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Based on clinical record review and interview, it was determined the facility failed to ensure an Important Message from Medicare was provided within two days prior to discharge for one of one (#2) Medicare patient who had been discharged. The failed practice created the potential for patients to be uninformed of their rights and could affect any Medicare patient admitted to the facility. Findings follow.

A. Review of the clinical record for revealed Patient #2 was admitted 08/07/15 through 08/12/15. There was no evidence of an Important Message from Medicare within two days prior to discharge.
B. During an interview on 08/14/15 at 1515, the Chief Nursing Officer confirmed the findings for the Important Messages from Medicare.

Based on Governing Board Meeting Minutes, Medical Executive Committee Meeting Minutes, and Quality Review Committee Minutes from August 2014 through July 2015 and interview, it was determined the facility failed to ensure two (Food and Nutrition Services and Emergency Services) of three (Food and Nutrition Services, Emergency Services, and Surgical Services) QAPI (Quality Assessment/Performance Improvement) indicators traced had the frequency of data collection documented. The failed practice did not ensure data was being collected in a manner specified by the Governing Board. Findings follow.

A. Review of QAPI indicators traced for Food and Nutrition Services and Emergency Services revealed there were no specifics as to the frequency for the data collection.
B. During an interview on 08/12/15 at 1355, the Director of Quality confirmed there was no frequency specified for data collection.

Based on interview, it was determined the facility failed to ensure staff was aware of how and whom to report a medication error or adverse patient event for two of two (Registered Nurse #1 and #2) staff interviewed. The failed practice did not allow for medication errors, and adverse events to be tracked and trended and had the potential to affect any patient in the facility due to lack of knowledge of trends. Findings follow.

A During an interview on 08/10/15 at 0950, Registered Nurse #1 was asked what she would do if a patient had an adverse reaction to a medication. She stated, "Stop the medication and notify the charge nurse and physician." When asked if there was a form to fill out to report the incident she replied, "no."
B. During an interview on 08/10/15 at 1020, Registered Nurse #2 was asked what she would do if a patient had an allergic reaction to a medication. She stated, "Tell the doctor immediately." When asked if there was a form to fill out to report the incident she replied, "no."

Based on review of August 2015 Monitor/Defibrillator and Crash Cart Check Records, review of policy and interview, it was determined the facility failed to ensure the contents of emergency supply kits/carts were checked each shift (per policy) in three (Medical/Surgical Unit, Emergency Services (ES) and Intensive Care Unit) of four (Medical/Surgical Unit, ES, Intensive Care Unit (ICU) and Surgical Services) areas toured. The potential existed for the emergency supply kits/carts not to have medications/supplies/functional equipment present for patient emergencies. The failed practice had the likelihood to affect all patients who needed medications/supplies/ functional equipment in an emergency. Findings follow:

A. During a tour of the facility on 08/10/15, the following carts had missing inspections documented on the August 2015 Monitor/Defibrillator and Crash Cart Check Records:
1) Medical/Surgical Unit 1-East was missing 1 AM shift (08/02) and 3 PM shifts (08/04, 08/05, 08/06);
2) ICU Cart #1 was missing 1 PM shift (08/06);
3) ICU Cart #2 was missing 2 AM shifts (08/06, 08/07) and 2 PM shifts (08/05, 08/06);
4) ES Cardiac Cart was missing 1 AM shift (08/03);
5) ES Trauma Cart was missing 1 AM shift (08/03);
6) ES Neonate Cart was missing 1 AM shift (08/03) and 3 PM shifts (08/06, 08/07, 08/09); and
7) ES Pediatric Cart was missing one AM shift (08/03).
B. A review of policy titled Crash Carts-Inspections, Maintenance and Exchange stated "The crash cart shall be checked each shift by licensed nursing personnel to: a. Verify the integrity of the locks; b. Assure that all equipment on the top and sides of the crash cart is available; c. Assure functioning of monitor/defibrillator."
C. The findings from Medical/Surgical Unit and ES were verified by the Chief Nursing Officer at the time of observation; the findings from ICU were verified by the Registered Nurse Consultant at the time of observation.

