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Based on observation and interview, it was determined the facility failed to develop a policy and procedure regarding the use of a camera that protected the personal privacy of surgical patients. The failure had the potential for unauthorized staff to have access to pictures of patients. The failed practice had the likelihood to affect any surgical patient. Findings follow:

A. Observation at 3:45 PM on 08/26/19 showed a camera located in the Surgical Suite Medication Room. Registered Nurse (RN) #1 was asked during an interview at 3:45 PM on 08/26/19, what the camera was used for. RN #1 stated that if a surgeon wanted a surgical specimen or other body part pictured, the staff would get the camera, take the picture(s), print the picture out, and attach to the patient's clinical record. RN #1 stated the pictures were supposed to be deleted off of the camera at that point.
B. Review of the camera showed numerous pictures of body parts (legs, arms, heads and faces) along with pictures of a doorknob, cabinets, and pictures of pictures of staff members and some family members . RN #1 stated that the camera was utilized for other things besides specimen or pathological pictures.
C. RN #1 stated during an interview at 3:47 PM on 08/26/19 that the facility did not have a policy and procedure that outlined access, use, picture retention, and security of the camera.
D. The Director of Surgical Services stated in an interview at 11:23 AM on 08/27/19 that the facility did not have a policy and procedure that outlined access, use, picture retention, and security of the camera.

Based on review of General Surgery Delineation of Privileges Requirements, review of Surgeons' Credential Files and interview, it was determined the facility failed to assure one (#4) of four (#1-#4) Surgeons was Board Certified and was still granted Category 4 Advanced Surgical Procedure Privileges. By allowing a surgeon that was not Board Certified to be privileged in Advanced Surgical Procedures, the facility could not assure the patients procedure would be done by a qualified surgeon and therefore put the patients at risk. The failed practice had the likelihood to affect all patients that had procedures at the facility by this surgeon. Findings follow:

A. Record review of General Surgery Delineation of Privileges Requirements showed to be eligible for Category 4 privileges, the Surgeon must be Board Certified.
B. Review of Surgeon #4's credential file showed his Board Certification expired 12/31/17. Review of the Surgeon's privileges that were granted and approved on 04/01/18 showed the surgeon was granted Category 4 privileges without current Board Certification.
C. During an interview on 08/28/19 at 3:10 PM, the Manager of Medical Staff Credential files verified the findings at A and B.

Based on clinical record review, and interview, it was determined the facility failed to ensure a Registered Nurse assessed and managed the care of five of five (#22-26) Behavioral Health Patients in that there was no evidence weekly weights were performed per Unit established practice and of the amount of supplements consumed. Failure to weigh and document a weekly weight and document the amount of supplements consumed did not give the treating physician access to information to make informed decisions regarding the patient's care and treatment. The failed practice had the likelihood to affect Patient #22-26. Findings follow:

A. The Nurse Manager of Behavioral Health and Intensive Care Unit (ICU) stated during an interview at 1:47 PM on 08/29/19, that all Behavioral Health patients were to be weighed every Wednesday.
B. Review of Patient #22's clinical record showed orders dated 08/23/19 for Ensure Enlive TID (three times a day). Review of the clinical record showed no evidence the amount of supplement consumed was recorded for five of five (08/24-28/19) days or a weight was recorded for one of one (08/28/19) day. The Nurse Manager of Behavior Health and ICU verified the findings during an interview at 1:44 PM on 08/29/19.
C. Review of Patient #23's clinical record showed orders dated 08/23/19 for a House Shake once a day. Review of the clinical record showed no evidence the amount of supplement consumed was recorded five of five (08/24-28/19) days or a weight was recorded on one of one (08/28/19) day. The Nurse Manager of Behavior Health and ICU verified the findings during an interview at 2:35 PM on 08/29/19.
D. Review of Patient #24's clinical record showed no evidence Patient #24 was weighed on two of two (08/21/19 and 08/28/19) days. The Nurse Manager of Behavior Health and ICU verified the findings during an interview at 3:07 PM on 08/29/19.
E. Review of Patient #25's clinical record showed orders dated 08/21/19 for a Mighty Shake with meals. Review of the clinical record showed no evidence the amount of supplement consumed was recorded for seven of seven (08/22-28/19) days or a weight was recorded for two of two days (08/21/19 and 08/28/19). The Nurse Manager of Behavior Health and ICU verified the findings during an interview at 3:33 PM on 08/29/19.
F. Review of Patient #26's clinical record showed orders dated 08/22/29 for Ensure Enlive TID. Review of the clinical record showed no evidence the amount of supplement was recorded TID for seven of seven (08/23-28/19) days or a weight was recorded on one of one (08/28/19) day.

