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Based on observation and interview, the provider failed to ensure temperatures were maintained at a safe level in one of one blanket warmer located in the isolation ante room. Findings include:

1. Observation on 8/6/13 at 3:00 p.m. of the blanket warmer located in the isolation ante room revealed:
*The thermostat was set to 175 degrees Fahrenheit (F).
*The blanket warmers thermometer read the interior of the cabinet was 185 degrees F.
*The interior of the cabinet was too hot to touch.
*No temperature logs were in sight for the blanket warmer.

Interview on 8/6/13 at 4:20 p.m. with registered nurse E regarding the above noted blanket warmer revealed:
*It was always set that warm.
*The blankets in that warmer were used for all the patients in the hospital.
*She was not aware of any temperature monitoring logs for the blanket warmer.

Interview on 8/6/13 at 4:30 p.m. with the nurse manager regarding the above noted blanket warmer revealed:
*No monitoring of the temperature of the blanket warmer was in place.
*No policy was in place for the proper monitoring and use of the blanket warmer.
*She was not able to locate the manufacturer's manual for the blanket warmer.
*She agreed having the blankets warmed to the above noted temperature could cause a burn to a patient.
*She immediately turned the temperature of the blanket warmer down to 130 degrees F.

Based on interview, record review, and medical staff bylaws review, the provider failed to ensure:
*One of two sampled surgeons (M) had surgical privileges approved by medical staff and the governing board.
*One of one sampled certified nurse practitioner (H) was properly credentialed.
Findings include:

1. Interview, record review, and medical staff bylaws review on 8/7/13 at 10:30 a.m. with the chief financial officer (CFO) regarding physician/surgeon M revealed:
*The surgeon's privileges had expired in April 2013 and no temporary privileges had been granted.
*The medical staff bylaws required privileges to be updated every two years.
*The privileges on file from April 2011 were signed by the medical staff and the governing board. However the surgeon had not signed or dated that privileges form.
*The CFO agreed proper approved privileges were not in place for physician M.
*The CFO agreed the medical staff bylaws had not been followed for the proper privileging of physician M.


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2. Review of certified nurse practitioner H's credentialing file and interview on 8/7/13 at 4:00 p.m. with the chief financial officer revealed there was no documentation of:
*An initial appointment.
*Delineation of clinical privileges.
-That document had been signed by the medical director, but it had not been completed.
*References regarding clinical competence.
*A statement of physical and mental health.
*National Practitioner Data Bank or the Physician Profile Query.

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Based on observation, interview, manufacturer's direction review, and policy review, the provider failed to ensure:
*Endoscopes were stored in a manner to prevent contamination in one of one sterilization area.
*Endoscopes were cleaned, rinsed, and high level disinfected according to manufacturer's directions for one of one sterilization area.
*Community use linen at one of one offsite physical therapy was disinfected when washed.
*Ensure patient care supplies were stored in a clean dry location and not under exposed waste water drain lines in one of one attached provider based clinic.
*Supplies were not maintained past the expiration dates in the operating room carts, operating room cupboards, attached provider based clinic, and nursing supply storage area.*Community use cloth mattresses were protected from contamination from bodily fluids in one of one sleep laboratory (lab).
*The attached provider based clinic, the sleep lab, and the offsite physical therapy clinic were integrated into the provider's infection control program.*Single-use items were not kept after opening in the operating room carts, operating room cupboards.
Findings include:

1. Observations, interviews, manufacturer's direction review, and policy review throughout the course of the survey revealed the provider's infection control program was not integrated and carried out throughout the above listed areas of the hospital and clinics. Refer to C278, findings 1-13.

