HospitalInspections.org

Based on document review, staff interviews, and observations, the hospital's administrative staff failed to ensure the staff members maintained patient privacy and dignity during incontinence cares for 3 of 3 patients receiving care during the initial tour. The hospital's administrative staff identified an average census of 21 patients per day at the hospital.

Failure to ensure the staff provide all patients with privacy and dignity during incontinence cares resulted in staff and visitors not involved in the patient's care viewing a patient's genitals from the main hallway.

Findings include:

1. Review of the policy "Patient's Rights," revised 5/2013, revealed in part, "You have the right to expect staff to respect your right to privacy and conduct treatments with discretion, providing as much modesty as possible".

2. Observations during the initial tour on 8/30/17 at 7:50 AM revealed Patient #1 laying on the bed in room 302. Patient #1 was not wearing clothes in the bed. The staff failed to place the bed sheets over Patient #1, thus allowing an observer from the hallway to see Patient #2's naked body.

3. Further observations at 7:55 AM further revealed staff providing care in the Intensive Care Unit (ICU) providing care to a patient. The observations revealed a staff member had removed the patient's clothes to provide care to the patient after the patient was incontinent (involuntarily released feces or urine). The staff attempted to use a draw curtain to protect the patient's privacy but the curtain was not wide enough to fully cover the room. While walking in the main hallway, the observer could easily see the patient's entire unclothed body, including the patient's genitals, while the staff cleaned the patient's body.

4. Observations on 9/6/17 at 9:10 AM revealed a patient sitting in their room. The staff member did not attempt to pull the privacy curtain on the patient's room prior to providing care. The staff member allowed an observer in the main ICU hallway to observe the staff member had raised the patient's shirt to change the dressing on a feeding tube placed into the patient's body. The observer could clearly see the patient's unclothed abdominal area.

5. During an interview at the time of the tours, the Quality Director acknowledged the staff failed to maintain the patient's privacy while the staff provided care to the patients. The Quality Director acknowledged the privacy curtain in the ICU room failed to cover the patient while the staff cleaned the patient after the was incontinent. The Quality Director stated the facility had curtains long enough to cover the full room and provide patients, but the staff failed to use a curtain that provided privacy to the patient from an observer in the hallway.

6. During an interview on 9/7/17 at 1:20 PM, the CEO stated they expected the staff members to maintain patient dignity and privacy during any care activity which resulted in the staff exposing part of the patient's normally clothed body.

Based on document review, staff interviews, and observations, the hospital's administrative staff failed to ensure the staff members secured all intravenous (IV) catheters in 1 of 19 patient rooms observed. The hospital's administrative staff identified an average daily census of 21 patients.

Failure to secure all IV catheters could potentially result in a patient or visitor obtaining the IV catheter and potentially using the catheter to stab themselves or another person, potentially resulting in a life or limb threatening injury.

Findings include:

1. Review of policy titled "Intravenous therapy: Short Peripheral and Midline IV Therapy," revised 7/1/2017, revealed in part, " ... discard ... supplies in appropriate receptacles."

2. Observations during a tour on 9/6/17 at approximately 11:30 AM revealed a staff member had placed an unopened IV catheter in the window sill of room 306. The staff member was not in the room at the time of the tour. The patient's spouse was in the room at the time of the observations.

3. During an interview on 9/7/17 at 1:20 PM, the CEO stated they expected the staff to remove all of the supplies from the patient's room after the staff place IV access. This included removing any IV catheters not used during the procedure from the patient's room.

Based on document review, staff interviews, and observations, the hospital's administrative staff failed to ensure 1 of 1 observed nurse (Registered Nurse M) failed to lock the medication cart during 3 of 3 observations. The hospital's administrative staff identified an average daily inpatient census of 21 patients.

Failure to secure the medication cart resulted in the nurse leaving the medication cart unattended with medications and needles available to anyone in the hallway. Leaving medications and needles unsecured could potentially allow a visitor or patient to take the medication and potentially consume a lethal combination of medications. Failure to secure needles could potentially result in a patient or visitor using the needles to stab themselves or others, potentially resulting in an injury or someone developing a life threatening infection.

Findings include:

1. Review of the policy, "Medication Administration," revised 7/1/2015, revealed in part, "The medication must be under direct observation when unlocked."

2. Observations on 8/30/17 at 8:45 AM revealed Registered Nurse (RN) M was assigned to administer medications to the patients. RN M had a cart full of patient medications and patient insulin so RN M could provide the patients with their scheduled medications. The medication cart had a mechanism allowing the nurse to lock the medication and insulin from unauthorized access when the nurse was not directly watching the cart. RN M walked approximately 50 feet away from the medication cart, around a corner, resulting in RN M's inability to provide direct observation of the medication cart. RN M failed to lock the medication cart when he walked away from the cart.

