HospitalInspections.org

The hospital reported a current census of 16 patients. Based on observations, medical record review, and staff interviews the hospital lacked evidence they informed and or provided a copy of patient rights to patients/representatives prior to providing care and services for 32 of 34 patient (#'s 1 -32) records reviewed. This deficient practice has the potential for all patients or their representatives receiving services from the hospital to lack awareness of their patient rights.

Findings include:

- Policy titled Rights and Responsibilities of Patients reviewed on 10/1/2015 at 8:00 AM directed " ...The following basic rights and responsibilities of patients shall apply to all patients at Pratt Regional Medical Center and shall be provided to the patient during the admission process ... "

- Patient #1's medical record reviewed on 9/29/2015 revealed an admission date of 7/15/2015 with a diagnosis of cardiac arrest. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #2's medical record reviewed on 9/29/2015 revealed an admission date of 2/28/2015 with a diagnosis of cellulitis (skin infection). The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #3's medical record reviewed on 9/29/2015 revealed an admission date of 2/28/2015 with a diagnosis of aortic Dissection (tear in the wall of the heart vessel). The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #4's medical record reviewed on 9/29/2015 revealed an admission date of 1/17/2015 with a diagnosis of subarachnoid bleed (bleeding in the brain). The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #5's medical record reviewed on 9/29/2015 revealed an admission date of 6/10/2015 with a diagnosis of chest pain. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #6's medical record reviewed on 9/29/2015 revealed an admission date of 6/15/2015 with a diagnosis of pregnancy. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #7's medical record reviewed on 9/29/2015 revealed an admission date of 7/21/2015 with a diagnosis of suicidal ideation. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #8's medical record reviewed on 9/29/2015 revealed an admission date of 8/10/2015 with a diagnosis of pregnancy. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #9's medical record reviewed on 9/29/2015 revealed an admission date of 8/18/2015 with a diagnosis of bipolar disorder. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #10's medical record reviewed on 9/29/2015 revealed an admission date of 8/28/2015 with a diagnosis of vomiting blood. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #11's medical record reviewed on 9/29/2015 revealed an admission date of 9/28/2015 for a bilateral knee replacement. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #12's medical record reviewed on 9/29/2015 revealed an admission date of 9/23/2015 for an open reduction and internal fixation of the right ankle (surgery to repair a fractured ankle). The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #13's medical record reviewed on 9/29/2015 revealed an admission date of 9/28/2015 for a right sided total hip replacement. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #14's medical record reviewed on 9/29/2015 revealed an admission date of 9/28/2015 for a mid-urethral sling urethroplexy placement (a surgery to implant a device to hold up the bladder). The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #15's medical record reviewed on 9/29/2015 revealed an admission date of 9/28/2015 for a mid-urethral sling urethroplexy placement (a surgery to implant a device to hold up the bladder). The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

Patient #16's medical record reviewed on 10/1/2015 revealed an admission date of 9/30/2015 for an open reduction of the fifth metatarsal on the left foot (surgical repair of a left foot fracture). The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

Patient #17's medical record reviewed on 10/1/2015 revealed an admission date of 9/30/2015 for a diagnostic hysteroscopy with dilation and curettage (a surgical procedure where a scope is used to identify abnormalities in the uterus with dilation of the cervix and removal of tissue from the uterine lining. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

Patient #18's medical record reviewed on 9/29/2015 revealed an admission date of 9/26/2015 with a diagnosis of hypertension (high blood pressure) and left side weakness. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

Patient #19's medical record reviewed on 9/29/2015 revealed an admission date of 9/25/2015 with a diagnosis of lightheadedness and hypotension (low blood pressure). The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

Patient #20's medical record reviewed on 9/29/2015 revealed an admission date of 9/26/2015 with a diagnosis of obstructed small bowel. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

Patient #21's medical record reviewed on 9/29/2015 revealed an admission date of 9/23/2015 with a diagnosis of left lower extremity deep vein thrombosis (clot in calf). The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

Patient #22's medical record reviewed on 9/29/2015 revealed an admission date of 9/25/2015 with a diagnosis of left ear pain. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

Patient #23's medical record reviewed on 9/30/2015 revealed an admission date of 8/27/2015 with a diagnosis of pyelonephritis and arthritis. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

