HospitalInspections.org

Based on review of the medical records (MR), facility policy and interviews with the staff, it was determined the facility failed to ensure the staff initiated a Plan of Care for each patient on a ventilator. This affected 1 of 1 medical records reviewed with a patient on a ventilator including, MR # 6 and had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy: Interdisciplinary Plans of Care Policy
Revision Date; 7/30/14

1. Introduction:

The Interdisciplinary Plan of Care provides the framework for coordinating communication of the health care team. The purpose is to facilitate optimal health during the admission and to guide the post discharge care and education of the patient/family/caregiver.

3. Procedure:

c. The plan of care documentation will be updated/reviewed at a minimum of every 24 hours as either met or not met; done or not done by nursing or therapist related to their actions completed or not completed throughout the shift...

d. Updating of IPOCs (Interdisciplinary Plan of Care) will be required to be completed every 8-12 hours or as directed according to the facility policy or within the E.H.R. (Electronic Health Record) system.

1. MR # 6 was admitted to the facility on 7/6/16 with diagnoses including Lower Gastrointestinal Bleed. The patient under went a Colonoscopy with a Perforated Cecum on 7/8/16. The patient suffered Respiratory Failure and was placed on a ventilator.

Review of the medical record on 7/12/16 at 2:00 PM revealed no documentation of an IPOC for a ventilator. The surveyor asked Employee Identifier (EI) # 14, Registered Nurse if there was a IPOC for a ventilator in the patient's record and the response was, "No."

Based on facility policies and procedures, review of medical records (MR) and interview with staff it was determined the facility failed to follow its own policies requiring:

a) All medical record entries to be complete, dated and timed.

b) A medical history and physical examination (H&P) be completed and documented within 24 hours prior to surgery.

This affected 2 of 32 records reviewed including MR # 9 and MR # 8, and had the potential to affect all patients served by the facility.

Findings include:

"Policy Title: Content of the Medical Record
Revision Date: 12/14/2015

I. Purpose:

To define the contents of patient medical records, whether in paper or electronic format, in such a way that it facilitates communication, coordination and continuity of care and promotes efficiency and effectiveness of treatment.

III. Procedure

A. All medical record entries, including handwritten and electronic, must be legible, complete, true and accurate, dated, timed and authenticated by the person responsible for providing or evaluating the services provided...

F. The medical record contains the following information as needed to provide care, treatment and services...

b) Any informed consent"


"Policy Title: History and Physical Content Management
Revision Date: 1/29/2015

II. Policy:

1. A medical history and physical examination (H&P) must be completed and documented within 24 hours following admission or prior to surgery, whichever comes first.

2. An H&P performed prior to admission (within 30 days of admission) may be accepted...An update to the H&P must be completed and documented within 24 hours after admission or prior to surgery / procedure when utilizing such an H&P.


1. MR # 9 was admitted for outpatient Robotic Laparoscopic Hysterectomy on 4/12/16.

Review of the MR revealed the History and Physical was signed by the physician but not dated therefore the surveyor could not determine if the H&P was completed within 24 hours of the surgery per the facility policy.

An interview was conducted on 7/13/16 at 10:30 AM with Employee Identifier (EI) # 8, Director of Medical Records, who provided the facility policies listed above and verified there was no date on the H&P and stated the form was a facility form kept in the Operating Room Department.

2. MR # 8 was admitted for a Right Total Knee Arthroplasty on 6/27/16.

Review of the Consent for Operation or Other Procedure revealed the section was blank and did not indicate if the patient consented or not to the transfusion of blood and blood products on page 1 of 2 pages.

Review of the Anesthesia Consent form revealed there was no date and time the patient signed the consent.

An interview was conducted on 7/12/16 at 2:00 PM with Employee Identifier # 5, Director of Speciality Services, who confirmed the findings for MR # 8.

Based on observations, medical record review and interview, it was determined the facility failed to ensure the patients received the amount of Acetylcysteine ordered by the physician for 2 of 2 respiratory treatments observed. This included Medical Record (MR) #s 37 and 36 and had the potential to effect all patients served by this facility.

