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Based on document review, observation, and personnel interview, the facility failed to provide a functional and safe environment related to availability of emergency eye wash station in 1 of 6 (Endoscopy Decontamination Room) areas toured.

Findings:
1. Material Safety Data Sheet for Endozime AW, was reviewed on 1/30/13 at approximately 2:45 PM, and indicated on pg. 2, under:
A. Signs/Symptoms of Exposure section, "Eyes- irritation and reddening."
B. Emergency and First Aid Procedures section, "Skin and eyes - flush with fresh water..."

2. While on tour 1/29/13 at approximately 2:21 PM, in the company of personnel P3, P5, and P6, the following was observed in the Decontamination Room:
A. personnel use Endozime AW to disinfect patient care equipment prior to sterilizing.
B. in order to access the emergency eye wash station, personnel may have to open the door from the Endoscopy Decontamination Room, walk approximately 10-12 feet and open double doors, then make a right turn walking approximately another 10-15 feet before reaching the eye wash station. It is located approximately 25 feet or more from the Endoscopy Decontamination Room.

3. Personnel P6 was interviewed on 1/29/13 at approximately 2:43 PM, and confirmed the emergency eye wash station was located approximately 25 feet or more from the Endoscopy Decontamination Room, with possible obstacles (closed doors) to personnel trying to gain access to it. Lacked a policy related to emergency eye wash stations.

Based on observation and personnel interview, the pharmaceutical service failed to appropriately store high risk/high alert drugs in 1 of 6 (Emergency Department [ED]) areas toured.

Findings:
1. While on tour of the ED on 1/29/13 at approximately 1:0 PM, in the company of personnel P3 and P2, the following was observed in the medication fridge: zemuron (rocuronium) and succinylcholine, which are paralytic drugs, were stored alongside other non-paralytic, high risk/high alert medications and were not clearly designated as high risk/high alert medications on the storage bins.

2. Personnel P3 was interviewed on 1/29/13 at approximately 1:42 PM, and confirmed the above-mentioned high risk/high alert medications were stored alongside other medications, and not clearly designated as high risk/high alert medications. Pharmaceutical services also lacked policy and procedure related to the procurement, storage, preparation, control, and dispensing of high risk/high alert medications.

Based on observation and personnel interview, the pharmaceutical service failed to develop, implement, and/or maintain written policies and procedures related to the safe storage of high risk/high alert mediations in 1 of 6 (Emergency Department [ED]) areas toured.

Findings:
1. While on tour of the ED on 1/29/13 at approximately 1:0 PM, in the company of personnel P3 and P2, the following was observed in the medication fridge: zemuron (rocuronium) and succinylcholine which are paralytic drugs were stored alongside other non-paralytic, high risk/high alert medications and were not clearly designated as high risk/high alert medications on the storage bins.

2. Personnel P3 was interviewed on 1/29/13 at approximately 1:42 PM, and confirmed the above-mentioned high risk/high alert medications were stored alongside other medications, and not clearly designated as high risk/high alert medications. Pharmaceutical services also lacked policy and procedure related to the procurement, storage, preparation, control, and dispensing of high risk/high alert medications.

Based on observation, document review, policy and procedure review, and personnel interview, the facility failed to provide a safe and healthful environment that minimizes infection exposure and risk to patients, health care workers, and visitors by failing to measure disinfectants in accordance with the manufacturers' instructions in 1 of 6 (Endoscopy Decontamination Room) areas toured.

Findings:

1. While on tour of facility on 1/29/13 at approximately 2:21 PM, in the company of P3, P5, and P6 the following was observed in the Endoscopy Decontamination Room: personnel are not measuring the enzymatic product and/or the water used to disinfect surgical instruments prior to sterilizing in the decontamination sink. The bottle containing Endozime AW had "2 squirts is plenty" handwritten on it and when personnel was asked to measure one squirt of product into a measuring cup, it equaled 1 ounce. So 2 squirts equals 2 ounces, which is more than what the manufacturer directions state.

2. Label titled, "Endozime AW", was reviewed on 1/29/13 at approximately 2:40 PM, and indicated, under Directions section, "1/2 ounce to 1 gallon of water."

3. Policy titled, "Infection Control: Equipment and Supplies" with a revision date of 11/10/10, was reviewed on 1/30/13 at approximately 11:25 AM, and indicated on pg. 2, under Procedure section, point 10 (a)(1)(c), "All equipment used in patient care must be cleaned after use according to established procedure."

4. Policy titled, "Infection Control Committee Duties" with a revision date of 2/11/11, was reviewed on 1/30/13 at approximately 11:25 AM, and indicated on pg:
A. 1, under Procedure section, point 1., "Advise when evaluating new equipment and procedures, cleaning, decontaminating, and sterilizing techniques."
B. 2, under point 2., "Infection Control Policy: Every Department Director has the direct responsibility for infection control of that specific department."

5. Personnel P6 was interviewed on 1/29/13 at approximately 2:43 PM and confirmed, the above-mentioned hospital approved disinfection solution and the water it is diluted with were not being measured according to manufacturer's directions. These should be measured appropriately to disinfect surgical instruments prior to sterilizing.

Based on document review and employee interview, the facility failed to notify the appropriate organ procurement organization, per contract, of all hospital deaths.

Findings:

1. Review of the contract between the hospital and the Indiana Organ Procurement Organization (IOPO) indicated the hospital shall provide "Timely Referral to IOPO as soon as possible of every individual whose death is imminent or who has died in the hospital".

2. Review of Donation 2012 Statistics and Benchmarks indicated 6 deaths occurred in January 2012 and only 5 deaths were reported.

3. Interview with Employee #A5 on January 29, 2013 at 2:30pm confirmed 6 deaths, 5 reports to IOPO for January 2012.