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Based on observation and interview, the provider failed to ensure the surgical environment was clean and orderly for one of one surgical suite. Findings include:

1. Random observation on 2/2/10 in the surgical suite revealed:
*The hallway leading into the operating room (OR) and post-anesthesia care unit (PACU) had a cluttered appearance due to excessive equipment and supplies routinely stored in that hallway. Patients were transported into the OR and PACU via that hallway.
*On the floor in the OR hallway a cardboard box with clean mop heads was stored next to the Twist-in-Fill disinfectant solution drain area. Outlines of old water marks were noted on the cardboard box.
*A patient was observed recovering in the PACU. The PACU was used as a storage area for additional equipment that was covered with a sheet. The privacy curtain that could have been closed was open, and that covered equipment could be viewed by the patient and staff.
*The sink in the PACU was used as a storage counter for sterilized linen packages, a linen sheet, and a set of unsterilized surgical instruments.
*A couple of dead bugs were observed in one of the PACU ceiling lights. The second ceiling light cover had a corner piece missing exposing the florescent bulbs. That could have been a safety hazard for patients if the bulbs broke.

Interview with the OR director at the time of the observations revealed there was a shortage of storage space for the OR. The areas observed did have a cluttered appearance.

A. Based on interview and review of credentialing privilege listings, the provider failed to ensure ten of ten privilege listings maintained in the operating room binder had current listings of the procedures an individual (physicians 1, 2, 3, 4, 5, and 6; certified registered nurse anesthetists {CRNA} 1, 2, and 3; and one operating room technician {1} was allowed to perform. Findings include:

1. Review of the surgical service's privilege binder revealed the privilege lists for the following individuals were more than two years old. Review of the last governing body approval date on those privilege lists were:
*Physician 1 - 5/25/07.
*Physician 2 - 4/22/02.
*Physician 3 - 9/23/02.
*Physician 4 - 9/23/02.
*Physician 5 - 7/30/07.
*Physician 6 - 4/22/02.
*CRNA 1 - 3/3/03.
*CRNA 2 - 12/10/01.
*CRNA 3 - 4/22/02.
*Operating room technician 1 - 1/20/03.

Interview on 2/3/10 at 11:00 a.m. with the director of surgical services revealed the operating room had a binder with privilege lists for staff that participated in surgical procedures. She did not maintain that binder; it was the responsibility of the credentialing staff member to ensure surgery had updated privilege listings.

Interview on 2/3/10 at 2:40 p.m. with the staff member responsible for credentialing revealed she was not aware it was her responsibility to ensure privilege listings were updated in the surgical services binder.

Review of the provider's By-Laws for the medical staff dated 9/28/09 revealed:
*"All appointments to the Medical Staff shall be for a period of two years only renewable by the Board of Directors after consultation with the Medical Staff."
*All applications for appointment to the Medical Staff shall be in writing and contain information regarding licensure and hospital privileges.




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B. Based on credential file review, rules and regulations review, and interview, the provider failed to ensure two of two allied health professionals (1 and 2) had documentation of required certification. Findings include:

1. Review of the provider's Medical Staff Rules and Regulations revealed allied health professionals included physician assistants and nurse practitioners. Physician assistants and nurse practitioners were required to be certified in Advance Cardiac Life Support (ACLS) and in the Neonatal Resuscitation Program (NRP).

Review of allied health professional 1's credential file revealed she was a physician assistant. Further review revealed no documentation she had ACLS and NRP certification.

Review of allied health professional 2's credential file revealed she was a certified nurse practitioner. Further review revealed no documentation she had ACLS and NRP certification.

Interview on 2/3/10 at 1:50 p.m. with the medical records director confirmed the certification documentation was not in those credential files. She was unsure where the documentation would have been maintained.

Interview on 2/3/10 at 2:25 p.m. with the director of nursing revealed the certification documentation for allied health professionals would have been in their credential files.

