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Based on record review, medical staff bylaws review, governing board bylaws review, and interview, the provider failed to ensure clinical competencies had been documented and reviewed by the credentialing committee for six of six sampled physicians (P, Q, R, S, T, and U) during the credentialing process. Findings include:

1. Review of the above physicians' credentialing files revealed no documented clinical competencies had been completed for the credentialing committee to review at the time those physicians had been reappointed to the medical staff.

Review of the provider's September 2012 Medical Staff bylaws revealed the extension of physician's privileges should have been based upon demonstrated competence through direct observation by the medical staff.

Review of the provider's September 2012 Governing Board bylaws revealed:
*The extension of further privileges should have been based upon the applicant's training, experience, and demonstrated competence.
*Only allied health professionals who were determined on the basis of documented references were eligible to have provided services in the hospital.
*The credentialing committee should have reviewed the performance of the applicant and made recommendations to the active medical staff.

Interview on 11/7/13 at 9:00 a.m. with the administrative assistant revealed getting references for clinical competences for the medical staff from other physicians had not been part of the credentialing process.

Interview on 11/7/13 at 9:50 a.m. with the administrator revealed:
*The chief of staff knew the applicants, so any discussions about clinical competence of the physicians would have been a verbal discussion and not a documented discussion.
*The credentialing process had not been done according to the medical staff bylaws and governing board bylaws process.

30170

Based on observation, interview, and policy review, the provider failed to ensure:
*A comprehensive infection control program was implemented under the directions of the infection control officer.
*High-risk error prone areas of the facility had been identified and were monitored by the infection control officer
*Four of four endoscopes were stored in a sanitary manner.
*Manufacturer's directions for rinsing Cidex OPA from endoscopes was followed for one of two surgery outpatient procedure rooms.
Findings include:

1. Interview on 11/6/13 at 9:30 a.m. with the director of nursing (DON) regarding the provider's infection control program revealed:
*She was the infection control nurse.
*She had performed handwashing audits with the hospital staff, but she had no documentation of the audits she had completed.
*The infection control program had not been developed and implemented into laboratory, radiology, emergency, laundry, housekeeping, endoscopic processing, outpatient services, and rehabilitation services of the hospital.
*She had only followed cultures performed on inpatients.
*All other departments had not been responsible for any audits, and had not brought any infection control concerns to the committee.
*She had not incorporated all of the hospital department managers into the infection control program.
*No specific forms had been developed to monitor infection control issues in the above listed departments.
*There had been only environmental audits performed and documented.

Refer to C278, finding 1.

2. Observation on 11/5/13 in the surgery outpatient soiled utility room revealed:
*There was a white bath blanket draped over the soiled utility room door. The top of each scope was positioned over the bath blanket and the tubular end dangled down the length of the door.
*The ends of the scopes touched the bottom edge of the door.
*There was a hopper (a large toilet) positioned approximately twelve inches from the scopes.

Interview on 11/5/13 at 1:30 p.m. with surgical technologist A regarding endoscope processing revealed:
*She did not rinse the endoscopes three times in copious amounts of water after removal from the Cidex OPA solution. She only rinsed them twice in a sink that had been cleansed with Lysol foaming disinfectant.
*She did not mix the enzymatic pre-soak per manufacturer's directions. She filled one of the two compartment sinks with an unknown amount of water and added an unknown amount of pre-soak to the sink. Review of the manufacturer's direction revealed one ounce should have been mixed with one gallon of water
*Hanging the endoscopes on the soiled utility room door was not the correct method for storage. She had requested and ordered a scope cabinet, but that had not arrived.

Refer to C320, findings 1 and 2.

