HospitalInspections.org

Based on tour, review of policy and procedures and interview with staff, in 6 of 36 facility units toured, the facility failed to ensure all chemicals and cleaning solutions are not available to patients and visitors.

Findings include:

Facility policy titled Cleaning Agents-Proper Usage #7.5 revised 2009 states under 3) "One precaution that is universal for all chemicals is a warning to keep all chemicals out of the reach of children. Employees using departmental chemical in areas where children may be present, especially in the pediatric inpatient and outpatient areas, must keep all chemicals in a child-resistant area when they are not using them."


13469

Examples by surveyor #13469
Cleaning solutions and chemicals are not secure from unauthorized access:

1. While touring the cardiovascular ICU (intensive care unit) on 10/4/10 at 10:40 AM with CNM C room B5507 had seven large containers of cleaning solution. Per interview with C, the room is not secured and as a result, patients and visitors have access to these caustic solutions.

2. While touring the Heart/Vascular ICU on 10/5/10 at 8:45 AM with CMN EE room E5/577, the dirty utility room, contained several shelves full of cleaning chemicals and several cleaning carts with cleaning solutions. Per interview with EE, the room is not secured and as a result, patients and visitors have access to these caustic solutions.

3. While touring the Cardio-Intermediate ICU on 10/5/10 at 9:45 with DMS D room F/4577 had a large container of glass cleaning fluid. Per interview with D, the room is not secured and as a result, patients and visitors have access to this cleaning solution.

4. While touring the Neurological ICU on 10/5/10 at 11:30 AM with CNM GG the soiled utility room had three bottles of phosphoric acid stool cleaner. Per interview with GG, the room is not secured and as a result, patients and visitors have access to this caustic cleaning solution.


26711

Findings by Surveyor #26711:

Review of the Material Safety Data Sheet (MSDS) for Neutral Quat Disinfectant Cleaner, a 3M product, indicates that this chemical cleaner should be kept out of the reach of children. It is corrosive (able to destroy or damage surfaces it comes into contact with) to the eyes, skin, throat, stomach and intestines and can cause serious burns to these areas.

A tour of the Pediatric Day Treatment Center was conducted on 10/4/10 AM and 10:30 AM accompanied by RN K, QI L, and NM M.

At 10:25 AM in room 1060 a bottle of Neutral Quat Disinfectant was discovered in a cabinet under the sink and the cabinet was unlocked. Any child, or adult, who was placed in this room could have had access to this chemical with the potential of causing significant adverse health effects.

At the time of discovery, NM M agreed that the cabinet the chemical was discovered in should have been locked.

Based on review of medical records (MR) and interview with staff, in 5 of 10 surgical MR (#2, 3, 28, 39 and 41) out of a total of 44 MR, the facility failed to ensure the pre-incision "time out" is documented as completed prior to incision time.

Findings include:


13469


Examples per surveyor #13469:
Documentation of the surgical incision being conducted before the surgical time-out:

1. Per MR review, on 10/4/10 at 11:30 AM, Pt #2 underwent the insertion of a left ventricular assist device on 9/16/10. Per intra-operative note dated 9/16/10, the surgical incision was conducted at 5:57 PM. The time-out was conducted at 6:48 PM. The time-out was conducted after the incision per record documentation. Per interview with DMS D on 10/4/10 at 11:30 AM the time-out is done prior to the incision but the electronic record does not reflect an accurate picture of this process.

2. Per MR review, on 10/4/10 at 2:25 PM, Pt #3 underwent an exploratory laparotomy with abdominal washout on 10/3/10. Per intra-operative note dated 10/3/10 the surgical incision was conducted at 12:34 PM. The time-out was conducted at 12:48 PM. The time-out was conducted after the incision per record documentation. Per interview with DMS D on 10/4/10 at 2:25 PM the time-out is done prior to the incision but the electronic record does not reflect an accurate picture of this process.

3. Per MR review, on 10/5/10 at 9:00 AM, Pt #39 underwent an open left radical resection of a groin mass on 9/30/10. Per intra-operative note dated 9/30/10 the surgical incision was conducted at 8:52 AM. The time-out was conducted at 9:09 AM. The time-out was conducted after the incision per record documentation. Per interview with DMS D on 10/5/10 at 9:00 AM the time-out is done prior to the incision but the electronic record does not reflect an accurate picture of this process.

4. Per MR review, on 10/5/10 at 1:35 PM, Pt. #41 underwent an exploratory laparotomy with lysis of adhesions for small bowel obstruction on 9/26/10. Per intra-operative note dated 9/26/10 the surgical incision was conducted at 6:49 PM. The time-out was conducted at 6:49 PM. The time-out was conducted at the same time the incision was done per record documentation. Per interview with DMSD on 10/5/10 at 9:00 AM the time-out is done prior to the incision but the electronic record does not reflect an accurate picture of this process.


