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Based on interview, record review and policy review, the facility failed to ensure the education and training of two physicians (Staff N and Staff EEE), of two physicians credentialing files reviewed, was part of the credentialing process upon hire or when re-credentialing. This had the potential for physicians to provide care for patients without the proper training. The facility census was eight.

Findings Included:

1. Review of the facility's policy titled, "Medical Staff Procedural Policy," revised 08/20/15 showed the following requirements shall be applicable to every applicant and appointee for Medical Staff Appointment or reappointment as a condition of consideration of such application, and as a condition of continued Medical Staff appointment, if granted: to participate in continuing education programs for the benefit of the applicant or appointee and for the benefit of other professionals and hospital personnel.

2. Review of Staff N and Staff EEE, Physicians, credentialing files, showed no evidence of education or training records included in the credentialing process.

During an interview on 03/13/18 at 1:30 PM, Staff Y, Medical Staff Coordinator, stated that physicians' medical school transcripts were not required upon hire, and proof of ongoing training was not required for re-credentialing. Staff Y stated that the physicians attested on their renewal for licensing that they had completed the required training and that renewal was sufficient to show they had received the required training.

Based on observation, interview, record review, policy review, and review of the United States Pharmacopeia (USP) Chapter 797, the facility failed to ensure the pharmacy staff followed USP standards for compound sterile preparations (CSP, mixing of fluids, medication and electrolytes) and provide a segregated compounding area (SCA, a separate area designated for drug compounding) that was free of paper products (shedding, potential for contamination). The facility also failed to ensure an anesthesia medication cart in the Operating Room (OR) was accessible to only authorized personnel and locked when appropriate, for one anesthesia cart of one anesthesia cart observed in the OR. These failures had the potential to increase the risk of cross contamination with infection, increase the risk of harm to any patients who received compounded medication and had the potential to allow unauthorized persons to access medications in anesthesia carts. The facility census was eight.

Findings included:

1. Review of the USP, Chapter 797, dated 2013, showed the Compounding Aseptic Isolator (CAI, a form of isolator, which provides a barrier to outside germs, specifically designed for compounding pharmaceutical ingredients or preparations), which is the Primary Engineering Control (PEC, a device or room that provides an environment for compounding medications), shall be in a segregated compounding area, restricted to sterile (free of germs) compounding activities, with a line of demarcation (defined line to separate) defining the SCA. Particle shedding objects (pencils, corrugated cardboard, paper towels, and cotton items) are prohibited in the SCA.

2. Although requested the facility failed to provide a policy on sterile compounding.

Observation on 03/16/18 at 10:40 AM in the pharmacy, showed the following items in the SCA:
- The CAI, in a room with no door or line of demarcation, approximately eight feet inside the entrance of the pharmacy, and open to the pharmacy activities;
- Multiple pieces of paper (shedding) hanging on the outside of the CAI; and
- A metal cart with three cardboard boxes (shedding) on the shelving units, approximately two feet from the CAI.

During an interview on 03/16/18 at 1:15 PM, Staff DDD, Pharmacist, stated that the pharmacy staff made four to five intravenous (IV, within the vein) compounded solutions per day, typically with only one medication additive, and that the pharmacy was USP 797 compliant.

3. Review of the facility's policy titled, "Medication Administration," dated 05/2016, showed that all medications must be secured or locked at all times when not being accessed by appropriate staff. Medications should never be laying on counters, top of carts, medication work areas when not attended by licensed staff.

Review of the facility's policy titled, "Anesthesia Equipment Checklist and Recommendations," dated 06/06/17, showed the following:
- All anesthesia carts and operating room cupboards shall be closed unless necessary to obtain supplies;
- All medicines opened for a patient and unused are discarded at the completion of the case; and
- All used syringes are discarded immediately after use.

