HospitalInspections.org

Based on observation, interview and record review the CAH failed to provide health care services in accordance with their written policies related to hand hygiene/glove use and testing for efficacy of disinfectant/sterilant in the machine used prior to endoscope/colonoscope (Instruments which can be introduced into the body to give a view of its internal parts.) cleaning. Findings include:

1.) Per observation on 10/4/23 at 10:35 AM of the cleaning of Operating Room (OR) #1, Staff #1 opened one of the doors of the OR with gloves on, left the room with the same gloves to get the mop, re-entered the OR with the same gloves; started to mop the floor; and proceeded to mop and clean other areas of the OR with the same gloves.
Per observation on 10/4/23 at 10:40 AM, Staff #2 left the OR area to go into a utility room, removed his/her right glove and without sanitizing his/her hands, touched a cabinet, removed dry cleaning cloths, and without sanitizing his/her hands, with a contaminated left glove, donned a clean glove on the right hand, applied Virex 256 (Solution used to clean the OR surfaces and floor) to the cleaning cloths and went back into the OR and continued to clean. This process was observed more than once with Staff #2.

Per interview on 10/4/23 at approximately 10:40 AM with Staff #1, S/He confirmed that when gloves are removed, you are to sanitize and/or wash your hands prior to donning new ones. S/He also stated that S/He should have removed his/her gloves and donned new gloves prior to entering and exiting the OR.

Per interview on 10/4/23 at approximately 12:15 PM with the infection preventionist, S/He confirmed that when gloves are removed hands should be washed and/or sanitized prior to donning new gloves.

Per review of the policy "Hand Hygiene" approved 1/31/23, it states, "1. Indications for Hand Hygiene 1.4 Before donning sterile or non-sterile gloves 1.5 After removing sterile or non-sterile gloves".

2.) Per observation of the cleaning of a colonoscope on 10/3/23 at approximately 11:30 AM, a bottle of Rapicide PA strips (Test strips used to test the efficacy of high-level disinfection.) was noted to be on the DSD Edge (Machine used to perform high level disinfection of endoscopes and colonoscopes.). There was no date to indicate when the bottle was opened and/or how long the strips were effective.

Per interview at that time with an endoscopy tech, S/He confirmed that there was no date and did not know when the bottle was opened and/or how long the strips were effective.

Per review of the policy "Endoscope Reprocessing Procedure" reviewed 3/4/20, it states, "G. High Level Disinfection ...Follow disinfectant/sterilant manufacturer's recommendations to achieve high-level disinfection of endoscopes. 1. Prepare the product according to disinfectant/sterilant manufacturer's label instructions. 2. Test the product for the MEC (Minimum Effective Concentration) according to the label on the test strip container. Note that: including, but not limited to, dilution, time/temperature, and number of uses. It is essential that the level of active ingredient be at or above that required to kill and/or inactivate the desired microorganisms (AAMI, 2006;2010). 4. Use a product-specific test strip and keep a log of the test results (Rutala et al., 2008)."

Based on interview and record review, the CAH failed to ensure that the use of bed rails was provided in accordance with the needs of the patient and per facility policy for 1 applicable patient (Patient # 7). Findings include:

Based on record review, Patient #7 was admitted with dementia, deconditioning, and was assessed to be a falls risk. Per review of nursing notes, bed rails were positioned in the up position for Patient #7 on the following dates:

Nursing notes dated 10-1-2023 indicate that two bed rails were raised during some hours of the night, and that three bed rails were raised during some hours of the night. A nursing note that evening also indicated that Patient #7 was restless and anxious as evident by crawling over side rails and getting out of bed frequently.
Nursing notes dated 10-2-2023 indicate that two bed rails were raised during the evening and overnight hours.
Nursing notes dated 10-3-2023 indicate that two bed rails were raised during some portions of the evening and early morning hours, and that three bed rails were raised during the overnight hours.
Nursing notes dated 10-4-2023 indicate that two bed rails were raised during portions of the night, that four bed rails were raised during some portion of the night.

Based on review of the "Patient Fall and Activity Policy for Inpatient Unit" approved on 12/16/2022; states "IV. Interventions-Guidelines for fall risk interventions: a. Universal environmental safety includes; x. Consider use of top side rails if appropriate per side rails assessment and policy".

Based on review of the facility policy "Clinical Guidance for the Assessment and Implementation of Side Rails" approved 4/12/2023, Under "Policy Considerations: "Use of side rails should be based on the patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team. Side rail effectiveness should be reviewed on a regular basis. The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted and determined not to be the treatment of choice for the patient".

Per observation and during an interview at approximately 11:00 AM on 10-4-2023, Patient #7 presented as not oriented to time or person, and was unable to answer questions about the side rails on their bed.

