HospitalInspections.org

Based on document review and interview, the facility failed to adopt a policy supporting a non-punitive approach to staff reporting of adverse patient events, medical errors, near misses/close calls, etc., and situations they consider unsafe.

Findings:

1. On 8-17-2015 at 11:154 am, employee #A1, Vice President Patient Care Services, was requested to provide documentation of a policy supporting a non-punitive approach to staff reporting of adverse patient events, medical errors, near misses/close calls, etc., and situations they consider unsafe.

2. In interview, on 8-18-2015 at 9:35 am, employee #A3, Director of Quality/Risk, indicated there was no such above-stated policy and no other documentation was provided prior to exit.

Based on document review and interview, the governing board failed to ensure the hospital's Quality Assurance Performance Improvement (QAPI) program included 5 of 56 services provided by all hospital departments and contracted services for calendar year 2014.

Findings:

1. Review of the hospital's QAPI program indicated the services of Animal Therapy (contract), Biohazard Waste Hauler (contract), Electroencephalography (EEG), Tissue
Transplant, and Transcription, were not included as part of the hospital's QAPI program.

2. In interview, on 8-17-2015 at 2:10 pm, employee #A3, Director of Quality/Risk, confirmed there was no documentation as stated above, and no other documentation was provided prior to exit.

Based on document review, observation, and interview, the facility failed to implement its policies related to: surgical attire for 3 staff (staff members #63, #64, and #66), TB (tuberculosis) testing for two of two dialysis nurses (staff members N5 and N6), respirator fit testing for 2 of 2 dialysis nurses (staff members N5 and N6), the lack of hand hygiene by 1 lab technician (staff member #65), and one medical doctor (MD21), the failure to disinfect the glucometer carry case, after being taken into a patient room, by 2 of 2 nurses (nurses #68 and #69), the lack of open and/or discard dating for the high and low glucometer control solutions located in the med/surg medication room, the failure of one of two nurses to clean/disinfect the rubber septum of a medication vial prior to drawing up medication for patient administration (nurse #62), the lack of blood administration training documentation for 2 of 2 contracted dialysis nurses (nurses N5 and N6), related to the failure to disinfect floors in patient rooms after discharge from the facility, the failure to ensure an organized OR (operating room) between case and terminal cleaning and minimum wet contact time process, and failure to doucment immunity to rubeola and varicella for 3 of 3 staff (EVS 12, EVS 13, A6).

Findings:
1. Review of the policy "Surgical Attire In The OR (operating room) Suite", policy number III.c., last revised on 12/13, indicated:
a. Under "Responsibility", it reads: "...2. Surgical attire consists of:...c. Masks (in restricted areas)...5. Masks are to be worn when entering surgery rooms with opened sterile fields...".
b. The last page indicated the reference for the policy was "2013 AORN (Association of periOperative Registered Nurses) Recommended Practices for Surgical Attire."

2. At 10:00 AM on 8/18/15, while touring the surgical patient care unit in the company of staff member #56, the RN (registered nurse) director of med/surg, it was observed that staff member #63, an anesthesiologist, was making patient rounds in surgical scrubs with their surgical mask down around the neck.

3. At 8:45 AM on 8/19/15, while on tour of the OS (out patient surgery) area/unit in the company of staff member #56, it was observed that anesthesiologist #63 was in the nursing station in surgical scrub attire with their surgical mask down around the neck.

4. At 8:55 AM on 8/19/15, while on tour of the OS in the company of staff member #56, it was observed that staff member #66, a radiology technician, was transporting the patient in bay #11 wearing surgical scrubs and with a surgical mask down around the neck.

5. At 9:10 AM on 8/19/15, while on tour of the OS in the company of staff member #56, it was observed that staff member #64 was in patient bay #5 wearing surgical scrubs and with their surgical mask down around the neck.

6. At 9:30 AM on 8/19/15, interview with staff member #52, the infection/risk/quality staff member, indicated that even though it is not specifically stated in the policy in 1. above, surgical masks, per AORN standards, and standards of practice, should not be worn outside the surgical suites down around the neck.

7. Review of the policy "Procedure For Volunteers, Employees, Physicians, Students, and Contract Employees For TB Screening", policy number RES. 1-6, last revised 6/12, indicated: "...Two-step testing will be done on all new employees,...The first TST (tuberculin skin test) will be administered at the time of the post offer physical. This TST will be read in 48-72 hours...".

8. Review of the policy "Employee Training On Respiratory Protection", policy number IC 416, last revised 7/12, indicated under section "II. Annual TB Testing:": "...b) The skin test is read in 48-72 hours...".

