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Based on record review and interview, the facility failed to provide a comprehensive Nuclear Medicine Department Policy and Procedure manual approved by the Medical Executive Committee and Board of Directors that is complete and clearly written in approved facility format to explain what types of health care services are available and which services are furnished through agreements or arrangements. The facility census was 16.

Findings included:

1. Record review of the Policy and Procedure manual for Nuclear Medicine showed a disorganized, non-indexed combination of photocopied pages from instruction manuals, text books, hand written procedures on lined tablet paper and various crude drawings illustrating different techniques and positioning guides for use in the Nuclear Medicine Department. There was no Scope of Practice and no evidence of current official review to authenticate the policies and procedures by the responsible department manager, Medical Executive Committee, Medical Director or CEO (Chief Executive Officer).

2. During an interview on 03/27/12, Staff OO, Radiology Manager, stated Staff PP, Nuclear Medicine Department Manager, lived and worked in another city and only worked at the hospital one or two days a week, based on patient's appointments scheduled in advance.

During an interview on 03/28/12, at 3:30 PM Staff W, QA/Risk Manager stated that the contracted Nuclear Med Technician wanted to manage her own policy and procedure manual and kept it in her office. She stated the facility has several departments who manage their own policy and procedure manuals, but they allow hospital administration and Quality Assurance to review and standardize them to an established uniform format.

During an interview on 03/28/12, at 3:30 PM Staff W, QA/Risk Manager stated that the contracted Nuclear Medical Technician wanted to manage her own policy and procedure manual and kept it in her office. She stated the facility has several departments who manage their own policy and procedure manuals, but they allow hospital administration and Quality Assurance to review and standardize them to an established uniform format.

During an interview on 04/09/12 at 12:50 PM., Staff PP, Nuclear Medical Technician, stated that every procedure she performed for Nuclear Medicine was clearly described in the policy and procedure manual she kept at the facility as her department's official reference. She stated that it did have an index/table of contents, though perhaps not right up front. She stated the manual was reviewed and approved by her immediate supervisor, Staff RR, President of the contracted company, who also serves the hospital as their Radiation Safety Officer (RSO). She admitted the Scope of Practice and table of contents may not have been " right up front" but it was the only copy she had. She stated she did not know the manual had to be approved by the facility's governing body or special appointed committee.

Based on observation, interview and record review the facility failed to date and initial two bottles of medication used for more than one patient (multi-dose medications). The practice had the potential to affect all patients in the facility. The facility census was 16.

Findings included:

1. Record review of the facility's undated policy titled, "Surveillance, Prevention, and Control of Infection", Policy No. 21-06, showed the following direction:
- USE OF MULTIPLE-DOSE VIALS - Multiple-dose vials are clearly marked by the manufacturer. The manufacturer's expiration date is applicable if the vial is unopened and stored per recommendations. Once the vial is opened, a beyond-use date must be applied to it;
- The healthcare professional first puncturing the vial must initial the vial, and place the date of first entry on the vial; and
- LENGTH OF USE OF MULTIPLE-USE STERILE MEDICATIONS - Multiple-dose vials may be used for up to 28 days after the initial entry, unless the manufacturer recommends a shorter time.

2. Observation on 03/27/12 at 8:10 AM showed two open multiple-dose medication bottles in the medical/surgical medication room. The medication room stores all the medications for all of the medical surgical patients and is accessed by all nurses administering medications to patients.

In a closed cabinet were one open and used bottle of Hydrogen Peroxide 3% USP 10 Volume 3% and one open and used bottle of 70% Isopropyl Alcohol (both medications are used for first aid antiseptic). Neither bottle was dated or initialed.

3. During an interview on 03/27/12 at 08:15 AM, Staff L, Licensed Practical Nurse (LPN) stated the bottles should have been dated and initialed. Staff L stated that when this happens the medications should be thrown away but she was going to check with pharmacy before she did that.

During an interview on 03/27/12 at 1:05 PM, Staff S, Registered Nurse (RN), Infection Control Nurse, stated that the multi-dose bottles of medication should have been dated and initialed.

