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Based on a review of facility policies and staff interviews, the facility failed to periodically test crash cart defibrillators as specified by facility policy.

Findings were:

A review of the Medication Room defibrillator testing checklist revealed the defibrillator was not checked on the following August 2014 dates: 1, 3, 4, 5, 8, 14, 16, and 17. The surveyors were onsite August 18 and 19, 2014.

A review of the Emergency Room defibrillator testing checklist revealed the defibrillator was not checked on the following August 2014 dates: 1, 2, 3, 4, 5, 6, 8, and 14. The surveyors were onsite August 18 and 19, 2014.

Facility policy entitled "Crash Carts" stated, in part: "A crash cart will be maintained in each Emergency Room...2. A licensed nurse is responsible for checking the crash cart every 24 hours to insure:...b. Any defective or missing equipment is replaced immediately. 3. Licensed nurse checking crash cart will validate action by signing/date crash cart checklist."

In an interview with the Director of Nursing on the morning of 8/19/14 during a tour of the facility, she stated the defibrillators were to be checked each day.

Based on a tour of the facility and staff interviews, the hospital failed to ensure that the hospital was maintained in a manner to ensure safety of patients and staff.

Findings included:

During a tour of the hospital the morning of 8/19/14, the following was observed:
In the women's bathroom next to the emergency department, there was an electric outlet installed in close proximity to and underneath a liquid soap dispenser located next to the sink. The liquid soap dispenser located above the electrical outlet in close proximity to the sink presents a possible risk for electrical shock for someone washing their hands.

In the Central Supply Room, there were boxes of laryngoscope blades stored on a shelf approximately 6 inches from the ceiling. All items should be stored at least 18 inches from the ceiling in order for the fire sprinkler system to be effective, as items above 18 inches block the full coverage of the sprinkler in the event of fire.

The above was confirmed in an interview the morning of 8/19/14 with the Chief Executive Officer and the Director of Nursing during the tour.

Based on a tour of the hospital and staff interviews, the facility failed to ensure drugs were stored according to acceptable standards of practice as medication refrigerator temperatures were not monitored.

Findings included:

During a tour of the hospital the morning of 8/19/14 accompanied by the Chief Executive Officer and the Director of Nursing, the following was observed:

In the hospital pharmacy, the pharmacy tech was asked for the temperature log for the refrigerator containing medications. The pharmacy tech was unable to provide a temperature log for the refrigerator or any other documented evidence that the refrigerator temperatures were monitored. In the hospital medication room, a nurse was asked for the temperature log for the refrigerator containing medications. The log was completed sporadically, with no temperature entries at all for weekend dates. The temperature log for the refrigerator/freezer for July and August 2014 had no temperatures documented for the following 2014 dates: July 9, July 17-18, July 22-23, July 30-31, August 6, and August 12-13. Failure to follow medication storage/temperature standards can result in subpotent medications. Without a temperature log indicating monitoring for the refrigerator, it could not be determined that the medications were maintained according to manufacturer specifications.

Facility policy entitled "Equipment" stated, in part: "Institutional pharmacies distributing medication shall have the following equipment...(B) refrigerator and a system or device (e.g., thermometer to monitor the temperature daily to ensure that proper storage requirements are met..."

The above was confirmed in an interview the morning of 8/19/14 with the Chief Executive Officer and the Director of Nursing during the tour of the pharmacy.

Based on a tour of the hospital and staff interviews, the facility failed to ensure that food and medication refrigerators were monitor to ensure proper control of temperatures.

Findings included:

During a tour of the hospital the morning of 8/19/14 accompanied by the Chief Executive Officer and the Director of Nursing, the following was observed:
? In the Patient Nourishment Room, the refrigerator containing patient food supplies was in need of cleaning as there were drips in the freezer. The temperature log for the refrigerator/freezer for July and August 2014 had no temperatures documented for the following 2014 dates: July 13, July 24, July 27, August 13, August 14, and August 17.
? In the Dietary Food Supply room, the temperature log for the refrigerator/freezer for July and August 2014 had no temperatures documented for the following 2014 dates: July 4, July 5, July 6, July 12, July 13, July 19, July 20, July 24, July 25, July 26, July 27, July 30, August 2, August 3, August 9, August 10, August 13, August 14, August 15, August 16, and August 17.
? In addition, the log sheets in the patient nourishment room and the Dietary Food Supply room gave no indication of the proper temperature ranges for either the refrigerators or the freezers; there were no instructions outlining the steps to be taken if the temperature was out of range.
? There was no way to determine that food products were maintained at a safe temperature during multiple days in July and August of 2014 which presents a risk for food-borne illness.
? In the hospital pharmacy, the pharmacy tech was asked for the temperature log for the refrigerator containing medications. The pharmacy tech was unable to provide a temperature log for the refrigerator or any other documented evidence that the refrigerator temperatures were monitored. In the hospital medication room, a nurse was asked for the temperature log for the refrigerator containing medications. The log was completed sporadically, with no temperature entries at all for weekend dates. The temperature log for the refrigerator/freezer for July and August 2014 had no temperatures documented for the following 2014 dates: July 9, July 17-18, July 22-23, July 30-31, August 6, and August 12-13. Failure to follow medication storage/temperature standards can result in subpotent medications. Without a temperature log indicating monitoring for the refrigerator, it could not be determined that the medications were maintained according to manufacturer specifications.

The above was confirmed in an interview the morning of 8/19/14 with the Chief Executive Officer and the Director of Nursing during the tour.

Based on observation and interview, the facility failed to assure fire safety by having alcohol hand sanitizer dispensers installed directly next to spark sources (light switches) in three locations.

Findings include:

During a tour of the emergency department the morning of 8/19/14, two alcohol hand sanitizer dispensers were found installed approximately 1/4 - 1/2 inch from the electrical light switch (spark sources) on the wall in 2 of 2 treatment rooms.

During a tour of Patient room 104 the morning of 8/19/14, one alcohol hand sanitizer dispenser was found installed approximately 1/4 - 1/2 inch from the electrical light switch (spark source) on the wall.

The dispensers contained alcohol-based hand rub, which is flammable, creating a fire hazard.The above findings were confirmed in an interview with the Chief Executive Officer and the Director of Nursing during the tour the morning of 8/19/14.

Based on review of facility policies, review of documents, staff interviews, and a tour of the hospital, the facility failed to ensure a sanitary environment to avoid sources and transmission of infections. In addition, the facility failed to ensure the infection control officer was qualified through current training to perform necessary infection control activities.

Findings included:

A tour of the hospital was conducted the morning of 8/19/14, accompanied by the Chief Executive Officer and the Director of Nursing.

In the Emergency Department, the following was observed:
? There were 13 out of 18 sterilized instruments were observed in the closed position or the clamps were closed; therefore not all surfaces were exposed to the sterilizing agent preventing effective sterilization. It could not be determined that the sterilizing agent penetrated all surfaces to ensure complete sterilization of all surfaces of the instruments.
? A tray containing lab tubes available for patient lab draws was in need of cleaning as there were drips and dust observed on the tray.
? There were two IV trays which were in need of cleaning as there drips and dust observed on the tray.
? There was dust on high horizontal surfaces throughout the emergency department.

In Patient room 104, available for patient use, there was dust on high horizontal surfaces.

In the Clean Utility Room, the following was observed:
? The linens, including sheets, towels, gowns, and blankets, available for patient use, were left uncovered, presenting a risk for cross contamination of the clean linen.
? There were three dirty, corrugated external shipping boxes in the clean utility room, presenting a risk of cross contamination of patient linen and supplies.

In the Central Supply Room, the following was observed:
? There were dirty, corrugated external shipping boxes observed on the shelves next to patient supplies available for patient use, including drinking cups, obstetrical towelettes, emesis basins, and other supplies.

In the Linen Closet, there were 3 bags containing clean linen bags which were observed to be stored on the floor along with other miscellaneous linen. This presents a risk for cross-contamination.

In the Main Clean Linen Storage Room, the following was observed:
? The industrial floor buffer was stored in the clean linen room next to a wire shelving unit containing uncovered towels available for patient use.
? The floor of the clean linen room was in need of cleaning as there was a dead roach and a dead moth on the floor and drips and dust on the floor.
? The linen, available for patient use, including sheets, blankets, pillow cases, patient gowns, and towels were not covered. This presents a risk for cross contamination.
? The lowest level of each of the metal wire shelving units where the patient linens were stored was opened without a solid impermeable barrier, which presents a risk for contamination of patient care linens when the area underneath is swept or mopped.