Based on observation, review of policy and interview, it was determined the facility failed to ensure prescription only medications were not available to non-licensed personnel in one (Surgical Services) of four (Surgical Services, Intensive Care Unit, Emergency Services and Medical/Surgical Unit) patient care areas toured. By not controlling prescription only medications, the facility could not assure the safety, integrity or efficacy of the uncontrolled medications. The failed practice had the potential to affect all patients that were admitted into the facility for procedures. Findings follow:
A. A tour of Surgical Services was conducted on 08/10/15 between 1355 and 1500; observation revealed the following prescription only medications unsecured in unlocked medication carts:

1) #1-Sodium Chloride 0.9 % 25 ml (milliliter) IV (intravenous) bag;
2) #14 -Promethazine 25 mg (milligram)/ml vials for injection;
3) #1-Nitrostat 0.4 mg vial;
4) #5-Promethazine 25 mg tablets;
5) #4-Ondansteron 4 mg tablets;
6) #7-Ondansteron 4 mg/2 ml vials for injection;
7) #3-Cefazolin 1 Gram vial for injection;
8) #1-Gentamycin 80 mg vial for injection; and
9) #77-Normal Saline Flushes 10 ml syringes.
B. Review of policy titled General Statements on Medications stated "Medications throughout the facility will be securely stored to prevent unauthorized access."
C. During an interview on 08/110/15 at 141, the Chief Nursing Operator verified the prescription medications were unsecured.

Based on observation, review of policies, review of manufacturer's recommendations and interview, it was determined the facility failed to follow manufacturer's directions in that one of one Tuberculin Purified Protein Derivative (PPD) was observed opened but not dated. By not dating the vial upon opening, the facility could not assure the safety or efficacy of the medication past 30 days. The failed practice had the likelihood to affect all employees/patients at the facility. Findings follow:

A. During a tour of the Medical/Surgical Unit on 08/10/15 at 1510, observation revealed a vial of Tuberculin PPD in the medication refrigerator, opened and not dated.
B. Review of policy titled General Statements on Medications stated "All medications will be stored to USPDI (United States Pharmacopoeia Drug Information) and manufacturer specifications."
C. Review of Manufacturer's recommendation for storage of Tuberculin PPD revealed "Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency." The facility was not aware of the manufacturer's recommendation of a 30 day expiration date.
D. During an interview on 08/10/15 at 1520, the Chief Nursing Officer verified the Tuberculin PPD was opened, available for use, and not dated to indicate when it was opened.

Based on review of policy, review of Medication Variance Reports and interview, it was determined the facility failed to notify the practitioner who ordered the medication of the medication variance (error) for 12 (Medication errors # 2-7,9-11, and 14-16) of 16 (Medication errors #1-16) reviewed. By not reporting medication errors to the prescribing physician responsible for the patient's care, the patients' physicians were not being kept abreast of the patient's condition and were not involved in the decisions of what to do after the error occurred. The failed practice had the potential to affect all patients. Findings follow:

A. Review of policy titled Medical Errors stated "Fill out a Variance Report...Notify in the following order: 1. The attending physician ...2. Notify Pharmacy if applicable ...3. Document on the report form the time and name of physician and response ..."
B. Review of Medication Variance Forms from 01/01/15 through 08/11/15 revealed Medication errors #2-7, 9-11 and 14-16 were not reported to the prescribing physician.
C. During an interview on 08/11/15 at 1500, the Director of Pharmacy verified the physician was not notified on the above mentioned medication errors.

Based on observation, interview and review of Accu-chek Inform II Procedure, it was determined the facility failed to assure the point of care device used to measure blood glucose was cleaned and disinfected after use for one of one patient (#2) observed at the time the blood glucose test was performed. Failure to clean and disinfect the point of care device did not assure patients would be protected from infection and communicable disease. The failed practice affected patient #2 and was likely to affect any patient with physician orders for bedside blood glucose testing.

A. Observation on 08/11/15 at 1100 on the Medical/Surgical Unit revealed Licensed Practical Nurse (LPN) #2 retrieved a rigid plastic case that contained the Accu-chek Inform II point of care device used to measure blood glucose, two by two gauze (not individually wrapped), self-retracting lancets and alcohol disinfecting wipes. LPN #2 took the case and contents into the room of Patient #2. The Accu-chek Inform II point of care device was placed directly on the patient's bed during use. Upon conclusion of the testing, the Accu-chek device was placed directly back into the case used for transport and returned to the nursing station. At the nursing station, LPN #2 placed the Accu-chek Inform II back in the charging dock at the nursing station. LPN #2 confirmed that she had completed the task. LPN #2 failed to disinfect the Accu-chek Inform II device or the case the contaminated device was placed in for transport at the conclusion of use. This was confirmed by LPN #2 and Registered Nurse (RN) #4 at 1106 on 08/11/15.
B. Registered Nurse (RN) #4 provided the document "Accu-chek Inform II Procedures" on 08/11/15 at 1110. The section "Cleaning and Disinfecting" stated: "Meters should be cleaned and disinfected between each patient use." and "Always use Clorox Germicide Wipes or Super Sani-Cloth Germicidal Disposable Wipes."