During an interview on 03/27/12 at 2:40 PM, Staff R, Doctor of Pharmacy (Pharm D.), Director of Pharmacy, stated that nursing staff should have followed policy and procedure which was to date and initial the bottles and she would follow up to waste the medications since an expiration date could not be determined.

Based on observation and interview, the facility failed to provide a safe environment consistent with nationally recognized infection control precautions as follows:
-Failed to date and initial Intravenous (IV) (tubes placed within the vein) tubing to clarify when the tubing should be replaced according to facility policy to prevent the risk of transmission of organisms that could cause infection for nine (Patients #2, #3, #8, #9, #12, #15, #16, #20 and #26) of nine patients observed with IV tubing;
-Failed to follow facility policy for hand hygiene and gloving guidelines to prevent the risk of transmission of organisms for four (Patients #1, #2, #6, and #16) of four patients observed;
-To ensure operating room (OR) table and cart mattresses were maintained in a functional, easily cleanable surface that would not harbor and transmit bacteria in three of four areas observed; and
-Failed to maintain a clean and sanitary environment in the CT scan room (CT-Computerized Tomography-a cross-sectional body scan using a series of X-ray views and computer processing to create cross-sectional images of bones and soft tissues in the body). The facility census was 16.

Findings included:

1. Record review of the facility's policy titled, "Peripheral I.V. Care: (Insertion and Maintenance) Tubing changes and Labeling" revised 06/11, showed the following direction:
- STATEMENT OF POLICY: IV tubing will be maintained and labeled for appropriate changes;
- To provide guidelines for changing IV tubing with appropriate labeling;
- Date and initial all tubing changes on tubing.

Observation on 03/26/12 at 1:40 PM showed Patient #2 with an IV and two separate lines of IV tubing administering medication. Each IV tubing line had a piece of paper taped to it with spaces provided to enter the date and the nurses initial but all spaces were blank.

Observation on 03/26/12 at 1:50 PM showed Patient #3 with an IV administering medication. The IV tubing had a piece of paper taped to it with a space provided to enter the date and the nurses initial but all spaces were blank.

Observation on 03/26/12 at 2:30 PM showed Patient #8 with an IV and two separate lines of IV tubing administering medication. Each line had a piece of paper taped to it with spaces provided to enter the date and the nurses initial but all spaces were blank.

Observation on 03/26/12 at 2:40 PM showed Patient #9 with two Intravenous (IV) tubing's that had stickers with spaces provided to enter the date and the nurse's initials but all spaces were blank.

Observation on 03/26/12 at 2:45 PM showed Patient #12 with three IV tubing's that had stickers with spaces provided to enter the date and the nurse's initials but all spaces were blank.

Observation on 03/26/12 at 2:55 PM showed Patient #15 with two IV tubing's that had stickers with spaces provided to enter the date and the nurses initials but all spaces were blank.

Observation on 03/26/12 at 3:00 PM showed Patient #16 with one IV tubing that had a sticker with spaces provided to enter the date and the nurse's initials but all spaces were blank.

Observation on 03/27/12 at 8:58 AM showed Patient #20 with an IV and two separate lines of IV tubing administering medication. Each line had a piece of paper taped to it with spaces provided to enter the date and the nurses initial but all spaces were blank.

Observation on 03/27/12 at 9:08 PM showed Patient #26 with an IV administering medication. The IV tubing had a piece of paper taped to it with spaces provided to enter the date and the nurses initial but all spaces were blank.

During an interview on 03/27/12 at 1:05 PM Staff S, RN, Infection Control Nurse, stated that the Director of Nursing had been working to resolve this issue and they were aware that the IV tubing was not getting labeled with the date or the nurses initials.

During an interview on 03/27/12 at 1:50 PM Staff A, DON, stated that staff were to date and initial the sticker put on the IV tubing when the IV tubing was changed.

