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Based on clinical record review and interview, the facility failed to document, whether or not the patient had executed an advanced directive in five (Patient #13,#14,#17,#18 and #20)of twenty (#1-#20) patient records. The failed practice did not allow the patient to provide guidance as to his/her wishes concerning provision of care in certain situations.The failed practice had the potential to affect all patients admitted to the facility. Findings follow:

A. During clinical record review on 07/12/12 between 1130 and 1400, it was revealed Patient #13,#14,#17,#18 and #20 did not have an answer to the Advance Directive question in the Admission Records.
B. Findings were verified through interview with Interim Medical Record Supervisor on 07/12/12 at 1406.

Based on observation, Surgery Department Daily Temperature/Humidity Log review, and interview, it was determined one of one Operating Room and one of one Endoscopy Room contained hazards due to the use of portable re-circulating air dehumidification units, improper airflow, and high humidity in the rooms that were not in accordance with the Rules and Regulations for Hospitals and Related Institutions in Arkansas (2007 edition). The use of portable dehumidification units did not prevent of contamination of the operating environment. Improper airflow increased the potential of infections due to the introduction of contaminants into the rooms. Humidity levels outside the required range had the potential for the creation of mold and mildew creation. These failed practices had the potential to affect all surgical patients. There were no patients scheduled for surgery on 07/09/12. The facility performed an average of 10 surgeries per month. The findings follow:

A. On a tour of the Surgical Suite on 07/09/12 at 1330 with the Maintenance Director and Operating Room Supervisor, the following observations were made:
1) The Operating Room had two portable re-circulating air dehumidification units that were in operation at the time of observation. The use of these units was not allowed by state licensure regulations.
2) A piece of paper was held at the bottom edge of the Operating Room door to determine the direction of airflow in the room. The paper was pushed into the room, demonstrating negative airflow. Operating rooms are required to have positive airflow per Rules and Regulations for Hospitals and Related Institutions in Arkansas (2007 edition).
3) A piece of paper was held at the bottom edge of the Endoscopy Room door to determine the direction of airflow in the room. The paper was pushed out of the room into the corridor, demonstrating positive airflow. Endoscopy Rooms are required to have negative airflow per Rules and Regulations for Hospitals and Related Institutions in Arkansas (2007 edition).
B. A review of the Surgery Department Daily Temperature/Humidity Log on 07/09/12 at 1345 revealed humidity in the Endoscopy Room was monitored beginning 06/22/12. Humidity above 60% was documented on 4 of 11 days endoscopic procedures were performed from 06/22/12 through 07/09/12. Humidity was required to be between 30% and 60% in Endoscopy Rooms per Rules and Regulations for Hospitals and Related Institutions in Arkansas (2007 edition).
C. In an interview on 07/09/12 at 1400, the Maintenance Director verified the use of the of portable re-circulating air dehumidification units, improper airflow in the Operating Room and Endoscopy Room, and high humidity levels in the Endoscopy Room.

Based on observation, Generator Log review, and interview, it was determined the facility did not meet Life Safety Code requirements as follows:

A. The facility failed to test the generator for at least 30 minutes for 4 of 18 months and inspect the generator for 30 of 72 weeks from January 2011 to June 2012. The failed practice had the potential to affect all patients because the reliability of the generator to provide emergency power was not tested and the ability to provide emergency power was not assured. See K144.
B. The medical gas alarms located in the Operating Suite and at the nurse station were not functioning. The failed practice had the potential to affect all patients served by medical gases in the facility because staff was not immediately notified in the event of a malfunction of the medical gas system. See K140.

