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Based on observation, review of manufacturer's guidelines, review policies and procedures, review of the Director of Perioperative Services personnel file and interview, it was determined the facility failed to assure: cleaning of the operating room (OR) between cases was performed and in accordance with the product manufacturer's guidelines; sterilized instruments and equipment was packaged, handled, labeled and stored to ensure sterility; endoscopes were stored to prevent contamination; a process was in place for fire prevention with the use of alcohol containing skin preps and the individual designated as responsible for the OR was experienced. The accumulative effects of the failed practices had the potential to affect the health and safety for all patients admitted for surgery. The facility had nine surgical patients scheduled for surgery on 08/23/11. The findings were:

A. Observation on 08/23/11 from 1410 to 1600 revealed ORs were unclean but were identified as clean and ready for use as follows:
1. OR #1 was identified by the Director of Perioperative Services as clean and ready for use. The Anesthesia cart had an accumulation of dust on the top and lower surfaces; Bair Hugger, Model 505, was noted with a red smeared area on the flexible white tubing, Surveyor #1 asked the Director of Perioperative Services if the smeared area was blood, she replied "could be". The Director of Perioperative Services confirmed the observations at 1455.
2. OR #2 was identified by the Director of Perioperative Services as clean and ready for use. Blue surgical towels were wrapped and taped around a 1000 milliliter bottle of Lactated Ringer's IV (intravenous) solution and was noted laying on the bottom shelf of a piece of equipment. Scrub Technician #1 stated, "we use it as an axillary roll." The Director of Perioperative services confirmed the findings at 1550 and stated "it wasn't used on the two previous cases. It was not used today." Leaning on the wall, two metal hooks were noted with a soiled porous type sling attached. Scrub Technician #1 confirmed the findings and stated "we use those to hold the feet for vaginal procedures." Confirmed they had been used previously and the items were disposable at 1555.
3. OR #4 was identified by the staff as the GI (gastrointestinal) Room. The Director of Perioperative Services stated the room was clean and ready for use. The room contained a procedure table, stored along one wall, with multiple items stored on top of the procedure table. Items on top of the table included: a cardboard box that contained 27 opened and unopened items and 16 sheets, 2 pillows, and three towels. The Director of Perioperative Services stated the OR table was "there if needed, the patients usually have their GI procedure while on the stretcher." Dust was present on the surface of equipment in the room. There were four endoscopes stored hanging along the wall, unprotected. The findings were confirmed by the Director of Perioperative Services at 1530.

B. Observation of the cleaning process for between surgical cases on 08/24/11 at 1128 in OR #4 revealed:
1. At 1132, RN (Registered Nurse) #1 was observed spraying the surface of the OR stretcher with a product labeled "Virex 256"and then immediately wiped it dry.
2. RN #1 was asked by Surveyor #1 in an interview at 1140, how the Virex 256 was to be used for cleaning. She stated "I don't know that it has an actual contact time." RN #1 stated she had only been working at this hospital three days. Stated she had not received any type of infection control training or training for cleaning between surgical cases.
3. ORT (OR Technician) #2 was identified by the Director of Surgical Services as a long term employee and was interviewed at 1145. ORT #2 identified the cleaning product used as Virex 256. Surveyor #1 asked ORT #2 how the cleaning product for the OR was used and she stated " We spray it on and then wipe it off. It stays on about 30 seconds."
4. Review of policy #B23 for Environmental Sanitation" on 08/25/11 revealed "At the end of a procedure all contaminated linen, supplies, and equipment are removed and the entire room is wiped down and the floor mopped using an approved germicidal solution."
5. In an interview with the Director of Perioperative Services 08/24/11 at 1145, the observation findings and label directions for the cleaning product were reviewed. The Director of Perioperative Services stated, "everyone always has infection control training, but we had a call in today, so she (RN #1) was following another nurse." The product label directions for the "Virex 256" stated, "Remove gross filth. Apply use solution to hard nonporous surfaces. Allow to remain wet for 10 minutes. Then wipe or allow to air dry."

