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Based on observations, interviews and record review, the facility failed to ensure equipment was inspected and maintained to ensure an acceptable level of quality. The facility failed to:

1.) Ensure the external pressure meters and alarm lights which monitor the negative pressure rooms were functional for 2 of 4 negative pressure rooms, and

2.) Ensure crash carts were free of expired and/or damaged supplies.

Findings include:

1.) Observations conducted on 1/12/16 at 10:10 a.m. of the negative pressure rooms, revealed that the rooms were equiped with an external pressure sensor meter and alarm light on the wall outside the anteroom external door, which lead to the main patient care hallway. When both the external and internal doors to the room were opened, allowing for a breech of the negative pressure enviornment, the pressure meters and alarm light on 2 of the 4 negative pressure rooms failed to alarm/ notify staff of the breech.

In an interview conducted on 1/12/16, at the time of discovery, the facility enviornmental director confirmed the meters and lights on the negative pressure room were not working.

Record review of the facility testing logs, dated 10/2015 to 1/2016, for the negative pressure rooms revealed no evidence that the external pressure sensor and/or lights had been checked to ensure they were functional.

2.) Observations conducted on 1/12/16 at 9:55 a.m., of the facility crash carts, revealed the following:

- Emergency cricothorotomy catheter set which expired in 2012
- Suction tubing which expired in 2014
- 8 packages of Endotracheal tubing (Used for intubation) were brown and discolored, with one of the tubes having a yellowish brown staining on the package.

In a interview conducted on 1/12/15, at the time of discovery, the director of Respiratory Therapy confirmed the above findings.

Based on observation, interview and record review, the facility failed to develop, and implement a system for identifying and controlling infections and communicable diseases within the hospital. The facility failed to ensure staffs were knowledgeable in disinfection protocol to include the use of disinfectant wipes used to disinfect equipment being removed from isolation rooms.

Findings include:
Observations conducted on 1/12/16 from 2:30 p.m. to 3:30 p.m. , with the facility Quality Assurance Nurse (QA), of the medical/ surgical floor revealed the following:
- Patient #19 was on isolation for C-Difficile (C-Diff) Toxin.
- Contracted dialysis Registered Nursing staff (RN)- A was in Patient # 19's isolation room providing dialysis treatment. At treatment termination, RN-A disinfected the dialysis machine next to the patient's bed, across the room from the exit door. He further failed to disinfect the machine in a sectional, top to bottom manner, disinfecting the machine's blood line chambers after wiping down the entire machine.

In an interview conducted on 1/12/16, at the time of observation, RN-A stated that the faciity had trained him in disinfection of isolation equipment. When asked by the surveyor what protocol he was using during the disinfection process, RN-A stated that he was using his own procedure for disinfection.

In an interview conducted on 1/12/16, at 3:00 pm, the facility QA nurse confirmed the above findings.

Record review of the facility policy entitled: Isolation Precautions, dated 10/1996 revealed in part the following:

3f.) Patient Care Equipment:

-When possible, dedicate the use of non- critical patient care
equipment to a single patient.

- If use of common equipment or items is unavoidable, adequately clean and disinfect them before use for another patient.