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Based on observation, interview, manufacturer's direction review, and policy review, the provider failed to ensure:
*Endoscopes were stored in a manner to prevent contamination in one of one sterilization area.
*Endoscopes were cleaned, rinsed, and high level disinfected according to manufacturer's directions for one of one sterilization area.
*Community use linen at one of one offsite physical therapy was disinfected when washed.
*Ensure patient care supplies were stored in a clean dry location and not under exposed waste water drain lines in one of one attached provider based clinic.
*Supplies were not maintained past the expiration dates in the operating room carts, operating room cupboards, attached provider based clinic, and nursing supply storage area.*Community use cloth mattresses were protected from contamination from bodily fluids in one of one sleep laboratory (lab).
*The attached provider based clinic, the sleep lab, and the offsite physical therapy clinic were integrated into the provider's infection control program.*Single-use items were not kept after opening in the operating room carts, operating room cupboards.
Findings include:

1. Observation and interview on 8/6/13 from 11:00 a.m. to 2:45 p.m. with patient care technician K in the soiled utility room of the operating suite revealed:
*The provider used five Olympus endoscopes on the days procedures were performed.
*The endoscopes came from other facilities and were cleaned and disinfected prior to use.
*After being disinfected the endoscopes were hung on a white rack on the wall to dry where they stayed until they were needed in the operating room.
*The rack was approximately three feet from the sinks where soiled endoscopes were cleaned. There was no case or enclosure to protect the endoscopes while they were in storage.
*The clean endoscopes stayed on the rack while the soiled endoscopes were being cleaned.
*The clean endoscopes were exposed to contamination from the cleaning process.
*She was not aware of any policy in regards to the storage of endoscopes.

2. Observation, interview, and manufacturer's direction review on 8/6/13 from 11:00 a.m. to 2:45 p.m. with patient care technician K in the soiled utility room of the operating suite revealed:
*The Olympus endoscopes were cleaned with a scope buddy and were rinsed for thirty seconds.
*She was not for sure how much fluid was flushed through the endoscope in thirty seconds.
*She had watched the video that came with the scope buddy as training on its use.
*She was not for sure why the endoscopes were rinsed for thirty seconds.
*The manufacturer's directions for the 180 series endoscopes refer to a scope buddy rinse matrix for the proper rinse time. That rinse matrix was not available at the facility and she was not aware of what it was or looked like.
*The scope buddy rinse matrix found online stated the time it would take to flush 90 milliliters of fluid through the endoscope.
*The time required to flush a minimum 90 milliliters of fluid through the 180 series Olympus endoscopes was listed as one minute and thirty seconds.

3. Observation, interview, and manufacturer's direction review on 8/6/13 from 11:00 a.m. to 2:45 p.m. with patient care technician K in the soiled utility room of the operating suite revealed:
*The provider used Rapicide high-level disinfectant and sterilant to disinfect the endoscopes.
*The strength of the Rapicide was tested once daily.
*Endoscope procedures were performed at the facility once a month. There could be as many as fourteen scope procedures performed in one day. Each scope used in a procedure would then be disinfected with the Rapicide.
*She was not aware the manufacturer's directions for Rapicide stated "Use Medivators Rapicide Glutaraldehyde Indicator Test Strips chemical indicator strips to monitor glutaraldehyde concentration prior to each reprocessing cycle in order to detect unexpected dilution."
*There was no policy or procedure for the testing of Rapicide.

Review of the provider's July 2010 endoscope cleaning policy revealed:
*"Mechanical cleaning is the first and most important step in removing the microbial burden from an endoscope. Retained debris may inactivate or interfere with the capability of the active ingredient of the liquid-chemical germicide to effectively kill and/or inactivate microorganisms."
*"To achieve adequate flow through all lumens, various adapters or channel restrictors may be required. Refer to the manufacturer's instructions."
*"Flush all channels with the detergent solution to remove debris. Prolonged soaking of the channels in the disinfectant solution may be beneficial if there has been a delay in beginning the cleaning process."
*"Thoroughly rinse the endoscope and all removable parts with clean water to remove residual debris and disinfectant."

4. Observation and interview on 8/6/13 at 5:00 p.m. with physical therapist assistant N at the offsite physical therapy revealed:
*The facility had a supply of linens such as towels, pillow cases, and sheets.
*The person responsible for cleaning the building also did the laundry.
*She did not know what procedures were in place to ensure the laundry was washed appropriately and disinfected.

