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Based on observation, review of facility policy and interviews with staff, it was determined the facility failed to ensure patient personal privacy on the Horizon Health unit for geriatric psychiatric (geri-psych) patients. This affected 15 of 23 beds, and had the potential to affect all patients admitted to the geri-psych unit.

Findings include:

Policy: Patient Right and Responsibilities
Review Date: 09/2017

Purpose: To respect and maintain the right of our patients within the Infirmary Health facilities..

Policy: The Infirmary Health staff should facilitate the Patient Rights and Responsibilities Plan to ensure the patient's right are respected and maintained during their stay at our facilities...

YOUR RIGHTS

...The right to personal privacy.

1. A tour of the Horizon Health unit for geri-psych patients was conducted on 6/4/19 at 1:00 PM. Employee Identifier (EI) # 4, Program Director, and EI # 3, RN (Registered Nurse) were present on the tour.

There were 15 of 23 beds in rooms without window coverings. The unit is located on the second floor with views of the roof outside the windows. Located outside the windows were air conditioner units and other equipment. EI # 3 stated, "...there are people on the roof all the time." EI # 4 explained if a patient complained it was too bright to sleep, they would tape construction paper over the window.

An interview was conducted on 6/6/19 at 11:40 AM with EI # 1, Chief Nursing Officer, who confirmed the above findings and stated window shades have now been approved for the older section.

Based on observation, review of policy and procedures, CDC (Center for Disease Control and Prevention) Injection Safety Information for Providers FAQs (Frequently Asked Questions) Regarding Safe Practices for Medical Injections and interviews, it was determined the facility failed to ensure staff prepared and administered single dose parenteral medications per CDC recommendations, and labeled multidose vials for injection.

This did affect 1 of 2 patients observed in the surgery department, including Patient Identifier (PI) # 31, and had the potential to negatively affect all patients receiving surgery and rehab services at this facility.

Findings include:

CDC Injection Safety Information for Providers FAQs Regarding Safe Practices for Medical Injections

FAQs Regarding Safe Practices for Medical Injections

Medication Preparation Questions
1. How should I draw up medications?
Parenteral medications should be accessed in an aseptic manner. This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment.

Medication Administration Questions
...4. Is it acceptable to reuse a syringe and/or needle to enter a medication vial for the same patient if the medication vial and the syringe will be discarded at the end of the procedure and not used for subsequent patients?

The safest practice is to always enter a medication vial with a sterile needle and sterile syringe, even when obtaining additional doses of medication for the same patient. This adds an extra layer of safety in case, for some reason, the medication vial is not discarded at the end of the procedure as it should be and is inadvertently used on a subsequent patient.

5. Is it acceptable to use the same syringe and/or needle to administer multiple injections to the same patient (e.g., in the case of numbing a large area of skin or to provide incremental doses of intravenous medication)?

The safest practice is for a syringe and needle to be used only once to administer a medication to a single patient, after which the syringe and needle should be discarded. This practice prevents inadvertent reuse of the syringe and protects healthcare personnel from harms such as needlestick injuries.
However, when this is not feasible (e.g., when administration of incremental doses to a single patient from the same syringe is an integral part of the procedure), reuse of the same syringe and needle for the same patient should occur as part of a single procedure with strict adherence to aseptic technique.

Questions about Single-dose/Single-use Vials
1. What is a single-dose or single-use vial?

A single-dose or single-use vial is a vial of liquid medication intended for parenteral administration (injection or infusion) that is meant for use in a single patient for a single case/procedure/injection. Single-dose or single-use vials are labeled as such by the manufacturer and typically lack an antimicrobial preservative.

2. Can single-dose or single-use vials be used for more than one patient?
No.
Vials that are labeled as single-dose or single-use should be used for a single patient and single case/procedure/injection ...
Even if a single-dose or single-use vial appears to contain multiple doses or contains more medication than is needed for a single patient, that vial should not be used for more than one patient nor stored for future use on the same patient.

