HospitalInspections.org

Based on interview and document review, the hospital failed to specify which categories of physician extenders were eligible for appointment to the medical staff and had medical privileges. This has the potential to affect all of the patients who were provided services by physician assistants (PAs).

Findings include:

The medical staff bylaws were reviewed by the governing body on 4/24/12. The Delineation of Privileges in the hospital bylaws identified the privileges for podiatry, certified nurse midwives, nurse practitioners, psychologists, physical and occupational therapists, speech-language pathologists, audiologists, massage therapists, and acupuncturists, however, did not include physician assistants (PAs).

On 9/12/12, at 9:45 a.m. the director of performance excellence verified the delineation of privileges for the PA's had inadvertently been omitted form the medical staff bylaws, approved by the governing body. She also verified PAs were employed by the hospital and worked in the emergency department and should have been incorporated in the delineation of privileges.

Based on interview and document review, the hospital failed to promote the rights for 4 of 4 outpatient services and all of the patients who reveived outpatient services, which included 8 of 9 outpatients (P29, P31, P27, P30, P41, P26, P33, P26) and for of 1 of 1 patient (P34) whose medical records were reviewed, when they failed to provide a safe environment for P34. This failure places the condition of participation related to Patient Rights out of compliance.

Findings include:

- The hospital failed to ensure the Patient Bill of Rights (BOR) was provided for outpatient Refer to A0117.
- The hospital failed to ensure patients were free from physical restraints when the hospital failed to implement a restraint in an appropriate and safe manner for 1 of 3 patients (P34) who was handcuffed without law enforcement present. Refer to A0154.
- The hospital failed to implement a restraint in an appropriate and safe manner as determined by hospital policy for 1 of 1 patient (P34) who was handcuffed without law enforcement present. Refer to A0167.
- The facility failed to use a restraint that had been ordered by a licensed practitioner for 1 of 1 patient (P34) who had been restrained. Refer to A0168.
- The facility failed to determine the rationale and develop a plan for the use of a restraint, for 1 of 1 patient (P34) who had a restraint. Refer to A0188.
- The facility failed to complete all training regarding the safe implementation of restraint for 1 of 1 patient (P34) who were restrained improperly. Refer to A0194.

Based on interview and document review, the facility failed to ensure the Patient Bill of Rights (BOR) was provided for 4 of 4 outpatient services, which included 8 of 9 (P29, P31, P27, P30, P41, P26, P33, P26) outpatient records. This has the potential to affect all of the patients who utilized the outpatient services.

Findings include:

Cardiac outpatient unit:
P29 started cardiac outpatient services on 8/28/12, and P29's medical record lacked evidence P29 was offered and/or received the BOR.
P31 started cardiac outpatient services on 7/24/12, and P31's medical record lacked evidence P31 was offered and/or received the BOR.
P27 started cardiac outpatient services on 8/29/12, and P27's medical record lacked evidence P27 was offered and/or received the BOR.
P30 started cardiac outpatient services on 9/17/12, and P30's medical record lacked evidence P30 was offered and/or received the BOR.
P41 started cardiac outpatient services on 6/15/12, and P41's medical record lacked evidence P41 was offered and/or received the BOR.

Registered nurse (RN)-B was interviewed on 9/12/12, at 1:30 p.m. and acknowledged the BOR was not provided in the outpatient cardiac unit.

Rehabilitation (rehab) outpatient unit:
The rehab unit reception area and unit was observed on 9/12/12, at 10:55 a.m. for Patient BOR information and none could be located.

Receptionist-C was interviewed on 9/12/12, at 10:55 a.m. at the rehab outpatient unit and was asked if she had given and/or offered patients the BOR when they came into the service unit. The receptionist, replied, "No."

P26 was interviewed on 9/12/12, at 11:00 a.m. P26 acknowledged he received outpatient rehab services. When asked about the Patient BOR and if he had received a copy or was offered a copy, he replied, "I can't say for sure."



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Sleep study unit:

P33's outpatient record was reviewed on 9/12/12. The record lacked documentation that the patient had been provided the Patient BOR's.

P33 was admitted to the outpatient sleep study unit on 8/14/12. P33 was admitted through the admissions department at the hospital, and was not provided the patient BORs.

On 9/12/12, at 1:00 p.m. the chief operating officer verified the BOR were not distributed to patients in the outpatient setting. On 9/12/12, at 2:20 p.m. the business office representative (employee-A) verified patients were not provided written and/or verbal information regarding their rights as patients of the hospital.



