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Based on tour of the facility with facility staff between August 11th through August 13th, 2014; this surveyor observed that the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effect of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients in 7 of 7 smoke compartments. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

Findings Include:
K-17: Corridor walls were not smoke tight;
K-18: Corridor openings were not smoke tight;
K-29: Hazardous areas were not enclosed with hourly rated fire barriers;
K-39: Corridors were not clear, unobstructed, and without combustibles;
K-56: Sprinkler system was not installed per NFPA 13;
K-67: Ventilation system created corridor plenums;
K-104: Smoke barrier penetrations were not sealed; and
K-130: Means of egress contained tripping hazards.

Please refer to the specific K-tags for additional details.

Based on tour of the facility with facility staff between August 11th through August 13th, 2014; this surveyor observed that the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effect of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients in 7 of 7 smoke compartments. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

Findings Include:
K-17: Corridor walls were not smoke tight;
K-18: Corridor openings were not smoke tight;
K-29: Hazardous areas were not enclosed with hourly rated fire barriers;
K-39: Corridors were not clear, unobstructed, and without combustibles;
K-56: Sprinkler system was not installed per NFPA 13;
K-67: Ventilation system created corridor plenums;
K-104: Smoke barrier penetrations were not sealed; and
K-130: Means of egress contained tripping hazards.

Please refer to the specific K-tags for additional details

Based on observation, record review and interview, the facility failed to follow infection control protocols in 2 of 2 observations of patient care (pt. #1, RN F), and in 2 of 2 observation of care areas (nursing unit and procedure room). This failure has the potential to affect all inpatients at the hospital during the survey, 8/11/2014 (7), 8/12/2014 (6), and 8/13/14 (5).

Findings include:

On 8/12/2014 at 2:15 pm a review of the P&P titled, Isolation Categories & Procedures effective 7/28/1995 was completed. The P&P states in part, "Visitors: Visitors should talk with a nurse prior to entering the room and if indicated, be instructed in the appropriate use of personal protective equipment and/or any other special precautions."

On 8/12/2014 at 5:00 pm a review of P&P titled, Sanitation of Hair Care Supplies dated 9/26/2001 was completed. The P&P states in part, "Curlers: Each resident will have her own set of curlers which will be stored in a container with the residents name on it. This container will be stored in the residents room and brought with the resident when they come for hair care."

On 8/13/2014 at 8:51 am a review of P&P titled, Infection Control - Hand Hygiene, effective 12/22/08 was completed. The P&P states in part, "Hand hygiene should occur, but is not limited to: 3) before and after patient encounter 4) before and after any procedures 8) after handling any soiled items."

On 8/13/2014 at 8:07 am a review of the P&P titled, Cleaning of Gastroscope and Colonoscope, effective 4/3/03 was completed. The P&P states in part, "11. Hang scope in the closet in the PAR (Patient Anesthesia Recovery) to dry."

On 8/12/2014 at 8:28 am an observation was made of the utility room on medical surgical unit with MCS E and CPCO A. Two plastic, unlabeled bins with hair rollers inside were observed in the cabinet. MSC E explained the rollers are used on swing bed patients. The rollers had hair on them and MSC E could not say if the rollers are sanitized after each use.

On 8/12/2014 at 8:58 am observation of pt. #1 with MSC E was made. Visitor G was observed entering pt. #1's room without any PPE on (pt #1 is in isolation requiring gown, gloves and mask). At 9:08 am MSC E asked visitor G if G was ever taught to wear PPE when visiting pt. #1. Visitor G responded, "Never", MSC E brought visitor G the necessary PPE and completed some teaching. Visitor G responded, "why this extra stuff now, never had to do this before." At 9:20 am Visitor G was interviewed, Visitor G explained pt. #1 was admitted 9 days prior and although staff have been wearing gowns in the room visitor G was never told to wear PPE.

On 8/12/2014 at 9:10 am RN F was observed removing the IV from pt. #1's hand. RN F held pressure on the site, then disposed of the old dressing and without changing gloves and performing hand hygiene went into the clean supply drawer in pt. #1's room with dirty gloves and gathered supplies to dress the IV site.

On 8/11/2014 at 3:15 pm with CPCO A and OR Mgr. D a observation of room # H136 was made. OR Mgr. D explained colonoscopy procedures are completed in the room, (formerly a pt. room) and clean scopes are stored in the procedure room behind a curtain.

Based on observation, record review, and staff interview the hospital failed to follow proper food storage in 4 of 4 food storage areas (kitchen refrigerator, kitchen freezer, kitchen dry storage and nursing unit kitchenette) and dietary staff failed to wear proper hair coverings in 6 of 7 staff (L, M, N, O, P, and R) observed working in the kitchen. This failure has the potential to affect all inpatients at the hospital during the survey, 8/11/2014 (7), 8/12/2014 (6), and 8/13/14 (5).