Based on observation, review of Xopenex Package insert, review of packaging of individually wrapped Xopenex and interview, the facility failed to ensure 49 of 49 Xopenex was stored in their foil wrapping as directed by the manufacturer. The failed practice could not assure Xopenex's safety or efficacy in patients who received it under this storage practice. Findings Follow:

A. During a tour of the Respiratory Department on 07/11/12 between 0900 and 0940, observation revealed:
1) 46 Xopenex 1.25 mg (milligram)/ 3ml (milliliter) vials (from a 12 pack foil pouch) for inhalation was stored in a clear plastic tub and not in the original foil package.
2) 3 individually wrapped Xopenex 1.25 mg/ml vials for inhalation, (from single wrapped pouch) was not in the original foil package in a box.
B. Review of the package insert for Xopenex inhalation solution stated "Store Xopenex Inhalation Solution in the protective foil pouch ....Keep unopened vials in the foil pouch. Once the foil pouch is opened, the vials should be used within 2 weeks. Vials removed from the pouch, if not used immediately, should be protected from light and used within 1 week."
C. Review of the packaging of the individually wrapped Xopenex vials stated "Open the foil pouch just prior to administration." When asked for a package insert from this particular package of Xopenex, it could not be produced.
D. During an interview on 07/11/12 at 0915 with Respiratory Therapist #1, it was verified the facility did not have a process in place to ensure that opened foil packages of Xopenex were used within the manufacturers recommended timeframes.

Based on observation and interview, the facility failed to ensure outdated medications were not available for patient use in three (Surgery Department, Geriatric/Psychiatric Unit, Emergency Department) of four (Surgery Department, Geriatric/Psychiatric Unit, Emergency Department and In-Patient Care Area) areas toured. By not removing medications before they expire, the facility could not assure the safety and efficacy of the product past the expiration date. The failed practice had the potential to affect all of the patients who would have received this medication. Findings follow:

A. A tour of the facility on 07/09/12 between 1330 and 1447 and on 07/10/12 between 0915 and 1100 revealed outdated medications were observed as follows:
1) Surgery Department Medicine Room Refrigerator: 8 Sodium Chloride Inhalation Solution 3 ml expired 05/2012;
2) Geriatric/Psychiatric Unit Respiratory Closet: Sterile Water for Irrigation 1500 ml opened and dated 05/22/12;
3) Emergency Department:
a) 3 bags Lactated Ringers and 5% Dextrose 1000 ml for injection expired 03/2012;
b) 2 bags Dextrose 5% and 0.45% Sodium Chloride 1000 ml for injection expired 04/2012;
c) 1 Lidocaine 2% 20 mg/ml 20 ml vial expired 06/01/2012; and
d) 1 Novolin 70/30 10 ml vial for injection expired 02/2012.
B. Findings were verified through interviews as follows:
1) Surgery Department findings verified by LPN(Liscensed Practical Nurse) Scrub on 07/09/12 at 1400;
2) Geriatric/Psychiatric Unit findings verified by Respiratory Therapist #1 on 07/11/12 at 0930; and
3) Emergency Department findings verified by RN (Registered Nurse) #2 on 07/10/12 at 1045.

Based on review of the Pharmacy Medication Area Inspection Logs, policy and interview, the facility failed to document medication storage area inspections on a monthly basis as required by policy "Medication Management: Storage: Medication Area Inspections." By not documenting inspection of the medication storage areas monthly, the facility could not assure that all floor stocks were properly controlled according to policy. Findings follow:

A. Review of Pharmacy Medication Area Inspection Logs for June 2012-January 2012 revealed the following:
1) June 2012 Log was completed on the computer and printed and was the exact same as January and February of 2012. The remark in the comment field was exactly the same as January and February 2012, and the comment had a mark through it and a new comment hand written.
2) May 2012 Log was completed on the computer and printed, no original writing on it, and was the exact same log as April 2012 and March 2012, same comment on the bottom and same "n's" ("n" =answer is no) in the same 2 boxes. No documentation of corrective action plan for areas that did not pass inspection.
3) April 2012 Log stated it was Inspected By: "(name) on 9-27-11" which was not proof this inspection occurred in April 2012.
4) March 2012 Log stated it was Inspected By: "(name) on 9-27-11" which was not proof this inspection occurred in March 2012.
5) February 2012 Log was completed on the computer and printed, the month "January" was crossed out and "February" was hand written underneath it, was the exact same log as June 2012 and January 2012, it had the same remark in the comment field as June 2012 and January 2012. There was no date on it other than "February 2012".
6) January 2012 Log was completed on the computer and printed, no original writing on it, and there was no date other than "January 2012".
B. Review of policy titled "Medication Management: Storage: Medication Area Inspections" stated "Pharmacy personnel shall conduct monthly inspections of all medication areas..."
C. Findings were verified through interview with Pharmacist #1 on 07/10/12 at 1345.

