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Based on hospital policy reviews, observations during tours, record reviews, staff interviews and as referenced in the Life Safety Report of Survey completed 07/20/2011, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The hospital failed to ensure the emergency patient care equipment was in safe operating condition as evidenced by failing to check the defibrillator on the crash cart in the Magnetic Resonance Imaging (MRI) unit; and failed to test the hospital sprinkler system in accordance with NFPA 25 - Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems (1999 edition).

~Cross refer to 485.623(b)(1) - Maintenance - Standard Tag C0222.

2. The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~Cross refer to 485.623(d)(1)&(3) - Life Safety From Fire - Standard Tag C0231.

Based on hospital policy reviews, observations during tours, record reviews, staff interviews, and as referenced in the Life Safety Report of Survey completed 07/20/2011, the hospital failed to ensure the emergency patient care equipment was in safe operating condition as evidenced by failing to check the defibrillator on the crash cart in the Magnetic Resonance Imaging (MRI) unit; and failed to test the hospital sprinkler system in accordance with NFPA 25 - Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems (1999 edition).

The findings include:

1. Review of the hospital's policy, "Equipment Checks", revised 01/2011, revealed, "Purpose: To make sure that equipment is in working order...and that emergency carts are always ready for use. ...Policy: Nursing staff assigned to a certain nursing unit are assigned certain items of equipment to check. The Charge Nurse is responsible for making sure these duties are completed. Documentation of checks are on clipboards next to equipment. Equipment check QA results are published for staff quarterly. Frequency of Equipment Checks: ...MRI Area: 1. Crash Cart: Checked every day (when MRI is open) by Radiology Manager or his/her designee. ...".

Observation during tour of the MRI unit on 07/21/2011 at 1030 revealed the MRI unit is across the parking lot from the Main Hospital. Observation of the area revealed a crash cart (emergency cart) with a defibrillator on top of the cart. Observation revealed no clipboard next to the equipment. Observation revealed no documentation that the defibrillator had been checked for working order.

Interview on 07/21/2011 at 1145 with administrative nursing staff revealed, "the defibrillator on the crash cart in the MRI has not been checked in over a year. My assistant left last year and that was his responsibility. I just forgot about it."



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Building 01:
2. Based on record review and staff interview, the facility sprinkler system was not being tested in accordance with NFPA 25 - Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems (1999 edition), specific findings include;

A. Documentation indicated failure to demonstrate inspection, testing and maintenance in accordance with NFPA 25 1-4.2.

B. Annual sprinkler system certification noted "Tamper 21 in basement did not work". The item had not been corrected at the time of the survey.

~ Cross refer to NFPA 101 Life Safety Code Standard - K062.

Based on observations as referenced in the Life Safety Report of Survey completed July 20, 2011, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

Building 01:
1. By observation on 07/20/11 at approximately noon the following exit access was non-compliant, specific findings include courtyard between the hospital and the long term care facility had lockable passage hardware.

~ Cross refer to NFPA 101 Life Safety Code Standard - K038.

2. By observation on 07/20/11 at approximately noon the following fire alarm system requirement was non-compliant, specific findings include, "ER/OR/LAB Chimes" was in a trouble condition after the fire alarm system was tested. The trouble reset itself after a period of approximately 10 minutes. This bypass switch was not touched during the testing of the fire alarm system and should not have been in a trouble condition during the survey.

~ Cross refer to NFPA 101 Life Safety Code Standard - K052.

3. By observation on 07/20/11 at approximately noon the facility's cooking system was not protected in accordance with NFPA 96 - Ventilation Control and Fire Protection of Commercial Cooking Operations. Specific findings include; the deep fryer was located next to a prep serving area without the required splash guard in the dietary kitchen.

~ Cross refer to NFPA 101 Life Safety Code Standard - K069.

4. By observation on 07/20/11 at approximately noon the following medical gas storage was non-compliant, specific findings include, the nitrous oxide and oxygen e-tanks in gas storage was gang chained together. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)]

~ Cross refer to NFPA 101 Life Safety Code Standard - K076.

Based on hospital policy review, "Clinical Nursing Skills" textbook review, manufacturer's recommendation for the use of a cleaning solution, observations during tour, and staff interviews, the nursing staff failed to disinfect the injection port of the primary intravenous (IV) solution tubing before connecting a secondary ("piggyback") IV medication bag's tubing to prevent cross-contamination for 1 of 1 secondary IV medication administration observed and failed to ensure a sanitary environment for the provision of surgical services by failing to ensure surgical equipment was disinfected according to manufacturer's recommendations.

The findings include:

1. Review of current hospital policy NUR 033 "Intravenous Therapy," reviewed/revised January 2011, revealed "Purpose: To provide safe and consistent standards for IV therapy..." Further review revealed "...Procedure: Refer to 'Clinical Nursing Skills' text at nurses' station. ..."

