HospitalInspections.org

Based on review of records and interview, the governing body failed to evaluate 3 of 3 organ donation contracts (Ocular Donor Services, Organ/Tissue Donor Services and the pool service contract) for quality of services performed. The governing body also failed to monitor and evaluate the contracted pool service that was to ensure the chemical treatment of the water feature/fountain.

Review of Organ Procurement Organization Agreement contracts revealed there were two contracts, Ocular Donor Services and Organ/Tissue Donor Services. Review of the Ocular Donor Services contract revealed the contract had expired on December 2, 2013; however, services were still being provided by the original contracted eye bank without a contract in force. Review of the Organ/Tissue Donor Services contract revealed it renewed automatically unless cancelled by one of the parties.

On 4/27/2017, the Quality/Risk Director (Staff #2) provided a list of contracted services that were reviewed by the Governing Body. The list provided was titled, "Contracted Patient Care Services Providers". The list did not include the two organ donation contracts.

Interview with Staff #2 confirmed that the contract and services are not reviewed through quality. Staff #2 was not able to explain why these patient services were not being reviewed annually for quality.




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Contracted pool (Fountain) service:

On 4/24/2017 during a morning tour of the hospital the water feature associated with the fountain was observed with green algae growing on the bottom and side of the containment trough, below the water line.

Interview with the Quality/Risk manager, staff #2, who gave the tour indicated the water in the fountain was cared for by an outside contracted pool service, weekly.

On 4/25/2017 an afternoon interview with the Director of Plant Operations, staff #21, confirmed the contracted service provider for the fountain and water feature came weekly and were scheduled to come 4/26/2017 and drain the water and clean the trough.


On 4/26/2017 in the afternoon the algae was still visible below the water line of the water feature. This was witnessed by staff #26. The coins in the water were visibly over grown with algae.


On the morning of 4/27/2017, the water was observed being drained from the trough. Interview with the Plant Operations Director, Staff #21, provided copies of the weekly chemical treatment that was provided by the contracted service provider. Copies of the weekly charges for chemical additives to the water were provided.

On 4/27/2017, the Quality/Risk Director, staff #2, provided a list of contracted services that were reviewed by the Governing Body. The list provided was titled, "Contracted Patient Care Services Providers". The list did not include the company which provided chemical treatment to the fountain and water feature on the lower floor of the hospital.

Although the company charged for weekly chemical treatment to the water, there was no evidence the hospital had evaluated the efficacy of the chemical additives to inhibit the growth of algae in the water. In fact the contracted service was not listed on the list of contracts reviewed by the Governing Body.

Based on observation, interview and review of records, the facility failed to:

A. provide patients with secure rooms on 1 unit (first floor medical/surgical unit) of 4 units toured.

B. ensure unsafe equipment was not being used in the Nuclear Medicine department.

On 4-24-17, a tour of the first floor medical/surgical unit was conducted. Six rooms were observed to have doors that opened into the atrium area. The atrium area had direct access for the public to enter and leave the hospital. The doors from the patient room to the atrium area did not have locks to prevent an unknown person from the community coming into the building and entering the patient room. This provided an opportunity for patients to be harmed while in their rooms or their belongings to be stolen if they were out of their room.


On 4-24-17 a tour of Nuclear Medicine was conducted. Staff #11 was observed sitting at a work station. Next to Staff #11, on the floor and under the counter was an electric space heater in operation.

Interview was conducted with Staff #11. When asked if it was a personal space heater or hospital space heater, Staff #11 confirmed it was a personal space heater. When asked if it had been checked out by plant operations staff for safety and approval of use, Staff #11 stated, "Probably not."

Review of policy titled "Electrical Safety", "SOP #: 11-0058.1" was conducted. Page 2 of 2, item 10 stated "Do not use portable space heaters."

Based on document review and interview the facility failed to establish threshold for improvement in departments where data was collected for 5 months, (November, December 2016 and January, February and March of 2017).


This deficient practice had the likelihood to effect all patients of the hospital.


Findings included:

On the afternoon of 4/24/2017 in the conference room, the Quality Control Logs (patient events) were reviewed.

