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Based on record review and interview, the hospital failed to ensure that the grievance process was implemented as evidenced by failing to thoroughly investigate grievances for 3 of 3 patient grievances reviewed (Patient #27, 28, 29).
Findings:

Review of the hospital policy titled, Grievance Policy, revealed in part that the Department Manager of alleged grievance shall coordinate the investigation. He/she will involve any and all necessary individuals in the investigation process. Written documentation shall be provided to the Patient Advocate within 15 business days stating: steps taken to investigate the complaint, employees involved in investigation, findings of investigation, opinion of validity of complaint and steps taken by Department Manager to correct or improve care in light of this complaint/grievance.

Patient #27
Review of the grievance intake dated 02/12/18 revealed that Patient #27 complained of the unprofessional staff in the admissions office. She further revealed that it took the staff too long to perform paperwork for an outpatient test and that the patient missed her scheduled MRI test that day.

There was no documentation of any investigation related to this issue. On 04/04/18 at 2:30 p.m., interview with S2Social Worker, who is also the Patient Advocate, revealed that she is responsible for overseeing patient complaints/grievances. She further revealed that the Department Manager of admissions was supposed to investigate this matter and counsel any employees involved. When asked for the documentation regarding the investigation, S2Social Worker stated that she had none.

Patient #28
Review of the grievance intake dated 01/15/18 revealed that Patient #28 complained that the ER physician (S7Physician) was rude and accused the patient of taking drugs. The patient further stated that she was on other medications that could show a false positive drug screen, but the physician would not listen to her.

Review of the only investigation documentation revealed it was performed by the Lab Director, stating that the medication that the patient was on could have resulted in a false positive drug screen. Further review revealed no investigation related to S7Physician.

On 04/04/18 at 2:40 p.m., interview with S2Social Worker revealed that the Lab Director investigated this complaint. When asked if the issues involving S7Physician were investigated, she stated that the Administrator was supposed to talk to him, but she was unsure if he had done that.

Patient #29
Review of the grievance intake dated 11/13/17 revealed Patient #29 complained that the ER physician (S8Physician) did not examine her when she came to the Emergency Room. She further stated that S8Physician came into the room but did not take his hands out of his pocket to examine her.

Review of the investigation documentation revealed a copy of the Emergency Room nurses notes, stating that the patient left AMA (against medical advice). There was no documentation from S8Physician. Further review of the investigation documentation revealed the issues regarding S8Physician were not addressed.

On 04/04/18 at 3:00 p.m., interview with S2Social Worker stated that she could provide no further investigation documentation regarding the complaint from Patient #29. S2Social Worker further confirmed that there was no documented evidence that the above complaints involving Patients #27, 28 and 29 were thoroughly investigated.

Based on record review and interview, the hospital failed to ensure grievance resolution letters to patients included the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion for 3 of 3 patient grievances reviewed (Patient #27, 28, 29).
Findings:

Review of the hospital policy titled, Grievance Policy, revealed in part that Patient Advocate will provide a written response to complainant regarding grievance process and action taken on behalf of the hospital within 7 days of completion of investigation. The letter shall include: steps taken on behalf of patient/complainant to investigate the grievance, results of grievance process, and the date of completion.

Patient #27
Review of a copy of a typed Grievance letter (undated), written in response to a grievance filed by Patient #27 on 02/12/18 revealed that the hospital apologized for the patient's unpleasant experience. The letter contained no documentation stating what measures had been taken to investigate the grievance, the results of the grievance process or the date of completion.

Patient #28
Review of a copy of a typed Grievance letter (undated), written in response to a grievance filed by Patient #28 on 01/15/18 revealed the hospital apologized for the patient's unpleasant experience. The letter contained no documentation stating what measures had been taken to investigate the grievance, the results of the grievance process or the date of completion.

Patient #29
Review of a copy of a typed Grievance letter (undated), written in response to a grievance filed by Patient #29 on 11/13/17 revealed the letter apologized for the behavior of the staff member involved. The letter contained no documentation stating what measures had been taken to investigate the grievance, the results of the grievance process or the date of completion.

