HospitalInspections.org

Based on policy review and interview, it was determined the facility failed to ensure there was a written policy regarding abuse of a patient by a staff member. The failed practice did not allow the facility to be knowledgeable, proactive, and timely in responding to allegations of patient abuse by staff and could affect any patient alleging abuse. Findings follow.

A. Policy #D5 titled "Abuse" and policy #F3 titled "Corporate Compliance Plan" were provided. The policies contained no information regarding allegations of patient abuse by staff.
B. During an interview on 02/26/15 at 1020, the Director of Quality confirmed there was no policy regarding patient abuse by staff.

Based on review of Governing Board Meeting Minutes, Medical Staff Meeting Minutes, and Performance Improvement Meeting Minutes for February 2014 through January 2015, and interview, it was determined the facility failed to ensure specifics of QAPI (Quality Assessment/Performance Improvement) data collection and frequency were determined by the Governing Body and failed to ensure three of three indicators traced had the frequency of data collection documented. The failed practice did not ensure the Governing Body was responsible for the QAPI program. Findings follow.

A. Review of Governing Board Meeting Minutes, Medical Staff Meeting Minutes, and Performance Improvement Meeting Minutes for February 2014 through January 2015 revealed the Governing Body failed to establish QAPI frequency and data collection details for the QAPI program.
B. Review of QAPI indicators traced for Food and Nutrition Services, Environmental Services, and Respiratory Therapy revealed there were no specifics as to the frequency for the data collection.
C. During an interview on 02/27/15 at 0915, the QA Director confirmed the Governing Body had not established frequency parameters for the QA program.

Based on review of Anesthesia policies and procedures, Anesthesia Contract and interview, it was determined the facility failed to assure performance improvement activities included Anesthesia Services, a high-risk, high-volume department. Failure to conduct performance improvement activities for Anesthesia Services prevented identification of potential aspects of patient care in need of improvement. The failed practice was likely to affect all patients undergoing anesthesia admitted to the facility. Findings follow:

A. Review of Anesthesia policy, "Performance Improvement Aspects of Care" revealed "Relevant list of indicators: adverse drug reaction or adverse interaction between drugs and/or anesthetic agent(s); improper choice of anesthetic agent; breathing circuit of anesthetic agent; syringe or ampule swap; drug overdose (technical or judgmental error); loss of oxygen or nitrous oxide supply; inadvertent change in gas flow; esophageal or endobronchial intubation; unintentional extubation; premature extubation; and wrong choice of airway management technique".
B. Review of Anesthesia Contract revealed "Services Generally. Group shall be responsible for providing all anesthesia...establishing and maintaining procedures to promote the overall quality of medical services provided by the Hospital including, but not limited to participating in Hospital's overall Quality Assessment and Improvement Program".
C. During interview with the Quality Assurance (QA) Director on 03/02/15 at 0905 when asked for Quality Assurance/Performance Improvement activities for Anesthesia, she stated Anesthesia staff participated in quality committees. No monitors specific to Anesthesia were presented for review.

Based on policy review, review of clinical records and interview, it was determined the facility failed to reassess patients after PRN (as needed) medication administration according to policy for three (#8, #9, and #11) of six (#7-12) patient records. By not following policy, the facility could not assure the patient's needs were being assessed and met. The failed practice had the potential to affect all patients who have orders for PRN medications. Findings follow:

A. Review of policy titled "Medication Administration: Nursing Responsibilities & Administration Procedures" stated "When PRN medications are administered, the nurse will document to the related intervention, and will also document the effectiveness of the PRN medication."
B. Review of patient clinical records revealed the following samples of one PRN medication administration traced for the length of the order per patient:
1) Patient #8 received Zofran 4 mg (milligram) IV (intravenous) for nausea/vomiting on 02/24/15 at 1709. The record revealed the effectiveness of the medication was not assessed.
2) Patient #9 received Tylenol 650 mg by mouth for pain/fever on 02/26/15 at 2205. The record revealed the patient was not reassessed and the effectiveness of the medication was not documented.
3) Patient #9 received Tylenol 650 mg by mouth for pain/fever on 02/27/15 at 0504. The record revealed the patient was not reassessed and the effectiveness of the medication was not documented.
4) Patient #11 received Zofran 8 mg by mouth for nausea/vomiting on 02/24/15 at 1948. The record revealed the patient was not reassessed and the effectiveness of the medication was not documented.
C. During an interview on 02/27/15 at 1428, Registered Nurse Manager #2 verified the patients were not reassessed and the effectiveness of the above administered PRN medications was not documented.

Based on review of policy, review of Healthcare Event Reporting Forms and interview, it was determined the facility failed to report all medication errors to the attending physician or covering physician in 15 (Medication Errors #1-15) of 29 (Medication Errors #1-29)reported medication errors from 11/25/14 to 02/25/15. By not reporting medication errors to the physician responsible for the patient's care, the patients' physicians were not being kept abreast of the patient's condition and were not involved in the decisions of what to do after the error occurred. The failed practice had the likelihood to affect all patients in the facility. Findings follow:

A. Review of policy titled Medication Event Reporting stated "Notify the physician if the medication reached the patient or in the case of a clinically significant omission or delay."
B. Review of Healthcare Event Reporting Forms revealed 29 medication errors had been reported from 11/25/14 to 02/25/15 and of those, 15 (Medication Errors #1-15) failed to have evidence physician notification occurred.
C. During an interview on 02/27/15 at 0930, the Director of Pharmacy verified the physicians were not notified for the 15 medication errors.

Based on review of policies and procedures, observation and interview, it was determined the facility failed to assure equipment was free of dust in four (Critical Care Unit, Pre-Operative Unit, Nursery, Operating Room 2) of eight (Critical Care Unit, Pre-Operative Unit, Operating Room 2, Post Anesthesia Care Unit, Medical Surgical Unit 1 East, Labor and Delivery, Nursery, Emergency Department) patient care areas. Failure to assure equipment was free of dust did not assure equipment was sanitary and was likely to affect all patients admitted to the facility. Findings follow:

A. A tour of the facility was conducted 02/26/15 at 0950 with the Performance Improvement (PI) Coordinator. Findings revealed the following:
1) In the Critical Care Unit, three computers on wheels, one EKG machine and one Respiratory cart had dust on their bases which did not assure they were sanitary;
2) In the Nursery along the left side of the room were four "care stations" (newborn bed/warmers). All four stations had dust on the bases which did not assure they were sanitary;
3) In the Pre-Operative Unit, one computer on wheels at Bay #11 had dust on its base which did not assure it was sanitary; and
4) In Operating Room 2, dust was on the computer keyboard which did not assure it was sanitary.
B. Review of Policy E7 revealed "All newborn bedding equipment will be thoroughly cleaned between each patient use and as needed".
C. Findings listed as A1-4 were verified with the PI Coordinator during interview at the time of observation.


Based on review of policies and procedures and interview, it was determined the facility failed to monitor home laundering practices for staff's surgical attire. Failure to monitor home laundering practices did not assure surgical attire was processed according to facility policy, did not assure microbial kill was accomplished during the laundry process and did not assure staff did not contaminate their home environment from soiled surgical attire. The failed practice was likely to affect all patients and staff in Perioperative Services. Findings follow:

A. Review of policy A5 revealed, "Surgical attire should be laundered, stored and transported in a manner which supports infection control. Home laundering surgical attire criteria: use an automatic washer and hot air dryer; water temperature should be the hottest setting available (110 degrees to 125 degrees) to facilitate microbial kill; chlorine bleach may be used; use detergent according to manufacturer's instructions; launder surgical attire in a separate load with no other items; wash hands immediately after placing laundry in the washing machine; keep laundry items completely submerged during wash and rinse cycle; use the highest drying setting possible that is safe for the material.
B. During interview with the Director of Surgical Services on 02/26/14 at 1445 she confirmed staff laundered their scrubs at home. When asked how home laundering practices (i.e. water temperature, use of bleach) were monitored, she answered, "We aren't; it is not possible. We are asking staff to follow the policy".


Based on review of policies and procedures, review of Immediate Use Sterilization Log Records and interview, it was determined for November 2014-February 2015 staff failed to follow facility policy requiring them to place their initials on the sterilizer's printout tape to verify completion of the sterilization cycle load run time and temperature for 11 (11/02/14, 11/06/14, 11/07/14, 11/11/14, 12/11/14, 12/12/14, 01/08/15, 01/12/15, 01/20/15, 02/03/15 and 02/09/15) loads. Failure to document verification by initialing the sterilization cycle load records did not assure items placed in the sterilizer were run for the required time or reached the required temperature for sterilization. The failed practice was likely to affect all patients undergoing surgery in the facility. Findings follow:

A. Review of policy, "Immediate Use Steam Sterilization" revealed "upon completion of the sterilization cycle, the load must be verified by: a) sterilization cycle time (5, 12 or 20 minutes); b) temperature (270F (Fahrenheit) or greater for 5 or 12 minutes); c) initial the bottom of printout tape to prove verification".
B. Review of Immediate Use Sterilization Log Records for November 2014, December 2014, January 2015 and February 2015 revealed the following:
1) Records for 11/02/14, 11/06/14, 11/07/14, and 11/11/14 had no evidence staff initialed the record verifying the run time or temperature of the sterilizer;
2) Records for 12/11/14 and 12/12/14 had no evidence staff initialed the record verifying the run time or temperature of the sterilizer;
3) Records for 01/08/15, two separate loads on 01/12/15, and two separate loads on 01/20/15 had no evidence staff initialed the record verifying the run time or temperature of the sterilizer; and
4) Records for 02/03/15 and 02/09/15 had no evidence staff initialed the record verifying the run time or temperature of the sterilizer.
C. Findings listed as B 1-4 were verified with the Manager for Central Sterilization during interview 03/02/14 at 1320.


Based on review of Gastroenterology (GI) Lab Scope Cleaning Log and interview, it was determined for December 2013-July 2014 staff failed to document which endoscope was used for a patient and failed to affix the computer readout tape to the log indicating disinfection time and temperature was met for 11 (12/31/13, 01/28/14, 02/12/14, 02/17/14, 03/24/14, 03/25/14, 05/20/14, 05/28/14, 05/30/14, 06/05/14 and 07/20/14) endoscope log entries. Failure to document which endoscope was used did not allow for tracking endoscope use in the event of infection or endoscope failure; and failure to affix the computer readout tape to the log did not assure staff were assured endoscopes placed in the automated endoscope processor reached the time and temperature to assure disinfection. The failed practices were likely to affect all patients undergoing GI procedures in the facility. Findings follow:

A. Review of GI Lab Scope Cleaning Logs for December 2013- July 2014 revealed patient labels were affixed to the log along with the endoscope processor's computer printout for the scope used. The endoscope processor's computer printout documented the scope's serial number, wash time, disinfection time, and temperature.
1) On 12/31/13 two entries on the log had no evidence which scopes were used for two separate patients. There was no evidence computer readout tapes were affixed to the patient labels which did not assure the endoscope processor reached the required time or temperature to assure disinfection;
2) On 01/28/14 there was no evidence which scope was used and no evidence the computer readout tape was affixed to the patient label which did not assure the endoscope processor reached the required time or temperature to assure disinfection;
3) On 02/12/14, there was no evidence which scope was used and no evidence the computer readout tape was affixed to the patient label which did not assure the endoscope processor reached the required time or temperature to assure disinfection;
4) On 02/17/14, there was no evidence which scope was used and no evidence the computer readout tape was affixed to the patient label which did not assure the endoscope processor reached the required time or temperature to assure disinfection;
5) On 03/24/14, there was no patient label affixed to the log for scope #521 and there was no computer readout tape which did not assure the endoscope processor reached the required time or temperature to assure disinfection;
6) On 03/25/14 two entries on the log had no evidence which scopes were used for two separate patients. There was no evidence computer readout tapes were affixed to the patient labels which did not assure the endoscope processor reached the required time or temperature to assure disinfection;
7) On 05/20/14 two entries on the log had no evidence which scopes were used for two separate patients. There was no evidence computer readout tapes were affixed to the patient labels which did not assure the endoscope processor reached the required time or temperature to assure disinfection;
8) On 05/28/14 two entries on the log had no evidence which scopes were used for two separate patients. There was no evidence computer readout tapes were affixed to the patient labels which did not assure the endoscope processor reached the required time or temperature to assure disinfection;
9) On 05/30/14 there was no evidence which scope was used and no evidence the computer readout tape was affixed to the patient label which did not assure the endoscope processor reached the required time or temperature to assure disinfection;
10) On 06/05/14 there was no evidence which scope was used and no evidence the computer readout tape was affixed to the patient label which did not assure the endoscope processor reached the required time or temperature to assure disinfection; and
11) On 07/20/14 there was no evidence which scope was used and no evidence the computer readout tape was affixed to the patient label which did not assure the endoscope processor reached the required time or temperature to assure disinfection.
C. Findings listed as A 1-11 were verified with the Manager for Central Sterilization during interview 03/02/14 at 1320.