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Cancer center:
P22 was admitted as an outpatient through the hospital's Cancer Center. The patient's medical record indicated the patient received chemotherapy treatments on 7/12/12, 8/1/12, 8/22/12, and 9/11/12, and the medical record lacked evidence to show the patient was informed of the patient BOR.
On 9/13/12, at 9:13 a.m. the leader of emergency outpatient verified the findings and stated the hospital did not obtain a consent for services form from patient's prior to treatment. Leader of emergency outpatient provided the patient's consent for services form signed by the patient on 9/11/12. Leader of emergency outpatient verified the form did not address the patient's BOR and stated the BOR posters were posted on the wall in the combined Cancer Center and Day Surgery waiting room.
On 9/12/12, at 1:47 p.m. business office (employee-A) staff person acknowledged, "No one in outpatient services receives the BOR nor are they referred to the poster that is hanging on the wall outside the office."

Based on interview and document review, the hospital failed to ensure patients were free from physical restraints when the hospital failed to implement a restraint in an appropriate and safe manner for 1 of 3 patients (P34) who was handcuffed without law enforcement present.

Findings include:

P34 was admitted on 8/26/12, at 6:00 p.m. to the hospital's emergency department (ED) for a potential overdose of a benzodiazepine (anti anxiety medication). The patient had a history of previous suicide attempt and medical diagnoses that included psychiatric problems. At 7:00 p.m. P34 was placed on a 72-hour hold. At approximately 7:30 p.m. P34 ran out the door of the ED to the outside. The ED staff was unable to restrain him. P34 left with an intravenous (IV) lock and telemetry (heart) monitors in place. The local police department was notified and P34 was returned to the ED within minutes, however, P34 had removed the IV.

P34 was then moved to the intensive care unit (ICU) for closer observation. At 9:00 p.m., P34 removed the monitoring equipment, informed the staff he was leaving, and walked out of the ICU. Security and the local police were called. Staff followed P34 to maintain his location until he was returned to the ICU by the security staff and the police.

Orders for non-violent/non-self-destructive 4-point restraints of either leather or vinyl were obtained at 9:20 p.m. with a maximum time frame of 24 hours. The medical necessity was listed as, due to risk of harm to self, and due to the removal of medical devices. The order was signed by the attending physician (MD) and nurse. The order form noted the house charge nurse was informed of the restraint order.

At 10:50 p.m., P34 requested the restraints be removed, and became angry when his request was denied. He then began to violently shake the bed and was able to get loose from the right wrist restraint and the left leg restraint. Security and the police were again called. The police officer replaced P34's right wrist restraint with handcuffs across his body to the left side of the bed frame, and left his left arm unrestrained. The officer then gave the key to the attending nurse and left the hospital.

Federal regulation explains that the use of a law enforcement device, such as a handcuff, would not be considered a safe and appropriate health care restraints for use by the staff. The regulations require the patient to be under direct supervision of the officer while in a law enforcement restraint. However, the facility restraint policy, dated September, 2001, indicated that law enforcement restraint devices were not considered restraints. The policy did not further explain or define the parameters for use, i.e. the officer must be in direct supervision. The medical record lacked evidence that the attending nurse reported the situation at the time the handcuffs were applied and the officer left her in charge.

The following day on 8/27/12, 6:54 a.m. a nursing note showed P34's right leg restraint was released at 1:15 a.m. and that the right wrist (handcuff) and left leg restraints had been on throughout the night. The note indicated that the MD had been updated of status at 6:35 a.m. At 8:00 a.m. the handcuff wrist restraint was removed. At 10:15 a.m. the left leg restraint was removed. Documentation revealed that P34 was monitored every 15 minutes while in restraints. Psychiatric placement was arranged and P34 was transported via ambulance at 10:50 a.m.

The leader of acute care was interviewed on 9/12/12, at approximately 3:00 p.m. She explained that when she arrived on duty at 8:00 a.m. on 8/27/12, she recognized that the handcuff restraint was inappropriate and ordered it to be removed immediately. She then completed an incident report. The leader explained that the restraints should have been ordered as behavioral rather than as non-violent. Also, through her investigations, she realized that the supervisor was aware of the handcuffs, but had not recognized the inappropriateness of the situation. The MD was also aware of the handcuff situation at 6:35 a.m., but took no action. The leader of acute care reported the situation to the police in the morning. The officer who came to the hospital to investigate was surprised that the previous officer had left the patient while he was handcuffed.

The facility restraint policy, dated September, 2001, described two separate procedures for restraints. One procedure was for non-violent/non self-destructive individuals. The second procedure was for violent/self-destructive behavior (behavioral restraint). The indication for use of the behavioral restraint read, "Use of restraints in an emergency situation to manage violent or self-destructive behavior due to a psychiatric condition to ensure the immediate physical safety of the patient, staff or others (Not for a confused patient or someone with an acute withdrawal syndrome)." The leader of acute care verified during the interview on 9/12/12, at approximately 3:00 p.m. the incident met the criteria for initiation of a behavioral restraint. If a behavioral restraint order had been initiated, then a face to face assessment would have been required to be conducted by a physician within one hour of placing the restraints, and the order would have expired in four hours according to regulations and hospital policy. The medical record lacked evidence of an MD face to face assessment within one hour and the restraints remained in place for greater than four hours without reassessment. The restraint policy also indicated that restraint devices by law enforcement such as hand cuffs, shackles or other devices were not considered restraints. However, the nurse manager verified that the handcuffs should have been considered a restraining device, since the officer did not maintain custody and direct supervision, but instead left hospital staff responsible for the safety of the patient.

