HospitalInspections.org

Based on policy review and interview, the facility failed to provide evidence that the medical staff by-laws had been approved by the governing body.

Findings include:

A review of the medical staff by-laws revealed that the governing body approval page had not been signed since 2008. There were also several edited items in the by-laws.

An interview with the administrator revealed that the governing body had reviewed the by-laws in 2009, but had not approved them until amendments were made. As of the survey date the amendments had not been completed.

Based on policy review, the facility failed to provide a definitive autopsy policy which delineated a mechanism for obtaining an autopsy by the physician.

Findings include:

A review of the autopsy policy revealed that in the case of all deaths the coroner was to be notified. There was no information of how a physician could obtain permission for an autopsy. The policy left autopsy decisions up to the county coroner.

Based on observation, interview and policy review, the facility failed to store intravenous fluids in a safe manner.

Findings include:

On 6/15/10, eight bags of 0.9% Sodium Chloride intravenous fluid were observed stored in the blanket warmer. The warmer did not contain a thermometer to identify the inside temperature of the device. The warmer temperature dial's lowest setting was 120 degrees. The dial was set to a level below 120 degrees but the exact temperature setting could not be identified. The intravenous bags were not labeled with the date they were placed in the warmer.

An emergency room nurse was interviewed on 6/15/10, and reported the fluids were used externally to heat the bodies of hypothermic patients. On 6/15/10, the Director of Nurses (DON) was interviewed and reported the intravenous fluids from the warmer were used intravenously on hypothermic patients. The DON confirmed there was no way to determine the exact temperature of the fluid prior to administration. She reported the fluid temperature could be checked by touching the bag or letting some fluid touch the wrist. She reported that the desired temperature of the intravenous fluid as per facility policy was 110 degrees at the time of infusion.

On 6/16/10, a bag of intravenous 0.9% Sodium Chloride solution was removed from the blanket warmer. The temperature of the intravenous fluid was taken using a thermometer. The initial temperature was taken at 9:36 AM and was found to be 120 degrees. The fluid temperature was 118 degrees at 9:39 AM, three minutes after removing the fluid from the warmer. At 9:42 AM, six minutes after removal from the warmer, the fluid temperature was 115 degrees. At 9:44 AM the intravenous fluid was 112 degrees. The intravenous fluid did not achieve 110 degrees until 9:49 AM, thirteen minutes after removal of the fluid
from the warmer.

The facility's policy regarding the warming of intravenous fluids was reviewed and did not indicate how staff were to determine when the temperature of the intravenous fluid was safe for transfusion.

The eight intravenous bags were not labeled with the date they were placed in the warmer so their discard date could not be determined. Review of the facility policy did not identify the amount of time the warmed bags of intravenous fluid could be maintained before disposal.

Review of the intravenous solution manufactures's recommendations revealed that solutions for injections in their overwraps could be warmed to a temperature not to exceed 104 degrees F and for a period no longer than two weeks (14 days).

Based on policy review, observation and interview, the facility failed to provide medications that were unexpired and usable.

Findings include:

On 6/15/10, the pharmacy refrigerator was observed. Two multidose vials of Tubersol were found in the refrigerator. One vial was opened but the date the vial was opened was not identified on the vial. The other vial of Tubersol had a label which indicated the vial was opened on 5/12/10.

Review of the hospital policy entitled "PPD Storage" effective 3/1/2002, revealed "PPD solution which has been entered and in use for 30 days should be discarded because of oxidation and degradation." In an interview with the Director of Nurses on 6/15/10, she reported that nursing staff was required to place the date of opening on the vial when it was first used to determine the date it was to be discarded. She reported that both vials should have been discarded since one vial was opened beyond the thirty day limit and discard date of the second vial could not be determined.




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On 6/15/10, observations in the following areas revealed:

1. Radiology storage cabinet: 72 vials of 0.9% Sodium Chloride, 50 milliliters (ml) each, had expiration dates of 5/10. One 50 ml bag of 0.9 Normal Saline, expiration date of 11/09. One 50 ml bag of 0.9 Normal Saline, expiration date of 12/09.
2. Operating room storage cabinet: one can of Cetacaine spray, expiration date of 6/07.

Interview with the registered nurse responsible for the checking of outdated medications revealed she checked the medications for outdates weekly.

Review of the facility's policy and procedure for medication administration and storage of medications revealed the medications were to be removed from stock when outdated.

Based on a review of policies and staff interviews, the facility failed to provide written instructions for the collection, preservation, transportation, receipt, and reporting of tissue specimen results.

Findings include:

There was no policy which could be located, or included in the faxed documents which described the steps for receipt and reporting of tissue specimens.

Staff interviews with the laboratory and nursing departments were unable to locate a policy. Interview with the nursing staff indicated the method used to log tissue specimens for surgery colonoscopies did not log the reporting of the tissue specimens. The report column was blank. Interview with the laboratory staff, and observation revealed a laboratory date sorter which contained a tissue report for a punch biopsy collected 6/8/10, however the request could not be located, and a tissue/biopsy request collected 5/28/10 with no report. The laboratory staff indicated that she checked the date sorter weekly.

Based on a review policies and staff interviews, the hospital failed to provide medical staff and pathologist approval for the list of tissues requiring macroscopic (gross) examination and both macroscopic and microscopic examinations.

