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Based on observation and interview it was determined the facility did not meet Life Safety Code requirements related to maintaining egress corridors free from obstructions.The failed practice had the potential to affect all patients, staff and visitors. The facility had a census of eight patients on 02/11/14. See K-72.

Based on review of policy, observation and interview, it was determined the facility failed to ensure outdated medications were not available for patient use in two of two (604 and 605) ORs (Operating Rooms) toured. By not disposing of expired medications, the facility could not assure the safety and efficacy of the product past the manufacturer's expiration date. The failed practice had the likelihood to affect all patients receiving medication from the operating rooms. Findings follow:

A. A tour of the facility on 02/12/14 between 1300 and 1445 revealed outdated medications as follows:
1) OR 605- Five Sodium Chloride 0.9% 100 ml (milliliter) IV (Intravenous) solutions expired 01/01/14.
2) OR 604
a) Five Sodium Chloride 0.9% 100 ml (milliliter) IV (Intravenous) solutions expired 01/01/14;
b) One Sodium Chloride 0.9% 250 ml (milliliter) IV (Intravenous) solutions expired 02/01/14; and
c) Two Sodium Chloride 0.9% 500 ml (milliliter) IV (Intravenous) solutions expired 11/01/13.
B. Review of policy titled "Storage of Pharmaceuticals" stated B.2."Inspection of the medications available to assure that: c. Any expired or discontinued medications have been removed."
C. Findings were verified, through interview, on 02/12/14 at 1340 with RN #2.

Based on review of policy, review of Controlled Substance Logs, and interview, it was determined the facility failed to complete audits of controlled substances each shift change(shift changes occurred at 0700 and 1900) on 2 (Medical-Surgical, Emergency Department) of 4 (Medical-Surgical, Emergency Department, Intensive Care Unit and Surgical Services) MedStation (Pyxis) departments surveyed. By not completing the controlled substance audits on each shift change, the likelihood existed for discrepancies to be in the inventory and to go unresolved. Findings follow:

A. Review of policy titled "Medications-Automated Dispensing System and Narcotic Inventory Process" stated "At the end of each shift, the off going and oncoming charge nurse/Licensed Radiology Technologist will check the MedStation (Pyxis) to verify that all discrepancies have been resolved."
B. Review of Controlled Substance Logs on 02/12/14 revealed the missing of two signatures on the following shift changes from 02/01/14 through 02/10/14:
1) Medical Surgical Unit: 02/01/14 at 0700 and 1900; 02/02/14 at 0700; 02/05/14 at 1900; 02/06/14 at 0700; 02/08/14 at 0700 and 1900; and 02/09/14 at 0700.
2) Emergency Department: 02/02/14 at 0700; 02/07/14 at 1900; 02/08/14 at 0700 and 1900; and 02/09/14 at 0700.
C. Findings were verified, through interview, by the Nursing Quality Coordinator on 02/12/14 at 1445.

Based on observation, policy and procedure review, review of logs and interview, the facility failed to have a process in place to minimize the potential spread of infection in that the facility failed to follow manufacturer's directions for minimum temperature of a disinfection solution used to process endoscopes; failed to store endoscopes in a manner to prevent potential environmental contamination from bacteria; and failed to assure storage cabinets, supplies, surfaces, and chairs were maintained to limit the spread of infection. It could not be assured infections would be prevented. The failed practice had the potential to affect the census of eight patients and any patient admitted to the facility. The findings were:

A. The facility failed to assure manufactures directions for minimum temperature of the disinfection solution was followed.
1) In an interview 02/12/14 at 1430 with RN (Registered Nurse) #2 and PCT (Patient Care Technician) #1 revealed the solution used for high level disinfection of the facility endoscopy equipment was an ortho-Phthalaldehyde Solution used for high level disinfection of semi-critical medical devices. Review of the directions for use revealed for high level disinfection manual processing, "Immerse device completely, filling all lumens and eliminating air pockets, in solution for a minimum of 12 minutes at 20 degrees C (Celsius) or 68 degrees F (Fahrenheit) or higher to destroy all pathogenic microorganisms."
2) Review of the high level disinfectant log on 02/12/14 at 1430 revealed the temperature of the solution was below the manufacturer's directions for minimum temperature of 68 degrees F for 17 of 17 opportunities from 05/13/13 - 02/05/14. The temperature was documented as 64 degrees F on 05/13/13, 05/20/13 and 05/29/13. The 15 temperatures documented from 06/05/13-02/05/14 was 60 degrees F.
3) The findings were confirmed at the time of observation by RN #2 and PCT #1.

B. The facility failed to assure endoscopes were stored in a manner to prevent potential environmental contamination from bacteria.
1) Observation on 02/12/14 at 1345 of the storage cabinet in the OR suite revealed the inner back surface was wooden. A cloth type tape was observed wrapped around four of four scope holders in the top portion of the cabinet. The wooden surface and cloth type tape created a porous surface and could potentially harbor bacteria and cause infection. By interview, RN #2 stated "we had to put that on there to protect the scopes." RN #2 confirmed the inner back and scope holders were made from wood at the time of observation.
2) Observation of the bottom portion of the endoscopy cabinet revealed two "Chux" that were visibly soiled. The tips of two of four endoscopes rested directly on the soiled Chux. RN #2 was asked how often the Chux were changed and he stated weekly or as needed. The findings were confirmed at the time of observation.

