HospitalInspections.org

Based on findings from document reviews and interviews, in 3 of 9 contracted services reviewed for hospital oversight, the governing body at United Health Services (UHS), known as the Board of Directors (Board), has not ensured oversight of these services.

Findings include:

-- Per review of a list of 50 contracted services provided by the hospital, "Sodexho" is a contracted service for Management of the Department of Food and Nutrition, and the Center For Donation and Transplant (also known as the Organ Procurement Organization/ OPO) is a contracted service for organ and tissue donation.

During interview with the Chief Operating Officer (COO) on 8/16/12 at 8:50 am, Sodexho arranges for a third party vendor to review the services Sodexho provides to the hospital. He/she was not able to indicate that these reviews are incorporated into the hospital wide quality improvement program. There is no oversight activity by the hospital.

Also see the findings in Tag A 701 which describe the kitchen managed by Sodexho at the Wilson Memorial Regional Medical Center as unclean.

During interview with the hospital's Organ Procurement Coordinator on 8/16/12 at 11:30 am, the OPO contract indicates that the OPO staff will provide the educational program about the organ procurement program and its requirements to nursing staff during each nursing orientation. However, during 2012 the OPO staff did not consistently fulfill this requirement and the hospital's qualified nurse educator filled in to provide the required educational program. This issue was not formally pursued with the OPO by the hospital.

--During interview with the Manager of Radiology on 8/16/12 at 9:05 am, he/she noted MRI (magnetic resonance imaging) services are provided by contract with Southern Tier Imaging. He/she acknowledged the hospital does not provide oversight for the MRI services.

Based on findings from document review and interviews, the governing body at United Health Services (UHS), known as the Board of Directors (Board), has not ensured maintenance of an accurate list of contracted services provided at the hospital. Specifically, the hospital's list of contracted services was incomplete, i.e., it did not include 4 contracted services provided at the facility. Also, the list contained a service no longer provided at the hospital.

Findings include:

-- Per review of the hospital's "Contract List, 'Hands On' Services to Patient(s), June 2012," the list included 50 contracted providers for the hospital.

-- However, during interview of the Director of Pharmacy on 8/16/12 at 9:10 am, he/she stated McKesson provides pharmaceutical equipment (automated pharmacy dispensing equipment) and staff to fill the equipment with medications, but confirmed the contracted services list provided did not include McKesson.

--During interview of the Chief Operating Officer on 8/16/12 at 9:15 am, he/she stated the hospital contracted with "Lab Corp" for laboratory services, but confirmed the contracted services list provided did not include Lab Corp.

--During interview of the Chief Medical Officer on 8/16/12 at 11:40 am, he/she indicated that Susquehanna Anesthesia Affiliates, P.C., is a contracted service providing anesthesia services to the hospital, but confirmed the contracted services list provided did not include Susquehanna Anesthesia Affiliates.

-- Also, during interview of the Senior Director, Clinical Operations and Support Services on 8/16/12 at 9:00 am, he/she acknowledged that the list provided included "Creative Orthodic and Prosthesis" which no longer exists and should have been removed from the list.

Based on findings from document review and interviews, in 2 of 15 medical records (MRs) reviewed, the name(s) of the physician performing the procedure and/or explaining the procedure to the patient were not entered on the consent forms completed. Additionally, the hospital's consent forms used to document a patient's informed decision about a surgical or non-surgical procedure lacked provisions to address and/or record a first assistant physician for the surgery/procedure, and the patient's wishes regarding the presence of a sales representative in the operating room (OR) and the filming and taking of photographs during the procedure.

Findings include:

-- Review of Patient A's MR revealed the patient signed two pre-printed Consent for Operation and/or Other Procedure forms on 8/9/12 (i.e., for "Right and Left Heart Catheterization and Coronary Angiography" and for "Emergency Coronary Artery Bypass Surgery").

The spaces provided (on each of the aforementioned consent forms) for the name of the physician performing the procedure and/or explaining the procedure to the patient, were blank.

-- Review of Patient B's MR revealed the patient signed 3 pre-printed Consent for Operation and/or Other Procedure forms on 2/7/12 (i.e., for "Right and Left Heart Catheterization and Coronary Angiography," for "Emergency Coronary Artery Bypass Surgery," and for "Percutaneous Transluminal Coronary Angioplasty"). On 2/7/12, Patient B also signed a Consent for Blood and Blood Derivatives Transfusion form.

