HospitalInspections.org

A. Based on clinical record review and staff interview, it was determined that the physician failed to specify feeding orders for 1 of 3 clinical records reviewed (Pt #10).

Findings include:

1. On 6/29/09 at approximately 12:00PM, the clinical record for Pt. #10 was reviewed. Pt. #10, a one month old premature infant was admitted to the nursery on 6/24/09 with a diagnosis of "Functional Feeding". The physician orders dated 6/24/09 at 7:20PM lacked feeding orders.

2. The above finding was conveyed to the Charge Nurse during an interview on 6/29/09 at approximately 12:15AM.

A. Based on policy review and staff interview, it was determined that the Hospital failed to ensure contracts were obtained for all services performed by an outside entity.

Findings include:

1. Hospital policy entitled, "Single-Use Devices (SUD)", reviewed on survey date 6/30/09 at 11:00 AM required, "Policy Statement: A. Medical devices will be reprocessed/resterilized according to the following chart...1) Non-critical...Used - SUD's will only be reprocessed by contracted third party reprocessor...2) Semi-critical...Used - SUD's will only be reprocessed by contracted third party reprocessor...3) Critical ...Used - SUD's will only be reprocessed by contracted third party reprocessor."

2. The Service Line Director of Surgical Services was interviewed on survey date 6/30/09 at 8:45 AM. During the interview, the Director stated that the Surgical Department sends single use items out, for reprocessing and reuse.

3. On survey date 6/30/09 at 8:45 AM, the Hospital's contract with the third party reprocessor was requested. The Service Line Director of Surgical Services stated the Hospital does not have a contract with the company.

4. The findings were conveyed to the Vice President of Nursing on survey date 6/30/09 at 10:45 AM.

A. Based on policy review, clinical record review and staff interview it was determined that in 1 of 1 (Pt #5) clinical record reviewed of a patient with restraint usage, the Hospital failed to ensure attending physicians were notified of restraint application timely.

Findings include:

1. Hospital policy entitled, "Restraint/Protective Devices," reviewed on survey date 6/29/09 at 12;30 PM required, "Policy Statement:...I. If the restraint order is written by any physician or LIP other than the patient's attending physician (on call physicians designated to be covering for the attending physician are considered the attending), the attending physician is to be notified of the restraint order as soon as feasible."

2. The clinical record of Pt #5 was reviewed on survey date 6/29/09. Pt #5 was an 88 year old female admitted with a diagnosis of Cardiac Arrhythmia. The clinical record contained a physician order date 6/26/09 at 8:00 PM, for a soft right ankle restraint. The order was not signed by the physician until 6/28/09 at 8:20 AM (32 hours and 20 minutes).

3. The finding was conveyed to the Intensive Care Unit Manager during an interview on survey date 6/29/09 at 11"30 AM.

A. Based on policy review, clinical record review and staff interview it was determined that in 1 of 1 (Pt #5) clinical record reviewed of a patient with restraint usage, the Hospital failed to ensure orders were received every day, as required.

Findings include:

1. Hospital policy entitled, "Restraint/Protective Devices," reviewed on survey date 6/29/09 at 12;30 PM required, "Policy Statement:...L. Renewal orders for restraints must be written each calendar day based on the ongoing assessment of need."

2. The clinical record of Pt #5 was reviewed on survey date 6/29/09. Pt #5 was an 88 year old female admitted with a diagnosis of Cardiac Arrhythmia. The clinical record contained a physician orders dated 6/26 and 6/27/09 at 8:00 PM, for a soft right ankle restraint. Clinical documentation indicated that Pt #5 had a soft ankle restraint in place through 6/29/09 without a physician order for the time frame 8:00 PM on 6/28/09 through 11:00 AM on 6/29/09 (date and time of survey).

3. The finding was conveyed to the Intensive Care Unit Manager during an interview on survey date 6/29/09 at 11"30 AM.

A. Based on stated hospital practice, a review of anesthesia substance control records and staff interview, it was determined that the hospital failed to ensure pharmacy review of controlled substance sheets in order to identify documentation discrepancies.

Findings include:

1. The Director of Pharmacy was interviewed on 7/1/09 at approximately 11:30AM. The Director stated that it is pharmacy practice to review all anesthesia controlled substance records for accuracy of documentation.

