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Based on review of personnel files and interview, it was determined the facility failed to assure 8 of 8 (#1, #2, #3, #4, #5, #6, #7, #8) clinical staff did not have criminal background checks performed. Failure to obtain background checks prior to hire did not assure each patient would be protected from abuse or neglect. The failed practice had the potential to affect all patients admitted to the facility. Findings follow:
A. Review of personnel files on 07/27/21 at 12:30 PM showed no criminal background check performed prior to hire for RN (Registered Nurse) # 1,2,3,4,5,6 and CRNA (Certified Registered Nurse Anesthetist) #1 and 2.
B. During an interview with the Medical Records/Quality Supervisor on 07/27/21 at 1:00 PM, she stated that "Criminal Background Checks had only been done on non-licensed personnel because the facility thought that the Board of Nursing had been doing the Criminal Background Checks every time a nurse renewed their license."

Based on review of Rules and Regulations for Hospitals and Related Institutions in Arkansas (2016), observation and interview, it was determined the emergency medications were not secured with a breakaway seal (per regulation) in one of one (Malignant Hyperthermia) emergency cart observed. By not maintaining emergency medications in a manner that makes them rapidly available, the facility could not assure they were ready for an emergent situation. The failed practice had the likelihood to affect all patients who needed emergency medications. Finding follow:

A. Record review of the "Rules and Regulations for Hospitals and Related Institutions in Arkansas (2016), Section 12.S.4, showed that emergency type medications were to be secured with a breakaway seal.
B. During a tour of Surgical Services on 07/26/21 from 12:27 p.m. until 2:25 p.m.; observation showed the Malignant Hyperthermia emergency cart was unlocked and it was not secured with a breakaway seal.
C. During an interview on 07/26/21 at 1:20 p.m., the Director of Surgical Services verified the emergency Malignant Hyperthermia medications were being stored in a cart that was not secured with a breakaway seal.

Based on review manufacturer's recommendations, observation and interview, it was determined the facility failed to adhere to accepted professional standards in that they did not follow manufacturer's recommendations for storage temperature of Mannitol for injection in one of one (Surgical Services) areas toured that stored Mannitol in a blanket warmer. By not following manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the medication available for patient use. The failed practice had the likelihood to affect all patients that have had procedures in the facility that required medications stored properly. Findings follow:
A. Review of Manufacturer's storage recommendations for Mannitol for injection showed the medication should be stored at room temperature, between 68- and 77-degrees Fahrenheit.
C. During a tour of the facility on 07/26/21 from 12:57 p.m. to 2:25 p.m., observation showed the following being stored in a warmer reading 100 degrees Fahrenheit in Surgical Services:
1. #6 - Mannitol 25% / 50 ml.
C. During an interview on 07/26/21 at 1:25 p.m., the Director of Surgical Services verified the Mannitol was stored in the warmer instead of room temperature.

Based on observation, review of Manufacturer's package insert and interview, it was determined the facility failed to date Succinylcholine and Rocuronium when removed from refrigerated storage on one of one (#1) anesthesia cart. By not dating the medications once removed from the refrigerator, the facility could not assure the medications wouldn't still be available for patient use beyond the Manufacturer's recommended expired date. The failed practice had the likelihood to affect all patients admitted for surgical procedures. Findings follow:
A. During a tour of the facility on 07/26/21 from 12:57 p.m. through 2:25 p.m. the following was observed on the Anesthesia Cart: #1 vial of Succinylcholine and #1 vial of Rocuronium not dated with the day removed from refrigerator.
B. Review of package insert for Succinylcholine showed "The multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency".
C. Review of packaging for the Rocuronium showed "Upon removing from refrigerator to room temperature, use within 60 days".
D. During an interview on 07/26/21 at 1:09 p.m. the Director of Surgical Services verified the findings at A.