2. Record review of the facility's policy titled, "Hand Hygiene," revised 09/08, showed the following direction:
- Decontaminate hands with antimicrobial soap (a bacteria reducing soap) when caring for a patient with suspected or confirmed Clostridium Difficile (C-Diff, a bacteria that is in the large intestine);
- Decontaminate hands before and after having direct contact with patients;
- Decontaminate hands before donning and after removing gloves.

Observation on 03/26/12 at 2:22 PM showed Staff C, Laboratory Technician, entered Patient #6's room to insert an IV catheter (small tube inserted into the vein). Staff C did not perform hand hygiene upon entering the room. Staff C donned gloves and inserted the IV catheter into the arm of Patient #6. Staff C removed the gloves, did not perform hand hygiene and exited the room.

Observation on 03/27/12 at 9:08 AM Showed Staff L, Licensed Practical Nurse (LPN), entered Patient #2's room and did not perform hand hygiene before donning gloves to administer an injection.

Observation on 03/27/12 at 9:15 AM showed Staff L entered Patient #1's room to administer an IV flush (procedure used to keep the IV catheter open when not administering medication). Staff L did not use hand hygiene before donning gloves to administer the IV flush.

During an interview on 03/27/12 at 1:05 PM Staff S, RN, Infection Control Nurse, stated the facility policy and procedure provided guidelines to all clinical staff to use hand hygiene before donning and after removing gloves.

Observation on 03/26/12 at 3:00 PM showed Staff G, Registered Nurse (RN), in Patient #16's room who was on Contact Isolation for C-Diff. Staff G completed tasks in the room, removed gown and gloves and used hand sanitizer before leaving the room.

During an interview on 03/26/12 at 3:15 PM Staff G stated that:
-It would be best to wash hands before leaving the room and not use hand sanitizer, but the only sink was inside the room across from the patient's bed.
-She would go up the hall to the Monitored Care Unit (MCU) and wash her hands.
Observation at the time of the interview showed the MCU was located approximately 30 feet from this patient's room.

During an interview on 03/27/12 1:05 PM Staff S, Infection Control Nurse, stated that:
-Staff must wash hands with soap and water and not use hand sanitizer when leaving a patient's room who is in Contact Isolation for C-Diff.
-She would expect staff to remove gown and go back into the room to wash their hands in the sink and try not to touch anything prior to leaving the room.

3. Observation on 03/28/12 at 12:15 PM in the Post Anesthesia Care Unit (PACU) showed the following:
-A cart mattress with a ripped, open area approximately the size of a dime, on the top surface. Above the open area was tape residue approximately one inch wide and two inches long.
-On the other side of the top surface of the mattress was an open area approximately the size of a pencil eraser head.

Observation on 03/28/12 at 1:15 PM in the operating room (OR) showed two arm board pads with tape covering each corner.

Observation on 03/28/12 at 1:55 PM in pre operative prep room #2 showed:
-A cart mattress with two pieces of tape on the top surface. Each piece was approximately two inches by three inches.
-On the back side of the pad was an approximately four inch long open area in a seam.

The open areas and tape/tape residue do not allow for a cleanable surface and increase the potential to harbor bacteria that can be transmitted.

During an interview on 03/28/12 at 3:30 PM Staff W, Director of Quality/Risk Management and Medical Staff Services, stated that there were not any facility policies regarding mattresses with torn, open areas, tape or tape residue.

4. Observation on 03/26/12 at 3:18 PM showed accumulated deposits of a thick white sticky substance on the base of a wheeled stand used for the remote control to the CT (Computed tomography or Computed axial tomography (CAT), used for medical imaging and industrial imaging) machin. Additional drops of the same material were splattered on the floor.

During an interview on 3/27/12 at 3:18 PM, Staff OO, Radiology Manager, acknowledged the observation.



