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Based on record review and interview, the staff failed to complete required safety checks on the scope buddy for 3 of 61 days (3/24/2017, 4/13/2017, and 4/14/2017) where procedures are performed. This deficient practice could affect all 44 patients who had procedures completed on 3/24/2017, 4/13/2017, and 4/14/2017.

Findings include:

Per review of Scope Buddy User/Service Manual on 5/10/2017 at 10:25 AM provided by Director of Clinical Operations T, stated under Daily Quality Assurance Test, to verify Scope Buddy is operating properly and delivering the correct amount of fluid, the Quality Assurance Flow Validation Test must be performed. This validation test should be performed prior to the first use of the day and quickly determines if the device is delivering the correct volume of fluid.

Per review of Scope Buddy Daily Quality Assurance Log on 5/10/2017 at 9:00 AM for the months of February 2017, March 2017, and April 2017 indicated the flow validation test was left blank on 3/24/2017, 4/13/2017, and 4/14/2017.

Per interview with Director of Clinical Operations T on 5/10/2017 at 10:15 AM confirmed that the clinic was open on 3/24/2017, 4/13/2017, and 4/14/2017 and performed procedures on those days for 44 patients. Director of Clinical Operations T stated the staff should have completed the Flow Validation Test daily. .

Based on record review, observation, and interview, the staff failed to administer medications per policy in 1 of 1 medication administration (RN V) and staff failed to perform hand hygiene in 2 of 5 staff ( RN W, and RN X ) observations completed. This deficient practice has the potential to affect all 15 patients having procedures completed at Riverwoods Outpatient Clinic on 5/10/2017.

Findings include:

Per review on 5/10/2017 at 9:40 AM of facility policy titled Hand Hygiene Protocol, policy #3540757, dated 4/2017 stated in part under Process 3. Indications for Hand Hygiene: Before entering any patient room, before and after patient contact, before donning gloves, after providing patient care and before exiting any patient room, after removing gloves ...

Per review on 5/10/2017 at 10:05 AM of facility policy titled Intravenous Therapy-Invasive Lines, policy #2092565, dated 1/2016 stated on page 12 under Needleless Connectors 1. C. Whenever the injection cap/valve is accessed, it is first cleansed with alcohol for at least 15 seconds, using friction, and allowed to dry completely.

Per observation on 5/10/2017 at 7:45 AM, RN W assisted pt. #9 with positioning on the table in procedure room, RN W left the room and did not complete hand hygiene before exiting the room or prior to entering the room. At 7:55 AM, during colonoscopy procedure RN W removed glove from right hand, grabbed supplies from cart, then put on a new glove on right hand without performing hand hygiene.

Per observation on 5/10/2017 at 7:51 AM of RN V administering intravenous medications to pt. #9, RN V did not use alcohol to clean the port prior to administration of 3 syringes of medication.

Per observation on 5/10/2017 at 8:30 AM, Reprocessing Nurse X placed the contaminated endoscope in the endoscope reprocessor, removed gloves, and put on a new pair of gloves without completing hand hygiene.

Per interview with Director of Clinical Operations T on 5/10/2017 at 9:40 AM, Director of Clinical Operations T stated "Staff is expected to use hand gel, when entering and leaving a room, and when gloves are removed".

Per interview with Director of Clinical Operations T on 5/10/2017 at 9:45 AM, Director of Clinical Operations T stated "Staff is expected to use alcohol pads to cleanse the valve/port prior to medication administration".

Based on record review, observation, and interview the staff failed to follow the time-out policy in 1 of 3 staff (Director of Gastroenterology U observed, and the staff failed to complete a time-out procedure in 1 of 4 patient (pt. # 10) medical records reviewed of surgical patients. This deficient practice has the potential to affect all patients who have procedures done at this facility.

Findings include:

Per review on 5/10/2017 at 9:45 AM of facility policy titled Final Verification- Time Out Process, policy #3494417, dated 4/2017 stated under Scope, "This policy applies to all staff, personnel and Physicians participating in a surgical or invasive procedures in all locations where surgical or invasive procedures are performed. Patients undergoing a surgical or invasive procedure will have a Procedure Verification process, and on page 5, under "Operating Room/Procedure Room Procedure Verification 5. The time out will occur once all activity has been suspended with each member of the team actively attentive and participating". 11. Document the Procedure Verification/Time out process on the Electronic Medical Record.

Per observation on 5/10/2017 at 7:55 AM, RN V was performing the time out procedure; Director of Gastroenterology U inserted the endoscope into pt. # 9 prior to the completion of the time out.

Per interview with Director of Clinical Operations T on 5/10/2017 at 9:20 AM, Director of Clinical Operations T stated "Staff is expected to stop all activity and be fully attentive to person talking during the time out procedure".

Per review of patient # 10 medical record with RN-Clinic Informatics R on 5/10/2017 at 1:10 PM, Pt. #10 had a colonoscopy completed on 5/3/2017. There was no documentation that a "time-out" was completed prior to the procedure being performed.

Per Interview with RN-Clinic Informatics R on 5/10/2017 at 1:50 PM, RN-Clinic Informatics R stated "I cannot find any documentation that a time out was completed" (on pt. # 10).