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Based on observation, review of manufacturer's instructions and facility policies, and staff interview, the facility failed to ensure instruments used in dental procedures were properly sterilized. The facility further failed to ensure a multi-use brush used for pre-cleaning dental instruments was disinfected or sterilized properly. In addition, the facility failed to ensure the blood glucose meter (glucometer) was sanitized in accordance with manufacturer's instructions between patient use (refer to A749). The cumulative effect of these deficiencies resulted in a determination that the hospital failed to meet the Condition of Participation for Infection Control.

Based on review of the patient rights handbook and staff interview, the facility failed to inform each patient of the right to receive visitors whom he or she designates. The findings were:

Review of the Patient Rights and Responsibilities Handbook showed the handbook did not specifically include the right to receive any visitor whom he or she chooses, including, but not limited to, a spouse, a domestic partner (including same-sex partner), another family member, or a friend. Interview on 5/5/15 at 9:25 AM with the client mediator revealed the patient handbook is what each patient receives on admission to inform them of their rights, which would include visitation.

Based on review of facility policies and the patient handbook, and staff interview, the facility failed to develop written policies to ensure equal visitation privileges consistent with the preferences of the patient. The findings were:

Review of the facility's policy "Visitation," revised 9/2014, showed it failed to ensure the facility would not restrict or limit visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. Interview on 5/5/15 at 9:25 AM with the client mediator revealed the patient handbook is what each patient receives on admission to inform them of their rights, which would include visitation. Review of the patient handbook showed it did not mention the facility would not restrict visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.

Based on medical record review, staff interview, and medical staff rules and regulations review, the facility failed to ensure verbal orders from a physician were authenticated within an acceptable timeframe for 9 of 30 sample patients (#2, #6, #7, #8, #10, #11, #15, #18, #19). The findings were:

Review of the medical staff rules and regulations, approved 3/3/15, showed "...verbal orders must be signed by the clinician within 24 hours." The following concerns were identified:

1. Review of the medical record for patient #2 showed a verbal order dated 1/26/15 for Synthroid (for hypothyroidism) 0.05 mg at 6 AM. Further review showed the order was not authenticated by the physician until 2/19/15 (24 days).

2. Review of physician orders for patient #6 revealed a 12/9/14 verbal order for Ativan (anti-anxiety) 1 mg twice per day. The order was not authenticated by the physician until 1/16/15 (38 days). Further review showed a verbal order dated 1/5/15 for Cogentin (for Parkinson's disease or to treat tremors) 0.5 mg twice per day, which was not authenticated until 1/16/15 (11 days).

3. Review of the medical record for patient #7 showed a 4/29/15 verbal order for Motrin (nonsteroidal anti-inflammatory drug) 800 mg every 6 hours as needed. Further review on 5/6/15 showed the order had not been authenticated yet by the physician (7 days).

4. Review of physician orders showed a verbal order dated 2/16/15 for Seroquel (anti-psychotic) 200 mg every morning for patient #8. Further review showed the order was not authenticated by the physician until 2/19/15 (3 days).

5. Medical record review for patient #10 showed a 9/29/14 verbal order for Zyprexa (anti-psychotic) 5 mg at bedtime which was not authenticated by the physician until 10/3/14 (4 days).

6. Review of the medical record for patient #11 revealed a verbal order dated 12/15/14 for Motrin (nonsteroidal anti-inflammatory drug) 800 mg three times per day as needed. Further review showed the order was not authenticated by the physician until 1/4/15 (20 days).

7. Review of physician orders for patient #15 showed a 9/12/14 verbal order for risperidone (anti-psychotic) m-tab 3 mg at 8 PM. Further review showed the order was not authenticated by the physician until 10/17/14 (35 days).

8. Medical record review for patient #18 revealed a 12/30/14 verbal order for risperidone (anti-psychotic) 37.5 mg extended release every 2 weeks (14 days). Further review showed the order was not authenticated by a physician until 1/13/15 (14 days).

9. Medical record review for patient #19 revealed a 2/23/15 verbal order for clonazepam (anti-seizure) 1 mg orally one time only, give as soon as possible. The review showed the order was not authenticated by a physician until 2/28/15 (5 days). Further review revealed a 2/23/15 order for olanzapine (anti-psychotic) 20 mg orally one time only, give as soon as possible. The review showed the order was not authenticated by a physician until 2/28/15 (5 days).