26180

Based on observation, policy review, and interview, the provider failed to ensure:
*The emergency department (ED) maintained accurate records for the disposition of two controlled pain medications (hydrocodone and codeine).
*Anesthesia inhalation medication stored in one of two surgical procedure rooms had been kept secured, and those medications had been destroyed upon their expiration dates.
*The temperatures in one of one Pyxis refrigerator had been monitored daily.
Findings include:

1. Observation and interview on 11/5/13 at 10:00 a.m. with the on-duty ED registered nurse (RN) D in the ED revealed:
*There was a locked cabinet labeled for storage of antibiotics.
*The cabinet contained multiple pre-packaged medications set-up for single dose administration.
*There were set-up packets of antibiotics and hydrocodone and acetaminophen with codeine (narcotics for pain control).
*The above medications would have been sent with an ED patient when they were discharged.
*When those medications were administered to a patient the nurses removed a yellow adhesive (sticky) tag that listed the medication, that dose from the packet, and placed it on the patient's ED admission face sheet
*The face sheets were turned into the pharmacist.
*They had not kept any daily count of the controlled substances.
*The pharmacist re-stocked the cabinet.
*A controlled substance could have been taken from the cabinet without anyone knowing the medications had been taken.
*In a one week period fourteen different nurses could have been scheduled to work and would have had access to the locked cabinet.

Interview on 11/5/13 at 10:30 a.m. with registered pharmacist C revealed:
*She filled the locked cabinet every Friday before the weekend.
*She tracked the use of the controlled substances through the yellow stickers that she had received.
*They had not put in place a system to count the controlled substances on a daily basis.
*She confirmed she would not have known if something was missing until she had performed the weekly re-stocking of those medications.

Review of the provider's 11/5/13 emergency room take-home medication packets policy revealed:
*"The pharmacist will maintain a prepackaged and labeled supply of medications that can be dispensed to ER [ED] patients for use until a retail pharmacy was open to fill an emergency prescription.
*Controlled substances take-home packets are stored in the locked cabinet in the medication room which is accessible only to nurses and pharmacy personnel.
*Controlled substances in take-home packets are counted at every shift change along with the other narcotics stored in the medi room cabinet."
*A list of the prepackaged take-home medication packets in the ER cabinet included the following controlled substances:
-Acetaminophen 300/30 milligram codeine.
-Hydrocodone - several strength doses.




30170

2. Observation on 11/5/13 at 9:50 a.m. in the surgical outpatient procedure room revealed:
*An anesthesia cart contained the following anesthesia inhalation medications used for surgery:
-Two bottles of Forane with expiration dates of November 2006.
-One bottle of Ultane with an expiration date of 11/1/06.
-One bottle of Halothane with an expiration date of September 2005.

Interview with surgical technologist A during the above observation revealed:
*No surgeries had been performed for many years that required general anesthesia.
*The room had been used as an outpatient procedure room for visiting physicians.
*She was unsure as to why the medications were still in the anesthesia cart.

Observation and interview on 11/5/13 at 10:00 a.m. with surgical technologist A revealed:
*The outpatient rooms were located in the surgical area.
*The surgical procedure rooms were unlocked.
*An exterior door was located by the surgical outpatient procedure area.
*The door was unlocked between the hours of 6:00 a.m. and 6:00 p.m.
*The door was not monitored and was accessible from the outside.
*Unauthorized individuals would have had access to any medication stored in the outpatient procedure room.
*Staff were not always present in the outpatient procedure area.

3. Observation on 11/5/13 at 12:00 noon at the nurses station revealed:
*A refrigerator was located by the Pyxis medication system.
*There was a 2013 Daily Refrigerator Temperatures record taped to the refrigerator door that revealed:
-In April there were eight days the temperature had not been monitored.
-In May there were eleven days the temperature had not been monitored.
-In June there were twelve days the temperature had not been monitored.
-In July there were eight days the temperature had not been monitored.
-In August there were seven days the temperature had not been monitored.
-In September there were fourteen days the temperature had not been monitored.
-In October there were thirteen days the temperature had not been monitored.

Interview with RN D immediately following the above observation revealed:
*The refrigerator temperatures had not been monitored daily.
*The ED nurse was responsible for checking the refrigerator temperatures every morning.

Interview on 11/6/13 at 10:20 a.m. with registered pharmacist G regarding temperature monitoring for the Pyxis refrigerator revealed:
*The Pyxis medication system had been in place since January 2013.
*The nursing staff would have been responsible for monitoring the refrigerator temperatures.
*She was unsure if the Pyxis computerized system would have been able to monitor the refrigerator temperature.

Review of the provider's pharmacy inventory of the Pyxis refrigerator revealed the following medications were stored in the refrigerator:
-IV (intravenous) antibiotics.
-Insulins (both long acting and fast acting).
-Acetaminophen suppositories (used for patients with pain or fever).
-Eye drops.
-Phenergan suppositories (used for nausea).

