HospitalInspections.org

Based on review of a list of hospital staff, personnel files and interviews with hospital staff, the hospital failed to maintain verification of current licensure and training for personnel working in the hospital.

Findings:

1. Staff # G, a registered nurse contracted to insert peripheral central catheters (PICC lines), did not have a license on file. There was no verification of licensure, proof of training, education, and qualifications to perform the procedure. Staff G was documented in Pt #21's medical record as providing PICC line placement.

2. Staff #F a ophthalmic technician who worked in the operating room - There was no verification of certification, proof of training, education, and qualifications to perform ophthalmic duties in the operating room. This finding was verified with Staff B, the operating room supervisor in an interview on 8/3/2011.

3. The facility listed magnetic resonance imaging (MRI) services as provided under contract. There was no information provided to the surveyors that the hospital verified licensure, proof of training, education, and qualifications to perform the procedures. There was no documentation the facility oriented and trained the MRI personnel.

4. Staff #A told surveyors the facility used agency nursing to provide patient care. There was no information provided to surveyors to document the hospital verified licensure, proof of training, education, and qualifications to perform patient care. There was no documentation the facility oriented and trained the contract agency personnel.

5. These findings were reviewed with administration at the exit conference 8/3/11. No further documentation was provided.

Based on record review and interviews with hospital staff, the governing body does not ensure that all functions pertaining to the duties required of the governing body are carried out.


1. The governing body does not ensure that services provided either under a contract or by employees are provided in a safe and effective manner.
(a) The hospital failed to maintain verification of current licensure and training for personnel working in the hospital. refer to tag 0023
(b) The hospital does not ensure that services provided by contract are evaluated through the quality assurance/performance improvement (QAPI) program. refer to tag 0083
(c) The hospital failed to ensure nursing service has a procedure in place to verify that hospital nursing personnel for whom current licensure is required have a valid and current licensure. refer to tag 0394
(d) The hospital failed to ensure the Director of Nursing (DON), or designee, provided orientation and evaluation of agency personnel. refer to tag 0398
(e) The hospital failed to have documentation showing all the personnel operating the imaging equipment are qualified and trained. refer to tag 0547
(f) The hospital failed to insure the surgical services were supervised by a qualified registered nurse with ongoing education, competency and training in surgical services. refer to tag 0942

2. The governing body does not ensure the hospital maintains an active ongoing program to prevent, control, and investigate infections and communicable diseases minimize infections and communicable diseases in patients and staff. Refer to tag 0474.

Based on record review and interviews with hospital staff, the governing body does not ensure that services provided by contract are evaluated through the quality assurance/performance improvement (QAPI) program.

Findings:

1. The hospital did not have a list of contracted services and their scope.

2. The QAPI program did not include an evaluation of contracted services.

3. Staff A verified on 08/03/11 that the hospital did not have a list of contracted and their scope.

Based on record review and interviews with hospital staff the hospital does not ensure that the hospital has a procedure that is implemented to inform patients how to submit a written or verbal grievance to the hospital. The hospital's grievance policy stated that the information for patients on how to submit a grievance will be in the hospital's admission handout. Review of the patient admission handout and an interview with Staff E on 08/02/11 in the afternoon verified that there was no information in the handout on how to submit a grievance.

Based on the review of abuse and neglect policies and procedures and interviews with hospital staff, the hospital does not have mechanisms/methods defined in a policy that clearly describe the procedures to follow when a patient alleges abuse by a hospital employee.

Findings:

1. The hospital provided policies for review that addressed child abuse, elder abuse, sexual abuse and spousal/domestic abuse concerning patients who present to the hospital. The policies did not clearly define the steps to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker and did not contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect .

2. Interviews with Staff A in the afternoon of 08/03/2011 verified that the hospital does not have a written policy that includes the required elements for effective abuse and neglect protection.

Based on review of personnel files and interviews with hospital staff, the hospital failed to ensure nursing service has a procedure in place to verify that hospital nursing personnel for whom current licensure is required have a valid and current licensure.

Findings:

1. On 8/2/11 the surveyors requested agency nurse's personnel file. Staff A told surveyors that information was kept at the agency. The hospital did not verify licensure on any agency nursing personnel

2. On 8/3/2011 the surveyors requested a registered nurses file who contracted with the hospital to provide peripherally inserted central line catheters (PICC) lines. Staff A told surveyors the facility did not have information on the contracted nurse. The hospital did not verify licensure on the contracted registered nurse.

