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Based on medical record review, observation, interview and review of facility policy, the facility failed to ensure timely identification and family notification for one patient (#60) of seventy patient's reviewed.

The findings included:

Building A

Patient #60 was admitted to Building A on June 18, 2012, at 9:48 a.m., with diagnoses including traumatic subarachnoid hemorrhage, facial laceration, traumatic intraventricular hemorrhage, left pelvis fracture, and kidney laceration.

Medical record review of the Emergency Department (ED) Clinical Summary, dated June 18, 2012, revealed the patient was unconscious, intubated and chemically sedated. Further medical record review revealed at the time of admission to the facility the patient had not been identified.

Medical record review of the ED Clinical Summary, dated June 18, 2012, at 10:42 a.m., revealed "...spoke with (named person) in nsg (nursing) office for consult ...getting scans and admitted to ICU (Intensive Care Unit)..."

Medical record review on June 19, 2012, at 2:00 p.m., revealed no documentation by case management of follow up regarding identification of the patient or family notification.

Observation on June 19, 2012, at 1:30 p.m., in the Surgical Trauma Intensive Care Unit (STICU), revealed the patient remained unconscious, chemically paralyzed, sedated, and on the ventilator.

Interview with Registered Nurse #1 on June 19, 2012, at 1:45 p.m., outside the patient's room in the STICU, revealed the resident remained unidentified. Further interview revealed "...security and nursing administration are aware but I have not heard anything about ...identification...Case management has not seen the patient...they usually see the patient with-in the first 24 hours of admission...the patient arrived here in the unit yesterday afternoon..."

Interview with the assistant nurse manager on June 19, 2012, at 1:50 p.m., outside the patient's room, revealed "...case management usually reviews the patient's record and follows up with the transferring agency, local and state police for any information related to identification...at this point they have not seen the patient while in the unit..."

Interview on June 19, 2012, at 2:40 p.m., with the case manager, in the STICU conference room, revealed case management had not reviewed the medical record since the patient was admitted to the STICU. Further interview revealed "...have not followed up at this point but...plan to look at the medical record, ED report, LIFEFORCE documentation and notify the police agency in the morning...we try to see the patient's with-in 24 hours..."

Review of facility policy "Doe Patient Identification/Registration",policy number 8316.950, with a revision date of 05/11, revealed "...assistance in identifying patient will be provided by guest representatives, patient access and house supervisor..."

Interview with the Assistant Nurse Officer, on June 19, 2012, at 2:50 p.m., in the STICU conference room, confirmed the patient remained unidentified, and there was no documentation in the patient's medical record regarding attempts to determine identification or family notification since the patient was admitted to the facility.

Based on observations, review of the facility's Patient Rights statement (a printed list of rights given on admission), and interview, the facility failed to provide personal privacy for one patient (#2) of seventy patients reviewed.

The findings included:

Building A

Observations of patient room #9138, on the Orthopedic Unit (North West 9) on June 18, 2012, at 11:25 a.m. revealed staff visible from the corridor, assisting Patient #2 to walk from the door to the bed. Further observation revealed staff did not close the door or pull the privacy curtain and the patient's hospital gown was open in the back with the buttocks and upper thighs exposed and visible from the public corridor. Continued observation revealed the patient was assisted to walk across the room to the bed and staff spread the back of the patient's gown open further, exposing more of the patient's buttocks and upper thighs, prior to having the patient sit on the bed.

Review of the facility's Patient Right's statement revealed, "You, the patient, have a right to...privacy in treatment and personal care..."

Interview with the Associate Nursing Officer, in the public corridor outside room #9138, on June 17, 2012, at 11:25 a.m., confirmed the patient's buttocks were exposed.

Based on interview and review of facility policy, the facility failed to ensure staff were knowledgeable about the activation of the Rapid Response Team (RRT) should a patent's condition decline.

The findings included:

Building A

Interview with radiology technician #1, on June 20, 2012, at 8:00 a.m., in the Radiology Oncology department, revealed the technician was not familiar with the Rapid Response team (activating critical care expertise to the bedside) or how to activate the system.

Interview with radiology technician #2, on June 20, 2012, at 8:05 a.m., in the Radiology Oncology department, revealed technician #2 was not familiar with the Rapid Response team or how to activate the system.

Interview with the Nurse Manager of the Radiology Oncology department, on June 20, 2012, at 8:15 a.m., revealed "...all staff are to be familiar with all emergency codes and the activation of systems that protect our patients...they would call out front and ask for a nurse immediately for help and stay with the patient..."

Interview with Certified Nuclear Medicine Technician (CNMT) on June 20, 2012, at 11:30 a.m., in the Nuclear Medicine Department located in the Emergency Department , revealed the technician was not familiar with the Rapid Response Team or how to activate the system.

Interview with the Associate Administrator, members of the Rapid Response Team (House Supervisor, Critical Care Nurse, Respiratory Therapy) on June 20, 2012, at 11:45 a.m., in the Emergency Department, confirmed the CNMT was unfamiliar with the RRT and revealed "...all staff have received education regarding the RRT response and activation..."

Review of the facility policy, Rapid Response Team, policy number PC 140, last revised on February, 2012, revealed "...rapid response team (RRT) should be called when a rapid assessment and intervention is deemed necessary for a declining patient based on the criteria indicators...the RRT will be activated by calling the RRT line at RRTX-7789..."

Based on observation and interview, the facility failed to ensure patient records were secure from unauthorized persons in the Imaging Center.

The findings included:

Building B

Observation of the Imaging Center, on June 19, 2012, at 12:30 p.m., revealed a public corridor had an unlocked closet with signage for "Storage". Observation inside the unlocked closet revealed bookcase-type wood shelving containing multiple sleeves of x-ray films and reports, organized in an alphabetical manner.

Interview with Computer Tomography (CT) Technician #1 on June 19, 2012, at 12:30 p.m., outside the storage closet, confirmed the closet was not locked and x-ray films and x-ray reports were stored in the closet.

Interview with the Administrator on June 19, 2012, at 12:45 p.m., in the Imaging Center, confirmed the medical records were not secured from unauthorized persons.

Based on observation, medical record review, facility policy review, and interview, the facility failed to ensure restraint assessment was completed for one patient (#69) of 11 patients on the Geriatric Psychiatric (gero-psych) Unit.

The findings included:

Building C

Observation of the gero-psych unit with the Administrator on June 18, 2012, at 2:50 p.m., revealed three merrywalkers (an enclosed device with a seat and wheels in which a patient can stand and walk or be seated) in the hall.

Interview with the Administrator on June 18, 2012, at 2:50 p.m., revealed the merrywalkers are used as assistive devices and not used as a restraint on the patients.

Interview with Patient Care Technician #1 in the hall on June 18, 2012, at 3:15 p.m., confirmed a merrywalker had been utilized on patient #69 who was currently asleep in bed.

Medical record review revealed patient #69 was admitted to the facility June 1, 2012, with diagnoses to include Dementia with Behavioral Disturbance and Bipolar Disorder.

Review of the Nursing Flow Sheet revealed documentation the merrywalker was utilized on the patient as follows:
June 12, 2012 - 7:00 a.m. -7:00 p.m., "...restless...assisted to merrywalker..."; June 12 - 7 p.m. - 7 a.m., "...Roaming about in the merrywalker..."; June 13 - 7:00 a.m. - 7:00 p.m. "...roaming day area and unit in merrywalker..."' June 13- 7:00 p.m. - 7:00 a.m. - "...walking around in merrywalker..."; June 14 - 7:00 a.m. -7:00 p.m. - "...roaming around unit in merrywalker ..."; June 14 - 7:00 p.m. - 7:00 a.m. - "...ambulates throughout unit in merrywalker..."; June 15 - 7:00 a.m. - 7:00 p.m., "...sat up in merrywalker about an hour..."; June 14 - 7:00 p.m. - 7:00 a.m., "...ambulated in merrywalker through unit..."; June 16 - 7:00 a.m. - 7:00 p.m., " ...wandering about dayroom in merrywalker, going to back door trying to get out..."; June 16 - 7:00 p.m. - 7:00 a.m., wandering, wanting to pace, merrywalker..."; June 17 - 7:00 a.m, - 7:00 p.m., "...merrywalker to ambulate..."; and June 17 - 7:00 p.m. - 7:00 a.m., "...merrywalker to ambulate..."

Review of the Physician's Progress Notes revealed the following: June 8, 2012, at 9:40 a.m., "...restless, intrusive, cannot sit still..."; June 8, no time noted - "...restless, intrusive, exit seeking, cannot sit still..."; June 9, at 10:15 a.m. - "still restless, wandering, intrusive, plunders and wanders into others rooms..."; June 10, at 10:10 a.m. - "...restless, intrusive, wandering about the unit, cannot sit still..."; and June 14, at 12:15 p.m. - "...unable to stay still, puttering about in merrywalker, going into others rooms..."

Review of the Physical Therapy Acute Care assessment, dated June 4, 2012, at 11:15 a.m., revealed the patient required minimal to stand by assistance (staff in arms reach) for transfers and ambulation, with gait and transfer training 1-2 times per day to be conducted. Review of the Rehab (Physical Therapy) Progress Notes revealed the following: June 4, 2012, at 2:25 p.m. - stood independently, ambulated 200 feet with CGA (contact guard assist - staff touching arm) of one; June 5, at 8:05 a.m., stood unassisted, ambulated 225 feet with CGA of one; June 6, at 2:00 p.m. - stood independently, ambulated without assist - ambulated 350 feet with supervision; June 7, at 9:50 a.m., stood independently, ambulated without assist 350 feet with supervision; June 8, at 8:15 a.m., stood unassisted, ambulated 300 feet; June 11, at 9:14 a.m., stood unassisted, ambulated with supervision 350 feet; June 12, at 8:20 a.m., stood unassisted, ambulated 300 feet with supervision; June 13, at 8:20 a.m., stood in merrywalker and ambulated 200 feet twice; June 13, at 2:30 p.m., stood in merrywalker and ambulated with supervision 350 feet, left in merrywalker secured with crossbar and safety belt; June 14, at 8:50 a.m., stood unassisted and ambulated 300 feet with supervision then placed in merrywalker and secured with crossbar and safety belt; June 15, at 11:50 a.m., stood from chair unassisted, ambulated 350 feet with supervision; and June 18, at 8:40 a.m., up in merrywalker, stood and ambulated in merrywalker with supervision 200 feet, left in merrywalker secured with crossbar and safety belt.

Review of the facility policy, Restraints/Protective Devices, Number PC.050, dated as revised November 2012, revealed "...any method of physically or chemically restricting a person's freedom of movement, physical activity, normal access to his or her body or any manual device or equipment attached to the patient's body that is not easily removed by the patient and which restricts movement is considered a restraint..."

Interview with the Physical Therapy Assistant (PTA) #1 on June 18, 2012, at 4:05 p.m., confirmed no assessment was conducted on patient #69 to determine if patient #69 could release self from the merrywalker without staff assistance.

Interview with the Administrator on June 18, 2012, at 4:20 p.m., confirmed the merrywalker would be considered a restraint device if an assessment was not done to determine if patient #69 was unable to self release from the merrywalker.

Based on medical record review and interview, the facility failed to obtain a written order from the physician for the use of restraints for one (#20) of seventy patients reviewed.

The findings included:

Building A

Medical record review revealed patient #20 was admitted to the facility on February 5, 2012 with diagnoses to include Left Parieto-Temporal Intracerebral Hemorrhage, Dysarthria (speech difficulties) and Right Hemiparesis.

Review of the Adult Clinical Justification Documentation for Restraints revealed restraints were applied because the patient attempted to pull out foley catheter and nasal cannula (device for delivery of oxygen). Continued review of this form dated February 6, 2012, at 8:00 a.m., revealed a verbal order for restraints written by the nurse caring for the patient but there was no physician's signature.

Review of the facility policy entitled Restraints/Protective Devices, PC.050, revealed "...written order based on face-to-face examination of the patient is entered by the physician on the Adult Clinical Justification Documentation for Restraints by the next calendar day of the initiation of restraints...".

During interview on June 19, 2012, at 11:30 a.m., in the Health Information Management office, the Statistical Coordinator confirmed there was no physician signature for the verbal order written by the nurse for restraints.

Based on medical record review, observation, interview and review of facility policy, the facility failed to maintain a current nursing care plan for three (#59, #61, #62) of seventy patients reviewed.

The findings included:

Building A

Patient #59 was admitted to the facility (Building A) on June 17, 2012, with diagnoses including C3-C4 neck fractures with cord involvement and Right Upper Extremity (RUE) hemiparesis.

Medical record review revealed the patient's care plan, dated June 18, 2012, did not include care planning for the C3-C4 fractures, post-surgical care and range of motion (ROM) related to the hemiparesis.

Interview with Registered Nurse (RN) #2, on June 19, 2012, at 1:25 p.m., in the STICU conference room, revealed the nursing care plan was initiated after the patient's admission to the unit. Further interview revealed the patient had surgery on June 18, 2012 for repair of the C3-C4 fracture and confirmed the care plan did not address the fractures, the post surgical care and the range of motion.

Interview with the assistant nurse manager on June 19, 2012, at 1:30 p.m., in the STICU conference room confirmed the care plan did not address the C3-C4 fractures, post surgical care or ROM.

Patient #61 was admitted to facility on June 18, 2012, with diagnoses including hypertension (elevated blood pressure), Diabetes Mellitus type 2 and Spinal decompression (spine surgery).

Medical record review revealed the patient's care plan, dated June 18, 2012, did not include care planning for Diabetes or hypertension.

Interview with the nurse manager on June 19, 2012, at 2:50 p.m., in the nurses station, confirmed the care plan did not address the hypertension or the diabetes.

Patient #62 was admitted to the facility on June 11, 2012, with diagnoses including Pneumonia, Adrenal Mass and Lung Cancer.

Medical record review on June 19, 2012, at 2:55 p.m., in the Central 7 Nurses Station, revealed the patients care plan did not address the pneumonia or the patient receiving chemotherapy.

Interview with RN #3 on June 19, 2012 at 2:55 p.m., in the Central 7 nurses station, confirmed the patient's care plan did not address pneumonia or the chemotherapy.

Review of the facility policy, Care Planning Process,policy number PC-007, with last revision date of July, 2011, revealed "...the interdisciplinary plans of care should address the active and current needs/problems/treatments that are related to the reason for the admission..."

Based on record review and interview the facility failed to provide a complete medical record for one patient (#60) of seventy patients reviewed.

The findings included:

Building A

Patient #60 was admitted to Building A on June 18, 2012, at 9:48 a.m., with diagnoses including traumatic Subarachnoid Hemorrhage, Facial Laceration and Traumatic Intraventricular Hemorrhage, Left Pelvis Fracture and Kidney Laceration.

Medical record review of the Emergency Department (ED) Clinical Summary, dated June 18, 2012, revealed the patient was unconscious, intubated and chemically sedated. Further medical record review revealed at the time of admission to the facility the patient had not been identified.

Medical record review of the Emergency Treatment/Invasive Procedure and/or Blood transfusion authorization, dated June 18, 2012, revealed no time to indicate the time of the authorization by the physician.

Interview with the assistant Nurse Manager, on June 19, 2012, at 2:20 p.m., in the Surgical Trauma Intensive Care Unit (STICU) conference room, confirmed the authorization form was not timed by the physician.

Review of facility policy, Informed Consent for Treatment/Procedures, policy number PC-014, with a last approval date of July, 2011, revealed "...the physician will indicate on the "Authorization for Treatment/Invasive/Procedures/Blood Administration form (15104) that unless treatment or procedure is performed immediately, the patient is in danger of losing life or limb..."

Based on medical record review and interview, the facility failed to ensure a discharge summary was completed for one (#24) of seventy patients reviewed.

The findings included:

Building A

Medical record review revealed patient #24 was admitted to the facility on April 7, 2012, with diagnoses to include Subdural Hematoma. Continued medical record review revealed the patient underwent evacuation of the Subdural Hematoma and was subsequently discharged home on April 15, 2012.

Further medical record review revealed no discharge summary in the record. Continued review revealed no documentation in the progress notes of the patient's discharge.

During interview on June 19, 2012, at 11:33 a.m., in the Health Information Management department, the Statistical Coordinator confirmed there was no discharge summary in the patient's record and physicians were required to complete the discharge summary within thirty days of the patient's discharge.

Based on observation, facility policy review, and interview, the facility failed to ensure medications brought from home were verified by the facility pharmacy.

The findings included:

Building A

Observation in the Pediatric GI (Gastrointestinal) Center on June 19, at 3:40 p.m., with the manager of the Pediatric GI Center revealed a locked refrigerator containing a prescription, dated May 14, 2012, with a patient name on the box which had not originated from the facility's pharmacy. Continued observation revealed 2 pre-drawn injections labeled Peginterferon Alfa 2B - 80 mcg (micrograms)/0.5 ml (milliliter) available for administration.

Review of the facility policy Medications Brought from Home, number PC-099, dated as revised November 2011, revealed "...Medications brought from home must be verified by the pharmacist prior to being administered by a nurse..."

Interview in the Pediatric GI Center with the Director of the Pediatric GI Center on June 19, 2012, at 3:40 p.m., confirmed the medications had not been sent to the pharmacy for verification prior to administration.

Based on observation and interview, the facility failed to ensure all medications were secured in the Wound Center.

The findings included:

Building A

Observation at the nursing station and interview with the Manager of the Wound Center on June 20, 2012, at 8:35 a.m., revealed an unlocked cabinet containing the following unsecured medications: Tylenol Extra-strength 500mg (milligrams) tabs - 500 packages and Ibuprofen 200 mg six tabs.

Interview with the Manager of the Wound Center on June 20, 2012, at 8:35 a.m., confirmed the medications were not secured and all medications were to be secured.

Based on observation and interview, the facility failed to ensure medications and schedule II narcotics were secured for one of four operating rooms and for the Medication Room on the Medical-Surgical unit.

The findings included:

Building B

Observation of Operating Room (OR) #4 on June 18, 2012, at 1:50 p.m., revealed no staff were in the room and the doors to the room were unlocked. Observation of the anesthesia cart in OR #4 revealed the cart was unlocked and contained multiple injectable medications used for pain control, blood pressure control, emergency resuscitation, and anesthetic agents including, Propofol, Fentanyl, Versed, Lasix, Brevibloc, Atropine, Robinul, Ephedrine, Toradol, Succinylcholine, and Vecuronium. Observation of the top drawer of the anesthesia cart revealed one syringe of Propofol 25 ml (milliliters), Versed 2ml, and two syringes of Fentanyl 2 ml, ready for administration.

Interview with the OR Manager on June 18, 2012, at 1:50 p.m., in OR #4, confirmed anesthesia carts were to be locked when no staff were present in the OR rooms and the medications were not secured.

Observation of the medication room on the Medical-Surgical (Med-Surg) unit on June 18, 2012, at 3:00 p.m., revealed the door to the medication room was locked, and in an unlocked cabinet inside the medication room, was a zip lock bag containing multiple bottles of one patient's personal medications brought from home, including approximately 19 tablets of Hydromorphone (schedule II narcotic) 2 milligrams.

Interview with the Med-Surg Manager on June 18, 2012, at 3:00 p.m., in the medication room, confirmed the Hydromorphone was not secured behind two locks as required by pharmacy law.

Based on observation and interview, building A dietary department failed to store, prepare and maintain food and equipment to prevent contamination in the hot food preparation area by the range top and broiler; and in the pot and pan washing area. Based on observation and interview, building B dietary department failed to store, prepare and maintain food to prevent contamination in the dry storage room; interior of the ice machine; in the reach-in refrigerator containing hot dogs; the shelf under the preparation table; the utensils hanging from the over head pot rack; no thermometer in freezer; storage of dietary staff personal item at the hand sink; and two dietary staff members failed to wear head covering. Based on observation and interview, building C dietary department failed to store, prepare, and maintain food to prevent contamination in the walk-in freezer and failed to dispose dietary waste to prevent contamination in the dumpster area.

The findings included:

Building A

Observation of building A dietary department on June 18, 2012, beginning at 10:45 a.m. and 1:34 p.m., with the Food and Nutrition Services General Manager (FNSGM) and the Patient Representative (PR) present, revealed the following:
1. A heavy black accumulation on the back splash of the range top by the tray line.
2. A heavy accumulation of sticky and dried debris on the exterior surfaces of the reach-in refrigerator and the convection oven adjacent to the range top.
3. Dried debris on the bottom of the interior of the oven with the range top.
4. A heavy accumulation of black debris hanging from the bottom perimeter of the broiler over the range top.
5. A heavy accumulation of black debris on the entire surface of the fan grate and fan blades of a wall mounted fan in the pot and pan washing area. The fan was blowing away from the dirty side of the pot and pan area toward a storage rack containing clean utensils, fryer baskets and other dietary equipment.
6. A dietary staff member placing paper mats onto wet patient trays for the patient tray line.

Interview at time of the observations in building A dietary department on June 18, 2012, beginning at 10:45 a.m. and 1: 34 p.m., with the FNSGM and PR, confirmed the above observations.

Building B

Observation of building B dietary department on June 18, 2012, beginning at 8:00 a.m., with the Patient Representative (PR) present, revealed the following:
1. Individual dressing packets had opened and soiled the interior of the storage container in the dry storage room.
2. The interior of the upper lid rim of the ice machine had black and brown colored debris accumulated that could fall onto the ice.
3. Hot dogs were stored in an opened plastic bag in an open box in the reach-in refrigerator.
4. The shelf under the preparation table had a storage bin filled with various sized bowls with the eating surfaces exposed. Next to the storage bin was a bucket of sanitizer solution with a rag used to clean equipment surfaces that could contaminate the exposed surfaces of the bowls when draining the rag.
5. Numerous ladles, spoodles and other utensils with a heavy accumulation of dust and debris were stored on the pot rack over the preparation table.
6. There was no thermometer in the ice cream reach-in freezer.
7. A 20-ounce bottle of hand lotion, identified as the personal property of a dietary staff member, was stored on the hand sink.
8. Two dietary staff members entered the dietary department without a head covering in place. One staff member, after putting on the head covering, left a strand of hair hanging out of the covering and failed to have all hair secured under the covering.

Interview at time of the observations in building B dietary department, on June 19, 2012, beginning at 8:00 a.m., with the PR confirmed the above observations.

Building C

Observation of building C dietary department on June 18, 2012, beginning at 1:35 p.m., with the facility Administrator present, revealed the following:
1. Ice accumulated on the walk-in freezer compressor unit, and boxes stored in the unit. There were two mounds of ice on the floor of the freezer unit.
2. The open doors on two dumpsters in the loading dock area exposed the trash contained inside the dumpsters.

Interview at time of the observations with the Administrator present on June 18, 2102, beginning at 1:35 p.m., confirmed the above observations.

Based on observation, interview and record review, the facility failed to maintain the physical plant and environment.
The findings include:
Observation, interview, and record review with the Director of Maintenance and Environmental Services, on June 18 through 20, 2012, between 8:00 a.m. and 5:00 p.m. confirmed the facility failed to maintain the means of egress accessible at all times, failed to maintain corridors clear and unobstructed failed to maintain corridor doors, failed to provide adequate exit signage and exit discharge lighting, failed to maintain portable fire extinguishers in accordance with NFPA 10, failed to maintain smoke detectors clear of air supplies, failed to maintain hazardous areas fire-rated construction, failed to maintain the sprinkler system, and failed to provide NO SMOKING signs where Oxygen is in use, (Reference Life Safety Tags: K021, K022, K025, K029, K038, K039, K045, K051,K062, K064, and K141.)

16867

Based on observation and interview, the facility failed to ensure the environment and supplies were maintained at an acceptable level of safety and quality.

The findings included:

Building A

Observation of the Emergency Department (ED) on June 19, 2012, between 8:10 a.m. and 11:00 a.m., revealed the following:

1. A stained and sagging ceiling tile in triage room one.
2. A baseboard in the trauma bay near the blood storage refrigerator was pulled away from the wall, revealing the concrete flooring underneath.
3. Two previously used intravenous fluid bags with tubing attached, one plastic outside liner bag for intravenous fluids, and used paper towels lying on the floor beside the trash can in exam room number 17.