4. Interview on 11/7/13 at 9:00 a.m. with the director of nursing revealed:
*The expired and unsecured anesthesia inhalation medications should have been destroyed upon the discontinuation of surgeries.
*The refrigerator temperatures should have been monitored daily to ensure the stability of the contents in the refrigerator.

Review of the provider's November 2009 Drug Storage policy revealed:
*All drugs/medications should have been stored in a well illuminated, well ventilated, locked area, cart, or Pyxis unit at a temperature suitable for drug storage.
*Medications and biologicals were to have been stored safely, securely, and properly following the manufacturer's and/or supplier's recommendations.
*The medications should have been accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to have administered medications.
*Controlled medication were stored in a locked cupboard in the medication room.
*Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were immediately removed from stock and disposed of according to procedures for medication destruction.

15036




30170

Based on observation, interview, record review, and policy review, the provider failed to ensure:
*The infection control program had been developed and implemented for eight of eight hospital departments (laboratory, radiology, emergency, laundry, housekeeping, endoscopic processing, outpatient services, and rehabilitation services).
*Two of two observed staff members (A and B) completed appropriate hand hygiene when disinfecting contaminated endoscopic equipment.
*Foam positioning wedges were cleanable in one of one radiology room. Findings include:

1. Interview on 11/6/13 at 9:30 a.m. with the director of nursing (DON) regarding the provider's infection control program revealed:
*She was the infection control nurse.
*She had performed handwashing audits with the hospital staff, but she had no documentation of the audits she had completed.
*The infection control program had not been developed and implemented into laboratory, radiology, emergency, laundry, housekeeping, endoscopic processing, outpatient services, and rehabilitation services of the hospital.
*She had only followed cultures performed on inpatients.
*All other departments had not been responsible for any audits and had not brought any infection control concerns to the infection control committee.
*She had not incorporated all of the hospital department managers into the infection control program.
*No specific forms had been developed to monitor infection control issues in the above listed departments.
*There had only been environmental audits performed and documented.

Interview on 11/7/13 at 9:00 a.m. with the DON regarding the provider's current infection control program revealed:
*She would have placed any patient in isolation that had nausea, vomiting, or were VIP (those having a history of MRSA or C.Diff (clostridium difficile) [a highly infectious organism in the colon spread by contact with the feces]).
*There had been no policies or procedures on MRSA or C.Diff that instructed the staff on the care of patients with that infection.
*She had used word-of-mouth to communicate with her current staff on in-patient infections.
*The ward clerk would have been responsible for communicating to other departments regarding a patient with an infection.
*There had been no policy or procedures available to the hospital staff regarding the current use of the hospital's disinfectants and antiseptics or the current recommendations staff should have been following.
*She agreed the current infection control policies and procedures should have been updated for the continuum of patient care.
*There was no orientation for staff to explain the infection control program, and the roles and responsibilities they had in the success of the infection control program.

Interview on 11/7/13 at 9:30 a.m. with registered nurse (RN) F regarding her infection control orientation revealed:
*She had started her employment approximately four months ago.
*She had been given a book on infection control to read upon hire and then had taken a written test.
*The current nursing staff had orientated her to isolation procedures.
*She would have used reference books at the nurses station if she had a question regarding an infection.
*She was not aware of any policies or procedures to have referenced for patients with C.Diff infection (a highly contagious diarrhea infection of the stomach and bowel).

2. Observation and interview on 11/5/13 at 4:35 p.m. of the radiology room with the radiology director revealed eleven positioning wedges without cleanable surfaces or covers. The radiology director stated the positioning wedges were not cleanable and could have been an infection control risk.

Review of the provider's infection control policies and procedures revealed:
*There had been no policies for the following areas:
-Monitoring and evaluating practices of asepsis (sterile technique).
-Disinfectants and antiseptics that were used according to manufacturer's instructions.
-Orientation of all new and current personnel to the infection control program.
-Health policies and procedures for infected and ill employee.
-Investigating hospital patients and employees infections.