Findings include:

1. MR # 37 was admitted to the facility on 6/28/16 with diagnoses including Acute and Chronic Respiratory Failure.

An observation of a respiratory treatment was conducted on 7/12/16 at 10:50 AM with Employee Identifier (EI) # 7, Respiratory Therapist. EI # 7 went to the medication room and obtained a 4 ml (milliliter) vial of Acetylcysteine 20%, which contained 200 mg (milligrams) per ml with a total of 800 mg per 4 ml vial. EI # 7 then withdrew 1 ml of Acetylcysteine 20%. The surveyor asked EI # 7 what would she do with the remaining 3 ml and the response was, "Throw it away in the biohazard container in the patient's room."

EI # 7 entered the patient's room and administered the Acetylcysteine 20%, 1 ml to the patient in a nebulizer treatment.

Review of the physician's orders dated for 7/12/16 revealed an order for Acetylcysteine 20%, 800 mg and not the 200 mg that was administered.

Review of the Medication Administration Record (MAR) dated 7/12/16 at 10:56 revealed documentation EI # 7 administered 800 mg (4 ml) of Acetylcysteine 20% and not the 200 mg that was administered.

2. MR # 36 was admitted to the facility on 7/1/16 with diagnoses including Acute Respiratory Failure on a Ventilator.

An observation of a respiratory treatment was conducted on 7/12/16 at 11:15 AM with EI # 7. EI # 7 went to the medication room and obtained a 4 ml vial of Acetylcysteine 20%, which contained 200 mg per ml with a total of 800 mg per 4 ml vial. EI # 7 then withdrew 1 ml of Acetylcysteine 20%. The surveyor asked EI # 7 what would she do with the remaining 3 ml and the response was, "Throw it away in the biohazard container in the patient's room."

EI # 7 entered the patient's room and administered the Acetylcysteine 20%, 1 ml to the patient in a nebulizer treatment.

Review of the physician's orders dated for 7/12/16 revealed an order for Acetylcysteine 20%, 800 mg and not the 200 mg that was administered.

Review of the MAR dated 7/12/16 at 11:9 revealed documentation EI # 7 administered 800 mg (4 ml) of Acetylcysteine 20% and not the 200 mg that was administered.

An interview was conducted on 7/12/16 at 2:00 PM with EI # 5, Director of Speciality Services who verified the above findings.

Based on observations and interview the hospital failed to assure the dietary department was operated in a sanitary manner. During the survey hospital staff failed to store dishes clean and dry, remove expired items from the refrigerator, date and label opened food items stored in the refrigerator, obtain and document temperatures of all food items on the tray line prior to plating breakfast for patients and assure all hot food items were served at the proper temperature. This had the potential to affect all patients served.

Findings include:

During a tour of the dietary department on 7/11/16 at 1:05 PM with Employee Identifier (EI) # 1, Dietary Manager, the following opened and used items were observed in the walk in refrigerator without a date and/or label:

White cheese - one package
Casa Solana Salsa - two bottles
Kikkoman Teriyaki Sauce - two, one gallon bottles
Ziploc bag with cooked brown meat item - one bag

During this same tour the surveyor and EI # 1 identified 14 pots and pans that were stored in the clean storage area wet nested and/or not thoroughly cleaned - greasy to touch or with visible food items inside. In addition to the the pots and pans there were 2 full and half sheet baking pans that were stored wet nested and greasy to touch.

On 7/12/16 at 7:40 AM, the surveyor observed breakfast trayline for delivery to patients. Dietary staff were observed plating breakfast food items. The surveyor requested the documentation of where the dietary staff obtained the food temperatures. EI # 1 obtained a log from the bulletin board, but there was no documented temperatures on the log for the 16 patient breakfast food trays that were loaded on the cart to carry to the floor for serving. Dietary staff stopped trayline and obtained food temperatures and documented the temperatures on the trayline food temperature log and continued trayline. The surveyor asked EI # 1 what the temperature of the breakfast meat was and confirmed the temperature reading was 120 degrees Fahrenheit (F).

