HospitalInspections.org

Based on record review, observation, and interview, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights by failing to ensure patients received care in a safe setting by failing to ensure patients who were a harm to themselves or gravely disabled were monitored at a frequency to ensure their safety. The deficient practice is evidenced by:
1) Failing to ensure psychiatric patients who were being held in the Emergency Department and were assessed to be a harm to themselves or gravely disabled were monitored at a frequency to ensure their safety for 4 (#6, #7, #8, and #9) of 4 patients placed on a Physician Emergency Certificate; and preventing the patients #7 from eloping from the Emergency Department (cross reference to findings cited at A-0144).

2) Failing to maintain a safe environment by allowing psychiatric patients who were being held in the Emergency Department and were assessed to be a harm to themselves the use of a bathroom that contained ligature risks without supervision for 3 (#7, #8, and #9) of 4 (#6,#7, #8, and #9) patients placed on a Physician Emergency Certificate.(cross reference to findings cited at A-0144).

Based on record review and interview, the hospital failed to ensure that each patient or patient representative was informed of their rights.
Findings:

Review of the admission packet given to all patients upon admit, provided by S6Admissions, revealed a statement stating, "I may receive a copy of Patient Rights upon request." Further review of the admission packet revealed that the patients were not informed of their rights.

On 05/15/18 at 1:00 p.m., S1DON confirmed that patients admitted to the hospital are not informed of their rights. She further stated that if they request, a copy of their rights will be given to them.

On 05/16/18 at 10:00 a.m., interview with S6Admissions confirmed that she does not provide the copy of the patient rights to every patient unless they request it.

Based on record review and interview, the hospital failed to ensure it implemented its grievance process as evidenced by failure to have documented evidence of the investigation of the grievance for 2 (#13, 14) of 2 patient grievances reviewed.
Findings:

Review of the policy titled "Grievance Process", presented as a current policy by S5Human Resources, revealed that if a grievance is regarding patient endangerment, it will be addressed immediately. Otherwise, the grievance will be addressed within ten working days. If after ten working days the grievance has not been resolved, the complainant will receive in writing that the grievance is still under investigation.

Patient #13
Review of the grievance form (not dated), signed by S5Human Resources, revealed that the patient's mother called and stated that the emergency department (ED) physician did not touch her baby and told her to You Tube fussy babies. The form stated that the mother then took her baby to another hospital to be treated.

A copy of a letter, dated 02/22/18, that was sent to the patient's mother was attached to the grievance form. Review of this letter revealed that the complainant was thanked for submitting the grievance. The letter further stated that the hospital would carry out a thorough investigation and "hope to write back to you within 10 working days of this letter". The letter was signed by S7Administrator.

Another copy of a letter, dated 03/26/18, was also attached to the grievance form. Review of this letter revealed that the hospital has "taken this matter very seriously and ensure you that we will do everything possible to make sure this does not happen again" and "Investigation closed 03/26/18". This letter was signed by S7Administrator.

There was no documented evidence of the investigation that occurred prior to the grievance being closed on 03/26/18.

Patient #14
Review of the grievance form dated 02/14/18 (signed by S5Human Resources) revealed handwritten notes jotted down which included, "triage too long, nasty attitude, no bloodwork, did nothing, never went to room".

A copy of a letter, dated 02/22/18, that was sent to the patient was attached to the grievance form. Review of this letter revealed that the complainant was thanked for submitting the grievance. The letter further stated that the hospital would carry out a thorough investigation and "hope to write back to you within 10 working days of this letter". The letter was signed by S7Administrator.

There was no other documented evidence of any further correspondence to the patient. There was no documented evidence of the investigation of the grievance filed by the patient.

On 05/16/18 at 9:00 a.m., interview with S5Human Resources revealed that she and S7Administrator are responsible for investigating patient grievances. At this time, she reviewed the documentation that was provided on Patients #13 and #14's grievances. She confirmed that there was no documented evidence that the grievances were investigated. She further stated that they were investigated, but nothing was written down.

Based on record review and interview, the hospital failed to ensure the patient's representative who had filed a grievance was notified, in writing, the steps taken to investigate the grievance and the results of the grievance process for 2 (Patient #13, 14) of 2 sampled patient grievance investigations reviewed.
Findings:

Review of the hospital policy titled, Grievance Process, revealed that once the grievance has been resolved, the complainant will receive in writing the resolution of measures taken to resolve the grievance. This correspondence must include the name of the hospital person to contact, steps taken on behalf of the patient to investigate the grievance, the results of the investigation of the grievance, and the date of completion.