C. Observation of the sterile supplies in Emergency Room and OR and interview revealed expired supplies were available for patient use as follows:
1. The Central Sterile Technician was interviewed on 08/24/11 at 1005 and stated "We don't use expiration dates, they are good unless it is damaged."
2. On 08/24/11, the Chief Nursing Officer provided a document from the sterilization wrap manufacturer that stated "Sterility Maintenance" Real-time testing simulating clinical use supports maintenance of package sterility for at least 30 days. Store wrapped packages as recommended in the ANSI/AAMI and AORN guidelines. Location should be clean dust free, and away from florescent or ultraviolet light, use first in, first out stock rotation. Caution do not stack trays. Stacking trays can result in damage to the wrap caused by undue pressure from the weight."
3. There were 30 items noted stored on a supply shelf in the "Cardiac Room" of the Emergency Services Area on 08/24/11 at 0920. The items were in a blue overwrap without a protected heat sealed dust cover that expired and had a sterilization date over 30 days as required by the manufacturer's guidelines. The items had a sticker in place with the date of sterilization and the statement "Indefinite date unless damaged or open" which was in conflict with the manufacturer guidelines of the blue overwrap.
4. Examples of observed items that were expired included: "ER Basins", dated 06/27/05; 03/27/07; 07/03/10;10/02/07; "ER Delivery tray" sterilized 03/07/11; OR #1: Medline 18 Fr suction catheter, 4 of 4 expired 03/11; Spinal Needle Tray, 1 of 1, expired 10/09; OR #4: Betadine Solution 16 oz., 1 of 2, expired 11/2010; Betadine Scrub 1 of 2 expired 05/2011; Suture Cart: Cuticular 4-0 Ethibond Excel 3/8 inch, 13 expired 01/2010; Prolene 5-0, Blue Monofilament, 12 expired 07/2011.

D. Observation on 08/23/11 at 1150 of the PACU (Post Anesthesia Care Unit) revealed supplies that were expired as follows:
1. Bed #1; T trach adapter, expired 07/06;
2. Bed #2 Portex First Responder Ambu Bag, expired 10/10.
3. Bed #3 T trach adapter, expired 12/09.
4. The findings confirmed by the Director of Perioperative Services 08/23/11 1150.

E. The facility failed to provide a policy and procedure for the use of alcohol based skin preparations that include fire prevention and safety, and failed to assure staff was trained in processes to assure safety. In an interview with the Director of Perioperative Services during tour 08/23/11, she confirmed the facility did use a product for skin prep that included alcohol. Review of documentation of training provided by staff revealed no specific training on fire prevention with the use of alcohol based skin preparations, such as allowing the product to dry completely prior to draping and avoiding pooling of product. The Chief Nursing Officer was interviewed 08/26/11 at 1400 and stated there was not a specific policy for the prevention of fires associated with skin preparation solutions that contained alcohol.

F. Review of the personnel file for the Director of Perioperative Services on 08/26/11 revealed there was no documentation of prior experience or specialized training in the OR or perioperative environment. Review of the job description, provided by the Chief Nursing Officer on 08/26/11, revealed "Primary Function: The Nurse Manager Surgical Services is responsible and accountable for the overall management of perioperative nursing services within a variety of settings: OR, PACU, CS (central sterile), OPS (outpatient services), and GI Lab." Prequisities were listed as "A minimum of three years of nursing experience in the speciality area preferred or other experience relevant to position requirements." By interview on 08/26/11 at 1140, the Chief Nursing Officer, confirmed the Registered Nurse identified as the Director of Perioperative Services was responsible for the supervision of the OR and did not have experience in the OR upon hire; no additional specialized training had been provided by the facility for the employee.

