HospitalInspections.org

Based on review of facility documents, personnel files (PF), observation, and staff interview (EMP), it was determined the facility failed to ensure respiratory fit testing was conducted on four of 16 personnel files reviewed (PF4, PF5, PF11 and PF12); the facility failed to established a time frame for determining regular intervals to perform personnel respiratory fit testing; the facility failed to ensure staff cleansed an area before administering a subcutaneous injection; the facility failed to maintain a clean environment during the cleaning of a patient room in the Intensive Care Unit (ICU); the facility failed to ensure linen was transported in a manner to prevent contamination; the facility failed to ensure a blood glucose meter was cleansed and disinfected after use in the intensive care unit (ICU); the facility failed to ensure proper temperature and humidity levels were maintained in OR1, OR2, OR5, OR6 and the post anesthesia care unit (PACU) 2; and the facility failed to ensure staff wore proper hair covering while in the restricted area of the surgical suite.

Findings include:

1) Review on July 2, 2015, of the facility's "Respiratory Protection Program - Fit Testing" policy, last revised September 2008, revealed "Affected Departments Hospital Wide Purpose: To prevent the transmission of tuberculosis Policy: Particulate filter respirators (PFR) are required by: 1. Persons entering rooms in which patients with known or suspected infectious TB [Tuberculosis] are being isolated. 2. Persons present during cough-inducing or aerosol-generating procedures performed on such patients. Medical Screening: Healthcare workers must be able to perform their duties while wearing a PFR. 1. A medical questionnaire will be used to determine the employee's ability to wear a PFR. (see attachment A) Employee Training: Each employee who wears a PFR must be educated on the correct use. It will be a team effort between Respiratory Therapy, Employee Health and Clinical Department Directors. ..."

Review of PF4 on July 2, 2015, revealed the facility hired this employee in April 2015. Further review of PF4 revealed no documentation the facility completed a respiratory fit test on this employee for wearing a particulate filter respirator.

Review of PF5 on July 2, 2015, revealed the facility hired this employee in May 2015. Further review of PF5 revealed no documentation the facility completed a respiratory fit test on this employee for wearing a particulate filter respirator.

Review of PF11 on July 2, 2015, revealed the facility hired this employee in August 2014. Further review of PF11 revealed no documentation the facility completed a respiratory fit test on this employee for wearing a particulate filter respirator.

Review of PF12 on July 2, 2015, revealed the facility hired this employee in March 2014. Further review of PF12 revealed no documentation the facility completed a respiratory fit test on this employee for wearing a particulate filter respirator.

Interview with EMP1, EMP2, EMP3 and EMP4 on July 2, 2015, at approximately 2:00 PM confirmed the facility did not perform respiratory fit testing on PF4, PF5, PF11 and PF12.

2) Review on July 2, 2015, of the facility's "Respiratory Protection Program - Fit Testing" policy, last revised September 2008, revealed no documentation the facility established a time frame for determining regular intervals to perform personnel respirator fit testing.

Interview with EMP1, EMP2, EMP3 and EMP4 on July 2, 2015, at approximately 2:15 PM confirmed the facility's Respiratory Protection Program - Fit Testing policy did not establish a time frame for determining regular intervals to perform personnel respirator fit testing.

3) Review of July 2, 2015, of the facility's "Medication Administration" policy, last revised October 2012, revealed "Expected Outcome: Registered nurse and licensed practical nurse will safely administer medications as ordered. ... II. Performance Phase: ... 4. Subcutaneous Injection ... d. Cleanse injection site with alcohol prep in a circular motion from center to a diameter of 3 inches. ..."

Observation on July 1, 2015, revealed EMP6 prepared to administer insulin to MR8. Further observation revealed EMP6 selected and administered MR8's insulin in the left upper arm. Continued observation revealed EMP6 did not cleanse the injection site prior to the administration of MR8's insulin.

