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Based on observation and interview, it was determined the facility failed to assure patient-care equipment was maintained in safe operating condition in that beside commodes did not have tips on legs to prevent slippage in 3 (#203, 206, and 208) of 5 (#203, #205, #206, #208 and #216) rooms. The failed practice did not assure the beside commodes would not slip potentially causing injury to the patient. Findings included:

Observation on 08/30/18 at 11:35 AM -12:00 noon with Licensed Practical Nurse (LPN) #1 showed beside commodes available for patient use did not have tips on the legs in Rooms #203, #206 and #208. The finding was confirmed by LPN #1 at the time of observation who stated that the bedside commodes were kept in the rooms.



40282

Based on observation, interview, and review of manufacturer's instructions for use, it was determined the facility failed to maintain two of two point of care blood glucose devices by not documenting open dates on one of one bottle of Easy Touch glucose test strips and six of six Easy Touch glucose control solution bottles to assure they were not beyond the use date of 90 days. The failed practice did not assure the glucose devices were safe for patient testing.

A. Record review on 8/27/18 of the manufacturer's instructions for Easy Touch control strips and control solutions for high and low showed that once the test strips and control solution bottles were opened they were stable for up to three months (90 days) or until the expiration date on the bottles.
B. Emergency Department
1) Observation on 08/27/18 at 1:45 PM showed two of two Easy Touch control solution bottles one low control and one high control were in use with no open date on the bottles.
2) The findings in B1 were verified by the Director of Nurses (DON) on 08/27/18 at 1:45 PM.
3) Observation of the Emergency Department (same as observed in B1) on 08/30/18 at 10:15 AM showed one of one bottle of Easy Touch test strips and two of two bottles of control solutions one low and one high control in use with no open date on bottles.
4) Findings in B3 were verified by Emergency Room Director on 8/30/18 at 10:20 AM.
C. Medical/Surgical Unit
1) Observation of the Medical/Surgical Nurses Station on 08/27/18 at 2:45 PM showed one of one Easy Touch bottle of test strips and two of two Easy Touch control solution bottles, one low and one high control, were in use with no open date on the bottles.
2) The findings in C1 were verified by the DON on 8/27/18 at 2:45 PM.

Based on observation and interview, it was determined the facility failed to ensure the Dietary Department was maintained and kept clean in that:
1) One of one vent hood over the stove and fryer had widespread peeling of paint directly over where food items were prepared for patient and public consumption.
2) One of one dry good storage area showed:
a. Two adhesive rodent traps on the top shelf with one on a partially used box of dried beans and a second one on a box of crackers. The second shelf in a box with six cans of soup was black droppings and torn paper.
b. A black substance and water drips were observed on the outside surface of the duct system.
c. Water was dripping from an overhead pipe that had rust, a black substance and exposed insulation onto an aluminum pan resting on 50 ounce cans of soup.
d. The overhead air vent had a thick accumulation of dust on the vent surface and the inside filter had a thick accumulation of dust.
3) Three of three overhead air vents had moisture accumulation on the outer surface directly above food preparation areas (a mixer and microwave and clean pot drying).
The failed practices did not ensure a clean environment and did not protect the health and safety of patients, staff and visitors. Findings included:

A. Observation of the Dietary Department on 08/29/18 from 9:53 AM-10:45 AM with the Food and Nutrition Services Supervisor showed:
1) The vent hood over the stove and fryer had widespread peeling paint directly over where food items were prepared for patient and public consumption.
2) The dry good storage area showed:
a. Two adhesive rodent traps on the top shelf with one on a partially used box of dried beans and a second one on a box of crackers. The second shelf in a box with six cans of soup was black droppings and torn paper.
b. A black substance and water drips were observed on the outside surface of the duct system.
c. Water was dripping from an overhead pipe that had rust, a black substance and exposed insulation onto an aluminum pan resting on 50 ounce cans of soup.
d. The overhead air vent had a thick accumulation of dust on the vent surface and the inside filter had a thick accumulation of dust.
3) Three of three overhead air vents in the kitchen had moisture accumulation on the outer surface directly above food preparation areas (a mixer, microwave and clean pot drying).
The Food and Nutrition Services Supervisor confirmed the findings in A. at the time of observation.
B. The Food and Nutrition Services Supervisor was interviewed on 08/29/18 at 10:32 AM and stated that the staff had reported a rodent problem over the weekend and maintenance had placed the sticky traps. The dripping water was an intermittent issue and the aluminum pan was to prevent it from dripping on the food products. The Food and Nutrition Services Supervisor stated that the dust and dripping water from the pipe had been reported to maintenance and that in June 2018 the Dietary Consultant had reported the peeling paint in her report. The Food and Nutrition Services Supervisor stated that she had informed the Facilities Manager on 6/19/18 via email (electronic mail) of the urgent attention needed to the inside of the vent hood due to the paint curling up on the inside of the hood and that could become a hazard to food. The Food and Nutrition Services Supervisor stated that no action had been taken.
C. The Facilities Manager was interviewed on 08/29/18 at 12:18 PM and stated that the duct and overhead filters were changed every 30 days, but no log or documentation was maintained. The filter in the dry good storage area was changed at the time of interview and observed with a thick accumulation of dust and the Facilities Manager stated that it did not look like it had been changed recently. The Facilities Manager stated the dripping water was from a valve that needed to be replaced and that he had an estimate to repaint the peeling paint on the vent hood. The Facilities Manager stated that he had not reported the information to administration.
D. The Director of Nursing and Administrative Assistant were interviewed at 12:29 PM on 08/29/18 in the kitchen and stated that they were unaware of the peeling paint or observations in A. The Administrator was interviewed on 08/29/18 at 2:15 PM and stated staff had informed him today, and that the vent hood was old and needed to be painted or replaced.

