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Based on policy and procedure review, clinical record review and interview it was determined 7 (#23-24, #26-30) of 10 (# 21-30) surgical patients did not receive their notification of patient rights upon admission. Failure to provide the notification of patient rights had the potential outcome of not allowing patients to understand their rights as a patient, the grievance process and where to lodge a complaint. The failed practice affected Patient #23-24 and # 26-30. Findings follow:

A. Review of policy and procedure titled, "Registration Procedure," received on 11/7/18 at 3:22 PM, showed all patients were to be given a declaration of patients' rights and responsibilities pamphlet, and the registrar would distribute the notice of Privacy practices brochure.
B. Review of clinical records on 11/7/18 from 12:15 PM to 3:00 PM and 11/8/18 from 8:15 AM to 10:00 AM showed Patient #23-24 and #26-30 did not receive their notice of patient rights.
C. During interview on 11/8/18 at 10:10 AM, Registered Nurse #1 verified the above findings in A and B.

Based on policy and procedure review, clinical record review and interview it was determined that 7 (#23-24 and #26-30) of 10 (#21-30#) surgical patients did not have signed consent for treatment. Failure to provide patients with consent for treatment on admission did not allow patients to make informed decisions regarding their care. The failed practice affected Patient (Pt) #23 and 24, and # 26-30. Findings follow:

A. Review of policy and procedure titled, "Registration Procedure," received on 11/7/18 at 3:22 PM showed the Conditions of Admissions/Treatment would be signed by the patient or family member, and then the registrar would also sign and date the form verifying/witnessing the signature.
B. Review of clinical records on 11/07/18 from 12:25 PM to 3:00 PM showed no signed consent for treatment for Patient #23 and 24 and Patient #26-30.
C. During interview on 11/8/18 at 10:10 AM , Registered Nurse #1 verified above findings in A and B.

Based on observation, interview, review of Radiation Dosimeter Reports, policies and manufacturer's instructions for use, it was determined the facility failed to have a process in place to assure personal radiation dosimeters were stored with control dosimeters (used to monitor radiation received in transit or storage) when not in use, away from radiation and with dosimeters of the same type and wear date in accordance with manufactures instructions. The failed practice did not ensure the reliability and accuracy of the amount of occupational radiation exposure each employee received and was likely to affect 61 of 61 individuals using dosimeters at the facility. Findings included:

A. Record review of the facility provided manufacturer's instructions for use on 11/07/18 at 3:00 PM showed control dosimeters were to be stored away from radiation, with dosimeters of the same type and wear date when not in use, and away from a radioactive source or in an x-ray room. The stated purpose of the control dosimeter was to monitor radiation received in transit or storage.
B. The Director of Radiology stated by interview on 1/08/18 at 8:58 AM that he was unaware of any policy or requirements for storage of control dosimeters with employee personal radiation dosimeter monitors and that the manufacturer's instructions regarding the storage of the dosimeters could be interpreted "both ways."
C. Observation of the Cardiopulmonary Department on 11/07/18 at 1:15 PM showed no designated area for the storage of personal radiation dosimeters when not in use by staff. Technician #1 was interviewed on 11/07/18 at 1:32 PM and stated that she took her personal radiation dosimeter home and left it in her purse usually. Registered Nurse #3 stated on 11/07/18 at 1:33 PM that she took her personal radiation dosimeter home or left it in a drawer in the department. Respiratory Therapist #1 stated that she usually left her badge in her purse when not wearing it. The Director of the Cardiopulmonary Department was interviewed on 11/07/18 at 1:48 PM and stated that the staff received their badges from the Radiology Department and there was not storage for them in the Cardiopulmonary Department.
D. Observation of the Radiology Department on 11/07/18 at 1:52 PM showed no designated area for the storage of personal radiation dosimeters when not in use by staff. The Radiology Coordinator was interviewed on 11/07/18 at 2:19 PM and stated that there was no designated storage for staff personal radiation dosimeters and some people took them home or stored them in a drawer.
E. During an interview on on 11/08/18 at 3:26 PM, the Director of Ambulatory Services provided the number 61 as the number of facility individuals who wore dosimetery badges.