Based on policy and procedure review, clinical record review, and interview, it was determined the facility failed to ensure pain medication was administered at the lowest ordered dose for two of two (#27 and #28) patients reviewed. Failure to start with the lowest dose did not allow the patient the opportunity for pain control with the lowest dose possible, had the potential for the patient to build a tolerance, and had the potential for overmedication. The failed practice had the likelihood to affect Patient #27 and #28. Findings follow:

A. Review of the policy and procedure titled "Ordering Medications and Biologicals," received from Pharmacist #1 at 4:23 PM on 08/29/19, showed if a range order provided for multiple doses/and or multiple frequencies within a single order, the range order should be administered starting with the lowest dose at the least frequent interval and titrated to response.
B. Review of Patient #27's clinical record showed an order dated 08/28/19 for Tramadol 50 mg (milligram) to 100 mg every 4-6 hours as needed for pain. Review of the Medication Administration Record (MAR) showed Patient #27 was given 100 mg at 5:06 AM on 08/29/19 for a pain score of 9 and at 12:52 PM on 08/29/19 was given 100 mg for a pain score of 7. The above findings were verified during an interview with the Nurse Manager of Behavior Health and Intensive Care Unit (ICU) at 4:07 PM on 08/29/19.
C. Review of Patient #28's clinical record showed an order dated 08/27/19 for Tramadol 50 to 100 mg every four hours as needed for pain. Review of the MAR showed Patient #28 was given 100 mg at 5:32 PM on 08/27/19 for a pain score of 5, 100 mg at 2:13 AM on 08/28/19 for a pain score of 7, 100 mg at 11:51 AM on 08/28/19 for a pain score of 5, 100 mg at 6:17 PM on 08/28/19 for a pain score of 5, and 100 mg at 2:30 PM on 08/29/19 for a pain score of 10. The above findings were verified during an interview with the Nurse Manager of Behavioral Health and ICU at 4:29 PM on 08/29/19.

Based on review of policy, review of a list of medication errors, review of clinical records and interview, it was determined the facility failed to maintain accurate records in that one (#2) of two (#1 and #2) clinical rocords with incidents of a wrong person medication error were not documented in the clinical record of the patient that received the medication in error. By not documenting the medication errors, the facility was not keeping an accurate record of the patient's course of treatment and care. The failed practice had the potential to affect all patients that are treated at the facility. Findings follow:

A. Record review of the facility's policy titled, "Medication Error Reporting," dated 03/10/10, showed the nurse was to notify the physician and enter the medication, as administered, in the medical record.
B. Review of medication errors for wrong person medication errors showed Incident #2 received a medication that was intended for another patient.
C. Review of clinical record showed there was no documentation of what medication the patient received in error.
D. During an interview on08/28/19 at 1:43 PM, the Director of Quality and the Director of Nursing both verified the findings at C.

Based on review of Rules and Regulations for Hospitals and Related Institutions in Arkansas (2016), observation and interview, it was determined emergency medications were not secured with a breakaway seal (per regulation) in two (Surgical Services #2 and Emergency Department #2-Obstetrics) of seven (Surgical Services #1 and #2, Emergency Department #1 and #2-Obstetrics, Geri-Psych, Medical/Surgical and ICU #1 and #2) emergency carts observed. By not maintaining emergency medications in a manner that makes them rapidly available, the facility could not assure they were ready for an emergent situation. The failed practice had the likelihood to affect all patients who needed emergency medications. Finding follow:

A. Record review of the "Rules and Regulations for Hospitals and Related Institutions in Arkansas (2016), Section 12.S.4," showed that emergency type medications were to be secured with a breakaway seal.
B. During a tour of Surgical Services on 08/26/19 from 2:37 PM until 3:40 PM; observation showed Emergency Cart #2 was not secured with a breakaway seal.
C. During a tour of the Emergency Department on 08/27/19 from 10:25 AM until 12:12 PM observation showed Emergency Cart #2-obstetrics was not secured with a breakaway seal.
D. During an interview on 08/26/19 at 3:11 PM, Register Nurse #1 verified the findings at B.
E. During an interview on 08/27/19 at 11:00 AM, Emergency Room Manager verified the findings at C.