Review of the provider's June through September 2013 Infections Worksheet Sites and Pathogens revealed:
*Cultures that had been monitored were:
-Throat.
-Blood.
-Urine.
-Sputum.
-Body fluids.
-Gastro-intestinal (stomach and bowel).
-Burns.
-Wounds.
-MRSA (methicillin resistant staphylococcus aureus)[a highly infectious disease]).

Review of the provider's 2013 Safety Inspection Log revealed:
*Inspection of the physical environment had been conducted quarterly.
*There was no documentation rounds and audits had been conducted specifically for infection control issues.

Review of the provider's Employee Orientation policy revised September 1998 revealed:
*All new employees should have been provided with information that assisted him/her in becoming a productive member of the hospital.
*There was no procedure in place for informing new employees about the infection control program.

Review of the provider's undated Infection Control Committee policy revealed:
*The purpose of the policy was the detection and surveillance of infections, monitoring of the methods of control, dispersal of information to other hospital personnel, and improving preventive measures of hospital acquired diseases.
*The Infection Control Committee should have:
-Reviewed the monthly data retrieved by the infection control nurse in regards to nosocomial (hospital acquired) infections.
-Recommended aseptic techniques and procedures to have been employed in high-risk areas.
-Examined environmental culture reports to determine possible reservoirs of infection.
-Monitored effectiveness of sterilizing techniques by culture tests of bacterial spores (infection causing bacteria).
-Supervised techniques used by laundry and housekeeping personnel.

Based on observation and interview, the provider failed to maintain the following items in a sanitary manner:
*The "aide" refrigerator in the kitchen.
*The ceiling of the kitchen.
Findings include:

1. Observation and interview on 11/5/13 at 9:00 a.m. with the dietary manager and the maintenance man revealed:
*The fan grate and the inside top of the refrigerator had a moderate amount of grey, fuzzy substance on them. Some of the grey, fuzzy substance was in uniform round mold like colonies (photo 1).
*The door gasket by the hinges had a six inch strip of black, fuzzy mold like residue on it (photo 2).
*The dietary department had the refrigerator on a cleaning schedule.
*The dietary department had not cleaned the fan grate or the inside top of the refrigerator.
*The dietary department should have notified maintenance to clean those areas.
*Those areas were not listed on the cleaning schedule.
*Maintenance would have cleaned those areas when they were notified they were dirty.

2. Observation and interview on 11/5/13 at 9:15 a.m. in the kitchen with the dietary manager and the maintenance man revealed:
*All of the registers for the air ducts had a moderate amount of black, fuzzy lint like residue on them (photo 3).
*The ceiling tiles around each air duct had the same residue on them.
*The ceiling and air registers would have been the maintenance department's responsibility to clean.
*Maintenance would have cleaned those areas when notified by the dietary department to do so.
*The ceilings and air registers were not on a cleaning schedule.

Based on record review, interview, and policy review, the provider failed to ensure three of three sampled patients (20, 34, and 35) had complete blood transfusion documentation and verification of blood products. Findings include:

1. Review of patient 20's 8/21/13 blood bank transfusion record revealed the following information had not been documented:
*Pre-transfusion hemoglobin (Hgb).
*Pre-transfusion platelet (Plt).
*Vital signs (blood pressure, temperature, pulse, and respirations).
*Infusion start date and time.
*The patient's name and blood identification number from blood bank (BB) wristband agree with those on the tag. Wristband number (WB#).
*Donor unit number and type on the tag agree with those on the unit.
*If the donor unit expiration date had been checked.
*A signed transfusion consent form.
*Verification the patient verbalized understanding of the symptoms of an adverse transfusion reaction.
*If an outpatient, the patient had received and understood the Adverse transfusion reactions form.
*There was only one nurse signature instead of the required two nurse signatures verifying the accuracy of the blood product information when it had been received.

2. Review of patient 34's 10/13/13 blood bank transfusion record revealed the following information had not been documented:
*Pre-transfusion platelet (Plt).
*Infusion start date and time.
*There was only one nurse signature instead of the required two nurse signatures verifying the accuracy of the blood product information when it had been received.

3. Review of patient 35's 10/25/13 blood bank transfusion record revealed the following information had not been documented:
*Infusion start date and time.
*There was only one nurse signature instead of the required two nurse signatures verifying the blood product when it had been received.

