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Based on document review and staff interview, it was determined for 1 of 4 (E#22) employees personnel files reviewed for completed competencies, the Hospital failed to ensure annual competencies were completed per Hospital policy, potentially affecting all patients receiving care in the Hospital. (Current census of 116).

Findings include:

1. On 06/19/19 at approximately 1:30 PM, employee files were reviewed for annual competencies with the Human Resources Director (E#5). The file for Lead Sterilization Technician's (E#22) lacked annual competency and education for Sterilization.

2. On 06/20/19 at approximately 9:00 AM, the Hospital policy "Position Descriptions and Competencies" revised by the Hospital on 10/18 was reviewed. The policy stated "Each employee is required to attend or complete Annual Re-orientation for Facility-wide on-going competency assessment..."

3. On 06/19/19 at approximately 1:45 PM, an interview with E #5 was conducted. E#5 stated, "We don't currently have the Sterilization annual competency on E#22 and the Department head is on vacation...the most recent Central Supply competencies are from May 2016."

4. On 06/19/19 at approximately 4:45 PM, an interview with the Central Sterilization Manager (E#23) was conducted. E #23 stated, "(E#22) was off on medical leave for awhile, but has been back since January of this year...so yes we should have the Sterilization competency completed.".

Based on observation, document review, and staff review, it was determined that the Hospital failed to ensure medications were properly maintained until use, potentially affecting all patients receiving care in the Hospital (Current census of 116 patients).

Findings include:

1. On 06/18/19 at approximately 09:00 AM, a tour of the Post-Anesthesia Care (PACU) was conducted. The CRNA (E #10) had a syringe labeled "Robinal" in the pocket of (E #10's) scrub shirt.

2. On 06/19/19 at approximately 1:30 PM, the Hospital policy "13-01-H Administration of Drugs Policy - General" (last revised by the Hospital on 10-1-2012) was reviewed. The policy required, "Administer individual drugs as soon as possible after the does has been prepared, particularly drugs for parenteral administration."

3. On 06/18/19 at 9:05 AM, an interview with the Infection Control Officer (E#7) was conducted. E#7 stated that the medication should have been kept in the procedure room where it was going to be administered.

4. On 06/18/19 at approximately 10:15 AM, a tour of the unoccupied and unsecured Operating Room #2 was conducted. A vial of Bupivacaine 5 mg/1 ml (milliliter/milligram), an analgesic agent, containing approximately 5 ml was on the anesthesia cart.

5. On 06/19/19 at 3:00 PM, the Hospital policy "RX09-02 Storage Floor Stock" (last revised by the Hospital on 4/1/2012) was reviewed. The policy required "Prescription medication must be maintained in locked storage unless in a supervised area to prevent unauthorized access."

6. On 06/18/19 at 10:30 AM, an interview with E#7 was conducted. E#7 stated that the medication should have been locked in the anesthesia cart.

Based on observation, staff interview, and document review, it was determined that the Hospital failed to ensure opened or outdated medications were disposed of according to Hospital policy, potentially affecting all patients receiving care in the Hospital (Current census of 116 patients).

Findings include:

1. On 06/18/19 at approximately 11:00 AM, a tour of the Gastro Intestinal (GI) suite was conducted with Registered Nurse (E#17). An open unlabeled bottle of sterile water was contained in a small locked refrigerator in procedure room three (3).

2. On 06/18/19 at approximately 11:15 AM, an interview with E#17 was conducted. E#17 stated, "There should not be an opened sterile water in the fridge. The sterile water should be used only for one patient then discarded...".

3. On 06/19/19 at approximately 10:00 AM , the Hospital policy "Unusable Drugs and Devices Policy" revised by the Hospital on 06/2018 was reviewed. The policy states "2.1.7...Otherwise unsuitable for administration or use (e.g., questionable integrity, effectiveness, and stability)...3.3.1...Unusable drugs and devices shall not be distributed or administered...".

Based on observation, documentation review and staff interview, it was determined the Hospital failed to ensure all Radiological Department's personal protection equipment was intact and safe for use. This has the potential to affect all Radiology staff and patients.

Findings include:

1. On 06/18/19 at 11:00 AM, a tour of Operating Room #6 was conducted. Lead apron #0-2, had a 10 inch tear on the binding, preventing proper protection from X-rays and proper cleaning/disinfecting.