Based on observation, review of Temperature Logs for Freezer, review of policy and interview, it was determined the facility failed to monitor the temperature in one of one (Women's Services) medication freezer that stored medication in it. By not monitoring the temperature, the facility could not assure medication were stored in proper conditions and could not assure their safety or efficacy. The failed practice had the likelihood to affect the patients admitted to the facility.
Findings follow:
A. Record review of the facility's policy titled, "Inventory Control for Medications and Biologicals," dated 12/17/14, showed that temperatures of the freezer were to be obtained and documented daily.
B. During a tour of Women's Services on 08/27/19 from 2:45 PM to 3:50 PM, observation showed a medication freezer that had a medication stored in it.
B. Review of Temperature Log for the freezer from 08/01/19 through 08/27/19 showed no documentation that the freezer temperature was being monitored.
D. During an interview on 08/27/19 at 3:13 PM, the Director of Nursing verified the absence of freezer temperatures on the temperature log.

Based on observation and interview, the facility failed to maintain the condition of the physical plant in a manner that assured the safety of patients in that three of three spot-type smoke detectors in the mechanical storage room were not installed on the ceiling as per NFPA 72:17.7.3.2.1 2010 edition, which compromises their ability to detect smoke. The failed practice had the likelihood to affect all patients and staff in that in the event of a fire in the mechanical storage area, fire detection would be significantly delayed and the fire could grow and spread before anyone was alerted of its presence. Findings follow:

A. Review of NFPA (National Fire Protection Agency) 72: 17.7.3.2.1 requirements showed spot-type smoke detectors shall be installed on the ceiling or on a sidewall no more than 12 inches below the ceiling.
B. Observation on 08/29/19 at 10:41 AM of the 3rd floor mechanical storage room showed three of three spot-type smoke detectors installed between the aisles were hanging 8 inches below the ceiling from wires wrapped around pipes. This finding was verified by the Director of Engineering at the time of observation.

Based on observation and interview, the facility failed to maintain the condition of the physical plant in a manner that assured the safety of patients in that one of one fire barrier wall was not sealed with fire-proof sealant in the 2nd floor mechanical room. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA (National Fire Protection Agency) 1: 12.9.6.2 requirements showed penetrations in a fire-rated barrier shall be protected by material restricting the transfer of smoke.

B. Observation on 08/29/19 at 10:15 AM of the 2nd floor mechanical room's fire wall showed one non-sealed hole of 1.5-inch diameter present containing wires in a metal tube which was not fire-proof sealed per NFPA 1: 12.9.6.2 to prevent the migration of fire and smoke. This finding was verified by the Director of Engineering at the time of observation.

Based on observation and interview, the facility failed to provide battery-powered emergency lighting for three of three emergency generators as required by NFPA 101, 2012 edition. The failed practice had the likelihood to affect all patients and staff in that in the event of a power outage emergency there would be no lighting to illuminate the work area around the generators, which would delay or prevent the maintenance required to keep the generators functioning. The findings were as follows:

A. Review of NPFA 101:9.1.3 2012 edition showed emergency generators must be installed and maintained in accordance with NFPA 110. Further review of NFPA 110:7.3.1 2010 edition showed emergency power equipment shall be provided with battery-powered emergency lighting.
B. Observation on 08/28/19 at 04:11 PM of the three generators showed that the overhead lighting present was powered solely by the main electrical system, and no battery-powered lighting was present. This finding was verified by the Director of Engineering at the time of observation.


Based on review of Patient Safety Meeting logs, review of NFPA 101:19.7.1.2 and interview, it was determined the facility failed to meet the provisions of the life safety from fire requirements in that no record was being kept of fire drills being conducted in four of four prior quarters (August 2018 to August 2019). The failed practice had the potential to affect all staff and patients in that in the event of a fire the staff would not be trained to respond to the emergency, which could result in injury or death if the proper actions are not taken to preserve the lives of patients and staff. Findings follow:

A. Review of NFPA 101:19.7.1.2 showed fire drills are to be conducted by the facility once per shift per quarter.
B. Review and interview on 08/29/19 at 9:28 AM of Patient Safety Meeting logs from August 2018 to August 2019 showed there were no records of fire drills being conducted quarterly as required per NFPA 101:19.7.1.2. This finding was verified by the Director of Engineering at the time of the review, who also commented "I found a 'Fire Drill' folder but it's empty."