3. The above findings were reviewed with the administrative team during the afternoon of 8/3/2011.

Based on review of personnel files and interviews with hospital staff, the hospital failed to ensure the Director of Nursing (DON), or designee, provided orientation and evaluation of agency personnel.

Findings:

1. On 8/2/11 the surveyors requested agency nurse's personnel file. Staff A told surveyors that information was kept at the agency. No documents were provided to surveyors on any agency nursing personnel orientation, training, competency, or evaluation.

2. On 8/3/2011 the surveyors requested a registered nurses file who contracted with the hospital to provide peripherally inserted central line catheters (PICC) lines. Staff A told surveyors the facility did not have information on the contracted nurse.

3. Staff F a ophthalmic technician who worked in the operating room - There was no verification of certification, proof of training, education, and qualifications to perform ophthalmic duties in the operating room. This finding was verified with Staff B, the operating room supervisor in an interview on 8/3/2011.

4. The above findings were reviewed with the administrative team during the afternoon of 8/3/2011.

Based on review of hospital documents, review of personnel files and interviews with administration, the hospital failed to have documentation showing all the personnel operating the imaging equipment are qualified and trained.

Findings:

1. On the morning of 08/2/2011 surveyors requested radiology policy and procedure manuals and radiology personnel files. Contract magnetic resonance imaging (MRI) was listed as a service provided at the facility. The facility was not able to provide files for the MRI staff.

2. There was no documentation the medical staff or the radiologist had developed, reviewed, and approved criteria designating personnel competent to perform MRI procedures. On the afternoon of 8/2/2011, Staff C confirmed this finding.

2. On 8/3/2011 these findings were presented to administration in the exit conference. No further documentation was provided.

Based on review of medical records, policies and procedures, dietary consultation reports, and interviews with staff, the facility failed to ensure dietary services were provided in an organized manner and problems identified in dietary were included in quality assurance performance improvement activities (QAPI).

Findings:

1. In an interview with Staff D on 8/3/2011 surveyors were told the dietary department did not participate in any hospital committees where departmental concerns would be addressed. Staff D told surveyors a temperature log was submitted but there was no committee where dietary concerns were reviewed. Review of ancillary committee, medical staff committee, and governing body committee meeting minutes did not include any dietary problems.

2. Patient #35's medical record included physician orders for dietary consult. There was no documentation in the chart that the dietitian had performed a dietary consult.

3. According to the hospital's policy on nutritional screen, all patients with skin breakdown will have a nutrition assessment. Pt's 22, 23, and 24 medical record included documentation the patients had skin break down. There was no evidence the dietitian assessed the patient's nutritional needs. In an interview on 8/3/2011 Staff D told surveyors the nutritional screen completed by the nursing staff would trigger a reflex order to the department for a nutritional assessment based on the screen. Staff D told surveyors there had not been a consistent contract dietitian sent to the hospital for the past several months. Staff D indicated because of this it was difficult to orient and train the dietitians on the computer and the reflex testing and computerized dietary assessment.

4. The hospital could not provide personnel information for the dietitians listed on the "consulting dietitians report". There was no evidence the dietitians had been oriented and trained. There was no documentation of licensure and qualifications for all of the dietitians listed on the consulting dietitian reports for 2011.

This information was provided to administration at the time of the exit conference. No further documentation was provided.

Based on medical record review, interviews with staff, and policy review the facility failed to provide nutritional assessments by a qualified dietitian when ordered.

Findings:

1. Patient #35's medical record included physician orders for a consult by the dietitian. There was no documentation in the chart the dietitian had performed a dietary consult.

2. According to the hospital's policy on nutritional screen, all patients with skin breakdown will have a nutrition assessment. Pt's 22, 23 and 24's medical record included documentation the patients had skin break down. There was no evidence the dietitian assessed the patient's nutritional needs.

3. These findings were confirmed in an interview on 8/3/2011 with the dietary supervisor.

Based on interviews with staff and review of hospital documentation, the hospital failed to maintain an active ongoing program to prevent, control, and investigate infections and communicable diseases to minimize infections and communicable diseases in patients and staff.