9. Review of personnel files indicated:
a. Contracted dialysis nurse N5 had:
A. A first step TB test given on 1/7/15, with no time noted.
B. A second step TB test given on 1/21/15 with no time noted.
C. The second step TB test read on 1/23/15 with no time noted.
b. Contracted dialysis nurse N6 had an annual TB test given on 7/6/15 with no time noted.

10. At 1:45 PM on 8/18/15, interview with staff members #60 and #61, HR (human resources) specialists, and #67, the director of occupational health, indicated it is unknown if the TB tests for staff members N5 and N6 were read within a 48 to 72 hour time frame, as required per facility policy, without the documentation of times given and/or read.

11. Review of the policy "Employee Training On Respiratory Protection", policy number IC 416, last revised on 7/12, indicated on page 2., under section "III. Protection:", "a) Engineering controls in this facility regarding ventilation systems can be found in six (6) areas:...Med/Surg...b) Personal Protective Equipment: 1) N95 respirators to which the employee must be fit tested. Arrange fit testing through Occupational Health...".

12. Review of personnel files indicated that neither dialysis nurse, N5 hired 6/10/15 nor N6 hired 5/30/13, had fit test documentation in their files.

13. Interview at 2:15 PM on 8/18/15 with staff member #52, the infection/risk/quality staff member, indicated that most likely, airborne isolation patients needing dialysis would be sent to another facility, but this is not implicit in facility policy so that at this time, all nursing staff, including dialysis nurses, are required to be fit tested.

14. Review of the policy "Standard Precautions", policy number IC 403, last revised 7/12, indicated on page 2 under the bullet point "Gloves": "Gloves are worn to prevent contamination of hands when: 1. Anticipating direct contact with blood or body fluids, mucous membranes, non intact skin and other potentially infectious material...Perform hand hygiene after removal of gloves...".

15. At 8:35 AM on 8/19/15, while on tour of the OS area in the company of staff member #56, it was observed that lab technician #65 was drawing blood on the patient in bay #3 and failed to perform hand hygiene after removing their gloves and went down the hallway to begin care on another patient.

16. At 8:40 AM on 8/19/15, interview with staff member #56 indicated agreement that staff member #65 did not perform hand hygiene after drawing blood on the patient in bay #3 and after removing their gloves.

17. Review of the policy "Point of Care Bedside Blood Glucose Testing", policy number AA-3/POC-3, last revised 1/14, indicated on page 4 under "Meter Cleaning Procedure": "Procedure 1. Disinfect meter with super Sani-Cloth or Clorox bleach wipe after each patient use. Clean accessory box if it was taken into patient room...".

18. At 11:00 AM on 8/18/15, staff nurse #68 was observed taking the accessory box into patient room 111 for a glucometer check, but failed to cleanse/disinfect the accessory box before returning to the medication room counter top.

19. At 11:30 AM on 8/18/15, staff nurse #69 was observed taking the accessory box into patient room 101 for a glucometer check, but failed to cleanse/disinfect the accessory box before returning to the medication room counter top.

20. At 11:40 AM on 8/18/15, interview with staff member #56 indicated this staff member also observed that nurses #68 and #69 failed to clean the glucometer accessory box after taking it into a patient room.

21. At 11:15 AM on 8/18/15, in the company of staff member #56, it was observed that two sets of glucometer control solutions (high and low control solutions in two separate accessory boxes) lacked dating when opened, or the 90 day expiration date.

22. Interview with staff member #56 at 11:15 AM on 8/18/15 indicated:
a. Even though dating the solutions when they are opened was not mentioned in the glucometer policy (see 17. above), it is expected to be done by nursing staff.
b. Other nursing areas had a post it note in the lid of the accessory box to alert staff when the control solutions were to be discarded (90 days after opening), but the two accessory boxes in the med/surg medication room lacked an attachment of a post it note, so that it could not be determined when these two sets of control solutions were either opened, or expired.

23. Review of the policy "Medication and IV (intravenous) Therapy Preparation and Administration", policy number FF-31, last revised 3/14, indicated under "Administration", "...Medication vials: a new sterile syringe/needle is used for every entry into a medication vial...Access diaphragms of vials are cleansed with sterile 70% alcohol immediately prior to entry...".

24. At 9:15 AM on 8/18/15, staff RN #62 was observed taking the cap off a Protonix vial and a NS (normal saline) vial and inserting the syringe/needle without cleansing the tops of the diaphragm/rubber septum on either vial.

25. At 9:25 AM on 8/18/15, interview with staff member #56 indicated agreement that staff RN #62 failed to cleanse the rubber septum on both medication vials before inserting the syringe/needle, as required to be performed per facility policy.