Patient #24's medical record reviewed on 9/30/2015 revealed an admission date of 7/30 /2015 with a diagnosis of abdominal pain and rupture appendicitis. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #25's medical record reviewed on 9/29/15 revealed an admit date of 9/25/15 with diagnoses of dyspnea (shortness of air) and congestive heart failure (when the heart cannot pump blood efficiently). The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #26's closed medical record reviewed on 9/30/15 revealed an admit date of 4/14/15 with a diagnosis of aspiration pneumonia (pneumonia caused by inhaling fluids/and or food). The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #27's closed medical record reviewed on 9/3015 revealed an admit date of 2/19/15 because of active labor. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #28's closed medical record reviewed on 9/30/15 revealed an admit date of 7/31/15 because of active labor. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #29's closed medical record reviewed on 9/30/15 revealed an admit date of 5/5/15 because of active labor. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #30's closed medical record reviewed on 9/30/15 revealed an admit date of 2/19/15 when born. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #31's closed medical record reviewed on 9/30/15 revealed an admit date of 7/31/15 when born. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

- Patient #32's closed medical record reviewed on 9/30/15 revealed an admit date of 5/5/15 when born. The medical record lacked evidence the hospital informed the patient or representatives of their patient rights.

Registered nurse staff Y observed on 9/30/2015 at 6:10 AM revealed them admitting patient # 16. Staff Y gave the patient a copy of patient rights but failed to have the patient acknowledge the receipt of patient rights in writing.

Registered nurse staff Y interviewed on 9/30/2015 at 6:15 AM revealed that surgical patients are given a copy of their rights during the admission process in the unit, but there are no places for the patient to acknowledge receipt of rights in writing.

Medical Records staff E interviewed on 9/29/2015 at 2:30 PM acknowledged the medical records lacked evidence patient rights were given to every patient or their representative.

Emergency department registration staff J interviewed on 9/29/2015 at 4:05 PM revealed they give patients a copy of the privacy policy but they do not have a copy of the patient rights to offer patients or their representatives.

Registration staff I interviewed on 9/29/2015 at 4:10 PM revealed they offer patients a written copy of their patient rights but they lack an area on the consent form to document it.

Administrative staff A interviewed 9/29/2015 at 5:10 PM revealed they believed there was an acknowledgement of receiving patient rights on the consent form but after reviewing it they agreed there is not a place for patients to acknowledge receipt of rights.

The hospital reported a census of 16 patients. Based on observations and staff interviews the hospital failed to ensure all drugs and supplies are maintained to safely meet patients' needs for both day-to-day operations and during emergencies in three of four Adult emergency supply carts (Medical -surgical unit, Intensive Care Unit (ICU), and Labor /Delivery /Postpartum, two of three pediatric emergency supply carts (ICU and Labor /Delivery /Postpartum), one of one Broselow (pediatric emergency supply) bags (ICU), one of one supply rooms (emergency department (ED)), one of two trauma rooms (Room #2), one of one obstetric (OB) operating rooms, one of two anesthesia supply carts (OB operating room), five of six Labor/Delivery/Postpartum rooms (#'s 1, 3, 4, 5, and 6), and three of three utility supply carts (ancillary, central supply, and epidural). This deficient practice or the failure of the facility to dispose of expired supplies places all patients at risk for receiving ineffective supplies.


Findings include:


- Policy titled " ...The Crash cart should be opened quarterly. Inventory supplies, check for outdates ... "


- Medical Surgical units adult emergency supply cart observed on 9/28/2015 at 1:50 PM revealed the following expired items:

13 packets lubricating Jelly with expiration date of 5/2014.

1 Laryngeal Mask airway (medical device to keep the airway open) with expiration date 6/28/2015.

5 Cuffed Tracheal Tube (tube inserted into the windpipe to assist breathing) with expiration dates 10/2011, 7/2013, 9/2002, 10/2009, and 2/2012.

3-20 gauge IV catheters (device used to introduce an IV catheter into a vein) with expiration dates of 7/2015, 3/2015, 6/2014.

3-18 gauge IV catheters with expiration dates of 3/2014, 5/2014, and 8/2012.

3-22 gauge IV catheters with expiration dates of 4/2014 and 10/2013.

3-14 gauge IV catheters with expiration dates of 4/2013.

3-16 gauge IV catheters with expiration dates 11/2012.

2-IV start kits (a kit containing a rubber band, tape, gauze pad, and tegaderm (waterproof dressing) with expiration dates of 3/2012, and 12/2012.

5 Providone-Iodine Swabsticks with expiration dates of 11/2014 and 3/2015.

3 Adult tongue depressors with expiration dates of 6/2015.


Registered nurse staff G interviewed on 9/28/2015 at 2:15 PM acknowledged the expired items in the emergency supply cart. Staff G revealed they required to check the cart monthly and after every code.