Based on review of policy and interview, it was determined the facility failed to dispense prescriptions safely in that the pharmacists do not always review the medication orders for appropriateness prior to the first dose being dispensed, for all orders after the pharmacist leaves for the day. By not allowing a pharmacist to review the order prior to dispensing, the facility can not assure the order has been reviewed for; therapeutic appropriateness, therapeutic duplication in the patient's medication regimen, appropriateness of the drug, dose, frequency, and route, medication-medication interactions, medication-food interactions, medication-lab interactions, medication-disease interactions, real or potential allergies or sensitivities or other contraindications. This failed practice had the likelihood to affect all patients who received new orders after the pharmacist left for the day. Findings follow:
A. Record review of the facility's policy titled, "Dispensing of Medications from the Pharmacy," showed in the absence of a pharmacist, nursing will enter the medication order into the computer. Then, after initial entry, a second nurse will deploy the order (approve and verify the medication entry by the first nurse. When the pharmacist returns, they will approve all orders entered by nursing.
B. During an interview on 7/28/21 at 10:45 a.m., the Director of Pharmacy verified a pharmacist does not review every order written after the pharmacist has gone for the day.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition, it was determined the facility failed to install two of two alcohol-based hand-rub (ABHR) dispensers in a manner that ensured a fire hazard would not be present. The failed practice created a fire hazard in the Clean Utility Room and Emergency Department. Findings follow:

A. Review of NFPA 101 2012 Edition: 19.3.2.6(8) showed alcohol-based hand-rub dispensers shall not be installed above an ignition source within a 1-inch horizontal distance from each side of the ignition source.
B. Observation of the Clean Utility Room on 07/26/21 at 01:40 PM showed an ABHR dispenser was installed directly above a light switch on the wall. This finding was verified with the Director of Surgical Services at the time of observation.
C. Observation of the Emergency Department Environmental Services (EVS) Room on 07/28/21 at 09:00 AM showed an ABHR dispenser was installed within a 1-inch horizontal distance from the light switch on the wall. The finding was verified with the Director of Surgical Services at the time of observation.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition, the facility failed to maintain six of six fire-rated door assemblies (Board Room, Cafeteria Corridor Entrance, Cafeteria Lobby Entrance, Kitchen Dry Storage, Kitchen Bathroom, Central Supply) as required by NFPA 101 2012 Edition as follows:

1. Four (Board Room, Cafeteria Corridor Entrance, Cafeteria Lobby Entrance, Kitchen Bathroom) of the six fire-rated door assemblies would not close and latch freely when released,
2. Two (Kitchen Dry Storage, Central Supply) of the six fire-rated door assemblies were not being kept closed and latched
3. Five (Board Room, Cafeteria Corridor Entrance, Kitchen Dry Storage, Kitchen Bathroom, Central Supply) of the six fire-rated door assemblies were not inspected or tested annually.

The failed practices had the likelihood for the fire-rated doors to be left open in the event of a fire, allowing smoke and fire to rapidly transfer into the adjacent spaces. The failed practices had the likelihood to affect all patients, staff, and visitors. Findings were as follows:

A. Review of NFPA 101 2012 edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80. Review of NFPA 80 2010 edition: 5.2.13.3 showed blocking or wedging of doors in the open position shall be prohibited.
B. Review of NFPA 101 2012 Edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80. Review of NFPA 80 2010 Edition: 5.1.3.2 showed fire-rated doors shall be kept closed and latched or arranged for automatic closing
C. Review of NFPA 101 2012 Edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80. Review of NFPA 80 2010 Edition: 5.2.1 showed fire door assemblies shall be inspected and tested not less than annually.
D. Observation of the Kitchen on 07/27/21 at 10:18 AM showed the entrance to Kitchen Dry Storage was constructed of a fire-rated door assembly consisting of a door leaf which was held open by a kickstand installed at the bottom of the door leaf. This finding was verified at the time of observation with the Dietary Manager.
E. Observation of the Administrative Corridor on 07/29/21 at 01:15 PM showed the entrance to Central Supply was constructed of a fire-rated door assembly consisting of a door leaf which was held open by a doorstopper wedged under the bottom of the door leaf. The finding was verified with the Maintenance Supervisor at the time of observation.
F. Observation of the Board Room on 07/27/21 at 9:00 AM showed the doorway connecting the Board Room to the adjacent hallway was constructed of a fire-rated door assembly consisting of a door leaf which did not fully close and latch when released. The finding was verified with the Maintenance Supervisor at the time of observation.
G. Observation of the Kitchen on 07/27/21 at 10:25 AM showed the entrance to the Kitchen Bathroom was constructed of a fire-rated door assembly consisting of a door leaf which did not fully close and latch when released. The finding was verified with the Dietary Manager at the time of observation.
H. Observation of the Cafeteria on 07/28/21 at 9:45 AM showed the Cafeteria Entrance connecting to the adjacent Corridor was constructed of a fire-rated door assembly consisting of a door leaf which did not fully close and latch when released. The finding was verified with the Maintenance Supervisor at the time of observation.
I. Observation of the Cafeteria on 07/29/21 at 01:30 PM showed the Cafeteria Entrance connecting to the Main Lobby was constructed of a fire-rated door assembly consisting of a pair of door leaves, one of which did not latch when closed. This finding was verified with the Maintenance Supervisor at the time of observation.
J. Review of the facility's Fire Door Checklist showed five fire door assemblies (Board Room, Cafeteria Corridor Entrance, Kitchen Dry Storage, Kitchen Bathroom, Central Supply) were not being inspected or tested annually. The finding was confirmed in an interview with the Maintenance Supervisor on 07/29/21 at 01:40 PM in which he confirmed the five aforementioned fire door assemblies were not part of the facility's routine fire door inspection and testing.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 2012 Edition Life Safety Code standards, it was determined the facility failed to maintain 3 fire-rated barriers in accordance with the requirements of NFPA 101 2012 Edition in that three of three fire-rated barriers (Cafeteria/Main Lobby, Administrative Corridor, Board Room) had penetrations which were not sealed with fire-proof sealant to restrict the transfer of smoke. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA 101 2012 edition: 8.3.5.1 showed penetrations for cables, conduits, pipes, and wires that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.
B. Observation on 07/30/21 at 09:40 AM of the fire-rated barrier separating the cafeteria from the Main Lobby showed five penetrating conduits were not sealed by a firestop system or device to prevent the transfer of fire and smoke. The finding was verified with the Maintenance Supervisor at the time of observation.
C. Observation on 07/30/21 at 09:55 AM of the fire-rated barrier in the Administrative Corridor showed one conduit penetrating the barrier was not sealed by a firestop system or device to restrict the transfer of fire and smoke. The finding was verified with the Maintenance Supervisor at the time of observation.
D. Observation on 07/30/21 at 10:10 AM of the fire-rated barrier separating the Board Room from the exit corridor showed one collar penetrating the barrier was not sealed by a firestop system or device to restrict the transfer of fire and smoke. The finding was verified with the Maintenance Supervisor at the time of observation.

Based on interview and review of NFPA 101 2012 Edition, it was determined the facility failed to maintain one of one automatic sprinkler system as required by NFPA 101 2012 Edition in that the automatic sprinkler system's backflow preventer was not maintained in accordance with NFPA 25. The failed practice had the likelihood to affect all patients, staff, and visitors in that the sprinkler system had to the potential to backflow into the potable water supply, contaminating the clean water meant for consumption. Findings follow:
A. Review of NFPA 101 2012 Edition: 9.7.5 showed all automatic sprinkler systems shall be inspected, tested, and maintained in accordance with NFPA 25. Further review of NFPA 25 2011 Edition: 13.6.2.1 showed all backflow preventers installed in fire protection system piping shall be tested annually.
B. Review of the facility's Fire Inspection log showed no backflow testing was performed in the 12 months prior to the survey (July 2020 - July 2021). In an interview with the Maintenance Supervisor on 07/29/21 at 11:15 AM he confirmed the facility's backflow prevention assembly had not been tested in more than 12 months.