Findings include:

Per review on 8/13/2014 at 9:30 am of facility policy titled Unit Refrigerator, policy # 520, dated 2/2008, stated in part, "Discard all foods that are older than time frame below. General shelf life of common items, Milk products- expiration date on package. Discard all perishable foods that do not have a date."

Per review on 8/13/2014 at 9:30 am of facility policy titled Dating Food Products, policy # 164, dated 10/2009, stated in part, "As specified in the USDA model food code, Dietary will label all ready to eat foods... All foods being placed in the freezer will have a date. All foods placed in dry storage will have a date to insure rotation."

Per review on 8/13/2014 at 9:30 am of facility policy titled Dress Code, policy # 175, dated 1/24/2008, stated in part, "6. A hair net is to be worn at all times."

Per observation on 8/12/2014 at 7:50 am of the kitchen was completed with Dietary Manager L, the following was noted; Dry storage area- 1 open bags of pasta with no date. Refrigerator- 4 slices of shortcake, 2 waffles, and 4 pancakes with no label or date. 4 containers of tofu with expiration date of 8/3/14. 18 plastic cups of jello and an opened bag of yellow cheese with no label or date. Freezer- Bag of frozen carrots with metal scoop inside bag, a bag of frozen corn and a bag of frozen beans all left open with no label or date.

Per observation on 8/12/2014 at 11:40 pm of the kitchen, the following was noted; 3 bags of dry cereal with no label or date, and 2 vitamin D milk cartons dated 8/4/2014.

Per observation on 8/12/2014 at 8:00 am the following was noted; Dietary Manager L wearing a visor, Diet Clerk M wearing a hair net with bangs uncovered, and Dietary Aide N wearing a hair net with bangs uncovered.

Per observation on 8/12/2014 at 11:45 am the following was noted; Dietary Aide O wearing a hair net with forehead hairline uncovered, Dietary Aide P wearing a hair covering but hair at nape of neck was uncovered, and Dietary Aide R walking through the kitchen not wearing a hair net.

Per observation on 8/12/2014 at 8:15 am, 2 of 4 garbage cans were uncovered. Meat grinder and Mixer were not being used and were uncovered. Ceiling tiles were noted to be discolored, layer of dust noted on stainless ducts above stove and ceiling vents. Cafe walls under window were noted with yellow-brown discoloration.

The above findings were shared with Dietary Manager L at time of observations.

Per interview with Dietary Manger L on 8/12/2014 at 8:30 am, Dietary Manager stated "All food that is opened should be labeled and dated, the staff will need a reminder."



26390

On 8/12/2014 at 8:05 am with CPCO A and MSC E observations of the nursing unit kitchenette were made. Two loaves of undated bread were observed in the pt. food freezer. Room that stored ice machine was observed to have a 2 foot by 13 inch area of black fuzzy looking material on the ventilation soffite directly above uncovered pt. coffee cups and drinking glasses stored on top of the ice machine. CPCO A was asked what the black substance could be. CPCO A responded, "probably mold or mildew, do not know for sure."

Based on record review, the facility failed to complete documentation of restraint application in 1 of 1 (#8) restraint records, out of a total of 20 patient medical records. This deficiency has the potential to affect all patients requiring the use of physical restraints.
Findings include:
Per review of facility policy on 8/13/2014 at 8:40 am titled Restraints, dated 1/3/2014 stated in part that the use of restraint must be "in accordance with the order of a physician ..." and "the condition of the restrained patient will be continually assessed, monitored and reevaluated at observed intervals not greater than 15 minutes. This will be documented on the restraint flow sheet." Documentation requirements listed within the policy include an interdisciplinary note that includes in part "the reason for the restraints, the patient's response and the condition/behavior required of the patient for release from restraints" as well as a restraint flow sheet to "be used for each incident of restraint."
Per review of pt. #8's medical record on 8/12/2014 at 10:55 am was completed and findings confirmed with RN I. Pt. #8's medical record failed to include a restraint flow sheet in conjunction with the use of restraints in the Emergency Department (ED). Patient #8 presented to the ED with police on 11/2/2013 at 11:40 am with "wrists cuffed behind" patient. Police applied leather restraints on the patient at 12:10 pm. An untimed MD progress note stated "Pt. is being restrained with 4 point restraints." Pt. was discharged from the ED at 3:28 pm.
The medical record did not include a physician's order for restraint application. Documentation within the medical record failed to illustrate patient #8's response to restraint application or the assessment, monitoring and reevaluation of patient #8 at 15 minute intervals. There is no documentation of the time the use of restraints was discontinued.