Review of a "Clinical Nursing Skills Basic to Advanced Skills Sixth Edition" textbook provided by nursing management staff revealed in "Chapter 28 Intravenous Therapy" on page 1027, the subtitle "Using A Secondary ('Piggyback') bag." Further review revealed "...Procedure....3. Cleanse injection port of primary tubing with antimicrobial swab. 4. Insert needleless cannula of secondary 'piggyback' tubing into primary tubing port..."

Observation on 07/19/2011 at 1543 during tour of the medical-surgical unit revealed during a medication administration pass for the patient in room 210, the registered nurse (RN) connected a secondary medication (Flagyl) bag's IV tubing to the injection port of the primary IV solution's (Potassium Chloride in 5% Dextrose) tubing and initiated the infusion via pump. Observation revealed the RN failed to disinfect the injection port of the primary IV solution's tubing with an approved antimicrobial/disinfectant swab prior to connecting the secondary medication bag's IV tubing to the injection port. Interview during the observation with the RN revealed "I usually wipe in between." Interview revealed "I did not have an alcohol wipe in my pocket at the time." Further interview revealed "I should have used alcohol and wiped the port."

Interview on 07/21/2011 at 0955 with nursing management staff revealed the hospital has adopted the "Clinical Nursing Skills" textbook as guidelines for nursing procedures. Interview revealed when connecting a secondary "piggyback" medication bag's tubing to a primary IV solution's tubing the nursing staff should clean and disinfect the injection port of the primary tubing with an alcohol wipe before connecting the secondary tubing. Interview revealed not cleaning the port would be an infection control concern. Interview confirmed the nurse failed to follow hospital policy and procedure.



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2. Review of the hospital's "High Level Disinfection of Endoscopes" policy revised December 2010 revealed "... High Level Disinfection: ... After meticulous cleaning, high level disinfection is achievable with a 20-minute soak at room temperature using a 2% glutaraldehyde solution that tests above its minimum effective concentration. Follow manufacturer's recommendations to achieve high level disinfection .... Prepare the germicide according to manufacturer's labeling instructions. Test the germicide for the MEC (minimum effective concentration) on each day of use and more frequently as dictated by the number of endoscopes being reprocessed. Use the test strip specific for the brand of germicide. Keep a log of the test results. The MEC may not be used to extend the use-life claim of the germicide."

Review of the manufacturer's instructions for the high-level disinfectant "Aldahol" Solution (a glutaraldehyde solution used to disinfect surgical instruments) revealed "Aldahol High Level Disinfectant is indicated for the high level disinfection or sterilization of heat-sensitive medical equipment that contacts mucous membranes when used and re-used for 14 days or until the glutaraldehyde concentration decreased to 2.1%, whichever comes first."

Observation during tour of the central sterile processing room on 07/21/2011 at 1225 revealed an "Olympus" reprocessor (machine used to provide high level disinfectant for endoscopes) that was in use. Interview with a Registered Nurse (RN) that processed the endoscopes revealed "Aldahol" was the high level disinfectant solution that was used in the Olympus reprocessor to disinfect the endoscopes. Observation of the Olympus reprocessor machine revealed a flashing light. The RN stated the flashing light meant that the Aldahol solution needed to be changed. The staff member stated "It just started flashing today. I was just getting ready to change the solution." Review during tour of the "Endoscope Reprocessor OER-Pro Inspection Checklist" revealed the Aldahol solution was last changed on 07/05/2011 (16 days prior). Review during tour of the "Disinfectant Efficacy Monitoring Log" dated 07/21/2011 revealed Scope #5191, #3620 and #5206 were circled and had corresponding patient numbers written by each scope number. Review of the log had a place to document the strength testing of the Aldahol solution as "pass" or "fail" beside each scope number. Review of the log revealed no documentation of pass or fail beside Scope #5191, #3620 and #5206 that were reprocessed on 07/21/2011.
Interview with the RN revealed the nurse that had disinfected the scopes failed to document the efficacy testing of the high level disinfectant Aldahol solution. Interview revealed the testing should be documented with each scope processed. Further interview revealed the Aldahol solution was changed whenever the Olympus reprocessor indicator began flashing. Interview confirmed the Aldahol solution was last changed on 07/05/2011 (16 days prior).

Interview with administrative surgical staff on 07/21/2011 at 1330 revealed the Aldahol solution is used for high level disinfectant of surgical instruments. The interview revealed that the manufacturer's recommendation regarding the use of Aldahol as a high level disinfectant required changing the solution every 14 days. Interview revealed the staff were changing the Aldahol solution when the indicator light on the Olympus reprocessor started flashing. Interview confirmed that the Aldahol solution should be changed every 14 days and was not done. Interview further revealed that the Aldahol solution should be tested with each scope reprocessed for efficacy. Interview confirmed there was no documentation of the Aldahol efficacy testing on 07/21/2001. Interview confirmed endoscopes were not disinfected according to manufacturer's recommendations.

