered, the medications shall be...placed in the credit box located in each secure medication room..."

2. Observations in the Urology/Nephrology Unit medication room on 11/28/16 at 10:30 AM, revealed a 10 milliliter (ml) vial of heparin stored in a patient's medication bin, opened and not labeled with the date, time or initials of when it was opened. An IV piggyback bag with a 1 gram vial of Vancomycin attached to it and a 250 ml bag of normal saline were stored in a patient's medication bin with no label listing the patient's name, date or time of preparation or beyond use date. The bag of normal saline was also spiked with IV tubing.

3. During an interview in the Urology/Nephrology Unit medication room on 11/28/16 at 10:35 AM, the Director of the Urology/Nephrology Unit confirmed the vial of heparin should have been labeled with the date, time and initials when the vial was opened. The Director confirmed the IV piggyback of Vancomycin and normal saline should have been labeled with the patient's name, the date and time of preparation and a beyond use date.

During an interview in the conference room on 11/30/16 at 2:47 PM, when asked about how opened vials of medication should be stored in a patient's medication bin, the Assistant Chief Nursing Officer (CNO) stated, "...should be labeled with name [preparer], date and time..." When asked if IV piggybacks should be stored in a patient's medication bin after spiked with IV tubing, the Assistant CNO stated, "...no..."

Based on policy review, observations and interview, it was determined the facility failed to have a full-time employee who demonstrated, through daily management that policies and procedures were followed as evidenced by the poor sanitation practices observed in the various kitchens under the hospital's control for 2 of 3 (11/28/16 and 11/30/16) days of observation during the validation survey.

The findings included:

During tours of the various kitchens, on 11/28/16 from 9:30 AM to 11:00 AM and on 11/30/16, from 2:00 PM to 3:00 PM, the following unsafe practices for food handling were observed:

1. Review of the hospital's policy dated 7/2015 and titled "Infection, Prevention and Control....Food and Nutrition Services....revealed, "under section VIII. Dishwashing G. 4. Check that water temperatures in each tank are correct: Final Rinse-Minimum of 180 degrees F."

Observations during the tour of the dietary department on 11/28/16 at 9:30 AM, revealed in the main kitchen, the high temperature dish machine was in service washing and sanitizing dishes. The temperature gauge on the dish machine documented the sanitizer rinse was at 165 degrees Fahrenheit (F) instead of the 180 degrees F sanitizer rinse required per facility policy.

During an interview on 11/28/16 at 9:35 AM, the Food Services Director confirmed the temperature gauge for the final rinse was at 165 degrees F rather than the required temperature of a minimum of 180 degrees F.

2. Review of facility's policy #E004 revealed the following documentation.."Facial hair must be effectively restrained as per local and state regulations. Mustaches and/or sideburns must be neatly trimmed."

Observations during the tour of the dietary kitchen on 11/28/16, at 9:45 AM revealed a dietary employee who was not wearing any head covering and a dietary employee who was wearing a cap that did not cover his long hair which hung down below the cap. Three employees had beards which were not restrained. Further observations in the facility's cafeteria on 11/28/16 at 11:20 AM, revealed a dietary employee who was not wearing any head covering over her long hair.

During an interview with the Food Service Director on 11/28/16, at 9:45 AM, he confirmed all dietary employees must wear hair nets or caps which covered all their hair according to food and nutrition service's policy and procedure.

3. Observations in the facility's kitchen on 11/28/16 at 11:00 AM revealed 4 dietary employees washing their hands. Two of four picked up the cover of a trash can to discard their paper towels re-contaminating their hands. In the first instance there was no trash can with foot controls under the hand washing sink and in the second instance the foot pedal did not work.

4. Review of the facility's policy under infection control, page 7 documented under number 8
"garbage cans shall have tight fitting lids".

Observations in the facility's kitchen on 11/28/16 between 9:30 AM and 11:00 AM revealed two trash cans containing food debris which were left uncovered. Observation at the Asian restaurant [under the hospital's supervision] on 11/28/16 revealed 2 uncovered trash cans with food debris.

5. Review of facility's jewelry policy revealed the following documentation under the uniform dress code, Policy #E004.. " Jewelry must be limited to wedding rings, service pins, watches, or button-type earrings. When preparing food, jewelry must be limited to a plain wedding-ring type band".

Observations in the facility's kitchen on 11/28/16 from 11 AM to 11:30 AM revealed 3 employees wearing jewelry. Two of the three employees were observed preparing food. One employee was wearing loop earrings and one employee had blue jewels on her earrings.