Based on observation and interview, it was determined the facility failed to ensure two of two Argon Bovie Gas cylinders were no secured to the wall or in a cart in the Surgical Services Storage Room. Failure to ensure the cylinders were secured to the wall or in a cart, had the potential to allow the canisters to be knocked over causing injury to patients, visitors, and staff. The failed practice had the likelihood to affect any patient or staff in the event a canister was knocked over. Findings follow:

Observation at 3:07 PM on 08/26/19 showed two Argon Bovie Gas canisters setting on the floor of the Surgical Services Store Room. The Director of Surgical Services stated during an interview at 3:07 PM on 08/26/19 that the canisters should be secured to the wall or in a cart tank to avoid being knocked over.


41857

Based on observation and interview, it was determined the facility failed to ensure an acceptable level of safety and quality was met in that medical gas tanks were being stored in combustible racks in one of one Respiratory Oxygen Storage location. Findings follow:

A. Review of NPFA 99:5.1.3.3.2 2005 edition showed storage racks for positive pressure gases shall be constructed of non-combustible or limited-combustible materials.
B. Observation on 08/29/19 at 10:00 AM of Respiratory Oxygen Storage showed 55 oxygen cylinders were stored in 5 combustible wooden racks. This finding was verified by the Director of Respiratory Care and the Director of Engineering at the time of observation.


Based on observation and interview, the facility failed to ensure supplies were stored 18 inches or more below the sprinkler deflector as required by NFPA 13:8.8.6, 2010 edition in that storage was stacked high enough that it was less than 18 inches below the sprinkler deflector and in the path of the sprinkler spray pattern. The failed practice had the likelihood to affect all patients and staff near the kitchen area in that a potential fire in the dry food storage room would not be immediately extinguished and could spread to other nearby areas due to the spray pattern of the activated sprinklers being obstructed. Findings follow:

A. Review of NFPA 13:8.8.6, 2000 edition showed the top of storage must be at least 18 inches below the deflector of the sprinkler.
B. Observation on 08/29/19 at 11:07 AM of the dry food storage showed one cardboard box stacked on a shelf 4 inches below a sprinkler deflector, one cardboard box stacked on a shelf 12 inches below a sprinkler deflector, and another cardboard box stacked on a shelf 4 inches below a sprinkler deflector. This finding was verified by the Director of Engineering at the time of observation.

Based on review of the Surveillance, Prevention and Control of Infection Program and Performance Improvement Plan/Goals for 2019-2020, policy and procedure review, and interview, it was determined the Infection Control Nurse failed to adhere to Arkansas Department of Health (ADH), Rules and Regulations for Hospitals and Related Institutions in Arkansas 2016, in that the facility did not have a functioning Infection Control Committee. Failure to develop, organize, and implement an Infection Control Committee did not allow the facility to have a mechanism or process to develop, implement, monitor, and analyze the Infection Control Plan, approve Infection Control policies and procedures, review and make recommendations for needed action based on study results. The failed process had the potential to affect the entire facility, patients, visitors, and staff. Findings follow:

A. Review of the Surveillance, Prevention and Control of Infection Program and Performance Improvement Plan/Goals for 2019-2020, received from the Director of Quality at 4:30 PM on 08/27/19, showed the facility was to be in compliance with current infection control guidelines and standards of regulatory agencies having jurisdiction [ADH, CDC (Centers for Disease Control) OSHA (Occupational Safety and Health Administration), EPA (Environmental Protection Agency, etc.]. Review of the Surveillance, Prevention and Control of Infection Program and Performance Improvement Plan/Goals for 2019-2020 showed under Processes that systematic evaluation of opportunities for performance improvement recommendations were to be made to the Infection Control Committee; and under Annual Evaluation the effectiveness of the Surveillance, Prevention and Control of Infection Program and Performance Improvement Plan was to be evaluated by the Infection Prevention and Control Committee annually.
B. Review of the Arkansas Department of Health (ADH), Rules and Regulations for Hospitals and Related Institutions in Arkansas 2016, Section 18 B., Infection Prevention and Control Committee, showed there was to be a multidisciplinary committee appointed by Administration to develop, implement and monitor direction for the Infection Prevention and Control program, the Medical Staff was to appoint a physician to serve as chairperson of the Prevention and Control Committee, and was to meet quarterly. The Infection Prevention and Control Committee was to assist in the development and approval of all infection prevention and control policies and procedures in the facility, ensure an antibiogram was prepared annually and compared to previous ones for trends, monitor any contractual services related to infection prevention, review any studies conducted in the facility, and provide oversight for disinfectants and sterilants.
C. During an interview with the Infection Control Nurse at 3:20 PM on 08/27/19 she was asked for the Infection Control Committee Meeting Minutes. The Infection Control Nurse stated the facility did not have an Infection Control Committee.
D. During a joint interview with the Director of Quality and the Infection Control Nurse at 3:15 PM on 08/28/19, the Director of Quality stated that there was no dedicated Infection Control Committee and had not been one since assuming her current role about three years ago

