HospitalInspections.org

Surveyor Preceptor: 23059
Based on observation, interview, and policy review, the provider failed to ensure:
*In the radiology department multiple containers of medications/biologicals were properly secured and were not expired.
*In the emergency suite (ES) and operating suite a process was in place for the proper dating/storage of multiple intravenous fluid bags and bottled fluids placed in the warmer for patient use.
*In the ES pediatric supplies were not expired.
*In the obstetric unit four of four bottles of sterile water were not expired.
Findings include:

1. Observation in the radiology department on 3/21/11 from 3:15 p.m. to 4:00 p.m. revealed:
*No patients or staff were in the various radiology patient testing rooms.
*All radiology testing rooms were unlocked and the doors were open.
*In a small office room next to the x-ray room was an unlocked, two-door wooden cabinet with a key located in the lock. The cabinet contained the following items:
-One bottle of Polibar Barium Sulfate Suspension 1900 milliliters (ml). The bottle stated Rx [prescription] only.
-Fifty-three 450 ml bottles of Creamy Smooth Vanilla Readi-Cat 2. Rx only.
-At least thirty bottles of Lafayette Enhancer Barium Sulfate powder. Rx only. Expiration date was October 2010.
-At least sixteen 180 gram (gm) bottles of Tonopaque Barium Sulfate Suspension. Rx only.
-One 100 ml of Medebar Plus Barium Sulfate Suspension expired April 2009.
-One bottle of Gastrografin. The bottle stated Rx only and "Do Not Inject."
-Nine 30 ml bottles of bacteriostatic 0.9% sodium chloride. Five expired May 2010, three expired January 2009, and one expired February 2009.
-Eight packets of Sparkles Effervescent granules. Each packet stated "For professional use only."
-One box of 50 packets and an additional open box of thirty-one 4 gm packets of EZ Gas 11 Effervescent granules for antacid/antiflatulent. Those packets expired in July 2010 and stated to "Keep out of Reach of Children."
-At least ten 100 ml syringes contained Isovue-370. Rx only.
*In the x-ray room next to the above office was an unlocked cabinet near the sink with a key located in the lock. The cabinet contained:
-One 1900 ml bottle of Liquid Polibar Barium Sulfate Suspension with 600 ml remaining.
-One 312 gm bottle of Lafayette Enhancer Barium Sulfate Suspension powder expired October 2010.
-One 1000 ml bottle of Medebar Plus Barium Suspension with 300 ml remaining expired June 2008.
*In the CT suite was an unlocked cabinet with the key located in the lock. The cabinet contained:
-Thirty-four 450 ml bottles of Creamy Vanilla or Banana Smoothie Readi-Cat 2. Rx only.
-Four glass bottles of Isovue-370. Rx only.
-Twelve 100 ml syringes of Isovue-370. Rx only.
-Three 120 ml bottles of Gastrografin. The bottles stated "Do Not Inject."
*In that same CT suite was an unlocked small refrigerator that contained eighteen 450 ml Creamy Vanilla or Banana Smoothie Readi-Cat 2. Rx only.

Interview on 3/21/11 at 4:00 p.m. with radiology technician G revealed she agreed the above items should have been locked-up and the key should not have been in the lock. She agreed the expired items should have been disposed of.

Interview on 3/22/11 at 9:30 a.m. with the radiology supervisor revealed:
-The cabinet in the x-ray room near the sink was broken and would not lock. He stated sometimes the locks would break and needed to be fixed. He was unaware if that broken lock had been reported.
-He agreed the cabinets with keys in the lock should have been locked, and the key should not have been left in the lock.
-He was not aware the Readi Cat 2 oral barium should have been stored in a locked cabinet or locked refrigerator.
-He agreed the above items were expired. He stated the safety officer periodically audited the radiology department for expired items.

Interview on 3/23/11 at 9:25 a.m. with the director of nursing (DON) revealed each department was responsible to check for expired medications/biologicals. The safety officer was not available for interview.

Interview on 3/23/11 at 9:40 a.m. with the pharmacist revealed pharmacy checked for expired medications/biologicals in the radiology department if pharmacy had supplied that item. Pharmacy would have supplied the 30 ml bacteriostatic 0.9% sodium chloride bottles. Pharmacy was unaware those expired bottles were in the radiology cabinet.

