State investigation finds expired supplies, improper cleaning techniques at old MRH clinic
An investigation by Colorado’s public health agency last year found some of Memorial Regional Health’s practices weren’t in line with regulations meant to protect the health and welfare of patients.
According to a July Colorado Department of Public Health and Environment investigation obtained by the Craig Press, MRH was using expired supplies, had improper cleaning and storage techniques inside patient rooms, and had patient records out in the open and easily accessible to the public.
The Craig Press attempted to identify some of the unnamed employees interviewed in the report, but MRH declined to identify anyone in the state’s investigation.
CDPHE’s investigation said it found the facility failed to ensure instruments for patient use were cleaned according to the manufacturer’s instructions.
“Manager #2 stated staff were not following processes and procedures for cleaning instrumentation to include cleaning instruments in general surgery room and then carrying them uncovered to staff offices,” the investigation said.
CDPHE said they also observed staff at the clinic using too much, or double the amount of enzymatic solution used to clean instruments.
CDPHE found there were some expired supplies still in use.
“The facility failed to ensure expired patient care supplies were removed from patient care areas and not available for immediate use by staff for patients during the initial tour of the facility,” their investigation said.
Those supplies may have been several years old.
“Examples of expired supplies included multiple blood collection tubes with pink, purple, green and yellow tops with expiration dates from 2018, intravenous catheters of different sizes which had expired from 2017, multiple normal saline 10 milliliter (mL) flushes which had expired 1/1/19,” the CDPHE investigation said.
CDPHE said the facility “failed to ensure single-use medications were not used for multiple patients and were discarded after each patient use.”
During the inspection of the facility, an observer said they found in a locked medication cabinet two bottles of single use medication, Xylocaine and Bupivacaine, opened and used when they should have been discarded.
“Further observations of the general exam room revealed an open bottle of ammonium lactate 12% moisturizing lotion, an open tub of Vick’s Vapo-Rub ointment, an open tub of aquaphor ointment, and an opened bottle of Dakin’s solution (a solution used to prevent and treat infection of the skin and tissue) which according to the label was single-use only,” the investigation found.
CDPHE said they found patient health records out in the open for anyone to read.
“Based on observations, interviews and document review, the facility failed to provide safeguards against unauthorized use of patient record information and protected health information,” CDPHE said in their report.
When an observer entered a family practice area accessible to other patients, they found several patient records out and in the open on a physician’s desk.
“An observation of a provider’s office located near the family practice exam rooms was conducted,” CDPHE said. “The providers office had two doors leading into hallways where patient exam rooms were located. Both doors were noted to be open immediately prior to and during the observation. Observations revealed patient information on the desk of physician assistant (PA) #12, with patient information observed face-up, uncovered and unsecured. Five patient records were observed on the desk. The records included visible names, dates of birth, medical histories, lab work and tests such as radiology and electrocardiogram (EKG). The observation also revealed patient information on the desk of provider #5, and in a file tray on top of the filing cabinet located next to the desk, with information observed face-up, uncovered and unsecured. Approximately 20 records were observed on the desk and filing cabinet of provider #2. The records included visible names, dates of birth, medical histories, lab work and tests such as radiology and EKG,” CDPHE said. “…During the entire observation, patients and families were noted to use the public hallway outside of the providers office. After the observation ended, the doors to the Providers Office remained open and the office unoccupied by staff.”
MRH brought in their own accreditation organization to do an inspection in early October after CDPHE conducted their observations. The company, The Compliance Team, didn’t find anything deficient.
“Their survey, one month later, found zero deficiencies,” said Jennifer Riley, vice president of MRH.
MRH CEO Andy Daniels said The Compliance Team’s inspection showed MRH had corrected any deficiencies.
“All of the noted deficiencies from the DHHS inspection conducted on August 1, 2019, were restricted to the 785 Russell Street location. All noted deficiencies were immediately corrected,” Daniels said in an email. “A validation survey was completed by our accreditation body, The Compliance Team https://thecomplianceteam.org shortly after DHHS submitted their report to CMS. The Compliance Team validated that all issues identified within the DHSS report were completely resolved and our patient care practices were in compliance, safe, and comprehensive.”
MRH also came up with a corrective action plan addressing each infraction, which was submitted and accepted by CDPHE. The corrective action plan included educating staff on updated protocols for suboxone and incident reporting, as well as training for staff to properly clean tools, schedule and monitor patients.
In an interview with Peter Myers, an information officer for the health facilities division of the Colorado Department of Public Health and Environment, confirmed the investigation was conducted by their department for the first time in Craig, and the deficiencies they found were against regulations.
“Those are deficiencies which are areas where the clinic was not following regulations and they were cited by our investigator,” Myers said.
As far as what comes next for MRH, Myers’ office plans to conduct a follow-up inspection and had not done so as of Christmastime.
“As far as the next step in the process, once we approve the plan of correction, we do perform another visit,” Myers said. “Depending on the severity of the deficiencies, we’ll either go back on site to see the facility, or we’ll do a documentation review on-site to ensure they put in place what they said they were going to put in place. That has not been conducted yet.”