Patient #13
Review of the grievance form (not dated), signed by S5Human Resources, revealed that the patient's mother called and stated that the emergency department (ED) physician did not touch her baby and told her to You Tube fussy babies. The form stated that the mother then took her baby to another hospital to be treated.

A copy of a letter, dated 02/22/18, that was sent to the patient's mother was attached to the grievance form. Review of this letter revealed that the complainant was thanked for submitting the grievance. The letter further stated that the hospital would carry out a thorough investigation and "hope to write back to you within 10 working days of this letter". The letter was signed by S7Administrator.

Another copy of a letter, dated 03/26/18, was also attached to the grievance form. Review of this letter revealed that the hospital has "taken this matter very seriously and ensure you that we will do everything possible to make sure this does not happen again" and "Investigation closed 03/26/18". This letter was signed by S7Administrator. This letter did not indicate the steps taken to investigate the grievance and the results of the grievance process

Patient #14
Review of the grievance form dated 02/14/18 (signed by S5Human Resources) revealed handwritten notes jotted down which included, "triage too long, nasty attitude, no bloodwork, did nothing, never went to room".

A copy of a letter, dated 02/22/18, that was sent to the patient was attached to the grievance form. Review of this letter revealed that the complainant was thanked for submitting the grievance. The letter further stated that the hospital would carry out a thorough investigation and "hope to write back to you within 10 working days of this letter". The letter was signed by S7Administrator.

There was no other documented evidence of any further correspondence to the patient. There was no evidence that the complainant was informed in writing of the steps taken to investigate the grievance and the results of the grievance process

On 05/16/18 at 9:00 a.m., interview with S5Human Resources revealed that she and S7Administrator are responsible for patient grievances. She stated that the letters sent to the patients filing grievances are standard form letters and do not inform the complainants of the steps taken to investigate the grievance or the results of the grievance process.

Based on record review, observation and interview, the hospital failed to ensure that care was provided in a safe setting. The deficient practice is evidenced by:
1) Failing to ensure psychiatric patients who were being held in the Emergency Department and were assessed to be a harm to themselves or gravely disabled were monitored at a frequency to ensure their safety for 4 (#6, #7, #8, and #9) of 4 (#6, #7, #8, and #9) patients placed on a Physician Emergency Certificate and preventing the patients from eloping for 1 (#7) of 4 (#6, #7, #8, and #9) patients who were placed on a Physician Emergency Certificate.
2) Failing to maintain a safe environment by allowing psychiatric patients who were being held in the Emergency Department and were a harm to themselves the use of a bathroom that contained ligature risks without supervision for 3 (#7, #8, and #9) of 4 (#6, #7, #8, and #9) patients placed on a Physician Emergency Certificate.

Findings:

1) Failing to ensure psychiatric patients who were being held in the Emergency Department and were assessed to be a harm to themselves or gravely disabled were monitored at a frequency to ensure their safety.

Review of hospital policy "Management of Potentially Suicidal Patients revealed, in part, the following:
Policy - It is the policy of the hospital to make every effort to protect the potentially suicidal patient from self-harming behavior while attending to the medical needs of the patient.
Procedure - 4. Patient's belongings will be inspected at the time suicidal ideation is suspected, and every 24 hours thereafter. The patient will not be allowed to keep the following items in the patient room. a. Ties, belts or any other long piece of clothing or material.
5. Direct observation of the patient will occur every hour and be documented.
6. The patient will be placed in the closest room to the nurse's station as possible for more easy access to the patient and the hourly checks required.

Review of the hospital policy "Patient Missing From Hospital" revealed, in part, the following:
In the event a patient is discovered to be absent from the assigned hospital room, the charge nurse is to be notified immediately.
An incident report should be completed by the charge nurse. All specific details of the incident should be included on the report.

Patient #6
Review of Patient #6's PEC (Physician Emergency Certificate) completed and signed by the physician on 8/2/17 at 12:15 p.m. detailed, in part, the following:
History of present illness - paranoid delusions.
Mental condition - visual and auditory hallucinations.
Previous psychiatric treatment - inpatient
Is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill. Gravely disabled. Unwilling to seek voluntary admission.