The log recorded,
Medication errors
Falls
Day of week
Process
Abuse of staff
Equipment
Rm/Mr (transfer)
Code Blue
Skin integrity
Decubitus
AMA (against medical advice)

An interview on the morning of 4/25/2017 with the Quality Manger, staff #2, confirmed the unit managers collected data through out the month and then it was turned into his department to collate and analyze. Data collected using the above log for 5 months, November, December, January, February and March was provided for review.


The Quality/Risk Director confirmed regularly scheduled meetings of the Quality Committee were conducted. A review of the meeting minutes were limited to statements, of the presentation of the topics for review, without including raw data that gave the reader an understanding of the nature and depth of the data collected. The meeting minutes did not include documentation of discussion, or analysis of the data collected. The minutes failed to include resolution to determine desired thresholds or changes that might have been needed to reach the desired reduction of falls, med errors or any other category listed on the Quality log.

Review of the raw data revealed there were no threshold identified, which would allow the committee to compare and analyze and determine if the strategies were successful in consistently reducing patient falls or the frequency and severity of medication errors.

An interview with the Quality/Risk Manager confirmed no thresholds were set. They monitored from month to month and Quarter to Quarter.



A review of the Quality Control Review (patient event) log reflected the following data collected on patient (pt) falls:

1. November 2016: 11 of 33 patient (pt) events documented within the following two units involved a patient fall.
Medical Surgical Unit: 7 of 27
Emergency Department: 4 of 6
2. December 2016: 8 of 22 pt events documented within the following two units involved a patient fall.
Medical Surgical Unit: 5 of 18
Emergency Department: 2 of 4
3. January 2017: 6 of 38 pt events documented within the following two units involved a patient fall.
4. February 2017: 3 of 18 pt events documented within the following two units involved a patient fall.
Medical Surgical Unit: 2 of 8
Emergency Department: 1 of 10
5. March 2017: 3 of 33 pt events documented within the following two units involved a patient fall.
Medical Surgical Unit: 2 of 28
Emergency Department: 1 of 5

A review of the medication errors for the facility for the same time period revealed the following:

November: 4 medication errors where identified.
1. Wrong dose. The rate of a total parenteral nutrition was not decreased as ordered and dextrose had to be hung until the new order could be obtained.
2. Omission. Acetaminophen Intravenous (IV) was hung but not connected. The IV med was not given.
3. Omission. Infed IV test doses done and acknowledged by nurse but the med never given.
4. Omission. Vancomycin and Zosyn (both antibiotics) were ordered in the ED (emergency department) and given prior to admission to the floor. The orders for the antibiotics did not cross over to the pharmacy so the pt did not receive any antibiotics since admission. MD (medical doctor) notified and med's (medications) ordered.

December: 3 medication errors were identified.
1. Omission. Oxycodone and Trazodone (narcotic and antipsychotic) medications were ordered STAT (immediately) Not given
Zither IV ordered STAT in ED, not given. STAT Po med's (oral doses) not given.
2. Wrong pt. Norco 5 mg (milligram) pulled to give to pt in 107 A. Given to pt in 106 A by mistake. Pt in 106 A had Norco ordered, dose was 7.5 mg.
3. Omission. Admitted from remote ED. Several orders not activated by admitting nurse including Seroquel (antipsychotic) and Gapapentin (used for nerve pain and treatment of seizures).

January: 2 medication errors identified.
1. Wrong Drug. Nurse hung D5W (Dextrose 5%) instead of 1/2 strength Normal Saline. IV fluid infused at 75 cc/hr for 2 hours. Pt blood sugar 266.
2. Wrong pt. Nurse gave Allopurinal (gout treatment), Heparin (blood thinner), Amlodipine (Cardiac drug), Magnesium Oxide (mineral replacement), Gabapentin (used for nerve pain and treatment of seizures), Lasix (diuretic), Carvedilol
(cardiac beta blocker), and Calcium (mineral replacement) to the wrong patient.

February: 5 medication errors identified.
1. Wrong medication. Cefotaxime on vial attached (SIC) Medication given to pt.
2. Wrong medication. Promethazine VC-Codeine (promethazine, phenylephrine and codeine) ordered. Promethazine with Codeine administered.
3. Wrong medication. (different pt) Promethazine VC-Codeine (Promethazine, phenylephrine and codeine) ordered. Promethazine with Codeine administered.
4. Omission. Lisinopriil ordered STAT. Not given.
5. Wrong dose. Vancomycin found hanging with only 1/2 dose infused.

March: 3 medication errors identified.
1. Wrong medication. Tknase (plasminogen activator) ordered. TPA (Plasminogen activator) given. (Not the same drug).
2. Omission. Order for Levoquin (antibiotic) now and routinely. At 20:00 (8:00 PM) overlooked. Med initiated the next day at 9:00 AM.
3. Wrong labeling. IV PB (piggy back) ordered. Medication bag labeled Zosyn. Vial attached to bag labeled Ceftriaxone. Pharmacy error. Pt did not receive medication.

Further interview with the Quality/Risk manager confirmed there were no thresholds discussed or created addressing the reduction of medication errors or addressing the significance of multiple medication errors. He confirmed the pharmacy was involved in monitoring medication errors and did provide education.

On 4/26/2017 in the morning, an interview with the Pharmacy Director revealed the pharmacy department conducted nursing education on medication errors, look alike sound alike medications, and monitored error trends. The department evaluated where medications were stored in the PIXUS to attempt to avoid like kind placed near each other in the storage trays. The pharmacy did not observe nurses during medication passes or physically monitor the nursing department for medication errors and did not set thresholds for acceptable medication error rates.

On 4/27/2017 in the late morning, an interview with the medical surgical manager indicated, the pharmacy did most of the education regarding medication errors. He did informal education with his staff on falls and medications errors. He stated, "He did not set threshold". He indicated, he did not feel they had many. The unit manager indicated he did not sit on the Infection Control/Pharmacy and Therapeutics committee.


Although data was being collected, there was no evidence of analysis. There had been no expectations determined and no measurable indicators established.

Based on observation and interview, the hospital failed to store medical records in a manner that protected them from fire and water damage in 1 (Off Site) of 2 storage areas.

On 4-25-2017, a tour of the offsite storage of medical records at the Materials Management building was conducted with Staff #13 and Staff #14 present. Approximately 120 cardboard boxes containing patient medical records were being stored on open metal shelving.

Staff #14 verified that these records had not been scanned in to electronic storage. Staff #14 verified that there was no fire sprinkler system protecting the records. Staff #14 verified that if a fire broke out in the storage area, the fire alarm would go off and the fire department would respond with fire hoses to extinguish the fire, potentially resulting in records being damaged from fire or the water used to extinguish the fire.

Based on interview and observation, the facility's dietary department failed to maintain an emergency supply of food and water for 6 months (November, December, January , February and March and April)


This deficient practice had the likelihood to effect all patients of the hospital.


Findings included.


On 4/25/2017 during a tour of the dietary department, the Food Services Supervisor (FSS), staff #6, was asked where the emergency food and water was stored. The FSS responded, he was not aware he was responsible for emergency food or water supplies. He indicated to his knowledge, there were none stored on the hospital grounds.

On 4/26/2017 an interview with the Plant Operations Director, staff #21, confirmed the emergency food and water supplies were stored in another city, 45 minutes to a hour away. None were stored at the facility.

The facility did not have emergency supplies of food and water on campus or within the city limits.

Based on observation, interview and record review, the facility failed to:

A. provide a sanitary environment in 14 of 15 departments, (Dietary, Pharmacy, Nuclear Medicine, Radiology, Gastroenterology Lab, Medical Surgical unit I, and II, Environmental Services, Contracted Services, ICU, Laboratory, Surgery, Rehabililtation, Obstetrics depatments) and Emergency Department.


This deficient practice had the likelihood to effect all patients of these departments.

Findings included:


Dietary Department:

On 4/25/2017 at 8:30 AM during a tour of the dietary department the following observations were made.

1. Patient food was being prepared on a mechanized tray line. Adjacent to the this tray line was three (3) shipping boxes on a lower shelf. The shipping boxes contained food items.
2. The oven was observed with dark brown discoloration. Streaks of baked on drippings were visible on the inside of the double glass panes of the oven door.
3. Bulk flour was observed in a rolling bin. The bin had a loose fitting lid. The bulk flour was stored in the receiving bay where dietary food and kitchen supplies were brought into the building.
4, Bulk sugar was observed in a rolling bin. The bin had a loose fitting lid. The bulk sugar was stored in the receiving bay where dietary food and kitchen supplies were brought into the building.
5. A mop closet between the shipping bay and dry storage room was observed with a large amount a water draining into the drain. The drain pipe stopped 6 inches above the drain and water splattered outside the drain containment. The Food Services Supervisor (FSS) indicated the water drained from the floor above. Further investigation confirmed the floor above held the surgery department and the water emptying into the mop closet of the kitchen was condensation from the sterilizers used to sterilize scopes used for upper and lower Gastrointestinal procedures.
6. A two tiered stainless steel shelf was observed with pots set upright within each other in graduated sizes. The FSS confirmed the pots were not hand dried and should be turned upside down to drain dry.
7. The lower shelf liner for the above shelf was visibly dirty with spilled liquids that had dried.
8. The walk in meat cooler door was observed ajar.
9. The walk in deep freeze was observed to have three bulk bags of frozen meat that had been opened and left open to the cold air. (2 bags of breaded meat fillets and one bag of frozen chicken breast).
10. 12 large sheet pans were observed with carbon build up on the outside corners. The surface of the sheet pans had been scrubbed off and the surface was pitted and dimpled.
11. The stand up freezer had a broken seal and ice was accumulating inside the door.
12. A large bag of pre-formed cookies was observed open and let open to the air.
13. Two (2) electric toasters were observed with the inside of the toasters stained brown.
14. Three of four (3 of 4) temperature logs sheets were attached to the wrong equipment. The freezer had a refrigerator temp sheet. The cooler had a refrigerator temp sheet, and the refrigerator had a freezer temp sheet. Temperatures were recorded on each log sheet.
15. The floor in the dry stock room had visible dust, onion skins and dirt from foot traffic. The edges of the floor at the wall had dried splash residue and a gray discoloration.
16. A single vacuum packed piece of meat was fully thawed in room temperature water contained in a tea pitcher.

The above observations were confirmed by the FSS (Food Service Supervisor), staff #6.


Pharmacy:

On 4/25/2017 in late morning a tour of the pharmacy department revealed:

1. Shipping boxes too numerous to count were observed in three storage rooms. Each storage room had opened and unopened shipping boxes. The opened shipping boxes held Intravenous (IV) fluids. Each bag of IV fluid was in an individual plastic cover. Some of the bags of IV fluids had been removed from their shipping box and left resting on another shipping box.

AAMI (American Association for Medical Instrumentation) recommendation, "shipping boxes are vector for dust, contamination, and insects, and should not be stored with sterile product". Interview with the Pharmacy director, staff #23, confirmed the outside bags of IV solution, that were resting on outside shipping boxes, could have become contaminated. The IV bags would be delivered to the nursing unit placing patients at risk.

2. Shelves which were being used to store medications were observed with heavy tape build up on the outside surface of the shelf. The tape residue was sticky and had collected visible dirt in places. Tape residue prohibits proper sanitation.

3. Two lower level storage metal shelves revealed rust where mopping had occurred. When a surface is broken (such as rust) the surface can no longer be sanitized completely.

The above findings were cofirmed by staff #23.


Nuclear Medicine:

On 4/24/2017 a tour of Nuclear Medicine services revealed:

1. A room that held 3 tread mills for stress test and 2 tomography machines. There was little space between each machine. making the room difficult to sweep or mop.
2. The ledge of a large window was being used as a shelf for supplies. The ledge was observed with visible debris. An outside shipping box was in direct contact with a stack of "clean linen", and positioning pillows were visibly discolored and stored on the window ledge.
3. A small brown bottle of white pills was identified on a table near one of the tread mills. The bottle of brown pills was not labeled with a patients name. The bottle did not have a "date opened" label or "use by" date label on it.
4. A small room identified as a staff break room was observed with both staff and patient nutrition stored together.
5. An anti room to the Magnetic Resonance Imaging room was observed with a staff members cell phone being charge. The phone was resting on an open sharps container placed on the floor.
6. A circular fan was observed next to the charging cell phone. The fan was on the floor and the fan blades were visibly dirty.
7. Multiple foam squeeze balls were observed with the surface broken making them unable to be safely sanitized.
8. A patient back board was observed standing up against the wall, the base was resting on the floor.
9. A portable caddy with IV start supplies was observed with a blue disposable tourniquet tied to the handle. The tourniquet was visibly soiled and brittle. The caddy was placed on the widow ledge.
10. The station used for blood draws was observed with tape residue on the surface and edges. APIC (Association of Professionals in Infection Control) recommends tape residue be removed from surfaces as hard surfaces can not be sanitized when tape residue is present.

