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The Governing Body failed to assure that the hospital was compliant with all Conditions of Participation in the area of Infection Control as it relates to gastrointestional (GI) scope re-processing.

See findings under Tag #747, 749 and 951.

Based on medical record review, interview and policy review, nursing staff do not complete restraint assessments every two hours per facility policy for 1 of 6 inpatients (Patient # 13).

Findings Include:

Review on 5/8/13 of policy "Restraints-Medical/Surgical" last revised 12/12 revealed re-evaluation of the patient for less restrictive restraint or removal is required every two hours or more frequently during the use of restraints. The release of restraints, proper restraint application if indicated, repositioning if needed, nutrition/hydration status, hygiene/elimination status, circulation/skin status, range of motion if indicated and physical/psychological status and comfort needs are to be assessed and met.

Review on 5/8/13 of the medical record for Patient #13 revealed the following:
- 2 point restraints (wrist) were ordered and applied from 4/23/13 at 7:48pm to 4/26/13 at 2:29pm due to confusion and to keep medical devices intact.
- The nursing restraint assessment was not conducted every two hours while the patient was in restraints. Examples include:
On 4/24/13 the patient was assessed at 12:09am. The next documented assessment is at 4:37am.
On 4/24/13 the patient was assessed at 6:15am. The next documented assessment is at 12:48pm.
On 4/25/13 the patient was assessed at 12:27pm. The next documented assessments are at 3:12pm, 6:24pm and 9:45pm.
On 4/26/13 the patient was assessed at 8:00am. The next documented assessment is at 2:29pm.

This finding was verified with the Quality and Patient Safety Director on 5/8/13.

Based on medical record and document review, the facility failed to ensure safe and accurate medication administration to 1 out of 25 patients. (Patient #1)

Findings include:

Review of Physician Orders dated 10/23/12 at 5:30pm revealed an order for Lantus insulin 10 units subcutaneously at bedtime.

Review of the Medication Administration Record revealed the patient received Lantus insulin 100 units on 10/24/12 at 1:05am and again at 9:50pm.

Review of the Rapid Response Form dated 10/25/12 at 8:19am revealed the patient was unresponsive. Interventions included: 2 amps of Dextrose 50 intravenously, CT of the head and blood work. Blood glucose was less than 29 and at 1:30pm the patient was transferred to the intensive care unit.

Review of the facility's internal review of the event revealed pharmacy dispensed 10 x the ordered dose of Lantus insulin to the unit, following which the nursing staff administered the 100 units without questioning the dose.

Based on medical record review, interview and policy review, clinical staff do not ensure all medical record entries and orders are signed, dated and authenticated for 1 of 6 patients (Patient #7).

Findings Include:

Review on 5/7/13 of policy "Documentation Requirement in the Medical Record" last revised 10/08 revealed every medical record entry is to be dated, timed, signed and the author identified.

Review on 5/7/13 of the Medical Staff Rules and Regulations dated 3/13 revealed telephone or verbal orders shall be transcribed immediately in a medical record entry, which shall include the date, time, name, title/status and signature of the person transcribing the order and the name of the prescribing practitioner.

Review on 5/7/13 of the medical record for Patient #7 who was admitted on 5/6/13 revealed the following:
- Verbal orders were obtained and documented on the Adult Preoperative pre-printed order form. No evidence was found to indicate the date, time and nurse who received the verbal orders, or the name of the prescribing physician.
- The Bedside Universal Protocol procedure record is signed by the nurse, physician and anesthesia provider but does not include a date.

This finding was verified with the Quality and Patient Safety Director on 5/8/13.

Based on medical record and document review the pharmacist failed to ensure the proper preparation and distribution of insulin to 1 out of 25 patients. (Patient #1)

Findings include:

Review of the Physician Orders dated 10/23/12 at 5:30pm revealed an order for Lantus insulin 10 units subcutaneous (SQ) every evening.

Review of the Medication Administration Record revealed Lantus insulin 100 units/1ml SQ was administered on 10/24/12 at 1:05am and again at 9:50pm.

Review of the facility's internal review of the event revealed the pharmacist entered the order as 100 units instead of 10 units and as such,100 units was dispensed to the unit for administration.

Based on observation, interview, policy review, medical record review and pertinent document review lapses in generally accepted infection control practices were identified in the cleaning of GI scopes.

See findings under tag #749 and 951.

Based on observation, interview, policy review, medical record review and pertinent document review the Infection Control Officer failed to ensure the implementation of infection control measures as they relate to gastrointestional (GI) scope re-processing.

Findings include:

Review on 5/8/13 of the Pentax Reprocessing/Maintenance Manual for Video GI Scopes 90 i/90k series dated 3/12 revealed that immediately after (at least within one hour) the completion of a procedure, the endoscope and its components should be thoroughly and carefully cleaned. To reprocess a scope, first a cleaning detergent and then a highlevel disinfectant or sterilant must be exposed to all internal lumens as well as to all external instrument surfaces and endoscope components. Exposure times, concentration, and temperature of detergent and disinfectant/sterilant must be strictly adhered to.