Again, the spaces provided for the name of the physician performing the procedure and/or explaining the procedure to the patient, were blank. Similarly, the space on the blood consent form where the name of the physician who explained the necessity of a transfusion and the alternative options could be recorded, was also blank.

During interviews on 8/13/12 between 11:15 am and 12:30 pm, the unit Nurse Manager, NM#1, and the CNO acknowledged that consent forms are considered incomplete if the name of the medical provider(s) is not entered on the lines provided.

Additionally,

-- The hospital form titled "Consent for Operation and/or Other Procedure," last revised 8/6/12, lacks a space to identify a first assistant physician (when applicable) for the surgery/ procedure, provision for the patient to refuse the presence of a sales representative in the OR, space for the name of the sales representative involved when the patient is agreeable to his/her presence, and provision for the patient to refuse being filmed and/or photographed during the procedure.

During interviews with the Vice President, Patient Care Services/Chief Nursing Officer (to be referred to as the CNO) and the Vice President, Quality & Patient Safety (VP Q&PS) on 8/13/12 at 1:40 pm, each acknowledged the new informed consent form was not adequate.

Based on findings from document reviews and interviews, in 12 sets of minutes reviewed for 12 meetings of the hospital's distinct quality committees, from June 2010 through June 2012, the hospital did not document actions aimed at performance improvement (PI) and/or measurements of the success of any PI actions taken in connection with concerns identified.

Findings include:

-- Per review of the Clinical Performance Improvement Committee (CPIC) meeting minutes from January 2011 to June 2012, except for the April 2011 minutes, the "Action" column corresponding to the "Topic" column in each set of minutes only contains the word "Information," even when the topic warranted an action. For example, despite concerns such as the hand hygiene compliance rate of 54% in September 2011 after August compliance rate of 100% (November 1, 2011 minutes) and an increase in vascular catheter associated infections, catheter associated UTIs (urinary tract infections) and DVT/PEs (deep vein thromboses/pulmonary embolisms) with total knee replacements (February 6, 2012 minutes), no follow up actions to address these concerns were described; just the word "Information" appears in the corresponding Action columns.

-- The CPIC minutes for April 2011 lack documentation of actions to be taken or subsequent follow up for 2 concerns identified.

Specifically;

Under the topic "AMI (Acute Myocardial Infarct)," the minutes contain the following statements and information:

* "Discussion ensued regarding issues with identifying charts of patients with EF (ejection fraction) >40 prior to discharge for documention of ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker) for LVSD (Left Ventricular Systolic Dysfunction). A suggestion was made to have a dedicated Case Manager to handle AMI and CHF (congestive heart failure) patients." Under the "Action" column the minutes indicate the Vice President of Quality and Patient Safety (VP Q&PS) will pull a team together to address the issue. However, despite AMI being listed as a "Topic" in subsequent CPIC meeting minutes for July 2011, September 2011, and November 2011, these meeting minutes lacked documentation of actions taken as a result of the April 2011 discussion concerning AMI.

* Additional discussion (still in the April 2011 CPIC meeting minutes) under the "Action" column includes the statements "A question was raised regarding what the process is when queries are not responded....Process will be brought to next meeting." However, review of the July, September and November 2011 meeting minutes reveal they lack follow up discussion about this issue.

Regarding the topic "SCIP (surgical care improvement project)," documentation of discussion in the April 2011 CPIC meeting minutes indicates a VTE (Venous Thromboembolism) prevention team was to be chaired, "utilizing unit based educators, developing new audit form." The minutes indicate "A quarterly VTE report will be brought to the next meeting." However, review of the July 2011 meeting minutes reveals they lack documentation regarding a quarterly VTE report. Also, there is no further discussion concerning this topic in subsequent meeting minutes reviewed for September 2011 and November 2011.