Per interview with the Special Projects Registered Nurse on 10-4-2023 at 12;10 PM, they confirmed that there was no evidence of a side rail assessment, nor a risk-benefit assessment done for Resident #7. Additionally, there was no evidence that the use of side rails was approved by the interdisciplinary team.

Based on interview and record review the CAH failed to show evidence that an informed consent was complete prior to a surgical procedure for three of four records reviewed (Patient #11, Patient #20, and Patient #21). Findings include:

1.) Per record review Patient #11 presented to the Emergency Department (ED) on 9/9/23 after a fall. S/He was found to have a right femur (leg) fracture (break); and was admitted to the hospital on the same day. On 9/10/23, Patient #11 underwent surgery to repair the fracture. Per review of the "Consent for Operation or Invasive Procedure" form, there was no time documented when this consent was reviewed with the patient.

2.) Per record review Patient #20 presented to the ED on 6/2/23 after a fall. S/He was found to have left femur fracture; and underwent surgery to repair the fracture later that same day. Per review of the "Consent for Operation or Invasive Procedure" form, there was no time documented when this consent was reviewed with the patient.

3.) Per record review Patient #21 has a history of hypertension, hypothyroidism (low thyroid hormone) and osteopenia (A condition that occurs when the body doesn't make new bone as quickly as it reabsorbs old bone.). On 10/2/23, S/He was admitted to the hospital and underwent an elective Left Total Knee replacement. Per review of the Consent for Operation or Invasive Procedure" form, there was no time documented when this consent was reviewed with the patient.

Per interview on 10/3/23 at approximately 11:30 AM with the Director of the Perioperative Services, S/He confirmed that the "Consent for Operation or Invasive Procedure" should be timed when reviewed with the patient.

Based on observation and interview, the facility failed to ensure patients medical records/information were protected from unauthorized access for 11 of 11 patients sampled. Findings include:

During tour on 10/3/23 at approximately 10:15 AM, with the Unit Director on the patient medical unit, an open laptop was observed in the hallway outside a patient's room. The laptop was in the open position with the laptop screen revealing the names of all the patients currently on the unit and no staff presence at the laptop.

Interview on 10/3/23 at approximately 10:15 AM, with the Unit Director, they confirmed the open laptop with patient information was visually accessible to passersby. The Unit Director addressed this issue with the staff member (Respiratory Therapist) who immediately exited the patient's room and lowered the laptop screen, however, the information was still visible/accessible to passersby. The Unit Director proceeded to lock the laptop screen and confirm that this is the expectation when staff are not present at the laptops to protect patients' rights to privacy.

Based on interview and record review the CAH failed to ensure that surgical patients prior to discharge were evaluated for proper anesthesia recovery regarding cardiopulmonary status, level of consciousness, follow-up care/observations, and complications for three of four records reviewed (Patient #3, Patient #11, and Patient #20). Findings include:

1.) Per record review Patient #3 has a history of high blood pressure, insomnia, and macular degeneration (loss in the center of the field of vision). S/He was admitted to the hospital with a right hip fracture on 10/2/23 and underwent surgery the same day. Per review of the "Post Anesthesia Note" from 10/2/23 at 1600 (4:00 PM), it states "VSS" (Vital Signs Stable); and able to be easily awakened.

2.) Per record review Patient #11 has a history of smoking, high cholesterol, and peripheral vascular disease (condition where narrowed blood vessels affect blood flow to the limbs). S/He was admitted on 9/9/23 after a fall with a right femur fracture and underwent surgery on 9/10/23. Per review of the "Post Anesthesia Note" from 9/10/23 at 1211, it states "VSS. Pt awake and alert. No apparent anesthesia complications".

3.) Per record review Patient #20 has a history of smoking, high blood pressure, and chronic obstructive pulmonary disease (lung disease that affects breathing). S/He was admitted on 6/2/23 with a left femur fracture and underwent surgery the same day. Per review of the "Post Anesthesia Note" from 6/2/23 at 1605 (4:05 PM), it states, "VSS"; and easy to wake up.

Per review of the policy "Post-anesthesia evaluation", reviewed 2/23/21, it states, " A post-anesthesia evaluation must be completed by an individual qualified to administer anesthesia ....The anesthesia recovery note must be based on an evaluation of the patient as outlined in the CMS Conditions of Participation ....The elements of an adequate post-anesthesia evaluation should be clearly documented and include: Respiratory function, including respiratory rate, airway patency, and oxygen saturation (level of oxygen in the blood); Cardiovascular function, including pulse rate, and blood pressure; Mental status; Pain; Nausea and vomiting; Post operative hydration."

Per interview on 10/3/23 at approximately 12:00 PM with the Director of Perioperative Services, S/He confirmed that the above post anesthesia evaluations do not follow the facility's policy and/or contain the required regulatory elements.