HospitalInspections.org

Based on staff interview and review of patient rights information, it was determined the hospital failed to provide the patient or the patient's representative a phone number and address for lodging a grievance with the state agency. This affected all patients who received care at the hospital. The lack of information had the potential to prevent patients from filing grievances with the state agency regarding their care. Findings include:

On registration and admission to the hospital, patients were given a copy of a pamphlet titled "Patient Rights." The pamphlet contained the hospital's privacy practices and rights related to medical records. The pamphlet did not include the state address or phone number if a patient wanted to file a complaint or grievance with the state agency.

The QA Manager was interviewed on 2/06/20 beginning at 3:00 PM. When asked if patients were provided the number or address to the state agency upon admission or during their hospital stay, he stated they were not. When asked what contact information was provided to patients if they wanted to file a complaint or grievance, he stated they were provided the number to the hospital compliance department. He confirmed patients were not given the contact information for the state agency.

The facility failed to provide patients with the phone number and address of the state agency.

Based on observation, policy review, and staff interview, it was determined the hospital failed to ensure shielding was maintained for staff use in the radiology department. This had the potential for inadequate safety precautions from radiation hazards for hospital staff. Findings include:

A hospital policy titled, "Lead Protective Equipment (Apron Shields and Glasses)," revised August 2018, stated, "A lead protective apron and thyroid shield will be repaired or removed from the department if deemed unsafe for use. The criteria below could deem the lead protection unsafe:

1. Tearing
2. Thinning ... "

This policy was not followed. An example includes:

A tour of the radiology department was conducted with the Director of Therapeutic and Urological Services on 2/04/20, beginning at 1:45 PM. During the tour, lead aprons were observed hanging from a wall hook next to the employee entrance of the X-ray/Fluoroscopy procedure room. One of the aprons had a tear and areas of thinning in the fabric.

The Director of Therapeutic and Urological Services was interviewed on 2/04/20, beginning at 2:10 PM. She confirmed the damaged apron should have been removed from radiology and tested for defects.

The hospital failed to ensure protective equipment was maintained for radiology staff.

Based on observation, review of hospital policy, and staff interview, it was determined the hospital failed to ensure kitchen staff properly stored and labeled food in the hospital's dietary department. This had the potential to compromise patient safety and nutritional value of food. Findings include:

A hospital policy titled "Nutritional Services Product and Food Storage," revised 8/19, stated:

- "G. Products that expire in the following month shall be marked and reported to the Head Chef, and all items not used by the expiration date, will be removed from inventory, no later than the day before expiration and disposed of in compliance with manufacturer guidelines and applicable laws and regulations."

- H. 2. All food products shall be marked with the date on the item was received by Nutritional Services, as well as appropriate out dates. Items or packages of items being removed from original cases, must be marked with these dates."

A tour of the hospital's dietary department was completed on 2/04/19 beginning at 9:50 AM, with the hospital's Head Chef and Dietary Manager. A container holding what looked to be Thousand Island dressing did not have a label on it. A container labeled "Pork Glaze" had a "use by date of 01/07" and "exp. [expiration] 12/17".

On 2/04/20 at 10:10 AM, the Head Chef and Dietary Manager observed salad dressing container and confirmed it should have a label on it per policy and that the container of "Pork Glaze" was either incorrectly labeled or should have been disposed of per policy.

The hospital failed to ensure prepared foods were properly labeled to determine the date they should be discarded.

Based on hospital policy review, observations, and staff interview, it was determined the hospital failed to ensure supplies and equipment were maintained at an acceptable level of safety and quality. The failure to maintain supplies and equipment had the potential to directly injure or expose all patients to illnesses. The findings include:.

1. A hospital policy titled, "Defibrillator Check," revised September 2019, stated, "The defibrillator shall be inspected and tested each day to ensure it is working properly." This policy was not followed. An example includes:

A tour of the Labor and Delivery unit was conducted with the DON on 2/03/20, beginning at 10:00 AM. The unit's crash cart was noted to include a defibrillator. The daily testing log for the defibrillator was reviewed. It did not include entries for the days of 11/11/19 and 12/29/19.

The DON was interviewed on 2/04/20, beginning at 9:00 AM and the daily testing log was reviewed in her presence. She confirmed there was no documentation for 11/11/19 and 12/29/19 that the defibrillator was tested according to hospital policy.

The hospital failed to ensure equipment was maintained to ensure patient safety.



