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Based on clinical record review and interview, it was determined the facility failed to ensure blood glucose, neurological status, and vital signs were checked as ordered by Physician for three (#7, #9, and #10) of 10 (#1-#10) inpatients. The failed practice did not assure all direct patient care staff were knowledgeable in the outcomes of blood glucose's, neurological checks and vital signs to provide ongoing continuity of care and to identify changes in the patient ' s health status; and could have affected any inpatient in the facility. Findings follow.

A. Review of the clinical record for Patient #7 revealed an order for blood glucose checks every 15 minutes starting 01/09/17 at 1756. There was no evidence of blood glucose checks from 01/09/17 at 1756 through 2102 and 01/09/17 at 2102 through the time the order was discontinued on 01/11/17 at 1557.
Findings were confirmed by the Quality Analyst during an interview on 01/13/17 at 0930.
B. Review of the clinical record of Patient #9 revealed:
1) An order on 01/09/17 at 1449 for neuro (neurological) checks every two hours. There was no evidence of neuro checks were performed for the following times:
a) 01/09/17 from 1449 through 01/10/17 at 0230,
b) 01/10/17 from 0638 to 1039, 1112 to 1500, 1500 to 1900, and 1900-2319
c) 01/11/17 from 0000 to 0318, 0318 to 0705, 1530 to 1910, and 1910 to 2313
d) 01/12/17 from 0000 to 0700, 0700 to 1100, 1100 to 1500, 1500 to 1900, and 1900 to 2329
e) 01/13/17 from 0000 to 0329 and 0329 to 0700
2) An order on 01/09/17 at 1449 for vital signs every hour. There was no evidence of vital signs for the following times.
a) 01/09/17 from 1449 to 01/10/17 at 0230
b) 01/10/17 from 0330 to 0500, 1729 to 1900, and 1900 to 2100
c) 01/11/17 from 0100 to 0705, 0705 to 0923, 0923 to 1128, 1128 to 1313, 1313 to 1530, 1530 to 1900, 1910 to 2100, and 2100 to 2300
d) 01/12/17 from 0000 to 0700, 0900 to 1100, 1100 to 1300, 1316 to 1500, 1500 to 1700, 1700 to 1900, and 1900 to 2100.
e) 01/13/17 from 0000 to 0700
3) Findings for Patient #9 in 1) and 2) were confirmed by the Quality Analyst during an interview on 01/13/17 at 0950.
C. Review of the clinical record of Patient #10 revealed:
1) An order on 01/09/17 at 1135 for neuro checks every two hours for one day, and an order on 01/07/17 at 1253 for neuro checks every six hours. There was no evidence of neuro checks for the following times:
a) 01/08/17 from 0700 to 1915, and from 1915 on 01/08/17 through 0933 on 01/09/17
b) 01/09/17 from 1315 to 1900, and 1900 to 2300
c) 01/10/17 from 0300 to 0700, 0900 to 1308, and from 1717 on 01/10/17 through 0701 on 01/11/17
d) 01/11/17 from 0701 to 1725, and from 1725 on 01/11/17 through 0810 on 01/12/17
e) 01/12/17 from 0810 to 1854, and from 1854 on 01/12/17 through 0700 on 01/13/17
2) An order for blood pressure checks for 24 hours beginning on 01/07/17 at 2112. Blood pressure was not checked during the following times:
a) From the start of the order on 01/07/17 at 2112 through 01/08/17 at 0203
b) 01/08/17 from 0203 to 0505, and 0658 to 1000
3)Findings for Patient #10 in 1) and 2) were confirmed by the Quality Analyst during an interview on 01/13/17 at 0920.

