HospitalInspections.org

C 0914 - Preventive Maintenance
Licensure Reference Number
9-006.14B


Based on observation, interview and record review, the facility failed to maintain a complete inventory of all facility equipment used in the care of patients and failed to provide ongoing preventive maintenance in accordance with manufacturer specifications for 5 of 31 sampled pieces of medical equipment.

Findings include:

Interview with Chief Executive Officer (CEO) on 6/24/2021 at 9:00 am revealed no inventory list was maintained by facility staff, as the facility contracted with a vendor who was responsible for logging all equipment and any information needed would be provided by "name of service technician", who comes onsite to log new equipment and provide preventive maintenance. Facility did not have any department specific equipment inventory to track preventive maintenance.

A. Surgery - Leak Tester #576
This piece of equipment was used for leak testing of endoscopes and colonoscopes (for viewing upper and lower gastrointestinal tracts). Vendor's Scheduled Work Orders dated April 2021 for #576 Olympus MU-1 was last inspected on 12/29/2003.

B. Surgery - Olympus Reprocessor ** (not numbered)
This piece of equipment was used for cleaning and disinfecting endoscopes. No bio-med sticker located. Information available regarding last safety inspection was provided that vendor was performing preventive maintenance, the last date was December 2020. Facility did not have piece of equipment listed in master log book.

C. Respiratory Therapy - Philips Trilogy EV300 Ventilator ** (not numbered)
This piece of equipment was used for blowing air or air with extra oxygen into airways and lungs. No bio-med sticker located and no information available regarding last safety inspection in the master log book.

D. Respiratory Therapy - Philips Trilogy 202 Ventilator ** (not numbered)
This piece of equipment was used for blowing air or air with extra oxygen into airways and lungs. No bio-med sticker located and no information available regarding last safety inspection in the master log book.

E. Outpatient Services - Procedure Light Source ** (not numbered)
This piece of equipment was used for light source for procedures. No bio-med sticker located and no information available regarding last safety inspection in the master log book.

C-1104
485.638(a) (2)

Compliance with Federal Laws and Regulations related to Medical Records and Documentation Practices.

Based on medical record reviews, staff interviews, and policy review, the facility failed to maintain accurate, complete and legible documentation in patient medical records in 10 out of 40 records reviewed. The facility also failed to follow the "Preoperative Evaluation" policy in three of six sampled patients and "Surgical Timeout" policy in five of six sampled patients. One of two sampled death records revealed facility failed to document verification with family regarding change in code status while patient in Emergency Room awaiting medivac transfer.

Findings include:

A. Surgical record review of six sampled patients revealed the "preoperative evaluation" form on patient 28 was signed and dated 28 days after the fact. Patient 31's form lacked authentication of provider signature and date. Patient 26 did not have a "preoperative evaluation" form in the medical record.

Policy review of "Preoperative Evaluation" dated 5/29/18 revealed "The qualified practitioner will see the patient immediately before the patient goes to surgery and sign, date and time the form".

Interview with HIM on 6/23/21 at 1:50 PM confirms that patient 26 did not have a "preoperative evaluation" form in the medical record and 2 of 6 were signed late or were illegible.

Interview on 6/22/21 at 9:30 AM with Director of Nursing (DON) and the Surgery RN, it was confirmed the that documentation of five of six patients did not have a "time out" documented on the surgical record and "preoperative evaluations" on three of six patients were either missing or signed after the fact. Surgery RN confirms these procedures are conducted but were not documented according to policy.

B. Surgical record review of six sampled patients revealed that five of the six patients, 26, 27, 28, 29, and 31, did not have documentation of a "time out" (a safety check done by the surgery team) being performed immediately before the surgery began.
Policy review of "Surgical Timeout" policy revealed that "The time out should be documented according to facility policy".

Interview with Health Information Manager (HIM) on 6/23/21 at 2:00 PM revealed that there was no other policy available as referenced in the "Surgical Timeout" policy.

Interview on 6/22/21 at 9:30 AM with Director of Nursing (DON) and the Surgery RN, it was confirmed the that documentation of five of six patients did not have a "time out" documented on the surgical record and "preoperative evaluations" on three of six patients were either missing or signed after the fact. Surgery RN confirms these procedures are conducted but are not documented according to policy.