Based on interview and document review, the hospital failed to implement a restraint in an appropriate and safe manner as determined by hospital policy for 1 of 1 patient (P34) who was handcuffed without law enforcement present.

Findings include:

P34 was restrained by law enforcement without proper authorization and monitoring.

On 8/26/12, at 6:00 p.m. P34 was admitted to the hospital's emergency department (ED) for a potential overdose of a benzodiazepine (anti anxiety medication). The patient had a history of previous suicide attempt and medical diagnoses which included psychiatric problems. At 7:00 p.m. P34 was placed on a 72-hour hold. At approximately 7:30 p.m. P34 ran out the door of the ED to the outside. The ED staff was unable to restrain him. P34 left with an intravenous (IV) lock and telemetry (heart) monitors in place. The local police department was notified and P34 was returned to the ED within minutes, however, P34 had removed the IV.

P34 was then moved to the intensive care unit (ICU) for closer observation. At 9:00 p.m., P34 removed the monitoring equipment, informed the staff he was leaving, and walked out of the ICU. Security and the local police were called. Staff followed P34 to maintain his location until he was returned to the ICU by the security staff and the police.

Orders for non-violent/non-self-destructive 4-point restraints of either leather or vinyl were obtained at 9:20 p.m. with a maximum time frame of 24 hours. The medical necessity was listed as, due to risk of harm to self, and due to the removal of medical devices. The order was signed by the attending physician (MD) and nurse. The order form noted the house charge nurse was informed of the restraint order.

At 10:50 p.m. P34 requested the restraints be removed, and became angry when his request was denied. He then began to violently shake the bed and was able to get loose from the right wrist restraint and the left leg restraint. Security and the police were again called. The police officer replaced P34's right wrist restraint with handcuffs across his body to the left side of the bed frame, and left his left arm unrestrained. The officer then gave the key to the attending nurse and left the hospital. The medical record lacked evidence to indicate the charge nurse or physician was made aware that the officer had left the patient handcuffed and in the charge of the hospital staff.

Federal regulation indicated the use of a law enforcement device, such as a handcuff, would not be considered a safe and appropriate health care restraints for use by the staff. The regulations require the patient to be under direct supervision of the officer while in a law enforcement restraint. However, the facility's Restraint Policy, revised September 2001, indicated law enforcement restraint devices were not considered restraints. The policy did not further explain or define the parameters for use, i.e. the officer must be in direct supervision.

The following day on 8/27/12, at 6:54 a.m. a nursing note revealed P34's right leg restraint was released at 1:15 a.m. and the right wrist and left leg restraints had been on throughout the night. The note indicated the MD had been updated of status at 6:35 a.m. At 8:00 a.m. the handcuff wrist restraint was removed. At 10:15 a.m. the left leg restraint was removed. Documentation revealed that P34 was monitored every 15 minutes while in restraints. Psychiatric placement was arranged and P34 was transported via ambulance at 10:50 a.m.

The leader of acute care was interviewed on 9/12/12, at approximately 3:00 p.m. She explained that when she arrived on duty at 8:00 a.m. on 8/27/12, she recognized the handcuff restraint was inappropriate and ordered it to be removed immediately. She then completed an incident report. The leader explained the restraints should have been ordered as behavioral rather than as non-violent. Also, through her investigations, she realized that the supervisor was aware of the handcuffs, but had not recognized the inappropriateness of the situation. The MD was also aware of the handcuff situation at 6:35 a.m., but took no action. The leader of acute care reported the situation to the police in the morning. The officer who came to the hospital to investigate was surprised that the previous officer had left the patient while he was handcuffed.

The facility Restraint Policy, dated September, 2001, described two separate procedures for restraints. One procedure was for non-violent/non self-destructive individuals. The second procedure was for violent/self-destructive behavior (behavioral restraint). The indication for use of the behavioral restraint read, "Use of restraints in an emergency situation to manage violent or self-destructive behavior due to a psychiatric condition to ensure the immediate physical safety of the patient, staff or others (Not for a confused patient or someone with an acute withdrawal syndrome)." The leader of acute care verified during the interview on 9/12/12, at approximately 3:00 p.m. the incident met the criteria for initiation of a behavioral restraint. If a behavioral restraint order had been initiated, then a face to face assessment would have been required to be conducted by a physician within one hour of placing the restraints, and the order would have expired in four hours according to regulations and hospital policy. The medical record lacked evidence of an MD face to face assessment within one hour and the restraint remained in place for greater than four hours without a reassessment. The restraint policy also indicated that restraint devices by law enforcement such as hand cuffs, shackles or other devices were not considered restraints. However, the nurse manager verified that the handcuffs should have been considered a restraining device, since the officer did not maintain custody and direct supervision, but instead left hospital staff responsible for the safety of the patient.

