HospitalInspections.org

The Hospital reported a census of 14 patients. Based on medical record review and interview, the hospital failed to ensure clinical records are completed within 30 days following the patient's discharge. This deficient practice affected one of four inpatient (Patient #8) closed medical records reviewed.

Findings included:

- Review of the hospital's policy "Medical Records" B 16 directed "...The medical record shall be complete within thirty (30) days of discharge. If the record remains incomplete twenty-seven (27) days after discharge, a notice will be provided to the practitioner ..., The practitioner will then have three (3) days to complete documentation. If the record remains incomplete at thirty (30) days, the Director of Medical Records shall notify the practitioner that his/her privileges to admit patients shall be suspended until the record is completed ... "

- Patient #8's medical record review on 11/18/14 revealed an inpatient admission date of 12/7/13 with a diagnosis of left hip infection with a discharge date of 12/24/13. The physician dictated the discharge summary on 2/7/14, 45 days after discharge.

Administrative staff D interviewed on 11/17/14 at 3:35pm acknowledged the physician failed to follow the hospital policy that requires the discharge summary completed within 30 days after discharge from the hospital. Staff H revealed the physician lacked delinquencies for reoccurring tardiness regarding discharge summaries.

Medical records staff G interviewed on 11/19/14 at 4:00pm verified the delinquent discharge summary and confirmed sending the physician a letter on day 27 reminding the physician to complete the discharge summary. The Hospital failed to suspend the physicians' privileges after 30 days per hospital policy. Staff G acknowledged the hospital failed to follow the policy and procedure for signing the discharge summary within 30 days of the patient's discharge.

The Hospital reported a census of 14 patients. Based on observation, policy/procedure review, manufacturer's guidelines, and staff interview the Hospital failed to ensure mislabeled biologicals are not available for patient use for one of one observed fluid warming cabinet. This failure placed patients at risk to receive expired biologicals.

Findings include:

- The Hospitals operating room policy titled, "Warmed storage of I.V. and irrigation solutions" reviewed on 11/19/14 at 11:25am directed, "IRRIGATION SOLUTIONS IN SEMI-RIGID PLASTIC CONTAINERS may be stored in the warming cabinet for a period NOT LONGER THAN 60DAYS at a temperature NOT TO EXCEED 150 DEGREES (65 DEGREES CENTIGRADE) ..."

- The manufacturer's guidelines (Hospira) titled, "Aqualite polyolefin plastic pour bottles (Semi-rigid containers", reviewed on 11/19/14 at 9:55am directed, "Solutions for irrigation ... in Hospira Aqualite plastic pour bottles ...may be warmed up to 40 degrees Celsius (C) (104 degrees Fahrenheit (F) ... and for a period no longer than two weeks (14 days) ..."

- Observation in the Operating Room (OR) area on 11/17/14 revealed a fluid warmer cabinet at 103 degrees (F) with the following Hospira, Aqualite polyolefin plastic pour bottles (semi-rigid containers of irrigation fluids) in it:
One-1000ml (milliliters) bottle of sterile water with a date of 11/11/14 when the staff put the bottle in the fluid warmer and a use by date of 1/11/15 when the bottle needed to be discarded.
Three-1000ml bottles of 0.9% Sodium Chloride with a date of 11/13/14 when the staff put the bottle in the fluid warmer and a use by date of 1/13/15 when the bottle needed to be discarded.
One-1000ml bottle of 0.9% Sodium Chloride with a date of 11/17/14 when the staff put the bottle in the fluid warmer and a use by date of 1/1/715 when the bottle needed to be discarded.
Two-1000ml bottles of 0.9% Sodium Chloride with a date of 11/14/14 when the staff put the bottle in the fluid warmer and a use by date of 11/14/15 when the bottle needed to be discarded.
Nursing staff J, interviewed on 11/17/14 at 3:30pm acknowledged the use by dates on the fluid containers in the warming cabinet were for 60 days from the date the staff place the fluids in the warming cabinet. Staff J explained they could keep the fluid containers in the warming cabinet for 60 days.
Administrative staff, C interviewed on 11/18/14 at 8:00am acknowledged the fluids in the fluid warmer have a use by date of 60 days after the staff place the fluids in the fluid warmer. Staff C explained the accrediting agency surveyor told them it was okay.
The Hospital failed to follow the manufacturer's guidelines, and failed to develop a policy/procedure that followed the manufacturer's guidelines for the use of the fluids in the warming cabinet.

The Hospital reported a census of 14 patients. Based on observation, policy/procedure review, manufacturer's guidelines, and staff interviews, the Hospital's infection control officer failed to develop an active infection control system ensuring hospital personnel followed basic infection control practices during one of one observed surgical procedure, one of one terminal cleaning of an operating room, and two of two observations in the operating rooms, and failed to provide a required usable hand washing sink for one of one nursery in the obstetric unit. This deficient practice places patients at risk for hospital acquired infections.