2. On 7/1/09 at approximately 10:30AM, anesthesia controlled substance records were reviewed from March 2009 through June 2009. Two of 8 records contained inaccurate documentation. This was unknown to the Director at the time of survey.

3. The above finding was conveyed to the Director during an interview on 7/1/09 at approximately 11:30AM.

A. Based on policy review, observation and staff interview, it was determined that the hospital failed to ensure correct labeling of previously frozen breast milk for 1 of 1 bottle of breast milk observed in a refrigerator in the nursery for Pt. #9.

Findings include:

1. The procedure used by the hospital for labeling breast milk was obtained from" Mosby's Nursing Skills" and reviewed on 6/29/09 at approximately 11:30AM. Mosby requires, " Thawed or fortified (high content of vitamins) milk may be...refrigerated ...for less than 24hours."

2. On 6/29/09 at approximately 11:00AM, a refrigerator in the nursery was inspected. The refrigerator contained a bottle of breast milk dated 6/19/09 at 10:30AM (date the mother actually expressed the milk). The label also included handwritten information "fortified 22 kal 6/27- 6/28" The label was incomplete for the time that the milk was thawed and placed in the refrigerator.

3. RN #1 was interviewed on 6/29/09 at approximately 11:00AM. RN #1 stated that the night nurse thawed frozen breast milk for Pt. #9, added Enfamil fortifier and then placed the milk in the refrigerator for future feedings. RN #1 stated that she did not know either the time the milk was refrigerated after thawing. The RN further stated that the milk was good for no longer than 24 hours.

4. The above finding was conveyed to the Charge Nurse during an interview on 6/29/09 at approximately 1:00PM.


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B. Based on review of contractual service policy, treatment list review, bicarbonate container rinse and disinfection log review, and staff interview, it was determined, for 7 of 8 treatment days in June 2009 (June 4, 5, 9, 11, 13, 18, and 19), that the Hospital failed to ensure that rinse and disinfection of bleach containers was completed, as required.

Findings include:

1. On 6/30/09 at 10:00 AM, the contracted dialysis company's (Davit) policy No. 7-05-09, titled: "Bicarbonate Concentrate System Disinfection and Logs" was reviewed. The policy required: "7. If individual bicarbonate containers are used to supply dialysis delivery systems, the containers and wands should be rinsed with dialysis quality water at the end of the treatment day and stored inverted to dry. Additionally, the containers and wands will be disinfected with household bleach to a 1:100 solution at least weekly."

2. On 6/30/09 at 8:00 AM, a list of patients treated with dialysis in June 2009 was reviewed. The log contained 8 treatment days in June 2009 (June 2, 4, 5, 9, 11, 13, 18, and 19).

3. On 6/29/09 at 1:55 PM, the dialysis bicarbonate container rinse and disinfection log for June 2009 was reviewed. The log lacked rinse and bleach documentation for 7 of 8 days in June 2009 (June 4, 5, 9, 11, 13, 18, and 19).

4. This finding was conveyed to the Hospital Director of Chemical Engineering and to the Dialysis Contractor Biomedical Chief Technician during an interview on 6/30/09, at 9:00 AM.

C. Based on review of Dialysis contractor's policy, clinical record review, and staff interview, it was determined, for 2 of 4 Hemodialysis patients (Pt. #19 & 21), that the Hospital failed to ensure that nursing intervened when pH levels, outside of acceptable range, were detected in dialysis machines.

Findings include:

1. The Dialysis contractor's policy No. 7-09-01, titled: "Prescription Verification and Safety Checks" required: "1. Trained dialysis teammates will verify the dialysis prescription and perform safety checks prior to treatment initiation... Manual pH - acceptable reading 6.9 to 7.6..."

2. On 7/1/09 at 9:00 AM, the clinical record of Pt. #19 was reviewed. Pt. #19 was a 71 year old male, admitted on 6/10/09, with diagnoses of Pneumonia, Anemia, and Chronic Renal Failure. The treatment sheet dated 6/11/09, indicated that the pH was 8, outside of acceptable range. A complete dialysis treatment was administered.

