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Based on observation and interview, the facility failed to assure a sanitary environment was maintained related to contaminants (i.e. dust, soiled furnishings, tape) in patient care areas and on equipment and furnishings used for patient care . The failed practice did not prevent contamination to patients, staff and visitors in the facility and had the potential to affect all persons in the facility. Findings follow:

A tour of the facility was conducted on 09/25/12 from 0900-1405 with the Vice President of Patient Care, Risk Manager, and unit directors/managers. The findings were:
A. In the CVICU (Cardiovascular Intensive Care Unit), Rooms 1 and 4, dust was observed on lights and monitors, biohazard waste containers, tops of towel dispensers and on underneath surfaces of the beds. In the Supply Room, 2 wheelchairs had a thick layer of dust buildup on the brakes and frames. The wheelchairs were stored in the same room with the balloon pumps. Findings were confirmed with the Director of the Medical/Surgical Unit and the Vice President of Patient Care at the time of the tour.
B. In the Emergency Services Department, Room 2, dust was observed on the monitor as well as a thick layer of dust was on the large exam lights and on shelving. The bed had a heavy amount of thick dark colored substance under the hinges of the bed rails as well as tape (porous) on the bed rails which cannot be disinfected or sanitized. In Room 25, tape (porous) was on the bed side rails and cannot be disinfected or sanitized; dust was observed on the computer on wheels (COW) and vital signs monitor. Findings were confirmed with the Director of the Emergency Room and the Vice President of Patient Care at the time of the tour.
C. In the Labor and Delivery Department, Room 232, dust was observed on the light in the patient bathroom and on the undersurface of the bed. In Room 240, tape (porous) was on the bed rail which cannot be disinfected or sanitized. In OR (Operating Room) 2, the baby warmer had peeling paint and rust on the frame and casters which has a porous nature and cannot be disinfected. In the Nursery, the "Care Center" (warming unit) was observed to have a large amount of dust within the suction canister compartment, a thick layer of dust was observed under the baby scales and Anesthesia cart. Findings were confirmed with the Risk Manager, the Supervisor for Labor and Delivery and the Vice President of Patient Care at the time of the tour.
D. On Unit 7A in Room 729, a thick amount of dust was observed on the top of the ceiling lift device. In the Clean Supply Room, there was dust and a brown powdery substance observed in the bottoms of storage bins.
E. Adjacent to the elevators on Unit 7B, a "Geri-Chair" was observed to have a thick layer of dust on the padding. A sling scale was observed to have a thick layer of dust on the frame and sling. In the Unit 7B Supply Room, a thick amount of dust was observed on the air intake vent. Findings were confirmed with the Unit Supervisor for 7A, the Unit Supervisor for 7B and the Vice President of Patient Care at the time of the tour.
F. In the Pre-Operative Unit, the "Interpreter Machine" was observed to have dust on the surface. Located at Bed 14, was a blue fabric chair which was stained with a dark discoloration. Findings were confirmed with the Unit Supervisor for Pre-Op (Operative)/PACU (Post Anesthesia Care Unit) and the Vice President of Patient Care at the time of the tour.


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Based on review of Physician Credentialing files and interview, it was determined the facility failed to assure four (#4, #6, #9, and #10) of ten (#1-10) members of the Medical Staff had a current TB (Tuberculin) skin test. The failed practice did not assure staff, patients and visitors were not exposed to infectious disease and had the potential to affect all persons in the facility. Findings follow.

A. Review of Physician Credentialing files revealed Physician #4, #6, #9, and #10 did not have a current TB skin test.
B. During an interview on 09/25/12 at 1305, the Director of Clinical Quality stated physicians were only required to obtain a TB skin test every two years upon reappointment.
C. Findings were confirmed by the Director of Clinical Quality at the time of the interview.

Based on clinical record review and interview, it was determined 14 of 14 (Patient #2, #3, #4, #6, #7, #8, #12, #26-#30, #32 and #33) operative reports did not contain the time of the surgery. Failure to record the time of surgery on the operative report did not allow the clinical record and operative report to be complete. The failed practice affected 15 of 15 patients and had the potential to affect all patients receiving a surgical procedure in the facility. The findings follow:

A. Review of Patient #2's clinical record on 09/28/12 revealed the "Operative Report" dated 09/09/12 did not contain the time of the procedure. The findings were confirmed with the Director of the Medical/Surgical Unit on 09/28/12 at 1000.
B. Review of Patient #3's clinical record on 09/27/12 revealed the "Operative Report" dated 09/21/12 did not contain the time of the procedure. The findings were confirmed with the Assistant Vice President of Critical Care on 09/27/12 at 1515.
C. Review of Patient #4's clinical record on 09/28/12 revealed the "Operative Report" dated 09/24/12 did not contain the time of the procedure. The findings were confirmed with the Director of Women's and Children on 09/28/12 at 1030.
D. Review of Patient #6's clinical record on 09/28/12 revealed the "Operative Report" dated 09/21/12 did not contain the time of the procedure. The findings were confirmed with the Director of Clinical Quality on 09/28/12 at 1025.
E. Review of Patient #7's clinical record on 09/28/12 revealed the "Operative Report" dated 09/23/12 did not contain the time of the procedure. The findings were confirmed with the Director of Clinical Quality on 09/28/12 at 1025.
F. Review of Patient #8's clinical record on 09/28/12 revealed the "Operative Report" dated 09/23/12 did not contain the time of the procedure. The findings were confirmed with the Director of Clinical Quality on 09/28/12 at 1025.
G. Review of Patient #12's clinical record on 09/28/12 revealed the "Operative Report" dated 09/18/12 did not contain the time of the procedure. The findings were confirmed with the Director of the Medical/Surgical Unit on 09/28/12 at 0925.
H. Review of Patient #26's clinical record on 09/28/12 revealed the "Operative Report" dated 08/31/12 did not contain the time of the procedure. The findings were confirmed with the Director of Clinical Quality on 09/28/12 at 1025.
I. Review of Patient #27's clinical record on 09/28/12 revealed the "Operative Report" dated 08/31/12 did not contain the time of the procedure. The findings were confirmed with the Director of Clinical Quality on 09/28/12 at 1025.
J. Review of Patient #28's clinical record on 09/28/12 revealed the "Operative Report" dated 08/31/12 did not contain the time of the procedure. The findings were confirmed with the Director of Clinical Quality on 09/28/12 at 1025.
K. Review of Patient #29's clinical record on 09/28/12 revealed the "Operative Report" dated 08/30/12 did not contain the time of the procedure. The findings were confirmed with the Director of Clinical Quality on 09/28/12 at 1025.
L. Review of Patient #30's clinical record on 09/28/12 revealed the "Operative Report" dated 08/30/12 did not contain the time of the procedure. The findings were confirmed with the Director of Clinical Quality on 09/28/12 at 1025.
M. Review of Patient #32's clinical record on 09/28/12 revealed the "Operative Report" dated 07/10/12 did not contain the time of the procedure. The findings were confirmed with the Director of Clinical Quality on 09/28/12 at 1025.
N. Review of Patient #33's clinical record on 09/28/12 revealed the "Operative Report" dated 07/14/12 did not contain the time of the procedure. The findings were confirmed with the Director of Clinical Quality on 09/28/12 at 1025.