Review on 5/7/13 of facility policy " Care & Handling of Endoscopes & Related Equipment" effective date 4/30/12 revealed endoscopes and related equipment will be decontaminated and cleaned immediately after use according to manufacturers recommended guidelines. Endoscopes will be high level disinfected and/or sterilized prior to use. Specific steps include the following:
- immediately after removing the endoscope from the patient, clean/wipe debris.
- place distal end of scope in detergent solution. Suction solution through channel alternating with air several times until solution is visible clean. Finish by suctioning air. Immediate flushing of the biopsy/suction and air/water channels precludes drying of organic and inorganic debris on lumen surfaces.
- transport endoscope and related equipment in a puncture resistant covered container.
- Disassemble equipment and leak test. If damage is detected, remove from service and contact manufacturer for repair.
- manually clean with enzymatic cleaner using brush. Flush all channels with detergent solution and rinse thoroughly.
- high level disinfection and/or sterilization.
- prior to storage, rinse with sterile water followed by forced air. Rinse with 70% or 90% alcohol followed by forced air drying.
- hang endoscopes vertically in a large, well-ventilated, dust free area with good ventilation to prevent moisture build up and discourage microbial contamination.

Observation on 5/6/13 at 10:40am revealed two "closets" where scopes are hung for storage with white cotton towels lining the bottom of both closets.

During interview on 5/6/13 at 10:45am with the GI Technician it was noted there is a travel cart for scopes to be used in the Emergency Department or Intensive Care Unit after hours. The GI oncall nurse will flush the scopes after use and leave them in the re-processing room to be cleaned the next morning. On Monday mornings there are usually one or two scopes left from the weekend waiting to be re-processed.

During interview on 5/6/13 at 11:00am with the Director of Perioperative Services and the GI Services Supervisor it was noted the travel cart is used for after hour and weekend procedures. There is always a GI nurse on-call. Scopes are cleaned by the on-call GI nurse and transported on top of the travel cart, wrapped in a Chux and placed in a "patient's belongings bag". The scopes are left for the GI technicians to re-process in the Medivator in the morning.

During interview with the GI nurse on 5/8/13 at 9:50am it was noted that on the weekends the nurse will wash the scopes following use. The scopes are placed in a bin with disinfectant and manual cleaning is done. Scopes are left in the bins located in the re-processing room with a patient sticker attached for staff on Monday. The manual cleaning and leak testing is not documented.

Medical record and medivator re-processing strip review on 5/8/13 at 9:15am indicated a delay in scope cleaning in 1 of 3 records reviewed. (Patient #23).
- On 5/4/13 at 11:35am scope #600 was used. The scope was not re-processed until 5/6/13 at 7:21am. No documentation was found to indicate manual cleaning including exposure times, concentration, and temperature of detergent disinfectant/sterilant and leak testing was performed immediately after use.

Based on document review, observation and medical record review, Surgical Services staff failed to implement a comprehensive policy related to GI scope re-processing.

Findings include:

Review on 5/7/13 of facility policy " Care & Handling of Endoscopes & Related Equipment" effective date 4/30/12 revealed endoscopes and related equipment will be decontaminated and cleaned immediately after use according to manufacturers recommended guidelines. Endoscopes will be high level disinfected and/or sterilized prior to use. Specific steps include the following:
- immediately after removing the endoscope from the patient, clean/wipe debris.
- place distal end of scope in detergent solution. Suction solution through channel alternating with air several times until solution is visible clean. Finish by suctioning air. Immediate flushing of the biopsy/suction and air/water channels precludes drying of organic and inorganic debris on lumen surfaces.
- transport endoscope and related equipment in a puncture resistant covered container.
- Disassemble equipment and leak test. If damage is detected, remove from service and contact manufacturer for repair.
- manually clean with enzymatic cleaner using brush. Flush all channels with detergent solution and rinse thoroughly.
- high level disinfection and/or sterilization.
- prior to storage, rinse with sterile water followed by forced air. Rinse with 70% or 90% alcohol followed by forced air drying.
- hang endoscopes vertically in a large, well-ventilated, dust free area with good ventilation to prevent moisture build up and discourage microbial contamination.
This policy does not include a time element in which scopes should be transported for reprocessing, how staff will document the steps of reprocessing and testing, the labeling of disinfected and re-processed scopes, the timeframe in which an unused GI scope would need to be re-processed to ensure integrity and what the protocol is for after hours scope cleaning and re-processing.

During interview on 5/6/13 at 10:45am with the GI Technician it was noted there is a travel cart for scopes to be used in the Emergency Department or Intensive Care Unit after hours. The GI oncall nurse will flush the scopes after use and leave them in the re-processing room to be cleaned the next morning. On Monday mornings there are usually one or two scopes left from the weekend waiting to be re-processed.

During interview on 5/6/13 at 11:00am with the Director of Perioperative Services and the GI Services Supervisor it was noted the travel cart is used for after hour and weekend procedures. There is always a GI nurse on-call. Scopes are cleaned by the on-call GI nurse and transported on top of the travel cart, wrapped in a Chux and placed in a "patient's belongings bag". The scopes are left for the GI technicians to re-process in the Medivator in the morning.

During interview with the GI nurse on 5/8/13 at 9:50am it was noted that on the weekends the nurse will wash the scopes following use. The scopes are placed in a bin with disinfectant and manual cleaning is done. Scopes are left in the bins located in the re-processing room with a patient sticker attached for staff on Monday. The manual cleaning and leak testing is not documented.

Review on 5/8/13 at 10:32am of a medivator "re-processing " strip for 5/3/13 revealed the strips of re-processed scopes are printed each day and placed in a plastic bag. There is no documentation to indicate how the strips will be maintained and utilized to ensure each GI scope is re-processed after use or after a period of non use.