HospitalInspections.org

Based on observation, document review and interview the hospital failed to safely secure drugs and biologicals in one of two procedure rooms observed at the hospital's Family Practice Clinic and one of four surgical rooms on the Surgical Unit.

Findings include:

- Hospital policy "Medication Guidelines" reviewed on 3/10, directed staff..."All medications must be locked and secured when not under direct surveillance by appropriate staff..."

- Observation on 9/1/10 at 11:00am revealed one unlocked and unattended cabinet in the procedure room at the hospital's Family Practice Clinic that contained the following medications:

1. Eight 10ml (milliliter) vials of lidocaine 2% (a numbing agent).
2. One hundred sixty six- 1ml (milliliter) cartridges of xylocaine 2% (a numbing agent).
3. Eleven 8ml containers of Lugol's Strong Iodine (a topical agent used to treat and prevent infection).
4. Twenty three 9ml Monsel's Ferric Subsulfate (used to stop topical bleeding).

Staff E on 9/1/10 at 11:00am acknowledged the Clinic's patient rooms contained multiple medications in the unlocked, unattended procedure room.


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- Observation on 8/31/10 at 11:00am revealed an unlocked and unattended anesthesia medication tray in operating room #31 of the surgery suite that contained the following medications:

Two vials of Cefazolin 1 gram (an antibiotic)
One 5 ml (milliliter) vial of Dexamethasone
One 20mg (milligram) vial of Furosemide (a diuretic)
One 10ml Heparin 1000 units/ml (a blood thinning agent)
One vial Solu-Cortef 100mg (a steroid)
One 30mg vial of Ketorolac (a pain medication)
One 10ml vial of xylocaine (a numbing agent)
One 2ml vial of Metoclopramide (used to promote stomach emptying)
One 5ml vial of Metoprolol (used to treat high blood pressure)
One 2ml vial of Ondansetron (used to prevent nausea)
One 5ml vial of Glycopyrrolate (used to decrease salivary secretions)
One 1ml vial of Naloxone (used to reverse the effects of narcotic drugs)
One 10ml vial of Neostigmine 1:1000 (used to counteract effects of muscle relaxants)
One vial Sodium Bicarbonate 50ml (an electrolyte supplement)
One 30ml vial of Bupivacaine 0.25% (a numbing agent)
One 30ml vial of Bupivacaine 0.25% with epinephrine (a numbing agent)
One 15ml vial of Enlon (used to prevent muscle contractions)
One 10mg vial of Vecuronium (used to relax muscles
One 20mg vial of Vecuronium
One 30ml vial of xylocaine 1% with epinephrine (a numbing agent)
One 30ml vial of Sensorcaine 0.25 (a numbing agent)
One vial of Cefatin 1 gram (an antibiotic)
Three 5ml syringes of Succinylcholine (used when a breathing tube is placed in the throat)
One 3ml syringe of Neostigmine (used to counteract effects of muscle relaxants)
One 10ml syringe of Atropine (used to decrease salivary secretions)
One 10ml syringe of Lidocaine 2% (a numbing agent)
One 10ml syringe Phenylephrine (used to prolong the action of spinal anesthesia)
One 40mg abboject (prefilled syringe) of Amidate (used to induce sleep and relaxation)
One 8ml vial of Labetalol Hydrochloride 20mg per 4ml (used to treat high-blood pressure)

Administrative staff C on 8/31/10 at 11:00am acknowledged the multiple medications in the unlocked, unattended anesthesia medications tray and verified medication trays were not to be left unlocked in operating rooms.

Based on observation, staff interview and document review, the hospital's infection control officer failed to ensure hospital personnel followed basic infection control policy and practices during 10 of 37 observations in patient care areas and when cleaning one of one patient's room after a patient discharge and cleaning one occupied patient room.

Findings included:

- Review of the hospital's Infection Control Plan on 8/31/10 revised 2/10, directed "...There is an effective organization-wide program for the surveillance, prevention and control of infections at the hospital...Surveillance incorporates activities to identify, assess, analyze, report, prevent, and control hospital acquired infections..."

