HospitalInspections.org

Based on document review and staff interviews, the acute care hospital's administrative staff failed to ensure staff recognized and reported 1 of 1 reviewed incidents of possible dependent pediatric abuse (Patient #1) in a timely manner. Failure to recognize and report incidents of possible dependent abuse in a timely manner may result in hospital allowing staff members to continue to work with patients after the staff member committed possible acts of dependent abuse. The hospital served approximately 16,353 patients (both inpatient and outpatient) per year.

Findings include:

1. Review of the policy "Child/Dependent Adult Abuse," dated 07/2019, revealed in part, "Each of the following classes of persons is required to report suspected or confirmed child abuse: ... Every health practitioner who, in his or her scope of professional practice examines, attends, or treats a child and who reasonably believes the child has been abused ... If you witness a potential abuse situation, our policy includes the following critical steps: ... Immediately report via phone call the suspected abuse to your supervisor, their designee or Patient Care Coordinator (PCC) who will assist you in taking appropriate action. If you are unable to reach one of these individuals, contact the Administrator of the Day (AOD) through the hospital operator."

2. During an interview on 01/06/2020 at 02:51 PM, Child Life Specialist (CLS) R revealed they assisted Patient #1 while RN A inserted a PICC line (where the hospital staff place a long thin tube through a vein in the patient's arm and pass the tube to the larger veins near the heart) in Patient #1 on 12/3/19. Patient #1's mother was also present to comfort Patient #1 during the procedure.

As soon as RN A entered Patient #1's room, RN A began making inappropriate comments. Patient #1 inquired about what RN A was doing, as RN A inserted the PICC line. RN A raised a scalpel close to Patient #1's face and stated that she had just cut Patient #1. Patient #1 became tearful and started yelling "OW," while remaining still. RN A informed Patient #1 that if Patient #1 did not stop yelling, RN A would become nervous and RN A would start shaking. RN A then raised their hands and demonstrated their hands shaking. CLS R informed RN A that their actions were causing Patient #1 to become anxious. RN A replied that Patient #1 should be scared.

CLS R was afraid to say anything else to RN A, out of fear that RN A might harm Patient #1 if CLS R said anything further. After the procedure, CLS R informed RN B (Patient #1's assigned nurse) and Hospitalist E (the physician in charge of Patient #1's care) about CLS R's concerns regarding RN A's behavior towards Patient #1. CLS R also contacted their manager, who instructed CLS R to file an incident report.


3. During an interview on 01/06/2020 at 03:33 PM, Patient #1's Mother discussed what happened when RN A inserted a PICC line into Patient #1's arm on 12/3/19.
RN A entered the room to explain the procedure to Patient #1 and Patient #1's Mother. Initially, RN A spoke in an appropriate tone of voice and had an appropriate demeanor. RN A soon began using a louder tone of voice and continued speaking in a loud and abrupt tone through the PICC line insertion. RN A showed the needle RN A would use during the procedure to Patient #1 (which frightened Patient #1), after Patient #1 inquired what RN A was doing. RN A then placed the scalpel very close to Patient #1's face, while wearing bloody gloves. RN A told Patient #1 that RN A had just cut Patient #1. Patient #1 then began screaming and yelling. RN A waved their bloody gloves in the air in front of Patient #1's face, and told Patient #1 to stop screaming, or RN A would start shaking and Patient #1 did not want RN A to have shaking hands. Patient #1's mother was concerned for Patient #1's safety, and was afraid if she intervened with RN A, the hospital may not have another nurse who could perform the PICC line insertion. Patient #1's mother was afraid if she voiced any concerns about RN A's behavior, then RN A would hurt Patient #1.


4. During an interview on 01/07/2020 at 03:34 PM, the Radiology Manager revealed that on Monday 12/2/19, they received an incident report from CLS R regarding an event which occurred on 12/1/19, involving RN A and Patient #1 (1 day after the incident occurred). When the Radiology Manager received the report, they contacted the Human Resources Department. The Human Resources staff instructed the Radiology Manager to investigate the incident before reporting the incident to the Department of Inspections & Appeals (DIA) and Department of Human Services (DHS), since RN A was not scheduled to work until the following weekend. The Radiology Manager acknowledged CLS R failed to follow the hospital's policy, which required CLS R to inform the hospital's administration immediately, instead of only filing an incident report. The Radiology Manager reported the incident to the DIA and the DHS on 12/6/19, and reported the incident to the Iowa Board of Nursing on 12/10/19.


