HospitalInspections.org

30170

Based on observation, interview, medication guidelines review, and policy review, the provider failed to ensure five of five pre-operative eye drops were administered according to manufacturers' directions by one of one registered nurse (RN) (G) for one of one sampled cataract surgical patient (42). Findings include:

1. Observation on 6/20/17 from 7:25 a.m. through 7:45 a.m. revealed RN G was assisting patient 42 with preoperative care prior to the scheduled left eye cataract surgery. The patient had a series of eye drops that were to have been administered prior to surgery.

Those eye drop medications were:
*Acular 0.5%.
*Mydfrin 2.5%.
*Cyclogyl 1%.
*Ocuflox 0.3%.
*Tetravisc 0.5%.
*Each of the eye drop medications were to have been one drop in the left eye five times.
*RN G started the administration of the above eye drops at 7:25 a.m. placing one drop of each eye medication into the left eye.
*She administered each of the eye medications into the left eye within thirty to forty-five seconds between medications.
*Then she would go to the computer and chart the administration of those medications.
*The entire eye drop medication administration took under twenty minutes.

Surveyor: 35625
Review of the instructions accessed on 6/22/17 on-line at https://www.drugs.com for each of the above medications revealed:
*Acular 0.5% required a five minute wait time between each drop and a ten minute wait time before using any other ophthalmic medication.
*Cyclogyl 1% required the application of pressure to the nasolacrimal sac for two to three minutes to reduce systemic absorption.
*Mydfrin 2.5% and Ocuflox 0.3% each required:
-After each drop pressure was to be applied to the nasolacrimal sac for two to three minutes to reduce systemic absorption.
-If more than one drop of this medication was used there was a five minute wait time between drops.
-If any other ophthalmic medication was used there was to have been a ten minute wait time between drops.
*Tetravisc 2.5% required a five to ten minute wait time between each eye drop.

Surveyor: 30170
Interview with RN G during the above observation regarding eye drop administration for patient 42 revealed if she waited two to five minutes between the administration of the preoperative eye drops she would not have been able to get the patient ready for the scheduled surgery in an appropriate amount of time.

Interview on 6/20/17 at 11:00 a.m. with director of the operating room A regarding the above observation revealed he agreed the eye drop medications were not administered in accordance to manufacturers' timeline recommendations.

Review of the provider's May 2017 Medication Administration General Guidelines policy revealed:
*The purpose of the policy was to have administered medications using general guidelines and safety precautions common to administration of all medications.
*Medications requiring specific timing for optimal effect was not addressed for eye drop medication instillation.

26632

Based on observation, record review, interview, policy review, and manufacturers' instruction manual review, the provider failed to ensure:
*Ten of ten defibrillators (obstetrics, emergency department [ED], operating suite, post-anesthesia care unit [PACU], intensive care unit, medical/surgical/pediatrics unit, cardiac rehabilitation, computerized axial tomography scan room, cancer center, and the Grassland clinic) were tested according to manufacturers' recommendations.
*Three of four walls in the ED soiled utility room were repaired when damaged. Exposed gypsum board was present making those surfaces uncleanable.
*One of three labor, delivery, recovery, and post-partum rooms (3316) wall had been repaired when damaged. Exposed gypsum board was present making the surface uncleanable.
*Two of three fetal/monitor carts with worn varnish had cleanable surfaces.
Findings include:

1. Review of the provider's August 2011, 24 Hour Crash Cart Checklist instructions revealed:*"Check monitor (plugged in and working), defib [defibrillator], pads, recording paper and electrodes."
*"Suction works. Yankauer & tubing attached."
*"Oxygen tank connected to tubing and ambu. Oxygen supply checked."
*"Med [medication] drawer locked with tag."
*"Crash cart locked with tag."
*"Weekly: Defibrillator test according to the manufacturer's recommendations."

Review of the 1998 CodeMaster XL+/XL Defibrillator/Monitor User's Guide revealed the defibrillator should have been tested every shift to ensure it functioned properly.

Surveyor: 18559
Review of the undated Philips Heartstart XL Instruction for Use manual revealed the defibrillator should have been tested every shift to ensure it functioned properly.

Interview on 6/20/17 at 10:00 a.m. with quality risk manager I revealed:
*All defibrillators had a delivered energy and shock button functional test performed weekly.
*Was not aware those defibrillators should have been tested on a daily basis as the manufacturers' had required.

Review of the provider's October 2016 Crash Cart Check List policy revealed:
*All items from the 24 hour crash cart checklist were have to have been completed daily.
*Defibrillator tests were to have been completed weekly according to manufacturer's recommendations.