Based on review of records of credentialed physicians, review of hospital policy, and interview, the Infection Control Officer failed to monitor Tuberculin Skin Testing and Hepatitis B Immunizations to prevent and control infections in that three (#2, #3 and #5) of six (#1-#6) physicians were current in Tuberculosis Skin Testing and two (#2 and #3) of six (#1-#6) physicians had received Hepatitis B Immunization or signed a declination as required by hospital policy. Failure to monitor and ensure all physicians were compliant with Tuberculosis Skin Testing and Hepatitis B hospital policy guidelines led to the likelihood of the spread of infection. Findings follow:

A. The policy "Tuberculosis Screening for Employees" and "Hepatitis B Immunization for Employees" was reviewed on 11/07/18. The policy on Tuberculosis Screening showed all employees would be screened annually. The policy on Hepatitis B Immunization showed all employees would be offered Hepatitis B Immunization. The employee could receive the Hepatitis B Immunization, provide evidence the immunization had been provided in the past, or decline immunization through a declination.
B. Records of credentialed physicians were reviewed on 11/07/18 at 9:30 AM. Three (#2, #3 and #5) of six (#1-#6) physicians lacked current evidence of annual Tuberculosis Skin Testing. Two (#2 and #3) of six (#1-#6) physicians lacked evidence of Hepatitis B Immunization or a signed declination.
C. During an interview on 11/07/18 at 11: 00 AM, the Director of Quality verified the policy referencing employees on Tuberculosis Skin Testing and Hepatitis B Immunization would also apply to all physicians. It was also verified through the same interview Physician #2, #3 and #5 had no evidence of current Tuberculosis Skin Testing and Physician #2 and #3 had no evidence of having had Hepatitis B Immunization or signed a declination.



27453

Based on observation, review of policies and interview, it was determined the Infection Control Officer failed to control infections by assuring infection prevention policies and procedures for a safe and sanitary environment were followed in the Dietary Department. Failure to follow infection prevention policies did not assure a sanitary environment for the preparation and storage of food items. The failed practice affected all patients, staff and visitors that consumed meals from the dietary department. Findings included:

A. Record review of the facility's policy titled, "Dietary-Infection Prevention," dated 11/17, showed that Utility carts were to be cleaned daily and that clean pots and pans were to be stored on clean shelves. Pots and pans were to be stored upside down. Work tables, cabinet shelves, microwave, steam jacketed kettle, pop dispenser, mixer, and meat slicer were to be cleaned daily. Convection ovens were to be cleaned weekly.
B. Record review of the facility's policy titled, "Dietary Cleaning Schedule for Environmental Services," dated 09/17, showed that environmental services employees were to sweep and mop kitchen floors daily.
C. Observation of the Dietary Department on 11/07/18 from 8:00 AM- 9:37 AM with the Director of Dietary showed:
1) Two cardboard boxes were observed on top of a stack of 20 clean baking pans that were stored facing up and on a cart. The baking pans were stored on the top shelf of a utility cart that had food crumbs and drips on the surface. The Hot Food Cook #1 stated at 8:30 AM on 11/07/18 that the trays were clean and that the boxes had been placed there "to get them off the floor."
2) A griddle, beside the steamer kettle, was observed with a thick accumulation of grease on the outside surface. The Director of Dietary on 11/07/18 at 8:32 AM stated that the equipment was the "chef griddle" and should be cleaned after use.
3) An accumulation of food particles, which included dried macaroni, was observed on the surface of the floor surrounding the steamer kettle and along the surface of the wall behind the steamer kettle. The floor surfaces in the dry food storage had an accumulation of dust and debris. The walk in freezer had an accumulation of food debris.
4) Two grates with an accumulation of rust were observed stored on the floor surface and under open shelving in the sink area.
5) The following food was observed stored opened and unsealed and the integrity of the food could not be assured:
a) Food preparation: one large bag of rice was opened and stored on an open shelf.
b) Walk in freezer: three packages of frozen beef; one bag of frozen mozzarella cheese sticks; one bag of frozen potatoes, and one package of frozen chicken breasts.
c) Dry storage: one large bag of dried beans was opened and stored on an open shelf.
D. The Director of Dietary confirmed the findings C 1-5 at the time of observation.


