HospitalInspections.org

Based on record review and interview, the hospital failed to have an internal log for documenting any deaths that occurred to patients within 24 hours after they were in restraints for 1 (Pt #18) of 1 (Pt #18) sampled patients. This deficient practice could result in CMS not receiving the requested information in a timely manner. The findings are:

A. Record review of the Quality Improvement Committee minutes dated 12/02/14 revealed that the death of Patient #18 occurred within 24 hours of the time the patient was in restraints.

B. Record review of Patient #18's clinical record revealed a physician order dated 07/16/14 for bilateral soft wrists restraints. Further review revealed that Patient #18 had died on 07/17/14.

C. On 05/20/15 at 2:00 pm, during interview, the Chief Quality Officer confirmed that Patient #18's death was not documented in a log and the information was not in the patient's hospital chart.

Based on record review and interview, the hospital failed to ensure that the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment document was signed by the patients for 4 (Pt #2, 3, 4 and 5) of 9 (Pt #1, 2, 3, 4, 5, 6, 7, 8, and 9) sampled mental health patients presenting to the Emergency Department (ED). This deficient practice has the potential to result in patients or patients' legal representatives from having the necessary information to evaluate the proposed treatment. The information would include risks and benefits for treatment based on clinical evidence and the responsible practitioner's professional judgment for proposed treatment. The findings are:

A. Record review of Patient #2, 3, 4 and 5's medical records revealed that the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment document was not signed by the patients.

B. On 5/20/15 at 11:00 am, during interview, the Director of Quality confirmed that consents for treatment were to be signed by the patients upon admission to the ED. She confirmed that the consents for Patient #2, 3, 4 and 5 had not been signed by the patients.

C. On 5/21/15 at 11:30 am, during interview, the Director of Registration confirmed that consents for treatment were to be signed by the patients upon admission to the ED. She confirmed that consents for Patient #2, 3, 4 and 5 had not signed by the patients.

D. Record review of the hospital's policy and procedure titled "Inpatient Admissions Policy," last revision dated 03/18/15, revealed the following: "...Obtain Preliminary information (Non-Pre-Admitted Patients). The registration clerk should ask the patient (or his/her legal representative) to sign the Inpatient/Outpatient Condition of Admission and Consent to Medical Treatment form. If the patient is unable to sign, the registrar should write UNABLE TO SIGN and initials. Hospital staff should continue attempts to have consent signed until patient has been discharged/transferred and document all attempts in the patient record."

Based on observations and interviews, the hospital failed to provide and maintain a clean and sanitary environment in the operating, procedural and patients' rooms by not following manufacturer's recommendations and standards of practice for cleanings. This deficient practice increased the amount of microorganisms in the environment and increased the potential for patients to contract an infection. The findings are:


A. On 05/19/15 at 3:40 pm, during observation, the surveyor witnessed a terminal cleaning of the operating rooms, accompanied by the Director of Surgery Services, the Infection Control Preventionist, the contracted Director of the Environmental Services and the evening supervisor.
1. As the Environmental Services (EVS) staff member #2 began to clean operating room (OR) #1, he was wearing the following: short-sleeved scrub uniform, glasses, gloves, hair cover and shoe covers. The manufacturer of the disinfectant recommends eye protection, mask, long sleeves, gloves and a gown to prevent exposure to the skin. The staff member was cleaning the walls and floor with "Virex II 256" and the equipment with "Oxycide Daily Disinfectant Cleaner."
2. The glove container for unsterile gloves had boxes of gloves on top of the glove container.
3. The Bair Hugger machine (produces warm air to warm the patient) and hoses were exposed.
4. A sealed spinal tray left on a red medical supply cart was exposed to potential splatter from the disinfectant cleaner used to clean the walls, ceilings and exterior surfaces.
5. Papers for documenting the room temperature and humidity were taped to a dry eraser board exposed.
6. A metal cart that contained yankauers (suction tips) and eye protectors were exposed to potential splatter from the disinfectant cleaner used to clean the walls, ceilings and exterior surfaces.
7. The four (4) air exchange vents in all of the operating rooms were dirty with some kind of splatter and were dusty.

B. On 05/19/15 at 4:30 pm, during interview, the Director of Surgery Services and the Infection Control Preventionist both confirmed that the EVS staff member #2 was not wearing the proper personal protective equipment (PPE) for the terminal cleaning and that there was medical equipment that should be covered or put away during the terminal cleaning of the OR and procedural rooms.

C. On 05/19/15 at 4:40 pm, during observation of the operating and procedural rooms, the surveyor was accompanied by the Director of Surgery Services, the Infection Control Preventionist, the contracted Director of the Environmental Services and the evening supervisor, witnessed the following:
1. OR #2 was set up for a Cesarean section surgery (a surgical procedure in which the abdomen and uterus are cut open for childbirth) with surgical supplies exposed to potential splatter from the disinfectant cleaner used to clean the walls, ceilings and exterior surfaces.
2. The procedural room indicated for endoscopies (scope used to examine the inside of organs and cavities) and colonoscopies (scope used to examine the rectum and bowels) was set up with surgical supplies already for a procedure, and the supplies were exposed to potential splatter from the disinfectant cleaner used to clean the walls, ceilings and exterior surfaces.

