HospitalInspections.org

Based on observation, policy review and staff interview, it was determined that the hospital failed to ensure patient medical record confidentiality for 28 of 123 patients (Patient #'s 9, 106, 107, 108 and 110 - 133) in the sample. Findings include:

The hospital policy entitled "Information Security - Computer Workstation Use and Security" stated, "...User Responsibilities...Secure laptops when used in public, semi-public, or physically unsecured area...Position the screen away from unauthorized users...Unacceptable workstation use includes...Leaving private or confidential information out in the open or unsecured..."

The hospital policy entitled "Privacy & Information Security- A Master Policy on Privacy" stated,"...Individually Identifiable Health Information...that relates to...present...physical condition of an individual; the provision of health care to an individual...De-identified health information cannot contain the following elements...Names...birth date...Medical record numbers..."

The following issues related to patient confidentiality were identified during observations at Christiana Hospital:

A. Emergency Department (ED)

1. 1/6/14 at 10:55 AM (Core B)
One (1) desk top computer was observed:
- unlocked and unmanned
- the computer screen, visible to the general public, contained Patient #133's personal and medical information

Director of Clinical Operations A, present at the time of discovery, confirmed this finding on 1/6/14 at 10:55 AM.

2. 1/6/14 at 11:54 AM (Core E)
One (1) medical record label sheet was observed:
- lying unattended, face up, on a table top in the thoroughfare
- the label sheet contained Patient #108's name, birth date, age, medical record number

Patient Care Services Director B, present at the time of discovery, confirmed this finding on 1/6/14 at 11:55 AM.

B. Medical Intensive Care Unit (MICU)
1. 1/6/14 at 2:55 PM
One (1) "Respiratory Orderlist with Labs..." containing physician orders for respiratory treatments was observed:
- unattended on the top of a mobile respiratory medication cart located at the entrance to the MICU corridor
- the document contained names, birth dates, ages, diagnoses, physician names, lab results, physician orders and medical record numbers for Patient #'s 9 and 110 - 127

Patient Care Services Director B, present at the time of discovery, confirmed this finding on 1/6/14 at 2:55 PM.

C. Labor and Delivery

1. 1/7/14 at 2:50 PM
One (1) work station on wheels (computer) was observed:
- unlocked and unmanned
- the computer screen, which was facing the general public, contained personal and medical information belonging to Patient #107

Interview with Assistant Nurse Manager B on 1/7/14 at 2:55 PM confirmed this finding.

D. Unit 5E
1. 1/9/14 at 4:00 PMFour (4) mobile medication cart computer screens were observed:
- unlocked and unmanned
- the carts/screens, located in the main corridor, contained patient information belonging to Patient #'s 129, 130, 131 and 132

Patient Care Coordinator B, present at the time of discovery, confirmed this finding on 1/9/14 at 4:00 PM.

E. Unit 4A

1. 1/9/14 at 2:05 PM
One (1) medical record was observed:
- on the ledge of the central area desk, visible to unauthorized individuals
- the medical record contained Patient #106's first and last names

Nurse Manager A and Assistant Nurse Manager A, present at the time of discovery, confirmed this finding on 1/9/14 at 2:05 PM.

F. Unit 6E

1. 1/10/14 at 9:43 AM
One (1) medical record was observed:
- unattended on the ledge of the nurse's desk, visible to unauthorized individuals
- the medical record contained Patient #128's first and last names

Patient Care Services Director D, present at the time of discovery, confirmed this finding on 1/10/14 at 9:43 AM.

Based on medical record review, review of hospital documents and staff interview, it was determined that the registered nurse (RN) failed to assess 1 of 1 patients (Patient #14) in the sample who had received dialysis treatment at Christiana Hospital. Findings included:

The hospital document entitled "Standards of Nursing Practice" stated, "...The Department of Nursing relies on standards of care (Clinical Practice Guidelines) and standards of professional nursing practice to guide nursing care...Ongoing evaluations...determined by the patient's response to care, or significant change in patient's condition..."

The Clinical Practice Guideline entitled "Hemodialysis: General Guidelines" stated, "...Pre-dialysis...Total physical assessment of patient...When providing hemodialysis treatment...the frequency of monitoring, assessment, and documentation should be every 15 minutes..."

A. Review of Patient #14's "Interdisciplinary Patient Progress Record" dated 1/4/14 at 12:45 PM revealed:
- dialysis treatment was started, and then ended early due to excessive bleeding at the insertion sites of the dialysis needles (right upper arm)
- the dialysis needles were removed from the patient's arm and a pressure dressing was applied to the needle insertion sites for 20 - 25 minutes

There was no evidence that the RN assessed Patient #14 prior to dialysis and during dialysis.

On 1/16/14 at 9:45 AM, Patient Safety Director A and Staff Education Specialist A confirmed this finding.

Based on medical record review, policy review and staff interview, it was determined that for 3 of 84 patients (Patient #'s 22, 80 and 81) in the sample that required a plan of care, staff failed to develop and/or revise the plan of care to reflect current needs. Findings include:

The hospital policy entitled "Standards of Nursing Practice" stated, "...Care is planned in a collaborative interdisciplinary manner, including the patient and the family in response to identified current needs and based on desired outcomes. The plan provides for continuity of care, and establishment of priorities for care. Planning includes...Identification of the patient's current active and potential problems from information gathered in the assessment...development of a written, individualized, plan of care...Implementation of the plan of care is necessary to achieve desired outcomes...The RN (registered nurse) reviews & documents the appropriateness and completeness of the plan of care at least once each 24 hours..."

Christiana Hospital

A. Patient #22 (Unit 4E Cardiovascular Stepdown)

Review of the medical record revealed:

1. "Arrival Information", dated 1/5/14, reported the "Stated Reason for Admission" was "...SOB (short of breath)..."

2. "H&P" (History and Physical), dated 1/5/14
- "...patient...with chronic condition of O2 (oxygen) dependent...developed...increasing shortness of breath...difficulty breathing and coughing..."

3. Physician "Orders" dated 1/5/14 included:
- Non-Invasive Ventilation (BIPAP - bilevel positive airway pressure, a pressure controlled ventilation system)
- Pulmonary (lung) physician consultation
- Oxygen to be administered via nasal cannula to maintain an oxygen saturation level greater than 90%
- "new respiratory medication orders" which included intravenous steroid (anti-inflammatory), respiratory inhalers and nebulizers (breathing treatments)

4. Plan of Care
- failed to address Patient #22's impaired breathing issues

On 1/8/14 at 4:15 PM, RN F confirmed that a plan of care failed to address Patient #22's impaired breathing issues.

B. Patient #80 (Cardiovascular Short Stay Unit)

Review of the medical record revealed:

1. "Intake and Interdisciplinary Record", dated 1/12/14
- chief complaint documented as "arm and jaw pain"

2. "Medication Administration Record ", dated 1/12/14
- pain medication administered at 8:52 PM

3. "Assessment Patient Care Flowsheet" dated 1/13/14 - assessment revealed complaints of body wide aches and chills at 4:20 AM

4. "History and Physical", dated 1/13/14
- physician documented "Left arm pain" on the "Problem List"

5. "Medication Administration Record", dated 1/13/14
- pain medication administered at 4:21 AM and 6:26 AM

6. Plan of Care
- failed to address pain management

Interview with Nurse Manager C on 1/13/14 at 10:25 AM confirmed this finding.

C. Patient #81 (Cardiovascular Short Stay Unit)

Review of the medical record revealed:
1. "Problems and Diagnoses", dated 1/12/14
- included diabetes (condition with high levels of sugar in the blood) as an active problem

2. "PowerChart (an electronic medical record)...Glycemic (measure of blood sugar)" documentation
- physician ordered blood glucose (sugar) testing before meals and at bedtime
- blood glucose levels were elevated at the following dates and times:

1/12/14 at 7:45 AM
1/12/14 at 11:50 AM
1/12/14 at 4:44 PM
1/12/14 at 10:18 PM
1/13/14 at 5:50 AM

3. Plan of Care
- failed to address high blood sugar management

Interview with Nurse Manager C on 1/13/14 at 11:00 AM confirmed this finding.

Based on medical record review, policy review and staff interview, it was determined that the hospital failed to include information necessary to monitor 1 of 1 patients in the sample (Patient #14) that received dialysis treatment. Findings include:

The hospital policy entitled "Documentation in the Medical Record" stated, "...It is the policy...that documentation in the medical record...Be standardized as a communication tool among patient care providers for planning and implementing care...support decision making..."

The hospital document entitled "Hemodialysis, arteriovenous (AV) access" stated, "...Documentation...Record the time the treatment began...predialysis assessment data and vital signs...Record the time the treatment was completed..."

The hospital document entitled "Hemodialysis: General Guidelines" stated, "...The information obtained from monitoring a patient will be documented on the Hemodialysis Treatment Record..."

Review of Patient #14's "Interdisciplinary Patient Progress Record" dated 1/4/14 at 12:45 PM revealed the following:
1. dialysis treatment was started, and then ended early due to excessive bleeding at the insertion sites of the dialysis needles (right upper arm)
2. dialysis treatment ended, pressure applied to needle insertion sites about 20 - 25 minutes to control bleeding
3. physician notified

The medical record failed to contain evidence of the following documentation for the 1/4/14 hemodialysis treatment:
- time dialysis treatment began
- pre-dialysis assessment data and vital signs
- "Hemodialysis Treatment Record"

Interview with Patient Safety Director A and Staff Education Specialist A on 1/16/14 at 9:45 AM confirmed these findings.

Based on observation, policy review and staff interview, it was determined that staff failed to ensure that 11 of 55 medication carts or individual medication and supply drawers were locked when not in use. Findings include:

The hospital policy entitled "Medication Administration" stated, "...Security...Medication and supply drawers will be kept locked except when in use..."

A. Environmental tours - Christiana Hospital

1/7/14

9:33 AM: Unit 4D
- 1 of 7 medication carts was observed to be unattended and unsecured

Interview with Nurse Manager G and Director of Facilities Engineering A, present at the time of discovery, confirmed this finding on 1/7/14 at 9:33 AM.

11:30 AM: Unit 3D
- 1 of 12 medication carts was observed to be unattended and unsecured

Interview with Patient Care Coordinator A and Director of Facilities Engineering A, present at the time of discovery, confirmed this finding on 1/7/14 at 11:30 AM.

1/8/14

11:40 AM: Unit 6C
- 1 of 6 medication carts was observed to be unattended and unsecured

Interview with Nurse Manager F and Assistant Chief Nursing Officer A, present at the time of discovery, confirmed these findings on 1/8/14 at 11:40 AM.

1/10/14

3:25 PM: Unit 2C
- 1 of 6 medication carts was observed to be unattended and unsecured

Interview with Unit Clerk A, present at the time of discovery, confirmed this finding on 1/10/14 at 3:25 PM.

B. Environmental tours - Wilmington Hospital

1/14/14

10:33 AM: Joint Center
- 1 of 10 medication carts was observed to be unattended and unsecured

Interview with Nurse Manager E, present at the time of discovery, confirmed this finding on 1/14/14 at 10:33 AM.

2:26 PM - 2:29 PM: Unit 4 North - District 3
- 3 of 3 medication carts were observed to be unattended and unsecured

Interview with Patient Care Services Director A, present at the time of discovery, confirmed these findings on 1/14/14 at 2:29 PM.

2:32 PM - 2:34 PM: Unit 4 West - District 3
- 2 of 6 medication carts were observed to be unattended and unsecured

Interview with Patient Care Services Director A, present at the time of discovery, confirmed these findings on 1/14/14 at 2:34 PM.

1/15/14

1:00 PM: Unit 5 North
- 1 of 5 medication carts was observed to be unattended and unsecured

Interview with Registered Nurse L, present at the time of discovery, confirmed this finding on 1/15/14 at 1:00 PM.

Based on observation, staff interview and policy review, it was determined that the hospital failed to control the availability of outdated/unusable drugs on 2 of 15 patient care units at Wilmington Hospital. Findings include:

The hospital policy entitled "Outdated/overstock drugs for credit" stated, "...Outdated/overstock drugs should be sent to the pharmacy storeroom by the nursing units and pharmacy satellites..."

The hospital policy entitled "Pharmacy pick up and Delivery Service to the Nursing Units" stated, "...Refrigerator Checks...All drugs with expired dates are to be removed..."

The hospital policy entitled "Multi-Dose Medication Vials" stated, "...Multi-dose vials containing preservatives (including insulin vials) require an expiration date and can be used: Until the 28th day after opening, then discarded unless otherwise specified by the manufacturer..."

A. Emergency Department (ED)

On 1/7/14 between 8:15 AM and 11:42 AM, Chief Nursing Officer A, Patient Safety Manager A and Nurse Manager D accompanied the surveyor on a tour of the ED. The following medications were found to be expired/unusable and were acknowledged/confirmed by Nurse Manager D, at the time of discovery:
1. ED Triage Area at 8:15 AM
- Hepatitis A vaccine - 2 vaccine doses/syringes, 1 milliliter (ml) each dose - Expired 10/13/13

2. ED Core A at 11:42 AM
- Hepatitis A Vaccine - 2 vaccine doses/syringes 1 ml each dose - Expired "OCT 2013"
- Integrilin (Registered Brand Name for the medication eptifibatide) 100 ml (single use) vial - Expired 10/13/13

B. Intensive Care Unit (ICU)

On 1/7/14, between 4:32 PM and 5:20 PM, Chief Nursing Officer A, Patient Safety Manager A and Clinical Nurse Specialist A accompanied the surveyor on a tour of the ICU. The following medications were found to be expired/unusable, and were acknowledged/confirmed by Clinical Nurse Specialist A and Patient Safety Manager A, at 5:20 PM:

- 2 vials Humulin R (a type of injectable insulin) - opened and dated 12/3/13
- 1 vial Lantus (a type of injectable insulin) - opened and unlabeled

Based on observation and staff interview, it was determined that the hospital failed to maintain the building in a manner to ensure the safety for 944 of 944 inpatients and for 4 of 8 off-campus designated provider-based entities. The hospital failed to meet the applicable provisions of the 2000 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (see the attached CMS-2567s referencing LSC deficiencies).

Based on observation, staff interview and policy review, it was determined that the hospital failed to maintain environmental surface cleanliness in a manner to assure patient safety in 12 of 70 patient care/support areas toured during the survey. Findings include:

The hospital policy entitled "Infection Prevention Policy" stated, "Environmental Services Department's Infection Prevention Policy is intended to minimize the risk of infections in patients and employees by adherence to...procedures as outlined...in the...Department Policy Manual..."

The Environmental Services/Infection Prevention Department policy entitled "Standard 10-Step Cleaning Procedure" stated, "...Sanitize all horizontal surfaces: Using a cleaning rag...wipe high touch surfaces with the hospital approved disinfectant solution. Spot clean walls, doors, partitions and glass...using a germicidal solution..."

The hospital policy entitled "Environmental Rounds of Patient Care Areas" stated, "...To ensure that patient care areas are properly maintained...Maintenance personnel inspect patient care areas on an annual basis..."

During tours conducted 1/6 - 1/10 and 1/13 - 1/15/14, the following was observed:

I. Christiana Hospital

A. 1/6/14
11:00 AM: Emergency Department Core D
- one (1) soiled undersink cabinet with improper storage of equipment

This finding was confirmed at 11:00 AM on 1/6/14 by Director Clinical Operations A and Director Patient Care Services B.

11:43 AM: Unit 6B
- tape and stickers on 2 medication refrigerators
2:53 PM: Unit 5E
- power pack for an automatic faucet extremely dusty

These findings were confirmed at 2:53 PM on 1/6/14 by Director of Environmental Services A.

B. 1/7/14
10:39 AM: Unit 3E
- tape and tape residue on one (1) medication refrigerator

This finding was confirmed at 10:39 AM on 1/7/14 by Director of Environmental Services A.

C. 1/10/14
8:50 AM: Christiana Care Surgery Center - Operating Room (OR) #7
- split flooring, uncleanable

This finding was confirmed at 8:50 AM on 1/10/14 by Nurse Manager H.

II. Riverside Health Center - Wound Care

A. 1/10/14
11:58 AM: Exam Room 5
- damaged wall surface adjacent to door
12:00 PM: Exam Room 6
- drywall damage at wall socket near the window
12:15 PM: Waiting Room
- wall damaged behind chairs (wall with glass blocks)

These findings were confirmed at 12:15 PM on 1/10/14 by registered nurse (RN) O.

III. Roxana Cannon Arsht Surgicenter

A. 1/10/14
2:15 PM: OR #5
- tape residue on OR table
2:20 PM: OR #2
- tape residue on OR table

These findings were confirmed at 2:20 PM on 1/10/14 by Nurse Manager I.

IV. Springside Plaza - Christiana Care Rehabilitation Services

A. 1/13/14
10:25 AM: Physical Therapy Treatment Room 6
- damaged drywall at end of treatment table
10:48 AM: Pediatric Speech Room 1
- damaged laminate on wall mounted table
10:50 AM: Pediatric Speech Rooms 2 and 3
- damaged dry wall
11:23 AM: Patient training kitchen
- interior of oven very dirty with food spatters

These findings were confirmed at 11:25 AM on 1/13/14 by Director of Rehabilitation Services A and Occupational Therapist Site Manager A.

V. Wilmington Hospital

A. 1/13/14
2:05 PM: Post Anesthesia Care Unit
- tape residue and tape pieces on outside of blanket warmer

This finding was confirmed on 1/13/14 at 2:05 PM by Nurse Manager J.

B. 1/14/14
1:30 PM: Patient Room #3N06
- 23 cracked floor tiles
- bump under one tile near the door

This finding was confirmed at 1:30 PM on 1/14/14 by Corporate Director of Facilities Engineering A.

2:30 PM: Oral and Maxillofacial Surgery and Dentistry - Exam Room 7
- counter top laminate damage

This finding was confirmed at 2:30 PM on 1/14/14 by Corporate Director of Facilities Engineering A.

C. 1/15/14
1:20 PM: Unit 5 North
- hard water deposit build up on ice machine

This finding was confirmed at 1:20 PM on 1/15/14 by Director of Environmental Services A.

VI. Center for Rehabilitation at Wilmington Hospital

A. 1/15/14
9:20 AM: Rehabilitation Therapy Gym
- under sink cabinet door laminate damaged
9:45 AM: Room 6N44
- sticker residue on outside of door
9:55 AM: Pantry
- peeling blue protective plastic on left side of ice machine

These findings were confirmed at 10:00 AM on 1/15/14 by Director of Rehabilitation Services B.

Based on observation, policy review and staff interview, it was determined that the hospital failed to ensure an acceptable level of safety and quality with respect to the cleanliness and condition of patient care equipment and supplies in 20 of 70 patient care and support areas. Findings include:

The hospital policy entitled "Infection Prevention Policy" stated, "...Environmental Services Department's Infection Prevention Policy is intended to minimize the risk of infection in patients and employees by adherence to policies/procedures..."

The hospital policy entitled "Infection Prevention - Equipment, Gym and Treatment Rooms" stated, "Equipment is cleaned after use by each patient and as needed with hospital approved disinfectant. Remove visible soil whenever noted..."

The hospital document entitled "Christiana Care Health Services FY (fiscal year) 2013 Medical Equipment Management Plan" stated, "...The Clinical Engineering Department is responsible for the overall management of medical equipment at CCHS (Christiana Care Health Services)...All personnel using medical equipment share in the responsibility of insuring its proper operation...Report inspection stickers that have expired..."

The hospital policy entitled "Office Cleaning in Satellite Facilities" stated, "...Cleaning of horizontal surfaces...will be done using a hospital grade disinfectant according to label instructions...Horizontal surfaces...should be thoroughly cleaned regularly depending on the patient population and types of procedures performed at the facility and whenever soiling has occurred..."

Observation during environmental tours revealed the following:

A. Christiana Hospital

1/6/14
10:35 AM: Unit 7E
- damaged vinyl covering on pull-out sofa in room 7E22
- adhesive residue on top of code cart #50
11:13 AM: Unit 6E
- computer on wheels had dusty/dirty bases
11:26 AM: Unit 6D
- tape on top of code cart #1
- clean linen vinyl cover torn
11:43 AM: Unit 6B
- broken linen cart frame
- two (2) linen carts with torn vinyl covers
- rolling computer with dusty base and taped signs

These findings were confirmed at 11:55 AM on 1/6/14 by Director of Environmental Services A.

11:00 AM: Emergency Department (ED) Core D
- one (1) medication refrigerator was found with a soiled, blue latex glove finger inside and substances spilled on the refrigerator floor

Director of Clinical Operations A and Patient Care Services Director C, present at the time of discovery, confirmed this finding on 1/6/14 at 11:00 AM.

2:30 PM: Unit 5E
- paper towels stored under pantry sink
- one (1) dusty electronic blood pressure monitor and with tape residue
- three (3) dusty electronic blood pressure monitors

These findings were confirmed at 2:30 PM on 1/6/14 by Corporate Director Facilities Engineering A.

