HospitalInspections.org

Based on credential files review, review of hospital contracts, review of the podiatry log and staff interview, the facility failed to ensure that all services provided in the facility were provided by medically appointed staff. The finding includes:

A review of the podiatry log was conducted on 8/9/17. The log identified that 87 patients received podiatry services by Podiatrist #1 during the period of time from 1/26/15 to 1/4/17. Review of hospital contracts on 8/9/17 indicated that on 11/21/14, the hospital was added to the podiatry contract of a sister facility for podiatry services to be provided to the hospital by Podiatrist #1. Review of credential files on 8/9/17 noted that Podiatrist #1's privileges and appointment to medical staff were not approved by the Governing Body until 1/5/17and therefore performed services at the facility without appointment and/or the granting of privileges. Review of Podiatrist #1's hospital contract and privilege documentation with the Chief Operating Officer on 8/9/17 at 4:30 PM indicated that prior privileging documentation for Podiatrist #1 could not be provided. The Governing Body Bylaws identified a responsibility to develop a mechanism to review credentials and delineate individual clinical privileges.
The Medical Staff Bylaws identified that the credentialing and privileging committee shall review applications and if approved, the application shall be submitted by the Medical Executive Committee to the Governing Body for further consideration and granting of medical staff membership or rejection thereof. The Bylaws further noted that each member shall have delineated clinical privileges that allow the provision of patient care services independently within the scope of the privileges granted.

Based on review of hospital documentation, review of governing body bylaws, and interview, the hospital failed to document that there was an effective, ongoing, hospital-wide quality program. The findings include:

Review of the Bylaws of the Governing Body (GB) identified that the governing body is comprised of persons to whom the Chief Operating Officer (CEO) has delegated the authority and responsibility for duties in his/her respective area(s) of administration, technical and clinical expertise. The bylaws identified that the GB includes a Quality Improvement Committee to ensure a planned, system-wide approach to improving quality and safety, focusing on outcomes of treatment, care and services. Review of the hospital organizational chart identified that 7 subcommittees, to include the IPC (infection prevention committee), reported to the MEC (Medical Executive Committee) who then reported to the GB. MEC meeting minutes dated 1/2015 to 7/2017 were reviewed on 8/9/17. The review identified that the MEC meeting minutes lacked documentation related to subcommittee data collection and analysis. Interview with the Director of Quality on 8/9/17 at 3:30 PM indicated that the MEC committee was the quality committee. Review of hospital documentation and interview with the Directory of Quality and the CEO on 8/9/17 identified that the subcommittees collect and analyze their own data which was discussed during the MEC was not documented and therefore, not reported up to the governing body. In addition, further review of the hospital's quality projects lacked documentation for review of contracted services to include podiatry.

Based on observation, review of hospital documentation, and interview for 3 of 3 inpatient units, the hospital failed to ensure that the physical environment was designed and constructed to maintain the safety of patients with suicidal tendencies and/or tendencies to cause harm to themselves or others and/or failed to implement immediate safety interventions to correct the environmental safety issues which resulted in immediate jeopardy. The findings include the following:

On 08/09/17 at 10:50 AM and at various times throughout the day, the surveyor, accompanied by the Chief Executive Officer, observed that patient bathrooms on the fifth (5th), sixth (6th), and seventh (7th) floors of the hospital contained multiple ligature points which included toilet tissue dispensers, plastic single pump soap dispensers, vanity sink water control valves, shower and bathroom grab bars, fire alarm audio/visual devices, surface mounted electrical wiring conduit, and wire molding. Further observations identified that non-tamper resistant screws were utilizing throughout the patient care units. Additionally, the surveyor observed in patient rooms on the fifth (5th), sixth (6th), and seventh (7th) floors of the hospital identified surface mounted electrical wiring conduit, wire molding, light switches and HVAC controls that provide ligature access points by the design of their installation. Documentation ("Suicide Risk Assessment Tool for Inpatient Unit") provided to the surveyor from the hospital staff dated 8/2/17, 10/12/16, 10/17/16, and 09/13/16 referenced the above documented risks and an information matrix that classified the scope and severity of the problematic areas as 1 (minimal risk of injury) to 5 (significant risk with history of injury). Although the hospital conducted environmental rounds and had documentation of identified environmental risks, the risks exhisted over a period of time. Interviews with the Facility Maintenance Staff conducted on 08/09/17 confirmed that staff use this document as a guideline on conducting the priority repairs as they are deemed hazardous to the patients.

The hospital submitted an action plan on 8/8/17 to address ligature points which included that the hospital planned to purchase supplies on 8/10/17 and have contracted with a vendor to begin the work on 8/14/17. The work is expected to be completed within 6 weeks. During this time, staffing will be adjusted as needed and ongoing clinical risk assessments of patients and acuity on the unit. Bathrooms will remain locked and staff will facilitate bathroom access and use. Suicide assessment risks will be conducted on each patient and will include whether the patient has independent use of the bathroom. Thermostat ligature risks in the bedroom will be addressed by removing the thermostats and replacing with a flush switch plate and secured with safety screws until an appropriate solution is chosen. Knockout boxes around the light switch will have a customized control to create a slope top. Clinical rounds will continue to be conducted every 15 minutes.

Based on observation, review of hospital documentation, review of policy and procedures, and interviews for 3 of 3 inpatient units (floors 5, 6, and 7) using glucometers, the hospital failed to ensure that a single use glucometer device was not used on multiple patients and/or failed to ensure that staff followed manufacturer guidelines on cleaning and disinfecting the glucometer after use and/or failed to ensure that staff did not perform control testing with out of date control solution solutions which resulted in immediate jeopardy. The findings include:

1. Observation during tour of the medication rooms on the fifth, sixth, and seventh floor inpatient units identified one glucose meter on each of the three units. Review of hospital documentation identified that there are a total of 13 patients from the three units that required finger stick blood glucose monitoring two to four times per day. Observation identified that there was only one glucometer on each the unit. Interview with LPN #2 on 8/8/17 at 1:17pm from the 5th floor identified that she cleans the glucose meter with an alcohol prep pad (70%) between patient use. Interview with LPN # 3 from the 6th floor 6 on 8/8/17 at 11am identified that she cleans the glucose meter with either alcohol or a Super Sani-Cloth after each use and that there is only one glucose meter on the unit for all the patients. Interview with LPN #1 from the 7th floor on 8/8/17 at 1:15pm identified that the glucose meter is cleaned with a Super Sani-Cloth every night whether the meter is used or not. Interview with the Infection Control Practitioner on 8/8/17 at 3:30pm identified that she was not sure how long the hospital had been using the current blood glucose meter, was not aware that the devices were for single patient use and was not aware that staff was not following proper cleaning or testing procedures.

Review of the manufacture guidelines for the blood glucose meter identified that the monitoring system is intended to be used by a single person and should not be shared and all parts of the kit are considered biohazardous and can potentially transmit infectious diseases from bloodborne pathogens, even after you have performed cleaning and disinfecting. Super Sani-Cloth has been approved for cleaning and disinfecting the meter and other cleaning or disinfecting solutions could result in damage to the meter.


2. Observation during tour of the medication room on the seventh floor on 8/8/17 at 1:15pm identified the control solution for the blood glucose meter labelled as Control 2 with a discard date of 4/19/17. Control 1 solution lacked a discard date and only had a manufacture expiration date although the product was opened and had been used for a few weeks according to the control testing log. Interview with LPN #1 on 8/8/17 at 1:15pm could not explain the expiration dates or lack of expiration date on the control solutions. Review of the manufacture guidelines for the blood glucose meter identified in part, that performing a control test lets you know the meter and test strips are working properly and that the control solution must be discarded 3 months from the date the control solution bottle was opened (discard date) or the "use by" date on the bottle label, whichever comes first.


The hospital submitted an immediate action plan to include purchasing additional glucometer units, one for each patient. Each glucometer will have the patient's name and each unit will train nursing staff to ensure that staff is familiar with the fact that each patient will have his/her own glucometer for use immediately and staff will follow manufacturers guidelines on proper cleaning of the device. Training will be verified by a nurse signature. On 8/9/17 during an onsite visit, the facility implemented their action plan as submitted.