22198

On 10/05/10 between 8:36 AM and 11:00 AM during a review of MR for Pt #28, the "time out" was identified at 8:06 AM however the incision time was 8:01 AM, 5 minutes before the "time out" was done. This was confirmed to Surveyor #22198 by AD Pre/Post Operative Care KK and DSS JJ, during the MR review.

Based on tour of facility units and interview with staff, in 2 of 36 units the facility failed to ensure all pt information is confidential and not available to unauthorized staff.

Findings include:


09948

Surveyor observations of the Pulmonary Clinic on 10/5/10 at approximately 2:45 PM reflects that copies of patient's prescriptions filled by Pharmacist zz are kept in an unlocked drawer.

It was confirmed through interview with Pharmacist zz and Director AAA that housekeeping staff clean the office sometime after 5 PM when pulmonary clinic staff have gone home. Housekeeping staff have unauthorized access to patient's medical records numbers as well as the names of the dispensed prescriptions.


20878

Examples by surveyor 20878:

During a tour of off-site clinic (University Station) on 10/04/10 at 11:00 AM with Construction coordinator ff and Building manager hh, 12 medical records were observed stored on an open shelf in a room also used to store janitorial supplies (L49). OT B confirmed that janitorial staff in the evening has access to the room and the medical records.

Based on tour of the facility and interview with staff, in 2 of 36 units toured, the facility failed to ensure the emergency crash carts containing medications are secure from unauthorized access.

Findings include:


26711

Findings by Surveyor #26711:

A tour of the Pediatric Specialty Clinic was conducted on 10/4/2010 between 10:30 AM through 11:00 AM, accompanied by RN K, QI L, and NM N.

It was discovered that the emergency crash cart situated in the Cardiac Stress lab in room 2340, that is used in the event of a breathing or heart emergency, was not always in view of clinic staff.

This cart, which contains medications to restore proper heart and breathing function, was equipped with breakaway locks making tampering possible and allowed for unauthorized access by patients/family.

At the time of discovery NM N confirmed that the cart is not always in view of a staff member.

A tour of unit D4/4 was conducted on 10/4/2010 between 1:00 PM and 1:30 PM, accompanied by RN K, QI L, and NM O.

It was discovered that the emergency crash cart was being stored in a small hallway and was not always in view of staff.

This cart, which contains medications to restore proper heart and breathing function, was equipped with breakaway locks making tampering possible and allowed for unauthorized access by patients/family/visitors.

At the time of discovery NM O confirmed that the cart is not always in view of a staff member.

Based on tour and interview with staff in 2 of 36 units, the facility failed to ensure medications that are open and undated are not available for patient use.

Findings include:


22198

Examples by surveyor 22198:

Operative Care (ADPPOC) KK, DSS JJ, MD HH and A II observed the following in the clean storage area:

On the wire racks were bags of Intravenous (IV) solution.
2 bags of normal saline were opened and not dated.
Medical Director HH confirmed to Surveyor #22198, staff KK & JJ, once the outside package of IV solution was opened, the contents should be discarded after 30 days per manufacturers recommendation.


26711

Examples by surveyor 26711:

A tour of the unit D4/4 was conducted on 10/4/2010 at 1:00 PM accompanied by RN K, QI L, and NM O. During the tour a bottle of undated, opened normal saline was found in a cupboard of a cleaned room 438.

Opened, undated solutions could be potentially contaminated and/or expired.

NM O agreed, this solution should not have been left in the room and should have been discarded when the room was cleaned after the patient was discharged.

Based on review of temperature logs, policy review, and staff interview, the facility failed to ensure temperatures are documented for storage and service of foods. In 2 of 36 kitchenettes on the patient care units failed to maintain sanitary food preparation equipment and failed to ensure that stock food items brought to the patient care units from the dietary department were labeled with a discard or use by date.

Findings include:

Policy #2402.27 states that staff are to check and record the temperatures of refrigeration and freezer units on a daily basis.

The Food and drug Administration Food Code for 2009 reflects at Chapter 3-501.17-Ready to Eat, Potentially hazardous Food, date Marking states under (B) "...refrigerated ready to eat potentially hazardous food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment, and if food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold or discarded, based on the temperature and time combinations specified...".

During Surveyor #05409's tour of the facility kitchen from 10:45 AM to 12:10 PM on 10/5/10, the refrigeration and freezer temperature logs revealed that temperature checks were not documented as done at the following times on the following dates:

7/30/10 at 1:00 PM and 7:30 PM; 8/15/10 at 5:30 AM and 1:00 PM; and 8/18/10 at 7:30 PM.

Executive Chef cc verified these findings with Surveyor #05409 at 12:00 PM on 10/5/10 and added that refrigerator and freezer temperatures are to be monitored at 5:30 AM, 1:00 PM, and 7:30 PM each day.

Based on steam table and Deli temperature log review sheets and staff interview, the facility failed to monitor temperatures to ensure that displayed hot and cold foods are held at appropriate temperatures.