-- Similarly, per review of the Hospital Quality Council (HQC) meeting minutes from July 2010 to June 2012, the minutes lack description of specific actions to be taken (and follow up to be done) when a topic warranted action. For example, despite concerns such as the question of whether radiation risk should be included in the consent form with a general statement noting the risk for all radiology procedures (January 6, 2012 minutes) and need for a clear policy of what materials are included in medical staff quality assurance files brought forth by the Medical Staff QA Committee (February 3, 2012 minutes), follow up actions to address these issues are not described; just the words "Report Accepted" appear in the corresponding Action columns.

-- Per review of the HQC's February 2012 meeting minutes, regarding the topic "Infection Control Plan 2012," discussion documented that "the isolation rooms sometimes need to be cleaned on the night shift. This is a concern because there are no longer any Environmental Services staff who are trained to clean isolation rooms working this shift. Disinfecting and cleaning of scopes was also discussed." However, the meeting minutes lacked follow up action planned for this topic. Also, there is no further discussion concerning this topic in subsequent meeting minutes reviewed for March 2012, April 2012 or June 2012.

During interview with the Manager, Infection Control (Mgr IC) on 8/16/12 at 1:40 pm, in regards to the above mentioned issue concerning cleaning of isolation rooms, he/she did indicate this issue was addressed but also acknowledged it was never again discussed at the HQC meetings.

-- During interview of the VP Q&PS on 8/15/12 at 10:40 am, he/she acknowledged the actions noted in the CPIC and HQC meeting minutes could be more detailed.

Based on findings from document reviews and interviews, the hospital's QAPI program did not include all services provided under contract or arrangement. See the findings under Tag A 083.

Based on findings from document review and interviews, in 2 of 4 medical records (MRs) reviewed in the ICU (Intensive Care Unit) and CCU (Cardiac Care Unit), physicians' progress note entries were not entirely legible or able to be read by the nursing staff.

Findings include:

-- Review of Patient A's MR reveals physician progress notes (cardiology) on 8/11/12 at 10:30 am and 10:30 pm were not legible.

-- Review of Patient C's MR reveals physician progress notes (neurosurgical services) on 8/10/12, 8/11/12 at 8 am and 8/11/12 at 11:44 pm were not legible.

-- During interviews conducted with NM #1 and the CNO on 8/13/12 between 10:30 and 11:45 am, each nurse was unable to read the progress notes in their entirety.

Based on findings from document review and interviews, the hospital's policy on Patient Controlled Analgesia (PCA) was not consistent with New York State regulations at Title 10, Part 80, Section 80.46 (e)(2)(v). Specifically, the policy did not require nursing staff to document the balance of narcotic medication remaining in the PCA machine cartridge at the time the patient's care is transferred from one nurse to another. Additionally, nursing staff did not document the disposition/wasting of a controlled substance (morphine) per hospital policy when Patient F's PCA pump was discontinued.

Findings include:

--The regulation at Title 10, Part 80, Section 80.46 (e)(2)(v) requires documentation, on the institutional administration sheet, of the balance on hand after each administration of a controlled substance.

--The hospital's policy titled "Patient Controlled Analgesia," last revised 3/12, indicated that the Controlled Substance Infusion Record form is used by nursing staff to document the initial time the infusion is started, the amount of medication initially in the PCA cartridge, the amount of drug administered to the patient, and the amount remaining in the syringe every 4 hours. The policy requires verification of the pump settings (dose(s), lockout interval, and 4 hour limit setting).

Although the policy requires nurses to count the dose administered to a patient and the amount remaining in the patient's PCA cartridge every 4 hours, it does not require nursing staff to "count" and record the balance of medication remaining when the patient's care is transferred between nursing staff.

--During interview of the Director of Pharmacy on 8/14/12 at 8:30 am, he/she acknowledged the policy lacked a requirement for a drug count when care is transferred between nursing staff.

Additionally,

--The hospital's policy titled "Controlled Substances," last revised 4/08, indicated that documentation of the destruction of the controlled substance is made on the Controlled Substance Infusion Record (when a patient is receiving controlled substances via continuous infusion). The nurse wasting the medication documents on the line for the amount wasted. The witness visually observes the first nurse wasting the medication and signs as a witness that the medication was discarded.

-- Per review of Patient F's "Controlled Substance Infusion Record" on Unit NW4 on 8/13/12 at 12:30 pm, the form lacked documentation indicating the amount of morphine that was discarded (wasted) on 8/11/12 at 11:30 am (when the infusion was discontinued), even though two RNs signed/witnessed the discard of the medication.

