HospitalInspections.org

Based on policy review, hospital document review, medical record review, and interview, the hospital failed to ensure staff abided by the hospital's policy and necessary care and services were provided to prevent potential mental anguish and physical harm to all patients for 3 of 3 (Patient #1, #2, and #3) sampled patients.

The findings included:

1. Review of the hospital policy, "Occurrence Reporting: Patient and Visitor," dated March 2022, revealed, " ...Purpose: To identify, evaluate, and take appropriate action to address serious or significant Events, Near-Miss Events, or Hazards involving patients and visitors, to track patient safety data trends, and report Events in accordance with applicable law ...Definitions ...Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness of a patient. An occurrence which is unrelated to the reason for the patient's hospitalization or the ordinary course of the patient's underlying condition and which results in death, permanent harm or significant temporary harm to the patient may be identified as "Neglect," following a review of relevant facts and circumstances (including, but not limited to, whether the occurrence arose from a significant or repeated deviation from an established or prescribed plan of care or treatment by one or more clinicians).

Review of the hospital policy, "Exposure to Communicable Diseases for Patients and Visitors," dated January 2023, revealed, " ...Purpose: To outline the process used when a patient or visitor has been exposed to a communicable disease and establish guidelines that determine follow-up ...Bloodborne pathogen exposure: An event in which blood or other potential infectious body fluid comes in direct contact with a person's blood, mucous membranes, or non-intact skin ...Communicable disease exposure: Unprotected exposure to contagious pathogens that require chemoprophylaxis, furlough, and/or symptom monitoring of the person exposed ...Patients or visitor exposure to communicable disease, bloodborne pathogen, sharps injury ...If an exposure event has occurred for the patient, the following actions are taken ...In consultation with Risk Management, the primary attending physician or designee discloses to the patient and appropriate family members the exposure circumstances and the need for testing ..."

2. Review of the hospital document, "GI [Gastrointestinal] Tech [Technician] Specialist ...Job Summary," dated 9/19/2024, revealed, "Assists GI Endoscopy Services Unit with the coordination of the daily patient endoscopy schedule with occasional guidance from the charge nurse, physician, or staff nurse. Facilitates patient care by assisting physician/nursing staff before, during and after endoscopy procedures by providing the instruments and supplies required by the proceduralist according to established plan for patient care with occasional guidance. GI Tech is able to perform competently most of the cases in a given service/shift. Cleans, disinfects and sterilize all flexible bronchoscopes, video scopes and related Endoscopy instruments for all areas ...Job Description ...Maintains the work environment in a safe, clean, orderly manner ...Prepares instrumentation and equipment according to recommended procedures and techniques in preparation for high-level disinfection and sterilization to support all perioperative areas and clinics. Operates all departmental equipment safely and effectively ...Departmental Policies & [and] Procedures (Novice): Possesses sufficient fundamental proficiency to successfully demonstrate knowledge of departmental policies and procedures in practical applications of moderate difficulty. Is attentive to existing departmental policies and procedures, and may recommend improvements to existing departmental policies and procedures within the work area ..."

Review of the hospital document, "Endoscopy Event Timeline," last updated 10/9/2024 (The hospital developed this document as a result of the identified potential exposure to bloodborne pathogens/communicable diseases during endoscopic procedures), revealed the following:
" ...Sep. [September] 17, 2024 ...Incident identified by RN [Registered Nurse] and escalated to manager ...
Sep. 18, 2024 ... Manager confirmed inappropriate practice isolated to one GI [Gastrointestinal] Tech [Technician] ...
Sep. 21, 2024 ...Began analysis of potentially exposed patients ...
Sep. 22, 2024 ...Determined time frame of potential exposures and identified source/exposed patients ...
Sep. 23, 2024 ...Validated analysis of potentially exposed patients ...
Sep. 24, 2024 ...Analysis of potentially patients completed ...
Sep. 27, 2024 ...Patient notification plan created ...
Oct. [October] 3, 2024 ...Began notifying patients and ordering/scheduling appropriate labs ...Total Completed Patient Notifications: 109 ...Total % [percent] of Patients Notified: 14%...
Oct. 4, 2024 ...Total Completed Patient Notifications: 271 ...Total % of Patients Notified: 34%...
Oct. 5, 2024 ...Total Completed Patient Notifications: 398 ...Total % of Patients Notified: 50%...
Oct. 6, 2024 ...Total Completed Patient Notifications: 517 ...Total % of Patients Notified: 65%...
Oct. 7, 2024 ...Total Completed Patient Notifications: 586 ...Total % of Patients Notified: 74%...
Oct. 8, 2024 ...Total Completed Patient Notifications: 617 ...Total % of Patients Notified: 78%..."