2. Observation and interview on 6/19/17 at 2:00 p.m. with ED coordinator H revealed:
*Three of four walls in the ED soiled utility room were damaged. Exposed gypsum board was present making those surfaces uncleanable.
*She agreed those surfaces were damaged and uncleanable.
*She had not put any work order in to have those walls fixed, as she had not been aware of the damage.

3. Observation and interview on 6/20/17 at 10:15 a.m. with the director of maternal and child care revealed:
*One of three labor, delivery, recovery, and post-partum rooms (3316) had exposed gypsum board present making that wall uncleanable.
*Two of three fetal/maternal monitor carts had the varnish worn off making them uncleanable.
*She confirmed those findings. She had not submitted a work order for those items.

A. Based on observation, interview, and policy review, the provider failed to ensure Yankauer suction catheters and tubing had remained packaged until use in all seven of the emergency department (ED) patient rooms and all five of the post-anesthesia care unit (PACU) rooms. Findings include:

1. Observation on 6/19/17 from 2:30 p.m. through 3:30 p.m. and again on 6/20/17 from 1:15 p.m. through 2:10 p.m. in the ED revealed all patient rooms had Yankauer suction catheters and tubing that had been opened, ready-for-use, and were hanging on the suction wall units.

Interview following those observations with ED coordinator nurse H and the director of quality-risk management I revealed:
*It was their usual practice for the suction catheters and tubing to be opened and ready-for-use in those patient rooms in case of an emergency.
*They confirmed those items were considered single-use equipment and should have been kept free of potential contamination until used.
*Single-use supplies should not have been opened prior to use.

Interview on 6/20/17 at 2:30 p.m. with ED director A revealed:
*He confirmed it was their usual practice to have the suction catheters and tubing opened and ready-to-use in case of emergency in all the ED patient rooms.
*He agreed there was a potential risk of contamination to those items when they had not remained in their packages.
*There was no policy that specifically addressed the process for keeping single-use equipment in the package until used.

Surveyor: 30170
2. Observation and interview on 6/19/17 from 3:15 p.m. through 3:30 p.m. with operating room (OR) director A in the PACU revealed:
*There were five bay areas for recovering patients after surgery.
*Each of those areas had suction extension tubing and the Yankauer suction in an opened package hanging on the suction unit on the wall.
*Those one-time disposable use items were placed in the PACU areas to ensure that equipment would have been ready and easily accessible in an emergency situation.
*He agreed those one time use items could have been compromised, and that multiple patients and staff were in and out of those areas continuously throughout the day.

3. Review of the October 2016 Reprocessing of Disposable "Single-Use" Medical Devices policy revealed:
*"A. A single-use device is defined as any disposable item marked 'single-use,' 'one time use,' or 'limited use' that is [was] intended for patient care.
*B. Reuse is defined as the use of a single use device that has been:
-1. Removed from its original package and has not been used for patient care.
-2. Removed from its original package and used for patient care.
-3. A device never removed from its original packaging, but exposed by manufacturers outdate."

B. Based on observation, interview, and policy review, the provider failed to ensure handwashing and glove use had been completed according to the provider's policy and procedure during six of six observed patients' (15, 16, 42, 56, 57, and an unidentified patient) care by six of six employees (registered nurse [RN] F, RN G, RN L, RN M, physician K, and patient care technician ). Findings include:

1. Observations on 6/20/17 from 1:15 p.m. through 1:50 p.m. in the emergency department (ED) revealed:
*Physician K, a physician's assistant (PA) student, and registered nurse L were working in the area.
*Physician K had purple disposable gloves on while working on the computer at the nurses station and was talking with the PA student.
*With those same gloves on physician K entered room 118, shook a visitor's hand, and went to the unidentified patient's bedside. The PA student then shut the door.
*Around 1:30 p.m. patient 56 arrived to room 117 by ambulance, and RN L started her initial assessment.
*The RN:
-Put gloves on.
-Got supplies for an intravenous (IV) access from the cupboard.
-Moved a rolling tray and stool to the patient's bedside.
-Started the patient's IV in his right arm.
-Went back to the cupboard with her gloves on and opened a drawer to get laboratory (lab) tubes out of it.
-Put blood into those lab tubes.
-Opened the door to request another staff person to check her lab tubes.
-Used a pen from her pocket to write on the lab tubes.
-Removed her gloves and left the room without doing hand hygiene.
*RN L returned a few minutes later and put on new gloves.
*At 1:45 p.m. physician K entered patient 56's room with purple gloves already on his hands.
-He got supplies out of the cupboard to do a rectal exam on the patient.
*Patient 56 had a large amount of blood on his pants and down his legs due to rectal bleeding along with incontinence of a small amount of bowel movement (BM).
*RN L assisted the patient onto his left side for the physician and PA to perform a rectal exam.
*The PA student performed the rectal exam.
-During that process the physician used a paper towel to wipe away some of the blood and BM from the patient's skin.
*After the exam the physician went back to the cupboard, got out supplies for a hemocult test, assisted the PA student with the test, then opened the door, and left the room with his contaminated gloves still on.
-He disposed of those gloves outside the patient's room, then he sat down at the computer at the nurses station while talking to the PA student again.
*Physician K had not performed hand hygiene during the above observation.
-He had touched multiple potentially contaminated surfaces before and after working with the patient with his same soiled gloves on.
*RN L was not observed performing hand hygiene before or after glove use.