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Based on observation, interview and record review the facility failed to ensure the nutritional needs of patients were met using recognized standards of nutrition and food sanitation including:
-Dietary staff failed to provide high quality nutritional care by failing to maintain an evaluation of the nutritional adequacy (calorie, protein, carbohydrate, fat, vitamin and mineral content) of the menus used for patient meal service.
-The dietitian failed to approve the menus used for patient meal service.
-The Dietary department failed to maintain a current diet manual and failed to ensure it was available for use by medical, nursing and dietary staff.
-The facility failed to ensure the dish washing machine consistently reached the required temperature of one hundred eighty degrees Fahrenheit (180 F) in the final rinse water to effectively sanitize dishes, silverware and utensils used in patient meal service.
-The Dietary staff failed to ensure foods removed from bulk containers were labeled with the common name.
-The Dietary staff failed to ensure foods labeled by the manufacturer as "refrigerate after opening" were refrigerated as required.
-The Director of Dietary failed to ensure Dietary department staff members were prohibited from wearing jewelry and fingernail polish that could cross contaminate foods while working in the kitchen.

These failures had the potential to affect all patients, staff and visitors who ate foods prepared in the Dietary department kitchen. The facility census was 16.

Findings included:

1. Review of the facility's policy titled "Menus", reviewed 03/07/07 showed direction for the facility dietitian to sign the menus.

Record review of a copy of the facility menus showed the menus were not signed by the facility dietitian.

During an interview on 03/26/12 at 1:55 PM Staff D, Director of Dietary confirmed the following:
-The current menus had been used for a number of years.
-She did not have a nutritional analysis for the current set of menus (did not know the calorie, protein, carbohydrate, fat, vitamin and mineral content of the menus) served to patients.
-The facility dietitian had not signed the current menus to signify approval of the menus for use with patients.

During an interview on 03/26/12 at 3:02 PM Staff E, Dietitian confirmed she did not have a nutritional analysis of the current menus served to patients and had not signed (approved) the menus.

2. During an interview on 03/26/12 at 1:56 PM Staff D, Director of Dietary stated the facility used the 2003 Missouri Diet Manual.

Record review of the facility diet manual provided by Staff D showed the 2003 Missouri Diet Manual (a nine year old reference), was approved for use on 04/13/09 by the medical staff and the administration.

During an interview on 03/27/12 at 9:50 AM at the nurses' desk Staff H, Charge Nurse stated that:
-She had worked in the facility for the last three years.
-She had never seen a facility diet manual.

3. Record review of the U.S. Department of Health and Human Services (USDHHS), Public Health Service (PHS), Food and Drug Administration (FDA), 2005 Food Code showed the following direction in Chapter 4-501.112 Mechanical Ware washing Equipment, Hot Water Sanitization Temperatures shall not be less than one hundred eighty degrees Fahrenheit (180 F).

Record review of the facility's policy titled "Dishwashing" dated 03/07/07 showed direction for facility staff to ensure the rinse temperature was 180 F.

Observation on 03/26/12 at 2:55 PM in the facility kitchen dish washing area showed a mechanical dish washing machine with a metal manufacturer's label attached to the front of the machine with operating instructions including the temperature of the final rinse water should be 180 F.

Record review of the "Dish Machine Daily Temperature Record Log" dated 03/12 showed the following:
-Staff were expected to record temperatures including rinse temperatures three times a day (at breakfast, lunch and dinner).
-The required rinse temperature should be 180 degrees F.
-Staff recorded values less than 180 F on five of seventy seven occasions.
-Staff failed to record remedial actions, notification of supervisory staff or re-measure the lower than required temperature.
During an interview on 03/26/12 at 2:55 PM Staff D, Director of Dietary confirmed the following:
-The facility served meals to isolated patients (patients with contagious diseases) on regular (non-disposable) dishes and silverware.
-The dietary department usually served meals to at least two isolated patients per day
-Those dishes and silverware were washed in the facility dish washing machine.
-Some of the temperatures recorded on the dishwashing machine log were below the required 180 F to properly sanitize the dishes and silverware.

Record review of the "Dish Machine Daily Temperature Record Log" dated 02/12 showed the following:
-Staff recorded eight temperatures below 180 F during eighty seven occasions.
-Staff failed to record any final rinse water temperatures on seven occasions during the
month.