3. Observations on 8/30/17 at 10:20 AM revealed RN M was administering medications using the medication cart. RN M walked approximately 50 feet away from the medication cart and was focused on performing a task. RN M could not provide direct supervision of the medication cart due to focusing on the other task. RN M failed to lock the medication cart when he walked away from the cart.

4. Observations on 8/30/17 at 12:25 PM revealed RN M was administering medications using the medication cart. RN M walked approximately 50 feet away from the medication cart and was focused on performing a task. RN M could not provide direct supervision of the medication cart due to focusing on the other task. RN M failed to lock the medication cart when he walked away from the cart.

5. During an interview at the time of the observations, the Director of Quality Management acknowledged RN M failed to lock the medication cart, as required by hospital policy, when RN M walked away from the medication cart. The Quality Director stated they provided reeducation to RN M following the observations on 8/30/17 at 8:45 AM.

I. Based on document review, staff interviews, and observations, the hospital's administrative staff failed to ensure the staff developed and implemented 1 of 1 policies instructing the nursing staff on how to clean the glucometers after the staff used the glucometers on patients. The hospital's administrative staff identified an average daily inpatient census of 21 patients.

Failure to develop and implement a policy instructing the nursing staff on cleaning the glucometers after use on a patient resulted in the nursing staff using a cleaning chemical (bleach) that the glucometer's manufacturer's instructions specifically instructed the user not to use while cleaning the glucometer. Using an unapproved cleaner could potentially result in the nursing staff failing to fully disinfect the glucometer or create microscopic holes that could potentially allow bacteria to grow, potentially resulting in the spread of potentially life threatening diseases between patients.

Findings include:

1. Observations on 9/7/17 at 8:10 AM revealed Registered Nurse (RN) L used the glucometer to check a patient's blood sugar. RN L used a Clorox Healthcare Bleach Germicidal Wipe to wipe down the glucometer after using the glucometer.

2. Review of the policy titled "Diabetes and Insulin Management," revised 10/1/16, revealed in part, "Glucometers 1. Please refer to the manufacturer's guidelines as to the use and maintenance of the equipment."

3. Review of the manufacturer's guidelines for the Precision XDCEED Pro Monitor glucometer, revised 1/4/2010, revealed in part, "Acceptable cleaning solutions include alcohol and ammonia based cleaners. Recommended solutions are Sani-Cloth HB, Sani-Cloth Plus and Super Sani-Cloth. Bleach or hydrogen peroxide based cleaners will fade the monitor keypad ...Cleaning solutions not listed have not been tested and may damage the monitor ..."

4. During an interview on 9/7/17 at 1:05 AM, the Director of Quality Management stated she instructed the nursing staff to use the bleach wipes on the glucometer. The Director of Quality management did not update the policy to reflect her decision for the nursing staff to clean the glucometers with a cleaning solution specifically not recommended by the glucometer manufacturer.



II. Based on document review, staff interviews, and observations, the hospital's administrative staff failed to ensure the housekeeping staff followed infection control procedures during 1 of 1 observed terminal room cleaning following the patient's discharge. The hospital's administrative staff identified an average of 28 patients discharged each month.

Failure to follow infection control procedures during the terminal room cleaning could potentially result in the housekeeping staff transmitting bacteria or viruses between surfaces in the room and potentially infecting a future patient with a potentially life threatening infection.

Findings include:

1. Review of the policy, "Cleaning Patient Room after Discharge," revised 7/2013, revealed in part, "Hospital has established appropriate procedures for cleaning a patient room ...4. Damp wipe grab bars, towel bars, towel dispensers, soap dispenser ...door handles ...6. Clean exterior of the toilet including the seat ... Floor cleaning: 2. Wet mop floors and baseboards in room and bathroom ..."

2. Observations on 8/30/17 at 10:20 AM revealed Environmental Services Staff Member (ESSM) C and ESSM D cleaning a patient room following the discharge of the patient. ESSM C and ESSM D wiped down the toilet in the patient room's bathroom using a chemical to kill bacteria and viruses. The staff members then wiped down the toilet handrails and bathroom door handles using the same cloth they used to wipe down the toilet. The staff members did not obtain a clean cloth after wiping down the toilet before moving to other bathroom surfaces or even rewet the cloth with the cleaning chemicals.

After ESSM C and ESSM D cleaned the bathroom, they used cleaning chemicals to mop the floor in the bathroom. The staff members did not wait to allow the chemicals to dry and kill the bacteria and viruses prior to walking on the floor.

