HospitalInspections.org

This deficiency was not corrected at the time of the revisit.

Based on review of meeting minutes and hospital documents, the hospital failed to review, analyze and trend incidents, grievances and complaints in order to develop plans to improve patient safety and clinical performance. Meeting minutes did not reflect this had occurred.

Based on record review and interviews with hospital staff, the governing body failed to ensure that adverse events such as incidences and medication errors are identified, tracked, analyzed and preventative actions taken. Adverse events were not tracked and analyzed as part of an ongoing Quality Assurance/Performance Improvement (QA/PI) program.

Findings:

1. There was no documentation of the analysis and trending of medication errors by hospital staff as part of an ongoing QA/PI program.

2. Staff C stated that there was no trending and analysis of medication errors.

3. Five medication errors committed by a single nurse did not have any analysis, investigation or documentation of counseling of the nurse by the hospital. The nurse's personnel file did have any documentation of the errors.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure all patients received a comprehensive nursing assessment upon admission. Findings:

A hospital policy titled, "Nursing Assessment", documented, "... A nursing assessment shall be completed by a registered nurse... Nursing Assessment (form W 204) shall be completed... An addendum shall also be completed on any youth between the ages of 6-17 yrs..."

On 03/05 and 03/06/13, twenty patient records were reviewed for comprehensive nursing assessments upon admission. None of the records had complete assessments performed by a registered nurse.

1. Some clinical records contained nursing assessment forms (W 204) that had some parts (physical history and assessment) completed by the patient or a parent/guardian, and not by a registered nurse. The patients or guardians were asked to complete the physical assessment portion of the document that included clinical terms such as hypertension, renal, GI, hemoptysis, malaise, dysphagia, nocturia, lethargy, syncopy, emetics, among others.

Much of the physical assessment portion of the form (completed by the patients or guardians) was left blank, indicating the patients/guardians did not understand the terminology. There was no evidence the nursing staff reviewed the assessment with the patient/guardian to ensure all relevant information about the patient's physical status was captured.

2. There was no documentation on the form that indicated the nursing staff performed a head to toe assessment of all systems, or included other basic elements of a nursing physical assessment such as heart/lung/bowel sounds.

However, the nursing assessments were signed by registered nurses as if they had completed it. When nursing staff were asked if the patients or guardians routinely completed the physical portion of the nursing assessment, they stated they did. The nurses also stated they signed the document when it was completed by the patient or someone else.

3. Some of the clinical records contained nursing assessment forms that had missing pages.

4. Some clinical records had a Patient Health History form completed by the patient, but did not contain a comprehensive nursing assessment at all.

The staff stated the Patient Health History form was always given to patients or guardians for completion. This form questioned patients about incontinence, aids for elimination, ADHA, assistive devices and other terms that are not widely understood by non-medical persons.

5. Some of the pediatric patients had an addendum form completed, but had no comprehensive nursing assessment attached. The addendum form was always completed by the parent or guardian.

6. The Nutritional Screening portion of the nursing assessment only addressed the presence of a diagnoses including "anorexia, bulemia, diabetes, malnutrition, pregnancy or a special needs diet," and the presence of food allergies.

The nursing nutritional screening did not address the presence of GERD, peptic ulcers, bowel disease, nausea and vomiting, mechanical difficulties with chewing and swallowing, recent significant weight loss or gain, or the use of stimulants, diuretics or emetics. The screening did not address the patient's dentition.

The screening did not address other abnormal eating habits such as binge eating or compulsive eating. It did not include assessment for the compulsive ingestion of non-food items.

The DON was asked if the nutritional screening portion of the comprehensive nursing assessment captured enough information to make appropriate referrals for consultation with the staff dietitian. No comment was made.

She was asked if the nutritional screening tool was developed in consultation with the dietitian. She stated she she was not sure.

Based on record review and interviews with hospital staff, the hospital failed to ensure that nursing personnel have orientation and training on the safe handling and administration of medications. Three ( #'s A, B & C ) of three nursing personnel files reviewed did not have evidence of any orientation or training concerning the handling and administration of medications.

Findings:

1. Incident reports documented several medication errors committed by nursing personnel. There was no evidence of any orientation and medication training in the nurses' personnel files.

2. There was no evidence of any inservices for nursing personnel concerning medication training.

3. There was no evidence that nursing personnel were trained according to approved policies and procedures concerning the proper storage, preparation, dispensing and administration of drugs.

4. Hospital staff verified on 03/06/13 in the afternoon that there was no medication orientation, training and competency for nursing personnel.

Based on record review and interviews with hospital staff, the hospital failed to ensure that current and accurate records of scheduled drugs are maintained and periodically reconciled. Controlled drug count sheet # 4265 did not document the beginning balance of Hydrocodone/APAP 10/325 so that a correct beginning count could be determined. On 01/09/13 a subtraction error on sheet # 4265 made the balance incorrect. There was no documentation that this error was reconciled and corrected.

Based on review of personnel files and meeting minutes, and interviews with hospital staff, the hospital failed to provide and designate a qualified, trained individual to develop, implement and maintain an ongoing infection control program based on current principals and methods of infection control.

Findings:

1. On the morning of 03/05/13, administrative staff told the surveyors that Staff C was the infection control officer/preventionist with Staff F helping to collect data.

2. Meeting minutes listed Staff F as the infection control preventionist and Staff C as the Director of Nursing.

3. Review of Staff C's personnel file did not contain evidence that Staff C had training or experience in infection control. The information provided did not contain documentation of training and experience on the principals and methods of infection control. The personnel file did not contain a job description for infection control preventionist.

4. Review of Staff F's personnel file did not contain evidence that Staff F had training or experience in infection control. Staff F's personnel file did contain a performance evaluation for Infection Control and Education Coordinator. Staff F does not have any medical background.

3. On the afternoon of 03/06/13, Staff C stated neither she nor Staff F had any infection control training, formal or documented courses or training in infection control principals or setting up an infection control program.

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to:

a. develop and implement a comprehensive bloodborne pathogen exposure control plan according to OSHA standards;

b. ensure the hospital's tuberculosis control plan was appropriate for the patient services provided and was implemented as required;

c. ensure employees were adequately immunized and screened for communicable diseases;

d. ensure transmissions of infections and communicable diseases did not occur between patients and staff;

e. develop and implement and ongoing infection control surveillance program to ensure infection control policies and procedures were followed;

f. ensure a sanitary environment was maintained;

g. ensure infection control policies and procedures and practices are based on current recognized standards.

Findings:

1. On 03/05/13, the hospital's bloodborne pathogen exposure control plan was reviewed. The plan was not reviewed and updated annually as required.

The hospital's infection control officer was not involved in the oversight of the bloodborne pathogen exposure control plan as described in the plan.

The plan did not follow the OSHA Bloodborne Pathogen Standard 29 CFR 1910.1030. Employee exposures to blood or other potentially infectious materials were not handled according to the OSHA Standard as evidenced by:

A. When employees were exposed, the source patient was not always identified.

B. When source patients were identified, there was no documentation of testing for bloodborne pathogens.

C. The hospital had no record of employee bloodborne pathogen test results.

D. The hospital did not have have evidence that exposed employee baseline blood samples were retained by the lab for 90 days (under applicable circumstances).

E. The hospital did not have evidence all required information and documents related to the exposure event and the employee's immunization status were provided to the healthcare professional responsible for evaluating the employee.

F. The hospital had no documentation of the healthcare professional's written opinion and no documentation a copy of the opinion was given to the employee.

G. The hospital had no documentation of exposed employees who refused exposure follow-up testing and/or prophylaxis.

H. The hospital had no sharp's injury log.

I. The hospital had no documented evidence exposure events were evaluated for a root cause analysis to prevent future occurrences.

J. The hospital had no documentation exposed employees were re-trained in infection control and safety measures to prevent exposures in the future.

In addition to the findings in the blood-borne pathogen exposure control plan, the human resources manager stated the hospital contracted with an occupational healthcare provider for post-exposure care and testing for employees. The hospital had no policies and procedures for this service that detailed the responsibilities for both the hospital and the occupational healthcare provider in the post-exposure protocol.

The hospital had not evaluated the occupational healthcare provider for the quality and appropriateness of it's care to employees for post-exposure follow-up.

The human resources manager was informed of the findings. No additional information was provided.

2. On 03/05/13, the hospital's tuberculosis control plan was reviewed. The plan documented the hospital had an "AFB isolation room" and also documented employees would use an N-95 particulate respirator when caring for known or suspected patients with active TB.

The director of nurses stated the hospital did not supply N-95 particulate respirators.

The plan documented actions to be taken by staff for the initiation of airborne isolation and that staff who provided care in this room should wear a "surgical mask". A surgical mask is not the appropriate protective equipment for airborne isolation.

The plan documented, "... Pediatric patients with pulmonary or laryngeal TB will be placed in airborne isolation until they are determined to be non-infectious..."

Some documentation in the plan indicated patients with active TB could be cared for by the hospital for extended periods. Other parts of the plan documented patients with active TB would be transferred out immediately.

