HospitalInspections.org

Based on review of 6 open medical records and 7 closed records, it was determined that 1 of 6 open records lacked the face-to-face documentation.


Patient #6 presented to the Emergency Department on 10/2/15 on Emergency Petition by police for agitation, homicidal ideation and threats toward his family. At 5:10 AM the patient was described as very agitated and combative with staff while security was in the patient room securing his belongings. The patient was placed in twice as touch restraints (4 point restraints) at 5:10 AM. Review of the medical record revealed no face-to-face was performed for patient #6. The restraint was discontinued at 5:25 AM. Although the restraint was discontinued before the practitioner arrived to perform the face-to-face, the practitioner was still required to see the patient face-to-face and conduct the evaluation within 1 hour after the initiation of the restraint.

Based on observation of the operating (OR) area and interviews of staff, it was determined that staff failed to follow specific preventive infection control measures associated with: line insertions, preparation of the surgical site, and maintenance of a sanitary environment. This was evident for three of three OR observations conducted on 10/13/15. The findings were:

1. During an observation of patient #10 being prepped for a procedure the Critical Care Tech (CCT) was observed inserting a peripheral intravenous line (PIV) into the left arm of patient #10. The CCT applied chlorhexidine, an antiseptic antibacterial agent, to cleanse the skin prior to placing the PIV. According to the manufacturer's directions, the solution should be applied with gentle back and forth strokes for 30 seconds, then allowed to dry on the skin for 30 seconds prior to continuing with the procedure. The CCT cleansed the skin area for 5 seconds with the chlorhexidine applicator, then immediately proceeded to insert the PIV.

The same CCT received a request from the anesthesiologist to obtain additional blood for ordered lab work for patient #10. The CCT again failed to follow the recommendations for skin prep with chlorhexidine prior to obtaining the blood from patient #10's right arm. This finding was observed and confirmed by the Patient Safety Officer.

2. During a tour of the Main Operating Room (OR) and observation of the room, cleaning and turnover staff failed to remove the mattress pad on the OR table. White, tacky adhesive tape was on the pad. Staff cleaning the room were observed wiping over the tape on the mattress pad with disinfecting wipes. Adhesive tape is a potential reservoir for bacteria that can lead to infection.

3. The Malignant Hyperthermia (MH) Cart contained within the inner core of the Main OR was observed having expired supplies (blood collection tubes (vacutainers) and bio-patches. The log used to track outdated medications and supplies was difficult to read and to determine the actual expiration dates. This finding was confirmed with the Nurse Clinical Leader and the Operating Room Nurse Manager.

Failure to follow specified preventative infection control measures potentially exposes the patients and staff to the spread of infection.