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Based on document review and interview the facility failed to ensure that their grievance process included timeframes for a response in relation to completion of a grievance resulting in the potential for unmet patient satisfaction. Findings include:

On 04/23/2014 at 1530 a review was conducted with staff HH (Patient Relations Coordinator) and staff B (Compliance Officer) of the facility's grievance policy and procedure. The document titled, "Patient Complaints and Grievances, Policy Number RM-25, Original Date 05/02, Review Date 11/13" revealed in the area titled, "Response To Complaints and Grievances" third (3rd) paragraph, "Response to complaints and grievances must be made within no more than 5 business days (or 7 calendar days) of receiving the complaint or grievance. Verbal or telephone response may be appropriate for complaints, but grievances require a written response. A grievance acknowledgement letter must be sent as soon as possible after receipt of the grievance, but no later than 5 business days after receipt..." The document then read in the section titled, "Documentation of the Grievance Procedure, The Compliance and Patient Relations Coordinator will: a. Send an acknowledgement letter and Patient Rights brochure if unable to resolve within 7 days, and enter initial information into MIDAS (grievance/complaint tracking database). b. Initiate investigation, and involve the appropriate staff as needed. c. Will send a final response letter and complete the MIDAS entry at the conclusion of the investigation."

During the policy and procedure review on 04/23/2014 at 1530, staff B was queried as to if the acknowledgement letter identifies a timeframe for when the complainant can expect to get further response back from the facility staff B stated, "the letter really does not specify a timeframe."

On 04/23/2014 at 1545 a review of grievance letters sent to patients #28 and #29 both were sent within the five (5) day timeframe acknowledging receipt of the grievance but lacked timeframes for when the complainant could expect further response from the facility.

On 04/23/2014 at 1550 during the review staff B brought up the Centers for Medicare Conditions for Participation for Hospital regulation for grievance procedures on a video screen, after reviewing the regulation staff B stated, "we do not have timeframes in the policy except for the first acknowledgement letter within the five days, we will need to change that."

Based on document review and interview the facility failed to set priorities for the quality improvement program. Findings include:

On April 23, 2014 at approximately 1600 during document review of the facility's quality improvement program dated from March 2013 to April 2014 it was determined the facility failed to prioritize quality plan initiatives.

On April 24, 2014 at approximately 0915 during an interview with staff DD and staff EE the question was asked if quality initiatives had been prioritized. Staff DD answered that initiatives were broken into categories but could not show that initiatives had priorities assigned within those categories.

Based on document review and interview the facility failed to include all areas representing hospital's organization and services for the quality improvement program. Findings include:

On April 23, 2014 at approximately 1620 during document review of the facility's quality improvement program dated from March 2013 to April 2014 it was determined the facility failed to include all areas representing hospital's organization and services for the quality improvement program. Departments that were identified as not turning in quality improvement plans were the cancer center, compensation, foundation, human resources, materials management, medical administration, medical education, and trauma services.

On April 24, 2014 at approximately 0930 during an interview with staff DD and staff EE the question was asked if all areas representing hospital's organization and services were included for the quality improvement program. Staff DD answered that the cancer center, compensation, foundation, human resources, materials management, medical administration, medical education, and trauma services departments had not submitted quality improvement plan initiatives.

Based on policy review, document review and interview, the facility failed to ensure that staff obtain a completed consent prior to blood transfusion for 2 (#24, #26) of 3 patients receiving blood resulting in the potential of denying patients of their right to be fully informed prior to a procedure. Findings include:

On 04/23/2014 at 1030 a review was conducted of the facility's policy titled, "Blood and Blood Products-Transfusion Administration For Adults." The document revealed in the section titled "General" bullet point number three "The informed consent procedure must be followed by the physician/provider performing the transfusion and a signed informed consent placed into the patient's chart, unless the situation is emergent."