Based on policy and procedure, manufacturer's instructions for use, observations and interview, it was determined the Infection Control Nurse failed to control infections in that semi-critical equipment (laryngoscope blades) was not processed, packaged and tracked to prevent recontamination and degradation in four of four areas (Operating Room (OR) #7, the Emergency Airway and Intubation Cart located in the OR hallway, Trauma Room #1, and the Women's Center). Failure to ensure the equipment was processed, packaged, and tracked to prevent contamination had the potential to allow dirty and faulty equipment to be used in patient care. The failed practice had the potential to affect any patient whose care required the use of the laryngoscope blades or the Endotracheal tubes (ETT) in the OR suite. Findings follow:

A. Review of the policy and procedure titled "Infection Control - Anesthesia," received from the Director of Surgical Services at 8:15 AM on 08/27/19, showed laryngoscope blades were to be thoroughly cleaned after use with disinfectant and water, followed by high-level disinfection with glutaraldehyde or STERIS per policy and procedure.
B. Review of the LMA (Laryngeal Mask Airway) Fastrach ETT instructions, received from the Director of Surgical Services at 3:36 PM on 08/26/19, showed a maximum use of ten times after steam sterilization.
C. Observation of the pediatric cart in OR #7 at 2:58 PM on 08/26/19, showed five (G-Mac 2, Miller 1, 2 Greenline 1, and one Heine Mac 0) laryngoscope blades lying unpackaged in the drawer of the pediatric cart. During an interview at 2:58 PM on 08/26/19, the Director of Surgical Services stated that the laryngoscope blades were supposed to be individually packaged in a sleeve after cleaning and confirmed findings in A.
D. Observation at 3:30 PM on 08/26/19 of the Emergency Airway and Intubation Cart located in the OR hallway showed the following laryngoscope blades lying unpackaged in a drawer: Miller 4, G-Mil 3, G-Mil 2, G-Mil 1, G-Mac 4, G-Mac 3, G-Mac 2, and G-Mac 1. Also observed in the cart were the following re-usable LMAs: 5 mm (millimeter), 4 mm, and a 3mm. During an interview at 3:23 PM on 08/26/19, the Director of Surgical Services stated that laryngoscope blades were supposed to be individually packaged in a sleeve after cleaning.
E. Observation at 3:30 PM on 08/26/19 of the Emergency Airway and Intubation Cart located in the OR hallway showed the following re-usable ETTs in individual peel packaging which contained a chemical indicator showing sterilization had occurred: 6 mm, 6.5 mm, 7 mm, 7.5 mm and 8 mm. The peel packages had one end cut off and were open to air. During an interview with the Director of Surgical Services at 3:30 PM she was asked how many times the ETTs had been sterilized and how the facility kept track of the number of times each ETT was sterilized. The Director of Surgical Services stated that the facility did not have a process to track the number of times the re-usables had been used and sterilized.
F. Observation of Trauma Room #1 at 11:21 AM on 08/27/19 showed one of three laryngoscope blades open and attached to the handle. The Director of Respiratory Therapy stated during an interview at 11:21 AM on 08/27/19 that laryngoscope blades should be cleaned by high level disinfection and then placed in a bag to prevent cross contamination.
G. Observation in four of four (#5302, #5303, #5304 and #5305) rooms in the Women's Center at 2:52 PM on 08/27/19 showed Miller and Mac laryngoscope blades stored in reusable ziplock bags along with the laryngoscope handles and batteries. The Women's Center Director verified the above findings during an interview at the time of observation.


Based on observation and interview, it was determined the Infection Control Nurse failed to ensure opened patient care supplies were not available for patient use in two of two (Operating Rooms (OR) #4 and #7). Failure to allow opened items to be available for patient use did not ensure staff were knowledgeable as to if the item was indeed clean/sterile, or had been used and placed back in the package. The failed practice had the potential to affect any patient whose care required the use of the opened items. Findings follow:

A. Observation of the Anesthesia Machine in OR #4 showed the Anesthesia circuit package and the Yankauer Suction Tip package was opened and hanging on the Anesthesia Machine. During an interview at 2:58 PM on 08/26/19 the Director of Surgical Services verified the above.
B. Observation of the Anesthesia Machine in OR #7 showed the Anesthesia circuit package and the Yankauer Suction Tip package was opened and hanging on the Anesthesia Machine. During an interview at 3:20 PM on 08/26/19 the Director of Surgical Services verified the above.


