Based on record review, the hospital failed to provide an environment free of mechanisms for self injury for 1 of 1 patients identified with suicidal ideation in a sample size of 20. Findings include: Review of the care plan for patient #1 created on 11/3/15 at 10:43 p.m. revealed the patient was identified at risk for suicide and the hospital would ensure the patient's safety by providing a therapeutic environment and appropriate interventions. This care plan remained in effect through discharge on 11/8/15. Review of the Activities in the Clinical Documentation Record revealed action items to provide a safe environment under the Suicide Safe Environment Checklist. Review of the nurses notes dated 11/6/15 at 12:50 a.m. revealed the checklist was not completed and items were left in the patient's room that the nurse had identified as instruments for self injurious behavior. These items were used on 11/8/15 at approximately 1:45 a.m. by patient #1 to attempt suicide.
Based on observation and interview, the facility failed to ensure that staff adhered to proper hand hygiene and/or infection control practice in two clinical settings. Findings include: During observation at the hospital's off-site Endoscopy suite on 9/5/12 in the morning, Staff G (RN Endoscopy) was observed in the pre-procedure prep area to pick up a computer mouse that had fallen onto the floor and place it into its holder adjacent to the computer without disinfecting the mouse or their hands, and subsequently Staff G went about the prep area touching other objects, until she was alerted to this issue by Staff D (Director Infection Prevention).
Based on observation the facility failed to ensure that all staff followed recognized infection control standards of practice while providing care during a medication pass. During medication observation on September 4, 2012 Staff C (Registered Nurse) donned her gloves while preparing IV medications to administer to one of her patients on the medical-surgical unit. During the administration the nurse made several contacts with the patient after which on two occasions Staff C placed her gloved hand into her pocket to retrieve alcohol wipes. This practice was described to Staff D (Director Infection Prevention) who stated that the observed practice was not in keeping with the standards of infection control that are followed at the facility.
Based on observation and interview, it was determined that the facility did not have an adequate system in place for controlling infections and communicable disease, due to mislabeling of a multi-dose medication vial, presence of the multi-dose vial in the patient's immediate prep care area, and lack of proper hand hygiene and environmental hygiene, as observed at one patient's room in the main hospital and/or at the off-site Endoscopy suite (Patient identifiers are #1 and #2). Also, based on observation it was found that the horizontal surfaces in 2 of the 4 operating rooms failed to be cleaned; based on tour of the surgical suites and review of the balance reports for the surgical suite the facility has failed to maintain the proper air changes from the original design; based on interview and record review the facility has failed to have current balance reports to maintain proper pressurization with their procedure rooms; and based on review of the facility documentation and monthly testing reports the facility has failed to maintain the proper negative pressure between the infection isolation rooms and the adjacent spaces. Findings include: Observation on 9/4/12 of the second floor hospital inpatient ward revealed Staff E (Charge Nurse), who had gowned and gloved, attending to Patient #1 alone in their room; Patient #1 was on contact precautions for C.diff. (Clostridium difficile) (per observation of signage at the room's entrance and interview with touring facility staff). Upon leaving the room, the Staff E removed gloves and gown, including use of a hand rub, then walked down the hallway from the patient's room to the nurses station where the sink was available for handwashing with soap and water. Staff E failed to do proper hygiene for C.diff. (soap and water) prior to exiting the patient's room. Observation at the hospital's off-site Endoscopy suite on 9/5/12 in the morning revealed in Procedure Room 3 that a floor pedal control which was positioned off the floor on top of a rectangular piece of electronic equipment. There was no barrier placed between this foot control and this equipment. Observation at the hospital's off-site Endoscopy suite on 9/5/12 in the morning revealed Patient #2 in a small individual pre-procedure prep area, when Staff F (Charge Nurse) drew up lidocaine from a multi-dose vial that was obtained from a cart just inside this same individualized prep area, and subsequently injected the lidocaine into Patient #2's upper extremity with the syringe. The cart the lidocaine vial was on was in the immediate pre-procedure treatment area for this patient, and observation of the vial shortly after its utilization revealed that it had two conflicting expiration dates marked on it, 9/23 and 9/28. When alerted to this issue by Staff D (Director Infection Prevention), Staff F was observed to replace with lidocaine vial with a new vial. Observation at the hospital's off-site Endoscopy suite on 9/5/12 in the morning revealed that at the end of the endoscopy procedure performed on Patient #2, in a different Procedure room than above, staff were discarding disposable PPE (personal protective equipment) into a garbage bin in the room which had a spring-type lid which one would push back to access the garbage bin then it would spread back into the closed position. However, as PPE was discarded into the bin, the PPE overflowed blocking the lid from closing completely and inviting staff to discard PPE to into the bin by pushing their PPE against the already discarded PPE that was protruding from the bin.
