HospitalInspections.org

Based on document review and interview, it was determined that the Hospital's governing body failed to ensure that the medical staff is accountable to review the ongoing quality assessment and improvement program ensuring the quality of care provided to patients.

Findings include:

1. On 07/28/2022, the Hospital's document titled, "Amended and Restated Bylaws" dated 12/19/2019 was reviewed and included, "...Section 7: ...A. The Board shall establish, maintain, support and exercise oversight of an ongoing Quality Assessment and Improvement Program that includes specific and effective review, evaluation and monitoring mechanisms to assess ...and improve the overall quality and efficiency of patient care in the Hospital ..."

2. On 07/28/2022 at 9:00 AM, the Hospital's document titled, "Medical Executive Committee Meeting Minutes" from 07/2021 to 07/2022 was reviewed included the following:

-July 2021 Medical Executive Committee minutes: Issues Discussed: COVID 19 Update, Administrative Financial Report, Medical Care Growth Update, Intensivist Program, Resignations, Change of Status, Physician Performance, Department Committee Reports - Medicine ...Pathology, Pediatrics, Psychiatry, ...Treasures Report, Credentials Committee, Vice-President's Report: on clinical excellence, quality and safety, Chief Medical Officer's Report, Patient Care Services Report.

- The Medical Executive Committee minutes lacked the Vice-President's Report on clinical excellence, quality and safety and Patient Care Services Report for the following months: August 2021, September 2021, October 2021, November 2021, February 2022, April 2022, and June 2022.

3. On 07/27/2022 at 1:30 PM, the Director of Clinical Excellence (E #10) was interviewed. E #10 stated that she leads the quality assessment and performance improvement meetings that are held on a monthly basis and the score card was reviewed by the president and chief nurse officer. E #10 stated that the reports are sent to the medical executive committee meetings.

4. On 07/27/2022 at 2:30 PM, the Chief Nursing Officer (E #22) was interviewed. E #22 stated that the quality reports must be discussed at the medical executive committee meetings for enhancement of quality of care and patient safety.

5. On 07/28/2022 at 12:30 PM, the Interim-President/CEO (E #23) was interviewed. E #23 stated, "We have to put a structure to the process and definitely include the monthly quality assessment and performance improvement reports both in the medical executive committee and governing body meetings."

6. On 07/28/2022 at 1:00 PM, the Chief Medical Officer (MD #4) was interviewed. MD #4 stated that he plans to reconstruct the agenda and the minutes in a manner that the quality and patient safety reports are included in the medical executive committee meetings.

Based on observation, document review, and interview, it was determined that for 3 of 3 patients (Pt.#14-Pt.#16) observed receiving intravenous (IV) therapy, the Hospital failed to ensure that the registered nurse supervised the care provided by ensuring that IV tubing was labeled with the date to be changed.

Findings include:

1. During an observational tour of the East 5- Medical Surgical Unit on 7/26/22, at approximately between 10:35 AM-10:50 AM, the following was observed:
-At approximately 10:37 AM, Pt. #14 was receiving an antifungal medication intravenously (IV), the tubing for the medication was not labeled with a date and time to be changed.
-At approximately 10:40 AM, in the room of Pt.#15, there was an empty bag of 0.9% normal saline hanging on the IV pole, the tubing for the medication was not labeled with a date and time to be changed.
-At approximately 10:45 AM, Pt.#16 was receiving Cefepime (antibiotic) 1gm (gram) in 100 ml(milliliters) normal saline IV , the tubing for the medication was not labeled with a date and time to be changed.

2. The Hospital's policy titled, "Vascular Access Devices Insertion and Maintenance" (revised 11/21) was reviewed and required, "V1. Tubing Management & Cap Changes... 3. All continuous administration sets, should be changed and labeled every 96 hours... 5. Intermittent administration sets that are disconnected from the primary set between infusions should be capped with a sterile cap when not in use and changed every 24 hours..."

3. An interview was conducted with the Manager of East 5 -Medical Surgical Unit (E#20) on 7/26/22, at approximately 10:48 AM. E#20 stated that IV tubing should be labeled to indicate the day it needs to be changed.

A. Based on document review, observation, and interview, it was determined that the Hospital failed to manage dietary dining services by ensuring that foods were labeled with an opened or use by date. This has the potential to affect the 169 patients receiving oral diets on 7/27/2022.