C. The facility failed to assure storage cabinets, supplies, surfaces, and chairs were maintained to prevent the spread of infection. Rooms in the OR Suite 610, 604 and 605 were identified as ready for patient occupancy at 1300 on 02/12/14.
1) Observation on 02/12/14 at 1330 revealed two of three ET (endotracheal) tubes were opened and available for use in the storage cart of OR (Operating Room) room 604. The label for each stated "do not use if package is open or damaged." The finding was confirmed by RN #2 at the time of observation.
2) Observation on 02/12/14 at 1310 of room 610 (GI room) revealed a cloth towel was present on the anesthesia cart and the GI cart. RN #2 stated the towels were changed one time per week and as needed. The items were secured with a cloth type tape. Both the cloth towel and the cloth type tape were porous and could not be sanitized between patients.
3) Observation on 02/12/14 at 1350 revealed a storage cabinet along the wall with glass panels in the OR area. Clean and sterile supplies were stored in the cabinet. The gaskets lining the glass panels were not attached to some of the glass panels. There were 5 of 12 glass panels secured with a duct and cloth type tape attached to the gaskets lining the glass panels. The cloth tape created a porous surface and had the potential to harbor bacteria. The findings were confirmed at the time of observation by RN #2.
4) Observation on 02/12/14 at 1410 in the Post Anesthesia Care Unit revealed two of two chairs for staff use in the common patient area were cloth and therefore porous. RN #2 confirmed the chairs were cleaned with surface wipes. Label directions were reviewed with RN #2 and the Director of Nursing and confirmed the product was for use on non-porous surfaces only.
5) Observation on 02/12/14 at 1455 of room 615 in the Emergency Department revealed a bedside chair with rips and tears in the upholstery. The rips created a porous and irregular surface that prevented sanitation between patients. The findings were confirmed by RN #1 at the time of observation.

Based on clinical record review and interview, it was determined the facility failed to ensure operative reports included the time of surgery for 3 of 3 (#5, #9, and #10) patients. The failed practice did not allow knowledge of which surgery happened first in the event of multiple surgeries in one day, and created the potential to affect any patient receiving an operation in the facility. Findings follow.

A. Review of Patient #5's operative report revealed the time of surgery was not documented. Findings were confirmed by the Clinical IT (Information Technologist) Physician Educator on 02/14/14 at 1000.
B. Review of Patient #9's operative report revealed the time of surgery was not documented. Findings were confirmed by the Clinical IT Physician Educator on 02/14/14 at 1000.
C. Review of Patient #10's operative report revealed the time of surgery was not documented. Findings were confirmed by the Director of Quality on 02/14/14 at 1240.

Based on review of Medical Staff and Advisory Board (Governing Body) Meeting Minutes for 2013, policy review, and interview, it was determined the facility failed to ensure one of 16 departments reported Quality Assurance on a quarterly basis per policy. The failed practice did not ensure the Medical Staff and Governing Body were aware of any potential performance improvement issues that needed to be addressed; and had the likelihood to affect any patient admitted to the facility. Findings follow.

A. Review of Quality Improvement and Performance Improvement (QA/PI) Annual Evaluation and Review stated, "Quarterly QA/PI reports of all services are submitted to the Advisory Board and the Medical Staff."
B. Review of 2013 Medical Staff and Advisory Board meeting minutes for 2013 revealed no discharge planning quality was reported for the second quarter of 2013.
C. Findings were confirmed by the Director of Nursing on 02/13/14 at 1500.

Based on review of Arkansas Lions Eye Bank Contract and interview, it was determined the facility failed to have an agreement with an eye OPO (Organ Procurement Organization) in that their contract with the Arkansas Lions Eye Bank had expired. By not having a current agreement with an eye OPO, the facility could not assure usable eyes were obtained from potential donors. The failed practice had the likelihood to affect all patients that had died in the facility since the contract expired. Findings follow:

A. Review of the contract between The Arkansas Lions Eye Bank & Laboratory and the Facility, revealed the contract expired 8/31/13.
B. Findings were verified, through interview, with the Chief Executive Officer on 02/11/14 at 1305.

Based on review of policies and procedures and interview, it was determined the facility failed to assure patient activities were provided by a qualified individual or by consultation with an occupational therapist, therapeutic recreation specialist, or other professions with recreation therapy education or experience. Without evidence of consultation It could not be assured the activity needs of the patients would be met. The failed practice had the potential to affect any patient admitted to swing-bed. The findings were:

A. The Director of Nursing on 02/14/14 at 1230 stated the person assigned to provide activity was not a certified activity professional. She stated they had an occupational therapist on staff that they met with. The Director of Nursing confirmed there was nothing documented of the consultation activities.
B. Review of the Activities policy for Swing Beds revealed "The swingbed activity coordinator organizes, provides, and documents the activities program under the supervision of the occupational therapist".
C. There was no evidence of supervision, documentation of consultation or an agreement to provide consultation with an occupational therapist for swing bed patient activities provided at the time of the survey.
D. The findings were confirmed by the Director of Nursing on 02/14/14 at 1230.