2. On 06/19/19 at 10:00 AM, the Hospital policy "Rad 032 - Annual Review of Lead Apparel Policy (last revised by Hospital on 2/11/16) was reviewed. The policy included..."Each piece of lead apparel/protective device will be visually radio graphically inspected and tested for shielding integrity annually. During the visual inspection, the lead apparel/protective device will be evaluated for cracking and visible signs of wear and tear. Any areas of concern will be noted on the log under the comment section."

3. On 06/18/19 at approximately 11:15 AM, an interview with the Operating Room Charge Nurse (E#9) was conducted. E#9 stated that the apron will be removed from service immediately.

Based on observation, document review, and staff interview, it was determined for 1 of 1 manual dish washing sink, the Hospital failed to ensure dietary staff followed manufacturer's guidelines for manual dishwashing. This has the potential to affect all patients, staff, and visitors receiving dietary services in the Hospital.

Findings include:

1. On 06/17/19 at 9:45 AM, a tour of the Dietary Department was conducted. The manual dish washing sink had a concentrated detergent machine above the sink with a hose leading to the inside of the sink. The sink did not have any markings to indicate water levels to ensure the sink had the correct amount of water/detergent mixture for dish washing.

2. On 06/10/18 at 1:00 PM, the "Product Specification Document" dated by the Hospital on 04/14/15 was reviewed. Under "Recommended Usage (Maximum)" it indicated 2.0 ounces of concentrate solid detergent should be mixed into 20 gallon (16 drops) for proper manual washing.

3. On 06/17/19 at 10:00 AM, an interview with the Food Service Supervisor (E#14) was conducted. E#14 confirmed the sink did not contain any markings to ensure the water and chemicals were mixed to the right proportion, ensuring proper cleaning and disinfection.

Based on observations during the survey walk-through, staff interview, and document review during the life safety code portion of a Sample Validation survey conducted on June 17 - 19, 2019, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the life safety code portion of the Sample Validation survey conducted on June 17 - 19, 2019, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation, document review, and interview, it was determined for 1 of 1 Radiology/Nuclear Medicine Department's weight scale and 1 of 2 Cardiac Rehab bicycle exercisers, the Hospital failed to ensure patient care equipment was safe for patient use. This has the potential to affect all patients receiving services in the Radiology and Cardiac Rehab Departments.

Finding include:

1. On 06/19/19 at 8:04 AM-9:06 AM an observational tour of the Radiology/Nuclear Medicine Department was conducted with the Director of Imaging Services and Cardiovascular Lab (E #13) and the Radiology Department Interim Director (E#15). The Radiology/Nuclear Medicine Department contained a weight scale that lacked a Preventive Maintenance (PM) tag, which indicated the last PM inspection.

2. On 06/18/19 at 10:00 AM - 10:30 AM a tour of the Cardiac Rehab Department was conducted with the Director of Respiratory Services (E#19) and the Director of Therapy Services (E#20). Within the Cardiac Rehab unit, one bicycle exerciser was available for use without a Preventive Maintenance tag, which indicated the last PM inspection.

3. The policy titled "Medical Equipment Management Plan" (revised by the Hospital on 8/21/17) was reviewed on 06/19/19 at 11:45 AM. The policy required that, "Biomedical Engineering establishes and maintains a current, accurate and separate inventory of all equipment in program of planned inspections or maintenance."

4. During an interview conducted with E#13 on 06/19/19 at 11:55 AM, E#13 confirmed the above findings and stated, "The scale is not on the preventive schedule and should be. Maintenance has put a preventive maintenance sticker on the scale and added it to the list."

5. On 06/19/19 at 1:30 PM, an interview with the Biomedical Engineer technician (E#21) was conducted. E#21 reported the Cardiac Rehab Department exerciser in question was acquired by another department and was not added to the current "Asset" list. Therefore, the exerciser was not included in the preventative maintenance schedule. E#21 agreed the equipment should be inspected for safety.


B. Based on observation, document review and staff interview, it was determined for 3 of 10 refrigerators/freezers and 1 of 1 warming units, the Hospital failed to ensure temperatures were monitored, potentially affecting all patients receiving care in the Hospital, currently a census of 116.

Findings include:

1. On 06/18/19 at approximately 11:00 AM, a tour of the Gastrointestinal (GI) suite was conducted with Registered Nurse (E#17). Two boxes of rapid urea broth (prepared culture media vials) used for biopsies taken during scope procedures were stored in a small locked refrigerator in procedure room three (3). No refrigerator temperatures were documented.

2. On 06/18/19 at approximately 11:15 AM, an interview with E#17 was conducted. E#17 stated, "I don't think the temperature affects the biopsy cultures...so I am not sure that we need to monitor the temperatures of the refrigerator".

