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A. Based on observation, interview with staff and review of documents, it was determined the hospital failed to develop and/or follow written policies which are based on accepted standards of practice referencing cleaning of each Operating Room. This has the potential to create a surgical environment that has not been cleaned in a way that will decrease the chance of infection or cross contamination of infectious diseases.

Findings include:

1. Review of hospital policy "Sanitation in the Surgery Department", last reviewed 2/2009, revealed the policy states: "At the end of each surgical day the following will be done: All flat surfaces in the OR suites will be wiped down using a facility-approved disinfectant."

2. The Operating Room (OR) suite has two (2) main procedure rooms which are currently being used for major surgical procedures. OR room #1 was observed on 4/26/2011 at 14:15. The OR Nurse Manager was present at the time of the observations and stated the surgical day had ended and both rooms #1 and 2 had been completely cleaned. There was an accumulation of dust under and behind the anesthesia cart and the "black cart" placed under the large television screen mounted on the wall. There was dust on the surfaces of boxes of utility gloves mounted to the wall. There was dust on the surfaces of the suction mechanism and the over head light control box which were both mounted on the wall.

3. OR room #2 was observed at about 14:30 on 4/26/2011. There was an accumulation of dust in all the same areas as was noted in room #1.

4. The OR Nurse Manager who was present in both rooms concurred with the findings.

5. Review of OR policies revealed there is currently no written policy which prohibits the storage of non-essential items on open shelves inside the OR surgical rooms.

6. During observations of OR room #2 at 14:30 on 4/26/2011, it was noted the large "black cart" had an open top and open shelves. On the second shelf, it was noted there were numerous small bottles of Betadine paint and Betadine scrub. There were also partially open disposable packs which are used for skin preps. On the top of the cart, it was noted that a rechargeable hair shaver was present and there was an accumulation of hair on and around the shaver. All shelves and items on the shelves were open and uncovered and available for an accumulation of dust or debris.

7. The OR Nurse Manager was present and concurred with the findings.


B. Based on observation, interviews and reviews of policies it was determined the facility failed to develop written policies and processes based on accepted standards of practice which ensure endoscopic scopes are cleaned, stored and transported in a manner which prevents potential cross contamination. This has the potential to have scopes which are not adequately disinfected prior to use on each patient.

Findings include:

1. The decontamination room in the OR and central sterile areas was observed between 14:40 and 15:00 on 4/26/2011. The OR Nurse Manager was present during the observations. An endoscopic procedure was being completed in the procedure room and preparations were being made to perform another endoscopic procedure. The cabinet for the clean endoscopes was mounted on the wall beside the sink area inside the decontamination room. A "tub cart" was in front of the sink with a tub of clean water and a tub of enzyme solution. The lid to the water solution was turned up and the clean endoscope was coiled on top of the turned up lid and was open to the air. The OR Nurse Manager stated the endoscope was ready to be used for the next procedure and the entire cart would be pushed into the procedure room for the next patient. When the first procedure was completed, the nursing staff brought in a second tub cart with the dirty endoscope and placed it within four (4) feet of the cart with the clean endoscope. The two (2) staff members proceeded to rinse and clean the dirty endoscopes in the proximity of the clean endoscope.

2. The OR Nurse Manager concurred that cleaning the dirty scopes in the same general area of the clean endoscopes may create a potential for cross contamination. She also concurred the clean endoscopes should be in a covered container and away from splashes in the process of transporting from one area to the next.

3. The OR policies were reviewed. The policies referencing decontamination of endoscopes, transport of endoscopes and storage of endoscopes failed to contain complete information on measures to be taken to ensure there will be no potential for cross contamination of the scopes.

Based on review of documents and staff interview the hospital failed to adequately provide complainants with a written response to their concerns in fifty (50) of sixty-five (65) (approximately seventy-seven (77) percent) complaints reviewed. This has the potential to limit complainants the right to have their concerns addressed by the hospital to include a written response as to the steps taken by the hospital (on the complainant's behalf) to resolve any problem and to reduce the potential for a recurrence.

Findings include:

1. The hospital's Complaint Policy dated 4/1/11 indicated (in part) that complaints would be addressed by transferring the complainant's concern to the Department Lead (where the complaint originated) for resolution. The policy failed to address the hospital's responsibility to provide the complainant with a written response with-in specified time periods.

2. Upon review of complaints from April 10, 2010 to April 11, 2011 the hospital failed to provide a written response to complainants in fifty (50) of sixty-five (65) complaints.

3. During interview with the Compliance Officer/Risk Manager on 4/27/11 in the a.m., he stated that he calls the majority of the complainants and addresses their concerns via telephone. He also stated he had provided some complainants with a written response. He indicated the Complaint Policy would be corrected to reflect that portion of the regulation regarding the hospital's obligation to provide the complainant with a written response and the steps taken by the hospital to address their concerns.

4. These findings were addressed again with the Risk Manager and with the CEO during the Exit Conference. Both agreed with the findings and indicated these issues would be corrected.

Based on review of medical records, observation and staff interview it was determined the hospital failed to ensure the use of restraints was done in accordance with a written modification to the patient's plan of care for one (1) of one (1) current patients who was restrained (patient #16). This has the potential to adversely impact the care of and condition of all patients who are restrained.

Findings include:

1. At approximately 0930 on 4/27/11 patient #16, diagnosis: seizure disorder/alcohol withdrawal, was observed to be in four (4) point soft restraints.

2. Review of the medical record revealed an order for the restraints written on 4/26/11. Review of the restraint flowsheet revealed the restraints were initiated at 0200 on 4/26/11. Review of the care plan revealed the restraint use was not included.

3. During the late morning of 4/27/11 this record was reviewed and discussed with the Medical/Surgical Nursing Supervisor. She agreed the care plan had not been modified to include the use of restraints.

Based on observation, review of documents and medical records and staff interview it was determined the hospital failed to ensure restraints were used in accordance with the order of a physician for one (1) of one (1) current patients who was restrained (patient #16). This failure creates the potential for an increase in the use of restraints. An increase in restraints may violate the rights of patients and may adversely impact the condition of patients.

Findings include:

1. At approximately 0930 on 4/27/11 patient #16, diagnosis: seizure disorder/alcohol withdrawal, was observed to be in four (4) point soft restraints.

2. Review of the medical record revealed a 4/26/11 order for the restraints. The order did not specify how long the restraints were to be used. The physician's signature on the order was not dated or timed. Review of the restraint flowsheet revealed the restraints were initiated at 0200 on 4/26/11.

3. The policy "Restraints," last reviewed and approved in 2010, was provided for review. It states in part: "Maximum duration of restraint order for patients with primary medical diagnosis is not to exceed 24 hours..."

4. During the late morning of 4/27/11 this record was reviewed and discussed with the Medical/Surgical Nursing Supervisor. She acknowledged the twenty-four (24) hour period covered by the restraint order expired at 0200 on 4/27/11.

Guidelines for Design and Construction of Health Care Facilities
3.9 Gastrointestinal Endoscopy Facilities.
3.2 Instrument Processing Room(s)
3.2.1.3 Layout. The cleaning area shall allow for the flow of instruments from the contaminated area to the clean assembly area and then to storage. A physical barrier shall be provided to prevent droplet contamination on the clean side. Clean equipment rooms, including storage, should protect the clean equipment from contamination.

This standard is not met as evidenced by:

Based on observation, it was determined the hospital failed to maintain adequate facilities for its services. This has the potential to adversely affect the safety of all hospital patients.

Findings include:

1. During a tour of the hospital decontaminate/central sterile area on 04/26/11 at approximately 3:05 p.m., it was noted that the process for cleaning contaminated endoscopes does not allow the proper flow.

a. The existing cleaning procedure allows contaminated endoscopes to enter contaminated and exit cleaned through the same door.

b. The cleaning of endoscopes does not allow the flow from the contaminated area to a cleaning process and then to clean storage area without the potential for droplet contamination.(i.e., Contaminated endoscopes are cleaned /rinsed in a sink, prior to being placed in an automatic disinfecting unit, which is adjacent to the sink. A cart for transporting clean endoscopes is adjacent to the sink/counter and disinfecting area. Disinfected endoscopes are stored in a cabinet above the sink/counter/cart area).

c. Due to the lack of a physical barrier, the potential for decontaminated endoscopes to be placed in the same area as cleaned would create the potential for cross contamination. Therefore, patients are at risk because of the potential for cross contamination.

Based on review of medical records, documents and interviews with staff it was determined the hospital failed to ensure an appropriate post-anesthesia evaluation occurred for all patients within forty-eight (48) hours after anesthesia has been administered for three (3) of four (4) applicable cases reviewed (patients #17, 21 and 22). This has the potential to affect the quality of care and anesthesia services provided to all patients.

Findings include:

1. Review of hospital policy "Anesthesia Follow-up on Post-Op Patients", last reviewed 1/2008, revealed the policy states: "The post-operative visit gives the anesthesia team member an opportunity to evaluate the patient and to identify any problems which may be related to the anesthetic administration...The anesthesia team member shall ask the patient if he or she has had any problems which might be related to the anesthetic experience. Examine the patient to investigate any complaints, and take appropriate action to resolve them. In particular check for post-operative nausea, vomiting, pain control and vital signs."

2. Review of the medical record for patient #17 revealed the patient received monitored anesthesia care (MAC) during a procedure on 2/22/2010. There was no post-anesthesia assessment documented in the record.

3. Review of the medical record for patient #21 revealed the patient received general endotracheal anesthesia during a procedure on 2/21/2011. Review of the record revealed the "anesthesia end time" was noted to be at 09:17, when the patient was handed off to the Post Anesthesia Care Unit (PACU) personnel. The "post anesthesia assessment" was documented at the same time, 09:17, and the assessment simply stated "No problems". It was documented by the PACU staff that the patient was still "unresponsive" at that time. The PACU staff documented the patient's oral airway was removed and the patient was responding to verbal stimuli at 09:47. There was no post-anesthesia evaluation completed after the patient sufficiently recovered from anesthesia, when the patient could participate in a complete and appropriate post-anesthesia assessment.

4. Review of the medical record for patient #22 revealed the patient received spinal anesthesia during a procedure on 2/9/2011. The "anesthesia end time" was noted to be at 10:34, when the patient was handed off to the PACU staff. The "post-anesthesia assessment" was documented at the same time, 10:34, and simply stated "No problems". It was documented by the PACU staff that the patient was not able to move his lower extremities at that time. There was no post-anesthesia evaluation completed after the patient sufficiently recovered from the spinal anesthesia to determine if there were any complications.

5. The records were reviewed with the Nurse Manager of the Operating Room (OR) in the afternoon on 4/27/2011 and she concurred with the findings.

Based on review of documents, medical records and staff interview it was determined the hospital failed to ensure the emergency department policy related to vital signs was followed for four (4) of six (6) records reviewed (patients #1, 2, 5 and 14). This failure creates the potential for the care of all emergency department (ED) patients to be adversely impacted.

Findings include:

1. The policy "Vital Signs in the Emergency Department," last reviewed 2/2009, was provided for review. It states in part: "Appropriate vital signs will be done prior to and following administration of sedative, hypnotic, vasoactive and/or antipyretic medications and at the time a patient is discharged."

2. Review of the record for patient #1 revealed the patient presented to the ED with a complaint of "sharp pains in lower back/abdomen, cramping, weakness/shaky/diaphoretic, nausea/vomiting" and was triaged at 2028 on 4/24/11. The patient's vital signs revealed the patient's pulse was 107 and pain was scaled as 5+ (on a 0-5 scale). Review of the record revealed the patient was discharged home at 2225 (approximately two (2) hours later). There was no record of the patient's vital signs being reassessed prior to discharge.

3. Review of the record for patient #2 revealed the patient presented to the ED with a complaint of "fever/chills/lethargic-per parent, gums bleeding, drowsy" and was triaged at 2233 on 4/24/11. The patient's vital signs revealed the patient's temperature was 99.9. Review of the record revealed the patient was discharged home at 0055 (approximately two (2) and a half (1/2) hours later). There was no record of the patient's vital signs being reassessed prior to discharge.

4. Review of the record for patient #5 revealed the patient presented to the ED with a complaint of "homicidal ideations" and was triaged at 1912 on 4/22/11. The patient's vital signs revealed the patient's pulse was 108. Review of the record revealed the patient was transferred at 1300 on 4/23/11 (approximately eighteen (18) hours later). There was no record of the patient's vital signs being reassessed prior to transfer.

5. Review of the record for patient #14 revealed the patient presented to the ED with a complaint of "breast biopsy 2/15, red and swollen" and was triaged at 2235 on 2/28/11. The patient's vital signs revealed the patient's temperature was 99.9. Review of the record revealed the patient was admitted at 0105 (approximately (2) and a half (1/2) hours later). There was no record of the patient's vital signs being reassessed prior to admission.

6. These records were reviewed and discussed with the ED Nurse Manager in the afternoon of 4/26/11. She agreed with these findings and acknowledged the department policy requiring that vitals signs are rechecked prior to discharge from the ED was not followed in these cases.

Based on review of documents and staff interview it was determined the facility failed to ensure residents have access to twenty-four (24) hour emergency dental care. This failure creates a potential for the dental care of all residents to be adversely impacted.

Findings include:

1. The policy "Dentist," last reviewed and approved 1/31/08, was provided for review. The policy states in part: "Patients, and/or family, have the right to choose which dentist they wish to be seen by. Dentists listed in the 2010 telephone book are:..."

2. A request was made for a dental contract or agreement reflecting the hospital's capacity to provide twenty-four (24) hour emergency dental care. During the afternoon of 4/26/11 the Quality Care Review Coordinator stated the hospital had no process to provide twenty-four (24) emergency dental care.