HospitalInspections.org

Based on staff interview and document review, the hospital's administrative staff failed to submit their 3-year capitol budget to the designated state planning agency for 1 of 1 years reviewed. The hospital administrative staff identified a census of 27 current inpatients at the start of the survey.

Failure to submit the hospital's 3-year capital budget to the state planning agency could potentially result in the hospital engaging in an expansion, or other major renovation to their facility, without the knowledge of the state planning agency. If the state planning agency did not know about a major change to the hospital, it could potentially result in the hospital offering services the state planning agency did not authorize the hospital to perform.

Findings include:

1. During an interview with Chief Executive Officer (CEO) A on 6/14/12 at 10:35 AM, CEO A stated the hospital administrative staff failed to submit a 3-year capitol budget to the state planning agency for Fiscal Year 2012. CEO A stated they spoke with the administrator for the state planning agency, and the state planning agency administrator confirmed the state planning agency did not receive a 3-year capital budget from the hospital.

2. During an interview on 6/14/12 at 10:35 AM, CEO A stated the hospital lacked a policy requiring them to submit a 3-year capital budget to the state planning agency.

I. Based on observation and staff interview, contracted services A (CSA) dialysis staff failed to disinfect all surfaces of the equipment and supplies used to dialyze a patient in an isolation room prior to removing the equipment and supplies from the patient room. The facility had a current inpatient census of 27. Fifteen of 27 inpatients were in isolation for Multiple Drug Resistant Organisms (MDRO). Two (Patients D1 and D2) of 27 patients received dialysis treatments. Both Patients D1 and D2 were in isolation for MDROs.

Failure to disinfect the entire surface of the dialysis equipment and supplies prior to moving the equipment and supplies out of an isolation room increases the risk of cross contamination of infectious disease and blood borne pathogens throughout the hospital.

Findings for 1 of 1 treatment day observed (6/13/2012) include:

1. Observation and interview on 6/13/12 at 10:20 AM with RN (Registered Nurse) DA showed Patient D1 received dialysis treatments, using a hemodialysis machine and portable RO (reverse osmosis) device, in the patient's hospital room and the patient was in isolation. Further observation at 1:50 PM showed RN DA cleaned and disinfected the dialysis machine after Patient D1's dialysis treatment. However, observation of the disinfection procedure revealed RN DA did not disinfect the back of the dialysis machine and the portable RO (reverse osmosis) unit prior to removing the dialysis machine and RO unit from the patient room and moving the dialysis machine and RO unit down the halls of the hospital to a dialysis room which contained other dialysis equipment and supplies such as other dialysis machines. Observation showed a sheet of paper hanging from the dialysis machine during the dialysis treatment and the sheet of paper (potentially contaminated from the dialysis treatment) remained on the dialysis machine during and after the disinfection procedure. Observation revealed disinfection of the paper did not occur with the disinfection procedure.

2. During an interview on 6/13/12 at 10:40 AM, RN DA reported, at the end of the dialysis treatment, if the acid concentrate container had acid solution remaining, staff would place a cap on the container, disinfect the container, and could use the solution for another patient treatment or a different patient dialysis treatment. Observation on 6/13/12 at 1:50 PM after Patient D1's dialysis treatment showed RN DA placed a cap on the acid concentrate container and disinfected the outside of the acid concentrate container. Interview and observation on 6/13/12 at 4:50 PM with RN DA showed during the patient's dialysis treatment, the staff's system included placing the cap of the acid concentrate container on the base shelf of the dialysis machine, with the inside of the cap facing upward or downward.

During an interview on 6/13/12 at 4:50 PM, RN DA acknowledged and verified the above findings. RN DA reported that staff should disinfect the back of the dialysis machine and the portable RO and any items that remained on the dialysis machine for the next patient's dialysis treatment. Interview with RN DA verified the staff's system regarding the acid concentrate container caps as described above failed to ensure staff maintained the caps in a manner to prevent the potential for possible contamination of the caps, which could result in the potential contamination of the acid concentrate solution.

II. Based on policy review, observation, and staff interview, the facility failed to have a system in place to protect patients, staff, and visitors from potential cross contamination when transporting patients with Multiple Drug Resistant Organisms such as Methicillin-resistant Staphylococcus aureus (MRSA) within the hospital. The facility had a current inpatient census of 27. Fifteen of 27 inpatients were in isolation for MDROs. Two (Patients D1 and D2) of 27 patients received dialysis treatments. Both Patients D1 and D2 were in isolation for MDROs.