Based on record review and interview, the facility failed to ensure medical orders are signed, dated and timed by a physician within 24 hours in 6 of 11 (#1, 11, 16-19) records reviewed, out of a total of 20 records.
Findings include:
Review on 8/13/2014 at 9:00 am of policy titled Medical Orders-Written or Verbal, dated 8/21/2012 stated, "All orders for patient treatment/care shall be in writing, and must be timed and dated." Telephone orders given to a Registered Nurse shall be "signed, dated, and timed" by the attending or primary physician "within 24 hours."
The following records were reviewed on 8/12/2014 between 11:20 am and 3:50 pm accompanied by RN I, RN U and RN E to confirm the findings.
Patient #1's medical record contained telephone orders that were not signed, dated or timed by the physician on 8/8/2014 at 3:30 pm, 8/8/2014 at 4:57 pm, 8/6/2014 at 3:03 pm, 8/3/2014 at 4:55 pm, 8/3/2014 at 6:05 pm, 8/3/2014 at 6:09 pm, and 8/3/2014 at 6:00 pm.
Patient #11's medical record contained telephone orders that were not signed, dated or timed by the physician on 8/9/14 at 1:50 am, 8/7/14 at 9:00 am, 7/18/2014 at 12:50 pm, 7/18/2014 at 2:56 pm; and not dated or timed by the physician on 8/4/2014 at 5:05 pm, 7/30/2014 at 9:45 am, 7/31/2014 at 9:15 am, 7/22/2014 at 9:45 am, 7/18/2014 at 7:30 am, 7/14/2014 at 9:00 pm, and 7/15/2014 at 12:50 pm.
Patient #16's medical record contained telephone admission orders that were not signed, dated or timed by the physician on 7/3/2014 at 4:26 pm; and additional telephone orders that were not signed, dated or timed by the physician on 7/8/2014 at 10:45 am.
Patient #17's medical record contained telephone orders that were not signed, dated or timed by the physician on 8/5/2014 at 4:00 pm, 8/6/2014 at 5:18 pm, and 8/8/2014 at 1:20 pm.
Patient #18's medical record contained telephone orders that were not signed, dated or timed by the physician on 8/5/2014 at 1:05 am, 8/5/2014 at 2:35 pm, 8/5/2014 at 3:35 pm, 8/5/2014 at 3:40 pm, 8/7/2014 at 4:35 am, 8/7/2014 at 6:25 am, and 8/8/2014 at 9:13 am.
Patient #19's medical record contained telephone orders that were not authenticated with a date or time by the physician on 5/30/2014 at 6:20 am. Telephone orders written in the medical record on 5/29/14 at 6:45 pm were signed, dated and timed by the physician on 7/7/2014 at 1:00 pm.
During an interview on 8/12/2014 at 11:30 am, RN U stated that the physician should be signing telephone and verbal orders within 24 or 48 hours.

Based on observation, record review, and interview, the facility failed to ensure medical records are secure from unauthorized access in 3 of 3 areas (HIM Department, Imaging Film Storage and nursing unit) where medical records are stored. This deficiency potentially affects all patients receiving services at this facility.

Findings include:

Per review on 8/13/2014 at 9:25 am of facility policy titled Confidential Information, policy #180, dated 6/2012 in part stated "only authorized personnel are to have access to medical information..." Per HIM Director Q on 8/13/14 at 9:25 am, the facility does not have a policy that addresses record security during cleaning in the HIM department.

On 8/11/14 at 2:10 pm during an observation of the Radiology Department accompanied by Imaging Manager S, noted an open shelving unit containing radiology films.

Per interview with Imaging Manager S, at the time of discovery, stated the Radiology film storage area is locked when Imagery staff are done for the day and the door is unlocked when staff arrive in the morning. The room the radiology films are stored is also used to store equipment used throughout the day along with a supply of linens for the department. When asked if housekeeping staff clean department when staff is present, Imaging Manager S stated that staff is not present during cleaning. Imaging Manager S also stated that the laundry staff (contracted service) comes into the unattended storage room to deliver linen daily and that all staff would have access to the storage room.

On 8/12/14 at 11:30 am during an observation of the HIM department accompanied by HIM Director Q, noted an open shelving unit containing medical records. Per interview with HIM Director Q, at the time of discovery, Q stated the HIM department is locked when HIM staff are not present. When asked if housekeeping staff clean department during HIM business hours, HIM Director Q stated housekeeping staff clean after hours and have a key to the area.

Per interview with Laundry Manager K on 8/12/14 at 9:00 am, Housekeeper W stated the medical records storage areas are cleaned at 4:30 am by housekeeping staff before HIM staff arrives for the day.


26390

On 8/12/2014 at 8:35 am observation of the nursing unit was made with CPCO A and MSC E. Outside isolation rooms #126 and #132 metal charting stations hang on the wall, both contained rounding documentation, Intake and output records and IV infusion records. All documentation contained pt. information. CPCO A and MSC E agreed the wall stations are not secure.