3. On 06/19/19 at approximately 10:00 AM, an interview with the Director of Laboratory Services (E#18) was conducted. E#18 stated, "Yes the temperature of the refrigerator should be monitored because the rapid urea broth (prepared culture media vials) have to be kept between 2 degrees Celsius and 8 degrees Celsius.

4. On 06/18/19 at approximately 10:50 AM, a tour of the Post Anesthesia Care Unit (PACU) was conducted with Registered Nurse (E#9). The temperature logs for the blanket warmer were reviewed. The log indicated 5 days during May 2019 that the temperature was above the acceptable range of 130F. Readings on 6/4, 6/5, 6/7, 6/14 and 6/15 were logged as 135-150 F. There was no documentation the out of range temperatures were reported until 06/17/19 and there was no corrective action noted.

5. On 06/19/19 at approximately 11:00 AM, a tour of the Post Anesthesia Care Unit (PACU) was conducted with E#7. One refrigerator and one freezer had temperatures out of range. The refrigerator temperature log indicated 8 days, from 6/11 through 6/18, with temperatures above the acceptable range of 41F. The freezer log indicated 4 days, 6/11, 6/12, 6/13 and 6/15, with temps below the acceptable 0* F. There was no documentation the out of range temperatures were reported or corrective action taken.

6. On 6/19/19 at approximately 3:00 PM, the Hospital policy "Care of Refrigerators and Ice Machines" reviewed by the Hospital on 09/18 was reviewed. The policy states "All refrigerators will be maintained and cleaned...A Daily Refrigerator Temperature Monitor will be placed on the door of each refrigerator for documentation of refrigerator and freezer temperatures..."

7. A review of the blanket warmer temperature check log form was completed on 06/19/19 at 3:30 PM. At the bottom of the form indicated "Instructions: Each day, record the temperature of the warmer ... If the temperature falls outside the acceptable range of 100-130F, please write corrective action below."

8. On 06/19/19 at approximately 11:30 AM, an interview with the Infection Control Coordinator (E #7) was conducted. E#7 reviewed the logs for the refrigerators and the blanket warmer and agreed the logs failed to indicate notification of the temperatures which were out of range and failed to indicate the corrective action taken.

A. Based on observation, document review, and interview, it was determined for 1 of 1 Radiology/Nuclear Medicine Department, the Hospital failed to ensure the environment was safe and sanitary in order to prevent/control infections and communicable diseases. This has the potential to affect all patients served in the Radiology/Nuclear Medicine Department.

Findings include:

1. On 06/19/19 at 8:04 AM-9:06 AM, an observational tour of the Radiology/Nuclear Medicine Department was conducted with the Director of Imaging Services and Cardiovascular Lab (E#13) and the Radiology Department Interim Director E#15. The following infection control issues were noted:

a. In the stress test room the wall oxygen gauge; computer work station monitor; weight scale; crash cart; and the wall bumper guard contained a large amount of removable gray fluffy debris.
b. The fire extinguisher outside the stress test room contained a large amount of removable gray fluffy debris.
c. The x-ray table contained a large amount of removable gray fluffy debris.
d. The CT (Computed Tomography-X-ray) room's equipment cart contained a large amount of a removable white sticky substance on the front and sides, and the inside of the cart contained three pairs of unpackaged scissors and a unpackaged pair of hemostats, which contained a removable yellow sticky substance.
e. The CT room's contrast injector's top and base contained a removable dark sticky substance.
f. The CT room's patient table contained an approximately 2 inch hole with surrounding cracks, which would not allow for proper cleaning and disinfecting.
g. The CT machine and power modem box contained a large amount of removable gray fluffy debris.
h. The hallway of the Radiology Department contained approximately six 12 inch lines of a removable sticky dark substance on the wall (identified by E #13 as a possible soda spill).

2. The policy titled "Ancillary Area Cleaning" (revised by the Hospital on 9/17) was reviewed on 06/19/19 at 10:00 AM. The policy required that, "Sanitize all horizontal surfaces using a green microdenier cloth soaked in disinfectant...clean work surfaces...spot wipe doors and walls..." The policy lacked any mentioned frequency of cleaning and disinfecting.

3. The policy titled "Procedure Room Cleaning" (Effective on 7/15) was reviewed on 06/19/19 at 10:05 AM. The policy required that, rooms and medical/patient equipment is to be cleaned daily.

4. During an interview conducted with E#13 and E#15, during the tour, E#13 confirmed the above findings and stated, "The housekeeping personnel is supposed to clean the Radiology/Nuclear Medicine unit and equipment every day.