Based on policy reviews, observations during tour, and staff interviews, the hospital's dietary staff failed to ensure foods were stored, prepared, and served in accordance with safe and sanitary practices; and cookware and dishware were cleaned and stored in a sanitary manner.

The findings include:

Observation during tour on 07/21/2011 from 1100 to 1200, of the main kitchen revealed:

In freezer storage areas:
1. Observation at 1100 of the inside of the walk-in freezer unit, revealed ice build-up on the upper 1/4 of the wall of the freezer unit where the cooling unit is mounted. Further observation revealed a two-plug electrical outlet adjacent to the cooling unit. Further observation revealed an electrical cord from the cooling unit was plugged into one of ports of the electrical outlet. Further observation revealed the electrical outlet was partially covered with a thick layer of ice. Interview with dietary management staff during tour revealed ice should not be built-up on the electrical outlet. Interview revealed the freezer is cleaned on a routine schedule. Interview revealed the ice built-up was most likely caused by condensation and the recent high temperatures outside.

In the Dry Storage area:
2. Observation at 1110 in the dry storage room, revealed two large covered bins containing brown and white rice being stored. Further observation revealed one scoop being stored inside each bin. Observation revealed the scoops were laying flat on top of the rice. Observation revealed each scoop handle was in contact with rice. Interview with dietary management staff during tour revealed, the two bins used to store rice are the only bins where the scoops are stored inside the bins. Interview revealed the scoops used for the sugar and flour bins are stored outside of the bins. Interview revealed the hospital does not have a policy for dry storage bin scoops.

In the Food Preparation area:
3. Review of current hospital policy DI-B02 "Dress Code" reviewed 04/2011 revealed "...8. Hair net or cap to cover hair. Long hair must also be pulled back and restrained in some fashion. No hair should be laying on then neck or shoulders without restraint. ..."

Observation at 1121 revealed a female dietary staff member carving cooked chicken with a knife at a counter. Observation revealed the dietary staff member had long hair. Observation revealed the staff member's hair was tied up in "a bun." Observation revealed a hair net covered the "bun" only. Observation revealed the hair net did not cover the dietary staff members hair completely. Interview during tour with dietary management staff revealed the dietary staff member's hair should be completely covered.

4. Review of current hospital policy DI-C09 "Sanitizing, Dishes and Flatware" reviewed 04/2011 revealed "...6. All items are to be air dried. ..."

Observation at 1130 of two clean dry storage racks revealed metal pans and serving pitchers being stored. Further observation revealed visible clear liquid on the outer and inner surfaces of greater than 6 items being stored on the dry storage racks. Interview with dietary management staff during tour revealed the metal pans and serving pitchers on the dry storage racks were considered clean and ready for use. Interview revealed the dietary staff are to inspect the items after being washed, make sure they are clean and air dried before stacking and storing the items on the clean storage racks. Interview confirmed the presence of visible clear liquids on outer and inner surfaces of the metal pans and serving pitchers.

At the patient tray line:
5. Observation at 1145 of the patient tray line (located in the SNF) revealed individual servings of three-bean salad (cold food) being stored in a metal container on top of ice. Observation revealed the temperature of a sampled serving of the three-bean salad was 55 degrees (F) Fahrenheit (cold foods should be maintained at 41 degrees F. or below when served from tray line). Interview with dietary management staff during tour revealed the three-bean salad was available for patient consumption. Interview revealed the temperature of the three-bean salad "should not be that high." Interview confirmed the temperature of the three-bean salad was 55 degrees Fahrenheit (elevated temperature).

Based on review of hospital policies and procedures, manufacturer's guidelines, medical record review and staff interview, the hospital's nursing staff failed to administer medication as ordered for 1 of 13 inpatient records reviewed (#13) and failed to document injection sites for 2 of 13 inpatient records reviewed (#19 and #8).

The findings include:

1. Review of the "Medication Administration Policy" revised January 2011 revealed "Medication are administered by RNs (Registered Nurses) and LPNs (Licensed Practical Nurses) in conjunction with a valid physician's order which has been verified by the nurse.... Medication orders are implemented as per scheduled dosing times in order to maintain consistency in setting medication dosing schedules and to avoid food and drug interactions.... Scheduled medications are given within one hour before or one hour after the medication time...."