Interview with the DON on 5/7/15 at 11:40 AM confirmed the "validate order" date on verbal orders was the actual date the physician authenticated orders, and should be done timely according to policy.

Based on staff interview, the facility failed to ensure there was a qualified dietitian on at least a consultant basis. The findings were:

During an interview on 5/5/15 at 11 AM, the CDM and ADON stated the facility's dietitian retired in April 2015. They stated the facility did not currently have a consultant dietitian.

Based on observation, review of manufacturer's instructions and facility policies, and staff interview, the facility failed to ensure instruments used in dental procedures were properly sterilized. The facility further failed to ensure a multi-use brush used for pre-cleaning dental instruments was disinfected or sterilized properly. In addition, the facility failed to ensure the blood glucose meter (glucometer) was disinfected in accordance with manufacturer's instructions between patient use. The findings were:

1. Observation on 5/5/15 at 1:30 PM at the clinic revealed the facility had an autoclave to sterilize instruments used in dental procedures. Interview at the time with LPN #1 confirmed the autoclave was used to sterilize the dental instruments. The LPN talked the surveyor through the steps of using the autoclave, which including using chemical indicators for each load. When asked about biological indicators (BI), the LPN replied they did not use any. During an additional interview on 5/6/15 at 10:35 AM the LPN stated the person who inspected the autoclave in September recommended doing biological indicators, but the LPN stated so far they hadn't received any. The LPN provided the surveyor with the manufacturer's instructions for the autoclave (Midmark M11 Self Contained Steam Sterilizer), which read "Recommended Steam Sterilization Monitoring Program:...process monitors (biological and chemical) indicate if conditions in sterilizing chamber were adequate to achieve sterilization." During an interview on 5/6/15 at 1:35 PM, the risk manager and the infection control nurse stated they thought biological indicators were being done in the autoclave. They stated they thought the indicator strip that was put in each load was a biological indicator, but confirmed that it was a chemical indicator. Interview with the risk manager on 5/6/15 at 3:55 PM revealed the dental clinic saw about 20 to 30 patients per month.

Review of the facility's policy "Infection Control Policy," revised 2/15, Chapter 6, Dental Instruments, revealed "...Proper monitoring of sterilization processes involves the use of mechanical techniques, chemical indictors, and biological indicators (spore tests). While biological monitoring provides the best assurance that sterilization equipment and procedures are working as they should, mechanical or chemical monitoring may provide the first indications of a sterilizer malfunction...monitor sterilizers at least weekly by using a biological indicator with a matching control."

Review of documentation provided by the facility entitled "American Dental Association...Monitoring Sterilizers" (undated) showed "...The CDC recommends that you monitor sterilizers at least weekly with biological indicators."

2. Observation in the clinic on 5/6/15 at 10:35 AM revealed a white handled brush with blue bristles next to the sink. Interview with LPN #1 at the time revealed the brush was used to clean instruments used in dental procedures before putting them in the sonic cleaner. She stated the brush was not discarded after use, but used multiple times. She stated at the end of the day on Wednesday she squirted the brush with Cavicide spray. Further review of the brush showed no manufacturer's name, therefore it could not be determined if the brush was high level disinfected or sterilized in accordance with manufacturer's instructions. During an interview on 5/6/15 at 1:35 PM the risk manager and infection control nurse stated the brush should be single use and discarded, or disinfected or sterilized in accordance with manufacturer's instructions.

3. During an interview on 5/6/15 at 1:35 PM the risk manager and infection control nurse stated the blood glucose meter (glucometer) was used for more than one patient and was cleaned after use by using an alcohol pad.

Review of the facility's "Infection Control Policy," revised 2/15, for glucometers showed "...The machine should be examined after each use, however, and cleaning carried out per the manufacturer's recommendations..."

Review of the user's manual for the glucometer (AccuData GTS Plus/GTS) revealed the machine could be cleaned using a dampened cloth with a 1:10 solution of hypochlorite in water or 70% isopropyl alcohol. However, the manual further revealed "...if your facility chooses to disinfect, a 1:10 solution of sodium hypochlorite in water (1 part of household bleach in 9 parts water) may be used."

Review of "Infection Prevention during Blood Glucose Monitoring and Insulin Administration," revised 5/2/12, by Centers for Disease Control and Prevention (CDC), (http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html, accessed 5/19/15) showed "...Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared."