HospitalInspections.org

Based on review of Medical Staff Credentialing files and interview, the facility failed to have a process for identifying and ensuring licenses were current for 7 (#3, #5-10) of 10 (#1-10) Medical Staff. The failed practice did not ensure licensed personnel were in good standing with their licensing body and had the potential to affect all patients in the facility. Findings follow:

A. Review of Medical Staff Credentialing files on 10/18/11 revealed 7 (#3, #5-10) of 10
(#1-10) Medical Staff did not have evidence of a current license.
B. The findings were confirmed in an interview with the Administrator on 10/19/11 at 1130.

Based on observation and interview, it was determined the facility did not meet Life Safety Code requirements related to monthly testing of the Line Isolation Monitor located in the Procedure Room. The failed practice did not assure the proper functioning of the Line Isolation Monitor to prevent electric shock. The failed practice had the potential to affect all patients admitted for procedures in the Procedure Room. The facility performed an average of 2 procedures per week. See Tag K130.

Based on interview, it was determined the facility did not monitor temperature and humidity in the single Procedure Room located in the facility in accordance with the Rules and Regulations for Hospitals and Related Institutions in Arkansas (2007 edition). Failure to monitor temperature and humidity had the potential of static electricity with low humidity and mold and mildew creation with high humidity. The failed practice had the potential to affect all patients who used the Procedure Room and there was an average of two patients per week. The findings follow:

A. In an interview on 10/19/11 at 1040 while touring the facility with the Engineering Director and Engineering Supervisor, the Procedure Room Nurse stated temperature and humidity in the Procedure Room was not monitored and there were no temperature and humidity logs available for review.
B. In an interview on 10/19/11 at 1130, the Engineering Director verified the temperature and humidity was not monitored in the Procedure Room and there was no documentation or logs available for review.

Based on observation, Environmental Services Manual review and interview, it was determined the facility failed to assure patient rooms were clean and readied for the next patient use for five (#102, #119, #120, #123 and #125) of five (#102, #119, #120, #123 and #125) rooms. Failure to maintain a clean and sanitary environment created the potential for the transmission of infections among patients and staff. The failed practice had the potential to affect all patients on census on 10/17/11 and all patients admitted to the facility. Findings follow:

A. A tour was conducted with Director of Nursing (DON) on 10/17/11 from 1015-1130 of rooms identified as cleaned and ready for the admittance of a patient. The following was observed:
1) Patient Room #102 was observed with a thick accumulation of dust on the mirror ledge and the toilet base was observed to have an accumulation of an unknown substance.
2) Patient Room #119 was observed with a thick accumulation of dust on the mirror ledge, the toilet base was observed to have an accumulation of an unknown substance and the trash can contained discarded waste.
3) Patient Room #120 was observed with a thick accumulation of dust on the mirror ledge and the toilet base was observed to have an accumulation of an unknown substance.
4) Patient Room #123 was observed with a thick accumulation of dust on the mirror ledge, the toilet base was observed to have an accumulation of an unknown substance and the wall guard corner mold also contained a stain of an unknown substance.
5) Patient Room #125 was observed with a thick accumulation of dust on the mirror ledge, a trash can with trash stored on the vanity and the toilet base was observed to have an accumulation of an unknown substance.
B. Review of the Environmental Services Daily Cleaning and Disinfecting of Patients Rooms policy # 8500.2407 on 10/17/2011 at 1125 revealed all trash was collected and removed to designated receptacle; mirrors and toilets are clean and disinfected.
C. In an interview with the Infection Control Nurse on 10/17/2011 at 1130, the above was confirmed.

Based on observation, review of the Cidexplus Solution Test Strips manufacturer's guidelines, review of the Infection Control Policy/Procedure Manual and interview, it was determined the facility failed to follow manufacturer's guidelines and their policy and procedure to ensure the Cidexplus Solution Test Strips bottle reflected the date opened and were within current date in one of one (#1) active Procedure Room of the hospital. Failure to ensure the facility policy and manufacturer's guidelines were followed had the potential to compromise the efficacy of the testing results of the Cidexplus 28 day solution and the disinfectant effectiveness of the equipment. The failed practice had the potential to affect all patients admitted to the facility who required the use of sterile equipment. Findings follow:

A. Tour of the Procedure Room #1 on 10/17/11 at 1045 with Procedure Nurse #1 #1 and Director of Nursing (DON) revealed two (bottle #1 and #2) of two bottles of Cidexplus Solution Test Strips with a expiration date of 02-2011. Bottle #1 was observed opened and did not reflect a recorded date as to when the strips were opened to determine the 90 days after opening. Procedure Nurse #1 identified the test strips as utilized daily to monitor the effectiveness of the Cidexplus solution concentration.
B. Review of the manufacture instructions on 10/17/11 at 1105 revealed "The shelf life (expiration date) for the unopened Cidexplus Solution Test Strips is stamped on the immediate container. When opening the bottle for the first time, record the date opened in the space provided on the label. Do not use any remaining strips 90 days after opening the bottle." Findings were confirmed by Procedure Nurse #1at the time of observation.
C. Review of the Infection Control Policy/Procedure # LT-9500.IC001-Items with a past expiration date on 10/17/11 at 1112 revealed "only items or supplies that have not reached their expiration date are maintained in the hospital for use. All items shall be periodically checked to insure they are in date and all items found that are beyond the expiration date shall be pulled from inventory and disposed of properly."
D. In an interview with the Procedure Nurse #1 on 10/17/11 at 1115, the above items were confirmed.

