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Unable to assess compliance due to on-going construction/renovation.

Orignal Findings:

Based on observation, record review and staff interview, it was determined the hospital failed to ensure:

a. the recovery area was adequately constructed, equipped and arranged to accommodate patients and was designed to ensure patient privacy. See Tag C-0221;

b. facilities, supplies and equipment were maintained for safety and quality. See Tag C-0222;

c. the premises was clean and orderly; See Tag C-0225;

d. temperature, humidity and ventilation was maintained within acceptable standards. See Tag C-0226 of original findings; and

e. failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. See LSC survey K Tags on original survey.

Unable to assess compliance due to on-going construction/renovation.

Original Findings:

Based on observation and staff interview, it was determined the hospital failed to ensure the recovery area was constructed, equipped and arranged to accommodate patients and was designed to ensure patient privacy. Findings:

On 07/24/13, a tour of the hospital's recovery area was conducted. The following observations were made:

An operating room was being used as a recovery room. The room held all the equipment needed in an operating room, including an anesthesia machine, anesthesia cart and various other items found in an operating room.

The room was not set up and constructed as a recovery room. Two sets of portable monitors and sets of other necessary equipment (all portable) for two patients was present. None of the recovery equipment was permanently installed and the room had not been modified as a "recovery room."

Two patient stretchers were found placed (within three feet of each other), side by side, in this recovery room. Staff I stated two patients were recovered at a time in this space.

The two recovery "bays" were not separated sufficiently to allow the ease of staff movement between the stretchers. The stretchers were crowded close together because of other equipment stored in the room.

The door to this room was propped open at all times.

The two recovery "bays" had no privacy curtain between them to protect each patient's privacy from the other, and had no curtain or other barrier, such as a screen, to guard the patients' privacy from people walking into the recovery area or walking by in the hallway.


The room was also being used to store various pieces of medical equipment. Old and unused equipment was stored around the perimeter of the room, including an old OR table, an obstetric delivery table, and an automated endoscope processor.

The room also held an infant warmer, a high-backed wheelchair, and a bedside commode.

The room was not equipped with a handwashing sink or a medication administration and preparation area as required by State Hospital Standards.

Unable to assess compliance due to on-going construction/renovation.

Original Findings:

Based on observation, record review and staff interview, it was determined the hospital failed to ensure facilities, supplies and equipment were maintained for safety and quality. Findings:

On 07/24/13 and 07/25/13, a tour was conducted of the hospital. The following observations were made:

1. The ceiling in the sterile processing area was constructed with acoustic tiles. The tiles were old, yellowed and water stained. Some tiles were bowed and loose from the framework.

2. Floors throughout the surgery department were chipped and showed signs of dirt, grime and wax build-up.

3. Sprinkler heads throughout the department were rusted.

4. See also LSC survey Tags K-067 and K-147.

Unable to assess compliance due to on-going construction/renovation.

Original Findings:

Based on observation and interview, it was determined the hospital failed to ensure the physical environment was uncluttered and that equipment and supplies were properly stored. The hospital also failed to ensure surfaces could be cleaned. Findings:

On 07/23, 07/24 and 07/25/13, the surveyors toured various areas of the hospital. The following observations were made:

1. The patient care unit hallways were cluttered with equipment and supplies.

2. The surgery department was cluttered with equipment from other departments and old equipment no longer in use. Supplies were stored in corridors.

3. The surgery department was unorganized and had a "haphazard" appearance. Sterile and non-sterile supplies were stored in their original shipping boxes that were grimy and dirty. These boxes were placed next to unpacked "clean" items. Sterile and non-sterile supplies were stored together.

4. Sinks in the surgery department were packed with items that had been washed and left there to dry, having never been put away.

5. The OR suite, the "recovery room", the decontamination room, the sterile processing room, the surgery corridors and storage closets and cabinets were cluttered and disorganized.

6. The cabinetry and closets in the surgery department were wood with a varnish finish that could not be cleaned and sanitized.

7. Floors throughout the surgery department were marred, chipped, discolored and dirty. The condition of the floors prevented adequate cleaning and decontamination.

8. Staff personal items, food and open beverage products were found in the sterile processing, operating room and recovery room.