Review of the hospital document, "Disclosure Outline for Call to Source Patient," (undated) (The hospital developed this document as a result of the identified potential exposure to bloodborne pathogens/communicable diseases during endoscopic procedures), revealed, " ...May I speak to [SOURCE PATIENT NAME]?...I need to speak with you for a few moments about your recent endoscopy procedure ...We recently become aware of an issue in how a solution was administered during certain endoscopy procedures at the [Hospital #1 Clinic]. Because you recently had an endoscopy procedure, we are calling to discuss this. During approximately half of endoscopy procedures, a solution can be administered into the scope to reduce air bubbles and make it easier for the physician to see. Because of an error in how the solution was administered, there is a risk that the bottle of solution used each day may have become contaminated, which may place patients at risk for infection ...We are recommending that you be tested for Hepatitis B and C and for HIV [Human Immunodeficiency Virus] ...Results will come to you through [Hospital #1's electronic health information portal], or you will get a phone call from one of our clinicians ...I'm sure this is a lot to process, and I am sorry if this information raises any concerns ..."

Review of the hospital document, "Frequently Asked Questions-Adult Endoscopy," (undated) (The hospital developed this document as a result of the identified potential exposure to bloodborne pathogens/communicable diseases during endoscopic procedures), revealed, "What happened? We recently discovered that a solution was improperly administered during some adult endoscopy procedures. We are investigating this issue extensively and have reported it to the Tennessee Department of Health. Specifically, in approximately half of adult endoscopy procedures, a solution called simethicone is used to decrease air bubbles to more clearly see the gastrointestinal (GI) tract through the scope. A sterile syringe with a needle attached is used to withdraw simethicone from a bottle, and the solution is then administered to the patient through the scope using a port at the end of the scope held by the physician ...We became aware that in certain endoscopy rooms when simethicone was administered, the needle used to withdraw simethicone from the bottle was re-inserted into the same bottle if more than one dose was needed for that patient. If the needle came in contact with biological material from the scope during any administration of simethicone and was reinserted into the bottle, it could have contaminated the bottle for subsequent patient examinations on that day and that used simethicone. If the bottle of simethicone used each day in that room was contaminated, it may place the patient at risk for infection. Since the administration of simethicone during an endoscopy is not documented in the medical record, we cannot verify with certainty which patients received it during their examination ...we are notifying every patient who had an endoscopy in the specific location during the period of risk ...Why am I being notified?...if you received simethicone during an endoscopy, and if the bottle of simethicone used in your procedure was contaminated, there are some viruses that could be transmitted, including HIV and hepatitis B and C. We are notifying patients who received endoscopy procedures at the [Hospital #1 Clinic] within the last four months and recommending testing for these viruses ...How will I know what the results are? If you have your testing done at [Hospital #1] and are enrolled in ...our electronic health information portal, your test results will post there. Otherwise, we will inform you of your lab results after the testing has been processed. Our team will reach out to you by phone for any results that require follow up testing or additional workup. It will take several days to get results back, so please be patient ...Will I need to come back for additional testing? It is likely that you will need to have follow-up lab testing over the next six months so that we can monitor for infection ...[A testing schedule is included: patients who have been exposed greater than or equal to 10 weeks should have a baseline test and 6 month test; patients who have been exposed between 4 to 10 weeks should have a baseline test, 12 week test, and 6 month test; patients who have been exposed less than 4 weeks should have a baseline test, 6 week test, 12 week test, and 6 month test] ...What if the lab test reveals something?...If you would benefit from additional testing or treatment based on the lab results, [Hospital #1] will help connect you with a medical team to guide the next best steps ...How long has this been going on?...Cases with possible exposure occurred during May-September 2024 ...Am I contagious to other people? Do I need to take any precautions? While the likelihood of a hepatitis or HIV infection is very low, we cannot rule out infection until testing is complete now and after six months. Hepatitis and HIV are spread through blood or body fluid. To reduce the risk of transmission during this period of time, it is recommended that you: cover cuts or open wounds; clean up blood or body fluid with alcohol or bleach-based solutions; avoid sharing personal care products, such as razors or nail clippers; and use barrier precautions during sexual activity ...Am I going to die from an infection that you gave me?...The risk of infection from this possible exposure is very low. In the case that a hepatitis C infection occurs, this is a curable infection that should not impact your long-term health. While hepatitis B and HIV are not yet curable, most people live full lives with well-tolerated treatment that can be taken as one pill once per day. The reason that we recommend laboratory testing now and in the future is to ensure that you receive the care that you need ..."

