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Based on clinical record review and interview, it was determined a Registered Nurse (RN) failed to assess and evaluate the patient's care, needs, and response to treatment ordered by the physician for four (#1, #2, #4, and #5) of 30 (#1-30) clinical records reviewed in that there was no documentation patients were turned every two hours as ordered, daily weights were obtained, and neurological checks were performed every one hour. Failure to turn patients every two hours had the potential to allow pressure ulcers to begin; failure to obtain and record daily weights and neurological checks every one hour did not give the responsible physician the necessary information to make informed decisions regarding the care and treatment of the patient. The failed practice had the potential to affect Patient #1, #2, #4 and #5. Findings follow:

A. Review of Patient #1's clinical record showed orders dated and timed 06/10/18 at 5:19 AM to turn patient every two hours and as necessary and for daily weights to be obtained. Review of Patient #1's clinical record showed no evidence Patient #1 was turned every two hours from 6:20 AM on 06/10/18 to 8:05 AM on 06/11/18, and from 8:05 AM on 06/11/18 to 7:00 PM on 06/11/18. Review of Patient #1's clinical record also showed no evidence the patient was weighed in one (06/12/18) of three (06/10/18 to 06/12/18) days. During an interview with the Clinical Information Technology Registered Nurse (CIT/RN) at 9:15 AM on 06/15/18 the above information was verified for Patient #1.
B. Review of Patient #2's clinical record showed orders dated and timed 03/13/18 at 11:39 PM for vital signs and neurological checks every one hour. Review of Patient #2's clinical record showed no evidence vital signs and neurological checks were performed and documented every one hour from 1:30 AM to 9:55 AM on 03/14/18. During an interview with the CIT/RN at 9:37 AM on 06/15/18 the above information was verified for Patient #2.
C. Review of Patient #4's clinical record showed orders dated and timed 03/30/18 at 3:28 PM to turn patient every two hours and as necessary and for daily weights to be obtained. Review of Patient #4's clinical record showed no evidence Patient #4 was turned every two hours from 2:46 PM to 7:30 PM on 03/31/18, from 8:40 AM to 8:00 PM on 04/02/18, and from 11:10 AM to 7:55 PM on 04/03/18. Review of Patient #4's clinical record showed no evidence Patient #4 was weighed in one (04/01/18) of five (03/30/18 to 04/04/18) days. During an interview with the CIT/RN at 10:10 AM on 06/15/18 the above information was verified for Patient #4.
D. Review of Patient #5's clinical record showed orders dated 04/10/18 for the patient to be weighed daily. Review of Patient #5's clinical record showed no evidence the patient was weighed in one (04/11/18) of four (04/10/18 to 04/13/18) days. During an interview with CIT/RN at 10:50 AM on 06/15/18 the above information was verified for Patient #5.

Based on observation, review of manufacturer's recommendations and interview, it was determined the facility failed to follow manufacturer's recommendations for temperature and length of storage, in that solutions were being stored above 104 degrees Fahrenheit and for longer than 14 days (per manufacturer) in two (Emergency and Surgical Services) of three (Emergency, Surgical Services and Labor and Delivery) departments that warmed fluids. By not following manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that have had procedures in the facility. Findings follow:

A. Review of the manufacturer's recommendations showed bags of Intravenous (IV) solutions for injection could be warmed at a temperature not to exceed 104 degrees Fahrenheit and for up to 14 days.
B. During a tour of the facility on 06/11/18 from 12:30 PM until 2:30 PM observation showed the following:
1) Emergency Department's fluid warmer was 150 degrees Fahrenheit with the following fluids in it:
a. One Normal Saline 1000 ml (milliliter) bag for IV dated 05/09/18 (should have removed on 05/23/18);
b. One Normal Saline 1000 ml bag for IV dated 05/06/18 (should have been removed on 05/20/18); and
c. Two Lactated Ringers 1000 ml bag for IV dated 05/06/18 (should have removed on 05/20/18).
2) Surgical Services' Department's fluid warmer was 110 degrees Fahrenheit with the following fluids in it:
a. One Normal Saline 1000 ml bag for IV; and
b. Eleven Lactated Ringers 1000 ml bags for IV.
C. During an interview on 06/11/18 at 1:48 PM, the Chief Nursing Officer verified the solutions were being stored above 104 Fahrenheit and the solutions in the Emergency Department were being stored longer than 14 days.

Based on review of United States Pharmacopeia Chapter 797 (2008), review of IV (Intravenous) Admixture Competency Checklist, review of Pharmacist's annual compounding skills and interview, it was determined the facility failed to:
1. Ensure gloved fingertip sampling for five of five (Pharmacy Technicians #1 and #2, Pharmacists #1, #2 and #3) pharmacy staff.
2. Ensure media fill testing for one (Pharmacist #3) of five (Pharmacy Technicians #1 and #2 and Pharmacists #1, #2 and #3) pharmacy staff was completed as part of the annual re-certification of Intravenous (IV) Admixture technique to compound medications in the Compounding Aseptic Isolator.

By not performing gloved fingertip and media fill testing on pharmacy personnel, the facility could not assure the sterility of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the Compounding Aseptic Isolator. Findings follow:

A. Review of United States Pharmacopeia Chapter 797, 2008 showed that gloved fingertip testing and media fill testing was to be completed as part of the annual re-certification of Intravenous (IV) Admixture technique.
B. Review of IV (Intravenous) Admixture Competency Checklist showed both gloved fingertip sampling and media fill testing was to be evaluated as part on the annual IV admixture competencies.
C. Review of Pharmacist's annual compounding skills performed by Pharmacy Technicians #1, #2 and Pharmacists #1, #2 and #3 showed gloved fingertip testing was not evaluated as part of the annual re-certification of Intravenous (IV) Admixture technique. It also showed media fill testing had not been evaluated for Pharmacist #3.
D. During an interview on 06/12/18 at 1:45 PM, the Director of Pharmacy verified the findings at B and C.

Based on review of policy, observation and interview, it was determined the facility failed to maintain security of medications and prescription drug pads in one (Medical/Surgical) of six (Medical/Surgical, Emergency, Intensive Care, Labor & Delivery, Nursery and Surgical Services) patient care areas toured. By not maintaining the security of medications and prescription pads, the facility could not assure unlicensed personnel could not access these items. The failed practice had the likelihood to affect all patients, staff and visitors. Findings follow:

A. Record review of the facility's policy titled, "Drug Storage-Pharmacy Inspections of Medication Areas," dated 08/2012, showed that medications were to be secured and inaccessible to unauthorized personnel.
B. Record review of the facility's policy titled, "Prescription Paper Security," dated 09/2017, showed that prescription pads were to be maintained in a secure storage to prevent theft.
C. During a tour of the facility on 06/11/18 from 12:30 PM until 2:30 PM, observation showed the following medications in an unlocked cabinet on the 1500 hall of the Medical/Surgical Unit:
1) One Nicotine Patch 14 mg (milligram);
2) One 1 Zosyn 2.25 mg 100 ml (milliliter);
3) One Celestone 30 mg/5 ml for injection;
4) One Cefepime 2 Gram/ vial for injection;
5) One Caffeine 500 mg for injection; and
6) Six blank prescription pads.
D. During an interview on 06/11/18 at 12:57 PM, the Chief Nursing Officer verified the contents of the unlocked cabinet listed in finding C.

Based on observation and interview, it was determined facility facility to ensure the Hi/Lo glucose and Ketone control solutions were maintained to ensure acceptable level of safety and quality in that the solutions were not dated when opened in one (Nursery) of three (Intensive Care, Nursery, and Pre-Operative) nursing units. Failure to date the control solutions when opened did not allow staff to know the expiration date and discard the control solutions before deterioration occurred. The failed practice had the potential to affect any Nursery patient whose care required the use of the glucometer. Findings follow:

A. Observation of the Hi/Lo Glucose and Ketone Control Solutions showed the bottles were opened and not dated when opened.
B. During an interview with Licensed Practical Nurse #1 at 1:32 PM on 06/11/18, she stated the Hi/Lo Glucose and Ketone Control Solutions were supposed to be dated when opened and discarded 90 days after opening.

Based on policy and procedure review, interview and observation, it was determined the facility failed to ensure food storage areas were monitored for temperature in that there were no temperatures recorded for five of five (Med [Medical]-Surg [Surgical] Nurses' Station refrigerator, the walk in refrigerator in the kitchen, the walk in freezer in the kitchen, or the reach in refrigerator in the kitchen) refrigerators. The failed practice affected all patients receiving food from the kitchen or the Med-Surg Nurses' Station. Findings follow:

A. Review of policy and procedure titled "Storage Temperatures" shows the supervisor will monitor storage temperatures as follows: temperatures are recorded at the opening and closing of the day for each storage area.
B. During tour of the kitchen on 06/13/18 at 10:15 AM showed:
1) The Med-Surg Nurses' Station refrigerator log did not have a temperature logged for all of April and no temperature logged for 05/22-31/18.
2) The kitchen walk in freezer did not have a temperature logged for all of April and no temperature logged for 05/25-31/18.
3) The kitchen reach in refrigerator did not have temperature logged for all of April 2018 and no temperature logged for 05/22-31/18.
4) The kitchen walk in refrigerator did not have temperature logged for all of April 2018 and no temperature logged for 05/23-31/18.
C. During interview with Director of Quality on 06/13/18 at 10:45 AM, the above findings in A and B were verified.

Based on observations, policy and procedure review and interview, it was determined the Infection Control Nurse failed to identify and control infections in that:
1. One of one syringe containing medication was dropped on the floor, picked up and placed on the clean work space,
2. Contaminated sheets were placed on one of one clean bed.
3. Five of five (#2-#6) over bed tables in the Intensive Care Unit (ICU) were dirty.
4. One of one Operating Room Technician/Central Sterile Technician (ORT/CST) did not wear eye protection while cleaning dirty surgical instruments as mandated per policy and procedure.

Failure to ensure only clean supplies and equipment were utilized during the provision of patient care had the potential for transmission of infections. Failure to utilize eye protection during the cleaning of dirty surgical instruments had the potential to allow splashing into the employee's eyes. The failed practice affected Patient #31, had the potential to affect any patient in ICU Rooms #2-#6 and the ORT/CST. Findings follow:

A. Review of the policy and procedure titled, "Instrument Cleaning/Processing," received on 06/13/18 showed that during decontamination, the person cleaning the instruments should wear an impervious gown, mask/face shield, rubber gloves extending to the elbow and protective eyewear. During observation at 12:00 PM on 06/13/18, the ORT/CST was observed cleaning dirty surgical instruments without wearing any protective eyewear. During an interview at 12:05 PM on 06/13/18 the ORT/CST was asked if she was supposed to be wearing eye protection and she stated she was.
B. During observation at 8:50 AM on 06/13/18 of the pre-operative care of Patient #31, Registered Nurse (RN) #1 was observed to drop a syringe containing the medication Decadron on the floor. RN #1 picked the syringe up off the floor, carried it to the patient's room and placed it on top of the over bed table along with the IV (intravenous) start kit, cathalons, alcohol preps, and IV tubing prior to administering the medication. During an interview with RN #1 at 9:20 AM on 06/13/18, RN #1 verified the above findings.
C. During observation of the cleaning of a discharged room at 1:30 PM on 06/14/18, Housekeeper #1 was observed to remove sheets, a pillowcase and a blanket from the nurse server. Housekeeper #1 was asked if the sheets were clean. Housekeeper #1 stated "I guess so, I have to make the bed from that closet (nurse server) and then throw the rest of them in the dirty laundry." During an interview with the Chief Nursing Officer (CNO) at 2:10 PM on 06/14/18, he stated that the sheets in the nurse server were considered dirty and should not have been used to make the clean bed.
D. During observation of the ICU at 1:00 PM on 06/11/18, the support leg and bases of five of five (#2-#6) over bed tables were observed to be dusty and stained with spots and drips of various colors and sizes. During an interview with the CNO at 1:15 PM on 06/11/18 the above findings were verified.


Based on observations, interviews and policy and procedure reviews, it was determined the Infection Control Nurse failed to identify, report and control infections in that all disinfectants and cleaning agents were not reviewed and approved initially and annually by the Infection Control Committee as mandated by policy and procedure. Failure to review and approve disinfectants and cleaning agents did not ensure the facility had researched and chosen cleaning supplies effective for its specific infection population. The failed practice had the potential to affect any patient whose care involved the use of equipment cleaned in the Radiology, Respiratory and Pharmacy departments. Findings follow:

A. Review of the policy and procedure titled, "Review and Approval of Soaps, Cleaners, Disinfectants and Antiseptics," received from the Infection Control Nurse at 8:45 AM on 06/14/18, showed all soaps, disinfectants, cleaners and antiseptics were subject to review and approval by the Infection Prevention Committee before being put into routine use and then annually. The departments included were listed as Environmental Services, OR, Radiology, Respiratory Therapy and all physician's offices. The above policy and procedure had a review/revision date of August 2017.
B. During an interview with the Director of Pharmacy by Surveyor #2 at 2:40 PM on 06/14/18, she stated the Pharmacy utilized Clorox Fusion to clean the hood in the pharmacy. Review of the chemical list received from the Infection Control Nurse on 06/14/18 did not show Clorox Fusion on the approved list of cleaning agents.
C. During an interview with the Director of Respiratory by Surveyor #1 at 9:45 AM on 06/13/18 the use of Wavicide-01 was verified as the chemical utilized by the Respiratory Therapy department to clean all re-usable equipment including ventilators, nebulizers, Bi-pap machines and laryngoscope blades. Review of the chemical list received from the Infection Control Nurse on 06/14/18 did not show Wavicide on the approved list of cleaning agents.


31039

Based on review of policy, observation and interview, it was determined the Infection Control Program failed to identify and prevent infection in that there was no thermometer in one of one breast milk refrigerator to assure the temperature was maintained at 39 degrees Fahrenheit. By not monitoring the temperatures of the refrigerator, the facility could not assure the breast milk was being stored at 39 degrees Fahrenheit (per policy) to inhibit microbial growth and contamination. The failed practice had the likelihood to affect all newborns who have their mother's breast milk stored in that refrigerator for future feedings. Findings follow:

A. Record review of the facility's undated policy titled, "Breast Milk Collection, Storage and Administration," showed the facility was to maintain the breast milk refrigerator at 39 degrees.
B. During a tour of the facility on 06/11/18 from 12:30 PM until 2:30 PM, observation showed a breast milk refrigerator in the nursery, with breast milk in it, and no thermometer in it, nor were the temperatures being monitored to ensure the temperature was maintained at 39 degrees Fahrenheit.
C. During an interview on 06/11/18 at 1:36 PM, the Chief Nursing Officer and RN #1 verified the findings at B.


38994

Based on review of manufacturer's recommendations, observation and interview, it was determined that the Infection Control Nurse failed to identify an control infections in that Wavicide-01 was used to clean respiratory reusable medical equipment without using a Wavicide MEC (minimum effective concentration) indicator test strip to ensure a MEC of 1.7%. The failed practice did not ensure the efficacy of the Wavicide solution was a high level disinfectant for semi-critical equipment including ventilators, nebulizers and Bi pap-machines. The failed practice had the potential to affect all patients requiring the use of re-usable respiratory equipment. Findings follow:

A. Review of the manufacturer's recommendations showed the concentration of the glutaraldehyde during reuse must be verified by Wavicide MEC indicator test strips to ensure a MEC of 1.7% was present. The medical equipment/device was to be immersed completely in the Wavicide-01 solution for 10 hours at 22 degrees Celsius to eliminate all microorganisms.
B Observation on 06/13/18 showed the Respiratory Department was using Wavicide solution to clean their instruments. Metricide test strips were used to check the Wavicide solution instead of a Wavicide MEC indicator test strip
C. During interview with the Director of Respiratory on 06/13/18 at 9:45 AM, the above findings in A and B were verified.

