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Based on observation, document review and interview, facility staff's infection control (IC) techniques were not consistent with generally accepted practices. Specifically, random observation of a Patient Care Technician's (PCT) IC techniques identified breaches in infection control practices regarding the cleaning of a shared blood glucose meter between patient use.
Findings:
During an observation on 11/6/13 at 10:00 am, PCT #1 was observed performing blood glucose testing using a shared blood glucose meter on Patient A. After completion of the test, PCT #1 was observed to not clean the blood glucose meter and place it back in its holder. This observation was brought to the attention of the Nursing Director of the Ambulatory Surgery Unit by the state surveyor.

During an interview with the Nursing Director on 11/6/13 at approximately 10:10 am, the Nursing Director stated that the blood glucose meter had been cleaned after being notified by the surveyor.

On 11/6/13 at 1:40 pm., facility policy # SM-6125-200, entitled "Point of Care Testing (POCT)- Glucose Nova Stat Strip Glucose Meter- Nove Biomedical, effective 10/2013 was provided to survey staff by the 5 North Nurse Manager. This policy provides guidelines for the proper cleaning of the glucose meter, in accordance with the manufacturer's cleaning guidelines, but failed to specifically indicate that the glucose meter was to be cleaned after being used on each patient.

In this action, the observed PCT's actions had the potential to spread blood borne infections between patients. Blood glucose monitoring systems, when shared among patients, have the potential to spread blood borne infections among patients. The hospital's failure to clean the machine in accordance with the machine manufacturer's directions for use puts all patients who undergo point of care glucose testing at risk for contracting an infection.

In addition to the above breaches in infection control, the following issues were noted:
-Hospital staff were observed providing care in the operating room. Multiple infection control concerns were identified. Equipment in three locations was not stored in a sanitary manner. (See A749).

-Review of infection control surveillance on 11/7/13 at 10:00 am failed to include monitoring of the perioperative area. for implementation of infection control measures.

A review of the hospital wide Quality Assurance and Performance Improvement (QAPI) program showed that staff audits for hand hygiene did not include observation of OR staff. (See A283 and A749).


20205

Based on medical record review and interview, the hospital failed to have a physician's order for the use of restraints. This was noted in medical record #19. Additionally, the hospital's Physical Restraints/Safety Flow Sheets were not consistently dated. This was noted on 3 of 5 flow sheets in the same medical record (#19). The evidence was as follows:

Review of medical record (#19) on 11/7/13 at 10:00 am identified that the Physical Restraints/ Safety Flow sheets were missing the following:

0800-1500 not dated
0000-0730 not dated
1600-2330 not dated

Review of the physician orders on 11/7/13 at 10:30 am in the medical record (#19) revealed one order for restraint use dated 2/13/13 at 0900. The Physical Restraint/Safety Flow Sheets reflected restraint use for more then 24 hours.

During an interview with the Director of Patient Safety/Quality Improvement on 11/7/13 at 11:00 am, the documentation of the physicians orders was requested. The provider was unable to produce the missing physician orders.

Review of the Hospital policy "Use of Restraints in Patient Care" ( last revised 8/11) revealed the maximum length of time for which a restraint may be ordered is 24 hours and the time period begins upon the writing of the order.

Based on document review and interview, the hospital failed to set priorities for its performance improvement activities. Specifically, the hospital failed to identify opportunities for improvement and changes that will lead to improvement. This was evidenced by lack of performance and documentation of hand hygiene surveillance of operating room personnel.

Review of the hospital's QAPI program on 11/7/13 at 10:00 am identified year to date (Jan 2013- present) audits of hand hygiene throughout the hospital's units. Review of the hospital's QAPI meeting minutes did not document the performance of hand hygiene audits of operating room personnel. (See A 749).

This finding was confirmed during interview of the Director of Patient Safety and Quality Improvement on 11/7/13 at 10:00 am.

Based on record review and interview, the hospital failed to ensure that physician orders were signed, dated or timed by the physician for four (4) out of forty-two (42) medical recrods reviewed (Medical records #4,#6,#38 and #39.) This was evidenced by:

Review of medical record #4 on 11/6/13 at :200 pm on the 5 North nursing unit revealed three (3) physician order entries were not authenticated, dated or timed by the physician. Specifically, three telephone orders on 10/31/13, 11/1/13, and 11/5/13 were not authenticated by the physician. Multiple physician progress notes entries on 10/23/13, 10/25/13, 10/26/13, 10/28/13, 10/29/13, 10/30/13, 10/31/13, 11/1/13, and 11/2/13 were not timed.

Review of medical record #6 on 11/6/13 at 2:00 pm on the 5 North nursing unit revealed that three physician order entries were not authenticated, dated or timed. Specifically, a telephone order on 11/4/13 was not authenticated by the physician and two (2) physician orders written on 11/4/13 and 11/5/13 were not timed.

Review of medical record #38 on 11/7/13 at 8:30 am identified that the 9/13/13 preoperative orders were not authenticated, dated or timed.

Review of medical record #39 on 11/6/13 at 8:30 am identified that the 4/9/13 preoperative antibiotic order was not authenticated, dated or timed.

During an interview with the Director of Patient Safety and Quality Improvement on 11/7/13 at 10:00 am, the findings were verified.

Based on document review, the hospital failed to ensure that the physician conducted an updated history and physical. This was noted for one of 14 medical records reviewed (medical record #38). This was evidenced by:

Review of medical record # 38 on 11/7/13 at 8:30 am identified that the patient underwent surgery on 4/9/13. The patient's history and physical was documented in the medical record as being performed by the physician on 4/4/13. The medical record did not contain documentation of an examination for changes in the patient's condition prior to the surgery.

