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Based on observation and interview, it was determined the facility failed to identify and control likely sources of infection in four (Emergency Department, Medical Unit, Sterilizer Room, Radiology Department) of five (Emergency Department, Medical Unit, Sterilizer Room, Radiology Department and Rehabilitation Unit) areas toured on 02/23/16 from 0900 to 1035. Failure to discard used patient supplies, and assure equipment was clean did not protect patients and staff from likely sources of infection. The failed practice was likely to affect all patients admitted to the facility. The findings were:

A. Observation on 02/23/16 at 0916 revealed the Soiled Utility Room on the Medical Unit contained an "Isolation Linen Only" sign written on porous tape that was overall soiled and discolored. On the cabinet in an open plastic container at 0925 a partially used tube of Permethrin Cream dated 01/08/16 with Patient #5's name. The plastic container included used combs, brushes and rollers. The Director of Nursing confirmed by interview at the time of observation the patient had been discharged and the items should have been discarded.

B. Observation in the Emergency Department on tour 02/23/16 at 0935 with the Assistant Director of Nursing revealed one cloth chair in Ambulatory Care room #2. The chair was porous and could not be cleaned or sanitized between patients. An EKG (electrocardiogram) machine observed in the hallway in the Emergency Department was soiled and dusty overall; there was a disposable razor, used with strands of hair attached, in the tray of the the EKG machine cart. The Assistant Director of Nursing confirmed the presence of the cloth chair and soiled EKG machine with used razor on 02/23/16 at 0956

C. Observation of the Sterilizer Room on 02/23/16 at 1015 revealed paper supplies on the floor and an AMSCO Eagle Ten + (plus), table top sterilizer with a porous tape that covered the printer door and paper dispenser of the sterilizer; an accumulation of brown powdery residue extending on either side of the heating element in the bottom of the sterilization chamber and a dime size area of rust was observed on the bottom shelf of the sterilizer. The findings were confirmed at the time of observation by the Infection Control Nurse.

D. During a tour of the Radiology Department on 02/23/16 from 1300-1320 the following was observed:
1) Handles on x-ray tube were wrapped with coban, which was topped with tape and thus unable to be cleaned.
2) Dust on the top of the mammography machine.
3) CT room - one pillow and a sleeve of Styrofoam cups were stored under the sink, creating the potential for these items to get wet in the event of a sink leak.
E. Findings were confirmed by the Radiology Director at the time of the tour.


Based on observation, review of sterilizer manual, biological monitors, and interview, it was determined the facility failed to identify and control likely sources of infection in that there was no evidence the facility provided required daily and weekly maintenance for one of one AMSCO Eagle Ten + table top sterilizer used in the faciltiy. Failure to perform preventive maintenance as described in the Equipment Manual did not assure the sterilizer would perform properly to sterilize instruments and that infection would be prevented. The failed practice affected any patient who required a procedure in which facility sterilized instruments were used. The findings were:

A. Observation of one of one AMSCO Eagle Ten + table top sterilizer on 02/24/16 from 0845 - 0920 revealed an accumulation of brown powdery residue extending on either side of the heating element in the bottom of the sterilization chamber. A dime size area of rust was observed on the bottom shelf of the sterilizer. The Infection Control Nurse drained the water reservoir in the presence of Surveyor #2 with an immediate return of green tinged liquid with solid particles of green material, for a total of 2700 milliliters drained at the time of observation. There was no evidence the water reservoir was drained weekly as required by the manufacturer.

B. Review of the AMSCO Eagle Ten+ Table Top Sterilizer manual dated 06/04/98 on 02/24/16 revealed: "All personnel involved in the use and maintenance of this equipment must carefully review and comply with the warnings, cautions and instructions contained in this manual." (page 5-1) "The following maintenance procedures and intervals are recommended for safe and proper operation of this sterilizer. A thorough preventive maintenance program is essential to safe and proper unit operation. This manual contains maintenance schedules and procedures which should be followed for satisfactory equipment performance. (Daily) Remove bottom shelf and trays from chamber. Use only deionized or distilled water to wash the inside of sterilizer, bottom shelf, and trays with a damp cloth, and if necessary, a mild detergent solution. (Weekly) Drain the reservoir by opening chamber door and removing water level tube from its holders, then twist elbow fitting 90 degrees to the left. With forefinger covering the end of tube, lower tube into the container and drain the reservoir. Clean the chamber filter by reverse flushing with water."