- Intensive Care Unit's (ICU) Adult emergency supply carts observed on 9/28/2015 at 2:30 PM revealed the following expired items:

1 Central Line dressing tray with expiration date 6/2014.

3 Adult tongue depressors with expiration date 6/2015.

2 Sensi touch gloves with expiration dates of 11/2014 and 6/2014.

2 Biogel gloves with expiration date of 11/2014.

1 Laryngeal Mask Airway with a damaged package.


- ICU Pediatric emergency supply cart observed on 9/28/2015 at 2:50 PM:

1 Heparin (medication used to decrease blood clotting) 5ml (milliliter) syringe with an expiration date 7/2014.

4 gauze sponges with expiration dates 12/2013.

1 Providone-Iodine Swabsticks with expiration dates of 12/2014.

1 Monoject (needle) 18 x 3 ½ with expiration date of 6/2011.

2 Monoject 0.7mm (millimeters) x 88.9mm with expiration date of 11/2008 and 11/2009.

1 Monoject 0.9mm x 88.9mm with expiration date of 11/2008.



Registered nurse staff I interviewed on 9/28/2015 at 2:34 PM acknowledged the expired supplies in the Adult and Pediatric emergency supply carts. Staff I acknowledged missing signatures and check marks on the daily emergency supply cart log. Staff I revealed the missing signatures indicated no checks were completed on those days.

- ICU's Broselow bag observed on 9/28/2015 at 3:10 PM revealed the following expired items:
1 Green Pediatric system with an I/O (intraosseous (into the bone)) module and Intubation module with expiration dates of 2/2010.
1 Orange Pediatric system with an I/O (intraosseous (into the bone)) module and Intubation module with expiration dates of 2/2010.
1 Blue Pediatric system with an I/O (intraosseous (into the bone)) module and Intubation module (airway management kit) with expiration dates of 2/2010.
1 White Pediatric system with an I/O (intraosseous (into the bone)) module and Intubation module with expiration dates of 2/2010.
1 Yellow Pediatric system with an I/O (intraosseous (into the bone)) module and Intubation module with expiration dates of 2/2010.
1 Purple Pediatric system with an I/O (intraosseous (into the bone)) module and Intubation module with expiration dates of 2/2010.
1 Red Pediatric system with an I/O (intraosseous (into the bone)) module and Intubation module with expiration dates of 3/2013.

Registered nurse staff D interviewed on 9/28/2015 at 3:55 PM acknowledged all supplies in the Broselow bag are expired. Staff D revealed that they had recently assigned staff to check the emergency supply carts monthly but had forgotten to include the Broselow bag in the inventory assignment.

- Emergency department supply room observed on 9/29/2015 at 8:55 AM revealed the following:
24 pair of Sensi touch gloves with an expiration date of 6/2015.
1-5.0 cuffed tracheal tube (opens airway) with an expiration date of 7/2015.

- Emergency department cabinet in Trauma Room 2 observed on 9/29/2015 at 8:45 AM revealed the following:
1 chest tube insertion kit (tube placed in the chest to help drain air or blood) large drape with an expiration date of 1/2015.
1-3.0 suture (material to hold body tissue) with an expiration date of 7/2015.


Registered Nurse Staff F interviewed on 9/29/2015 at 8:55 AM acknowledged the outdated supplies should have been disposed of properly.

- Observations of the Labor/Delivery/Postpartum area on 9/28/15 between 12:25 PM to 4:55 PM revealed the following:
A cabinet in the Cesarean Section operating room contained the following:
2 culture swab kits with an expiration date of 2/2015.
3 Providine Iodine (antiseptic used to clean the skin) packages with an expiration date of 5/2013.
2 sterile tongue blades with an expiration date of 10/2001.
1 sterile tongue blade with an expiration date of 3/2005.
2 scalpels (surgical knife) one with an expiration date of 3/2006 and one with an expiration date of 5/2006.
4 sterile cotton tipped applicators with an expiration date of 5/2014.
2 suture packets #4-0 with an expiration date of 5/2009.
4 sterile cotton tipped applicators with an expiration date of 4/2011.
3 culture swabs with an expiration date of 6/2015.
1 single 50cc bulb syringe (for irrigation) with an expiration date of 3/2015.
2 sterile 4x4 gauze sponges with an expiration date of 1/2015.
1 sterile drape with an expiration date of 2/2015.
1 Uterine Suction Curette set with an expiration date of 10/2014.