The DON stated the hospital would not care for patients in airborne isolation.

The TB control plan also documented employees would participate in TB screening on an annual basis. When employee health files were reviewed, not all employees had documented PPD testing and/or symptom screening.

The hospital did not provide two-step TB testing for those employees without documentation of TB testing within the last year as required by the TB control plan and by national infection control standards.

3. On 03/05/13 and 03/06/13, employees health records were reviewed.

The health file for staff A had no documentation of TB skin testing upon hire and no documentation of a previous TB skin test within the previous year. There was no documentation of MMR vaccination.

The health file for staff P had no documentation of TB skin testing upon hire and no documentation of a previous TB skin test within the previous year. Two months later, a one step TB test was performed, rather than a two-step skin test as required.

The health file for staff J had no documentation of MMR vaccination.

4. The hospital's infection control logs did not contain data about staff infections and communicable diseases. Not all infections were captured on the log. Patients with head lice and scabies are not placed on the log.

Staff C confirmed on 03/06/13 that neither she nor Staff A received information about staff illnesses or infections and no analysis was performed to ensure transmissions of infections and communicable diseases occurred.

5. No surveillance data was provided to the surveyors for review. Staff C told the surveyors that the hospital did not monitor to ensure infection control policies and procedures were followed, including monitoring of:
A. Hand hygiene,
B. Isolation
C. Disinfectants.

6. Disinfectants used by the facility are not reviewed by infection control to ensure they are effective.

A. The disinfectant used by the facility, Buckeye Eco Neutral Disinfectant, is not effective against clostridium difficile or tuberculosis.

B. Meeting minutes did not reflect the disinfectants for head lice and scabies have been reviewed and approved.

7. Policies and procedures did not reflect current standards by CDC (Centers for Disease Control).

A. The hospital's adopted definition for nosocomial (hospital acquired infections - HAI) does not follow CDC guidelines. On the morning of 03/05/13, Staff C stated they had contacted similar hospitals and were going to use 7 days to define nosocomial infections. The hospital policy documented that Parkside "will use a time period of 7 (seven) days for incubation period of pneumonia and other types of lower respiratory infections."

B. The hospital policies for head lice and scabies documented, "Special cleaning or lice spray on furniture is not recommended." This does not reflect current recommendations. On 03/06/13, Staff E stated the hospital staff did spray the furniture with appropriate insecticides.

C. The hospital's current list of State reportable diseases and organisms is not current.

Based on review of infection control data, medical records and meeting minutes and interviews with hospital staff, the hospital does not ensure the infections control program has a current log/tracking mechanism for patients and staff to track infections and possible transmissions of infections and communicable diseases.

Findings:

1. The sample of the infection control log attached to the hospital infection control log policy contained the required elements as required by State Hospital Standards. This form was not utilized by the hospital.

2. The forms provided to the surveyors as the infection control logs used by the hospital were not standardized. Each month log was different and contained different information. None of these logs indicated if a culture was done and if so if the antibiotic used was appropriate. The logs did not contain information about staff illnesses.

3. The logs do not identify if any patients were placed in isolation or what type of isolation.

Review of a patient record revealed the patient had head lice two months after admission. The patient's name was not on the infection control log. No incident/occurrence report was completed. Meeting minutes did not reflect this incident was reviewed to ensure hospital infection control protocols were followed or analyzed to determine if protocols were adequate and transmission of the infection did not occur.

4. The hospital does not have a current list of diseases and infections reportable to the State and County Health Departments.

5. Meeting minutes for 2011 and 2012 did not reflect a review of the infections with analysis and review of staff infections to ensure transmissions between staff and patient and staff and other staff did not occur. Meeting minutes did not reflect review of patient conditions requiring isolation were reviewed and analyzed to ensure isolation was used and it was used appropriately.

6. On 03/06/13 at 1530, Staff C told the surveyors that she and Staff F did not receive data about staff illnesses and that no review to ensure transmission did not occur was performed.

Based on review of hospital documents and meeting minutes concerning infection control, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, were processed through Quality Assessment and Performance Improvement (QAPI) and:
1. Were monitored, reviewed and analyzed;
2. Corrective actions were taken to prevent, identify and manage infections and communicable diseases with measures that resulted in improvement on an ongoing basis; and
3. Corrective actions were followed to ensure improvement resulted and alternative solutions/actions were not needed.

