HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to:
1. Ensure gowns with metal snaps were not stored in the warming unit with incorrect temperature.

2. Ensure the warming unit was maintained at the correct temperature.

These failures had the potential for patients to receive a burn from the heated metal snaps.

Findings:

1. During a concurrent observation and interview with Registered Nurse (RN) 6, on 5/16/16, at 2:20 PM, in the GI (Gastrointestinal- area where procedures are performed on individuals to examine the food pipe, stomach, and small intestine) laboratory, the temperature on the warming cabinet read 144° (degrees) Fahrenheit (F). Inside the warming cabinet was a patient gown with metal snaps. RN 6 stated "That (gown) shouldn't be in here." RN 6 verified the temperature of the warming cabinet.

2. During an observation on 5/16/16, at 2:45 PM, in the Emergency Room, the warming cabinet (top chamber) temperature read 141° F. The Director of Emergency Services (DES) verified the findings. The DES made no further comment.

The hospital policy and procedure titled: "Warming Parenteral, Irrigation, Peritoneal Dialysis Solution and Patient Care Blankets," revised date 2/2014, indicated: "A. Warming Recommendations 4. Patient Care Blankets a. Patient care blankets can be warmed to temperatures up to 130° F. B. 1. Warming cabinets will be monitored on a daily basis in compliance to recommended temperature ranges."

Based on observation, interview, and review of its infection control and prevention program, the hospital failed to monitor and collect information of a construction area located in the sterile processing area. This failure had the potential to compromise the sterility of the surgical supplies and instruments.

Findings:

During a tour of the hospital's Central Sterile Processing Area, on 5/17/2016, at 9 AM, with the Project Manager for Construction (PM), Epidemiologist (EPI), Sterile Processing Supervisor (SPS), Chief Nursing Officer (CNO), and Director of Preoperative Services (DPS), a plastic barrier, 42 feet long by 12 feet high, which separated a construction area from the rest of the central processing area was observed. Inside the construction area, there were exposed pipes due to missing ceiling tiles. The base of the plastic was not secured to the floor which allowed air to lift the barrier off the floor. There were multiple holes in the plastic barrier which were covered with tape. Air was blowing from the construction area into the Central Sterile Processing area. Directly adjacent to the plastic barrier were a number of stainless steel wire carts containing sterile supplies and surgical packs, waiting to be transported to the operating room for patient use. It was also observed there were several "crash carts" stored directly adjacent to the plastic barrier. When the carts, crash carts and stainless steel storage carts were wiped with a clean white cloth, there was a visible black residue on the cloth, indicating possible contamination of sterile supplies on the carts.

During an interview with EPI, CNO, DPS and the SPS, on 5/17/16, at 9:30 AM, they were not aware of the amount of dust and dirt recovered. The EPI then provided a hospital policy and procedure titled "Infection Control Construction Permit". This permit, dated 3/22/16 and posted next to the construction site, indicated the construction would be completed within two weeks and would be "small scale, short duration" and at "Medium Risk". The purpose of the construction was to repair and fix the leak in the area from a flooding incident occurred in September last year. The work would involve major demolition and new construction of the area and would affect all patients seeking treatment at the hospital (also called Class IV construction requiring the most protective measures to minimize risk of hospital acquired infections). The Permit posted next to the construction was marked as a "Class 2." However, review of the hospital "Infection Control Risk Assessment Tool" revealed Sterile Processing Department was in Group 4, the highest risk area for infection control.

During interviews with the EPI and the SPS, on 5/17/16, at 9:45 AM, the hospital staff stated the daily inspections had not been performed because of the expected short duration of the construction. A state of Immediate Jeopardy was declared because the dust and dirt contamination could not be consistent with sterile surgical supplies and equipment.

Based on observations, interviews, and review of documents, the hospital's governing body failed to assume the legal responsibility to ensure its quality assurance and performance improvement program addressed the condition of the construction area in the Sterile Processing Department as cited in the original re-certification survey.

This failure had the potential to affect the sterility of ready-for-patient-use surgical supplies and sterile surgical packs stored in the Sterile Processing Department and unsafe care to all patients in the hospital.

Findings:

During a tour of the central processing area of the hospital, on 5/17/2016, at 9 AM, with the Project Manager for Construction (PM), the Epidemiologist (EPI), the Sterile Processing Supervisor (SPS), the Chief Nursing Officer (CNO), and the Director of Preoperative Services (DPS), the condition of the old autoclave (equipment used to sterilize surgical tools) area was inspected. It was observed that sterile supplies were stored on numerous stainless steel storage carts and several crash carts outside the construction area. A plastic barrier covered the outside of the construction area to contain the dust and debris caused by the construction. There were several tears in the plastic barrier held together by construction tape. The barrier was not secured to the floor by paper tape and left enough space for air to blow from the construction area to the Sterile Processing Department. The PM stated the duration of the construction should have been only two weeks, starting 3/22/16.

The policy and procedure on "Construction/Renovation and Infection Control" was reviewed on 5/17/16. The hospital's policy and procedure indicated the PM and contractor were responsible for "daily compliance monitoring per Daily Monitoring Form."

During an observation on 5/17/16, at 9:30 PM, when the carts, crash carts and stainless steel storage carts were wiped with a clean white cloth, there was a visible black residue on the cloth, indicating possible contamination of sterile supplies on the carts. The EPI, CNO, the DPS and the SPS were not aware of the amount of dust and dirt generated by the construction.

During interviews with the EPI and the SPS, on 5/17/16, at 9:45 AM, both stated the daily inspections had not been performed because of the expected short duration of the construction.

Based on interview and record review the hospital failed to:

1. Have a discharge plan for one (3) of 30 sampled patients.

2. Have a discharge plan in a timely manner for one (4) of 30 sampled patients.

This failure had the potential to have patients needs go unmet.

Findings:

1. During an interview with the Director of Telemetry (DT), on 5/17/16, at 4:25 PM, she reviewed the electronic medical record (EMR) for Patient 3. Patient 3 was admitted on 5/13/16 at 5:20 PM. The DT was unable to find a discharge planning assessment.

2. During an interview with the DT, on 5/17/16, at 4:45 PM, she reviewed the EMR for Patient 4. Patient 4 was admitted on 5/6/16, and initial discharge planning assessment was done on 5/12/16 (six days later). The DT verified the findings.

The hospital policy and procedure titled "Discharge Planning" review date 1/2015, indicated "B. Each patient will have a Discharge Planning Assessment completed by Case Management Staff (Case Manager, Social Worker, and/or Discharge Planner) within 24 to 48 hours upon admission..." I. Discharge Planning is an on-going process in which patients are re-assessed... Re-assessment will be done every 4th day from their last assessment."