Interview on June 19, 2012, between 8:10 a.m. and 11:00 a.m., in the ED, with the Associate Administrator of Surgical Services, the Program Director for Emergency Services, and the Emergency Department Manager confirmed the ceiling tile needed to be replaced, the baseboard needed to be fixed, and the trash was not be on the floor.

Observation in the High Risk Perinatal Unit on June 18, 2012, at 11:30 a.m., with Registered Nurse (RN) #4, revealed one vacutainer (sterile blood collection tube) labeled with an expiration date of January, 2012, and two vacutainers labeled with expiration dates in March, 2012.

Interview with RN #4 on June 18, 2012, at 11:35 a.m., in a supply room, confirmed the vacutainers were outdated and available for patient use.


Observation in the Labor and Delivery anesthesia medication room with RN #5 on June 18, 2012, at 11:55 a.m., revealed one of one Central Venous Access Kits labeled with an expiration date of January, 2012.

Interview with RN #5 on June 18, 2012, at 11:56 a.m., in the anesthesia medication room, confirmed the Central Venous Access Kit was outdated and available for patient use.


30553

Observation on June 20, 2012 at 11:30 a.m., in the Medical Mall (Building A) Gastrointestinal (GI) Laboratory procedure area, revealed a Christmas musical figurine stored in the cabinet with patient care supplies.

Interview with the Assistant Nurse Manager on June 20, 2012, at 11:35 a.m., confirmed the musical figurine was stored with patient care supplies.

Observation on June 19, 2012, in the Emergency Department (ED) in Building C, at 3:00 p.m., in the nutrition room, revealed soft drinks and crackers stored on the same supply rack with patient care supplies such as laboratory needles and blood tubes.

Interview with the ED Nurse Manager on June 19, 2012, at 3:00 p.m., in the nutrition room, confirmed the nutritional supplies were stored with patient care supplies.





21160

Building C

Observation in the Radiology Department with the Administrator on June 18, 2012, at 10:55 a.m., revealed a computer work station with the protective covering pulled away from the wood on the right corner exposing 2 - 3 inches of wood.

Interview at the work station area with the Administrator on June 18, 2012, at 10:55 a.m., confirmed the work station surface could not be cleaned with the wood exposed.

Observation in the CT (Computerized Tomography) room on June 18, 2012, at 11:30 a.m., revealed a sponge; a device utilized to assist in transfers from a stretcher to the CT table; and a container of germicidal wipes located in the cabinet under the sink.

Interview in the CT room with the Administrator on June 18, 2012, at 11:30 a.m., confirmed the items were not to be stored in the cabinet under the sink.

Building A

Observation with the ED Manager in the Emergency Department (ED) on June 19, 2012, at 1:40 p.m., revealed the bathroom located in the "sick child" waiting area had an emergency notification device on the wall located about 2 ½ feet from the floor by the toilet and had a cord no longer than 1 ½ inches.

Interview with the ED Manager in the ED on June 19, 2012, at 1:40 p.m., confirmed the emergency pull cord was to have a cord long enough to be reached if someone was on the floor. Continued interview confirmed the 1 ½ inch cord could not easily be reached from the floor and was non-functional for this purpose.

Building A

Observation with the ED Manager in the ED on June 19, 2012, at 1:50 p.m., revealed bathroom located in the "injured child" waiting area. Continued observation revealed the emergency pull cord on the wall was located about 2 ½ feet from the floor by the toilet was wrapped several times around the grab bar beside the toilet.

Interview with the ED Manager in the ED on June 19, 2012, at 1:50 p.m., confirmed the emergency pull cord was unable to be activated when wrapped around the grab bar and was non-functional when wrapped around the grab bar.

Building A

Observation and interview with the Outpatient Surgery Center Manager of the Plaza on June 20, 2012, at 10:10 a.m., revealed a bathroom located between two patient pre-assessment rooms. Continued observation revealed the emergency pull cord on the wall was located about 2 ½ feet from the floor by the toilet and was wrapped several times around the grab bar beside the toilet.

Interview with the Outpatient Surgery Center Manager of the Plaza on June 20, 2012, at 10:10 a.m., confirmed the emergency pull cord was unable to be activated when wrapped around the grab bar and was non-functional when wrapped around the grab bar.

Building A

Observation with the Outpatient Surgery Center Manager of the Plaza on June 20, 2012, at 11:30 a.m., revealed the clean utility room contained two warmer lights with a heavy build up of dust and several surgery positioning devices located on the floor with a heavy buildup of dust.

Interview with the Outpatient Surgery Center Manager of the Plaza on June 20, 2012, at 11:30 a.m., confirmed all items in the clean utility room were to be free of dust build up and were to be off the floor.

Building A

Observation in the Wound Center with the Manager of the Wound Center on June 20, 2012, at 8:40 a.m., revealed a drawer containing three Vicryl 5-0 sutures dated as expired January, 2012.