Findings include:

A review of the policy faxed 6/17/10 for "Department of Surgery, Department of Pathology" did not indicate medical staff approval, and the initials and dates were unable to be identified to indicate pathologist approval. Interviews with the laboratory and nursing staff on 6/15/10 were unable to locate the policy requested and confirm medical staff and pathologist approval.

Based on observation, staff interviews and policy and procedure review, the facility failed to correctly identify the disposal date for a high level disinfectant, failed to consistently follow hospital policy and manufactures's recommendations for the cleaning of instruments and failed to perform routine and quarterly preventative maintenance on the autoclave.

Findings include:

On 6/14/10, a container of prepared Cidex Plus was observed. The central stores person was interviewed on 6/14/10, and explained that the container of Cidex Plus was used to perform high level disinfection of a scope following a colonoscopy. She reported that the Cidex Plus solution was tested prior to each high level disinfection procedure. She presented a form entitled "Scope Sterilization Log" which revealed the following:

? On 4/16/10, the Cidex Plus solution was changed. The activation date was noted as 4/16/10. The discard date was identified as 5/15/10 which was 29 days from the activation date. No colonoscopies or scope processing had taken place on the 29th day of the solution.
? On 5/17/10 the Cidex Plus solution was again changed. The activation date was noted as 5/17/10. The discard date was identified as 6/16/10 which was 30 days from the activation date. No colonoscopies or scope processing took place on the 29th or 30th day of the solution.

The hospital policy and procedure entitled "Cleaning/Disinfecting Endoscopes", revised 12/16/2008, was reviewed. The policy and procedure revealed the Cidex solution was viable for 14 days from the mix date. Review of the manufacturer's directions for use revealed the Cidex Plus solution could be used up to a maximum of 28 days.

On 6/15/10, the central store person was observed cleaning instruments. The processing room had two sinks. One sink contained instruments that were soiled but had dried. The other sink contained instruments that were placed in a plastic tub filled with water. The central store person did not know if the tub contained any cleaning agents. She reported the nursing staff placed the dirty instruments into the basins in the sink following their use. She reported that she did not know what the nurses used to clean instruments. Two containers of Insta Klenz and four containers of Sklar Disinfectant were observed on the floor of the dirty processing area. She reported she did not use the solutions and did not know what they were used for.

The central store person was observed to fill a plastic tub in the sink with Medline High Suds Liquid Detergent concentrate and water. The tub held approximately two gallons of water. She then squirted each instrument with Zymex, an enzymatic cleaner, and immediately placed each instrument into the basin of water with detergent. The Zymex was not allowed to remain in contact with the instrument to begin the cleaning of the bioburden as recommended by the manufacturer. She allowed the instruments to soak in the detergent solution for 30 minutes prior to scrubbing them with instrument polish.

Review of the policy entitled "Nye Regional Medical Center Sterilization Policy" posted in the dirty processing room revealed that soiled instruments were to be soaked in a germicidal solution for 30 minutes. Neither Zymex nor Medline High Suds Liquid detergent possess germicidal properties. The policy revealed that one ounce of germicidal solution to 1/2 gallon of water was to be used.

On 6/15/10, a Registered Nurse was interviewed. She reported that she sprayed dirty instruments with Zymex after placing the instruments in the processing sink. A Licensed Practical Nurse was also interviewed on 6/15/10, and reported she sometimes used Zymex but also used a product she called H5 instead of Zymex. She reported H5 was a germicidal solution and she sprayed the solution on the soiled instruments.









23119

On 6/14/10, the central stores person was interviewed. She reported she was responsible for the sterilization of the instruments and scopes. She reported she had been trained by the previous person responsible for the sterilization of instruments. She explained that she did not perform routine weekly or monthly maintenance on the Amsco sterilizer. She reported if the loading rack "didn't look good" she would ask maintenance to pressure wash it.

On 6/15/10, the technician from the medical company responsible for the preventive maintenance on the hospital equipment was interviewed. He reported there was annual, six month and quarterly maintenance that should be performed on the Amsco sterilizer.

The manufacturer's guidelines for the machine was not available. Information for routine maintenance of steam sterilizers suggested cleaning the sterilizer chamber with a soft cloth or sponge on a regular basis and to clean the loading equipment periodically.

Review of the preventive maintenance for the machine revealed the last service and preventive maintenance was performed on 12/28/09.

Based on record review, it was determined the facility failed to ensure that the organ procurement organization (OPO) was notified of all hospital deaths.

Findings include:

A review of five hospital charts resulting in the death of the patient in the facility revealed there was no evidence the OPO was notified of the death in two of the records. An interview with the director of nurses revealed there was a reporting log for such cases. A review of the log did not indicate that the two deaths in question were reported to the OPO.

Based on a review of policies and an organizational chart, and an interview with the respiratory therapist on duty, the hospital failed to provide evidence of oversight of the respiratory care department by an MD or DO with the education and experience to direct the respiratory care services when the physician who was verbally designated as the director was off-duty. There was no evidence of oversight activities.

Findings include:

Interview with the respiratory therapist on duty (who was intoduced as the director), said the physician usually works 4 weeks on and 4 weeks off, and was unaware of who to contact during the 4 weeks off for supervisory oversight. The policy manual did not indicate review and approval, and the organizational chart did not provide fixed lines of authority from the person indicated as the director of respiratory care to the respiratory department.

Based on a review of records and staff interview, the hospital failed to designate in writing the amount of supervision required to perform specific procedures and competency assessment for one of two respiratory therapists.

Findings include:

Records of competency assessments, including the amount of supervision required for specific procedures were not available for one of two respiratory therapists.