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A. Based on document review, observation and interview, it was determined the Laboratory Department improperly stored potentially infectious biohazard waste. This has the potential to affect all laboratory staff.

Findings include:

1. The "Blood Borne Pathogen (BBP) Exposure Control Plan (IN1002)" was reviewed on 5/12/15. The plan required "J. Housekeeping...5. ...Broken glass is disposed of in the Red bag storage boxes. K. Regulated Waste Disposal: 1. Contaminated sharps will be discarded as soon as feasible in sharps containers... sharps containers are red, puncture resistant and posted with biohazard label warnings...2. Regulated waste other than sharps will be placed in appropriate red bag containers. Red bag containers are white step on cans with red bag liners and are located... in each department."

2. During an observational tour of the laboratory department on 5/12/15 at approximately 9:15 AM, six (6) large sharp containers were observed throughout the department without lids. The sharp containers contained broken glass from blood tubes, urine containers, vial boxes, needles and other potentially infectious biohazard miscellaneous items.

3. During an interview on 5/12/15 at approximately 9:15 AM, the Laboratory Director (E#7) stated the sharps container lids were not properly placed is that some items are too large to fit through the lids opening. E#7 stated one of the sharps containers was not used for biohazard items and verbally agreed the containers were not marked as to which container was suppose to be used for potentially infected sharps or used for a garbage can.

4. During an interview on 5/12/15 at approximately 2:30 PM, the Vice President of Support Services (E#6) and the Director of Quality and Safety (E#13) stated they toured the laboratory and observed the open sharps containers. E#6 and E#13 verbally agreed the sharp containers contained potentially biohazard waste and did not have the lids on and this was an unacceptable practice. E#6 and E#13 stated the laboratory should be using the same process for biohazard disposal as the rest of the hospital.


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B. Based on observation, document review, and interview the Hospital failed in 1 of 1 nursing unit (C-Wing) to ensure cleaning supplies were securely stored, as required.

Findings include:

1. On 5/12/15 at approximately 9:45 AM an observational tour was conducted on the C-Wing medical surgical unit. The unit had a current census of three patients (Pt. #1-Pt. #3). The C-Wing dirty utility room was unlocked. The C-Wing dirty utility room shelves, which were approximately 1-4 feet off the ground, contained an unsealed gallon container of floor disinfectant, a can of disinfectant spray and an unsealed 16 ounce bottle of glass cleaner.

2. On 5/15/15 at approximately 8:45 AM, the policy titled "Hazardous Materials and Waste Management Plan" (revised 2014) was reviewed. The policy required "Chemicals: Department managers for those departments, with an inventory of hazardous materials, are responsible for implementing the appropriate procedures and controls for safe selection, storage, handling, use, and disposal of those hazardous materials."

3. During an interview with C-Wing Charge Registered Nurse (E#4) and Director of Support Services (E#6) conducted 5/12/15 at approximately 10:00 AM, E#4 and E#6 stated the dirty utility room is never locked and there was nothing preventing a patient from accessing the cleaning chemicals.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on June 12, 2015, the surveyor finds the facility does not comply with the applicable provisions of the 2000 Edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies on the associated K-tags.

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Based on document review, observation and interview, the CAH (Critical Access Hospital) failed to ensure outdated biological's were not available for patient use. This has the potential to effect 100% of patients serviced by the Hospital.

Findings include:

1. During an observational tour of the laboratory department on 5/12/15 at approximately 9:15 AM, the following was observed:
a) Laboratory refrigerator, the quality controls labeled Iris Spec CA 100 ml and Iris Spec CB 100 ml expired 4/28/15
b) Pathology room, a bottle labeled OCT compound was dated 10/1/07. It was unable to be determined if the date reflected the open or expired date or when product should have expired.

2. During an interview on 5/12/15 at approximately 9:15 AM, the Laboratory Director (E#7) stated, "I've been meaning to throw that out. That is an old mounting medium that we don't use anymore. The pathologist brings in his/her own supplies. All this stuff probably needs to be removed."

3. During an interview on 5/12/15 at approximately 2:30 PM, the Vice President of Support Services (E#6) and the Director of Quality and Safety (E#13) stated they toured the laboratory and the OCT compound had been thrown away but stated the pathology area needed cleaned out and multiple products discarded.