Based on observation and interview it was determined the facility failed to assure equipment was stored and maintained to prevent infection in the Surgical Suite in that the bronchoscope was stored coiled in a drawer;Yankauer Suction was opened; bins had broken lids that were used to transport instruments; and failed to assure an expired Straight Tubing Connector was not available for use on patients in the post anesthesia recovery unit. The facility could not assure patients would be protected from infection. The failed practice was likely to affect all patients who have surgery at the facility. The findings were:
A. Observation on tour 08/10/15 from 1420-1520 revealed a Pediatric Bronchoscope (Olympus LF2-2412607) that was coiled, resting on a small cloth and stored in the drawer of a metal cart, identified by the Surgical Services Director as the "Difficult Airway Cart." The Surgical Services Director stated he was not aware of the last time the bronchoscope had been used. There was no documentation available of the last time the scope had been high level disinfected as stated by the Surgical Services Director at the time of observation.
B. On 08/10/15 at 1445 the Director of Surgical Services confirmed Operating Room #3 was ready for patient occupancy. Observation on 08/10/15 at 1445 revealed a Yankauer Suction device, in an opened package, attached to suction tubing and was confirmed by the Surgical Services Director at the time of observation.
C. Observation of the sterile processing decontamination room on 08/10/15 at 1500 revealed bins identified by the Central Sterile Coordinator as used to transport soiled equipment from the operating room to the decontamination room. At the time of observation four of seven bins had cracked lids and missing portions that created open areas in the lids that exposed the contents during transport. The findings were confirmed by the Central Sterile Coordinator on 08/10/15 at 1500.
D. Observation of Bay #3 in the Post Anesthesia Recovery Unit on 08/10/15 at 1420 revealed one of one Medi-Vac, 5 in 1, Straight Tubing Connector, at the bedside with a manufactures expiration date of 10/31/14. The Director of Quality confirmed the finding of expired connector at the time of observation.


Based on observation, interview, review of policy and Olympic Mini Pasteurmatic logs it was determined the facility failed to assure the Pasteurmatic and Olympic Sterile Dryer used to process equipment in the Cardiopulmonary Department was cleaned, was cycle timed, had temperature verification, had bi-weekly check of the water temperature, and had maintenance performed as required per policy. The facility could not assure patients would be protected from infection. The failed practice is likely to affect patients who required the use of the equipment. The findings were:

A. Observation of the Respiratory/Cardiopulmonary Department on 08/12/15 from 1400-1430 revealed an Olympic Mini Pasteurmatic and Olympic Sterile Dryer. The Director of Cardiopulmonary stated the Pasteurmatic and Olympic Sterile Dryer were used to process equipment in the Cardiopulmonary Department and Sleep Disorder Center.
B. Observation on 08/12/15 at 1400 of the Olympic Sterile Dryer revealed an accumulation of dust on the inner surface of the equipment. The Director of Cardiopulmonary stated at the time of observation there was no documentation of when the dryer had been cleaned or the last maintenance.
C. Review of the policy "Disinfecting with Pasteurmatic", last review date 08/14, revealed: "Allow at least two hours for tank to reach minimum pasteurization temperature (166 degrees Fahrenheit). Press the start button located on the panel along the top center of pasteurizer. Cycle will last 30 minutes. A print out will display with time and temperature of the current Pasteurized cycle completed. Initial printed slip to verify cycle was complete before removing items from Pasteurmatic." "Pasteurmatic Maintenance: Twice a month, wipe all of the interior surface of the tank and lid with vinegar to prevent hard water stains and promote cleanliness. Bi-weekly check water temperature with the NBS (NIST- National Institute of Standards and Technology) Certified thermometer and record temperature on log sheet."
D. The Director of Cardiopulmonary confirmed there was no documentation of to verify cycle time and temperature, twice per month cleaning or bi-weekly water check as required by policy on 08/12/15 at 1430.
E. The Olympic Mini Pasteurmatic log provided by the Director of Cardiopulmonary was reviewed on 08/12/15 at 1430 and revealed the Pasteurmatic had not been cleaned since 11/15/13 and the temperature had not been documented since 11/08/13. The Director of Cardiopulmonary confirmed the log findings at the time of review.
F. The Maintenance Supervisor was interviewed on 08/12/15 at 1430 and confirmed that neither the Olympic Mini Pasteurmatic nor the Olympic Sterile Dryer in the Cardiopulmonary Department had documentation of routine maintenance.
G. The Registered Nurse Consultant and Director of Cardiopulmonary confirmed by interview on 08/13/15 at 1145 that neither the Olympic Mini Pasteurmatic nor the Olympic Sterile Dryer in the Cardiopulmonary Department had been serviced by the BioMedical Department.