Based on policy and procedure review, clinical record review and interview it was determined the Facility failed to follow its policy to perform a post anesthesia evaluation on 3 of 5 surgery patients. The failed practice did not ensure patients receiving anesthesia for surgery were fully recovered from anesthesia and free from post anesthesia complications. The failed practice had the potential to affect all patients requiring anesthesia. Findings follow:

A. Review of policy titled, "Pre and post Anesthesia Evaluation Policy," showed all patients receiving general, regional, or monitored anesthesia shall have a post anesthesia evaluation completed and documented by a practitioner qualified to administer anesthesia.
B. Review of clinical records for surgery Patients #21, 23, and 25 they did not have post anesthesia evaluation documented.
C. During interview with the Director of Labor and delivery on 06/14/18 at 9:10 AM, the above findings in A and B were verified.

Based on review of Rehabilitation Services Agreement, review of Speech Therapists' personnel files and interview, it was determined one (#3) of four #1-#4) Speech Therapists' did not have evidence they were qualified in CPR (Cardio-Pulmonary Resuscitation) per the Rehabilitation Services Agreement. By not having evidence of these qualifications, the facility could not assure services provided to patients would be given by a qualified therapist trained in CPR in the event of an emergency. The failed practice had the likelihood to affect all patients that receive Rehabilitation Services. Findings follow:

A. Record review of the Rehabilitation Services Agreement showed that the therapists should have CPR certification.
B. Review of Speech Therapists' personnel files showed no evidence of CPR certification for Speech Therapist #3.
C. During an interview on 06/13/18 at 2:11 PM, the Director of Quality verified the findings at B.

Based on clinical record review and interview it was determined the facility failed to develop an activities calendar for five of five (#1-#5)Swing-Bed patients. Failure to develop an activities calendar did not allow the swing bed patient and/or family to be knowledgeable of available activities and choose which activities they would like to participate in. The failed practice had the potential to affect any Swing Bed patient. Findings follow:

A. Review of clinical records for Swing-Bed Patients #1-5 revealed no activities calendar was present.
B. During interview with Swing-Bed Patient #3 on 06/13/48 at 1:25 PM she stated no one had asked her what activities she enjoyed participating in and that she enjoyed crocheting and coloring.
C. Review of Swing-Bed Patient #3's Activity plan showed the patient was observed watching TV (television), magazine use and visiting.
D. During observation on 06/13/18 at 1:25 PM of Swing-Bed Patient #3's room showed no posted activities calendar.
E. The above findings in A, B, C, and D were verified with the Director of Labor and Delivery on 06/14/18 at 10:00 AM.

Based on policy and procedure review and interview, it was determined the facility failed to have a dentist on staff or an agreement with a dentist to provide 24 hour emergency care for its Swing-Bed patients. Failure to ensure the availability of dental care to the Swing-Bed patients did not ensure the needs of the patient would be met. The failed practice affected all patients admitted to Swing Bed. Findings follow:

A. Review of policy titled. "Dental Services," showed the facility would assist patients in obtaining routine and emergency dental care.
B. During interview with the Chief Nursing Officer on 06/15/18 at 9:40 AM, he stated the facility did not have a dentist on staff or an agreement with a dentist to provide dental care to the Swing-Bed patients.
C. The above findings in A and B were verified with the Chief Nursing Officer on 06/15/18 at 2:05 PM.