HospitalInspections.org

Based on personnel file review, policy and procedure review and interview, it was determined the Facility failed to ensure three of three (#1-#3) physicians reviewed were trained on the use of restraints. The failed practice did not ensure the physicians were aware of and trained on the requirements for the application of restraints. The failed practice had the potential to affect all patients on which restraints were applied. The findings follow:

A. Review of the "Restraint and Seclusion Policy" on 05/04/16 revealed the following:
1) "8. Training. 8.1 Hospital and medical staff members shall receive training in the following subjects as appropriate to assigned duties performed under this policy."
2) "8.1.1 Such training shall take place prior to restraint usage in new associate orientation and yearly thereafter."
3) "8.1.2 Physicians who order restraint or seclusion shall be trained in the requirements of this policy."
B. In an interview with the Chief Quality Officer on 05/04/16 at 1530, Physicians #1-#3 were identified as physicians that could order restraints for patients. A request was made for evidence Physicians #1-#3 received restraint training as outlined in the Facility's policy.
C. In an interview with the Chief Quality Officer on 05/04/16 at 1530, she confirmed there was no evidence Physicians #1-#3 had received restraint training.

Based on observation and interview, it was determined the Facility failed to ensure Room #281 was maintained in that tissue paper was inserted in the window of the room. The failed practice did not ensure the temperature of the room could be maintained for patient comfort. The findings follow:

A. Observation of Room #281 on 05/02/16 at 1325 revealed tissue paper was inserted in the window of the room to seal out air from the outside.

B. The findings were confirmed in an interview with the Chief Quality Officer on 05/02/16 at 1325.

Based on observation, review of Manufacturer's directions for use and interview, it was determined the Infection Control Officer failed to control infection in that two of two (Room #266 and #272) bottles of Sterile Water for Irrigation observed labeled as single patient use was not disposed of or discarded after single patient use. The failed practice promoted the spread of infection through cross contamination and had the potential to affect all patients on which the single use item was used. The findings follow:

A. Observation on 05/03/16 at 1330 revealed Registered Respiratory Therapist (RRT) #1 completed a respiratory therapy treatment on the patient in Room #266. RRT #1 rinsed the updraft nebulizer with water from a 1000 ml (milliliter) bottle of Sterile Water for Irrigation. The bottle of Sterile Water for Irrigation had approximately 500 ml of water remaining in the bottle.
B. Observation on 05/03/16 at 1345 revealed RRT #1 completed a respiratory therapy treatment on the patient in Room #272. RRT #1 rinsed the updraft nebulizer with water from a 1000 ml (milliliter) bottle of Sterile Water for Irrigation. The bottle of Sterile Water for Irrigation had approximately 250 ml of water remaining in the bottle.
C. Review of the "Sterile Water for Irrigation" Manufacturer's directions for use on the side of the bottle on 05/03/16 at 1330 revealed, "No antimicrobial agent or other substance has been added. Discard unused portion."
D. The findings were confirmed in an interview with the Intensive Care Unit Director and the Chief Quality Officer on 05/03/16 at 1400.


Based on observation and interview, it was determined the Infection Control Officer failed to control infection in that three of three (#281, 283 and #287) patient rooms observed were not maintained to prevent the spread of infection (large amount of dust and dirt, dried fluids and dead insects). The failed practice promoted the spread of infection and had the potential to affect all patients admitted to those rooms. The findings follow:

A. Observation of rooms designated as clean during a tour of 2-West on 05/02/16 from 1325 to 1340 revealed the following:
1) In Room #281 there was a large amount of dust on the blinds in the windows; a large amount of dust and dirt on the windows; a dark dried stain on the inside drawer of the over-bed table; an oily substance with hair in it on the head of the bed frame; thick dust on the controls at the foot of the bed; and a large thick amount of dust on the vent in the bathroom.
2) In Room #283 there was a large amount of dust on the blinds in the window; thick dust and dirt on the windows; and a large thick amount of dust on the vent in the bathroom.
3) In Room #287 there was a large amount of dust on the blinds in the window; thick dust and dirt on the windows; and a large thick amount of dust on the vent in the bathroom.
4) In the Medication Room there was a large amount of dust on the windows and dead flies and bugs in the window seal.
B. The above findings were confirmed in an interview with the Chief Quality Officer on 05/02/16 at 1340.



Based on observation and interview, it was determined the Infection Control Officer failed to ensure equipment (Intravenous (IV) Poles and Harmonic Scalpel) was maintained to prevent the spread of infection (rust and buildup of dirt). The failed practice promoted the spread of infection and had the potential to affect all patients on which the equipment was used. The findings follow:

A. Observation of Operating Room #2 on 05/03/16 revealed three of four IV poles had a buildup of rust on the casters of the poles which could not be disinfected due to the porous nature of the rust. The Ultrasonic Harmonic Scalpel had a buildup of dirt in the crevices of the machine. The findings were confirmed in an interview with the Director of Quality and Safety Officer on 05/03/16 at 0935.
B. Observation of Intensive Care Unit Room #272 on 05/03/16 revealed two of two IV poles with rust on the casters of the poles which could not be disinfected due to the porous nature of the rust. The findings were confirmed in an interview with the Intensive Care Unit Director and the Chief Quality Officer on 05/03/16 at 1400.



Based on observation and interview, it was determined the Infection Control Officer failed to ensure 5 of 16 linen carts containing linen and scrub attire stored in the Linen Room were covered. The failed practice did not ensure cleanliness was maintained and the linen was protected from dust and soil. The failed practice had the potential to affect all patients on which the linen was used and all staff that wore the scrubs. The findings follow:

A. Observation of the Linen Room on 05/03/16 at 1425 revealed 5 of 16 linen and scrub attire carts were not covered to maintain cleanliness or to protect them against dust and dirt contamination.
B. The findings were confirmed in an interview with the Director of Environmental Services on 05/03/16 at 1425.



Based on observation and interview, it was determined the Infection Control Officer failed to ensure Registered Respiratory Therapist (RRT) #1 disinfected her stethoscope after use on one patient prior to use on the next patient. The failed practice promoted the spread of infection from cross contamination and had the potential to affect all patients admitted to the Facility. The findings follow:

A. Observation on 05/03/16 at 1330 revealed RRT #1 used her stethoscope on the Patient in Room #266 then at 1345 used her stethoscope on the Patient in Room #272. RRT #1 did not disinfect her stethoscope after using it on the Patient in Room #226 or prior to using it on the Patient in Room #272.
B. The findings were confirmed in an interview with the Director of the Intensive Care Unit and the Chief Quality Officer on 05/03/16 at 1400.