Based on observation, interview, review of "Weekly Test and Inspection Log" and policy and procedure review, it was determined the facility failed to have a policy and process in place to assure negative pressure was maintained in the AII (Airborne Infection Isolation) room if occupied by a patient for airborne isolation purposes. The facility could not be assured patient and staff would be protected from potential sources of infection without daily visual monitoring to assure negative pressure would be maintained. The failed practice had the potential to affect all patients and staff at the facility. The findings were:

A. On 07/10/12 at 1100, the Infection Control Nurse provided a copy of the "Weekly Test and Inspection" Log for Airborne Isolation Room 215. Review of documentation reflected weekly checks of isolation Room 215, 01/2012 to "week one" of 07/2012 and listed "Negative Pressure Capable." The Infection Control Nurse confirmed on 07/11/12 at 1100 that no additional monitoring was performed if the room was occupied by a patient that required airborne isolation and stated she was not aware of any patient who required airborne infection isolation in the past year.
B. The CDC (Centers for Disease Control and Prevention),"Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, Morbidity and Mortality Weekly Report, Vol 54", page 65-66 stated "Periodic checks are required to maintain the desired negative pressure and the optimal operation of monitoring devices. AII rooms should be checked for negative pressure before occupancy. When occupied by a patient (for airborne isolation), an AII room should be checked daily with smoke tubes or other visual checks for negative pressure. If pressure-sensing devices are used in AII rooms occupied by patients with suspected or confirmed TB (Tuberculosis) disease, negative pressure should be checked daily by using smoke tubes or other visual checks. If the AII rooms are not being used for patients who have suspected or confirmed TB disease, but potentially could be used for such patients, the negative pressure should be checked monthly."
C. In an interview with the Infection Control Nurse on 07/11/12 at 1430, she presented sample training documentation for three employees and stated "that's all I have." The training was titled "Job Breakdown sheet, Setting up negative pressure room." The documentation "important steps, key points, and reasons" of the training did not include a requirement that a visual check of the room for negative airflow was performed. The Infection Control Nurse confirmed at the time of the interview that the facility did not have a policy or process in place to perform daily visual checks to assure negative airflow was maintained when the AII room was occupied by a patent who required airborne isolation.

Based on observation 07/09/12 from 0920-1100 of the Surgery Department, Emergency Department, Acute Unit, and observation of the Radiology Department on 07/10/12 at 1030, it was determined the facility failed to assure equipment was clean, upholstery was intact and bedrail surfaces were not peeling in two ( Room 212 and 205) of eight rooms viewed on the acute unit, one of one (ER #1) treatment room in the Emergency Department, and the Radiology Department. The failed practice had the potential to increase the opportunity for the spread of infectious organisms due to the accumulation of dust, and exposure of porous and irregular surfaces that could not be disinfected. The failed practice had the potential to affect the facility census on 07/09/12 of 6 patients on the acute unit, patients seen in the Emergency Department and Radiology Department. The findings follow:

A. Observation on 07/09/12 revealed the surface was peeled from the side rails of Bed A and B in room 212. Room 205 was identified by LPN (Licensed Practical Nurse) #2 as clean and awaiting an admission. The recliner upholstery was observed with a six inch long by a one-half inch wide split in which the cushion of the upholstery was exposed. The side rail's peeled finish and the cracked upholstery created an irregular surface that could not be disinfected. The findings were confirmed at the time of observation by LPN #2.
B. Observation of Emergency Room #1 on 07/09/12 at 1020 revealed a cart stored inside the door of the room with an accumulation of dust on the surface, along each of the drawers, and along the bottom. RN (Registered Nurse) #2 confirmed the findings and stated "that's were we keep some of our medicine."
C. During a tour of the Radiology Department on 07/10/12 at 1030, a three tiered rolling cart was observed. The middle level of the cart contained opened boxes of non-sterile bandages. The top layer, above the bandages had a thick layer of dust and sand on it along with various maintenance tools. When asked about the cart, the Director of Radiology stated, "That is not our cart, that belongs to the ER (emergency room), they just ran out of storage space down there and are storing it here." During a tour of the X-ray Room, in the bottom of the storage cabinet, four dark colored drops of an unidentified residue were observed. The Director of Radiology stated, "We never use this cabinet." She then asked a nearby employee if they knew what the residue was and she said, "no." Findings were confirmed by the Director of Radiology at the time of the tour.

