HospitalInspections.org

Based on direct observation and staff interview, the Critical Access Hospital failed to ensure that all drugs and biologicals were stored appropriately. The hospital reported 191 acute inpatients for the most recent fiscal year. Findings are:

A. On 1/31/12 at 4:00 PM a tour of the Outpatient Clinic area revealed drugs and biologicals were not stored appropriately, as injectable Varicella Zoster vaccine and gel packs available for patient use were stored in the freezer section of the refrigerator along with with employee lunches.

B. The soiled utility room of the Outpatient Clinic area contained a cryosurgical system, podiatric supplies, such as shoes and casting materials, all available for patient use. In addition, there were 7 boxes of clinic records labeled "destroy 1-11".

C. An interview conducted with the Outpatient Clinic supervisor (Employee 11) confirmed employee lunches should not be stored with injectable medications for patients and that the podiatric supplies and other items should not be stored in the soiled utility room.

All of the above items were corrected at the time of the survey exit conference.

Based on direct observation and new employee orientation records, the Critical Access Hospital's infection prevention program failed to assure nursing personnel were adequately trained in urinary catheter insertion sterile technique. (An indwelling urinary catheter is a flexible, narrow tube attached to a bag, utilized in a variety of medical conditions, which is inserted through the urethra (bladder opening) to collect urine and remains in place for an extended period of time. Patients with these catheters are at increased risk of developing severe urinary tract infections, which can be life threatening. The hospital reported 191 acute inpatients for the most recent fiscal year. Findings are:

A. On 2/8/12 at 2:00 PM, during the attempted instillation of an indwelling urinary catheter for Patient 18 by Employee 7, the surveyor intervened because the RN failed to wash her hands prior to donning the sterile gloves, as required by current infection prevention practices.

B. A second attempt to place the urinary catheter by Employee 8 resulted in the catheter being placed in the vaginal vault. After subsequently removing the catheter tip, Employee 8 asked, "Is this still sterile?" and proceeded to attempt another insertion; however, Employee 9 stopped Employee 8 and said, "Go get another one."