Interview with EMP6 on July 1, 2015, at approximately 12:05 PM confirmed this employee did not cleanse the injection site prior to the administration of MR8's insulin. Further interview with EMP6 revealed this employee never thought to cleanse the injection site area prior to administration of MR8's insulin.

4) Review on July 2, 2015, of the facility's "Cleaning Patient Room-Discharge/Transfer" policy, last reviewed August 2012, revealed "Policy: All patient rooms will be cleaned when a patient has been discharged or transferred using our 7 step cleaning process. ... Procedure: ... Damp wipe overbed tables, bedside tables, telephone, chairs, ledges, light switches, lamps and spots on wall or cabinets with a hospital approved germicidal solution. ..."

Observation of EMP5 on July 1, 2015, revealed this employee cleaning a discharged patient room. Further observation revealed EMP5 obtain a cleaning bucket from the housekeeping cart. The cleaning bucket was placed on a contaminated surface, filled with water and the hospital approved germicide. EMP5 then placed the cleaning bucket on the contaminated over bed table. EMP5 lifted the contaminated cleaning bucket, damp wiped the over bed table, and then placed the contaminated cleaning bucket back on the cleaned over bed table.

Interview with EMP3 on July 1, 2015, at approximately 1:45 PM confirmed EMP5 obtained a cleaning bucket from the housekeeping cart, placed it on a contaminated surface, filled with water and the hospital approved germicide. Further interview confirmed EMP5 then placed contaminated cleaning bucket on the contaminated over bed table. Continued interview confirmed EMP5 lifted the contaminated cleaning bucket, damp wiped the over bed table, and then place the contaminated cleaning bucket back on the clean over bed table.

5) Review on July 2, 2015, of the facility's "Storage, Collection and Transportation of Linen" policy, last reviewed September 2012, revealed "Policy: All linens will be stored, handled, transported and processed in a manner that prevents the transmission of microorganisms to other patients and areas. ..."

Observation of EMP5 on July 1, 2015, revealed this employee carried clean linen from the linen cart to a patient room. Further observation revealed EMP5 carried the clean linen against their uniform.

Interview with EMP3 and EMP5 on July 1, 2015, at approximately 1:30 PM confirmed EMP5 carried clean linen against their uniform. Further interview with EMP3 revealed clean linen should be carried away form the uniform because of potential contamination from the employee's uniform.

6) Review on July 2, 2015, of the facility's "Whole Blood Glucose by [Brand name of glucose meter]" policy, effective May 1, 2014, revealed "Purpose: This intent of this policy is to provide guidelines for Bedside Blood Glucose (BBG) testing with [Brand name of blood glucose monitoring system] in the point-of-care setting. ... X. Patient Testing ... 15. While still gloved, clean the meter [sic] every patient encounter: a. Obtain a [Brand name of disinfectant cloth] from the dispenser in the patient room. b. If the wipe is extremely wet, blot the excess moisture with a clean, dry paper towel. c. Holding the meter in the horizontal position (to avoid getting liquid in the test strip port), disinfect the meter by wiping all surfaces 3 times in each direction. Discard the used wipe. d. Allow a 2 minute dwell time. ..."

Observation on July 1, 2015, at approximately 11:15 AM revealed EMP6 performed a blood glucose check on MR8. Further observation revealed EMP6 completed the blood glucose test, removed the test strip from the blood glucose monitoring meter, and discarded the test strip and gloves in the trash. Continued observation revealed EMP6 returned the blood glucose monitoring meter to the charging station behind the nurse's station. EMP6 did not cleanse or disinfect the blood glucose meter after use or before placing it on the charging station.

Interview with EMP6 on July 1, 2015, at approximately 11:15 AM confirmed this employee did not did not cleanse or disinfect the blood glucose meter after using it on MR8 or before placing it on the charging station. Further interview with EMP6 revealed this employee was not aware of the requirement to cleanse or disinfect the blood glucose meter after use or before placing it on the charging station.

