HospitalInspections.org

Based on record review and interview, the hospital failed to ensure contracted services were provided in a safe and effective manner.

This failed practice had the potential to affect all current patients due to the lack of evaluation of the safety and effectiveness of services provided by contracted services.

Findings:

A document titled "MediTract View Contract By Site" listed services provided to the hospital under contract including professional services, lease agreements, management services, consultant and administrative services. The document showed no evaluation of the safety and effectiveness of the services provided by the contracted staff.

On 08/03/17 at 8:53 am, Staff C stated there was no documented review of contracted services for safety and effectiveness.

Based on record review and interview the hospital failed to provide documentation of written notice to each patient reporting the grievance resolution within 7 working days as policy stated for 1 of 3 grievance records (Patient #22) reviewed.

This failed practice has the potential risk to allow communication barriers, such as lack of attention and/or interest, toward filed grievances.

Findings:

The hospital's policy titled, "Patients/Family Complaints/Grievance" documented an initial response letter will be sent to the patient or patient representative no later than 7 days after receipt of the grievance.

On 04/08/17, Patient #22 submitted a grievance; letter was sent on 04/21/17. A period of 13 days after the grievance was filed.

On 08/03/17 at 9:10 AM, Staff C stated an individual who filed a grievance should receive a response letter within 7 days after submission.

Based on record review and interview the hospital failed to provide a policy that includes the components implemented for abuse/neglect protection from an alleged employee. Necessary components include screening, identifying, training, protecting, investigating, and reporting.

This failed practice had the potential to increase risk of abuse to all patients who seek care at the hospital.

Findings:

A hospital policy titled, "Identifying and Reporting Suspected Abuse/Neglect" did not contain information protecting patients from abuse/neglect from an alleged employee during an investigation.

On 08/02/17 at 3:17 PM, Staff C stated the policy did not contain the necessary components to protect patients from an alleged employed abuser during an investigation.

Based on record review and interview the hospital failed to:

A. ensure nursing staff evaluated patient's pain using a pain scale to determine the effectiveness of pain control measures and facilitate regular reassessments per hospital policies

B. Ensure the registered nurse in the Emergency Department (ED) evaluated the neurological status of patients with neurological conditions on a regular basis for signs of clinical deterioration

This failed practice had the potential to affect patient safety as diligent nursing surveillance can lead to timely recognition of early clinical deterioration.

Findings:

A. Pain Assessments

Document entitled "Pain Management" showed healthcare providers should assess and document patient's report of pain or observable responses to pain utilizing an appropriate pain scale ...documented before and after pain medication ...

4 (Patient #1, 2, 4 and 7) of 17 records showed nursing staff failed to assess and reassess pain after the administration of pain medication. Medical Records failed to show consistent use of a pain rating scale to assess pain or evaluate the effectiveness of pain medication per hospital policy.

On 08/03/17 at 11:30 am, Staff C stated nurses should be assessing their patients for response to pain medications using an appropriate pain scale within a reasonable time frame; and reported if the patient is sleeping the expectation would be the medication has been effective.

B. Neurological Assessments in ED

Document entitled "Assessment/Reassessment" showed reassessments are performed when the patient's condition warrants an assessment and to determine the response to treatment or to determine a change in condition.

During record review there was no evidence of a Policy & Procedure or protocol in the ED for assessment and reassessment of neurological status for patients presenting to the ED.

American Stroke Association Guidelines state neurological assessments using a standardized tool should be performed frequently.

American Heart Association Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient Scientific Statement show neurological assessments should be done frequently.

American Association of Neurological Nurses Guideline for Mild Traumatic Injury recommends hourly assessment of neurological status and more frequently if there is a change in condition

4 (Patient #10, 12, 16, and 17) of 17 records showed patients with neurological conditions had no evidence of a standardized neurological assessment or check performed by nursing staff on a regular basis to determine any clinical deterioration.

On 08/03/17 at 3:00 pm, Staff H stated there is no policy in the ED for identifying assessment criteria and frequency of neurological assessments for patients with neurological conditions; and reported expectation is for assessments to be done every 15 minutes for acute presentations and if nothing abnormal then every 1 hour. Staff U stated for stroke patients who have received tPA (tissue plasminogen activator - also known as the "clotbuster"), the tPA protocol is followed for neurological assessment but there is no standard or policy for those patients with stroke who do not receive tPA.

