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Based on policy and procedure, clinical record review and interview, it was determined the facility failed to obtain consent for treatment for two (#21 and #27) of ten (# 21-30) medical/surgical clinical records reviewed. Failure to obtain consent for treatment did not allow the patients or their caregivers to make knowledgeable, informed and clear decisions regarding their care. The failed practice had the likelihood to affect all patients admitted to the Facility. Findings follow:

A. Review of policy titled Patient Rights and Responsibilities received 10/08/18 at 10:00 AM showed that patients had the right to participate in the development, implementation and decisions of the medical care, to the extent permitted by law, that included the right to request and/or refuse treatment.
B. Review of clinical records on 10/10/18 from 9:45 AM-1:40 PM showed no consent for treatment for Patient #21 and #27.
C. The above finding in A and B were verified with the Quality Director during interview at 10/10/18 at 1:47 PM.

Based on policy and procedure, clinical record review and interview, it was determined the facility failed to ensure Physician's orders were authenticated by the ordering practitioner for 4 (#21, #24, # 28 and #29) of 10 (#21-#30) surgical patients. By not authenticating orders, the facility could not ensure the care being provided was in accordance with the physician's plan of care. The failed practice had the likelihood to affect all patients who are admitted to the facility for procedures. Findings follow:

A. Review of policy on 10/10/18 at 9:45 AM titled, "Written/Telephone Treatment Orders," showed the responsible practitioner shall authenticate, date and time any order , including but not limited to medication orders, as soon as possible, such as during the next patient visit, and in no case longer than 48 hours from dictating the order.
B. Clinical record review revealed the following orders that were not authenticated by the ordering practitioner:
1) Patient #21's Nursing Order # 900 were not authenticated;
2) Patient #24's Nursing Order # 600 and # 800 were not authenticated;
3) Patient # 28's Nursing Order # 700 were not authenticated;
4) Patient #28's Ancillary Orders # 1000 and #1100 were not authenticated;
5) Patient #29's Ancillary Orders # 2100, #2200, and # 2800 were not authenticated;
C. During an interview on 10/10/18 at 9:50 AM, the Quality Director verified the physician's orders were not authenticated.

Based on review of clinical records and interview, it was determined the facility failed to assure an updated examination was documented to confirm the patient's condition had not changed since the History and Physical (H&P) was originally completed for 6 (#1, #3, #4, #6, #8 and #9) of 10 (#1-#10) surgical patients. Failure to assure the patient's condition had not changed since the H&P was originally completed did not assure any changes in the patient's condition would be identified prior to surgery. The failed practice affected Patient #1, #3, #4, #6, #8 and #9 and was likely to affect all surgical patients. Findings included:

A. Record review of the clinical records on 10/11/18 showed:
1) Patient #1 had an H&P dictated on 09/20/18 and was admitted to the facility on 09/24/18 for a surgical procedure. There was no evidence of an updated examination prior to surgery to confirm the condition of Patient #1 had not changed.
2) Patient #3 had an H&P dictated on 07/30/18 and was admitted on 07/31/18 for a surgical procedure. There was no evidence of an updated examination prior to surgery to confirm the condition of Patient #3 had not changed.
3) Patient #4 had an H&P dictated on 08/09/18 and was admitted on 08/10/18 for a surgical procedure. There was no evidence of an updated examination prior to surgery to confirm the condition of Patient #4 had not changed.
4) Patient #6 had an H&P dictated on 09/24/18 and was admitted on 09/25/18 for a surgical procedure. There was no evidence of an updated examination prior to surgery to confirm the condition of Patient #6 had not changed.
5) Patient #8 had an H&P dictated on 09/27/18 and was admitted on 09/28/18 for a surgical procedure. There was no evidence of an updated examination prior to surgery to confirm the condition of Patient #8 had not changed.
6) Patient #9 had an H&P dictated on 09/27/18 and was admitted on 09/28/18 for a surgical procedure. There was no evidence of an updated examination prior to surgery to confirm the condition of Patient #9 had not changed.
B. The Chief Nursing Officer confirmed the findings in A 1-6 in an interview on 10/11/18 at 2:35 PM.

Based on observation, review of manufacturer's recommendations and interview, it was determined the facility failed to meet pharmaceutical services in that intravenous solutions were being stored for longer than 14 days in a fluid warmer in one (Emergency) of two (Emergency and Surgical Services) departments that warmed fluids. By not following manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that have had procedures in the facility. Findings follow:

A. Review of the manufacturer's recommendations showed bags of Intravenous (IV) solutions for injection could be warmed for up to 14 days.
B. During a tour of the Emergency Department on 10/08/18 from 1:38 PM until 2:08 PM observation showed the following fluids in the fluid warmer:
1) #1 Normal Saline 1000 ml (milliliter) bag for IV dated 10/31/18 (should have had a removal date of 10/14/18); and
2) #1 Lactated Ringers 1000 ml bag for IV dated 10/31/18 (should have had a removal date of 10/14/18).
C. During an interview on 10/08/18 at 1:48 PM, the ER/Trauma Program Director verified the fluids were being stored longer than 14 days. They explained they were dating them with a 30-day expiration date and not 14.

Based on review of United States Pharmacopeia Chapter 797 (2008), review of annual compounding skills and interview, it was determined the facility failed to ensure Gloved Fingertip Sampling was completed as part of the annual re-certification of Intravenous (IV) Admixture technique for three (#1-#3) of three Pharmacists trained to compound medications in the Laminar Flow Hood. By not preforming Gloved Fingertip Testing on the personnel, the facility could not assure the sterility of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the Laminar Flow Hood. Findings follow:

A. Review of United States Pharmacopeia Chapter 797, 2008 showed that Gloved Fingertip Testing was to be completed as part of the annual re-certification of Intravenous (IV) Admixture technique.
B. Review of annual compounding skills performed by Pharmacists #1-#3 showed Gloved Fingertip Testing was not evaluated.
C. During an interview on 09/13/17 at 12:30 PM, the Director of Pharmacy verified Gloved Fingertip Testing was not done as part of the annual re-certification of Intravenous (IV) Admixture technique.

Based on observation, review of policy, review of Arkansas Department of Health, Rules and Regulations for Hospitals and Related Institutions in Arkansas, Section 12, Medications and interview, it was determined the facility failed to ensure refrigerated controlled substances were double locked and secured in one of one Pharmacy refrigerator observed. By not double locking controlled substances, the facility could not ensure their security. This failed practice had the likelihood to affect all patients in the facility. Findings follow:

A. Record review of the facility's policy titled, "Distribution of Controlled Substances," dated 12/01/02, showed that the facility will follow all state regulations.
B. Record review of Arkansas Department of Health, Rules and Regulations for Hospitals and Related Institutions in Arkansas, Section 12, Medications showed refrigerated controlled substances shall meet the requirement for double-lock security.
C. During a tour of the Pharmacy on 10/10/18 from 1:30 PM to 2:30 PM, observation showed 30-Lorazepam (controlled substance) 2 milligram/milliliter injections in the medication refrigerator unlocked.
D. During an interview on 10/10/18 at 1:43 PM, Pharmacist #1 verified the Lorazepam injections were not double locked in the refrigerator.

Based on policy and procedure review, Refrigerator and Freezer Temperature Log review for 08/01/18 through 09/30/18 and interview, it was determined the Dietary Director failed to organize the department to ensure employees followed policy in that refrigerator and freezer temperatures were not documented three times per day for six of six (Reach-in refrigerator, Walk-in refrigerator, Reach-in freezer, Walk-in freezer, Nursing station refrigerator/freezer, and Senior Care refrigerator/freezer) refrigerators and freezers. Failure to document temperatures three times per day created the potential for a refrigerator or freezer malfunction to go unnoticed and could affect any patient receiving meals from the kitchen. Findings follow.

A. Review of the policy and procedure on 10/08/18 at 9:45 AM, titled, "Food Storage," showed all cold storage equipment temperatures would be documented upon opening, at mid-day and closing of the department using the appropriate form
B. Review of Refrigerator and Freezer Temperature Logs for 08/01/18 through 09/30/18 revealed the following:
1) Reach-in refrigerator-temperatures were not documented three times per day for 8 out of 61 days.
2) Walk-in refrigerator-temperatures were not documented three times per day for 7 out of 61 days.
3) Reach in freezer-temperatures were not documented three times per day for 8 out of 61 days.
4) Walk in freezer-temperatures were not documented three times per day for 8 out of 61 days
5) Nurses station refrigerator/freezer- temperatures were not documented three times per day for 17 out of 61 days.
6) Senior Care refrigerator/freezer - temperatures were not documented three times per day for 9 out of 61 days.
C. During an interview on 10/08/18 at 1:30 PM, the Dietary Director confirmed the temperatures were not documented three times per day.


Based on policy and procedure review, Refrigerator/ freezer log review and interview, it was determined the Dietary Director failed to organize the department to ensure employees who documented temperatures out of range documented corrective action for six of six (Walk-in refrigerator, walk-in freezer, reach in refrigerator, reach in freezer, Nurses Station refrigerator/freezer and Senior Care refrigerator/freezer) refrigerators and freezers. Failure to document corrective action and documenting temperatures out of range created the potential for a refrigerator or freezer malfunction to go unnoticed and could affect any patient receiving meals from the kitchen. Findings follow:

A. Review of the facility's policy and procedure on 10/08/18 at 10.00 AM, titled, "Food Storage," showed if temperatures were out of range, the Food Service Worker should note the action taken; if maintenance was contacted proper documentation using a work order should be made.
B. Review of Refrigerator and Freezer Temperature Logs for 08/01/18 through 09/30/18 revealed the following:
1) Reach-in refrigerator-Out of range temperature were documented 1 out of 61 days.
2) Walk-in refrigerator-Out of range temperatures were documented 4 out of 61 days.
3) Reach in freezer-Out of range temperatures were documented 26 out of 61 days.
4) Walk in freezer-Out of range temperatures were documented 26 out of 61 days
5) Nurses station refrigerator/freezer-Out of range temperatures were documented 40 out of 61 days.
6) Senior Care refrigerator/freezer-Out of range temperatures were documented 42 out of 61 days.
C. During an interview on 10/08/18 at 1:30 PM, the Dietary Director confirmed the temperatures were documented out of range and did not have any corrective action taken.


Based on policy and procedure review, Sanitizing Solution Temperature/Concentration Record log review and interview, it was determined the Dietary Director failed to organize the department to ensure employees checked the dish water temperature and sanitizing solution concentration after each meal service. Failure to ensure the dish water temperature was at least 70 degrees at all times and the sanitizing solution parts per million (ppm) was greater than 200 ppm did not ensure that the dishware was clean, sanitary and free of contaminates. Findings follow:

A. Review of policy and procedure on 10/08/18 at 10:10 AM, titled, "Pot and Pan Wash," showed the sanitizing water must be at least 70 degrees at all times and the test strip should read 200 ppm each time the sink was refilled with the results documented.
B. Review of policy and procedure on 10/08/18 at 10:10 AM, titled, "Cleaning and Sanitation," showed that results will be documented at each meal (3 times daily).
C. Review of Sanitizing Solution Temperature/Concentration record from 08/01/18 to 09/30/18 showed:
1) Water temperature after the morning meal service was not documented 20 out of 61 days.
2) Sanitizing Solution ppm documentation after the morning meal service was not documented 21 out of 61 days.
3) Water temperature after the lunch meal service was not documented 47 out of 61 days.
4) Sanitizing Solution ppm documentation after the lunch meal service was not documented 45 out of 61 days.
D. During interview on 10/08/18 at 1:30 PM, the Dietary Director verified the findings in A-C.


Based on policy and procedure review, Trayline Time and Temperature Form review for 08/01/18 through 09/30/18 and interview, it was determined the facility failed to organize the department to ensure employees follow its policy on checking food temperatures at the beginning and ending of Trayline in that temperatures were not documented before the meal 6 out of 183 times; and temperatures were not documented after meals 176 out of 183 times. The failed practice did not allow the kitchen staff to know if hot foods were above 140 degrees Fahrenheit and cold foods were less than 40 degrees Fahrenheit through the duration of the Trayline service. The failed practice had the potential to affect anyone receiving food from the kitchen. Findings follow.

A. Review of the facility's policy titled, "Food Preparation," showed that the beginning and ending temperatures and time would be recorded by the cook each meal. Ending temperatures would be obtained when Trayline service exceeded 15 minutes.
B. Review of Trayline Time and Temperature Forms for 08/01/18 through 09/30/18 revealed the there was incomplete documentation as to how long Trayline lasted at each meal. Therefore, it was unknown as to whether or not food temperatures should be taken at the end of Trayline.
1) There was no temperature documentation before the meal service 6 out of 183 times.
2) There was no temperature documentation after the meal service 176 out of 183 times.
3) There was no documentation of the Trayline begin time for 50 of 183 times.
4) There was no documentation of the Trayline end time for 61 of 183 times.
C. During an interview on 10/08/18 at 1:35 PM, the Dietary Director confirmed the times and temperatures were not documented.

Based on observation, interview, review of Radiation Dosimeter Reports, and manufacturer's instructions for use, it was determined the facility failed to ensure personal radiation dosimeters were stored with controls. The failed practice did not ensure the facility could accurately monitor the amount of radiation exposure for each employee. The failed practice affected all employees in the Radiology and Surgery Department. Findings included:

A. The manufacturer's instructions for storage of the personal radiation dosimeters used by staff was requested from the Chief Nursing Officer. On 10/10//18 at 1:10 PM, the Chief Nursing Officer (CNO) provided a manufacturer's document that stated dosimeters were to be stored with controls.
B. Observation of the Surgery Central Core area on 10/10/18 at 11:39 AM, where dosimeter badges were stored, showed no control badge in the area.
C. Observation of the Radiology Department on 10/10/18 from 12:30 PM to 1:00 PM showed no control badge in the storage area where staff stored their dosimeter badges when not in use. Interview with Radiology Technician # 1 on 10/10/18 at 12:45 PM, he stated that all dosimeters where stored in the closet outside of the Computerized Tomography Room when not in use.
D. The above findings in A-D were verified by the CNO on 10/10/18 at 1:20 PM.

Based on review of temperature and humidity logs and interview, it was determined the facility failed to maintain temperature and humidity levels within facility established temperature range of 68 - 73 degrees Fahrenheit (F) and humidity parameters of 30 - 60 % in three of three (Operating Room (OR) #1, #2 and endoscopy) rooms in surgical services. The failed practice did not assure microbial growth and risk of infection would be prevented. The failed practice affected all patients who had surgery in the facility. Findings include:

A. Review of temperature and humidity logs for 09/01/18 - 10/10/18 showed:
1) OR #1 had a temperature documented out of the 68-73 degree F range a total of 11 of 11 days from 09/01/18 - 09/30/18 and 3 of 3 days from 10/01/18 - 10/11/18 when surgical procedures were performed. Humidity levels were documented as out of the 30 %- 60% range 4 of 11 days from 09/01/18 - 09/30/18 and 3 of 3 days from 10/01/18 - 10/11/18 when surgical procedures were performed.
2) OR #2 had a temperature documented out of the 68-73 degree F range a total of 12 of 12 days from 09/01/18 - 09/30/18 and 6 of 6 days from 10/01/18 - 10/11/18 when surgical procedures were performed. Humidity levels were documented as out of the 30 %- 60% range 5 of 12 days from 09/01/18 - 09/30/18 and 5 of 6 days from 10/01/18 - 10/11/18 when surgical procedures were performed.
3) Endoscopy had a temperature documented out of the 68-73 degree F range a total of 5 of 7 days from 09/01/18 - 09/30/18 and 3 of 3 days from 10/01/18 - 10/11/18 when endoscopy procedures were performed. Humidity levels were documented as out of the 30 %- 60% range 3 of 7 days from 09/01/18 - 09/30/18 and 1 of 3 days from 10/01/18 - 10/11/18 when endoscopy procedures were performed.
B. During an interview on 10/10/18 at 11:39 AM, Registered Nurse #1 confirmed the findings in A and stated that the nursing staff in the OR document the temperature and humidity levels and usually called maintenance if it was out of the range on the form.
C. During an on 10/11/18 at 2:44 PM, the Facilities Director stated that OR staff phoned him if the humidity or temperature levels were out of range; there was no documentation of interventions or maintenance provided when he was notified.

Based on observation, review of policies, review of Association of periOperative Registered Nurses (AORN) guidelines and interviews, it was determined the Infection Control Coordinator failed to prevent and control likely sources of infection in that Laryngoscope blades were not packaged to prevent contamination after high level disinfection in two (Emergency Department (ED) and Surgical Services) of four (Emergency Department, Surgical Services, Medical Surgical and Behavioral Health) patient care areas observed. Failure to package laryngoscope blades after high level disinfection did not ensure items were not contaminated during storage. The failed practice was likely to affect all patients who may require intubation in the Emergency Department or Surgical Area. Findings included:

A. Record review of the facility's policy titled, "Cardiopulmonary: Cleaning Equipment," dated 02/22/13 showed that laryngoscope blades were to be processed in Cidex for high-level disinfection.
B. The Surgical Services Director stated by interview on 10/08/18 at 3:24 PM that the department adhered to AORN standards. Review of the AORN document "Guidelines for PeriOperative Practice," (2018 edition), showed that reusable semi critical items processed by high-level disinfection should be stored in a manner that protects them from damage or contamination.
C. Observation on 10/08/18 of the ED and Surgical Services showed laryngoscope blades stored unprotected:
1) ER Trauma room: At 2:00 PM in the "Difficult Airway Box:" Identified as clean and ready to use, observation showed five of five straight (Miller), one of one curved (Macintosh) blade and two of two handles that were not packaged to protect from contamination. Findings were verified at the time of observation by Chief Nursing Officer.
2) Operating Room (OR) #1: 2:40 PM, two of two laryngoscope blades were laying on top of the anesthesia medication cart and not packaged to protect from contamination. The finding was verified at the time of observation by the Surgical Services Director.
3) OR #1 Emergency Cart: 2:53 PM, one of one straight blade, two of two curved blades and one of one handle not packaged to protect from contamination. Findings were verified at the time of observation by the Surgical Services Director.
3) OR #2 Emergency Cart: 3:00 PM on 10/08/18 "Pediatric Emergency Kit:" Identified as clean and ready to use, observation showed one of one straight and four of four curved blades and one of one handle not protected from contamination. Findings were verified on 10/08/18 at 3:10 PM by the Surgical Services Director.
4) OR Endoscopy Room Emergency Cart: 3:05 PM, two of two laryngoscope blades not packaged to protect from contamination. The findings were verified at the time of observation by the Chief Nursing Officer.
D. The Infection Control Coordinator was interviewed on 10/11/18 at 1:06 PM and confirmed the laryngoscope blades and handles should be packaged and stored and packaged to prevent contamination after high level disinfection.


Based on observation and interviews, it was determined the Infection Control Coordinator failed to prevent and control likely sources of infection and maintain a sanitary hospital environment in two (ED and Surgical Services) of four (Emergency Department, Surgical Services, Medical Surgical and Behavioral Health) patient care areas observed in that there was an accumulation of dust and rust (cannot be cleaned or disinfected due to porous nature) on furnishings, cracks in floors coverings and tile, cobwebs, dusty vents and corrugated paper infectious waste container and paper signage. The facility could not be assured patients would be protected from likely sources of infection and was likely to affect all patients treated at the facility. Findings included:

A. Observation of the ED and Surgical Services showed:
1) ED:
a) On 10/08/18 at 1:38 PM, in the Triage Room, there was a blue cart that was broken along the right top surface from the front to the back and could not be cleaned and disinfected. Infant weight scales were located on the broken surface. The Director of the EDverified the finding at the time of observation.
b) On 10/08/18 at 1:58 PM, the Decontamination Room had an accumulation of dust, cobwebs, dried tree leaves on the surface of the floor and corners of the room. A wheelchair located in the room was soiled and cobwebs were observed on the wheelchair. An emergency eye wash station was present and had an overall accumulation of dust. An air vent in the room had an accumulation of dust and rust on the surface. The Facilities Director verified the findings at the time of observation.
c) On 10/08/18 at 2:00 PM, Exam Room #4, identified by the Facilities Director as the airborne isolation or negative pressure room, had a crack in the floor covering close that did not allow for effective cleaning and disinfectin. A chair was present in the room with rust on the metal back and legs of the chair. The air vent in the room had dust and rust present. The Facilities Director verified the findings at the time of observation.
d.) On 10/08/18 at 2:18 PM, the trauma room had rust present on an overbed table. The Facilities Director verified the findings at the time of observation.
2) Surgical Services:
a) On 10/08/18 at 2:39 PM, Operating Room (OR) #1 had one of two chairs with rust on the wheels. Paper signage was observed on the computer work station and the C-arm computer screen that could not be cleaned or disinfected because it was paper and porous. The findings were verified by the Surgical Services Director at the time of observation.
b) On 10/10/18 at 11:53 AM, the Endoscopy Procedure Room had an infectious waste container that was constructed of corrugated paper. The container had stains on the surface that were dried. The container could not be cleaned or disinfected and rested directly on the floor surface. Three corrugated paper boxes were stored on the top shelf of the endoscope storage cabinet, and three additional corrugated paper boxes were stored beside the cabinet with one resting directly on the floor surface, none of which could be cleaned or disinfected. A cracked floor tile was observed which did not allow for effective cleaning an disinfection. The Surgical Services Director verified the findings on 10/10/18 at 12:58 PM.
B. The findings were reviewed with the Infection Control Coordinator on 10/11/18 at 1:06 PM. Policies for maintenance and cleaning were requested from the facilities department and no policy was provided by the end of the survey.


Based on observation and interview, it was determined the Infection Control Coordinator failed to identify and control the spread of infection in that medical supplies were available for use beyond the expiration date as established by the manufacturer on one (#1) of two (#1 and #2) emergency carts located within the Surgical Services Department. The availability of medical supplies beyond their expiration date did not ensure patients would be protected from likely sources of infection or that the integrity of the medical supplies would be maintained beyond their expiration date. The failed practice was likely to affect all surgical patients. Findings included:

A. Observation of Surgical Service Department Emergency Cart #1 on 10/08/18 at 2:53 PM showed the following expired supplies:
1) Intravenous (IV) start kit, (3) expired 04/14 and (1) expired 10/13.
2) Small-bore extension set, (2) expired 12/17
3) IV cathlon, 20 gauge, (1) expired 08/17.
4) Safety glide needle, 18 gauge, (2) expired 08/15
5) Safety glide needle, 21 gauge, (1) expired 05/15; (1) expired 01/15
6) Safety glide needle, 22 gauge, (1) expired 01/15
7) Safety glide needle, 23 gauge, (1) expired 06/15.
8) Quick ABG, (4) expired 01/15
9) Winged introcan 20 gauge, (1) expired 08/17
10) Laryngeal mask airway, (1) expired 06/15
11) 0.9% Sodium Chloride, 100 milliliter (ml); (1) expired 05/14; (1) 250 ml expired 04/14.
B. The findings of expired supplies in A. were verified by the Chief Nursing Officer and Surgical Services director on 10/08/18 at 3:10 PM.


Based on observation, interview, review of policy and AORN standards, it was determined the facility failed to follow its policy for drying endoscopes prior to reuse for one of one (Patient #10) colonoscopy observed. Failure to assure that the lumen of the endoscope was completely dry between patients procedures did not ensure each patient would be protected from likely sources of infection. The failed practice affected Patient #10 and was likely to affect all patients who had endoscopic procedures at the facility. Findings included:

A. Record review of the facility's policy titled, "Infection Control: Disinfection of GI and Respiratory Endoscope Guidelines," dated 09/18/00, showed that GI (gastrointestinal) endoscopes were to be thoroughly rinsed with sterile water or tap water followed by a 70% ethyl or isopropyl alcohol rinse. The scope was to thoroughly air dry or have direct compressed air through the lumens to facilitate drying.
B. The Surgical Services Director stated by interview on 10/08/18 at 3:24 PM that the department adhered to AORN standards. Review of the AORN document "Guidelines for PeriOperative Practice," (2018 edition)," showed that effective drying of the internal and external surfaces of the endoscope was as important as effective cleaning and disinfection or sterilization. The long narrow channels of the endoscope make it difficult to verify thorough drying. Any moisture remaining on the exterior and interior surfaces of the endoscope can facilitate microbial growth and biofilm formation.
C. Observation on 10/08/18 at 8:45 AM showed the endoscope for Patient #10 was removed from the automated processor after high level disinfection, then placed on a clean towel in a rigid container and taken to the Endoscopy Procedure Room. The endoscope was not flushed with alcohol, then air after high level disinfection and before reuse on Patient #10 as described in the facility policy.
D. Scrub Technician #1 and the Surgical Service Director stated by interview on 10/10/18 at 9:22 AM, that alcohol, and then air were not used to dry the endoscope lumens between each patient (after high level disinfection) and that it was only done at the end of the day, after the last endoscope was processed and prior to storage in the storage cabinet.
E. The Infection Control Coordinator was interviewed on 10/11/18 at 11:11 AM and verified the endoscope lumens should be dried before use by flushing with alcohol and then air prior to reuse.


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Based on observation, review of APIC (Association for Professionals in Infection Control and Epidemiology) position paper and interview, it was determined the facility failed to mitigate risks of healthcare related infections by not identifying the practice of storing MDV (Multiple Dose Vials) once opened, in immediate patient treatment areas, in two of two (Room #1 and #2) OR (Operating Rooms) toured. By not identifying the risk this practice carries, the facility could not assure their patients safety. This failed practice has the likelihood to affect all patients receiving procedures in the facility. Findings follow:

A. Review of APIC position paper, titled "Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016)," showed MDV should never enter the immediate patient care area, and if they do, they must be dedicated for single patient use and discarded immediately after use.
B. During a tour of Surgical Services on 10/08/18 from 2:11 PM to 3:15 PM, observation showed the following on the anesthesia medication carts:
1) Anesthesia Cart in OR #1:
a) #1 Xylocaine 1% 500 mg (milligram)/ 50 ml (milliliter) MDV, opened, dated 09/11/18 was stored on the cart, and available for another patient's use. Dating the vial indicated it was to be kept and used again on another patient; and
b) #1 Xylocaine 1% 500 mg / 50 ml MDV, opened, dated 10/08/18 was stored on the cart and available for another patient's use. Dating the vial indicated it was to be kept and used again on another patient.
2. Anesthesia Cart in OR #2:
a. #1 Succinylcholine 200 mg/ ml MDV, opened, dated 09/11/18, stored on the cart, available for another patient's use. Dating the vial indicates it was to be kept and used again on another patient.
b. #1 Labetolol 100 mg/ 20 ml MDV, opened, dated 09/14/18 was stored on the cart and available for another patient's use. Dating the vial indicated it was to be kept and used again on another patient.
C. During an interview on 10/08/18 at 2:59 PM, the Surgical Services Director verified the findings at B.

Based on observation and interview, it was determined the Infection Control Officer failed to identify one (Rehab) of four (Rehab, Surgical Services, Emergency Department and Medical/surgical) units toured, had been self-laundering their sheets, pillow cases and towels instead of using offsite commercially laundered linens. By not identifying this failed practice, the facility put their patients at risk for healthcare related infections. The failed practice had the likelihood to affect all patients that received treatment in Rehab. Findings follow:
A. During a tour of Rehab Department on 10/10/18 from 9:30 AM to 10:10 AM, observation showed a household grade washer and dryer in the Rehab Department.
B. During an interview on 10/10/18 at 10:06 AM, Physical Therapist #1 verified they were washing/drying the Rehab Department's sheets, pillow cases and towels in the machines, instead of using the off-site commercially laundered linens that the rest of the facility used.
C. During an interview on 10/10/18 at 10:15 AM, the Infection Control Coordinator (ICC) stated the facility was to use offsite commercially laundered linens. The ICC stated there was no monitoring of the temperature of the water in the washing machine that Rehab used to wash patient linens.

Based on review of policy, review of physician's TB (Tuberculosis) records, and interview, the Infection Control Officer failed to identify that nine (#1-6 and #8-10) of ten (#1-#10) physicians and two of two(#1 and #2) Certified Registered Nurse Anesthetists (CRNA) were not being screened annually for TB. By not assuring the Healthcare workers were screened annually, the facility couldn't assure they were controlling infections and communicable diseases of patients and personnel. The failed practice had the likelihood to affect all of the employees and patients in the facility. Findings follow:

A. Record review of the policy titled, "Screening Employees for Tuberculosis/Exposure to Tuberculosis," showed that all employees were to be tested and or screened for TB upon hire and annually thereafter.
B. Review of the physician's Tuberculosis records showed the following:
1) Physician #1-had no evidence of being screened since their start date, 07/2004;
2) Physician #2-had no evidence of being screened since their start date, 07/2018;
3) Physician #3-had no evidence of being screened since their start date, 12/2017;
4) Physician #4-had no evidence of being screened since their start date, 11/2017;
5) Physician #5-had no evidence of being screened since their start date, 07/2003;
6) Physician #6-had no evidence of being screened since their start date, 08/2016;
7) Physician #8-had no evidence of being screened since their start date, 12/2006;
8) Physician #9-had no evidence of being screened since their start date, 12/2016;
9) Physician #10-showed they were due to be rescreened 05/2018;
10) CRNA #1-showed they were due to be rescreened 04/2017; and
11) CRNA #2-had no evidence of being screened since their start date, 05/2018.
C. During an interview on 10/09/18 at 2:18 PM, the Chief Nursing Officer verified the findings at B.

Based on review of policies, review of cleaning lists for the hydrocollators (stores and heats hot packs) and paraffin baths and interview, it was determined the Infection Control Officer failed to identify that Rehabilitation Services were not cleaning the hydrocollator on a monthly basis and paraffin bath every 6 months in one of one (outpatient) rehabilitation gym toured. By not cleaning the hydrocollator and paraffin baths per policy, the facility could not assure the sanitary environment when patients used these items. The failed practice had the likelihood to affect all rehabilitation patients who received hot pack or paraffin therapy. Findings follow:

A. Record review of the facility's policy titled, "Equipment Cleaning and Care," dated 09/01/1999, showed the hydrocollator was to be cleaned monthly and the paraffin bath was to be cleaned with the paraffin replaced every six months.
B. Review of cleaning lists showed the following for the previous 12 months (10/01/17-09/28/18):
1) Hydrocollator was not cleaned November and December 2017, February, March, April, May, June, August and September 2018; and
2) Paraffin bath was not clean and paraffin not replaced once in the previous 12 months.
C. During an interview on 10/10/18 at 10:03 AM, Physical Therapist #1 verified the findings at B.


38994

Based on observation review of product label and interview, it was determined the facility failed to control infections by using one of one single use bottle of Omnipaque contrast medium for multiple patients in the Computerized Tomography (CT) room. The failed practice did not ensure the Omnipaque solution was free of contaminants and had the potential to affect all patient requiring oral or intravenous Omnipaque contrast. Findings follow:
A. Review of the Omnipaque label showed "single dose bottle."
B. During tour of the Radiology Department's CT Room on 10/10/18 at 12:45 PM showed a single use bottle of Omnipaque contrast medium in the cabinet ready for use with the next patient.
C. During interview with the Radiology Technologist # 1 on 10/10/18 at 12:50 PM, he stated that each Ominpaque bottle was used on multiple patients.
D. The above findings in A, B, and C were verified with RT # 1on 10/10/18 at 12:55 PM.

Based on observation and interview, it was determined the facility failed to assure a tracheotomy set was available to one of one Operating Room Suite. Failure to have a tracheotomy set did not ensure the supplies needed in the event of an emergency would be available. The failed practice affected all patients who had surgical procedures at the facility. Findings included:

Observation on 10/08/18 and 10/10/18 of the Operating Room Suite showed no tracheotomy set. The Surgical Services Director stated 10/10/18 at 12:58 PM that there was not a tracheotomy set.

Based on clinical record review and interview, it was determined the facility failed to ensure the time of the operation was included in the operative report for 7 (#1, #3-#6, #8 and #9) of 10 (#1-#10) patients' surgical records. Failure to include the time of surgery did not allow knowledge of the time of the surgical procedure and in what order the surgery was performed for multiple surgeries on the same day. The failed practice likely affected all surgical patients. Findings included:

Record review of operative reports showed there was no time of surgery included in the operative report for Patient #1, #3-#6, #8 and #9. The finding was confirmed by the Chief Nursing Officer on 10/11/18 at 2:35 PM.

Based on clinical record review and interview, it was determined the facility failed to develop an activities calendar for one of one (Patient # 33) Swing-Bed patient. Failure to develop an activities program and calendar did not allow the swing bed patient and/or family to be knowledgeable of available activities and choose which activities they would like to participate in. The failed practice had the potential to affect any Swing Bed patient. Findings follow:

A. Review of clinical record for Swing-Bed Patient #33 showed that there was no evidence of on-going activities provided from 07/06/18 to 07/13/18 . Review of Swing-Bed Patient #33s Patient Care Note dated 07/09/18 at 10:58 AM showed "patient refused all activities on list."
B. During interview with Activity Therapist on 10/11/18 at 1:25 PM, she stated that she passes out a list of activities at the time patients were admitted to swing-bed. Patient #33 was admitted to Swing-Bed on 07/06/18 and was not offered any activities until 07/09/18 at 10:58 AM.
C. The above findings in A and B were verified with the Activity Therapist on 10/11/18 at 1:30 PM.