HospitalInspections.org

Based on observation and interview, the facility failed to post the current address of the California Department of Public Health (CDPH) in the lobby of two primary care clinics covered under the main facility's license. This failure could delay a patient or family member's attempt to contact CDPH for a grievance issue by mail.

Findings:

During an observation and concurrent interview with Administrative Staff W and Administrative Physician X, on 6/28/11 at 9:10 am, at Mercy Family Health Center, the postings in the main lobby were reviewed. The mailing address posted for CDPH was incorrect. This observation was confirmed with Administrative Staff W and Administrative Physician X.

During an observation and concurrent interview with Administrative Physician X and Administrative Nurse Y, on 6/28/11 at 10 am, at Mercy Maternity Clinic, the postings in the main lobby were reviewed. The mailing address posted for CDPH was incorrect. This observation was confirmed with Administrative Physician X and Administrative Nurse Y.

Based on document review, the facility failed to ensure a patient's right to make informed decisions regarding care when Patient 54 was not informed of the consequences of refusing Buspirone, Escitalopram, Enoxaparin, and Docusate.

Findings:

A review of the hospital policy, "Patient Rights and Responsibilities," dated 05/03/11, indicated, "The hospital's policies and procedures support the following rights of the patient to ...Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure. "

Clinical record review indicated that Patient 54 had a medical history of constipation, depression, anxiety, and deep vein thrombosis (blood clotting disorder). Patient 54 had physician's orders for Buspirone and Escitalopram which were used to treat anxiety and depression. Patient 54 was also on Enoxaparin for the deep vein thrombosis, and Docusate for constipation.

A review of Patient 54's Medication Administration Record, dated 06/19/11, indicated Patient 54 had refused taking Buspirone, Escitalopram, Enoxaparin, and Docusate. There was no indication in the clinical record that the patient was informed of the consequences of refusing these medications.

The hospital did not provide evidence that Patient 54 was fully informed of the consequences of refusing Buspirone, Escitalopram, Enoxaparin, and Docusate.

Based on observation, interview, and document review, the nursing staff did not administer medications in accordance with physician's orders and standards of practice as evidence by:
1. The hospital failed to administer Advair as ordered by the physician when a nurse administered Advair two puffs daily instead of one puff daily.
2. The hospital failed to ensure the safe use of medications when intravenous (IV) fluids were not administered in accordance with physician's orders which resulted in 3 medication errors out of 3 IV fluid patients.
3. The hospital failed to administer Norepinephrine safely when Norepinephrine was tapered down without a physician's order, and at a faster rate then hospital protocol.
4. The hospital failed to administer Magnesium Sulfate as ordered by the physician when a nurse did not follow the hospital protocol and under-dosed a patient who should have received 3 grams of Magnesium Sulfate instead of 2 grams.

Findings:

1. Clinical record review indicated that Patient 55 had a medical history of asthma that was being treated with an Advair (Fluticasone/Salmeterol) diskus inhaler one puff twice daily.

An observation of Patient 55's Advair inhaler, on 06/28/11 at 10:43 am, showed that two days of medication was administered out of Patient 55' s Advair inhaler.

A review of Patient 55's clinical record indicated that Advair was started on 06/27/11. The Medication Administration Record (MAR) indicated that one day of medication was administered.

There was a discrepancy of one extra day administered when comparing the actual Advair inhaler to the clinical record.

During an interview, on 06/28/11 at 10:50 am, Nurse 1 stated she was the nurse that administered Patient 55's Advair. She also stated the reason why there was a one extra day administered discrepancy was because the patient administered two puffs twice daily instead of one puff twice daily as ordered by the physician.

2. On 06/28/11 at 3:40 pm, Patient 56 was observed, in the obstetrics gynecology post operative anesthesia care unit (OB/GYN-PACU), receiving intravenous (IV) fluids without an IV pump. In order to determine the rate of fluid administered, you would have to count drops and calculate the rate. The observed calculated rate was 80 ml/hr. The clinical record indicated the physician's order was for 125 ml/hr. When asked, Nurse 2 stated that she did not know the IV rate.

On 06/28/11 at 4:25 pm, in the post operative anesthesia care unit (PACU), IV fluids were observed being administered to the following patients without an IV pump. The observed calculated rates were as follows:
Patient 57- No IV fluids were running
Patient 58 - IV fluids were being administered at 100 ml/hr

A review of clinical records for Patients 57 and 58 indicated IV fluid physician orders that should have been administered in the PACU:
Patient 57-100 ml/hr
Patient 58-125 ml/hr

There were a total of three medications errors in which IV fluids were not administered in accordance with physician's orders.

3. A review of the hospital policy, "Management of Medications," dated 06/07/11, read, "The following have been defined as high risk and/or high alert medications ...Vasopressor Agents [includes Norepinephrine]."

On 06/29/11 at 11:12 am, Patient 59 was observed in the intensive care unit (ICU), on Norepinephrine (Levophed) for septic shock. The rate of administration was being tapered down at a rate of 1.008 mcg/min. A review of the clinical record did not indicate a physician's order to taper down the Levophed.

A review of the hospital's Levophed protocol, dated 05/13/09, for tapering down Levophed indicated "To discontinue infusion, with physician's order, taper Norepinephrine infusion at 4 ml/hr (1 mcg/min) every 30 minutes."

A review of Patient 59's flowsheet indicated that the rate prior to 1.008 mcg/min was 2.8 mcg/min.

Patient 59 did not have physician's order to taper down the Levophed. The Levophed was not tapered down in accordance to hospital protocol because the tapering schedule was faster then 1 mcg/min (changed from 2.8 to 1.008).

4. A review of Patient 60's clinical record indicated that he had a medical history of low magnesium (electrolyte imbalance). His low magnesium was being treated with intravenous magnesium sulfate per hospital protocol.

A review of the hospital protocol, "Magnesium Sulfate IV Replacement Protocol for Adults," dated 03/11/10, read, "IV magnesium sulfate replacement ...If magnesium level is less than or equal to 1.6 mg/dL, give 1 gram magnesium sulfate diluted to 50 ml IV solution over 1 hour times three doses for a total of 3 grams in 3 hours ...If magnesium level is equal to 1.7-1.9 mg/dL, give 1 gram magnesium sulfate diluted in 50 ml IV solution over 1 hour times two doses for a total of 2 grams in 2 hours."

A review of Patient 60's clinical record indicated that his magnesium level was 1.20 on 06/22/11. There were physician's orders for magnesium replacement per protocol on the same day. Based on the protocol 1 gm of magnesium sulfate every hour for a total of 3 gm should have been administered. Instead, according to Patient 60's MAR, on 06/22/11, 2 grams of magnesium sulfate was administered by the nurse.

The nurse did not follow the hospital protocol, and did not administer 3 grams of magnesium sulfate as ordered by the physician.

Based on interview and record review, the facility failed to implement the facility's policy and procedure for conscious sedation (sedative and analgesic induced, mild depression of consciousness for anxiety and discomfort) as evidence by:
* Failing to follow the facility policy, for monitoring 2 sampled patients (Patients 103 and 105) receiving conscious sedation. (refer to items 1 and 2)
* Failing to document the order and administering of a local anesthetic (lidocaine, numbing agent) used before starting an intravenous line for Patient 101. (refer to item 3)


Findings:

The "Immediate Reassessment" section of the facility's "Sedation/Analgesia (Minimal-Moderate) Procedure" policy, dated 3/30/11, read "Assess and document the following a minimum of every five minutes during medication administration, and every five minutes for 30 minutes after medication administration: respiratory rate, pain intensity, oxygen saturation, heart rate, and blood pressure (vital signs)."

1. On 6/24/11 at approximately 2 to 3 am, Patient 103 received conscious sedation (versed and fentanyl) for a bronchoscopy procedure (a fiberoptic tube passed through the nose into the tracheobronchial tree for visualization and removal of tissue/secretions).

On 6/29/11 at 4:45 pm, Patient 103's record was reviewed with Administrative Nurse (AN) BB. AN BB confirmed there was no documentation of vital sign monitoring during the bronchoscopy procedure when Patient 103 received conscious sedation.

2. On 6/29/11, Patient 105's record was reviewed. Patient 105 had an esophagogastroduodenoscopy (EGD, a fiberoptic tube passed through the mouth, esophagus, stomach and duodenum for visualization and removal of tissue or a foreign body) on 6/14/11. The following day, 6/15/11, he had a colonoscopy (a flexible fiberoptic endoscope for visualization and removal of tissue of the entire colon). The following were identified in the record.
a. Documentation for the EGD showed that Patient 105 received sedation for the procedure, however, the time(s) of administration was not documented, and there was no documentation that vital signs were taken every 5 minutes for a minimum of 30 minutes after the last dose of medication was administered.
b. The documentation for the colonoscopy had vital signs (every 5 minutes) from 1:49 pm to 2:08 pm, however, the last dose of sedation (versed) was given at 2:09 pm. There was no documentation that Patient 105's vital signs were monitored every 5 minutes for 30 minutes after the last dose of medication was administered.

3. On 6/23/11, Patient 101 had a procedure that required the administration of fluids and medications into a vein (IV - intravenous).

On 6/27/11 at 11:30 am, Patient 101 stated that before her IV was started, she asked the nurse to use lidocaine (anesthetic) under the skin to numb the area, and that the nurse complied with her request.

On 6/27/11, Patient 101's record was reviewed. There was no documentation that the nurse obtained an order for lidocaine prior to administering the medication, and no documentation that she administered the medication prior to starting the IV.

On 6/30/11 at 11:45 am, Licensed Nurse (LN) AA stated that she injected lidocaine under Patient 101's skin prior to starting the patient's IV. LN AA stated that she did not document that she gave the medication, and did not write and order to give the lidocaine, because the order came from the written protocol for starting IVs.

Based on interview and record review, the facility failed to ensure medical record entries were dated and timed for 3 of 50 sampled patients. (Patients 114, 115, and 117) The outcome could result in miscommunication of events, results of actions, and inability to identify actual and potential problems.

Findings:

The facility's "Management of Information" policy, dated 7/06, read, "All entries must be time, dated and authenticated."


26611

1. On 6/29/11, Patient 114 and 115's records were reviewed. Patients 114 and 115's records contained Initial Patient Assessment forms which did not indicate the time that the assessment was completed.

2. On 6/29/11, Patient 117's record was reviewed. Patient 117's record contained an Initial Patient Assessment form which did not indicate the time or date that the assessment was completed.

On 6/30/11 at 12:15 pm, Administrative Nurse Z acknowledged that Patient 114, 115, and 117's initial assessment forms should have been dated and/or timed.

26611

Based on interview and record review, the facility failed to ensure verbal orders were countersigned within 48 hours for two of 50 sampled patients. This failure had the potential for an undetected medication error to persist throughout the patient's stay. (Patients 116, and 117)

Findings:

The facility's Medical Staff Bylaws, dated 5/11, read, "Telephone/verbal orders shall be countersigned, dated and timed by the prescriber, or another physician if the prescriber is not available, within forty-eight (48) hours."

On 6/27 through 6/30/11, Patients 116 and 117's records were reviewed. These records were found to have verbal orders which did not have evidence of a countersignature within 48 hours, as follows:
1. Patient 117's record contained nine verbal orders, dated 6/16 and 6/17/11, which were not signed until 6/20/11, three and four days later.

2 a. Patient 116's record contained a verbal order, dated 6/4/11, which was not signed until 6/20/11, 16 days later.
b. Patient 116's record contained a verbal order, dated 6/6/11, which was not signed until 6/21/11, 15 days later.

On 6/30/11 at 12:25 pm, Administrative Nurse Z acknowledged Patient 116 and 117's verbal orders should have been countersigned within 48 hours of the verbal order.

Based on observation, interview, and document review, medications were not controlled by the pharmacy in accordance with applicable standards of practice as evidence by:

1. The hospital pharmacy quality program failed to ensure the safe administration of medications when six medications errors were not identified and addressed in the pharmacy quality program. (Patients 55, 56, 57, 58, 59, 60, and
2. The hospital pharmacy failed to notify a patient of the consequences of refusing Lovenox (Enoxaparin) which could result in serious harm. (Patient 54)

Findings:

A review of the hospital's "Management of Medications" policy, dated 06/07/11, read, "MEDICATION ERRORS - A medication error is considered any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer."

a. A review of Patient 55's clinical record indicated that he had a medical history of asthma that was being treated with an Advair (Fluticasone/Salmeterol) diskus inhaler one puff twice daily.

An observation of Patient 55's Advair inhaler, on 06/28/11 at 10:43 am, showed there was a discrepancy of one extra day administered when comparing the actual Advair inhaler to the clinical record.

During an interview, on 06/28/11 at 10:50 am, Nurse 1 stated the patient was administered two puffs twice daily instead of one puff twice daily as ordered by the physician.

b. On 06/28/11 at 3:40 pm, Patient 56 was observed, in the obstetrics gynecology post operative anesthesia care unit (OB/GYN-PACU), on intravenous (IV) fluids without an IV pump. In order to determine the rate you would have to count drops and calculate the rate. The observed calculated rate was 80 ml/hr. The clinical record indicated the physician's order was for 125 ml/hr.

c. On 06/28/11 at 4:25 pm, in the post operative anesthesia care unit (PACU), the following patients were being administered IV fluids without an IV pump. Patient 57's IV, that was ordered to run at 100 ml/hr, was not running, and when observed and calculated, Patient 58's IV rate was running at 100 ml/hr, instead of 125 ml/hr as ordered by the physician.

There were a total of three medications errors in which IV fluids were not administered according to physician's orders.

d. On 06/29/11 at 11:12 am, Patient 59 was observed in the intensive care unit (ICU) receiving Norepinephrine (Levophed) for septic shock. The infusion rate was being tapered down at a rate of 1.008 mcg/min. A review of the clinical record did not indicate a physician's order to taper down the Levophed.

e. A review of the clinical record indicated that Patient 60 had a medical history of low magnesium (electrolyte imbalance). His low magnesium was being treated with intravenous magnesium sulfate per hospital protocol. Patient 60's magnesium level was 1.20 on 06/22/11. There was a physician's order for magnesium per protocol on the same day. Based on the protocol, Patient 60 was to receive 1 gm of magnesium every hour for a total of 3 gm. A review of Patient 60's Medication Administration Record (MAR) indicated 1 gm of magnesium every hour, for a total of 2 grams, was administered on 06/22/11.

The hospital pharmacy quality program (medication error reduction program) did not provide evidence to show that the above six medication errors were identified and addressed to improve medication safety and reduce medication errors.

2. A review of the clinical record indicated Patient 54 had a history of deep vein thrombosis (blood clotting disorder). Patient 54 was also on Lovenox (Enoxaparin) for this condition. A review of the MAR dated 06/19/11 indicated that she had refused to take Enoxaparin.

A review of a document titled, "Anticoagulant Dosage Return Monitoring," dated 06/21/11, indicated a daily report of medications that were returned to the pharmacy. The report indicated that Patient 54 refused her Enoxaparin.

During an interview, on 06/28/11 at 2:25 pm, the Director of Pharmacy (DOP) stated the daily report of returned medications indicated Patient 54 refused her Enoxaparin. Based on this information the pharmacist should have ensured Patient 54 was fully informed of the consequences of refusing Enoxaparin. Refusing Enoxaparin could result in a serious blood clot.

A review of the clinical record did not indicate that Patient 54 was fully informed of the consequences of refusing Enoxaparin. There was no indication in the clinical record that refusing Enoxaparin could result in serious harm.

The hospital did not provide evidence that Patient 54 was fully informed of the consequences of refusing Enoxaparin.

Based on food storage observations, the hospital failed to ensure that food items were dated when they were opened. Failure to date items may reduce palatability of foods due to extended storage timeframes.

Findings:

Hospital policy titled, "Labeling, Dating, Covering Food," dated 7/10, guided staff that all refrigerated food will have a label that identifies the item, date opened, and a use by date.

Freezer #3 contained 3 boxes of cookie dough, and 1 box of brownies, that were open and undated. Similarly, in the walk-in freezer there was a box of tilapia, carrots, and omelets that were opened and undated.

In a concurrent interview with DMS A she stated that the policy was to date items upon arrival, and to again date the item when it was opened. She acknowledged that all open items should have two dates.

Based on dietary staff interview, and dietary document review, the hospital failed to ensure comprehensive sanitation training for one cook. Failure to ensure proper cleaning of fixed food production equipment may result in cross contamination.

Findings:

An undated hospital document titled, "Guidelines for the Cleaning and Sanitizing of the Meat Slicer" guided staff to wash the equipment using soapy water, rinse and then sanitize.

In an interview, on 6/27/11 beginning at 3:30 pm, the surveyor asked Dietary Staff (DS) D to describe the process for cleaning fixed food production equipment, in particular the meat slicer. DS D stated that she would run the removable parts through the dishwasher. She also stated she would wipe off the foodstuffs, after which, she would spray the equipment with sanitizer and cover it with plastic.

Based on trayline observations, and dietary staff interview, the facility failed to ensure that the diets delivered to patients were those that were ordered by the physician for two of nine patients reviewed for nutrition care (Patients 161 and 163).

Findings:

During trayline observations on 6/27/11, beginning at 12 pm, it was noted that there were complex diets, with multiple therapeutic restrictions, for Patients 161 and 163.

On 6/27/11 at 3:15 pm, in an interview with Dietary Staff (DS) F she was asked to describe the diet entry system. She stated that the diets were entered on the individual medical units and were transmitted to the diet office. She also stated that the meal tray tickets were printed shortly before each trayline to ensure patient's received the most recent diet order.

DS F was asked to print the noon meal ticket for Patients 161 and 163. It was noted that the tray ticket for Patient 161 was a diabetic, cardiac, 2 gram sodium restriction diet. Similarly, the tray ticket for Patient 163 was cardiac, low cholesterol, low fat, no concentrated sweets diet with a 4 gram sodium restriction.

Review, on 6/28/11 beginning at 10 am, of the physician ordered diet for Patient 161, dated 6/26/11, was an ADA cardiac diet. The physician did not order a sodium restriction. The physician ordered diet for Patient 163, dated 6/26/11, was a cardiac diet. The physician did not order a no concentrated sweets diet.

Based on Registered Dietitian interview, and dietary document review, the hospital failed to have a diet manual that was specific to the diets that the hospital routinely ordered, and provides guidance to medical, nursing and food service staff for the ordering and preparation of patient diets.

Findings:

In an interview, on 6/28/11 beginning at 9 am, Registered Dietitian (RD) C stated that the hospital utilized the American Dietetic Associations' online Nutrition Care Manual (NCM) as the diet manual. She stated that the NCM did not provide information on the specific diets that the hospital provided to its' patients, but instead provided information on many different diets for a specific diagnosis, whether or not the facility had those diets available for patients.

A review of the hospitals diet list, dated 6/27/11, revealed that there were a variety of diets including multiple levels for dysphasia patients, cardiac diets, renal, and clear liquid diets.

In an interview, on 6/28/11 at 10 am, RD E acknowledged that the NCM did not provide specific guidance on the hospitals' diets. He also stated that during the past several years he had been working on developing the specifications for the hospital offered diets; however the document has not yet been implemented as an adjunct to the NCM.

Review of the hospital document titled, "Diet Manual" dated 6/09, noted that the dietitian(s) will develop or adopt a diet manual in cooperation with the medical staff. It was also noted that while the medical staff approved the use of the electronic NCM as the diet manual, there was no indication that the physicians were advised of the shortcomings of the document.

Based on food storage observations, and facilities staff interview, the hospital failed to ensure disaster preparedness supplies were stored within the general acute care hospital. Storage of disaster supplies outside of the hospital may result in the unavailability of supplies in the event of a widespread disaster.

Findings:

During review of disaster preparedness, on 6/27/11 at 3:45 pm, it was noted that while the hospital had a supply of food and water to be utilized in the event of a disaster, the supplies were not stored within the hospital. Rather, they were stored in an adjacent medical office building.

In an interview, on 6/28/88 at 1 pm, Facilities Management Staff E acknowledged that while the adjacent building was built at the same time as the hospital, it was not part of the licensed general acute care hospital.

8. In the walk-in refrigerator there were 12 chubs of ground beef each weighing approximately 5 pounds, fully thawed, with a thaw date of 6/24 and a use by date of 6/30 (6 days later); 4 pans each containing four-5 pound bags of raw beef, fully thawed, with no thaw date and a use by date of 4/26; 6 bags of stew meat, thawed on 6/27 and a use by date of 7/2 (6 days later). In the refrigerator adjacent to the walk-in refrigerator there were several bags of cooked roast beef with no thaw date and an expiration of 6/26.

In a concurrent interview with DMS A she was asked to describe the system to determine the length of time foods would be held under refrigeration. She stated that the hospital had a consistent menu and the meats would be thawed approximately 3 days prior to being used. She also stated that the hospital had a food storage guideline policy. She also stated that the meats should have been dated at the time they were pulled from the freezer in addition to the date for which they were to be used.

In an interview on 6/27/11 at 3 pm, with Dietary Staff (DS) D she stated that she pulled the pre-cooked roast beef on 6/23 (4 days prior).

The hospital policy titled, "Food Storage Guidelines," dated 10/04, guided staff that ground, stewing meats and variety meats should not be held for longer than 1-2 days.

9. During general food production observations on 6/27/11 beginning at 11:30 am, it was noted that there was a pan of cream of rice in the under counter refrigerator adjacent to the tray line. Cream of rice is considered to be a potentially hazardous food (PHF) and is capable of supporting bacterial growth associated with food borne illness. To ensure food safety PHF's should be monitored for time/temperature control (Food Code, 2009). The surveyor took the temperature of the item and noted it to be 115?F.

In a concurrent interview,DS B stated that there was a patient that received the item with each meal. He also stated that the item was cooked at 7 am, and that at 9 am he checked the temperature of the item and found it to be 70?F. On 6/27/11 at 11:40 am, the surveyor requested he take the temperature which was noted to be 110?F. DS B was unable to explain the difference in the temperatures. In a follow up interview with RD C on 6/27/11 at 3:30 pm, she acknowledged the item was likely not monitored and that holding of foods for multiple meals was not usually the standard of practice.

Review of hospital document titled "Food Cooldown/Chill Down Tracking Log" for 6/27/11, noted that the item was not entered on the log. The log also guided staff that the temperature of the item should be 70?F or below within 2 hours, and 40?F or less, within an additional 4 hours.

10. During review on 6/28/11 at 1:30 pm, of food holding practices in the cafeteria, it was noted that there were several PHF's that were above 41?F. The temperature of the items were as follows: egg salad - 48?F, chicken salad - 52?F; deli meat - 48?F and deli meat that was held in the grill area-55?F. In a concurrent interview with DMS A the surveyor asked her to describe the process for monitoring time/temperature for the identified food items. She stated that the temperature of the items was obtained when the items were first set up at approximately 8 am. She sated a follow up temperature would be taken a second time in the late afternoon, around 4 pm, prior to opening for dinner. She also stated that while the cafeteria closed from 2:30-4 pm, the foods in the deli/salad bar area would remain within the unit. She also stated that she would not be able to tell how long the items were out of temperature range.

Hospital document titled "Holding Temperature Log" for 6/28/11 noted that the acceptable temperature of cold foods was less than or equal to 40?F. The standard of practice would be to ensure that PHF ' s remained under time/and or temperature control to ensure food safety for a period of time that does not allow food temperatures to be above 41?F for more than 4 hours cumulatively (Food Code, 2009).

11. During review of sanitation procedures on 6/27/11 at 2:40 pm, it was noted that in the dish room dietary staff was storing racks that held cleaned and sanitized dishes directly in front to the manual dishwashing sink. It was also noted that the power scrubber on the sink were turned on and there were soiled bowls in the sink. In a concurrent interview with RD C she stated that due to limited space in the dish room dietary staff found it necessary to utilize the space in front of the sink while waiting for the dishes to be run through the dish machine and acknowledged the proximity of the sanitized dishes to the manual dishwashing area may result in cross contamination.

Review of hospital policy titled "Dishwashing and Pot and Pan Washing Guidelines" dated 10/04 revealed that while the document provided procedures for dishwashing it did not address storing cleaned/sanitized dishes to ensure the prevention of cross contamination.




28991

Based on observation, interview, and document reviews, the facility failed to develop and implement effective systems for identifying, investigating, monitoring, and controlling infectious and communicable diseases of patients and personnel, and failed to ensure safe food handling practices as evidenced by:

1. The hospital failed to have an effective system in place to ensure personnel were consistently screened for infectious diseases in accordance with national standards.

2. The hospital failed to have an effective system in place to ensure appropriate identification of restricted areas and traffic patterns in a surgical area in accordance with national standards.

3. The hospital failed to ensure personnel used a high level disinfectant in accordance with national standards.

4. The hospital failed to have an effective system in place to ensure endoscopes were cleaned and disinfected at a minimum of every five days in accordance with national standards.

5. The hospital failed to have an effective system in place to ensure sharps and syringes were disposed of in accordance with national standards.

6. The hospital failed to have an effective system in place to ensure Methicillin Resistant Staphylococcus Aureus (MRSA) testing, for eligible patients, was performed within 24 hours of admission to the hospital. MRSA refers to the Staphylococcus Aureus bacteria (germ) strains that do not respond to some of the antibiotics used to treat staph infections. Additionally, the facility failed to have a system in which physicians document notification of positive MRSA test results to patients who test positive for the organism in accordance with State standards.
7. The hospital failed to have an effective sytem in place to ensure glucometer cleaning was performed in accordance with national standards.
8. The hospital was holding thawed foods for extended timeframe's.
9. The hospital lacked monitoring of potentially hazardous food during the cool down phase.
10. The hospital lacked an effective system for time/temperature control of cold potentially hazardous foods.
11. The hospital stored cleaned dishes in a manner that left them susceptible to cross contamination.
Failure in identifying, investigating, monitoring, and controlling infectious and communicable diseases of patients and personnel, and not ensure safe food handling could expose patients to infections, illnesses, hospital complications, and compromise the safety and health for all patients.
Findings:
1. On 6/27/11, Family Nurse Practitioner (FNP) SS's credential file was reviewed. The review identified that FNP SS had her privileges to practice at the hospital suspended on 4/1/11, pending provision of a current tuberculosis PPD skin test. The review identified FNP SS had a skin test for tuberculosis on 4/13/11. The results of the skin test were read approximately 24 hours later and determined to be negative. FNP SS had her privileges to practice at the hospital reinstated on 4/26/11.

During an interview, on 6/29/11 at 10:40 pm, Administrative Nurse DD acknowledged the screening test for tuberculosis should have been read 48 to 72 hours after placement of the test for the result to be valid. Administrative Nurse DD indicated that FNP SS's privileges to practice at the hospital would need to be suspended until a valid result of the tuberculosis skin test was obtained.

Review of the hospital's tuberculosis screening policy and procedure titled "Screening For Tuberculosis Infection-Policy 3008" dated 7/1987 and reviewed 1/10, established that hospital health care providers, including nurse practitioners, are required to be screened for tuberculosis upon hire and annually thereafter using the skin test method. The policy did not contain information of the time interval required between placement of the skin test and reading the result.
According to the 2005 Center for Disease Control (CDC) Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005: The tuberculosis skin test result should be read by a designated, trained HCW (Health care worker) 48-72 hours after the skin test is placed. If the test was not read between 48-72 hours, ideally, another skin test should be placed as soon as possible and read within 48-72 hours. Certain studies indicate that positive skin test reactions might still be measurable from 4-7 days after testing. However, if a patient fails to return within 72 hours and has a negative test result, the skin test should be repeated.
The hospital did not have an effective system in place to ensure personnel were adequately screened for tuberculosis. This placed hospital patients and personnel at potential risk for exposure and infection from tuberculosis.

2. On 6/27/11 at 2:10 pm, Administrative Nurse DD was observed entering the hospital's cardiac catheterization laboratory without wearing surgical attire. There was no signage or floor marks that indicated the lab was a restricted area. As Administrative Nurse DD entered the lab she stated, "As long is nothing is open we can come in (indicating surgical attire was not required)."

On 6/27/11 at 2:10 pm, during an interview, Administrative Nurse DD indicated that pacemaker insertions were performed in the cardiac catheterization laboratory.

On 6/28/11 at 9:35 am, during a concurrent interview, Administrative Nurse DD and Administrative Nurse EE acknowledged that pacemaker insertion was a surgical procedure, and that all personnel should consider the cardiac catheterization lab a restricted area, and wear appropriate surgical attire when in the lab. The Infection Control Nurse stated "We should put a sign on the door (referring to the cardiac catheterization lab door) that it is a restricted zone."

The Association of periOperative Registered Nurses (AORN) 2011 Edition, Recommended Practices for Traffic Patterns (page 95), read, "Traffic patterns should be designed to facilitate movement of patients and personnel into, through, and out of defined areas within the surgical suite. Signs should clearly indicate the appropriate environment controls and surgical attire required. The restricted area includes operating rooms, procedure rooms, and the clean core area; surgical attire and hair coverings required, masks required when sterile supplies open. Movement of personnel from unrestricted areas to either semi-restricted or restricted areas should be through a transition zone. A transition zone exists where one can enter the area in street clothing and exit into the semi-restricted or restricted zone in surgical attire..."

3. On 6/28/11 at 1:25 pm, a bottle of Metricide, a high level cleaning and disinfectant solution, was observed in a cabinet in the EEG area. An EEG -electroencephalogram, is a test that measures and records the electrical activity of the brain by using sensors, and a head cap.
During an interview with Registered Technician RR, on 6/28/11 at 1:30 pm, she explained that she used the Metricide solution to clean the patient EEG. Registered Technician RR acknowledged she did not wear any personal protective equipment (PPE), such as gown, gloves, and face mask, when using the Metricide to clean. Registered Technician RR indicated she disposed of the Metricide solution down the sink drain, then flushed the sink drain with water.
During an interview, Administrative Nurse DD indicated that she was not aware Registered Technician RR was using Metricide. Administrative Nurse DD acknowledged Registered Technician RR should have only used this product in a ventilated area, wearing appropriate PPE.

Review of the manufacturer's information for Metricide indicated, individuals should only use the product in a ventilated area and wear appropriate barrier protection such as latex gloves, gowns, masks or eye coverings.

Failure to use the product according to the manufacturer's instructions placed the employee at risk for exposure to potential toxic effects of the disinfectant.

4. On 6/27/11 at 6 pm, the hospital's endoscopic cleaning log was reviewed for the dates 3/1/11 through 6/30/11. Four endoscopes, endoscopes 2919, 0606, 6772, and 0411, were selected from the log for review. All four endoscopes were documented as having one or more periods of time where they went unused for six to 29 days before being reprocessed.

During an interview, on 6/29/11 at 9:30 am, Licensed Nurse CC acknowledged that the hospital did not have a system in place to ensure endoscopes were reprocessed every five days if unused. Licensed Nurse CC stated, "I was not the aware of this standard."

Failure of the hospital to ensure endoscopes were reprocessed every five days, if unused, placed patients at increased risk for contamination and infection from pathogenic growth on the endoscope. The 2011 edition of the Perioperative Standards and Recommended Practices, a nationally recognized resource for perioperative services standards, page 421, under recommendation IX. b.: read, "Flexible endoscopes should be reprocessed before use if unused more than five days,".. studies have shown pathogenic growth to be present on endoscopes after five days of no use.

5. On 6/27/11 at 2:50 pm, in the obstetrics recovery room, a syringe and an unsheathed needle with blood on it's tip were observed sitting on top of a sharps disposal container, (a specially designed receptacle for the safe disposal of needles). The sharps container was slightly less than half full, and located less than five feet from a patient bed.

During an interview with Licensed Nurse QQ on 6/17/11 at 2:55 pm, she explained she had placed the used syringe, and needle on top of the sharps disposal box because the box opening was blocked.

An interview was conducted with Administrative Nurse DD on 6/27/11 at 3:00 pm. When shown and asked what she thought about the presence of the unsheathed needle, syringe, and medication vial on top of the sharps disposal box, Administrative Nurse DD replied "It's not ok, another sharp container should have been obtained and used."

A review of the hospital policy titled "Infectious Waste Identification," dated 8/07, indicated wastes materials such as syringes and syringes should be considered as potentially infectious and handled as infectious waste.

A review of the hospital policy titled "Needle Box Handling," dated 8/07, indicated in an emergent need, environmental service staff will remove the needle box and replace the container.

According to the Association for Professionals in Infection Control and Epidemiology (APIC) position paper titled "Safe Injection, Infusion, and Medication Vial Practices in Health Care," dated 2010, used needles and syringes should be disposed of at the point of use in an approved sharps container.

Failure to dispose of a used needle and syringe in an approved sharps container placed hospital patients and personnel at risk for exposure and infection from pathogens potentially present on these items, including blood borne pathogens.

6. Patient 138 was admitted to the hospital on 6/15/11 with diagnoses that included an altered level of consciousness, and anemia, a condition in which the body does not have enough healthy red blood cells that provide oxygen to the body.

On 6/28/11 at 12:45 pm, during a review of Patient 138's medical record, it was noted that she was tested for MSRA five days after her admission to the hospital.

During an interview on 6/28/11 at 1:45 pm, Administrative Nurse DD was asked if she was aware that Patient 138 did not receive a MSRA test until 5 days after her admission to the hospital. Administrative Nurse replied "No," and stated, "this is a systems failure when we do not get patients tested for MRSA within 24 hours of admission to the hospital."

Review of the hospital's standardized procedure for MRSA screening titled "MRSA Screening Program, dated 6/13/11, indicated all patients, except those known to have past or current MRSA infection or history of MRSA colonization and the newborn population, should be screened for MSRA within 24 hours of admission to the hospital.

Failure to ensure that patients are screened for MRSA according the hospital policy placed patients and staff at risk for exposure to and infection from MRSA.

7. During an interview with Licensed Nurse PP on 6/27/11 at 12:00 pm she explained she cleaned the glucometer machine by wiping it down with one PDI super sani cloth, letting it sit for about two minutes, then wiping it dry with the same cloth.

On 6/27/11 at 2:15 pm, the manufacturers' instructions for the disinfectant towelettes was reviewed. Instructions on the manufacturers' label read that one towelette was to be used to clean the surface, and a second towelette was to be used to keep the surface wet for two minutes for disinfection to occur.

On 6/27/11 at 2 pm, Administrative Nurse DD was interviewed. Administrative Nurse DD acknowledged the cleaning and disinfection process for the glucometer was a two step process. The first step was necessary to remove any organisms, and the second step was needed to disinfect the equipment. Administrative Nurse DD replied, "No" when asked if she was aware that hospital staff were using a one step process to clean and disinfect the patient shared glucometer equipment.

The hospital failed to ensure that equipment, potentially contaminated with blood, was cleaned and disinfected between each patient use. Failure to ensure that equipment was cleaned and disinfected between patients increases the risk of exposure to and infection from blood-born pathogens.

Based on medical record review, observation, and staff interview, the hospital failed to ensure for two of 50 medical records reviewed that prior to elective surgical procedures the medical record contained a Medical History and Physical Examination (H&P) that had been performed and recorded no more than 30-days prior to the procedure.

Findings:

On 6/29/11, commencing at 1 pm, closed Electronic Medical Records (EMR) were reviewed and two of 50 records (Patients 41 and 43) did not contain an H&P at the time of surgery.

On 6/30/11, commencing at 9:35 am, the main Peri-Anesthesia and Surgery (PAS) area was toured. It was observed that the hospital did have a system in place to assure that all pre-surgical patients had a complete H&P in their medical record before they were taken to the Operating Room (OR). At 10 am, the Director of Peri-Operative Services (Staff XX) was interviewed and the medical records of Patients 41 and 43 were reviewed. Staff XX stated: "This one (these) got thru the system .... The rule is no one leaves the PAS without an H&P on the chart."

On 6/30/11 at 11:50 am, the Vice President of Medical Affairs (Staff YY) was interviewed and the medical records of Patient 41 and 43 were reviewed. Staff YY stated that the hospital does strive to ensure that a complete and comprehensive H&P is in the medical record prior to any non-urgent surgery, but in these two cases that goal had not been achieved.