HospitalInspections.org

Based on observation and interview, the hospital failed to ensure all electrical equipment was maintained in safe operating condition as evidenced by 4 (Rooms b, c, d, e) of 20 licensed beds failing to have operational bed side-rail nurse call bells.
Findings:

On 01/30/23 at 1:00 p.m. a tour of the inpatient beds revealed Rooms b, c, d and e had beds with non-operational side rail nurse call buttons.

In an interview on 01/30/23 at 1:40 p.m. S1DON stated that she was aware that the above beds had side rail nurse call buttons that were non-operational.

Based on observations and interview, the CAH failed to maintain a clean and sanitary environment to avoid sources and transmission of infection as evidenced by: 1) failing to ensure patient care equipment was free of dried blood; 2) failing to ensure staff sanitized their hands after patient care; 3) failing to ensure that a bag of normal saline was not used for multiple patients over an 8 day period in the CT room; and 4) failing to ensure patient use items in the outpatient therapy treatment areas were maintained to prevent the possible spread of infectious diseases.
Findings:

1. On 01/30/23 at 1:00 p.m., observation of Room a revealed the over-bed table had a dried blood spot on the side of the table and several brown stains on the bedspread. At 1:30 p.m., interview with S7LPN revealed that this room had been cleaned and was ready for a new admit. At that time, the surveyor pointed out the dried blood on the table and the stains on the bedspread. S7LPN stated that the room was in need of further cleaning.

On 01/30/23 at 1:10 p.m., observations of Room f revealed the over-bed table with a streak of dried blood on the right side of the table and an area with a sticky substance and grime and debris on the left side of the seat cushion of the patient's armchair. S8ES confirmed the findings and acknowledged the room was not properly cleaned.

2. On 01/31/23 at 9:30 a.m., observation in the lab revealed that S6Phlebotomist was drawing blood from an outpatient. Further observations revealed that after the blood draw was completed, the patient left and S6Phlebotomist removed her gloves and walked the blood tubes into the lab testing area. S6Phlebotomist was not observed to perform any hand hygiene after removing the gloves or after handling the blood tubes. The patient's chair was not observed to be sanitized after the blood draw. Observations of the side of the chair revealed dried blood.

On 01/31/23 at 9:45 a.m., interview with S6Phlebotomist revealed that she wipes down the lab chairs about four times a day. She further stated that during the height of Covid, she would wipe them down after every patient's blood draw, but does not do that anymore. At that time, the surveyor pointed out the dried blood on the chair and S6Phlebotomist confirmed the chair was in need of disinfecting.

3. On 01/31/23 at 10:00 a.m., observation of the CT room with S2Rad Tech revealed a half filled 250 mL bag of Normal Saline with tubing connected hanging from an IV pole. Observation of the bag revealed it was dated "01/22/23" with a black marker. Interview with S2Rad Tech at that time revealed that the Normal Saline was used for contrast during CT scans and that the bag could be used multiple times for different patients for seven days only. The surveyor pointed out that the bag had been hanging for eight days and S2Rad Tech stated it should have been thrown away.

On 02/01/23 at 12:35 p.m., interview with S9Pharmacist revealed saline bags are to be changed every 24 hours with tubing sets being patient specific and radiology procedures requiring saline are for single patient use only.

4. On 02/01/23 at 9:30 a.m., observations of the outpatient therapy treatment areas revealed 6 of 8 pillows used on the treatment tables had rips/tears to the vinyl coverings which prevents proper cleaning of the pillows. Further observation failed to reveal the paraffin bath and hydrocollator were maintained by monthly changing of the paraffin and water from January 2022 through January 2023.

On 02/01/23 at 9:45 a.m., interview with S7PTA revealed the pillows with rips/tears to the vinyl covering should have been discarded and not available for patient use. She continued to state they failed to document the required monthly paraffin and water changes for the bath and hydrocollator.