On 04/04/18 at 3:30 p.m., interview with S2Social Worker revealed that she is also responsible for patient grievances. She reviewed the above letters and confirmed that the patient letters did not include a date the letter was written, measures taken to investigate the grievance, the results of the grievance process or the date of completion.

Based on record review, observation, and interview, the hospital failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals were not be available for patient use.
Findings:

Review of the hospital's policy titled, Use of Multidose Vials, revealed, in part, the following: Open Multidose Vials will be discarded 28 days after use.

I. Observation of the nursing station Medication Supply room on 04/02/18 at 12:00 p.m. revealed the following:
a. Lantus Insulin 100 units/ml (milliliter) 10ml noted with an open date of 2/28/18.
b. Levimer Insulin 100 units/ml (milliliter) 10ml noted with an open date of 3/1/18.
c. Humulin Insulin 70/30 100 units/ml (milliliter) 10ml noted with an open date of 3/1/18.
d. Six (6) vials of Pneumococcal vaccine note with an expiration date of 3/18.
e. One (1) Tuberculin vial noted with an open date of 2/26/18.

During an interview on 4/2/18 at 12:15 p.m., S11RN Charge Nurse acknowledged the noted outdated and expired medications should not have been available for patient use.

II. Observation of the medication refrigerator in the Infection Control office on 04/02/18 at 2:05 p.m. revealed the following:
a. Tuberculin vial noted with an open date of 2/14/18.
b. Influenza vial noted with an expiration date of 11/2017.
c. Two (2) unlabeled syringes containing unknown liquid inside a plastic container.

During an interview on 04/02/18 at 2:15 p.m., S10QA/PI acknowledged the unlabeled, outdated, and expired medication should not have been available for use.

III. Observation of the medication refrigerator in the Intensive Care Unit revealed an opened vial of Humalog insulin that was not labeled with the first puncture date. At that time, S1DON confirmed the opened multidose vial was not labeled.




17450

Based on observation, record review and interview, the hospital failed to maintain a sanitary environment as evidenced by: 1) failing to maintain radiology equipment, 2) failing to maintain patient care equipment, 3) storing food items in a medication refrigerator and failing to keep a refrigerator temperature log, 4) failing to maintain the rehabilitation equipment and 5) failing to maintain a sanitary kitchen environment.
Findings:

1. Observation on 04/03/18 at 8:40 a.m. revealed two contrast filled and uncapped syringes on a washcloth in the computed tomography (CT) room. During an interview on 04/03/18 at 8:42 a.m., S13Radiology tech acknowledged the contrast was prepared for administration and leaving the syringes uncapped was an infection control issue.

Observation of X-ray room #2 on 04/03/18 at 9:18 a.m. revealed the x-ray table mat had a tear in the covering on each side of the mat. During an interview on 04/03/18 at 9:20 a.m., S13Radiology manager acknowledged the table could not be properly disinfected due to the tears in the mat.

Observation of X-ray room #1 on 04/03/18 at 9:25 a.m. revealed a grime covered oxygen tube attached to the oxygen flow meter. During an interview on 04/03/18 at 9:27 a.m., S13Radiology manager acknowledged the grime covered oxygen tubing was an infection control issue.

2. Observation of Clean Supply Closet on 04/02/18 at 11:15 a.m. revealed the following:
a. Black mold covering the surface of a ceiling tile
b. Two feeding pumps with a grimy build up noted on the outer surfaces.
c. Five intravenous infusion pumps noted with a grimy build up noted on the outer surfaces.
d. Six sequential compression device pumps noted with a grimy build up on the outer surfaces.

During an interview on 04/02/18 at 11:40 a.m., S11RN Charge Nurse acknowledged the black mold on the ceiling in the clean equipment room and confirmed the grime covered patient care equipment were infection control issues.

Observation on 04/02/18 at 11:30 a.m. of the Intensive Care Unit (ICU) revealed the following:
- The monitor at bed 5 had old pieces of tape on the ekg leads
- The drawer in the nurses station labeled "pulse ox cords" revealed it contained 3 pulse ox monitors with old used tape still stuck to them

On 04/02/18 at 11:40 a.m., interview with S1DON confirmed the above infection control issues in the ICU.

3. Observation on 04/02/18 at 2:05 p.m. revealed a medication refrigerator in the infection control office, which had food items stored with the medication. Continued observation failed to reveal a thermometer or a temperature log in this refrigerator.