Closed medical record review on 07/20/2011 for Patient #13 revealed a 98 year-old female admitted 07/12/2011 with a left hip fracture. Review of the record revealed the patient had an open reduction internal fixation (ORIF) surgical repair completed on 07/13/2011. Review of physician's orders dated 07/12/2011 at 1202 for Lovenox (blood thinner) 30 milligrams (mg) subcutaneous (SQ) daily. Review of the patient's medication administration record (MAR) revealed no documentation that the Lovenox was administered.

Interview on 07/20/2011 at 1150 with a nursing administrative staff member revealed the Lovenox should have been given on 07/12/2011. Interview confirmed the Lovenox was not given as ordered. Interview revealed a medication error report would be initiated and an investigation conducted to determine why the Lovenox was not given.

Interview on 07/21/2011 at 1530 with a pharmacist revealed the Lovenox order was received by pharmacy and placed on the MAR for administration at 1300 on 07/12/2011. Interview revealed the Lovenox was delivered to the nursing unit at 1305 and should have been administered. Interview revealed the medication was ordered to prevent the formation of blood clots after the hip surgery and should have been given on 07/12/2011. Interview confirmed the Lovenox was not given as ordered.



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2. Review of the manufacturer's guidelines for Lovenox (blood thinner) provided by hospital staff revealed, "...2.4 Administration...Administration should be alternated between the left and right anterolateral and left and right posterolateral abdominal wall. ...".

Open record review for Patient #8 revealed a 96 year-old female admitted 07/18/2011 with chronic obstructive pulmonary disease. Record review revealed a physician's order dated 07/18/2011 at 1720 for Lovenox 30 mg (milligrams) SQ (subcutaneously) daily. Review of the patient's medication administration record (MAR) revealed Lovenox 30 mg SQ was administered 07/18/2011 at 1822. Review of the patient's MAR and the nurse's progress notes revealed no documentation of the site of the Lovenox injection.

Interview on 07/21/2011 at 1505 with administrative nursing staff revealed the nurse should be documenting the site of all injections. Interview revealed the hospital does not have a policy regarding documentation of injection sites. Interview confirmed the nurse did not document the injection site for Lovenox 30 mg SQ for Patient #8 on 07/18/2011 at 1822.

3. Closed medical record review on 07/20/2011 for Patient #19 revealed a 54 year-old female admitted on 06/10/2011 with diabetes and gangrene of the left foot. Review of physician's orders revealed an order dated 06/09/2011 at 1134 for NPH Insulin 12 units after breakfast and lunch and 8 units after dinner. Further review of the orders revealed "Use low type sliding scale." Review of the patient's medication administration record (MAR) revealed NPH Insulin was administered on 06/09/2011 at 1316, 1820, on 06/10/2011 at 0940 and 1240. Review of the MAR revealed 4 units Regular Insulin was administered on 06/09/2011 at 1711 and 6 units Regular Insulin was administered on 06/10/2011 at 1240.
Review of the patient's MAR and the nurse's progress notes revealed no documentation of the sites of the Insulin injections.

Interview on 07/21/2011 at 1520 with a nursing administrative staff member revealed the nurse should be documenting the site of all injections. Interview revealed the hospital does not have a policy regarding documentation of injection sites. Interview confirmed nursing staff failed to document the injection sites for Insulin for Patient #19.

Based on review of hospital policies and procedures, manufacturer's guidelines, medical record review and staff interview, the hospital's nursing staff failed to document injection sites for 1 of 5 swing bed medical records reviewed (#4).

The findings include:

1. Review of the manufacturer's guidelines for Lovenox (blood thinner) provided by hospital staff revealed, "...2.4 Administration...Administration should be alternated between the left and right anterolateral and left and right posterolateral abdominal wall. ...".

Open record review for Patient #4 revealed a 98 year-old female admitted 07/15/2011 with a fractured left hip, status post open reduction and internal fixation. Record review revealed a physician's order dated 07/15/2011 at 0928 for Lovenox 30 mg (milligrams) SQ (subcutaneously) daily. Review of the patient's medication administration record (MAR) revealed Lovenox 30 mg SQ was administered 07/15/2011 at 1109, 07/16/2011 at 0952, 07/17/2011 at 1059, 07/18/2011 at 1108 and 07/19/2011 at 1034. Review of the patient's MAR and the nurse's progress notes revealed no documentation of the site of the Lovenox injection.

Interview on 07/19/2011 at 1300 with a staff registered nurse revealed, "we don't document injection sites although it is important to know where it was given before". Interview revealed the hospital does not have a policy regarding documentation of injection sites. Interview confirmed the nurse did not document the injection site for Lovenox 30 mg SQ for Patient #4 on 07/15/2011 at 1109, 07/16/2011 at 0952, 07/17/2011 at 1059, 07/18/2011 at 1108 and 07/19/2011 at 1034.