Findings:

1. On 08/03/2011 at 0900 Staff A, the person identified as responsible for infection control, told the surveyors the hospital does not have an infection control log for patients and staff to track infections and possible transmissions of infections and communicable diseases.

2. Staff A and Staff B told the surveyors that no one monitored the use of the hospital disinfectant, both on the inpatient units and surgery, to ensure the disinfectant was applied appropriately according to manufacture guidelines. Review of meeting minutes containing infection control headings did not contain evidence the hospital's infection control program chose the disinfectants or was responsible for selection of the disinfectants to ensure they were effective for the organisms that might occur in the hospital.

3. With the exception of reference to OSHA (Occupational Health and Safety Administration), the infection control policy and plan did not reflect the hospital chose/adopted nationally recognized infection control practices or guidelines, such as CIC (Centers for Disease Control and Prevention), APIC, (Association for Professionals in Infection Control and Epidemiology, or WHO (World Health Organization).

4. The current infection control plan, with an adoption/review date of July 2010 and again January 2011, stipulated, "The committee shall meet monthly, at least ten (10) times a year." Review of meeting minutes reflected infection control was conducted quarterly as part of the Ancillary Services Committee. This was verified with administration on 08/03/2011.

5. The hospital's infection control program did not specify the types and frequencies of surveillance activities. The hospital's infection control program did not monitor to ensure policies and practices developed to provide a sanitary and safe environment and prevent transmission of infectious and communicable diseases were followed. Staff A stated on the afternoon of 08/02/2011, with the exception of handwashing, no other surveillance activities were conducted.

6. The hospital's infection control program did not review its sterilization practice with corrective actions to limit the use of unwrapped/"flashed" instruments and did not maintain records that identified which instruments were used on each patient.
a. On 08/03/2011 at 1410, Staff U told the surveyors that eye instruments were "flashed" unwrapped with no dry time.
b. On the afternoon of 08/03/2011, Staff B and U stated they did not report "flash"/shortened unwrapped cycles to infection control for review or analysis of practices with corrective actions to limit use. This was confirmed by review of infection control meeting minutes and interview with Staff A.
c. The "flash" tape brought to the surveyors for review on the afternoon of 08/03/2011, did not correspond with the "flash" notebook also brought for review. No additional data was presented.
d. Staff B did not know the type (gravity or pre-vacuum) of sterilizer the hospital had - other that it was steam.

7. Review of staff, allied health and physician health files did not reveal the infection control program reviewed and developed corrective actions to ensure all had complete immunization histories. Eleven of eleven physicians, two of two allied health and six of twelve staff did not have complete immunization histories. Staff A stated she did not report this to infection control and knew they were behind.

8. Meeting minutes did not reflect infection control issues/concerns, surveillances, and practices were monitored, reviewed and analyzed with corrective actions to prevent, identify and manage infections and communicable diseases with measures that result in improvement on an ongoing basis.

Based on record review and interviews with hospital staff the hospital does not ensure that a log of all infections and communicable diseases is maintained that identifies incidents of infection and communicable diseases in both patients and staff that would enable the hospital to evaluate the data contained in the log to determine whether the infections were either present on admission or health-care associated and to protect both the patients and staff from infections.

Findings:

1. On 08/03/2011 at 0900 Staff A, the person identified as responsible for infection control, told to the surveyors the hospital does not have an infection control log that contains identification and location of the patient, the date of admission, onset of infection, the type of infection, the cultures taken, the results when known, any antibiotics administered (and whether the organism is sensitive or resistive to the medication), and the practitioners responsible for care of the patient.

2. At the same time, Staff A stated the hospital did not have an infection control log that tracked employee health.

Based on interviews with staff, review of personnel files and policy and procedures the facility failed to insure the surgical services were supervised by a qualified registered nurse with ongoing education, competency and training in surgical services. On 08/3/11 surveyors reviewed Staff B, Operating Room Supervisor's personnel records. Documentation in the file did not indicate any training in the operating room other than on the job. There was no documentation indicating Staff D had current education and training as the Operating Room Supervisor. On 8/3/2011 Staff B told surveyors the staff did not have access to outside resources such as Association of Perioperative Nursing (AORN). A skills checklist was documented in Staff B's personnel file. The list was not specific to the operating room and operating room equipment. The skills checklist for Staff B the OR supervisor was the same as all the nursing staff from all areas and was not specific to the operating room and pre or postoperative areas.