1. On 7/27/2022, the Hospital's policy titled, "Food and Supply Storage" (date revised 1/22) was reviewed and required, "...Cover, label and date unused portions and open packages... "

2. On 7/27/2022 at 10:30 AM, a tour of the Dietary Department was conducted and the following was observed in the walk-in refrigerators:
-one bag of opened blue cheese, undated
-one bin of apples, undated
-one box of open broccoli, undated

3. On 7/27/2022 at 10:35 AM, an interview was conducted with the System Chef (E #16). E #16 stated that the bag of blue cheese should have been dated.

B. Based on document review, observation, and interview, it was determined that the Hospital failed to manage daily dietary services by not ensuring that foods which had expired were discarded. This has the potential to affect the 169 patients receiving oral diets on 7/27/2022.

Findings include:

1. The Hospital's policy titled, "Food and Supply Storage" (date revised 1/22) was reviewed and required, "...Foods past the use by, sell by, best by or enjoy by date should be discarded..."

2. On 7/27/2022 between 10:00 AM and 11:00 AM, a tour of the Dietary Department was conducted and the following was observed:

-At 10:15 AM, the walk-in freezer contained 1 bin of frozen turkey with expiration date of 4/21/2022, 1 bin of frozen turkey with expiration date 6/22/2022, and 1 bin of frozen turkey with expiration date of 7/20/2022.

-At 10:20 AM, the walk-in freezer contained 6 bags of curly fries with an expiration date of 4/2022.

-At 10:40 AM, the reach-in freezer contained a bin of approximately 10 ice cream containers with expiration date of 4/24/2021.

3. On 7/27/2022 at 10:45 AM, an interview was conducted with the System Chef (E #16). E #16 stated the trays of expired frozen turkey should have been thrown out. E #16 stated that he was not sure why the curly fries had the date of 4/2022.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted July 26 - 28, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on document review, observation, and interview, it was determined, that the Hospital failed to ensure the Operating Area (OR) was maintained in such a manner that the safety, health, and well-being of patient was assured, potentially affecting the health of between approximately 250 to 325 surgical cases per month in the OR.

Findings include:

1. On 7/28/2022, the Hospital's policy titled, "...[The Hospital] utilizes a Computerized Maintenance Management System (CMMS) to assist with the reporting, assigning and tracking of any requests for services submitted to the Plant Operations Department."

2. On 7/27/2022 at 8:00 AM, an observational tour was conducted in the OR. The following was found:

- In the corridor, opposite of OR suite #4, there was an approximately 4 inches by 2 inches hole in the lower wall.

- In OR suite #2, there was an approximately 5 inches by 5 inches gap in the upper wall, but the gap was not covered and included loose wiring.

- In the corridor, outside of OR suite #2, there was an approximately 10 inches tear/separation in the floor.

- In the Cystoscopy Room, there was an approximately 3 inches by 4 inches broken/missing window on the X-ray box and the video table surface contained approximately 1 inch by 5 inches or rust.

3. On 7/27/2022 at 8:45 AM, in operating room #3, the following was observed:
-Tape and tap residue on the operating table padded arm board;
-Operating table padded arm board in disrepair with fabric tears; and
-Operating table pads in disrepair with fabric tears.

4. On 7/27/2022 at 8:50 AM and on 7/28/2022 at 9:45 AM, interviews were conducted with the Director of Perioperative Services (E #14). E #14 stated that:

- The hole in the wall outside OR suite #4 must have recently happened and has not been reported to Plant Operations

- The clock that is missing in OR suite #2, was reported to Plant Operations, but the gap in the wall has not been covered.

- The floor tear outside of OR room #2 has not been reported to Plant Operations.

- The broken X-ray window and rusty video table in the Cystocopy Room have not been reported to Plant Operations.

5. On 7/27/2022 at approximately 9:00 AM, an interview was conducted with the Operating Room Nurse Manager (E #17). E #17 stated that tape should not be placed on the operating room equipment. E #17 stated that the pads should be replaced when they have tears.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted July 26 - 28, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on document review and interview, it was determined that for 1 of 1 diagnostic machine in the Laboratory Department, the Hospital failed to ensure that the daily maintenance checks were conducted to ensure the diagnostic machine was performing properly. This has the potential to affect all patients requiring diagnostic testing in the Hospital.