Based on observation, interview and review of policy and procedure for high level disinfection (HLD) of laryngoscope blades, and review of Center for Disease Control (CDC) Guidelines, it was determined the facility failed to meet the Condition of Participation for Provision of Services and there was an Immediate Jeopardy to patient health and safety in that the facility failed to:

1) Have a current policy and procedure for high level disinfection (HLD) of 13 of 13 laryngoscope blades; (Cross Refer to C-0271 for details)
2) Have a policy and procedure to ensure manufacturer's instructions and Centers for Disease Control and Prevention (CDC) Guidelines were followed for HLD of laryngoscope blades; (Cross Refer to C-0271 for details)
3) Have a policy and procedure on how to store laryngoscope blades after HLD; and (Cross Refer to C-0271 for details)
4) Use a disinfectant that was approved for HLD of semi-critical equipment. (Cross Refer to C-0278 for details)
The facility could not be assured patients would be protected from likely sources of infection and affected any patient who required intubation. Findings included:

The cumulative effect of these failed practices resulted in an Immediate Jeopardy to patient health and safety in that failure to follow manufacture instructions for HLD of laryngoscope blades did not assure patients would be protected from likely sources of infection.

The Immediate Jeopardy was abated with the following plan on 08/28/18 at 6:30 PM:
1. Respiratory Therapy removed all non-disposable Laryngoscope blades and handles from the Emergency Room Crash Cart at 11:00 AM. The instruments were cleaned according to Konig manufacturer's instructions for cleaning the laryngoscope system with a presoak enzymatic cleaner and then sterilize according to manufacturer's instructions.
2. New disposable Laryngoscope blades and handle was placed on the Emergency Room Crash Cart at 11:00 AM by Respiratory Therapy staff.
3. All licensed Nursing Staff received in-service training regarding disposable Laryngoscope blades and handles placed on the Emergency Room Crash Cart at 1200 today. It was emphasized when these disposable products are used they are to be discarded in the biohazard container.
4. Respiratory Therapy policies and procedures were revised to reflect disposable instruments.
5. When autoclaved laryngoscope blades and handle are received today, we will remove the remaining reusable Laryngoscope blades and handle from Medical/Surgical floor Crash Cart. Respiratory Therapy staff will clean according to Konig manufacturer's instructions for cleaning the laryngoscope system a\with a presoak enzymatic cleaner and then sterilize according to Konig manufacturing instructions.
6. Place the autoclaved laryngoscope blades and handles on the Medical Surgical Crash Cart upon receiving this afternoon.
7. Respiratory Therapy staff will order additional disposable laryngoscope blades today, August 28, 2018.



Based on observation and interview, it was determined the facility failed to ensure the Dietary Department was maintained and kept clean in that:
1) One of one vent hood over the stove and fryer had widespread peeling of paint directly over where food items were prepared for patient and public consumption.
2) One of one dry good storage area showed:
a. Two adhesive rodent traps on the top shelf with one on a partially used box of dried beans and a second one on a box of crackers. The second shelf in a box with six cans of soup was black droppings and torn paper.
b. A black substance and water drips were observed on the outside surface of the duct system.
c. Water was dripping from an overhead pipe that had rust, a black substance and exposed insulation onto an aluminum pan resting on 50 ounce cans of soup.
d. The overhead air vent had a thick accumulation of dust on the vent surface and the inside filter had a thick accumulation of dust.
3) Three of three overhead air vents had moisture accumulation on the outer surface directly above food preparation areas (a mixer, microwave and clean pot drying).
The failed practices did not ensure a clean, orderly environment and did not protect the health and safety of patients, staff and visitors. The cumulative effects of these failed practices resulted in an Immediate Jeopardy to patient health and safety. Cross refer to C-0278 for details.

