HospitalInspections.org

Based on observation, Emergency Department (ED) registration documents, review of 15 ED records, and staff interviews, it was determined the hospital failed to ensure ED patients were informed of their right to lodge a grievance with the State agency (SA) and ED patients were provided the phone number and address for lodging a grievance. This affected 15 of 15 ED records reviewed and had the potential to affect all patients treated at the hospital ED.

Findings include:

On 11/13/18 at 9:45 AM, a tour of the ED was completed which included the ED registration area and lobby. The Patient Bill of Rights and Responsibilities was posted in the ED lobby and contained the following documentation: "...You have the Right to ...Be told of how and whom you may voice a complaint..."

There was no documentation how and to whom the patient was to report a complaint and no address and phone number for the State agency on the Patient Bill of Rights and Responsibilities.

In an interview on 11/13/18 at 9:45 AM, Employee Identifier (EI) # 5, ED Director reported upon registration all ED patients receive written information on how and to whom a complaint is to be reported.

On 11/13/18 at 10:00 AM, the surveyor requested and reviewed ED registration documents provided which included a copy of "A Patient's Bill of Rights and Responsibilities" and "SpeakUp About Your Care." The documents failed to contain information about how to lodge complaints with the State agency. There was no State agency phone number included in the documents provided to ED patients.

In an interview on 11/13/18 at 1:00 PM, EI # 6, Director of Intensive Care confirmed the hospital had failed to provide ED patients with the SA agency phone number and instructions on to report a complaint. EI # 6 also reported the SA phone number was now posted in the ED lobby.

Review of 15 of 15 ED records from 11/13/18 to 11/15/18 failed to contain documentation ED patients were told how to or were provided documentation of their right to lodge a complaint/grievance with the State agency.

Based on observations in the 15 bed Senior Behavioral Unit (SBU) and interviews with staff it was determined the facility failed to ensure:

a) a safe and ligature free environment for psychiatric patients.

b) all medications were labeled for use.

c) all single use medication vials were discarded after use.

d) multidose medication vials were labeled with the open date / discard date.

e) patient personal items were not stored with patient medications.

A tour of the facility's SBU was conducted on 11/13/18 at 2:00 PM to 4:00 PM with Employee Identifier (EI) # 12, Director of Acute Care, and EI # 20, Director of SBU.

During the tour the surveyor observed the patient beds each had open side rails, openings in the headboards and footboards, and the power cords were not shortened thereby posing ligature risks.

Additionally, the surveyor observed round door knobs on 2 doors in the hallway, one opening to the patient belongings closet and one to the mechanical room.

When asked why the unit had medical beds and not psych appropriate beds EI # 20 stated the beds were medical beds due to their patient population, age 55 and up.

EI # 20 further stated if they had a patient at risk for suicide the patient would be placed on 1:1 observation at all times.

EI # 20 further stated the replacement door knobs for the 2 doors in the hallway had been ordered.

The surveyor observed in each patient room the shower head and handles had been removed. EI # 20 confirmed there were no operable showers in the patient rooms and all 15 patients used one hall shower. When asked how the staff ensured all patients personal care needs were met EI # 20 stated the baths were divided between the night shift and the day shift.

The tour on 11/13/18 continued to the medication room. The surveyor observed a medication storage bin labeled with room numbers. Inspection of the medication storage bin revealed the following items mixed in with the patient medications:

G 300 - an open, unlabeled, single use vial of sterile water for injection.
G 301 - an open, unlabeled, multidose vial of Xylocaine 1 %.
G 302 - 2 pairs of eyeglasses, a piece of hard candy, and a ½ tablet of an unidentified medication loose in the drawer.
G 305 - a toothbrush and tooth paste.
G 307 - trail mix, popcorn, and unlabeled eye drops.
G 308 - a tube of Fixadent (denture cream).
G 309 - eyeglasses, comb, and 2 plastic hair curlers.
G 311 - an eyeglass case.
G 313 - Ziprarasidone HCL (hydrochloride) 40 mg (milligram) capsule loose in the drawer with no dispensing label.
G 314- eyeglasses, hearing aid, and batteries.

Unlabeled bin drawer - an open, unlabeled, single use vial of sterile water for injection.

EI # 12 confirmed during the inspection of the medication storage bins, the vials of sterile water for injection were single use vials and should have been discarded after use.

The facility failed to maintain safe, sanitary medication storage separate from personal items, failed to ensure multidose vials were labeled with the open / discard date and failed to ensure single use vials were discarded after use.

An interview conducted 11/13/18 at 3:30 PM with EI # 12 confirmed the above findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on review of facility policies and procedures, Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQ's) regarding Safe Practices For Medical Injections , Cardinal Health CHB5066 manufacturer's directions for use, observations and interviews with the staff, it was determined the facility failed to ensure the staff:

a) followed the facility policy and procedure for proper hand hygiene after removal of gloves.

b) maintained clean supply carts and discarded single use supply items.

c). cleaned the septum of medication vials prior to piercing the vial per CDC guidelines and facility policy.

d) followed principles of clean versus dirty when preparing and administering IV medications.

e) cleaned equipment in the Therapy Department between patients.

f) washed hands after glove removal after performing a finger stick blood sugar.