Observation on 03/13/18 at 10:15 AM in OR suite #2, showed Staff T, Certified Registered Nurse Anesthetist, (CRNA) accompanied Patient #6 out of the OR suite and to the ICU. The anesthesia cart was located within the OR suite with the top lid open and medication drawers unlocked. The anesthesia equipment had one unused syringe with 10 cubic centimeter (cc, unit of measure) of Propofol (short-acting medication used in general anesthesia), 1cc of Fentanyl (pain medication also used with other medications for anesthesia). Staff R, Registered Nurse (RN), Staff P, Certified Scrub Technician and Staff Q, Certified Scrub Technician were left in the room after Staff T had exited. Shortly after, Staff R and Staff Q exited the OR suite, and left Staff P in the OR suite by herself.

During an interview on 03/16/18 at 10:30 AM, Staff P, Certified Scrub Technician, stated that typically Staff T, CRNA, accompanied patients out of the OR, and left his anesthesia cart open, after the completion of a surgery.

During an interview on 03/16/18 at 10:40 AM, Staff T, CRNA, stated that his process was to leave the drugs out and cart open because he did not have the available equipment to waste (dispose of properly) medications inside the OR suite, and could not leave the surgical patient unattended.

Based on observation, interview, record review and policy review, the facility failed to ensure staff followed infection control policies for patient care when they failed to:
- Appropriately clean and dress a central line catheter (CL, thin, flexible catheter placed into a large vein like the superior vena cava near the heart for therapeutic or diagnostic purposes to administer medicines or fluids over a long period of time) for one patient (#6) of one patient observed.
- Perform hand hygiene (clean hands with sanitizer or soap and water) after glove use, and change gloves appropriately after touching inanimate objects, during nursing or respiratory procedures for four patients (#6, #23, #24 and #30) of four patients observed during nursing or respiratory procedures.
- Perform proper hand hygiene after exiting a contact enteric precaution (isolation classification for patients infected with clostridium difficile, C-diff, a highly contagious disease that causes diarrhea) room, for one patient (#31) of one patient observed in contact enteric precautions.
- Appropriately wear undergarments under surgical scrubs so that the undergarments were not visible for one OR staff of one observed.
- Ensure that patient equipment was stored in a clean environment after it had been cleaned and was ready for patient use.
These failed practices had the potential to expose all patients to cross contamination and increase the potential to spread infection to patients, staff and visitors. The facility census was eight.

Findings included:

1. Review of the facility's policy titled, "Central Line Dressing Changes," reviewed 05/2017 showed the following:
- After removal of old dressing, prepare sterile (without contaminants) field (area designated only for sterile instruments, supplies and medications);
- Wash hands;
- Put on mask and gloves (sterile) supplied in central line dressing kit;
- Cleanse with approved skin antiseptic Chlorhexidine Gluconate (skin cleanser), and cleanse in a back and forth scrubbing motion; and
- Apply dressing.

Review of the Chlorhexidine Gluconate package label indicated to cleanse the dry surgical site with a gentle repeated back and forth strokes for three minutes and allow the solution to completely dry for a minimum of three minutes.

Review of the facility's policy titled, "Hand Hygiene," reviewed 02/26/18 showed the following guidelines for hand hygiene:
- Before inserting indwelling catheters;
- Soap and water is required when caring for patients known or suspected to be infected with C-diff;
- Before putting on gloves and after removal of gloves; and
- Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent contamination of the hands and/or surrounding environment.

2. Observation on 03/13/18 at 8:15 AM in OR suite #2 showed Staff O, Registered Nurse, (RN) touched multiple pieces of equipment, supplies and Patient #6, while she wore the same pair of gloves. After Staff N, General Surgeon, had inserted Patient #6's CL, Staff O, RN opened and prepared the CL dressing kit wearing the same pair of gloves (contaminated, not sterile) that she had worn since the beginning of the surgical case. Staff O then scrubbed the CL insertion site with the Chlorhexidine cleanser in a circular motion, starting at the insertion site and moving outward, and not back and forth per policy. Staff O, RN then placed a dressing over the insertion site.

Sterile technique should be followed with the placement and care of CL's as a CL may serve as an entry point for pathogenic organisms (an organism capable of causing disease or infection).