Based on record review and interview, the hospital failed to ensure:
a. OK Board of Nursing's disciplinary action were considered for terms of employment, and
b. scrub technicians were approved and qualified to perform endoscopic tattooing injections.

This failed practice had the potential to increase the risk to patients by allowing staff to perform tasks for which their qualifications and competency had not been validated.

Findings:

a. Nursing Board Discipline

A review of the OK Nursing license for Staff N showed past disciplinary action.

A review of the hospital policy titled, "License and Certification 10/15" failed to address terms of employment for nurses who have been disciplined by the Board of Nursing.

On 08/03/17 at 11:00 am, Staff C, the CNO, stated the hospital had no policy that addressed the process for managing nurses disciplined by the Board of Nursing, and stated due to a change of human resource staff, Staff N's disciplinary issues were not reviewed and terms of employment approved by the Governing Body.

b. Tattooing Injection

A review of the hospital document titled, "Competency Validation Checklist-Surgical Technologist" failed to provide evidence of competency to perform endoscopic tattoo injection.

A review of the hospital policy titled, " Tattooing or Tissue Staining in the GI Lab 07/16" failed to specify what staff was qualified to perform endoscopic tattoo injection.

On 08/02/17 at 12:30 am, Staff F, OR Manager, stated endoscopic scrub technicians perform tattoo injection during endoscopic procedures.

Based on record review and interview the hospital failed to ensure healthcare providers completed a history and physical examination (H&P) in the patient's electronic health record within 24 hours of admission per hospital policy.

This failed practice had the potential for delayed recognition of medical conditions that could influence recovery, functional status and quality of life.

Findings:

Document titled "Legal Record" showed an H&P should be completed within 24 hours of patient admission.

Document titled "Assessment/Reassessment Guidelines" showed a complete H&P should be done within 24 hours on patients who are admitted.

1 (Patient #2) of 17 records showed the patient was admitted on 07/11/17, the H&P was not dictated until 07/13/17, transcribed and electronically signed on 07/27/17.

On 08/03/17 at 11:36 am, Staff U, stated the admitting physician is responsible for completing the H&P for a patient within 24 hours of a patient being admitted; and reported a surgeon can be assigned as an attending physician.

Based on observation, document review and interview, the hospital failed to maintain proper safety precautions against radiation hazards.

This failed practice had the potential to effect personnel providing and patients receiving radiology services due to the lack of monitoring of radiation hazards exposure.

Findings:

Document titled "Maintenance of Personal Radiation Monitoring Devices" states usage and storage of personal devices will be accurately monitored for occupational exposure to radiation.

On 08/02/17 at 11:15 am, an unidentified lead skirt was observed hanging in the Radiology Department. Staff in the department were unable to identify when the lead skirt was put into service or if it had been deemed safe for use.

On 08/03/17 at 10:24 am, Staff C stated the lead skirt had been put into use without being checked appropriately.

Based on observation and interview, the hospital failed to maintain equipment to ensure an acceptable level of safety and quality.

This failed practice had the potential to increase the safety risk of all patients admitted to the hospital due to lack of maintenance.

Findings:

On 08/03/17 at 1:50 pm, four pieces of equipment (mixer, steam kettle, soup kettle and meat slicer) were found in the kitchen area and had safety inspections dated 2008. There was no indication the equipment was not in use.

On 08/03/17 at 1:50 pm, Staff X stated the equipment was not used and had not been inspected since 2008.

Based on record review, interview, and observation, the hospital failed to ensure:
a. proper hand hygiene practices,
b. proper storage of clean and manufacturer's sterile supplies, and
c. the endoscopic reprocessing policy was based on manufacturer's guidelines.

This failed practice had the potential to increase the infection control risk to all patients receiving in-patient and out-patient services.

Findings:
a. Hand Hygiene

A review of the hospital policy titled, "Hand Hygiene 02/17" showed hand hygiene was indicated after contact with bodily fluids or secreations....

On 08/02/17 at 12:51pm, during a tour of the ED, while wearing gloves, Staff R was observed placing urine specimen in a bag and left the unit with the specimens; gloves remained intact. Staff R returned to the ED wearing gloves, picked up a medical record file to document and exited the nursing station area still wearing the same gloves. No hand hygiene was observed.