9. See also LSC survey Tags K-147.

Staff I was asked about the condition of the surgery department. She stated the area had been in that condition so long that no one noticed it any more. She stated repairs had not been made because they were expecting to move into a new hospital sometime in the future. She stated there was not enough storage space anywhere in the hospital and the operating room was the only place some equipment could be stored.

Unable to assess compliance due to on-going construction/renovation.

Original Findings:

See LSC survey Tags K-018, K-052, K-072, K-130.

Unable to assess compliance due to on-going construction/renovation.

Original Findings:

Based on observation, interview and review of hospital documents, the governing body failed to provide the following:

1. That all practitioners providing patient care are qualified and have current appointments and licenses and privileges granted. See Tag C-0241

2. Policies and procedures were developed with advice from healthcare professionals and were based on recognized national standards and guidelines. See Tag C-0272;

3. Departmental policies and procedures included a description of services furnished directly and those furnished through agreement or arrangement. See Tag C-0273;

4. That non-licensed pharmacy personnel were trained, evaluated and had a job description. See Tag C-0276;

5. A developed and maintained active on-going infection control program. See Tag C-0278;

6. That dietary services policies and procedures were developed and implemented and that the consultant dietitian fulfilled minimum responsibilities for the hospital's nutritional services. See Tag C-0279;

7. That hospital polices for anesthesia, radiology, dietary, surgery and central sterile were reviewed at least annually. See Tag C-0280;

8. That personnel assigned to the Sleep Study Lab were qualified and trained, and the department had oversight by a manager.
See Tag C-0281;

9. That radiology services were supervised and performed according to accepted national standards. See Tag C-0283;

10. That a list of all services provided through arrangement, contract or agreement was maintained describing the nature and scope of the services. See Tag C-0291;

11. That nursing staff were trained and evaluated on competency to perform the essential functions of the job. See Tag C-0294; and

12. That a registered nurse assessed and evaluated the nursing care for each patient. See Tag C-0296.

13. That the recovery area was adequately constructed, equipped and arranged to accommodate patients and was designed to ensure patient privacy. See Tag C-0221;

14. That adequate facilities, supplies and equipment were maintained for safety and quality. See Tag C-0222;

15. That the premises was clean and orderly; See Tag C-0225;

16. That temperature, humidity and ventilation was maintained within acceptable standards. See Tag C-0226; and

17. That the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association are met. See LSC survey K Tags.

18. That surgical procedures, central sterile processes and contracted services providing patient care in the hospital are evaluated for quality and appropriateness of care provided. See C-0337

At the time of the revisit on 09/29/14, this deficiency was not corrected.
* * * * * * *

Based on review of hospital documents and meeting minutes, and interviews with staff, the facility failed to:

a. Develop and maintain an active on-going infection control/infection prevention (IC) program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases among patients and staff;

b. Analyze infection preventionist (IP) surveillance data and concerns, develop corrective actions when needed and conduct follow-up to ensure corrective actions are appropriate and sustained to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel; and

Findings:

1. The facility failed to develop a written infection control plan with details of:
a. When and and where the business of infection control committee would occur; and
b. How often the infection control program would conduct surveillance/monitoring to ensure all departments complied with infection control policies and standards of practice for infection control.

2. Meeting minutes did not reflect all departments/areas were monitored and surveillance/monitoring and concerns were:
a. Reviewed,
b. Analyzed, and
c. Corrective actions identified with
d. Follow-up to ensure corrective actions were effective and maintained.
e. Example: while the IP had data about isolation carts being stocked, there was no data whether staff were compliant with isolation precautions.

3. These findings were reviewed during the exit conference with administrative staff. No additional information was provided.

Unable to assess compliance due to on-going construction/renovation.

Original Findings:

Based on observation, document review, policy and procedure review and staff interview, it was determined the hospital failed to ensure surgical procedures were performed in a manner that conformed to national standards of practice as evidenced by failure to:

a. define the scope of surgical services;
b. provide supervision of surgical services by an experienced registered nurse;
c. develop and implement surgical policies and procedures based on recognized national standards;
d. maintain an operating room register that included all the required elements;
e. conform to standards of practice for peri-operative care and the high level disinfection of endoscopes;
f. clean between surgical cases and perform terminal cleaning of the surgical area; and
g. failed to provide emergency supplies and equipment dedicated to the operating room and recovery areas.

