HospitalInspections.org

A. Based on observation, document review and staff interview it was determined the facility failed to follow its policy and procedure for maintaining infection control in two (2) of two (2) wound care beds in the wound care center. This failure has the potential to put all patients who receive care in the wound care center at risk for infection.

Findings include:

1. During a tour of the wound care clinic on 05/14/18 at 12:25 p.m. with the Chief Nursing Officer (CNO), it was observed that two (2) dirty stretchers from the Emergency Room were stored in the wound care room. Equipment (a vital signs machine and an intravenous (IV) infusion machine) was noted to be uncovered. Clean linen supplies were noted to be covered with a sheet at the bedside.

2. A tour of the wound care clinic on 05/15/18 at 8:40 a.m. with the CNO revealed there were cleaning supplies (Clorox hydroperoxide, sunburst deodorizer) stored next to the face mask and gloves which were stored on top of the supply cabinet. The supply cabinet was also noted to have a telephone book in a drawer with sterile syringes. Wound vac supplies were noted to be stored in boxes on the floor.

3. Review of the policy titled "Infection Control Wound Clinic", last revised 05/01/15, revealed it states, in part: "The Wound Care Nurse is responsible for the infection control of the Wound Clinic. Terminal Cleaning per housekeeping policy shall be followed."

4. An interview was conducted on 5/15/18 at 11:30 a.m. with the CNO. She concurred with the above findings and stated it is her expectation that housekeeping standards for terminal cleaning are to be maintained for the wound care clinic.

B. Based on observation, document review and staff interview it was determined the facility failed to follow the expectation set forth by the Chief Nursing Officer (CNO) for maintaining emergency crash cart checks, by conducting twice daily checks, in one (1) of one (1) emergency crash carts in the radiology department. This failure has the potential to cause harm to any patient who would need cardiac resuscitation.

Findings include:

1. During a tour of the radiology unit on 05/15/18 at 12:05 p.m. an observation of the emergency crash cart revealed a twice daily crash cart check had not been completed, per staff expectation, on 04/09, 04/11, 04/15, 04/22, 04/24, 04/26, 04/27, 04/28, 04/30, 05/03, 05/04, 05/10, 05/11, 05/12 and 05/13/18.

2. An interview was conducted on 05/15/18 at 12:25 p.m. with the CNO. She stated, in part: "Although we have a policy that says once a day, the staff failed to complete it once a day, so I had a staff meeting to educate all staff that the new expectation is to check the crash cart twice a day. I accept the fact that they have failed to complete my expectations."

3. Review of staff meeting minutes from January 2018 through March 2018 revealed staff was educated on the expectation of crash cart checks to be increased to twice a day.