HospitalInspections.org

Based on observations and staff interview it was determined the hospital failed to maintain the condition of the physical plant in a manner to protect the safety and well-being of patients.

Findings include:

1. On 02/24/15 at approximately 11:29 a.m., the hospital kitchen ceiling was observed with rusted ceiling track.

2. These findings were discussed with the hospital maintenance director on 02/24/15 at approximately 11:40 a.m. and he agreed the kitchen ceiling track was rusted.

A. Based on document review and observations it was determined the Infection Control Officer failed to enforce hospital policies that require all personnel to use hand hygiene after contact with patients' skin and after contact with inanimate objects in the immediate vicinity of the patient. This deficient practice was observed in two (2) of two (2) observations of patient medication preparation and administration. When staff do not perform hand hygiene after touching patients or objects in the vicinity of the patient it can result in patient cross contamination with possible negative outcomes.

Findings include:

1. Review of the current policy for hand hygiene states, in part, the following: "Hands are to be decontaminated after contact with the patient's intact skin and after contact with inanimate objects in the immediate vicinity of the patient."

2. On 2/25/15 at 8:30 a.m. Registered Nurse #2 (RN 2) was observed at medication cart #2 pouring medications into a medication cup and then taking them to the patient in Room 403. RN 2 handed the patient her medications, removed the patient's breakfast tray from the overbed table where the patient was sitting, and returned the tray to the food cart. Without hand hygiene, RN 2 went back to the medication cart and prepared additional mediations for the patient in Room 403 and returned to Room 403 and handed the patient the medications. While in the room, RN 2 filled the patient's water cup from a pitcher at bedside. She then returned to the medication cart and without hand hygiene touched the cart and moved it down the hall. After this, the nurse did use hand sanitizer for hand hygiene.

3. On 2/25/15 at about 8:40 a.m., RN 2 prepared another cup of medications from the cart and took them to the patient in Room 404, Bed 2. While in the room, she assisted the patient to raise his shirt to check the incision on his back. She then went back to the medication cart and without hand hygiene prepared additional medication for the same patient. After administering the medication to the patient, she returned to the medication cart and without hand decontamination made an entry in the medication administration book located on top of medication cart #2.

B. Based on observations and staff interview it was determined the Infection Control Officer failed to enforce policies for the cleaning of the medication cart which specifies the cart top is to be cleaned each shift, the entire exterior of the cart is to be cleaned weekly and the supply drawers should be cleaned monthly. This deficient practice was discovered in one (1) of two (2) medication carts (medication cart #2). Failure to routinely clean medication carts can result in patients being exposed to contaminated items resulting in negative outcomes.

Findings include:

1. Review of the policy for cleaning of the medication cart (revised 03/09) states, in part, the following: "Spills are cleaned immediately by the person involved in the spill. The top of the cart is cleaned with Dispatch each shift. The entire cart exterior should be cleaned weekly as needed. Supply drawers should be cleaned monthly."

2. On 2/25/15 at 8:30 a.m. the top of medication cart #2 was found to have splattered looking areas of brown discoloration. Registered Nurse #2 was questioned about the appearance of the medication cart and she agreed the top appeared splattered and said, "I think someone may have spilled coffee on it." The nurse was asked how often the carts are cleaned and who is responsible for cart cleaning and she said she thought the night team cleans the cart but was unsure how often it occurred.

3. Charge Nurse #2 (CN 2) was interviewed on 2/25/15 at 9:30 a.m. She said the medication cart is usually cleaned at midnight but she was unable to find documentation of when the cart was cleaned and what staff was assigned or responsible for the cleaning. She was unable to determine when the medication carts were last cleaned.

C. Based on observations and staff interview it was determined the Infection Control Officer failed to enforce the hospital policy for cleaning of the janitor's closet which requires the room to be clean, including the sink and plumbing. This deficient practice was discovered in the janitor's closet which is located at the end of the hall on the nursing care facility. When housekeeping carts, buckets, supplies and equipment are stored in an area which is dirty, it can result in the contamination of the supplies and equipment that can lead to the spread of germs in the hospital care areas with possible patient infections and negative outcomes.

Findings include:

1. Review of the policy entitled, "Janitors Closets" (effective 1/1/09), states, in part, the following:
"It is imperative for janitors closet to be maintained in a neat, orderly and clean fashion. Clean interior of sink and wipe dry. Wash all pipes, fixtures and porcelain with germicidal deterrent and wipe dry. Thoroughly scour janitorial equipment and carts that are kept or maintained in this area and clean daily."

2. On 2/25/15 at 9:55 a.m., the janitor's closet was toured with the acute hospital housekeeper. The floor surface of the room appeared dirty with a dark discoloration and loose debris at the floor baseboard junction around the perimeter of the room. The utility sink was heavily soiled with a gritty like feel to the surface. Additionally, the sink had large areas of rust appearing discoloration. There were drain pipes coming from the ceiling above the utility sink which extended into the sink. The housekeeper stated during this tour the pipes were for draining air conditioners. Both of the drain pipes were heavily soiled. The end of one of the pipes was metal and had a heavy coat of rust throughout the surface.