4. Interview on 11/6/13 at 2:15 p.m. with registered nurse V revealed:
*She was unable to find in the electronic medical record (EMR) any documentation of the date and start time of the infusions/transfusions for patients 20, 34, and 35.
*The outpatient care flow sheet should have been completed and scanned into the EMR. The flow sheet had not been completed properly.

Interview on 10/6/13 at 1:30 p.m. with the director of nursing revealed:
*Two nurses should have signed the patient blood bank transfusion record.
*The nurse's signature verified the information on each unit of blood matched the information documented on the transfusion record. That was the professional standard.
*There should not have been blanks on the blood bank transfusion record.
*They should have recorded the infusion start date and time.

Review of the provider's April 2010 blood transfusion policy revealed it had not addressed documentation.

Based on record review, interview, and policy review, the provider failed to ensure the patients' history and physical reports had been completed within the time frame outlined in the governing body and medical staff bylaws for two of five sampled swing bed patients (3 and 5) reviewed. Findings include:

1. Review of patient 3's medical record revealed he had been admitted on 10/30/13 for pneumonia. There was no history and physical documented in his medical record.

2. Review of patient 5's medical record revealed she had been admitted on 7/31/13 and had been discharged on 8/22/13. Her history and physical had been dictated by her physician on 10/9/13.

3. Interview on 11/7/13 at 9:00 a.m. with the director of nursing confirmed history and physical reports should have been completed in a timely manner. She stated she had not been reviewing patients' charts for their history and physical reports.

Review of the provider's By-Laws and Rules and Regulations of the Medical Staff revealed a complete medical history of the patient and physical examination should have been recorded or dictated in the medical record of all hospital patients no more than 30 days before or 24 hours after an admission.

30170

Based on observation, interview, and policy review, the provider failed to ensure all endoscopic patient information was kept confidential. Findings include:

1. Observation on 11/5/13 at 9:45 a.m. in the surgical area across from the central supply room revealed:
*There was a black file cabinet and the drawers were unlocked. One of the drawers contained patient information pertaining to anesthesia.
*The information was accessible to other patients and staff.

Interview with surgical technologist A during the above observation revealed:
*The patient information was the anesthetist records.
*The patient information was accessible to unauthorized persons and should have been locked.
*The staff did not know where the key was located.

Interview on 11/7/13 at 9:00 a.m. with the director of nursing regarding the above findings revealed all patient information should have been kept confidential and unaccessible to unauthorized persons.

Review of the provider's undated Patient Handbook revealed all communications and medical records related to patient care would have been kept confidential.

30170

Based on observation, interview, and policy review, the provider failed to ensure:
*Four of four endoscopes (long tubular instruments used to look in the stomach and large and small bowels) had been processed per the manufacturer's enzymatic and Cidex OPA directions for use.
*Four of four endoscopes had been processed and stored in a sanitary manner in the surgical outpatient soiled utility room.
*Supplies used in the surgery area were kept sterile and outdated supplies were not available for patient use.
*Two of two observed surgical technologists (A and B) performed appropriate hand hygiene during one of one endoscopy procedure.
*Sterilized items were sanitarily maintained in one of one emergency triage room and one of one emergency rooms.
Findings include:

1. Observation on 11/5/13 at 8:15 a.m. in the surgery outpatient soiled utility room revealed:
*There was a white bath blanket draped over the soiled utility room door. The top of each scope was positioned over the bath blanket, and the long tubular end dangled down the length of the door (Photo 4).
*The ends of the scopes were touching the bottom edge of the door.
*There was a hopper (a large toilet) positioned approximately twelve inches from the scopes.
*There were two gastroscopes (used to visualize the esophagus [throat] and the stomach) and two colonoscopes (used to visualize the small and large intestines [bowels]) hanging from the surgical outpatient soiled utility room door.

2. Observation on 11/5/13 at 9:50 a.m. of the surgery outpatient room supply cabinet revealed:
*An anesthesia IV (intravenous) tray used to start IVs on patients prior to endoscopic procedures.
*The tray contained three syringes out of the packages, sitting upright in the tray, and touching other supplies in the tray.
*There were numerous outdated (expired) tissue specimen containers (used for biopsies from the endoscopes) in a plastic bin.

Interview on 11/5/13 at 1:30 p.m. with surgical technologist A regarding the gastroscopes and colonoscopes during the cleaning and disinfection process revealed she:
*Had used an enzymatic cleaner to pre-soak the scopes after patient procedures.
*Would have filled the sink with water and would have added two squirts of the enzymatic cleaner to the sink full of water.
*Had not measured the exact amount of water used in the sink.
*Cleansed and disinfected the endoscopes the day before scheduled procedures, and then hung them from the soiled utility room door.
*Wiped the scopes down the day of the scheduled procedures with an alcohol soaked cloth.
*Used Lysol foam cleaner to disinfect the sinks after she had soaked the soiled scopes.
*Was unsure if the Lysol foam cleaner was an approved hospital disinfectant.
*Was not rinsing the endoscopes three times with tap or sterile water after the Cidex OPA twelve minute soak as required by the directions. She only rinsed the scopes twice.
*Was aware the storage of the scopes on the soiled utility door was not sanitary.
*Had made recommendations to her supervisor for an appropriate storage cabinet.
*Should have been checking supplies on a monthly basis for expiration dates and should have removed the outdated supplies from the patient care areas.

3. Observation on 11/6/13 at 7:15 a.m. of patient 36's gastroscope and colonoscope cleaning in the surgical outpatient soiled utility room revealed surgical technologist A had:
*Assisted the physician during the procedure.
*Removed her contaminated gloves, had not performed hand hygiene, and had left the procedure room.
*Returned to the procedure room with a specimen container.
*Put clean gloves on her contaminated hands.
*Had not washed or sanitized her hands.

Observation on 11/6/13 at 8:07 a.m. with surgical technologist B in the surgical outpatient soiled utility room after patient 36's gastroscope revealed:
*She had finished cleaning the endoscope, had removed her gloves, and had not washed or sanitized her hands.
*She then put on a set of clean gloves without washing or sanitizing her hands.

Observation on 11/6/13 at 8:17 a.m. with central supply room (CSR) technologist C in the surgical outpatient area soiled utility room revealed:
*She had disposed of the rinse water from the three clear plastic containers into the hopper.
*The plastic containers had touched the sides of the hopper during the disposal of the rinse water.
*She cleansed the inside of the plastic containers with the Sani-cloth wipes.
*She had not cleaned the outside of the plastic containers that had touched the unclean hopper.
*She removed her contaminated gloves, had not performed hand hygiene, and then put a clean set of gloves on.

4. Interview on 11/7/13 at 9:00 a.m. with the director of nursing (DON) regarding the above concerns revealed:
*The endoscopes had not been cleaned, disinfected and stored in a sanitary manner.
*The endoscopes should have been rinsed three times after the disinfection process had been completed.
*The syringes in the anesthesia tray should have been discarded once they had been opened and should not have been left in the anesthesia tray.
*The surgical technologist and CSR technologist should have been checking for outdated supplies used in the surgical outpatient procedure area.
*The surgical technologist and CSR technologist should have performed hand hygiene before and after glove use.

Review of the provider's October 2013 revised Cleaning of Gastroscope or Colonoscope policy revealed:
*"Sink 1 is filled with tap water and enzymatic cleaner. Remove detergent from the sink.
*Fill sink 2 with clean tap water. Flush all the ports with copious (large) amounts of tap water. Remove water from sink and flush all channels with air 6-8 times with a 30 cubic centimeters (cc) syringe.
*Sink 1 and 2 are sprayed with a bleach cleaner. The cleanser is left on the surface for a dwell (length) time of 5 minutes. Sink 1 and sink 2 are rinsed.
*Submerge scopes in Cidex OPA and let scope soak for 12 minutes.
*Remove scope from Cidex OPA and flush all channels with air 6-8 times with 30 cc syringe to remove Cidex.
*Place scope in sink filled with clean tap water.
*Flush all channels with channel irrigator and 30 cc syringe 6-8 times to rinse scope.
*Remove scope from the water and flush scope 6-8 times with air. *Flush all channels with alcohol/air. Dry the outside and hang scope vertically to dry/store.
*At the end of the Endoscopy day a high level disinfection is done.
*Hang scope in the Endoscopy drying/storage cabinet."