On 08/03/17 at 4:00 pm, Staff A stated he had observed Staff R's lack of hand hygiene.

b. Storage Supplies

The surveyor requested a hospital policy that addressed clean supply storage, and none was provided.

On 08/02/17 at 11:45 am, during a tour of the Medical Surgery unit, uncovered pillows stored in closets in patient rooms 210 and 213. In other areas of the hospital pillows designated at "clean" were observed enclosed in clear plastic bags.

On 08/02/17 at 11:45 am, during the tour of the Medical Surgery unit, CPAP/ BIPAP respiratory equipment was observed in patient rooms 233 and 234. Two of the equipment set-ups were labeled with specific patients' names, and 4 of the set ups contained clear liquid in the chambers.

On 08/02/17 at 1:00 pm, Staff K and Staff A stated patient rooms 233 and 234 were clean and ready for use, and the respiratory equipment was being stored awaiting bio-med inspections prior to patient use. The equipment was identified as both patient owned and rental.

On 08/02/17 at 3:00 pm, Staff L, the Respiratory Manager stated the hospital did not use patient owned equipment, and the equipment in room 233 and 234 were set up by respiratory therapist and were awaiting patient use. She stated the liquid in the CPAP/BIPAP chambers was water that was changed every 24 hours. She stated the hospital did not have a policy regarding setting up respiratory equipment. She stated the hospital had no process for communicating the dirty/clean CPAP/BIPAP equipment status, ready for use, or date/time the unit's chamber was filled or changed.

On 08/02/17 at 11:14 am, during a tour of the GI Lab, clean and manufacturer's sterile endoscopic supplies were observed on an uncovered large, wire rack within the endoscopic procedure rooms.

On 08/02/17 at 12:30 pm, Staff F stated the endoscopic supplies on the cart were used during endoscopic procedures.

c. Endoscopic Reprocessing Policy

A review of endoscopic manufacturers guidelines titled, "Reprocessing Manual Fuse Colonoscope showed for "Wet Leak test- Prepare a basin with clean water. Completely submerge the endoscope in water while the endoscope is still pressurized."

A review of hospital policy titled, "Cleaning and Disinfection, and Reprocessing of Flexible Gastrointestinal Endoscopes 10/19 showed the endoscope should be leak testing in a mixture of enzyme and water. (The purpose of the leak test to find holes in the endoscope and enzyme can foam and obscure the bubbles.)

On 08/03/17 at 3:00 pm, Staff F stated enzyme was added to pre-cleaning water after the leak test was performed.

Based on record review and interview, the hospital failed to identify patients at high risk for adverse health consequences for 1 (Patient #20) of 4 records reviewed for discharged patients.

This failed practice had the potential to affect all patients due to the potential lack of adequate care following discharge.

Findings:

A policy titled "Discharge Planning" listed "Readmission within 30 days" as an indication a patient was at high risk for adverse events and required a discharge assessment.

Patient #20

A review of records showed the patient was discharged from inpatient care on 01/19/17. The patient was readmitted to inpatient care on 01/22/17.

The patient was included in a list of patients readmitted within 30 days of discharge. A review of records showed no documentation of a discharge planning assessment.

On 08/03/17 at 1:16 pm, Staff V stated a discharge planning assessment was not done.

Based on record review and interview, the hospital failed to ensure the discharge planning evaluation was included in the clinical record for 1 (Patient #21) of 4 records reviewed for discharged patients.

This failed practice had the potential to affect all patients due to the lack of information for other members of the health care team to determine needed resources.

Findings:

A policy titled "Discharge Planning" listed "Readmission within 30 days" as an indication a patient was at high risk for adverse events and required a discharge planning assessment. The policy failed to address the requirement of inclusion of the assessment in the clinical record.

Patient #21

A review of records showed the patient was discharged from inpatient care on 06/06/17. The patient was readmitted to inpatient care on 06/13/17.

The patient was included in a list of patients readmitted within 30 days of discharge. A review of the clinical record showed no documentation of a discharge planning assessment.

On 08/03/17 at 12:41 pm, Staff V stated readmission assessments were documented on a paper form and kept in the office, but not included in the clinical records.