Review of the hospital document, "Current Data as of 10/9/24" (The hospital developed this document as a result of the identified potential exposure to bloodborne pathogens/communicable diseases during endoscopic procedures) revealed, "Total patients involved (source only and exposed) = 796 ...As of this morning, 631 contacted (~ [approximately] 80%) ...Original Source: By procedure room and date, a patient who was the first case where the tech assisted. This patient does not need any testing beyond baseline ...Reclassified Source: A patient who was originally classified as Exposed but can be reclassified as a source due to negative baseline BBP [Bloodborne Pathogens] testing in all patents [patients] preceding the patient that day in that room beginning from the first case in the room(s) where the tech assisted. This patient does not need any additional testing beyond baseline ...Solo source: A patient who was the only case in that room where the tech assisted. This patient does not need any testing beyond baseline. If the Solo Source is baseline lab negative (or only HBV [Hepatitis B Virus] Surface Antibody positive [indicates immunity against the hepatitis B virus either through a past infection or from receiving the hepatitis B vaccine]), this will clear all subsequent patients in that room for that day ...Permanently Exposed: An exposed patient who had a procedure in a room where the tech had worked that day and who follows either a) a deceased patient, b) a patient with a history of BBP as defined by IP [Infection Prevention], or c) a patient with baseline lab testing positive for any test except HBV Surface Antibody (Ab) with or without positive HBV Core Antibody (Ab). These patients must be followed for the full 6 months with the entire complement of testing, as we will not have enough baseline data to clear the patients who were in the room before them."

3. Medical record review for Patient #1 revealed a procedure date for an esophagogastroduodenoscopy (EGD) on 9/9/2024 with a preoperative diagnosis of Dysphagia.

Medical record review for Patient #2 revealed a procedure date for an upper GI endoscopy on 8/6/2024 with a preoperative diagnosis of Cirrhosis Rule out Esophageal Varices.

Medical record review for Patient #3 revealed a procedure date for a colonoscopy on 7/3/2024 with a preoperative diagnosis of High Risk Colon Cancer Surveillance, Personal History of Colonic Polyps.

4. During an interview on 10/7/2024 at 9:27 AM, the Chief Hospital Epidemiologist stated that on 9/17/2024, nursing personnel identified that one staff member (GI Tech #1) was reusing the same needle and syringe to draw up simethicone, and there was a chance that the simethicone and saline solution could become contaminated. The Chief Hospital Epidemiologist stated that if the physician could not get a good visual during an endoscopic procedure, the physician may use simethicone through the scope. The Chief Hospital Epidemiologist stated the simethicone was mixed with sterile saline and injected through the scope with a 60 cubic centimeter (cc; equal to 1 milliliter) syringe. The Chief Hospital Epidemiologist stated they (hospital investigation team) had identified that the syringe was discarded after each patient, but one GI Tech (GI Tech #1) used the dirty syringe to draw up the simethicone mix which contaminated it. The Chief Hospital Epidemiologist stated that there was no documentation in the patient's medical record whether simethicone was used or not. The Chief Hospital Epidemiologist stated that the identified staff member started working on 5/22/2024 as a GI Tech in Endoscopy Center #1, and the hospital identified 680 patients who could have possibly been exposed to a communicable disease due to the error in practice. The Chief Hospital Epidemiologist stated that 20 of those patients have passed away, so the hospital will attempt to contact the remaining 660 patients to inform them of the potential exposure and recommend testing for hepatitis B and C and HIV.