During an interview on 03/13/18 at 10:50 AM, Staff O, RN, stated that she kept her original gloves on during the entire procedure, because she didn't touch the end of the Chlorhexidine cleanser (portion that touches the patient's skin), and therefore did not contaminate the CL insertion site.

Observation on 03/13/18 at 8:35 AM in OR suite #2, showed Staff O, RN, prepared to insert an indwelling urinary catheter (tube placed in the bladder to drain urine) in Patient #6. With gloved hands, Staff O cleaned the patient's urinary meatus (opening into the urinary system) then removed her gloves but did not perform hand hygiene. She opened the interior package of the urinary catheter kit and put on sterile gloves. Staff O requested another pair of sterile gloves because the pair inside the kit had a hole in one glove. She removed the first pair of sterile gloves and without performing hand hygiene she put on the second pair of sterile gloves and inserted the urinary catheter. Staff O then removed her sterile gloves and put on a clean pair of gloves without first performing hand hygiene and proceeded to prepare the patient's abdomen with Chlorhexidine cleanser in a circular motion (not back and forth per policy).

During an interview on 03/13/18 at 10:50 AM, Staff O, RN stated that she always prepped in a circular motion then, at the end of cleansing, would go back and forth at the top of the prep site like "a rainbow."

During an interview on 03/13/18 at 10:55 AM, Staff M, OR Supervisor, stated that she expected nursing staff to follow sterile technique with any CL site and that Staff O, RN did not follow sterile technique when she failed to wear sterile gloves and failed to perform hand hygiene between glove changes.

During an interview on 03/14/18 at 2:28 PM, Staff EE, RN, Infection Control Officer, stated that the proper way to use the Chlorhexidine cleanser was to scrub in a back and forth motion, per manufactures policy. She also stated that she expected the OR nurse to have used sterile technique with the manipulation of the CL catheter site, and that the OR Supervisor and the surgeon should speak up if staff do not follow policy, as it was their OR.

Review of the facility's policy titled, "Contact (Enteric) with Bleach Precautions," reviewed 02/2018 showed the following:
- Purpose was to describe responsibilities, procedures and guidelines for all employees in the prevention and control of transmission of acute diarrhea with unknown cause, C-diff;
- Hand hygiene with alcohol based hand rub or soap and water should be performed upon entry to the patient room; and
- Hand hygiene with soap and water should be performed any time gloves are removed in the patient environment and prior to exiting the patient room.

Observation and subsequent interview on 03/14/18 at 11:40 AM on the medical surgical floor, showed Staff BBB, Social Service Provider, in the doorway of Patient #31's contact enteric precaution room with gown and gloves on. Staff BBB removed her gown and gloves, exited the room, and used the hand sanitizer in the hallway outside the patient's room. Staff BBB stated that she didn't know why Patient #31 was on isolation, but that she performed hand hygiene in the hallway with the hand sanitizer.

Patients in Contact Enteric precautions require hand hygiene with soap and water not with hand sanitizer prior to exiting the patient's room.

Review of Patient #31's lab showed on 03/10/18, C-diff was detected.

Observation on 03/14/18 at 10:30 AM, showed Staff JJ, RN, prepared to start an intravenous (IV, in the vein) catheter (small, flexible tube) on Patient #23, and:
- Wore gloves and touched inanimate (non-living) objects (which contaminated her gloves) in the patient's room, before she touched the patient to provide patient care.
- Removed the soiled gloves and failed to perform hand hygiene.
- Left the patient's room and returned, and failed to perform hand hygiene before she put gloves on.

During an interview on 03/14/18 at 11:50 AM, Staff JJ, RN, stated that it was okay to use the same gloves throughout a procedure unless the gloves were soiled or torn.

Observation on 03/14/18 at 10:42 AM, showed Staff KK, RN, prepared to start an IV on Patient #24. Staff KK removed her gloves, failed to perform hand hygiene, put on gloves, and started the patient's IV.

During an interview on 03/14/18 at 12:00 PM, Staff KK, RN, stated that her normal practice was to perform hand hygiene before she put on gloves.

Observation on 03/15/18 at 1:10 PM, showed Staff YY, Respiratory Therapist, entered Patient #30's room to administer a breathing treatment (medication administered through inhalation of mist). Staff YY repeatedly touched inanimate objects in the patient's room with her gloved hands, and then touched the patient.

During an interview on 03/13/18 at 1:25 PM, Staff YY, Respiratory Therapist, stated that she never thought about inanimate objects contaminating her gloves, and added that her typical process was to wear the same gloves from entry to exit of the patient's room.

3. Review of the facility's policy titled, "Dress Code - Patient Services," dated 2014, showed that surgical attire for hair covering was to include all possible head and facial hair shall be covered with a clean disposable cap or hood when entering the semi-restricted and restricted areas. Additional undergarments needed for warmth may be worn but may not be visible and must be covered by the scrub clothes and/or warm up jacket.

Observation on 03/13/18 at 8:10 AM in OR suite #2, showed Staff T, Certified Registered Nurse Anesthetist, (CRNA) with a surgical cap on that exposed approximately two to three inches of his hair under the cap. Staff T also had a shirt on underneath his V-neck scrub top. The shirt was a collared three button shirt with all three buttons and collar exposed.

During an interview on 03/13/18 at 10:35 AM Staff T, CRNA, stated that the type of cap he wore and his shirts he wore under his scrubs had never been a problem before.

Review of a facility document titled, "Health and Safety Rounds Infection Prevention," dated 03/17/17, showed that previous observations were made in the OR of anesthesia personnel with personal clothing exposed through their scrub top. The recommendation was for adherence to dress code.

During an interview on 03/14/18 at 2:28 PM, Staff EE, RN, Infection Control Officer, stated that she was aware of previous issues where anesthesia staff wore personal clothing that was exposed through scrub tops, but she expected the OR Supervisor to have taken care of it. Staff EE added that the Chief Nursing Officer (CNO) was also aware that this was an issue.

During an interview on 03/15/18 at 11:15 AM, Staff B, CNO stated that she "missed this one," and that she saw the CRNA in the hallways everyday, but it never occurred to her that his personal shirt showing through the scrubs was a concern. She added that she must have missed it (previously reported infection control surveillance) on the report.

4. Review of the facility's policy titled, "Central Supply Cleaning and Disinfecting of Patient Equipment," reviewed 02/2018 showed:
- The purpose was to provide patient equipment in a clean, safe and functional working condition;
- Soiled equipment will be cleaned/disinfected in the soiled utility area;
- Upon completion of cleaning/disinfecting equipment place in designated area; and
- Equipment is cleaned by nursing staff.

Observation and subsequent interview on 03/12/18 at 3:20 PM on the Medical Surgical floor showed a Soiled Utility room. The room contained dirty linens in bags, a trash can, sink for cleaning and two items covered in plastic on top of the counter. Staff K, RN, Charge Nurse, stated that the plastic covered items were cleaned patient equipment that were ready to be used for patient care. She stated that after the equipment was cleaned, the staff wrapped it in plastic and placed it on the counter in the same room until it was needed for patient use.

During an interview on 03/15/18 at 9:30 AM, Staff EE, RN, Infection Control Officer, verified that the Soiled Utility room contained two cleaned, wrapped pieces of patient equipment on the counter inside the room, ready for patient use. Staff EE stated that this was not how the staff were trained and that once the equipment was cleaned it should be removed from the room and placed in a designated clean area.

Based on interview and record review, the facility failed to ensure the list of services provided under contract or agreement included the nature and scope of those services provided for 16 of 16 contracts listed. These failures increased the potential for patient care services by arrangement to be inappropriately utilized. The facility census was eight.

Findings included:

1. Review of the facility list of contracts provided by Staff A, Chief Operating Officer (COO), showed 17 contracts or service agreements. It was determined that one of the 17 agreements was no longer active. There was no indication of the nature or scope of the services provided by 16 of 16 contractors.