On 7/13/16 at 9:25 AM, in an interview with EI # 2, Registered Dietitian (RD), EI # 2 confirmed food temperatures should be taken before trayline is started, hot food items such as meat should be at least 135 degrees F when serving and pots and pans should not be stored wet and unclean. During the interview EI# 2 was asked if she conducted sanitation reviews of the dietary department and stated that was not something she did, but the other RD had in the past.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by the hospital.

Findings include:

Refer to Life Safety Code violations for findings.

Based on observations, review of facility policy and interviews with facility staff it was determined the facility failed to provide preventative maintenance on all equipment as directed per the facility policy.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Maintenance Management Strategies Policy
Revision Date: 2/9/16

Policy: It is the policy of South Baldwin Regional Medical Center and it clinics to identify the activities in writing for maintaining, inspecting and testing for all medical equipment on the inventory...

All medical equipment used for treatment, diagnosis, monitoring and care of patients, operated within or by...must pass an inspection for safety, performance and compliance with the manufacture's specifications prior to use with patients.

A tour of the Labor and Delivery Rooms was conducted on 7/11/16 at 12:20 PM with Employee Identifier (EI) # 3, Director of OB/Nursery and Pediatrics. The following equipment was observed in the following rooms with no documentation of Preventative Maintenance (PM):

Room 235 - Delivery Lamp
Room 231 - Delivery Lamp
Room 230 - Fetal Heart Rate Monitor

An interview was conducted on 7/11/16 at 12:45 PM with EI # 3, who verified the above findings.

Based on observations, review of the facility policies and procedures, Centers for Medicare and Medicaid (CDC) standards and interviews, it was determined the facility failed to ensure the staff:

a) Followed and performed hand hygiene and gloving per the facility policy and procedure.

b) Followed the facility policy and procedure for cleaning of equipment after use.

c) Wore appropriate personal protective equipment (PPE) when caring for patients in contact isolation.

This had the potential to negatively affect all patients served by this hospital.

Findings include:

Facility Policy/Procedure: Contact Isolation
Policy/Procedure #: 3.103
Approval Date: 10/02

Introduction: In addition to Standard Precautions, Contact Precautions are to be used for patients known or suspected to be infected, or colonized with epidemiologically important microorganisms. These microorganisms can be transmitted by direct contact with the patient, or through indirect contact with the patient's environment.

Policy:

I. In order to reduce the risk of transmission of microorganisms, Contact Precautions will be routinely practiced by all...personnel whenever indicated...

Specific Requirements

II. Use of Personal Protective Equipment (PPE)

A. Gloves
1. Wear gloves whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails).
2. Don gloves upon entry into room or cubicle.

B. Gowns
1. Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient.
2. Don gown upon entry into the room or cubicle.

************

Facility Policy/Procedure: Hand Hygiene
Policy/Procedure #: 2.100
Approval Date: 10/02

I. Introduction:

Hand hygiene is considered the single most important procedure for preventing healthcare associated infections. Bacteria are easily spread in the hospital environment from patient to patient via hands of healthcare workers...

II. Purpose:

The purpose of hand hygiene is to remove dirt, organic materials, and transient microorganisms or to reduce resident flora. Hand hygiene is only part of a comprehensive approach to providing the patient with a sanitary environment, thus reducing the risk of infection.

B. Indications for hand hygiene:

4. After contact with inanimate environmental sources likely to be contaminated.
5. After contact with all patients and equipment.
6. After removing gloves.

C. Technique for hand washing:

6. Rinse under running water.
7. Use a paper towel, or single-use cloth towel to dry hands.
8. Avoid recontamination of hands on sink components after washing by using a paper towel to turn off faucets.

G. Other aspects of hand care and protection (glove use).

1. Gloves should be used as an adjunct, not a substitute for hand hygiene.
2. Gloves should be changed, and hand hygiene performed after using gloves for contaminated activities.
3. Gloves should be changed when caring for a single patient when moving from one procedure to another.