--During interview on 8/14/12 at 9:30 am, the Director of Pharmacy acknowledged that nursing staff should have documented the amount of morphine that was discarded on 8/11/12 at the time the morphine was discarded.

Based on findings from document review and interviews, the hospital's pharmacy did not ensure that the active medication profile for a patient (Patient G) contained information indicating that the patient was self administering insulin via his own insulin pump, even though the medication order was sent and received by pharmacy at the time of the patient's admission. Additionally, the hospital's policy on insulin pumps did not indicate that a pharmacy representative was involved in the approval of the policy.

Findings include:

--Per 8/15/12 review of Patient G's MR, on 8/4/12 at 06:00 am admitting Physician #1 provided an order, for Patient G to receive his own Novalog insulin via his insulin pump, on the patient's Admission Medication Reconciliation Order form. Nursing documentation on the Patient Self Administration of Insulin Log sheets indicated that Patient G managed his own insulin pump from admission to 8/15/12. However, there was no information on Patient G's Active Medication Profile screen in the eMR (electronic MR) indicating that the patient was receiving insulin via insulin pump.

-- Per interview with the Director of Pharmacy on 8/15/12 at 2 pm, the medication order for the Patient G's self administered insulin should have been entered in the medication profile by the pharmacist reviewing the patient's admission medication orders, but it was not.

Based on findings from observation and interview, the kitchen located in the Wilson Memorial Regional Medical Center was not maintained in a clean and sanitary manner.

Findings include:

--Per observation at 12:00 pm on 8/13/12, the floors and walls in the kitchen were found to be coated with dirt and grease.

--The Facilities Coordinator who was present concurred with this observation.

Note: The hospital has a contracted service, Sodexho, to manage the kitchen noted above (see the findings in Tag A 083).

Based on findings from observation and interview, the corridor in the Birthing Center was not protected from the transfer of smoke as required by NFPA 101 (2000), Chapter 18.

Findings include:

-- Per observation at 11:00 am on 8/13/12, the areas above the drop ceilings in the electrical room, clean room, and medicine room were found to form a continuous conduit permitting the transfer of smoke into the corridor of the Birthing Center located on the fourth floor of the East Wing of Wilson Hospital.

--The Facilities Coordinator who was present concurred with the observation that the continuous conduit would not form a barrier limiting the transfer of smoke into the Birthing Center.

Based on findings from observation and interview, the pass-through door between the soiled and prep & pack rooms of the Sterile Processing Department (SPD) at Wilson Memorial Regional Medical Center was not properly designed to prevent communication (airflow) between the rooms.

Findings include:

--Per observation at 3:00 pm on 8/14/12, the pass-though door was not properly designed to prevent communication (airflow) between the soiled room (a contaminated area) and prep & pack room (a clean area) of the SPD. The door was not self-closing nor was it sealed along its edges.

--The Facilities Coordinator who was present concurred that the pass-through was not properly designed.

Based on findings from document review and interviews, although the hospital's policy requires labeling of multidose medication vials with the date opened and the date of expiration (beyond use date), nursing staff's practice was to label a multidose vial with only the date of opening. Additionally, pharmacy personnel indicated that policy was to label vials with just the expiration date.

Findings include:

--The hospital's policy titled "Single and Multi-dose Vial Handling and Beyond Use Dating," last revised 7/10, indicated that at the time of the first use of a multi-dose vial, the user labels the vial with the date the vial was opened, the initials of the staff member who opened the vial, and the new expiration (beyond use) date.

-- Per observation of medication administrations on Unit 5 South Tower at 10:10 am on 8/13/12, a vial of NPH insulin noted was labeled with initials and the date of opening, 6/21/12. The expiration date was not documented.

-- Per interview with RN #2 on 8/13/12 at 10:10 am, multidose vials are labeled with the date the vial is opened.

-- Per interview with the Pharmacy Medication Safety Liaison on 8/15/12 at 11:00 am, multidose vials are labeled with expiration dates.

--During interview with the hospital's Manager of Infection Control on 8/16/12 at 11:30 am, he/she acknowledged the discrepant findings noted above.