1/7/14
8:30 AM: Unit 5A
- one (1) dusty electronic blood pressure monitor

Interview with Nurse Manager K at 8:30 AM on 1/7/14 confirmed this finding.

9:27 AM: Unit 4C
- sticker and residue on one (1) electronic blood pressure monitor
10:30 AM: Unit 3E
- paper towels stored under pantry sink
10:59 AM: Unit 3E Equipment Room
- two (2) intravenous (IV) pumps with adhesive residue

These findings were confirmed at 10:59 AM on 1/7/14 by Director of Environmental Services A.

1:00 PM: Unit 2E
- clean linen vinyl cover torn
1:30 PM: Unit 2C
- damaged mattress cover (on bed in staff elevator lobby)
2:30 PM: Unit 2A
- tape on top surface of code cart #5

These findings were confirmed at 2:30 PM on 1/7/14 by Corporate Director of Facilities Engineering A.

1/8/14
1:45 PM: ED Core E
- stretcher #218 had a torn mattress cover
2:07 PM: ED Core C
- clean utility closet labeled "Orthopedic and Pediatric Supplies" contained seven (7) corrugated boxes
- one (1) slit lamp (used to examine eyes) with darkened adhesive residue
- one (1) rolling otoscope (for examination inside the ear)/ophthalmoscope (used for examination of the eye) unit with darkened adhesive residue
- one (1) procedure light with darkened adhesive residue
- one (1) fluid warmer with darkened adhesive residue
- two (2) cast saws with darkened adhesive residue
- four (4) exam lights with darkened adhesive residue

These findings were confirmed at 2:40 PM on 1/8/14 by Director of Clinical Operations A.

1/9/14
1:13 PM: Prep & Hold/PACU (Post Anesthesia Care Unit)
- very dusty stretcher bases in Bay A7 and Bay A8
- folded blanket inappropriately stored on base of stretcher in Bay A8
1:46 PM: Operating Room (OR) C2 (Trauma Room)
- anesthesia cart with adhesive tape on door
- adult trauma cart with multiple pieces of tape and date stickers

These findings were confirmed at 1:46 PM on 1/9/14 by Director of Perioperative Services A.

1/10/14
3:30 PM: Unit 3D
- one (1) medication refrigerator was found soiled with flaky particulate scattered over surfaces/shelves of the interior

Patient Care Services Director D, present at the time of discovery, confirmed this finding on 1/10/14 at 3:30 PM.

B. Christiana Care Hospital Surgery Center (Outpatient - Off Campus)

1/10/14
8:50 AM: OR #7
- rusted casters on ring stand, back table, side table and the video tower

This finding was confirmed at 8:50 AM on 1/10/14 by Nurse Manager H.

C. Riverside Health Center - Wound Care (Outpatient - Off Campus)

1/10/14 at 12:00 PM:
- Exam Room 2: dust on scale and stretcher base
- Exam Room 3: podiatry chair with damaged vinyl
- Exam Room 4: hole in green vinyl chair seat covering, dirt on seat, sticker residue on cast cart, clumps of dust on stretcher base
- Exam Room 5: podiatry chair footrest cushion had a damaged vinyl cover, the surface beneath the cushion was soiled
- Exam Room 6: hole in vinyl stool covering
- Exam Room 7: dried lumpy casting material adhered to foot stool of podiatry stool
- Exam Room 8: torn stretcher mattress, sticker remains on paper towel holder

These findings were confirmed at 12:50 PM on 1/10/14 by Registered Nurse O.

D. Roxana Cannon Arsht Surgicenter (Outpatient - Off Campus)

1/10/14
2:40 PM: PACU
- adhesive and sticker residue on adult code cart

This finding was confirmed at 2:40 PM on 1/10/14 by Nurse Manager I.

E. Springside Plaza - Christiana Care Rehabilitation Services

1/13/14
10:25 AM: Physical Therapy Area
- fabric covered (not cleanable) chair seats in each of six (6) treatment rooms
- Treatment Room 2: damaged vinyl upholstery on treatment table
- two rolls of papers towels on counter adjacent to sink
- three (3) green, open foam (not cleanable) exercise mats
10:47 AM: Neurological Rehabilitation Area
- Pediatric speech room: fabric covered (not cleanable) patient chair
- Pediatric gym: damaged vinyl cover on bench
- Patient training kitchen: dried food spatter in microwave oven
12:05 PM: Waiting room
- eleven (11) wood framed and fabric covered (not cleanable) patient chairs

These findings were confirmed at 12:05 PM on 1/13/14 by Accreditation/Performance Improvement Coordinator A.

F. Wilmington Hospital

1/13/14
2:05 PM: PACU Clean supply room
- yellow cart supporting electroconvulsive therapy (use of electric shock to produce convulsions) equipment, paper scraps and dust on surface
- malignant hyperthermia (life-threateningly high body temperature complication of certain general anesthesia drugs) kit covered with dark gray dust

These findings were confirmed at 2:05 PM on 1/13/14 by Nurse Manager J.

2:23 PM: OR #12
- rolling prep table with adhesive tape, tape residue and rusty casters
2:31 PM: OR #8
- prep table with stickers and tape
- gel positioning pad with damaged surface
- stool with damaged vinyl upholstery and rusted frame, stand and casters

These findings were confirmed at 2:31 PM on 1/13/14 by Manager of Surgical Services A.

