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Based on review of personnel files and interviews with hospital staff, the hospital failed to ensure contract personnel are oriented, trained and evaluated specific to the facility. The hospital did not have documentation that nurses employed by DaVita a contracted dialysis service providing dialysis services for hospital inpatients were competent and trained to provide dialysis services to the hospital's patients.

Findings:

1. On 10/27/11 at 2:30 pm the surveyor asked Staff ( I ) if the nurses providing dialysis services for DaVita, a dialysis service providing inpatient dialysis had documentation of facility specific orientation, training, evaluation and current licensure. Staff ( I ) stated they did not.

2. These findings were reviewed with administration during the exit interview on 10/27/11. No further documentation was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure a list of all contracted services is maintained which includes the scope and nature of the services provided.

Findings:

1. Hospital staff (A) stated on 10/27/11 that all the contracts were electronic and the surveyor could review the list on the computer.

2. The electronic contract list was reviewed and did not have a complete list of all contracted services.

3. Inpatient dialysis services provided by DaVita were not listed on the electronic contract list.

4. The contracted list reviewed had a dialysis service listed that was no longer providing inpatient dialysis service.

Based on the review of abuse and neglect policies and procedures and interviews with hospital staff, the hospital does not have mechanisms/methods defined in a policy that clearly describe the procedures to follow when a patient alleges abuse by a hospital employee.

Findings:

1. The hospital policies provided for review addressed abuse that occurred prior to when the patient presented to the hospital. The policies did not clearly define the steps to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker and did not contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect by these individuals.

2. Interviews with Staff D and E in the afternoon of 10/26/2011 verified that the hospital does not have a written policy that includes the required elements for effective abuse and neglect protection that occurred in the hospital.

Based on review of medical records and interviews with staff, the facility failed to enforce the required bylaws and ensure a history and physical examination was performed within 30 days of admission, or 24 hours after admission or prior to a procedure which required anesthesia. This was evident in four (chart #'s 10, 18,19, and 20) of four OB charts reviewed.

Findings:

1. Four (1,2,3,4) of four (1,2,3,4) patient's admitted for pain management treatment did not have a current history and physical on the chart prior to the procedure.
2. Two(5,7) of two (5,7)patient's admitted for gynecological surgery did not have a current history and physical on the chart prior to surgery.
3. Hospital staff were interviewed on the afternoon of 10/27/2011 and told surveyors they were unaware of the need for "updated" history and physicals prior to surgery.
4. The history and physical for Patient #17 was not dictated until the date of discharge, 02/16/2011, and the record did not contain an admission note with the required information for a history and physical.

Based on review of medical records, hospital documents and personnel files, and interviews with hospital staff, the hospital failed to ensure that the care of each patient is assigned to personnel who are trained, qualified, and competent to care for patients with specialized needs. This occurred for ten out of ten personnel charts for review.

1. Staff V, W, X, Y, Z, Aa, Bb, Cc, Dd, and Ee personnel files did not have evidence of department specific yearly competencies or evaluation of skills to verify nursing personnel's qualifications and ability to care for the individual needs of each patient and area in which they are assigned.

Based on record reviews and interviews with hospital staff, the hospital does not ensure that medical records are complete, retained and properly filed for prompt retrieval.

Findings:

1. On the morning of 10/26/2011 administrative staff told the surveyors that all patient medical records were maintained on computer/electronic medical records. Later in the morning surveyors were provided access to the electronic medical record and instructions on where documents could be found.

2. On the afternoon of 10/27/2011 surveyors reviewed medical records policy and procedures. A majority of the policies did not have revision since 2002. Administrative staff at the facility indicated electronic documentation had initially been implemented several years ago. The policy and procedures did not reflect the current medical records practice. There were no policies addressing use of the electronic documentation system and how the clinicians accessed particular documents.

