HospitalInspections.org

The Hospital reported a census of 17 patients. Based on observation and staff interview the Hospital failed to protect medical records safe from fire or water damage for 74 boxes of medical records stored directly on the floor of a "shed".

Findings include:

- Observation on 2/8/12 at 10:45am of the inside of the "shed", a wood building next to the Health Information Management (HIM) building, revealed 74 boxes of purged, expired, and multi-volume medical records stored directly on the wooden floor. The entrance door of the "shed" once closed; revealed a gap, open to the outside, between the top of the door and the ceiling of the "shed" approximately two inches wide. A wall of the "shed" had closed and locked double doors that revealed a gap open to the outside, between the top of the door and the ceiling of the "shed" approximately one to one and a half inches wide.

Administrative staff A interviewed on 2/8/12 at 10:45am acknowledged the Hospital failed to store the medical records safe from fire or water damage.


25604

The Hospital reported a census of 17 patients. Based on medical staff By-Laws reviewed, policy review, medical record review and staff interview the Hospital failed to assure medical staff dated and/or timed all entries in the medical record for 21 of 36 sampled medical records (#'s 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 36).

Findings include:

- The Hospital's policy titled "Verbal Orders" reviewed on 2/8/12 at 1:00pm directed, "Verbal order must be signed, timed and dated by physicians within 24 hours."

- The Hospital's Medical Staff Rules and Regulations reviewed on 2/9/12 at 11:30am directed "...All clinical entries in the patient's medical record shall be legible, complete, dated, timed, and authenticated..."

- Patient #13's medical record reviewed on 2/7/12 revealed an admission date of 2/2/12 with a diagnosis of aspiration pneumonia. Patient #13's medical record revealed two progress notes and one physician order between 2/2/12 to 2/7/12 lacked a time when authenticated (signed). Patient #13's medical record revealed one telephone order on 2/14/12 lacked a date and time when authenticated.

- Patient #22's closed medical record reviewed on 2/8/12 revealed an admission date of 12/11/11 with diagnosis of weakness and dehydration. Patient #22's medical record revealed four progress notes and three physician orders between 12/11/11 to 12/14/11 lacked a time when authenticated (signed).

- Patient #23's closed medical record reviewed on 2/8/12 revealed an admission date of 11/1/11 with diagnoses of shortness of breath and anemia (low red blood count). Patient #23's medical record revealed five progress notes and five physician orders between 11/1/11 to 11/3/11 lacked a time when authenticated (signed). Patient #23's medical record revealed six verbal and/or telephone orders lacked a date and time the physician authenticated (signed) the orders.

- Patient #36's medical record reviewed on 2/8/12 revealed an admission date of 2/6/12 for a right total knee replacement surgical procedure. Patient #36's medical record revealed an admission pre operative order and an anesthesia pre, intra, and post operative orders between 2/6/12 to 2/8/12 lacked a time when authenticated (signed).

Administrative staff A interviewed on 2/8/12 at 10:15am acknowledged the medical records lacked a date and/or time the physician authenticated (signed) entries in the medical records.

This deficient practice also affected patient #'s 11, 12, 14, 15, 16, 17, 18, 20, 21, 24, 25, 26, 27, 28, 29, 30, and 31.


25604

The hospital reported a census of 17 patients. Based on observation, policy review, and staff interview the hospital failed to ensure maintenance of equipment in the dietary department in a manner to assure the safety of patients in one of one dietary department observation.

Findings include:

- The hospital's policy "Housekeeping/Cleaning of Food Prep Area" reviewed on 2/8/12 at 3:15pm directed "...To ensure food prep area is clean and sanitized in order to prevent the spread of bacteria by cross contamination..."

- Observation on 2/8/12 between 1:10pm and 2:45pm in the hospital kitchen revealed the following:
1. A steam cabinet with debris around the base and control switches.
2. A pan on the steam table shelf with dried food debris inside.
2. A flat grill with a build up of debris in corners and the grease drain.
3. Debris along the sides of two ovens and on the shelves above the ovens.
4. A commercial mixer with debris across the top where mixer paddles would
insert.

Staff C interviewed on 2/8/12 at 2:15pm acknowledged the need to clean the build up of debris on the steam cabinet base, grill top and drain, sides and shelves of two ovens, and mixer.

Administrative staff B interviewed on 2/8/12 at 2:50pm acknowledged the build up of debris on the steam cabinet, flat grill and drain, along the sides and shelves of the two ovens.

The hospital reported a census of 17 patients. Based on observation, policy review, and staff interview the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices for one of one observed cleaning of a discharged patient room, two of three operating room observations, one of one daily cleaning of a patient room, and one of one glucometer test observation.