Interview in the Wound Center with the Manager of the Wound Center on June 20, 2012, at 8:40 a.m., confirmed the three Vicryl 5-0 sutures had expired January, 2012 and were available for patient use.

Based on observation, interview, review of the American Society for Clinical Pathology guidelines, manufacturers instructions, and review of facility policies, the facility failed to ensure instruments were thoroughly decontaminated and cleaned for sterilization, failed to store clean and sterile supplies in a sanitary manner, and failed to clean patient care areas of blood spills.

The findings included:

Building B

Observation on June 18, 2012, at 11:15 a.m., of the Soiled Utility room in Urgent Care, revealed a sink containing a blue plastic basin, a washcloth, and a 3.78 liter bottle of enzymatic cleaner for cleaning surgical instruments. Further observation revealed a metal stand next to the sink containing peel packs (special sealed pouches used for surgical instruments during sterilization) and chemical indicators (used in sterilization process). Observation of the enzymatic cleaner revealed an expiration date of January 1, 2010, and the instructions on the bottle for cleaning instruments were to use one fluid ounce of cleaner for every one gallon of water.

Interview with Registered Nurse (RN) #2 on June 18, 2012, at 11:15 a.m., in the soiled utility room, revealed the staff in Urgent Care used sterile surgical instruments for treatment of patient injuries, and cleaned and disinfected the instruments in the soiled utility room to send to the Sterile Processing Department (SPD). Further interview confirmed the process for cleaning the surgical instruments was to use "some" of the expired enzymatic cleaner (demonstrated a short pump on the bottle of cleaner) into the basin of water, "...because that does not hold a gallon of water..." Further interview confirmed the enzymatic cleaner was expired and the staff had not measured how much cleaner or water was utilized. Further interview confirmed the staff cleaned the instruments only using the washcloth and no scrub brushes were available. Further interview confirmed, once the instruments were cleaned, they were placed in the peel packs with a chemical indicator, sealed, and sent to SPD for sterilization.

Review of facility policy "Decontaminating and cleaning of instruments and equipment" number 6207.05, reviewed April, 2011, revealed, "...Decontamination: According to Occupational Safety Health Administration, 'the use of physical or chemical means to remove, inactivate, or destroy blood-borne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe or disposal'...At the completion of pre-rinse, instruments are inspected for visible debris before entering the washer/decontaminator..."

Interviews with Sterile Processing Tech #1 and with the Manager of SPD on June 18, 2012, at 2:15 p.m., in SPD, confirmed Urgent Care sent instruments to SPD cleaned, sealed, and ready for sterilization. Further interviews confirmed SPD did not inspect the instruments, re-clean the instruments, and were unaware of how the instruments were being cleaned in Urgent Care. Interviews confirmed the instruments were not cleaned and processed following standards for decontamination of instruments or the facility's policies and procedures.

Observation of the loading dock and Materials Distribution area on June 19, 2012, at 8:30 a.m., revealed a large concrete rectangular area with two loading dock bay doors on the left side and, on the right side, a storage room for receipt and storage of patient care items upon delivery with an unlocked Biohazardous Waste room, which contained multiple containers of biohazardous waste and sharps boxes (containing contaminated needles and sharps) next to the storage room. Observation of the loading dock bay doors revealed the first bay was open and available for trucks to load or unload and the second door opened to a large trash compactor. At the farthest one-third end of the loading dock area, next to the bay door leading to the trash compactor and slightly past the biohazardous waste storage room was stored the following: a large plastic transport bin, overflowing with soiled laundry; multiple pallets of delivered patient care supplies including items such as at least twenty shipping containers of supplies for Labor and Delivery, sterile supplies used during delivery, more than 10 boxes of baby formula, multiple boxes of sterile syringes, boxes of diaper bags, and various other sterile and clean patient care supplies; a wire container full of used cardboard boxes; and a large trashbin container full of dirty mop heads.

Interview with the Distribution Clerk on June 19, 2012, at 8:30 a.m., in the loading dock area, confirmed the biohazardous room was unlocked, and soiled laundry and soiled mop heads were always brought and stored in the area to be picked up by a contracted laundry service. Further interview confirmed the area was also used for delivery of patient care items and "extra" patient care items were stored in the same area as the soiled laundry, soiled mop heads, and at the entrance to the facility's trash compactor.

Interview with the Administrator on June 19, 2012, at 8:30 a.m., in the loading dock area, confirmed the sterile and clean patient care items were not being stored separate from soiled and biohazardous waste to prevent possible contamination.

Building A

Observations of the Surgical Intensive Care Unit (SICU) at Building A, on June 20, 2012, at 8:40 a.m, revealed the unoccupied patient bed in Room 3 had an approximately 2 centimeter spot of dried blood on the right side of the mattress.

Review of the facility's policy and procedure titled, "Bloodborne Pathogen Exposure Control Plan", review date April 2007, revealed, "...All patient care and other work areas are to be kept clean, orderly, and sanitary..."