Record review of the "Dish Machine Daily Temperature Record Log" dated 01/12 showed the following:
-Staff recorded five temperatures below 180 F on ninety three occasions.
-Staff failed to record any final rinse water temperatures on three occasions during the
month.

4. Record review of the USDHHS, PHS, FDA, 2005 Food Code showed the following direction in Chapter 3-302.12 working containers holding food or food ingredients that were removed from their original packages shall be identified with the common name of the food.

Observation on 03/27/12 at 8:58 AM through 9:39 AM in the facility kitchen showed:
-Staff stored an unlabeled plastic squeeze bottle of a thick white liquid on a shelf over the food prep table.
-Staff stored an unlabeled plastic container of white powder on a shelf over the food prep table.

During an interview on 03/27/12 at 8:59 AM Staff O, Cook stated the following:
-The unlabeled plastic squeeze bottle of thick white liquid might be glaze for doughnuts but was unsure.
-The unlabeled plastic container of white powder was not supposed to be stored like that (unlabeled), should have a label and may be powdered sugar but was unsure.

Observation on 03/27/12 at 11:20 AM in the facility kitchen showed staff stored an unlabeled plastic container of red and white colored powder on a shelf over the cook's prep table.

During an interview on 03/27/12 at 11:20 AM Staff D stated she did not know what was in the unlabeled plastic container of red and white colored powder.

5. Observation on 03/27/12 at 8:58 AM through 9:39 AM in the facility kitchen showed the following:
-Staff stored a plastic squeeze bottle of chocolate flavored dessert topping with a manufacturer's label directing "for best quality refrigerate after opening" unrefrigerated on a shelf over the cook's prep table.
-Staff stored an opened, partial container of soy sauce with a manufacturer's label directing "refrigerate after opening" unrefrigerated on a shelf below the cook's prep table.

During an interview on 03/27/12 at 8:59 AM Cook O confirmed the container of soy sauce was usually stored on the shelf below the cook's table.

During an interview on 03/27/12 at 11:20 AM Staff D stated the plastic squeeze bottle of chocolate flavored dessert topping was usually stored out on the shelf after opening and she was not aware that the manufacturer's label recommended refrigerated storage of the opened container.

6. Record review of the USDHHS, PHS, FDA, 2005 Food Code showed the following direction for dietary staff:
-Chapter 2-302 Fingernails; a food employee may not wear fingernail polish when working with exposed food.
-Chapter 2-303 Jewelry; while preparing food, a food employee may not wear jewelry on arms or hands.

Observation on 03/27/12 at 9:15 AM showed Staff P, Diet Aide wore a bracelet dangling from her wrist, portioned fruited gelatin for patient meal service and allowed the bracelet to periodically touch the surface of the gelatin.

Observation on 03/27/12 at 9:25 AM showed Staff P wore nail polish, wiped the work table with a cloth then, moved foods and utensils to the refrigerator.

Based on interview and record review the facility failed to have an eligible outside entity review the quality and appropriateness of the diagnosis, treatment or outcome of treatment provided by each physician who provided patient care services. The failure had the potential to affect all patients in the facility. The census was 16.

Findings included:

1. Record review of eight credentialing (the system by which a hospital checks that its healthcare practitioners are properly qualified) records for four (Staff Z, AA, BB and DD) Medical Doctors, and four (Staff X, Y, CC, and EE) Doctors of Osteopathy, showed no Quality Assurance evaluation of clinical practice for the physicians currently providing patient care.

Record review of the facility's directory listed 71 physicians as currently providing patient care services.

2. During an interview on 03/28/12 at 8:54 AM, Staff W, Registered Nurse (RN), Director Quality/Risk Management, Medical Staff Services, stated that none of the current physicians have been reviewed for the quality and appropriateness of diagnosis, treatment or outcome of treatment and no examples of any reviews could be provided for the prior 12-24 months by an eligible outside entity. Staff W also stated that there were no policies and procedures regarding this requirement.