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Based on observation, interview, and policy review, the provider failed to ensure:
*Four of ten expired pre-filled 10 cubic centimeter normal saline syringes were removed from one of one outpatient procedure room cart.
*One of one oxygen (O2) extension tubing remained packaged until use in one of one outpatient procedure room.
*One of one Ambu-bag remained enclosed in a package until use in one of one outpatient procedure room.
*One of one suction tubing remained packaged until use in one of one operating room (OR).
*One of one O2 extension tubing remained packaged until use in one of one physical therapy room.
Findings include:

1. Observation on 10/25/16 at 9:10 a.m. in the outpatient procedure room revealed:
*An O2 extension tubing hanging from the O2 flow meter.
*An opened uncovered Ambu-bag placed on top of the linen cupboard.
*The outpatient medication cart had four outdated normal saline syringes. One syringe had expired on 5/1/16, and three syringes had expired on 10/1/16.

Interview at the time of the above observation with licensed practical nurse (LPN) E revealed:
*The O2 extension tubing was opened and was ready for emergency use.
*She was unsure why the Ambu-bag was out of its package, and it was lying on top of the linen cupboard.
*She agreed single use supplies should not have been opened prior to use.
*The normal saline syringes should have been removed prior to the expiration date.

2. Observation and interview on 10/25/16 at 10:00 a.m. in the OR with LPN E revealed one extension suction tubing was opened and hanging from the suction machine. She agreed the single use items should not have been opened prior to patient use.

3. Observation and interview on 10/25/16 at 11:30 a.m. in the physical therapy room with physical therapist (PT) H revealed:
*There was O2 tubing and a mask connected to an O2 meter on the wall.
*The PT H was unsure how long the O2 tubing and mask had been hanging there.
*He thought it had been there for quite sometime, and would have been ready to have been used in an emergency.

4. Interview on 10/26/16 at 12:45 p.m. with infection control nurse A regarding the above observations revealed single use patient supplies should not have been opened prior to patient use due to the increased risk of cross-contamination.

Review of the provider's June 2016 Disposable versus Non-disposable Equipment policy revealed any disposable sterile packaged item that had been opened or damaged was considered contaminated and should have been discarded.

Based on observation, interview, and policy review, the provider failed to ensure contact precautions were followed for two of two sampled patients (1 and 3) with known infections. Findings include:

1. Observation on 10/26/16 at 7:30 a.m. revealed patient 3 was on contact infection precautions. There was a contact precaution sign attached to the outside of the door that directed staff and visitors to gown and glove prior to entering the room.

2. Observation on 10/26/16 at 7:42 a.m. revealed nurse aide (NA) F entered patient 3's room with a breakfast tray. She had not gloved or gowned prior to entering the patient's room. Upon leaving the room the NA was not observed washing or sanitizing her hands.

3. Observation and interview on 10/26/16 at 7:48 a.m. with registered nurse (RN) G outside patient 1's room revealed:
*The patient was on contact infection precautions.
*There was no sign on the outside of the door to let staff and visitors know that when entering the room they had to gown and glove.
*RN G confirmed patient 1 was on contact precautions and there should have been a sign outside the patient's door that indicated the proper procedure to ensure infection control practices were followed.

Interview on 10/27/16 at 12:35 p.m. with infection control preventionist A regarding the above observations and interviews revealed:
*Staff should have followed contact precautions as directed by the signage on the door.
*NA F should have gowned and gloved prior to entering patient 3's room with the breakfast tray. She should have washed or sanitized her hands prior to leaving the room.
*The contact precaution sign should have been posted outside of patient 1's room to ensure infection control practices were followed by staff and visitors.

Review of the provider's June 2015 Contact Precautions policy revealed:
*The purpose of the policy was to use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's room.
*Hand hygiene should have been completed prior to putting on gloves.
*Gloves and gown should have been worn when entering the room.
*Gloves and gown should have been removed before leaving the patient's room and hand hygiene performed immediately.

A. Based on observation, interview, review of manufacturer's instructions, and policy review, the provider failed to ensure:
*Proper hand hygiene and glove use by one of one licensed practical nurse (LPN) B during one of one sampled patient (31) colonoscopy procedure.
*Appropriate sterilization of one of one observed Olympus Exera II endoscope by licensed practical nurse (LPN) B after the completion of one of one sampled patient (31) colonoscopy procedure.
Findings include:

1. Observation on 10/26/16 from 8:25 a.m. through 9:15 a.m. in the procedure room during a colonoscopy for outpatient 31 revealed:
*LPN B gowned and gloved prior to the procedure.
*She had coughed into the left side of her gowned arm and then crossed her arms. Her gloved hand had come in contact with the area on the disposeable gown that she had just coughed into.
*She had removed her gloves several times and put on new gloves without washing or sanitizing her hands during the colonoscopy procedure.
*She handled all the snares and biopsy equipment used during the procedure to retrieve specimens. She had never washed or sanitized her hands after changing her gloves and putting on new gloves during the entire procedure.