Findings:

1. The prior infection control plan documented infection control was to meet every other month on the 3rd Wednesday of the month. This did not occur in 2011 and 2012. This finding was confirmed with Staff C and R on 03/06/13. The current infection control program documented the infection control committee would meet the 4th Wednesday of the month during January, April July and September. The last infection control meeting minutes supplied to the surveyors was October 24, 2012. The surveyors were told no meeting minutes since that time had been completed.

2. Meeting minutes that contain infection control data reported nosocomial infections and personnel exposures. The meeting minutes did not contain analysis or plans of action taken to reduce infections or exposures. Employee illnesses and infections were not reported and no analysis of transmissions were conducted.

2. The QAPI program has not provided oversite of the infection control program to ensure a safe environment. Staff C stated on 03/06/13 that neither she nor Staff F have not conducted any surveillance/monitoring to ensure infection control policies were followed. This included, but not limited to:
a. Hand hygiene practices;
b. Isolation practices;
c. Disinfectant practices.

3. Review of infection control data showed patients with infectious diseases and patients who acquired nosocomial infections while in the hospital. Meeting minutes did not contain evidence the hospital leadership analyzed the data; developed a plan of action to reduce and/or prevent transmission of organisms; and provide follow-up to ensure corrective actions taken were effective.

4. Although the meeting minutes containing infection control data documented the current "green" disinfectant products were discussed, the meeting minutes did not contain a review to ensure the disinfectants used were appropriate. The one used by staff, Buckeye Eco Neutral Disinfectant is not effective for tuberculosis or clostridium difficile. Although the hospital administrative staff stated they did not accept patients for treatment with known tuberculosis, the facility has no procedure/protocol to follow should a patient, who was already admitted, was discovered to have tuberculosis or a disinfectant that would be effective.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to appoint/designate a physician, with knowledge, experience and capabilities to supervise and administer the service properly, to be the director of respiratory care services for the hospital.

Findings:

1. Hospital policies documents the hospital can provide respiratory services of hand held nebulizers and C-PAP (continuous positive airway pressure). The policies did not contain evidence they were developed by or with consultation by a respiratory therapist and a physician director with knowledge and experience.
This was confirmed by interview with hospital staff on 03/06/13.

2. Review of the hospital's department head list and meeting minutes did not show that a physician had been designated as director for respiratory services

Based on review of hospital documents, and personnel files, and interviews with hospital staff, the hospital failed to provide respiratory services in accordance with acceptable standards of practice and Oklahoma State Hospital Standards Licensure requirements by trained staff and supervised by a respiratory therapist.


Findings:

1. The hospital has policies documenting the hospital provides respiratory services of hand held nebulizers and C-PAP (continuous positive airway pressure). Documentation did not contain evidence the policies were developed by or in consultation with a respiratory therapist.

On the afternoon of 03/06/13, Staff K and R stated the hospital did admit patients with asthma that could need hand held nebulizers and that the hospital had a nebulizer on the children's unit. On 03/06/13, Staff C agreed respiratory services of hand held nebulizers and patient C- PAPs could be utilized in the facility.

2. Review of the hospital's department head list, contracts and employee list did not show respiratory services. This was confirmed with administration on 03/06/13.

3. State Licensure Hospital Standards, Subchapter 23-6(a) requires that "respiratory therapy services, including equipment, shall be supervised by a licensed respiratory therapist. Staff C, G, and Q confirmed on 03/06/13, that the hospital did not employee a respiratory therapist and did not have a contract with a respiratory therapist to provide supervision and training to staff providing respiratory services.

4. Staff C and R told the surveyors that nursing personnel would provide the hospital's respiratory services, but confirmed a respiratory therapist had not provided training.

5. Review of meeting minutes did not demonstrate respiratory services provided at the hospital were integrated and reviewed in the quality assessment and performance improvement and infection control programs.

Based on review of hospital documents, personnel files and interview with staff, the hospital failed to ensure that respiratory services/procedures were administered by trained staff with each respiratory therapy procedure performed by each employee designated in writing, including the amount of supervision required when performing each procedure. Three of three licensed nursing personnel (Staff A, B, and N), whose personnel files were reviewed or the staff were interview, did not have documented training and competencies performed by a respiratory therapist.

Findings:

1. According to hospital policies, the hospital could provide respiratory services of hand held nebulizers and C-PAP (continuous positive airway pressure). This was finding confirmed with administrative staff on the afternoon of 03/06/13.

2. Staff C, K and N stated nursing would provide respiratory treatments if patients required them.

3. Personnel file review for Staff A and B did not contain the required documentation of respiratory competencies.

3. Staff N stated no one had trained her to provide nebulizer treatments at the hospital, but that the children's unit had a nebulizer for patient use.