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A. Based on record review and interview, the provider failed to ensure infection control data was reviewed and assessed for problem areas in a timely manner for patients and employees. Findings include:

1. Interview on 3/25/10 at 9:07 a.m. with the infection control coordinator (ICC) revealed infection control data for January 2010 had been reported to the appropriate committees. She had received February 2010 culture and sensitivity (C&S) information from the laboratory on 3/24/10 but had not completed a review of that data. Continued interview with the ICC revealed:
*Every month an infection control committee met the first Thursday at Sanford hospital, Sioux Falls, and the second Friday at the Vermillion hospital.
*Infection control data for February 2010 and March 2010 had not been reported, because she had not received culture and sensitivity (C&S) results from the laboratory.
*Normally C&S information was provided to her by the 10th of each month.
*She had not received any C&S information for the month of March.
*Receiving patient infection data at the end of the month might cause the provider to miss infection trends that could occur early during the month, and an opportunity to put in place prevention interventions.
*When employees called in sick they called the emergency room (ER) and reported their symptom(s) or reason for being sick. That information was documented on an employee sick slip maintained in a binder in the ER. The staff member that answered the call was responsible for documenting sick call information. There was no schedule established for the collection of employee sick slips. The slips were not collected on a daily bases and could be in the book for a week or longer.
*Infection and illness information was provided to the employee's supervisor. She was aware of infections and illnesses for employees in the nursing department and in the emergency room. She was not aware of infection and illness information for employees in other departments of the hospital.
*The employee health nurse provided an employee illness report monthly to the quality improvement committee.

Interview on 3/25/10 at 10:20 a.m. with the employee health nurse confirmed employee health information was reported to quality improvement monthly.

Review of the Performance Measurement Quality Report, fourth quarter, revealed infection control information had been reported for January 2010.




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B. Based on observation and interview, the provider failed to minimize the potential sources of infectious disease by allowing the use of a cloth, non-cleanable surface (cloth chair) in room 127. Findings include:

1. Observation at 9:00 a.m. on 3/23/10 revealed a cloth chair in room 127. The chair was made of an absorbent material that could not be disinfected between uses.

Interview with the environmental service manager at that time revealed:
*Room 127 was a patient care room.
*The staff would line the chair with disposable absorbent pads to protect the chair when a patient sat in it.
*There was no way to ensure a pad was placed on the chair every time the chair was used.
*Housekeeping did not have a method to disinfect the cloth chair between uses.

C. Based on record review, label review, and interview, the provider failed to follow manufacture's directions for the use of CIDEX OPA for one of one surgical suite. Findings include:

1. Interview on 3/23/10 at 1:30 p.m. with registered nurse (RN)1 revealed:
*The CIDEX OPA solution was used for 14 days.
*The CIDEX OPA solution strength was tested weekly and recorded.
*Scopes were manually processed with that solution

Review of the Glutaraldehyde/OPA concentration and solution change record used to document changing and testing of the CIDEX OPA solution revealed:
*"Policy requires monitoring concentration 2 x for 14 day solutions, 4 x for 28 day solutions: at least 5-7 days after opening the solution bottle, and then every 7 days."
*The solution was mixed one week then tested the following week and recorded as pass or fail.

Review of the CIDEX OPA instructions for use revealed:
*"Manual Processing: High Level Disinfectant at a minimum of 68 degrees Fahrenheit. CIDEX OPA Solution is a high level disinfectant when used or reused, according to the Directions for Use, at or above its Minimum Effective Concentration (MEC) as determined by CIDEX OPA Solution Test Strips, with an immersion time of at least 12 minutes for a reuse period not to exceed 14 days."
*"Reuse Period for Disinfection: CIDEX OPA Solution has demonstrated disinfection efficacy in the presence of 5% organic soil contamination and microbiological burden during reuse. CIDEX OPA Solution may be reused for up to a maximum of 14 days provided the required conditions of ortho-phthalaldehyde concentration and temperature exist based upon monitoring described in the Directions for Use. DO NOT rely solely on days in use. Concentration of this product during its reuse life must be verified by the CIDEX OPA Solution Test Strip prior to each use to determine that the concentration of ortho-phthalaldehyde is above the MEC of 0.3%. The product must be discarded after 14 days, even if the CIDEX OPA Solution Test Strip indicates a concentration above the MEC."