The Immediate Jeopardy was abated with the following plan on 08/29/18 at 4:00 PM:
1) Loose flaking paint inside the vent hood above the range: The stove top is out of service effective 3:30 PM on 08/29/18. Maintenance will begin scraping the loose paint from the vent hood at 5:00 PM 08/29/18. An alternate method of cooking will be in the convection oven until vent hood is completed.
2) Duct system with black mold on outer surfaces and water dripping onto dry good storage: Remove dry good products in the affected area to another location until issue is resolved. Maintenance will address the issue with reworking and rewrap the chill water system.
3) Air Filter System: the disposable filter was replaced 08/29/18. Maintenance will remove grate and clean inside of the air system and clean the grate.
4) Condensation collecting on the vent and dripping on the surface below: relocate the microwave and other small appliances and clean pots from under the vents.
5) Rodent Issue: The sticky traps were removed from the dry good boxes and placed on the floor under the metal shelving. Terminix Pest control last service date June 2018.

Based on observation, review of policies and procedures, manufacturer's instructions, review of the Centers for Disease Control and Prevention (CDC) Guidelines and interview, it was determined the facility failed to:
1) Have a current policy and procedure for high level disinfection (HLD) for 13 of 13 laryngoscope blades;
2) Have a policy and procedure to ensure manufacturer's instructions and Centers for Disease Control and Prevention (CDC) Guidelines were followed for HLD of laryngoscope blades;
3) Have a policy and procedure on how to store laryngoscope blades after HLD; and
4) Use a disinfectant that was approved for HLD of semi-critical equipment.
The facility could not be assured patients would be protected from likely sources of infection and affected any patient who required intubation. Findings included:

A. Record review of policies and procedures for the Respiratory Therapy Department on 08/28/18 at 10:00 AM provided by the Respiratory Therapy Director showed a policy titled, "Infection Control General Measures," showed that reusable equipment soiled with blood or body fluid was to be placed in a bag and placed in the soiled utility area for decontamination, unless it was too large to bag then it was to be cleaned thoroughly with 1:10 dilution of chlorine bleach or other germicide before transporting to central service.
B. Record review of a policy titled, "Infection Control," Respiratory Care Department, dated 10/17 showed that the Medical Director or Manager of Respiratory Care was responsible for the investigation, control and prevention of infection within the Respiratory Care Department and for implementation of infection control procedures and to review practices of Respiratory care staff serving the healthcare organization. The Respiratory Care Manager responsibility was to assure proper equipment cleaning and maintenance, review and assure compliance with established infection control policies and procedures.
C. Record review of the manufacturer's instructions for Konig laryngoscope blades and handles (reusable) provided by the Respiratory Therapy Director on 08/28/18 at 1530 showed:
1) Immediately after use, the laryngoscope system was to be rinsed under cool running tap water until all visible soil was removed
2) Immerse the laryngoscope system in a presoak enzymatic cleaner solution for a minimum of two minutes
3) Remove the device from the enzymatic cleaner solution and rinse with lukewarm running tap water for a minimum of one minute then immerse in an enzymatic detergent then rinse under running deionized water to remove detergent residuals then dry with a ling free cloth or filtered pressurized air.
4) High level disinfection with Cidex OPA or 2.4% glutaraldehyde solution could be used according to manufacturer's instructions or sterilization after cleaning.
D. Record review of CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities, showed that respiratory equipment such as laryngoscope blades were semicritical items and were to be high-level disinfected at a minimum.
E. Review of the CDC-10 manufacturer's label showed Spartan CDC-10 was a ready to use foam designed for cleaning and disinfecting walls, partitions, shower stalls and doorknobs and other similar hard non porous surfaces and that the product was not to be used as a terminal or high level disinfectant on any surface or instrument that was introduced directly into the human body, either into or in contact with the bloodstream or sterile areas of the body or that contacts intact mucus membranes.
F. Observation on 08/27/18 at 1:43 PM showed four curved and three straight laryngoscope blades in the Emergency Department crash cart drawer that were stored on a piece of blue foam that had brown spots on the surface. The laryngoscope blades were stored without a cover or packaged to protect from contamination. The finding was confirmed at the time of observation by the Director of Nursing.
G. Observation on 08/27/18 at 2:30 PM showed three straight and three curved laryngoscope blades stored loose in a drawer in the Medical Surgical crash cart. The laryngoscope blades were stored without a cover or packaged to prevent contamination. The Respiratory Therapy Director confirmed the findings at the time of observation.
H. During an interview on 08/28/18 at 9:21 AM, the Respiratory Therapy Director stated that she was responsible for reprocessing laryngoscope blades and that reprocessing of the laryngoscope blades was done using the Spartan CDC-10 product in the ready to use handi-spray foam. The Respiratory Therapy Director stated the CDC-10 product was left on the laryngoscope blade for about 15 seconds, then put into a stainless steel sink, and was wiped off. Bleach was then poured on the laryngoscope blade and rinsed off with tap water. The Respiratory Therapy Director stated that she was aware the current procedural practice was not correct and planned to obtain all disposable products.
I. On 08/28/18 at 9:47 AM the Director of Nursing (DON) was interviewed regarding what product or process was used for high level disinfection of laryngoscope blades and stated "I thought we soaked them in Cidex. That was years ago when we did surgery."
J. On 08/28/18 at 9:48 AM in an interview the Infection Preventionist stated that there was no infection control monitor for the reprocessing of laryngoscope blades with a HLD and she thought that disposable laryngoscope blades and handles were in use.
K. During an interview on 08/28/18 at 10:00 AM, the Respiratory Therapy Director stated that there were no policies for HLD in accordance with manufacturer's directions for use or storage of the laryngoscope blades. The Respiratory Therapy Director stated that she was not aware of the manufacturer's instructions for disinfection of the laryngoscope blades.

Based on observation, review of manufacturer's instructions and interview, it was determined the facility failed to follow manufacturer's instructions to use Pedialyte (oral electrolyte solution) within 48 hours after opening. The integrity of the oral electrolyte solution could not be assured without a date or process to ensure it would be used or discarded within 48 hours. The failed practice was likely to affect any patient who required Pedialyte. Findings included:

A. Observation on 08/27/18 at 2:30 PM of the Medical/Surgical Unit's nutrition room refrigerator showed one of one open and partially used one liter bottle of Pedialyte.
B. Review of the manufacturer's label instructions showed that after opening, to replace cap, refrigerate and use within 48 hours.
C. The Director of Nursing stated on 08/27/18 at 2:30 PM that the solution should have been dated and discarded.


31039

Based on review of manufacturer's recommendations, observation and interview, it was determined the facility failed to adhere to accepted professional standards in that they did not have a process to follow manufacturer's recommendations for length of storage for medications/fluids in one (Emergency Department) of two (Emergency Department and Medical-Surgical) units toured. By not having a process to follow manufacturer's recommendations for length of storage, the facility could not assure the safety and efficacy of the medications/fluids available past recommended length of storage, for patient use. The failed practice had the likelihood to affect all patients that have had procedures in the Emergency Department that required medications/fluids. Findings follow:

A. Record review of manufacturer's recommendation for length of storage once the package was opened for Levalbuterol Inhalation Solution showed once the foil pouch was opened the individual vials stored inside should have been used in two weeks.
B. Record review of manufacturer's recommendation for length of storage once placed in a fluid warmer for Baxter brand IV (Intravenous) Solutions and Irrigation Solutions in plastic pour bottles showed the solutions should not be stored for more than 14 days and 60-days respectively.
C. During a tour of the facility on 08/27/18 from 1:35 PM to 3:10 PM, observation showed the following medications stored in the medication refrigerator in the Emergency Department:
1) Levalbuterol 0.31 mg (milligram)/3 ml (milliliter) package of twelve opened, eight remaining in the foil package and the package was not dated to indicate when the 2-week storage time would be reached;
2) Levalbuterol 0.63 mg/3 ml package of twelve opened, with 10 remaining in the foil package and the package was not dated to indicate when the 2-week storage time would be reached; and
3) Levalbuterol 1.25 mg/3 ml package of twelve opened, with 6 remaining in the foil package and the package was not dated to indicate when the 2-week storage time would be reached.
D. During a tour of the facility on 08/27/18 from 1:35 PM to 3:10 PM, observation showed the following solutions stored in the fluid warmer in the Emergency Department:
1) Two Sterile Water for Irrigation, 500 ml, plastic pour bottle not dated to indicate when the 60-day storage length was reached;
2) One 0.9% Sodium Chloride for Irrigation, 500 ml, plastic pour bottle not dated to indicate when the 60-day storage length was reached;
3) One 0.9% Sodium Chloride for Irrigation, 1000 ml, plastic pour bottle not dated to indicate when the 60-day storage length was reached;
4) Two 0.9% Sodium Chloride for Injection, 1000 ml, plastic bag not dated to indicate when the 14-day storage length was reached; and
5) Two 0.45% Sodium Chloride for Injection, 1000 ml, plastic bag not dated to indicate when the 14-day storage length was reached.
E. The Director of Nurses verified the medications/solutions were not dated to indicate how long they had been stored at the time of the observations.