3. Three of five medical records (Records #20, 22 and 23 of Records #19, 20, 21, 22 and 23), reviewed for organ procurement requestor forms,did not contain the requestor forms, either in the electronic or original paper records. Nursing notes for Records #22 and 23 document the organ procurement was called. This finding was verified with Staff E on the afternoon of 10/27/2011.

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital has written instructions for the proper receipt and reporting of tissue specimens. The hospital does not have written policies addressing the process of receipt and reporting of tissue specimens electronically.

Findings:

1. The hospital has converted to electronic policies and procedures.

2. The policies and procedures provided for review did not provide instructions on how to receipt and report tissue specimens using the electronic process. The policies and procedures were instructions for how to receipt and report tissue before the hospital converted to electronic policies and procedures.

3. Staff G stated that he could verbalize the process, but had not revised the policies and procedures to reflect the current electronic method.

Based on staff interviews and review of hospital records, the hospital failed to ensure the infection control officer maintained a comprehensive system for controlling infections and communicable diseases. The infection control officer did not monitor the surgery department to ensure appropriate measures were taken regarding the sterilization of surgical instruments.

Findings:

1. According to Staff B the facility has two sterilizers used for flash sterilization. On 10/26/11 and 10/27/11 surveyors reviewed the "flash sterilization logs" for the two sterilizers. Documentation by staff in the flash log indicates during October 2011 shoulder, knee, dental, and laparoscopic sets and instruments were sterilized using a shortened cycle. Staff B told surveyors in an interview on 10/26/2011 the shortened cycles were used if there weren't enough sets or if equipment was dropped. Staff B told surveyors he had reviewed the sterilization log June and September for equipment needs. Staff B said he did not take the information to committee he took it to administration and requested equipment based on the needs. Staff B also told surveyors he did not give information to the infection control practitioner (ICP). Staff B did not know of any surveillance done by the ICP in the surgical suite.

2. According to the policy "Flash Sterilization" stipulated in Policy "Documentation of cycle information and monitoring results is maintained to provide for tracking of the flashed item(s) to the individual. Procedure 4. "Place a chemical integrator and chemical indicator with pertinent information in each tray of items to be sterilized. Each sterilization cycle should be monitored to verify that parameters required for sterilization have been met. 5. Documentation would be maintained to allow for traceability of every load to the patient for whom the instruments were used. A sterilization log or database should include information on each load, including: a. the device(s) processed; b. the patient receiving the item(s); c. the reason for flash sterilization; d. date and time; e. cycle information; f. operator information (initials of staff member performing flash).

"Flash" sterilization: The Centers for Disease Control (CDC -- from Infection Control and Hospital Epidemiology, "Guideline for Prevention of Surgical Site Infection", April 1999, page 261) and Prevention and the Association of Operating Room Nurses (AORN -- Perioperative Standards and Recommended Practices, pages 460, 2010 edition) do not recommend the use of "flash" sterilization for the routine sterilization of instruments, reasons of convenience or as an alternative to purchasing additional instrument sets or to save time. "Flash" sterilization, according to current CDC guidelines, should -be limited to the purpose of sterilizing a surgical instrument in an emergency, such as when a needed instrument has been dropped or otherwise become contaminated.


Review of the October flash sterilization logs included two instances where personnel documented "no card run" indicating the chemical integrator/indicator was not run with the flash load. For another instance of shortened cycle, personnel documented a laparoscopic cholecystectomy tray was flashed. No sterilizer tape for the load could be found. There are multiple instances where the sticker with Julian Calendar Date and Load ID did not match dates on the sterilizer tapes or cards. On 10/19/11 a load was documented as "T&A" no patient name was placed in the log for tracking. On 10/3/11 a load identified as "ACL instr" (anterior cruciate ligament) did not have patient's name attached although review of the surgery log for the day indicates a ACL repair took place. On 10/10/11 cycle 101002 had "no info" documented. Hospital staff failed to follow policy for tracking flash sterilization loads. These findings were not monitored by infection control in conjunction with the operating room (OR) director or manager to investigate and monitor measures that can be taken in order to reduce the potential risk of infection in a surgical patient.