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Based on document review, observation and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure a sanitary environment to prevent cross contamination. This has the potential to affect all patients receiving laboratory services, laboratory staff, and all patients and staff in the affected areas.

Findings include:

1. On 5/15/15 at approximately 7:45 AM, the policy titled "Cleaning Patient Areas Office/Clinic" (reviewed/ 10/01/14) was reviewed. The policy required "Purpose: To clean and/or disinfect equipment and surfaces used for patient care in order to ensure a safe environment for patients... Process: e. clean infected/contaminated surfaces with EPA/infection control approved disinfectant if any equipment is... procedure has been performed where body fluid exposure is likely."

2. The policy titled "Blood Borne Pathogen (BBP) Exposure Control Plan (IN1002)" was reviewed on 5/13/15. The policy required "G Specimens:... 3. If outside contamination of the primary container occurs, the primary container will be placed within a secondary container that prevents leakage during...storage..."

3. During an observational tour on 5/12/15 at approximately 10:45 AM of the cardiac rehabilitation unit, 4 stationary bicycles were observed to have cloth covered foam seats.

4. During an interview with cardiac rehabilitation technician (E#5) conducted on 5/12/15 at 11:00 AM, E#5 stated the "bike seats were cleaned with disinfectant wipes between each patient.

5. During an interview with Director of Support Services (E#6) conducted on 5/12/15 at approximately 11:15 AM, E#6 stated "there was no absolute way to ensure the stationary bicycles were disinfected, since the seats are cloth covered foam."

6. During an observational tour of the laboratory department on 5/12/15 at approximately 9:15 AM, the following was observed:
a) A yellow fluid filled specimen cup labeled with a patient's name and as "urine" was observed on the top shelf of the microbiology refrigerator uncontained. The top shelf also stored clean unused culture petri dishes with agar and multiple clean supplies on each shelf below the contaminated uncontained urine specimen.
b) A 64 ounce plastic bottle labeled as "Bleach 10%" was observed on the laboratory countertop. The bottom 4 inches of the bottled was grossly discolored (brown) and dirty.

7. During an interview on 5/12/15 at approximately 9:15 AM, the Laboratory Director (E#7) stated "We always put patient specimens in the refrigerator. I don't see it as a big deal...We mix the bleach solution weekly to clean the counter tops...I agree the bottle looks bad."

8. During an interview on 5/12/15 at approximately 2:30 PM, the Vice President of Support Services (E#6) and the Director of Quality and Safety (E#13) stated they toured the laboratory, observed the dirty bleach bottle and the solution should not have been used to clean surfaces due to gross contamination. E#6 and E#7 stated the urine specimen cup was observed in the refrigerator with the clean supplies and "E#7 didn't think this was a bad practice but we agree, all those clean supplies have the potential to be contaminated and that's not safe practice."

Based on document/record review and interview, it was determined for 2 of 20 patients (Pt #2 Pt. #10), the Hospital failed to ensure the plan of care (POC) included goals specific to patient care needs.

Findings include:

1. The policy titled "Patient Care Planning" (revised 11/4/14) was reviewed on 5/15/15 at approximately 9:00 AM. The policy required "2. The plan of care is based on the patients' goals and assessed needs... 3. The plan of care and associated goals are updated based on re-assessment of the patients' needs, response to treatment, and preference."

2. The clinical record of Pt. #2 was reviewed on 5/13/15 at approximately 1:30 PM with Registered Nurse Clinical Information Coordinator (E#12). Pt. #2 was admitted on 5/11/15 with a diagnosis of cellulitis (infection) of the left foot. Pt #2 had at least 3 wounds on the left foot and required dressing changes. The plan of care had no specific goals related to the left foot wound care.

3. The clinical record of Pt. #10 was reviewed on 5/13/15 at approximately 2:30 PM with Registered Nurse Clinical Information Coordinator (E#12). Pt. #10 was admitted on 12/31/14 with a diagnosis of malignant lymphoma (cancer of lymph nodes) and died at the hospital on 1/12/15. Pt. #10 was placed on comfort measures on 1/9/15. The plan of care was not updated to include specific goals related to comfort measure status.

4. During an interview with Registered Nurse Clinical Information Coordinator (E#12) on 5/13/15 at 3:00 PM, E#12 stated there were no POC specific goals or interventions for Pt# 2's wound issues nor Pt. #10's change to comfort measure status.