Based on interview and record review, the facility failed to use a restraint that had been ordered by a licensed practitioner for 1 of 1 patient (P34) who had been restrained.

Findings include:

P34 had a handcuff restraint applied that was not ordered.

Orders for non-violent/non-self-destructive 4-point restraints of either leather or vinyl were obtained for P34 on 8/26/12, at 9:20 p.m. with a maximum time frame of 24 hours. The medical necessity was listed as, due to risk of harm to self, and due to the removal of medical devices. The order was signed by the attending physician (MD) and nurse. The order form noted the house charge nurse was informed of the restraint order.

At 10:50 p.m. P34 requested the restraints be removed, and became angry when his request was denied. He then began to violently shake the bed and was able to get loose from the right wrist restraint and the left leg restraint. Security and the police were again called. The police officer replaced P34's right wrist restraint with handcuffs across his body to the left side of the bed frame, and left his left arm unrestrained. The officer then gave the key to the attending nurse and left the hospital.

The following day on 8/27/12, 6:54 a.m. a nursing note showed P34's right leg restraint was released at 1:15 a.m. and that the right wrist and left leg restraints had been on throughout the night. The note indicated that the MD had been updated of status at 6:35 a.m. At 8:00 a.m. the handcuff wrist restraint was removed. At 10:15 a.m. the left leg restraint was removed. Documentation revealed that P34 was monitored every 15 minutes while in restraints. Psychiatric placement was arranged and P34 was transported via ambulance at 10:50 a.m.

The leader of acute care was interviewed on 9/12/12, at approximately 3:00 p.m. She explained that when she arrived on duty at 8:00 a.m. on 8/27/12, she recognized that the handcuff restraint was inappropriate and ordered it to be removed immediately. She then completed an incident report. The leader explained that the restraints should have been ordered as behavioral rather than as non-violent. Also, through her investigations, she realized that the supervisor was aware of the handcuffs, but had not recognized the inappropriateness of the situation. The MD was also aware of the handcuff situation at 6:35 a.m., but took no action. The leader of acute care reported the situation to the police in the morning. The officer who came to the hospital to investigate was surprised that the previous officer had left the patient while he was handcuffed.

The facility restraint policy, dated September, 2001, indicated that restraints shall be ordered by a physician of the medical staff on the Restraint Initiation Physician Order form. As needed orders were not allowed, and the order should specify the method of restraint used.

Based on record review and interview, the facility failed to determine the rationale and develop a plan for the use of a restraint, for 1 of 1 patient (P34) who had a restraint.

Findings include:

P34 was not assessed prior to the application of a law enforcement restraint to determine the necessity for the restraint. There was no plan for the release of the restraint.

Orders for non-violent/non-self-destructive 4-point restraints of either leather or vinyl were obtained for P34 at 9:20 p.m. with a maximum time frame of 24 hours. The medical necessity was listed as, due to risk of harm to self, and due to the removal of medical devices. The order was signed by the attending physician (MD) and nurse. The order form noted the house charge nurse was informed of the restraint order.

At 10:50 p.m., P34 requested the restraints be removed, and became angry when his request was denied. He then began to violently shake the bed and was able to get loose from the right wrist restraint and the left leg restraint. Security and the police were again called. The police officer replaced P34's right wrist restraint with handcuffs across his body to the left side of the bed frame, and left his left arm unrestrained. The officer then gave the key to the attending nurse and left the hospital.

The following day on 8/27/12, 6:54 a.m. a nursing note showed P34's right leg restraint was released at 1:15 a.m. and that the right wrist and left leg restraints had been on throughout the night. The note indicated that the MD had been updated of status at 6:35 a.m. At 8:00 a.m. the handcuff wrist restraint was removed. At 10:15 a.m. the left leg restraint was removed. Documentation revealed that P34 was monitored every 15 minutes while in restraints. P34 had become more calm and cooperative throughout the night and slept at times. Psychiatric placement was arranged and P34 was transported via ambulance at 10:50 a.m. without incident.

The facility restraint policy, dated September, 2001, indicated that restraints shall not be used when less restrictive interventions would be effective, and that alternatives should be considered. Although P34 became more cooperative as the night went on, and the leather restraints were released, the handcuff restraint was not released.