Interview with the Nurse Manager of the SICU, at 8:40 a.m., on June 20, 2012, at 8:40 a.m., in Room 3 of the SICU, confirmed there was an approximately 2 centimeter spot of dried blood on the right side of mattress. Further interview with the nurse manager revealed Room 3 was unoccupied, and had been cleaned and prepared for a patient admission. Further interview with the nurse manager confirmed blood spills are to be cleaned from all surfaces immediately when they occur.


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Observation on June 18, 2012, at 3:20 p.m., on the Geriatric Psychiatric Unit with RN #3 revealed the unit had a glucometer (blood sugar measuring device) which RN #3 confirmed was cleaned with an alcohol pad after each patient use.

Review of the manufacturer's instructions revealed "Infection Control. Use Universal Blood Precautions. All patient samples and materials with which they come in contact are considered biohazards and should be handled as if capable of transmitting infection."

Review of the ASCP's (American Society for Clinical Pathology) Summary of Glucometer Cleaning Guidelines - February 2010...ASCP has researched individual glucometer manufacturers' cleaning recommendations, along with the Centers for Disease Control and Prevention (CDC), Environmental Protection Agency
(EPA) and American Diabetes Association (ADA) guidelines on this matter. The information provided below should be helpful when developing or assuring the adequacy of your facility's or facilities' policies and procedures. Be sure you are familiar with which glucometer manufacturer(s) your facility(ies) use(s) and the cleaning procedures recommended by that manufacturer(s). If the manufacturer does not provide specific cleaning recommendations or as a conservative approach to infection control for glucometers with minimal cleaning requirements, facilities may want to consider cleaning glucometers with high-level disinfectants. Be familiar with the amount of time the disinfectant solution is supposed to contact the equipment or how long active cleaning should be performed to ensure complete disinfection. For example, simply wiping equipment with a disinfectant-soaked swab may not be adequate. Wiping for a specific length of time or ensuring the equipment is "wet" or saturated for a specific length of time may be required. Cleaning timeframes may be dictated by CDC guidelines or by the disinfectant manufacturer in
their "instructions for use."

Review of the facility policy Disinfection and Sterilization, number 8304.040, dated as revised June 2009, revealed "All medical/surgical equipment will be sterilized/disinfected according to the guidelines in this policy...Decontamination...use of chemicals or physical means to remove, inactivate, or destroy bloodborne pathogens on a device surface..."

Interview at the Geriatric psychiatric unit nursing station on June 18, 2012, at 3:20 p.m., with the Administrator, confirmed the use of alcohol pads to clean the glucometer did not follow the facility policy to decontaminate the glucometer and a viracidal wipe or bleach solution was to be used.

Building A

Observation with the Emergency Department Manager of the T. C. Thompson Children's Emergency Department (ED) on June 19, 2012, at 1:20 p.m., revealed 2 handmade blankets made by volunteers and stored in a cabinet with various items intended to be given to patients in the ED.

Interview with the ED Manager in the ED on June 19, 2012, at 1:20 p.m., confirmed the handmade blankets cleanliness could not be assured and were available for use for the patients in the ED.

Building A

Observation in the Wound Center Soiled Utility Room with the Manager of the Wound Center on June 20, 2012, at 8:20 a.m., revealed a drawer filled with ready to use oxygen masks and tubing.

Interview with the Manager of the Wound Center on June 20, 2012, at 8:20 a.m., confirmed the oxygen masks and tubing were intended for patient use and were not to be stored in the Soiled Utility Room.

Building A

Observation at the nursing station with the Manager of the Wound Center on June 20, 2012, at 8:35 a.m., revealed a cabinet containing venipuncture (devices utilized to draw blood from patients for laboratory studies) equipment located next to an open box of breakfast type toaster pastries and a drawer containing syringes and needles in addition to a chart stamp device, pens, and charting paperwork.

Interview with the Manager of the Wound Center on June 20, 2012, at 8:35 a.m., confirmed food items are not to be stored with patient use items and the syringes and needles were intended for patient use and were not to be stored with unclean items.

Building A

Observation of the surgical pre-assessment area in the Outpatient Surgery Center located in the Plaza on June 20, 2012, at 10:50 a.m., with the Manager of the Outpatient Surgery Center, revealed a cabinet at the nursing station containing patient items to include a sweater and glasses stored alongside a stethoscope, charting papers, and facility medications.

Building A

Observation with the Outpatient Surgery Center Manager of the Plaza on June 20, 2012, at 11:10 a.m., revealed the pre-operative area had six pre-operative beds. Continued observation revealed an over bed table located at each bedside. Continued observation revealed an open basket located on the over bed table containing supplies to start IV's (devices utilized in insertion of a intravenous catheter for the delivery of fluids).

Interview with the Outpatient Surgery Center Manager of the Plaza on June 20, 2012, at 11:10 a.m., confirmed the open IV baskets on each over bed table remained at the bedside. Continued interview confirmed individual supplies needed to start each patient's IV were to be brought to the bedside to start each IV and not maintained in bulk at the bedside.