26. Review of the policy "Annual Mandatory Education", policy number RES.1-10, last revised 1/15 indicated annual training is "...in the form of self-learning packets..." and that "...Each Department Director is responsible for scheduling and assuring the completion of all department staff for this mandatory education and training...".

27. Review of education documentation for nurses (registered nurses N1, N2, N5, and N6) indicated that N1 and N2 had competencies for blood administration, but N5 and N6 were lacking such documentation.

28. At 3:30 PM on 8/17/15, while on tour of the med/surg unit in the company of staff member #56, the director of med/surg, it was observed that RN N5, a contracted dialysis nurse, was preparing to administer blood to patient #1 in room 104.

29. Review of the transfusion records for pt. #1 on 8/18/15 indicated that nurse N5 started the unit of blood at "1810" hours on 8/17/15 and completed the documentation, including vital signs, for both units given.

30. At 2:15 PM on 8/17/15, interview with staff member #52, the infection/risk/quality staff member, indicated:
a. Included, but not specified, in the annual competency policy (see 26. above), is blood administration competencies required for all nursing staff.
b. Even though it is not specific in the policy, facility nurses are to begin any blood transfusions and stay through the first 15 minutes of the transfusion, then they can allow the contracted dialysis nurses to monitor the rest of the infusion and documentation required.
c. Since the dialysis nurse did all of the documentation for the two units given to pt. #1 on 8/17/15, it cannot be determined that the facility staff followed the expected facility practice.
d. There was no documentation of education in the files for nurses N5 and N6, regarding blood administration competency, as required to be completed prior to administering blood in the facility.

31. Review of the personnel files for contracted dialysis nurses N5 and N6 indicated there was no documentation of training and education related to blood administration requirements at the facility.

32. Interview with staff members #60 and #61, HR specialists, at 2:15 PM on 8/18/15 and 10:00 AM on 8/19/15, indicated no training/education related to blood administration could be found for the contracted dialysis nurses N5 and N6.

33. Review of the policy "Isolation Discharge Room Cleaning Procedure", policy number (environmental services) 3-4, last reviewed on 4/12, indicated on page 3 in the section "Fifth Step:" "11. Place a "Caution" sign in the doorway...damp mop surface of the floor beginning with the corners and edges...Damp mop the restroom last...".

34. At 4:05 PM on 8/17/15, interview with staff member #58, an EVS (environmental services)/housekeeping staff member, indicated:
a. A product called Tri-Base is used on floors of patient rooms after discharge.
b. Tri-Base is a general purpose cleaner, not a disinfectant.
c. Wexcide is the disinfectant and is used on bathroom floors.

35. Review of the policy "Infectious Waste Spills", EVS policy number 4-4, last reviewed on 4/12, indicated under "Procedure:" "...2...c. flood area with disinfectant solution...".

36. At 2:15 PM on 8/18/15, interview with staff member #52, the infection/risk/quality staff member, indicated:
a. Currently, EVS staff are not disinfecting the floors of patient rooms, including isolation patients, at the time of discharge.
b. Per the infectious waste spill policy (see 35. above), spills should be disinfected.
c. EVS staff would have no idea whether a spill had occurred in a patient room during their hospitalization, or if one had been disinfected appropriately, so that disinfecting the room at discharge would be the only way to be certain this had occurred.


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37. During an observation on 8-19-15 at 0920 hours, in the interventional radiology area of the facility, the physician MD21 failed to perform hand hygiene upon completing the procedure.

38. During an interview on 08-19-15 at 0920 hours, the administrative director of imaging A6 confirmed that the MD21 failed to perform hand hygiene upon completing the procedure.

39. The policy/procedure Infection Control Program (revised 7-12) indicated the following: "The ICC (infection control committee) monitors and provides direction as indicated for ...decontamination/sterilization processes ..." The program plan failed to indicate the professionally accepted IC standards and guidelines selected for use at the facility.

40. The Association of periOperative Nurses (AORN) Recommended Practices for Environmental Cleaning (2014) indicated the following: "Cleaning an area in a methodical pattern establishes a routine for cleaning so that items are not missed during the cleaning process. The method for cleaning may limit the transmission of microorganisms to reduce the risk of cross contamination of environmental surfaces...Cleaning should progress from clean to dirty areas. Cleaning should progress from top to bottom areas...Cleaning of high-touch objects after each patient use should include cleaning of any soiled surface of the item and any frequently touched areas of the item (control panel, switches, knobs, work area, handles)...Disinfectants should be applied, and reapplied as needed, per manufacturer's instructions, for the dwell time required to kill the targeted microorganism...".