Based on record review and interview, the hospital failed to ensure an effective quality assurance program collected data for all services (organ procurement, laundry, housekeeping, biohazards) and compiled aggregate data of adverse occurrences to identify high risk and/or problem-prone trends and patterns. This occurred in 3 of 3 quality assurance interviews conducted (C, K, and W), and has the potential to affect all patients receiving services at this hospital.

Findings include:

Per review of 2014-2015 Performance Improvement Plan on 8/13/14 at 9:00 am, revealed under "SCOPE: Performance improvement at Rusk Co. Memorial Hospital (RCMH) requires skills, expertise, and support of all leaders, employees, physicians, and customers. The scope of the performance improvement includes all services provided by RCMH."

Per review of 2014-2015 Performance Improvement Plan on 8/13/14 at 9:00 am, revealed under "E. Department Managers: RCMH Department Managers are responsible for performance improvement within their departments and lead participation in interdisciplinary performance improvement initiatives with their area. Department Managers report specific quality indicators to the Performance Improvement Committee on a scheduled basis."

Per interview with Quality Improvement Manager (QIM) C on 8/12/14 at 1:35 pm, QIM C stated "Not all departments are feeding projects or results of the projects to the QIM. Department Managers complete Plan Do Check Act (PDCA) but data is not tracked, trended or analyzed to complete the deeper dive of data."

Per interview with QIM C on 8/12/14 at 10:35 am, QIM C stated that the Organ Procurement department of the hospital is not involved in the QAPI (Quality Assurance Performance Improvement) program, QIM C stated currently the facility is just making sure staff are being trained to identify potential donors and make the initial contact with the contracted service.

Per interview with Laundry Manger K on 8/12/14 at 9:00 am, Laundry Manger K stated that there is no current project for QAPI at this time for the hospital.

Per interview with Housekeeper W on 8/12/14 at 9:15 am, Housekeeper stated that the housekeeping department has no current projects on the hospital side for QAPI at this time.

Requested a list of contracted services on 8/11/14 at 12:45 from Chief Executive officer (CEO) B at entrance conference. A second request for a list of contracted services was made on 8/12/14 at 4:30 pm at the end of day meeting to Chief Patient Care Officer (CPCO) A. CPCO A stated that "there may not be an inclusive list of the contracted services". On 8/12/14 at 7:30 am, CPCO A did provide a list of contracted services. Stericycle, which is a contracted service, was not included as a hospital service on the list of contracted services provided.

Based on record review and interview, the hospital failed to ensure the Quality Improvement Council reviewed Performance Improvement Projects with each hospital department per Performance Improvement Plan in 3 of 15 hospital departments (Imaging, Speech Therapy and Dietary). This could potential affect all patients receiving services at this hospital.

Findings include:

Per review of 2014-2015 Performance Improvement Plan on 8/13/14 at 9:00 am, revealed under "SCOPE: Performance improvement at Rusk Co. Memorial Hospital (RCMH) requires skills, expertise, and support of all leaders, employees, physicians, and customers. The scope of the performance improvement includes all services provided by RCMH."

Per review of 2014-2015 Performance Improvement Plan on 8/13/14 at 9:00 am, revealed under "E. Department Managers: RCMH Department Managers are responsible for performance improvement within their departments and lead participation in interdisciplinary performance improvement initiatives with their area. Department Managers report specific quality indicators to the Performance Improvement Committee on a scheduled basis."

Per interview with Quality Improvement Manager (QIM) C on 8/12/14 at 1:35 pm, QIM C stated "Not all departments are feeding projects or results of the projects to the QIM. Hospital Department Managers complete Plan Do Check Act (PDCA) but data is not tracked, trended or analyzed to complete the deeper dive of data."

Per interview with QIM C on 8/12/14 at 1:35 pm, QIM C stated "the Quality Council meets monthly."

Per email received from CEO B on 8/13/14 at 7:25 pm stated in part, "The Quality Committee reviews data such as core measures bimonthly due to very low volumes and lack of critical mass to make a statistically sound evaluations on a number of indicators. In some areas, only quarterly data is available for assessment. All departments are scheduled for required reports, at a minimum once annually."

Per review of "2014 schedule for presenting quality projects at Quality Improvement Council on 8/13/14 at 9:00 am: January- blank. February- No meeting, March- blank, April- No meeting, May- Imaging, June- No meeting, July- Laboratory (deferred due to vacation). August- No meeting, September- Speech therapy, October- No meeting, November- Dietician, December- No meeting. Only 3 departments of the hospital presented at Quality Improvement Council per the 2014 schedule. QIM C confirmed that the schedule did not include all departments of the hospital.