C. Review of Attest biological Monitoring system for steam sterilization on 02/23/16 revealed from 01/02/15 to 02/23/16, an Attest biological monitor for steam sterilization was performed 41 times. On 02/24/16 at 1025, the Infection Control Nurse stated "I always do a biological any time I run the sterilizer" and confirmed there was no other sterilization log maintained.

D. The Infection Control Nurse stated on 02/24/16 at 1025 that she did not clean the chamber of the sterilizer as described in the sterilization manual and had never drained the reservoir. She stated "I just do it the way they trained me." Stated she had been handling the sterilization of instruments at the facility for three years. No policy or procedure was available for sterilization. The Infection Control nurse referenced a brown paper type towel on the wall with the time and temperature settings for the sterilizer.



Based on observation, interview and review of "Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008" and "Sterilization Technology for the Health Care Facility", it was determined the facility failed have a system in place to control infection in that there was no evidence 41 of 41 sterilizer loads from 01/02/15 - 02/23/16 were monitored with mechanical (time, temperature, pressure) indicators. Failure to monitor the time, temperature and pressure of each sterilization load did not assure the effectiveness of the sterilization process and that patients would be protected from potential sources of infection. The failed practice likely affected all patients in which facility sterilized instruments were used. The findings were:

A. Observation of AMSCO Eagle Ten + (plus), table top sterilizer on 02/24/16 from 0845 - 0920 revealed tape covered the printer door and paper dispenser of the sterilizer. The Infection Control Nurse confirmed in an interview at the time of observation that the printer to the sterilizer did not work and the time, temperature and pressure were not monitored for each cycle and that an Attest Biological monitor was done with each load sterilized.

B. Review of the "Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008" on 02/24/16 revealed the following statement: (page 76) "The sterilization procedure should be monitored routinely by using a combination of mechanical, chemical, and biological indicators to evaluate the sterilizing conditions and indirectly the microbiologic status of the processed items. The mechanical monitors for steam sterilization include the daily assessment of cycle time and temperature by examining the temperature record chart (or computer printout) and an assessment of pressure via the pressure gauge." (page 91) "Monitor each load with mechanical (e.g. time, temperature, pressure) and chemical (internal and external) indicators."

C. Review of the facility provided "Sterilization Technology for the Health Care Facility", (1993) on 02/23/16 revealed the statement (page 176) "Monitoring the Sterilization Process: Mechanical or Physical Monitors. Mechanical or physical control monitors include gauges, lights, timers, and charts on the sterilizers that measure temperature, time, and pressure/vacuum. The Association for the Advancement of Medical Instrumentation (AAMI)) has stated that at the beginning of the cycle, the operator must mark the correct date, the sterilizer identification, and cycle identification on the chart and ensure that the recording device is functioning properly. Sterilizer printout from the digital printers will have some of the information. At the end of the cycle and before the items are removed from the sterilizer, the operator must examine the record to verify that cycle parameters were met. The examining person should be identified on the printout or chart. "






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Based on observation, review of policy and interview, the facility failed to maintain therapy equipment/ seats in a manner that prevented thorough cleaning between patients in two of two (In-Patient and Out-Patient) Rehabilitation areas toured. By not maintaining therapy equipment/ seats in a way that allowed them to be thoroughly cleaned, the facility could not assure the sanitary environment when patients used these items. The failed practice had the likelihood to affect all patients that receive therapy services using the equipment/ chairs. Findings follow:

A. A tour of In-Patient Rehabilitation Services on 02/23/16 at 1020, revealed a treatment table with a mat torn in 3 places with some tape partially adhered to it, 2 fabric covered chairs the chairs were porous and could not be cleaned or sanitized between patients) and one walker with tape/stickers on it (not able to disinfect)
B. A tour of Out-Patient Rehabilitation Services on 02/24/16 at 1330, revealed 4 fabric chairs, a Shuttle Machine with foam and tape on it, and the following with stickers/tape on it: 1 cane; 1 patient wheelchair; 1 set of crutches; and 4 walkers (not able to disinfect).
C. Review of policy titled Rehabilitation Services-Sanitizing Equipment stated "All permanent equipment used in patient care, i.e. walker, crutches, parallel bars, canes, wheelchairs, shall be wiped with a hospital approved germicidal/tuberculocidal agent following direct contact with a patient of questionable contamination."
C. During an interview on 02/24/16 at 1410, the In-Patient Rehabilitation Director verified the equipment/chairs on the In-Patient Rehabilitation Unit that were not able to be thoroughly cleaned.
D. During an interview on 02/24/16 1400, Out-Patient Rehabilitation Director verified the equipment/ chairs on the Out-Patient Rehabilitation Unit that were not able to be thoroughly cleaned.

Based on observation, review of policy and interview, it was determined the facility failed to secure medications in that two (Emergency Department and Rehabilitation Unit) of three (Emergency Department, Rehabilitation Unit and Medical Unit) inpatient units toured had medications unsecured. By not securing medications, the facility could not assure they were not available to non-licensed personnel. The failed practice had the likelihood to affect all patients' medications on the two units. Findings follow:

A. During tours of the facility, observations revealed the following:
1) On 02/23/16 at 1010, the Medication Room in the Emergency Department was unlocked;
2) On 02/23/16 at 1035, the Medication Cart in the Rehabilitation Unit area was unlocked; and
3) On 02/24/16 at 1010 the Medication Room in the Emergency Department was unlocked.
B. Review of policy titled Safety Policy stated "All pharmaceuticals are stored under proper conditions of sanitation temperature, light, moisture, ventilation, segregation and security."
C. Observation 1 was verified at the time of observation by the Director of Nursing;
Observation 2 was verified at the time of observation by the In-Patient Rehab Director; and Observation 3 was verified at the time of Observation with the Director of Pharmacy.

Based on observation, review of sterilizer manual, biological monitors, and interview, it was determined the facility failed to identify and control likely sources of infection in that there was no evidence the facility provided required daily and weekly maintenance for one of one AMSCO Eagle Ten + table top sterilizer used in the facility. Failure to perform preventive maintenance as described in the Equipment Manual did not assure the sterilizer would perform according to manufacturer's standards to sterilize instruments to prevent infections. See C 278 for details.

Based on observation, interview and review of "Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008" and "Sterilization Technology for the Health Care Facility", it was determined the facility failed have a system in place to control infection in that there was no evidence 41 of 41 sterilizer loads from 01/02/15-02/23/16 were monitored with mechanical (time, temperature, pressure) indicators. Failure to monitor the time, temperature and pressure of each sterilization load did not assure the effectiveness of the sterilization process and that patients would be protected from potential sources of infection. See C 278 for details

Based on review of Respiratory Care services offered, respiratory personnel files and interview, it was determined the facility failed to have a policy for staff performance of EKG (electrocardiogram) and failed to assure three of three (#1-#3) Respiratory Department staff received training for the performance of EKG. The facility could not be assured EKG would be performed consistent with manufactures instructions or practices consistent within the facility. The failed practice likely affected all EKG tests performed by the Respiratory Therapy staff. The findings were:

A. Review of Respiratory Department Policy and Procedure Manual on 02/23/16 revealed the Respiratory Care Services offered included EKG. Respiratory Therapist #1 confirmed by interview 02/23/15 at 1510 that Respiratory Therapy staff #1- #3 performed EKG. There was not a policy or procedure for staff performance of an EKG noted in the policy and procedure manual.
B. Respiratory therapy staff personnel files (#1, #2 and #3) were reviewed on 02/23/16. The personnel files did not include competencies or staff training for the performance of EKG by respiratory therapy staff. Evidence of training for personnel #1-#3 in the performance of EKG was requested from Respiratory Therapist #1 on 02/23/16 at 1510. Respiratory Therapist #1 confirmed 02/23/16 at 1510 that staff training evidence was not available.
C. On 02/24/15 at 0930, Respiratory Therapist #1 reviewed policies and procedures and did not provide an EKG policy.