Interview on 10/27/16 at 8:20 a.m. with LPN B regarding the observation during the outpatient colonoscopy procedure on 10/26/16 revealed:
*She had worked at the hospital for ten years.
*She confirmed she had not washed or sanitized her hands in-between glove changes. She stated if you were working with the same patient she was not required to wash or sanitize her hands after each glove change.

2. Observation and interview on 10/26/16 at 9:25 a.m. with LPN B in the procedure work room during the cleaning of the Olympus Exera II endoscope revealed:
*She had a gown and gloves on prior to the cleaning of the endoscope.
*She had not put on a mask or goggles.
*The water and Empower enzymatic solution had already been placed in the one compartment sink prior to the observation.
*She had placed two pumps of the enzymatic solution into the one compartment sink with an unknown amount of tap water. The water had not been measured prior to adding the Empower enzymatic solution. She thought there was approximately two gallons of water placed in the sink.
*The flexible endoscope was placed in the water of the one compartment sink. The endoscope had not been fully immersed into the enzymatic solution. Some of the flexible endoscope had been sticking out of the water and exposed to the air. Parts of the endoscope touched other parts of the endoscope. She stated she would attempt to push the endoscope into the enzymatic solution in the sink with her gloved hands.
*The Scope Buddy was utilized in the process to assist pushing the enzymatic solution through the inside of the endoscope.
*The endoscope was rinsed with tap water. She then placed the endoscope into the Cidex OPA high level disinfectant. The endoscope had not been completely immersed into the disinfectant solution. Parts of the endoscope protruded out of the solution and exposed to the air. Parts of the endoscope touched one another.
*LPN B had not performed a leak test to ensure there was no leaking from inside the endoscope.
*She stated she had never performed a leak test on the endoscopes she disinfected.
*She had never used sterile water to rinse the scope after the Cidex OPA soaking.
*She had only used tap water to rinse the endoscope.
*She was unsure about the appropriate temperatures required for the water and the Empower enzymatic solution.
*There was no policy and procedure on the Scope Buddy and how to use it, because they had just purchased that equipment two months ago.
*She stated the provider usually performed at least twenty endoscopes a month.
*She stated she had taught herself how to clean the endoscopes by watching a You Tube video. She had never had any formal training on that.

3. Interview on 10/26/16 at 9:40 a.m. with surgical technician C regarding the cleaning of endoscopes revealed she:
*Had started her position at the hospital three months ago.
*Had been taught to clean the endoscopes by LPN B.
*Never measured the water prior to placing the Empower enzymatic solution into the water for cleaning. She just knew how much water to add into the sink.
*Was unaware of the appropriate required temperature of the solution.
*Used tap water to rinse the endoscope and not sterile water.
*Had not rinsed the endoscopes with 30 cubic centimeters of rubbing alcohol.

4. Interview on 10/26/16 at 10:10 a.m. with LPN B and surgical technician C regarding the manufacturer's instructions for the Olympus Exera II endoscope revealed they:
*Both were unsure where the instructions were kept for it.
*Were unable to provide the manufacturer's instructions for the Cidex-OPA and the Empower enzymatic solution upon request for them.

Review of the Exera II endoscope manufacturer's instructions revealed:
*"Make sure items immersed in the detergent solution do not contact one another.
*Fill a small basin with clean water. Use a basin which is deep enough to allow all equipment to be completely immersed.
-Fill a small basin with the detergent solution at the temperature and concentration recommended by the detergent manufacturer. Use a basin which is deep enough to allow all equipment to be completely immersed.
*Immerse all other equipment in the detergent solution.
*After the detergent solution cleaning:
-Remove all equipment from the detergent solution and inspect it.
-Immerse all equipment in the clean water.
-Gently agitate the equipment to thoroughly rinse.
*High-level disinfectant (Cidex-OPA).
-Warning: completely remove air bubbles from all equipment. Disinfection effects cannot be obtained if air bubbles remain on the equipment.
-All disinfection steps should have been performed with all equipment completely immersed. If any part of the equipment is not immersed completely while they are immersed, disinfectant solution may not adequately contact all surfaces.
*Leakage Test:
-During leakage testing, a continuous series of air bubbles emerging from a location on the endoscope indicates a leak at that location. That meant the water would be able to penetrated the inside of the endoscope. If you locate a leak, remove the endoscope from the water with the leakage tester connect and contact Olympus.
-Never connect or disconnect the water cap or the leakage tester's connector cap while immersed.
-Rotate the leakage tester's connector cap until it stops. If it is not fully and properly attached, the endoscope's interior will not be pressurized and accurate leakage testing will be impossible."