Based on observation, interview and review of National Fire Protection Association (NFPA) 99 Health Care Facilities Code 2012 Edition, it was determined the facility failed to use multiple-receptacle power cords in accordance with NFPA 99 standards in two of two patient care areas (Operating Room 1 and Gastrointestinal Procedure Room). The failed practices had the likelihood to affect all patients receiving care in the vicinity of the power cords in that there were no processes in place to ensure the cords would not exceed their ampacity and cause a fire or electrical shock. Findings follow:

A. Review of NFPA 99 2012 Edition: 10.2.3.6 showed flexible power cords with two or more receptacles shall be permitted to be used provided they are permanently attached to the assembly they are powering, the sum of all appliances connected to the outlets does not exceed 75% of the power cord's ampacity, and means are employed to ensure additional devices or nonmedical equipment cannot be connected to the power cords after leakage currents have been verified as safe.
B. Observation on 07/26/21 at 01:00 PM of Operating Room 1 (OR 1) showed electrical patient care equipment was being powered by a flexible power cord with more than 2 receptacles which was plugged into a wall receptacle and resting loose on the floor near the equipment the power cord served. The power cord did not have any means implemented to prevent additional devices from being plugged in to it. The finding was verified at the time of observation with the Director of Surgical Services.
C. Observation on 07/27/21 at 01:30 PM of the Gastrointestinal Procedure Room (Scope Room) showed electrical patient care equipment was being powered by a flexible power cord with more than 2 receptacles which was plugged into a wall receptacle and resting loose on the floor near the procedure bed. The power cord did not have any means implemented to prevent additional devices from being plugged in to it. This finding was verified at the time of observation with the Director of Surgical Services.

Based on observation, interview, and review of the facility's Safety Manual, it was determined the facility failed to use electrical extension cords in accordance with the policies stated in the Safety Manual in two of two extension cord locations (Kitchen and Operating Room 2). The failed practice had the likelihood to affect patients and staff in that there was a risk of electrical shock, fire hazard, and trip hazard present in the Kitchen and Operating Room 2. Findings follow:

A. Review of the facility's Safety Manual showed a policy on page 43 which states: "The use of extension cords shall only be in emergency situations and when used, shall only be on a temporary basis." Further review of the Safety Manual showed an additional policy on page 53 which states: "Do not use extension cords except in an emergency."
B. Observation on 07/27/21 at 10:15 AM of the kitchen showed an extension cord was powering a stereo sitting on a shelf. The finding was verified at the time of observation with the Dietary Manager.
C. Observation on 07/26/21 at 01:25 PM of OR 2 showed a brown extension cord was powering a laptop adjacent to a storage cart.

Based on observation, interview, and review of the Rules for Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to provide an emergency call system for patients in one of one Post-Operative patient bathroom. The finding had the likelihood to affect all patients recovering from surgery in that they would be unable to signal for assistance if they were injured or in pain in the patient bathroom. Findings follow:

A. Review of the Rules for Hospitals and Related Institutions in Arkansas 2021, Section 76: Electrical Standards: F.2 showed an emergency call system shall be provided at each inpatient toilet room.
B. Observation of the Post-Operative area on 07/26/21 at 02:15 PM showed no nurse call system was installed in the patient toilet room. This finding was verified with the Director of Surgical Services at the time of observation.

Based on interview and review of the Rules for Hospitals and Related Institutions 2021 and the facility's Relative Humidity log, it was determined the facility failed to provide the required levels of relative humidity for five of five (Operating Room 1, Operating Room 2, Scope Room, Recovery Room) areas. The failed practice had the likelihood to affect all patients undergoing procedures in these spaces in that a sterile environment was not ensured and an elevated risk of infection was present. Findings follow:

A. Review of the Rules for Hospitals and Related Institutions 2021 showed operating rooms and endoscopy rooms shall be provided with a relative humidity of 20% - 60% and recovery areas shall be provided with a relative humidity of 30% - 60%.
B. Review of the facility's Relative Humidity log showed OR 2 had a relative humidity level greater than the maximum amount of 60% relative humidity for 82 of 100 days recorded in the four months prior to the survey (April 2021, May 2021, June 2021, July 2021), OR 1 had a relative humidity level greater than the maximum amount of 60% relative humidity for 86 of 100 days recorded in the four months prior to the survey (April 2021, May 2021, June 2021, July 2021), the Scope Room had a relative humidity level greater than the maximum amount of 60% relative humidity for 83 of 92 days recorded in the four months prior to the survey (April 2021, May 2021, June 2021, July 2021), and the Recovery Room had a relative humidity level greater than the maximum amount of 60% relative humidity for 80 of 90 days recorded in the four months prior to the survey (April 2021, May 2021, June 2021, July 2021).