2. Observation on 3/22/11 at 2:00 p.m. in the operating suite revealed:
-A fluid warmer with a digital temperature gauge located on the outside of the warmer. The gauge read 123 degrees Fahrenheit (F).
-No internal temperature moniter was present.
-The warmer contained sixteen 500 ml bottles of sodium chloride and one 1000 ml bag of sodium chloride.
-The bottles and the bag were not dated when they had been placed in the warmer.

Interview on 3/23/11 at 8:10 a.m. and at 9:00 a.m. with the operating room (OR) supervisor revealed:
-An internal temperature was taken with a temperature probe placed in the OR warmer. It read 121.1 F.
-Items placed in the warmer were not dated when placed inside.
-She was not aware they were to be dated and how long they were to be stored in the warmer.

Interview on 3/23/11 at 9:10 a.m. with the DON revealed:
-No policy or procedures were in place for the process of bag and bottle solutions kept in the warmer.
-She was not aware of the proper temperature, time storage, or dating process for solutions placed in the warmer.


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3. Observation on 3/21/11 at 3:15 p.m. of a warming cabinet in the ES revealed it contained seven 1000 ml bags of sodium chloride IV solution, twelve 1000 ml bags of Ringers Lactate solution, one 50 ml bottle of 25% Mannitol medication. The outside temperature gauge was set at 120 degrees F. Observation of the IV solution bags and bottle of medication revealed none had been labeled with the date they had been placed in the warming unit. No containers had a date stating when they should have been removed from the unit. There was no documentation of the daily temperature of the cabinet, and no thermometer inside to check the temperature.

Interview on 3/21/11 at 4:30 p.m. with the ES director confirmed the IV bags and medication bottle were not dated as to when they had been placed in the warming unit. She was not aware they were to have been warmed for only a limited amount of time and then removed from the warmer.

Interview on 3/23/11 at 10:15 a.m. with the pharmacist revealed she was not aware the solutions could only be stored in the warming cabinet for a limited amount of time. She stated the nursing service had stocked the IV solutions in the warming cabinet, and the pharmacy stocked the Mannitol in the warmer. She confirmed the medication had not been dated as to when it had been placed in the warmer. It was placed in there to prevent crystallization of the medication.

Interview on 3/23/11 at 10:30 a.m. with the DON confirmed she was not aware when the IV solutions and Mannitol medication had been placed in the warmer. She confirmed there was no date on the containers. She further confirmed the provider did not have a policy for handling warmed IV solutions and bottles of Mannitol.

Review of a letter dated 3/23/11 from the manufacturer for IV solutions revealed:
*Solutions for injection and irrigation in plastic flexible containers, in their overwraps, could be warmed at a temperature not to exceed 104 degrees F for a period no longer than two weeks or 14 days.
*Once the product was removed from the warming cabinet it should have been clearly labeled with a revised expiration date.
*Solutions should not be re-warmed.

Review of the manufacturer's package insert revised June 2009 for the Mannitol medication revealed:
*To dissolve the crystals in the fliptop vial, warm the bottle in hot water at 80 degrees Celsius.
*Periodically shake the container vigorously.
*Store at 68 to 70 degrees F.

4. Observation on 3/21/11 at 3:15 p.m. of the supplies in the ES revealed twenty eight pediatric electrode pads were labeled with a May 2010 manufacturer's outdate. The outdated electrode pads were found in all three supply areas for the three stations used in the ES.

Interview on 3/21/11 at 4:30 p.m. with the ES director confirmed the pediatric electrodes were outdated and should have been removed from the area. She further confirmed there were staff assigned to check for outdated items. A provider policy was not available.


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5. Observation at 2:50 p.m. on 3/21/11 and again at 8:45 a.m. on 3/23/11 of the obstetrical (OB) storage room revealed four bottles of sterile water stored in a warmer. Two of those bottles had expiration dates of 7/17/10 and another two bottles had expiration dates of 2/24/11.