This is a reoccurring deficiency, last cited on 02/05/18.
Based on interview, the facility failed to follow professional acceptable standards in that the person who handled the compounded medications did not have annual re-certification of IV Admixture technique for one of one (Director of Pharmacy) personnel trained to compound medications in the CAI (Compounding Aseptic Isolator) per United States Pharmacopeia Chapter 797, 2008. By not evaluating the competencies of the personnel, the facility could not assure the sterility of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the CAI. Findings follow:
A. IV Admixture competencies were requested at the entrance conference on 08/27/18 and Surveyor #1 did not receive any.
B. During an interview on 08/27/18 at 1:11 PM, the Director of Pharmacy stated he did not have IV hood competencies.

Based on observation and interview, it was determined the facility stored prescription only IV fluids in an unlocked room and accessible to unlicensed person(s), therefore not securing them, in one (Medical-Surgical) of two (Medical-Surgical and Emergency Department) units toured. By not securing IV fluids, the facility could not assure the integrity and safety of these IV fluids. The failed practice had the likelihood to affect all patients' IV fluids in the hospital. Findings follow:

A. During tours of the facility on 08/27/18 from 1:25 PM to 3:10 PM, observations showed the following examples of IV fluids stored in an unlocked clean utility room and accessible to unlicensed persons:
1) Three 5% Dextrose/ ¼ Normal Saline 1000 ml;
2) Three 5% Dextrose/ 1/2 Normal Saline 1000 ml;
3) Three 5% Dextrose 1000 ml;
4) Five 0.9% Normal Saline 1000 ml; and
5) Three 5% Dextrose 500 ml.
B. The Director of Nurses verified the IV fluids were not secured at the time of the observations.

Based on observation and interview, it was determined the facility failed to identify and control infections to ensure the Dietary Department was maintained and kept clean in that:
1) One of one vent hood over the stove and fryer had widespread peeling of paint directly over where food items were prepared for patient and public consumption.
2) One of one dry good storage area showed:
a. Two adhesive rodent traps on the top shelf with one on a partially used box of dried beans and a second one on a box of crackers. The second shelf in a box with six cans of soup was black droppings and torn paper.
b. A black substance and water drips were observed on the outside surface of the duct system.
c. Water was dripping from an overhead pipe that had rust, a black substance and exposed insulation onto an aluminum pan resting on 50 ounce cans of soup.
d. The overhead air vent had a thick accumulation of dust on the vent surface and the inside filter had a thick accumulation of dust.
3) Three of three overhead air vents had moisture accumulation on the outer surface directly above food preparation areas (a mixer, microwave and clean pot drying).
The failed practices did not protect the health and safety of patients, staff and visitors in that they would not be protected from likely sources of infection. Findings included:

A. Observation of the Dietary Department on 08/29/18 from 9:53 AM - 10:45 AM with the Food and Nutrition Services Supervisor showed:
1) The vent hood over the stove and fryer had widespread peeling of paint directly over where food items were prepared for patient and public consumption.
2) The dry good storage area showed:
a. Two adhesive rodent traps on the top shelf with one on a partially used box of dried beans and a second one on a box of crackers. The second shelf in a box with six cans of soup was black droppings and torn paper.
b. A black substance and water drips were observed on the outside surface of the duct system.
c. Water was dripping from an overhead pipe that had rust, a black substance and exposed insulation onto an aluminum pan resting on 50 ounce cans of soup.
d. The overhead air vent had a thick accumulation of dust on the vent surface and the inside filter had a thick accumulation of dust.
3) Three of three overhead air vents in the kitchen had moisture accumulation on the outer surface directly above food preparation areas (a mixer, microwave and clean pot drying).
The Food and Nutrition Services Supervisor confirmed the findings in A. at the time of observation.
B. The Food and Nutrition Services Supervisor was interviewed on 08/29/18 at 10:32 AM and stated that the staff had reported a rodent problem over the weekend and maintenance had placed the sticky traps. The dripping water was an intermittent issue and the aluminum pan was to prevent it from dripping on the food products. The Food and Nutrition Services Supervisor stated that the dust and dripping water from the pipe had been reported to maintenance and that in June 2018 the Dietary Consultant had reported the peeling paint in her report. The Food and Nutrition Services Supervisor stated she had informed the Facilities Manager on 6/19/18 via email of the urgent attention needed to the inside of the vent hood due to the paint curling up on the inside of the hood and that could become a hazard to food. The Food and Nutrition Services Supervisor stated that no action had been taken.
C. The Facilities Manager was interviewed on 08/29/18 at 12:18 PM and stated that the air filters were changed every 30 days, but no log or documentation was maintained. The filter in the dry good storage area was changed at the time of interview and observed with a thick accumulation of dust and the Facilities Manager stated that it did not look like it had been changed recently. The Facilities Manager stated the dripping water was from a valve that needed to be replaced and that he had an estimate to repaint the peeling paint on the vent hood. The Facilities Manager stated that he had not reported the information to administration.
D. The Director of Nursing and Administrative Assistant were interviewed at 12:29 PM on 08/29/18 in the kitchen and stated that they were unaware of the peeling paint or observations in A. The Administrator was interviewed on 08/29/18 at 2:15 PM and stated staff had informed him today, and that the vent hood was old and needed to be painted or replaced.