2. On 7/1/09 at 10:00 AM, the clinical record of Pt. #21 was reviewed. Pt. #21 was an 80 year old female, admitted on 6/6/09, with diagnoses of Gastrointestinal Hemorrhage, End Stage Renal Disease, and Heart Failure. The treatment sheet dated 6/9/09, indicated that the pH was 8, outside of acceptable range. A complete dialysis treatment was administered.

4. This finding was conveyed to the Service Line Director of Surgical Services during an interview on 7/1/09 at 12:00 PM.


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D. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 1 (Pt. #7) patient with pressure ulcers identified on 3 East, the Hospital failed to ensure pressure ulcers were photographed as per policy.

Findings include:

1. The Hospital policy titled "Pressure Ulcer Prevention & Identification" was reviewed on 6/29/09 at 12:00 PM. The policy included " ..F. Pressure ulcers should be photographed at the time of identification and weekly...vi. Position a ruler in the picture whenever possible to provide a reference point".

2. The clinical record of Pt. #7 was reviewed on 6/29/09 at 10:20 AM. Pt. #7 was a 62 year old male admitted on 6/27/09 with the diagnoses of Pancreatic Cancer, Ascites and Severe Edema. The clinical record included documentation of a Stage II pressure ulcer on the coccyx that was identified on 6/28/09 at 10:20 AM. The clinical record lacked a photograph or measurements of the pressure ulcer.

3. The above finding was conveyed to the Nursing Team Leader of 3 East on 6/29/09 at 11:30 AM, during an interview.

A. Based on Hospitals policy review, record review and staff interview, it was determined that on 3 of 3 patient records reviewed (Pt #9, Pt #10 and Pt #11) the Hospital failed to ensure that a written care plan was provided in the patient's record.

Findings include;

1. The Hospitals policy titled, "FHN Departmental Policy, subject Charting - Authorization to - Nursing.Method of Implementation" was reviewed on 6/29/09 at approximately 1:15 P.M. The policy requires, "1. RN's are responsible for initiating and maintaining the individualized plan of care throughout the patient stay."

2. A record review was completed on survey date of 6/29/09 at approximately 1:00 P. M. In 3 of 3 records reviewed (Pt #9, Pt #10, Pt #11) there were no written care plans.

3. These findings were conveyed to the Charge Nurse of the Nursery on 6/29/09 at approximately 1:30 P.M.


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B. Based on review on Hospital policy, clinical record review and staff interview, it was determined that in 2 of 3 (Pt. #2 & 3) clinical records reviewed in the 3 North Unit, the Hospital failed to ensure care plans are updated to reflect isolation precautions status.

Findings include:

1. The Hospital policy reviewed on 6/29/09 at 12:30 AM, titled "Charting-Authorization to - Nursing" required, " 1. The RN's are responsible for initiating and maintaining the individualized plan of care throughout the patient stay" Attachment I: "Procedure for Nursing Documentation...Plan of Care...The Plan of Care is reviewed every shift and updated as needed."

2. The clinical record of Pt. #2 was reviewed on 6/29/09. Pt. #2 was a 83 year old female admitted on 6/28/09 with diagnoses of Febrile Illness, and Urosepsis. The admission documentation on 6/28/09 included contact precautions. However, the plan of care lacked inclusion of the isolation precautions for Pt. #2.

3. The clinical record of Pt. #3 was reviewed on 6/29/09. Pt. #3 was an 83 year old old female admitted on 6/25/09 with diagnoses of Gastrointestinal Bleed secondary to Diverticulitis, Dementia and a history of MRSA. The admission documentation dated 6/25/09 included contact precautions. However the plan of care lacked inclusion of the isolation precautions for Pt. #3.

4. The above findings were conveyed to the Nursing Team Leader on 6/29/09 at 11:30 AM, during an interview.

A. Based on clinical record review and staff interview, it was determined, for 3 of 4 Hemodialysis patients (Pt. #19, 20, & 22), that the Hospital failed to ensure that all drugs were administered in accordance with the orders of the Practitioner responsible for the patient's care.