Based on review of Pharmacy Policy #PH7.14, review of monthly Medication Area Inspections for year 2016, and interview, the facility failed to ensure 7 (Sleep Unit, Pediatrics, Obstetrics/Nursery, Critical Care Unit, Surgery, Post Anesthesia Care Unit, Cath Lab) of 18 (Sleep Unit, Pediatrics, Obstetrics/Nursery, Critical Care Unit, Surgery, Post Anesthesia Care Unit, Cath Lab, 5th Floor Nursing Unit, Outpatient Unit, Transition Unit, Heart Station, Emergency Department, Cardiac Unit, Wound Unit, Rehabilitation Unit, Psychiatric Unit, Radiology, Magnetic Resonance Imaging Unit) areas maintaining medications were monitored monthly as required by hospital policy to ensure proper control of medications. The potential existed for medication not to be stored according to manufacturer/hospital guidelines as well as expired medications to be present for patient use and could affect all patients. Findings follow:

A. Pharmacy Policy #PH7.14 was reviewed on 01/09/17 at 1330. The policy stated "All drug storage areas in the hospital will be inspected monthly by a pharmacist responsible for the area."
B. The monthly Medication Area Inspections for 2016 were reviewed on 01/09/17 at 1415. Following were the number of months for seven units in which monthly medication areas were not monitored:
1) Sleep Unit-five months;
2) Pediatrics-seven months;
3) Obstetrics/Nursery-four months;
4) Critical Care Unit-seven months;
5) Surgery-three months;
6) Post Anesthesia Care Unit-one month; and
7) Cath Lab-three months.
C. The Director of Pharmacy was interviewed on 01/10/17 at 1345 in which the findings were verified.

Based on review of American Society of Health-System Pharmacist (ASHP) standard of practice for labeling, observation, and interview, the facility failed to ensure labels on medications prepared for intravenous (IV) administration by Pharmacy personnel reflected the identification of the responsible compounding individual. The deficient practice was observed on IV medications prepared by Pharmacy personnel and sent to three (Cardiac Care Unit, 4th Floor Nursing Unit, 5th Floor Nursing Unit) of seven (Cardiac Care Unit, 4th Floor Nursing Unit, 5th Floor Nursing Unit, Rehabilitation Unit, Pediatrics, Emergency Department, Surgery) patient areas toured. The potential existed for patient safety to be affected since there was no accountability of Pharmacists and/or Pharmacy Technicians who prepared and/or checked prepared IV medications. The deficient practice affected seven patients and had the potential to affect all patients receiving IV medications prepared in the Pharmacy. Findings follow:

A. A tour of the facility was conducted on 01/11/17 between 0920 and 1330. Intravenous medications were observed for seven patients in three patient care areas in which the labels did not reflect the Pharmacy personnel who prepared and/or checked the preparation of the medications. Finding follow for the IV medications reflecting this deficient practice:
1) Cardiac Care Unit
a) Patient #1-Three IV preparations of Doribax 500 milligrams (mg); and
b) Patient #2-Three IV preparations of Vancomycin 1250 mg.
2) 4th Floor Nursing Unit
a) Patient #3-Three IV preparations of Unasyn 1.5 grams;
3) 5th Floor Nursing Unit
a) Patient #4-Three IV preparations of Vancomycin 1250 mg;
b) Patient #5-One IV preparation containing Magnesium Sulfate, Thiamine, Multivitamin, Folic
Acid;
c) Patient #6-Two IV preparations of Gentamycin 80 mg; and
d) Patient #7-Two IV preparations of Vancomycin 1250 mg.
B. The ASHP standard of practice for labeling of IV medications was reviewed on 01/11/17 at 1340. The standard stated the identification of individuals preparing IV medications should be reflected on the label.
C. An interview was conducted with the Director of Pharmacy on 01/11/17 at 1330 in which the observations were verified. The interview also revealed labels of IV medications prepared in the Pharmacy should reflect the identification of Pharmacy personnel preparing and/or checking the preparation of the medications.

Based on observation, interview and review of manufacturer's instructions for blood glucose control testing, it was determined the facility failed to assure two of two (Level 1 and Level 2) expired control solutions were not used to determine if the point of care blood glucose testing device was performing accurately for one of one control testing procedure observed. Accurate assessment of patient blood glucose results could not be assured and was likely to affect any patient who had the device was used to determine blood glucose results. The findings were:

A. Observation on 01/12/17 at 1055 revealed Registered Nurse (RN) #2 performed quality control checks for a blood glucose machine. The Level 1 and Level 2 quality control solutions had a white label attached to each that read "Exp 01/31/16." The solution expiration date as written 01/31/16 was confirmed by RN #2 and the Infection Control Nurse at the time of observation.
B. Review of the manufacturer's instructions for control testing of the Accu-Chek blood glucose device on 01/13/17 revealed "Testing control solutions with known glucose levels establishes that the operator and the system are performing acceptably. Control results must be within the defined acceptable ranges before valid patient testing is allowed. Note: Write the date the bottle was opened on the bottle label. The control solution is stable for three months from that date or until the "use by" date on the bottle label, whichever comes first."