The hospital also failed to:

i. make available a current roster of each practitioner's surgical privileges to be located in the surgery department and also where scheduling of cases is performed. See Tag C-0321; and

j. failed to provide acceptable pre-anesthesia and post-anesthesia evaluations. See Tag C-0322.

Findings:

1. On 07/23/13 and 07/24/13, the surveyors conducted a survey of the hospital's surgical services. The administrative staff were asked to provide policies and procedures and other documents related to the provision of surgical services.

There was no documentation of a written scope of surgical services currently provided by the hospital.

2. The DON stated she was responsible for supervision of surgical services. The hospital had no documentation the DON had formal training or experience in peri-operative care and no documentation of specialized certification.

The DON stated her only training and experience was "on the job" at this hospital. The hospital had no job description and no defined qualifications for a manager/director of surgical services. There was no documentation of skills competencies required for this position.

3. Policies and procedures related to surgery, anesthesia services, post anesthesia care and central sterile processing were outdated, many were not applicable, and many were not in line with current standards of practice. None of the policies and procedures had evidence they were developed based on a nationally recognized source.

The surgery emergency operations plan was dated 2008.

The conscious sedation policy was dated 2005 and information contained within the policy was based on sources much older. None of the nurses who provided conscious sedation had documentation of training, experience and skills competency to provide this levelof care. The DON said the documentation to show evidence of training and competency was lost.

A policy, titled, "Post Anesthesia Nursing Practice Standards," was dated 1991.

A malignant hyperthermia policy was dated 1997 and did not include current guidelines and information.

An endoscope cleaning process policy was dated 2004.

Many policies were missing, including:

~aseptic practices and surveillance
~identification of infected versus non-infected cases
~housekeeping requirements and procedures
~pre-operative work-up and history and physical examination requirements
~informed consents
~clinical procedures and protocols
~OR safety practices, i.e., alcohol prep, use of electrocautery, etc.
~patient identification
~surgical staff job duties and job descriptions
~OR attire
~flash sterilization
~surgery scheduling
~unique pre-op/OR/recovery personnel policies
~resuscitative techniques (Code Blue policies) and special OR procedures related to resuscitation
~special requirements for surgical "Do Not Resuscitate" status
~care and processing of surgical specimens
~use of reversal agents and special patient recovery requirements

On 07/23/13 and 07/24/13, the DON was asked about specifics within the surgery, anesthesia and central sterile processing policies and procedures. She stated she was not familiar with the policies in those manuals and could not answer any questions.

4. The operating room register did not include the patient's pre and post operative diagnosis and the patient's age. The policy regarding the operating room register was written in 2003 and updated in 2010, but did not require documentation of all the CMS elements.

5. Staff assigned to work in surgery stated endoscopes were cleaned in the procedure room while procedures were in progress. The staff did not clean the scopes in the surgery department decontamination room.

Staff I stated she worked as an OR tech assisting the physician during procedures and also carried out scope cleaning and disinfection between cases. She stated the scopes were cleaned by hand. Staff stated one tub was filled with cidex for disinfection and one tub was filled with water for rinsing. The staff did not say the scopes were first cleaned with an enzymatic cleaner, rinsed and hard dried prior to disinfection with cidex.

In addition to the deficient practice of cleaning/disinfecting scopes in a clean/aseptic environment, the patients and staff were exposed to environmental contamination and potentially to the cidex vapors.

There was no documentation the cidex solution was checked for adequate concentration levels between cases. There was no documentation of scope disinfection (exposure) time for each case. The cidex bottle was not dated when it was opened.

There was no policy and procedure that described this process. Staff I stated the physician told the staff to set up the scope cleaning process in this manner and that it was "OK."

There were no department records of disinfection by scope number and patient ID. There was no documentation of who processed the scopes. None of the clinical records reviewed had this documentation.

The staff stated scope procedures were performed one day a week, twice a month. The operating room registered documented procedures may only be done once a month. Staff I stated when the scopes were cleaned at the end of the day, they were hung in a closet. She stated the scopes were not reprocessed after a period of non-use. She stated there was no policy related to this.

2013 AORN Standards recommend that flexible endoscopes should be reprocessed before use if unused for more than five days.