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2. The patient treatment areas throughout the hospital contained a total of 4 ice machines dedicated for patient use. The ice machines manufacture's recommended cleaning intervals included:

- "Drain line - weekly
- Drain Pan/Drip Pan - weekly
- Condenser - monthly
- Dispenser and components - semi annually
- Ice machine - Semi-annually
- Transport Tube - semi-annually
- Ice Storage Area/bin - semi-annually
- Pressurized water sanitizing - semi- annually."

When asked how often the machines were cleaned and serviced the QA Manager stated the machines were wiped down several times a day. When asked for a log of the above recommended cleanings he stated there was no log.

The facility failed to follow the manufactures' recommended cleaning instructions for patient ice machines.



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3. A tour of the Medical/Surgical unit was conducted with the QA Manager on 2/04/20, beginning at 8:40 AM. The following supplies were found to be expired:

- Forty lab vacutainers, expiration date, 12/31/19.
- Five yellow lab vacutainers, expiration date, 9/03/19.
- An 8 ounce unopened container of Walgreens' Regular Strength Thickener Powder, best by 7/17.
- Three Joey pump sets, Anti-free flow 1000 milliliter, expiration date, 9/03/19.
- One ComfortSampler Arterial Blood Gas Collection Kit expiration date 2/19.
- Ten Cultureswab Plus Collection and Transport systems, expired 8/18.
- One unopened bottle of Iodoform packing strip expired 4/17.

The QA Manager was interviewed on 2/04/20, beginning at 9:10 AM and the expired supplies was reviewed in his presence. He confirmed the supplies were expired.

The quality and safety of the hospital's supplies were not ensured.

4. A tour of a an offsite urgent care was conducted on 2/06/20 beginning at 12:20 PM, with the charge RN. The following supplies were found to be expired:

- Two PICC dressing change kits, expiration date, 10/01/19.

The Charge RN was interviewed on 2/06/20, beginning at 12:20 PM and the expired supplies were reviewed in her presence. She confirmed the supplies were expired.

The quality and safety of the urgent care's supplies were not ensured.

Based on observation, policy review, CDC guidelines review, and staff interview, it was determined the hospital failed to ensure staff followed effective infection prevention practices, including hand hygiene, laundry and sanitation of equipment. This directly affected 6 of 7 patients (#1, #22, #23, #24, #25, and #26) whose care was observed and had the potential to affect all patients. Findings include:

1. A hospital Policy titled "Care and Use of Implanted Central Venous Ports" dated approved 07/2019 included:

"Wash hands - put on mask"

"Have co-worker spray Skin over port site with local anesthetic spray for numbing effect prior to needle insertion if patient requests."

A hospital policy titled "Hand Hygiene - CDC guidelines", dated approved 08/2019 included:

"All staff shall use the hand-hygiene techniques, as set forth in the following procedure. The CDC has recommended guidelines on when to use non-antimicrobial soap and water, and antimicrobial soap and water or alcohol-based hand rub.

1. Before coming on duty
2. When hands are soiled
3. Before each patient encounter
4. Before applying sterile gloves and inserting a central intravascular catheter
5. Before applying gloves and inserting indwelling catheters, peripheral vascular catheters, other invasive devices that do not require a surgical procedure.
6. After coming in contact with patient's intact skin, i.e. taking a patient's blood pressure, pulse, lifting moving the patient ...
10. After contact with medical equipment/supplies in patient areas.
11. Always after removing gloves or face masks. "

These policies were not followed. Examples include:

Care observations were conducted with the Oncology Manager and another surveyor on 2/06/20 beginning at 9:00 AM.

a. The following infection control breaches were identified during the observation of Patient #22's care on 2/06/20 beginning at 9:10 AM.

- RN A donned gloves prior to accessing Patient #22's port. No hand hygiene was performed prior to donning gloves.

- With gloved hands and after touching Patient #22 RN A retrieved supplies from a common supply cart and placed the cart adjacent to Patient #22. RN A did not change gloves or perform hand hygiene prior to retrieving supplies from a common area.

- RN A accessed Patient #22's port. She was not wearing a mask as required by policy.

- RN A drew Patient #22's labs. She held the lab tubes in her gloved left hand and removed the glove on her right hand. She proceeded to touch the supply cart, computer, nurses station desk, and pen. RN A did not perform hand hygiene after removing her glove on her right hand.

- RN A moved the supply cart to a common area away from Patient #22. She did not clean or disinfect the common supply cart.

b. The following infection control breaches were identified during the observation of Patient #23's care on 2/06/20, beginning at 9:20 AM.