5. During an interview on 01/08/2020 at 12:19 PM, the Assistant Vice President (AVP) of Nursing revealed they learned of the incident on 12/1/19 between RN A and Patient #1 on 12/5/19 (4 days after the incident occurred), after the Radiology Manager emailed the AVP of Nursing. The AVP of Nursing realized the incident involved a potential allegation of abuse, and instructed the Radiology Manager to report the incident to the DIA and the DHS (4 days after the incident occurred). The AVP of Nursing acknowledged the hospital staff failed to report the incident to the DIA and DHS until 4 days after the incident occurred.

I. Based on observation, document review, and staff interviews, the Hospital surgical staff and Maternity Services staff failed to ensure surgical staff and Maternity services staff sanitized their hands before donning gloves for aseptic tasks and after glove use during 1 of 1 observed surgical procedures (Patient #2) and 1 of 1 Cesarean section (C-section). Failure to ensure surgical staff and maternity services staff followed approved infection control standards of practice in accordance with the hospital-wide Hand Hygiene policy could potentially result in the surgical staff and maternity services staff failing to remove bacteria which contaminated their hands during a procedure and potentially transmit the bacteria to another patient, potentially causing a life-threatening infection. The Hospital's administrative staff identified the surgical staff perform approximately 1,050 surgical procedures per month and approximately 108 C-sections per month..

Findings include:

1. Review of the "Hand Hygiene" policy, reviewed 07/2018, revealed in part: "Hand hygiene is absolutely essential for the prevention and control of infections. It is the single most important thing that can be done to prevent the spread of infections. 'Hand hygiene' is a general term that applies to handwashing, antiseptic hand wash, or antiseptic hand rub, (alcohol based hand rub)." The policy also revealed in part ... "Procedure: When hands are visibly dirty, soiled or contaminated with blood or other body fluids, wash hands with either plain soap and water or an antimicrobial soap and water. If hands are not visibly soiled, it is preferable to use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations ... before and after having direct contact with patients, before donning gloves (sterile or other) when inserting invasive devices that do not require a surgical procedure (i.e. peripheral IV insertion/inserting Foley catheters), ... after removing gloves ..."

2. Observations on 01/06/2020, beginning at 1:58 PM during Patient #2's surgical procedure, Dilation & Curettage (D&C) with partial Polypectomy (a procedure to remove tissue from inside the uterus), revealed the following:

--2:08 PM Registered Nurse (RN) C removed their non-sterile gloves, failed to perform hand hygiene and proceeded to leave the room.

--2:27 PM RN C failed to perform hand hygiene prior to donning sterile gloves prior to performing the vaginal prep on Patient #2.

--2:30 PM RN C removed their sterile gloves and failed to perform hand hygiene. RN D removed their non-sterile gloves and failed to perform hand hygiene before getting the doctor's stool and assisting with draping the patient.

--2:40 PM RN C removed their non-sterile gloves, proceeded to leave the room, returned, and then opened sterile items to the sterile field before hand hygiene completed.

--2:50 PM RN C removed their non-sterile gloves and failed to perform hand hygiene.


3. During an interview on 01/07/2020 at 10:10 AM, Executive Director of Surgical Services stated " Hand hygiene is an ongoing issue. The hand rub is not always conveniently located for ease of use." The Director of Surgical Services acknowledged they exptected the surgical services staff to perform hand hygiene according to the hospital's Hand Hygiene policy.


4. Observations on 01/07/2020, beginning at 7:25 AM during Patient #3's surgical procedure, Cesarean section (use of surgery to deliver babies), revealed the following:

--7:26 AM Anesthesiologist F failed to perform hand hygiene prior donning sterile gloves to administer a spinal block (a form of regional anesthesia that delivers medicine through shots in or around the spine to numb parts of the body) to Patient #3.

--7:30 AM Anesthesiologist F removed their sterile gloves and failed to perform hand hygiene before proceeding to apply monitor pads to Patient #3.

--7:31 AM RN G failed to perform hand hygiene prior to donning sterile gloves and placing a Foley catheter in Patient #3.

--7:32 AM RN G failed to perform hand hygiene prior to donning sterile gloves before performing the abdominal prep on Patient # 3.

--7:35 AM RN G removed their sterile gloves and failed to perform hand hygiene.

--7:41 AM RN G proceeded to open sterile item to sterile field.

--7:50 AM RN G failed to perform hand hygiene prior to donning sterile gloves while preparing specimens of cord blood and placenta to be delivered to the lab for examination.

--7:54 AM RN G removed their sterile gloves and failed to perform hand hygiene before leaving the C-section room.

--7:55 AM RN H removed their non-sterile gloves and failed to perform hand hygiene before proceeding to work at the computer.