Based on observation, interview, review of Environmental Services (ES) contract personnel files and review of policies and procedures, it was determined the Infection Control Officer failed to identify and prevent likely sources of infection in that two of two contract staff (ES Employee #1 and #2) observed did not perform cleaning and disinfection for one of one operating room (OR #2) observed in accordance with facility policy; and failed to assure five of five (#1-#5) contract staff were trained in processes for cleaning and disinfection in the surgical areas. The failed practice did not assure all surgical patients would be protected from likely sources of infection. The findings were:

A. Observation on 01/10/17 at 1135 revealed ES Employee #1 mopped Operating Room #2 between surgical procedures. ES Employee #1 began mopping at the operating room table (dirty) and proceeded outward toward the periphery (clean) area of the operating room and back toward the operating room table. The sequence was repeated over the entire surface of the floor. The OR table was not moved for mopping the floor space underneath the table.
B. The Surgical Services Director was interviewed on 01/10/17 at 1148 and confirmed the findings in A.
C. Observation of Terminal Cleaning process with the Infection Control Nurse on 01/10/17 at 1516 of OR #2 revealed ES Employee #2 cleaned and disinfected equipment from top (clean) to bottom (dirty) and back again. Examples include cleaning the IV (intravenous) pole on the bottom and then the wheels and then the pole itself; then proceeded to clean the monitor and lines for anesthesia cart, and pulse oximeter probes with the same cloth. Wiped the trash can lid, then the chair, suction canister and tubing, infectious waste receptacle, all top to bottom and bottom to top. OR #2 was mopped from the peripheral area of the room toward the center where the OR table was located. The front of the red cart in OR #2 was not cleaned during the terminal cleaning procedures. The top drawer of the cart had a paper type card taped to the outer surface. This was not removed for cleaning purposes. The corner of the wall, adjacent to the fire extinguisher was observed with a chipped area and revealed the plaster beneath. Tape was observed on the wall of OR #2 that secured the warming cabinet thermometer to the wall and was not removed when the walls were cleaned. The Infection Control Nurse confirmed the findings at the time of observation.
D. Review of facility policy #MOR4023 revealed the statement "Operating rooms will be cleaned after every surgical procedure. All flat surfaces are cleaned by spraying approved germicidal detergent solution onto a dampened wet towel or onto the surface and wiping it off with dry disposable wipes. Flat table surfaces are cleaned first. Table wheels are cleaned by rolling the table over floor cleaning solution. The cleaning sequence is from the periphery of the room to the center of the room. The area cleaned is that which has contained the operating team (approximately three feet around the table). The OR table is moved to allow cleaning underneath."
E. Review of five of five ES contract staff files identified by the Safety Officer as those assigned to surgical services on 01/11/17 and 01/13/17 revealed no evidence of specific training or competency assessment for cleaning of Surgical Services and Labor and Delivery Cesarean Section rooms. Job duties included "Cleans Labor and Delivery after delivery procedures. Cleans in Surgery when Surgery Housekeeping is absent." The Safety Officer and Chief Nursing Officer confirmed the lack of training documentation for the specialty areas of surgery and labor and delivery on 01/13/17.