Review of the provider's June 2015 Cleaning of Endoscopic Equipment and Storage Unit policy revealed:
*The purpose was to prevent cross-contamination of patients when using the endoscope for multiple procedures.
*Endoscopes which had come in contact with mucous membranes, were considered semi-critical and would have received high level disinfection after each use. Following disinfection, the endoscope should have been rinsed with sterile water.
*Use proper personal protective equipment (PPE) that included a gown, gloves, mask and goggles. The cleaning solution would cause staining, and PPE was very important.
*After soaking in the Cidex OPA solution use sterile water to rinse the scope.
*After the sterile water rinse the scope should have been rinsed again with 30 cc of rubbing alcohol for drying purposes.

Interview on 10/26/16 at 12:45 p.m. with surgical supervisor/infection control nurse A regarding the above observations, interviews, and record reviews revealed:
*She had occasionally observed the cleaning of the endoscopes.
*She agreed the staff were not cleaning and disinfecting the endoscopes according to the manufacturer's guidelines and the provider's policy.
*There was a high risk of cross-contamination if the endoscopes were not appropriately disinfected as directed by the manufacturer's guidelines and the provider's policy.
*The staff should have been following the guidelines and policies of the manufacturer and the provider.

Interview on 10/27/16 at 8:50 a.m. with chief nursing officer and assistant chief nursing officer D regarding glove use during the outpatient colonoscopy procedure with LPN B revealed:
*They would not have expected the staff to wash or sanitize their hands after each glove use if their hands were not visibly soiled.
*LPN B coughing into her gown, then crossing her arms, and contaminating her gloves would have been questionable for proper infection control technique.

Review of the provider's June 2015 Hand Hygiene policy revealed:
*The purpose of the policy was to ensure hand hygiene was conducted appropriately.
*Hand hygiene was the single most important procedure to reduce the risks of transmitting microorganisms from one person to another or from one site to another.
*Personnel should always decontaminate their hands during the 5 moments for hand hygiene:
-Before patient contact.
-Before an aseptic task.
-After body fluid exposure risk.
-After patient contact.
-After contact with patient surroundings.
*Wearing gloves should not have replaced the need for hand hygiene because gloves might have small unapparent defects, might be torn during use, and could have become contaminated during the removal of the gloves.
*Hand sanitizer might have been used in place of washing hands with soap and water as long as hands were not visibly soiled.




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B. Based on record review, interview, policy review, and professional standard's review, the provider failed to ensure the circulating registered nurse in the operating room assessed and documented wound classifications for three of three sampled closed in-patient surgical records (27, 28, and 29). Findings include:

1. Review of patient 27's medical record revealed:*On 8/19/16 she had a failed vaginal hysterectomy that had resulted in an open abdominal hysterectomy.
*The wound classification was blank on her operative nursing assessment form.

2. Review of patient 28's medical record revealed:
*On 9/20/16 she had a surgical procedure to drain a right labial abscess.
*The wound classification was blank on her operative nursing assessment form.

3. Review of patient 29's medical record revealed:
*On 9/23/16 she had a laparoscopic procedure for fulguration of endometrial implants.
*The wound classification was blank on her operative nursing assessment form.

4. Interview on 10/26/16 at 12:20 p.m. with director of surgical services A revealed:
*She confirmed the above patients had not had wound classifications completed by the circulating nurse.
*The circulating nurse had never completed the wound classifications on surgical patients.
*The circulating nurse should have been completing the wound classifications on all surgical patients.
*She agreed the operative nursing assessment form had a place to document wound classifications.
-The above forms had not been fully completed, and they should have been.

Interview and record review on 10/26/16 at 2:15 p.m. with the director of nursing revealed:
*She confirmed the above patients findings.
*Wound classifications should have been done for surgical patients and documented on the operative nursing assessment form.
*They had not followed their policy for operative records and assessments.
-That policy had referenced another policy on surgical wound classification that could not be located.
*The Association of peri-Operative Registered Nurses (AORN) guidelines were the professional standards they followed for surgical services.

Review of the provider's copy of the 2015 AORN guidelines for the Surgical Wound Classification Decision Tree revealed:
*If there was no wound then there would have been no wound classification.
*If there was a wound there was a decision tree to identify which class it would have been. Those included:
-Class I, clean.
-Class II, clean-contaminated.
-Class III, contaminated.
-Class IV, dirty or infected.

Review of the provider's revised June 2015 OR Record/Assessment policy revealed:
*"Operative record should reflect evidence of continued assessment and planning during the operative phase. When charting on the form, where the boxes are used, checkmark what is applicable. Use the N/A when indicated. You do not have to put N/A in other boxes that do not apply in that particular area."
*Documentation should have included: "Appropriate wound classification as outlined in policy and procedure on surgical wound classification."
-That policy was requested on 10/26/16 during the interview with the chief nursing officer, and it could not be located.