Based on review of policy, review of Acute Care Therapy Staff employee files, and interview, it was determined the infection control officer failed to have a process in place to ensure the Hepatitis B risk status was assessed for 8 (Physical Therapists (PT) #1-4, Physical Therapist Assistant (PTA) #1, Speech Language Pathologist (SLP) #1, Therapy Technicians #1 and 3) of 11 (Physical Therapists (PT) #1-4, Physical Therapist Assistant (PTA) #1, Occupational Therapist (OT) #1, Certified Occupational Therapist Assistant (COTA) #1, Speech Language Pathologist (SLP) #1, Therapy Technicians #1-3) Acute Rehabilitation Therapists. By not assuring the Acute Rehabilitative Staff were screened prior to working, the facility couldn't assure they were controlling infections and communicable diseases of patients and personnel. The failed practice had the likelihood to affect all patients that received Acute Rehabilitative Care. Findings follow:

A. Review of Employee Health policy titled "Pre-Employment Health Screening" stated "Hepatitis B risk status. Offer Hepatitis B vaccination & let prospective employee decide to accept or decline vaccination."
B. Review of Acute Rehabilitative Staff employee files revealed no evidence of a Hepatitis vaccination or declination in the files for PT #1-4, PTA #1, SLP #1, Therapy Technician #1 and 3.
C. During an interview on 02/27/15 at 1505, the Director of Quality verified the lack of evidence of a Hepatitis vaccination or declination in the above mentioned Therapists' files.

Based on clinical record review and interview, it was determined the operative report for 7 of 7 (#2 and #25-#30) surgical patients did not include the time of the operation. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow:

A. Review of the operative reports revealed the time of surgery was not documented for Patient #2 and #25-#30.
B. During an interview on 03/02/15 at 1213, the Clinical Applications Analyst confirmed there was no time on the operative report for Patient #2.
C. During an interview on 03/02/15 at 1355, the Nurse Manager confirmed there was no time on the operative report for Patient #30.
D. During an interview on 03/02/15 at 1415, Registered Nurse #1 confirmed there was no time on the operative report for Patient #25-#29.

Based on review of Anesthesia policies and procedures, review of Perioperative Inservice sign-in sheets for January 2014-January 2015 and interview it was determined 13 of 13 (#1-#13) Certified Registered Nurse Anesthetists (CRNA) failed to attend safety training. Failure to attend safety training prevented CRNAs from becoming familiar with protocols designed to protect patients and staff from injury in an emergency (i.e. fire in the operating room, tornado, information systems failure, earthquake). The failed practice was likely to affect all CRNAs and patients undergoing anesthesia in the facility. Findings follow:

A. Review of Anesthesia policy, "Safety Program" revealed "All staff members will participate in all safety drills and post-evaluation meeting. Participation will be documented in annual performance appraisals."
B. Review of Perioperative Inservice sign-in sheets for January 2014-January 2015 which included safety topics (i.e. fires) revealed no evidence CRNA #1-#13 attended any safety training.
C. During interview with the Quality Assurance Director on 02/26/15 at 1315 a request was made for evidence CRNAs attended safety training. On 03/02/15 at 0905, the Quality Assurance Director confirmed there was no evidence CRNAs attended safety training.