During the dietary tour from 10:45 AM to 12:10 PM by Surveyor #05409 on 10/5/10, review of the steam table log sheets revealed that the steam table temperatures were not documented at the following times on the following dates:

7/21/10 at 7:00 PM; 7/26/10 at 7:00 PM; 8/1/10 at 4:00 PM; 8/5/10 at 7:00 PM; 8/21/10 at 4:00 PM and 7:00 PM; and 9/7/10 at 11:00 AM.

Per review of Deli (cold food) temperature log sheet review during the 10:45 AM to 12:10 PM kitchen tour on 10/5/10, Surveyor #05409 noted that cold food temperatures were not documented at the following times on the following dates:

7/10/10 at 6:00 AM; 7/25/10 at 4:00 PM; 8/4/10 at 4:00 PM; 8/6/10 at 6:00 AM; 9/16/10 at 4:00 PM; and 9/17/10 at 4:00 PM.


09948

Examples by surveyor 09948:

1) Surveyor observations at approximately 10:55 AM on 10/5/10 of the Orthopedic Floor (B6) reflects the kitchenette that serves patients on this unit has a microwave with dark liquid stains and debris in it's inner surface and had a greasy appearance on the outer door. The toaster had a build-up layer of dark debris on it's bottom surface and a greasy outer appearance.

The refrigerator, when opened , had the following undated food stuffs: ice cream cups out of their original packaging, magic cups out of their original packaging. The "Patient Refrigerator Audit Tool-Oct . 2010" reflects "1. Any items older that 4 days will be thrown out. 2. Unlabeled items will be thrown out. 3. Outdated items will be thrown out." There was no label or date on these items to reflect how long they had been in this refrigerator.

This observation was verified by DON JJ at the time above.

2) Surveyor observations at approximately 2:30 PM on 10/4/10 of the Inpatient Rehab. Unit (B44) reflects the kitchenette that serves patients on this unit has a microwave with dark liquid stains and debris in it's inner surface and had a greasy appearance on the outer door. The toaster had a build-up layer of dark debris on it's bottom surface and a greasy outer appearance.

The refrigerator, when opened , had the following undated food stuffs: ice cream cups out of their original packaging, 1 12 inch pizza, 2 Lean Gourmet frozen food dinners, and 1 uncooked cookie loaf. There were no patient/staff names or use-by or discard dates on these food items.

This observation was verified by DON JJ at the time above.

Based on observation, staff interviews and review of maintenance documents, the facility did not construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. The facility did not have a facility free of life safety deficiencies.

FINDINGS INCLUDE:
1. In the Clinical Sciences Center portion of UW Hospital surveyors #12187, 12316, 14105, and 14105 observed that the facility had the following 19 deficiencies: K11-Separation Walls, K15-Finishes, K17-Corridor Walls, K20-Vertical Openings, K21-Door Hold-Opens, K27-Smoke Barrier Doors, K29-Hazardous Rooms, K47-Exit Signage, K51-Fire Alarm Installation, K52-Fire Alarm Inspections, K56-Sprinkler Installation, K62-Sprinkler Inspections, K67-Ventilation, K72-Egress Obstructions, K76-Medical Gases, K77-Medical Gas Piping, K130-Miscellaneous, K143-Oxygen Transfer, and K147-Electrical codes

2. In the American Family Children's Hospital portion of UW Hospital surveyors #12316 and #22219 observed that the facility had the following 16 deficiencies: K12-Building Construction, K17-Corridor Walls, K18-Corridor Doors, K20-Vertical Openings, K25-Smoke Barrier Walls, K27-Smoke Barrier Doors, K29-Hazardous Rooms, K38-Egress, K47-Exit Signage, K51-Fire Alarm Installation, K56-Sprinkler Installation, K62-Sprinkler Inspections, K72-Egress Obstructions, K130-Miscellaneous, K147-Electrical, and K211-Alcohol Based Hand Rubs.

3. In the Orthotics Clinic outpatient portion of UW Hospital, surveyor #12187 observed that the facility had the following 1 deficiency: K130-Miscellaneous.

4. In the University Station outpatient portion of UW Hospital, surveyor #12187 observed that the facility had the following 1 deficiency: K130-Miscellaneous.

Please refer to the full description of the deficient practices at the cited K-tags in the appropriate building. This observed situation was not compliant with CFR 482.41.

______________________________________

Based on observation, staff interviews and review of maintenance records, the facility did not construct, install and maintain the building systems to ensure a life safety environment in the building to meet the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and "Existing Healthcare Occupancy" chapters of this code. The facility did not have a facility free of life safety deficiencies.

