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Based on observation and interview, it was determined the facility failed to follow standards of practice in the organization of Pharmaceutical Services in that unlicensed personnel had access to the anesthesia medications in two of two (Room #4 and Room #5) Anesthesia Carts observed. By not assuring only licensed personnel have access to the medications, the facility could not assure the safety, integrity, or efficacy of the medications. The failed practice had the potential to affect all patients that were admitted into the facility for procedures. Findings follow:

A. Review of Arkansas Rules for Hospital and Related Institutions Section 12.S.2 showed access to medications shall be limited to licensed personnel at all times.
B. During a tour of Surgical Services on 11/15/23 from 1:50 PM to 3:00 PM, observation showed the Anesthesia Tech (non-licensed personnel) entered both room #4 and room #5 with the anesthesia cart keys and opened both carts for inspection of the anesthesia medications.
C. During an interview on 11/15/23 at 2:24, The Clinical Director of O.R. (Operating Room) verified the findings at B.

Based on observation, review of Manufacturer's package inserts and interview, it was determined the facility failed to date Succinylcholine and Rocuronium when removed from refrigerated storage on two of two (Room #4 and Room #5) anesthesia carts observed. By not dating the medications once removed from the refrigerator, the facility could not assure the medications wouldn't still be available for patient use beyond the Manufacturer's recommended expired date. The failed practice had the likelihood to affect all patients admitted for surgical procedures. Findings follow:

A. During a tour of Surgical Services on 11/15/2023 from 1:50 PM to 3:00 PM, the following were observed not dated with the day they were removed from refrigerated storage, nor a date when it was recommended they not be used:
1) Room #4's Anesthesia Cart contained #3 vials of Succinylcholine 200 mg (milligram)/ 10 ml (milliliter) and #3 vials of Rocuronium 50 mg/ 5 ml; and
2) Room #5's Anesthesia Cart contained #1 vial of Succinylcholine 200 mg / 10 ml and #1 vial of Rocuronium 50 mg/ 5 ml;

B. Review of the package insert for Succinylcholine showed "The multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency".

C. Review of the package insert for the Rocuronium showed "Upon removing from refrigerator to room temperature, use within 60 days".

D. During an interview on 11/15/23 at 2:44, the Clinical Director of O.R. (Operating Room) verified the finding at A.

Based on observation of the kitchen, Fourth Floor and Labor and Delivery and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of infection and/or placed the patients at risk of fire. The failed practice had the likelihood to affect all patients, staff and visitors, Finding follow:

A. Observation of the kitchen on 11/14/23 at 2:18 PM showed rusted and peeling air vents over food.

B. Observation of patient Room #1418 on 11/13/23 at 1:07 PM showed a broken and chipped door.

C. Observation of the Labor and Delivery Suite on 11/13/23 at 2:27 PM showed a broken sprinkler head incusion in the storage closet.

D. Observation of the Labor and Delivery Suite on 11/13/23 at 2:17 PM showed that all exhaust fans in the labor and delivery suit were dirty.

E. Observation of the Critical Care Unit on 11/13/2023 at 3:12 PM showed the floors were dirty.

F. Observation of the Kitchen on 11/14/2023 at 1:07 PM showed the floors were dirty.

G. Observation of the Kitchen on 11/14/2023 at 1:08 PM showed a large penetration in the wall above the shelving that housed the fountain drinks and also showed a broken door frame leading into the pantry.

H. Observation throughout the hospital on 11/13/2023 showed electrical panels were unlocked and opened.

I. Observation of the storage room on the fourth floor on 11/13/2023 at 1:56 PM showed dead roaches on the floor.

J. Observation of Operating Room #7 on 11/14/2023 at 3:12 PM showed an electrical panel was blocked by equipment.

K. The above findings were verified by the Maintenance Director on 11/13/23 at 3:23 PM



Based on above ceiling observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure that the facility was maintained in a manner to ensure the safety and well-being of patients in that one of two fire barrier walls was not sealed in one location with fire-proof sealant. The failed practice placed the patients at risk of fire or smoke spreading had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA 101, 12.9.6.2 showed penetrations for conduits that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, shall be protected by a system or material capable of restricting the transfer of smoke.

B. Observations of above ceiling in the corridor in the Radiology hallway on 11/14/23 at 12:20 PM, showed a fire wall penetration. In addition to this it was noted that the incorrect fire protection foam was used.