Based on observation, interview and review of facility policy for indwelling urinary catheter, it was determined the facility Infection Control Officer failed to assure one of one (Patient #31) indwelling urinary catheter observed was maintained (urinary bag was placed on the floor) to prevent likely sources of infection and in accordance with facility policy and procedure. Failure to hand the indwelling urinary catheter on the bed frame affected Patient #31 and was likely to affect any patient who had an indwelling urinary catheter. The findings were:

A. Observation on 01/12/17 from 1005-1032 revealed Patient #31 had an indwelling urinary catheter placed while on the delivery table in Delivery Room #1 by Registered Nurse #1. The urinary catheter bag was allowed to rest on the floor beside the delivery table and the patient was draped and the cesarean section was started. The Infection Control Nurse confirmed the observation of the urinary catheter bag placement on the floor on 01/12/17 at 1025.
B. Review of policy #F-5, "Foley Catheter Insertion, Maintenance, Specimen Collection and UTI (urinary tract infection) Prevention" on 01/12/17 revealed "Hang urine receptacle on bed frame, ensuring that tubing does not lie below collection bag or underneath legs." Also for "Maintaining the Foley: Keep drainage bag below the level of the bladder and off the floor."


Based on observation, review of policies and procedures and interview, it was determined the Infection Control Officer failed to prevent likely sources of infection in that single use items were not disposed of after opening (Delivery Room #2, Operating Room (OR) #2, and Gastrointestinal (GI) Room C); soiled instruments were not covered for transport to the (OR #6); and surfaces were not free from rust and tape (Surgical Services). The failed practice did not protect patients from likely sources of infection and was likely to affect all patients treated at the facility. The findings were:

A. Yankauer Suction
1) Observation on 01/12/17 at 1045 revealed one open Yankauer suction attached to suction tubing in one (#2) of two delivery rooms. The package revealed the suction was single use only and sterile unless opened. The finding were confirmed at the time of observation by the Infection Control Nurse.
2) Observation on 01/10/17 at 1600 of OR #2 revealed 2 of 3 Yankauer suction open and attached to suction tubing. the package revealed the suction was single use only and sterile unless opened. The findings were confirmed at the time of observation by the Infection Control Nurse.
3) Observation on 01/13/17 at 1137 of GI (gastrointestinal) room C revealed one Yankauer suction open and attached to suction tubing. The package reveled the suction was single use only and sterile unless opened. The findings were confirmed at the time of observation by the Infection Control Nurse.
B. Transportation of Instruments
1) Observation in OR #6 on 01/10/17 at 1136 revealed surgical instruments that were opened for the surgical procedure but not used were placed in an open tray and placed on top of an enclosed bin with soiled instruments The opened tray was not covered before transport to the soiled instrument processing area.
2) The Surgical Services Director confirmed the opened but not used instruments were transported uncovered and on top of the cart on 01/10/17 at 1200.
3) In an interview with the Central Sterile Manager on 01/10/17 at 1510 she stated "No. They do not cover the opened but not used instruments. They put them in a tray on top of the soiled instruments and bring them to us."
4) Review of policy #MOR0058 revealed "Instruments which were not used for the case must also be cleaned and decontaminate prior to reprocessing. To expedite clean-up these instruments may be placed in an instrument tray, covered and taken to the soiled utility room."
C. Observation of the inner core of Surgery Services Department on 01/10/17 at 1042 with the Surgical Services Director revealed a cart outside OR #6. The cart included
a sandbag that was used for positioning that had cracks in the vinyl surface which was covered with tape. The findings were confirmed by the Surgical Services Director at the time of observation. The failed practice did not allow for cleaning/and disinfection prior to the next patient's use.
D. Observation on 01/10/17 at 1200 revealed a leg holder, a cloth type material visibly soiled and discolored that remained attached to OR #6's table after the room was cleaned in preparation for the next patient. The Director of Surgical Services confirmed at the time of observation the leg holder was reused but was unable to produce manufacturer's instructions or packaging to assure it was reusable or to provide manufacturer's instructions for cleaning.
E. Observation on 01/10/17 at 1505 of the Instrument Reprocessing Room revealed an area on the front of the cabinets used for precleaning instruments had pealed paint with rust, that created an irregular surface in which bacteria could accumulate. There were three separate areas on the cabinet. The findings were confirmed by the Central Sterile Manager at the time of observation.

Based on review of Policy and Procedure Manuals and interview, it was determined the facility failed to provide a policy and procedure to describe the criteria for patient discharge from the Post Anesthesia Care Unit (PACU). Failure to provide a policy which identified the PACU's discharge criteria did not assure patients had recovered from anesthesia prior to discharge. The failed practice was likely to affect all patients admitted to the facility for surgical procedures. Findings follow:

A. Review of Nursing Policy and Procedures on 01/10/17 at 1400 revealed no evidence of a policy defining PACU's patient discharge criteria.
B. Findings in A were verified by interview with the Surgical Services Director on 01/11/17 at 1338.