Based on observation, review of policies and procedures, manufacturer's instructions, review of the Centers for Disease Control and Prevention (CDC) Guidelines and interview, it was determined the facility failed to identify and control infections in that:
1) There was not a current policy and procedure for high level disinfection (HLD) for 13 of 13 laryngoscope blades;
2) There was no policy and procedure to ensure manufacturer's instructions and Centers for Disease Control and Prevention (CDC) Guidelines were followed for HLD of laryngoscope blades;
3) There was no policy and procedure on how to store laryngoscope blades after HLD; and
4) The disinfectant used to reprocess laryngoscope blades was not approved as a HLD for semi-critical equipment.
The facility could not be assured patients would be protected from likely sources of infection and affected any patient who required intubation. Findings included:

A. Record review of policies and procedures provided by the Respiratory Therapy Director on 08/28/18 at 10:00 AM showed a policy titled, "Infection Control General Measures," and showed that reusable equipment soiled with blood or body fluid was to be placed in a bag and placed in the soiled utility area for decontamination, unless it was too large to bag then it was to be cleaned thoroughly with 1:10 dilution of chlorine bleach or other germicide before transporting to Central Service.
B. Record review of a policy titled, "Infection Control," Respiratory Care Department, dated 10/17 showed that the Medical Director or Manager of Respiratory Care was responsible for the investigation, control and prevention of infection within the Respiratory Care department, for implementation of infection control procedures and to review practices of Respiratory care staff serving the healthcare organization. The Respiratory Care Manager responsibility was to assure proper equipment cleaning and maintenance and to review and assure complaince with established infection control policies and procedures.
C. Record review of the manufacturer's instructions for Konig laryngoscope blades and handles (reusable) provided by the Respiratory Therapy Director on 08/28/18 at 3:30 PM showed:
1) Immediately after use, the laryngoscope system was to be rinsed under cool running tap water until all visible soil was removed.
2) Immerse the laryngoscope system in a presoak enzymatic cleaner solution for a minimum of two minutes
3) Remove the device from the enzymatic cleaner solution and rinse with lukewarm running tap water for a minimum of one minute then immerse in an enzymatic detergent then rinse under running deionized water to remove detergent residuals then dry with a lint free cloth or filtered pressurized air.
4) High level disinfection with Cidex OPA or 2.4% glutaraldehyde solution could be used according to manufacturer's instructions or sterilization after cleaning.
D. Record review of CDC Guidelines for Disinfection and Sterilization in Healthcare Facilitiies, showed that respiratory equipment such as laryngoscope blades were semicritical items and were to be high-level disinfected at a minimum.
E. Review of the CDC-10 manufacturer's label showed Spartan CDC-10 was a ready to use foam designed for cleaning and disinfecting walls, partitions, shower stalls and doorknobs and other similar hard non porous surfaces and that the product was not to be used as a terminal or high level disinfectant on any surface or instrument that is introduced directly into the human body, either into or in contact with the bloodstream or sterile areas of the body or that contacts intact mucus membranes. The Respiratory Therapy Director stated she was aware this was not the correct procedure and planned to obtain all disposable products.
F. Observation on 08/27/18 at 1:43 PM showed four curved and three straight laryngoscope blades in the Emergency Department crash cart drawer that were stored on a piece of blue foam that had brown spots on the surface. The laryngoscope blades were stored without a cover or packaged to protect from contamination. The finding was confirmed at the time of observation by the Director of Nursing.
G. Observation on 08/27/18 at 2:30 PM showed three straight and three curved laryngoscope blades stored loose in a drawer in the Medical Surgical crash cart. The laryngoscope blades were stored without a cover or packaged to prevent contamination. The Respiratory Therapy Director confirmed the findings at the time of observation.
H. During an interview on 08/28/18 at 9:21 AM, the Respiratory Therapy Director stated she was responsible for reprocessing laryngoscope blades and that reprocessing of the laryngoscope blades was done using the Spartan CDC-10 product in the ready to use handi-spray foam. The Respiratory Therapy Director stated the CDC-10 product was left on the laryngoscopy blade for about 15 seconds, then put into a stainless steel sink, and was wiped off. Bleach was then poured on the laryngoscope blade and rinsed off with tap water.
I. On 08/28/18 at 9:47 AM the Director of Nursing (DON) was interviewed regarding what product or process was used for high level disinfection of laryngoscope blades and stated "I thought we soaked them in Cidex. That was years ago when we did surgery."
J. On 08/28/18 at 9:48 AM in an interview the Infection Preventionist stated Infection control did not monitor the process for HLD of laryngoscope blades and that she thought that disposable laryngoscope blades and handles were in use.
K. During an interview on 08/28/18 at 10:00 AM, the Respiratory Therapy Director stated that there were no policies for HLD in accordance with manufacturer's directions for use or storage of the laryngoscope blades. The Respiratory Therapy Director stated that she was not aware of the manufacturer's instructions for disinfection of the laryngoscope blades.