C. The above findings were verified on 11/15/2023 at 12:20 PM by the Maintenance Director.



Based on observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure that the fire rated doors were maintained in a manner to ensure the safety and well-being of patients in that the fire rated door closer was placed on the incorrect side of the door when closed in the Psychiatric Unit. The failed practice did not ensure the safety of psychiatric unit patients and had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Observation of the adolescent psychiatric unit on 11/16/2023 at 10:12 AM showed the door closer facing was on the side leading into the common room.

B. This finding was verified with the Maintenance Director on 11/16/2023 at 10:12 AM.

Based on observation, review of National Fire Protection Agency (NFPA) 101 standards and interview, it was determined the facility failed to provide battery-powered emergency lighting as required by NFPA 101, 2012 edition. The failed practice had the likelihood to affect all patients and staff in that in the event of a power outage emergency there would be no lighting to illuminate the work area and had the likelihood to affect all patients undergoing procedures. Findings follow:

A. Observation on 11/14/23 at 1:15 PM showed that there were no battery powered emergency lights provided in 2 of 2 outside generators.

B. The finding in A was verified with the Maintenance Director on 11/15/2023 at 1:15 PM.

Based on observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure an emergency stop switch was installed on the generators. The failed practice did not ensure the facility had the means of stopping the generators in the event of an emergency. The failed practice had the likelihood to affect all patients, staff and visitors. Findings follow:

A. Observation of the generators on 11/15/2023 at 3:04 PM showed there was no emergency stop switch installed 10-15 feet away from the generators.

B. The finding in A were verified by the Director of Maintenance on 11/16/2023 at 3:04 PM.



Based on observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure safety from fire in that that there were boxes on the floor of a dirty linen closet. The failed practice placed the patients at risk of fire and had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Observation of the Labor and Delivery Suite on 11/13/2023 at 2:52 PM showed boxes were stacked on the floor in a dirty linen closet.

B. The finding in A was verified by the maintenance director on 11/13/2023 at 2:52 PM.



Based on observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure that temperature tray warmers in the kitchen were at the established temperatures. The failed practice placed the patients at risk of food-borne pathogens and had the likelihood to affect all patients. Findings follow:

A. Review of NFPA 86 standars, referred by NFPA 101 2015 edition, showed that tray warmer temps must not exceed 150 degrees

B. Observation of the kitchen on 11/15/2023 at 1:07 PM showed a food tray warmer with a thermostat reading of 199 degrees Fahrenheit.

C. The finding in A was verified by the Director of Maintenance on 11/15/2023 at 1:08 PM.

Based on observation and interview, it was determined the facility failed to ensure the sprinkler heads were maintained to disperse water effectively in the event of a fire in the Labor and Delivery Unit. The failed practice placed the patients at risk of harm from fire and had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Observation of the Labor and Delivery Unit on 11/15/2023 at 2:17 PM showed the sprinkler heads in the storage closets were blocked in that the tops of the storage cabinets were slanted which prevented water from reaching the shelving in the event of a fire.

B. The findings of A were confirmed in an interview with the Maintenance Director on 11/15/2023 at 2:17 PM.

Based on policy and procedure review and interview, it was determined the facility failed to conduct an infrared breaker check on an annual basis. the failed practice had the likelihood to affect all patients and staff in the even of an emergency. Findings Follow:

A. Review of NFPA 70E standars, referred by NFPA 101 2015 edition, showed infrared inspections of the electrical distribution systems must be conducted on an annual basis

B. Review of the facility's policy and procedures on 11/15/23 showed the facility was to maintain an annual Infrared breaker check.

C. A request was made on 11/15/2023 at 4:15 PM for evidence of electrical panel infrared testing. In an interview with the Director of Maintenance on 11/15/23 at 4:15 PM, the Director of Maintenance stated the facility had not conducted electrical panel infrared testing.


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Based on observation, review of manufacturer's recommendations, and interview it was determined the facility failed to ensure the accuracy of four of four (Emergency Department, Critical Care Unit, Medical Surgical, New Life) glucometers by not writing the expiration date on glucose controls and test strips. The failed practice did not ensure the glucose test results were accurate beyond the expiration date and had the likelihood to affect all patients requiring blood glucose tests. Findings follow:

A. Review of the facility's policy titled, "Accu-Chek Inform II Bedside Glucose Testing," dated May 2016, showed Accu-Check Inform II control solutions expire on the date printed on the vial label or three months from opening, whichever came first. When an operator opens a vial of controls they must handwrite the expiration date on the vial, which would be three months from opening or the printed vial label. Review of the manufacturer's instructions for use for the Accu-Chek Inform II Control Solutions showed the solutions expire three months after opening and should be marked as such.
B. Observation on 11/13/2023 at 1:20 PM showed Accu-check Inform II control solutions and strips, Level I and II in the Emergency Department were not dated to show the three-month expiration date after opening. The finding was verified by Assistant Vice President of Medical Services at the time of observation.
C. Observation on 11/13/2023 at 1:44 PM showed Accu-check Inform II control solutions and strips, Level I and II in the Medical Surgical floor were not dated to show the three-month expiration date after opening. The finding was verified by Assistant Vice President of Medical Services at the time of observation.
D. Observation on 11/13/2023 at 2:34 PM showed Accu-check Inform II control solutions and strips, Level I and II in the New Life unit were not dated to show the three-month expiration date after opening. The finding was verified by Assistant Vice President of Medical Services at the time of observation.
E. Observation on 11/13/2023 at 2:49 PM showed Accu-check Inform II control solutions and strips, Level I and II in the Critical Care Unit were not dated to show the three-month expiration date after opening. The finding was verified by Assistant Vice President of Medical Services at the time of observation.

Based on observation and interview, it was determined the Infection Control Supervisor failed to identify and control infections in that five of five laryngoscope blades were found to be unwrapped in an airway tray found on Cardiopulmonary Departments desk and five of five laryngoscope blades were found to be unwrapped in the airway tray in the Radiology Crash Care. The failed practice did not ensure the equipment remained clean or sterilized and stored in a manner to ensure protection or contamination. The failed practice had the likelihood to affect all patients who needed the use of a laryngoscope for intubation. Findings follow:

A. During tour of the Cardiopulmonary Department on 11/15/2023 at 2:15 PM, five of five laryngoscope blades were found to be unwrapped in an airway tray for crash carts on the Cardiopulmonary Department desk.
B. The findings in A were verified with the Director of Cardiopulmonary on 11/15/2023 at 2:15 PM.
C. During tour of the Radiology Department on 11/16/2023 at 9:05 AM, five of five laryngoscope blades were found to be unwrapped in the airway tray of the department's crash cart.
D. The findings of B were verified with Director of Radiology on 11/16/2023 at 9:05 AM.


Based on observation and interview, it was determined Infection Control Supervisor failed to identify and control infections in that in the Department's Pulmonary Function Test room there was a drawer containing numerous "T" pieces for use in the Pulmonary Function Testing machine. The "T" pieces were unwrapped and unprotected from infectious material. This failed practice did not ensure the equipment remained clean and stored in a manner to ensure protection from contamination. The failed practice had the likelihood to affect all patients undergoing Pulmonary Function Testing at the facility. Findings follow:

A. During tour of the Cardiopulmonary Department on 11/15/2023 2:25 PM, it was observed that there were many "T" pieces unwrapped and unprotected in the drawer in the Pulmonary Function Testing room.
B. Findings in A were verified with the Director of Cardiopulmonary on 11/15/2023 at 2:25 PM.



Based on review of policy, observation and interviews it was determined the Infection Control Supervisor failed to ensure infection prevention and control in the Surgical Services Department in that surgical staff were allowed to home launder their surgical scrubs. Failure to perform surveillance activities to assure staff compliance with infection control prevention policies for home laundered scrubs did not ensure patients and staff would be protected from bloodborne pathogens or other infectious materials. The failed practice had the likelihood to affect all surgical patients and staff. The findings follow:

A. Review of the policy and procedure titled "Surgical Suite Dress Code and Traffic Control," showed the following under Semi-restricted Areas; "Freshly laundered scrub suits may be worn from home. Street clothes are never worn beyond the semi-restricted and restricted areas ..." and under Restricted Areas: l. Authorized personnel only. Proper attire consists of: Shirt/pants and socks/stockings. 2. Hospital laundered Surgical Attire, or freshly laundered Surgical Attire (See Home Laundering of Surgical Attire Policy and Policy #6700.6167). Review of the above policy and procedure referenced "CDC (Centers for Disease Control), Background G. Laundry and Bedding 1. General Information 11/2015."
B. Review of policy and procedure titled, "Home Laundering of Surgical Attire," showed all Surgical Services personnel participate in home-laundering program to include recommendations derived from CDC Recommendations.
C. During an interview on 11/14/2023 at 10:45 AM, the Director of the Operating Room (OR) stated, "we are following CDC and AORN (Association of Perioperative Registered Nurses) Guidelines both for Surgical Services."
D. Review of the current AORN Guidelines for Perioperative, 2019, showed staff in the semi-restricted and restricted areas should wear scrub attire that has been laundered at a health care-accredited laundry facility or disposable scrub attire provided by the facility and intended for use within the perioperative setting.
E. During an interview with the AVP (Administrative Vice President) of Surgical Services, on 11/16/2023 at 10:30 AM, she stated that the surgical staff were given an option to home launder their surgical scrubs or the facility will send them out to be laundered, but staff was reminded that scrubs may get lost when sent out to be laundered.
F. During an interview on 11/16/2023 at 10:40 AM, The AVP of Surgical Services confirmed the facility policy did not conform to AORN standards, and verified the findings at A through D.



Based on observation, policy review and interview, it was determined the Infection Prevention Nurse failed to control infections in that staff stored a medical instrument in the Cardiac Care Unit (CCU) in a designated patient refrigerator. The failed practice did not ensure patient's food and drink were free of cross-contamination and the medical instrument was acessible to unauthorized individuals. The failed practice had the likelihood to affect all patient's food and drink in the patient refrigerator. Findings follow:

A. Observation on 11/13/2023 at 2:50 PM showed a Sengstaken-Blakemore tube was stored in the patient nutrition refrigator in the CCU.
B. During an interview on 11/13/2023 at 2:55 PM, the AVP (Administrative Vice President) Medical Services verified the findings in A.

Based on observation and interview, it was determined the facility failed to mitigate the risk of cross contamination in that they were storing soiled Bio-Hazard, linen, and trash bags in one of one (New Life) janitor's closet observed. By not storing dirty separate from clean, the facility could not assure the clean janitorial supplies would not get contaminated by the soiled bags that were stored in the closet. The failed practice had the likelihood to affect all patients that are treated in New Life. Findings follow:

A. During a tour of the facility on 11/13/23 from 1:11 PM to 3:05 PM, observation showed 4 red Bio-Hazard bags, 2 blue linen bags, and 3 clear trash bags full, piled, stored on the floor and leaned into a wire rack which stored supplies to turn over rooms (clean mops, bags), two clean empty sharps containers, multiple full Avagard soap refills and two clean dust mop heads. There was also a cardboard box that this surveyor could not discern the contents of, due to the bags that were stacked in front of and leaning against it.
B. During an interview on 11/13/23 at 2:38 PM, the Director of New Life verified the findings at A.
C. During an interview on 11/14/23 at 8:10 AM, the Director of Environmental Services stated the red Bio-Hazard, blue linen, and clear trash bags were not supposed to be deposited in the janitor's closet, but were supposed to be deposited in the soiled utility closet for Environmental Services to retrieve and dispose of.



Based on observation and interview, it was determined the facility failed to assure a sanitary environment in the Cardiac Care Unit (CCU) in two of two (#1103 and #1104) rooms observed. The failed practice promoted the spread of infection and had the likelihood to affect patients in Cardiac Care Unit (CCU). Findings follow.

A. Observation on 11/13/2023 at 3:05 PM showed the bed in CCU Room #1103 had brown colored stains in the middle section of a care pressure mattress and the recliner had multiple ripped areas on the back of the recliner with foam exposed.
B. Observation on 11/13/2023 at 3:05 PM showed the bed in CCU Room # 1104 had brown colored stains at the upper top portion of the mattress.
C. The findings A and B were confirmed in an interview with the AVP (Administrative Vice President) of Medical Services on 11/13/2023 at 3:10 PM during the tour.

Based on observation, review of Association of periOperative Registered Nurses (AORN) Standards and interview, it was determined the Registered Nurse (RN) operating room circulator failed to remain in the operating room for the duration of the surgical procedure. The failed practice did not ensure continual monitoring for safe, quality patient care during the procedure, and did not ensure immediate interventions in case of an emergency. The failed practice had the likelihood to affect all patients having surgery in the operating room. Findings follow:

A.During an interview on 11/14/2023 at 10:45 AM, the Director of the operating room (OR), she stated, "We are following CDC (Centers for Disease Control and Prevention) and AORN guidelines both for Surgical Services."
B. During observation of a surgical procedure on 11/15/2023 from 9:45 AM to 11:15 AM, the registered nurse circulator left the surgical procedure three times to a do task. The first task was to remove a cable from the operating room, the second was to get a specific gauze for the surgeon, and the third was to retrieve an irrigation solution. The registered nurse circulator was the only registered nurse in the operating room.
C. Review of the AORN Position Statement on Perioperative Registered Nurse Circulator Dedicated to Every Patient Undergoing an Operative or Other Invasive Procedure Position Statement, 2019, showed the RN circulator was to be in the operating suite and available to respond/intervene immediately and physically to provide necessary interventions in emergencies.
D. The findings in A, B and C were confirmed with the Director of Same Day Surgery on 11/15/2023 at 11:25 AM, during the observation of surgical procedure.