Review of Patient #6's Nursing Notes dated 8/2/17 revealed Patient #6 was not monitored with direct observation for 2 hours and 50 minutes from 11:50 a.m. to 2:40 p.m.

Patient #7
Review of Patient #7's PEC completed and signed by the physician on 8/10/17 at 4:15 p.m. detailed, in part, the following:
History of present illness - Took 20 20/25 Lisinopril/HCTZ. Still wants to kill herself.
Mental condition - Depressed with suicidal attempt.
Patient currently suicidal
Is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill. Dangerous to self. Unwilling and unable to seek voluntary admission.

Review of Patient #7's Nurses Notes revealed the following:
8/10/18 at 7:34 p.m. - Patient not found in room, staff notified of same, physician says he did not see patient leave.

Patient #7 eloped from the hospital after PEC admit with a diagnosis of suicidal ideation and an attempted suicide.

Patient #8
Review of Patient #8's PEC completed and signed by the physician on 9/18/17 at 9:52 p.m. detailed, in part, the following:
History of present illness - Hopeless and depressed and wants to commit suicide.
Previous psychiatric treatment - inpatient
Patient currently suicidal
Is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill. Dangerous to self. Unable to seek voluntary admission.

Review of Patient #8's Nursing Notes dated 9/18/17 revealed Patient #8 was not monitored with direct observation for 3 hours and 50 minutes from 9:52 p.m. to 12:42 a.m.

Patient #9
Review of Patient #9's PEC completed and signed by the physician on 2/5/18 at 9:35 a.m. detailed, in part, the following:
History of present illness - Complains of suicidal ideation. Put belt around his neck last night but did not kill himself.
Previous psychiatric treatment - inpatient
Patient currently suicidal
Is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill. Dangerous to self. Unwilling to seek voluntary admission.

Review of Patient #9's Nursing Notes dated 2/5/18 revealed Patient #9 was not monitored with direct observation for 3 hours and 30 minutes from 10:07 a.m. to 1:37 p.m.

After reviewing the medical records, S1DON acknowledged on 5/16/18 at 11:00 a.m., the hospital did not follow its policy and did not monitor every hour, with direct observation, Patients #6, #7, #8, and #9. S1DON also acknowledged Patient #7 eloped from the hospital.

2) Failing to maintain a safe environment by allowing psychiatric patients who were being held in the Emergency Department and were assessed to be a harm to themselves, the use of a bathroom that contained ligature risks without supervision.

During an interview on 5/15/18 at 9:00 a.m., S4RN stated the Emergency Department has rooms designated as Room g, room h, and room i, which is an isolation room and used for observing psychiatric patients because it is directly across from the nurse's station and has a window with blinds left raised when needed.

Observation on 5/15/18 at 09:00 a.m. of Room i revealed the following:
Room i is directly across from the nurse's station and has a window in the door approximately 24 x 24 inches.
A patient bed within Room i cannot be completely observed through the widow when viewed from the nurse's station. To view all aspects of the room, the door would have to be open and the viewer would have to be within the threshold of the doorway.
Within Room i, there is a patient bathroom on the most distant side of the right hand wall. The adjoining bathroom area is completely out of view of the window. To see into the bathroom, you would have to be standing in the doorway of the bathroom.
The bathroom has two handicap handrails next to the sink and toilet and the handrails are ligature points. The sink has standard faucet handles, which are ligature points.

During an interview on 5/15/18 at 9:10 a.m., S4RN acknowledged that Room i could not be completely visualized through the window when viewed from the nurses station, that the bathroom in Room i could not be monitored through the window and acknowledged the handrails and faucet handles in the bathroom of Room i were ligature points.

Based on interview, the hospital failed to ensure the Emergency Department (ED) direct care staff received the education, training and demonstrated knowledge in the use of non-physical intervention skills.

Findings:

Review of the ED's log dated 7/29/17 through 5/14/18 revealed 4 patients who required a PEC for care in the ED.

During an interview on 5/16/18 at 1:40 p.m. S1DON stated the staff in the ED and the staff who are pulled to assist in the ED have not been trained in the use of non-physical intervention skills.

Based on record review and interview, the hospital's governing body failed to ensure that the hospital's QAPI (Quality Asurance Prformance Improvement) program reflected the complexity of the hospital's organization and services. This deficient practice was evidenced by failure of the hospital to 1) include all services in the hospital in the QAPI plan and 2) failure to identify an elopement of a PEC'd patient from the ER.