Based on review of the Rules for Hospitals and Related Institutions 2021 and interview, it was determined the facility failed to ensure OR 1, OR 2, and the Scope Room were maintained at the required temperature range of 68-73 degrees Fahrenheit. The failed practice had the likelihood to affect all patients undergoing procedures in these spaces in that there was no practice in place to ensure a temperature conducive to a sterile environment was provided and an elevated risk of infection was present. Findings follow:

A. Review of the Rules for Hospitals and Related Institutions 2021 showed operating rooms and endoscopy rooms shall be provided with a dry bulb temperature of 68-73 degrees Fahrenheit.
B. In an interview on 07/29/21 at 09:30 AM the Maintenance Supervisor stated there was no process in place to monitor the temperatures of OR 1, OR 2, or the Scope Room.

Based on observation and interview, it was determined the facility failed to mitigate the risk of cross contamination in that they were storing a clean optical medications/devices refrigerator in one of one Soiled Utility room in Surgical Services. By not storing clean separate from dirty, the facility could not assure the clean optical medications/devices would not get contaminated by being stored in the Soiled Utility room (dirty area). The failed practice had the likelihood to affect all patients that are treated in Surgical Services. Findings follow:

A. During a tour of the facility on 07/26/21 from 12:57 p.m. to 2:25 p.m., observation showed a clean optical medications/devices refrigerator in the Soiled Utility room in Surgical Services. Inside the refrigerator was:
#27- Duovisc (optical surgical agent);
#1- 1000 milliliter bag of Sodium Chloride Intravenous Solution; and
#20- doses of Hylenex (hyaluronidase human injection).
B. During an interview on 07/26/21 at 1:40 p.m., the Director of Surgical Services verified the findings at A.


40282

Based observation and interview it was determined the facility failed to follow standards of practice of maintaining a sanitary environment in that there was no implementation of the Arkansas rules and regulations for Hospitals and Related Institutions 2021 for Table 9 by not monitored the water temperature at the washer site daily to assure the water temperature was found to be below 120 degrees Fairenheight (F). The failed practice did not ensure textiles and fabrics were free from contaminants and patients would be protected from likely sources of infection. The failed practice had the potential to affect all patients and staff. Findings follow:
A. During tour of the Laundry Room on 07/28/21 at 1:30 PM there was no documentation or logs of laundry water being tested for temperaturesat the washer site.
B. During interview with the Maintenance Director on 07/30/19 at 10:40 AM, he stated that there was no documentation or monitoring of the laundry water only at the boiler site once per month.
C. The above findings in A verified with the Environmental Service Manger on 07/28/21 at 2:00 PM.


42990

Based on manufacturer's instructions for use, observation, review of AORN (Association of periOperative Registered Nurse) guidelines, and interview, it was determined the facility failed to provide a sanitary environment in the High Level Disinfection of four of four Endoscopes in the Endoscopy Lab. By not assuring Endoscopes were cleaned according to Manufacturer's Instructions for use, the facility could not assure patients would be protected from infection and had the likelihood to expose all patients having Endoscopy procedures to possible sources of infection. Findings follow:
A. Review of manufacturer's instructions for use for the Olympus 180 PCF-Q180AL/1 Gastroscope showed, "following high-level disinfection, it was very important not to recontaminate the endoscope and accessories with potentially infectious microorganisms."
B. During observation of the cleaning of tan endoscope after use on 07/27/21 at 12:10 PM Surveyor #1 observed Surgical Technician #1 placing the Gastroscope and accessories back onto the contaminated field prior to placing them in the automated washer after she had leak tested and washed them in the detergent solution.
C. Review of AORN guidelines for sterilization and disinfection of flexible endoscopes showed, "cleaning should progress from clean to dirty areas." "Cross contamination can result when soiled items were placed in close proximity to clean items or were placed on surfaces upon which clean items were later placed. Separation of the decontamination area from the clean area minimized the potential for contamination of clean and processed endoscopes."
D. In an interview with the Director of Surgery/Endoscopy on 07/29/21 at 11:00 AM, she confirmed Surgical Technician #1 was not following the manufacturers' instructions for use for the Olympus 180 PCF-Q180Al/1 Gastroscope or AORN guidelines for sterilization and disinfection of flexible endoscopes. She confirmed the facility followed AORN guidelines for High Level Disinfection of Endoscopes.