Findings include:

1. On 7/1/09 at 9:00 AM, the clinical record of Pt. #19 was reviewed. Pt. #19 was a 71 year old male, admitted on 6/10/09, with diagnoses of Pneumonia, Anemia, and Chronic Renal Failure. The hemodialysis order dated 6/11/09 at 9:30 AM, required a 4 hour treatment with Heparin 2000 units bolus and 500 units administered each hour. The treatment sheet dated 6/11/09, lacked documentation that Heparin 5000 units was administered each hour during the treatment.

2. On 7/1/09 at 9:30 AM, the clinical record of Pt. #20 was reviewed. Pt. #20 was an 82 year old male, admitted on 6/8/09, with diagnoses of Diabetes Mellitus, End Stage Renal Disease (ESRD), and Cardiomyopathies. The physician order dated 6/17/09 at 4:00 PM, included hemodialysis orders for 6/18/09: administration of Zemplar, 0.5 mcg, intravenous (IV) and Venofer, 50 mg, IV. The treatment sheet dated 6/18/09, lacked documentation that Zemplar and Venofer were administered.

Pt. #20's hemodialysis order dated 6/18/09, required: "Give 25 Gm. Albumin IV times 2 regardless of blood pressure." The treatment sheet dated 6/18/09, lacked documentation that Albumin was administered during treatment.

3. On 7/1/09 at 10:30 AM, the clinical record of Pt. #22 was reviewed. Pt. #22 was a 70 year old female, admitted on 5/31/09, with diagnoses of Fall, Heart Failure, and ESRD. The physician order dated 6/1/09, required hemodialysis treatment on 6/2/09 with Heparin 2,000 units bolus and 1,000 units administered mid-treatment. The treatment sheet dated 6/2/09, included documentation that Heparin 2,000 units was administered mid-treatment, instead of the prescribed 1,000 units.

4. This finding was conveyed to the Service Line Director of Surgical Services during an interview on 7/1/09 at 12:00 PM.

A. Based on policy review, clinical record review and staff interview, it was determined that in 1 of 1 (Pt #4) clinical records reviewed on the Intensive Care Unit (ICU) of a patient admitted over 48 hours, the Hospital failed to ensure all telephone orders were signed within 48 hours, as required.

Findings include:

1. Hospital policy entitled, "Physician's Orders/Verbal/Telephone/Pre-printed/Faxed," reviewed on survey date 6/29/09 at 12:15 PM, required, "..B...4. Telephone orders will be signed, dated, and timed by a physician within 2 calendar days..."

2. The clinical record of Pt #4 was reviewed on survey date 6/29/09. Pt #4 was a 54 year old female admitted on 6//23/09 with a diagnosis of Bowel Obstruction. The clinical record contained physician orders dated 6/23, 6/24, 6/25, and 6/26/09 for medications, colonoscopy prep, and treatments that remain unsigned and dated by the physician.

3. The findings were conveyed to the ICU Unit Manager during an interview on survey date 6/29/09 at 11:30 AM.

A. Based on policy review, a review of Anesthesiologist controlled substance records and staff interview it was determined, that in 2 of 8 controlled substance records reviewed, pharmacy failed to ensure accurate substance control records.

Findings include:

1. The Hospital's policy titled "Controlled Substance Monitoring System" was reviewed on 7/1/09 at approximately 11:20AM. The policy included, " F. Any dose of controlled substance wasted by department personnel shall be documented using...the respective controlled substance documentation sheet in the specified waste documentation area. All wastage shall require the additional signature of a witness to the destruction..."

2. On 7/1/09 at approximately 9:30AM, anesthesia controlled substance records were reviewed from March, 2009 through June 2009.

* The record contained a column for "quantity used". There was inconsistent documentation for specifying the dosages used.

* The form contained a " balance"column. Documentation on 4/9/09 indicated a starting quantity of 4 vials of Fentanyl ( each vial contained 250mcgs/5ml) there was an inaccurate dose documentation on 4/9/09 indicating that 1 vial of Fentanyl was missing from the count.

* On 5/19/09 and 3/13/09 a two person signature and reason for "wastage" not on on the controlled substance sheet.


3. The above finding was conveyed to the Director of Pharmacy Services during ani interview on 7/1/09 at approximately 11:30AM.

A. Based on observation, review of Hospital policy and staff interview it was determined that the Hospital failed to ensure that outdated medications were not available for patient use.