Based on interview and record review, the facility failed to complete all training regarding the safe implementation of restraint for 1 of 1 patient (P34) who were restrained improperly.

Findings include:

Education and policy revision for the proper use of restraint had not yet been implemented following the improper placement of a restraint for P34.

The leader of acute care was interviewed on 9/12/12, at approximately 3:00 p.m. She explained that when she arrived on duty at 8:00 a.m. on 8/27/12, she recognized that a handcuff restraint was inappropriate and ordered it to be removed immediately. She then completed an incident report. The leader explained that the restraints should have been ordered as behavioral rather than as non-violent. Also, through her investigations, she realized that the supervisor was aware of the handcuffs, but had not recognized the inappropriateness of the situation. The MD was also aware of the handcuff situation at 6:35 a.m., but took no action. The leader of acute care reported the situation to the police in the morning. The officer who came to the hospital to investigate was surprised that the previous officer had left the patient while he was handcuffed.

At the time of the interview, the leader of acute care initiated a plan of correction, and at the time of the survey had implemented the following: Immediately sent a memo out to all staff explaining the situation, spoke directly to the staff involved, began revising policies and planning mandatory training for all staff to include the contracted security personnel, began revising the second check practice for the house supervisor, communicated with the police department, and planned to present the incident at the next board of directors meeting. At the time of the survey, the plan of correction had not been fully implemented.

The facility restraint policy, dated September, 2001, indicated that initial nursing and paramedic staff training will be done at nursing orientation. Initial and ongoing training will include the ability to demonstrate competency in the application of restraints as well as monitoring, assessing and providing patient care for a patient with restraints. Physicians and other providers will have a working knowledge of the policy.

Based on interview and document review, the hospital failed to ensure bylaws were signed and approved by the governing body. This had the potential to all of the patients at the hospital.


Findings include:

The medical staff bylaws were reviewed by the governing body on 4/24/12, however, the bylaws were not signed by the chairperson of the board.

On 9/12/12, at 9:45 a.m. the director of performance excellence verified the medical staff bylaws were not approved and signed by the governing body, but should have been.

Based on interview and document review the hospital failed to include the duties and scope of practice for each category of practitioner. This has the potential to affect all of the patients who were provided services by physician assistants (PAs).

Findings include:

Although the hospital employed PAs, they were not identified in the delineation of privileges section of the medical staff bylaws.

The medical staff bylaws were reviewed by the governing body on 4/24/12. The Delineation of Privileges included privileges for podiatrists, certified nurse midwives, nurse practitioners, psychologists, physical and occupational therapists, speech-language pathologists, audiologists, massage therapists, and acupuncturists, however, the PAs who worked in the hospital's emergency department were not included.

On 9/12/12, at 9:45 a.m. the director of performance excellence verified that the delineation of privileges for the PAs had inadvertently been omitted form the governing body's approval of medical staff bylaws. The director verified the PAs were employed by the hospital, worked in the emergency department, and should have been included in the delineation of privileges.

Based on interview and document review, the hospital failed to ensure practitioners were competent to provide procedures prior to authorizing privileges for 1 of 10 physicians (MD)-B whose credentials were reviewed.

Findings include:

The privilege delineation for MD-B was reviewed for the period from 8/1/11 through 7/31/13. The MD requested special privileges to perform Focused Assessment for Sonography in Ultrasound (F.A.S.T.) In requesting special privileges the form also indicated the MD was to provide documentation of the minimum number indicated procedures he/she had performed in the past two years or the training he/she had received to support the request. Although the MD failed to provide either of the documents, privileges were granted by the chair person of the emergency department/out patient (ED/OP) service committee.

On 9/12/12, at 2:00 p.m. the director of performance excellence was interviewed and stated that MD-B should never have been granted the privilege without the provision of proper documentation. The director did explain MD-B had not yet performed the procedure. The director contacted MD-B regarding the issue. The MD said that he had studied the procedure in medical school, and did not think it was necessary to submit the information. The director also contacted the MD who granted the privilege, who agreed the information should have been provided prior to granting MD-B privileges to perform the testing.

Based on observation, interview, and document review, the hospital failed to ensure all medications were securely stored to prevent access by unlicensed/unauthorized persons. This had the potential to affect all patients on the medical/surgical unit.

Findings include:

On 9/10/12, between 2:00 and 2:50 p.m. a tour of the medical/surgical unit was conducted with the registered nurse, leader of acute care, and director of nursing. During the tour the medication room on the unit was observed. Access to the medication room was restricted to only those employees who knew the access code. The hospital utilized the Accudose system to ensure most medications in the room were secured. In addition, to the Accudose system, the hospital utilized a blue bin system that was labeled with a room number for medications that were not routinely stocked in the Accudose system. The blue bins were not secured and anyone who entered the medication room would have access to medications stored in the bins. Also, on the counter in the medication room was a Ziploc bag that contained P6's medication supply brought from home. The Ziploc bag contained three bottles of prescription medications which included Metoprolol (used to treat chest pain and high blood pressure) 25 milligrams (mg), Trazodone (an anti-depressant) 100 mg and vitamin B12 (a nutrient that keeps the body's nerve and blood cells healthy).