The CDC recommends acute care hospitals limit transport and movement of patients in isolation with MDROs outside of their room to medically necessary purposes. Failure to evaluate the facility ' s need to limit transporting isolation patients to and from dialysis 3-times per week from rooms without water and drain access to patient rooms with water and drain access increases the potential for cross contamination of infectious disease to other patients, staff, and visitors.

Findings for 1 (of 1) observation of an isolation patient transported within the hospital includes:

1. Observation and interview on 6/13/12 at 9:40 AM, with RN (Registered Nurse) DB showed Patient D2 received dialysis treatments, using a hemodialysis machine and portable RO (reverse osmosis) device, 3-times per week in a patient room on the 100 hall designated for dialysis treatments (dialysis room). The Patient was in contact isolation for a MDRO with a contact isolation alert sign posted on the Patient ' s door. Further observation showed RN DB transport Patient D2, in the patient ' s bed without sanitizing the side rails, foot or headboard, or placing clean linen over the patient, from the Patient ' s room, on the 300 hall, to the dialysis room. RN DB moved the Patient down 2 hallways past patients, staff, and visitors. The patient spent 41/2 -hours in the dialysis room receiving hemodialysis; staff failed to post a sign on the dialysis room door indicating the patient ' s isolation status.

Observation on 3/13/2012 at 2:00 PM, showed RN DB transporting Patient D2 from the dialysis room back to the Patient ' s assigned room in the same manner described above. During the transport, Maintenance Person B grabbed a hold of the foot of the bed with an ungloved hand and helped move the bed through the hallways past patients, staff, and visitors. Staff B helped push the bed into the Patient ' s room, then walked away, down the hall and around a corner, without washing or sanitizing his hands. At the surveyor ' s request, the CEO went to the Maintenance Staff B and requested Staff B wash hands.

2. Document review showed the facility had failed to develop or implement a policy for transporting patients with MDROs within the hospital.

3. During an interview on 6/13/12 at 4:45 PM, RN DB reported the facility transports dialysis patients to the 100 hall for dialysis because there are 5 patient rooms on the 100 hall with water access and drains plumbed into the wall, leaving the sink free for hand washing. The other patient rooms require staff to connect the dialysis equipment to the hand-washing sink in the patient rooms to access water and drain. Staff would not have access to hand-washing sinks in the other patient rooms.

Staff DB verified the above findings and confirmed the facility did not have a policy or procedure for moving patients with MDROs, safely, through the hospital. When asked, Staff DB did not know why facility staff did not admit dialysis patients with MDROs to the rooms plumbed for dialysis treatments to reduce the risk of cross contamination of MDROs.

III. Based on policy review, observation, and staff interview, CSA dialysis staff failed to scrub the patient's dialysis catheter lumen in accordance with facility policy, prior to disconnecting the bloodlines from the dialysis catheter lumen at the end of the dialysis treatment. The facility had a current dialysis patient census of 2, 1 dialysis patient with catheter access.

When disconnecting the bloodlines from the dialysis catheter lumen, at the end of the dialysis treatment, the catheter is open to air prior to capping the lumen. Failure to disinfect the lumen in accordance with facility policy increases the risk of introducing bacterial contamination directly into the patient's blood supply.

Findings for 1(of 1) treatment day observation (6/13/2012) of 1 (of 1) patient (Patient D1) with catheter access includes:

1. The hospital had a policy and procedure titled "Termination of Treatment Using a Central Venous Catheter," Effective date 1/16/2009, which stated in part, "... Clean and individually wrap each catheter lumen and blood line connection with gauze saturated with the appropriate antimicrobial solution to disinfect and prevent contamination of the catheter. Scrub each lumen for one full minute and soak for three to five minutes depending on antimicrobial used..."

2. Observation on 6/13/12 at 1:30 PM showed RN DA preparing to discontinue the dialysis treatment for Patient D1. Patient D1 had a catheter that staff used for the dialysis treatment. Observation near the end of the patient's dialysis treatment showed RN DA wrapped each catheter lumen and blood line connection with gauze saturated with an antimicrobial solution, scrubbed each lumen and blood line connection site for 30 seconds, and then left the gauze wrapped around each catheter lumen and connection site for approximately 5 minutes.

3. During an interview on 6/13/12 at 4:50 PM, RN DA acknowledged and verified the above findings. During the interview, RN DA acknowledged in the above instance, RN DA had not followed the approved policy and procedure regarding the amount of time staff scrubbed each lumen of the catheter. RN DA further reported staff should follow the written policy and procedure.