- An Anesthesia Cart in the Cesarean Section operating room contained the following:
6 Intravenous (IV) Catheters 16 gauge with an expiration date of 1/2014.
3 packages of sterile gloves, one with an expiration date of 1/2012, one with an expiration date of 3/2015, and one with an expiration date of 8/2015.
6 packages of Latex Biogel sterile gloves, four with an expiration date of 12/2014, one with an expiration date of 7/2015, and one with an expiration date of 8/2015.
2 Laryngeal Mask (used to insert a breathing tube into the wind pipe), one with an expiration date of 7/2013 and one with an expirations date of 3/2013.
1 large non-sterile glove box with an expiration date of 8/2015.
1 can Alcare Plus Antiseptic hand rub (clean hands) with an expiration date of 10/2005.
5 emptied 5cc syringes with needle out of sterile package each labeled Ephedrine (medication to increase blood pressure).
1 emptied 5cc syringes with needle out of sterile package labeled Fentanyl (medication to help with pain).
1 emptied 5cc syringe with needle out of sterile package labeled Lidocaine (medication to numb tissue).
1 emptied 5cc syringe with needle out of sterile package labeled Versed (medication to cause sleepiness).
1 emptied 5cc syringe with needle out of sterile package labeled Zemuron (medication to relax muscles).
1-5cc syringe with needle out of sterile package.
1 emptied 3cc syringe with needle out of sterile package labeled Zemuron (medication to relax muscles).
2 emptied 10cc syringes with needle out of sterile package labeled Succinylcholine (medication to relax muscles).
1 emptied 30cc syringe out of sterile package.
3 Whitacre (used in spinal column) needles 25gauge 3 with an expiration date of 8/2014 and 9/2014.
1-10cc syringe with needle out of sterile package labeled Phenylephrine (medication to treat nasal and sinus congestion).
1-10cc syringe with needle out of sterile package labeled Robinul (medication to help control secretions).
2-20cc syringes out of sterile package with unknown expiration date.
2 LMA Laryngeal Mask (opens airway) single use size 5 with an expiration date of 11/28/2014 and 3/28/2012.
6 sterile cuffed Tracheal tube (opens airway) packages with an expiration date of 9/2012, 10/2009, 8/2015, 6/2011, 4/2010.
1 Nasopharyngeal airway (opens airway) 26 French with an expiration date of 11/2014.
1 Glide Scope sheath (provide clear view of airway) #4 with an expiration date of 10/4/2014.
1 Glide Scope sheath (provide clear view of airway )#3 with an expiration date of 10/23/2014.
1 Laryngeal tube (opens airway) size 4 with an expiration date of 9/2012.
1 single sterile Laryngeal mask (opens airway) with an expiration date of 3/2013.
1 King LTS Laryngeal tube (opens airway) size 5 with an expiration date of 11/2012.

- Labor/Deliver/Postpartum room # 1 revealed the following:
1 laboratory cord blood tube with an expiration date of 1/2015.
6 dressings used to cover an IV site, four with an expiration date of 9/2014 and two with an expiration date of 11/2008.
1 IV catheter (22 gauge) with an expiration date of 5/2015.
1 Yankauer (suction applicator) with an expiration date of 6/2005.

- Labor/Delivery/Postpartum room #3 revealed the following:
1 IV catheter (22gauge) with an expiration date of 5/20/15.
3 dressings used to cover an IV site, two with an expiration date of 8/2014 and one with an expiration date of 3/2014.
1 surgical glove size 6 ½ with an expiration date of 1/2015.
1 surgical glove size 6 with an expiration date of 10/2014.


- Labor/Delivery/Postpartum room #4 revealed the following:
1 package of size 6 sterile gloves with an expiration date of 6/20/15.
1 surgical glove size 6 ½ with an expiration date of 1/2015
1 surgical glove size 6 with an expiration date of 10/2014.
3 sterile Tuberculin Syringes with an expiration date of 8/2012, 7/2008, 11/2010.
2-22 gauge IV (needle placed in patient arm for medication) with an expiration date of 12/2014 and 8/2010.


- Labor/Delivery/Postpartum room #5 revealed the following:
1 package of size 6 sterile gloves with an expiration date of 6/2015.
1 Surgical sterile glove size 6 with an expiration date of 6/2015.
3 red top lab tubes with an expiration date of 3/2015
3 Tuberculin syringes with an expiration date of 11/2011 and 12/2012.
2-22gauge IV (needle placed in patient arm for medication) with an expiration date of 5/2009 and 12/2014.