Interview on 6/20/17 at 1:55 p.m. with ED coordinator nurse H and director of quality-risk management I regarding the above concerns revealed:*The director of quality-risk management had seen the same concerns with physician K's gloves at the nursing station and when he entered the patients' rooms.
*Appropriate infection control practices related to glove usage and hand hygiene had not occurred in the above observations.
*Hand hygiene should have been completed before and after glove use.
*There was a risk of spreading microorganisms and an increased risk of infection to the patient when glove use and hand hygiene were not done properly.



30170

2. Observation on 6/20/17 from 7:25 a.m. through 7:55 a.m. on the same day surgery unit with RN G administering preoperative eye drops to surgical patient 42 for his cataract surgery revealed she:
*Put gloves on her hands.
*Then administered the eye drops into the patient's left eye.
*Returned to the computer and documented with those gloved hands the administration of those eye drops.
*Then removed her gloves and failed to sanitize or wash her hands.
*Continued to document in the electronic medical record (EMR).
*Then continued through the process of administering the preoperative eye drops changing her gloves three times without washing or sanitizing her hands in between administration and documentation on the EMR.
*Then took the stethoscope hanging on the wall in patient 42's room and listened to his lungs and heart sounds without washing or sanitizing her hands.
*Then washed her hands and put on a new set of gloves to obtain a blood sample for a glucometer test.
*Removed her gloves after completion of the glucometer test, left the patient's room, and sanitized her hands in the hallway.

Interview on 6/20/17 at 11:00 a.m. with director of the operating room A regarding the above observation revealed RN G should have washed or sanitized her hands in-between glove use.

Surveyor: 15036
3. Observation on 6/21/17 of patient 57's cystoscopy procedure revealed:
*At 10:29 a.m. RN M exited the room and reentered the room after notifying the physician the patient was ready for his procedure. RN M did not perform hand hygiene upon exiting the room or reentering the room.
*At 10:36 a.m. After the procedure the physician removed his contaminated gown and gloves, handled the patient's chart, shook the patient's hand, and exited the room.
*Physician N had not performed hand hygiene after removal of his contaminated gown and gloves or before exiting the procedure room.



26180

4. Observation on 6/19/17 at 3:45 p.m. of patient 15 with patient care technician (PCT) E revealed:
*The patient was on contact isolation.
*The PCT gowned and gloved prior to entering the room.
*The PCT checked the patient's vital signs including blood pressure and pulse.
*The PCT was carrying documents that had patient information on it.
-She laid the documents on the blood pressure monitor to write the vital sign information on it.
-She then laid those documents on the patient's bedside table.
*When she completed her task in the patient's room she carried the documents out of the room.

Interview at that time with PCT E revealed:
*The documents she carried with her contained the information on each patient she had received at the start of her shift.
*She confirmed the patient was on contact isolation for methicillin-resistant staphylococcus aureus (MRSA).
-She was unable to recall where in the patient the MRSA was.

Interview on 6/21/17 at 9:15 a.m. with nursing coordinator C revealed:
*The above patient did not have active MRSA.
*The PCT should not have laid documents on patient care surfaces and then taken them out of the room.

5. Observation on 6/20/17 at 9:10 a.m. with RN F with patient 16 revealed she:
*Administered medications to the patient.
*After finishing the medications she responded to the patient's request to loosen an ACE bandage she had around her leg/knee, as she complained it was too tight.
*Put gloves on and began unwrapping the ACE bandage.
*Received three phone calls and each time she:
-Left her gloves on.
-Pulled the phone from her pocket and answered it.
-Returned the phone to her pocket.
-Did not disinfect the phone.

Interview on 6/21/17 at 9:15 a.m. with nursing coordinator C revealed:
*She would not have expected the above nurse to answer the phone if she was in an isolation room.
*She would expect the nurse to disinfect the phone, as it was used in a patient's room during care.