Based on online policy and procedure review, and interview, it was determined the Infection Control Nurse failed to develop and implement a policy and procedure that defined what set of instructions the facility would follow in the event of discrepancies between a device manufacturer's instructions and the sterilizer's manufacturer's instructions for completing sterilization. Failure to develop and implement a policy which defined what manufacturer's instructions the facility would follow had the potential for inconsistency in the sterilization of surgical equipment. The failed practice had the likelihood to affect all patients whose care required the use of sterilized equipment. Findings follow:

The Director of Nursing stated during an interview at 10:19 AM on 08/29/19 that the facility did not have a policy and procedure that defined which set of manufacturer's instructions the facility would abide by in the event of inconsistency.


Based on observation and interview, it was determined the Infection Control Nurse failed to control infections in that a discharged room was not cleaned in a clean to dirty order. Failure to clean in a clean to dirty order had the potential to allow cross contamination among patients, visitors, and staff. The failed practice had the potential to affect any patient, visitor, and staff utilizing the over bed tables, and the bathroom in Room 5203. Findings follow:

A. Observation of the cleaning of a discharged room at 9:57 AM on 08/28/19 showed Housekeeper #1 cleaned the top of over bed table #1, the leg, and the base. Housekeeper #1 then cleaned the top of over bed table #2, the leg, and the base using the same rag.. Housekeeper #1 cleaned three trashcans in the following order: inside, outside, bottom, and the rim with the same rag. In the bathroom, Housekeeper #1 cleaned the sink, mirror, hand rails around the bathroom, and shower handles. Housekeeper #1 laid that rag on the toilet ledge at the back of the toilet, and cleaned the toilet bowl with a brush. Housekeeper #1 then picked up the rag from the toilet ledge, and cleaned the toilet seat, the underneath the toilet seat, the underneath of the toilet bowl, cleaned up the toilet pipe, the flush handle, the trash can (inside, outside, bottom and rim). Housekeeper #1 then cleaned the bedside commode seat, the back, the inside of the bucket, the right and left arms of the bedside commode frame, and the back over the items, again with the same rag.
B. During an interview at 11:03 AM on 08/28/19, the Environmental Services Manager verified the above findings.


Based on review of policy and procedure, observation and interview, the Infection Control Nurse failed to decrease risk of patient infection by ensuring safe injection practices in one of one surgical procedures (Patient #10). Failure to ensure safe injection practices increased patient's risk for healthcare-associated infection. The failed practice affected Patient #10 on 8/27/19. Findings follow:

A. Review of policy titled, "Inventory Control for Medications and Biologicals," insulin vials should be swabbed with alcohol when accessed. Infection Control Nurse stated that there were no other policies regarding safe injection practices.
B. Observation of surgical procedure for Patient #10 at 11:55 AM on 8/27/19 showed Physician #1 removed top of medication vial and immediately entered the vial with a sterile syringe without cleaning rubber septum. Physician #1 then removed cap from a second medication vial using a new needle without cleaning top of vial. At 11:56 AM, Physician #1 injected first needle into a port on patient's IV tubing without cleaning port. Immediately following, Physician #1 injected second needle into same port on IV (intravenous) tubing without cleaning port. During an interview at 12:16 PM on 8/27/19, RN #4 stated she was unaware that alcohol disinfection of septum and IV port was necessary.


Based on observations and interview, it was determined the Infection Control Nurse failed to ensure dirty items were cleaned prior to being placed back in a clean drawer, and personal clothing, food, and coolers were stored on the same storage shelf as patient care blankets. Failure to ensure patient care equipment was cleaned prior to being placed back in the drawer and failure to ensure employee and food items were not stored with patient linens had the potential to allow cross contamination of patient care items and equipment. The failed practice had the likelihood to affect any patient whose care required the use of the equipment or the blankets. Findings follow:

A. Observation at 10:45 AM on 08/27/19 showed RN #3 retrieved a stethoscope from a mobile cabinet, listened to the front and back chest of Patient #10, then placed the stethoscope back into the drawer without cleaning it first. RN #2 removed the cabinet from the room, retrieved the stethoscope and cleaned it, then placed it back into the same drawer. RN #2 verified the above findings during an interview at 11:10 AM on 08/27/19.
B. Observation of the laundry area at 9:10 AM on 08/29/19 showed one beige and one purple jacket, an opened package containing 4 peanut butter crackers, one black fanny pack, and one black and teal insulated cooler, all belonging to employees. The Environmental Services Manager verified the above findings at 9:13 AM on 08/29/19.