Based on observation and interview, it was determined the facility failed to identify and control infections in that;
1. A black substance was observed on the air vent in one of one Ultrasound Room;
2. One of one bedside commode in Room 214 had rust (porous nature that cannot be cleaned or disinfected) on the legs;
3. One of one intravenous (IV) pole in Room 206 had an accumulation of rust on the bottom;
4. One of four laboratory trays observed in the Emergency Department had tape residue (harbors bacteria) present on the surface of the tray that cannot be cleaned or disinfected; and
5. In the clean Utility Room in the Emergency Department showed an accumulation of rust on the top surface of the metal linen cabinet and dust was accumulated on the top of one of one blanket warmer.
The facility could not be assured patients would be protected from likely sources of infection. The failed practice was likely to affect all patients who receive care at the facility. Findings included:

A. Observation on 08/30/18 at 9:30 AM of the Ultrasound Room showed an accumulation of black substance on the air conditioner ventilation unit. The finding was confirmed at the time of observation by the Radiology Manager.
B. Observation on 08/30/18 from 11:35 AM to 12:20 PM showed rust on the bedside commode legs in Room 214; there was rust on the bottom of the IV pole in Room 206. The findings were confirmed by Licensed Practical Nurse #1 at the time of observation.
C. Observation on 08/27/18 at 2:14 PM of the Emergency Department showed one of four plastic trays used by the laboratory staff had an accumulation of tape residue along the top surface. The finding was confirmed by the Laboratory Manager at the time of observation.
D. Observation on 08/27/18 at 2:18 PM of the Clean Utility Room in the Emergency Department showed an accumulation of rust on the top surface of the metal linen cabinet. There was an accumulation of dust on the top of the blanket warmer. The findings were confirmed by the Director of Nursing on 08/27/18 at 2:45 PM.


Based on observation, review of policy, manufacturer's instructions and interview, it was determined the facility failed to identify and control infections in that the point of care blood glucose testing device was not cleaned or disinfected between two of two (#6 and #9) patients observed prior to returning the device to the storage container. The failed practice did not ensure Patient #6 or #9 and any other patient who required blood glucose testing would be protected from likely sources of infection. Findings included:

A. Record review of the facility's policy titled, "Blood Glucose Monitoring," dated 01/03/07, showed that glucometers were to be cleaned after each patient use to remove organic and inorganic soil on all surfaces of the devices while disinfecting to kill bloodborne pathogens and cleaning and disinfecting could be completed by using disinfectant towelettes.
B. Record review of manufacturer's instructions for use showed that it was approved for professional settings and that users should follow guidelines for prevention of blood-borne transmittable diseases in a healthcare setting for potentially infectious human blood specimens as recommended in the National Committee for Clinical Laboratory Standards.
C. Continuous observation on 08/30/18 at 11:08 AM to 11:29 AM showed:
1) Licensed Practical Nurse (LPN) #1 performed bedside blood glucose testing for Patient #6 using the Easy Touch blood glucose device. LPN#1 returned the device to the basket storage container at the nursing station.
2) LPN #1 performed blood glucose testing for Patient #9 at 11:12 AM using the Easy Touch blood glucose device. LPN#1 returned the device to the basket storage container at the nursing station.
3) The Easy Touch glucose testing device was returned to the clean storage area basket (storing clean single use lancets and test strips) at the nurses' station without cleaning or disinfection before or after use. The clean single use lancets and test strips were potentially contaminated from the unclean glucose testing device.
4) LPN #1 confirmed the findings in C1-3 on 08/30/18 at 11:21 AM.