Based on interview, the facility failed to have policies and procedures in place to ensure annual re-certification of Intravenous (IV) Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood per United States Pharmacopeia Chapter 797, 2008. By not evaluating the competencies of the personnel, the facility could not assure the sterility or accuracy of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the Laminar Flow Hood. Findings follow:

During an interview on 02/24/16 0915, the Director of Pharmacy verified they do not have policies and procedures in place to ensure annual re-certification of IV Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood.


Based on observation, review of policy, and interview, it was determined the facility failed to identify home medications before administering for five of five (#3, 4, 22, 23 and 24) patients that had home medications in their medication drawer. By not identifying the home medications before administering, the facility could not assure their identity. The failed practice had the likelihood to affect all patients who are administered their own home medications. Findings follow:

A. During a tour of the facility on 02/23/16 from 0900 to 1030, the following home medications were in patient medication drawers with no evidence the medications were identified:
1) Patient #3-CoQ10 100mg (milligram) and Omega 3 Krill Oil 350 mg;
2) Patient #4-Carbidopa/Levodopa 10mg/100mg;
3) Patient #22-Fergon Iron tablets;
4) Patient #23-Latuda 30 mg; and
5) Patient #24-Omeprazole 20 mg.
B. Review of policy titled "Medications Brought into the Hospital by Patient" stated "If the physician writes an order that the patient may take his own medication, then the medications are to be brought to the pharmacy for identification and labeling ...Once the medication has been identified and labeled by pharmacy the medications are to be returned to the patient's medication drawer."
E. During an interview on 02/24/16 at 1030, the Director of Pharmacy verified home medications were not being identified by pharmacy, per policy, before being put in the patient's drawer for administration.

Based on observation, review of policy and interview, it was determined the facility failed to ensure controlled substances were double locked and therefore secured, per policy in the Pharmacy refrigerator. By not double locking controlled substances, the facility could not ensure there security. This failed practice had the likelihood to affect all patients in the facility. Findings follow:

A. During a tour of Pharmacy on 02/24/16 from 0900 to 1030, revealed 60 Lorazepam 2 milligram/milliliter injections in the medication refrigerator unlocked. Lorazepam was a controlled substance and must be double locked at all times.
B. Review of policy titled Storage of Pharmaceuticals stated "Controlled substances are stored in a double locked cabinet."
C. During an interview on 02/24/16 at 0920, the Director of Pharmacy verified the Lorazepam injections were not double locked in the refrigerator.

Based on observation, review of policy and interview, it was determined the facility could not ensure medications from undated opened MDVs (Multiple Dose Vials) were not made available for patient use beyond 28 days once opened per policy in one (Emergency Department) of three (Emergency Department, Medical Unit and Rehabilitation Unit) patient care areas. By not dating the MDVs once opened, the facility could not ensure the medication would not be used beyond the 28 days. The failed practice had the potential to affect any patient who received these medications. Findings follow:

A. A tour of the Emergency Department on 02/23/16 at 0935 revealed the following MDVs opened and not dated:
1) One Terbutaline 1 mg (milligram)/ml(milliliter);
2) One Xylocaine 1% 200mg/2ml;
3) One Succinylcholine 200mg/20ml; and
4) One Tuberculin 5 Units/0.1 ml.
B. Review of policy titled Expiration Labeling of Multidose Vials stated "All opened multidose vials used in the hospital are to be assigned a date when opened ...All opened multidose vials may be kept for 28 days from date opened provided proper storage has been maintained."
C. During an interview on 02/23/16 at 0945, the Director of Nursing verified the MDVs were opened and not dated.