3. How many times may individual single-dose or single-use vials be entered for a single patient?

The safest practice is to enter a single-dose or single-use vial only once so as to prevent inadvertent contamination of the vial and infection transmission. Single-dose or single-use vials should be used for a single patient and a single case/procedure/injection. Therefore, they should require only a single entry into the vial.

Policy: Single Dose and Multidose Vials
Review Date: 11/08/2018

Purpose

To provide guidelines for the safe injection practices and the prevention of misuse of vials.

Policy

Staff should follow safe injection and infection control practices...

Procedure

...Needles or other objects should not be left in the vial entry diaphragms between uses, as this may contaminate the vial's contents.

Once a mutiple-dose vial is punctured it should be assigned a "beyond use" (expiration date), which is 28 days or the manufacturer's expiration date.

1. An observation was conducted by the surveyor on 6/5/19 at 8:00 AM in Endoscopy Room # 1 on PI # 31 for an Esophagogastroduodenoscopy (EGD) and Colonoscopy.

Upon entering the room with Employee Identifier (EI) # 5, Operating Room Manager, the surveyor observed EI # 7, Anesthesia Assistant (AA) with a syringe in his/her front shirt pocket. The surveyor asked EI # 5, what was in the syringe in EI # 7's front shirt pocket. EI # 5 then asked EI # 7 what was in the syringe in his/his front shirt pocket. EI # 7 pulled the syringe out of his/her front pocket which revealed a syringe with the needle inserted and attached to the medication vial. EI # 7 stated, "It is Versed (single use medication vial), I have already given her (PI # 31) 1 mg (milligram) and I will give her 1 more mg before I put her to sleep".

At 8:04 AM EI # 7 withdrew the vial of Versed with the syringe and needle inserted into the vial top from his/her front pocket and administered the single dose medication to PI # 7.

EI # 7 failed to ensure he/she used a new syringe and needle when administering medications to ensure aseptic technique. EI # 7 failed to ensure that medications were not stored for future use on the same patient as recommended per CDC for use of single dose vials.

At 8:06 AM the surveyor observed a vial of Propofol 200 mg/ml (milliliter) sitting on top of the anesthesia cart opened and dated 6/5/19 at 7:19 AM. The vial read "For Single Patient Use Only".

At 8:06 AM the EGD procedure was complete and at 8:10 AM EI # 7 withdrew medication from the Propofol vial sitting on top of the anesthesia cart and administered to PI # 31 for the Colonoscopy procedure. The surveyor asked EI # 7 if PI # 31 had already received Propofol from this medication vial. EI # 7 stated, "Yes, 50 mg".

EI # 7 failed to ensure that medications were not stored for future use on the same patient as recommended per CDC for use of single patient/dose vials.

An interview was conducted on 6/6/19 at 9:35 AM with EI # 1, Chief Nursing Officer, who verified the aforementioned findings.


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2. A tour of the Rehabilitation Services department was conducted on 6/5/19 at 9:05 AM with EI # 2, Physical Therapist. The following was observed in the locked medication cabinet:

1- multidose vial Dexamethasone 20 mg/ 5 ml, opened and unlabeled with a beyond use date.

An interview was conducted during the tour with EI # 2, who confirmed the above findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on a tour of the Dietary Department and staff interview it was determined the facility failed to maintain dishmachine rinse temperature per the facility policy.
This had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Sanitation and Infection Prevention/Control
Policy Number: F 019
Revised: 1/18

Policy:
Dishmachine wash and rinse water should be maintained at temperatures as stated below.
...Final rinse temperature 180 degree F (Fahrenheit) - 194 degree F

A tour of the dietary department was conducted on 6/5/19 at 1:30 PM with Employee Identifier (EI) # 18, Dietary Manager.

The surveyor observed the washing of dishes used for the facility lunch via the dishmachine for a total of 6 loads.

During the observation, the dishmachine failed to reach 180 degree F until the sixth consecutive load of dishes.