- Observation on 8/31/10 at 10:15am in the trauma room of the surgical suite revealed a cart labeled "WAC Trauma Cart". The supply cart contained three open intravenous (IV) tubing that staff failed to date when opened.

Administrative staff C on 8/31/10 at 10:15am acknowledged staff failed to date the IV tubing when opened to ensure the tubing had not been opened for over 24 hours.

- Review of the manufacturers information sheet for Alaris Medical Systems IV tubing directed "...Replace IV tubing every 24 hours once opened..."

- Observation on 8/31/10 at 1:50pm in the Medical Intensive Care Unit (MICU) room #21 revealed patient #21 required contact isolation. Staff D and staff M wearing an isolation gown and gloves provided care to patient #21. Following patient care staff D removed their gown and hung the soiled gown up in the doorway of the contact isolation room. Staff D disposed of their gloves, performed hand hygiene, and left the room. At 2:00pm staff D reused the soiled isolation gown from the hook in the doorway and entered isolation room #21. Staff D preformed a blood glucose test while wearing the soiled gown. Staff D, removed their gown and re-hung the same soiled isolation gown up in the doorway of the contact isolation room. Staff D disposed of their gloves, performed hand hygiene, and left the room.

Administrative staff B and staff Q on 8/31/10 at 2:00pm acknowledged staff D reused the isolation gown and stated MICU staff were allowed to reuse isolation gowns.

- Document review on 8/31/10 of the hospital's policy titled "Contact Precautions", revised 11/09, directed "...Remove gown before leaving the patient's room, ...After gown removal, ensure that clothing does not contact potentially contaminated surfaces to avoid transfer of microorganisms to other patients or environments..."

Administrative staff A interviewed on 9/1/10 at 11:55am stated isolation practices of the hospital did not include reuse of isolation gowns.

- Observations on 8/31/10 at 3:20pm in the Surgical Intensive Care Unit (SICU) revealed staff P pulled a plastic bag of soiled cleaning cloths down the hallway.

Administrative staff B on 8/31/10 at 3:20pm acknowledged staff P failed to follow basic infection control practices when they allowed the plastic bag of soiled cleaning cloths to touch the floor.

- Observation on 8/31/10 at 3:30pm in SICU in room #10 of a patient room identified as clean and available for occupancy revealed a used cervical collar in the second cabinet drawer.

Staff K acknowledged on 8/32/10 at 3:30pm the cervical collar belonged to a previous patient and cleaning staff failed to thoroughly clean room #10. Observation on 8/31/10 at 3:37pm in room #14 identified as clean and available for occupancy revealed soiled linen inside a laundry bag in the room.

Staff K on 8/31/10 at 3:30pm acknowledged cleaning staff failed to remove the soiled linen from room #14.

- Observation on 9/1/10 at 8:55am in room #533 of the Post Partum Unit revealed a desk chair with a three inch tear in the seam of the back with foam padding visible and a recliner with torn areas in the seat and arm rests creating an un-cleanable surface.

Staff R on 9/1/10 at 8:55am acknowledged the open area on the chairs and the surfaces were un-cleanable.

- Observation on 9/1/10 at 9:05am in room #553 of the Post Partum Unit revealed a recliner with tears in the seat and one armrest creating an un-cleanable surface.

Staff R on 9/1/10 at 9:05am acknowledged the un-cleanable open area on the recliner.


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- Review on 8/30/10 of the manufactures information sheet for "EnVerros SaniMaster 4 " directed staff to leave the surface wet (dwell) for 10 minutes to ensure a total disinfection.

- Review on 8/30/10 of the manufacturers information sheet for "EnVerros toilet bowl cleaner" directed staff to empty the toilet bowl before applying cleaner.