During an interview on 03/15/18 at 12:50 PM, Staff A, COO, stated that the list was current except for the agreement that had not been renewed.

Based on observation, interview and policy review, the facility failed to ensure that the confidentiality of patients' paper medical records were protected against loss, destruction, unauthorized use, and unauthorized access and/or tampering (by individuals who were not providing care for those patients), by failing to establish safeguards against unauthorized access of the paper medical records in the main Medical Records Department office. This deficient practice had the potential to permit unauthorized individuals access, review, and/or possibly alteration of the documented health information in patients' paper medical records located in that area. The facility census was eight.

Findings included:

1. Review of the facility's policy titled "Privacy of Patient Information" dated 12/2017, showed the following direction:
- Patient Health Information (PHI) collected and/or generated within the Facility's Health System will be maintained in such a manner that access to it is restricted to those with a need to know.
- It is the responsibility of the Vice President of Compliance, the Privacy Committee and the Facility's department managers to monitor employees, volunteers and medical staff for violations of the Facility's Policies and Procedures related to the privacy of patient information.
- The Vice President of Compliance will have authority for the implementation, monitoring and enforcement of privacy activities. The Vice President of Compliance reports to the President and the Chief Executive Officer (CEO).
- The Privacy Committee shall assist the Vice President of Compliance in the development, implementation and enforcement of the Privacy Policy and Procedures.

2. Observation on 03/13/18 at 2:30 PM, of the Medical Record Department office area located in the basement of the facility, showed patient medical records, including patient X-ray films, Surgery Department records, and Laboratory records.

3. During an interview on 03/13/18 at 2:30 PM, Staff U, Medical Records Technician and Analyzer, stated the following:
- The Medical Records Department was staffed Monday through Friday, from 7:00 AM until 4:30 PM.
- Medical Records were scanned daily and then stored in a box in this office until the box was full, typically every three to four days. Once the box was full it was sent to an off-site location.
- Housekeeping staff cleaned and vacuumed in the Medical Records Department office after hours.
- Maintenance entered at 5:00 AM for generator testing, which was located in the Medical Records office closet.

4. During an interview on 03/13/18 at 2:45 PM, Staff W, Release of Information Clerk, stated that the contracted housekeeping company had a key that they used to access the medical records office for cleaning after hours and maintenance had a key to access the medical records office closet to perform the generator testing at 5:00 AM.

The facility failed to ensure that unauthorized individuals did not have access to the patients' medical records.

Based on observation and interview, the facility failed to ensure that the Surgery Department had a tracheotomy (a surgical procedure that opens up the windpipe, performed in emergency situations, in the operating room, or at the bedside of a critically ill patient) kit on hand and readily available. This failure had the potential to affect all patients who received care at the facility by increasing their risk for the potential for delayed care if in the event of a medical emergency. The facility census was eight.

Findings included:

1. Observation and concurrent interview on 03/13/18 at 10:00 AM, showed no tracheotomy kit in the supply area of the Surgery department. Staff M, Surgery Supervisor, obtained a tracheostomy kit (a sterile, single use tray designed for care of patients who have had tracheostomies, the opening into the trachea through the neck to allow passage of air). She stated that they didn't have a tracheotomy kit, just the tracheostomy kit.

A tracheostomy kit would not contain the needed items to perform the actual tracheotomy, it only contained basins to clean, soak and rinse, tracheostomy dressing, pipe cleaners, sponges and one cleaning brush. It would not contain the surgical instruments needed to perform the tracheotomy.

Based on interview and record review, the facility failed to ensure Swing Bed (a specific type of reimbursement for patients that need a skilled service, such as therapy, but do not need the level of care in a regular patient bed) patients were informed of their Medicare rights with the Important Message from Medicare (IM, a standard notice that must be delivered to all Medicare inpatients within two days of admission and no more than two calendar days before discharge) for two current Swing Bed patients (#4 and #5) of two current Swing Bed patients reviewed and for four discharged Swing Bed patients (#25, #26, #27 and #28) of four discharged Swing Bed patient records reviewed. This failed practice had the potential to prevent patients the knowledge to formalize an appeal process for premature discharge, and could affect all Swing Bed patients. The total facility census was eight, which included two Swing Bed patients. The facility had admitted 154 patients over the last 11 months to the Swing Bed Program.