EI # 18 did confirm the temperature of the dishmachine during the tour.

Based on observations, review of policies and procedures, Center for Disease Control and Prevention (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) and Last Updated 2019, Steam Flash Sterilization logs, and interviews, it was determined the facility failed to:

a) Maintain an adequate number of sterilized surgical instruments available to prevent the need to flash / sterilize instruments for the scheduled procedure(s) on a routine basis.

b) Ensure staff performed hand hygiene per the facility policy.

c) Ensure staff followed the facility policy for cleaning the septum of medication vials prior to piercing the vial per CDC guidelines and facility policy.

d) Ensure staff provided a clean environment for medications prior to administration.

e) Ensure staff maintained clean technique throughout rendering of wound care.

f.) Ensure cleaning of reuseable medical equipment per the facility policy.

This did affect Patient Identifier (PI) # 21, PI # 31, PI # 16 and 3 Unsampled Patient's and had the potential to negatively affect all patients served by this facility.

Findings include:

CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)
Last Updated: May 2019

Flash Sterilization

Overview:
"Flash" steam sterilization was originally defined by Underwood and Perkins as sterilization of an unwrapped object at 132°C (Celcius) for 3 minutes at 27-28 lbs. of pressure in a gravity displacement sterilizer ... Flash sterilization is a modification of conventional steam sterilization (either gravity, prevacuum, or steam-flush pressure-pulse) in which the flashed item is placed in an open tray or is placed in a specially designed, covered, rigid container to allow for rapid penetration of steam. Historically, it is not recommended as a routine sterilization method because of the lack of timely biological indicators to monitor performance, absence of protective packaging following sterilization, possibility for contamination of processed items during transportation to the operating rooms, and the sterilization cycle parameters (i.e., time, temperature, pressure) are minimal ...

Uses:
Flash sterilization is considered acceptable for processing cleaned patient-care items that cannot be packaged, sterilized, and stored before use. It also is used when there is insufficient time to sterilize an item by the preferred package method. Flash sterilization should not be used for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time ...

Facility Policy: Immediate Use Steam Sterilizer (IUSS)
Date Revised: 03/15

Location:

1. The Immediate Use Steam Sterilizer (IUSS) is located in each sub-sterile room.

Usage:

1. It is used to flash instruments that have been dropped.
2. It is used to flash instruments that are needed for consecutive cases, in which there is not enough instrumentation.

Facility Policy: Hand Hygiene Guidelines
Effective Date: 2/2018

Policy:

Hand Hygiene is the most effective technique for preventing the spread of infection ...

Procedure:

The CDC recommends the following ...:

A. Indications for hand washing and hand antisepsis

...3. Decontaminate hands before having direct contact with patients.
...6. Decontaminate hands after contact with a patient's intack skin...
7. Decontaminate hands after contact with body fluids or excretions, ... non-intact skin and wound dressings.
...9. Decontaminate hands after contact with inanimate objects, (including medical equipment), in the immediate vicinity of the patient.
...10. Decontaminate hands prior to applying and after removing gloves....

B. Hand Hygiene Technique

...2. Soap and Water Wash:
...f. Use disposable towel to turn off the faucet....

Facility Policy: Guideline for Appropriate Glove Use and Glove Technique
Effective Date: 02/2018

"Procedure:

The following list serves as a guideline for appropriate glove wearing ...

Hand hygiene must be performed immediately after removing gloves.

...D. Gloves should be changed:
Note: Hand hygiene should be performed after every removal of gloves".

Facility Policy: Single-Dose & Multi-Dose Vials
Effective Date: 09/2014

Policy: Staff should follow safe injection control practices as outlined below, in addition to preventing misuse of vials thereby preventing the spread of infection.

Procedure: ...The vial rubber septum should be disinfected by wiping with a sterile alcohol pad before entry.

Facility Policy: General Departmental Infection Control Policy
Approval Date: 11/8/18

Purpose: To provide guidelines for...the prevention and control of infection.

Policy:

...IX. Cleaning of Reusuable Equipment

A. Patient care equipment should be cleaned between each patient use....

...C. If the equipment is not identified as "clean" or "dirty", it should be considered dirty, and should be cleaned prior to use...

1. During a tour of the Operating Room (OR) with Employee Identifier (EI) # 5, OR Manager, on 6/5/19 at 7:10 AM the surveyor observed 2 Immediate Use (Flash) sterilizers in the OR. The Flash Sterilizers were labeled Autoclave # 2 (located between OR # 2 and OR # 3) and Autoclave # 3 (located in a room next to OR #1). EI # 5 stated, we use them to flash our trays. The surveyor asked EI # 5, "How often does the facility perform flash sterilization? EI # 5 stated, "We use them all the time because we don't have enough trays. The surveyor asked what types of trays were being flashed sterilized routinely and EI # 5 replied, "Orthopedics mostly."

Review of the Steam Flash Sterilization logs on 6/5/19 at 9:30 AM for April 2019 revealed the facility flashed sterilized trays routinely on the following days:

Autoclave # 2:

4/1/19:
Lap (Laparoscopic) Tray x (times) 1

4/2/19:
Saw/Drill Tray x 1
Stryker Misc (Miscellaneous Tray) x 1

4/5/19:
Ats (Arthroscopy) Tray x 1

4/9/19
Small Bone Tray x 1
TK (Total Knee) Osteotomes Tray x 1,
Old Saw & (and) Drill Tray x 1
Lg (Large) Bone Tray x 1

4/19/19
Ats Tray x 1
Bose Scissors x 1
Fondren Ats Tray x 1

Autoclave # 3

4/5/19
Ats Tray x 1

4/8/19
Vag (Vaginal) Tray x 1

4/9/19
Small Bone x 2
Orthoplastic x 2
TK Osteotomes x 2
Saw/Drill Tray x 2

4/12/19
Dull Case Wright Medical Tray x 1

4/16/19
Large Bone Tray x 1

4/19/19
Orthoplastic Tray x 1
Joe Graspers x 1

4/23/19
Ats Tray x 1

4/25/19
Lap Tray x 2
Vag Tray x 2

4/29/19
Lapc (Laparoscopic) Tray x 1
D & C (Dilation and Curettage) Tray x 1

4/30/19
Fondren Ats Tray x 1

The facility was routinely flash sterilizing trays and did not follow CDC guidelines for disinfection and sterilization.

An interview was conducted on 6/5/19 at 10:20 AM with EI # 5, who verified the aforementioned findings.

An interview was conducted on 6/6/19 at 9:35 AM EI # 1, Chief Nursing Officer (CNO), who confirmed the above findings.

2. An observation was conducted by the surveyor on 6/5/19 at 7:32 AM to observe staff set up OR # 1 on PI # 21 for a Laparoscopic Hysterectomy.

The surveyor observed EI # 6, Scrub Technician, apply gloves and clean and disinfect the OR tables and trays. EI # 6 then removed his/her gloves, applied clean gloves and began opening sterile supplies without performing hand hygiene as directed per facility.

3. An observation was conducted by the surveyor on 6/5/19 at 8:00 AM in Endoscopy Room # 1 on PI # 31 for an Esophagogastroduodenoscopy (EGD) and Colonoscopy.

At 8:10 AM the EGD procedure was completed and all staff including EI # 10, Surgeon, EI # 9, Registered Nurse (RN), EI # 7, Anesthesia Assistant, and EI # 8, Scrub Technician removed his/her gloves and applied clean gloves without performing hand hygiene as directed per facility policy.

At 8:29 AM the Colonoscopy procedure was completed and EI # 7, EI # 9 and EI # 8 removed his/her gloves without performing hand hygiene.

An interview was conducted on 6/5/19 at 11:15 AM with EI # 5, OR Manager, who verified the aforementioned findings.