6. Observation in facility's refrigerators on 11/28/16, at 10:00 AM, revealed a chicken breast which was not dated and bacon dated 11/15/16. Observation on 11/30/16, at 2:30 PM, in the refrigerator of the Asian Restaurant revealed the following items which were not dated: salmon, spring rolls, egg rolls, shrimp, crab meat and oysters.

7. Observations in the dry food storage room on 11/28/16, at 10:30 AM, revealed a wet mop which was a black color left unattended against a wall. Items were stacked above the line circling the storage room, above which no items were to be stored.

During an interview with the Chief Clinical Dietitian on 11/28/16, at 10:30 AM, she confirmed items were not to be stacked above that line and must be at least 18 inches from the ceiling.

Based on policy review, medical record review, observation and interview, the facility failed to ensure measures to prevent the potential spread of infection were in place, staff educated patients and visitors on isolation protocols, staff failed to clean care mobile devices and equipment, staff failed to inform dietary for the need of disposal trays for patients/patients visitors in isolation rooms for (2 of 2 observation days), staff failed to perform hand hygiene for 1 of 1 (Staff #85) Radiology Technicians observed and failed to ensure proper placement of foley drainage bag for 1 of 3 (11/28/16) observation days.

The findings included:

1. Review of the facility's "Barcode Medication Administration (CareMobile)" policy revealed, "...Equipment Care:1. The CareMobile device should be disinfected after contact with a patient or patient's environment...If the patient is in isolation, the CareMobile device should be placed in a clear plastic bag. The bag should be removed and disposed of in the patient's room."

2. Review of the facility's "Infection Control Department and General Guidelines" policy revealed, "...23. Glucose meters are disinfected between each patient's use. When taking the bedside blood glucose meter into an isolation room, place the meter in a plastic bag before entering the room. After the test is performed, discard the strip and the plastic bag in the patient's room..."

3. Review of the facility's "Nursing Policy and Procedure" policy revealed, "...Isolation Technique Process 1. Explain procedure to patient and/or visitor. Give patient or family education sheet on specific isolation...Clostridium Difficile Surveillance Protocol...10. Educate family and patient on Special Care Contact Isolation..."

4. Review of the facility's "Contact Precaution" policy revealed, "...Rules for visitors. If there is a "Contact Precaution " sign on the door: You must check with the nurse before going into the room. You should check with the nurse if you plan to eat or drink in the room. You should ask the nurse about using or touching any items in the room. If allowed in the room:Wash your hands with soap and water or use hand sanitizer before entering room. Put on a gown and gloves before entering room. As you leave room:Take off your gown and then your gloves. Leave them in the room as told. Wash your hands with soap and water or use hand sanitizer ... "

5. Review of the facility's "General Infection Prevention and Control Guidelines" policy revealed, "...Hand Hygiene...Hands must be washed...after any contact with contaminated equipment...contaminated surfaces...Decontaminate hands after contact with inanimate objects..."

6. Review of the facility's "Nursing Policy and Procedure, Urinary Catheter - Nurse Driven Protocol" policy revealed, "Appendix CAUTI (Catheter Associated Urinary Tract Infections) Prevention Bundle...2. Proper insertion and Maintenance...Assure that urine flow is not obstructed. (no kinks in tubing, drainage bag is below the level of the bladder) Assure that there is no reflux into the bladder. (Keep the bag below the knees/level with the bladder when moving the patient..."


7. Review of the facility's "Nursing Policy and Procedure, Urinary Catheterization" policy revealed, "...For continuous drainage...Hang drainage bag on bed frame at side of bed...Keep tubing free of dependent loops and kinks...Education...caution the patient to keep urinary drainage bag below the level of the bladder..."

8. Observation on the Medical Intensive Care Floor in Room B763 on 11/28/16 at 8:30 AM revealed Staff #60 entered the patient's room, using the care mobile devise to scan the patient's Identification band. The staff member then placed the care mobile devise (CMD) on the patient's bed sheets. The staff member, after collecting blood samples from the patient, placed the CMD on top of a box of clean gloves located on the lab cart without cleaning the CMD.

During an interview on 11/30/16 at 10:25 AM, the laboratory manager verified the CMD should be cleaned after use and should not be placed on patients bed.

9. Observations on the Medical Surgical Floor in Room B 885 on 11/28/16 at 1:20 PM revealed Staff #61 entered the patient's room, washed hands, donned gloves, and placed banding scissors and CMD on the patient's bed. The staff member used the scissors to open a Fentanyl Patch and then placed scissors into her pocket without cleaning them. The staff member then picked up the CMD from the bed and scanned the patient's Identification band. The staff member placed the Fentanyl Patch on the patient and left the room with the CMD. The staff member did not clean the CMD before placing it at the nursing station.

