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Based on record review and interviews, the facility failed by not enforcing the bylaws and carrying out its responsibilities by the medical staff. This deficient practice has the likelihood to affect patient care and safety due to lack of oversight.
The findings are:

A. Facility's Medical Staff Bylaws Appendix C "Hospital Policy Regarding Disruptive Practitioner Conduct dated 7/30/2013 states:
1. Documentation of disruptive conduct is critical. Physicians, nurses and other hospital employees who observe or are otherwise made aware of disruptive behavior by a Practitioner (a person actively engaged in a profession, especially medicine) much document the behavior. Such documentation shall be provided to the hospital's Chief Executive officer (CEO) as soon as practicably possible.
2. Once received, a report will be investigated by the CEO and the Chief of Staff. As part of the investigation, the CEO will interview the employee or other person completing the report as soon as reasonably practical. Usually within two business days of having received the report, in order to gather additional, more complete information. If the CEO is unable to complete the report within this time period, the documentation of the investigation will indicate why the interview could not occur within two business days. The CEO will document the time, date and substance of this meeting, and such documentation will be made a part of the investigative file.
3. Reports which are determined to be credible, based on the facts and information gathered during the investigation, will be addressed through the procedure set out below and will become a part of the physician's quality credential file. If the report is determined to be credible, the practitioner who is the subject of the report shall be interviewed prior to conclusion of the investigation.
4. If at any time it appears to the Chief of Staff, the CEO or any committee charged with implementation of this policy that a practitioner's behavior may result from an impairment, the procedure set forth in the impaired practitioner policy shall be followed.

B. Record review of Electronic Reporting System (ERS) revealed:
1. On 5/23/2020 staff complaint filed stated, Staff (S)#15 (Certified Registered Nurse Anesthetists (CRNA) refused to assist with patient care, refusal to wear appropriate Personal Protective Equipment (PPE) while providing patient care, demeanor and treatment of other coworkers was unacceptable.
2. On 6/3/2020 staff complaint stated, S15 (CRNA) "was called to assist with Intravenous access (IV) on a patient requiring IV antibiotics and transfer to [another facility] for higher level of care. S15 (CRNA) refused to come in stating, if the nurse can't get it, I cant either. S15 (CRNA) has history of refusing to come in when called."
3. On 6/20/2020 staff complaint filed stated, "When setting up for a sterile case [S15 (CRNA)] was explaining where the new Pyxis (an automated dispensing system that performs the storage, dispensing, and distribution of medications) was going to be. I was scrubbed in and my tables were sterile, he then pushed a cart too close to my table almost hitting it. S15(CRNA) was told to stop multiple times and continued. I told S15(CRNA) was about to contaminate my set up. S15 (CRNA) then responded with you're going to need to learn to adapt to change. After the case when cleaning up I noticed a white Yeti (product name) coffee mug was sitting on his table, as well as his speaker that leaves the hospital and goes in ENDO (operating room). The speaker was not covered with a bag.
4. On 6/3/2021 staff complaint filed stated, S15 (CRNA) "refuses to wear a N95 (filtering facepiece respirator, commonly abbreviated N95 respirator, is a particulate-filtering facepiece respirator that meets the United States National Institute for Occupational Safety and Health (NIOSH) N95 classification of air filtration, meaning that it filters at least 95% of airborne particles) despite being told this is a requirement for employees who have NOT been vaccinated for Covid (upper respiratory infection)."
5. On 9/28/2021 staff complaint filed stated, "Surgical tech reported to director that medication bottles had been left on the anesthesia pyxis machine. Surgical tech notified S15 that they were left on the pyxis, tech stated S15 (CRNA) replied must have been the other CRNA. When tech reminded S15 (CRNA) he was the last to do a surgical case S15(CRNA) ignored him and left the facility. Medication bottles still left on the pyxis. Infection control Registered Nurse (RN) and pharmacy notified. "

C. On 01/14/2022 at 1:00 PM during telephone interview S2(Chief Executive Officer (CEO)) confirmed there are no detailed documentation of investigation meetings held with S14 for complaints filed by medical staff members. "I can be better about formally documenting those and sticking them in a file somewhere."

Based on observation, interview, and record review, the facility failed to maintain an ongoing infection control program that would prevent, identify, and manage infections or contagious diseases increasing the likelihood of transmission of COVID-19 (coronavirus, respiratory viral infection.) And to ensure items utilized for direct patient care are furnished appropriately by not using items past expiration dates and not identified as being under an extended use authorization by the United States Food and Drug Administration. Certain expired medications are at risk of bacterial growth and antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. And failed to ensure single use care items and equipment are not reused. This failed practice is likely to lead to poor treatment and delayed progression to goals and bacterial growth due to using expired medical supplies and lead to cross contamination and increased spread of potentially infectious organisms; and places patients at risk for infections while receiving treatment.