During the tour the leader of acute care was asked who had access to the medication room. She replied, "Licensed and housekeeping staff." The leader of acute care stated the housekeeping staff knows the security code to the medication rooms so they can clean them. When asked if the housekeeping staff were accompanied by licensed staff when they cleaned the medication rooms she replied, "No they were not."

Although an access code was required to enter the hospital's medication rooms, the hospital lacked a policy regarding which staff was authorized to access the medication rooms. Some of the medications stored in the room were not secured and were readily available to anyone who had access to the medication room.

On 9/13/12, at 8:45 a.m. the leader of acute care verified the findings and stated the hospital did not have a policy to address who had access to the secured medication rooms.

Based on observation and interview, the facility was found not in compliance with Life Safety from Fire found at CFR 482.41 (b). This had the potential to affect all of the patients at the hospital.

Findings include;

Refer to Life Safety Code deficiencies K0011, K0012, K0018, K0025, K0029, K0033, K0038, K0050, K0052, K0056, K0062, K0076, and K0147 for additional information.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure safety from fire, therefore, they were unable to meet the condition.

Based on interview and document review, the hospital failed to implement policies and procedures related to blood products distributed by the American Red Cross for 3 out of 6 patient (P36, P37, P38) files that were reviewed for blood transfusion look back periods and the hospital failed to develop a system to identify and investigate potential infection control practices that could potentially lead to infections and to use proper infection control practices in 2 of 4 outpatient areas observed.

Findings include:

Appropriate action had not been taken when the District One Hospital Blood Bank Transfusion Service was notified by the American Red Cross of possible infectious blood components received by the facility.

P36 was transfused on 9/9/09, with B positive platelet pheresis leukoreduced blood. The recall letter from the American Red Cross dated 9/23/09, revealed that there was a potential the platelet blood product may not have been leukoreduced and the recipient may have an increased risk of developing human leukocyte antigen (HLA) antibodies and febrile reactions. In recipients that require cytomegalovirus, (CMV-a white blood cell based virus) safe blood there may be an increased risk of CMV transmission. The letter further included that the final determination of the safety of this product rest with the recipients physician. There was no physician notification found in the medical record that this had been addressed.

P37 was transfused on 2/25/09, with B positive frozen plasma. The recall letter from the American Red Cross dated 7/23/09, revealed that the donor reported he had been diagnosed with Ehrlichiosis (infectious disease transmission by a tick) but had no clear onset of symptoms. The donor recalls recent tick exposure. The letter further included that the final determination of the safety of this product rests with the recipient's physician. There was no physician notification found in the medical record that this was addressed.

P38 was transfused on 7/8/09, with fresh frozen plasma. The recall letter from the American Red Cross dated 4/27/11, revealed the donor was diagnosed with Epstein Barr Virus (human herpesvirus) with hepatitis/jaundice. The reported date of diagnosis was 6/1/07. The letter further directed that if the product had been transfused, "please evaluate the need to inform the recipient." There was no physician notification found in the medical record related to the American Red Cross recommendation.

The infection prevention manager interviewed at 8:40 a.m. on 9/12/12, indicated that she was unaware of the recall letters from the American Red Cross. The letters were unfamiliar to her, and had not been discussed at any of the facility's infection control meetings. After reviewing the recall letters the infection prevention manager stated that she would have expected to be notified of the recall letters. The infection prevention manager was shown the letters from the Red Cross. The infection prevention manager noted it was the pathologist who signed off on the letters and not the primary physician. She further stated the physicians should have responded to patients who received blood mentioned in the recalls.

The Hospital Blood Bank Transfusion Service Look back Procedure (dated 3/17/98 with a review date of 6/11/12), identified the purpose of the procedure was to define appropriate action when the hospital is notified of any blood component received by the facility when the donor was found subsequently positive with HIV testing or other positive infectious disease testing, such as hepatitis or subsequently developed an infectious disease. Following notification that blood components had been previously received from the blood supplier and that subsequent information revealed that the blood donor had at a later date developed reactive infectious disease screening test or additional medical history had been acquired that disqualified the blood donor, the hospital will "determine whether the blood component has been transfused or is in the inventory, remove from inventory and quarantine the component identified if not transfused, document removal from inventory in blood bank records, make a record of quarantine and final disposition in the look back identification record and log if not transfused and complete other documentation required by the blood supplier." Hospital staff was to initiate an investigation, notify the medical director or designated alternative physician to carry out further steps. All unit information relayed to the hospital from the blood supplier was to be recorded onto the look back investigation record, a look back investigation file was to be created with a unique file number for each notification by the blood supplier, and all suspected units were to be logged indicating the date of the notification in the look back unit log.