Interview on 8/7/12 with the rehab manager revealed:
*She confirmed the person responsible for cleaning the building also did the laundry.
*She was not aware of any policy and procedure for the washing of the linen at the offsite physical therapy.
*She was not for sure how that laundry was washed or if it was disinfected.
*There was no policy available for the processing of laundry at the offsite physical therapy.

5. Observation on 8/6/13 at 8:30 a.m. in the medical equipment storage room revealed:
*Seven of seven Povidone Iodine swabsticks had expired November 2012.
*Five of eight individual packets of two-by-two guaze sponges had expired May 2008.

6. Observation and interview on 8/7/12 from 9:40 a.m. to 10:20 a.m. with the clinic manager in the attached provider based clinic revealed:
*Patient care supplies such as Chucks, latex gloves, and paper towels for hand washing stations were stored under the sinks in examination (exam) room 1, exam room 2, and the multipurpose room.
*She was not aware those items were being stored under the sinks.
*The staff had been trained that those items were not to be stored under the sinks.
*Three boxes of outdated sutures were found in the multipurpose room. The sutures had expired March 2008, July 2007, and January 1990.
*She was not aware of the outdated sutures.

Review of the 5/21/13 Infection control policy provided by the clinic manager revealed:
*No under sink storage.
*Monitor for outdated supplies.

7. Observation and interview on 8/7/12 at 1:50 p.m. with respiratory therapist L at the sleep lab revealed:
*The sleep lab had two cloth type mattresses for clients to sleep on.
*The mattresses did not have water proof covers protecting them when clients slept on them.
*She agreed the mattresses would be community use equipment and should have had a cleanable water proof cover to prevent them from becoming contaminated with bodily fluids.

8. Interview on 8/7/13 at 10:50 a.m. with the infection control provider in regards to findings 1-3 revealed:
*She did operating room surveillance every six months.
*She was not sure when the endoscope cleaning process was last monitored.
*She agreed the clean scopes should not have been stored where they were exposed to potential contamination from the cleaning of dirty endoscopes.
*She had never observed the use of the scope buddy during the cleaning process of the endoscopes.
*She was not familiar with Rapicide and was not aware of the manufacturer's instructions for testing the strength for every scope processed.

Interview on 8/8/13 at 10:00 a.m. with the infection control provider in regards to findings 4, 6, and 7 revealed she had not been over to the clinic, sleep lab, or the offsite physical therapy. She had not done any surveillance of those facilities.



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9. Interview on 8/7/13 at 11:00 a.m. with the infection control provider revealed:
*The provider had not integrated the attached provider based clinic into the infection control program.
*She never did environmental rounds in the clinic.
*She was not aware the clinic was part of the hospital.
*She agreed the provider based clinic should have been apart of the provider's infection control.

10. Observation on 8/6/13 at 9:00 a.m. of the operating/intensive care emergency cart revealed:
*The following supplies had expired:
-Two adult #5 laryngeal masks expired August 2011.
-Two Combitubes, one expired May 2009 and the other expired June 2013.
-One endotracheal tube expired July 2002.
*One endotracheal tube had been opened and put back in with the clean supplies

11. Observation on 8/6/13 at 9:30 a.m. of the operating room storage cabinets revealed
*The following supplies had expired:
-One package of 6-0 Vicryl suture had expired October of 1999.
-One package of 8-0 Vicryl suture had expired January 2011.
*The following single-use items had been opened and placed back in with the clean supplies:
-Two packages of suction tubing.
-One Yaker suction handle.
-One Captiflex gastrointestinal device.
-Two opened unlabeled 1000 milliliter bottles of fluid.

12. Observation on 8/7/13 at 2:00 p.m. of the nursing supply storage room in the patient care hallway revealed the following catheter supplies had expired:
*One eighteen French catheter tray expired November 2012.
*One twenty-six French catheter expired July 2009.

13. Interview on 8/7/13 at 4:00 p.m. with the nurse manager regarding findings 8-11 revealed she agreed:
*The provider based clinic should have been integrated into the provider's infection control program.
*The supplies noted in findings 9-12 should have been removed from service.
*The single-use equipment found in findings 10 and 11 should not have been returned to clean supply once opened.
*No formal policy was available related to checking expirations of supplies.