Findings include:

1. The Hospital's document titled, "8100 Daily Maintenance" (undated) was reviewed and required, "1. Bring the system to standby and make sure the line is clear of tubes ... 9. Perform Data clean up in control unit ... 10. Clean and check all modules, remove dust and any spills ... 14. Perform leak check ... confirm there is no dripping ... If there are drips manually make sure all the pipette fittings are not loose and repeat the leak check ... 15. Mark in maintenance book that it was done and initial.. THESE STEPS NEED TO OCCUR DAILY TO MAKE SURE THE 8100 IS PERFORMING PROPERLY."

3. The Hospital's "Cobas 8100 Automated Workflow Series Maintenance Logs" from 11/1/21 through 7/26/22, were reviewed and indicated that the daily maintenance checks were not being conductedas required, on the following dates: 11/14/21, 11/22/21, 12/3/21, 12/4/21, 12/6/21, 12/7/21, 12/11/21, 12/12/21, 12/13/21, 12/15/21, 12/17/21, 12/18/21, 12/21/21, 12/23/21, 12/24/21, 12/30/21, 1/7/22, 1/9/22, 1/13/22, 1/16/22, 1/20/22, 1/24/22, 2/2/22, 2/3/22, 2/12/22, 4/7/22, 4/14/22, 6/3/22, 6/11/22, 6/21/22, 6/22/22, and 7/9/22.

4. On 7/27/22 at approximately 1:25 PM, an interview was conducted with the Supervisor of Laboratory Department (E#21). E#21 stated that the Laboratory Technicians are responsible for running the daily maintenance checks of the Cobas 8100 (machine used to run diagnostic tests on patient specimens). E#21 stated that there have not been any issues with the Cobas 8100, if there is problem with the machine there is an alarm system in place to alert staff. E#21 stated that she will start auditing the daily logs to ensure the daily checks are being conducted daily.

A. Based on observation, document review and interview, it was determined that for 4 of 7 patients (Pt #2, Pt #4, Pt #13 and Pt #14) reviewed for infection control practices with isolation, the Hospital failed to ensure methods for prevention and controlling the transmission of infection were implemented for patients in isolation.

Findings include:

1. On 7/26/2022 at 9:30 AM, the Hospital's policy titled, "Contact Precautions" (reviewed 12/4/2019) was reviewed and required, "...Wear gloves when entering the room...In addition to wearing gloves, wear a gown (a clean, nonsterile gown is adequate) when entering the room..."

2. On 7/26/2022 at 9:45 AM, the Hospital's policy titled, "Special Respiratory and Contact Precautions" (reviewed date 1/1/2022) was reviewed and required, "The purpose of this document is to appropriately isolate a COVID positive patient...Patient door is kept closed at all times..."

3. On 7/26/2022 at 10:00 AM, an observational tour was conducted on the West 4 (Medical Unit) and East 5 (Medical Unit) and the following observations were noted:
- Room 402 - Pt #2 was in contact isolation for pseudomonas (infection) in the urine. Z1 (visitor) was observed in Pt #2's room with no gown or gloves and mask below his nose. E #5 (Patient Care Technician) was observed entering the room without any gown or gloves on.
-Room 415 - Pt #4 was in special respiratory and contact precautions for positive COVID. Pt #4's door was open (should have been closed).
-Room 579 - Pt #24 was in special respiratory and contact precautions for positive COVID. Pt #13's door was open (should have been closed).
-Room 581 - Pt #14 was in contact isolation for C - difficile (a germ infection that causes severe diarrhea). Nursing staff observed in Pt #14's room without wearing any gowns or gloves.

4. On 7/26/2022 at 10:10 AM, an interview was conducted with the Manager (E #4). E #4 stated that employees and staff should wear a gown and gloves in a patient's room for contact isolation. E #4 stated that the door should be closed all the time for a COVID positive patient.






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B. Based on document review, observation, and interview, it was determined, for 1 of 2 hydrocollators (machine used to heat hot packs, used in physical therapy), on the 2 Rehabilitation Units, the Hospital failed to ensure methods for preventing and controlling the transmission of infections were included in the infection prevention and control program, including cleaning hydrocollators, potentially affecting the health of 13 patients on the second floor Rehabilitation Unit.