- RN B retrieved a common supply cart and placed it directly adjacent to Patient #23. RN B cleaned Patient #23's port area with Choloroprep disinfectant with bare hands. She did not perform hand hygiene prior to disinfecting Patient #23's port.

- RN B proceeded to push the used Chloroprep disinfectant wand into the trash can touching the plastic liner. RN A donned gloves, she did not perform hand hygiene prior to donning gloves.

- RN B accessed Patient #23's port. She was not wearing a mask as required by policy.

- RN B touched the common supply cart with gloved hands after touching Patient #23. The common supply cart was then moved away from Patient #23. RN B did not clean or disinfect the common supply cart. The common supply cart was then immediately taken to Patient #24 by RN C.

- RN B had Patient #23's lab tubes in her left hand and removed one glove. She proceeded to touch the supply cart, computer, and nurses desk prior to performing hand hygiene.

c. The following infection control breaches were identified during the observation of Patient #24 care on 2/06/20, beginning at 9:25 AM.

- RN C retrieved the common supply cart and placed it next to patient #24. RN C donned gloves. He did not perform hand hygiene prior to donning gloves.

- With gloved hands RN C cleaned Patient #24's port with Chloroprep disinfectant. He then retrieved ethyl chloride freezing spray to numb Patient #24's skin from the common supply cart without changing gloves or performing hand hygiene.

- RN C accessed Patient #24's port and drew labs. He then removed one glove and touched the computer, pen, nurses station counter top, and common supply cart prior to performing hand hygiene.

d. The following infection control breaches were identified during the observation of Patient #25's care on 2/06/20, beginning at 9:30 AM.

- RN D cleaned Patient #25's port with Chloroprep disinfectant. She removed her gloves and donned sterile gloves. She did not perform hand hygiene between glove changes.

- RN D retrieved supplies for Patient #25 in the common supply cart with gloved hands, she did not change gloves or perform hand hygiene before or after touching the common supplies.

- RN D drew a sample of Patient #25's blood for a blood glucose test. She touched the blood glucose meter with gloved hands. She performed the blood glucose test on the common supply cart. She did not disinfect the blood glucose meter prior to returning it to the common area behind the nurse's station.

- RN D removed the common supply cart from Patient #25's station. She did not clean or disinfect the cart after touching it with gloved hands.

e. The following infection control breaches were identified during the observation of Patient #26's care on 2/06/19, beginning at 9:40 AM.

- RN E retrieved a common supply cart and placed it directly adjacent to Patient #26. She did not perform hand hygeine after touching the common supply cart and before donning gloves. She did not perform hand hygeine after touching Patient #26 and then accessing common supplies. She did not perform hand hygiene or disinfect the common supply cart after touching Patient #26 when the procedure was completed.

The Manager of Oncology was interviewed on 2/06/20 beginning at 10:45 AM, and observations were reviewed with her. She confirmed RN's A - E did not follow facility policy or CDC guidelines related to hand hygiene and infection control. She confirmed hand hygiene should be performed prior to donning gloves and immediately after removal of gloves. She confirmed she did not see the common supply cart disinfected between patients. Additionally she confirmed staff should not be retrieving supplies with gloved hands.

The hospital failed to follow their policy.

2. A tour of the off-site cancer institute was conducted with the Oncology Manager and another surveyor on 2/06/20 beginning at 9:00 AM.

A Hospital policy titled "Infection Prevention and Control - Laundry Services" included:

"M. To remove significant quantities of microorganisms from grossly contaminated linens, use:

1. Water temperatures of at least 160 degrees F and 50-150 PPM of chlorine bleach, or
2. Water temperatures of less than 160 degrees F with laundry chemicals suitable for low- temperature manufactures."

Per CDC website, https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/laundry.html, accessed on 2/12/20, laundry should be washed at:

- "A temperature of at least 160°F (71°C) for a minimum of 25 minutes is commonly recommended for hot- water washing."

These guidelines were not followed. An example includes:

During the tour the facility was noted to have a onsite laundry room. When asked what gets laundered the Oncology manager stated they wash blankets that are provided to patients. When asked how the facility is monitoring the water temperature to ensure proper disinfection, the Oncology Manager stated they are not monitoring temperature. When asked what chemicals they are using for disinfection she stated they are using household Tide detergent. She confirmed they are not following facility policy and CDC guidelines related to laundry services.

The Infection Preventionist was interviewed 2/06/20 beginning at 3:00 PM. She confirmed the hospital was following CDC guidelines for their infection control program.

The facility failed to follow CDC guidelines and facility policy related to laundry services.