This did affect Patient Identifier (PI) # 16, # 20, # 19, # 1 and had the potential to negatively affect all patients served by this facility.

Findings include:

Policy: Hand Hygiene
Updated: 1/24/18

"Policy:

These recommendations are designed to improve hand-hygiene practices of health care workers and to reduce transmission of pathogenic microorganisms to patient and personnel in health care settings.

Standard:

Hand hygiene will occur ...

1. Before touching a patient ...

2. Before clean/aseptic procedure ...

3. After body fluid exposure risk ...

4. After touching a patient ...

5. After touching patient surroundings ...

Other considerations

D. Glove use

2. Gloves should be used when hand-contaminating activities are possible. Gloves should be removed and hands washed when such activity is completed, when the integrity of the gloves is in doubt, and between patients."


Policy: Standard Precautions
Revised: 1/9/18

" ...Equipment or items in the patient environment are considered contaminated and must be disinfected before placing in a clean environment."


CDC Frequently Asked Questions (FAQ's) regarding Safe Practices For Medical Injections

"Medication Preparation Questions

1. How should I draw up medications?

Parenteral medications should be accessed in an aseptic manner. This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it."

Policy: Injections, Preparation-Administration
Reviewed: 12/16

"Procedure:

...5. Prepare the medication

A. Remove the syringe from the package.

B. Using a circular motion, cleanse top of medication vial with alcohol prep pad. Discard pad."

Manual: Therapy Department
Policy: Equipment Cleaning
Date Reviewed: 11/17

"Policy

Equipment that comes into direct contact with patients will be cleaned with purple top Sani-Wipes after each patient..."

1. During an observation of care conducted on 11/13/18 at 10:57 AM, EI # 21, RN Medical Surgical Unit (MSU), performed a finger stick blood sugar on PI # 1, discarded the used lancet, removed gloves and donned clean gloves without performing hand hygiene after glove removal as directed per facility policy.

An interview conducted 11/15/18 at 12:25 PM with EI # 12, Director of Acute Care, confirmed the above findings.

2. During an observation of care on 11/13/18 at 11:30 AM, EI # 15, RN MSU, spiked the IV antibiotic and began to prime the tubing. EI # 15 went to the opposite side of the bed while holding the IV tubing, picked up the patient's trash can with his/her clean, ungloved hand and brought the trash can to the side of the bed with the IV pump. EI # 15 continued to prime the IV tubing, connected the tubing to the patient's current IV line, and started the IV medication without performing hand hygiene after picking up the trash can.

EI # 15 failed to follow principles of clean versus dirty when preparing and administering IV medication.

An interview conducted 11/15/18 at 12:30 PM with EI # 12 confirmed the above findings.

3. On 11/13/18 at 11:40 AM in the Emergency Department (ED) at station 9, EI # 3, ED RN, opened and cleansed 2 vials of Toradol 30 mg using the same alcohol prep pad, then withdrew the injectable medication into the syringe and administered Toradol intramuscular to an unsampled ED patient.

EI # 3 failed to clean the second Toradol vial with a new/unused alcohol prep pad.

4. During a tour of the facility's Senior Behavioral Unit (SBU) conducted on 11/13/18 at 2:00 PM the surveyor observed in the medication room a medication storage bin labeled with room numbers. Inspection of the medication storage bin revealed the following items mixed in with the patient medications:

G 302 - 2 pairs of eyeglasses, a piece of hard candy, and a ½ tablet of an unidentified medication loose in the drawer.
G 305 - a toothbrush and tooth paste.
G 307 - trail mix, popcorn, and unlabeled eye drops.
G 308 - a tube of Fixadent.
G 309 - eyeglasses, comb, and 2 plastic hair curlers.
G 311 - an eyeglass case.
G 314- eyeglasses, hearing aid, and batteries.

The medication storage bin observed and inspected by the surveyor was dusty and dirty.

EI # 12 confirmed, during the inspection of the medication storage bins, the personal care items should be in the patients' personal belonging area and not with the medications.

5. An observation was conducted on 11/14/18 at 7:55 AM in Operating Room (OR) # 2 to observe Employee Identifier (EI) # 17, OR Scrub Technician, set up OR Room for PI # 16.

EI # 17 disinfected the OR tray table with sani-cloths and removed his/her gloves. EI # 17 then touched the clean supplies on the clean supply cart without performing hand hygiene.

After EI # 17 completed the OR table set up, he/she removed and discarded his/her gown and gloves in the trash receptacle. EI # 17 then closed the lid of the trash receptacle with his/her bare hands and retrieved his/her lab coat without performing hand hygiene.