The above findings were confirmed by the Radiology Director, staff #27.


Radiology:

On 4/26/2017 a tour of the Radiology department revealed:

1. The department utilized Cidex OPA "Brand of sterilent". The manufacture's recommends utilizing the below listed log to insure the efficacy of the Cidex OPA when sanitizing procedural equipment. The log sheet provides monitoring of the following categories:
A. Date solution Poured
B. Date solution expires
C. Date
D. Tray Number
C. Test start time
D. Test end time
E. Pass/Fail
F. Tested by (initials)
G. Temperature before use
H. Time equipment in Cidex; Time equipment out of Cidex.

A review of the log being utilized by the department included the following:
A. Date
B. Strip lot number (Test strip)
C. Strip results (Pass/Fail)
D. Cidex lot number
E. Label Expiration date
F. Cidex poured
G. Date poured expires

An interview with an unnamed ultra sound tech who sanitized the instruments, indicated he did not take temperature. He stated, "I've never been told I needed to". The label on the bottle of Cidex OPA indicated the temperature must be at least 68 degrees Fahrenheit.

The tech confirmed he used a timer for the instrument soak time, but did not record the start or stop time on a log. The log in use failed to capture manufacturer's recommended components to insure efficacy of the Cidex solution.

The above was confirmed by staff #27.


GI (Gastroenterology) lab:

A tour of the surgery department, specifically the gastroscopy services revealed a tech sanitizing lower endoscopy scopes. An unnamed tech confirmed she used Cidex OPA. The same log was in use, as used by the radiology tech. The GI tech confirmed she did not record a temperature and had never been told she should.

The log in use failed to capture manufacturer's recommended components to insure efficacy of the Cidex solution.


Staff #12 witnessed the above findings.


Medical Surgical unit I:

During a tour of the Medical Surgical (MS) unit, the negative pressure isolation room #108 was determined to be positive pressure. When a tissue was placed at the base of the door the air blew the tissue into the hallway.

The above was witnessed by the MS Director, staff #25.


Medical Surgical unit II:

During a tour of the Medical Surgical (MS) unit, the negative pressure isolation room #208 was determined to be positive pressure. When a tissue was placed at the base of the door the air blew the tissue into the hallway.

The above was witnessed by staff #26.



Environmental services:


An interview with the Director of Environmental Services, staff #24, confirmed there were no policies for the contracted linen service. There were no policies regarding how the contracted service laundered the linen, how the linen was returned to the hospital for use, how it was brought into the units, or how the soiled linen was collected, stored and returned to the contracted service provider.

An interview with the Director of plant operations indicated clean linen was delivered by a delivery truck, in large rolling bins. Once the clean linen was delivered to the units, the same bins would then be used to collect soiled linen and the service provider would pick them up and remove them from the hospital for laundering.

During a tour of the hospital, soiled white linen was observed in at the bottom of a transport bin. Bagged soiled linen was observed placed on top of the white linen in the bin. The staff failed to demonstrate infection control when unbagged soiled linen was placed in the soiled linen transport bins. The Environmental Services Director could not say with certainty the soiled delivery bins would be sanitized after pick up.


Contracted services (Water feature/fountain):

On 4/24/2017 during the entrance tour of the hospital, the large water feature, which runs the depth of the main floor of the hospital, was observed with pale green algae growing on the bottom of the containment structure (resembling a shallow river). Coins which had been tossed into the water by visitors were observed with algae over growing them. This was confirmed by staff #26.

An interview with the Director of Plant Operations confirmed the water feature and fountain were maintained by an outside contracted company. The service logs indicated weekly treatment for algae control, however algae was visibly present on 4/24/2017. Documentation of water quality testing was for legionnaires one time yearly. There was no other indication the algae growing on the bottom of the fountain had been evaluated as a potential infection control risk.


ICU:

On 4/24/2017, an empty room was inspected and the following was found:
1. The IV pump was found with a single brown drop of a dried liquid. The dried spot was not identified on the top of the IV pump.
2. The zippered cover of the mattress was unzipped to reveal lint and debris, that was collected when fingers were wiped across the inside of the zipper.


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Laboratory:

On 4-25-2017 a tour of the Laboratory was conducted with Staff #20 and Staff #13 present. In the main laboratory area on a shelf under an analysis machine were four corrugated cardboard boxes containing chemicals. These chemicals were required for use to analyze blood specimens sent to the lab for testing.

Fourteen of the same boxes were found in the storage room with shipping labels on them.

Staff #20 was interviewed. Staff #20 stated that with small orders the boxes come with shipping labels on them. On large orders the company will place the boxes on pallets and wrap them in plastic wrap and place the shipping label on the pallet rather than the boxes. Staff #20 confirmed that the chemicals inside of the container must remain in the corrugated cardboard due to requirements of the analysis machine. Staff #20 confirmed that no other steps were taken to seal the boxes or protect the laboratory from possible contaminants that the boxes may have come in contact with during shipping and storage.

Review of recommendations from professional organizations such as the Association for Professionals in Infection Control and Epidemiology (APIC), Texas Society of Infection Control and Prevention (TSICP), and Healthcare Facilities Today was conducted. All highlighted the risks of allowing corrugated cardboard shipping containers to remain in a variety of healthcare areas.

http://apic.org/Resource_/TinyMceFileManager/Education/Preventing-Inf-in-Amb-Care-Winter2012-FINAL.PDF

The review of an Infection Prevention and Control Clinic Survey Tool presented by APIC and developed by Duke University Health System under item "3. c. Supplies are stored on shelves and off floors.", directs the surveyor to look for "Removed from shipping cartons or cardboard boxes before storage to prevent contamination with soil/debris that may be on cartons" and "Do not leave outer shipping boxes in clinical areas (due to risk of environmental contamination)."

This checklist was designed for an ambulatory care setting, but is applicable to the acute care setting also.

http://www.tsicp.org/web_documents/cardboard_boxes.pdf

The TSICP supports, "Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. A corrugated box has more than one layer including channels of paper to give it added strength ..." with a picture of moth larvae inside the channels of paper. They continued on with, " ...corrugated shipping boxes are not permitted in either clean or sterile storage areas. WHY? Because, the boxes may harbor dust, bacteria, and small insects that have entered during shipping .....and besides the "critters" inside these boxes, they are physically dirty, dusty, wet and moldy from the transportation route. There's just no telling where these boxes have been!"

http://www.healthcarefacilitiestoday.com/posts/QA-Corrugated-cardboard-boxes--13520

Healthcare Facilities Today supports the following:

"This is part of infection control because corrugated cardboard boxes are susceptible to moisture, water, vermin and bacteria during warehouse or storeroom storage, as well as transportation environments. The hospital must provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases and all areas of the hospital must be clean and sanitary. This includes all hospital units, campuses and off-site locations.

Cardboard boxes are manufactured and imported from many areas around the world without means of decontamination, especially for a sterile environment. Also, prior to delivery to a hospital cardboard boxes have been stored in different types of warehouses, with no protection for a sterile environment. Since cardboard boxes cannot be washed, they cannot be part of your regular required cleaning schedule.

Cardboard boxes are usually delivered to hospital receiving docks from other shipping dock locations on carts or pallets, prior to arriving into a health care facility. Mice, insects, vermin, dirt with pathogenic organisms can be carried into a hospital within the cardboard boxes used as external shipping cartons. Also, corrugated cardboard boxes can and do shed particles that contribute to dust in hospital environments, whereby microorganisms can hitch a ride. If corrugated cardboard becomes wet, it becomes a source for bacterial growth."


Rehabilitation Department:

On 4-25-2017 a tour of the Rehabilitation Department was conducted with Staff #13, #16, and #19 present. A room in the department was designated for wound care. Wounds in various stages of healing were treated in this room per physician orders. Equipment for physical therapy use was also located in this room behind a cloth curtain and under a cloth sheet. The equipment stored back there included a Continuous Passive Motion (CPM) machine placed on patients who have had knee replacement surgery to eliminate problems with stiffness after surgery.

An interview with Staff #16 was conducted. Staff #16 confirmed that the wounds treated in the wound care room could be infected with various bacteria at the time of treatment. Staff #16 confirmed that the CPM machines were being removed from the wound care room and taken to the postoperative knee replacement patient's room and placed the same day of surgery.

Obstetrics Unit:

On the afternoon of 4-24-2017, a tour of the Obstetrics Unit was conducted. Labor and Delivery room 267 was toured. In the room, the following conditions were found:

-The drawers in the cabinet that housed the ultrasound machine had dust, dirt, and debris in them.
-The corner of the room next to the storage cabinets had dust and dirt pushed up into the floor coving.
-The cabinet area under the sink had three dead crickets in it.
-The plastic boot covering the mechanism that allowed the foot of the bed to be converted from a labor bed to a delivery bed was cracked. This could allow body fluids from patient deliveries to seep into the boot and harbor bacteria.


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Surgical Department

A tour of the Surgical Department was conducted on 04/25/2017 at approximately 9:30am with the Surgical Director and with the Staff Education Director. A wooden bumper rail approximately 2 X 6 inch was observes affixed to the walls throughout the surgical department. The protective finish on the wooden bumper rail was worn and exposed unfinished wood creating a porous surface.

A review of a document titled Environmental Cleaning Guidelines for Healthcare Settings revealed in Chapter 2 Selection of Finishes and Surfaces in the Health Care Setting in Areas Where Care is Delivered

c. Choose materials that are less likely to support microbial growth e.g. plastic and metal. Wet organic substrates (e.g. wood) should be avoided in hospital areas with immunocompromised patients.3

3. Streifel AJ, Stevens PP, Rhame FS. In-hospital source of airborne Penicillium species spores. J Clin Microbiol 1987;25(1):1-4

An interview on 04/25/2017 at approximately 9:30am with the Director of Surgery revealed porous surfaces could not be disinfected.



B. provide follow through for infection control findings identified during an Environment of Care survey round conducted on 01/17/2017.

A review of the document provided by staff #9 and titled 01/17/2017 EOC Rounds revealed Location: Dining Area and Dietary Department, Employees present: Director of Plant Services, Director Environment Services, Dietary Services and Infection Preventionist.

Items found in Dining Room:
Vector light not plugged in.
Microwave, stand and high chair dirty.
Table and chairs dusty
Several ceiling tiles have stains and need to be replaced (above vending machines and salad bar).
Cabinet for utensils and trays was dusty.
Ceiling area dusty on pole near cash register checkout.
Vending machine dusty on top.
Decorative items and clock dusty.
Tray line, drink area, dirty in several areas. (Serving and receiving food side).
Drink Machine/ ice machine area dirty.
Thermometer log for ice cream cooler not present.
Purell hand sanitizer date expired.
Vents dirty and dusty.

Items found in dish room (dirty and clean side):
Water leak at sink area. Container for collecting water underneath sink.
Floor, baseboard, and walls dirty.
Hole in wall where door latch should be located/ latch hook missing.
Rust on equipment.
Trash cans dirty/vents dusty.
Loose paint near light fixtures.
Open flame yellow box not in use. Located near ceiling area.
Insect repellent in cabinet.
Temperature log not filled out.
Light fixture above door at separation of clean dish room side and kitchen area need to be fixed.
Light out in women's bathroom.
Dietary office has some chips in formica, loose trim in office.
Several light bulbs out through out.
Kitchen light fixtures dirty.
Items on floor between cabinets.
Stainless steel dirty in most areas refrigerators, freezers and other equipment.
Some cabinets missing screws.
Receiving bay has storage of supplies that needs to be moved (will be repairing floor).
Oven area dirty.

An interview with staff #5, 9, 21 and staff #22 confirmed no follow up was done as a result of the 01/17/2017 EOC Rounds.

An interview with staff #21 and staff #22 confirmed no work orders could be located as a result of the 01/17/2017 EOC Rounds.

An interview with staff 9, 21 and staff #22 confirmed no EOC Rounds were conducted since the 01/17/2017 EOC Rounds. The interview with staff 9, 21 and staff #22 confirmed the findings of the 01/17/2017 EOC Rounds were not reported to the Infection Control/ Pharmacy and Therapeutics Meeting, Environment of Care Meeting and/or Patient Safety Meeting.



C. follow the policy, Infection Control Committee. The facility failed to provide evidence of an Infection Control Committee.

