HospitalInspections.org

Based on staff interview and record review, the hospital failed to assure that there was a policy to address the requirements for physician review and signature of the records of mid-level providers (per state requirements) in all settings. Findings include:

The hospital failed to have a policy to address supervising physician responsibilities regarding physician assistants in all areas of the hospital and provider practices where employed.
Per interview with the Director of Quality regarding requirements for supervising physicians for PAs (physician assistants) in the inpatient and outpatient settings, it was discovered and confirmed that the hospital's policy addressing this issue had expired on 4/16/16. At the time of survey, the hospital did have a physician assistant working on the medical surgical unit and in the outpatient practice offices under the hospital's provision of services.

Based on observation and staff interview, the pharmacy service failed to ensure that policies and procedures for the safe storage, handling, and monitoring of drugs throughout the hospital were followed in accordance with accepted professional principles. Findings include:

During a tour of the radiology department with the department director on 10/18/16 beginning at 8:30 AM, the following drug storage and safety issues were identified and confirmed:
1. In the CT (computerized tomography) room, 30 vials of Isovue 370 and 2 vials of Conray (IV contrast solutions) were observed stored in a unlocked warming cabinet. A door to the room was verified by the radiology director as being unlocked and accessible by a common hallway used by patients and staff. The Pharmacy policy, Medication Security (revised 04/2016) states under section B. "All medication shall be locked in the PYXIS or in a cabinet/drawer, or stored in a locked medication room, when not in use... G. Access to medication storage areas will be approved for licensed healthcare professional (RNs, providers, pharmacists) that provide patient care in the immediate area ..."
2. Also in the CT room, a bag of Normal Saline IV (intravenous) solution labeled for single patient use was being used to prime and flush IV contrast for multiple patients. Per the 2007 CDC recommendations for Safe Injection Practices to Prevent Transmission of Infections to Patients, section IV.H.8. states "Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients 453, 1006."
3. In a storage cupboard in x-ray room #2, an open bottle of gastrografin 37% labeled for single use was not discarded. The pharmacy policy Inspection of Medications (Revised 12/2015), section II. Procedure, states that "The member of the Pharmacy Department conducting the inspection is responsible for assuring all medications are in date, properly secured... Outdated, expired, and/or tainted medications will be bagged by the inspector and brought back to the pharmacy for proper disposal."

Based on observations, interviews and record review the Infection Control Program failed to ensure that staff consistently maintained infection control standards of practice throughout all areas and departments of the hospital. Findings include:

1. During a tour of the Perioperative department on the afternoon of 10/18/16 at 3:20 PM and a tour of OR #2 on 10/19/16 at 11:30 AM accompanied by the Director of Perioperative services, a laryngoscope blade on an anesthesia cart did not have a protective covering along with a laryngoscope blade stored in the pediatric code cart.. The laryngoscope blades are used by Anesthesiologists and CRNAs (Certified Registered Nurse Anesthetists) when performing an endotracheal intubation for general anesthesia. After use and contact with a patient's mucus membranes the laryngoscope blades requires high-level disinfection (which eliminates all microorganisms in or on the instrument to prevent transmission of infection). Without a covering for protection and date, it was unclear if and when the laryngoscope blades had been reprocessed, had been recently used and/or were safe for patient use. Per CDC (Centers for Disease Control and Prevention) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 states: Semi critical items contact mucous membranes or nonintact skin. This category includes respiratory therapy and anesthesia equipment......laryngoscope blades. These medical devices should be free from all microorganisms.....Semi critical items minimally require high-level disinfection using chemical disinfectants..."
2. Per observation on the morning of 10/18/16 in the Central Sterile Decontamination room, a staff member performing the reprocessing of an Endoscope (a scope used to perform a colonoscopy) failed to wear adequate PPE (personal protective equipment) to include a face shield during the cleaning of the endoscope. Per CAH policy/procedure for Reprocessing Endoscopes last revised 6/2016 states: " Cleaning: Goggles or face shield should be worn during the cleaning process. " The face shield is necessary to protect staff from possible exposure from disinfectant, debris and microbial burden from the endoscope. Per interview on the afternoon of 10/18/16, the Infection Control Coordinator confirmed appropriate PPE is required during the reprocessing of an Endoscope.
3. Per observation during the morning of 10/18/16 a mop bucket filled with floor cleaning solution, a mop, small blue bucket with cleaning solution and a housekeeping cart were observed stored across from OR #2 in an alcove in close proximity to the clean linen cart, a rack of suture material and other perioperative equipment. On 10/19/16 at 11:30 AM the Director for Housekeeping confirmed the housekeeping supplies used by perioperative staff when cleaning the operating rooms between surgical cases should not be stored in the alcove near clean and sterile supplies.
4. Per observation in OR #2 on 10/18/16 at 8:51 AM a surgical technician was observed using a CaviWipes (a disinfectant towelette) to clean a soiled area on the floor. After discarding the CaviWipes, the surgical technician failed to sanitize his/her hands. The surgical technician was also observed at approximately 9:25 AM during surgery raising his/her foot and attempting to reposition a drape at the end of the operating room table with their foot. A staff member intervened and stopped the technician from continuing to use their foot, and proceeded to adjust the surgical drape.
5. During a tour of the radiology department on 10/18/16 beginning at 8:30 AM, single use 02 tubing was observed unpackaged and wound over the wall connector in the two x-ray rooms and in the Nuclear medicine room; radiology staff could not confirm whether the tubing had been used or not. In the nuclear medicine room, the top of the suction canister was soiled with dust; the canister was not on a cleaning/monitoring schedule. In the CT (computerized tomography) room, a bag of Normal Saline IV (intravenous) solution labeled for single patient use was being used to prime and flush IV contrast for multiple patients. Per the 2007 CDC recommendations for Safe Injection Practices to Prevent Transmission of Infections to Patients, section IV.H.8. states "Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients 453, 1006." At the time of the tour, the Radiology director confirmed that the above observations were not compliant with infection control standards.
6. Per observation of a venipuncture (blood draw) in the out-patient lab on 10/17/16 at approximately 2:45 PM, the phlebotomist failed to sanitize the equipment tray table (where supplies were held for the procedure) after placing a soiled gauze pad on the surface. (The pad had been in contact with the patient's venipuncture site). The phlebotomist also failed to sanitize the venipuncture chair arm after direct (patient) skin contact during the procedure. The phlebotomist stated that the chair arm was sanitized only if there was visible soiling. Additionally, the phlebotomist did not remove gloves or sanitize hands prior to cutting tape from a roll that s/he confirmed was used for multiple patients. Following the procedure, the lab director confirmed that the lack of sanitization of equipment between venipuncture patients could pose an infection control issue. Per review, the hospital's Venipuncture policy (effective 8/5/2016), under Procedural Instructions states that Universal Precautions apply (when performing a venipuncture). The 2007 CDC Guidelines for Contact Precautions states in section V.B.5a , "If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient."

http://www.cdc.gov/injectionsafety/ip07_standardprecaution.html

The CAH failed to store medical records in a manner to ensure that they are safeguarded against loss and destruction. Findings include:

1. During a tour on 10/17/16 at 12:50 PM with the Director for Health Information Management the following observations of medical record storage was made:
a. In File Room #2, paper patient records were stored on shelves which incorporated 5 levels. The top levels of shelving were open and unprotected from potential water damage from near by sprinkler heads located above the shelves.
b. In a large room identified as the "Attic", several hundred patient paper records were stored. On the back wall of the "Attic" multiple shelves extended for approximately 20 feet, records were stored unprotected from potential water damage and some of the shelving was up against an outside window, where further potential for sun and water damage was also noted. Viewing the length of the "Attic" room, shelving extended for approximately 18 feet with the bottom shelves and records in direct contact with the floor and the top shelves were unprotected and exposed to sprinkler heads. The Director of Health Information acknowledged the storage of patient records has been a concern, however presently there has not been a active plan to protect the records or a solution for the storage.