A. Based on observation, interview, and policy review, the provider failed to ensure all infection prevention and control practices were implemented for:
*Glove use and hand hygiene during observation for one of one patient's (1) wound care.
*Sterilization of surgical equipment.
*Cleanabilility of surfaces within the operating room (OR) and post anesthesia care unit (PACU).
*Storage of equipment and cleaning supplies within the OR and PACU.
Findings include:

1. Observation of a nurse performing wound care for patient 1 at 2:05 p.m. on 2/2/10 revealed she entered the room and removed gloves from the glove box. She placed one glove on her left hand and then left the room to obtain help to reposition the patient. She returned to the patient's room with an aide and placed the other glove on her right hand. No handwashing was observed at either time she entered the room. With those gloved hands the nurse:
*Adjusted the bed position.
*Sprayed cleanser on the wound site.
*Wiped the wound area with gauze.
*Opened a drawer by the sink and retrieved a clean underpad.
*Placed that clean underpad on the bed.
*Sprayed the wound site again with cleanser.
*Again wiped the wound area.
*Rolled the soiled gauze and underpad beneath the patient.
*Placed the clean underpad beneath the patient.
*Touched the patient's leg and gown to reposition her.
*Adjusted the patient's catheter tubing.
*Moved the patient up in bed.
*Adjusted the patient's pillow.
*Adjusted the bed position.
It was not until this time that the nurse removed her soiled gloves and used hand sanitizer.

Interview with the above nurse at 2:15 p.m. on 2/2/10 revealed that was her usual procedure. She stated she was not aware she was touching clean items with soiled gloves.

2. Observation of the aide assisting the nurse with wound care for the above patient revealed he entered the room at 2:05 p.m. on 2/2/10 with gloved hands. No handwashing was observed upon entry into the room. With those gloved hands the aide:
*Touched the bed rails.
*Assisted the patient to move onto her side.
*Touched the patient's gown, back, and leg.
*Assisted the patient to move to her other side.
*Pulled the soiled underpad and gauze from under the patient.
*Assisted the patient to reposition in the bed.
*Touched the bed rails again.
*Pulled the blankets up to the patient's face.
It was at that time the aide removed his soiled gloves and used hand sanitizer.

Interview with the above aide at 2:18 p.m. on 2/2/10 revealed he had put on the gloves immediately prior to entering the room. Further interview revealed he had touched the door handle with those gloves upon entering the room. He also stated he was not aware he was touching clean items with soiled gloves.

Interview with the infection control nurse at 9:15 a.m. on 2/3/10 revealed all staff had been taught appropriate hand hygiene and glove use at orientation and at least annually. She further revealed she made rounds to observe staff practices at times and would immediately correct errors in hand hygiene when she observed them.

Review of the provider's body substance isolation policy reviewed February 2009 revealed:
*All patients were considered to be potential sources of infectious illness or disease.
*All body fluids were to be considered infectious.
*Gloves were to be worn when it was anticipated there would be hand contact with body fluids or non-intact skin.
*Clean gloves were to have been donned just before touching non-intact skin.
*Gloves were to have been removed promptly before touching non-contaminated items or environmental surfaces.

Review of the provider's hand hygiene policy reviewed February 2009 revealed:
*Hands were to have been decontaminated with waterless antimicrobial hand rub or antiseptic soap and water before having direct contact with patients.
*The use of gloves did not eliminate the need for hand hygiene.
*Gloves were to have been changed when moving from a contaminated site to a clean site during patient care.



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3. Observation on 2/2/10 at 9:18 a.m. in the OR revealed after a surgical case had ended the OR technician hand carried contaminated instruments from the operating room to the clean-up (decontamination ) room. Interview with the OR technician revealed that practice was commonly done in the OR and perhaps that was not the best method to transfer dirty instruments.

Interview immediately after the above observation with the OR director revealed there was the potential for spreading contamination when instruments were not protected when removed from the OR.

Review of the Association of periOperative Registered Nurses, Perioperative Standards and Recommended Practices, 2009 Edition, Denver, CO, p. 615, revealed*"During transport to a decontamination area, soiled instruments must be contained in a manner to prevent exposure of patients or personnel to bloodborne pathogens and other potentially infection organisms."
*"Hand-carried items must be contained (eg, enclosed by a plastic bag, container with a lid)."

4. Random observation on 2/2/10 of the OR sterile packages revealed:
*Numerous sterilized instrument packs without the processing date on the packages. Interview with the OR director at the time of the observation revealed the processing dates should have been on each package. The processing date indicated when an item had been sterilized and was important in the event a recall of those packages were required. Interview at the time of the observation with the OR director revealed the staff had been trained to put the processing date on sterile packages.
*Two instrument peel pack pouches with holes. Interview at the time of the observation with the OR director said the instruments would no longer be considered sterile because of the damaged packaging.
*A cardboard box containing head covering worn by OR staff had an outside shipping label. Interview with the OR director at the time of the observation revealed cardboard boxes with outside shipping labels should not have been stored in the OR. That type shipping container had the potential for bringing outside contaminants into the OR.

