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Based on observation, review of policy and interview, the Infection Control Officer failed to identify the likelihood for infection control negative outcomes in that therapy equipment was not maintained in a manner to prevent a thorough cleaning between patients for three (#1, #2 and #3) of four (#1-4) walkers with multiple paper stickers on them (not able to disinfect) and one of one ARJO padded stand-up piece of equipment with medical tape and paper stickers (not able to disinfect) which were located in the Rehabilitation equipment closet. By not maintaining therapy equipment in a way that allowed them to be thoroughly cleaned, did not assure a sanitary environment when patients used those items. The failed practice had the likelihood to affect all patients that received therapy services with the therapy equipment. Findings follow:

A. During a tour of Rehabilitation on 04/25/17 from 0925 until 1000, observation revealed three patient walkers stored in a Rehabilitation equipment closet. The walkers had paper stickers in multiple places on them. Also observation revealed one ARJO padded stand-up piece of equipment that paper stickers and medical tape on it.
B. Review of policy titled Infection Prevention Equipment: Cleaning Guidelines stated "Reusable equipment such as Thermometers, Blood Pressure Cuffs, Pulse Oximetry Probes, Stethoscopes, Glucoscans, Slide Boards, etc. must be cleaned between each patient use ..."
C. During an interview on 04/25/17 at 0945, the Supervisor of Rehabilitation verified the paper stickers/medical tape that was on the equipment.


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Based on observation, review of policies and procedures, review of Contact Precaution instructions, Enteric Contact Precaution instructions and interview, it was determined the facility failed to prevent and control infections for one of one (#1) Swing-Bed patient with Clostridium Difficile (C-diff) infection with the posted Contact Precautions (hand hygiene with alcohol based rub or soap and water) sign instead of the Enteric Precautions to instruct staff and visitors to clean hands with soap and water upon entering and exiting room. Failure to educate staff and visitors to clean hands with soap and water after contact with a C-diff patient did not assure the spore forming bacteria (C-diff) would be removed from hands. The failed practice had the potential to affect all patients, staff and visitors in the facility. Findings follow:

A. During tour of the hospital on 04/25/17 at 1015, the Contact Precautions sign for Patient #1's room was observed. The sign instructed staff and visitors to clean hands with alcohol-based hand rub or soap and water upon entering and exiting the room. The patient was on isolation for C-diff infection. Enteric Precautions should have been posted to instruct staff and visitors to use soap and water for hand washing prior to exiting the room.
B. Review of the signage for Contact Precautions revealed "Clean Hand with alcohol-based rub or soap and water upon entering and exiting room."
C. Review of signage for Enteric Contact Precautions revealed "Clean hands with alcohol-based hand rub when entering room. Wash hands with SOAP and WATER upon exiting room."
D. Review of Hand Hygiene Policy on 04/26/17 at 1230 revealed "Hand hygiene with soap and water is required when spore-producing pathogens (e.g., Clostridium difficile) are suspected or confirmed."
E. Finding in A was verified by the Nurse Manager on 04/25/17 at 1018.

Based on Refrigerator and Freezer Temperature Log review, policy review, and interview, it was determined the facility failed to ensure temperatures for two of two refrigerators and two of two freezers in the kitchen were documented three times per day as stated in facility policy. The failed practice created the potential for a refrigerator or freezer malfunction to go unnoticed and could affect any patient receiving foods from those refrigerators and freezers. Findings follow.

A. Review of policy titled "Food Storage" stated, "A daily temperature log will be maintained for all refrigeration and freezer units. Temperatures will be recorded three times per day, according to the ADH (Arkansas Department of Health) regulations."
B. Review of Temperature Logs for two of two freezers (Reach In Freezer and Walk In Freezer) and two of two refrigerators (Reach in Refrigerator and Walk In Refrigerator) for 01/01/17 through 04/23/17 revealed temperatures were documented only one time per day.
C. During an interview on 04/26/17 at 0923, the Dietary Supervisor confirmed the temperatures were not documented three times per day.

Based on clinical record review and interview, it was determined there was no evidence the plan of care was implemented for two (#7 and #9) of six (#2, #3, #5, and #7-#9) patients in which the physician ordered sequential compression devices (SCDs). The failed practice did not assure the SCDs were applied to prevent a blood clot. Findings follow.

A. Review of clinical records revealed the following:
1) Patient #7 had an order for SCDs beginning on 04/23/17 at 2130 and was discontinued upon discharge on 04/26/17 at 1421. The clinical record revealed no evidence as to whether the SCDs were ever placed on the Patient.
2) Patient #9 had an order for SCDs beginning on 04/23/17 at 0211 and was discontinued upon discharge on 04/26/17 at 1845. The clinical record revealed no evidence as to whether the SCDs were ever placed on the Patient.
B. During an interview on 04/27/17 at 1020, the RN Systems Analyst #2 confirmed there was no documentation related to SCDs for Patients #7 and #9.

