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Based on staff interview, review of employee files, and review of North Dakota Administrative Code (NDAC), the Critical Access Hospital (CAH) failed to comply with federal and state regulations to ensure current registration with the North Dakota Board of Nursing (NDBON) for 1 of 1 surgical technician (#3) reviewed. Failure to ensure unlicensed assistive persons (UAPs) applied to the NDBON registry limited the CAH's ability to ensure qualified staff to assist with patient care/procedures.

Findings include:

The NDAC 54-01-03-01 stated, ". . . 79. 'Technician' means an unlicensed assistive person who may perform limited nursing functions within the ordinary, customary, and usual roles in the person's field. Examples may include surgical and dialysis technicians and medical assistants. . . . 54-07-02-02.1. Unlicensed assistive person registry status. Unlicensed assistive persons who carry out delegated nursing interventions must hold current registry status either on the board registry or on another state registry recognized by the board.
. . ."

Review of the employee files on 11/20/19 showed a surgical technician (#3) lacked registration with the NDBON.


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During interview on the morning of 11/20/19, an administrative nurse (#1) and human resourses staff member (#4) verified the surgical techician (#3) utilized in the surgical department had not registered as a UAP with the NDBON.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to maintain an environment free of accident hazards on 2 of 3 days of survey (November 18-19, 2019). Failure to securely store chemicals utilized by housekeeping and other staff placed patients who display confusion and wandering behaviors, as well as children and other visitors, at risk for accidents due to accessibility to hazardous chemicals.

Findings include:

Observation of the nursing unit on the afternoon of 11/18/19 and the morning of 11/19/19 identified the following unsecured hazardous chemicals:
* In the unlocked clean utility room
- Barbicide 16 ounce (oz) bottle located on the counter beside the hand sink labeled, "Hazardous to humans. Corrosive. Irreversible eye damage and skin burns. . . ."
- HB Quaternary (Quat) Disinfectant Cleaner in a large spray bottle labeled, ". . . eye, skin, nose and throat irritation."
* In the unlocked dirty utility room
- Asepti-Zyme one gallon bottle located on the counter beside the sink labeled, "May cause eye irritation. May cause allergic respiratory reaction."
- Quat Disinfectant Cleaner located under the sink labeled, "May cause eye and skin irritation."
*In the nursing unit unlocked tub room
- HB Quat disinfectant cleaner located on the side of the bathtub labeled, ". . . eye, skin, nose and throat irritation."
* In the unlocked Same Day Center area
- MBS Disinfectant Cleaner Concentrate spray bottle located on a table beside the nurses' station labeled "Precautions. Corrosive. Irreversible eye damage and skin burns."

During interview on 11/19/19 at 11:40 a.m., a nurse manager (#2) indicated no knowledge of the chemicals in the unlocked areas and stated the facility had no policy regarding the storage of chemicals.

During interview on 11/20/19 at 11:15 a.m., a supervisory nurse (#1) verified staff should secure all chemicals in a locked area.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to store medication in a manner that prevented unauthorized access for 1 of 1 anesthesia cart located in a procedure room in the operating room area. Failure to store all medications securely may result in unauthorized access to medications.

Findings include:

Review of the policy titled, "Medication Storage, Handling and Labeling" occurred on 11/19/19. This policy, revised 07/25/19, stated, ". . . 2. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. . . ."

Observation of the procedure room occurred on the morning of 11/19/19 with the nurse manager (#2) and showed an unlocked anesthesia cart with the key to access the cart attached to the side of the cart. Medications in the cart included Zofran (anti-nausea), atropine, beta blockers, steroids, epinephrine, and Toradol (pain).

During interview on 11/19/19 at 9:30 a.m., the nurse manager (#2) stated it is the responsibility of the certified registered nurse anesthetist (CRNA) to lock the cart after completion of procedures.

During interview on 11/20/19 at 8:00 a.m., an administrative nurse (#1) stated she expected staff to lock the anesthesia cart after completion of procedures.



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Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed appropriate infection control practices for 1 of 1 sterilizer (autoclave). Failure to follow appropriate infection control practices including biological testing may result in transmission of organisms and pathogens from equipment to patients.

Findings include:

Review of the policy titled "Central Sterilization" occurred on 11/19/19. This policy, reviewed April 2019, stated, ". . . Purpose: To ensure proper sterilization of Central Sterilizing. Policy: Central sterilization shall follow strict procedure to ensure quality assurance. Procedures: A spore-biological challenge test is done daily when autoclave is in use to monitor and ascertain proof of sterilization adequate to kill spores . . ."

Observation of the sterilization room on the morning of 11/19/19 with the operating room (OR) manager (#2) and the nurse in charge of sterilization (#5) showed a steam autoclave utilized for sterilizing equipment. The nurse (#5) explained the process and products utilized for the biological testing of the steam autoclave. The nurse (#5) identified staff utilized the Comply SteriGage (labeled Steam Chemical Integrator Test Pack #41360) for the biological testing. Further review showed staff utilized a Spordi (biological testing device) when sterilizing equipment in a One Tray (approved for occasional immediate use sterilization) placed in the steam autoclave.

Review of the daily Sterilization Record from October through November 19, 2019 showed utilization of the steam autoclave ten times to sterilize instruments from the OR, ED, acute care department, physical therapy, and clinic.

During interviews on the morning of 11/20/19, the OR manager (#2) identified the sterilization process failed to utilize the correct testing pack for biological testing (Comply SteriGage #41380, not #41360). The manager provided documentation of the last biological testing completed utilizing a Spordi with the One Tray in the autoclave as 04/04/19 with no issues noted. She stated staff failed to ensure the training of new staff included the correct process for biological testing of the autoclave sterilization process.


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