5. Observation in the OR and the PACU area revealed uncleanable wall surfaces:
*The varnish on the operating room door was gouged in several places exposing the wood surface underneath. The door was no longer a smooth cleanable surface.
*Inside the OR several wall tiles were cracked and chipped.
*The PACU wall had a two inch by two inch hole exposing the plaster.

6. Random observation on 2/2/10 of the OR positioning devices revealed:
*A pair of black stirrups with numerous cracks in the padding creating an uncleanable surface.
*A leg holder with white chipped paint and the end portion of an OR table was stored next to the hopper in the clean-up room (decontamination). Interview with the OR director at the time of the observation revealed both items should have been removed; they were no longer used for patient care. Stored next to the hopper those patient care items had the potential for being contaminated.




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B. Based on interview, the provider failed to implement an infection control policy for the proper cleaning of an isolation room used for isolation of Clostridium difficile (C.diff). Findings include:

1. Interview with a housekeeping staff person at 10:25 a.m. on 2/2/10 revealed:
*The housekeeping staff were responsible for cleaning all isolation rooms.
*The housekeeping staff were not notified by the nursing staff as to what infectious agent the room was isolated for.
*All rooms were disinfected with a quaternary ammonia product.
*She was not aware quaternary ammonia products were not acceptable to disinfect against C. diff.

Interview with the infection control nurse at 2:00 p.m. confirmed housekeeping staff were not notified of the infectious agent.

C. Based on observation and interview, the provider failed to minimize the sources of infectious disease by allowing the use of non-cleanable surfaces in two randomly observed rooms (hospice and LDRP). Findings include:

1. Observation at 11:00 a.m. on 2/2/10 revealed a carpeted area approximately 12 feet by 12 feet in the southwest corner of the LDRP room.

Interview with a housekeeping staff person at that time revealed:
*The room was used as a labor and delivery room.
*Women in labor had access to the carpeted area of the room causing a potential for the carpet to be contaminated with body fluids.
*The facility did not have a process to disinfect the carpet if it became contaminated with body fluids.

2. Observation at 11:15 a.m. on 2/2/10 revealed a cloth chair and a cloth loveseat in the hospice room. The furniture was made of absorbent material that could not be disinfected between uses.

Interview with a housekeeping staff person at that time revealed:
*The room was primarily used by families of hospice patients.
*The room was also used by patients taking chemotherapy.
*Patients sat on the cloth furniture during the administration of chemotherapy.
*The furniture was not disinfected between uses by patients and family members.
*The furniture was absorbent and could not be cleaned or disinfected between uses.

Based on policy review and interview, the provider failed to annually review and revise policies as needed for two of two departments (surgical services and anesthesia services). Findings include:

1. Review of the surgical services and anesthesia policy and procedure manuals revealed the policies had not been revised or updated within the last two years. Numerous policies in the surgical and anesthesia manuals had 2002, 2003, 2004, and 2005 as the last year reviewed and/or revised.

Review of the cover signature sheet located in the binder pocket for the surgical services policy manual revealed the last approval signature was dated 3/8/05. There was no cover signature sheet in the anesthesia policy and procedure manual indicating when it was last approved.

Interview on 2/3/10 at 11:10 a.m. with the director of surgical services revealed:
*The surgical services policies had not been updated.
*The policy manual did not include a policy for fire prevention in the operating room.
*The policy for autoclave steam sterilization parameter verification did not reflect the provider's current method for ensuring steam sterility parameters had been met. The provider no longer used biological spores to test their steam sterilizers ability for killing microorganism. The provider used Verify SixCess Challenge Packs indicators for sterility assurance monitoring of steam sterilized loads.

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Based on record review, interview, and policy review, the provider failed to ensure all sampled medical record entries from different patient service areas were authenticated with signatures, dates, or times. A sample of 339 medical record entries revealed 199 instances where either the signature, date, or time of the entry was not recorded. Findings include:

1. Review of 105 written physicians' orders during review of medical records on all patient care areas revealed 4 were not signed, 7 were not dated, and 7 were not timed.

2. Review of 34 telephone physicians' orders during review of medical records on all patient care areas revealed 7 were not signed, 6 were not dated, and 6 were not timed.

3. Review of 83 physicians' progress notes during review of medical records on all patient care areas revealed 3 were not timed.

4. Review of 117 miscellaneous forms regarding physician or staff contact with the patient during review of medical records on all patient care areas revealed 12 were not signed, 53 were not dated, and 94 were not timed.

5. Interview with the director of nursing and the patient support service quality risk manager at random times during the review of medical records revealed they were aware all entries should have been signed, dated, and timed.