6. Surveyor: 26632
Review of the provider's reviewed March 2017 Hand Hygiene and Other Infection Prevention Practices policy revealed:
*If hands were not visibly soiled nor contaminated with blood or body fluids an alcohol based handwash agent could have been used.
*Handwashing with soap and water or with an alcohol based handwash agent was to have been done:
-Before applying gloves.
-After contact with a patient's intact skin.
-When moving from contact with a contaminated body site to a clean body site.
*Other aspects of hand hygiene included:
-Wear gloves when in contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin.
-Remove gloves after caring for patients.
-Do not wear the same pair of gloves for the care of more than one patient.
-Change gloves during patient care if moving from a contaminated body site to a clean body site.



25107

C. Based on observation, interview, and policy review, the provider failed to maintain the cleanable surfaces of:
*Two of two arm board cushions and one randomly observed stool in operating room two
*One of one arm board cushion and two randomly observed stools in the urology procedure room.
*One of one obstetric (OB) wire metal cart.
Findings include:

1. Observation on 6/20/17 at 3:15 p.m. in operating room two revealed:
*The black vinyl finish of the two arm boards of the operating table were cracked and broken exposing the foam cushion.
*One random stool had the seat covered in tape.
-The tape was cloth like and appeared to have been absorbent.

2. Observation on 6/20/17 at 3:20 p.m. in the urology procedure room revealed:
*The black vinyl finish of the single arm board was cracked and broken exposing the foam cushion.
*Two randomly observed stools had white tape across the seats.
-The tape appeared to be non-absorbent but left an uneven surface on the seat of the stool.
-The edges of the tape on one of the stools were jagged and had formed a crevice approximately an inch in length in the middle of tape.

Interview and observation on 6/20/17 at 3:25 p.m. with the operating room/post-anesthesia care unit/emergency department coordinator D revealed:
*They had recently ordered new arm board cushions, so she knew some needed to be replaced.
*She was not aware the two arm boards in operating room two and the one in the urology procedure room were broken through and had exposed foam.
*She agreed those three arm boards were no longer cleanable.
*She was not aware of the cloth type tape on the stool in operating room two.
-She agreed the tape was not cleanable.
*The tape on the stools in the urology procedure room was to identify those stools for a specific person or purpose.
*She agreed the uneven surfaces of the tape would not be cleaned easily.

Interview on 6/20/17 at 4:04 p.m. with the director of operating room/post anesthesia care unit/emergency department A revealed he agreed those surfaces would not be cleanable.



26632

3. Observation and interview on 6/20/17 at 11:00 a.m. and again on 6/21/17 at 11:00 a.m. of the OB soiled utility room with the director of maternal child care and nursery and the OR/PACU/SDS coordinator revealed:
*A metal cart with open wire shelves.
*On that cart were five plastic containers that would have held contaminated surgical instruments and one that would have held clean and/or sterilized surgical instruments.
*Under each plastic container that would have held contaminated surgical instruments was a towel.
*The four plastic containers that would have held contaminated surgical instruments were on shelves above the plastic container that would have held clean and/or sterile surgical instruments.
*One of the towels that had a small red spot on it that appeared to be blood.
*That cart was used to transport contaminated and clean/sterile surgical instruments from the OB soiled utility room to the sterile processing department (SPD).
*After the contaminated items were taken to the SPD the plastic containers were disinfected and placed back on the towel covered wire shelves. Any items that had been cleaned/and or sterilized were sent up in the clean container.
*The towels were changed and the cart was disinfected on a weekly basis.
*They had not considered those towels and shelves could have re-contaminated the plastic containers.
*They had not considered the clean and/or sterilized instruments located under the contaminated instrument containers had the potential to have become contaminated.

Review of the provider's revised February 2017 Preparation of Contaminated Instruments for Transport to the Sterile Processing Department (SPD) policy revealed:
*Contaminated instruments should not have been transported with instruments that were clean or sterile due to cross-contamination of all stored products.
*SPD staff would disinfect their transport cart.

Based on interview and policy review, the provider failed to ensure the activities program for all swing bed patients had been directed by a qualified professional. Findings include:

1. Interview on 6/20/17 at 4:00 p.m. with director of the swing bed unit C regarding the swing bed activities program revealed:
*The swing bed activity coordinator was a patient care technician (PCT).
*The PCT had not completed a training course approved by the state.
*The PCT had been trained by the previous activity coordinator.
*The previous activity coordinator had retired last August.
*She was aware the activities program had not been directed by a qualified professional.
*She had planned to meet with the new occupational therapy department to discuss directing the activities program.

Review of the provider's November 2016 Activity Programming for Swing Bed Patients policy revealed consultations would be provided to the activities coordinator by a qualified activity coordinator consultant.