Further interview with RN 1 revealed she was not aware of the manufacture's directions for CIDEX OPA.

D. Based on interview, the provider failed to maintain a high level of disinfection for scopes being removed from CIDEX OPA disinfectant. Findings include:

1. Interview on 3/23/10 at 1:30 p.m. with RN 1 revealed:
*When scopes were removed from CIDEX OPA disinfectant they were placed into a designated clean pan for rinsing.
*The designated clean pan was washed with enzymatic detergent and rinsed but was never high level disinfected between uses or before scopes were placed in the pan.
*RN 1 agreed placing disinfected scopes into a pan that was not disinfected would not maintain the high level disinfection required for scopes.

Based on record review and interview, the provider failed to assess and document the patients' heart rates, respirations, blood pressures, pain assessments, and effectiveness of medications administered during the patients' emergency (ER) visits and at the time of discharges for three of six sampled patients (1, 2, and 3). Findings include:

1. Interview on 3/24/10 at 2:10 p.m. with registered nurse (RN 4) revealed:
*When patients presented to the ER vitals signs (pulse, respiration, and blood pressure) should have been taken at the time of admission, during the ER visit, and at the time of the patient's discharge.
*The effectiveness of medications administered during the patient's ER visit should have been documented on the patient's ER chart.
*For patients 1, 2, and 3 vital signs and the effectiveness of medications administered during those patients' ER visits had not been consistently documented.

a. Review of patient 1's Emergency Nursing Record Chest Pain Complaints form revealed he presented to the ER on 3/21/10 at 6:18 p.m. and was transferred later that day at 7:25 p.m. to another healthcare facility. A total of one hour and seven minutes was spent in the ER. Further review of that form revealed:
*Vitals signs had been documented at the time of the patient's admission. There were no vital signs documented on that form for the time spent in the ER nor at the time of the patient's transfer.
*A section for documentation of vital signs had been provided on that form. That same section had a statement that indicated vital signs should have been taken at a minimum of every hour. In that section was handwritten "See Print Out."
*There was no print out strip in the patient's medical record for vital sign monitoring.
*A section for documentation of medications administered had been provided. With each entry the nurse was provided a response choice to circle: No change or improved.
*Cardiac medications and pain medications had been administered to patient 1. There was no documentation for response to those interventions provided by the nurse.

b. Review of patient 2's Emergency Nursing Record General Medicine Complaints form revealed he presented to the ER on 3/19/10 at 5:50 p.m. and was transferred on 3/20/10 at 12:15 a.m. Patient 2 had complaints of not eating, refusal to walk, and not swallowing. Further review of that form revealed:
*A total of 6 hours and 40 minutes were spent in the ER.
*Vital signs (blood pressure, pulse, respiration, and oxygen saturation) had been documented on admission.
*The patient's pulse and respirations had been documented at 7:00 p.m., 8:00 p.m., 10:00 p.m., and 11:00 p.m. There were no blood pressure readings documented at those times.
*At 10:00 p.m. oxygen saturation of 96 percent had been documented.
*The last vital signs were documented on 3/19/10 at 11:00 p.m. The patient was transferred on 3/20/10 at 12:15 a.m. There were no vital signs documented at the time of the patient's transfer.
*Intravenous normal saline, morphine for pain control, and a cough suppressant had been administered during the patient's ER visit.
*There was no pain assessment when pain medication had been administered or at the time of the patient's transfer. There was no documentation for the effectiveness of pain medications that had been administered.

c. Review of patient 3's Emergency Nursing Record General Medicine Complaints form revealed she presented to the ER on 2/16/10 at 12:50 p.m. and was transferred at 4:00 p.m. Patient 3 had presented to the ER with complaints of left sided abdominal pain that worsened with leg movement and a urinary tract infection. Further review of that form revealed:
*A total of 3 hours and 10 minutes had been spent in the ER.
*Vital signs had been documented on admission. There were no vital signs documented during the patient's ER visit. Vital signs had been documented at the time of the patient's transfer at 4:00 p.m.
*Intravenous morphine at 1:10 p.m., 1:50 p.m. and Toradol at 1:18 p.m. had been administered for pain. There was no pain assessment documented on the pain scale when pain medications had been administered.