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|BELMONT BEHAVIORAL HOSPITAL||4200 MONUMENT AVENUE PHILADELPHIA, PA 19131||July 17, 2015|
|VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES||Tag No: A0749|
|Based on observations, review of facility documents and interviews with staff (EMP), it was determined the facility failed to develop and implement a comprehensive hospital-wide infection prevention and control program to ensure a sanitary hospital environment.
Review of Centers for Disease Control and Prevention (CDC) "Safe Injection Practices to Prevent Transmission of Infections to Patients," dated April 1, 2011, revealed " ... Recommendations IV.H. Safe injection practices, the following recommendations apply to the use of needles, cannulas that replace needles, and, where applicable intravenous delivery systems ... IV.H.1. Use aseptic technique to avoid contamination of sterile injection equipment IV. H.4. Use single-dose vials for parenteral medications whenever possible IV.H.5. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use ... IV.H.7. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable ..."
1) Observation on July 15, 2015,of the Electro Convulsive Treatment (ECT) suite revealed three multi-dose vials of injectable medications contained in the treatment area. EMP2 was observed drawing up medications, in the ECT patient care treatment area, from the multi-dose vials into a syringe.
Interview on July 15, 2015, at 11:00 AM, with EMP2 confirmed that there were three multi-dose vials of injectable medications stored in the ECT treatment area. EMP2 confirmed that the three vials of multi-dose medications were prepared in the ECT patient care treatment area.
2) Review of the manufacturers insert for "Diprivan," (Propofol) dated January 2014, revealed " ... Diprivan injectable Emulsion is a single access parental product (single patient infusion vial) ... Diprivan injectable vials are never to be accessed more than once or used on more than one person. ... "
Observation on July 15, 2015, of the ECT suite revealed an opened vial of Diprivan stored in the ECT treatment area. EMP2 accessed the Diprivan vial more than once for multiple patients.
Interview on July 15, 2015, at 11:05 AM, with EMP2 confirmed that EMP2 stored an opened single use vial of Diprivan in the ECT treatment area and accessed the Diprivan vial more than once for multiple patients in the ECT treatment area.
3) Review of facility document "ECT Guidelines," no date, revealed " ... Mouthguards: In the morning, fill the basin (bottom cabinet across from the sink) with warm water a cap full of detergent (in lower cabinet near window) for the nurse anesthetist. ... At end of day, put them into a plastic bag (in cabinet near sink) with a label, then, put in drawer with detergent bottle. On Fridays, take bag of bite blocks to mail room ... They go to Einstein hospital for autoclaving. ... "
Review of the "Steris Enzymatic Cleaner" manufacturer instructions revealed " ... Manual / Ultrasonic Applications: Dilute 1 fl.oz. per gallon of warm water (8 ml per L). Soak a minimum of 2 to 5 minutes. ... After soaking, rinse thoroughly or transfer to next cleaning operation. ... "
Observation on July 15, 2015, of the ECT suite's work room revealed a basin marked at one liter increments filled with a liquid substance, which contained multiple used mouthpieces.
Observation on July 15, 2015, of the ECT suite's work room revealed a plastic bag of multiple mouthpieces that had been already soaked in the enzymatic cleaner.
Observation on July 17, 2015, of the ECT suite's work room revealed a basin void of a liquid substance, which contained multiple mouthpieces.
Interview on July 17, 2015, at 11:15 AM, with EMP10 revealed that the milliliters of enzymatic cleaner to liters of water is not determined when filling the assigned basin. EMP10 stated that one or two caps of enzymatic cleaner is added to the basin, without knowing what the measurement was contained in each cap. EMP10 revealed that the facility's document "ECT Guidelines," didn't specify to thoroughly rinse the mouthpieces after the mouthpieces have been soaked in the basin's enzymatic / water mixture. EMP10 confirmed that the observed mouthpieces had not been rinsed after soaking in the enzymatic cleaner.
4) Review of facility policy "Safety Management," dated May 31, 2002, revealed "Policy: A. The Environmental Services Division will provide a clean, safe and orderly environment for our patients ... "
Observation on July 17, 2015, of the "One Center"geriatric psychiatric nursing unit revealed the following: the hygiene closet had various amounts of food particles and debris on the floor, the linen closet had a towel and other unknown debris on the floor, Patient Room M144 had debris and food particles located under the patient's bed, and Patient Room M146 had debris and food particles located under the both patients' beds in the room.
Interview on July 17, 2015, at 9:40 AM, with EMP1 confirmed the above findings.
Observation on July 17, 2015, of the "One South" psychiatric unit revealed the following:
Patient Room 160 had debris and food particles located on the carpet in the room; two used staff gloves were noted on one of the patient storage cabinet's, Patient Room 161 had food particles along the edges of the wall, Patient Room 162 had black discoloration on the wall; there was an observed hole in the wall; and there were debris and food particles located on the carpet in the room, Patient Room 163 had debris and food particles located on the carpet in the room, and Patient Room 166 had debris and food particles located on the carpet in the room. The ceiling of the shower area contained a blackened, bubbled discoloration.
In the dayroom food particles and debris noted in the gap from the floor to the wall; there were six ceiling tiles noted with a brownish stain. The kitchen area had different color stains located behind and adjacent to the sink area. The kitchen area's storage closet contained debris and food particles on the floor and the storage closet had a foul odor coming from the closet.
Interview on July 17, 2015, at 10:05 AM, with EMP1 confirmed the above findings.
Observation on July 17, 2015, of the "Two South" adolescent psychiatric unit revealed the following: Patient Room 242 bathroom's sink had two patient toothbrushes. The bristles of the toothbrushes were observed in direct contact with the sink. The nurses station had an opened half gallon of fruit punch and an opened half gallon of orange drink stored outside of the refrigerator. The containers instructed to "keep refrigerated." The pantry countertop, in the pantry room, contained multiple areas of blackened discoloration. The kitchen area storage closet had a various amount of debris on the floor. The classroom had two chairs where the cushioned protective outer barrier had been ripped and there were seven chair cushions noted to have a stained discolorations.
Interview on July 17, 2015, at 10:30 AM, with EMP1 confirmed the above findings.
Observation on July 17, 2015, of the "Two Center" psychiatric unit revealed the following:
The day room had a chair where the chair's cushioned protective outer barrier had been ripped. Patient Room 228 bathroom's sink had a toothbrush. The toothbrush's bristles were observed in direct contact with the sink. Patient Room 241 carpet was stained; an area of the carpet was pulled away from the wall; and there was a various amount of food particles and debris located on the floor. The unit's medication room had two opened half gallon fruit punch and orange drink containers stored outside of the refrigerator. The containers indicated to "keep refrigerated".
Observation of the "Three South" psychiatric unit on July 17, 2015, revealed the following:
Patient room 346 had a floor tile broken in the room and Patient room 360 had four loose floor tiles.
Interview on July 17, 2015, at 11:30, with EMP1 confirmed the above findings.