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Based on review of policy, review of job description, observation and interview, it was determined Pharmacy Services failed to be in control of all medications in the facility in that Pharmacy Services did not have access to six of six (#1-#6) stocked anesthesia medication carts, and where not inspecting them routinely (monthly), per policy. Pharmacy Services must ensure safe and appropriate storage and usage of medications used in immediate patient care areas (operating rooms) in which anesthesia medication carts were rolled into and medications were administered from, during procedures and surgeries. By not having had access to Anesthesia Services' medications, there was no way Pharmacy Services could assure the safety and appropriate storage of these medications. This failed practice had the likelihood to affect all patients that had procedures/surgeries in the facility. Findings follow:

A. Record review of the policy titled, "Pharmacy Unit Inspections Policy," revised 06/19/18, showed Pharmacy Services was responsible to inspect all areas in the hospital where medications were dispensed, administered or stored, routinely.
B. Review of the Director of Pharmacy Services position description showed the Pharmacist in Charge was responsible for the control of all medications and for the proper provision of all pharmaceutical services.
C. During a tour of Surgical Services on 04/29/19 from 1:17 PM until 2:21 PM, observation showed six locked anesthesia carts.
D. During an interview on 04/29/19 at 1:59 PM, the Director of the Operating Room was asked to unlock the carts for inspection. The Director of the Operating Room stated that he did not have access to the carts, nor did Pharmacy Services. He stated that the anesthesia providers were the only ones who had access to their individual anesthesia carts.
E. During an interview on 4/30/19 at 2:00 PM, the Director of Pharmacy verified Pharmacy Services did not have access to the medications stored on the anesthesia carts and they were not inspecting them monthly, like they were medication stored in other areas of the hospital.

Based on review of policy, review of medication errors, review of a patient's clinical record and interview, it was determined the facility failed to document in the clinical record, a drug administration error and notification of the error to the patient's physician for one of one (#31) wrong patient medication administration error. By not documenting the drug administration error and notification of the patient's physician, the patient's medical condition could not have been known to health care providers for continuity of care and medical treatment decisions. This failed practice had the likelihood to affect all patients treated at this facility. Findings follow:

A. Review of policy titled, "Administration of Drugs Policy-Documentation in Patient Record," revised 07/18/19, showed Drugs administered (including those in error) shall be documented in the patient's clinical record.
B. Review of a list of medication administration errors from 04/30/18 through 04/30/19 showed one "wrong person" medication error on 11/10/18.
C. Review of Patient #31's clinical record showed there was no documentation of the unordered medication, Methylprednisolone, that was administered at 04:03 AM and no documentation the patient's physician was notified of the patient receiving the medication in error.
D. During an interview on 04/30/19 at 03:30 PM, the Chief Executive Officer and the Clinical Informatics Officer verified the medication was given in error nor notification of the patients physician was documented anywhere in the Patient #13's clinical record.

Based on observation and interview, it was determined the infection control officer failed ensure refrigerated foods were labeled and dated and that expired foods were not available for use. The failed practice created the potential for patients to experience a foodborne illness due to receiving expired foods and was likely to affect any patient who received those food items. Findings included:

Observation on 04/29/19 from 1:46 PM - 3:00 PM of the kitchen and Dietary Department showed:
1) Cooler:
a) One small pan identified by the Dietary Director as a two-inch batter pan, without a date or label to identify the contents. The Chef identified the contents as a pineapple cake and confirmed there was no label or date on 04/29/19 at 2:06 PM.
b) One large sheet pan, identified by the Dietary Director as containing corn bread was dated 04/26/19 with an expiration date of 04/28/19. During an interview on 04/29/19 at 2:06 PM, the Dietary Director confirmed the expiration date of the cornbread.
2) Ambassador Refrigerator:
a) One pan of green color gelatin, dated as prepared 04/22/19 at 3:15 PM and dated expired 04/27/19. During an interview at 2:24 PM on 04/29/19, the Dietary Director confirmed the gelatin was expired.
b) A total of 14 white Styrofoam cups and 14 clear cups were not labeled with the contents or dated. During an interview on 04/29/19 at 2:40 PM, the Dietary Director confirmed there was no label or date on the Styrofoam cups that contained Juven or the clear cups that contained pudding.
c.) One large pan of cubed green color gelatin and six additional pans of gelatin dated 04/28/19 that did not have a date of expiration. During an interview on 04/29/19 at 2:40 PM, the Dietary Director confirmed the findings in 2b and c.
3) Patient line refrigerator: two pans of green color gelatin were not dated. During an interview on 04/29/19 at 2:44 PM, the Chef confirmed the lack of date on the gelatin.


Based on observation, review of work assignments and interview, it was determined the infection control officer failed to ensure a clean and sanitary environment in the kitchen in that there was an accumulation of dust on two of two cooler vents; pans, dry mop and a grill brush were stored on the floor surface beside the grill; and there was an accumulation of grease on and around the oven and fryers. Failure to ensure a clean and sanitary environment in the kitchen did not protect patients and staff from likely sources of contamination. Findings included:

A. Observation on 04/29/19 from 1:46 PM-3:00 PM of the kitchen and Dietary Department showed:
1) Dust accumulation on the air vent in the dish room and the patient line refrigerator. During interview at 2:44 PM on 04/29/19 the Chef confirmed the dust on the air vent.
2) Grease accumulation observed as thick drips down the front left of the grill, down the wall behind the grill, on the cooktop/oven burner knobs and on the pipes behind the oven. There was a thick accumulation of grease down the sides of two of two fryers. The column behind the fryers, on the wall beside the windows, had a large thick accumulation of grease drips extending from the top toward the lower one-third length of the column.
3) Two sheet pans, a dry mop and a grill brush were observed stored beside the grill and on the floor surface.
B. During an interview on 04/29/19 at 3:00 PM, the Dietary Director and the Chef confirmed the observations in A. The Chef stated that it was the Porters responsibility to clean the fryers, stove and grills on Saturdays and was supposed to have been done this past Saturday, 04/27/19.
C. On 05/03/19 the Chief Quality Officer provided a document titled, "Cleaning Assignments for the PM Porter" that showed on weekends the deep fat fryers were to be cleaned as needed and any other duties as assigned were to be completed.