FINDINGS INCLUDE:
1. In the Clinical Sciences Center portion of UW Hospital surveyors #12187, 12316, 14105, and 14105 observed that the facility had the following 19 deficiencies of Chapter 19 (existing health care) of the Life Safety Code: K11-Separation Walls, K15-Finishes, K17-Corridor Walls, K20-Vertical Openings, K21-Door Hold-Opens, K27-Smoke Barrier Doors, K29-Hazardous Rooms, K47-Exit Signage, K51-Fire Alarm Installation, K52-Fire Alarm Inspections, K56-Sprinkler Installation, K62-Sprinkler Inspections, K67-Ventilation, K72-Egress Obstructions, K76-Medical Gases, K77-Medical Gas Piping, K130-Miscellaneous, K143-Oxygen Transfer, and K147-Electrical codes

2. In the American Family Children's Hospital portion of UW Hospital surveyors #12316 and #22219 observed that the facility had the following 16 deficiencies of Chapter 18 (new health care) of the Life Safety Code: K12-Building Construction, K17-Corridor Walls, K18-Corridor Doors, K20-Vertical Openings, K25-Smoke Barrier Walls, K27-Smoke Barrier Doors, K29-Hazardous Rooms, K38-Egress, K47-Exit Signage, K51-Fire Alarm Installation, K56-Sprinkler Installation, K62-Sprinkler Inspections, K72-Egress Obstructions, K130-Miscellaneous, K147-Electrical, and K211-Alcohol Based Hand Rubs.

3. In the Orthotics Clinic outpatient portion of UW Hospital, surveyor #12187 observed that the facility had the following 1 deficiency of Chapter 39 (existing business) of the Life Safety Code: K130-Miscellaneous.

4. In the University Station outpatient portion of UW Hospital, surveyor #12187 observed that the facility had the following 1 deficiency of Chapter 39 (existing business) of the Life Safety Code: K130-Miscellaneous.

Please refer to the full description of the deficient practices at the cited K-tags in the appropriate building. This observed situation was not compliant with CFR 482.41.

Based on observations and interview with staff, in 2 of 36 units the facility failed to ensure the environment was free of defects in the walls and ceiling.

Findings include:

Surveyor observations on 10/5/10 at approximately 1:40 PM of the Dirty Utility Room (E5/577) reflects missing wall plaster (holes and cracks in plaster), displaced ceiling tiles and a square white device hanging from the ceiling on a wire (unknown ceiling device). This was confirmed by DON jj at the time above.

Surveyor observations during the tour of the Respiratory Therapy storage room (C5/115B), where oxygen tanks are stored, reflects multiple dust balls too numerous to count and blue caps (oxygen covers) strewn across the floor. The vent fan has excessive build-up of dust debris. This was confirmed by DON jj at time of observation above.

Based on observation, staff interviews and review of maintenance records, the facility did not construct, install and maintain a proper ventilation and temperature control system in pharmaceutical, food preparation, and other appropriate areas. The facility did not have a ventilation system that was installed and maintained in accordance with state regulations and manufacturer recommendations and provide less than recommended negative pressure in one air borne infectious isolation (AII) and less than recommended positive pressure one protective environment room. This deficient practice had a potential of causing contamination and infection. This deficiency occurred in 1 of the 83 smoke compartments, and had the potential to affect 10 of the 1000 staff that were working.

FINDINGS INCLUDE:

1. During a tour of the facility with Staff cc (building trade supervisor) on 10/4/2010, Surveyor #12316 observed at 2:23 pm that the air velocity reading on the monitoring device located on the wall of the Patient Room 5418 on the 5th Floor was 174 fpm positive, indicating flow from the protective environment room into corridor. The 174 fpm air velocity, when converted into pressure difference, is approximately equal to 0.0026 in. of water, which is less than the CDC and AIA guidelines recommended pressure differential of 0.01 in. of water. This condition was acknowledged at the time of discovery by a concurrent observation and interview with Staff cc (Building Trade Supervisor), and verified with the Staff aa (director of plant engineering) and Staff gg (senior maintenance mechanic).

2. While on a tour of the facility with Staff cc (building trade supervisor) on 10/5/2010, Surveyor #12316 observed at 11:21 am that the air velocity reading on the monitoring device located on the wall of the Patient Room 4430 on the 4th Floor was 250 fpm negative, indicating airflow from corridor into the negative pressure room 4430. The 250 fpm air velocity, when converted into pressure difference, is approximately equal to 0.0054 in. of water, which is less than the CDC and AIA guidelines recommended pressure differential of 0.01 in. of water. This observed situation was not compliant with the current standard of practice - maintaining 0.01 in. of water column pressure difference in AII and protective environment rooms in accordance with the CDC and AIA guidelines. This condition was acknowledged at the time of discovery by a concurrent observation and interview with Staff cc (Building Trade Supervisor), and verified with the Staff aa (director of plant engineering) and Staff gg (senior maintenance mechanic) on 10/7/2010 at 12:40 pm.

3. On 10/7/2010 at 9:43 am surveyor #14105 observed in the E7/3 smoke compartment on the 3rd floor in the 325-Dirty Repro Room, that the ventilation to the space could not be confirmed to be compliant with accepted standards. Air from this room blows into the corridor with positive pressure. This observed situation was not compliant with CFR 482.41(c)(4). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

______________________________________

Based on tour, observation and interview with staff, in 6 of 9 staff observed performing patient care, (A, J, S, Z, AA and FF) the facility failed to ensure aseptic technique is used when performing patient cares. In 16 of 36 units, the facility failed to ensure a sanitary environment to control and prevent potential cross contamination and infections.