Based on observation of the clinical record storage area and interview, it was determined the facility failed to assure clinical records were protected from potential fire and water damage when stored out of the Medical Records Department. It could not be assured the clinical records were protected from fire and water damage due to storage conditions with flammable substances and positioned directly on the floor surface of the storage building. The failed practice affected all clinical records stored in the "Brown Building" storage. The findings follow:

A. Observation on 07/12/12 from 1230-1245 with Medical Records Clerk #1 of the "Brown Building" revealed clinical records were stored in cardboard file boxes on wooden shelving. Five cardboard file boxes were stored directly on the concrete floor where water could pool and damage the records. Also stored in the Brown Building, was a riding lawn mower and gas can, hedge cutter, two electric heaters, table saw, ladder, 10 inch miter saw, pressure washer, two brooms, and a weed trimmer. The building did not include a fire extinguisher and the gas can and riding lawn mower contained gasoline, which was flammable.
B. A copy of the off site storage was provided and reviewed on 07/12/12 by Medical Records Clerk #1. Review of the "Brown Building" storage list revealed it included "2000 to 2010 no numbers, 2004 some of the purged boxes, 2008 purge boxes, 2007 to 2008 Senior Care purge, and Multiple Death Chart Boxes."
C. In an interview with Medical Records Clerk #1 at the time of observation , she confirmed the findings and stated "the maintenance staff have a key to the building and they store those things in here." Medical Records Clerk #1 estimated there were "300 or more" cardboard file boxes stored in the building at the time of the tour.

Based on observation of the Surgical Suite, review of policy and procedures, and interview, it was determined the facility failed to assure the disinfectant used to clean Operating Room (O.R.) #2 was used in accordance with product directions for use, in that the disinfectant was not applied to thoroughly wet the surface so that it could remain on the surface for a minimum of 10 minutes; failed to assure the Operating Room was free of dust; failed to have a policy and procedure for fire safety with the use of a skin prep that contained alcohol and failed to maintain airflow and humidity levels as required. The facility could not assure the services offered were performed in a manner that assured the health and safety of the patients. The failed practice affected the 10 average number of surgeries per month, and had the potential to affect any patient who had surgery at the facility. The findings were:

A. On 07/10/12 from 1500 - 1535, LPN (Licensed Practical Nurse) Scrub #1 was observed cleaning OR #2. LPN Scrub #1 retrieved a container and mixed the disinfectant product, "Lem-O-Quat Disinfectant Cleaner Deodorizer." The product was mixed and measured two ounces per one gallon of water. LPN Scrub #1 placed a cleaning cloth in the solution, wiped a metal side table top surface, then down each leg of the table, then returned the cloth to the same disinfectant solution. LPN Scrub #1 retrieved the cloth, then proceeded to clean the side table, and 16 other pieces of equipment in OR#2 in the same manner. The same cleaning solution and cloth were used on each item cleaned, and the disinfectant was not applied to thoroughly wet the surface so that it could remain on the surface for a minimum of 10 minutes; LPN Scrub #1 was asked by Surveyor #1 if the cleaning solution had to remain wet on the equipment for any certain amount of time, she stated "no, I change the cleaning solution and cleaning cloth when I do the OR table and overhead lights."
1) On 07/10/12 at 1550, the manufactures directions for use of the product used for cleaning the OR was requested from the Infection Control Nurse. Review of the product information provided revealed, "Disinfection/Cleaning/Deodorizing Directions: ...thoroughly wet surface with a use-solution of 2 ounces of the concentrate per gallon of water...let solution remain on surface for a minimum of 10 minutes."
2) On 07/11/12 at 1500, the Surgery Supervisor was interviewed regarding results of between case cleaning observation of O.R. #2 that was observed on 07/10/12 by LPN Scrub #1. The facility policy for cleaning the OR between cases was provided by the Surgery Supervisor on 07/11/12 at 1530. The policy provided was, "Surgery Cleaning by Housekeeping" and did not include duties to be performed by LPN Scrub #1. In an interview with the Surgery Supervisor, she stated "Administration changed the procedure and the nurses now clean the OR. The policy has not be updated." Policy #1:07 was provided, "Disinfectant, Antiseptic and Germicide Use" that stated "all disinfectants, antiseptics and germicides will be used in accordance with the manufacturer's directions." The findings were confirmed with the Surgery Manager on 07/11/12 at 1545.
B. Observation of the Surgical Suite on 07/09/12 at 1330 with the Surgery Supervisor, and LPN Scrub #1, the following observations were made:
The Post anesthesia Care Unit, consisted of two stretchers (gurneys) that had an accumulation of dust on the lower surface. The suction unit and two suction cannisters above both stretchers had an accumulation of dust on the surface and the suction tubing had red tinged areas within the tubings. LPN Scrub #1 confirmed the findings at the time of observation and stated she did not know what the red tinged areas within the tubing were. O.R. #2 had an accumulation dust on the Xray viewer. The Endoscopy Room, toured at 1435, had an accumulation of dust over the surfaces of wall suction and equipment in the room. The bottom of the cabinet for the storage of the scopes had a cut out section and was open to the floor below. The floor below the storage cabinet was covered in a black substance. The findings were confirmed by the Surgery Supervisor at the time of observation.
C. On 07/09/12 while on tour, the Surgery Supervisor stated the facility used "DuraPrep", a product, that contained alcohol as a skin prep for general surgical procedures. Review of product label on 07/11/12 revealed "Warning, Flammable. Solution contains alcohol and gives off flammable vapors. Do not drape or use ignition source (i.e. cautery, laser) until solution is completely dry (minimum of 3 minutes on hairless skin; up to 1 hour in hair). Avoid getting solution into hairy areas. Wet hair is flammable. Do not allow solution to pool. Remove all solution stained material." A policy and procedure was requested for use of the skin prep product that contained the alcohol. The Policy and Procedure provided by the Surgery Supervisor on 07/12/12, "Fire and Evacuation Plan" and "Fire Prevention" did not include fire safety measures specific to the use of skin preparation solutions that contained alcohol. The facility policy for "Skin Preparation" was reviewed on 07/09/12 that stated "(item III. A.) Flammable germicides and antiseptics are not used for preoperative skin preparation." The findings were confirmed by interview with the Surgery Supervisor on 07/12/12 at 1115.
D. Based on observation, Surgery Department Daily Temperature/ Humidity Log review, and interview, it was determined one of one actively maintained Operating Room (#2) and the Endoscopy Room contained hazards that had the potential to affect the health and safety of all surgical patients due to the use of portable re-circulating air dehumidification units, improper airflow, and high humidity in the rooms. See C 226.

Based on review of Pharmacy Quality Improvement Studies, review of facility Quality Improvement Plan and interview, the facility failed to develop and assure indicators and activities for pharmacy related patient care and patient safety issues were planned, measured, tracked, analyzed and reported and that modified plans for improvement were reviewed and/or instituted. The failed practice did not assure actions were taken to improve quality and performance in pharmacy related patient care and safety and had the potential to affect all patients receiving pharmacy services in the facility. Findings follow:
A. Review of Pharmacy Quality Improvement Studies dated July 2011, August 2011, September2011, October2011, November 2011, January 2012, February 2012, March 2012, April 2012, and June 2012 revealed they did not have evidence of pharmacy patient care or patient safety issues being planned, measured, tracked, analyzed or reported.
B. Review of the facility Quality Improvement Plan stated "Studies will reflect direct patient care and patient safety issues."
C. Findings were verified through interview with Director of Pharmacy on 07/10/12 at 1345.