1/14/14
1:05 PM: Third Floor Psychiatry
- Group room: six (6) soiled fabric covered (not cleanable) chair seats
- Dining Room/Kitchen: damaged laminate on kitchen cabinets, eleven (11) fabric covered (not cleanable) chairs with soiled seats

These findings were confirmed at 1:30 PM on 1/14/14 by Nurse Manager M.

1/15/14
1:28 PM: ED Room A (Red Triage)
- electrocardiograph machine (a machine to monitor the heart) covered with stickers and adhesive residue

This finding was confirmed on 1/15/14 at 1:28 PM by Interim Nurse Manager A.

G. Center for Rehabilitation at Wilmington Hospital

1/15/14
9:20 AM: Therapy Gym
- six (6) electronic blood pressure monitors with adhesive residue
9:25 AM: Outpatient Gym
- four (4) vinyl upholstered exercise mats with damaged covers
- tape on exterior surface of hot pack unit
- dusty traction table
- hard black substance on table frame
- dusty motor unit
- dusty traction machine
9:30 AM: Outpatient Gym
- therapeutic ultrasound machine (delivers deep heat to tissues) soiled with adhesive residue
- damaged vinyl upholstery on traction table in room 6N91B
9:40 AM: Outpatient Gym
- splint pan had a very dusty lid
- dusty counter top in splint area
- two (2) hot pack units with rusted areas on lids
- two (2) electrical muscle stimulation (stimulates muscles for re-education and pain relief) machines soiled with adhesive residue
9:45 AM: Outpatient Gym
- damaged vinyl upholstery on therapy table in room 6N44
- therapeutic ultrasound machine soiled with sticker residue, dust and tape on cart supporting the machine

These findings were confirmed at 9:50 AM on 1/15/14 by Director of Rehabilitation Services B and Vice President Rehabilitation and Orthopedic Services A.

1:20 PM: Unit 5 North
- ice machine soiled with hard water deposits
- one (1) electronic blood pressure monitor soiled with adhesive residue

These findings were confirmed at 1:20 PM on 1/15/14 by Director of Environmental Services A.

I. Based on observation, staff interview, hospital document review and medical record review, it was determined that for 9 of 76 patient care observations (Patient #'s 9, 10, 45, 79, 95, 102, 109, 134 and 135) in the sample, staff failed to follow the hospital's infection control policies. Findings include:

The hospital's job specification entitled "Infection Control Manager" stated, "Primary Function: To...coordinate hospital infection control policies and practices throughout the Medical Center..."

The hospital policy entitled "Standards of Nursing Practice" stated, "The RN/LPN (registered nurse/licensed practical nurse) assumes responsibility and accountability for assuring that a stated level of quality of care is maintained...This is evidenced by...Incorporating principles of infection control in the implementation of nursing care..."

A. Hand Hygiene - Christiana Hospital

The hospital policy entitled "Hand Washing/Alcohol Hand Sanitizer Procedure" stated, "...follows the Centers for Disease Control and Prevention's Handwashing Guidelines...use an alcohol-based hand rub for routinely decontaminating hands...When entering and/or leaving the patient room...Before and after having direct contact with patient's intact skin...After contact with body fluids or...non-intact skin...When moving from a contaminated body site to a clean body site during patient care...After contact with inanimate objects...Before donning and after removing gloves and other personal protective equipment (PPE)..."

1. Patient #109 (Emergency Department [ED])

On 1/6/14 between 10:15 AM - 10:46 AM, the following technique was observed during patient care provided by RN C:

- sanitized hands
- donned gloves
- repositioned patient off sling and into bed
- removed sheet from under patient and placed in soiled linen cart
- removed gloves and placed on counter
- removed stethoscope from around neck
- listened to patient's lungs with stethoscope
- placed stethoscope around neck
- sanitized hands
- retrieved soiled gloves from counter and discarded in trash
- entered data into the bedside computer
- retrieved supplies from supply cabinet
- removed blood pressure cuff and applied tourniquet to patient's right arm
- disinfected patient's wrist and inside elbow areas
- donned gloves
- unsuccessful attempt to insert intravenous (IV) needle
- removed tourniquet
- removed gloves
- reached behind curtain into supply cabinet
- retrieved additional supplies
- re-applied tourniquet to patient's right arm
- donned new gloves
- unsuccessful attempt to insert IV needle into patient's right arm
- removed tourniquet
- removed right glove
- discarded supplies
- removed left glove
- performed hand hygiene

RN C failed to perform hand hygiene:
- after glove removal
- before/after patient contact- after contact with inanimate objects
- before donning gloves

The care of Patient #109 by RN C was witnessed by Patient Care Services Director D, who confirmed these findings on 1/6/14 at 10:46 AM.

Interview on 1/14/14 at 8:00 AM with Infection Control Manager A and Infection Preventionist A revealed that the observed practice did not conform to the hospital's infection prevention policy for hand hygiene.