In the Physical Therapy Department, the following was observed:
? There was a dead spider on top of the wax in the paraffin wax bath.
? There were towels, pillow cases, and gowns on shelving units which were uncovered in 2 physical therapy patient rooms. This presents a risk for cross-contamination.

The west side external door and the south side external doors had insufficient door seals or weather stripping, leaving a gap between the doors and the frame with outside light visible seen from inside the building. The lack of weather stripping or seals prevents a risk for contamination from the weather and the entry of insects and other environmental contaminants such as dust and debris.

In the Phlebotomy area of the laboratory, on one of two phlebotomy trays, the sharps container was full with contaminated items to the brim of the container. Biohazard sharps at the top of the contaminated sharps container present a risk for injury and exposure to contaminated sharps.

In the Radiology Department, there were uncovered linens in the patient x-ray room, which presents a risk for cross-contamination.

In the Central Storage Supply Room, there were 8 dirty, corrugated external shipping boxes on the shelves with opened patient supplies, such as tape, ted hose, gauze, adult diapers, sterile water, syringes, surgical masks, and other supplies available for patient use. There were 7 dirty, corrugated external shipping boxes which were stored on the floor of the room. The above creates a risk for cross-contamination.

In the Instrument Sterilization Room during the tour the morning of 8/19/14, the Infection Control Director was asked for sterilization log book. The Infection Control Director, responsible for sterilizing surgical instruments stated that there was no log book for documenting sterilization activities of chemical and biological indicator test results. When asked, she stated that spore testing was only done monthly. In an interview the afternoon of 8/19/14, the Infection Control Director stated that she researched the CDC guidelines and confirmed that biological monitoring should be done at least weekly. The Infection Control Director referred to a printed page from the CDC which stated, "How often should I perform biological monitoring (BI) (spore testing)? Correct functioning of sterilization cycles should be verified for each sterilizer by the periodic (at least weekly) use of BIs."

Based on the lack of documented evidence that the time, temperature, and pressure requirements were met, there is no way to ensure that the instruments used were properly sterilized. This increases the risk for transmission of infection and cross contamination.

Facility policy entitled "Housekeeping" stated, in part: "The Housekeeping Department is responsible for the cleanliness of:..4. Anything attached to the walls and floors:
a. Towel dispensers and toilet paper holders
b. Light fixtures
c. Window sills and shelves in patient areas
5. All over shelves..."

Facility policy entitled "Cleaning Patient Rooms - Daily" stated, in part: "Clean patient rooms as follows:...3. Damp dust tables, window sill, light fixtures, chairs and doors..."

Facility policy entitled "Emergency Rooms" stated, in part: "2. Damp dust furniture, gooseneck lamp, suction and machine table, wheelchairs, oxygen tank, and shelf over the sink with disinfectant spray. Wipe dry with a soft clean clot after dusting each piece. 3. Damp dus the counter with disinfectant spray. Lift each article off the shelf, wipe clean and dry..."

Facility policy entitled "Janitors' Closet" stated, in part: "6. Closet floors should be cleaned by dust mopping and damp mopping daily."

A review of the personnel file of the Infection Control Officer revealed no documented evidence of training in infection control that was in-depth or current. The Position Description for the position of Infection Control Officer included the following, in part: "Qualifications...Maintain certifications and continuing education requirements needed to perform job..."

All of the above findings were confirmed during the tour by interview the morning of 8/19/14 with the Chief Executive Officer and the Director of Nursing.

Based on a tour of the facility and staff interviews, the facility failed to ensure the confidentiality of each patient by having a patient room which was monitored by video with no facility consent form for such monitoring, with the video feed viewable by anyone standing at the nurses' station in the facility lobby.

Findings were:

During a tour of the facility on the afternoon of 8/19/14, it was noted there was an "Isolation Room" which had a small sign outside the door, in English only, stating the room was video monitored. The monitor receiving the video signal was kept at the nurses' station and was visible by anyone standing in the lobby near the station. It was also viewable from a hallway on the other side of the station. The patient room was currently unoccupied.

In an interview with the Administrator, Chief Nursing Officer, and other nursing staff during the tour, the Administrator admitted the facility had no form which a patient or his/her legally authorized representative would sign to allow video monitoring. They also agreed it was a violation of patient confidentiality to have a patient's video image easily viewed by anyone in the facility lobby.