Based on observation, review of policy and procedure and interview, it was determined the facility failed to assure supplies were not available for use beyond the expiration date in the emergency department and failed to assure equipment was clean and ready for patient use in the Emergency Department and Medical/Surgical Unit. The facility could not assure patients would be protected from potential sources of infection. The failed practice likely affected patients who received care in the Emergency Department and on the Medical/Surgical Unit. The findings were:

A. Observation on 08/10/15 at 0920 of the Emergency Services Department revealed supplies were available for use beyond the manufactures expiration date as follows:
1) Trauma room:
a) Female specimen catheter kit, (one) expired 01/2015 and (one) expired 02/2015
b) Bard urethral catheter tray, (one) expired 07/2014 and (one) expired 08/2014.
c) Bard Piston tray, open in the cabinet and available for use. The manufacturer's label stated "contents sterile unless open."
2) The regulator for a portable suction canister holder had an accumulation of brown material on the surface. The findings of expired supplies and soiled suction regulator were verified by Registered Nurse (RN) #3 on 08/10/15 at 0925.
B. Review of the policy "Cleaning and stocking of Emergency Department Rooms" as provided on 08/13/15 revealed "(Cleaning) Wash all equipment with Clorox Bleach wipes. This includes suction equipment, examination lights, oxygen equipment, Mayo stands, IV (intravenous) poles, step stools, B/P (Blood/Pressure) stands, doctors stools, stretchers, counters, IV pumps."
C. The "Procedure Stocking and Ordering Supplies for ER" revealed "Treatment rooms will be checked monthly for outdated supplies/trays."
D. Observation on the Medical/Surgical Unit on 08/10/15 at 1355 revealed in the Clean Equipment Room a chair with cloth type tape across the back and a wheelchair (Roho) cushion with an accumulation of dust.
E. RN #4 identified Room 107 as clean and ready for patient occupancy 08/10/15 at 1400. Observation revealed a fan with cloth tape noted on the fan housing and motor. The tape was porous and could not be sanitized between patients. The fan had an accumulation of dust on the surface.
F. RN #4 confirmed the findings of soiled cushion and fan and tape on the fan and chair at the time of observation 08/10/15 at 1400.


29485

Based on observation, review of manufacturer's guidelines, review of Disinfectant Efficacy Monitoring log and interview, it was determined the facility failed to follow manufacturer's guidelines in that the solution used for high level disinfection was not changed every 14 days for one of one AER (automatic endoscope reprocessor). Failure to change the solution every 14 days did not ensure the efficacy of the solution was maintained for minimal disinfection of the scopes. The failed practice affected all patients whose care necessitated the use of the scopes. Findings follow:

A. Observation of the Disinfectant Efficacy Monitoring Log on 08/13/15 at 0900 determined the Cidex OPA utilized in the AER was not changed every 14 days. Per the instructions on the container label the solution was to be changed every 14 days. Review of the manufacturer's guidelines revealed the following: Automatic Endoscope Reprocessors that can be set to a minimum of 25 (degrees) C (Celsius): High Level Disinfectant at a minimum of 25 (degrees) C (77 degrees). CIDEX OPA Solution is a high level disinfectant when used or reused in a legally marketed automatic endoscope reprocessor (that can be set to a minimum of 25 degrees C) according to the Directions for Use, at or above its Minimum Effective Concentration (MEC) as determined by CIDEX OPA Test Strips, with an immersion time of at least 5 minutes for a reuse period not to exceed 14 days."
B. Review of the Disinfectant Efficacy Monitoring Log from 01/01/15 through 07/31/15 revealed the CIDEX OPA solution was not changed every 14 days per the container label and manufacturer's guidelines for one of one AER.
C. During an interview with the Chief Nursing Officer at 0910 on 08/13/15 the findings in A and B were verified.