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Based on interview, and review of Tuberculosis (TB) skin tests, it was determined the Infection Control Nurse failed to prevent and control infections in that:
1. One (Certified Scrub Technician (CST) #2) of 15 (#1-11 RNs and #1-4 CSTs) current Operating Room employees had no follow-up after a positive TB skin test
2. One (RN #7) of fifteen (#1-11 RNs and #1-4 CSTs) current Operating Room employees did not have a current TB skin test.

Failure to ensure all staff had a current TB screening and failure to follow up on a positive TB skin test had the potential to allow TB exposure to patients, visitors and other staff members. The failed practice had the likelihood to affect patients, visitors and other staff members. Findings follow:

A. The Infection Control Preventionist (ICP) stated during an interview at 9:30 AM on 05/01/19 that all employees were required to have a TB skin test annually. The ICP stated that if an employee had a positive TB skin test, it was repeated. If the second TB skin test was positive, a (QuantiFERON-TB) Gold was performed. The ICP stated that the facility considered an induration of > (greater than) 10 mm was a positive reading, any case of confirmed TB was reported to the Arkansas Department of Health, and the facility paid for any necessary treatment needed by the employee.
B. Review of CST #2's TB skin test showed a TB skin test result dated 07/26/18 with a positive reading at 15 mm (millimeters). The ICP stated during an interview at 1:51 PM on 05/02/19 that there was no follow-up of the positive TB skin test for CST #2.
C. Review of RN #7's TB skin test showed it was placed on 08/22/18. Review of RN #7's Healthcare Personnel Immunization Record showed no results of the TB skin test done on 08/22/18. The Chief Quality Officer verified the above findings during an interview at 3:02 PM on 05/02/19.


Based on policy and procedure review, observations and interview, it was determined the Infection Control Preventionist failed to identify and prevent infections in that single dose medication vials and access ports were not cleaned prior to puncture with a needle in one of one (#32) patient's surgical procedure observed. Failure to cleanse the top of the single dose medication vial prior to inserting a needle to withdraw medication and to clean the access port prior to administering medications did not ensure the cleanliness of the vial top and the access port. The failed practice had the likelihood to affect Patient #32 on 04/30/19. Findings follow:

A. Review of the policy and procedure titled, "Guidelines for Infection Control in Intravenous Therapy," received from the Chief Quality Officer at 8:55 AM on 05/02/19, showed access ports were to be wiped with 70% (percent) alcohol prior to accessing the port.
B. Observation during the surgical procedure of Patient #32 showed the following on 04/30/19:
1) At 8:46 AM, Physician #1 did not clean the top of the vial containing Xylocaine 2% 5 ml (milliliter) prior to inserting a needle and withdrawing the medication.
2) At 8:51 AM, Physician #1 did not cleanse the access port prior to administering Diprivan.
3) At 8:52 AM, Physician #1 did not cleanse the access port prior to administering Succinylcholine.
4) At 9:28 AM, Physician #1 did not clean the tops of the vials containing Zofran 4 mg (milligram)/2 ml and Reglan 10 mg/5ml prior to inserting a needle and withdrawing the medication.
5) At 9:30 AM, Physician #1 did not clean the top of the vial containing Ephedrine 50 mg/ml prior to inserting a needle and withdrawing the medication.
6) At 9:44 AM, Physician #1 did not clean the tops of three vials, each containing Robinul, prior to inserting a needle and withdrawing the contents of each of the three vials and did not cleanse the access port prior to administering the Robinul and a pre-filled syringe containing Neostigmine.
C. The One Day Surgery Director verified the above findings during observation of the surgical procedure from 8:30 AM to 9:50 AM on 04/30/19.
D. During an interview with the Operating Room Director and the One Day Surgery Director at 10:05 AM on 04/30/19, both stated that it was practice to cleanse the top of a vial prior to inserting a needle and to cleanse the access port prior to inserting a needle to administer anything.

Based on clinical record review and interview, it was determined the facility failed to ensure the operative time was included in the operative report for ten (#2-#6, #8-#10, #13 and #14) of twelve (#1-#10, #13 and #14) patients. Failure to assure the operative time was notated in the operative report did not allow knowledge of which surgical procedure was performed in what order in the event a patient underwent multiple surgeries in one day. The failed practice affected Patients #2-#6, #8-#10, #13 and #14. Findings follow:

A. Review of the operative reports for Patients #2-#6 and #8-#10 showed the operative reports did not contain the time of the surgical procedure.

B. During record review from 8:45 AM to 10:15 AM on 05/03/19, the findings in A were verified by the One Day Surgery Director.

C. Review of the operative reports for Patients #13 and #14 showed that the operative reports did not contain the time of the surgical procedure. Review of Patient #13's clinical record showed it contained two operative reports, both dated 04/28/19, and neither contained the time of surgery.

D. The Chief Quality Officer verified the findings in C during an interview at 11:00 AM on 05/03/19.