AORN (Association of periOperative Registered Nurses) 2009 Edition Page 439. Recommended Practices for Environmental Cleaning in the Perioperative Setting. Recommendation 1 The patient should be provided a clean, safe environment. 1.b All horizontal surfaces in the OR (eg, furniture, surgical lights, booms, equipment should be damp dusted before the first scheduled surgical procedure of the day. Plasma and monitor screens should be cleaned according to manufactures' instructions. Dust is known to contain human skin and hair, fabric fibers, pollens, mold, fungi, insect parts, glove powder, and paper fibers among other things. Airborne particles range in size form 0.001 microns to several hundred microns. Contamination for particles can come from an external source (eg, ventilation, doors) or an internal source... Based on observation with Staff A (Clinical Coordinator of Surgical Services) it was found that the horizontal surfaces had failed to be cleaned. Findings include: During tour on 9/4/12 of the surgical suite it was observed by surveyor and shown to Staff A that 2 of the 4 operating rooms horizontal surfaces had build up of dust on multiple pieces of equipment on their horizontal surfaces. ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Standard 170-2008 Ventilation of Health Care Facilities Page 11 #8. Planning, construction, and system startup. 8.1 Overview. For HVAC systems serving surgery and critical care spaces, compliance with this standard requires preparation of an acceptance testing plan. 8.5 documentation of New or Remodeled HVAC Systems. Owners shall retain an acceptance testing report for their files. In addition, the design shall include requirements for operations and maintenance staff training that is sufficient for the staff to keep all HVAC equipment in a condition that will maintain the original design intent for ventilation. Training of operating staff shall include a explanation of the design intent. The training materials shall include, at a minimum, the following: a. O&M procedures b. Temperature and pressure control operation in all modes c. Acceptable tolerances for system temperature and pressures d. Procedures for operations under emergency power or other abnormal conditions that have been considered in the facility design. Based on tour of the surgical suites and review of the balance reports for the surgical suite the facility has failed to maintain the proper air changes from the original design. Findings include: During tour of the surgical suites on 9/4/12 it was noted and shown to Staff A (Clinical Coordinator of Surgical Services) that the air returns in three of the four operation rooms were very poor. The fourth operating room could not be tested due to a surgical case being performed. A paper test was performed by holding a paper in front of the return were the paper would be pulled in. When this was done the paper would fall to the floor and not be drawn in toward the return showing very little air movement On review of the facility's airflow report dated 1/18/12 which is the most current balance report it shows as follows: Supply Air OR #1 Design Actual 10 150 139 11 175 134 12 175 157 13 175 145 14 175 224 15 175 162 16 175 215 17 175 205 Total 1375 1381 18 159 20 19 175 156 20 175 168 21 175 224 22 175 203 23 175 126 24 175 281 25 175 216 Total 1375 1394 Return Air Design Actual 26 1125 793 27 1125 964 Supply Air OR #2 Design Actual 45 175 130 46 175 170 47 175 246 48 175 253 49 175 58 50 175 66 51 175 218 52 175 197 53 175 177 54 175 153 55 175 167 56 175 162 Total 2100 1997 Return Air Design Actual 57 950 877 58 950 265 Supply Air OR #3 Design Actual 65 100 89 66 180 197 67 180 188 68 180 179 69 180 186 70 180 177 71 180 154 72 180 188 73 180 206 74 180 200 75 180 175 Total 1900 1939 Return Air Design Actual 76 800 403 77 800 688 Supply Air OR #4 Design Actual 84 180 182 85 180 167 86 180 171 87 180 204 88 Not Used 89 180 162 90 180 197 91 180 196 92 180 131 93 180 189 94 180 200 Total 1800 1799 Return Air Design Actual 95 800 213 96 800 942 All numbers above represent the as built design. The first number is the diffuser or vent, the second number is the design as built number and the third number is the actual air volume at the time the system was balanced, during the time of the balance report. ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Standard 170-2008 Ventilation of Health Care Facilities A1. O&M IN HEALTH CARE FACILITIES A1.1 Operating Rooms. Each operating room should be tested for positive pressure semi-annually or on a effective preventative maintenance schedule. When HEPA filters are present within the diffuser of operating rooms, the filter should be replaced based on pressure drop. Based on interview and record review the facility has failed to have current balance reports to maintain proper pressurization with their procedure rooms. Findings include: During review of maintenance records and Interview with Staff B (Director of Plant Operations) on 9/5/12 it was also confirmed that the facility has not had the HVAC system balance for the endoscope procedure room since January 1, 2007. ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Standard 170-2008 Ventilation of Health Care Facilities. 7.2 Additional Room Specific Requirements. 7.2.1 Airborne Infection Isolation (AII) Rooms. Ventilation for AII rooms shall meet the following requirements whenever an infectious patient occupies the room: (a) Each AII room shall comply with requirements of Tables 6-1, 6-2, and 7-1. AII rooms shall have a permanently installed device and /or mechanism to constantly monitor the differential air pressure between the room and adjacent spaces of the room when occupied by patients with an airborne infectious disease. A local visual means shall be provided to indicate whenever negative differential pressure is not maintained.... (f) Differential pressure between AII rooms and adjacent spaces that have a different function shall be a minimum of -0.01. wc (-2.5 Pa). Based on review of the facility documentation and monthly testing reports the facility has failed to maintain the proper negative pressure between the infection isolation rooms and the adjacent spaces. Findings include: Review of the facility's maintenance logs on pressurization readings shows all five isolation rooms having a alarm setting at (-0.0039 wc) which is below the minimum standard. When tested by the facility on 8/30/12 which was provided by Staff B (Maintenance Director) the following areas pressurization readings are as follows: 1) ED-c tested (-0.0239 wc) within range 2) 213 tested (-o.0095 wc) out of range 3) ICU 5 tested (-0.0048 wc) out of range 4) 327 tested (-0.0090 wc) out of range 5) IMCU 4 (-0.0082 wc) out of range Also the facility was unable to provide air balance reports to show that the negative pressure rooms were negative 12 ACH (Air Changes per Hour)
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