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Based on observation, record review and interview the facility failed to ensure relative humidity and air exchanges were monitored to ensure they were in the required range. Failure to ensure the the relative humidaity and air exchanges were in the required range had the potential to affect the health and safety of surgical patients.


Findings include:


Relative Humidity


- Record review of CMS (Centers for Medicare/Medicaid Services) S&C (Survey & Certification Group) letter dated 4/19/13 revealed the following:
" SUBJECT:
Relative Humidity (RH). Waiver of Life Safety Code (LSC) Anesthetizing Location Requirements ...
B. Categorical Waiver for RH Levels in Anesthetizing Locations ...
CMS strongly recommends that facilities maintain RH in a range of (greater than or equal to) 20 - (Lesser than or equal to) 60 percent in all anesthetizing locations.
C. Waiver Does Not Apply If:
-More stringent RH levels are required under State or local laws and regulations; or
-The reduction of RH would negatively affect ventilation system performance.
D. Facilities Option to Elect to Use the Waiver
Facilities that elect to use the categorical waiver must document their decision to do so .... At the entrance conference for any survey assessing LSC compliance, a facility that has elected to use this waiver must notify the survey team of this fact, as well as the fact that it meets the minimum RH standard of (greater or equal) 20 percent. The facility must provide documentation of its prior election to apply the waiver option ...
E. Ongoing Requirements
Facilities must monitor RH levels in anesthetizing locations and be able to provide evidence that the RH levels are maintained at or above 20 percent .... In addition, facilities must provide evidence that timely corrective actions are performed successfully in instances when internal monitoring determines RH levels are below the permitted range."


- Observation on 5/18/16 at 11:50 p.m. in the OR (Operating Room) Suite with OR Director I revealed the temperature and humidity were being monitored by a wall mounted monitor in ORs #1 and #2.


During an interview at this time with OR Director I, she said she did not have a log that recorded temperature and humidity. She said they were recorded in the patient's electronic medical record. She said she was in the process of getting new monitors. She said she usually had 5 monitors, one in both ORs, the minor room, decontamination room and reprocessing room. She said she only had them in the ORs now because three had ceased to function. She said she could download the monitors' readings to her computer. She said she would get copies to show what was being monitored.


- Record review on 5/19/16 of the downloaded data dated 5/19/16 for OR 2 revealed the following for June 2014 to October 2015:
- The temperature was consistently between 60 and 70 degrees F (Fahrenheit).
-The relative humidity (RH) was consistently between 60 and 80 percent from June to October 2014 and June to September 2015.
-The RH was below 30 and 20 percent multiple times from November 2014 to April 2015.


- Record review on 5/19/16 of the downloaded data dated 5/19/16 for PACU (Post Anesthesia Care Unit) revealed the following for June 2015 to March 2016:
-The temperature was consistently between 60 and 70 degrees F.
-The RH was consistently between 60 and 80 degrees from June 2015 to September 2015.
-The RH was below 30 and 20 percent multiple times from October 2015 to March 2016.


During an interview on 5/19/16 at 10:00 a.m. with OR Director I, she was asked about the RH being out of the required 30 to 60 percent ranges. She said AORN (Association of periOperative Registered Nurses) association had put the lower range to 20 percent. When she was asked if the Governing Body had approved the RH to be lowered to 20 percent or if they had requested a waiver to have the RH lowered to 20 percent, she said she did not know. She said she did not know anything about requesting a waiver. When she was asked for the Policy and Procedure for RH, she said it had not been revised to show the RH was lowered to 20 percent. OR Director I said she had been more worried about the RH being above 60 percent. She said she raised the temperature to get the RH back below 60%. When she was asked if she documented when she did that, she said she had no documentation. She said she did not do anything about the RH being below 30 or 20 percent. She said by the graft she could not say exactly how long the humidity was below 30 or 20 percent for any given date.