- Labor/Delivery/Postpartum room #6 revealed the following:
1 Yankauer suction tube (a rigid hollow curved tube made of disposable plastic used to remove thick secretions during suctioning of the throat area) with an expiration date of 2/2014.
2 packages of size 61/2 sterile gloves with an expiration date of 1/2015.
1-22 gauge IV (needle placed in patient arm for medication) with an expiration date of 6/2015.
1-18 gauge IV (needle placed in patient arm for medication) with an expiration date of 5/2013.
1 Tegaderm film (dressing to protect skin) with an expiration date of 3/2014.
3 red top lab tubes with an expiration date of 1/2015.


- Antepartum room (a room used to monitor patients to determine if they are in labor) revealed the following:
1 package of size 7 sterile gloves with an expiration date of 1/2014.
1 package of size 8 sterile gloves with an expiration date of 11/2014.
5 packages of size 6 ½ sterile gloves with an expiration date of 1/2015.
4 packages of size 6 ½ sterile gloves with an expiration date of 6/2015.
2 culture swabs (collect tissue) with an expiration date of 2/2014.
3 cotton tipped applicators with an expiration date of 1/2014 and 5/2014.
3 specimen collecting kits with an expiration date of 7/2015.

- Labor/Delivery/Postpartum area's adult emergency supply cart in the revealed the following:
1 tube of lubricating jelly (4ounces) with an expiration date of 3/2014.
2 packages of electrodes (discs placed on the patient's chest to monitor their heart) one with an expiration date of 4/28/2014 and one with an expiration date of 11/28/2014.

- Labor/Delivery/Postpartum area's pediatric emergency supply cart in the revealed the following:
2 glide scopes (provide clear view of airway) with an expiration date of 10/6/2014 and 11/11/2014.
3 tuberculin needles with an expiration date of 5/2009 and 3/2010.
1 single U-bag specimen (collect urine) with an expiration date of 10/2004.
4 Surgipro (suture material to hold body tissue) with an expiration date of 5/2009 and 2/2015.
2 disposable scalpel (small knife with thin, sharp blade) with an expiration date of 1/2013 and 3/2015.
2 culture swabs (collect tissue) with an expiration date of 2/2015.
3 Povidone Iodine (disinfects skin) with an expiration date of 5/2013, 8/2013, and 2/2014.

- Clean utility room in the Labor/Delivery/Postpartum area revealed the following:
-An ancillary cart with one 16 French Foley tray (to empty urine from bladder) with an expiration date of 10/2014.
-Central supply cart six-22 gauge IV (needle placed in patient arm for medication ) with an expiration date of 5/2012, 10/2013, 3/2014, 12/2014, and 5/2015.
One-18 gauge IV (needle placed in patient arm for medication) with an expiration date of 3/2014.
Six-24 gauge IV (needle placed in patient arm for medication) with an expiration date of 6/2011, 10/2013, and 4/2014.
One medipore pad (wound dressing) with an expiration date of 6/2015.
One sterile glove size 8 ½ with an expiration date of 5/2004.
One large exam glove box with an expiration date of 8/2015.
-Epidural cart (a procedure to inject numbing medicine in the back before delivery) with the following:
19 Povidone Iodine Swabsticks (disinfects skin) with an expiration date of 11/2011, 6/2013, 8/2013, 9/2013, 11/2013, 1/2014, and 8/2015.
Seven Tracheal Tubes (opens airway) with an expiration date of 5/2003, 6/2003, 5/2005, 3/2007, and 9/2013.
Four spinal needles with an expiration date of 4/2015
Five endotracheal tubes (a tube in the throat to help the patient breath) size 8, two with an expiration date of 3/2005, two with an expiration date of 9/2007, and one with an expiration date of 4/2007.

Registered Nurse Staff S interviewed on 9/28/2015 at 4:55pm acknowledge the outdated supplies should have been removed.

- Policy reviewed on 9/29/15 at 4:55pm revealed the hospital failed to develop a policy to ensure removal and disposal of expired supplies.