During an interview on 11/30/16 at 8:30 AM, the clinical director for the Medical Surgical Floor confirmed the CMD and scissors should not be placed on the bed and should have been cleaned.

10. Observation on the Urology unit in Room A 417 on 11/28/16 at 3:20 PM revealed a correctional officer removing leg shackles from Patient #44 in isolation. The patient is in isolation for Clostridium Difficile (C-DIF). The officer was not wearing gloves or gown. The non-gloved officer then stepped out of the room placing the shackles on top of the isolation cart in the hall. The non- gloved officer cleaned the shackles with Sani- Wipes taking the shackles back into the room.

During an interview on 11/29/16 at 3:25 PM, the correctional officer stated he had not been informed by the staff on isolation precautions and procedures.

During an interview on 11/29/16 at 3:36 PM, the urology clinical director verified isolation precautions were not followed.

11. Observations during surgery on 11/29/16 at 9:00 AM revealed Staff #85 picked up gloves off the floor, threw them in the contaminated waste receptacle, then proceeded to touch medical equipment without first performing hand hygiene.

12. Observation on the urology unit on 11/30/16 at 11:05 AM, revealed Staff #86 donned gloves and gown, entering room (A417). Patient #44 is in isolation for C-DIF. The nurse carried a blood glucose monitor into the room without placing the monitor in a plastic bag per hospital protocol.

During an interview on 11/30/16 at 11:10 AM, the urology clinical director verified the nurse did not follow hospital protocol.

13. Observations on the Oncology (B9) floor on 11/30/16 at 8:24 AM, revealed two dietary meal trays sitting on top of an isolation cart outside of room B982. One meal tray was partially uncovered.

During an interview on 11/30/16 at 8:32 AM, Staff #87, was asked if it was acceptable to place meal trays on top of the isolation cart. Staff #87 stated, "...Not usually." When asked how you could tell a meal tray was dirty, Staff #87 stated, " ...you don't know ...it looks like this one [meal tray that was partially uncovered] is dirty..."

During an interview on 11/30/16 at 8:33 AM, Staff #88, was asked what room the partially uncovered meal tray had been taken into. Staff #88 stated, " 82 [B982] would be my guess since he is in isolation [contact isolation] ... " .

During an interview on 11/30/16 at 9:55 AM, Staff #89, was asked who is responsible for passing out the meal trays. Staff #89 stated, "The nurse or the caregiver...". When asked where staff put the meal trays, Staff #89 stated, "...Usually they sit them [meal trays] on the isolation carts..."

14. Observation on the urology unit in Room A417 on 11/30/2016 AM revealed two correctional officers sitting in Patient #44's room at bedside. The patient is in isolation for C-DIF. The officers were not wearing gowns or gloves per hospital protocol.

During an interview on 11/30/16 at 8:40 AM, the correctional officers verified they had not been informed by the staff of the isolation precautions and procedures and had been entering and leaving the room without washing their hands and had not been wearing gowns and gloves.

During an interview on 11/30/16 at 8:44 AM, when asked who was responsible for ensuring visitors were made aware of isolation protocols/procedures, the urology clinical director stated the nurse was supposed to educate anyone going into the room about the type of isolation, what to wear, and what to do before leaving room. The urology clinical director verified visitors had not been made aware of the type of infection, or of isolation protocols and procedures. The Director stated the staff did not have visitors stop at the nurse's station before entering isolation rooms.

15. Observation in the Labor and Delivery recovery room on 11/28/16 at 10:15 AM revealed Pt #13 was resting with the head of the bed elevated. Observations of Pt #13 revealed no evidence of a Foley catheter drainage bag on the side of the bed.


In an interview in the recovery room on 11/28/16 at 10:15 AM, Staff #9 stated the patient had a Cesarean section delivery that morning, would remain in the recovery room until her vital signs were checked 2 more times, and would be transferred to the Mother-Baby unit at approximately 10:40 AM.


In an interview in the recovery room at the patient's bedside on 11/28/15 at 10:25 AM, Staff #9 verified the patient had a Foley catheter. Staff #9 raised the bed linens from the patient's legs and revealed a catheter drainage bag containing yellow urine on the bed between the patient's knees. Staff #9 stated the drainage bag was to be placed on the bed frame except during transport. The nurse repositioned the catheter drainage bag to the right side of the bed and attached it to the bed frame.