Based on staff interviews and record review, the facility failed to ensure that surgical services maintained standards of safe patient care.

Findings:

1. On 8/2/11 surveyors reviewed operating room policies. Several policies last review and revision date were 2008. The facility did not have a current policy on "flash sterilization".

2. Staff stated during an interview in the afternoon 8/2/11 that flash sterilization was utilized routinely for cataract surgeries because they did not have sufficient instrument sets. The facility has two sets of instruments for cataract surgeries. Sterilization logs provided to surveyors did not have flash loads recorded. This was verified with operating room staff on 8/2/11. The facility does not have a process for tracking flash loads.
"Flash" (unwrapped) sterilization:
The Centers for Disease Control (CDC -- from Infection Control and Hospital Epidemiology, "Guideline for Prevention of Surgical Site Infection", April 1999, page 261) and Prevention and the Association of Operating Room Nurses (AORN -- Perioperative Standards and Recommended Practices, pages 578 through 581, 2008 edition) do not recommend the use of "flash" sterilization for the routine sterilization of instruments, reasons of convenience or as an alternative to purchasing additional instrument sets or to save time. "Flash" sterilization, according to current CDC guidelines, should be limited to the purpose of sterilizing a surgical instrument in an emergency, such as when a needed instrument has been dropped or otherwise become contaminated.

3. During a tour of the operating room on 8/2/2011 at 1600, a surveyor found normal saline and irrigation fluid in a blanket warmer. The blanket warmer thermometer indicated the temperature in the warming chamber was 140 degrees Farenheit. At this temperature fluids used for irrigation or intravenous administration have potential to cause burns. The manufacturer recommended temperatures for warming fluids is to a maximum of 120 degrees. This finding was verified with the Chief Executive Officer and maintenance at the time of the observation.

Based on review of medical records and rehabilitation policies and procedures and interviews with staff, the hospital failed to ensure physical therapy (PT) services were provided as ordered for two of two (Patients # 35 and 37) patients, who had orders for PT and whose medical records were reviewed.

Finding:

1. The rehabilitation services policies and procedures did not specify that PT would only be provided Monday through Friday or define that daily therapy orders meant five times a week.

2. Record #35 - On 05/09/2011 at 1103, a clarification order for PT specified treatment be provided twice a day. PT treatment was not provided or offered on 05/14 and 15/2011. Documentation did not demonstrate PT was provided on the morning of 05/16/2011 - only the 1900 treatment was documented.

3. Record #37 - On 05/19/2011 at 1570, a clarification order for PT specified treatment be provided two times daily. PT treatment was not provided or offered on 05/21 and 22/2011.

4. On 08/03/2011, Staff A and T confirmed Findings #2 and #3 and told the surveyors that PT only saw/treated patients Monday through Friday.

Based on review of medical records and personnel files and interviews with hospital staff, the hospital failed to provide ongoing activities to swingbed patients that were based on a comprehensive assessment performed by a qualified activity coordinator/professional. This occurred in two of two (Patients #35 and 37) swingbed patients, whose medical records were reviewed.

Findings:

1. Staff P - According to personnel files review, the person identified by the administration as the activity coordinator for the hospital's swingbed program was not a recreation specialist, licensed or registered recreation therapist, occupational therapist or occupational therapy assistant and had not completed the course approved by the State. This finding was reviewed and confirmed with Staff P and his supervisor, Staff S on the afternoon of 08/03/2011.

2. Swingbed Patients #35 and #37 did not have comprehensive activity assessments documenting the patients interests and physical, mental and psychosocial needs. This was confirmed with Staff T at the time of chart review on 08/03/2011.

3. Swingbed Patients #35 and #37 did not have documentation of activities being provided. This was confirmed with Staff T at the time of chart review on 08/03/2011.

4. On the afternoon of 08/03/2011, Staff P stated he did not always know when swingbed patients were admitted and did not present to the floor unless he was notified. He stated he spent most of his time on the geriatric psychiatric unit providing activities for those patients.