The hospital reported a census of 16 patients. Based on observation, policy reviews and staff interviews the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices for: surgical attire in two of three observed operating rooms (rooms 4 and 6 involving staff L, M, N, and 2 unidentified staff), one of two observed wheelchairs (emergency department), one of one observed standing scale (equipment room), one of one observed staff handling linens (staff Z), five observed breeches in hand hygiene (staff R, P, U, Z, and X), one breech of staff entering a restricted area (unidentified construction worker), one observed breech in storing ice (dietary kitchen on the medical/surgical unit), breeches in infection control practices for two of three laboratory (lab) staff observed collecting blood lab samples (staff Q and P), one of three mat tables (Physical Therapy Unit), two observed breeches in the use of personal protective equipment (PPE) (two unidentified radiology staff and one unidentified staff in the cafeteria), for six of six observed Intensive Care Unit patient bathrooms (rooms 1-6 ), for 20 of 20 observed patient bathrooms on the medical/surgical unit (rooms 1101-1123), for six of six observed sinks in Labor/Delivery/Postpartum rooms (rooms1-6), one of one observed sink in the Nursery, and two observed breeches in use of equipment (Cesarean Section room).


Findings include:

Policy titled Surgical Attire reviewed on 10/1/2015 at 8:15 AM directed " ... (no surgical skull cap allowed unless covered by a surgical cap) ... and ...Shoe covers shall be worn if it is anticipated that splashes or spills will occur ... "

- AORN (Association of periOperative Registered Nurses) 2012 Recommendation IV reads: "All personnel should cover their head and facial hair when in the semi-restricted and restricted areas. Hair coverings should cover facial hair, sideburns and the nape of the neck ...Skulls caps are not recommended because they do not completely cover the wearer's hair and skin: they fail to cover the side hair above and in front of the ears and the hair at the nape of the neck.

- Physician staff N observed on 9/30/2015 at 8:05 AM in operating room suite 6 wearing a " skull cap " . Staff N failed to cover their hair at the nape of their neck.

- Anesthesia staff M observed on 9/30/2015 at 8:05 AM in operating room suite 6 wearing a " skull cap " . Staff M failed to cover their hair at the nape of their neck.

- Anesthesia staff K observed on 9/30/2015 at 9:50 AM entering the post anesthesia care unit (PACU) wearing a "skull cap". Staff K failed to cover their hair at the nape of the neck.

- Physician staff L observed on 9/30/2015 at 2:45 PM in operating room suite 6 wearing a " skull cap " . Staff L failed to cover their hair at the nape of their neck.

- Two unidentified male staff observed on 9/30/2015 at 2:50 PM in operating room suite 4 wearing " skull caps " and without shoe covers. The two unidentified male staff members failed to cover their hair at the nape of their neck and wear the required shoe covers.

- Unidentified male construction worker observed on 9/30/2015 at 2:43 PM in the restricted surgical area in street clothing and without any hair or shoe coverings.

Registered nurse staff O interviewed on 9/30/2015 at 3:00 PM acknowledged all staff should be wearing bouffant hair covers and shoe covers unless they have dedicated surgical shoes. Staff O indicated there is a red tape line that construction workers are not to cross while doing construction in operating room suite 1. The construction workers are to enter through the designated door and immediately cross the hallway (approximately 3 feet) to the construction area without crossing the red tape line secured to the floor. Operating rooms (# ' s 1, 2, and 3) down this hallway are not currently in use during construction.

- Anesthesia staff R observed on 9/30/2015 at 10:50 AM leaving pre/post-surgical room 1 after conducting a pre-surgical physical assessment without performing hand hygiene.

Registered nurse staff Y interviewed on 9/30/2015 at 10:55 AM acknowledged all staff should perform hand hygiene before entering patient care areas, after leaving patient care areas, and before or after glove changes.

- Laboratory staff Q observed on 9/30/2015 at 6:55 AM with a lab supply tray entering pre/post-surgical room 1. Staff Q failed to clean the supply tray before placing it on patient ' s bedside table or clean the tray after leaving the patients room

- Laboratory staff P observed on 9/30/2015 at 10:35 AM with a lab supply tray entering pre/post-surgical room 1. Staff P failed to clean the supply tray before placing it on the sink basin or clean the tray after leaving the patients room. Staff P failed to perform hand hygiene after removing their gloves.

Laboratory staff Q interviewed on 9/30/2015 at 6:55 AM revealed they never clean the lab supply tray before or after entering a patient ' s room. Staff Q acknowledged they were unsure if there is a policy directing them to clean them or leave them outside the patient rooms.

- Emergency department supply room observed on 9/29/2015 at 8:45 AM revealed a flushable hopper (basin used to dispose of liquid waste) without a shield or PPE nearby.

Registered nurse staff F interviewed on 9/29/2015 at 9:00 AM indicated staff should use PPE when dumping material into a hopper without a shield. Staff F acknowledged staff would have to go find the PPE because there is not any in the room.