2. Patient #10 (ED)

The following was observed during a medication administration pass and care provided by RN N on 1/6/14 between 11:08 AM and 11:22 AM:

- obtained patient's medications and a cup
- left common area of ED and entered Room 4
- donned gloves
- pressed key on vital signs machine
- changed blood pressure cuff from the patient's left to right arm
- pressed key on vital signs machine
- entered information into keyboard of bedside computer
- touched vital signs monitor screen
- touched patient's wrist and obtained pulse rate
- opened medication packet, dropped pill into medication cup
- administered medication
- touched computer screen
- opened medication packet, dropped pill into medication cup
- administered medication
- touched computer screen
- removed gloves

RN N failed to perform hand hygiene:
- before donning gloves
- after touching inanimate objects- before patient contact

Patient Care Services Director B, present during the observation, confirmed these findings on 1/6/14 at 11:22 AM.

3. Patient #134 (Cardiovascular Intensive Care Unit Stepdown)

The following was observed during the nursing care and medication administration provided by RN E on 1/8/14 from 10:35 AM - 10:50 AM:

- performed hand hygiene
- donned gloves
- retrieved blood pressure/vital signs machine
- placed blood pressure cuff around patient's arm
- touched blood pressure machine
- adjusted patient's seat/recliner
- using key, unlocked medical supplies drawer
- obtained two medication packets from drawer
- removed gloves
- performed hand hygiene
- donned new gloves
- scanned medication packets
- opened medication packets and dropped pills into medication cup
- touched patients arm/side offering the patient the cup
- when the patient refused the small cup, reached back into the medication supplies drawer and retrieved a second cup, touching contents of the drawer
- placed medication in second, larger cup
- removed gloves
- performed hand hygiene
- offered patient the medications in the second cup

RN E failed to remove gloves and perform hand hygiene:
- after patient contact prior to reaching into the medication supply drawer

This finding was witnessed and confirmed by Patient Care Services Director B on 1/8/14 at 10:50 AM. Patient Care Services Director B stated that the nurse should have removed the gloves and completed hand hygiene before touching the contents of the drawer.

4. Patient #'s 45 and 135 (Neonatal Intensive Care Unit)

The following was observed during provision of care by RN G on 1/9/14 between 1:20 PM and 1:30 PM:

a. First observation

- washed hands
- touched inanimate objects in the areas surrounding Patient #45's crib- obtained towelettes
- donned gloves
- moistened towelettes at sink
- removed diaper and provided skin care- removed gloves- sanitized hands

b. Second observation
- touched equipment and other inanimate objects in Patient #45's area
- exited Patient #45's area and proceeded to Patient #135's area
- touched Patient #135's crib and other equipment in Patient #135's area
- exited Patient #135's area- returned to Patient #45's area- touched equipment in Patient #45's area

RN G failed to perform hand hygiene:
- after touching inanimate objects
- prior to donning gloves
- prior to patient contact
- when entering or leaving a patient area

These findings were confirmed by Nurse Manager B and Clinical Nurse Specialist B, on 1/9/14 at 1:38 PM.

5. Patient #9 (Medical Intensive Care Unit)

On 1/6/14 between 1:30 PM and 1:55 PM, the following was observed as RN D administered medications via Patient #9's oral gastric tube (a thin tube inserted through the mouth and into the stomach):

- obtained: a beaker containing water to flush the oral gastric tube, the patient's liquid medication in a cup, and a 60 milliliter syringe to flush the tube and administer the medication
- placed these items (medication cup and the beaker with syringe inside) directly on lid of a linen cart containing soiled linens
- the RN's gloved hand touched the medication, beaker and the surface of the soiled linen cart lid, immediately prior to patient contact and prior to administration of the medication into the patient's oral gastric tube

RN D:
- failed to perform hand hygiene and change gloves after contact with the soiled linen cart, before administration of medication to the patient
- administered medications from a likely contaminated surface (soiled linen cart lid)

Patient Care Services Director B, who witnessed the observation, confirmed these findings on 1/6/14 at 1:58 PM.

On 1/14/14 at 8:00 AM, these observations were reviewed with Infection Control Manager A and Infection Preventionist A who confirmed that the RN failed to follow infection prevention requirements when preparing medications.

B. Practices to prevent needle stick injuries - Christiana Hospital

The hospital document entitled "Infection Prevention Precautions" stated, "...Needles and Sharps:...needle stick...exposure...If recapping or separating the needle from the syringe is necessary, use a mechanical device. In emergency situations, a one-handed method may be used. One-handed Recapping Method: lay the cap on a level surface; remove your hand from the cap; hold the syringe (with needle attached) by the barrel...insert the needle into the cap (using a fishing technique) and lift the cap with the needle; tilt the capped needle...so that the cap slides freely down over the needle; grasp the cap with your empty hand near the hub of the needle...pull gently until the cap locks onto the needle..."

1. Patient #79 (Electrophysiology Lab)

The following care, provided by RN H, was observed during a procedure to change the implantable pacemaker on 1/13/14 between 1:26 PM and 2:30 PM:

- inverted a medication vial and using a syringe with needle attached, withdrew medication into the syringe
- inverted a second medication vial, and withdrew contents into same syringe
- with syringe and exposed needle, walked to supply cabinet to retrieve alcohol prep wipes
- wrapped alcohol wipe around hub of needle, where needle was attached to syringe
- detached the needle from syringe

RN H failed to use either a mechanical device or the one-handed recapping method to safely detach the needle from the syringe.

This observation was witnessed and confirmed by Assistant Nurse Manager C on 1/13/14 at 1:37 PM. The observation was reviewed with Patient Care Services Director A on 1/13/14 at 2:22 PM who confirmed that RN H failed to follow the hospital's protocol for Infection Prevention.