IV. Based on policy review and staff interview, CSA staff failed to disinfect the dialysis machines, prior to patient treatments, when staff had not used the machines for more than 48-hours. Problems identified with 4 of 4 dialysis machines. The facility had a current dialysis patient census of 2.

Failure to disinfect the dialysis machine after more than 48-hours of non-use increases the risk of infection for patients by potentially introducing waterborne microorganisms during the patient ' s dialysis treatment.

Findings include:

1. The hospital had a policy titled "Fresenius 2008K Machine: Acid Clean and Chemical Disinfection," Effective date 8/18/2010, which stated in part, "Purpose The purpose of this policy is to maximize machine efficiency, control waterborne microorganisms and reduce biofilm in the internal fluid pathway of the dialysis machine... Chemical disinfection or heat disinfection must also be performed before treatment any time the machine has not been used for more than 48 hours..."

2. During an interview on 6/13/12 at 6:10 PM, RN DA and DB reported staff did not routinely use the dialysis machines over the weekend, for a period of more than 48 hours, and staff did not have a system in place to disinfect the dialysis machines, if staff had not used the dialysis machine for more than 48 hours over the weekend, before use of the dialysis machine for a patient dialysis treatment. During the interview, RN DA and DB verified the hospital's written policy as stated above and showed staff should follow the written policy.

V. Based on observation and staff interview, the facility failed to ensure a system was in place delineating a procedure for disinfecting and rinsing the bicarbonate and acid caps & wands to ensure they were free of residual bleach prior to patient use. The facility had a current dialysis patient census of 2.

Failure to ensure the bicarbonate and acid caps & wands are thoroughly rinsed could potentially expose dialysis patients to bleach possibly causing severe illness and/or death.

Findings include:

1. Observation and interview on 6/13/12 at 4:50 PM with RN DA showed RN DA disinfected the bicarbonate and acid caps and wands (pick-up tubes) with a bleach solution, rinsed each of the caps and wands separately with RO water, placed all the caps and wands in a container of RO water, swished the caps and wands in the water, discarded the rinse water, refilled the container holding the caps and wands with RO, swished the caps and wands in the water, and then tested the RO water in the container for residual bleach. During the observation RN DA reported the staff disinfected the acid and bicarbonate caps and wands one time a week.

2. Interview on 6/14/12 at 2:40 PM with RN DA and RN DB showed the hospital lacked a written policy and procedure addressing the system for the disinfection and rinsing procedure for the acid and bicarbonate caps and wands, including the system for testing the caps and wands for residual bleach. In addition, the interview with RN DA showed the hospital lacked a system to document completion of the disinfection procedure. During the interview, RN DA and RN DB verified the hospital should have a written policy and procedure addressing the system for the disinfection and rinsing procedure and a system to document completion of the procedure.


VI. Based on review of manufacturer's information, observation, and staff interview, Contracted Service A (CSA) staff failed to perform quality control tests for the WaterCheck RC Residual Chlorine test strips and the Hach Sterichek Sensitive Low Range Water Hardness Reagent Strips in accordance with manufacturer's recommendations. The facility had a current dialysis patient census of 2.

Failure to perform quality control tests according to manufacturer's recommendations potentially inhibits the staff 's ability to determine the amount of residual chlorine in the water used for patient dialysis accurately; potentialy resulting in severe illness or death.

Failure to perform the water hardness test according to manufacturer's recommendations could potentially result in inaccurate results related to failure of the water softener, thereby causing damage to the RO (reverse osmosis) membrane. Damage to the RO membrane could potentially cause delays in patient's hemodialysis treatments.

1. The manufacturer's information for the residual chlorine test strips titled.... stated in part,... " QUALITY CONTROL ...Perform QC [quality control] test on one bottle from each box of the same lot received. More frequent if required .... "

The manufacturer's information for the water hardness test strips titled.... stated in part,... " For Quality Control: Each facility should determine its own quality control procedure ....Regular use of Quality Control procedures will increase user proficiency, and will provide the user with a warning of a possible test strip error, potential use of outdated test strips, or of improperly stored or handled test strips .... "

2. During an interview on 6/14/12 at 12:55 PM, BioMed Technician DC reported staff did not currently perform quality control tests for the WaterCheck RC Residual Chlorine test strips and the Hach Sterichek Sensitive Low Range Water Hardness Reagent Strips. During the interview, BioMed Technician DC reported staff should perform quality control tests for the WaterCheck RC Residual Chlorine test strips. During an interview on 6/14/12 at 3:35 PM, the Technical Program Manager reported staff should perform quality control procedures for the Hach Sterichek Sensitive Low Range Water Hardness Reagent Strips.