Refer to tag A0748

Based on document review and interview, the facility failed to follow the policy, Infection Control Committee. The facility failed to provide evidence of an Infection Control Committee.

A review of the document titled Infection Control Committee revealed Purpose: to serve as a multidisciplinary subcommittee of the Medical Staff, report to the Executive Committee.
The infection Control Committee will establish and execute policies to prevent the acquisition and cross contamination of Healthcare Associated Infections (HAIs).
The Infection Control Committee will have input into the establishment of staff member health programs that will control infectious disease among hospital personnel.

Meetings: The Infection Control Committee shall meet no less than quarterly.

A review of the document titled Authority Statement, Policy revealed It is the policy of ETMC Athens that the infection Control Authority Statement of the Infection Control Committee will be utilized to intervene in patient care.

An interview with staff #9 revealed that infection control reported at the Infection Control/ Pharmacy and Therapeutics Meetings.

No evidence of an Infection Control Committee was provided by the facility other than the above mentioned policies titled Infection Control Committee and Authority Statement.

Based on review of records and interview, the facility failed to maintain 1 (Ocular Donor Services) of 2 organ donation contracts.

Review of Organ Procurement Organization Agreement contracts revealed there were two contracts, Ocular Donor Services and Organ/Tissue Donor Services. Review of the Ocular Donor Services contract revealed the contract had expired on December 2, 2013.

Interview with Staff #2 confirmed that no other contract had been in force since that time period.

Based on document review and interview, the facility failed to properly consent 5 of 5 (patients #12, 14, 15, 34 and #35) patients for anesthesia. The facility was not following the established policy that required the Licensed Independent Practitioner to obtain a separate consent for anesthesia sedation.

A review of the medical records for patients #12, 14, 15, 34 and #35 revealed single page consents for procedures, consent for anesthesia, consent for blood and consent to have students and/or manufacturer's technical representatives in the room during the procedure.
A review of the document titled Informed Consent Guidelines, Procedure: revealed 4. A separate consent must be obtained for anesthesia/moderate sedation for procedures requiring full disclosure of specific risks and hazards.

A review of the document titled Texas Administrative Code, Title 25 Health Services, Part 7 Texas Medical Disclosure Panel, Chapter 601 Informed Consent:

Rule 601.2 Procedures Requiring Full Disclosure of Specific Risks and Hazards--List A

(a) Anesthesia.

(1) Epidural.
(A) Nerve damage.
(B) Persistent back pain.
(C) Headache.
(D) Bleeding/epidural hematoma.
(E) Infection.
(F) Medical necessity to convert to general anesthesia.
(G) Brain damage.
(H) Chronic pain.

(2) General.
(A) Permanent organ damage.
(B) Memory dysfunction/memory loss.
(C) Injury to vocal cords, teeth, lips, eyes.
(D) Awareness during the procedure.
(E) Brain damage.

(3) Spinal.
(A) Nerve damage.
(B) Persistent back pain.
(C) Bleeding/epidural hematoma.
(D) Infection.
(E) Medical necessity to convert to general anesthesia.
(F) Brain damage.
(G) Headache.
(H) Chronic pain.

(4) Regional block.
(A) Nerve damage.
(B) Persistent pain.
(C) Bleeding/hematoma.
(D) Infection.
(E) Medical necessity to convert to general anesthesia.
(F) Brain damage.

(5) Monitored Anesthesia Care (MAC) (conscious sedation).
(A) Permanent organ damage.
(B) Memory dysfunction/memory loss.
(C) Medical necessity to convert to general anesthesia.
(D) Brain damage.
Rule 601.9 Disclosure and Consent Form for Anesthesia and//or Perioperative Pain Management (analgesia) revealed:

The Texas Medical Disclosure Panel adopts the following form which shall be used to provide informed consent to a patient or person authorized to consent for the patient of the possible risks and hazards involved in anesthesia and/or perioperative pain management (analgesia). Providers shall have the form available in both English and Spanish language versions ....

An interview with staff #4 confirmed the facility was not using a separate consent for anesthesia. Staff #4 revealed some of the procedure consent were signed in the physicians' office. The consent would be signed by the patient before the Anesthesia could meet with the patient to explain risks and before the aesthesia plan was developed.