Based on medical record review, review of hospital contracts, review of hospital documentation and interviews, the hospital failed to ensure that infection control practices performed by contracted staff were compliant with standards of care to prevent the potential for the transmission of infection. The finding includes:

Patient #14's was admitted to the hospital on 2/22/17 and diagnoses included schizophrenia, post traumatic stress disorder, diabetes, and hypertension, pacermaker/defibrillator. Consult documentation identified that Patient #14 received podiatry services by Podiatrist #1 on 3/2/17 and 5/27/17, was diagnosed with a fungal infection on 5/27/17 and depth shoes was the recommended treatment. Review of the podiatry log noted that 105 patients were provided podiatric services by Podiatrist #1 during the period of time from 1/26/15 to 6/26/17. The current contract with Podiatrist #1 dated 8/26/15 indicated, in part, that services would include shaving or cutting of corns and calluses as well as nail thinning and debridement. The contract lacked documentation for the provision and/or disinfection of podiatric instrumentation. A letter from Podiatrist #1 to the Hospital dated 11/21/16 indicated that instruments used at the Hospital were returned to his office, cleaned and soaked in Glutaraldehyde solution overnight. The letter did not indicate how the instruments were disinfected between patient uses. A subsequent letter from Podiatrist #1 to the Hospital dated 6/29/17 noted, in part, that instruments were wiped down with a Sani Cloth germicidal wipe after use and soaked in a disinfectant from the hospital (unnamed disinfectant). Interview with the ICP (Infection Control Practitioner) on 8/8/17 at 3:30 PM indicated that she was not aware of the Podiatrist's disinfection practices before June 2017 and that she had just started the position of ICP in December of 2016. Review of the hospital policy and procedure manual index on 8/9/17 noted a lack of podiatry and or disinfection policies for podiatric instrumentation. The ICP job description identified a duty in part, to monitor patient care activities which may constitute a risk of originating or transmitting infections and review sterilization and disinfection methods practiced in all areas of the facility. The hospital terminated the contract with Podiatrist #1 on 6/30/17 and the hospital is in the process of contracting with another podiatrist.



Based on observation and interview for 1 of 3 nourishment refrigerators (6th floor) in the medication room and/or for 1 of 3 refrigerators in the dining pantry (6th floor) and/or the stoves (5th and 6th floors), the hospital failed to ensure that the refrigerators and stoves were clean and maintained. The finding includes:

1. Observation during tour of the medication room on the 6th floor on 8/8/17 at 11:50am identified a nourishment refrigeration contained patient juices. The refrigerator contained a lock box and when opened contained an orange colored solution with white chunks floating in the solution. Interview with the QI Nurse at that time failed to identify the solution and attributed it to juice that may have leaked in the box.

2. Observation of the refrigerator in the dining pantry on the 6th floor on 8/8/17 at 11:45am identified that the inside of the door was cracked and the shelves were stained with brown, sticky food. Interview with the Nurse Manager Nurse at that time identified that housekeeping staff routinely clean the kitchen and could not explain why the refrigerator was in disrepair.

3. Observations on 8/8/17 of the 5th and 6th floor stoves in the dining pantry identified a buildup of food and debris on and in the oven or stove drawer. Review of the Unit Cleaning Log dated July and August 2017 identified inconsistent documentation for daily cleaning to reflect that regular cleaning had been completed.


Based on observation, review of hospital documentation, and interviews for 1 of 3 day rooms (6th floor) and for 1 of 3 seclusion room (5th floor), the hospital failed to maintain a clean and comfortable environment. The findings include:

Observation during tour of the 6th floor on 8/8/17 at 10am with the QI Nurse and DNS #2 identified the radiator in the patient day room had a thick coating of dust and debris. Observation during tour on the 5th floor on 8/8/17 with DNS #2 identified a dust buildup on the radiator and floor in the seclusion room. Interviews with the QI Nurse and DNS #2 identified that the housekeeping staff have a cleaning schedule. Review of the Unit Cleaning Logs for the 5th and 6th floors dated July and August 2017 identified inconsistent documentation for daily cleaning to reflect that regular cleaning had been completed.