- Observation on 8/30/10 at 2:15pm of housekeeping staff I cleaning room #4-332 after a patient discharge revealed staff I used a cleaning cloth saturated with the disinfectant SaniMaster 4 to clean the sink, cabinet, table, chairs, bed and other flat surfaces. The sink, cabinet, and flat surfaces remained wet for less than four minutes, not the required 10 minutes contact time for total disinfection. Staff I swabbed a solution of EnVerros Bowl Care in the toilet bowl, without emptying the bowl of water prior to applying the toilet bowl cleaner. Staff I returned to the cleaning cart, wearing the gloves used to clean the toilet, and obtained toilet paper and trash bags. Staff I returned to the room placed the toilet paper in the bathroom and the trash bags in the trash cans wearing the soiled gloves used to clean the toilet.

Staff I, on 8/30/10 at 3:00pm acknowledged the flat surfaces in room #4-332 failed to remain wet for the required ten minutes of contact time.

- Observations on 8/31/10 at 3:25pm of the playroom on the Pediatric Unit revealed a chair with a six-inch slit in the upholstery with foam exposed, and a chair with a two inch slit with foam exposed creating an un-cleanable surface.
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Staff L on 8/31/10 at 3:25pm acknowledged the slits in the upholstery on the chairs created an un-cleanable surface.

- Observations on 8/30/10 between 12:25pm and 12:46pm on the Hospitalist Unit room #1033 (a room identified as a contact isolation room) revealed contracted housekeeping staff cleaned the room performed with a clean microfiber cleaning cloth saturated with the disinfectant/germicidal cleaner " SaniMaster 4 ". Staff cleaned the sink, cabinet, and other flat surfaces. Staff applied the cleaner at 12:34am but the surfaces remained wet for six minutes (12:40pm) instead of the ten minutes contact time for total viricidal/germicidal cleaning. At 12:40am housekeeping staff swabbed a solution of " EnVerros Bowl Care " in the toilet bowl, without emptying the bowl of water prior to applying the toilet bowl cleaner. Staff took out the trash and flushed the stool cleaner at 10:44am or within 4 minutes of application. Housekeeping staff failed to allow the cleaner to remain in the toilet bowl the required 10 minutes.

Staff J, contracted housekeeping staff, on 8/30/10 at 12:45pm acknowledged the SaniMaster 4 Disinfectant and Germicidal cleaner and bowl cleaner was to remain wet on the surfaces for 10 minutes. Staff failed to follow the manufactures guidelines for a 10 minute wet/dwell time for total disinfection/germicidal cleaning. Staff O, on 8/31/10 at 2:45pm stated housekeeping staff received annual education and through "staff huddles" on the manufactures instructions including the 10 minute wet/dwell time for the SaniMaster products. Staff O verified that housekeeping staff was expected to follow the manufactures instructions for use including the required 10 minute wet/dwell time.

- Observation on 8/30/10 at 1:50pm of the 9th floor tower, Medical/Surgical Physical Therapy room revealed 10 crutches with foam arm pads that were cracked and broken.

Staff A on 8/31/10 at 3:00pm acknowledged any equipment with surface's that are broken is to be taken out of service, a work order initiated and repaired or replaced.

- Observation on 8/30/10 at 3:00pm on the 6th floor Tower of two Dialysis rooms revealed station #1 dialysis chair's had a tear in the right arm's vinyl covering. The chair's seam was torn and frayed, the left arm vinyl covering had a ? in tear and the vinyl foot rest had a ? inch tear. Chair #2's vinyl covering had a 1 inch tear on the foot rest, the upper chair back vinyl covering had a 1 inch slit. The right and left arm rest had multiply worn frayed areas along the vinyl seamed area and the left table top on the chair had a 4 inch by ? inch piece of formica missing leaving these chairs un-cleanable. Chair #3's right formica table top had a 1 inch by ? inch of formica missing creating an un-cleanable surface. Chair #4's head rest had a 2 inch crack in the vinyl covering. The left tabletop had a 2 inch long missing piece of formica creating an un-cleanable surface.

Staff N on 8/30/10 at 3:15pm acknowledged the chairs and table tops had cracks, tears and missing pieces of formica. Staff N acknowledged dialysis treatments exposed chairs and equipment to body fluids and all surfaces should be cleanable to prevent cross contamination. Staff N indicated the routine process for un-cleanable furniture and equipment should be for staff to take the furniture/equipment out of service and replace or repair it.