Findings include:

Faciltiy policy titled 13.08 Hand Hygiene dated 6/1/09 states under III. A. "Hand hygiene is indicated in the following situations:...4. Between "dirty" and "clean" patient care activities performed on the same patient: (e.g., hand hygiene is mandatory after a dirty procedure such as changing a wound dressing or toileting a patient, before performing a clean procedure such as central line site care or oral care on the same patient). 5. Before gloving, prior to the insertion of an invasive medical device..." and under "V. Appropriate glove use: A. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur. B. Remove gloves after caring for a patient. Do not wear the same pair of gloved for the care of more than one patient. Exam gloves should never be rinsed or washed. C. Change gloves during patient care if moving from a contaminated body site to a clean body site. D. Hand hygiene must be performed after glove removal."


05409


Surveyor #05409 observed the following on 10/4/10:

RN A administered Fentanyl IV (intravenously) push to Pt. #1 at 11:04 AM, placed the used syringe in RN A's scrub top pocket, and with the same contaminated gloves proceeded to remove staples from the skin graft over Pt #1's burns at 11:07 AM.

At 11:20 AM with gloved hands, RN A picked up a used alcohol prep pad from the floor, threw it in the waste receptacle, and removed the nasogastric tube from Pt #1's nose with the same contaminated gloves. These findings were observed by Surveyor #05409 without other staff present. As of 3:22 PM on 10/12/10, the facility has not brought forth any information to dispute these findings.

At 1:15 PM on 10/4/10 Surveyor #05409 observed a bag of IV Lactated Ringers solution without the protective outer wrapping (the outer wrapper had been removed) in the supply room on B4/3 Burn unit. Without the protective wrapper, the IV solution is at risk for being tampered with and possible contamination. This was verified with NM qq at this time.

At 2:22 PM on 10/4/10 Surveyor #05409 observed a bundle of paper towels under the sink in Room #2 in the EMG (Electromyography) center. The bundle of white towels was stained brown through approximately 1/2 of the bundle. The brownish stain poses risk for contamination of the towels that are available for staff use. This was verified with NM rr at this time.


09948

Surveyor observations during tour of the Hand Clinic on 10/5/10 at approximately 2:55 PM reflects that 2 of 3 wheelchairs and 1 of 2 tilt tables had cracked vinyl surfaces exposing cotton batting underneath that could not be properly disinfected between patient use due to the absorbent nature of the exposed materials. This was shared and verified at the daily exit conference on 10/5/10 at 3:45 PM.

Surveyor observations of the Inpatient Rehab. Room on 10/4/10 at approximately 2:30 PM reflects that the patient's vinyl exercise tables have cracked vinyl exposing cotton batting around the perimeter edges. Two (2) hospital wheel chairs had cracked vinyl arm rests and leg support pads. These surfaces could not be properly disinfected between patient use due to the absorbent nature of the exposed materials. This was shared and verified at the daily exit conference on 10/5/10 at 3:45 PM.

Surveyor observations on 10/5/10 at approximately 1:40 PM of the Dirty Utility Room (E5/577) reflects missing wall plaster (holes and cracks in plaster), displaced ceiling tiles and a square white device hanging from the ceiling on a wire (unknown ceiling device), allowing for uncleanable surfaces. This was confirmed by DON jj at the time above.

Surveyor observations during the tour of the Respiratory Therapy storage room (C5/115B), where oxygen tanks are stored, reflects multiple dust balls too numerous to count and blue caps (oxygen covers) strewn across the floor. The vent fan has excessive build-up of dust debris. This was confirmed by DON jj at time of observation above.


13469

Examples per surveyor #13469:
Staff not following Universal Precautions

Per observation, on 10/4/10 at 1:30 PM, RN J set-up a PCA (pain controlled analgesia) pump for an ICU (intensive care unit) patient in room #B6/321. Prior to the pump set-up RN J was in a conference room in an interview with surveyor #13469. RN J went directly from the conference room to the medication dispensing unit to retrieve the Dilaudid without washing her hands. RN J entered the patient ' s room and began to set-up the pump without washing her hands. RN J donned a pair of gloves to hook up the PCA pump tubing to the patient ' s central line without washing her hands. RN J did not remove her gloves and wash her hands after contact with the patient before going to cupboards in the room to begin collecting supplies for an abdominal dressing change.

Per observation, on 10/4/10 at 1:30 PM, RN J changed a large and deep abdominal wound, from a dehiscence, for an ICU patient in room #B6/321. With the same gloves used from setting up a PCA pump RN J went from contact with the patient to a cupboard to collect supplies for the dressing change without removing her gloves and washing her hands. RN J removed her gloves half way through collecting supplies without washing her hands after removing the gloves.

RN J then put on another pair of gloves without washing her hands first and removed the old abdominal dressing. She removed the gloves and without washing her hands again went to the cupboard for more dressing supplies.