Based on review of the Patient Handbook "How to Report Complaint or Grievance" brochure, Notice of Privacy Practices, Patient's Rights and Responsibilities, and Complaint/Grievance Policy and interview, the facility failed to ensure each patient or patient's representative received the address and phone number for lodging a grievance with the Arkansas Department of Health. The failed practice did not ensure patients or their representatives were provided information for mailing a written complaint or grievance to the Arkansas Department of Health. This practice had the potential to affect all patients admitted to the facility. The findings follow:

A. On 08/24/11 at 1400, review of the facility's Patient Handbook did not include the address for the Arkansas Department of Health.
B. On 08/25/11 at 1015, review of the facility's How to Report Complaint or Grievance brochure did not include the address for the Arkansas Department of Health.
C. On 08/24/11 at 1435, review of the facility's Notice or Privacy Practices did not include the address for the Arkansas Department of Health.
D. On 08/24/11 at 1410, review of the facility's Patient's Rights and Responsibilities did not include the address for the Arkansas Department of Health.
E. On 08/24/11 at 1500, review of the facility's policy, Complaint/Grievance Policy did not include the address or phone number for the Arkansas Department of Health.
F. The findings were confirmed in an interview with the Chief Nursing Officer on 08/25/11 at 1305.

Based on clinical record review, review of Medical Staff Bylaws and Rules and Regulations 2010 and interview, the facility failed to ensure physician orders were authenticated within the 24 hour timeframe as established by the Medical Staff Bylaws and Rules and Regulations 2010 for 11 (#3, #4, #8, #10, #11, #22, #23, #25, #26, #27 and #28) of 28 (#1-#28) patients. The failed practice did not allow for early identification and correction of errors or the physician's agreement with the order documented in the clinical record . The failed practice had the potential to affect all patients admitted to the facility. The findings follow:

A. Review of physician orders for Patient #3 revealed verbal orders written on 08/17/11 at 0745, 08/17/11 at 0800, 08/17/11 at 0850, 08/17/11 at 1400 and 08/17/11 at 1900 without evidence of a physician signature authenticating the orders.
B. Review of physician orders for Patient #4 revealed verbal orders written on 08/19/11 at 1445; telephone orders written on 08/17/11 at 2230, 08/19/11 at 1414; "Pre CVL/PICC (Central Venous Line/Peripherally Inserted Central Catheter) Line Placement Radiology" orders on 08/19/11 at 1130 and "Post CVL/PICC Line Placement" orders on 08/19/11 at 1430 without evidence of a physician signature authenticating the orders.
C. Review of physician orders for Patient #8 revealed verbal orders written on 08/21/11 at 1550, 08/22/11 at 1030; telephone orders written on 08/21/11 at 1845, 08/21/11 at 2015, 08/23/11 at 1840, and "Present on Admission Orders" written on 08/21/11 at 0410 without evidence of a physician signature authenticating the orders.
D. Review of physician orders for Patient #10 revealed verbal orders written on 08/22/11 at 0730, 08/22/11 at 1230, 08/22/11 at 1235, 08/23/11 at 1000, 08/23/11 at 1015; telephone orders written on 08/22/11 at 0645, 08/22/11 at 1415 and "Routine Pre-Operative Anesthesia Orders" on 08/22/11 at 0645 without evidence of a physician signature authenticating the orders.
E. Review of physician orders for Patient #11 revealed verbal orders written on 08/17/11 at 2145, 08/20/11 at 0930, 08/21/11 at 0815, and 08/21/11 at 1800 without evidence of a physician signature authenticating the orders.
F. Review of physician orders for Patient #22 revealed verbal orders written on 08/03/11 at 2330, 08/06/11 at 1500, 08/10/11 at 1240, 08/10/11 at 1245 and telephone orders on 08/04/11 at 1745 without evidence of a physician signature authenticating the orders.
G. Review of physician orders for Patient #23 revealed Pre-Op orders written on 08/17/11 without evidence of a physician signature authenticating the orders.
H. Review of physician orders for Patient #25 revealed verbal orders written on 08/22/11 at 0730 and 08/22/11 at 0845 without evidence of a physician signature authenticating the orders.
I. Review of physician orders for Patient #26 revealed verbal orders written on 08/18/11 at 0715, 08/18/11 at 1100, 08/18/11 at 1300; "Routine Pre-Operative Anesthesia Orders" on 08/18/11 at 0715; "Pre-Op Orders for Dr. (named)" on 08/18/11 at 0715 and "Post-Op Orders for Dr. (named)" on 08/18/11 at 1330 without evidence of a physician signature authenticating the orders.
J. Review of physician orders for Patient #27 revealed "Routine Pre-Operative Anesthesia Orders" written on 08/08/11 at 0815 without evidence of a physician signature authenticating the orders.
K. Review of physician orders for Patient #28 revealed verbal orders written on 08/01/11 at 1440, 08/01/11 at 1445 and 08/04/11 at 1805 without evidence of a physician signature authenticating the orders.
L. The findings were confirmed in interviews with the Chief Nursing Officer on 08/25/11 at 1305, the Director of Quality/Risk on 08/25/11 at 1500 and the Director of the Medical Surgical Unit and House Pool on 08/26/11 at 1005.