2. During a tour of the basement at Outpatient Clinic A on 10/19/16 at 9:00 AM, there were six separate rooms in which medical records were stored. The medical records were being stored from many different medical practices. In 3/3 rooms there were boxes of medical records stored on pallets on the ground with several boxes of records stored on the floor. In all six rooms, many of the tops of the shelving units, which contained boxes of medical records, were close to the sprinkler systems and were uncovered. In one of the rooms there was a sign on one of the shelving units that denoted there was mold. Per interview on 10/19/16 at 9:14 AM with the Lead RN, s/he stated that there was a flood many years ago in the basement and Health Information Management had been cleaning up the records from this. S/he confirmed that all records were not stored in a manner to protect them from damage from water or other elements.

3. During tour of Outpatient Clinic B on the morning of 10/18/16, cardboard boxes of patient medical records were observed to be stored on the floor of the basement directly under sprinklers, creating an opportunity for potential water damage. The observation was confirmed by the practice manager at the time of the observation.

Based on observation and interview the Condition of Participation for Surgical services was not met as evidenced by the failure of Perioperative Services to limit access to the operative and recovery areas to only authorized personnel and failure to adhere to maximum hair coverage when entering ORs and during surgical procedures. Findings include:

Throughout the days of survey, observations were made of the accessibility of unauthorized individuals to potentially enter the Perioperative area which included the operating rooms (ORs), Post Anesthesia Recovery Unit (PACU) and Central Sterile Supply. During a tour on 10/17/16 at 3:15 PM accompanied by the Director of Perioperative Services, the entrances into the Perioperative area were not secure from unauthorized individuals. Doors remain unlocked with minimal posting on the doors warning unauthorized individuals not to enter the hallways which lead to the operating rooms, Central Sterile and PACU (Post Anesthesia Care Unit). The Director confirmed during the evening and night hours the doors remain locked and can only be accessed by CAH staff with OD badge authorization.

Per observations on 10/18/16 from 8:45 AM to 9:30 AM during the course of a surgical procedure in OR #2, multiple staff involved in a surgical procedure were observed wearing Personal Protective Equipment (PPE) hair covering that failed to completely cover their hair which was protruding from under the protective hat at the nape of necks or around ears while actively involved in the surgical procedure. Per AORN (Association of Perioperative Registered Nurses) Journal, January 2012 Vol 95 No 1 "Implementing AORN Recommended Practices for Surgical Attire, states, " 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. Perioperative nurses can help minimize the risk of surgical site infections by covering head and facial hair...." AORN further states " Skull 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 on the nape of the neck". In addition, per CAH policy Perioperative Infection Control last reviewed 6/2016 states: III. Procedure: A. Dress Code: 3. All head and facial hair, including sideburns, beards, and neckline hair, must be completely covered ....".

Based on staff interview and record review, Anesthesia Services failed to conduct a post- Anesthesia follow-up which included all necessary elements to assess recovery from the administration of anesthesia for 6 of 6 applicable records. (Patients # 2, 11, 12, 16, 17, 18) Findings include:

1. Per review of anesthesia records for Patient's #2, 11, 12, 16, 17, 18, staff from Anesthesia services, to include both Anesthesiologist or a CRNA, failed to address in their follow-up documentation in each patient's record the cardiopulmonary status, level of consciousness, any follow-up care and/or observations and any complications occurring during post-anesthesia recovery. Per interview on 10/19/16 at 9:15 AM, the Chief for Anesthesia confirmed the post anesthesia checks being conducted by anesthesia staff were incomplete by failing to address all the necessary components when assessing recovery of patients who had received some form of anesthesia.

In addition, for Patient #17, who was discharged on 6/12/16, the post anesthesia follow up was not completed until 5 days later, on 6/17/16. The CNO (Chief Nursing Officer) confirmed during interview on the afternoon of 10/19/16, that the post anesthesia follow up did not occur until 6/17/16, during a post discharge telephone interview between the anesthesia provider and Patient #17.

Based on review of facility policies, and confirmed through staff interview, the CAH failed to include all components in their patient visitation policy that would assure it is consistently implemented by staff in an appropriate manner that would not limit or restrict the visitation rights of patients. Findings include:

Per review, the CAH's policy titled Welcoming Policy, dated 05/2016, did not address how staff who are involved in controlling visitor access to patients will be trained to assure ongoing consistent implementation of the policy, and avoid unnecessary limitations or restrictions on visitation for patients.

The Director of Quality acknowledged, during interview on the afternoon of 10/19/16, that the policy did not address staff training regarding the visitation policy.