41. The policy/procedures Surgery Cleaning (revised 4-12) and OR (operating room) Sanitation (revised 7-13) failed to indicate a methodical procedure for OR cleaning to ensure items are not missed and to minimize the contamination of previously disinfected surfaces. The policy/procedues failed to indicate the minimum wet contact time for disinfecting products used for between case and terminal OR cleaning by environmental services (EVS) personnel.

42. During an interview on 8-17-15 at 1530 hours, the director of surgical services A4 confirmed the policy/procedures failed to indicate an organized procedure to prevent contamination of previously contaminated surfaces including the general standards for cleaning high to low, clean to dirty and all high-touch surfaces.

43. During a tour on 8-17-15 at 1640 hours, while accompanied by the director of surgical services A4, the staff EVS11 was observed while performing a terminal room cleaning in OR room 7. The staff EVS11 indicated they dust the room after removing all trash, wipe down all surfaces in a circular pattern with a disinfectant, and clean the OR table before mopping the suite. As the EVS staff was observed to clean the OR table, the presence of accumulated dust on the angled top surfaces of two wall cabinets was identified to the director of surgical services A4.

44. During an interview on 8-17-15 at 1645 hours, the director of surgical services A4 confirmed the presence of duct on the cabinet tops after the EVS staff had performed dusting and surface disinfecting in the OR suite.

45. Review of the technical data sheet (TDS) for the Wex-Cide-128 disinfectant used for cleaning and disinfecting in the OR suites indicated the following: "Surfaces must remain wet for 10 minutes."

46. During an interview on 8-17-15 at 1635 hours, the staff EVS11 indicated that the OR surfaces must remain wet for a minimum of 5 minutes when using the indicated disinfectant.

47. During an interview on 8-17-15 at 1645 hours, the director of surgical services A4 confirmed the minimum wet contact time was 10 minutes when using the disinfectant.

48. During a tour on 8-18-15 at 1330 hours, the staff EVS12 was observed while performing a between case cleaning in OR room 3. As the EVS staff was observed to clean the OR table, the surfaces were observed to remain wet for only about 4 minutes while using a disinfectant with a 10 minute wet contact time. The staff EVS12 was observed to clean the top and bottom of a ceiling-mounted boom light located immediately over the OR table after completing the OR table cleaning and failed to wipe down the 4 integral loop handles spaced evenly around the outside edge of the OR boom light to ensure the high-touch surfaces were disinfected between surgical procedures.

49. During an interview on 8-18-15 at 1333 hours, the staff EVS 12 confirmed they had not wiped down the boom light handles with disinfectant.

50. The policy/Procedure Employee Health Program (revised 6-12) indicated the following: "Measles, mumps, and rubella (MMR) immunization will be administered if there is no proof of laboratory evidence, documentation of physician diagnosis, or two documented dosesof MMR vaccine. Varicella immunization will be administered to those employees with no disease history and no laboratory evidence of immunity".

51. Review of the personnel files for 2 EVS staff (EVS12, EVS13) and the administrative director of imaging A6 indicated lack of documentation of immunity (titres) or acceptable proof of vaccinations for rubeola and varicella.

52. During an interview on 8-18-15 at 1600 hours, the human resources staff A9 confirmed that the personnel files for EVS12, EVS13 and A6 lacked documentation of immunity to the infectious diseases.

Based on document review and interview, the infection control officer, and committee, failed to ensure that the chief executive officer (CEO), medical staff and director of nursing were made aware of the implementation and successful corrective action taken in one issue that occurred in the pharmacy.

Findings:
1. Review of the documents for surface sampling done in the pharmacy from 1/14/14 to 10/23/14 indicated that:
a. In January, "1 colony of an unspecified bacteria" was found on the cart in the IV (intravenous) room.
b. In February, the "transport bin" had 1 colony of Staphylococcus, and an air return vent had 8 colonies of Bacillus and 2 of interococcus.
c. In September, one colony of mold was found on the chemo room table, the chemo room "frig" (refrigerator) top, and the "pass through" area.
d. In October, there was "No growth observed in any cultures. Weekly cleaning appears to be working so will be continued."

2. At 9:40 AM on 8/19/15, interview with staff member #52, the infection/risk/quality staff member, indicated there was no documentation that the problems found when performing random cultures in the pharmacy, and implementing an action plan to address these, was presented to:
a. The medical staff
b. The CEO.
c. The quality committee.
d. The director of nursing.

3. Review of the May 28, 2014 "Board of Trustees Executive Session" meeting minutes indicated that a report regarding infection committee actions failed to include the corrective action plan for the pharmacy infection control issues addressed.