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patients. Based on the hospital's QA/PI (Quality Assessment/Process Improvement) plan reviewed, hospital board of trustees meeting minutes reviewed, and staff interview the hospital's governing body failed to specify the frequency and detail of data collection.


Findings include:

- The hospital's QA/PI plan approved on 9/17/14 and reviewed on 4/22/15 at 9:25am stated, "...The Hospital's QA/PI obligations require the governing body to establish a culture of safety and quality and to define the importance of QA/PI activities throughout the organization...these requirements will be met by Board to : 1) review and approve an annual QA/PI plan; 2) receive and accept Quarterly QA/PI reports from the CEO (Chief Executive Officer); 3) receive and accept of a year-end QA/PI report from the CEO; and 4) involvement in QA/PI priority setting during the annual strategic planning session..."

- The hospital's Board of Trustees' Bylaws approved on 2/18/15 and reviewed on 4/22/15 at 9:25am stated, "...The Board shall establish, maintain, support and exercise oversight of an ongoing quality review and utilization management program with increased specific review, evaluation and monitoring mechanisms to assure, preserve and improve the overall quality and efficiencies of patient care in the Hospital..."

- The Board of Trustees meeting minutes provided by the hospital and reviewed on 4/23/15 at 10:00am revealed the meeting minutes for January 23, 2013, August 21, 2013, October 15, 2014, June 18, 2014, and February 18, 2015 lacked evidence the CEO presented the QA/PI reports to the board of trustees.

Administrative staff N interviewed on 4/22/15 at 9:25am acknowledged the reports from the QA/PI committee go to staff T. Staff N confirmed he/she does not take the reports to the governing body.

Administrative staff W, interviewed on 4/22/15 at 2:45pm confirmed they did not present the QA/PI reports to the governing body because he/she did not want to present data he/she could not understand and that choice was on him/her not to present data to the governing body. The governing body did not specify the frequency or detail of the data collection.

The hospital reported an average census of 3.3 patients with a current census of three swing bed patients. Based on the hospital's QA/PI (Quality Assessment/Process Improvement) plan reviewed, hospital board of trustees meeting minutes reviewed, and staff interview the hospital's governing body failed to determine the number of specific improvement projects on an annual basis.


Findings include:

- The hospital's QA/PI plan approved on 9/17/14 and reviewed on 4/22/15 at 9:25am stated, "...The Hospital's QA/PI obligations require the governing body to establish a culture of safety and quality and to define the importance of QA/PI activities throughout the organization...these requirements will be met by Board to : 1) review and approve an annual QA/PI plan; 2) receive and accept Quarterly QA/PI reports from the CEO (Chief Executive Officer); 3) receive and accept of a year-end QA/PI report from the CEO; and 4) involvement in QA/PI priority setting during the annual strategic planning session..."

- The hospital's Board of Trustees' Bylaws approved on 2/18/15 and reviewed on 4/22/15 at 9:25am stated, "...The Board shall establish, maintain, support and exercise oversight of an ongoing quality review and utilization management program with increased specific review, evaluation and monitoring mechanisms to assure, preserve and improve the overall quality and efficiencies of patient care in the Hospital..."

- The Board of Trustees meeting minutes provided by the hospital and reviewed on 4/23/15 at 10:00am revealed the meeting minutes for January 23, 2013, August 21, 2013, October 15, 2014, June 18, 2014, and February 18, 2015 lacked evidence the governing body conducted an annual determination of the number of specific improvement projects for the QA/QI hospital.

Administrative staff W, interviewed on 4/22/15 at 2:45pm confirmed the governing body was not involved in determining the QA/PI projects for the hospital.

The hospital reported an average daily census of 3.3 patients with a current census of three swing bed patients. Based on medical record review, Medical Staff Rules and Regulations, and staff interview the hospital failed to ensure the providers complete a history and physical within twenty-four hours after admission for two of ten discharged patients sampled (#18 and 19). This deficient practice had the potential to affect the patient's planned course.

Findings include:

- The hospital's Medical Staff Rules and Regulations reviewed on 4/23/15 at 4:00pm directed, "...A complete history and physical examination shall be recorded within 24 hours of admission..."

- Patient #18's closed medical record reviewed revealed an admission date of 12/25/14 and discharged on 12/30/14 with diagnoses of pneumonia. Patient#18's history and physical indicated a dictation date of 8/28/14 (3 days after admission).

- Patient #19's closed medical record reviewed revealed an admission date of 2/6/15 and discharged on 2/12/15 with diagnoses of pneumonia. Patient #19's history and physical indicated a dictation date of 2/10/15 (4 days after admission).

Medical Records Staff L interviewed on 4/23/15 at 10:55am acknowledged hospital Medical Staff failed to complete a history and physical within twenty-four hours after admission for patients #18 and #19.

The hospital reported an average daily census of 3.3 patients with a current census of three swing bed patients. Based on medical record review, Medical Staff Rules and Regulations, and staff interview the hospital failed to ensure the providers complete a medical record within thirty days after discharge for two of ten discharged patients sampled (#19 and 22). This deficient practice had the potential for inadequate post-hospitalization follow-up care.

Findings include:

- The hospital's Medical Staff Rules and Regulations reviewed on 4/23/15 at 4:00pm directed, "...If a medical record remains incomplete after 21 days, the practitioner shall be notified by mail that his admitting privileges shall be suspended seven days from the date of notice..."

- Patient #19's closed medical record reviewed revealed an admission date of 2/6/15 and discharged on 2/12/15 with diagnoses of pneumonia. Patient #19's medical record revealed the history and physical and telephone orders for 2/6/15 and 2/7/15 lacked a practitioner's signature. The medical record failed to be complete.

- Patient #22's medical record reviewed on 5/21/14 revealed an admission date of 2/3/15 and discharged on 2/5/15 for a C-section (delivery of a baby by a surgical procedure). Patient #22's surgical consent failed to be signed and completed by the practitioner on 4/23/15. The medical record failed to be completed 75 days after discharge.

Medical Records staff L interviewed on 4/23/15 at 10:55am acknowledged hospital Medical Staff failed to complete a medical record within thirty days after discharge for patient #19 and 22.

The Hospital reported an average daily census of 3.3 patients with a current census of three swing bed patients. Based on observation, policy review, manufacturer ' s information sheet, and staff interview the Hospital failed to ensure outdated, mislabeled drugs and biologicals are not available for patient use for one of one anesthesia medication cart, one of one emergency department (ED) medication room, one of three crash carts, and one of one obstetric department. This deficient practice places patients at risk for medication errors and the potential to receive unstable drugs.

Findings include:

- The hospital's policy "Unusable and Outdated Drugs" reviewed on 4/21/15 at 10:00am directed, "...All discontinued patient drugs, contaminated drugs, improperly stored drugs and containers with worn, illegible or missing labels shall be returned to the Pharmacy Department for proper disposal..."

- The hospital's policy " Use of Multiple Dose Vials "reviewed on 4/21/15 at 10:00am directed, "...Multiple dose vials, the expiration will occur 30 days after the vial has been opened/punctured..."

- The hospital's policy "Expiration Dates" reviewed on 4/21/15 at 10:00am directed, "...Pharmacy will check for expiration dates on all medications and solutions monthly..."

- The anesthesia medication cart in the anesthesia office observed on 4/21/15 between 9:50am and 10:15am revealed the following unusable and expired medications:

The top of the anesthesia medication cart contained the following:
1. A syringe containing 4ml (milliliter) clear fluid labeled Versed (used to sedate a patient)
2. A syringe containing 10ml clear fluid labeled Succinylcholine (relaxes muscles during surgery
3. A syringe containing 3ml clear fluid labeled Zofran (a medication used for nausea)
4. A syringe containing 4ml clear fluid labeled Zemuron 10mg/ml (a muscle relaxant)
5. A syringe containing 5ml clear fluid labeled Atropine (used to keep a heart rate stable and decrease oral secretions)
6. A syringe containing 10ml clear fluid labeled Ephedrine (a medication used for breathing problems)

The top drawer of the anesthesia medication cart contained the following:
1. A syringe containing 10ml clear fluid labeled NeoSynephrine (causes blood vessels to constrict)
2. A syringe containing 1/4ml clear fluid labeled Nubain (a narcotic pain medication)

The labels on the syringes failed to contain the person who prepared the medications, the date when prepared, the strength of the medication, and the date the medications expired.

Operating Room Supervisor Staff C, interviewed on 4/21/15 at 10:00am indicated the Certified Registered Nurse Anesthetist (CRNA) kept medication drawn in the syringes on top of the anesthetic medication cart for emergencies and the CRNA was responsible for the anesthesia medication cart.


Review of the manufacturer's information sheets for Versed, Succinylcholine, Zofran, Zemuron, Atropine, Ephedrine, NeoSynephrine and Nubain failed to indicate these medications could be pre-drawn for later use or the effectiveness or safety when pre-drawn.

The top drawer of the anesthesia medication cart contained the following outdated medications:

1. Zantac (an antacid) 50mg (milligrams)/ml(milliliters) IV (intravenous), 3 vials with an expiration date of 4/14 and 1 vial with an expiration date of 8/14
2. Butorphanol (an opioid pain medication) 4mg IV, one vial with an expiration date of 5/1/14 and one vial with an expiration date of 11/1/14
3. Neostigmine (affects chemicals in the body that are involved in the communication between nerve impulses and muscle movement) 10mg/ml IV, one 10ml vial with an expiration date of 9/14 and one 10ml vial with an expiration date of 6/14
4. Propranolol (used for heart of circulator conditions)1mg, IV, three vials with and expiration date of 12/14
5. Diphenhydramine (an antihistamine) 50mg, IV, one vial with an expiration date of 11/13 and one vial with an expiration date of 8/14
6. Furosemide (a diuretic) 40mg, IV, one vial with an expiration date of 9/1/14
7. Droperidol (a sedative) 5mg, IV, two vials with an expiration date of 8/14
8. Vasopressin (used to increase blood pressure) 20 units IV, one vial with an expiration date of 11/14
9. Naloxone (reverses the effects of narcotics)0.4mg/ml, IV, one 10ml vial with an expiration date of 11/1/14
10. Ketamine (an anesthetic drug) 500mg IV, one vial with an expiration date of 11/14

The top drawer of the anesthetic medication cart contained the following open medication vials without the date when opened:

1. Glycopyrrolate 5ml IV one vial (reduces body secretions)
2. Labetalol 5mg/ml, IV, one 20ml vial (used to treat high blood pressure)
3. Flumazenil 0.5mg/5ml, IV, one 20ml vial (reverses the effects of narcotics)
4. Dopram 400mg IV (a respiratory stimulant)
5. Ondansetron 40mg IV (used to prevent nausea)

OR Supervisor Staff C interviewed on 4/21/14 at 10:15am acknowledged the expired and unusable medications in the anesthesia medication cart. Staff C acknowledged the open vials of medication lacked a date when opened and the hospital's policy required open medications vials disposed of after 30 days.

- The obstetrical department observed during tour of the unit on 4/20/15 at 1:05pm revealed the following medications used for mothers and infants exceeded the end date for use:
Two-vials of infasurf (a medication for infants to prevent respiratory distress) 6 ml (milliliters) with an expiration date of 3/17/15
1. One-1000cc (centimeters) bag of lactated ringers 5 %( solution for salt and mineral replacement in the body) intravenous fluid with an expiration date of 3/1/15.
2. Three-250cc bag of 10% dextrose (a form of sugar fluids) intravenous fluid with an expiration date of 2/1/15.
3. One-10ml syringe of normal saline for intravenous flush with an expiration date of 1/15.
4. One-pre-filled syringe of epinephrine 1:10000mg (milligrams)/ml epinephrine (medication used for allergic reactions or emergency heart problems) with an expiration date of 1/15.
5. One-pre-filled syringe of infant sodium bicarbonate 4.2 %( a medication used in emergency situations) with an expiration date of 1/15.
6. Four-vials of Ampicillin 250mg (an antibiotic) intramuscular (IM) with an expiration date of 8/14.
7. One-vial of Lidocaine 10mg/ml (5ml) (a medication used for local anesthesia and used in emergency situations for heart beat irregularities) with an expiration date of 5/1/14.
8. One-vial of Naloxone 1ml (a medication used to reverse the effects of narcotic medications) with an expiration date of 2/1/15.
9. One-vial of Dopamine 400mg/ml (5ml) (medication to help increase blood circulation) with an expiration date of 9/14.
10. Two-ampules of Lanoxin 1ml (used to slow down a rapid heartbeat) with an expiration date of 2/15.
11. One-pre-filled syringe of Lidocaine 1% (50mg) with an expiration date of 1/1/15.
12. Two-pre-filled syringes of Epinephrine 1:10,000 with an expiration date of 11/14.
13. Two-250cc bags of 10% Dextrose with an expiration date of 3/1/14.
14. One-ABG kit (used to draw arterial blood to test) contained a 3cc syringe with 1 unit of Heparin (a blood thinner) with an expiration date of 2/15.

Registered Nurse (RN) Staff H interviewed on 4/20/15 at 3:10pm confirmed the medications still in use exceeded the end date for use.

- The manufacturer's guidelines for the warming of intravenous and irrigation solutions directs,"...Solutions for injection and irrigation in polyvinyl chloride (PVC) and CR3 (polyester) plastic flexible containers, in their overwraps, may be warmed at a temperature not to exceed 40 degrees Celsius (104) Fahrenheit..."
- The warming cabinet in the obstetrical department observed on 4/20/15 at 2:00pm revealed one 1000cc bottle of 9% normal saline for irrigation, one 1000cc bottle of sterile water for irrigation, and two 1000cc bags of lactated ringers for intravenous use. The temperature of the warming cabinet read 128 degrees Fahrenheit. Review of the daily temperature logs for March 2015 and April 2015 revealed the temperature of the warming cabinet range from 124 to 131 degrees Fahrenheit. The temperature of the warming cabinet exceeded the manufacturer's guidelines for the warming of fluids for injection and irrigation.

RN Staff P interviewed on 4/20/15 at 2:00pm confirmed the temperatures of the warming cabinet and was unaware of the manufacturer ' s guidelines for the appropriate temperature of the warming cabinet to warm fluids.

- The hospital's policy "Expiration Dates" reviewed on 4/21/15 at 10:00am directed Emergency Staff, "... check all expiration dates on medications and solutions open or unopened that are stocked in the Emergency Room area...ER staff will check for expiration dates on all medications and solutions monthly...All expired medications or solutions will be pulled...The crash cart will also be checked monthly by ER staff for outdates and replaced by Pharmacy."

- Crash cart located in the emergency department observed on 4/20/15 at 1:00pm revealed one 25mg (milligram) bottle of Nitroglycerin in 5% dextrose (medication used to lower blood pressure) with an expiration date of 3/15.

Registered Nurse (RN) staff O interviewed on 4/20/15 at 1:00pm acknowledged the outdated bottle of Nitroglycerin in 5% dextrose and indicated ER staff should have removed it during monthly checks.

- Emergency Department medication room observed on 4/20/15 at 1:30pm revealed seven 100ml (milliliter) bags of 0.9% Sodium Chloride IV solution (used to supply water and salt to the body located in the upper right cabinet. Five bags with an expiration date of 4/1/14, one bag with an expiration date of 12/13, and one bag with an expiration date of 3/15.

Registered Nurse (RN) staff O interviewed on 4/20/15 at 1:30pm acknowledged the seven outdated 100ml (milliliter) bags of 0.9% Sodium Chloride.

The Hospital reported an average daily census of 3.3 patients with a current census of three swing bed patients. Based on observation, policy review, document review and interview the hospital failed to provide for the safety of patients in one patient room with a portable oxygen tank. This deficient practice has the potential to cause harm to patients and other staff members.

Findings include:

- The Joint Commission on Awareness and Education reviewed on 4/27/15 at 5:20pm indicated "...Oxygen tanks are stored under extremely high pressure. A sudden release of these gases may cause a cylinder to become a missile-like projectile...Cylinders or very hazardous when exposed to damage from falling over ... "

- The hospital's policy "Oxygen Supply" reviewed on 4/23/15 at 12:15pm directed, "...All personnel and students must be properly trained to handle cylinders, trucks, support valves and protection caps...Small cylinders (A, B, D, and E) in use must be attached to a cylinder stand or therapy apparatus..."

- Patient #34's room observed on 4/23/15 at 11:20am revealed an E oxygen tank stored against the south wall. The E oxygen tank failed to be secured in a cylinder stand or therapy apparatus.

Respiratory Staff O interviewed on 4/23/15 at 11:20am acknowledged the unsecured E oxygen tank in Patient #34's room and indicated the tank should be in a cylinder stand.

Administrative Nursing staff A interviewed on 4/23/15 at 11:45am in patient #34's room, acknowledged the unsecure E oxygen tank and they did not know why someone would leave an oxygen tank unsecured.

Based on observation, staff interview and document review, the hospital's infection control officer failed to: develop an active infection control system (refer to A-0749).


The cumulative effect of the systematic failure to develop an active infection control system resulted in the hospital's inability to provide care in a safe and effective manner.

The hospital reported an average daily census of 3.3 patients with a current census of three swing bed patients. Based on observations, staff interview and document review the hospital's infection control officer failed to ensure hospital personnel followed basic infection control practices for one of one dressing changes, one of two discharged patient room cleaned, one of one preoperative/postoperative unit, one of one storage of used IV tubing, four of six medication administrations, one of one observed glucometer (blood sugar analyzer) tests, and three of three negative air pressure rooms. This deficient practice places patients at risk for hospital-acquired infections.

Findings include:

- The hospital's policy "Infection Control /Prevention Program" reviewed on 4/27/15 directed staff "...provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable disease...Surveillance is the monitoring of the facility regarding the practice of infection control and strategies for the prevention and control of HAI's (hospital acquired infections) and multi-drug resistant organisms (MDRO)..."

- Infection Control Officer Staff G interviewed on 4/20/15 at 2:00pm indicated they used secret shoppers (unknown staff members sent to different departments to identify infection control breeches by hospital personnel) for surveillance of breeches in infection control. Staff G indicated most of the staff does not want to get coworkers in trouble. Staff G conducted surveillance but failed to identify infection control areas of concern. Staff G indicated they follow CDC guidelines and APIC (Association for Professionals in Infection Control) to guide their infection control practices.
- The hospital's policy titled "Hand Hygiene" reviewed on 4/22/15 at 3:25pm directed staff "...All personnel will use hand hygiene techniques, as set forth in the following procedure...Before each patient encounter...Always after removing gloves..."

- Licensed Practical Nurse (LPN) Staff J observed on 4/20/15 at 2:15pm during a medication pass revealed staff J entered patient #27's room to provide an oral medication. Staff J entered patient #27's room and failed to perform hand hygiene when entering the room and providing medications.

- Licensed Practical Nurse (LPN) Staff J observed on 4/20/15 at 4:05pm during a medication pass revealed staff J entered patient #28's room to provide an intravenous medication. Staff J entered patient #28's room and failed to perform hand hygiene when entering the room, provided the IV medication, then exited the room and failed to perform hand hygiene when leaving patient #28's room.

- Administrative Nurse Staff A interviewed on 4/20/15 at 4:30pm acknowledged they expected all staff to perform hand hygiene when entering a patient room.

- The manufacturer's guidelines for the use of "HB Quat Disinfectant Cleaner Concentrate" reviewed on 4/21/15 at 11:20am directed, "...Apply use solution to hard inanimate, non-porous surfaces thoroughly wetting surfaces with a cloth, mop, sponge, or sprayer...treated surfaces must remain wet for 10 minutes..."

- The manufacturer's guidelines for the use of "Crew" toilet bowl disinfectant cleaner reviewed on 4/21/15 at 11:20am directed, "... pour 1ounce (30millileters) of product on applicator remove water from bowl by forcing over trap with applicator scrub entire unit especially under the rime at water outlets wait 1 minute, then flush..."

- The hospital's policy "CLEANING PATIENT ROOMS UPON DISMISSAL" Reviewed on 4/21/15 at 11:20am directed, "...When cleaning things, remember to start at the top and work to the floor. Do not ever touch anything clean to something dirty, it will cause recontamination...Prepare a solution of HB Quat Disinfectant into a container...using the solution and cleaning cloth, wipe down window sill, closets, sink areas...drawers, cabinets under the sink and syringe container...with solution and cleaning cloth wipe off top of over bed table, leg and base...wipe off all furniture with the solution...clean shower walls and shower curtain with solution...wipe trash receptacle inside and out with solution..."

- The hospital's policy titled, "CLEANING TOILETS" reviewed on 4/21/15 at 11:20am directed, "...flush the toilet use Crew Toilet Bowl Cleanser in bowl...scour the inside of the bowl and area under the rim with the bowl brush...do not flush..."

- Terminal cleaning of a discharged obstetrical patient's room observed on 4/20/15 between 2:30pm and 3:00pm revealed staff Q and staff R, housekeeping staff wearing gloves entered the room with a container of HB Quat disinfectant solution and set the container on a counter in the room. Staff Q using a cloth, wet with the HB Quat disinfectant wiped the shower head, shower curtain, and shower walls. Using the same cloth staff Q re-wet the cloth in the container of HB Quat solution wiped the sink, and outside of the toilet. Staff R using the "Crew" toilet bowl disinfectant, poured an unmeasured amount of the disinfectant on the toilet bowl brush, and cleaned the inside of the toilet. Staff Q removed their gloves applied clean gloves, and using a clean cloth wet the cloth in the container of HB Quat solution and cleaned the inside and outside of the trash container in the bathroom. Staff R wet their cloth in the same container of HB Quat solution and wiped the doors to the room and bath room, chairs, couch, closet, and waste basket, re-wetting the cloth in the HB Quat solution four times. Staff R using the same gloves wet a clean cloth in the HB Quat solution and wiped the pillow and over bed table. Staff Q using the same gloves wet a clean cloth in the HBQquat disinfectant solution, staff R using the same gloves re-wet their cloth in HB Quat solution, and they cleaned the bed frame and bed. The surfaces remained wet for six to eight minutes, not the required 10 minutes to achieve disinfection of the surfaces. Staff Q failed to measure the toilet bowl disinfectant and remove the water from the toilet bowl. Staff Q and staff R failed to change their cloths to prevent cross contamination of the surfaces they cleaned.
Housekeeping Staff Q and Staff R interviewed on 4/20/15 at 3:10pm acknowledged they were not aware of the process to clean a room going from clean to dirty.
Administrative staff S, interviewed on 4/21/15 at 10:35am explained they trained the staff the way they were trained to use the same solution and cloth. Staff S acknowledged they were unaware of the procedure to remove the water from the toilet bowl.

Registered Nurse Staff K observed on 4/21/15 at 8:15am prepared an intravenous antibiotic to administer to patient #16. Staff K used a 20 cc (centimeter) syringe with needle attached entered the rubber port on the 100cc normal saline intravenous bag and removed 20cc of fluid. Staff K entered the rubber stopper on the vial of antibiotic and put the 20cc of normal saline in the antibiotic vial. After mixing the antibiotic Staff K using a clean needle on the same syringe withdrew the antibiotic solution and entered the port of the 100cc bag of normal saline. Staff K failed to clean the port of the 100cc of normal saline and antibiotic vial before entering them with a needle.

- The manufacturer's instruction for "Nova StatStrip Glucose Hospital Meter " reviewed on 4/22/15 at 2:00pm directed, "...dilute bleach a 10%solution of household bleach may be used..."

- Registered Nurse (RN) Staff K, observed on 4/21/15 at 11:15am, performed a glucometer test on patient #33. Staff K entered patient #33's room, perform hand hygiene, laid the glucometer and the patient's bedside table, applied gloves, and completed the blood test, removed their gloves, performed hand hygiene. Staff K returned to the nurse's station and placed the glucometer in the charger. Staff K failed to clean the glucometer that lay directly on patient #33's bedside table and placed the contaminated glucometer in the charger at the nurse's station.

Staff K interviewed on 4/21/15 at 11:20am acknowledged they failed to clean the glucometer after use on patient #33.

- Registered Nurse Staff F observed on 4/21/15 at 8:15am during medication pass revealed staff F entered Patient #28's room to provide a new IV bag. Staff F entered patient #28 ' s room, failed to perform hand hygiene, found the IV tubing required changing, left the room and failed to perform hand hygiene. Staff F returned to patient #28's room, failed to perform hand hygiene, removed the cap from the new IV tubing to place on the antibiotic tubing, the laid the uncapped tubing on the patient's bedside table. Staff F hung the bag of IV fluids and used contaminated uncapped IV tubing that lay directly on patient #28's bedside table.

RN Staff F interviewed on 4/21/15 at 8:25am acknowledged they placed uncapped IV tubing that lay on patient #28's bedside table and used the contaminated tubing on an IV bag.

- The Medline Yankauer Suction package reviewed on 4/22/15 directed, "...Do not use if package is opened or damaged..."

- Observation on 4/21/15 at 1:00pm of the pre-operative/post-operative unit revealed three Yankauer suction handles and tips with tubing package opened and hooked up to the suction canister.

Operating Room Supervisor Staff C, interviewed on 4/21/15 at 1:00pm acknowledged nursing staff open the Yankauer package and hooked the tubing to the canister to have ready for patient use. Staff C verified the open Yankauer package and the manufacturer's instruction not to use if open.


- Registered Nurse (RN) Staff F observed on 4/22/15 at 9:30am provided a dressing change to patient # 33's left lower leg at an amputation site. Staff F cleansed the wound, changed gloves, applied new gloves, the applied gauze pads and an ace wrap bandage. Staff F removed their gloves and adjusted patient #33's bed control. Staff F failed to preform hand hygiene between glove changes and after removal of gloves before touching the patient's bed adjustment controls.

RN Staff F interviewed on 4/22/14 at 9:32am acknowledged they failed to perform hand hygiene between glove changes and after removing gloves.

- Emergency department medication room observed on 4/21/15 at 8:00am revealed a used IV tubing set timed and dated with patient #32's (an outpatient receiving a series of IV antibiotics) information. The used tubing and bags of medication were stored in the medication room without being contained. Failure to contain the used tubing has the potential to contaminate all items in the medication room placing all patients admitted into the emergency department at risk for infection.

- Registered Nurse (RN) Staff O interviewed on 4/21/15 at 8:00am indicated IV tubing is reused for outpatients for up to 72 hours per hospital policy. The used medication bag and IV tubing is stored in the medication room until the patient returns for their next IV infusion. A New medication bag obtained from the Pyxis (medication distribution system) and attached to the used IV tubing.

- Administrative staff D acknowledged the hospital failed to have a policy directing staff on how store used IV tubing for outpatients.

- Medical-Surgical unit observed on 4/20/15 at 9:00am and Obstetrical Unit 4/20/15 at 3:10pm revealed three negative air pressure rooms (a type of room to ensuring that contaminated air cannot escape from the room).

- Request for the hospital maintenance log on 4/23/15 at 10:05am revealed the hospital failed to have a maintenance log of testing for the three negative airflow rooms.

- Administrative staff D interviewed on 4/23/15 at 10:05am acknowledged the hospital did not have a maintenance policy for testing of the three negative airflow rooms. Staff D indicated the hospital maintenance staff did not have instructions on how or how often the negative airflow rooms need testing and they will need to contact the manufacturer.

- Administrative Staff E interviewed on 4/22/15 at 4:50pm indicated the negative air pressure rooms were tested in 2009 on the date of the systems installation.