19200

On 9/12/12, at 2:00 p.m. an environmental tour, which included a tour of the hospital's morgue was conducted with the director of logistics. The body holding container was in the autopsy room behind a closed door wall container. The body was then was brought to the autopsy room, where it would be placed on a metal slab in the wall container. The metal slab was not disinfected between bodies. After the mortician retrieved a body, however, the area was not routinely cleaned with any type of disinfectant.

The Patient Care Infection Control policy and procedure revised 9/11, directed staff to clean the morgue after use. The director of logistics said the container was cleaned monthly when interviewed at 3:00 p.m. on 9/12/12. He explained that the entire container including the slab was wiped down with HB Quat 25 which killed all organisms except Clostridium Difficile Spores (C-diff). If a patient had C-diff then the staff would use Dispatch which was effective in killing the C-diff organism. He said they would not know which cleaner to use, when asked how they would know if they should use Quat or Dispatch. The supervisor was unsure why the area was not cleaned after each use.

The leader of infection prevention was interviewed on 9/13/12, at 8:40 a.m. She said she was unaware the morgue was not being cleaned after each use, but said it should have been. She said she would need to review the procedure the type of products used.



25482

The hospital failed to ensure patient multi-use equipment was disinfected between each patient use.

At 11:45 a.m. on 9/11/12, a registered nurse (RN)-E was observed to check P15's blood glucose level. RN-E obtained the blood glucose monitoring device from its docking station at the nursing desk. RN-E proceeded to check the patient's blood glucose level and then returned the device to its docking station. RN-E did not disinfect the device prior to returning it to the docking station. In an interview immediately following the observation, RN-E stated she was not aware of any policy regarding the disinfection of glucometers between each patient use. RN-E stated she believed the nursing assistants were responsible for cleaning the glucometers.

On 9/11/12, at 2:30 p.m. the director of nursing (DON) was questioned regarding the cleaning glucometers between each patient use. The DON stated if the patient whose blood glucose was being monitored was in isolation, the glucometer should be placed in a special plastic bag prior to entering the patient's room. The DON stated in all cases the glucometer must be cleaned with a disinfecting wipe between each patient use.

On 9/11/12, at 4:30 p.m. the hospital's infection control nurse stated she taught staff to clean the glucometer between each patient use with a water moistened cloth and a mild detergent as that was what the manufacturer recommended. The infection control nurse stated the glucometer should be placed in a plastic bag for all patients not just those who are in isolation.

The hospital's Glucometer policy revised April 2011, directed staff to place the glucometer in an isolation bag prior to each use and cleanse the outside of the device daily with a water moistened cloth and mild detergent.

On 9/10/12, between 2:00 and 2:50 p.m. a tour of the Intensive Care Unit was conducted with the leader of acute care and the DON. Noted in the soiled utility room, was multiple boxes of clean Precision PCx blood glucose monitoring test strips. Immediately following the observation leader of acute care was questioned regarding the storage of clean patient care supplies in the soiled utility room. She immediately removed the blood glucose monitoring supplies from the soiled utility room and stated the test strips should be stored in the supply room.

On 9/13/12, at 9:56 a.m. the hospital's infection control nurse stated the hospital did not have a policy regarding the storage of clean patient care supplies. The infection control nurse stated clean patient supplies should not be stored in the soiled utility rooms.



18623

Cardiac rehabilitation (rehab):
On 9/12/12, at 9:15 a.m. the tour of the cardiac rehab tour began. At 9:20 a.m. P27 was noted to be on a stationary recumbent bicycle. At 9:35 a.m. P30 was noted to be on the same bicycle. Also P29 and P31 were observed to be using the same stationary bicycle without being disinfected.

P27 started cardiac outpatient services on 8/29/12, with a diagnosis of atrial fibrillation.
P30 started cardiac outpatient services on 9/17/12, with a diagnosis of hypertension.
P29 started cardiac outpatient services on 8/28/12, with a diagnosis of myocardial infarction.
P31 started cardiac outpatient services on 7/24/12, with a diagnosis of coronary artery disease.

Registered nurse (RN-B) was interviewed on 9/12/12, at 9:35 a.m. RN-B was asked if the equipment had been disinfected between patients, RN-B indicated, "No, they had not."

Rehab:
A tour of the Rehab One therapy area began on 9/12/12, at 10:55 a.m. P25 was observed to be on the stationary bicycle after the tour was in progress. At approximately 11:15 a.m. P26 was noted to be riding the same stationary bicycle P25 had been riding.