Based on interview, record review, and medical staff bylaws review, the provider failed to ensure:
*One of five sampled surgical patients (18) had a pre-operative history and physical (H&P) on record.
*One of five sampled surgical patients (16) had a pre-operative H&P within thirty days of the procedure.
*One of one sampled in-patient on hospice (14) had an H&P.
Findings include:

1. Review of patient 18's electronic and paper medical record revealed she had no pre-operative H&P on record for her 2/14/13 operation.

2. Review of patient 16's electronic and paper medical record revealed:
*He had an operation on 7/11/13.
*The last time an H&P had been completed was on 6/1/13. No update to that 6/1/13 was completed by physician M prior to performing the 7/11/13 procedure.

3. Interview and medical staff bylaws review on 8/7/13 with the nurse manager revealed:
*She agreed surgical patient 18 should of had a documented H&P on record prior to her 2/14/13 operation.
*She agreed surgical patient 16 should of had an updated H&P prior to going to surgery on 7/11/13.
*The undated medical staff bylaws called for H&Ps to have been completed for every surgical patient prior to surgery.
*The undated medical staff bylaws required physicians to complete and update a patient's H&P if the the prior H&P was completed greater than thirty days prior to surgery.



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4. Closed record review of patient 14 revealed she had been admitted on 2/9/13 and passed away on 2/10/13. Review of that record revealed there had been no H&P recorded for that stay. She had last been seen by her hospice physician on 2/4/13 for recertification of hospice. There was no documentation that recertification statement had been reviewed and acknowledged by the admitting physician.

Interview on 8/7/13 at 11:20 a.m. with the nurse manager revealed there should have been an H&P completed for patient 14's stay at that time. She stated the need for H&Ps to be completed had been addressed numerous times at medical staff meetings.

Interview on 8/7/13 at 2:05 p.m. with the medical records manager revealed all medical records were reviewed weekly to ensure completion of all required forms. She stated when incompletions were found the physician would have been notified to complete the dictation. She stated because patient 14 had been a hospice patient they did not require an H&P to have been completed. She confirmed that patient had been admitted to the hospital as an acute care inpatient on the admission form.

Review of the provider's January 2011 Inpatient Hospice Admission policy revealed if a patient had been admitted to acute care an H&P was required to have been completed.

Based on interview and policy review, the provider failed to ensure contracted dietary services had a quality assurance program. Findings include:

1. Interview on 8/7/13 at 9:30 a.m. with the dietary manager revealed she was unaware of any quality assurance measures that had been completed.

Interview on 8/7/13 at 1:20 p.m. with the nurse manager revealed the dietary services were a contracted service. She had reviewed the quality assurance records and had been unable to find any documented reports for dietary services.

Interview on 8/7/13 at 1:30 p.m. with the contracted service's assisted living center manager stated she was not aware of any quality assurance program directly related to dietary services.

Review of the provider's undated Quality Assurance/Improvement policy revealed:
*Steps would be taken to assure quality and safety of food served, and adequacy of nutrition services and documentation.
*Quality assurance surveys might include sanitation audits, meal preparation and service audits, steam table and tray line audits, meal round audits, customer service questionnaires, meal audits, chart audits, documentation audits, nourishment audits, or meal surveys.

Based on interview, record review, and policy review, the provider failed to ensure activities were provided under the supervision of a qualified activity coordinator for all swing bed patients. Findings include:

1. Interview on 8/6/13 at 9:00 a.m. with registered nurse F revealed:
*The nurse manager was responsible for coordination of activities.
*The patient care technicians were responsible for doing the activities with the patients.

Interview on 8/7/13 at 9:30 a.m. with the nurse manager revealed:
*She was responsible for patient activities.
*She had multiple responsibilities and had not had time to focus on activities.
*She did not have an activity consultant.
*She had not done anything with the development of an activity calendar.

Interview on 8/8/13 at 8:00 a.m. with the director of finance revealed the provider did not have a qualified activity coordinator that supervised the activity program.

Review of the provider's undated activity policy revealed "Activity staff will act under the supervision of a qualified activity coordinator."