The findings are:

A. On 12/28/2021 at 11:45 am, during tour of the ER (Emergency Room), observed the following:
1. Visible stained floors not swept or mopped, per a staff member due to not having consistent housekeeping for the past six months

2. A bed in a patient room appeared to not have been wiped down and did not have a bed sheet. In the ER's computer system the room was marked as ready for an incoming patient per a staff member

3. In the soiled utility room (storage for biohazard (a risk to human or the environment arising from biological work, especially with microorganism) sink, there was a yellow liquid which appeared to be urine. A staff member verified urine was dumped in the sink and was not flushed

4. In the decontamination room (the process of removing contaminants on an object or area, including chemicals, micro-organisms or radioactive substances) floor appeared to not have been swept or mopped

5. In the Fast-Track area (a separate pathway for patients with less serious conditions who can be treated and discharged more quickly), dry blood stains on the countertop near the sink, where Ortho Glass supplies are stored (Ortho-Glass® Synthetic Splinting Systems are packaged in roll form, allowing the practitioner to measure and cut as needed. These roll Form Plaster Splints are ideal for emergency rooms, operating rooms, ambulances, and casting rooms)

6. Next to the sink with the blood stains, a used blue head bonnet (head covering) and two 100 ml (measurement) half empty clear bags of saline (used to clean wounds and treat dehydration)

7. Three (3) empty cafeteria trays stacked on trash can marked biohazard (trash receptacle used primarily for waste containing infectious materials or potentially infectious substances such as blood), located outside of soiled utility room door

8. Two (2) tape strips hanging on guardrail of stretcher used for transporting patients into ED from outside helipad (landing and takeoff area for helicopters) located in ambulance entrance.

9. Two (2) tape strips hanging on Intravenous (a procedure where a needle inserted directly into a vein to deliver liquids to the blood stream) pole (device used to hang intravenous bags full of medicine or fluid in place), located in ambulance entrance

10. Four (4) Intravenous poles with Intravenous pump (pump attached to intravenous line that sends medication and or sterile solution into an intravenous catheter (a hollow tube used to thread through a vein to provide a route to administer medications, and fluids directly into the bloodstream] in a slow and steady manner), in ED hallway with no identification of being clean, or dirty

11. Christmas tree adapter also known as Universal Oxygen Nut and Nipple Connection (used to secure oxygen tubing to an oxygen delivery source. Most used in the hospital setting is a device that attaches to the wall where an oxygen source is mounted in each patient treatment area, specified for one patient), attached to oxygen delivery source in patient treatment room #3. The Christmas tree adapters per manufacturer's recommendation are single-use (one time) and should be discarded after every patient.

B. On 12/28/2021 at 12:30 pm, during tour of the Pre-Op area, observed the following:
1. The Surveyor observed Christmas tree adapter in rooms 1, 2, 3, and 4. Per manufacturer's recommendation Christmas tree adapters are single-use (one time) and should be discarded after every patient.

C. On 12/28/2021 at 12:35 pm, during observation of the medical supply room in the OR (Operating Room) revealed the following to include expired (exp) products used in direct patient care:
1. Three (3) BD 30 ml (measurement) Syringe (product name) (used with a fitted needle for injecting or withdrawing fluids): exp on 11-30-2021.

2. Three (3) Magellan (product name) needle, 25G (size) x 1 1/2 (inch) (a small hollow needle used for injection of material into or beneath the skin): exp on 12-01-2021.

3. Two (2) Protexis P1 (product name) Surgical Gloves size 6 (designed for use in Orthopaedic bone and joint surgeries): exp on 02-01-2021.

4. One (1) Chlora Prep with Tint (product name), (a plastic applicator with a sponge tip containing rubbing alcohol to clean and disinfect): exp on 02-01-2021.

5. Christmas tree adapter attached to oxygen delivery source in room 2, and room 3. Per manufacturer's recommendation Christmas tree adapters are single-use (one time) and should be discarded after every patient.