Interview with the DON at 8:45 a.m. on 3/23/11 revealed those bottles of sterile water were to have been checked and changed monthly. She stated sterile water was not used frequently on the OB unit. She stated those bottles of sterile water should not have been available for use with expired dates.

Review of the provider's revised August 2006 OB department infection control policy revealed sterile water in the warmer should have been rotated to prevent outdated supplies.

Based on observation, interview, and policy review, the provider failed to:
*Complete proper handwashing procedures for one of two observations of medication administration.
*Maintain appropriate infection control practices for five of five whirlpool tubs.
Findings include:

1. Observation on 3/23/11 at 8:10 a.m. revealed registered nurse (RN) H set up medications for a patient in the medication room. After setting up the medications RN H :
*Was called away from the medication room for a moment to remove some electrodes from another patient.
*Returned to the medication room and without washing her hands took the medications to the patient's room.
*Without washing her hands removed each oral medication from it's packaging, placed them in a medication souffle cup, and touched three different medications with her bare hands.
*Administered the medications to the patient and left the room without washing her hands.
*Returned to the medication room and began setting up another patient's medications without washing her hands.

Observation in the patient's room during the medication administration by RN H revealed a sign on the wall that stated "It's OK to ask, Did your healthcare worker wash their hands or use alcohol gel before caring for you?"

Interview on 3/23/11 at 9:55 a.m. with the director of nursing and infection control nurse revealed:
*Each healthcare worker was trained in proper handwashing procedures through Healthstream training annually.
*Each healthcare worker was trained to cleanse the hands before and after having direct contact with patients.
*When nurses gave medications, they should not touch the medications with their bare hands.
*The infection control nurse monitored the staffs handwashing procedures when she worked as a staff nurse.

Interview on 3/23/11 at 10:05 a.m. with RN I who also gave medications revealed he cleansed his hands after direct contact with a patient and before leaving the patient's room.

Review of the hand washing policy last reviewed and approved March 2011 revealed when to wash your hands or use hand sanitizer:
*"Before having direct contact with patients."
*"After contact with a patient's intact skin."



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2. Interview at 11:00 a.m. on 3/22/11 with the housekeeping supervisor revealed housekeeping staff were cleaning the whirlpool tubs in the intensive care unit (ICU) and obstetrical (OB) wing rooms with Cascade with bleach after each patient use. She stated the housekeeping staff were disinfecting those tubs weekly by filling them with water above the jets and adding three cups of bleach. She stated the parts per million (ppm) of the bleach product was not checked on a routine basis.
Interview at 3:20 p.m. on 3/22/11 with the infection control nurse revealed staff had been trained to clean the whirlpool tubs by running Cascade in a tub of water through the jets. She stated the Cascade contained bleach and would be effective against most germs.
Interview at 8:45 a.m. on 3/23/11 with the director of nursing confirmed the above cleaning policy. She stated she was not aware of any information provided to them regarding the amount of bleach in the Cascade product. She stated the whirlpool tubs in the ICU and OB wing were cleaned weekly with bleach even if they had not had a patient use them. She confirmed those tubs should have been cleaned with bleach after each use. She confirmed the ppm of bleach should be checked with each cleaning.
Review of the provider's revised August 2006 OB department infection control policy revealed the tubs were to have been scrubbed with quaternary solution between patients followed by running Cascade through the jets.

Based on interview, record review, and policy review, the provider failed to ensure five of eight sampled nursing employees (A, B, C, D, and E) performance evaluations were completed annually. Findings include:

1. Review of the performance evaluations for employees A, B, C, D, and E revealed their last performance evaluations had not been done within the past year.

Interview on 3/22/11 at 2:30 p.m. with the administrator confirmed annual performance evaluations had not been completed for the above employees. She stated she just had not gotten the performance evaluations completed.

Review of the provider's performance appraisal policy revised July 1995 revealed:
*To provide the employee with a formalized method of recognizing his/her abilities in performing the duties of his/her position, to identify areas of needed growth and improvement, and to reinforce those duties which are performed above the expected levels of performance.
*An appraisal of each employee's performance would be done:
-Six months after their hire date, the date they were transferred to another position, or the date they were promoted.
-At least annually or prior to any merit salary adjustment for all other employees.







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