Based on review of temperature log, observation, and interview, it was determined the facility failed ensure one of one refigerators in the PACU was maintained to operate within the defined parameters of 36-45 degrees on 134 of 137 days from 01/01/21 to 07/ 21/21. The failed practice did not assure acceptable levels of safety and quality for items stored in the refrigerator and had the liklihood to affect all patients in the receiving care in the PACU. Findings follow:
A. During a tour of the PACU on 07/26/21 at 2:15 PM, the refrigerator log was reviewed. The temperature log showed a defined temperature range of 36-45 degrees Fahrenheit. On 134 of 137 days form 01/01/21 to 07/21/21, the temperature was out of range without evidence of corrective action taken.
B. In an interview with the Director of Surgery/Endoscopy during a tour of the PACU on 07/26/21 at 2:15 PM she stated that she "was aware the temperatures were not within the defined temperature range; the refrigerator was old and if you adjusted the temperature just a little bit the temperature would be easily out of range." She verified the temperatures were out of range.

Based on review of AORN guidelines, observation and interview, it was determined the facility failed to achieve and maintain high standards of medical practice and patient care by not performing a "time-out" (transfer of information) prior to the beginning of an endoscopy procedure. By not performing a "time-out" prior to beginning an endoscopy procedure, the facility could not assure prevention of communication breakdown and had the likelihood to affect all patients having endoscopy procedures. Findings follow:
A. Review of AORN guidelines for Transfer of Patient Care Information Recommendation 1 showed, 1) "A transfer of patient information process should be developed, standardized, and based upon the best available and most current evidence. Standardization of transfer of patient information processes improves the accuracy, reliability, and quality of information. Standardized hand offs and transfer protocols were identified as methods to prevent communication breakdowns." 2)
"All phases of patient care should be addressed in the process for transferring patient information. Phases of care should include, but not be limited to, the surgeon's office; scheduling department; preanesthesia testing unit; preoperative holding unit; OR; procedure room; PACU; and other areas where postoperative care was provided."
3) The Intraoperative transfer of information phase should include:
a) Verification of correct patient (ie. two identifiers), site, position, and procedure
b) Allergies
c) Diagnosis, surgeon, and anesthesia type
d) Current or pending laboratory or other test results
e) Precautions
f) Advanced directive (if indicated)
g) Special equipment, instrumentation, implants (if indicated)
h) Surgical count status (if indicated)
i) Family communication (if indicated)
j) Available blood products and blood loss (if indicated)
k) Catheter and/or invasive lines present
l) Medications (including dose and time)
m) IV irrigation and fluids
n) Specimens
o) Thermal interventions (if indicated)
p) DVT prophylaxis (if indicated)
q) Patient family and/or significant other information (if indicated)
B. During observation of an endoscopy procedure on 07/27/21 at 11:50 AM, it was noted the staff failed to perform a "time-out" prior to beginning the procedure.
C. In an interview with the Director of Surgery/Endoscopy on 07/29/21 at 11:00 AM, she confirmed the facility was not doing "time-outs" on Endoscopy Procedures performed at the Facility. She stated that the Facility staff were only doing the "time-outs" for surgical procedures. She confirmed that the Facility followed AORN Guidelines for Peri-Operative Practice.