D. On 12/29/2021 at 12:35 pm, during observation of the medical supply room in the OR (Operating Room) designated for the Anesthesia (administration of gases or the injection of drugs before surgical operations) Unit revealed the following:
1. Three (3) Teleflex Medical (product name) Laryngeal Mask Airway (medical device that keeps a patient's airway open during anesthesia or while they are unconscious): exp 08-28-2021

2. One (1) Miller 4 blade (a straight blade designed to obtain a view of the vocal cords) package open. Per staff member this package should be closed after the handle is sterilized (process of making something free from germs)

3. One (1) Laryngoscope Handle (a device used to obtain a view of the vocal folds which is the space between the vocal cords) package open. Per staff member this package should be closed after the handle is sterilized (process of making something free from germs.)

E. On 12/28/2022 at 1:05 pm, during tour of the Endoscopy procedural room within the Operating Room, observed the following:
1. Two (2) size 7 Protexis (product name) Sterile Polyisoprene Surgical glove (glove to help prevent surgical site infection and reduce the risk of exposure to blood and body fluid pathogens): (1) exp on 09-01-2021 and (1) exp on 01-01-2021

2. Three (3) size 8 Protexis Sterile Polyisoprene Surgical glove): exp on 12-01-2020

3. Two (2) BD Alaris (product name) Intravenous Infusion set (plastic tubing that is used for the infusion of drugs or medication from the infusion bag/bottle to the vein of the patient): (1) exp on 09-05-2021 and (1) exp on 11-06-2021

4. Three (3) Teleflex Medical (product name) Laryngeal Mask Airway (medical device that keeps a patient's airway open during anesthesia or while they are unconscious): exp 06-28-2021.

F. On 12/30/2021 at 12:05 pm, during tour of the Medical Surgery Unit the following was revealed:
1. In Patient Room 203, in one of the corners of the patient room there was an oxygen tank (a tank used for medical purpose filled with oxygen gas, these tanks are resistant to high pressure), on the floor standing upright behind a circular table (oxygen tanks should be stored in a stand or cart to prevent tipping and falling.) (Unsecured tanks should be stored by placing it flat on the floor. The tank should not stand or lean in an upright position while unsecured.)

G. On 12/28/2021 at 11:45 am, during an interview with Staff S#7 (Emergency Department Registered Nurse) stated, "If equipment is in the ambulance bay, it is considered clean."

H. On 12/28/2021 at 11:49 am, during an interview with S#6 (Emergency Department Registered Nurse) stated, "room 3 is clean, and ready for a patient. I don't know if the (Christmas tree) was changed in this room, they should be changed out after each patient."

I. On 12/28/2021 at 12:06 pm, during an interview with S#4 (Chief Nursing Officer) stated, "I do not know if those IV (Intravenous) poles have been cleaned."

J. On 12/28/2021 at 12:36 pm, during an interview with S#9 (Surgical Services Director) stated, "I don't believe they change those (Christmas tree adapter) out; I don't know the policy on that."

K. On 12/28/2021 at 1:08 pm, during an interview with S#12 (Surgical Technician) stated, "we don't inventory or look at expiration dates on the Anesthesia equipment, they (Anesthesia) are in charge of their carts."

L. On 12/29/2022 at 11:50 am, during an interview, Staff (S)#3 (Chief Quality Officer) and S#7 (ER RN), confirmed the visible stained floors not swept or mopped in the ER.

M. On 12/29/2022 at 11:55 am, during an interview, S#3 and S#7 confirmed the bed in the patient not wiped down and did not have a bed sheet, and in the ER's computer system marked as ready for an incoming patient.

N. On 12/29/2022 at 12:00 pm, during an interview, S#7 confirmed the yellow liquid in the sink was urine and the sink and was not drained (cause the water or liquid in (something) to run out, leaving it empty.)

O. On 12/29/2022 at 12:05 pm, during an interview, S#4 confirmed the floor in the decontamination room appeared to not have been swept or mopped.

P. On 12/29/2022 at 12:10 pm, during an interview, S#4 confirmed the dry blood stains on the countertop near the sink in the Fast-Track area, the blue head bonnet and the two half empty clear bags of saline.

Q. On 12/29/2022 at 12:35 pm, during an interview, S#12 confirmed the expired medical supplies and the open medical supply packages that should be closed after being sterilized in the medical supply room in the OR (Operating Room) designated for the Anesthesia unit.

R. On 12/30/2021 at 8:48 am interview with S#3 (Chief Quality Officer) presented the process on "Oxygen Tree" usage, not dated. S#3 stated, "this was the previous process that was approved, it's not being followed, there is no current process in place or policy."

S. On 12/30/2022 at 12:10 pm, during an interview, S#14 (ICU (Intensive Care Unit) Director) confirmed the oxygen tank on the floor behind the circular table in room 203.


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