On 04/23/2014 at 1100 a review of the medical record for patient #24 revealed a document titled "Blood or Blood Products Transfusion Consent/Refusal." The consent contained an area to be signed, dated and timed by the patient and then signed, dated and timed by a witness. The consent located in patient #24's record lacked documentation of a time as to when the patient consented to a transfusion. Due to the lack of documentation, it could not be determined if the patient was informed and consented prior to or after the transfusion.

A second review was conducted on 04/23/2014 at 1110 of the medical record for patient #26, it revealed a document titled "Blood or Blood Products Transfusion Consent/Refusal, a document that lacked a time for both the patient and the witness as to when the consent was signed.

On 04/23/2014 at 1115 during an interview with staff II she confirmed that the consents for patients #24 and #26 lacked times as to when the patient's consents were obtained. When queried about the findings staff II stated, "I believe that they are supposed to be filled out completely." She then stated, "I always make sure that they are filled out completely when I am going to give blood."

On 04/24/2014 at 1030 during an interview with staff B a request was made for the policy that the "Blood Consent" speaks to titled "Informed Consent." At 1045 staff B produced a policy titled "Informed Consent For Procedures/Surgery-Adults and Minors, Policy Number LAB 16, Original Date 04/96, Effective Date 05/12" the document reads in the section titled "When Is Informed Consent Required? Informed consent is required prior to: (bullet point #8) administration of blood and blood products." In the area of the document titled, "What Is Required In Completing The Consent Form?" bullet point #10 reads, "The consent form must be signed, dated and timed by the patient or person authorized to give informed consent for the procedure...." Bullet point #11 reads, "The consent form must be signed, dated and timed by a witness..."

On 04/24/2014 at 1100 staff B also confirmed the the Blood Transfusion Consents for patients #24 and #26 were incomplete.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated April 23, 2014.
K-0011
K-0017
K-0018
K-0022
K-0025
K-0027
K-0029
K-0033
K-0051
K-0072
K-0076

Based on observation, document review, and interview it was determined that the facility failed to ensure that: 1. patient nutrition areas including refrigerators and microwaves are kept clean, 2. pill crushers and pill splitters are cleaned after use, 3. mats in the physical therapy and radiology departments are cleaned between patients, 4. glucose strips and controls have opened/expiration date and are disposed of when beyond manufacturers' expiration, 5. paper towels are kept clean and protected from splash contamination, 6. ice machines are cleanable and maintained, 7. blanket warmers are maintained at the recommended temperature, 8. all areas are free from dust, resulting in the potential for patient harm for all patients being treated at this facility. Findings include:

On 4/22/2014 at approximately 1030 during the tour of the Emergency department (ED) the ice machine in the patient nutrition areas on both side A and side B was found to have a crack in the bottom tray that was open enough for water to seep under the machine. This finding was confirmed with staff P the ED manager on 4/22/2014 at approximately 1030.

On 4/22/2014 at approximately 1045 in the medication room of the ED side A, the hand washing sink was found to have a basket of paper towels positioned under the soap dispenser on the edge of the sink within the splash contamination zone, this finding was confirmed by staff P on 4/22/2014 at approximately 1045. Further inspection of the medication room refrigerator for medications only revealed dirt and debris accumulation in the bottom. Staff P stated, "that is the responsibility of Pharmacy to keep it cleaned and stocked.
The glucose machine on side A had control vials (high and low) that were open and undated or opened and beyond the expiration date. This was confirmed with staff P on 4/22/2014 at approximately 1045 .

On 4/22/2014 at approximately 1100 during continued tour of the ED side B medication room refrigerator for medications was found with dirt and debris accumulation in the rubber seal, and the refrigerator in the nutrition area was found to have dirt and debris in the bottom. Staff P stated, "the nutrition area refrigerator is the responsibility of the nurses and the medication refrigerator is the responsibility of the pharmacy".