RN J then put on sterile gloves without washing her hands and began the dressing change. RN J began packing the wound with a roll of gauze. As she was packing the upper part of the wound the gauze was rubbing the patient ' s gown all the way into the wound thus exposing the wound bed to contaminants.

RN J then took off her gloves, threw away used supplies and without washing her hands went to the light switch to turn down the lights and then to the blinds in the room to raise them. RN J then left the patient ' s room without washing her hands.

Per interview, with DMS D following the observations, RN J did not follow universal precautions when setting up the PCA pump and changing the abdominal dressing in room #B6/321.

Per observation, on 10/5/10 at 10:10 AM in Cardiac ICU room F/4552, RN FF removed an IV (Intravenous) line from the patient. After removing the dressing and IV line RN FF cleaned the IV site with Chlorohexadine swabs. As she cleaned the IV site she wiped up and down on the IV site instead of using a circle moving outward from the IV site. In addition, she cleaned outward from the site into the hair line using the same up and downward movements and then went back into the center of the IV site thus allowing for cross-contamination of the IV site.

Floors and patient supplies are not kept clean:

While touring the Cardiovascular ICU with CNM C on 10/4/10 at 10:40 AM the equipment storage room floor was dirty. It was sticky and had black residue that could be scrapped up with a thumb nail. Per interview with RN E she agreed the floor was dirty and it is unclear how often the floor is cleaned.

During the same tour storage room #B4536 had the same sticky black residue on the floor.

While touring the Heart/Vascular ICU on 10/5/10 at 8:45 AM with CNM EE it was noted that in clean storage room D4/546 had two boxes of clean patient supplies resting directly on the floor allowing for cross contamination and staff inability to clean the floor. Per interview with EE the boxes should not be on the floor.

Staff food is stored with clean patient supplies.

Per observation, while touring the Trauma Life Support Center ICU with RNS I on 10/4/10 at 1:30 PM it was noted that a large container of a white liquid (milk) and a lunch bag full of food was placed on a shelf next to clean patient supplies. Per interview with I, staff lunches should not be stored in the clean patient supply room.


22198

Examples by surveyor 22198:

Surgical area:
Operative Care (ADPPOC) KK, DSS JJ, MD HH and A II observed the following:
On 10/05/10 from 8:30 AM through 12:00 PM Surveyor #22198 along with AD Pre/Post
Main Operating Department:
Equipment used in surgery was stored in the hall way.
Body warmer equipment was stored on the floor of a surgical suite.
A room identified as the "clean supply" room had no door or means of containing the room and its contents to ensure clean supplies remained clean and the air flow was appropriate for a clean storage area.
The wall where it met the ceiling above the desk at the entrance of the clean storage area had a 1 inch gap. Black dust/debris was hanging off the wall and ceiling tile.
Clean linens were stored on a 4 tiered rack uncovered, in the hallway.
#1 Stryker equipment towers had 4 pages left on the printer. Three of the 4 pages were of gastrointestinal track dated 09/10/10. ADPPOC- KK confirmed this tower was cleaned and available for use on a new surgical case.
#2 Stryker equipment tower had 4 pieces of orthopedic positioning equipment left in-between the tower and the pieces of Stryker equipment. ADPPOC- KK confirmed this tower was cleaned and available for use on a new surgical case.
Paper signs taped onto the Stryker towers and taped up in the clean storage area were ripped and torn. ADPPOC- KK confirmed the above.

The Post Anesthesia Care Unit (PACU):
The clean storage area, had no door, and its contents to ensure clean supplies remained clean and the air flow was appropriate for a clean storage area.
The dirty utility room located in the PACU patient treatment area, was propped open and contained biohazardous waste. Propping the dirty utility room door open allows for potential cross contamination, related to disrupting the defined air flow specific to dirty areas.

Sterile supply and processing:
Clean linen carts were stored out in a high traffic area and were not covered.
The wash machines for cleaning dirty surgical equipment prior to sterilization had a ECOLAB system of dispensing soap and sanitizing solutions into the washers.
Sterilization Manager VV confirmed to Surveyor #22198, that the ECOLAB dispensing system did not have a system for quality checks to ensure that soap and/or sanitizer was dispensed in the proper amounts.
Sterilization Manager VV confirmed to Surveyor #22198, that the ECOLAB dispensing system could not monitor if the wash machines were receiving solution from the system.
Sterilization Manager VV confirmed to Surveyor #22198 that the system would only alarm if the soap/sanitizer containers were empty.
Sterilization Manager VV confirmed to Surveyor #22198 confirmed that the hospital was aware of the problem.

On 10/05/10 from 1:15 PM to 2:20 PM Surveyor #22198 and AD Pre/Post Operative Care (ADPPOC) KK, DSS JJ, MD HH and A II observed the following:

Gastro-Intestinal (GI) /Urology Suite:
Room #D6-224A labeled Endoscope storage identified by GI M YY as a clean storage area for housing clean gastro scopes was open and did not have a door to enclose the clean area. Having no door on a clean supply area allows for potential cross contamination, related to disrupting the defined air flow specific to clean storage area.