3. In review of employee health files, the infection control nurse did not ensure that all employees had their Measles, Mumps, Rubella (MMR) immunization status completed. Staff Cc, W, and D personnel files did not contain the immunization status for measles, mumps, rubella (MMR).

Based on review of the hospital's death register, the referral request forms sent to OPO (organ procurement organization - LifeShare of Oklahoma), and medical records and interviews with hospital staff, the hospital failed to develop and implement written protocols that ensure all deaths were reported to the OPO. The hospital failed to integrate this program in the the quality performance improvement (QAPI) program.

Findings:

1. On the morning of 10/26/2011, the surveyors requested the list of deaths that occurred in the hospital and the OPO activity reports for 2011. Staff E and Staff H brought the surveyors the list of deaths that occurred in the hospital, inpatient and emergency department. On 10/26/2011, Staff D and E told the surveyors they did not know who was responsible for keeping the OPO activity report, or if the hospital had received any reports from OPO. On the afternoon of 10/26/2011, Staff D stated she would ensure the OPO reports would arrive on the morning of 10/27/2011 for surveyor review.

2. Three of five medical records (Records #20, 22 and 23 of Records #19, 20, 21, 22 and 23), reviewed for organ procurement requestor forms,did not contain the requestor forms, either in the electronic or original paper records. Nursing notes for Records #22 and 23 document the organ procurement was called. This finding was verified with Staff E on the afternoon of 10/27/2011.

3. Staff D stated, on the afternoon of 10/27/2011, that no one checked to ensure all deaths/imminent deaths were called to the OPO and the OPO program/policies were not a part of the QAPI program.

Based on staff interviews and record review, the facility failed to ensure that surgical services maintained standards of safe patient care.

Findings:

1. On 10/26/11 surveyors reviewed operating room policies. Several policies last review and revision date was 2008. The facilities flash sterilization policy was dated 2008. .

2. Staff stated during an interview in the afternoon 10/26/11 that flash sterilization was utilized for some surgeries because they did not have sufficient instrument sets. Staff B told surveyors Surgical Services had looked at the sets being flashed and notified administration when more sets were needed. In a review of flashed cases provided to surveyors, June 2011 and September 2011 had incidence of multiple flash occurrences for eye, orthopedic (shoulder and total joint).

3. According to the hospital's policy "Flash Sterilization" stipulates within the section(Policy) "Documentation of cycle information and monitoring results is maintained to provide for tracking of the flashed item(s) to the individual." The section labeled "Procedure" further stipulates 4. "Place a chemical integrator and chemical indicator with pertinent information in each tray of items to be sterilized. Each sterilization cycle should be monitored to verify that parameters required for sterilization have been met. 5. Documentation should be maintained to allow for traceability of every load to the patient for whom the instruments were used. A sterilization log or database should include information on each load, including: a. the device(s) processed; b. the patient receiving the item(s); c. the reason for flash sterilization; d. date and time; e. cycle information; f. operator information (initials of staff member performing flash).

Review of the October flash sterilization logs included two instances where personnel documented "no card run" indicating the chemical integrator/indicator was not run with the flash load. Another instance of shortened cycle personnel documented a laparoscopic cholecysectomy tray was flashed. No sterilizer tape for the load could be found. There are multiple instances where the sticker with Julian Calendar Date and Load ID did not match dates on the sterilizer tapes or cards. On 10/19/11 a load was documented as "T&A" no patient name was placed in the log for tracking. On 10/3/11 a load identified as "ACL instr" (anterior cruciate ligament) did not have patient's name attached although review of the surgery log for the day indicates a ACL repair took place. On 10/10/11 cycle 101002 had "no info" documented. Hospital staff failed to follow policy for tracking flash sterilization loads. These findings were not monitored by infection control in conjunction with the operating room (OR) director or manager to investigate and monitor measures that can be taken in order to reduce the potential risk of infection in a surgical patient.