38994

Based on review of policies and procedures, review of the manufacturer's recommendations, review of the Metricide OPA Plus Solution Testing Log Sheet, and interview, it was determined the Infection Control Officer failed control infections by not assuring the policy and procedure and the manufacturer's recommendations for use of Metricide OPA Plus was performed for Quality Control testing of a new bottle of test strips for one of one (10/01/18 to 10/31/18) month reviewed. The failed practice did not assure instruments cleaned by High level Disinfection (HLD) were thoroughly cleaned and disinfected prior to patient use. The failed practice had the potential to affect all patients who came in contact with instruments cleaned by HLD in the Endoscopy Unit. Findings follow:

A. Review of policy and procedure received 11/7/18 at 12:15 PM titled, Using OPA [ortho-Phthalaldehyde] Solution for HLD," stated to test OPA solution prior to use with OPA solution test strips (verify the minimum effective concentration). Review of policy and procedure received 11/07/18 at 12:15 PM titled Cleaning, Disinfecting and Sterilization of Flexible Endoscopes stated to use a product specific test strip to test the Minimum effective concentrate (MEC) and follow the directions on the test strip container. Some chemical test strips recommend the use of a quality-control procedures to ensure the strips perform properly.
B .Review of the Metricide OPA Plus test Strip manufacturer's recommendations received 11/7/18 at 10:30 AM showed that 3 test strips should be submerged in a positive and negative control solution. The 3 strips dipped in the full strength positive control should exhibit a complete magenta color on the indicating pad at 60 seconds. The 3 strips dipped in the diluted negative control should either remain completely yellow or exhibit an incomplete color change, mixture of yellow and magenta, when read at 60 seconds. It is recommended that the testing of positive and negative controls be performed on each newly opened test strips.
C. Review of the Metricide OPA Plus Solution testing log sheet from 10/01/18 to 10/31/18 showed no documentation of the Quality Control procedure being performed when a new bottle of test strips were opened.
D. During interview with the Directory of Endoscopy on 11/7/18 at 10:30 AM, she stated that she was not aware of the Quality Control procedure recommended by the manufacturer when opening a new bottle of test strips.
E. The above findings in A, B, C and D were verified in an interview with the Director of Endoscopy on 11/7/18 at 10:30 AM.


Based on review of the Association of Operative Registered Nurses (AORN) guidelines for perioperative practice for 2018, the Centers for Disease Control (CDC) guidelines for Disinfection and Sterilization, Central Sterile Immediate Use Steam Sterilization 2018 Report, Immediate Use Steam Sterilization Records and interview, it was determined the Infection Control Officer failed to provide a plan of action for preventing, identifying and managing infections in that Immediate Use Steam Sterilization (IUSS) was not used according to the AORN and CDC guidelines from 10/01/18 to 10/31/18 in that the facility was using IUSS as a substitute for sufficient inventory of surgical instruments. The failure to use IUSS according to AORN and CDC guidelines did not assure the sterility of surgical instruments prior to use. The failed practice had the potential to affect any patient requiring surgery using instruments that were sterilized by IUSS. Findings follow:

A. Review of AORN guidelines for 2018 showed should be kept to a minimum and should be used only in selected clinical situations and in a controlled manner. IUSS should not be used as a substitute for sufficient instrument inventory.
B. Review of the CDC guidelines for Disinfection and Sterilization showed Flash sterilization (now known as IUSS) should not be used for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time.
C. Review of the Immediate Use Steam Sterilization 2018 report showed a code 2 (reason for IUSS) meant the facility had multiple cases and not enough time to reprocess in Central Sterile. Code 2 was used 29 times in the 1st quarter of 2018, 64 times in the 2nd quarter of 2018, and 77 times in the 3rd quarter of 2018.
D. Review of the Immediate Use Steam Sterilization Record for the month of October 2018 showed code 2 was used 50 times due to multiple cases and not enough time to reprocess in Central Sterile.
E. During interview with the Director of Central Sterile on 11/06/18 at 9:25 AM she stated that the increase in use of IUSS was directly related to the increase in number of cases and not having enough instruments on hand for the increased caseload.



