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Based on observation it was determined the Facility failed to maintain the building physical structure in a state of good repair in three [Patient Room #114, Laundry, and the outside oxygen storage area] of six areas observed. The failed practice had the potential to affect all patients, staff, and visitors due to the potential for injury and infection control issues. Furthermore, unsecured oxygen cylinders in the outside oxygen area had the potential to fall over which could damage or cause the heads to break off which could have made a dangerous projectile of the head or cylinder. Findings follow:

A. While on tour of the facility on 08/15/2017 at 10:00AM, observation showed chipping paint and cracked plaster in the bathroom of patient room #114.
B. While on tour of the facility on 08/15/2017 at 10:30AM, observation showed chip in the chips and scratches in the wooden door separating the clean and soiled linen areas of the laundry.
C. While on tour of the facility on 08/15/2017 at 12:30AM, observation showed two of fourteen unsecured oxygen cylinders in the outside oxygen storage areas.
D. During the tour, the Maintenance Engineer verified the failed practices.

Based on observation and interview, it was determined the facility failed to provide the door to one (the Emergency Department) of five hazardous areas observed with a mechanism or system to self-close. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:

A. While on tour of the facility with the Maintenance Engineer on 08/15/2017 at 10:15am, observation showed the door to storage room across from exam rooms #2 and #3 in the Emergency Department was not equipped with a mechanism or system to self-close.
B. During the tour, the Maintenance Engineer verified the door did not have the ability to self-close.
C. See K321.

Referenced code: NFPA 101; 2012 edition, Section 8.4.3.5

Based on review of Policy and Procedure Manuals and interview, it was determined the facility failed to have a written policy to address the use of a log to verify disinfection standards of exposure time, temperature and minimum effective concentration (MEC) for high-level disinfection of semi-critical devices. Without a log, the facility could not assure semi-critical devices had been high-level disinfected per manufacturer's directions for use. The failed practice did not assure semi-critical devices would be free from sources of infection and was likely to affect any patient admitted to the facility requiring a procedure utilizing a semi-critical device. Findings follow:

A) Review of Policy and Procedure Manuals on 08/15/17 at 10:02 AM showed no evidence of a policy and procedure instructing staff to maintain a log for high-level disinfection of semi-critical devices.
B) Findings in A were confirmed with the Chief Nursing Officer during an interview on 08/15/17 at 10:55 AM.

Based on observation, review of manufacturer's recommendations and interview, it was determined the facility failed to follow manufacturer's recommendations for length of storage in that solutions were being stored at 110 degrees Fahrenheit, and the length of storage of was not being monitored. By not following manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that have had procedures in the facility. Findings follow:
A. During a tour of the facility on 08/15/17 from 10:00AM to 10:40AM observation showed the following solutions in a warmer at 110 degrees Fahrenheit:
1) #2- 1000 ml (milliliter) bags of 0.9% Sodium Chloride for injection made by B. Braun;
2) #1- 1000 ml bottles of 0.9% Sodium Chloride for irrigation made by Baxter; and
3) #1 vial of Mannitol 25% for injection.
None of the items observed were dated as to when they were put into the warmer.
B. Review of the manufacturer's recommendations showed the following:
1) B. Braun- the labeling for this product contained a statement that exposure of pharmaceutical products to heat should be minimized and that excessive heat should also be avoided. The labeling recommended the product be stored at room temperature (25 degrees Celsius/77 degrees Fahrenheit); however, brief exposure at 40 degrees Celsius (104 degrees Fahrenheit) does not adversely affect uncompromised product in an intact overwrap bag. Product that has been exposed to 40 degrees Celsius and not used within four weeks must be discarded and not returned to storage. The facility was storing these solutions at a higher temperature than was recommended and not monitoring how long they were being stored in the warmer.
2) Baxter- the labeling of the product contained a statement that saids discard after 60 days of warming. The facility was not monitoring the length of stay in the warmer.
3) APP Pharmaceuticals in reference to Mannitol showed to store the product at Room Temperature between 20-25 degrees Celsius (68-77 degrees Fahrenheit). If crystals were visible, re-dissolve by warming the solution up to 70 degrees Celsius (158 degrees Fahrenheit), with agitation. The product information did not give recommendations for storing the Mannitol in the warmer.
C. During an interview on 08/15/17 at 10:16 AM, the Chief Nursing Officer verified the solutions were being stored in the warmer and the facility did not have a process to monitor the length of time and recommended temperature they were to be stored at. The Chief Nursing Officer also verified the manufacturer for Mannitol did not have recommendations for storing the Mannitol in the warmer.

