HospitalInspections.org

Based on document review and staff interview, it was determined that the facility failed to ensure that the Utilization Review (UR) committee members consists of at least two doctors of medicine or osteopathy.

Findings include:

Reference: The "Governing Body Bylaws of Healthsouth Rehabilitation Hospital of Vineland, Effective: February 26, 2013," states on page 12, "V.6. Utilization Review. ... The Hospital shall have a UR committee consisting of two or more practitioners who are members in good standing of the Medical Staff, at least two of whom shall be doctors of medicine or osteopathy. Doctors of podiatric medicine may also serve as members of the Hospital's UR Committee. ..."

1. The minutes of the Utilization Review Committee for the October 29, 2013, January 28, 2014, and April 28, 2014 meetings revealed that only one physician was present on the committee.

2. This was confirmed by Staff #1 on 11/6/14 at 11:05 AM.

A. Based on observation and staff interview conducted on 11/5/14, it was determined that the facility failed to ensure that sterile and semicritical items are stored and maintained in a manner that renders it safe for patient use.

Findings include:

Reference #1: AAMI [Association for the Advancement of Medical Instrumentation] ST 79 Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities, 2013 section 8.9.2 states, "Sterile items should be stored in a manner that reduces potential for contamination. ... Items should be [positioned so that packaging is not crushed, bent, compressed or punctured and so that sterility is not otherwise compromised."

1. At 10:35 AM, during the inspection of the emergency crash cart, the following sterile items were secured together with rubber bands:

a. Five (5) small bore IV (intravenous) extension sets

b. Four (4) 3-ml.(milliliter) 25 gauge Safety Glide syringe sets

c. Six (6) Kendall safety needles

d. Two (2) Protect IV Plus safety IV catheters

e. Five (5) Introcan safety needles

f. Ten (10) 18-gauge needles

g. Two (2) 19-gauge filter needles

2. Securing packaged sterile items with rubber bands causes the sterility of the items to be compromised.

3. This finding was confirmed by Staff #3 and Staff #6.

Reference #2: AAMI [Association for the Advancement of Medical Instrumentation] ST 79 Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities, 2013 section E.2 (b) states, "Semicritical devices are instruments or objects that contact intact mucous membranes, or nonintact skin of the patient during use, ... Examples include ... laryngoscopes, respiratory therapy equipment ... Semicritical items should be sterilized, if possible. However, ... the device, at a minimum, must be subject to a high-level disinfection process..."

1. At 10:35 AM, in the presence of Staff #3 and Staff #6, the Nursing Unit emergency crash cart was inspected and the following was observed:

a. Three (3) oropharyngeal airways, 3 Mac laryngeal blades (#2, #3, and #4), 2 Miller laryngeal blades (#2 and #3), were in the drawer uncovered and exposed.

b. Storing these semicritical items without covers exposes them to possible environmental contamination, and does not ensure that the items are safely available for use in an emergency.

c. This finding was confirmed by Staff #3 and Staff #6.

B. Based on observation and staff interview conducted on 11/5/14, it was determined that the facility failed to ensure that all areas, including areas with limited access such as locked medication rooms are kept clean to sight and touch.

Findings include:

1. During a tour of the locked Medication Room, the following was observed:

a. At 10:50 AM, the handwashing sink was soiled with white stains, dust and debris. The sink drain stopper was heavily stained with white stains.

b. At 10:53 AM, plastic protectors on top of both medication preparation carts were soiled with brownish/yellowish stains and a sticky residue.

c. These findings were confirmed by Staff #3, Staff #7 and Staff #8.

2. During a tour of the Soiled Holding Room at 11:06 AM, the following was observed:

a. The counter adjacent to the sink was soiled with multiple white stains and was in general disrepair.

b. The sink was soiled with dirt, dust and white residue.

c. These findings were confirmed by Staff #3 and Staff #9.

Based on staff interview and document review conducted on 11/5/14, it was determined that the facility failed to ensure that a system for identifying, reporting, investigating, and controlling infectious and communicable diseases of personnel is implemented.

Findings include:

Reference: CDC [Centers for Disease Control and Prevention] Guideline for Infection Control in Healthcare Personnel, 1998 (updates and replaces "Guideline for Infection Control in Hospital Personnel, 1983") states, "Ensuring that personnel are immune to vaccine-preventable diseases is an essential part of successful personnel health programs. ... Screening tests are available to determine susceptibility to certain vaccine-preventable diseases (e.g., hepatitis B, measles, mumps, rubella, and varicella).

1. The employee health file for Staff #17 lacked documentation of screening for Rubella and Rubeola immunity.

2. At 12:50 PM Staff #1 stated, "We do not check for Rubella and Rubeola on our physicians. We only check for TB [tuberculosis]."