HospitalInspections.org

Based on staff interview, observation, and policy review, the facility failed to properly store medications, maintain and store Pyxis (automated medication dispensing system) medications and maintain the cleanliness of the refrigerated units. This deficient practice affected one (Patient 62) in a sample of 82 patients as well as any patients served from the facility's pharmacies. The facility failed to ensure medications, in particular insulin and intravenous antibiotics, were labeled for specific patient use and stored properly. This affected one of one medication refrigerators on unit G51. The facility census on 07/27/12 was listed as 940.

Findings include:

Observation on 07/25/12 at 1:50 AM revealed Patient 62 who was admitted to the facility on 07/24/12 with diagnoses which included slurred speech and chronic obstructive pulmonary disease was observed to have a cortisone-based inhalant medication kept on the unsecured surface adjacent to the bedside. Review of the medical record revealed the patient did not have a physician's order for keeping medications at the bedside. Review of the policy and procedure entitled "Medications kept at the bedside" with an effective date of 10/06/08 directed medications may be kept at the bedside with a physician's order written specifically for each drug to be kept at bedside and secured in a locked drawer or device. This deficient practice was verified in an interview with Staff YY on 07/25/12 at 1:50 PM.
Inspection of the Avon Richard E. Jacobs Family Health Center completed on 07/26/12 revealed the ophthalmology procedure room Pyxis (automated medication dispenser machine) freezer contained four zippered plastic bags each containing multiple one milliliter pre-filled medication syringes. These syringes contained a variety of different medications including two different antibiotics, a cortisone-based medication, and a medication used to reduce blood clots. All the bags contained the same medication and the individual syringes were labeled with regard to contents with a small adhesive label wrapped around the syringe. However, there was no identifying signage on the exterior of the zippered plastic bags and the four zippered plastic bags were communally stored on the freezer's shelf.
Activation of the Pyxis machine for dispensing of the individual medications directed the user to a specific drawer and specific pocket in the freezer. When the freezer was opened there were no pockets (bins) or other means to separate the different bags of medication from each other. The bags contained no labeling on the exterior of the bag and were communally placed on the freezer's shelf. The facility failed to ensure medications within the Pyxis were stored in labeled bins and separated from other medications. This deficient practice had the potential to affect any patients who might have need for these medications during an ophthalmologic procedure.
Additionally, inspection of the pyxis freezer revealed a heavy build up of frost about a half to one inch deep on the roof of the freezer unit. Review of the facility's policy and procedure entitled "Refrigerator and Freezer Temperature Monitoring and Cleaning Policy" with a most recent revision date of 11/2008 directed that all refrigerators and freezers must be cleaned regularly and that managers and supervisors provided monitoring to ensure effectiveness of the process and in maintaining the cleanliness of the storage areas.
Interview on 07/26/12 at 9:37 AM with Staff ZZ verified that the Pyxis directed staff to a drawer and individual pocket but no separate pockets were identified in the freezer. Staff ZZ further verified the presence of the icy build up.




29377


Observations on unit G51, a post anesthesia care unit, were begun on 07/27/12 at 10:05 AM. At that time, Staff Q, the unit manager, was asked to open the medication refrigerator for inspection. Upon unlocking and opening the refrigerator utilizing the Pyxis (automated medication dispensing system), the following medications were observed:

3-50 milliliter bags of Cefazolin (antibiotic) on the first shelf
8 vials of regular insulin on the second shelf, 1 opened
6 vials of Humalog insulin on the second shelf, 1 opened
3-50 milliliter bags of Zosyn (antibiotic) on the third shelf

Staff Q confirmed at that time none of the medications noted above was patient specific (labeled) and they are not routinely stored within a bin or drawer labeled for specific patient use. These medications were considered "floor stock."

Review of facility policy Insulin Dispensing (04-120) revealed the following, "all other insulin products, exclusive of regular insulin, will be dispensed from pharmacy on a per patient basis pursuant to a prescriber's order for that product. All vials/cartridges of patient-specific insulin will be stored in the patient's medication bin located on the Nursing Unit."

Further review of the policy revealed that "regular human insulin is also the only insulin product supplied as floor stock."

Based on observation and interview, the facility failed to ensure all drugs and biologicals were kept in a secure area, and locked when appropriate. This had the potential to affect approximately 600 patients per month.