During an interview on 04/02/18 at 2:15 p.m., S10QA/PI acknowledged storing medications and food together was an infection control issue. She continued to state a thermometer should have been inside the medication refrigerator and a temperature log was supposed to be maintained for the medication refrigerator.

4. Observation of the rehabilitation unit on 4/3/18 at 11:15 a.m. revealed the following:
a. Paraffin wax warmer with grime on the upper surface and lid.
b. Hand cycle device with grime on the framework and mechanism.
c. Treadmill will grime on the handrail/hand rest and device settings panel.
d. Tear on the cover of the high-low table.

During an interview on 4/3/18 at 11:30 a.m., S14Occupational Therapist acknowledged the grimy equipment and the torn table were an infection control issue.

5. On 04/03/18 at 10:30 a.m., observation of the food storage areas in the dietary department revealed the following:
In the freezer - an opened bag of meat patties which was undated and unlabeled (identified as turkey by S5DM);
In the refrigerator - seven half-gallon containers of buttermilk expired 03/18/18; half of a pound cake in an undated and unlabeled bag; a container of beverage not dated or labeled;
In the pantry - an opened box of dry potatoes not sealed.
An interview with S5DM at this time confirmed stored foods should be dated, labeled and sealed and that expired foods should be removed from available food storage.

On 04/03/18 at 10:45 a.m., further observation revealed 2 large metal pans covered with aluminum foil were sitting in the sink. Interview with S5DM at this time confirmed the pans contained chicken pieces which were thawing and were to be marinated for use the following day. There was no running water flowing over the thawing meat.

On 04/03/18 at 10:55 a.m., observation of the dishwashing area revealed a log for recording sanitizer levels dated April 2018 was hanging on the wall by the dishwashing machine. There was no documentation noted on the log. Interview with S5DM at this time confirmed that the sanitizer levels should be recorded prior to using the machine after each meal every day. She further confirmed that nothing was recorded on the log for the month of April. Observation of a test strip check of the sanitizer level by S5DM revealed the level was 20 parts per million (ppm). S5DM stated that the level should be between 50-100ppm.

On 04/03/18 at 11:05 a.m., observation of the 3 compartment sink revealed there was nothing documented on the log for the month of April. Observation of a test strip check of the sanitizer level in the 3 compartment sink by S5DM revealed a reading of 20 ppm. S5DM confirmed the reading should be between 50 - 100 ppm. She further confirmed that there was no documentation of the sanitizer levels on the log for the 3 compartment sink for the month of April 2018.

Review of the manufacturer's instructions for the dishwashing machine confirmed the sanitizer concentration levels should be 50 ppm minimum to 100 ppm maximum. If concentration is incorrect contact your chemical supplier.
Review of the hospital's procedure for the 3 compartment sink revealed the third compartment should be filled with water and chemical sanitizer (follow product directions). On 04/03/18 at 11:10 a.m., an interview with S5DM confirmed she had not contacted the manufacturer or supplier about any concerns with the sanitizer levels in the dish washing machine or the 3 compartment sink.






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17450

Based on record review, observation, and interviews, the hospital failed to ensure the Surgical Services Department followed acceptable professional standards of practice as evidenced by:
1) failing to ensure that expired supplies were not available for patient use;
2) failing to ensure that staff adhered to the manufacturer's instructions for the use of the high level disinfectant for semi-critical items;
3) failing to ensure that the maintenance department was notified of potential equipment failures when the humidity levels in the operating room were outside the desired parameters;
4) failing to ensure that the biological indicator tests were conducted as per manufacturer's instructions; and
5) failing to ensure that the towels used in the drying process of surgical instruments that were to be sterilized were lint-free;
Findings:

1) Failing to ensure that expired supplies were not available for patient use;

On 04/02/18 at 2:00 p.m., observation in the endoscopy procedure room revealed 10 packages of surgical snares with an expiration date of 07/2016 were stored on a open shelf in the procedure room with other supplies available for patient use. An interview with S3Director of Surgery at this time confirmed the supplies were expired and should not be available for use.