See A 952.

Based on findings from observations and interviews, the Hospital failed to maintain a clean environment in the pharmacy.

Findings include:

During an observation at 11:20 a.m. on 11/5/13, clean, sterile, and general storage items such as medicines, empty plastic trays, and corrugated boxes filled with records were being stored in the pharmacy. The plastic trays were stored on shelves throughout the pharmacy while the paper records were being stored on shelving within the pharmacy near the entrance as well as in the rear of the pharmacy.

During an observation at 1:10 p.m. on 11/6/13, pharmacy staff were eating lunch in the pharmacy near the area where medicines were being dispesensed and stored.

During an interview with the Director of Facilities Operations at 11:20 a.m. on 11/5/13, he/she stated that the record boxes could be placed into storage and should not be stored in the pharmacy.

During an interview with the Infection Control Preventionist at 1:10 p.m. on 11/6/13, he/she stated that pharmacy staff should not be eating lunch in the pharmacy.

Based on findings from observations and interview, the Hospital failed to maintain the fire rating required for a general storage room or for ventilation of a room used for clean storage.

Findings included:

NFPA 101, section 19.3, requires that rooms used for general storage be safe-guarded by self-closing doors while Table 7-1 of the guidelines for Design and Construction of Health Care Facilities (2010) requires positive air pressure in rooms used for clean storage. Supply air is required to maintain positive pressure in clean storage rooms while an intact ceiling is required to inhibit the transfer of smoke/fire.

During observations at 11:12 a.m. on 11/4/13, several ceiling tiles were missing from the storage room in the emergency department adjacent to room 3787, the door leading to the storage room was not equipped with a door closer, and there was not supply air diffuser in the room.

During observations at 11:20 a.m. on 11/4/13, there were no supply air diffusers in rooms 3819 and 3820. Per Table 7-1 of the Guidelines for Design and Construction of Health Care Facilities (2010) supply air diffusers are required to maintain positive air pressure in rooms used for clean storage.

During an interview with the Director of Facilities Operatatons who was present at the time of the above observations, he/she stated agreement with the above findings.

Based on observation, interview and record review the hospital failed to implement infection control practices that minimize the risk of transmission of infections among patients. Findings are:

During a tour of the operating room (OR) and while observing a surgical case in OR #6 on 11/5/13 from 9:30 am- 11:00 am, the following events were observed:

The inserted Foley and catheter bag and tubing were left on the floor during the procedure which lasted approximately one and one half hours.

The circulating nurse was observed to pick up a bloody glove off the floor and was observed not changing his gloves and did not use hand sanitizer.

The circulating nurse was observed going through the non-biohazard waste receptacle, went through the refuse looking for directions for equipment. He failed to perform hand hygiene. At this time he handed the assistant nurse the instructions over the sterile field for the OR instruments.

The circulating nurse was observed not using the foot pedals of the non-biohazard waste receptacles and was opening the receptacles with his gloved hands, and failed to perform hand hygiene.

The surgeon, physician assistant and circulating nurse failed to practice appropriate hand hygiene at the end of the case.

The surgeon failed to wear protective eyewear during the surgery.

Oral airways were found left open and not covered in anesthesia carts in OR #6 and #7 and in the corridor of the operating room.



20205

Based on document review, the hospital failed to ensure that the physician conducted an updated history and physical prior to surgery or a procedure requiring anesthesia services.. This was noted for one of 14 medical records reviewed (medical record #38). This was evidenced by:

Review of medical record # 38 on 11/7/13 at 8:30 am identified that the patient underwent surgery on 4/9/13. The patient's history and physical was documented in the medical record as being performed by the physician on 4/4/13. The medical record did not contain documentation of an examination for changes in the patient's condition prior to the surgery.

See A 461.

Based on record review and interview, the hospital failed to ensure that post anesthesia evalutions were completed within 48 hours after surgery or prior to the patient being discharged. This was noted in 8 of 14 medical records. (Medical records #37, #34, #33, #7, #39, #31, #41, #40).

Findings:

#7: The patient underwent surgery under general anesthesia on 3/11/13. The patient was admitted to the hospital after surgery and was discharged 3/13/13. A review of the medical record conducted on 11/6/13 at 3:00 pm revealed no post anesthesia evaluation was conducted by the anesthesia provider.

#37: The patient underwent surgery under general anesthesia as an outpatient on 4/3/13. The patient was discharged 4/3/13. A review of the medical record conducted on 11/6/13 at approximately 4:00 pm revealed no post anesthesia evaluation was conducted by the anesthesia provider.

#34: The patient underwent surgery under general anesthesia as an outpatient on 3/14/13. The patient was discharged 3/14/13. A review of the medical record conducted on 11/6/13 at approximately 4:00 pm revealed no post anesthesia evaluation was conducted by the anesthesia provider.

#33: The patient underwent surgey on 1/3/13. Post anesthesia evaluation was not documented.

#39: The patient underwent surgey on 9/13/13. Post anesthesia evaluation was not documented.

#31: The patient underwent surgey on 2/4/13. Post anesthesia evaluation was not documented.

#41: The patient underwent surgey on 11/5/13. Post anesthesia evaluation was not documented.

#40: The patient underwent surgey on 10/21/13. Post anesthesia evaluation was not documented.

The hospital's anesthesia Policy Manual contains a policy (effective date 2012) requiring the performance of preoperative and postoperative anesthesia evaluations.

The finding was confirmed with the Director of Patient Safety and Quality Improvement on 11/7/2013 at approximately 10 AM.