Findings include:

Tour of the Cole Eye Institute surgical area in the "I" building was completed on 07/23/12. During tour of operating room 3, an unopened box containing a prefilled 5 milliliter syringe of 2% Lidocaine was found in an unlocked equipment cart. Staff K confirmed the medication should be stored in a locked cabinet. Staff K confirmed this finding on 07/23/12 at 2:25 PM.

Based on observation, interview and review of facility policy, the facility failed to ensure controlled substances were locked and secured. This affected 1 of 3 medical supply carts inspected on unit G51. The current unit census was 4 and the facility census was 940.

Findings include:

Tour of unit G51 on 07/27/12 beginning at 10:05 AM revealed a medication/supply cart stationed at bed 12. The department nurse manager, Staff Q, was asked to open the top drawer of the cart for observations. Staff Q stated the drawer was not presently locked and stated that sometimes staff have to "mess with it" in order to get the drawer to lock.

Within the drawer an empty vial labeled fentanyl 250 micrograms per 5 milliliters was attached to a medication syringe by a sticky label. The syringe appeared to contain approximately 240 micrograms of a liquid substance, which Staff Q identified as fentanyl (a schedule II controlled substance used to treat severe pain).

Review of facility policy Medication Control and Securement (M7), revealed the manner in which controlled medications were to be stored. Per policy controlled medications, like fentanyl, are to be secured within the Pyxis (automated medication dispensing system) or within a "secure cabinet with a locked area."

Based on observation, review of facility documentation, review of policy and procedure and staff interviews, the director of the dietary department failed to ensure food safety by removal of expired food items, maintaining and monitoring refrigerator temperature logs, and food temperature logs, and preparing food under sanitary conditions. This deficient practice affected 661 patients served from this facility.
Findings include:
Inspection of the facility's 16 pantries was completed on 07/24/12. Review of the facility's pantries' refrigeration temperature logs revealed the temperatures were inconsistently monitored for temperature or the temperatures were outside of the recommended temperature parameters. These logs directed that staff monitor and record temperatures twice daily and to document corrective action if temperatures were out of the recommended parameters.
Review of the refrigerator temperature logs for the facility's G80 unit revealed there were no refrigerator temperatures documented until 07/12/12, except one the afternoon of 07/10/12 when the refrigerator temperature was recorded at 44.4 degrees Fahrenheit (recommended refrigerator temperatures range was 34 to 38 degrees Fahrenheit). Additionally, the temperature logs revealed these refrigerators were out of recommended refrigeration ranges most days from 07/12/12 through 07/23/12 with temperatures ranging between 40 and 44.4 degrees F on many days. Review of the facility's M30 and J-5 facility units' refrigerator logs documented the refrigeration units also documented temperatures above the recommended 38 degrees on most days of the month of July 2012 to date 07/23/12. Interview on 07/23/12 at 12:10 PM with Staff WW revealed the facility was unable to provide any documentation that these malfunctions were reported or that any corrective action was taken to correct freezer/refrigerator malfunctions.
Interview with Staff XX on 07/24/12 at 10:10 AM revealed all the pantries were equipped with 'monthly red books' which were not distributed to the facility's pantry staff until approximately 07/05/12. These books were designed for dietary staff to daily log and track food temperatures, refrigerator and freezer temperatures, as well as any concerns in the dietary area for that day. The interview further revealed that all the facility's refrigerator and freezer temperature logs completed prior to 07/01/12, when the current food service company began its service contract, were no longer available at the facility.
Additionally, Staff XX further verbalized that there were no food temperature logs available prior to 07/01/12. Staff XX verbalized that dietary staff previously only checked oven temperatures and had not completed food temperature logs.
Review of the new food service company's in-service agendas presented to the facility dietary staff on 07/12/12 and on 07/19/12 directed that facility pantry coordinators were responsible to ensure food temperatures were obtained for each meal service and documented on all foods which included milk.
Review of each of the 16 pantries' red books conducted with facility staff was completed on the evening of 07/24/12. The documentation revealed milk was rarely checked for temperature during the month of July 2012 on any of the 16 pantry units. This finding was verified with Staff WW and XX at the time of finding on 07/24/12.
Review of the facility's policy and procedure entitled Cooking and Reheating Manager's Quick Guide with a revision date of 05/01/12 at page 61 item 5 directed dietary staff to record all final cooking/reheating temperatures and corrective actions on the company's Final Cooking & Reheating Temperature Log, record discarded foods on the waste sheet, and maintain records on location for one year unless more stringent local or regulatory requirements existed. Additionally, page 79 directed to maintain milk, cream and half and half at 41 degrees or below.
Review of the facility dietary spread sheets during the week of survey from 07/23/12 through 07/30/12 revealed milk was offered at each meal service at the facility. Per the Ohio Uniform Food Safety Code milk is considered a potentially hazardous food item that required temperature control and monitoring.
Interview on 07/24/12 at 5:45 PM Staff WW and XX verified some facility refrigeration temperature logs indicated the refrigerators on several units were often above the recommended 38 degree Fahrenheit level and that milk was stored and served from these refrigerators. Staff also verified that milk temperatures were rarely documented in the facility's food temperature logs and that patients were offered and served milk that had been stored in these refrigerated units.
Observation on 07/24/12 at 8:50 AM inspectional tour of the G-11 pantry revealed a dietary staff member was observed preparing cold luncheon meal items. This staff member had placed a large silver tray across the work surface counter. The work surface and tray were directly adjacent to the pantry's only hand washing sink. The end of the tray was less than 8 inches from the hand washing sink and at the same level as the sink. This tray was filled with individual plates and bowls of prepared food products, which were covered with paper towels. The end of the tray closest to the sink had two individual bowls of uncovered cottage cheese which were potentially exposed to any spray or splash generated by the hand washing sink. This deficient practice was verified at the time of finding with Staff XX who then instructed the employee to prepare food away from the hand-washing sink.
Inspection of the nursing units of the patient use refrigerators was completed on 07/25/12 at 8:15 AM. Inspection of the G-91 unit which primarily served pulmonary and some surgery patients revealed the patient-use refrigerator was observed to contain expired food products.
Observed were a blueberry yogurt bearing the expiration date of 07/21/12, three half pint cartons of fat free milk with an expiration date of 07/01/12, two marked expired on 07/09/12, one half pint of chocolate milk which contained an expiration date of 07/22/12, and two four ounce containers of a nutritional supplement marked with an expiration date of 07/12/12. Review of the facility's policy and procedure entitled "Refrigerator and Freezer Temperature Monitoring and Cleaning Policy" with a most recent revision date of 11/2008 directed that all refrigerators and freezers must be cleaned regularly and that managers and supervisors provided monitoring to ensure effectiveness of the process and in maintaining the cleanliness of the storage areas. Review of facility documentation revealed each unit had a daily log sheet which directed night shift staff to check refrigerator temperatures, clean refrigerators, and check for expired or unlabeled foods. These findings were all verified at the time of finding with Staff XX.