21 feet (walked off by Anesthesiologist II) from the opened clean storage room was the dirty utility room #D6-220 that contain biohazardous waste and the door to the dirty utility room was propped opento the hall way. Propping the dirty utility room door open allows for potential cross contamination, related to disrupting the defined air flow specific to dirty areas.

There were 7 procedure rooms all contained hanging cloth curtains. Procedures included upper and lower GI scopes as well as high risk procedures like bronchoscopies. GI M YY told Surveyor #22198 that curtains were cleaned monthly and after isolation cases. M YY confirmed to Surveyor #22198, there was no documentation of the curtain cleaning schedule. Department policy and procedure for curtain cleaning specific to GI suites was requested, however no policy and procedure was provided.
Clean supply storage had a shipping box in it. ADPPOC-KK confirmed to Surveyor #22198, that shipping boxes should not be in a clean storage area.

On 10/05/10 from 2:20 PM to 3:10 PM Surveyor #22198, RNM uu and Scribe tt completed the tour with Cardiac Catheter Unit, Hemo-Infusion and Dialysis Units and observed the following:
Cardiac Catheter Unit:
A clean storage room contained cleaned equipment that had dried red streaked matter on the base and the key board of equipment.
Radiology shields were stored in with the clean storage. However no cleaning record existed for the radiology shields, and 5 radiology shields were hanging on the floor. These findings were confirmed with Cadiac Catheter Unit RNS yy and RNM xx.

In the Hemo-Infusion department:
RN vv was observed in an isolation room wearing Glove, gown and mask. The room was labeled Contact precautions.
RN vv was observed with a 2 inch separation between the gloves and gown on both arms exposing RN vv's wrist and watch while performing cares.

Hemo Infusion Manager ww confirmed to Surveyor #22198, RN vv was not wearing the PPE appropriately.


26390

Examples by surveyor 26390:

On 10-4-2010 at 11:29 AM observation of RN, S administering medication was completed. RN S obtained a portable, hand held scanner (used for patient and medication identification) from the medication room. RN, S went to Pt #13's room, completed the medication and patient check and put the scanner down on the counter of Pt #13's room. The medication was administered and upon leaving the room RN, S picked up the scanner and proceeded to the medication room. RN S, placed the scanner back in the holder on the counter of the medication room without cleaning the scanner. RN S explained that the scanners are not assigned to any certain nurse or patient, so the scanners are handled by many nurses and are taken into many different patient rooms.

On 10-5-10 at 9:24 AM an observation of medication administration and a dressing change with Pt #25, Wound Care (WC) RN, Z and RN, AA was completed. RN, AA administered an intravenous medication, when finished RN, AA removed gloves and did not wash hands before putting on another pair of gloves. WC RN Z removed pt. 25's old dressing from the right buttock area, disposed of the dirty dressing, removed dirty gloves and put on a clean pair of gloves without washing hands in between. WC RN, Z proceeded to examine the wound, removed gloves, opened a package of sterile gloves and put on sterile gloves without washing hands in between glove change. WC RN Z inserted fingers into the wound for examination, removed gloves, turned on a light and opened another package of sterile gloves, put sterile gloves on without washing hands in between. WC RN Z proceeded to pack the wound with gauze, and covered wound with a clean dressing, when finished removed dirty gloves and put on a pair of clean gloves without washing hands. WC RN Z then applied an additional dressing to the area, removed gloves and put on a clean pair without washing hands in between. WC RN Z proceeded to clean up supplies and trash, removed gloves and put on a clean pair of gloves without washing hands in between. WC RN Z proceeded to reposition pt. 25 and remained in the pt room.


26711

Findings by Surveyor #26711:

A tour of the Pediatric Specialty Clinic was conducted on 10/4/2010 with RN K, QI L, and RN N. At 10:40 AM the laboratory rooms (2646 and 2647) were observed to have disposable blue tourniquets on top of their work cart for use during blood draw procedures.

It was confirmed by laboratory staff (name unknown) that these disposable items are reused between patients and are not discarded unless, "They become grossly contaminated or fall on the floor."

The tourniquets are not cleaned between uses on different patients. This practice has the potential for cross contamination of organisms between patients.

These findings were confirmed by RN K and RN N at the time of the discovery.

NM O agreed, this solution should not have been left in the room and should have been discarded when the room was cleaned after the patient was discharged.

On 10/6/2010 at 10:27 AM surveyor #14105 observed in the F7/3 smoke compartment on the 3rd floor in the 300A-Stairwell, that visable accumulation of dirt and dust were present in this health care environment. The door frame was covered with visible dust. This observed situation was not compliant with CFR 482.42(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).


14105

Example by surveyor 14105:

On 10/6/2010 at 10:27 AM surveyor #14105 observed in the F7/3 smoke compartment on the 3rd floor in the 300A-Stairwell, that visable accumulation of dirt and dust were present in this health care environment. The door frame was covered with visible dust. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Construction Manager dd.