Based on observation, review of policy and interview, it was determined the facility failed to maintain two (Medical Unit and Rehabilitation) of four (Medical Unit, Rehabilitation, Pharmacy and Emergency Department) refrigerators at the recommended temperature per policy. By not maintaining the temperatures in the required range, the facility could not assure the safety, integrity and effectiveness of medications and biologicals stored outside the recommend range. The failed practice had the likelihood to affect all patients who receive medications from the refrigerators. Findings follow:

A. During tours of the facility on 02/23/16 from 0900 to 1025 and 02/24/16 from 0900 to 1030, revealed the following Medication Refrigerators were not maintained at the recommended temperatures:
1) Medical Unit-the temperature log for the medication refrigerator revealed "The temperature ranges to be maintained are: Refrigerator: between 32-40 degrees Fahrenheit" The temperatures documented on the sheet for 02/01-24/16 were all below the recommended 36-46 degree range per policy.
2) Rehabilitation Unit-the temperature log for the medication refrigerator revealed "The temperature ranges to be maintained are: Refrigerator: between 32-40 degrees Fahrenheit"
10 out of 24 days had temperatures documented on the sheet for 02/01-24/16 that were below the recommended 36-46 degree range per policy.
B. Review of policy titled Storage of Pharmaceuticals stated "A refrigerator is a cold place in which the temperature is maintained thermostatically between 2 and 8 degrees Celsius (36 and 46 degrees Fahrenheit)."
C. During an interview on 02/24/16 at 0945, the Director of Pharmacy verified the Medical Unit and Rehabilitation medication refrigerators were not being maintained at the proper temperature.

Based on observation, review of policy and interview, it was determined the facility failed to ensure narcotics remained secured in one (Emergency Department) of three (Emergency Department, Medical Unit and Rehabilitation Unit) patient care areas toured in that keys to the narcotic cabinet were found in a drawer at the Nurses' Station instead of in possession of the Registered Nurse (RN) or Licensed Practical Nurse (LPN) per policy. By storing the keys in a drawer, the facility could not assure the security of the narcotics. The failed practice had the potential to affect all patients in the facility. Findings follow:

A. During a tour of the facility on 02/22/16 from 0900 to 1025, revealed the keys to the narcotic cabinet in the Emergency Department were in a drawer at the Nurses' Station.
B. Review of policy titled Narcotic Security/ Possession of Narcotic Keys stated "The narcotic keys will always remain in the possession of the RN or LPN on shift."
C. During an interview on 02/23/16 at 0945, the Director of Nursing verified the keys were in the drawer.

Based on observation, review of Safe Temperature for Fluids and Blankets article and interview, it was determined the facility failed to monitor the temperature of one of one blanket warmers observed used to warm 0.9% Sodium Chloride 1000 milliliter bags in the Emergency Department. By not monitoring the temperature, the facility could not assure the fluids would not cause harm when infused at the wrong temperature. The deficient practice had the likelihood to affect all patients in the Emergency Department. Findings follow:

A. During a tour of the Emergency Department on 02/23/16 from 0935 to 1010, revealed 2 bags of 0.9% Sodium Chloride 1000 milliliters were stored in a blanket warmer. The bags were swollen and very hot to the touch. There was neither a thermometer in the blanket warmert nor any record the temperatures had been monitored.
B. Review of the article taped to the blanket warmer titled Safe Temperature for Fluids and Blankets [October 2005] stated "Based on current literature, claims experience, manufacturer's recommendations, and ECRI recommendations, HCA Quality Standards and HCI Risk Management recommend the following:-Blanket Warmer Temperature: No greater than 43 degrees Celsius (110 degrees Fahrenheit)-Fluid Warmer Temperature: No greater than 40 degrees Celsius (104 degrees Fahrenheit). Following these recommendations will decrease the chance of a patient burn and improve patient care."
C. During an interview on 02/23/16 at 1000, the Assistant Director of Nursing verified the temperature of the fluids were not being monitored and the Department was using the article as a guide, as there was not a policy for warming fluids.