Based on interview, record review, and observation, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association, specifically, to ensure corridor doors had means suitable to stay closed, doors to exit stairways closed completely and latched, all exits were marked by readily visible signs, , doors to hazard areas self closed, exits access areas were free of clutter, suites of rooms had two exit access doors (one of which that did not exit into another suite), there was battery lighting in generator rooms, that sprinklers were clean and free from obstructions, that fire extinguishers were mounted at a proper height, that smoke dampers were tested, that chute rooms complied with NFPA 82, that trash collection receptacles were stored in space sufficient for their collective size, that medical gases were properly protected, and that electrical wiring complied with NFPA 70.

Findings:

See A710.

Based on observation and staff interview, the facility failed to ensure all clean storage areas and recently discharged patient rooms were properly cleaned and maintained. This had the potential to affect all 940 facility patients.

Findings include:

On 07/23/12 at 1:45 PM an observation in the nuclear medicine unit revealed a room marked as "Clean Utility JB-245" in which the tile floor had visible piles of dust. This room contained two carts with clean linen and a blanket warmer. This finding was verified with Staff F 07/23/12 at 1:45 PM. Staff F stated the floor should not look like that and he/she would get someone in to clean it.

On 07/24/12 at 9:20 AM an observation in the R10 Taussig Cancer Center revealed a closet marked as "Storage Utility Clean Linen" in which the carpeted floor had visible piles of dirt and dust. This closet held shelves full of clean linens. This finding was verified with Staff G 07/24/12 at 9:20 AM. Staff G stated the housekeeping people are responsible for vacuuming and they should take care of the floor in this closet.

On 07/24/12 at 4:30 PM an observation on the G70 Solid Tumor unit of an empty patient room marked as "G70-26" revealed a cabinet in which the suction canister was one-third full with secretions. This finding was verified with Staff H 07/24/12 at 4:30 PM. Staff H stated that this room had been cleaned by environmental services and was ready for a new patient. Staff H stated that the suction canister should have been changed out and he/she would get someone to take care of this right away.