- Policy titled " Equipment repair " reviewed on 10/1/2015 at 1:30 PM directed to " ...When a piece of equipment is suspected of being defective or malfunctioning it should be immediately removed from service ... "

- Physical therapy unit observed on 9/30/2015 at 10:30 AM revealed a small tear approximately 2 inch x 2 inch on the patient ' s Mat table.

Physical therapy staff T interviewed on 9/30/2015 at 10:30 AM acknowledged the tear on the patient ' s Mat table. Staff explained the tear occurred a month ago and not sure if it has a work order started.

- Emergency department observed on 9/29/2015 at 8:30 AM revealed one wheelchair with a tear on back covered with approximately 4 inch x 4 inch piece of duct tape.

Administrative staff A interviewed on 10/1/2015 at 1:00 PM acknowledged wheelchair in Emergency room need of repair or replaced.

- Observation on 9/28/15 at 12:25pm of the C-Section (Cesarean) procedure room revealed an anesthesia cart with an opened package that contained an endotracheal tube (a plastic curved tube to place in the patient ' s windpipe to help them breath) with a syringe attached to the endotracheal tube used to insert air into the endotracheal tube balloon. This rendered the endotracheal tube no longer sterile.
- The manufacturer ' s guidelines for the Yankauer suction tube, directs " Do not use if unit package is opened or damaged. "

- Observation on 9/28/15 at 12:25pm of the C-section procedure room revealed an anesthesia machine with a opened Yankauer tube attached to suction tubing.

Staff R, Certified Registered Nurse Anesthetist (CRNA) acknowledged the open endotracheal tube and opened Yankauer suction tube.

- Observation on 9/29/15 at 10:40am of the equipment room revealed a large wheeled, stand up scale with two tears in the black material the patients stand on and a black foam cover on the handle of the scale torn. The torn surfaces rendering the surfaces uncleanable.

- Observation on 9/29/15 at 10:40am of the dietary kitchen on the medical/surgical unit revealed a plastic container on the counter with two ice scoops in it not covered.

Staff W Registered Nurse (RN) interviewed on 9/29/15 at 10:40am acknowledged that the ice scoops lacked a cover and explained the wash them periodically in the sink to freshen them up.

- The Hospital ' s policy/procedure titled " Exposure Control Plan " reviewed on 10/1/15 at 8:20am directed " ...Hands are to be washed after removing gloves ...all procedures involving blood or other body fluids are to be performed in a manner that minimizes splashing and spraying ... "

- Observation on 9/29/15 at 8:50am of a medication administration to patient #25 revealed staff U, RN failed to perform hand hygiene when entering the patient ' s room.

- Observation on 9/29/15 at 1:55pm of the medical/surgical unit revealed staff Z, RN entering patient room 1103 and failed to perform hand hygiene.

- Observation on 9/29/15 at 11:25am of the medical/surgical unit revealed staff X, RN performing a blood sugar test in room 1111. Staff X performed the blood sugar test, removed their gloves, and applied clean gloves. Staff X failed to perform hand hygiene after removing their gloves and before applying clean gloves.

The Hospitals policy/procedure titled " Exposure Control Plan " reviewed on 10/1/15 at 8:20am directed " ...it is the responsibility of each Department Director to ensure that adequate equipment is available on their unit ...all PPE will be provided by the hospital, and maintained, cleaned or replaced by the hospital ... "

- Observation on 9/29/15 at 8:30am of the Intensive Care Unit revealed six patient rooms with bathrooms in each room. Observation of the six bathrooms revealed a toilet with an attached spray wand (a metal pipe, that when put in a down position over the toilet emits a spray used to clean bedpans, urinals, and commode pails). The patient rooms lacked the necessary PPE for the staff to wear when cleaning body fluids from the patient ' s bedpans, urinals, and/or commode pails to prevent contamination of the staff ' s clothes.

Staff U, RN interviewed on 9/29/15 at 8:50am acknowledged the lack of PPE in the patient rooms for the staff to use when cleaning the patient ' s bedpans, urinals and/or commode pails. Staff R explained the patient rooms did have the disposable gloves available.

- Observation on 9/29/15 at between 3:00pm and 3:15pm of the medical/surgical unit revealed 20 patient rooms with bathrooms in each room. Observation of the 20 bathrooms revealed a toilet with an attached spray wand (a metal pipe, that when put in a down position over the toilet emits a spray used to clean bedpans, urinals, and commode pails). The patient rooms lacked the necessary PPE for the staff to wear when cleaning body fluids from the patient ' s bedpans, urinals, and/or commode pails to prevent contamination of the staff ' s clothes.
Staff W RN, interviewed on 9/29/15 at 3:15 acknowledged the lack of PPE in the patient rooms for the staff to use when cleaning the patient ' s bedpans, urinals and/or commode pails.