Findings include:

1. On 7/27/2022, the Hydrocollator Manufacturer's User Manual was reviewed. The User Manual included, "Maintenance... 2. Clean regularly for optimal service and operation... Cleaning Tips: 1. The interior of the unit should be cleaned, at least every two weeks..."

2. On 7/27/2022, the "Comprehensive Rehab Cleaning List" for July 2022, for both units was reviewed. The lists required monthly cleaning for the hydrocollators, not every 2 weeks, and indicated that neither hydrocollators had been checked in July 2022.

3. On 7/26/2022 at 1:50 PM, an observational tour was conducted on the Rehabilitation Units. There were 2 units, one on the first floor and another on the second floor. Each unit had an exercise/treatment room and a hydrocollator. Thelid of the hydrocollator located on the second floor, was lifted and a thick brown substance was seen on the upper inside rim. A dry gauze was able to remove most of the brown substance.

4. On 7/26/2022 at 1:55 PM, an interview was conducted with the In-patient Therapy Manager (E #15). E #15 saw the thick brown material collected on the gauze and stated that the hydrocollator had not been cleaned in July.

Based on document review, observation, and interview, it was determined that for 1 of 2 (MD #3) Physician/Residents reviewed for medication preparation and storage, the Facility failed to ensure adherence to infection prevention and control policies and procedures by hospital personnel by failing to ensure that rubber diaphragms medication vials were cleansed and that medication syringes were stored properly.

Findings include:

1. On 7/27/2022, the Hospital's policy titled, "Injectable Medication Vials" dated 5/1/2019, was reviewed. The policy required, "...1. Utilize strict aseptic technique when manipulating a multidose vial wash hands and use alcohol swab to prepare vial, i.e., cleanse the rubber diaphragm of the multidose vial with alcohol before inserting a device into the vial..."

2. On 7/27/2022 at approximately 9:44 AM, in operating room #3, a Surgical Resident (MD #3), using a needle and a syringe withdrew 1% Lidocaine (local anesthesia) and 0.25% Bupivicane (local anesthesia), from two separate vials, without cleansing the rubber diaphragm with alcohol and then placed the medication syringes in his pocket.

3. On 7/27/2022 at approximately 9:55 AM, an interview was conducted with the Director of Perioperative Services (E #14). E #14 stated that the rubber diaphragm on medication vials must be cleansed before needle insertion and syringes should not be kept in the pocket.

Based on document review, observation, and interview, it was determined that for 1 of 1 patient (Pt. #19) reviewed for surgical procedure time out, it was determined that the Hospital failed to ensure that policies governing surgical care were implemented to assure the achievement and maintenance of high standards of medical practice and patient care, by ensuring a time out was performed prior to starting a surgical procedure.

Findings include:

1. On 7/27/2022, the Hospital's policy titled "Universal Protocol Policy Site Verification-Time Out" dated 5/20/2019, was reviewed. The policy required, "...Verification of the correct person, correct site, and correct procedure occurs at the following times: At the time the procedure is scheduled...Anytime the responsibility for care of the patient is transferred to another person (including the anesthesia providers at the time of, and during , the procedure)...C. Time-out takes place in the procedure room, after the patient is prepped and draped, immediately prior to starting the procedure for final verification. It must involve the entire procedure team who will be participating in the procedure at its inception..."

2. On 7/28/2022, Pt. #19's clinical record was reviewed. On 7/27/2022, Pt. #19 had a bilateral feet removal of hardware under monitored anesthesia care (local anesthesia together with sedation and analgesia).

3. On 7/27/2022 at approximately 9:35 AM, Pt. #19 was brought into operating room #3, and placed under monitored anesthesia care, by the Anesthesiologist (MD #2). At 9:47 AM, the Surgeon (MD #1) injected medication into Pt. #19's right great toe area (operative site). The time out was not initiated prior to sedation or injection to Pt. #19's operative site.

4. On 7/27/2022 at approximately 9:48 AM, an interview was conducted with the Operating Room Nurse Manager (E #17). E #17 stated that the time out must be completed before the procedure is started.