D. On 05/19/15 at 4:40 pm, during interview, the Director of Surgery Services stated that OR #2 was a trauma room and that the staff had already set up the room just in case the hospital has a patient needing a Cesarean section. When asked if OR #2 had been terminally cleaned, she stated it had not. She was then asked if the procedural room had been terminally cleaned, and she stated that it too had not been terminally cleaned.

E. Review of the "Virex II 256" Safety Data Sheet dated 10/09/2014 revealed the following: "Handling and Storage Handling: Avoid contact with skin, eyes and clothing...Avoid breathing vapors or mists." "Exposure Controls/Personal Protection: Eye protection: Chemical-splash goggles. Hand protection: Chemical-resistant gloves. Skin and body protection: Protective footwear. If major exposure is possible, wear suitable protective clothing and footwear. Respiratory protection: In case of insufficient ventilation wear suitable respiratory equipment. A respiratory protection program that meets OSHA's 29 CFR 1910.134 and ANSI Z88.2 requirements must be followed whenever workplace conditions warrant a respiratory's use."

F. Review of the "Oxycide Daily Disinfectant Cleaner" Safety Data Sheet dated 06/25/13 revealed the following: "Precautionary statements Prevention: Due to the form and packaging of the product, no protective equipment is needed under normal use conditions. Chemical splash goggles, impervious gloves and apron should be used when there is a likelihood of exposure to concentrated product."

G. On 05/20/15 at 3:00 pm, during observation, the surveyor witnessed the cleaning of a patient's room:
1. The Environmental Services (EVS) staff member #1 began to clean room #204 using "Virex II 256."
2. At 3:04 pm, the EVS staff member #1 began to wipe down the hospital bed and side tables.
3. At 3:05 pm, the EVS staff member #1 began to wipe down a brown chair.
4. At 3:10 pm, the bed and side tables were completely dry.
5. At 3:11 pm, the EVS staff member #1 began to wipe down two blue chairs and the brown chair was completely dry.
6. At 3:15 pm, the two blue chairs were completely dry.
7. At 3:15 pm, the EVS staff member #1 began cleaning the patients bathroom using "Virex Tb."
8. At 3: 25 pm, the EVS staff member #1 began mopping room 204's floor.
9. At 3:30 pm, room 204's floor was completely dry.

H. On 05/20/15 at 3:30 pm, during interview, the EVS staff member #1, who has been with the hospital since April 2015, explained Virex II 256 has a "wet time of ten minutes." When questioned about "wet time," the EVS staff member stated, "Ten minutes wet time means the cleaning rags have to soak in the bucket for ten minutes before using them."

I. On 05/21/15 at 10:15 am, during interview, the EVS staff member #2, who has been with the hospital for the last 8 years, explained that Virex II 256 has a "wet time of ten minutes." When asked to explain what a "wet time" is, the EVS staff member #2 stated, "You wipe down the room and wait ten minutes before you can use the room."

J. On 05/21/15 at 10:45 am, during interview, the Director of Environmental Services, who has been the Director of EVS since March 2015, stated, "Virex II 256 has a wet time of ten minutes, which means it [furniture and/or equipment] stays wet for ten minutes."

K. Review of the "Virex II 256" Reference Sheet dated 2010 revealed the following: "This product can be applied by mop, sponge, cloth, paper towel, coarse trigger sprayer, auto-scrubber or foam gun. Change cloth, sponges or towels frequently to avoid redisposition of soil. For disinfection, all surfaces must remain wet for 10 minutes."

L. On 05/19/15 at 11:00 am, during observation, the Certified Registered Nurse Anesthetist (CRNA) #1, who has worked at the hospital for 2 years and has been a CRNA for 40 years, did not wash his hands after completing an epidural procedure. (The anesthesia is delivered by inserting an injection or a catheter in the epidural space, a membranous area in the spine.)

M. On 05/19/15 at 11:30 am, during interview, the Registered Nurse (RN) #6 stated that the CRNA washed his hands when he entered the room but did not wash his hands when he left the room.

N. On 05/19/15 at 1:00 pm, during interview, the Chief Quality Officer stated that the CRNA should have washed his hands before and after the epidural procedure.

O. On 05/20/15 at 3:45 pm, during interview, the Chief of Anesthesia stated that the CRNA should wash his hands before a procedure and after a procedure.

P. Review of the Hand Hygiene policy dated 05/19/2014 revealed the following: "Introduction: Hand hygiene is considered the single most important procedure for preventing nosocomial infections. Due to the 2012 Patient Safety Initiative, the CDC (Centers of Disease Control and Prevention [sic], the Association for Professionals in Infection Control and Epidemiology (APIC), and the World Health Organization (WHO), recommendations and mandates for national practice guidelines to include practice of hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves."