HospitalInspections.org

Based on observation and interview, it was determined that the facility did not always practice effective infection control.
Findings were:
In an article published by Spectrum Health in July, 2014 it was stated "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."

The Centers for Disease Control and Prevention (CDC) article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf, states on page 74 that hinged instruments and instruments that are closed should be opened during the process of sterilization
Tour of the hospital on 5/14/2019 revealed the following infection control concerns:
*Throughout the hospital corrugated shipping boxes were found that were stored with clean supplies. These boxes are considered dirty as they have been found to house vectors. Storing a clean item with a dirty item could lead to cross contamination.
*Patient Rooms #104, #105, #106, #109 and #110, contained a cloth material recliner chair making it impossible to clean/disinfect properly.

*A biohazard trash can in the CT Scan room did not have a lid, a high risk infection contamination. Several Blankets were stored in an open corner of the CT area on a dusty corrugated box.

*In the Laboratory area several items were stored under the sink.

*ED Room #2 ceiling tile had a hole, and the air conditional ceiling vent was dirty and dusty, an A broken/cracked infant weight scale was available for use.

*Two of three outdoor garbage dumpster were not appropriately closed.

The above findings were confirmed on 05/14/2019 by the Director of Nursing.

Based on observation and interview, it was determined that the facility did not always adhere to applicable standards of practice when expired drugs and medical supplies were available for patient use.

Findings were:

Tour of the facility on 5/14/19 revealed the following expired drugs and supplies:
Emergency Room #1 following expired medication
" 0.9% Sodium Chloride Irrigation X2 500ml bottles, expired 5/1/2019
" Succinylcholine 200mg (20mg/ml) X17 vials held in a locked refrigerator, expired 3/1/2019.
" Iodoform Packing String (sterile gauze) was opened and available for use.

The above expired drugs and medical supplies were confirmed by the Director of Nursing on the morning of 5/14/19.

Based on a tour of the facility, review of facility policies, and staff interview, the facility failed to
ensure that unusable drugs were not available for patient use. Four opened multi-dose medication vials were not dated when opened.
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Findings were:

"Centers for Disease Control and Prevention Injection Safety Multi-dose vials," states in part,
"Medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopeia (USP) General Chapter 797 recommends the following for multi-dose vials of sterile pharmaceuticals: · If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date. The manufacturer's expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The beyond-use-date should never exceed the manufacturer's original expiration date."
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Facility document entitled, "Multi-Dose Vials," stated in part, "It is the policy of Hamlin Memorial Hospital that all multi-dose vials will be discard after 28 days from initial puncture to prevent the growth of infection.
1. Each vial will be labeled with date of first puncture.
2. The vial is good for 28 days after the first puncture.
3. Return vial to pharmacy for proper disposal after 28 days.
4. Nursing Staff will check vials monthly during monthly inventory checks
5. Pharmacy tech will check vials every 2 weeks (Thursdays opposite payroll) and document on calendar days' vials were checked and action taken if applicable.

During a tour of the medication room on the morning of 05/14/2019, the following multi-dose drugs were available for immediate use and not dated when the vial was initially punctured.

" Humulin Insulin70/30 10 ml multi-dose vial, not dated when it was opened.
" Influenza Vaccine multi-dose vial, not dated when it was opened.
" Humulin Regular Insulin 10 ml multi-dose 10ml vial, not dated when it was opened.
" Levemir Insulin100ml/unit multi-does vial, not dated when it was opened.

The above findings were confirmed on 05/14/2019 by the DON.

Based on observation and interview, it was determined that the facility did not always ensure staff were informed of drugs listed as high-alert and/or high risk.

Findings included:

The following High Alert/High Risk drug were stored in the refrigerator rack side by side, increasing risk for mediation errors.

" Humulin Insulin70/30 10 ml multi-dose vial, not dated when it was opened.
" Influenza Vaccine multi-dose vial, not dated when it was opened.
" Humulin Regular Insulin 10 ml multi-dose 10ml vial, not dated when it was opened.
" Levemir Insulin100ml/unit multi-does vial, not dated when it was opened.

The above findings were confirmed by the Director of Nursing and the Pharmacy Tech on the morning of 5/15/19.

Based on observation and a tour of the facility, it was determined that the facility was not always maintained in a manner to ensure patient safety.

Findings were:

Tour of the facility on 5/14/19 revealed the following patient safety concerns:
" A broken/cracked infant weighing scale in ED #2 was available for patient use.

Emergency pull alarm cord were not installed in the following patient and visitor areas:
" Bathroom in the Emergency Department hallway,
" Bathroom in emergency room # 3.
" Male and female bathroom in the main hospital lobby

The above finding was acknowledged by the facility Director of Nursing on the morning of 05/14/2019.

Based on a review of documentation and interview, it was determined the facility fail to conduct an annual Emergency Prepareness drill.

Findings were:

Review of documentation revealed the Disaster Preparedness Plan was reviewed by staff member # 1 in 2018, but no documentation of an annual drill was available for review. Not conducting an annual drill may result in inadequately prepared to respond to an all hazard disaster.

This was verified in an interview on 05/15/2019 by staff member #2.