3. A tour was conducted with the QA Manager on 2/05/20 beginning at 9:00 AM. The following environmental issues were noted:

a. During the tour of the Post-Operative Care Area, there were several areas of countertop in the nurse's station that were cracked and broken exposing the plywood underneath.

When asked how the areas would be effectively cleaned and disinfected, the QA Manager stated they would not be able to be cleaned or disinfected effectively.

The facility failed to maintain a sanitary environment.

b. The Physical Therapy Area was a dedicated area with approximately 20 pieces of workout equipment. The area was carpeted.

When asked how often the carpet was cleaned or disinfected, the QA Manager stated, the carpet was cleaned every Sunday. When asked for a log of the cleaning he stated there was none.

The facility was unable to provided evidence the carpets were being cleaned.

4. A tour of the offsite urgent care facility was conducted on 2/06/20 beginning at 12:20 PMwith the charge RN and another surveyor. The following environmental issues were noted:

- The "Procedure Room 1" floor was observed to be in a state of disrepair with several cracks and appeared the white linoleum flooring covering had been worn down to show the black sub-layer of the linoleum. Underneath the lip of the cabinets where the floor met the cabinets contained a layer of dust and debris. The charge nurse confirmed the findings

- Patient rooms 2 and 3 both contained black chairs. The arms of the chairs were torn and the foam underneath the vinyl covering was exposed. When asked how the chairs would be effectively cleaned and disinfected between patients the RN stated, they would not be able to be disinfected.

- The nurses station cabinet directly adjacent to patient rooms 2 and 3 was broken and the plywood underneath was exposed. When asked how the nurses station cabinet would be effectively cleaned and disinfected between patients the RN stated, they would not be able to be disinfected.

5. A hospital policy titled, "Cleaning Imaging Services Department," revised September 2019, stated the Imaging Services staff responsibilities included, "All x-ray equipment shall be damp dusted with hospital-approved disinfectant daily and before each special procedure." The policy also listed the staff's biweekly responsibilities including, "All storage cabinets are cleaned with hospital-approved disinfectant." This policy was not followed. Examples include:

A tour of the radiology department was conducted with the Director of Therapeutic and Urological Services on 2/04/20, beginning at 1:45 PM. The CT room's overhead equipment structure was noted to have a layer of dust. The X-ray/Fluoroscopy room's overhead equipment structure and an equipment cabinet were noted to have a layer of dust.

The Director of Therapeutic and Urological Services was interviewed on 2/04/20, beginning at 2:10 PM. She confirmed the procedure rooms had not been properly cleaned.

The hospital failed to maintain a sanitary environment.



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6. Patient #1 was a 34 year old male that had a left achilles tendon rupture repair and his surgery was observed on 2/4/20.

a. AORN Guidelines 2015, "Clean surgical attire should be worn in the semi-restricted and restricted areas of the perioperative setting, Recommendation I.m," states, "Cell phones, tablets, and other personal communication or hand-held electronic equipment should be cleaned with a low-level disinfectant." This guideline was not followed.

b. A hospital policy titled, "Mobile Device Usage," revised 5/19, states:

"Infection Control:

A. Cell phone cleaning is essential to minimize the possibility of infection by cross-contamination.

B. All staff will be instructed in the cell phone cleaning procedure.

1. Cell phones are to be cleaned immediately before contact with the patient or his/her surroundings, and immediately after contact if the phone is touched or used during patient contact." This policy was not followed. Examples include:

Surgery was observed on 2/04/20 beginning at 4:20 PM. The CRNA arrived after surgery had started. He placed a personal cell phone at his workstation with ungloved hands, he did not perform hand hygiene before or after touching the cell phone. The CRNA manipulated his cell phone 4 times between 4:50 PM and 5:01 PM during the surgery. It was unclear how the CRNA's cell phone was sanitized for the OR setting.

The CRNA was interviewed immediately after the surgery was completed. When asked how often he sanitized his cell phone, he replied "I try to do it 2 times a day." When asked what hospital policy was, the CRNA replied "whatever is prudent," but declined to define prudent. The CRNA confirmed he had not sanitized his cell phone prior to this surgery.

The Infection Preventionist was interviewed 2/06/20 beginning at 3:00 PM. She confirmed the CRNA should be following hospital policy related to disinfection of his mobile device.

c. AORN Guidelines 2015, "Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair, Recommendation III.a," states, "A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of neck should be worn." This guideline was not followed.

The CRNA's beard did not have a covering.

The Infection Preventionist was interviewed 2/06/20 beginning at 3:00 PM. She confirmed the CRNA should be AORN guidelines and should have worn a beard cover durring surgery.