During an interview on 10/7/2024 beginning at 9:27 AM with the Chief Hospital Epidemiologist, the Chief Medical Officer (CMO) of Adult Clinics, the Vice President and Chief Nursing Officer (CNO) of Ambulatory Nursing, the Senior Quality and Patient Advisor, and Accreditation and Standards Specialist #1, it was stated the hospital had travel staff working for the previous 18 months. The hospital gave the travel staff a prolonged training, but "we failed to give [GI Tech #1] that training ...in the training program ...we had a lot of management changeout ...this was his [GI Tech #1] first endo [endoscopy] job. He had a short amount of training ...cut short due to leadership being short at that time ...We had an appropriate training plan ...it just wasn't followed ..."

During an interview on 10/7/2024 at 4:16 PM, the Senior Quality and Patient Advisor confirmed the Board of Directors for the hospital were notified of the incident on 10/4/204. The Senior Quality and Patient Advisor stated the Risk Management Body met (date not stated) and discussed the incident and decided the incident did not meet the definition of "Neglect." The Senior Quality and Patient Advisor confirmed the hospital did not report the incident to the state agency.

During an interview on 10/8/2024 at 12:30 PM, the Executive Vice President (VP) of Quality Safety stated that the incident with the potential exposure during endoscopic procedures was reported to the Risk Management Committee, and the Committee made the decision whether to report the incident to the state agency. The Executive VP of Quality Safety stated they had an agreement with the state on "Neglect" that told them what needed to be reported. The Executive VP of Quality Safety confirmed the incident was not reported to the state, but it would have been if one of the patients was found to be newly infected with the HIV or hepatitis virus. The Executive VP of Quality Safety stated that situation would clearly be viewed by the hospital as neglect and would then be reportable.

During a virtual interview on 10/9/2024 at 11:46 AM, GI Tech #1 confirmed he was hired as a GI Tech at Hospital #1 on 5/20/2024 and had training on the job. GI Tech #1 stated he had multiple preceptors and had hands on training with a check sheet. When asked what he was taught during orientation about the use of simethicone during an endoscopic procedure, GI Tech #1 stated, " ...draw it up out of the jug [simethicone mix] when the provider asks for it ...after each patient ...throw away the needle and syringe and get a fresh one ..." When asked about the simethicone mix, GI Tech #1 stated, " ...we use the same jug. We would discard the jug at the end of the day ..." GI Tech #1 stated Registered Nurse (RN) #4 told him he was not drawing up the simethicone mix correctly and showed him the correct way to draw it up.

During an interview on 10/9/2024 at 12:10 PM, RN #4 stated that she had prepared two 60 cc syringes with the simethicone mix, but the physician requested more. RN #4 stated GI Tech #1 used one of the dirty syringes to draw the simethicone mix from the jug and pushed the plunger up and down in the mix. RN #4 stated she told GI Tech #1 that he cross contaminated the mix, and he told her that he had been following that same process. RN #4 stated she reported the incident to Nurse Manager #1.

During an interview on 10/9/2024 at 1:34 PM, the Vice President and Chief Nursing Officer (CNO) of Ambulatory Nursing stated the hospital had an extended orientation period of 3 months. The Vice President and CNO of Ambulatory Nursing stated GI Tech #1 was the first person in the program for the extended orientation, but he received 3 weeks of orientation instead of 3 months. The Vice President and CNO of Ambulatory Nursing stated the nurse educator was not doing a weekly check in with the employee.

During an interview on 10/9/2024 at 1:55 PM, the Director of Risk Management stated the hospital would only report an incident as "Neglect" if actual harm was identified for a patient.

During a phone interview on 12/23/2024 at 10:46 AM, Patient #1's husband stated he spoke with the representative from Hospital #1 by phone when the hospital called to inform Patient #1 about the potential exposure from contaminated equipment during an endoscopy procedure. Patient #1's husband stated that Patient #1 had a laryngeal procedure, and she had difficulty talking on the phone. Patient #1's husband stated Patient #1 had been tested once for hepatitis and HIV, and the results were negative. When asked about how the incident affected them, Patient #1's husband stated, "I was shocked ...hepatitis and HIV ...pretty bad sounding infections ...it's kind of scary ...you get a phone call out of the blue. We're getting older and trying to hold on to the days we have left ...it scared us."