P25 was admitted to the outpatient rehab on 9/12/12, with a diagnosis of total knee replacement.
P26 was admitted to the outpatient rehab on 8/15/12, with a diagnosis of status post arthroscopy. Neither patient had any history of an infectious disease.

When physical therapist (employee)-D was interviewed on 9/12/12, at 11:15 a.m. she acknowledged the patient equipment was to be disinfected between patients. When employee-D was asked if the equipment was disinfected between P25 and P26, she indicated, "No, it had not."

The infection control officer was interviewed on 9/13/12, at 8:45 a.m. and verified staff should be wiping down the equipment between patient use.

The Cleaning of Electronic Equipment policy revised September 2012, indicated equipment which was in contact with patients and/or touched by multiple staff members would be wiped down thoroughly with germicidial disposable wipes.

Based on observation, interview and document review the hospital failed to identify the discharge planning needs for 1 of 1 patient (P6) in the sample who was admitted with a pressure ulcer.

Findings include:

P6 was admitted to the hospital on 9/9/12, for an acute psychological changes and possible stroke. The history and physical dated 9/9/12, indicated the patient lived with her daughter and required 24 hour supervision. A physician's progress note dated 9/9/12, indicated the patient was orientated to self only.

Review of the Admission Assessment Report dated 9/9/12, revealed the patient had a stage two (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) pressure ulcer on the coccyx at the time of admission. The report failed to identify the wound characteristics other than it was a small, vertical open slit. A Daily Focus Assessment Report Integumentary note dated 9/10/12, indicated the patient had an intact Duoderm (dressing) on the coccyx.

The dietician's progress note dated 9/10/12, indicated a registered nurse (RN) had ordered a nutrition screen for the pressure ulcer and as a result the patient would receive a high protein supplement twice daily to increase protein intake.

Although the hospital had identified a stage two pressure ulcer on the patient's coccyx, a Care Rounds & D/C {discharge} Planning note dated 9/10/12, and another dated 9/11/12, indicated the interdisciplinary team identified no discharge planning needs. The patient's medical record lacked evidence or patient and/or family education regarding the development, treatment and prevention of pressure ulcers. The patient's discharge orders failed to identify pressure ulcer care instructions and the dietician's recommendations for increased protein intake.

On 9/11/12, at 3:41 p.m. the RN-D and the leader of acute care verified these findings. The leader of acute care stated care of the pressure ulcer should have been included in the patient's discharge instructions.

The hospital's Admission of Patients policy (no date) indicated, "The medical records of all patients shall document pertinent instructions to the patient and/or family at the time of discharge."

Based upon observation, interview and record review, the hospital did not ensure safe surgical practices were followed in accordance with acceptable standards of practice related to the safe use of electrocautery equipment in the surgical suite for 1 of 2 (P28) surgical procedures observed in which electrocautery equipment was used. This had the potential to affect most of the patients undergoing surgery at the hospital.

Findings include:

Physician (MD)-A did not utilize a holster device to place the electrocautery device during an observed surgery.

During observation on 9/11/12, at 10:07 a.m. P28 underwent a right shoulder arthroscopy rotator cuff repair procedure. The surgical technician clipped the holster to the drape on mid-abdomen of P28. The observed procedure the electrosurgical (cautery) wand was not holstered immediately following use by MD-A, but was placed on the surgical drape of P28 which was located on patient's lower abdomen by MD-A.
- 10:07 a.m. MD-A utilized the wand and placed on drape.
- 10:16 a.m. cautery used and placed on drape,
- 10:24 a.m. MD-A used the wand and placed on drape,
- 10:36 a.m. MD-A placed the cautery device in the holster (29 minutes later).

The circulation nurse (RN)-C was present at the above date and time and verified that the cautery wand was not holstered and was laying on the surgical drape of P28, which was located on the patient's lower abdomen. Even though the circulation nurse was aware that the cautery was laying on the surgical drape of P28, no one removed it or asked MD-A to holster the cauterizing pencil.

Upon interview with MD-A on 9/12/12, at 11:00 a.m. he confirmed that he usually used the holster for the cautery, and verified the holster was clipped on the drape for P28. MD-A said he was unaware he had not used the holster, but if he was observed not using the hostler, he had meant to do so.

Review of the undated Edge Pencil Blade Electrode Manual, with the subject title, "Warning Fire Hazard", directed staff, "Do not place active accessories near or in contact with flammable materials (such as gauze or surgical drapes). Electrosurgical accessories which are activated or hot from use can cause a fire. Use a holster to hold electrosurgical pencils and similar accessories safely away from patients, personnel, and surgical drapes. When not in use, place active accessories in a holster or in a clean, dry, nonconductive, and highly visible area not in contact with the patient. Inadvertent contact with the patient may result in burns."