************
CDC Guidelines for Injection Safety
CDC. org

IV. Standard Precautions

Injection Safety

Medication Storage and Handling
Cleaning and Disinfection of Devices and Environmental Surfaces

D. Injection Safety

Injection safety refers to the proper use and handling of supplies for administering injections and infusions (e.g., syringes, needles, fingerstick devices, intravenous tubing, medication vials, and parenteral solutions). These practices are intended to prevent transmission of infectious diseases between one patient and another, or between a patient and healthcare personnel during preparation and administration of parenteral medications...

1. General Safe Injection Practices

...Cleanse the access diaphragms of medication vials with 70% alcohol and allow the alcohol to dry before inserting a device into the vial.

1. An observation of care was conducted on 7/12/16 at 7:45 AM. The surveyor observed Employee Identifier (EI) # 15, Director of the Intensive Care Unit (ICU) in room # 3, which was under contact isolation, at the mediation pump without a gown or gloves resetting the pumps.

2. An observation of care and medication pass was conducted on 7/12/16 at 7:50 AM with Employee Identifier (EI) # 6, Intensive Care Unit (ICU) Registered Nurse (RN) # 1. EI # 6 was preparing medications for an unsampled patient who was on a ventilator, had a nasogastric (NG) tube, and a foley catheter.

EI # 6 donned gloves to remove medication from a blister package. EI # 6 then removed the gloves and began crushing the pills without first performing hand hygiene after removing the gloves.

EI # 6 entered the patient's ICU room, donned gloves, assessed the patient's breath sounds and bowel sounds, turned the water on at the faucet with a gloved hand, mixed the crushed medication with the water in a 60 cc (cubic centimeter) syringe, assessed the placement of the NG tube, placed the tip of a gloved finger (same gloved used to turn on the faucet) over the spout of the 60 cc syringe to mix the water and medication and administered the medication using the same 60 cc syringe. EI # 6 did not change gloves during the above process.

With the same pair of gloves on, EI # 6 then obtain the bottle of Antimicrobial Cleanser from the patient's bedside table and sprayed around the foley catheter at the penis area and used a bath wipe to perform catheter care.

Without changing gloves EI # 6 began suctioning the patient's Endotracheal tube using a suction catheter and then used a yankauer to suction the patient's oral cavity. EI # 6 then went to the computer in the ICU room and began typing with the same pair of gloves.

EI # 6 removed the gloves and washed hands with soap and water. EI # 6 turned the faucet off with the clean hands without using paper towel.

3. An observation was conducted on 7/12/16 at 8:05 AM on the Medical Surgical Unit to observe the EI # 11, Staff Nurse administer oral medication to an unsampled patient. EI # 11 failed to perform hand hygiene prior to obtaining medicine from the Pyxis Medication Dispenser.
EI # 11 rolled the rolling patient chart stand into the patient room to administer the medication. After the medicine was administered, EI # 11 rolled the rolling chart stand out of the patient's room into the nursing station without decontaminating the rolling chart cart.

An interview was conducted on 7/12/16 at 1:40 PM with EI # 10, who verified the above findings.

4. An observation of an intravenous medication administration was conducted on 7/12/16 at 8:40 AM with EI # 9, ICU RN # 2. EI # 9 obtain a vial of Morphine Sulfate (MS) 4 mg (milligram), removed the top and inserted a needle into the septum without disinfecting with alcohol first.

5. An observation of care was conducted on 7/12/16 between 9:00 and 9:25 AM in the Outpatient Therapy Department. The surveyor observed multiple Licensed Physical Therapy Assistants (LPTA) and Physical Therapist (PT) perform therapy to multiple patients. The LPTAs and PT were observed donning and removing gloves numerous times without hand hygiene after removing the gloves. The LPTAs and PTs were also observed going from computer to computer with out hand hygiene.

An interview was conducted with EI # 10, Infection Control Officer on 7/12/16 at 9:20 AM who verified the staff were to perform hand hygiene after each glove removal.