7) Review on July 2, 2015, of the facility's "Maintaining a Safe, Functional Environment" policy, last reviewed and revised January 2014, revealed "Policy In accordance with The Joint Commission standards, it is the policy of Berwick Hospital Center to develop and implement plans, programs and processes to promote and maintain a safe, functional, controlled and comfortable environment suitable to the care, treatment and services provided by the hospital. ... EC.02.06.01.13 ... 6. Monitoring and recording of temperature and humidity conditions shall be the responsibility of the Facilities Management Department. ... d. Except where state of local laws/regulations are not stringent, temperature conditions in anesthetizing locations shall be maintained in accordance with ASHRAE [American Society of Heating, Refrigeration, and Air-Conditioning Engineers] Standard 170-2008, Addendum D (i.e. 68-75 [degrees Fahrenheit]) Surgeons or surgical procedures may require room temperatures that exceed the minimum/maximum indicated ranges. These accommodations shall be permitted so long as humidity conditions are not adversely affected. The necessity for lower or higher temperatures shall be determined by the medical staff and authorization shall be documented ... f. Except as noted above, temperature and humidity conditions observed outside the permissible ranges shall be reported to Plant Operations immediately. Plant Operations will take the corrective actions and document their response (e.g. written notification in temp/humidity log, work order, building automation system record, etc.). Documented response of corrective action must be correlated to the specific incident and must also be readily available for a period of at least 3 years. g. Patient safety, staff safety and infection control standards shall be considered at all times and appropriate actions will be taken based on the individual circumstances. The Surgical Services Director and Infection Control Practitioner shall be informed and consulted on an as needed basis. ..."

Review on July 1, 2015, of the facility provided Temperature and Humidity log for May and June 2015 revealed the facility determined the acceptable temperature range for operating rooms (OR) 1, 2, 3, 4, 5 and 6 as 68 to 73 degrees Fahrenheit and 70 to 75 degrees Fahrenheit for the Post Anesthesia Care Unit (PACU) .

Review on July 1, 2015, revealed the facility recorded temperatures for OR1 of 63 to 65 degrees Fahrenheit for May 1, 2, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31, 2015.

Review on July 1, 2015, revealed the facility recorded temperatures for OR2 of 65 degrees Fahrenheit for May 11, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30, 2015.

Review on July 1, 2015, revealed the facility recorded temperatures for OR5 of 64 to 65 degrees Fahrenheit for May 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28 and 29, 2015.

Review on July 1, 2015, revealed the facility recorded temperatures for OR6 of 63 to 67 degrees Fahrenheit for May 21, 22, 23, 24, 25, 27, 28 and 29, 2015.

Review on July 1, 2015, revealed the facility recorded temperatures for PACU2 of 76 to 78 degrees Fahrenheit for May 12, 17, 18, 19, 24 and 31, 2015.

Review on July 1, 2015, revealed the facility recorded temperatures for OR1 of 63 to 67 degrees Fahrenheit for June 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30, 2015.

Review on July 1, 2015, revealed the facility recorded temperatures for OR2 of 63 to 66 degrees Fahrenheit for June 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30, 2015.

Review on July 1, 2015, revealed the facility recorded temperatures for OR4 of degrees 65 degrees Fahrenheit for June 11, 12, 21, 22 and 23, 2015.

Review on July 1, 2015, revealed the facility recorded temperatures for OR5 of 64 to 68 degrees Fahrenheit for June 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30, 2015.

Review on July 1, 2015, revealed the facility recorded temperatures for OR6 of 63 to 65 degrees Fahrenheit on June 3, 4, 5, 6, 11, 12, 16, 17, 21, 22, 23, 24, 25 and 26, 2015.

Review on July 1, 2015, revealed the facility recorded temperatures for PACU2 of 76 to 77 degrees Fahrenheit on June 2, 3, 21, 22, 24, 25, 26 and 27, 2015.

There was no documentation the facility corrected the out of range temperatures noted above for OR1, OR2, OR5, OR6 and PACU2; performed re-checks to ensure temperatures were in the acceptable range of 68 to 73 degrees Fahrenheit; notified the Surgical Services Director and Infection Control Practitioner in order to determine the safety of having out of range temperatures; or, notified the operating surgeon in order to determine the safety of performing the scheduled surgical procedures with the out of range temperatures.