Findings included:

1. Review of current Patient #4's medical record showed she was admitted to the Swing Bed Program on 03/07/18 for generalized weakness after an acute admission for pneumonia (infection that inflames the air sacs of the lungs which may fill with fluid). Patient #4's medical record did not contain the IM notice.

Review of current Patient #5's medical record showed he was admitted to the Swing Bed Program on 02/12/18 for long term antibiotic therapy for a perirectal abscess (a painful boil-like swelling near the anus most often as a result of an infection from small anal glands). Patient #5's medical record did not contain the IM notice.

Review of discharged Swing Bed Patients #25, #26, #27 and #28's medical records, showed that they did not contain the admission IM notice or the discharge IM notice.

During an interview on 03/14/18 at 8:50 AM, Staff BBB, Social Service Provider, stated that she was not aware that the IM was to be given to Swing Bed patients.

During an interview on 03/14/18 at 4:00 PM, Staff MM, Director Social Services, stated that Swing Bed patients did not receive the IM notice and added that it was only to be given out to acute inpatients.

Based on interview, record review and policy review the facility failed to ensure that Swing Bed patients (a specific type of reimbursement for patients that need a skilled service, such as therapy, but do not need the level of care in a regular patient bed) were given a list of charges for items that may not be covered by Medicare, therefore, the items would be the responsibility of the patient for two current Swing Bed patients (#4 and #5) of two current Swing Bed patients reviewed. This had the potential for all Swing Bed patients that requested and received items that were their financial responsibility without knowing the actual charge for the item. The total facility census was eight, which included two Swing Bed patients.

Findings included:

1. Review of the facility handbook for Swing Bed patients listed 15 personal care items that were not covered by Medicare, therefore, those items were the responsibility of the patient. There was no monetary value listed for any of the items.

During an interview on 03/16/18 at 4:00 PM, Staff MM, Director of Social Services, stated that she was unaware of the need to give the patient actual charges for those items.

Based on observation, interview, and policy review the facility failed to display a monthly calendar in the patient care area and within the patients room, showing activities being offered to Swing Bed patients (a specific type of reimbursement for patients that need a skilled service, such as therapy, but do not need the level of care in a regular patient bed) for two current Swing Bed patients (#4 and #5) of two current Swing Bed patients observed. This had the potential to negatively impact the quality of life for the Swing Bed patient during their admission to the facility, by failure to ensure patient awareness of the activities offered. The total facility census was eight, which included two Swing Bed patients.

Findings included:

1. Review of the facility's policy titled, "Activity Program, Swing Bed," reviewed 03/2018 showed that a large monthly calendar is posted in a clearly visible area to reflect all activities being offered. A copy of the monthly activities calendar is also placed in each Swing Bed patient's room for their convenience.

2. Observation on 03/12/18 at 3:00 PM showed no activity calendar posted in the patient care area, or in the rooms of Patient #4 or Patient #5.

Observation and concurrent interview on 03/12/18 at 3:55 PM, in Swing Bed Patient #4's room showed no activities calendar. Patient #4 stated that she wasn't aware what activities were offered.

Observation and concurrent interview on 03/12/18 at 4:10 PM, in Swing Bed Patient #5's room, showed no activities calendar. Patient #5 stated that he wasn't aware of what activities were offered.

Observation on 03/13/18 at 7:20 AM, in the locked activities room located on a different level from the patient rooms, showed an eight inch by 11 inch calendar for the current month tacked on the bulletin board. The calendar had activities listed on each day but it was not titled.

During an interview on 03/14/18 at 11:15 AM, Staff CCC, Therapeutic Services and Activities Coordinator stated that she made a monthly activities calendar and posted it in the central conference room.

The activity room was not accessible to patients as it was not located on the same floor as the inpatient unit.