During a phone interview on 12/23/2024 at 11:01 AM, when asked about the incident with the potential exposure from the endoscopy procedure, Patient #2 stated, " ...I don't think that was appropriate. No one should ever have to go through that." When asked how she responded to the information when she received the phone call from Hospital #1, Patient #2 stated, "Shock and despair. I was scared."

During a phone interview on 12/23/2024 at 11:06 AM, when asked about the incident with the potential exposure from the endoscopy procedure, Patient #3 stated, "It scared me plumb to death. I've lost a lot of sleep because of this. I have other health issues, and my liver couldn't take HIV or hepatitis ...I've been tested once at the Health Department. I went back to get tested again, but I panicked. I got so anxious, I just put the clipboard down at the Health Department and walked out ...I plan to go back after Christmas and get tested again. The woman at the Health Department that I would have to get tested up to a year. I have to go through this whole thing for a year before I am in the clear. I'm still losing sleep over this."

5. The hospital failed to provide goods and services necessary to avoid the mental anguish of patients. The hospital failed to provide adequate training and monitoring of a new employee which resulted in the potential exposure of multiple patients to communicable diseases. The hospital notified 631 patients at the time of the investigation that they may have been exposed to hepatitis B, hepatitis C, or HIV, and recommended the patients get tested for these viruses. This deficient practice has the possibility of causing mental anguish for the patients. Although some of the patients were recommended the need for only baseline testing, many were recommended testing for up to 6 months which can cause and can continue to cause further mental anguish for the patients.

Based on policy review, email review, observation, and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area for 2 of 3 (Endoscopy Procedure Center #1 and #3) Endoscopy Procedure Centers.

The findings included:

1. Review of the hospital policy, "Medication Storage and Handling," dated May 2024, revealed, " ...Medications are stored and handled in a manner that ...Maintains medication integrity ...Authorized Staff - For the purposes of this policy, authorized staff refers to those staff members involved in procurement, delivery, dispensing, or administration of medications ...Medications are stored ...In locked storage areas or containers unless they are under constant surveillance by an authorized individual ...Medications are obtained from locked medication storage areas ...or containers immediately prior to administration of the product and for one patient at a time ...Once removed, medications are not left unattended ...Procedural areas are restricted to authorized staff and are considered secure when authorized staff are actively providing care to patients or are present in the procedural room preparing to receive patients. Medication storage in these areas is considered to be secure when these criteria are in place. Medication storage in these areas is secured by locking medication carts or locked cabinet when these criteria are not in place ..."

2. Review of an email dated 10/7/2024 at 6:26 PM, revealed the Director of Anesthesia Advanced Practice Nursing sent an email to [Hospital #1] Nurse Anesthesia, "We have consistently provided reminders on the importance of proper medication preparation, storage, and disposal. While our recent focus has been on end-of-shift clean-up and secure storage, we must also remain vigilant with our medication preparation processes. Medications and syringes should not be prepared in advance. They must only be opened, spiked, and ready for use immediately before the imminent patient arrives in the OR [Operating Room] or procedural setting. This protocol appiles to every patient, case, and procedure, regardless of turnover times. If there is any production pressure from anesthesia, nursing, surgery, proceduralists, or other team members, do not compromise best practices. Instead, please report the situation to your CRNA [Certified Registered Nurse Anesthetist] leaders so that we can address it appropriately."

Review of an email dated 10/9/2024 at 2:43 PM, revealed Pharmacy Manager #1 responded, " ...When propofol [Diprivan] vial is spiked, it should be immediately administered. We utilize USP [United States Pharmacopeia; non-profit organization that establishes standards for the quality, purity, and identity of medications and dietary supplements] to define what immediate administration means, which says the product needs to be administered within 4 hours ...While a BUD [Beyond Use Date] of 4 hours can be used to define how long a propofol vial is spiked in the procedural area, I've asked that staff only prep [prepare] one case in advance. This is to limit the amount of propofol being spiked, decrease the potential for drug waste, and decrease the potential for medication errors. Also, the propofol should only be used on a single patient ..."

3. Observations in Endoscopy Center #1 on 10/7/2024 at 2:39 PM, revealed two bottles of Diprivan (medication used for the induction of general anesthesia) 500 milligrams/50 milliliters which were spiked and stored in the bottom of the Certified Registered Nurse Anesthetist (CRNA) medication cart in Procedure Room #18. The CRNA medication cart was unlocked and unattended, and the Diprivan was not labeled with the date or time the medication was spiked.