An interview was conducted on 11/14/18 at 12:30 PM with EI # 1, OR Nurse Manager, who confirmed the aforementioned findings.

6. An observation was conducted on 11/14/18 at 8:30 AM to observe medication passes performed by EI # 13, RN, on the 2nd floor Acute Care unit.

EI # 13 donned gloves to remove a Nicotine Patch from Unsampled Patient (UP) # 1's upper right arm. Then applied a new patch to UP # 1's left upper arm. EI # 13 removed her/his gloves and failed to perform hand hygiene.

The next medication pass was to UP # 2. EI # 13 donned gloves to place pills directly in UP # 2's mouth. EI # 13 removed gloves and failed to perform hand hygiene before donning another pair of gloves and administering a subcutaneous injection of Lovenox.

During an interview conducted on 11/14/18 at 3:00 PM with EI # 10, the above findings were confirmed.

7. On 11/14/18 at 8:50 AM in the ED Disposition Room, EI # 4, ED RN, sanitized hands, donned gloves and started an intravenous (IV) line on the unsampled patient. After the IV access was obtained, EI # 4 collected blood specimens in multiple lab tubes. EI # 4 removed gloves and donned clean gloves but failed to perform hand hygiene after glove removal.

EI # 4 then administered Toradol IV, flushed the IV site with normal saline and applied an IV dressing label. EI # 4 removed gloves, donned clean gloves and labeled the lab tubes. EI # 4 failed to perform hand hygiene after glove removal.

EI # 4 failed to follow the hospital hand hygiene policy.

8. During an observation on 11/14/18 at 9:25 AM in the Endoscopy/Gastrointestinal Unit, the surveyor observed EI # 7, Environment Services Staff, (EVS) and EI # 8 (EVS), wearing gloves and performing cleaning and disinfection of Endoscopy/GI Recovery Bay # 6 after a patient was discharged. EI # 7 and EI # 8 removed his/her gloves and obtained clean linen for the bed without performing hand hygiene.

An interview was conducted on 11/14/18 at 11:00 AM with EI # 2, Day Surgery Unit Manager, who confirmed the aforementioned findings.

9. PI # 19 was admitted to Outpatient Therapy on 10/23/18 for diagnoses including Pain in Left Knee, and Unspecified Internal Derangement of Left Knee.

A tour of the Outpatient Therapy Department was conducted on 11/14/18 at 12:45 PM. During the tour, the surveyor observed care provided to PI # 19, by EI # 16, Physical Therapist (PT).

PI # 19 was observed performing exercises on the leg press machine. EI # 16 then instructed PI # 19 to move to another piece of equipment. EI # 16 failed to clean the equipment after patient contact per policy.

During the tour on 11/14/18 at 12:45 PM, the surveyor observed a locked cabinet containing medications and supplies. Inside the cabinet was a basket containing single dose vials of dexamethasone. Also in the basket, were two opened 3 cc (cubic centimeters) syringes with needles attached. EI # 14, PT, Clinical Director, explained these syringes were used to apply the dexamethasone to the Electronic Iontophoretic Drug Delivery System patches. The surveyor asked if the single use syringes and needles were used more than once. EI # 14 answered, "Yes, I have no idea how long we've used these syringes and needles."

During an interview conducted on 11/14/18 at 1:45 PM with EI # 14, the above findings were confirmed.

10. During an observation on 11/15/18 at 8:45 AM the surveyor observed EI # 18, Registered Nurse, administering an Intravenous push (IVP) medication in the Oncology Treatment Center to PI # 20. Upon completion of the IVP medication, EI # 18 removed the tourniquet and threw it on the clean supply cart which landed on a box of clean gloves. EI # 18 then placed the contaminated syringes used for the IVP medications on a barrier lying on the clean supply cart which also contained a large roll of tape, therefore contaminating the roll of tape. EI # 18 then retrieved the large roll of tape and the tourniquet and placed the contaminated supplies in the clean supply cart drawer. EI # 18 failed to discard single use supplies after use and maintain clean supply carts.

At 9:00 AM on 11/15/18 the surveyor observed EI # 19, RN, preparing medications in the Pharmacy Room in the Oncology Treatment Center. EI # 19 opened an injectable vial of Decadron and pierced the septum of the vial without cleaning with alcohol as directed per the CDC guidelines.

An interview was conducted on 11/15/18 9:28 AM with EI # 9, Director of Hematology/Oncology and EI # 11, Quality Director, who verified the aforementioned findings.

An interview was conducted on 11/15/18 at 10:55 AM with EI # 10, Infection Control Director, who confirmed the aforementioned findings and stated that tourniquets are for single use only and should be discarded after use.

At 11:00 AM on 11/15/18 a review of the Cardinal Health CHB5066 manufacturer's directions for use of tourniquets revealed a "2" with a red circle and a line thru it, which indicates a single use item.


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