- Observation on 9/29/15 at 4:00pm on the medical/surgical unit revealed a patient in an isolation room for droplet precautions. At the time of the observation two unidentified radiology staff wearing gowns, gloves, and masks came out of the patient ' s room with the patient in a wheel chair wearing a mask. The radiology staff wheeled the patient down the hall wearing their gown, gloves and mask

Staff V RN, infection control officer acknowledged that any one exiting an isolation room will not wear the PPE outside of the room.

- The Hospital ' s policy /procedure titled " Surgical Attire " reviewed on 9/29/15 directed " ...masks shall cover the nose and mouth and shall be discarded whenever remove ... "

- Observation on 9/30/15 at 8:10am of the cafeteria area revealed an unidentified male sitting at a table eating wearing a surgical mask hanging down around their neck.

- Observation on 9/29/15 at 1:55pm on the medical/surgical unit revealed staff Z coming out of patient room 1103 with the patient ' s bed linen up against their body, that they took to the dirty utility room.

- Kansas Hospital Regulations dated November 2001 read in part: 28-34-18a. Obstetrical and newborn services. (c) Facilities and equipment. (2) Each delivery room shall have access to the following: (H) a scrub sink with foot, knee, or elbow control; (3) Each normal or neonatal intensive care nursery shall have access to the following: (E) sink with foot, knee, or elbow control.

- Observation on 12:25pm of the Labor/Delivery/ Postpartum Unit revealed six patient rooms and one nursery with hand washing sink with " wing " (a handle that is flat and wing like) handles. In trying to shut off the water, once turned on, by using the elbows against the handles, the water would not shut off. The inability to have hands free sinks in these rooms had the potential of cross contamination of the staff ' s hands once they washed them.

Staff S RN, interviewed on 9/28/15 at 4:55pm acknowledged the sinks in the patient rooms and nursery did not have hands free sinks and the potential for cross contamination of the staff ' s hands.

The hospital reported a census of 16 patients. Based on medical record review and staff interview the hospital failed to ensure the surgeon dictated and signed an operative report describing techniques and findings immediately following surgery for two of five surgical patients records reviewed ( patient's #12 and 14). This failure has the potential to cause poor patient outcomes due to the incomplete medical records for surgical patients.


Findings include:

Policy titled Transcription reviewed on 10/1/2015 at 7:55 AM directed " ...The HIM clerk checks each report in CPSI (electronic health record system) and performs deficiency maintenance ... "

- Patient #12's medical record reviewed on 9/29/2015 revealed an admission date of 9/23/2015 for an open reduction and internal fixation of the right ankle (surgery to repair a fractured ankle). The medical record lacked evidence the surgeon completed and signed an operative report immediately following surgery.

- Patient #14's medical record reviewed on 9/29/2015 revealed an admission date of 9/28/2015 for a mid-urethral sling urethroplexy placement (a surgery to implant a device to hold up the bladder). The medical record lacked evidence the surgeon completed and signed an operative report immediately following surgery.

Medical Records staff E interviewed on 9/29/2015 at 2:30 PM acknowledged the medical records lacked evidence the surgeon completed and signed an operative report immediately following surgery and deficiency maintenance had not been completed.

The Hospital reported a census of 16 patients. Based on observation, policy reviews and staff interviews the hospital failed to post all required signage in the emergency department's admission area, waiting room, and or treatment rooms. Failure to post all required signage has the potential to prevent patients from understanding their rights to emergency treatment.

Findings include:

- Emergency Department observed on 9/29/2015 at 8:50 AM revealed no Emergency Medical Treatment and Labor Act (EMTALA) signs posted where they are likely to be seen by the public including the admissions area, the waiting room and the treatment rooms.

Registered nurse staff F interviewed on 9/29/2015 at 9:00 AM revealed the hospital is currently doing construction projects and the EMTALA signs have not been mounted on the walls in the emergency department. Staff F indicated the signs are on the floor in the patient reception area and are not posted where they are likely to be seen by patients, but there is an EMTALA sign posted at the hospital's front entrance.

Policy reviewed on 10/1/2015 at 8:00 AM revealed the hospital failed to develop a policy to ensure Emergency Medical Treatment and Labor Act (EMTALA) signs are posted to ensure they are likely to be seen by patients.