Record review of the facility's Policy and Procedure for Temperature/Humidity OR Suite/PACU dated 12/2006 and revised on 6/2010 revealed the following:
" POLICY: According to the recommendations of the Association of Operating Room Nurses (AORN 2006), the Center for Disease Control and Prevention (CDC), and the American Institute of Architect ' s Academy of Architecture, it is the policy of (hospital) that temperature in the operating room be maintained between 68 and 73 degrees Fahrenheit and that the humidity will be maintained between 30 and 60%...
PROCEDURE:
1. Temperature and Humidity will be monitored in PAXCU/Preop., Minor Surgery, OR 1, and OR 2 utilizing the Dickson SM320 Temperature/Humidity Logger ...
3. The Temperature/Humidity Loggers will have stored data downloaded every Friday and transferred to the Temperature/Humidity Log.
4. Surgical Services Staff will monitor the temperature/humidity daily and make adjustments as needed for patient comfort and safety. Any deviations from accepted parameters will be reported to the (hospital) Plant Operations Department. "


Air exchanges


During an interview on 5/18/16 at 12:00 p.m. with OR Director I, she was asked how air exchanges were monitored. She said air exchanges were monitored yearly. She was asked for the records of when air exchanges were documented. She said the company had been asked to check the air exchanges when the facility was thinking about doing total hip surgeries. She said maintenance may have a way to monitor air exchanges.


- Record review of the documentation presented by OR Director I revealed the last time the air exchange was tested by an outside company was 5/16/11. Air exchanges were at 22 times per hour in both ORs with the minimum requirement at 15 exchanges per hour.


Interview on 5/18/16 at 1:10 p.m. with Maintenance Director Q, he said he thought the company who maintenance their air handlers could monitor the air exchanges remotely. He said he would call them to find out.


On 5/19/16 at 10:00 a.m. OR Director I was asked for her Policy and Procedure for monitoring air exchanges. She said she did not have one.


Interview on 5/19/16 at 3:10 p.m. with Maintenance Director Q, he said the air handler company could not monitor air exchanges remotely. He said he had contacted several other hospital maintenance directors to see how often they should monitor air exchanges and they said they did it yearly. He said he guessed if the air handlers malfunctioned, the air flow would have to be reevaluated then also.


- Record review of the AORN (Association of periOperative Registered Nurses) Journal dated June 2009 revealed the following:
" A relative humidity that is too high can result in damp or moist supplies with added opportunity for mold growth. A relative humidity level that is too low can result in excessive bacteria-carrying dust in the surgical environment or static electricity ...Log should be maintained on humidity, temperature and air exchanges. "


- The recommended settings were in a table and were as follows for the American Institute of Architects (AIA):
Humidity in all areas: 30 to 60%
Air Exchanges per hour: OR - 15
Decontamination - 10
Prep and packaging - 4

Based on observation, record review, and interview, the facility failed to ensure IV solutions were removed from use when expired and test strips were dated after being opened.


Findings include:


- Observation on 5/18/16 at 11:20 a.m. in the Operating Room (OR) Suite with OR Director I revealed Cidex OPA test strips (measures the solution for its disinfecting abilities) were open in a drawer in the endoscopy processing room. There was a space on the label to write the date opened and a space labeled discard date. Both were blank.


Interview at this time with Operating Room (OR) Director I, she said she thought the strips could be kept for 90 days and knew they should have been dated. She said the facility used the strips well before 90 days and thought that was why the staff had not dated them.


- Record review of the manufacturer's product insert revealed the recommendation was to discard the strips within 90 days of opening or by the expiration date, whichever came first.


- Further observation at this time in OR #2 revealed a 3000 ml (milliliter) IV (Intravenous-in the vein) bag of Sodium Chloride (a salt solution) with an expiration date of 11/2015. There were three 1000 ml bags of Sodium Chloride with expiration dates of 3/2016.


Interview at this time with OR Director I, she said they should have been checking the items for expiration dates monthly.


Interview on 5/18/16 at 2:10 p.m. with Pharmacist N, she said the medication dispensing equipment was supplied in each department with adequate IV solutions. She said staff should not be storing the solutions outside the equipment because that was why they were outdated. The medication system was set up to watch for out of date supplies.


- Observation on 5/20/16 at 9:05 a.m. with Chief Nursing Officer (CNO) B and Therapy Director U in the Therapy Department revealed a multi-dose vial of Dexamethasone ( a steroid used to reduce inflammation) in a drawer. The vial had been used with an open date of 3/4/16. The vial was good for 28 days according to the date label. There was a syringe with a needle attached lying in the drawer.


Interview at this time with Therapy Director U, he said the department used the Dexamethasone topically on a pad for certain procedures. He said they used the same syringe to draw medication from the vial. He said he would put the opened vial in the sharps container along with the syringe and needle.


Interview at this time with CNO B, she said even though the Dexamethasone was used topically, the vial still needed to be used with a new syringe and needle each time.

Based on observation, record review and interview, the facility failed to ensure there was a system for identifying and investigating infections and providing a clean environment as evidenced by:

1. 2 of 3 RNs (Registered Nurses) ( F and E) did not:

a. Clean the glucometer after use or the strip bottle on 2 of 2 patients (#s 9 and 10)
b. RN F did not dispose of the lancet and test strip in the biohazard box after use
c. Neither RN F or E cleaned the computer on wheels after contaminating them
d. RN F did not perform hand hygiene after taking a finger stick blood sample

2. Cooked food was being held in the refrigerator too long

3. The ED (Emergency Department) and Therapy Department had thick layers of dust on furnishings and equipment.

4. Single packaged hinged instruments were not processed in the closed position.



Findings include:


Nursing Services


- Observation on 5/18/16 at 10:35 a.m. in the Medical/Surgical unit with CNO (Chief Nursing Officer) B revealed RN F was preparing to get a blood glucose level for Patient #9. He took Glucometer 3, a lancet, and a bottle of testing strips into the room. After touching the patient, he opened the strip bottle, removed a strip, and inserted it into the glucometer. After getting a reading, RN F threw the strip and lancet in the trash. With his contaminated gloves still on, he picked up glucometer 3 and the testing strip bottle and put them on the Computer on Wheels outside the room. The Computer on Wheels did not have any disinfecting wipes stored on it. He removed his gloves. He picked up the glucometer and test strip bottle and took them to the medication room, putting the bottle on the counter and the glucometer in a charger. He did not perform hand hygiene after removing his gloves and did not disinfect the glucometer or testing strip bottle.


During an interview at this time with RN F, he was asked if it was alright to put the lancet and test strip in the regular trash. He said the lancet was self-retracting and could not be reopened so was appropriate to put in the trash along with the test strip.


Interview on 5/18/16 at 10:45 a.m. with CNO B, she said the lancet and test strip should have been disposed of in the biohazard container.


- Observation on 5/18/16 at 10:55 a.m. in the Medical/Surgical unit with CNO B revealed RN E was preparing to get a blood glucose level for Patient #10. She had glucometer #2 and a bottle of testing strips on the top of a Computer On Wheels. There was a container of disinfecting wipes on the Computer On Wheels. The Computer On Wheels was taken into the Patient's room. After performing hand hygiene, she put on a pair of gloves. She cleaned the patient's finger with alcohol. Then she scanned the patient's arm band and strip bottle. Then she opened the strip bottle and removed a strip. After getting a reading, she put the glucometer and strip bottle back on the Computer On Wheels. She used a mouse and typed information into the computer. She opened drawers on the Computer On Wheels and got items out of her pocket with the contaminated gloves still on. She then removed her gloves and performed hand hygiene. She took the Computer On Wheels out of the room to the Nurses' Station without disinfecting the glucometer, the strip bottle or the Computer On Wheels.


During an interview on 5/18/16 at 2:40 p.m. with CNO B, she said she saw the same problems with the glucometers, testing strip bottles and Computer On Wheels. She said they all needed to be disinfected before they left patient rooms.


- Record review of the Accu-Chek Inform II manufacturer's insert revealed the following: "Important Safety Information...
-Follow your facility's infection control procedures when handling blood-contaminated items. Always adhere to the recognized procedures for handling objects that are potentially contaminated with human material...
-Disinfect the meter after use on each patient. The ACCU-CHEK Inform II system may only be used for testing multiple patients when Standard Precautions and the ACCU-CHEK Inform II system disinfecting procedures are followed ... "


- Record review of the facility's Policy and Procedure (P&P) for Accu-Chek Inform II Meter - 2014 (no date) revealed the following:
" Cleaning and Disinfection:
You must clean the meter after every patient. "


- Record review of the facility's P&P for Cleaning Responsibilities of Nursing Staff dated 9/18/13 and reviewed on 9/2015 revealed the following:
" POLICY: Nursing Staff play a critical role in helping to control the spread of infection at (hospital). The following procedures for patient care equipment, patient rooms and treatment areas will be used by Nursing Staff to provide a clean and safe environment.
PURPOSE: To prevent the spread of infection and present a neat and clean environment for the public, patients, and employees ...
PROCEDURE: Nursing Staff will clean and disinfect as listed below ...
A. Patient Care Equipment: (Blood Pressure monitors, Leg Pumps, Glucose Monitors, ect ...)
1. Shared Patient Care Equipment will be cleaned and disinfected after each use and prior to moving to another Patient Care area .... "

Kitchen


- Observation on 5/19/16 at 9:40 a.m. with CNO B and Dietary Manager (DM) R revealed a plastic container of black beans dated 5/1/16, green beans dated 5/12/16, and pizza sauce dated 5/2/16.


Interview at this time with DM R, he was asked how long cooked food could be kept in the refrigerator. He said between 5 and 7 days. When he was asked about the black beans, he said he would throw them out. When he was asked about the pizza sauce, he said it had been frozen and was thawed out on Monday, 5/16/16. He said they used the sauce to make pizzas at different times through the week. He said the staff should have re-dated the label for when it was thawed.


Phone interview on 5/20/16 at 10:10 a.m. with Dietitian S, she said cooked food should only be held in the refrigerator for 72 hours (3 days). She said once food was thawed it should be cooked right away and then discarded.


Record review of the facility's Policy and Procedure for General Requirements For Food Supply and Storage (not dated) revealed the following:
" E. Leftover items which are not frozen are held no longer than three (3) days before they are used or disposed.
F. Hot foods are reheated only once. "

The facility did not have a policy on use of thawed foods.


Environment


- Observation on 5/18/16 at 1:35 p.m. of the Emergency Department (ED) with CNO B revealed a thick layer of dust on the bottom section of two stretchers in Emergency Room (ER) 2. There was a layer of dust on the arm of the wall mount for the monitor and on the top of the monitor. There was a layer of dust on the legs of the vital sign machine. The emergency cart had a layer of dust on the top of the cart and the suction machine. The procedure room bed had a thick layer of dust on the shelf under the bed and on the arm of the ceiling exam light.


Interview at this time with CNO B, she said the ED staff would need to do some more cleaning.


- Observation on 5/20/16 at 9:05 a.m. of the Therapy Department with Director U and CNO B revealed the bed in the wound room had a layer of dust on the frame under the bed. The treatment room bed had a thick layer of dust along with the legs on the weight equipment. Two three tiered carts with a Solaris dynatron machine ( used to provide electrical stimulation to muscles) on top had layers of dust on the shelves. The high/low bed, two exercise machine legs and a bed in a treatment room had thick layers of dust.


Interview at this time with Director U, he said housekeeping cleaned the therapy department. He said he would have to check with them to see what they were cleaning and maybe his staff would have to do some scheduled cleaning themselves.


Record review of the facility's Policy and Procedure for Cleaning Responsibilities of Nursing Staff dated 9/2013 and reviewed on 9/2015 revealed the following:
" POLICY:
Nursing Staff play a critical role in helping to control the spread of infection at (hospital) ...
KEY DISINFECTING PRINCIPLES: ...
-Dust with microfiber cloth moistened with disinfectant. (Do not dry dust.)
-Keep surfaces wet per time indicated on disinfectant's label ... "


Hinged Instruments


- Observation on 5/18/16 at 11:40 a.m. with OR Director I revealed single packaged hinged instruments in the storage area were not in the open position.


Interview at this time with the OR Director, she said she did not know that the single packaged hinged instruments had to be in the open position. She said she knew the ones on strings in the instruments sets had to be open and now realized the single wrapped ones should also be open for the same reason. She said all sterile supplies in the facility were processed in the OR suite.