Findings:

1) Review of the hospital's "Quality Assurance Plan" revealed, in part, the following:
I. Introduction - All departments of the hospital will support an ongoing, comprehensive Quality Assurance Process (QAP) program designed to insure that high quality patient care is rendered in the hospital
III. Authority and Responsibility - The Governing Body of the hospital is ultimately responsible for overseeing the Quality Assurance Program and for insuring the effectiveness of the program.
IV. Policy - A. The Hospital Administrator is responsible for assuring the Quality Assurance Process is implemented and maintained
VI. Quality Assurance Committee - F. Functions 1. Required the participation of all departments in Quality Assurance activities.

Review of the hospital's QAPI program documentation, presented as current by S9Infection Control revealed the following:
No documented evidence that Risk Management, Laboratory, Housekeeping, Maintenance and Medical Records were included in the hospital's QAPI for March 2018.
No documented evidence that Administrator, Grievance, Risk Management, Laboratory, Housekeeping, Maintenance, Pharmacy, and Medical records were included in the hospital's QAPI for February 2018.
No documented evidence that Grievance, Risk Management, Laboratory, Radiology, Respiratory, Housekeeping, Maintenance, Pharmacy, and Medical Records were included in the hospital's QAPI for January 2018.

During an interview on 5/16/18 at 11:20 a.m., S9Infection Control acknowledged the hospital failed to include all services furnished in the hospital in the QAPI plan.

2) Review of the hospital policy "Patient Missing From Hospital" revealed, in part, the following:
In the event a patient is discovered to be absent from the assigned hospital room, the charge nurse is to be notified immediately.
An incident report should be completed by the charge nurse. All specific details of the incident should be included on the report.

Review of Patient #7's PEC completed and signed by the physician on 8/10/17 at 4:15 p.m. detailed, in part, the following:
History of present illness - Took 20 20/25 Lisinopril/HCTZ. Still wants to kill herself.
Mental condition - Depressed with suicidal attempt.
Patient currently suicidal
Is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill. Dangerous to self. Unwilling and unable to seek voluntary admission.

Review of Patient #7's Nurses Notes revealed the following:
8/10/18 at 7:34 p.m. - Patient not found in room, staff notified of same, physician says he did not see patient leave.

Patient #7 eloped from the hospital after receiving a PEC with a diagnosis of suicidal ideation and an attempted suicide.

During an interview on 5/16/18 at 2:00 p.m. S5Human Resources stated an Incident Report was not completed for Patient #7 and the hospital failed to follow its policy.

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed a current nursing care plan for each patient. The deficient practice is evidenced by failure to include care plans for the diagnoses of diabetes for 5 of 5 patients (#3, #5, #11, #19, #20), chronic obstructive pulmonary disease for 1 of 1 patient (#16), and hypertension for 1 of 1 patient (#18).
Findings:

Patient #3
Review of the medical record for patient #3 revealed she was admitted on 05/14/18 with a diagnosis of Type 2 diabetes mellitus. Review of the physician orders revealed an order for accuchecks before meals and at bedtime with administration of insulin per sliding scale. Review of the care plan for patient #3 revealed no evidence of a plan of care for diabetes.
On 5/15/18 at 2:00 p.m., an interview with S1DON confirmed there was no care plan developed for patient #3 related to the diagnosis and treatment of diabetes.

Patient #5
Review of the medical record for patient #5 revealed she was admitted on 05/14/18 with a diagnosis of diabetes mellitus. Review of the physician orders revealed an order for accuchecks before meals and at bedtime with administration of insulin per sliding scale. Review of the care plan for patient #3 revealed no evidence of a plan of care for diabetes.
On 5/15/18 at 2:00 p.m., an interview with S1DON confirmed there was no care plan developed for patient #5 related to the diagnosis and treatment of diabetes.

Patient #11
Review of Patient #11's medical record revealed an admit date of 4/13/18 with, in part, the following diagnoses: abdominal pain, Type 1 diabetes mellitus.
Review of Patient #11's Care Plan failed to reveal a plan of care for diabetes.
During an interview on 5/15/18 at 4:05 p.m., S1DON acknowledged patient #11's Care Plan did not include a plan of care for diabetes.