Review of the provider's September 1998 Handwashing policy revealed:
*"Handwashing would have been recognized as the most effective mechanism for the removal of transient microbial contamination acquired by recent patients or other source contact, and the prevention of transfer of microorganisms which may have caused diseases."
*Handwashing indications:
-Before and after contact with wounds or other invasive procedures and devices.
-After removing gloves.
-"After" becomes "before" when hands are washed immediately following one procedure, but immediately proceeding another procedure."




25107

4. Observation on 11/6/13 from 8:30 a.m. to 9:00 a.m. in the emergency triage room and emergency room revealed:
*One package of forcep was water stained and was not sealed. There was a brown flaky residue on the forceps handle.
*One package of long alligator clamp had a rust colored stain and was water stained.
*Two packages of Nancy needle holders were water stained.
*The jaws of two wire cutters had a moderate amount of rust. The packaging of one wire cutter was not sealed.

Interview on 11/6/13 at 12:06 p.m. with the DON revealed the people in charge of sterilizing equipment would have been in charge of monitoring the sterilized packages of equipment.

Observation and interview on 11/6/13 at 1:03 p.m. with surgical technologist A revealed:
*The majority of reusable instruments were sent to a contracted facility for sterilization.
*The provider was sterilizing some miscellaneous instruments including the equipment listed above.
*She considered the instruments listed above to be compromised because of the brown flaky residue (old tape), rust, unsealed packages, and water stains.
*The items should have been pulled from service.
*The staff from central supply were in charge of monitoring supplies in the hospital for out dates. The staff consisted of her and CSR technologist C.
*They checked the sterilized item for out dates but had not checked the packaging or condition of the equipment.
*CSR technologist C had recently been trained in sterilization and had processed the equipment in question.
*She had not been monitoring CSR technologist C when she sterilized equipment.
*She was not sure why the packages had been water stained.

Interview on 11/6/13 at 1:15 p.m. with surgical technologist A and CSR technologist C revealed:
*CSR technologist C had processed all of the equipment in question.
*She was not aware she should have checked the packages to make sure they were sealed or for water stains.
*The instruments were not rusty when she had last sterilized them.
*She was not aware they could rust in the package.
*They were only checking for out dates and were not monitoring the integrity of the packages or equipment in them.

Review of the provider's July 2001 shelf-life of sterilized items and visual inspection for compromised packages policy revealed:
"Supplies that have been properly wrapped or are in autocalvable pouches and are properly sterilized with autoclave tape, indicators are considered sterile for one year when in a sealed pouch. If pouch is damage it is considered unsterile. If item is wrapped in a cloth material and not in a sealable pouch the item is sterile for six weeks. Each package is dated.

Supplies sterility are based on the date stamped on the product. Any item that is outdated will be removed from the shelf and disposed of. If they are used or damaged, they are "unsterile."

Supplies are carefully examined after sterilization and before use.

Supplies are checked each month for outdates."

Based on interview, the provider failed to have the patient activities program directed by a qualified professional as required for one of one activity program. Findings include:

1. Interview on 11/7/13 at 8:45 a.m. with the director of nursing (DON) revealed she had been designated as the activities director for the provider's swing bed program. She stated she had not completed any specific training related to therapeutic recreation. There was no consultant in place for the activities program. The DON had thought as a registered nurse she was qualified to direct the activities program.

Based on record review and interview, the provider failed to have an interdisciplinary team periodically review and revise care plans for two of two sampled swing bed patients (5 and 7) with hospital stays over seven days. Findings include:

1. Review of patient 5's medical record revealed:
*She had been admitted on 7/31/13.
*She had been discharged on 8/22/13.
There was no documentation of an interdisciplinary team meeting to periodically review and revise her care plan.

2. Review of patient 7's medical record revealed:
*She had been admitted on 4/4/13.
*She had been discharged on 5/15/13.
There was no documentation of an interdisciplinary team meeting to periodically review and revise her care plan.

3. Interview on 11/7/13 at 8:50 a.m. with the director of nursing revealed:
*There was no policy or procedure for an interdisciplinary team to meet periodically to review and revise swing bed patients' care plans.
*The patient, patient's family, nurse, and/or doctor would have requested an informal meeting to discuss a patient's care plan, but there was no formal process in place.
*There had been no documentation of the informal care plan meetings maintained in a patient's medical record.