Based on clinical record review, policy and procedure review and interview, it was determined the facility failed to assure a complete and accurate clinical record as follows:
1. The Operative Report for 1 (#15) of 6 (#10-#15) surgical records did not include the time of surgery. Failure to assure the time a surgical procedure took place did not establish a time-line of surgical events in the course of a patient's admission to the facility. The failed practice was likely to affect all surgical patients admitted to the facility.
2. The Operative Report for 1 (#13) of 6 (#10-#15) surgical records was not written or dictated within 24 hours as directed by hospital policy. Failure to have a complete clinical record did not assure continuity of patient care and had the likelihood to affect all patients admitted to the facility for surgical procedures
3. The Operative Report for 1 (#15) of 6 (#10-#15) surgical records was not signed within 72 hours as directed by hospital policy. The failed practice did not assure an accurate and complete clinical record and had the likelihood to affect all patients admitted to the facility for surgical procedures.

The findings were:

A. Review of Patient #15's Operative Report dated 04/17/17 on 04/27/17 at 0935 revealed no evidence of the time of the surgical procedure. During interview with Registered Nurse (RN) System Analyst #1 on 04/27/17 at 0949, she confirmed the time of the surgical procedure was not in the operative report.
B. Review of Patient #15's Operative Report dated 04/17/17 on 04/27/17 at 0935 revealed a dictation date of 04/17/17 at 1745 with no evidence of the physician's signature. During interview with RN System Analyst #1 on 04/27/17 at 0949, she confirmed the operative report was not signed by the physician within 72 hours.
C. Review of Patient #13's Operative Report dated 04/13/17 on 04/27/17 at 0900 revealed a dictation date of 04/26/17 at 1614. During interview with the Market Director of Quality on 04/27/17 at 0905, she confirmed the dictation date was past 24 hours.
D. Review of Policy and Procedure for Subject: Medical Record Content Requirements, Department: Health Information Management on 04/27/17 at 0915 revealed "A complete operative report must be written or dictated immediately (or as soon as possible, but not to exceed 24 hours) following surgery."
E. Review of Policy and Procedure for Subject: Medical Record Content Requirements, Department: Health Information Management on 04/27/17 at 0915 revealed "All operations performed shall be fully described by the operating surgeon. Operative reports shall be written or dictated immediately following surgery and be authenticated within 72 hours."

Based on Performance Improvement and Safety Plan review, Quality Reporting Schedule review, Quality Meeting Minutes review, and interview, it was determined the facility failed to ensure 3 (Care Management, Medical Records, and Swing Bed) of 14 (Nursing, Rehab Services, Surgical Services, Sterile Processing, Swing Bed, Care Management, Medical Records, Lab, Environmental Services, Emergency Services, Pharmacy, Radiology, Respiratory, and Food and Nutrition Services) departments reported QA (Quality Assessment) data every six months as per the Reporting Schedule. The failed practice did not ensure departments were knowledgeable as to the status of the quality indicators, and thus were not aware of which items needed corrective action. Findings follow.

A. Review of Quality Meeting Minutes for May 2016 through March 2017 revealed QA data was reported only once for Care Management (March 2017) and Swing-Bed (May 2016) and none for Medical Records.
B. During an interview on 04/26/17 at 1445, the Market Director of Quality stated each department was expected to report QA data every six months. She confirmed the lack of QA data for Care Management, Swing Bed, and Medical Records at that time.

Based on review of Swing-Bed policies and procedures and interview, it was determinedthere were no policies and procedures addressing patient's rights to work in the facility during their hospitalization. The failed practice did not assure patients with a need for therapeutic work rehabilitation were allowed to work or were allowed to refuse to work during their hospitalization and was likely to affect all patients needing work rehabilitation in the facility. Findings follow:

A. Review of Swing-Bed policies and procedures revealed no evidence of policies addressing patients working or refusing to work while admitted to the facility.
B. During an interview on 04/25/17 at 1015, the Market Director of Quality confirmed there was no policy regarding patient's right to work.

Based on policy review, Medical Staff review, and interview, it was determined there was no evidence of a contractual agreement with a dentist. The failed practice did not ensure a dentist would be available to provide emergency dental needs for patients. The failed practice had the potential to affect any patient admitted to a Swing-bed. The findings follow:

A. Review of list of Physicians on the Medical Staff revealed no evidence of a Dentist.
B. During an interview on 04/24/17 at 1409, the Market Director of Quality confirmed the facility did not have a contractual agreement with a Dentist.