5. During an interview conducted during the tour, the lead CT Technician (E#16) stated, "The scissors are used to open patient care equipment and the hemostats are used to clamp the patient's contrast infusion lines. I usually just wash them with hand soap when they get dirty."


B. Based on document review and interview, it was determined that for 16 of 18 ice machines, the Hospital failed to ensure ice machines were safe and sanitary in order to prevent/control infections and communicable diseases. This has the potential to affect all patients and staff.

1. On 06/19/19 at 11:00 AM, the Log titled "Ice Machine Inventory & Service Schedule for 2018-2019" (identified by E #13 as the Hospital's ice machine disinfection log) was reviewed. The log indicated that ice machines: 6th Floor South, 5th Floor South, 4th Floor North, 4th Floor North, 3rd Floor South, 2nd Floor South, 1st Floor South, Kettler A, Kettler B, Kettler C, 1st Floor North, Cath Lab, Emergency Department, Kitchen #1, Kitchen, #2, 3rd Floor North, were disinfected and cleaned on 8/6/19-8/15/19 and were not cleaned and disinfected again until 1/24/18-2/19/19 (greater than 120 days)

2. On 06/19/19 at 11:15 AM the document titled, "AMME Monthly Monitoring Plan" (no revised date) was reviewed. The document required that, "Ice Beverage Machines-Routine cleaning by EVS (environmental Services) and quarterly Sanitization by Faculties Management..."

3. During an interview with E#15 conducted on 06/19/19 at 11:30 AM, E#15 confirmed the above findings and policy.


C. Based on observation, document review, and staff interview, it was determined the Hospital failed to ensure the morgue was maintained in a sanitary manner, potentially affecting all patients, visitors and staff, receiving services at the Hospital, current census 116.

Findings include:

1. On 06/19/19 at 10:20 AM a tour of the Morgue was conducted. The area was very malodorous and on the floor there were approximately 30 dead bugs; four (4), what appeared to be, used towels on the autopsy table; a stained drape on the pathology table; and large dust balls on the floor underneath the pathology table.

2. On 06/19/19 at 10:20 AM, the contract cleaning company's policy "Procedure Room Cleaning" dated by the contract cleaning company on 07/2017 was reviewed. Under "Procedure:" third bullet indicated "Remove all debris from the floor and place in trash container. Place any items dripping with blood or body fluids in a red (biohazard) container."

3. On 06/19/19 at 11:00 AM, an interview with Chief Executive Officer (E#3) was conducted. E#3 confirmed the room was malodorous, there were bugs on the floor, and dirty towels on the autopsy table. (E#3) stated "This room shouldn't be in this condition, and it will be cleaned immediately."


D. Based on observation, document review and staff interview, it was determined for 1 of 1 surgical patient (Pt#21), the Hospital failed to ensure 1 of 1 Employee (Surgery Circulator/Registered Nurse- E#11) followed infection control practice in order to prevent and control infections. This failure has the potential to affect all patients receiving surgical services, currently an average of 283 procedures per month.

Findings include:

1. During an observation on 06/18/19 at 9:38 AM, Pt#21 was to have a right total knee replacement procedure performed in operating room #1. In the presence of the Infection Control Coordinator (E#7) and prior to the start of the procedure, E#11 crawled under the surgical table holding a monitor cable, touched the floor with bare hands, and plugged the monitor cable into the corresponding plug. E#11 crawled back to the original location, rose up to the table, and opened a sterile package without performing hand hygiene or applying gloves. After opening the package, E#11 then applied sterile gloves without performing hand hygiene.

2. On 06/18/19 at 9:40 AM, E#7 stated (for the above mentioned procedure), "That is not our process."

3. At approximately 9:45 AM Pt#21 had a urinary catheter inserted. Prior to insertion of the urinary catheter, E#11 cleansed the penis of Pt#21 with a sanitizing cloth without donning gloves.

4. On 06/18/19 at 9:47 AM, E#7 stated that Standard Precautions were not followed during the catheter insertion and E#11 should have worn gloves.

5. On 06/19/19 at 9:30 AM, the Hospital policy, "STANDARD PRECAUTIONS" (created by the Hospital on 05/2003) was reviewed. The policy indicated under "B. Hand Hygiene, Perform hand hygiene before contact with particularly susceptible patients (i.e. severely immunocompromised, burn patients, surgical patients...). Perform hand hygiene after contact with inanimate environmental sources, likely to be contaminated. C. Gloves,"Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Change gloves between tasks and procedures on the same patient".









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