Based on interview, record review, and observation, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients present during the survey. The facility census was documented as 940 patients on 7/27/12.

Findings:

K-18 Ensure corridor doors had means suitable to stay closed. H building corridor doors failed to close and latch properly.
K-20 Stairwell doors for buildings G,S,T and J failed to close properly.

K-21 Doors to exit stairways closed completely and latched. Doors in building M and T failed to close.

K-22 All exits were marked by readily visible signs. Exit signs in G building and H building were not properly signed.

K-27 Doors in smoke barriers equipped with self closing devices. Buildings M and E smoke barrier doors were not equipped with self closing devices.

K-29 Hazardous areas are protected with one hour fire rated construction. Door in hazardous rooms of buildings M, H, R, T and Crile failed to latch properly.

K-38 Exit access are readily accessible at all times. Exit access of M building blocked.

K-42 Suites are to have at least two exit accesses not going through intervening rooms. Suites in buildings J and Q had suites which had exits going through intervening suites.

K-46 Emergency lighting must be provided. Building one, generator room failed to have battery operated emergency lights.

K-62 Sprinkler system continuously maintained. Buildings G,H, M, J, H and Cole-I found with dirty sprinklers and storage impeding the spray of sprinkler.

K-64 Fire extinguisher not mounted properly. Portable fire extinguishers mounted above the five foot requirement within the J and T buildings.

K-67 Fire and smoke dampers tested. Buildings H, M, G and E had fire dampers which had not been tested.

K-71 Trash and laundry chutes must be secured. Buildings H and G had trash and linen chutes which were not secured with key locks.

K-75 Trash collection receptacles were stored in space sufficient for their collective size. Building Cole-I had large trash container stored in corridor.

K-76 Medical gases were properly protected. Buildings H, E and J found to not have medical gasses stored properly.

K-130 Miscellaneous citations in business occupancies. Building 15 had excessive storage which was located in an unprotected room. Doors propped open with unauthorized devices in building P and 15. Building C had pallets of paper stored in the corridor.

K-147 Electrical wiring complied with NFPA 70. Building H was found to have power strips plugged into additional power strips.

Please refer to the Life safety code violations for additional details.

Based on observation and interview, the facility failed to ensure expired or unusable supplies were not available for patient use and failed to ensure preventative maintenance was performed on patient utilized hospital equipment and the outpatient therapy swimming pool water was routinely tested and recorded. The facility census was 940.

Findings include:

Tour of the surgical area (CEI) in the "I" building was completed on 07/23/12. During tour of operating room 5 at 2:30 PM, two 18 centimeter double ended Nitinol guidewires used as a guide for intravenous catheter insertion were found affixed with tape to a supply cart. Both had an expiration date of 07/01/09. This finding was confirmed with Staff J during tour on 07/23/12 at 2:30 PM.

Tour of the heart/vascular surgical area in the "J" building was completed on 07/24/12. During tour of operating room 72 at 9:30 AM, two 1,000 cc bags of lactated ringers were noted hanging, spiked and tubing primed and ready for intravenous administration. One bag was marked as having been hung on 07/23/12 at 4:35 PM, the other was marked 07/23/12 at 9:00 AM. Staff I confirmed the two intravenous bags were hung for a procedure or surgery that wascanceled. Staff I also confirmed that once the bags are spiked and primed, they are good only for 24 hours. Staff I confirmed these findings while on tour with the surveyors on 07/24/12 at 9:30 AM.


29377

Observations on 07/24/12 at 3:12 PM on facility unit M-43 revealed a respiratory room with a low tidal volume (LTV) 1200 machine that had last been serviced by clinical engineering in 08/2011. This finding was verified by Staff W and X at the time of the tour. A record of the clinical engineering maintenance log for the LTV 1200 was also requested at that time but had not been provided as of exit on 07/30/12.

Tour of the Twinsburg location rehabilitation and sports medicine department was conducted on 07/26/12 beginning at 11:10 AM. A parabath machine was observed to have been due for maintenance by clinical engineering in 10/2011. The department manager, Staff V, confirmed this finding at the time of the tour and stated "it must have been missed by engineering." A record of the clinical engineering maintenance log for the parabath was also requested but had not been provided as of exit on 07/30/12.

Tour of the outpatient rehabilitation services department on 07/27/12 beginning at 11:10 AM revealed a biomechanics platform (equipment used for managing balance) that was due to be serviced by clinical engineering in 07/2011. Staff R, regional rehab manager, confirmed this finding at the time of the tour. A record of the clinical engineering maintenance log for the equipment was then requested. Review of the clinical engineering work log for the biomechanics platform revealed it was last serviced on 07/16/10 and was scheduled to have preventative maintenance (PM) on 07/16/12. Staff R confirmed the PM had not been completed as of 07/27/12.

A tour of the outpatient pool area was also conducted at this time. Staff R stated engineering was responsible for the maintenance of the pool, including checking the levels of chemicals on a daily basis. Staff R then called engineering and requested the logs of testing be brought over for review. Two patients were observed in the pool at this time receiving therapy services.

Staff S from clinical engineering then arrived with a log book that included record of daily testing performed on the pool. Per S, the pool is tested twice a day, usually between 2 and 4 AM and then again between 2 and 4 PM. Staff S stated he had not yet tested the pool water today. This was also verified by Staff R and W who were also present at the time. Staff S then proceeded to collect a sample of the pool water and begin testing. The following results were observed:

pH: 7.4
Free chlorine: 4.2
Combined chlorine: 0.8
Alkalinity: 160
Calcium hardness: 240
Total dissolved solids: 2800

Staff S was asked how long the indicator solutions used for testing the pool water are good for. Staff S stated he/she believed they were good for two years. Staff S and this surveyor proceeded to examine several of the bottles containing the indicator solutions and noted they were not dated. Staff S was unable to say with certainty when they were opened and when they would expire. Upon closer examination of the pool water test kit, Staff S stated the kits (and solutions) were good for two years. Staff S then verified the kits had not been dated when they were opened and again could not say for certain when they would expire.

Staff S was then asked to explain what the results meant and what levels were acceptable. When Staff S was unable to say with certainty what the acceptable ranges or levels were, Staff S was asked to produce a reference guide or policy. Staff S stated there was no policy.

As of 4:00 PM on 07/27/12 no policy or procedure on the testing and/or monitoring of the outpatient swimming pool water quality had been provided.

On 07/30/12 at 12:45 PM, Staff Y produced said policy and stated there had not been one in place prior to now. Staff Y was asked to explain how or where the acceptable levels/ranges came from and stated he/she would have to find out.

On 07/30/12 at 1:54 PM, Staff Y brought a photocopy of the water quality guidelines from the test kit used by the facility. Per review, free chlorine should be 2-4 parts per million and total dissolved solids should be 1500 parts per million maximum. On 07/27/12 both values were over the recommended guidelines













31007

During the tour of G101 Transplant floor on 07/24/12 at approximately 10:00 AM, observation was made of expired items located in the supply drawers of patient rooms 25 and 26. This included 11 of the 12 "Providone Iodine Swabs" examined. One had an expiration date of 10/2011, two with an expiration date of 12/2011, two with an expiration date of 03/2012, and six with an expiration date 04/2012. This was verified by Staff F on 7/24/12 at 10:05 AM.
During the tour of H80 PCNA Nursing floor on 7/25/12 at approximately 9:55 AM, observation was made of expired items located in the clean utility room on a storage shelf. This included all of the seven "Accu Check Comfort Curve test strips" packages examined. One box had an expiration date of 03/31/12, two had an expiration date of 01/31/12, and four had an expiration date of 06/30/12. This was verified by Staff E on 07/25/12 at 10:00 AM.


31597

Observation on 7/23/12 at 1:30 PM of Operating Room(OR) #5 showed five Applicare Providone-Iodine Ointment packets with expiration dates ranging from 10/2010 through 03/2011 and 6 BD syringes with expiration dates ranging from 03/2011 through 05/2012 in the room. An interview was conducted with Staff J who confirmed the findings at the time of discovery.

Observation on 07/24/12 at 9:15 AM of OR #64 showed a perfusionist and scrub nurse in surgery with the bottom of their masks not secured to their faces. Staff O of the unit was interviewed and confirmed that their masks were not correctly on their faces.
Observation on 07/24/12 at 9:15 AM of OR H showed an Ecozyme (a multi-enzymatic detergent used to sterilize surgical instruments) bottle with an expiration date of 6/2012 on a counter outside of an operating room. Staff O stated that the Ecozyme was used to sterilize surgical equipment. Staff O confirmed that the bottle was expired and it cannot be used.
Observation on 7/25/12 at 9:00 AM of OR E showed the 2A sub-sterile storage area to have 6 boxes of sterile gloves that had expiration dates ranging from 12/31/09 through 7/2011. An interview was conducted with Staff M and the findings were confirmed.
Observation on 7/25/12 at 9:00 AM of OR #3 was observed to have a bag of 1000ml 0.9% Sodium Chloride hanging with an expiration date of 7/23/12 11:00 AM. An interview was conducted with Staff M who confirmed the findings.