Based on MR (medical record) review, policy and procedure review, and interviews with facility staff, in 10 of 10 surgery MR reviewed (#1, 2, 3, 9,16, 17, 19, 38, 39, and 41 out of total of 44 MR reviewed, the hospital failed to ensure that surgical patients are protected from fire. Failure to ensure that flammable alcohol based skin preps are dry during the time out process could lead to patient surgical fires.

Findings include:

Per surveyor 18816 interview with Educator BBB on 10/6/10 at 10:50 AM, there is no facility policy that includes dry time of alcohol based skins preparations in the surgical time out.

Per operating room policy and procedure review by surveyor #13469 on 10/5/10 in the afternoon, the operating room policies do not include a policy to reduce the risks of fires due to the use of alcohol-based skin preparations in anesthetizing locations and include confirmation the alcohol preparation is dry is in the time out.

Per interview, by surveyor #13469 with DMS D on 10/5/10 at 1:50 PM, the hospital operating room policies and procedures do not address the use of alcohol-based skin preparations in anesthetizing locations. The surgery department does use the following alcohol based skin preps: Duraprep, Chlorhexidine, and Povidone-Iodine.

Examples per surveyor #13469:
1. Per MR review, on 10/4/10 at 11:30 AM, Pt. #2 underwent the insertion of a left ventricular assist device on 9/16/10. Per intra-operative note dated 9/16/10 Duraprep and Chlorhexidine were used as a skin preps. The intra-operative note does not identify if the staff ensured that these alcohol-based skin preps were dry during the time-out process. This was confirmed by DMS D on 10/4/10 at 11:30 AM.

2. Per MR review, on 10/4/10 at 2:25 PM, Pt. #3 underwent an exploratory laparotomy with abdominal washout on 10/3/10. Per intra-operative note dated 10/3/10 Povidone-Iodine was used as a skin prep. The intra-operative note does not identify if the staff ensured that this alcohol-based skin prep was dry during the time-out process. This was confirmed by DMS D on 10/4/10 at 2:25 PM.

3. Per MR review, on 10/5/10 at 9:00 AM, Pt. #39 underwent an open left radical resection of a groin mass on 9/30/10. Per intra-operative note dated 9/30/10 Povidone-Iodine and Duraprep were used as a skin preps. The intra-operative note does not identify if the staff ensured that these alcohol-based skin prep were dry during the time-out process. This was confirmed by DMS D on 10/5/10 at 9:00 AM.

4. Per MR review, on 10/5/10 at 1:35 PM, Pt. #41 underwent an exploratory laparotomy with lysis of adhesions for small bowel obstruction on 9/26/10. Per intra-operative note dated 9/26/10 Duraprep was used as a skin prep. The intra-operative note does not identify if the staff ensured that this alcohol-based skin prep was dry during the time-out process. This was confirmed by DMS D on 10/5/10 at 1:35 PM.

Findings by Surveyor #26711:
Pt #9's surgical intraoperative record was reviewed on 10/5/2010 at 11:00 AM with RN Y. Pt #9 had the skin preparation DuraPrep, an alcohol based preparation, used prior to surgery. There is no documentation regarding the preparation being dry prior to draping in the "time out". This finding was confirmed by RN Y at the time of discovery.

Pt #16's surgical intraoperative record was reviewed on 10/5/2010 at 11:17 AM with Staff F. Pt #16 had DuraPrep used prior to surgery. There is no documentation regarding the preparation being dry prior to draping in the "time out". This finding was confirmed by Staff F at the time of discovery.

Findings of Surveyor #05409:

During the medical record review of Pt #1 by Surveyor #05409 with NM qq from 1:30 PM to 1:57 PM. on 10/4/10, it was noted that Pt #1 had surgical procedures done on 9/14/10, 9/21/10, and 9/28/10. The surgical intraoperative records for these surgeries revealed that Chlorhexidine, which is an alcohol based flammable product, was used prior to the surgeries. There is no documentation of the Chlorhexidine being dry prior to draping in the "Time Out" sections of the intraoperative reports. This was confirmed by NM qq at the time of the record review.


During the medical record review of Pt #38 by Surveyor #05409 with NM qq beginning at 9:55 AM on 10/5/10, it was noted that Pt #38 had a surgical procedure on 10/5/10 which was completed at 8:45 AM. The intraoperative report revealed that Chlorhexidine had been used prior to the surgery. There is no documentation of the Chlorhexidine being dry prior to draping in the "Time Out" section of the intraoperative report. This was confirmed by NM qq at the time of the record review.


18816

Examples by surveyor 18816:

Pt #17's MR review by surveyor 18816 on 10/5/10 at 10:00 AM the surgical time out does not include the confirmation of dry time for the alcohol based skin prep. This is confirmed in interview with IPP F on 10/5/10 at 10:00 AM.

Pt #19's MR review by surveyor 18816 on 10/6/10 at 3:00 PM the surgical time out does not include the confirmation of dry time for the alcohol based skin prep. This is confirmed in interview with IVPPS F on 10/6/10 at 3:00 PM.