Based on observation, preventative maintenance documentation review and interview, it was determined the facility did not meet Life Safety Code requirements related to the use of maintenance-free batteries on generators and monthly testing of Line Isolation Monitors. The use of maintenance-free batteries are prohibited on Type 1 Essential Electrical Systems per NFPA 110, Section 3-5.4.5. Battery cells cannot be inspected on maintenance-free batteries, which assure batteries are capable of starting the generator if normal power was lost. Failure to test Line Isolation Monitors monthly had the potential to affect the health and safety of patients in all critical care areas served by the monitors as the proper functioning of the monitors to prevent electrical shock could not be assured. The failed practices had the potential to affect all patients admitted to the facility. The facility had 39 patients on the first day of the survey (08/23/11). See Tags K106 and K130.

Based observation of the building air conditioning control computer system and interview, it was determined temperature (68-73 degrees Fahrenheit) and humidity (30-60%) levels were not monitored as specified in the Arkansas Department of Health, Rules and Regulations for Hospitals and Related Institutions (Section 26.B.1; Section 74.D.1-Table 3) in four of four Operating Rooms and failed to take corrective action when the levels were outside the required ranges. Failure to monitor temperature and humidity and take corrective actions when outside the required ranges had the potential to affect the health and safety of surgical patients due to the potential of bacterial growth and compromising of wrapped sterile instruments. The failed practice had the potential to affect all patients admitted for surgery. The facility had nine surgical patients scheduled for surgery on 08/23/11. The findings follow:

A. In an interview on 08/23/11 at 1500, the Director of Engineering was requested to demonstrate the method of monitoring temperature and humidity in the operating rooms. He demonstrated the function of the building air conditioning control computer system that was capable of displaying the temperature and humidity in the rooms at the present time. He stated the system did not maintain historical tracking logs. He stated maintenance staff periodically monitored the computer station throughout the day, but readings were not recorded.
B. On 08/23/11 at 1515, observation of the computer control system display revealed the humidity in Operating Room #1 was 64.79%, in Operating Room #2 was 76.55%, in Operating Room #3 was 65.85% and in Operating Room #4 was 85.93%.
C. In an interview on 08/23/11 at 1515, the Director of Engineering stated the Engineering Department did not document corrective actions taken when humidity levels outside the required range was displayed on the computer control system.at 1805 without evidence of a physician signature authenticating the orders.
L. The findings were confirmed in interviews with the Chief Nursing Officer on 08/25/11 at 1305, the Director of Quality/Risk on 08/25/11 at 1500 and the Director of the Medical Surgical Unit and House Pool on 08/26/11 at 1005.

Based on review of the personnel file for the Director of Perioperative Services and interview with the Chief Nursing Officer, it was determined the facility failed to assure the Registered Nurse identified as responsible for the supervision of the operating room, was a registered nurse with experience in the provision of surgical services. The failed practice had the potential to affect the health and safety of all patients admitted for surgery. The facility had nine surgical patients scheduled for surgery on 08/23/11. See A-0940 for details.