Further tour of the ED revealed a large amount of accumulated dust on window sills and surfaces on side B, staff P stated, "housekeeping is supposed to keep surfaces dusted". The blanket warmer on side B was found to be 160 degrees- the sticker on the door said it should be 125-130 degrees for patient use-the thermostat dial had been turned all the way up to 150 degrees, staff P stated, "its not supposed to be that hot, I don't know how it got turned up so high" .

On 4/23/2014 at approximately 1300 during tour of the surgical recovery area, the ice machine lower tray was found to be cracked and open enough for water to seep under the machine, this finding was confirmed by staff Z, the OR clinical manager.


32164

On 4/22/14 at approximately 1049 while on observational tour of the Obstetrical (OB) unit it was found in the pantry of Post Partum side "A" that the microwave was dirty with dried spills and crumbs. The pantry drawers were dirty with dried spills and accumulated crumbs. The ice machine had a layer of accumulated dust on top of the machine. A tour of Post Partum side "B" found that the microwave in the pantry was dirty with dried spills and crumbs. Additionally, in the pantry of Labor & Delivery (L&D) section it was found that the refrigerator contained dried spills, the pantry cabinet shelves had dried spills and crumbs, and the ice machine had an accumulated layer of dust on top of the machine. Findings were confirmed at the time of observation with staff H. Staff H was queried as to whose responsibility it was to clean the refrigerators, microwave, and dust the ice machine to which she replied, "I would say housekeeping."


02967

On April 22, 2014, at approximately 1100 during the initial tour of the facility accumulation of dust and lint were noticed on top of the high surface of medication dispensing units, "Pyxis" in clean utility/medication rooms, serving patient care units, located on the second, third, fourth, fifth, and sixth floors.

On April 22, 2014, at approximately 1300 during the tour and interview with staff "T" the findings were confirmed.


28273

On 04/22/2013 at 1015 during the observation of the 3rd floor with staff A (Executive Vice President) and staff C (Clinical Director) , it revealed a pill cutter and a pill crusher located in the medication room. Both pieces of equipment were noted to have medication residue located in/on them. When staff C was queried about how the items are cleaned in between patients she stated, "I am not really sure about the pill cutter but the pill crusher has the small plastic envelopes that the medication is placed inside of and then it is crushed. When queried as to what the white substance could be inside of the crusher staff C replied, "it looks like it could be from a medication." When queried as to if the piece of equipment would be used for something other than crushing medication staff L replied, "not that I know of." When asked how they clean the crusher staff C replied "I am not sure but guess they should wipe it out between each use."

On 04/24/2014 a between 1130-1200 a focused review was completed on the all medication rooms of the 4 th, 5 th and 6 th floors in regards to cleaning the pill cutters and pill crushers between use. Staff CC and staff L were both present on the 6 th floor and observed that the pill crusher and the pill cutter contained medication residue from the previous use. The same findings were observed and confirmed by staff CC throughout all of the other medication rooms on the 4 th and 5 th floors.

On 04/24/2014 at 1200 a request was made to staff B for a policy that directs/instructs staff about cleaning of the equipment between patient use. At 1230, staff B stated that she was not able to locate a policy that address cleaning of the equipment.

A review of the manufactures instructions for the "EZY Dose, Locking Tablet Cutter" reads on the back of the package "Cleaning Instructions: After every use, brush residue off with a thick washcloth being careful not to come into direct with the blade. Rinse with hot water and allow to air dry."

On 04/23 2014 between 1000-1215 a review was conducted of two of the facility's off site Physical Therapy Units. The Physical Therapy Unit at Facility B was reviewed with staff U (Physical Therapy Team Lead). During the observation, it revealed that after a patient had completed their physical therapy and left the unit staff X (Physical Therapist) went over to a treatment table removed the sheet and pillow case and then applied clean linens without cleaning the equipment prior to applying them. At this time, an inquiry was made to staff X and staff U about cleaning the equipment between patient use. Staff U replied, we do not have to clean it between patients if we have a sheet down as a barrier, the equipment gets cleaned at the end of the day with the cleaner in the bottle" (pointing at a spray bottle sitting on a shelf. When staff X was queried as to if that was what was stated in the policy she replied, "I think it is."
Staff U provided a policy at 1030 titled "{Facility A}-Physical Medicine Department, Infection Prevention, Policy Number PMR-D117, Original Date May 1995, Effective Date January 2014, Procedure, Step 5 A. Exercise mats and plinths will be covered with linen during patient use as appropriate. B. Pillowcases will be changed between each patient, C. All tables and counters are cleaned with HAD (Hospital Approved Disinfectant) after each patient use..."

On 04/23/2014 at 1130 during review of the off site Physical Therapy Department with staff U at {Facility C} an inquiry was made to staff U in regards to if the same cleaning process of not cleaning the equipment between patients was being performed at this facility staff U replied, it is."


29955

On April 22, 2014 at approximately 1120 during a tour of the intensive care unit the microwave for patient and staff use was found to be dirty.

On April 22, 2014 at approximately 1122 during an interview with staff HH the findings were confirmed that the microwave was in need of cleaning.

Based upon on-site observation and interview the facility failed to ensure that isolation procedures are followed by both staff and visitors resulting in potential for spread of infectious disease amongst the patients receiving treatment at the facility, visitors and staff.
Findings include:


28273


On 04/23/2014 at 0945 during observation of the third (3rd) floor unit with staff A (Executive Vice President) and staff L (Clinical Coordinator), revealed that on the closed door of room 326 was a sign that read "Contact Isolation." During the observation staff K (Medical Resident) was observed exiting the room, when staff K was queried as to if he had worn a cover gown per the contact isolation requirements he stated, "No, I did not have one on." When queried if he had performed hand hygiene he stated, I was just going to the dispenser to do that."

When staff C was queried as to where the isolation gowns are kept she opened a small closet door located just outside of the patient's room.

On 04/24/2014 at 1130 during an observation of the sixth (6 th) floor, it was noted that the patient in room 625 was in "Contact Precautions." It was also noted at this time that there were three (3) other people sitting in the patient's room. Two of the three were not gowned or gloved. Staff A and C were queried at this time in regards to if visitors are required to wear a gown and gloves and about educating the family about this. Staff C stated, they are supposed to wear it, some do refuse and that is documented in the patient's medical record along with the education that is provided to both the patient and family." A review of the patient's medical record at this time showed evidence that the patient's family was educated in regards to isolation precautions on 04/23/2014 at 0600. There was no documentation in the patient's record indicating that the family was refusing to wear the isolation gown or gloves.
On 04/24/2014 at 1140, after introduction, an interview was conducted with the three people sitting in room 625. It was learned that one of the people sitting in the patient's room and wearing a gown and gloves was a "sitter" provided by the hospital as an intervention to prevent the patient from falling. The other two visitors identified themselves as the patient's wife and daughter. When queried as to if they had been educated in regards to the isolation precautions both stated, "No" and queried as to what I was talking about. the surveyor explained to the visitors that the hospital had placed the patient in isolation due to either an identified or potential infection that could possibly be spread. When queried as to if they had seen the sign on the door, the patient's daughter stated, "I seen there was a sign there, but there are a lot of signs hanging in places, I did not read it." When explained to them that they are supposed to wear a gown and gloves when visiting, the daughter stated, "Where are we supposed to get that stuff from." This surveyor informed the patient's daughter that that was a really good question and that I would let staff know that you asked that.. The patient's wife and daughter were thanked for taking the time to be interviewed.

On 04/24/2014 at 1150, after speaking with the patient's family, an inquiry was made to staff C about how are visitors supposed to know where to get the gowns from? She stated, that they are in the closet outside of the patient's room. This was agreed too from previous explanation to the surveyor, but how are visitors supposed to know this. Staff C stated, "I guess staff would need to tell them that."