Findings include:

1. A tour of the Post-op area was conducted on 6/30/09 from 7:00 AM to 7:30 AM. At approximately 7:20 AM, the medication cabinet was observed having two Racepinephrine inhalation packets available for use. One packet had expired 2/09 and one had expired 3/09.

2. The above finding was conveyed to the Service Line Director Surgical Services on 6/30/09 at 7:35 AM, during an interview.


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3. Hospital policy #1.730.026 entitled, "Multi-Dose Vial (MDV)," was reviewed on 7/1/09 at approximately 9:00 A.M. The policy requires, "The shelf life of MDVs shall be the manufacturer's expiration date marked on the container up to 28 days after opening..."

4. On 6/30/09 at approximately 9:30 A.M., a tour of the Outpatient Rehabilitation area was conducted. There was an opened 30 mL vial of Dexamethasone, dated 4/6/09, that was available for patient use.

5. The Director of Rehabilitation, during an interview on 6/30/09 at approximately 9:30 A.M., stated that the Dexamethasone was good "for a couple of months" after opening.

6. The above findings were conveyed to the Director during another interview on 6/30/09 at approximately 1:00 P.M.

A. Based on review of Hospital policy, observation and staff interview,it was determined that the Hospital failed to ensure Food Service staff adhered to policy governing attire.

Findings include:

1. The Hospital policy titled "Food and Nutrition Services Personnel (Health, Education and Personal Hygiene) was reviewed on 6/30/09, at 12:45 PM. The policy required, "...basic orientation for all new FNS(Food &Nutrition Services) personnel shall include personal hygiene...."

2. The Food and Nutrition Services New Employee Department Orientation Manual was reviewed on 6/30/09 at 12:50 PM. The manual required, "...Dress code: Jewelry should be minimal... Personal Hygiene...At Work: Remove all jewelry (except sooth surface rings)...."

3. A tour of the Food and Nutrition Services was toured and observed on 6/30/09, between 10:50 AM and 11:30 AM. E #5, 6, 7 and 8 were observed wearing large hoops or dangling earrings.

4. The above findings were conveyed to the Clinical Nutrition Manager on 6/30/09 at 11:30 AM during an interview.


B. Based on review of Hospital policy, review of temperature logs and staff interview, it was determined that in 2 of 12 refrigerator logs reviewed the Hospital failed to ensure refrigerator temperatures were documented as required by policy.

Findings include:

1. The Hospital policy titled, "Safety-Food and Nutrition Services" was reviewed on 6/30/09 at 1:20 PM. The policy required, "All refrigerator will operate at a maximum temperature of 40 degrees F...all walk-in cooler, refrigerator, and freezer temperatures will be recorded by appropriate staff on the refrigerator and freezer temperature log (attachment 1)...."

2. Attachment 1 titled "Refrigerator/Freezer Temperature" was reviewed on 6/30/09 at 11:15 AM required, "Temperature must be recorded a minimum of twice during each 24 hour period."

3. The refrigerator/ temperature logs for June 2009 were reviewed on 6/30/09 at 11:15 AM 1 walk in cooler lacked documentation of temperature for 1 of 29 days. The upright cooler located in the food line lacked documentation of a the temperature for 3 of 29 days and the second temperature taken each day for 29 of 29 days.

4. The above findings were conveyed to the Clinical Nutrition Manager on 6/30/09 at 11:30 AM during an interview.

A. Based on review of Hospital policy, equipment monitor logs, and staff interview, it was determined for 3 of 5 nursing units (Intensive Care Unit {ICU}, Telemetry Unit {4E}, and Medical Surgical Unit {3N}), that the Hospital failed to ensure equipment was checked daily, as required.

Findings include:

1. Hospital policy titled: "Crash Carts - Replacement" was reviewed on 6/29/09 at 12:30 PM. The policy required: "D Each unit/department on which a crash cart is located shall be responsible for verifying and documenting the integrity of the crash cart's plastic lock at least daily... J. Each unit will be responsible for checking of supplies and functionality of the Equipment located outside the drawers of the cart..."

2. The following units failed to perform daily crash cart or defibrillator checks:

- ICU crash cart #1 - 1 day in June 2009
- ICU crash cart #2 - 1 day in June 2009

- 3E defibrillator #1 - 10 days in June 2009
- 3E defibrillator #2 - 10 days in June 2009

3. The following units failed to perform daily medication refrigerator checks:

- 3E med refrigerator #2 - 9 days in June 2009
- 3E med refrigerator #3 - 9 days in June 2009

- 3N med refrigerator #1 - 10 days in June 2009

4. These findings were conveyed on 6/29/09, during interviews with:

- ICU - ICU Manager at approximately 11:30 AM

- 3E - 3E Charge Nurse at approximately 10:30 AM

- 3N - 3N Nursing Team Leader at approximately 10:15 AM.

A. Based on review of Hospital policy, observation and staff interview it was determined that in 4 of 9 ( #1, #2, #5 and #6) patients observed in isolation precautions the Hospital failed to ensure all visitors adhere to isolation policies.

Findings include:

1. Hospital policy titled "Isolation" reviewed on 6/28/09 at 1:40 PM, required "... do the following: 1:::indicate type of isolation on the care plan...2. place contact isolation sign, ..3. Wear gown; ... Droplet Isolation...Place droplet isolation sign on the patient's door,... wear surgical mask when working within three feet of the patients.:

2. The 3 North unit was toured on 6/29/09 between 9:45 and 10:30 AM. Room 3226, and room 3263, each with an orange contact isolation precaution signage. Visitors in the 2 isolation rooms were not wearing the required personal protective equipment (gown, mask).

3. The above findings were conveyed to the Nursing Team Leader of the 3 North during interview on 6/29/09 at 11:30 AM.


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4. A tour was conducted of the Intensive Care Unit on survey date 6/29/09 between 10:00 AM and 11:30 AM. During the tour it was observed that room 4321 had signage posted requiring Contact Precautions be maintained.

5. The clinical record of Pt #5 was reviewed on survey date 6/29/09. Pt #5 was an 88 year old female admitted on 6/26/09 with a diagnosis of Cardiac Arrhythmia. The clinical record contained documentation that Pt #5 was admitted with a history VRE in the urine (Vancomycin Resistant Enterococcus). It was observed that during the unit tour Pt #5 had from 2 to 3 visitors at any time. None of the visitors were observed wearing Personal Protective Equipment and the clinical record lacked documentation of teaching to visitors regarding the usage of PPE.

6. The findings were conveyed to the Intensive Care Unit Manager during an interview on survey date 6/29/09 at 11:30 AM.


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7. A tour of the 3 East unit was conducted on 6/29/09 from 9:45 AM to 10:30 AM. Room 3305 was identified with signage as a contact isolation room.

8. The clinical record of Pt. #6 was reviewed on 6/29/09 at 10:40 AM. Pt. #6 was an 81 year old Male admitted with Abdominal Pain. Pt. #6 was placed on contact isolation on 6/26/09. The visitor in the room was observed sitting in a chair next to the Pt#6's bed. The visitor was not wearing Personal Protective Equipment (PPE) - gown or gloves. The visitor denies ever being told of the need for wearing PPE.

9. The above finding was conveyed to the Nursing Team Leader of 3 East on 6/29/09 at 11:30, during an interview.

A. Based on observation and staff interview, it was determined, for 5 of 5 bronchoscopes in the 4 East procedure room, that the Hospital failed to ensure that bronchoscopes were disinfected.

Findings include:

1. On survey date 6/29/09 between 10:00 AM and 11:30 AM, a tour was conducted of the Telemetry Unit (4E). Five bronchoscopes were contained in a wall mounted storage cabinet. A bronchoscope disinfection log was lacking to document when disinfection occurred. A bronchoscope disinfection policy was lacking to provide guidance for frequency of disinfection.

2. An interview was conducted with the Chief Nursing Officer (CNO) on 6/29/09 at approximately 3:45 PM. The CNO stated there was no log for disinfection of bronchoscopes and no policy for the frequency of disinfection for bronchoscopes. The findings were conveyed to the CNO during the interview.

B. Based on observation and staff interview, it was determined, for 1 of 1 Restricted Central Core in the Operating Area (OR), the Hospital failed to ensure that equipment, walls, and ceiling were maintained to reduce potential contamination of sterile packages.

Findings include:

1. On 6/30/09 between 7:10 AM and 7:30 AM, a tour was conducted in the restricted central core in the OR. The following was observed:

- One of 1 metal shelving rack holding rapid sterilizer trays contained rust.

- One of 1 Steris sterilizer cart contained peeling paint.

- One of 1 Flash sterilizer closet contained dust and was open to the central core.

- One of 1 wall section, where the urethral catheter boxes were located, was torn through, exposing interior dry wall.

- Several metal ceiling tile included rust stains.

2. These findings were conveyed to the O R Manager during an interview on 6/30/09 at 7:35 AM.

A. Based on a review of the manufacturer's recommendations for "Avagard"(antiseptic hand prep), observation and staff interview, it was determined that the hospital failed to ensure Avagard was used in accordance with manufacturer's recommendations for 1 of 1 scrub technician observed (E#2)in OR room #1.

Findings include:

1. The manufacturers's recommendations for Avagard antiseptic hand prep was reviewed on 6/30/09 at approximately 9:50AM. The recommendation's included, "...to facilitate drying, continue rubbing hand prep into hands until dry"

2. On 6/30/09 at 8:12AM, E#2 entered OR #1 after applying Avagard antiseptic hand prep to her hands and forearms. E#2 was observed fanning her arms back and forth to facilitate the drying process. Hence the potential of spraying droplets on the sterile surgical field.

3. The above finding was conveyed to the Surgical Nurse Manager during an interview on 6/30/09 at approximately 9:30AM.


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B. Based on review of Hospital policy, observation and staff interview, it was determined the Hospital failed to ensure that staff adhered to operating room policies on attire.

Findings include:

1. The Hospital policy titled "Infection Control, Traffic Control in the Operating Suite " was reviewed on 6/30/09 at 9:30 AM. The policy included "A. Traffic Control Zones: 1. Unrestricted: ..d. Scheduling area. 2. Semi - restricted: ..b. Internal suite hallway..f. Pre-op Room.... B. Personnel Traffic: ..2. Upon leaving the surgical suite, all individuals dressed in surgical attire will don a clean cover coat".

2. The Hospital policy titled "Infection Control - Dress Code Within Operating Room" was reviewed on 6/30/09 at 9:30 AM. The policy included "A. Only persons wearing appropriate scrub clothes with caps and appropriate shoe/shoe covers will be allowed in the semi-restricted and restricted areas of the Surgical Suite".

3. A tour of the pre-op area was conducted on 6/30/09 from 7:00 AM to 7:30 AM. At approximately 7:12 AM, a Physician (E #3) was observed entering the Pre-op room from the internal suite hallway wearing a long lab coat. E#3 then left the pre-op room into the unrestricted hallway by the scheduling area. E#3 reentered the pre-op room with the same lab coat and walked into the internal suite hallway without removing the lab coat.

4. A tour of the Operating suite was conducted on 6/30/09 from 7:00 AM to 7:30 AM. At approximately 7:10 AM, a Physician (E#9) was observed entering the semi - restricted area in street clothes.

5. The above findings were conveyed to the Service Line Director Surgical Services on 6/30/09 at 7:35 AM, during an interview.

C. Based on review of the Hospital's Standard Procedures, observation and staff interview, it was determined that the Hospital failed to ensure that I.V. injections were given in accordance with the Hospital's procedures.

Findings include:

1. The Hospital's Standard Procedure titled "I. V. bolus injection, Giving injections through an existing I. V. line." was reviwed on survey date 6/12/09 at approximately 12:00 P. M. The Procedure requires, "close the flow clamp, wipe the injection port with an alcohol pad, and inject the medication as direct injection."

2. A tour was conducted of operating room #1 at approximately 6:54 A. M. on survey date of 6/30/09. The anesthesiologist (E #4) was observed injecting medication through an I.V. without wiping the injection port with alcohol at approximately 8:30 A.M. At approximately 8:32 A.M. the anesthesiologist was observed using the same syringe and needle to draw up medication from the same vial that he failed to wipe with alcohol, then the anesthesiologist proceeded to reinject the medication to the same I.V.port without wiping the port with alcohol at approximately 8:33 A.M.

3. These findings were conveyed to the Director of the Operating Room on 6/29/09, at approximately 9:00 A. M.