Observations in Endoscopy Center #1 on 10/7/2024 at 3:00 PM, revealed a 2 ml syringe of vasopressin (medication which raises arterial blood pressure and increases the amount of solute-free water reabsorbed back into circulation) and a 10 ml syringe of nicardipine (medication used to treat high blood pressure and chest pain) were stored on the CRNA medication cart in Procedure Room #20. The CRNA medication cart was unlocked, and the medications were left unattended. There were several, partially filled bottles of Diprivan discarded in a blue plastic biohazard box. The box had a large opening in the lid which allowed easy access to the discarded bottles of Diprivan.

Observations in Endoscopy Center #3 on 10/8/2024 at 2:29 PM, revealed a glycopyrrolate (medication used to decrease mouth, throat, or stomach secretions) injection 0.2 mg/1 ml and a single use vial of acetaminophen (medication used to treat pain) injection 1000 mg/100 ml stored on the CRNA medication cart. The acetaminophen injection vial was spiked, and both medications were left unattended.

4. During an interview on 10/7/2024 at 3:11 PM, when asked about the CRNA medication carts being left unlocked and unattended, Pharmacy Manager #2 stated, " ...the gold standard is to lock the cart ..." When asked about the Diprivan discarded in the blue plastic biohazard box, Pharmacy Manager #2 confirmed this was the accepted practice to discard used bottles of Diprivan.

Based on review of the Food and Drug Administration (FDA) standards of practice, facility policy review, observation and interview, the hospital failed to ensure infection control measures were followed by staff to prevent and control the transmission of infections within the hospital. The hospital failed to adhere to the manufacture's guideline for the storage and usage of expired supplies in 3 of 3 (Endoscopy Center #1, #2, and #3) Endoscopy Procedure Centers. The hospital failed to ensure staff followed appropriate hand hygiene measures for 4 of 4 (Registered Nurse (RN) #3, Gastrointestinal (GI) Technician (Tech) #1, and #2, and Certified Surgical Technologist (CST) #1) staff members observed during an endoscopic procedure.

The findings included:

1. Review of the FDA's recommendations dated 7/25/2024, revealed "A medical product is typically labeled by the manufacture with an expiration date. This reflects the time period during which the product is expected to remain stable or retain its identity, strength quality and purity...Medical Countermeasures (MCMs) that have reached their expiration date in most cases cannot be used..."

2. Observations in Endoscopy Center #1 on 10/7/2024 beginning at 2:10 PM, revealed the following supplies stored open, undated or past their expiration dates:

a. The Adult Emergency Crash Cart had an opened suction yankauer (a rigid, curved, plastic suction tip used in medical procedures to remove fluids and debris from the body) attached to suction tubing, opened to air and had dust on the tubing, packaging, and suction canister sitting on top of the Emergency Crash Cart.

Multifunction Defibrillator Pads (disposable sensors that can detect and correct irregular heartbeats) were stored on the Emergency Crash Cart with an expiration date of 4/24/2022.

During an interview on 10/7/2024 at 2:15 PM, RN #1 confirmed the Multifunction Defibrillator pads had expired, and the opened suction yankauer hooked to suction had dust on the tubing, packaging, and suction canister.

b. The Procedure Room #18 nurses' cart had a Suction Catheter Kit with an expiration date of 6/30/2024.

During an interview on 10/7/2024 at 2:24 PM, RN #2 verified the Suction Catheter Kit was stored past the expiration date.

c. Procedure Room #20 had an Endotracheal (ET) tube 7.5 millimeters (mm) stored opened with an opened syringe attached.

During an interview on 10/7/2024 at 2:36 PM, RN #2 verified the ET tube with a syringe attached was stored while opened.

3. Observations in Endoscopy Center #2 on 10/8/2024 beginning at 9:38 AM, revealed the following stored opened, undated or past their expiration dates:

a. Procedure Room #4 had four small oval flexible single use polyepectomy (polyp removal) snares (a wire loop to remove polyps) in single use packages with an expiration date of 10/4/2024 stored in a Technician Cart.

There were three suction tubings stored opened and unpackaged in the bottom drawer of the supply cabinet.