Findings include:

- The hospital's "Infection Prevention and Control Program" reviewed on 2/9/12 at 11:30am directed "...The hospital will implement an infection prevention and control program to identify and minimize risks of acquiring and transmitting infection among patients, staff, visitors, and the community...To provide a framework for a comprehensive program of infection surveillance, prevention, and control..."

- Staff G interviewed on 2/8/12 at 1:20pm verified they were responsible for the management of the infection control program. The hospital infection control committee reviews policies and procedures and approves hospital wide cleaning products. Staff G acknowledged they did not have a comprehensive surveillance program with criteria for staff and environmental practices observing breaches in infection control in all areas of the hospital.

- Review of the manufacturer's guidelines for the use of the Virex 256 One-Step Disinfectant cleaner on 2/7/11 at 11:30am directed, "...To disinfect, all surfaces must remain wet for 10 minutes..."

- Review of the manufacturer's guidelines for use of Crew Bowl and Bathroom disinfectant cleaner on 2/7/12 at 11:30am directed, "...Remove water from bowl...pour 1 ounce of product onto applicator...scrub entire unit...wait 1 minute then flush..."

- Observation of staff D, staff E and staff F on 2/6/12 between 1:40pm and 2:15pm cleaning room 1 east, a discharged patient room, revealed the following breaches in infection control practices regarding disinfectant wet time per manufacturer's recommendation, hand hygiene and cleaning from dirty areas to a less dirty area. For example:

Staff F, wearing gloves, applied Virex 256 disinfection cleaner to the bed, pillows, IV pole, and chair. The surfaces remained wet between one to five minutes not the required 10 minutes for total disinfection.

Staff E, wearing gloves, applied Virex 256 disinfecting cleaner to the closet, cabinet, and bedside table. The surfaces remained wet for five minutes not the required 10 minutes for total disinfection.

Staff D poured an unmeasured amount of Crew Clinging Toilet Bowl cleaner in the toilet bowl without removing the water from the bowl. Staff D cleaned the outside of the toilet then cleaned the sink with the same cleaning cloth. Staff H failed to empty the toilet bowl of water or measure the amount of crew cleaner. Staff H moved from dirty to a less dirty area with the cleaning cloth used on the toilet then on the sink of the bathroom.

Staff D and staff F failed to perform hand hygiene when they completed the cleaning of room 1 east.

Staff D interviewed on 2/6/12 at 2:15pm acknowledged they moved from dirty to a less dirty area when they used a cleaning cloth on the toilet then on the bathroom sink. Staff D and staff F acknowledged cleaned surfaces in the room failed to remain wet 10 minutes for total disinfection and they failed to perform hand hygiene when they completed the cleaning of the room.

- Staff G, interviewed on 2/8/12 at 1:20pm, acknowledged the hospital's policy for hand hygiene failed to direct staff to perform hand hygiene before and after wearing gloves.

- Observation on 2/6/12 at 9:50am revealed staff D performing a daily cleaning of ICU Intensive Care Unit) room, bed three and four. Staff D with gloves on wiped the sink area in the patient room and bathroom, returned to the cleaning cart in the hall, retrieved a wet mop from the cleaning cart, mopped the floor in the nurse's charting area and part of the patient's room, returned the mop to the cleaning cart, removed the trash bag from the cleaning cart and walked down the hall with the trash bag. During this observation staff D failed to change their gloves and/or sanitize their hands when reentering the patient's room.

- Observation on 2/7/12 at 2:00pm revealed staff H performing a blood sugar test using a glucometer machine on patient #13. Staff H wearing gloves placed the glucometer case on the patient's bed, opened the case, removed the glucometer machine placing it on the patient's bed, and performed the blood sugar test. Staff H after performing the blood sugar test returned to the nurse's station, placed the glucometer case on a stand, wiped off the glucometer machine with an alcohol swab, placed the glucometer machine in the case and placed the case in a drawer in the stand. Staff H failed to clean the outside of the glucometer case before placing it in the drawer.

- Observation in the surgical suite room one on 2/8/12 at 10:35am revealed three open endotracheal tubes (a plastic tube used to assist a patient in breathing during surgery) ready for use, and one open Yankauer suction tip (a rigid hollow tube made of disposable plastic with a curve at the distal end to facilitate the removal of thick secretions during oral pharyngeal suctioning) ready for use. The package on the endotracheal tubes and Yankauer suction tip directed sterile unless opened or damaged.

- Observation in the surgical suite room four on 2/8/12 at 10:40am revealed two open endotracheal tubes ready for use. The package on the endotracheal tube directed sterile unless opened or damaged.

- Staff I interviewed on 2/8/12 between 10:35am and 10:40am acknowledged the open endotracheal tubes and Yankauer suction tip.