Based on policy and procedure review, observation and interview, it was determined the Infection Control Officer failed to identify and control infections in that the Decontamination Area in the Emergency Room was not clean, accessible, and ready to accept a patient. The failed pracxtice had the likelihoodl for decontamination procedures to be delayed. The failed practice had the likelihood to affect any person whose treatment required decontamination. Findings follow:

A. Review of the "Emergency Management" procedure showed if a disaster condition was declared, the decontamination area was to be used to decontaminate patients and provide emergency lifesaving care by personnel wearing personal protective equipment.
B. Observation of the Decontamination Area located in the Emergency Room at 10:47 AM on 08/27/19 showed the entrance fron the outside for the "Hot Side" of the Decontamination Area was blocked by a car. Observation of the Decontamination Area itself showed portable hazmat (hazardous materials) supplies (heater, bags, tent parts, poles, portable unit flooring,and portable shower sets) stored in the room. Observation also showed dirt, dead bugs, and spider webs in the room.
C. The Director of Nursing verified the above findings during an interview at 10:47 AM on 08/27/19.


31039

Based on observation, review of APIC (Association for Professionals in Infection Control and Epidemiology) position paper and interview, it was determined the facility failed to identify the practice of storing MDV (Multiple Dose Vials) once opened, in immediate patient treatment areas in three (Operating rooms #4, #7 and C-Section Suite) of five (Operating Rooms #1, #4, #5, #7 and C-Section Suite) Anesthesia carts. By not identifying the risk of this practice, the facility could not assure their patients safety. This failed practice has the likelihood to affect all patients receiving procedures in the facility. Findings follow:

A. Review of APIC position paper, titled "Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016)," showed MDV should never enter the immediate patient care area, and if they do, they must be dedicated for single patient use and discarded immediately after use. Examples given by APIC of immediate patient care areas include operating rooms and anesthesia carts.
B. During a tour of Surgical Services on 08/26/19 from 2:37 PM to 3:40 PM and during a tour of Women's services on 08/27/19 from 2:45 PM to 3:50 PM, observation showed the following on the anesthesia medication carts:
1) Operating Room #4 had one Xylocaine 2% 400mg/ml 20 ml MDV opened, dated 09/24/19, stored on the cart, available for another patient's use. Dating the vial indicated it was to be kept and used again on another patient; and
2) Operating Room #7 had one Lidocaine 2% 20 milligram/milliliter (mg/ml) 20 ml MDV opened, dated 09/25/19, stored on the cart, available for another patient's use; and
3) C-Section Suite had one Lidocaine 1% 200mg/20ml MDV opened, dated 09/17/19, stored on the cart, available for another patient's use.
C. During an interview on 08/26/19 at 2:32 PM, RN #1 verified the findings at A 1 & 2. During an interview on 08/27/19 at 3:50 PM, RN #1 verified the findings at A 3.


Based on review of policy, observation, review of freezer temperature logs and interview, it was determined the Infection Control Officer failed to identify and control infections in that freezer temperatures were not monitored to prevent microbial contamination of breast milk in one of one (Women's Services) breast milk freezer. By not monitoring the temperatures of the freezer, the facility could not assure the breast milk was being stored at 0 degrees Fahrenheit to inhibit microbial growth and contamination. The failed practice had the likelihood to affect all newborns who had their mother's breast milk stored in that freezer. Findings follow:

A. Record review of the facility's policy titled, "Protocol: Breast pumping, Storage of Expressed Breastmilk, and Heating Breastmilk," showed the facility was to maintain the freezer at 0 degrees Fahrenheit for the storage of breast milk.
B. During a tour of Women's Services on 08/27/19 from 2:45 PM to 3:50 PM, observation showed a freezer that stored breastmilk in it.
C. Review of Temperature Log for the freezer from 08/01/19 through 08/27/19 showed no documentation that the freezer temperature was being monitored.
D. During an interview on 08/27/19 at 3:13 PM, the Director of Nursing verified the absence of freezer temperatures on the temperature log.