During an interview on 10/8/2024 at 9:42 AM, the Associate Operating Officer (AOO) verified the four polypectomy snares were stored past the expiration date, and the three suction tubings were stored opened and unpackaged.

b. The Clean Supply Room had seven Multiple Band Ligator bands (used to place band to halt the blood flow) stored with a use by date of 7/26/2024.

During an interview on 10/8/2024 at 10:32 AM, the AOO verified the 7 bands were stored past the use by date.

c. The Crash Cart at the nurses' station had six, 10 milliliter (ml) syringes with 18 G (Guage) 1 ½ (inch) blunt fill needle stored with expiration dates of 5/31/2024.

Adult/(and)Child Multifunction Defibrillator Pads were stored in the Crash Cart with an expiration date of 7/1/2024.

A Chest Tube Tray was stored in the Crash Cart with an expiration date of 9/30/2024.

During an interview on 10/8/2024 at 11:19 AM, Accreditation and Standards Specialist #1 verified the syringes with needles and defibrillator pads were stored past the expiration date.

During an interview on 10/8/2024 at 11:25 AM, RN #2 confirmed the Chest Tube Tray was stored past the expiration date.

d. The Post-Anesthesia Care Unit (PACU) Crash Cart had the following supplies:

Non-conductive suction tubing with an expiration date of 12/1/2022
Electrodes with an expiration date of 8/31/2023
Two carbon dioxide detectors with an expiration date of 2/14/2024
Three-3 lumen (allows for multiple treatments to be administered at once) central venous catheters with an expiration date of 4/30/2024
two pairs of sterile surgical gloves with an expiration date of 4/30/2024

During an interview on 10/8/2024 at 11:30 AM, Accreditation and Standards Specialist #1 verified the supplies listed above were stored in the PACU Crash Cart past the expiration date.

4. Observations on 10/8/2024 beginning at 1:30 PM, revealed Endoscopy Center #3 had the following stored opened, undated or past their expiration dates:
The Special Procedure Room #1 supply cart had eleven catheter tip (syringe without a needle) 50 ml syringes with an expiration date of 8/31/2024.
The Gastrointestinal (GI) cart had a disposable transducer (a medical device used to provide accurate measurements) with an expiration date of 5/31/2024.
During an interview on 10/8/2024 at 3:06 PM, Infection Preventionist #1 verified the supplies listed above were stored past the expiration date.

5. Review of the hospital's "Standard Precautions" policy effective date 1/2022 revealed, "...Standard precautions are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood body fluids, non-intact skin...mucous membranes... Hand hygiene is performed before entry and after exit of the patient environment... Gloves are worn when touching blood, bodily fluids, or items potentially contaminated with blood or body fluids, regardless of the presence of visible blood..."

Review of the hospital's "Hand Hygiene" policy effective date 3/2024 revealed, "...provide guidelines to promote hand hygiene practices...Hand hygiene measures are an essential prevention strategy to avoid healthcare associated infections (HAI).All faculty and staff who enter a patient's environment adhere to the hand hygiene practice guidelines that are consistent with the Centers for Disease Control and Prevention (CDC) recommendations... Decontaminate hands at the following times...Each patient contact ["Before and After"] ...Gloving ["Before"]...Glove removal ["After"]...Handling contaminated objects ["After"]..."

6. Observations in Procedure Room #16 on 10/7/2024 at 11:53 AM, revealed RN #3 donned gloves and assisted in positioning the patient for a procedure, removed gloves, donned a new pair of gloves without preforming hand hygiene, RN #3 used a computer at the nurses cart, gloves were removed, no hand hygiene was performed, and a new pair of gloves was donned to assist in position patient after the procedure, removed the gloved and used alcohol-based hand rub.

Observations in Procedure Room #16 on 10/7/2024 at 12:30 PM, revealed GI Tech #1 cleaned the GI cart and equipment with disinfecting wipes and his bare hands after an endoscopic procedure. GI Tech #1 did not wear gloves while cleaning the GI cart.

Observations in Room #1420 on 10/21/2024 at approximately 12:15 PM, revealed CST #1 removed gloves and failed to perform hand hygiene before a new pair of gloves were donned.

Observations in the Decontamination Room on 10/21/2024 at 12:41 PM, revealed GI Tech #2 removed gloves and donned new gloves without performing hand hygiene.