Based on observation, policy and procedure review and interview, it was determined the CRNA (Certified Registered Nurse Anesthetist) retrieved a package containing Salem Sump Naso-gastric tube from a trash can, placed it on the anesthesia machine cart and used it on one of one (#30) surgical patient observed. Failure to ensure the separation of clean and dirty equipment had the potential for contaminated items to be used for patient care. The failed practice affected Patient #30 on 08/13/15. Findings follow:

A. During observation of a surgical procedure at 1030 on 08/13/15, CRNA (Certified Registered Nurse Anesthetist) was observed to knock an unopened Salem Sump Naso-gastric Tube into the trash can sitting next to the anesthesia machine cart. The CRNA retrieved the Salem Sump Naso-gastric Tube from the trash can and placed it on the working surface of the anesthesia machine cart. At 1215 on 08/13/15 CRNA opened the Salem Sump Naso-gastric Tube, lubricated it and inserted it into the nare of Patient #30.
B. Review of the policy and procedure titled "Anesthesia Infection Control" revealed the following: "II Equipment, A. Equipment that has become soiled or potentially contaminated during the procedure should be kept separate from the clean working area of the anesthesia cart or machine."
C. During an interview with CRNA at 1237 on 08/13/15 he verified the findings in A.


Based on observation, review of maintenance logs and interview, it was determined the facility failed peform preventive maintenance on two of two autoclaves, one of one processor and one of one washer to ensure they were functional for their intended task. Failure to ensure equipment received preventive maintenance did not assure devices or instruments for had been cleaned and sterilized before patient use. The failed practice affected all patients whose care required the use of sterile items. Findings follow:

A. Preventive maintenance documents from 08/01/12 through 08/14/15 received from the Chief Nursing Officer on 08/14/15 revealed no preventive maintenance performed on the autoclave in Central Sterile, the autoclave in the Operating Suite, the System 1 Processor in the gastrointestinal lab, and the washer in Central Sterile Processing.
B. The above findings were verified by the Chief Nursing Officer at 1115 on 08/14/15.



31039

Based on review of policy, review of Speech Therapist's employee files, and interview, it was determined that one (#1) of two (#1 and 2) Speech Therapists failed to have evidence of an annual Tuberculin (TB) screening. By not assuring the Speech Therapists were screened annually (per policy), the facility couldn't assure they were controlling infections and communicable diseases of patients and personnel. The failed practice had the likelihood to affect all patients that received Speech Therapy. Findings follow:

A. Review of policy titled "TB Control Plan" stated "TB screening is a component of annual health evaluation."
B. Review of Speech Therapist's employee files revealed no evidence of an annual TB screening for Speech Therapist #1.
C. During an interview on 08/12/15 at 1350, the Director of Quality verified the lack of evidence of annual TB screening in Speech Therapist #1's employee file.


30634

Based on observation and interview, it was determined the facility failed to ensure door handles, knobs, and drawer pulls were free of residue, and failed to ensure foods were refrigerated according to manufacturer's instructions. The failed practice created the potential for a patient to receive contaminated foods and could affect anyone consuming those foods. Findings follow.

A. During a tour of the kitchen on 08/10/15 from 0920-0940 the following was observed:
1) One gallon soy sauce, one gallon teriyaki sauce, and one gallon of barbeque sauce - all opened, all labels stated "refrigerate after opening," and all were stored in a non-refrigerated area.
2) During the tour, numerous door handles, door knobs, and drawer pulls were observed to contain a sticky/gummy residue on them.
B. The findings were confirmed by the Certified Dietary Manager at the time of the tour.

Based on clinical record review and interview, it was determined the facility failed to ensure the time of the operation was included in the operative report for four of four (#1, #3, #4, and #30) surgical patients. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow:

A. Review of operative reports revealed the time of surgery was not documented for Patients #1, #3, #4 and #30.
B. During an interview on 08/14/15 at 1515, the Chief Nursing Officer confirmed the time of surgery was not on the operative report.