Review of the provider's documentation policy reviewed March 2009 revealed all documentation in the medical record should have met state, federal, and facility guidelines. That policy did not include a requirement for the above entries to be signed, dated, and timed.

Based on interview and policy review, the provider failed to ensure quality assurance program improvement included one of one anesthesia department. Findings include:

1. Interview on 2/3/10 at 3:29 p.m. with the primary certified registered nurse anesthetist (CRNA)
revealed:
*Anesthesia services did not participate in the hospital-wide quality assurance performance improvement program.
*There were two CRNAs that made up anesthesia services, and they would know if things were not meeting standard. Why collect data if there were no problems.
*There was no need for collecting data to monitor anesthesia services.
*As a small facility with a small anesthesia staff she was not sure what could have been monitored.
*She had checked literature and did not find information on what should be monitored for a small facility.

Review of the provider's Quality Management/Improvement Plan revealed:
*One purpose of the plan included fulfillment of regulatory and statutory requirements that related to the quality management program.
*Collaboration across disciplines and departments to identify and prioritize important areas for improvement based on organizational goals and reflecting high risk, high volume, or problem prone issues.
*Design new processes and improve existing processes consistent with:
-The organization's mission.
-The expectations and needs of the patients, residents, physicians, and staff.
-Current standards as well as anticipated processes and outcomes.
*Collection and assessment of data relevant to:
-The design of new processes.
-The measurement of performance and stability of important existing functions, processes and outcomes.
-Identification of areas for improvement.

Based on record review and interview, the provider failed to implement an admission process that included information regarding chargeable and nonchargeable services for three of three sampled swingbed patients (30, 46, and 47). Findings include:

1. Review of the swingbed medical records for patients 30, 46, and 47 revealed:
*Patient 30 was admitted on 12/01/09.
*Patient 46 was admitted on 9/17/09.
*Patient 47 was admitted on 1/28/10.
*There was no documentation in those patients' medical records to indicate they had been informed of chargeable and nonchargeable services prior to their swingbed admission.

Interview on 2/3/10 at 2:00 p.m. with the chief nursing officer (CNO) confirmed skilled swingbed patients were not provided information regarding available covered and non-covered services. The CNO revealed intermediate care swingbed patients that were private payers were provided that information. Continued interview with the CNO revealed intermediate care patients were provided the Intermediate Care/Services Available/Basic PerDiem Fees Covered and Non-Covered form. The patients and a witness signature was required on that form.

Based on record review, and interview, the provider failed to ensure there was an effective activity program for three of three sampled closed swingbed records (30, 46, and 47). Findings include:

1. Interview on 2/2/10 at 1:50 p.m. with the activity coordinator revealed:
*An activity calendar was normally provided to swingbed patients but as of the date of the survey she had not posted activity calendars for swingbed patients.
*The activity calendar provided a listing of activities held at the nursing home attached to the hospital, and patients were encouraged to attend.
*She was responsible for completing activity assessments on the swingbed patients.
*The activities patients participated in were not consistently documented in their medical records.
*Most swingbed patients were not interested in activities. They were focused more on getting better and being discharged.
*The activity documentation flowsheet had a section for comments and 'R' could have been documented on the day the patient refused activities. Documentation of activity refusal and comments were rarely made on the flowsheet.

a. Review of patient 30's medical record revealed she was admitted on 12/01/09 and discharged on 12/16/09. Patient 30's Swing Bed Activity Interest Profile revealed she enjoyed crafts and/or arts and watching television.

Review of patient 30's activity documentation flowsheet revealed there were no activities documented as being performed on 12/15/09.

b. Review of patient 46's medical record revealed she was admitted on 9/17/09 and discharged on 10/05/09.

Review of patient 46's Swing Bed Activity Interest Profile dated 9/18/09 revealed she enjoyed watching television and conversing.

Review of patient 46's activity documentation flowsheet revealed there were no activities documented for 9/21/09, 9/22/09, 9/24/25, 9/25/09, 9/28/09, 9/29/09, and 9/30/09. The last date activity participation had been documented as being performed was on 10/1/09.

c. Review of patient 47's medical record revealed he was admitted on 1/13/10 and discharged on 1/28/10.

Review of patient 47's Swing bed Activity Interest Profile dated 1/14/10 revealed he enjoyed talking and helping others.

Review of patient 47's activity documentation flowsheet revealed there was no activity participation documented for 9/14/09, 9/17/09, 9/21/09, 9/23/09, 9/24/09, 9/25/09, 9/25/09, and 9/27/09.