Based on clinical record review, review of Medical Staff Rules and interview, it was determined the facility failed to assure Operative Reports included the time of surgery in 9 of 9 (#7 and #13-#20) surgical records. Failure to assure the time a surgical procedure took place did not establish a time-line of surgical events in the course of a patient's admission to the facility. The failed practice was likely to affect all surgical patients admitted to the facility. Findings follow:

A. Clinical record review was conducted on 01/12/17 from 1310-1530 and 01/13/17 from 0845-1245 and revealed the following:
1) Operative Report dated 12/30/16 for Patient #13 revealed no evidence of the time of the surgical procedure.
2) Operative Report dated 12/27/16 for Patient #14 revealed no evidence of the time of the surgical procedure.
3) Operative Report dated 12/28/16 for Patient #15 revealed no evidence of the time of the surgical procedure.
4) Operative Report dated 12/29/16 for Patient #16 revealed no evidence of the time of the surgical procedure.
5) Operative Report dated 12/25/16 for Patient #17 revealed no evidence of the time of the surgical procedure.
6) Operative Report dated 12/24/16 for Patient #18 revealed no evidence of the time of the surgical procedure.
7) Operative Report dated 12/28/16 for Patient #19 revealed no evidence of the time of the surgical procedure.
8) Operative Report dated 12/30/16 for Patient #20 revealed no evidence of the time of the surgical procedure.
9) Operative Report dated 01/09/17 for Patient #7 revealed no evidence of the time of the surgical procedure.
B. Review of Medical Staff Rules Page 107 #12.7.1.2 and 12.7.1.2.2 on 01/10/17 at 1300 revealed "An operative report containing at least the following: date and times of the surgery or procedure"
C. Findings in A were verified at time of the clinical record review by Clinical Informaticist #1 for Patient #13-#20 and Quality Analyst for Patient #7.

Based on review of Anesthesia Policy and Procedure Manuals, clinical record review and interview, it was determined the facility failed to assure a post anesthesia evaluation was completed for 8 (#7, #13 and #15-#20) of 9 (#7 and #13-#20) surgical procedures. Failure to complete the post anesthesia evaluation did not assure patients had been assessed for the absence or presence of anesthesia related complications and was likely to affect all patients admitted to the facility for surgical procedures. Findings follow:

A. Clinical record review was conducted on 01/12/17 from 1310-1530 and 01/13/17 from 0845-1245 and revealed the following:
1) Anesthesia Record dated 12/30/16 for Patient #13 revealed no evidence of a post anesthesia evaluation within 24-72 hours.
2) Anesthesia Record dated 12/28/16 for Patient #15 revealed no evidence of a post anesthesia evaluation within 24-72 hours.
3) Anesthesia Record dated 12/29/16 for Patient #16 revealed no evidence of a post anesthesia evaluation within 24-72 hours
4) Anesthesia Record dated 12/23/16 for Patient #17 revealed no evidence of a post anesthesia evaluation within 24-72 hours.
5) Anesthesia Record dated 12/24/16 for Patient #18 revealed no evidence of a post anesthesia evaluation within 24-72 hours.
6) Anesthesia Record dated 12/28/16 for Patient #19 revealed no evidence of a post anesthesia evaluation within 24-72 hours.
7) Anesthesia Record dated 12/30/16 for Patient #20 revealed no evidence of a post anesthesia evaluation within 24-72 hours.
8) Anesthesia Record dated 01/09/17 for Patient #7 revealed no evidence of a post anesthesia evaluation within 24-72 hours.
B. Review of Anesthesia Policy and Procedure Manual on 01/10/17 at 1500 revealed "Area: Anesthesia-Policy #028: At least one post-anesthetic visit will be recorded, within 24-72 hours, describing the presence or absence of anesthesia related complications."
C. Findings in A were verified at time of clinical record review by Clinical Informaticist #1 for Patient #13 and Patient #15-#20 and Quality Analyst for Patient #7.