- Observation on 5/18/16 at 1:35 p.m. with CNO B and Emergency Department (ED) Director L revealed packages of single wrapped hinged instruments were not in the open position.


Interview at this time with ED Director L revealed all instruments were processed in the OR department.


- Observation on 5/20/16 at 9:05 a.m. in the Therapy Department with CNO B and Therapy Director U revealed multiple packages of hinged instruments in the closed position. Three packages had scissors in the open position on top.


Interview at this time with Therapy Director U revealed the open scissors had been used earlier in the week.


- Record review of an on-line reference for Sterilization by AORN dated 2015 when asked if instruments with sharp points and edges be sterilized in the open or closed position revealed the following:
" All hinged instruments should be sterilized in the open position, unless the manufacturers' instructions advise against this practice. If hinged instrument are on stringers, racks, or instrument pegs, the instruments should be kept open and unlocked. The rationale behind the practice is to expose all surfaces to the sterilant. "

Based on record review and interview the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of 3 of 4 swing bed patients (#s 2, 4, and 5) reviewed. Failure to provide activities to swing bed patients had the potential for patients to not have all of their needs met and to ensure their highest level of well-being.


Findings include:


Patient #2

- Record review of Patient #2's electronic medical record (EMR) revealed he was admitted on 5/10/16 for atrial fibrillation, medical deconditioning and pneumonia. There was no activity assessment in the record. There was nothing in the social service notes about an activity assessment or if any activities were being provided.


- Record review of Patient #2's Skilled Swing Bed Care Plan Meeting dated 5/17/16 revealed nothing documented for activities. An activity was not listed on the form.


Patient #4

- Record review of Patient #4's EMR revealed he was admitted on 5/13/16 for weakness, debility and dehydration. There was no activity assessment in the record. There was nothing in the social service notes about an activity assessment or if any activities were being provided.


- Record review of Patient #4's Skilled Swing Bed Care Plan Meeting dated 5/17/16 revealed nothing documented for activities. An activity was not listed on the form.


Patient #5

- Record review of Patient #5's EMR revealed she was admitted on 5/9/16 for COPD (Chronic Obstructive Pulmonary Disease) exacerbation, and pneumonia. There was no activity assessment in the record. There was nothing in the social service notes about an activity assessment or if any activities were being provided.


- Record review of Patient #5's Skilled Swing Bed Care Plan Meeting dated 5/17/16 revealed nothing documented for activities. An activity was not listed on the form.


- Record review of the facility's Policy and Procedure for Swing bed Services Plan of Care dated 5/2010 and reviewed on 9/2014 revealed nothing about assessing for and providing activities. Members of the Care Plan Committee were Social Services, Utilization Review Coordinator, Dietary, Pharmacy, Nursing/ Chief Nursing Officer (CNO), Therapy, and the patient/family members. Social Services was to provide consultative services and weekly progress notes. There was nothing about providing activities.


- Record review of the facilities Social Services -Swing Bed Program dated 5/10 and reviewed on 9/14 revealed the following:
" ROLE AND RESPONSIBILITIES OF THE SOCIAL SERVICE DESIGNEE ...
B. Principle Duties and Responsibilities ...
6) Develop a schedule of activities for each patient.
7) Facilitate the patient's participation in activities.
8) Coordinate activities with the nursing staff, taking into account established routines and patient medical needs.
9) Invite and encourage patients to participate in appropriate activities.
10) Maintain required equipment and supplies ... "


Interview on 5/20/16 at 2:30 p.m. with Social Service Designee T, she said she would find out what patients liked to do and then would provide them with those activities. She said she would read the Bible to patients, give them puzzles, music by CDs, talking books, provide magazines and some patients just wanted to watch TV. She said she would document this in the computer notes. She said she ran the weekly Plan of Care meetings on Tuesdays. She was asked if they discussed activities during those meetings and she said, "No."


During an interview on 5/20/16 at 3:45 p.m. with Chief Nursing Officer (CNO) B, she was informed of the lack of assessment for activities and provision of activities. She said she thought that was right. She said she would be getting a new employee working with Social Services to take on the role of Activity Director after she got the training.