31039

This is a reoccurring deficiency, last cited on 02/05/15.
Based on review of policy, review of physician TB records, and interview, the Infection Control Officer failed to identify risks of TB transmission to patients and personnel by not annually screening four (#2, #3, #6 and #7) of seven (#1-#7) Contract Emergency Room Physicians. By not assuring the physicians were screened annually, the facility couldn't assure they were controlling infections and communicable diseases of patients and personnel. The failed practice had the likelihood to affect all of the employees and patients in the facility. Findings follow:

A. Record review of the facility's policy titled, "Tuberculosis Screening," showed all employees would be tested and or screened for TB upon hire and annually thereafter.
B. Review of the Physician's Tuberculosis records showed the following:
1) Physician #2-showed no evidence of a screening in the past 12 months and last evidence of a TB screen was 01/05/10;
2) Physician #3-showed no evidence of a screening in the past 12 months and last evidence of a TB screen was 02/12/15;
3) Physician #6- showed no evidence of a screening in the past 12 months and last evidence of a TB screen was 12/10/13; and
3) Physician #7-showed no evidence of a screening in the past 12 months and last evidence of a TB screen was 03/30/16.
C. During an interview on 08/29/18 at 12:10 PM, the Director of Medical Records verified the findings at B.


Based on observation, review of manufacturer's recommendations and interview, it was determined the facility failed to mitigate the risk of health-care associated infections in that they did not identify the practice of storing used SDV (Single Dose Vials) instead of discarding unused portions (per manufacturer) which allowed the SDV to be reused in one (Emergency Department) of two (Emergency Department and Medical-Surgical) units toured. By not identifying this practice, the facility could not assure the use of SDV were only being used one time and discarded after use. The failed practice had the likelihood to affect all patients in the facility. Findings follow:

A. Record review of the manufacturer's recommendation for Sterile Water for injection showed the vial was not to be reused and the unused portion was to be discarded. Also, this product did not contain a bacteriostat or antimicrobial, therefore organisms could have grown in it once used.
B. Record review of the manufacturer's recommendation for Sodium Chloride for injection showed the vial was not to be reused and the unused portion was to be discarded. Also, this product did not contain a bacteriostat or antimicrobial, therefore organisms could have grown in it once used.
C. During a tour of the facility on 08/27/18 from 1:35 PM to 3:10 PM, observation showed the following SDV opened, used and stored in the Emergency Department:
1) One 50 ml (milliliter) Sterile Water for injection was dated 05/28/18, stored and available for further patient use; and
2) One 10 ml 0.9% Sodium Chloride for injection was stored and available for further patient use.
D. The Director of Nursing verified the SDV were open and being stored instead of discarded after use, at the time of observation.


40282

Based on observation, it was determined facility failed control infections in that dirty linen was stored in the Clean Linen Storage Closet. Failure to ensure the clean linens did not mingle with dirty linen had the potential to allow contaminated linens (patient gowns, towels, sheets and blankets) to be used in patient care. The failed practice had the potential to affect current patients and any patient admitted to the hospital.

A. Observed on 8/27/18 at 3:00 PM showed an area designated as the Clean Linen Storage Closet. One yellow biohazard bag labeled infectious material was on the floor open with solid linen and a band aid attached to one piece of the linen items.
B. The findings in A were verified by the Director of Nurses on 8/27/18 at 3:05 PM.

Based on review of policies and interview, it was determined the facility failed to have policies and procedures to ensure the integrity of the record system for one of one (CPSI [Computer Programs System, Inc.]) electronic health records system. By not having current policies and procedures, the facility could not ensure the integrity of the electronic health records. The failed practice had the likelihood to affect all patients whose records were electronic. Findings follow:

A. Record review of policies showed the last revision of the Medical Records Department was 01/2007. The facility installed their electronic health records system, CPSI, in spring of 2008. The policies have not been revised to reflect the new system.
B. During an interview on 08/29/18 at 12:22 PM, the Director of Medical Records verified they did not have policies and procedures that addressed the new electronic health records system.