Based on review of Physician's Tuberculosis records, policy and interview, the Infection Control Program failed to mitiagate the risk of spreading infection by not annually screening three (#1, #3 and #6) of six (#1-#6) Physicians for TB (Tuberculin) as per policy. By not assuring the Physicians were screened annually, the facility couldn't assure they were controlling infections and communicable diseases of patients and personnel. The failed practice had the likelihood to affect all of the employees and patients in the facility. Findings follow:
A. Review of the Physician's Tuberculosis records showed the following:
1) Physician #1 had no evidence of a screening;
2) Physician #3's last screening was 07/22/14; and
3) Physician #6's last screening was 08/06/15.
B. Review of policy "TB Surveillance" showed the facility will screen employees annually.
C. During an interview on 08/15/17 at 02:48 PM, the Chief Nursing Officer verified the findings at A and B.


36533

Based on review of Glutaraldehyde Plus Disinfecting Solution directions for use, Endocavitary (Vaginal) Transducer Operation Manual, Policy and Procedure Manuals and interview, it was determined the facility failed to prevent and control infections in that there was no evidence of a monitoring log for the high-level disinfection of one of one vaginal transducer to assure exposure time, temperature and minimum effective concentration (MEC) were achieved. Without a log, the facility could not assure the vaginal transducer had been high level disinfected per manufacturer's directions for use. The failed practice did not assure the transducer would be free from sources of infection and was likely to affect any patient admitted to the facility requiring an ultrasound utilizing the vaginal transducer. Findings follow:

A) Review of the Endo-Vaginal Ultrasound Policy on 08/15/17 at 10:02 AM showed:
"The probe will be disinfected between uses per hospital policy and the manufacturer's specifications."
B) Review of the Endocavitary Transducer Operation Manual on 08/14/17 at 15:15 PM showed:
"Disinfect the transducer using Glutaraldehyde Plus."
C) Review of Glutaraldehyde Plus Disinfecting Solution indications for use for High-Level Disinfection for a Semi-critical Device (vaginal transducer) showed:
"Immerse medical device completely in Glutaraldehyde Plus for a minimum of 90 minutes at 25 degrees Celsius. Efficacy of this product must be verified by a 1.8% glutaraldehyde test indicator to determine that the MEC of 1.8% is present."
D) Radiologic Technician Registered (RTR) #1 was interviewed on 08/14/17 at 3:10 PM. She stated the vaginal transducer was disinfected using Glutaraldehyde Plus after each use. She stated they did not measure the temperature or use an indicator strip to check MEC. She confirmed they have no evidence of the high level disinfection for the vaginal transducer.


38994

Based on observations, interviews and policy review, it was determined the facility failed to prevent and control infections in that the facility had no policy to provide instruction for the cleaning of reusable trauma shears in two of three Emergency Department rooms. Failure to establish a policy for cleaning reusable trauma shears did not assure trauma shears remained free from contamination and sources of infection and had the likelihood to affect all patients admitted to the facility through the Emergency Department. Findings follow:

A. During tour of the Emergency Department 08/15/17 at 1015, trauma shears were observed unwrapped in an open container attached to the wall in 1 and 2 Emergency Department rooms.

B. Review of Policy and Procedure Manuals on 08/14/17 at 1100 Am revealed no evidence of a policy providing instructions for cleaning reusable trauma shears.

C. An interview on 08/15/17 at 1015, the Chief Nursing Officer verified there was no policy for the cleaning of reusable trauma shears.

Based on review of Board of Director's Meeting Minutes, Quality Improvement Plan, Quality Assurance Reporting Schedule and interview, it was determined the facility failed to ensure 1 (Physical Therapy) of 14 departments (Dietary, Lab, Emergency/Outpatient, Ambulance, Clinic, Nursing, Medical Records, Sterile Supply, Environmental Services, Pharmacy, Physical Therapy, Radiology, Respiratory and Infection Control) reported Quality Assurance on a quarterly basis per policy and schedule. The failed practice did not ensure the Medical Staff and Governing Body were aware of any potential performance improvement issues that needed to be addressed; and had the likelihood to affect all patients receiving care from that service. Findings follow:
A. Review of Board of Director's Meeting Minutes from July 2016 through June 2017 showed Physical Therapy did not report Quality Assurance in that time range.
B. Review of the "Quality Improvement Plan" showed Physical Therapy was to preform Quality Improvement activities.
C. Review of "Quality Assurance Reporting Schedule" showed Physical Therapy was to report in March (1st quarter), June (2nd quarter), September (3rd quarter) and December (4th quarter).
D. During an interview on 08/14/17 at 10:30 AM, the Director of Quality Assurance stated that Physical Therapy has not reported any Quality Assurance for the previous 12 months(4 quarters).