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Based on record review and staff interview, the facility failed to provide a preventive maintenance program to ensure the building physical plant equipment is properly maintained which may result in failed building equipment that could adversely affect all occupants of the building.

Findings include:

1. On 12/15/2020 at approximately 1540 during document review, the facility was not able to provide historic maintenance documentation for specific pieces of physical plant equipment and did not have documents that described what tasks were included in the routine maintenance of specific physical plant equipment items such as exhaust fans. Note: There was documentation for all the medical equipment, which is completed by a third party. Also, the facility did have documentation of life safety equipment such as fire doors, fire dampers, and emergency generator. When asked if routine maintenance was completed on the exhaust fan # 9, Staff I explained that it was done but no records are being kept.

2. On 12/15/2020 at approximately 1450 during the building tour, observed that the 125 KW emergency generator was equipped with two starter batteries that were the sealed type. Staff I was asked if the battery condition was tested on a monthly basis by means of a battery challenge test. Staff I reported that the test was not being done and that they did not have the test equipment to perform this test.

Based on observation and interview the facility failed to ensure four endoscopes were properly stored resulting in the potential for the spread of infectious disease amongst all patients receiving endoscopic procedures at the facility. Findings include:

On 12/15/2020 at 1320 accompanied by Staff P (the Surgical Manager) a tour of Surgical Services was conducted. Upon opening a locked door to the "scope closet" four endoscopes (a flexible tube with a light and camera attached to it, to examine the interior of a hollow organ or cavity) were observed to be hung along a wall of the "storage room". The storage room housed other equipment such as a fluid pump, tables and other miscellaneous supplies and equipment as well as a hand sink. The four endoscopes were hung against a wall (two scopes were touching the wall and one scope was observed to be in contact with a chipped laminate counter and within a splash zone of the hand sink). The scopes were not housed in a protective cabinet leaving them subject to dust and other elements that could negate the high-level disinfection (HLD) process used to ensure patient safety. A white towel was observed on the floor beneath the four hanging endoscopes. (note a finger was run across the stored table and revealed a build up of dust). At the time of observation Staff P was queried as to what the purpose of the white towel was, if the endoscopes would be considered clean after touching the wall and being open to the environment, whether endoscopes should be touching anything after HLD has taken place and if equipment to be used on patients should be in a splash zone. Staff P stated, "the towel is to catch any drips that come from the scopes after they are cleaned. No, scopes should be hanging free from touching anything. I can not ensure they are not contaminated and yes, they could be exposed to the environment. I did not think about the sink, the splash zone and I did see that dust. Scopes should be kept in a closet specific for scopes with ventilation and to safeguard from lint, dust, and the environment, we have always used this room to store them."

On 12/16/2020 during review of the policy titled "Endoscope Storage" last revised 2018, stated ..."1. Following proper disinfection, endoscopes will be hung to dry in the clean room of OR. This room is kept locked. Unlocked on days of procedures. 2. Scopes shall be hung so they do not touch each other on individual scope hangers. 3. Scopes shall be hung so they allow for airflow around each individual scope. 4. A clean scope protector will be placed on the distal end of the endoscope.

Based on observation and interview the facility failed to provide appropriate amount of ventilation to ensure healthy room pressure relationships resulting in poor indoor air quality with adverse health affects to all patients and staff using the rooms.

Findings include:

1. On 12/15/2020 at approximately 1040 during the facility tour, observed that there was no discernible exhuast air flow into the Soiled Utility room by the elevator. This was confirmed by Staff H.

2. On 12/15/2020 at approximately 1340, observed that there was no exhaust ventilation to provide a net negative pressure in the Endoscope Cleaning Room within the surgical suite. This was confirmed by Staff I. Staff I also went on the roof and confrimed that the motor for exhaust fan # 9 which serves this room and the Soiled Utility Room by the elevator was burned out.

3. On 12/15/2020 at approximately 1435, observed that the Sterile storage room was under a slight negative pressure. This was confirmed by Staff H & I. Staff I.

Based upon observation, interview and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 485.62(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated December 17, 2020.
K-0223
K-0321

Based on observation and interview the facility failed to ensure that expired medications and normal saline (irrigation) solutions were removed from available stock and not available for patient use in the Emergency Department (ED) triage room and at the medical floor medication refrigerator resulting in the potential for less than optimal patient outcomes for all patients. Findings include:

On 12/15/2020 at 1030 during tour of the Emergency Department (ED) triage room it was noted that there were three (3) bottles of opened normal saline that were partially used. Manufacturer's recommendation on the bottle stated to "discard any unused portion." Staff B confirmed at 1033 that the bottles "were supposed to be a onetime use".




38269

On 12/15/2020 at 1100 while on tour of the facility's patient care area, in a "medication refrigerator" located behind the main nursing station the following medications were found outdated:

1) Nine (9) expired (25 mg/5 ml) 5 ml single dose vials of "Diltiazazem Hydrochloride Injection" with an expiration date of 09/2020 were found in the medication refrigerator expired and available for use.
2) One (1) box containing 12, (120 mg each), "Acetaminophen suppositories USP,120" with an expiration date of 09/2020 was found in the refrigerator available for use.
All outdates were confirmed by staff B (Director of Nursing) who was present during the observations.

On 12/16/2020 a policy review was conducted and revealed the following: date created 10/24/2019 approved 07/23/2020, "Subject: Inspection of Medication Storage, Administration, and dispensing Areas. Purpose: To ensure the integrity and availability of drugs and biological in the hospital and maintain regulatory requirements.
Policy: The Pharmacist (or designated representative) will at least monthly inspect all drug storage, administration, and dispensing areas.
Procedure: 1. Once a month, the Pharmacist (or designated representative) will perform an inspection of all drug storage, administration, and dispensing areas. This includes acute care areas as well as clinic and ambulatory areas to verify proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security. 2. a ..., b ..., c...., d ..., e ...
f. There are no outdated or otherwise unusable drugs present. g ..., h ..., 3. Complete inspection forms are to be maintained in the pharmacy department ...

Based on document review and interview, the Infection Control Preventionist (Staff L) failed to communicate the poor outcomes of hand washing surveillance audits and conduct periodic evaluations (with action plans) to the quality assurance program, resulting in the potential for an increase in the spreading of infections to all patients receiving care at the facility. Findings include:

On 12/16/2020 at 1315 during a review of the quality program and review of monthly quality meeting minutes from the time period of January 2020 to November 2020 occurred. The documentation of hand washing surveillance audits were not reported to the quality assurance program.

On 12/16/2020 at 1330 during an interview with the director of the quality program, it was determined that she did not know that "Hand washing with PT (physical therapy) and maintenance was so bad". The director of quality agreed that she "needed to be more aware of the audits and get a plan of corrective action in place".