HospitalInspections.org

Based on interview and record review, the facility failed to ensure staff members B and F were current on their BLS (Basic Life Support) certification. Findings include:

During an interview on 8/22/19 at 9:15 a.m., staff member O stated the BLS certification for staff member F expired in 8/2015, and the BLS certification for staff member B expired in 8/2016. Staff member O stated staff members B and F did not have a current BLS certification.

Review of employee files showed staff members B and F did not have a current BLS certification.

Based on interview and record review, the facility failed to obtain a physician's order prior to initiation of a restraint for 1 (#7) of 20 sampled patients. Findings include:

During an interview on 8/21/19 at 5:25 p.m., staff member C stated an order for a restraint for patient #7 could not be located.

Review of patient #7's medical record showed monitoring, assessments and discontinuation for restraints, but did not show a physician's order for restraints.

Review of the policy for Limb Holder Restraints showed ...A. obtain a provider's order for the use of a limb holder...and for Waist Holder Restraints...1. obtain a doctor's order for the use of waist restraint...

Based on observation, interview and record review, the facility failed to ensure patient care areas were disinfected after use and in-between patients to mitigate transmission of infections and communicable diseases in the radiology department. This affected all patients receiving ultra sound services in the radiology department. Findings include:

During an observation and interview on 8/21/19 at 11:00 a.m., staff member A stated the radiology department used the green top PDI Sani-Cloth HB, to cleanse the probe of the ultrasound equipment in-between patients. The instructions on the wipes showed the surface area was to be kept wet for 10 minutes to provide disinfection of the surface. Staff member A stated she was unsure if she waited a full ten minutes or if the wipes remained wet the full ten minutes, during the disinfection process.

Review of the LOGIQ E9 user guide, for the ultrasound equipment, under probe handling and infection control showed adequate cleaning and disinfection were necessary to prevent disease transmission.

Review of the facility policy, with an approval date of July 2018, showed Cidex disinfectant was to be used in the ultrasound department. The policy showed all personnel would be trained in the safe use of Cidex for disinfection of the probes for use in ultrasound procedures.