C. Death record review of patient 20 revealed that the patient came into the hospital Emergency room on 10/9/2020 at 1035 AM and was listed as a full code. Patient was 17 days status post CABG (Coronary Artery Bypass Graft Surgery). Initial vital signs for the emergency crew from the rescue squad report indicated patient's blood pressure was 114/60, heart rate 124, respirations 40 and oxygen saturations 79%. Presentation to Emergency Department with vital signs 126/86, respirations 24-30 per minute, oxygen saturations 89-91% on 7 Liters of oxygen. Multiple labs, chest x-ray, cardiac monitoring and Code Procedure (indicating patient was a full code) were part of the orders upon admission to the Emergency Room. Calls were made by Physicians Assistant to Bryan Medical Center in Lincoln, where a Cardiologist agreed to admit patient back to Bryan. Patient was placed on BiPap (a type of ventilator device that assists with breathing) at 1315. Patient was intubated (a tube inserted into a person through the trachea for ventilation) by facility nurse anesthetist as the flight crew from MARC (Medical Air Rescue Company) waited to transport patient to Bryan Hospital in Lincoln. Vital signs at 1400 were blood pressure 161/99, heart rate 116, respirations 10, and oxygen saturations 96%. Next vital signs obtained at 1420 were blood pressure 97/62, heart rate 113, and oxygen saturations 57%. Vital signs continued to deteriorate. Physician A who was in attached clinic seeing patients, was called to come assist with the patient during this course of events. The Emergency Room Note documented by Physicians Assistant read: "While I was out speaking (on phone) with the radiologist and Cardiologist, Physician A was attending at the patient's side. The patient at 1440, had a blood pressure of 72/37, becoming more ashened, and had a Foley catheter placed. The patient continued to deteriorate. I returned to the room and Physician A went to speak with the (spouse). The patient was ashened (SIC), and no longer had a pulse. Cardiac stand still was verified with ultrasound. Efforts were ceased at 1445".

There was no documentation of a change of code status found in the medical record. There was no documentation from physician or physician's assistant to indicate there had been a change in code status, or of the discussion with the patient's (spouse) during this event, as patient had come into the Emergency Room listed as a Full Code.

Interview with Director of Nursing on 6/22/21 at 11 AM while reviewing charts revealed that documentation in the medical record pertaining to a change in code status for patient 20 could not be found.

The facility failed to follow their Legionella Water Management Plan and based on staff interviews and policy review, the facility failed to prevent and control the transmission of potential infections related to Legionella, and failed to promote water safety to prevent the growth of coliform spore bacteria that promotes Legionella (as required for all health care facilities since 2017).

Findings include:

Interview with Infection control Nurse on 6/23/2021 at 4:30pm , revealed that the facility did not have any records of flushing water lines as per their policy extablished in October 2019. Review of policy for Water Management Plan/Legionella Disease revealed under prevention :
"A: Water will be run for 3-5 minutes in all sinks and showers in the facility twice a month."
" B. This process will be completed by Environmental Services and documented on a spread sheet. This documentation will be kept in a binder in the Environmental Services Department. "

Interview with two (2) Housekeeping staff on 6/23/2021 at 3:22pm revealed certain floor drains have water poured down them weekly but no flushing of water pipe lines or monitoring of water systems was being completed. Interview with Department Supervisor over-seeing Envirormental Services (EVS) staff on 6/24/21 at 8:35am revealed no flushing of water lines/fixtures/ sinks/showers etc was currently being completed by EVS Staff .

Interview with Maintenance Supervisor on 6/23/21 at 2:45pm revealed that the two Decontamination showers off the ambulance bay, were flushed at least monthly or twice a month by maintenance staff. however, No logs were kept of this flushing practice.

Facility Staff had no record of any meeting minutes for Legionella prevention/Water Safety. Facility policy stated:
Water Management team at facility will consist of the Infection Preventionist, THe Maintenance Supervisor, The CEO (Chief Executive Officer) and others as needed.

C-1235
485.640(c) and Licensure reference number 9-006.08A(3)(5)(8)

Compliance with Federal and State Laws and Regulations related to Infection Control Program and Practices.

Based on policy review, interviews, data review and meeting minute reviews, the facility failed to have an Infection Control Program that followed regulations and current nationally recognized guidelines (instructions for the Infection Control Program to follow), failed to perform surveillance of infections to ensure nosocomial (Health Care Acquired) infections are identified, investigated and controlled. The facility further failed to have a system for early detection of outbreaks and prevention. Review of the past year of the facility Quality Assurance (QA) /Department Supervisor meetings and Medical Staff meeting minutes lacked any discussion of surveillance data, infection rates of patients and staff infection rates. This practice had the potential to affect all patients using the hospital facilities.

Findings include:

A. Interview with the Infection Control (IC) Nurse on 6/22/2021 at 2:50 PM revealed that all the tracking and trending of infections should be located on the Infection Control Log (the form used to track and trend infections in the facility) and that "other information is kept in my head or on the lab sheets". The interview also revealed that the policy with the criteria for determining if an infection is nosocomial (an infection that occurred in the hospital) or not, was not being followed.