Based on review of job descriptions, employee transcripts, and interview, it was determined three (#1, #5 and #6) of six (#1, #2, #5-8) Registered Nurses (RN) in Surgical Services did not have current PALS (Pediatric Advanced Life Support) certification as required by Surgical Services Job Descrptions. Failure to ensure the RNs were currently PALS certified did not ensure availability of a nurse competent in life saving measures for pediatric patients. The failed practice had the likelihood to affect any pediatric patient in the event of a cardiac emergency. Findings follow:

A. Review of the job descriptions for the Pre-Operative (Pre-op) RN, the RN Circulator, and the Recovery Room RN showed PALS certification was to be obtained within one year of hire.
B. Review of RN #1's transcript showed no current PALS certification. Review of hire date provided by the Supervisor of Pre-op/PACU (Post Anesthesia Care Unit) showed a hire date of 02/18/05, and assigned to the Surgery/Operating Room.
C. Review of RN #5's transcript showed no current PALS certification. Review of hire date provided by the Supervisor of Pre-op/PACU showed a hire date of 09/06/13, and assigned to the Surgery/Operating Room.
D. Review of RN #6's transcript showed no current PALS certification. Review of hire date provided by the Supervisor of Pre-op/PACU showed a hire date of 06/22/17, and assigned to the Surgery/Operating Room.
E. During an interview at 9:37 AM on 08/29/19, the Supervisor of Pre-Operative/PACU verified the findings in B, C, and D.


Based on policy and procedure review, observation, and interview, it was determined the facility failed to ensure four (RN #4, Scrub Technician (ST) #1, and #2) of five (RN #4, Scrub Technician (ST) #1, #2, and Physician #1) surgical staff covered all head hair during a surgical procedure in accordance with developled policy and procedure. Failure to ensure all head hair was covered had the potential to allow the dispersal of microorganisms from staff hair. The failed practice had the potential to affect Patient #10 on 08/27/19. Findings follow:

A. Review of the policy and procedure titled "Operating Room Attire," received from the Director of Surgical Services at 8:15 AM on 08/27/19 showed all head and facial hair was to be covered in the restricted areas of the surgical suite.
B. Observation in Operating Room #3 from 11:50 AM to 12:46 PM on 08/27/19 showed Physician #1, RN #4, and T #2 all had wisps of hair hanging out of their surgical hair covers. ST #1 had one to two inches of hair uncovered from ear, around neck to ear. RN #4 verified the above findings during an interview at 12:16 PM on 08/27/19.
C. Observation at 8:31 AM on 08/29/19 in the surgical suite showed ST #4 with three inches of hair hanging out of the surgical hair cover. The Supervisor of Pre-op/PACU (Post Anesthesia Care Unit) verified the above findings during an interview at 8:32 AM on 08/29/19.

Based on review of the operating room log and interview, it was determined the facility failed to ensure 1 (age) of 13 (Patient name, identification number, date of operation, inclusive or total time of operation, name of surgeon, name of circulator, name of scrub technician, type of anesthesia used and name of person administering it, operation performed, pre-operative diagnosis, post-operative diagnosis, and age of patient) elements was not included in the operating room log. Failure to ensure the operating room log contained all of the required elements did ensure the facility would be able to retrieve information useful in monitoring complications, infections, and other outcomes. The failed practice had the likelihood to affect all patients who have undergone procedures in the operating room. Findings follow:

Review of the operating room log showed age was not listed. During an interview with the Surgical Services Secretary at 8:24 AM on 08/29/19, it was confirmed age was not in the Operating Room Log.

Based on review of Speech Therapist Job description, review of the Arkansas Rules and Regulations for Hospitals 2016, Section 23, review of Speech Language Pathologist's (SLP) personnel file and interview, it was determined one (#1) of two (#1 and #2) SLP did not have evidence of current CPR (Cardio-Pulmonary Resuscitation) certification. By not having evidence of this qualification, the facility could not assure services provided to patients would be given by a qualified therapist. The failed practice had the likelihood to affect all patients that receive Speech Language Rehabilitation Services. Findings follow:

A. Record review of the Speech Therapist Job description, dated 07/01/19, showed the SLP was required to comply with the State of Arkansas's regulations.
A. Record review of the Arkansas Rules and Regulations for Hospitals 2016, Section 23, showed all SLPs shall maintain competency in life support measures.
C. Review of SLP #1's personnel file showed no evidence of a current CPR certification. The previous CPR certification expired 12/15/18.
D. During an interview on 08/29/19 at 11:00 AM, the Director of Nursing verified that SLP #1's CPR certification had expired 12/15/18.