2) Failing to ensure that staff adhered to the manufacturer's instructions for the use of the high level disinfectant for semi-critical items;

Review of he hospital's policy Infection Control Policy Surgical Suite effective 03/15/06, reviewed 06/28/17 recommendations for XIV. Cleaning Instruments revealed: Effective decontamination of instruments is essential...C. If a washer sterilizer is not available: 1. Instruments may be immersed in trays that contain a chemical cleaner/disinfectant, and soaked according to the manufacturer's directions.
On 04/02/18 at 2:30 p.m., during observation of the decontamination procedure room, an interview with S4Scrub Tech revealed she prepares the solution for cleaning endoscopes by filling a 4 gallon plastic tub about half full of water (approximately 2 gallons) and adding "about 8-10 pumps" of enzymatic solution to the water.
Observation of the tub revealed there were no markings to indicate where the fill line should be.
Review of the manufacturer's label for the Prolystica 2X concentrate enzymatic presoak and cleaner revealed it should be diluted by adding 1/8 to 1/2 fluid ounces per gallon (1 to 4 ml per liter) of warm water.
When asked how much of the concentrate was in one pump, S4Scrub Tech stated she wasn't sure. Demonstration by S4Scrub Tech confirmed that one pump contained 20 ml of the concentrate. Further interview with S4Scrub Tech and S3Director of Surgery confirmed that 8-10 pumps in 2 gallons of water was an excessive amount of concentrate (160-200cc), and that based on 2 gallons of water, the concentrate should be no more than 1 ounce (30cc).

3) Failing to ensure that the maintenance department was notified of potential equipment failures when the humidity levels in the operating room were outside the desired parameters;

Review of the hospital's Policies and Procedures for Anesthesia Safety and Safety Regulations effective 03/15/06 and reviewed 06/28/17 revealed the HI-E DRY 195 dehumidifier maintains relative humidity between twenty and sixty percent within the OR. If the humidity falls below twenty percent or above sixty percent, maintenance with be notified to correct.
On 04/02/18 at 3:00 p.m., observation of the operating room revealed it contained a portable dehumidifier (HI-E DRY 195). Review of the daily logs used to record the humidity levels within the operating room revealed the following recorded humidity levels: 01/11/18 - 77%; 02/21/18 - 65%; 02/22/18 - 75%.
An interview with S4Scrub Tech at this time confirmed she records the humidity levels in the daily logs. She stated on the above dates she adjusted the machine by turning it off and back on again, but did not record the corrective actions, or record a followup reading. She further confirmed the findings were not reported to the maintenance department for inspection.

4) Failing to ensure that the biological indicator tests were conducted as per hospital policy and manufacturer's instructions;

Review of the hospital's policy Biological Incubator Instructions effective 03/15/06, reviewed 08/04/17 revealed: E. After 24-48 hours, remove test indicators and check for growth.

Review of the manufacturer's instructions for the 3M Attest1262 Biological Indicator is designed for monitoring steam sterilization processes...The final readout of a negative result is made after 48 hours of incubation...12. Incubate processed and control biological indicators for 48 hours...Indication times: Early detection 12 hours...18 hours...24 hours... Final detection 48 hours.

On 04/02/18 at 3:30 p.m., observation of the sterilization room revealed biological indicators were sitting in the incubation containers on the top of the counter. Review of the testing log and interview with S4Scrub Tech at this time revealed there was no testing at the 48 hour incubation period. S4Scrub Tech confirmed she places the indicator in the incubator whenever the load is completed for the day, usually in the afternoon. She further stated she removes the indicator the next morning when she comes in, reads it, logs it, and discards it. She confirmed it may or may not be 24 hours, and that she does not keep and read it at the 48 hour final detection requirement.

5) Failing to ensure that the towels used in the drying process of surgical instruments that were to be sterilized were lint-free;

An observation on 04/02/18 at 3:45 p.m. of the sterilization room revealed surgical instruments were lying on top of a white bath towel that contained lint.
An interview at this time with S4Scrub Tech revealed that she had cleaned the instruments and was allowing them to dry on the towels until the next day, when she planned to run them through the sterilizer. She confirmed the towels were not de-linted, and she could not be certain that lint would not be adhered to the instruments when they were transferred to the sterilizer for processing, and subsequently be introduced into the surgical site of a patient during a procedure.