Findings include:

- The Hospital's policy/procedure titled, "Hand Hygiene" reviewed on 11/19/14 at 5:00pm directed, "...The frequency of hand washing is essential in prevention and control of infections...after removing gloves ..."
- The Hospital's policy/procedure titled," Dress Code, Surgery Department " reviewed on 11/19/14 at 11:30am directed, " ...Masks should be carefully removed and discarded after use. Masks should not be saved by hanging around the neck or tucking into a pocket ... "

- The Hospital's policy/procedure titled, "Surgery Department Cleaning" reviewed on 11/19/14 at 11:30am directed, "...GERMICIDAL DETERGENT: All cleaning and mopping is done with Film Free Germicidal Disinfectant Detergent ..."

- The manufacturer's guidelines for "Virex II 256 One-Step Disinfectant Cleaner and Deodorant" reviewed on 11/19/14 at 4:00pm directed, "...Apply Solution to hard, non-porous environmental surfaces. All surfaces must remain wet for 10 minutes ..."

- Housekeeping staff K observed on 11/17/14 between 3:50pm to 4:30pm performed terminal cleaning of Operating Room (OR) #2. Staff K using a cloth wet with "Virex II 256" solution wiped the counter, ventilator grate in the wall, inside of the doors, outside of the supply cabinets, and the large overhead lights. The surfaces remained wet from 2.5 minutes to 5 minutes, not the required 10 minutes as required to disinfect surfaces.

- Observation in OR #2 after the cleaning process and before they washed the floor on 11/17/14 at 4:00pm a revealed a black five drawer "Craftsman's" cart up against the wall by the anesthesia machine. The top flat surface of the cart held three sterile packages of laryngoscopes with blades. The flat surface had a layer of thick dust on it. Alongside of the black cart revealed a silver three tiered cart with equipment on the shelves used during surgery with a layer of thick dust on all three shelves.

- Observation of OR #1 on 11/17/14 at 4:15pm revealed a black five drawer "Craftsman's" cart with four sterile packages of laryngoscopes with blades on the top flat surface. The top surface of the cart revealed a thick layer of dust on it.

Administrative staff A and nursing staff J interviewed on 11/17/14 at 4:15pm confirmed through observation the dust on the carts and the lack of appropriate cleaning of all surfaces in the OR rooms. Administrative staff A and staff K housekeeping staff acknowledged the cleaning solution Virex II 256 required a wet time of 10 minutes to disinfect the surfaces. Staff K lacked knowledge that the surfaces did not remain wet for the required 10 minutes.

- Observation in the pre-operative area on 11/18/14 at 8:15am revealed staff I, registered nurse (RN) at the desk with a surgical mask dangling around their neck.

- Observation in the pre-operative area on 11/18/14 at 8:17am revealed staff L walked into patient #18's room to start an intravenous catheter used for the administration of intravenous fluids, applied unused non-sterile gloves performed the procedure, removed the gloves, and left the room. Staff L failed to perform hand hygiene when entering the patient's room and applying gloves and when removing the gloves.

- Observation in OR on 11/18/14 between 8:38am to 9:54am revealed staff I, RN, removed and applied non-sterile gloves seven times without performing hand hygiene.

- Observation in OR on 11/18/14 at 9:42am revealed staff C, RN, standing at the door to the OR with a surgical mask dangling around their neck.

- Observation in OR on 11/18/14 at 9:57am revealed staff I, RN, after completion of the surgical procedure and before exiting the OR removed their face shield and mask and put them in the pocket of their jacket.

Administrative staff C, RN interviewed on 11/18/14 at 8:00am explained the Operating Room uses the Association of PeriOperative Registered Nurses (AORN) recommendations and practice standards.

Infection Control Officer Staff H, interviewed on 11/19/14 at 3:30pm acknowledged they were responsible for the management of the infection control program. Staff H explained the Hospital has a hand hygiene surveillance program that includes observations by staff of staff throughout the Hospital performing hand hygiene. The information is compiled and trended. Staff H, explained they were unaware of breaches that occurred regarding infection control issues in the OR.

- Observation of the nursery on 11/17/14 at 2:05pm revealed a hand washing sink with "wing" (a handle that is flat and wing like) handles. In trying to shut off the water, once turned on, by using the elbows against the handles, the water would not shut off.

- Demonstration by infection control officer staff H in the nursery on 11/19/14 at 3:35pm of turning the water off on the hand washing sink using the elbows against the handles confirmed the water was difficult to shut off using the elbows because of the location of the sink and accessibility. The sink in the nursery did not meet the requirement for the use of the elbow controls.


Staff H interviewed on 11/19/14 at 3:35pm acknowledged the hand sink in the nursery did not meet the requirement because of the location of the sink and the inaccessibility of the handles.