Based on review of the medical records (MR), facility policy and interviews with the staff, it was determined the facility failed to ensure the staff initiated a Plan of Care for each patient on a ventilator. This affected 1 of 1 medical records reviewed with a patient on a ventilator including, MR # 6 and had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy: Interdisciplinary Plans of Care Policy
Revision Date; 7/30/14

1. Introduction:

The Interdisciplinary Plan of Care provides the framework for coordinating communication of the health care team. The purpose is to facilitate optimal health during the admission and to guide the post discharge care and education of the patient/family/caregiver.

3. Procedure:

c. The plan of care documentation will be updated/reviewed at a minimum of every 24 hours as either met or not met; done or not done by nursing or therapist related to their actions completed or not completed throughout the shift...

d. Updating of IPOCs (Interdisciplinary Plan of Care) will be required to be completed every 8-12 hours or as directed according to the facility policy or within the E.H.R. (Electronic Health Record) system.

1. MR # 6 was admitted to the facility on 7/6/16 with diagnoses including Lower Gastrointestinal Bleed. The patient under went a Colonoscopy with a Perforated Cecum on 7/8/16. The patient suffered Respiratory Failure and was placed on a ventilator.

Review of the medical record on 7/12/16 at 2:00 PM revealed no documentation of an IPOC for a ventilator. The surveyor asked Employee Identifier (EI) # 14, Registered Nurse if there was a IPOC for a ventilator in the patient's record and the response was, "No."

Based on facility policies and procedures, review of medical records (MR) and interview with staff it was determined the facility failed to follow its own policies requiring:

a) All medical record entries to be complete, dated and timed.

b) A medical history and physical examination (H&P) be completed and documented within 24 hours prior to surgery.

This affected 2 of 32 records reviewed including MR # 9 and MR # 8, and had the potential to affect all patients served by the facility.

Findings include:

"Policy Title: Content of the Medical Record
Revision Date: 12/14/2015

I. Purpose:

To define the contents of patient medical records, whether in paper or electronic format, in such a way that it facilitates communication, coordination and continuity of care and promotes efficiency and effectiveness of treatment.

III. Procedure

A. All medical record entries, including handwritten and electronic, must be legible, complete, true and accurate, dated, timed and authenticated by the person responsible for providing or evaluating the services provided...

F. The medical record contains the following information as needed to provide care, treatment and services...

b) Any informed consent"


"Policy Title: History and Physical Content Management
Revision Date: 1/29/2015

II. Policy:

1. A medical history and physical examination (H&P) must be completed and documented within 24 hours following admission or prior to surgery, whichever comes first.

2. An H&P performed prior to admission (within 30 days of admission) may be accepted...An update to the H&P must be completed and documented within 24 hours after admission or prior to surgery / procedure when utilizing such an H&P.


1. MR # 9 was admitted for outpatient Robotic Laparoscopic Hysterectomy on 4/12/16.

Review of the MR revealed the History and Physical was signed by the physician but not dated therefore the surveyor could not determine if the H&P was completed within 24 hours of the surgery per the facility policy.

An interview was conducted on 7/13/16 at 10:30 AM with Employee Identifier (EI) # 8, Director of Medical Records, who provided the facility policies listed above and verified there was no date on the H&P and stated the form was a facility form kept in the Operating Room Department.

2. MR # 8 was admitted for a Right Total Knee Arthroplasty on 6/27/16.

Review of the Consent for Operation or Other Procedure revealed the section was blank and did not indicate if the patient consented or not to the transfusion of blood and blood products on page 1 of 2 pages.

Review of the Anesthesia Consent form revealed there was no date and time the patient signed the consent.

An interview was conducted on 7/12/16 at 2:00 PM with Employee Identifier # 5, Director of Speciality Services, who confirmed the findings for MR # 8.

Based on observations, medical record review and interview, it was determined the facility failed to ensure the patients received the amount of Acetylcysteine ordered by the physician for 2 of 2 respiratory treatments observed. This included Medical Record (MR) #s 37 and 36 and had the potential to effect all patients served by this facility.