The hospital had two EGD scopes and two colonoscopes available for use. On 07/23/13, the OR register documented the following procedures had been performed, including procedure times:

July 17, 2013 Start time 7:13 a.m. EGD and Colonoscopy
End time 7:27 a.m.
Total surgery time: 14 minutes

Start time 7:43 a.m. EGD
End time 7:45 a.m.
Total surgery time: 2 minutes

Start time 8:06 a.m. Colonoscopy
End time 8:11 a.m.
Total surgery time: 5 minutes

Start time 8:30 a.m. EGD
End time 8:44 a.m.
Total surgery time: 14 minutes

This indicated one team performed five separate procedures, and concurrently processed the endoscopes, in one hour and thirty one minutes. Staff I stated a single team had performed as many as seven procedures in an hour and a half.

A further review of the operating room log documented the following:

On 06/19/13, an EGD and colonoscopy was performed on a patient in five minutes total surgery time.

On 05/22/13 the following procedures were performed in the following order:

Colonoscopy with biopsy: 15 minutes
EGD: no times listed
Colonoscopy: 46 minutes
EGD/Colonoscopy: 14 minutes
Colonoscopy: 8 minutes
EGD/Colonoscopy: 15 minutes
EGD: 6 minutes

This indicated 9 surgical procedures were performed by one team in three hours and six minutes.

On 05/08/13, a colonoscopy was performed in five minutes.

On 04/24/13, an EGD and colonoscopy was performed in 35 minutes.

On 04/10/13, two colonoscopies and one EGD was performed in under an hour.

On 03/27/13, two colonoscopies were performed in 38 minutes.

On 03/13/13, two EGDs and one colonoscopy were done in 48 minutes.

On 02/13/13, two EGDs and two colonoscopies were done in 53 minutes.

6. Staff I stated there was no procedure room cleaning between cases and the surgery department was not terminally cleaned at the end of the day. No cleaning logs were available. She stated she was the person responsible for cleaning the surgery department. She stated there was no schedule for deep cleaning the entire department.

The files for Staff I had no documentation of formal training and experience as an OR technician, in sterile processing or endoscope processing. There was no documentation of skills competencies and job specific evaluations. The file contained no job descriptions.

7. Staff I was asked if the surger and/or recovery departments had an emergency crash cart. She stated, "No." She stated the staff "borrowed" the crash cart from the emergency room for use in the OR/recovery when procedures were being done. The OR and recovery areas did not have dedicated emergency equipment.

There was no evidence the medical staff had not determined what emergency equipment must be available in these areas.

Unable to assess compliance due to on-going construction/renovation.

Original Findings:

Based on document review and staff interview, it was determined the hospital failed to maintain a current roster with each practitioner's specific surgical privileges available to the surgery department and in the area where surgeries are scheduled.

Findings:

On 07/23/13, the DON was asked to provide this information. None was provided.

Unable to assess compliance due to on-going construction/renovation.

Original Findings:

Based on clinical record review and staff interview, it was determined the hospital failed to ensure a qualified practitioner provided a comprehensive pre- and post anesthesia evaluation.

Findings:

On 07/24/13, anesthesia policies and procedures were reviewed. The anesthesia policies had not been updated and approved.

There was no documentation of the scope of anesthesia services provided by the hospital. There was no policy that addressed pre and post anesthesia evaluations. There was no documentation the hospital no longer provided general anesthesia services.

Clinical records for three endoscopy patients were reviewed. One record indicated an American Society of Anesthesiologist's (ASA) score was documented by the physician prior to the procedure. Two records had no documentation of an ASA score.

The records had no documentation by the physician of the type of anesthesia/sedation planned, any potential problems identified, and the patient's condition prior to induction.

The hospital medical staff had not delegated who could perform a post-anesthesia assessment and what should be included in the assessment.

The clinical records indicated patients were assessed post anesthesia by nursing staff only. The records had no documentation of the presence or absence of post-anesthesia recovery complications. One patient required the administration of a reversal agent. There was no documentation as to why this medication was given.

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital had an annual program evaluation that determined whether the utilization of services was appropriate, established policies were followed and any changes were needed. The hospital did not have an annual program evaluation that documented whether any changes to hospital services or policies were added or revised because of information from an annual program evaluation. This was verified by administration on the afternoon of 09/29/14.