2. Patient #95 (Neuro-Intensive Care Unit)

The following was observed during medication administration and care provided by RN I on 1/13/14 between 3:58 PM and 4:05 PM:

- obtained multi-use vial of Regular Insulin (a type of injectable insulin) from the patient's medication/supply drawer
- inverted vial
- using syringe with attached needle, withdrew medication into syringe
- detached needle from syringe using gloved hand

RN I failed to use either a mechanical device or the one-handed recapping method to safely detach the needle from the syringe.

This finding was witnessed and confirmed by Patient Care Services Director A on 1/13/14 at 4:05 PM.

C. Failure to Disinfect Medication Vial Stopper - Wilmington Hospital

The hospital policy entitled "Medications for Injection Single And Multi-Dose" stated, "...For single-dose or multidose vials...wipe the stopper of the medication vial with an alcohol pad, and then draw up the prescribed amount of the medication..."

The following was observed during the preparation of medication for Patient #102 performed by RN J on 1/15/14 at 11:50 AM:

- removed the cap of one (1) single dose medication vial
- accessed vial with needle and syringe

RN J failed to cleanse the rubber stopper of the medication vial with alcohol prior to the insertion of a needle.

Interview with Nurse Manager E and Director of Patient Care Services A on 1/15/14 at 12:08 PM confirmed this finding.

II. Based on observation, policy review and staff interview, it was determined that for 3 of 6 patients that underwent an oral surgical procedure on 1/14/14, hospital
staff failed to protect sterile instrument packs from potential contamination. Findings include:

The hospital policy entitled "Sterile Supplies - (Packing and Handling of)" stated, "...Sterilized articles will be handled with care and be stored in a well-ventilated area with controlled temperature and humidity...Storage areas will be dry, protected from condensation, and free from vermin or excreta..."

A. During an environmental tour of the Wilmington Hospital Oral, Maxillofacial & Dental Unit on 1/14/14 at 2:30 PM, three (3) sterile packs for patient procedures were found stored on a shelf on a windowsill in Exam Room #7. The sterile packs were next to the window and unprotected from temperature changes and exposure to potentially infectious matter produced during dental procedures.

This finding was confirmed by Department Supervisor A at 2:30 PM on 1/14/14.

III. Based on observation, policy review and staff interview, it was determined that for 84 of 84 patients seen in the Springside Plaza - Christiana Care Rehabilitation Services on 1/13/14, staff failed to follow the linen handling policy resulting in improper processing of linen at the facility. Findings include:

The Christiana Care Rehabilitation Services policy entitled "Infection Prevention Policy" stated, "...This Department's Infection Prevention (IP) policy is intended to minimize the risk of infection in patients...Infection Prevention - Linen Handling...To provide clean linen for patient rehabilitation and therapy...Linen will be machine washed...using hot water...Bleach and detergent are added to each load according to manufacturer instructions..."

Observation during a tour of the facility on 1/13/14 at 10:15 AM revealed that there was no bleach in the laundry area where the detergent was stored. Interview with Director of Rehabilitation Services A on 1/13/14 at 10:25 AM confirmed that there was no bleach in the clinic.

IV. Based on observation, hospital document review and staff interview, it was determined that for 17 of 17 patients that underwent an endoscopic (a surgical instrument that is inserted into the body) procedure at Christiana Hospital on 1/8/14, the hospital failed to follow manufacturer's guidelines for the preparation of enzymatic cleaner used for precleaning of scopes. Findings include:

The hospital policy entitled "Scope (Laryngoscope, Endoscope, Bronchoscope) - Post-Procedure Disinfection/Sterilization" stated, "...Follow the directions of the manufacturer of cleaning and disinfection solutions: Prolystica (Trademark) Enzymatic Cleaner - contains detergent and enzymes that will remove debris from the instrument..."

The hospital document for Prolystica Enzymatic Presoak and Cleaner stated, "...Instructions for use: The product is concentrated and should be diluted. Dilute at 0.2 - 0.8 mL (milliliters) per L (liter) of water..."

Observation in the Gastrointestinal Lab Decontamination Room on 1/8/14 at 11:15 AM revealed that the water used to dilute the disinfection solution had not been measured.

Interview with Patient Care Technician B at 11:25 AM on 1/8/14 confirmed this finding.

V. Based on observation, policy review and staff interview, it was determined that 1 of 1 patient care technicians observed performing endoscope reprocessing at Christiana Hospital failed to don eye and face protection. Findings include:

The hospital policy entitled "Personal Protective Equipment" stated, "...provide protection for employees from occupational safety and health hazards through the use of Person Protective Equipment (PPE). Employees engaged in work that presents biological, chemical...or other hazards shall wear their assigned PPE...Safety glasses are the minimum level of protection from hazards such as: ...Patient care tasks...Goggles and/or face shields are required to protect employees from...Chemical splash hazards...Masks and face shields must be worn to protect eyes, nose, and mouth from biological hazards such as: body fluids, Secretions/Excretions, Other splash/spray generating procedures..."

At 11:15 AM on 1/8/14, Patient Care Technician A was observed washing an endoscope without the proper PPE for eye, nose and mouth protection. This finding was confirmed at 11:15 AM on 1/8/14 by Patient Care Technician A and Nurse Manager O.