40282

Based on observation, policy and procedure review, and interview it was determined the Infection Control Officer failed to control infections to ensure a sanitary environment. During observation on 11/07/18 at 9:25 AM RN #2 failed to clean the septum of the vial of Fentanyl on two entries and the vial of Midazolam on one entry for the delivery of intravenous (IV) medications. The failed practice did not provide aseptic technique and assure the vials and port were free of contaminants. The failed practice affected Patient #31 on 011/07/18 at 9:25 AM. The infection control officer or officers failed to develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. The infection control officer or officers failed to monitor compliance with all policies, procedures, protocols and other infection control program requirements.

A. Review of the policy and procedure titled, "Anesthesia Department -"Infection prevention," received 11/05/18 at 2:00 PM from Director of Ambulatory Services, showed strict aseptic technique would be utilized in the insertion of intravascular needles and catheters and in the administration of anesthetic agents, medications, and intravenous infusion.
B. During observation of RN #2, she failed to clean the septum of the vial of Fentanyl on two entries and the vial of Midazolam on one entry for the delivery of intravenous (IV) medications. RN #2 failed to use an alcohol swab on the medication septum or the port of the medication injection port.
C. During interview on 11/07/18 at 10:45 AM with the Director of Ambulatory Services, the above findings were verified.


Based on observation, policy and procedure review, and interview it was determined the Infection Control Officer failed to ensure sources of infection were controlled in that a surgical face mask was not worn by one of one (#5)physician during a spinal injection procedure. Failure to wear a face mask did not assure the sterile field remained free of contaminants. The failed practice was likely to affect all patients undergoing spinal injections.

A. Review of the policy and procedure titled, "Epidural Anesthetic Administration," received from Director of Ambulatory Services at 10:40 AM on 11/08/18, showed to put on gloves and a face mask were to be worn.
B. During observation on 11/08/18 at 9:00 AM, Physician #5 failed to wear a face mask during a spinal injection procedure.
C. During an interview with Director of Ambulatory Services on 11/08/18 at 10:48 AM, the above findings in A and B were verified.

Based on policy and procedure review and clinical record review, it was determined 3 (#24, 26, and 30) of 10 (#21-30) surgical records and 1 (# 11) of 10 (# 11-20) inpatient records did not have a time of operation included in the Operative Report; the policy and procedure titled, "Provider Documentation Completion Requirements," did not include that the name and hospital identification number, date and times of the surgery, name of the surgeon and assistants, name of the specific surgical procedure performed, type of anesthesia administered, complications if any, and any prosthetic devices, grafts, transplants, or devices implanted if any to meet the requirements for the mandatory components of an operative report. The failed practice did not ensure staff had complete information to care for the post-surgical patient prior to transition of the patient to the next level of care. Findings follow:

A. Review of policy and procedure titled, "Provider Documentation Completion Requirements," received on 11/1/3/18 at 2:40 PM, showed the policy did not include name and hospital identification number, date and times of the surgery, name of the surgeon and assistants, name of the specific surgical procedure performed, type of anesthesia administered, complications if any, and any prosthetic devices, grafts, transplants, or devices implanted if any to meet the requirements for the mandatory components of an operative report.
B. During review of operative reports for Patient #11, 24, 26, and 30 11/07/18 from 12:20 PM to 3:00 PM and 11/08/18 from 09:00 AM to 10:45 AM, showed no time of operation was included.
C. The above findings in A and B were verified with Registered Nurse #1 on 11/08/18 at 10:45 AM.