Interview with EMP7 and EMP8 on July 2, 2015, at approximately 1:00 PM confirmed the out of range temperatures for OR1, OR2, OR5, OR6 and PACU2; there was no documentation the facility corrected the above out of range temperatures for OR1, OR2, OR5, OR6 and PACU2; the facility did not performed re-checks to ensure temperatures were in the acceptable range of 68 to 73 degrees Fahrenheit; the Surgical Services Director and Infection Control Practitioner were not notified in order to determine the safety of having out of range temperatures; or, the operating surgeon was notified in order to determine the safety of performing the scheduled surgical procedures with the out of range temperatures.

Review on July 1, 2015, of the facility provided Temperature and Humidity log for May and June 2015 revealed the facility determined the acceptable humidity range for operating rooms (OR) 1, 2, 3, 4, 5 and 6 as 30 to 60 percent and 20 to 60 percent for PACU.

Review on July 1, 2015, revealed the facility recorded the humidity for PACU2 as 72 percent on May 31, 2015.

Review on July 1, 2015, revealed the facility recorded the humidity for OR2 as 61 percent on June 30, 2016.

Review on July 1, 2015, revealed the facility recorded the humidity for OR3 as 61 percent on June 16, 2016.

Review on July 1, 2015, revealed the facility recorded the humidity for OR6 as 62 to 68 percent on June 6, 12, 16 and 17, 2015.

Review on July 1, 2015, revealed the facility recorded the humidity for PACU2 as 63 to 87 percent on June 1, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 28, 29, and 30, 2015, and July 1, 2015.

There was no documentation the facility corrected the out of range humidity levels for OR2, OR3, OR6 and PACU2; performed re-checks to ensure the humidity levels were in the acceptable range of 30 to 60 percent; notified the Surgical Services Director and Infection Control Practitioner in order to determine the safety of having out of range humidity levels; or, notified the operating surgeon in order to determine the safety of performing the scheduled surgical procedures with the out of range humidity levels.

Interview with EMP7 and EMP8 on July 2, 2015, at approximately 1:00 PM confirmed the out of range humidity levels for OR2, OR3, OR6 and PACU2; there was no documentation the facility corrected the out of range humidity levels noted above for OR2, OR3, OR6 and PACU2; the facility performed re-checks to ensure the humidity levels were in the acceptable range of 30 to 60 percent; the Surgical Services Director and Infection Control Practitioner were notified in order to determine the safety of having the out of range humidity levels; or, the operating surgeon was notified in order to determine the safety of performing the scheduled surgical procedures with the out of range humidity levels.

8) Review on July 2, 2015, of the facility's "Surgical Attire" policy, last reviewed and revised September 2009, revealed "Expected Outcomes: 1. High level cleanliness and hygiene will be promoted within the surgical environment. 2. A barrier to contamination that may pass from patient to personnel as well as from personnel to patient will be provided. 3. Personnel will be protected against exposure to infectious micro-organisms and hazardous materials. Standard: A. All persons who enter the semi-restricted and restricted areas of the surgical suite will wear surgical attire intended for use within the surgical suite. ... b. Head and facial hair will be covered when in the semi-restricted and restricted areas in the surgical suite. 1. All hair will be confined in a clean, low lint surgical hat, preferably bouffant or hood style. ..."

Observation of EMP1 on July 2, 2015, revealed this employee removed the hair covering while in the restricted area of the surgical suite and approximately 10 feet from the semi-restricted area.

Interview with EMP2, EMP3 and EMP7 on July 2, 2015, at approximately 9:30 AM confirmed EMP1 removed the hair covering while in the restricted area of the surgical suite and approximately 10 feet from the semi-restricted area. Further interview with EMP7 revealed hair covering must be worn at all times in the semi-restricted and restricted area.