Patient #16
Review of Patient #16's medical record revealed an admit date of 2/16/18 with a diagnosis of chronic obstructive pulmonary disease (COPD).
Review of Patient #16's Care Plan failed to reveal a plan of care for COPD.
During an interview on 5/16/18 at 11:10 a.m., S12Medical Records acknowledged patient #20's Care Plan did not include a plan of care for COPD.

Patient #18
Review of Patient #18's medical record revealed an admit date of 2/27/18 with the diagnoses of hypertension and headache.
Review of patient #18's Care Plan failed to reveal a plan of care for hypertension.
During an interview on 5/16/18 at 11:15 a.m., S12Medical Records acknowledged patient #18's Care Plan did not include a plan of care for hypertension.

Patient #19
Review of Patient #19's medical record revealed an admit date of 2/28/17 with the following diagnoses: chest Pain, coronary artery disease, congestive heart failure, and Type II diabetes mellitus.
Review of Patient #19's Care Plan failed to reveal a plan of care for Diabetes.
During an interview on 5/16/18 at 11:20 a.m., S12Medical Records acknowledged patient #19's Care Plan did not include a plan of care for Diabetes.

Patient #20
Review of Patient #20's medical record revealed an admit date of 3/1/18 with, in part, the following diagnoses: abdominal pain, Type II diabetes mellitus, chronic kidney disease and urinary tract infection.
Review of Patient #20's Care Plan failed to reveal a plan of care for Diabetes.
During an interview on 5/16/18 at 11:25 a.m., S12Medical Records acknowledged patient #20's Care Plan did not include a plan of care for diabetes.


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17450

Based on record review and interview, the nursing staff failed to administer medications in accordance with hospital policies and procedures by failing to conduct timely follow up assessments after the administration of pain medication for 2 of 2 patients reviewed for PRN pain medications in a total sample of 30. (Patient #3, 24).
Findings:

Review of the hospital's policy and procedure for pain management revealed in part .... C. Re-assess pain intensity after each pain management intervention in at least 30 minutes for IV medication, 60 minutes for PO medication.

Patient #3
Review of the medical record for patient #3 revealed she was admitted 05/14/18 from the emergency department with diagnoses including abdominal pain and right flank pain. Review of the physician orders revealed an order for Norco 5/325mg 2 tablets by mouth every 12 hours as needed for pain.
Review of the Medication Administration Record revealed a dose of Norco was administered by the nurse on 05/14/18 at 8:56 p.m. Continued review revealed the follow up assessment was conducted at 11:36 p.m, 2 hours and 40 minutes later.

On 05/15/18 at 2:00 p.m., an interview with S1DON confirmed that the follow up assessment for the pain medication administered to patient #3 was not conducted in a timely manner, in accordance with the hospital's policies and procedures.

Patient #24
Review of the medical record for patient #24 revealed a physician order dated 04/03/18 for Morphine 2mg intravenous every 6 hours as needed. Further review revealed the patient was administered Morphine on 04/04/18 at 2:30 a.m. There was no follow up assessment of the patient until 4:00 a.m., one and half hours later.

On 05/16/18 at 2:15 p.m., interview with S1DON confirmed that the follow up assessment for the pain medication administered to patient #24 was not conducted in a timely manner, in accordance with the hospital's policies and procedures.





17450

Based on observation and interview, the hospital failed to ensure paper medical records stored in the medical records department were protected against loss or destruction in the event the sprinkler system was activated.
Findings:

Observation of the medical records department on 05/14/18 at 1:40 p.m. revealed the room had a sprinkler system in the ceiling. Further observation revealed approximately 50 medical records on a cart, dating back to January 2018. At that time, interview with S3Medical Records Director revealed that the medical records on the cart had not yet been scanned into the electronic medical record. She stated that it could take a week or longer for the records to be scanned into the computer system after a patients discharge, and that the records waiting to be scanned were placed on this cart. S3Medical Records Director further confirmed that the records were not protected from water damage if the sprinklers were activated.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.
Findings:

Review of the hospital pharmacy's policies and procedures revealed no evidence that a pharmacist would review all medication orders prior to the first dose being administered.
The Policy and Procedure for Pharmacy Services and Drug Control revealed in part ... D. the most commonly used drugs will be dispensed by the pharmacy into the AcuDose machine which is located in the medication room at the nurses' station. E. The purpose of maintaining this supply of drugs is to provide a source of medications that can be used until new order can be filled by the Pharmacist.