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D. Based on document review and observation it was determined the facility failed to ensure staff decontaminated hands when indicated. Ineffective hand hygiene places all patients at risk of exposure to transmissible organisms.

Findings include:

1. A review of the facility policy entitled, "Hand Hygiene", last revised 2009, revealed it states, in part, that hand washing and hand antisepsis should occur "after contact with body fluids" and "after removing gloves".

2. An observation was conducted of medication administration by RN #1 on 2/25/15 from 8:05 a.m. to 9:00 a.m. While receiving oral medications, the patient was observed spitting out a small piece of paper onto his shirt. RN #1 was observed picking up and discarding the piece of paper with a bare hand, then handing the patient his inhaler with the same hand, with no hand decontamination noted.

3. An observation was conducted of Housekeeper #1 on 2/25/15 from 10:10 a.m. to 11:30 a.m. during her routine daily cleaning of a patient room. The housekeeper was noted removing soiled gloves two (2) times with no hand decontamination performed. Following the third glove change she then washed her hands. She was then observed donning new gloves and removing trash from the room and removing her gloves with no hand decontamination. She donned new gloves, continued cleaning room surfaces, then removed her gloves and was noted moving the patient's personal items on the overbed table without hand decontamination. She then donned new gloves, cleaned the overbed table, removed her gloves and replaced the patient's personal items on the overbed table with no hand decontamination.

E. Based on observation, staff interview and document review it was determined the facility failed to ensure staff dated and initialed the date of first use of a multi-dose vial of injectable medication. Failure to indicate the date of first use creates the potential for contaminated medication to be used on patients, creating a risk for all patients receiving that medication.

Findings include:

1. An observation was conducted of the facility's Outpatient Therapy Gym on 2/14/15 at 9:15 a.m. Two (2) punctured vials were noted, one labeled "Lidocaine injection" and one labeled "Dexamethasone injection". Both were noted to be partially used, with puncture holes noted in the rubber stoppers.

2. An interview was conducted with the facility Infection Control Officer on 2/25/15 at 11:20 a.m. She stated the facility uses Center for Disease Control and Prevention (CDC) guidelines for standards of infection control practices in the facility. She stated her expectation is for all multi-dose vials to be dated and initialed at the time of first use.

3. A review of CDC guidelines for Safe Injection Practices for Multidose Vials, last updated 2/9/11, revealed it states, in part: "If a multidose vial has been opened or accessed (e.g. needle-punctured) the vial should be dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different (shorter or longer) date for that opened vial."

F. Based on document review, staff interview and observation it was determined the facility's Infection Control Officer failed to provide documented evidence of active monitoring and surveillance of infection control practices. Failure to ensure staff compliance with infection control policies and procedures places all patients in the facility at risk of exposure to transmissible healthcare-associated infections.

Findings include:

1. The facility's Infection Control Plan for the year 2015 was reviewed on 2/23/15. It states, in part: "The goal of this plan is to provide a program of surveillance, prevention, and control of infection..." It further states: "The Infection Control Program members will perform an on-going review and evaluation of all aseptic, isolation and sanitation techniques employed throughout the organization."

2. An observation was conducted of the facility's Outpatient Therapy Gym on 2/14/15 at 9:15 a.m. Two (2) punctured vials were noted, one labeled "Lidocaine injection" and one labeled "Dexamethasone injection". Both were noted to be partially used, with puncture holes noted in the rubber stoppers.

3. An observation was conducted of medication administration by RN #1 on 2/25/15 from 8:05 a.m. to 9:00 a.m. While administering oral medications to her patient, the patient was observed spitting out a small piece of paper onto his shirt. RN #1 was observed picking up and discarding the piece of paper with a bare hand, and using that hand then handing the patient his inhaler, with no hand decontamination noted.

4. An observation was conducted of Housekeeper #1 on 2/25/15 from 10:10 a.m. to 11:30 a.m. during her routine daily cleaning of a patient room. The housekeeper was noted removing soiled gloves two (2) times with no hand decontamination performed. Following the third glove change she then washed her hands. She was then observed donning new gloves and removing trash from the room and removing her gloves with no hand decontamination. She donned new gloves, continued cleaning room surfaces, then removed her gloves and was noted moving the patient's personal items on the overbed table without hand decontamination. She then donned new gloves, cleaned the overbed table, removed her gloves and replaced the patient's personal items on the overbed table with no hand decontamination.

5. An interview was conducted with the Infection Control Officer on 2/25/15 at 11:20 a.m. When informed of the observations noted above, she stated all of the observations indicated breaches in infection control standards of which she had not previously been aware. When asked if she or a designated staff person conducts surveillance activities to monitor compliance with infection control policies on Wing Four (4), patient rooms 401 through 411, she stated, "I sometimes walk onto the unit and observe the staff". When asked if she, or a designated staff person, periodically observes and documents staff compliance with hand washing, medication administration, housekeeping procedures, use of personal protective equipment, isolation techniques, or any other infection control procedures, she stated, "No, nothing is documented." When asked if she, or a designated staff person, conducts periodic surveillance activities of infection control practices in the Inpatient Rehabilitation or Outpatient Therapy units, she stated, "I don't take care of those departments".