Based on observation, review of policy, review of Rules and Regulations for Hospitals and Related Institutions in Arkansas 2007 [part of the Policy and Procedure Manual] and interview, it was determined the facility failed to store medical records per policy in that over 600 medical records were stored on the ground. By not storing medical records properly, the facility could not assure the integrity of the records. The failed practice had the likelihood to affect all patients' records stored in medical records. The findings follow:

A. On a tour of the Medical Records Department on 02/22/16 at 1340 with the Director of Medical Records over 600 medical records were observed stored on the floor of the department.
B. Review of policy titled General Health Information Management Policies stated "All Federal, state, and local regulations relative to medical records shall be complied with".
C. Review of Rules and Regulations for Hospitals and Related Institutions in Arkansas 2007, Section 14-A 16 stated "All patient records, whether stored within the Health Information Management Department or other areas, either within the facility or away from the facility, shall be protected from destruction by fire, water, vermin, dust, etc."
D. During an interview on 02/22/16 at 11400, the Director of Medical Records verified the medical records stored on the floor.

Based on clinical record review, Medical Staff Rules and Regulations review, and interview, it was determined the facility failed to ensure verbal orders were timed and dated by the ordering Physician within 24 hours for 12 (#1-#3, #5, and #8-#15) of 15 (#1-#15) inpatients and two of two (#1 and #2) Swing-Bed patients having verbal orders. The failed practice did not indicate the physician had reviewed the chart to assure the verbal order was transcribed as directed and created the potential to affect any patient under the care of those physicians. Findings follow.

A. Review of Medical Staff Rules and Regulations stated, "Verbal orders ....shall be signed by the person to whom dictated, with the name of the staff member giving the orders per his or her own name, and countersigned by the staff member within twenty-four (24) hours."
B. Review of inpatient clinical records revealed the following verbal orders were not dated and timed as to when they were signed (all entries were outside the 24 hour window at the time of record review):
1) Patient #1-19 of 19 orders
2) Patient #2-11 of 11 orders
3) Patient #3-7 of 7 orders
4) Patient #5-3 of 3 orders
5) Patient #8-5 of 5 orders
6) Patient #9-4 of 4 orders
7) Patient #10-6 of 6 orders
8) Patient #11-5 of 5 orders
9) Patient #12-8 of 8 orders
10) Patient #13-5 of 5 orders
11) Patient #14-5 of 5 orders
12) Patient #15-6 of 6 orders
C. Review of Swing-Bed clinical records revealed the following verbal orders were not dated and timed as to when they were signed (all entries were outside the 24 hour window at the time of record review):
1) Patient #1-7 of 7 orders
2) Patient #2-13 of 13 orders
D. During an interview on 02/25/16 at 1025, the Director of Nursing confirmed the orders were not dated and timed.

Based on review of Swing-Bed policies and procedures and interview, it was determined the facility failed to assure there were policies and procedures addressing patient ' s rights to work in the facility during their hospitalization. The failed practice did not assure patients with a need for therapeutic work rehabilitation were allowed to work or were allowed to refuse to work during their hospitalization and was likely to affect all patients needing work rehabilitation in the facility. Findings follow:

A. Review of Swing-Bed policies and procedures revealed no evidence of policies addressing patients working or refusing to work while admitted to the facility.
B. During an interview on 02/24/16 at 0930, the Director of Nursing confirmed there was no policy regarding patient ' s right to work.

Based on review of Swing Bed policies and procedures and interview, it was determined the facility failed to assure there were policies and procedures addressing when married couples admitted to the facility could room together. Failure to assure policies allowing married couples to room together did not assure married couples' choices to room together were honored and was likely to affect all married couples admitted to the facility. Findings follow:

A. Review of Swing-Bed policies and procedures revealed no evidence of policies addressing married couples rooming together while admitted to the facility.
B. During an interview on 02/24/16 at 0930, the Director of Nursing confirmed there was no policy regarding married couples.

Based on Swing Bed policy review and interview, it was determined the facility failed to ensure there was a written policy regarding abuse of a patient by a staff member. The failed practice did not allow the facility to be knowledgeable, proactive, and timely in responding to allegations of patient abuse by staff and could affect any patient alleging abuse. Findings follow.

A. Review of Swing Bed policies revealed no evidence of an abuse policy.
B. During an interview on 20/24/16 at 1005, the Director of Nursing confirmed there was no policy regarding abuse of a patient by a staff member.