Based on observation, policy review and staff interview the facility failed to ensure the facility was cleaned in order to prevent the spread of infection. This affected the outpatient radiology and the emergency department in Twinsburg. This also affected the play room on M33 and the storage room on M30. The census on Unit M33 was 16 pediatric patients. The average daily census for M30 was 8 patients. In addition, the facility failed to identify and control infections of patients and personnel by having dust build-up and frayed, chipped insulation on water pipes. This had the potential to affect approximately 600 patients each month.

Findings include:

Observation on 07/25/12 revealed the playroom on Unit M33 had toys, tables and children's furniture. The child's vinyl sofa and small chair were torn through the vinyl and the interior cloth was exposed. A large mat folded up was torn in numerous places in the seams with the interior cloth exposed. These openings made these items not intact therefore, making them unable to be completely cleaned. The facility policy called "Care of Equipment and Environmental Infection Prevention" revised on 2/03/2011, number 5 revealed that upholstery furniture that is torn must be repaired or replaced. In addition, there was a large mat on the floor of the playroom that held large toys. Staff were observed to walk on this mat with street shoes. The mat appeared dirty. Interview of the volunteer (Volunteer N) on 7/25/12 at 11:00 AM revealed that a group of volunteers were assigned to clean the playroom Monday through Friday and signed a log of the cleaning completed. The weekends had no evidence of the playroom being cleaned on the weekends. The facility also had a large container for storage of toys that had been used. The parents were responsible for putting used toys in the bin. The bin could not hold the large toys in the room.

A tour of the Twinsburg location emergency department was conducted on 07/26/12 beginning at 9:46 AM. The inside of a microwave oven used for heating/reheating patient food was found to be covered in dried food and/or liquid particles. This finding was confirmed by the department's nurse manager, Staff U, at the time of the tour.

A tour of the Twinsburg location radiology department was conducted on 07/26/12 beginning at 10:00 AM. Observation of a CT scan room began at 10:15 AM and revealed the floors were dirty with loose dirt throughout the scanning area. This finding was confirmed by the department's manager, Staff T, at the time of the tour, who further stated the room was maintained by housekeeping and was cleaned approximately once in the evening.




20866


Tour of the colorectal surgical area in "G" building was completed on 07/24/12. During tour of the surgical core area, the air vent between the two "flash" sterilization areas was noted to have dust build-up. Staff L confirmed this finding during tour on 07/24/12 at 3:25 PM.

Tour of the pediatric surgical area in the "M" building was completed on 07/25/12. During tour of the sub-sterile area, the hot water pipes that feed the sterilizer were noted to have frayed, chipped insulation falling off the hot water pipes. Staff M confirmed this finding during tour on 07/25/12 at 9:40 AM.

Based on review of hospital policy and procedures relating to surgical site preparation, medical record review and staff interview, surgical services were not maintained to assure patient safety from fire in the operating rooms. This had the potential to affect all patients who receive surgery at this facility.

Findings include:

Interview on 07/25/12 at 4:15 PM, with the Quality Assurance Staff VV and UU revealed no alcohol based skin preps were being used in the operating rooms, however, interviews on 07/26/12 of circulating nurses TT and SS confirmed the surgical scrub Hibiclens was being used. The surgical scrub product Hibiclens 4% Chlorhexidine Gluconate was observed on tour of the hospital's operating rooms. The label on the bottle read product contains inactive ingredients of isopropyl alcohol 4%.

Review of the surgical operations facility policy and procedure #1112 with revision date 4/12 revealed surgical prep solutions containing alcohol are not to be used.

Based on staff interview and medical record review, the facility failed to secure informed consent for surgery according to the facility's policy for one of 21 surgical records reviewed.

Findings include:

Record review for Patient 44 was completed on 07/27/12. The patient was a minor and the facility obtained informed consent from the patient's grandmother. The facility did not have evidence that the grandmother was the client's legal guardian. An interview with Staff C on 07/27/12 at 9:00 AM confirmed the grandmother was not the legal guardian of the patient and the hospital did not obtain consent per the facility's policy.