Findings include:

1. MR # 37 was admitted to the facility on 6/28/16 with diagnoses including Acute and Chronic Respiratory Failure.

An observation of a respiratory treatment was conducted on 7/12/16 at 10:50 AM with Employee Identifier (EI) # 7, Respiratory Therapist. EI # 7 went to the medication room and obtained a 4 ml (milliliter) vial of Acetylcysteine 20%, which contained 200 mg (milligrams) per ml with a total of 800 mg per 4 ml vial. EI # 7 then withdrew 1 ml of Acetylcysteine 20%. The surveyor asked EI # 7 what would she do with the remaining 3 ml and the response was, "Throw it away in the biohazard container in the patient's room."

EI # 7 entered the patient's room and administered the Acetylcysteine 20%, 1 ml to the patient in a nebulizer treatment.

Review of the physician's orders dated for 7/12/16 revealed an order for Acetylcysteine 20%, 800 mg and not the 200 mg that was administered.

Review of the Medication Administration Record (MAR) dated 7/12/16 at 10:56 revealed documentation EI # 7 administered 800 mg (4 ml) of Acetylcysteine 20% and not the 200 mg that was administered.

2. MR # 36 was admitted to the facility on 7/1/16 with diagnoses including Acute Respiratory Failure on a Ventilator.

An observation of a respiratory treatment was conducted on 7/12/16 at 11:15 AM with EI # 7. EI # 7 went to the medication room and obtained a 4 ml vial of Acetylcysteine 20%, which contained 200 mg per ml with a total of 800 mg per 4 ml vial. EI # 7 then withdrew 1 ml of Acetylcysteine 20%. The surveyor asked EI # 7 what would she do with the remaining 3 ml and the response was, "Throw it away in the biohazard container in the patient's room."

EI # 7 entered the patient's room and administered the Acetylcysteine 20%, 1 ml to the patient in a nebulizer treatment.

Review of the physician's orders dated for 7/12/16 revealed an order for Acetylcysteine 20%, 800 mg and not the 200 mg that was administered.

Review of the MAR dated 7/12/16 at 11:9 revealed documentation EI # 7 administered 800 mg (4 ml) of Acetylcysteine 20% and not the 200 mg that was administered.

An interview was conducted on 7/12/16 at 2:00 PM with EI # 5, Director of Speciality Services who verified the above findings.

Based on observations and interview the hospital failed to assure the dietary department was operated in a sanitary manner. During the survey hospital staff failed to store dishes clean and dry, remove expired items from the refrigerator, date and label opened food items stored in the refrigerator, obtain and document temperatures of all food items on the tray line prior to plating breakfast for patients and assure all hot food items were served at the proper temperature. This had the potential to affect all patients served.

Findings include:

During a tour of the dietary department on 7/11/16 at 1:05 PM with Employee Identifier (EI) # 1, Dietary Manager, the following opened and used items were observed in the walk in refrigerator without a date and/or label:

White cheese - one package
Casa Solana Salsa - two bottles
Kikkoman Teriyaki Sauce - two, one gallon bottles
Ziploc bag with cooked brown meat item - one bag

During this same tour the surveyor and EI # 1 identified 14 pots and pans that were stored in the clean storage area wet nested and/or not thoroughly cleaned - greasy to touch or with visible food items inside. In addition to the the pots and pans there were 2 full and half sheet baking pans that were stored wet nested and greasy to touch.

On 7/12/16 at 7:40 AM, the surveyor observed breakfast trayline for delivery to patients. Dietary staff were observed plating breakfast food items. The surveyor requested the documentation of where the dietary staff obtained the food temperatures. EI # 1 obtained a log from the bulletin board, but there was no documented temperatures on the log for the 16 patient breakfast food trays that were loaded on the cart to carry to the floor for serving. Dietary staff stopped trayline and obtained food temperatures and documented the temperatures on the trayline food temperature log and continued trayline. The surveyor asked EI # 1 what the temperature of the breakfast meat was and confirmed the temperature reading was 120 degrees Fahrenheit (F).

On 7/13/16 at 9:25 AM, in an interview with EI # 2, Registered Dietitian (RD), EI # 2 confirmed food temperatures should be taken before trayline is started, hot food items such as meat should be at least 135 degrees F when serving and pots and pans should not be stored wet and unclean. During the interview EI# 2 was asked if she conducted sanitation reviews of the dietary department and stated that was not something she did, but the other RD had in the past.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by the hospital.

Findings include:

Refer to Life Safety Code violations for findings.

Based on observations, review of facility policy and interviews with facility staff it was determined the facility failed to provide preventative maintenance on all equipment as directed per the facility policy.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Maintenance Management Strategies Policy
Revision Date: 2/9/16

Policy: It is the policy of South Baldwin Regional Medical Center and it clinics to identify the activities in writing for maintaining, inspecting and testing for all medical equipment on the inventory...

All medical equipment used for treatment, diagnosis, monitoring and care of patients, operated within or by...must pass an inspection for safety, performance and compliance with the manufacture's specifications prior to use with patients.

A tour of the Labor and Delivery Rooms was conducted on 7/11/16 at 12:20 PM with Employee Identifier (EI) # 3, Director of OB/Nursery and Pediatrics. The following equipment was observed in the following rooms with no documentation of Preventative Maintenance (PM):

Room 235 - Delivery Lamp
Room 231 - Delivery Lamp
Room 230 - Fetal Heart Rate Monitor

An interview was conducted on 7/11/16 at 12:45 PM with EI # 3, who verified the above findings.

Based on observations, review of the facility policies and procedures, Centers for Medicare and Medicaid (CDC) standards and interviews, it was determined the facility failed to ensure the staff:

a) Followed and performed hand hygiene and gloving per the facility policy and procedure.

b) Followed the facility policy and procedure for cleaning of equipment after use.

c) Wore appropriate personal protective equipment (PPE) when caring for patients in contact isolation.

This had the potential to negatively affect all patients served by this hospital.

Findings include:

Facility Policy/Procedure: Contact Isolation
Policy/Procedure #: 3.103
Approval Date: 10/02

Introduction: In addition to Standard Precautions, Contact Precautions are to be used for patients known or suspected to be infected, or colonized with epidemiologically important microorganisms. These microorganisms can be transmitted by direct contact with the patient, or through indirect contact with the patient's environment.

Policy:

I. In order to reduce the risk of transmission of microorganisms, Contact Precautions will be routinely practiced by all...personnel whenever indicated...

Specific Requirements

II. Use of Personal Protective Equipment (PPE)

A. Gloves
1. Wear gloves whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails).
2. Don gloves upon entry into room or cubicle.

B. Gowns
1. Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient.
2. Don gown upon entry into the room or cubicle.

************

Facility Policy/Procedure: Hand Hygiene
Policy/Procedure #: 2.100
Approval Date: 10/02

I. Introduction:

Hand hygiene is considered the single most important procedure for preventing healthcare associated infections. Bacteria are easily spread in the hospital environment from patient to patient via hands of healthcare workers...

II. Purpose:

The purpose of hand hygiene is to remove dirt, organic materials, and transient microorganisms or to reduce resident flora. Hand hygiene is only part of a comprehensive approach to providing the patient with a sanitary environment, thus reducing the risk of infection.

B. Indications for hand hygiene:

4. After contact with inanimate environmental sources likely to be contaminated.
5. After contact with all patients and equipment.
6. After removing gloves.

C. Technique for hand washing:

6. Rinse under running water.
7. Use a paper towel, or single-use cloth towel to dry hands.
8. Avoid recontamination of hands on sink components after washing by using a paper towel to turn off faucets.

G. Other aspects of hand care and protection (glove use).

1. Gloves should be used as an adjunct, not a substitute for hand hygiene.
2. Gloves should be changed, and hand hygiene performed after using gloves for contaminated activities.
3. Gloves should be changed when caring for a single patient when moving from one procedure to another.

************
CDC Guidelines for Injection Safety
CDC. org

IV. Standard Precautions

Injection Safety

Medication Storage and Handling
Cleaning and Disinfection of Devices and Environmental Surfaces

D. Injection Safety

Injection safety refers to the proper use and handling of supplies for administering injections and infusions (e.g., syringes, needles, fingerstick devices, intravenous tubing, medication vials, and parenteral solutions). These practices are intended to prevent transmission of infectious diseases between one patient and another, or between a patient and healthcare personnel during preparation and administration of parenteral medications...

1. General Safe Injection Practices

...Cleanse the access diaphragms of medication vials with 70% alcohol and allow the alcohol to dry before inserting a device into the vial.

1. An observation of care was conducted on 7/12/16 at 7:45 AM. The surveyor observed Employee Identifier (EI) # 15, Director of the Intensive Care Unit (ICU) in room # 3, which was under contact isolation, at the mediation pump without a gown or gloves resetting the pumps.

2. An observation of care and medication pass was conducted on 7/12/16 at 7:50 AM with Employee Identifier (EI) # 6, Intensive Care Unit (ICU) Registered Nurse (RN) # 1. EI # 6 was preparing medications for an unsampled patient who was on a ventilator, had a nasogastric (NG) tube, and a foley catheter.

EI # 6 donned gloves to remove medication from a blister package. EI # 6 then removed the gloves and began crushing the pills without first performing hand hygiene after removing the gloves.

EI # 6 entered the patient's ICU room, donned gloves, assessed the patient's breath sounds and bowel sounds, turned the water on at the faucet with a gloved hand, mixed the crushed medication with the water in a 60 cc (cubic centimeter) syringe, assessed the placement of the NG tube, placed the tip of a gloved finger (same gloved used to turn on the faucet) over the spout of the 60 cc syringe to mix the water and medication and administered the medication using the same 60 cc syringe. EI # 6 did not change gloves during the above process.

With the same pair of gloves on, EI # 6 then obtain the bottle of Antimicrobial Cleanser from the patient's bedside table and sprayed around the foley catheter at the penis area and used a bath wipe to perform catheter care.

Without changing gloves EI # 6 began suctioning the patient's Endotracheal tube using a suction catheter and then used a yankauer to suction the patient's oral cavity. EI # 6 then went to the computer in the ICU room and began typing with the same pair of gloves.

EI # 6 removed the gloves and washed hands with soap and water. EI # 6 turned the faucet off with the clean hands without using paper towel.

3. An observation was conducted on 7/12/16 at 8:05 AM on the Medical Surgical Unit to observe the EI # 11, Staff Nurse administer oral medication to an unsampled patient. EI # 11 failed to perform hand hygiene prior to obtaining medicine from the Pyxis Medication Dispenser.
EI # 11 rolled the rolling patient chart stand into the patient room to administer the medication. After the medicine was administered, EI # 11 rolled the rolling chart stand out of the patient's room into the nursing station without decontaminating the rolling chart cart.

An interview was conducted on 7/12/16 at 1:40 PM with EI # 10, who verified the above findings.

4. An observation of an intravenous medication administration was conducted on 7/12/16 at 8:40 AM with EI # 9, ICU RN # 2. EI # 9 obtain a vial of Morphine Sulfate (MS) 4 mg (milligram), removed the top and inserted a needle into the septum without disinfecting with alcohol first.

5. An observation of care was conducted on 7/12/16 between 9:00 and 9:25 AM in the Outpatient Therapy Department. The surveyor observed multiple Licensed Physical Therapy Assistants (LPTA) and Physical Therapist (PT) perform therapy to multiple patients. The LPTAs and PT were observed donning and removing gloves numerous times without hand hygiene after removing the gloves. The LPTAs and PTs were also observed going from computer to computer with out hand hygiene.

An interview was conducted with EI # 10, Infection Control Officer on 7/12/16 at 9:20 AM who verified the staff were to perform hand hygiene after each glove removal.