Review of the Infection Control Log revealed that the gathering of data needed for determining criteria for nosocomial infections was not documented and several sections on the form were not utilized correctly, which resulted in incomplete data. Facility failed to identify and document onset of symptoms and location of infection. The data was being entered by non-nursing staff member on the Infection Control Log.

Policy review of the Infection Control Policy Folder on 6/23/2021 at 12:45 PM with Director of Nursing and IC Nurse revealed and confirmed that there was a policy with criteria for determining nosocomial infections, and this policy was not being followed by the facility. The Policy Review also revealed that there were policies in the folder that were no longer in use, and that the nationally recognized guidelines from National HealthCare Safety Network (NHSN) and Centers for Disease Control (CDC) were outdated for greater than 10 and 15 years respectively.

B. Interview with the Infection Control (IC) Nurse on 6/22/2021 at 2:50 PM revealed that the Infection Control Committee met one time in 2020 due to COVID (Coronavirus) and typically only met twice a year. Infection Control data reports were given to QA after these meetings were held. IC Nurse also reported that Infection Control data was reviewed at monthly Department Supervisor meetings. (Current CDC/CMS recommendations are for minimum of quarterly meetings to review IC data and report on to QA and Medical Staff).

Review of Monthly Department Supervisor meeting minutes from the past year, held on: 5/7/2020, 6/4/2020, 7/2/2020, 9/10/2020, 10/01/2020, 11/5/2020, 12/3/2020, 1/7/2021, 2/4/2021, 3/4/2021, 4/1/2021, 5/6/2021 and 6/3/2021, revealed that there was no mention of surveillance data or infection rates of patients and staff infection rates. Only data mentioned was brief COVID updates.

Review of Medical Staff meeting minutes from the past year, held on: 6/8/2020, 7/13/2020, 8/10/2020, 9/14/2020, 10/12/2020, 11/9/2020, 12/14/2020, 1/11/2021, 2/8/2021, 3/8/2021, 4/12/2021 and 5/10/2021, revealed the same sentence verbiage every month of "The quality assurance activities including death report, surgical indicators report, transfusion reports, and the trauma program (inclusive of case reviews) were conducted". No mention of surveillance data or infection rates of patients and staff infection rates were discussed the entire year.

C-1237
485.640(c)

Compliance with Federal Laws and Regulations related to Quality Assurance oversite of Infection Control Program.

Based on policy review, staff interview, and meeting minute reviews, the facility failed to follow the Quality Assurance Plan policy and ensure infection control data was reviewed by the Quality Assurance Program and Medical Staff.

Findings include:

A. Interview with the Infection Control (IC) Nurse on 6/22/21 at 2:50 PM revealed that "infection control data is taken to monthly Department Supervisor meetings".

Interview the Quality Assurance (QA) Nurse on 6/23/2021 at 2:00 PM revealed that "all Quality Assurance data goes to the Governing Body and Medical Staff quarterly, which includes a monthly report to the Governing Body". IC Nurse confirmed that there was no producible evidence of monthly IC reports. The Infection Control Log with incomplete data was all that was available. No compilation of data for infection rates was being prepared, therefore no system surveillance of risk or potential for infection, including transmission and monitoring healthcare-associated infections.

Policy Review of the Quality Assurance Plan revealed, "Ongoing monitoring and data collection to include but not be limited to review of Quarterly Departmental Reports, audits and surveys". It was also documented in this policy that, "A written Quality Assurance Report will be presented to the Governing Board (GB) on a monthly basis". Facility's current practice was for the Infection Control Committee (ICC) to meet only two times a year, and turn in data at that time. The facility could not meet their own policy of monthly reporting to the GB, additionally the ICC only met once in the past year (2020) due to COVID.
Review of Monthly Department Supervisor meeting minutes from the past year, held on: 5/7/2020, 6/4/2020, 7/2/2020, 9/10/2020, 10/01/2020, 11/5/2020, 12/3/2020, 1/7/2021, 2/4/2021, 3/4/2021, 4/1/2021, 5/6/2021 and 6/3/2021, revealed that there was no mention of surveillance data or infection rates of patients and staff infection rates. Only data mentioned was brief COVID updates.

Review of Medical Staff meeting minutes from the past year, held on: 6/8/2020, 7/13/2020, 8/10/2020, 9/14/2020, 10/12/2020, 11/9/2020, 12/14/2020, 1/11/2021, 2/8/2021, 3/8/2021, 4/12/2021 and 5/10/2021, revealed the same sentence verbiage every month of "The quality assurance activities including death report, surgical indicators report, transfusion reports, and the trauma program (inclusive of case reviews) were conducted". No mention of surveillance data or infection rates of patients and staff infection rates were discussed the entire year.