3. During an interview on 9/7/17 at 1:40 PM, the Director of Plant Operations (DPO) stated he expected ESSM C and ESSM D to understand that wiping other bathroom surfaces with the same cloth used to clean the toilet could lead to the staff transferring bacteria or viruses from the toilet to the other surfaces. The DPO stated ESSM C and ESSM D should not have walked across the bathroom floor before the cleaning chemicals dried, since walking on the wet floor could lead to the staff tracking bacteria and viruses onto the freshly cleaned floor.


III. Based on observation, and staff interviews, the hospital's administrative staff failed to ensure the environmental services staff used 1 of 1 cleaning chemicals registered with the Environmental Protection Agency (EPA) to kill bacteria and viruses, while cleaning the hospital. The hospital's administrative staff identified an average daily census of 21 inpatients.

Failure to use an EPA registered disinfectant to clean surfaces in the hospital could potentially result in the staff failing to kill the bacteria or viruses that cause life threatening infection on surfaces in the hospital, which could potentially result in the bacteria or virus spreading to another patient and potentially causing a life threatening infection.

Findings include:

1. Observations on 8/30/17 at 10:20 AM revealed ESSM C and ESSM D cleaning a patient room following the patient's discharge. ESSM C and ESSM D used Ecolab QC 35 Maxx Dual Action Floor Cleaner (Bright Speed) to mop the patient room's bathroom and bedroom floor.

2. During an interview on 9/14/17 at 12:40 PM, the Director of Quality Management stated the QC 35 cleaning product failed to contain chemicals registered with the EPA to disinfect healthcare surfaces. The Director of Quality Management stated the hospital staff used the QC 35 cleaning product to clean the floors in the patient rooms. The Director of Quality Management acknowledged the QC 35 product lacked the ability to kill bacteria or viruses on the hospital's floors and the hospital staff needed to change to a different cleaning product designed for use in hospitals.

I. Based on staff interviews and document review, the hospital administrative staff failed to ensure the respiratory staff changed the inner cannula on patients with tracheostomies (an hole in the neck into the trachea allowing the patient to breath through the hole) for 1 of 1 closed patient records reviewed (Patient #1). The hospital administrative staff identified 2 current inpatients with tracheostomies.

Failure to change the inner cannula of a tracheostomy could potentially result in bacteria growing on the inner cannula and potentially result in the patient developing a life threatening pneumonia or bronchitis infection.

Findings include:

1. Review of the policy, "Trach Care," issued 1/1/2016, revealed in part, "Disposable inner cannula ... changed once daily and [as needed] ...Document procedure [completion] and any issues identified."

2. Review of Patient #1's closed medical record revealed the respiratory care staff (staff members with specialized training in care of the patient's airway and breathing passages) failed to document they changed the inner cannua daily on 8/2/17, 8/6/17, 8/20/17, 8/28/17, 8/30/17, and 9/1/17. Review of the medical record revealed Patient #1 was admitted on 8/1/17 and discharged on DATE.

3. During an interview on 9/7/17 at 1:30 PM, the Respiratory Manager stated the policy required the respiratory care staff to change the inner cannula on patients with tracheostomies every day. The Respiratory Manager expected the respiratory care staff members to document they performed the procedure every day. The Respiratory Manager acknowledged if the staff failed to document they changed the inner tracheostomy cannula, the staff did not actually change the inner tracheostomy cannula.



II. Based on document review, staff interview, and observations, the hospital's administrative staff failed to ensure the staff followed the hospital's policy for cleaning the endoscope during of 1 of 1 observation of the staff cleaning an endoscope. The hospital's administrative staff identified an average of 12 endoscopic procedures performed at the hospital per month.

Failure to follow the hospital's policy while cleaning the endoscope could potentially result in the staff failing to kill all of the bacteria and viruses on the endoscope and potentially transmit the bacteria or viruses to another patient, potentially resulting in the second patient developing a life threatening infection.

Findings include:

1. Review of the policy, "Cleaning and Disinfecting Endoscopes," revised 7/1/2017, revealed in part, "[after cleaning and disinfecting the endoscope (a flexible instrument inserted into the body to allow a physician to view the patient's body cavity)] [u]sing a sterile, lint free cloth moistened with alcohol, thoroughly wipe the external surfaces of the endoscope and suction-cleaning adapter."

2. Observations on 9/5/17 at 3:30 PM revealed Staff Member D cleaned an endoscope following a procedure using an endoscope on a patient. Staff Member D cleaned the endoscope but failed to wipe the external surfaces of the endoscope with alcohol using a sterile, lint free cloth.

3. During an interview on 9/7/17 at 1:10 PM, Staff Member D stated they lacked knowledge of the requirement to wipe down the external surfaces of the endoscope and suction adapter with alcohol using a sterile, lint free cloth.