On 05/16/18 at 9:30 a.m., interview with S11Pharmacist confirmed that there was no hospital policy indicating that first dose reviews were to be performed for all new medications. S11Pharmacist revealed that the pharmacy hours are 8:00 a.m. - 5:00 p.m daily, including weekends. S11Pharmacist further revealed that if the nurses obtain any physician orders for new medication after pharmacy hours, the nurses will administer the first dose of the medication and a pharmacist will review the medication orders the next day.

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

Findings:

A. Observation tour of the Emergency Department, accompanied by S4RN on 5/14/18 1:00 p.m. revealed the following expired medications:
(2) liters Dextrose 5% with ½ Normal Saline, one expired June 2017 and one expired January 2018.
(1) liter Normal Saline expired October 2017
(5) liters Lactated Ringers expired October 2017
(4) liters Lactated Ringers Dextrose 5% expired March 2018

B. Observation of the Emergency Department Medication Room accompanied by S4RN on 5/14/18 2:00 p.m. revealed the following expired medications:
(1) Ofloxacin Ophthalmic Solution 0.3% expired 4/2018
(5) bottles of 5 milligram Haloperidol expired 4/2018
(4) bottles of Labetolol 100 mg/20 milliliters 2/1/2018
(1)Budesonide 0.25mg/2ml expired 4/2018
(3) liters Lactated Ringers 5%Dextrose - 2 expired October 2017 and 1 expired on March 2018
(1) liter Dextrose 5% expired October 2017
(1) liter Dextrose 5% Saline 0.45% expired June 2016


C. Observation of the crash cart on the inpatient nursing unit with S1DON on 05/15/18 at 10:00 a.m. revealed the following expired medications:
- (5) Phenytoin 250/5ml (5 ml vials), expired March 2018
- (5) Amiodorone 150mg/3ml vials, expired March 2018
- (10) Normal Saline flushes (10ml syringes), expired September 2017



17450

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of 2 of 2 patient beds (Room a, Room b) with call buttons on the hand rails out of 23 total beds.
Findings:

On 05/14/18 at 9:50 a.m. an observation was made of the hospital's inpatient rooms with S1DON. The observation revealed that the patient beds in Room "a" and Room "b" had a non-functional nurse call feature on the siderail of the bed. The button was pressed on the side rail and no alert of any type was generated when it was pressed.

At that time, S1DON confirmed that the nurse call feature on the siderails of the above two beds was not functional. She reported patients/patient families were instructed to use the nurse call feature on the corded call light located at the patient's bedside to call for staff assistance. The surveyor discussed the possibility of patient/patient family/visitor confusion with having the non-functional nurse call feature available for use as well as the nurse call feature on the corded call light and the potential of the non-functional nurse call feature being pressed to summon help from staff. S1DON indicated she understood what the surveyor was saying when asked if having the non-functional nurse call feature available for use could result in potential confusion when calling for staff assistance.

Based on record review and interview, the hospital failed to ensure the person designated as an infection control officer was qualified through education, training, experience or certification to oversee the infection control program.
Findings:

Review of the personnel file for S9Infection Control Officer revealed no documented evidence of education, training, experience or certification in oversight of an infection control program.

On 05/16/18 at 11:30 a.m., an interview with S9Infection Control Office confirmed she had received no specialized training or certification in infection control.

Based on observation and interview, the hospital failed to maintain the hospital's systems for controlling infections as evidenced by the infection control officer 1) failing to maintain a sanitary environment, 2) failing to perform hand hygiene surveillance, 3) failing to ensure hand hygiene was performed before and after donning gloves, 4) failing to ensure the area in the outpatient lab where blood draws were performed was disinfected after each patient and
5) failing to discard expired medical devices intended for patient use.
Findings:

1) Failing to maintain a sanitary environment

a.) On 05/14/18 at 9:50 a.m., tour of the hospital with S1DON revealed the following:
- Room c had old, used tape on the clean IV pump (covered with plastic bag, indicating clean). Old, used tape was observed stuck to the sides of the overbed table. The electrical outlet covers were coated with dust.
- Three electric blood pressure machines were stored in the hallway. Observation of the machines revealed brown spills and stains were on the bases of machines. The bases of the machines were also coated with a thick build up of dust and grime.
- Room d had a privacy curtain with multiple brown stains on it. The electrical outlet covers were coated with a thick build up of dust.
- Room a had a build up of debris and hair wrapped around the call bell cord in the bathroom.
- Room e had a thick build up of dust on top of all electrical outlets. The air unit vents were coated with dust and debris.
- Room f had dead bugs in the window sill. The clean IV pump (covered with plastic bag) had blue spills and a brown substance on the top of pump. A potato chip, old food particles and a hair was observed on the bed frame next to the mattress. All of the electrical outlets were coated with dust.
- The clean linen closet had a large build up of dust on the vents in the ceiling.
- The central supply room had cabinets and carts that contained clean supplies. Multiple dead bugs were observed in these areas. The drawers of the cart were coated with dust and debris. The isolation cart was observed to have hairs and a build up of dust and debris on the top of it. A package of opened 4x4 gauze was in the cabinet. The treatment cart contained an opened suture removal kit, and an opened Incision & Drainage kit.
- The nurses medication room contained a refrigerator that stored medications. The refrigerator shelving was coated with a build up of dirt and debris. Multiple hairs were noted on the shelves.
- Three IV start plastic containers were noted in the nurses station. The containers had old tape stuck to the sides and a brown sticky substance on them.
On 05/14/18 at 11:00 a.m., S1DON confirmed the above infection control issues.

b.) Tour of the Emergency Department accompanied by S4RN on 5/14/18 1:00 p.m. revealed the following:
- Room i , EKG machine was soiled and grimy
- Room h, Pediatric supply cart soiled and grimy and Adult supply cart soiled and grimy
- Room g, EKG machine soiled and grimy
- Room j, Infant weight scale was soiled and grimy. Blood pressure machine was soiled and grimy.

During an interview on 5/14/18 at 1:00 p.m., S4RN acknowledged the soiled equipment was not sanitized and acknowledged this was an infection control issue.

2) Failing to perform hand hygiene surveillance

On 05/16/18 at 11:30 a.m., review of the infection control plan and interview with S9Infection Control Officer confirmed she had not conducted any surveillance of handwashing procedures by staff since she had assumed the role of Infection Control Officer in January 2018.

3) Failing to ensure hand hygiene was performed before and after donning gloves

On 05/16/18 at 12:25 p.m., observation revealed S8Lab Assistant entered the outpatient lab room wearing gloves and carrying supplies. Further observations revealed Patient #23 was already sitting in the chair waiting for his blood to be drawn. Observations revealed S8Lab Assistant tore pieces of tape and placed them on the table and then stuck the patient with the same gloves that she had on when she entered the room. After sticking the patient, S8Lab Assistant removed her gloves, gathered paperwork and left the room. She was not observed to perform hand hygiene at any time.

On 05/16/18 at 12:40 p.m., observation revealed S10Lab Director obtained blood for ABGs (arterial blood gas) from Patient #23. After drawing the patient's blood, S10Lab Director removed his gloves and left the room without performing any hand hygiene.

4) Failing to ensure the area in the outpatient lab where blood draws were performed was disinfected after each patient.

On 05/16/18 at 12:40 p.m., observation revealed S10Lab Director drew blood from Patient #23 in the outpatient lab area. Further observations revealed that after Patient #23 left, another random outpatient entered the room and sat in the same chair that Patient #23 was sitting in for his blood draw. The chair was not disinfected prior to the next patient sitting in it.

On 05/16/18 at 2:00 p.m., interview with S10Lab Director revealed that the outpatient lab room is cleaned once daily per housekeeping. He further stated that he was unaware that the chair should be disinfected after use on each outpatient.

5) Observation tour of Room g in the Emergency Department, accompanied by S4RN on 5/14/18 1:00 p.m., revealed the following:

(1) Adult Stat-Padz defibrillator pads expired 2/21/17
(1) CPR Complete defibrillator pads expired 3/26/18
(2) Multi-lumen Central Lines expired 4/30/18
(2) enema-tubing expired 11/2011.
(2) Bard Levin gastric tubes with wet packaging
(4) chest tubes - 2 expired 11/17, 1 expired 10/17 and 1 expired 12/17.

During an interview on 5/14/18 at 1:00 p.m., S4RN acknowledged the expired patient use items and acknowledged this was an infection control issue.




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