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4. An observation was conducted on 6/5/19 at 8:11 AM to observe EI # 14, Registered Nurse, perform a medication pass, contact isolation precautions, and wound care in the Intensive Care Unit (ICU) for PI # 16.

During the observation, EI # 14 failed to clean the septum the Rocephin vial and Sterile Water vial prior to drawing up the medications.

EI # 14 placed the prepared medication syringes in his/her uniform pocket (a dirty area), thereby failing to maintain the prepared medications in a clean area prior to administration.

EI # 14 donned gloves, moved trash can adjacent to the patient's bed with gloved hand, and proceeded to prepare sterile wound care supplies, remove wound dressing, and perform wound care without performing hand hygiene or changing gloves.

EI # 14 failed to remove gloves and perform hand hygiene a total of 3 times between touching the garbage can and applying a new dressing to the surgical wound.

An interview was conducted on 6/6/19 at 12:38 PM with EI # 12, Medical/Surgical and ICU manager, who confirmed the above findings.


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5. An observation for medication pass was conducted on 6/5/19 at 8:20 AM on the Horizon Geriatric Psychiatric Unit with EI # 19, RN. EI # 3, RN, was also present.

EI # 19 prepared and administered oral medications to an unsampled patient. The patient required prompting and guiding the medications to her/his mouth, by EI # 19. EI # 19 failed to perform hand hygiene following medication administration.

EI # 19 then returned to the medication room and failed to perform hand hygiene before preparing the next patient's medications.

An interview conducted on 6/5/19 at 8:35 AM with EI # 3, confirmed the above findings.


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6. An observation was conducted on 6/5/19 at 8:55 AM with EI # 15, RN, to observe medication administration on a unsampled patient.

During the observation EI # 15 failed to:

a. Perform hand hygiene prior to assessment of patient's chest and back.
b. Perform hand hygiene prior to opening and the preparation of the 0.9 % Sodium Chloride IV bag, IV tubing including priming the tubing line, and direct contact with the patient.
c. Clean the computer on wheels after leaving the patient's room and returning it to the nurses station.

An interview was conducted on 6/6/19 at 11:22 AM with EI # 1, who confirmed the above findings.

7. An observation was conducted on 6/5/19 at 9:05 AM with EI # 17, RN, to observe wound care on a unsampled patient.

Review of the Dressing Change...Order dated 6/3/19 at 2:22 PM revealed a wound care order to cleanse "both (bilateral) great toes" with saline, apply Bactroban ointment, cover with telfa pad, and secure with paper tape daily.

During the observation, EI # 15 failed to:

a. Perform hand hygiene prior to removing the wound dressing on the bilateral great toes.
b. Perform hand hygiene after glove removal 4 times during patient care .
c. Complete wound care on one wound and perform hand hygiene prior to performing wound care to the second wound.
d. Use a disposable towel to turn off the sink faucet after performing hand hygiene.
e. Clean the computer on wheels after leaving the patient's room and returning it to the nurses station.

An interview was conducted on 6/6/19 at 11:25 AM with EI # 1, who confirmed the above findings.

Based on observation and interviews with staff, it was determined the facility failed to ensure all anesthesia carts were secured and locked in the facility. This had the potential to negatively affect all patients receiving care in this facility.

Findings Include:

1. A tour of the Surgery Department was conducted by the surveyor on 6/4/19 at 7:05 AM with Employee Identifier (EI) # 5, the OR (Operating Room) Manager.

At 7:10 AM the surveyor and EI # 5 entered OR # 2 to conduct an observation of the Anesthesia Cart which contained medications. The Anesthesia Cart was unlocked and the medications were left unattended.

The surveyor asked EI # 5, if the Anesthesia Cart should be left unlocked and unattended? EI # 5 stated, "No".

An interview was conducted on 6/7/19 at 7:30 AM with EI # 1, Chief Nursing Officer, who verified the aforementioned findings.