Based on interview, review of the manufacturer's instructions for use and the Procedure Room's policy and procedures, it was determined the facility failed to follow manufacturer's instructions and their policy and procedure in the constituting of Asepti-Zyme cleaner solution. Without accurately following the facility policy and procedure and the manufacturer's guidelines, it could not be assured the constituting of Asepti-Zyme met the manufacture's concentration requirements for the effective removal of bioburden from instruments and equipment. The failed practice had the potential to affect all patients admitted to the facility undergoing procedures requiring the use of equipment or instruments processed by high level disinfection. Findings follow:

A. Tour of Procedure Room #1 with the Procedure Nurse #1 on 10/17/11 at 1120 revealed the use of Asepti-Zyme Enzymatic cleaner. Procedure Nurse #1 (who was responsible for performing the constituting of the Asepti-Zyme Enzymatic solution) was asked how you constitute the ingredients to yield the required concentration for a presoak detergent. Procedure Nurse #1 stated "I use three squirts and fill the sink with water to clean the endoscopes and bronchoscopes."
B. Review of the manufacture instructions for use on 10/17/11 at 1120 revealed "Add ? U.S. fluid (fl.) ounce of Asepti-Zyme per 1 U.S. gallon (7-8 mL/L) of water (warm or cold). For heavy organic load, 1 U.S. fluid ounce per U.S. gallon (15.6mL/L) of water may be required."
C. Review of the policy and procedure titled "Cleaning/Disinfecting Product List" #6650.0359 on 10/17/11 at 1140 revealed for fiberoptic endoscope cleaning to add one ounce of the Asepti-Zyme Enzymatic liquid cleaner to one gallon of warm water.
D. During an interview on 10/17/11 at 1135, Procedure Nurse #1 confirmed there was no method utilized to determine or confirm the volume of three squirts was equivalent to ? ounce (oz) or 1 oz of Asepti-Zyme and the volume of water in the sink was equivalent to a gallon of water as required per manufacturer's instructions and the facility policy and procedure.


30580

Based on review of Medical Staff Credentialing files and interview, the facility failed to ensure a system for identifying infections and communicable diseases of personnel. Ten of ten (#1-
#10) Medical Staff credentialing files did not have current TB (tuberculin) skin test results documented. The failed practice did not ensure staff, patients and visitors were not exposed to infectious disease and had the potential to affect all persons in the facility. Findings follow:

A. Review of Medical Staff Credentialing files on 10/18/11 revealed 10 (#1-#10) of 10 (#1-#10) did not have evidence of current TB skin test results.
B. Findings were confirmed during an interview with the Administrator on 10/19/11 at 1130.

Based on review of Governing Board Meeting Minutes 2011, Medical Executive Committee Meeting Minutes 2011, Quality Assurance Meeting Minutes 2011, policies and procedures and interview, the facility failed to ensure the Physical Therapy Department and Radiology Department participated in ongoing Quality Assurance/Performance Improvement (QA/PI) activities. The failed practice did not ensure development, implementation and maintenance of an ongoing QA/PI program and failed to assess and/or improve the quality of care and services provided by the Physical Therapy and Radiology Departments. The practice had the potential to affect all patients undergoing physical therapy or radiological services in the facility. The findings follow:

A. On 10/18/11, review of the Medical Executive Committee Meeting Minutes 2011 revealed no evidence that QA/PI activities for the Physical Therapy or Radiology Departments were discussed.
B. On 10/18/11, review of the Governing Board Meeting Minutes 2011 revealed no evidence QA/PI activities for the Physical Therapy or Radiology Department were discussed.
C. On 10/18/11, review of the Quality Assurance Meeting Minutes 2011 revealed no evidence QA/PI activities for the Physical Therapy or Radiology Departments were discussed.
D. Review of policy, "General Manual Quality Improvement" revealed "....will reflect the complexity of the Hospital's organization and services, involve all Hospital departments and services (including those services under contract or arrangement)...."
E. Review of policy, "Quality Management Quality Improvement" revealed "Quality Management activities are performed on an ongoing basis and are designed to identify opportunities for improvement. Associates and contracted vendors participate in establishing objective monitors or important functions of care which are high risk, high volume, or problem prone."
F. The findings were confirmed in an interview with the Infection Control/Quality Assurance Manager on 10/20/11 at 1020.