--7:56 AM RN I removed their non-sterile gloves and failed to perform hand hygiene before working with the paperwork for the baby.

--7:58 AM RN H removed their non-sterile gloves and failed to perform hand hygiene.

--8:01 AM RN H removed their non-sterile gloves, failed to perform hand hygiene, and opened sterile packages to the sterile field.

--8:03 AM RN H removed their non-sterile gloves and failed to perform hand hygiene. RN J removed their sterile gloves and failed to perform hand hygiene before donning non-sterile gloves.

--8:04 AM RN H removed their non-sterile gloves and failed to perform hand hygiene.

--8:08 AM RN H removed their non-sterile gloves and failed to perform hand hygiene.

--8:13 AM RN H removed their non-sterile gloves, failed to perform hand hygiene, and opened sterile packages to the sterile field.

--8:15 AM RN H removed their non-sterile gloves and failed to perform hand hygiene.

--8:19 AM RN H removed their non-sterile gloves and failed to perform hand hygiene.

--8:22 AM Surgeon K removed their sterile gloves and failed to perform hand hygiene before leaving the C-section room.

--8:23 AM Medical Student L removed their sterile gloves and failed to perform hand hygiene before leaving the C-section room.

--8:25 AM Certified Surgical Technician M removed their sterile gloves and failed to perform hand hygiene.

--8:35 AM Licensed Practical Nurse N, before removal of sterile gloves, proceeded to the decontamination room (an area separate from patient care where dirty equipment are kept) with the C-section instruments, removed their sterile gloves and failed to perform hand hygiene before leaving the decontamination room.


5. During an interview on 01/07/2020 at 1:30 PM, Nurse Manager Maternity Services, Labor and Delivery Supervisor, and Mom/Baby Supervisor agreed the Maternity services staff are expected to perform hand hygiene according to the hospital Hand Hygiene policy.

6. During an interview on 01/07/2020 at 10:40 AM, Infection Preventionist O, Infection Preventionist P, and Infection Preventionist Q discussed the hospital-wide Hand Hygiene policy. They noted that the maternity services hand hygiene was recently identified as a problem but had not yet implemented a plan to correct the noted problems with Hand Hygeine. They agreed the surgical staff and maternity services staff are expected to perform hand hygiene according to the hospital Hand Hygiene policy.




II. Based on document review, observation, and staff interview, the Hospital failed to ensure 1 of 1 observed Anesthesiologist (Anesthesiologist F) cleansed the medication vial rubber seals on 3 of 3 vials and the IV tubing hub site during 3 of 3 medication administrations of 1 of 1 observed Cesarean section (C-section) procedures (Patient #3). Failure to cleanse the medication vial rubber seals and the IV tubing hub site could potentially result in the Anesthesiologist F introducing bacteria, viruses, or fungi into the medication vials and the IV tubing, which could potentially result in the patient developing a life threatening infection. The Hospital's administrative staff identified Maternity services staff perform approximately 108 C-sections per month.

Findings include:

1. Observations on 01/07/2020 starting at 7:25 AM, during Patient #3's C-section revealed Anesthesiologist F failed to cleanse the medication rubber seal with an alcohol swab prior to drawing up medications from 3 different medication vials. Anesthesiologist F failed to cleanse the IV tubing hub site with an alcohol swab prior to administration of 3 medications.

2. Review of the "Skills, Medication Administration : Injection Preparation from Ampules and Vials" policy, published 03/2019, provided by the Pharmacy Operations Manager revealed in part ... "Firmly and briskly wipe the surface of the rubber seal (of the medication vial) with an alcohol swab, being sure to apply friction, and allow the alcohol to dry....".

3. Review of the "Mosby Nursing Skill Addendum, Scrub the Hub" policy, reviewed 03/2018, revealed in part, "...every time a peripheral IV (intravenous), PICC line and central venous catheter ( forms of intravenous access used for prolonged administration of medication), or infusaport (a small device used to deliver medications directly into a patient's bloodstream) is accessed scrubbing the hub promotes patient safety by preventing infection and reducing hospital cost....all staff accessing...the hubs...will vigorously scrub the hub with a Chlorhexidine (a disinfectant)/Isopropyl alcohol swab pad....for 15-30 seconds. Friction is the key to effective bacterial removal...".

4. 5. During an interview on 01/07/2020 at 1:30 PM, Nurse Manager Maternity Services, Labor and Delivery Supervisor, and Mom/Baby Supervisor agreed the Maternity services staff and anesthesia providers are expected to use Chlorhexidine/Isopropyl alcohol swab pads prior to draw up of medications from a vial and administration of medication is expected.