HospitalInspections.org

Based on review of the hospital's documents, and interviews, it was determined that the hospital failed to require that contracted services were evaluated for quality, and regulatory compliance, and a report provided to the Governing Body for review.

Findings include:

Document titled "Corporate By-Laws of Yavapai Community Hospital Association" (04/2020), revealed: "...Objectives...the hospital shall strive to provide quality care...Board of Trustees...Duties...ensure quality care...monitor plans and procedures to ensure continued compliance with the laws, rules, and regulations of Federal, State, and local governments...Quality Improvement...monitor the hospital's quality of care primarily through its regular review of number of established quality indicators...present the results of...monitoring and evaluation...to the Board on a regular scheduled basis...annually review the effectiveness of the Continuous Quality Improvement Program...develop policies and procedures...to improve the quality of care continuously...."

Documents titled "Quality/Patient Safety Meeting Minutes", "Quality Board", and "Governing Board Meeting Minutes", revealed the following:

Quality/Patient Safety Meeting Minutes:

i. Minutes dated: 09/05/2019, 10/03/2019, 11/07/2019, 12/05/2019, 01/02/2020, and 02/06/2020, revealed no documented evidence that contracts were reviewed and/or evaluated.

Quality Board Meeting Minutes:

i. Minutes dated: 12/12/2019, 02/13/2020, 04/09/2020, 06/11/2020, and 08/13/2020, revealed no documented evidence that contracts were reviewed and/or evaluated.

Governing Board Meeting Minutes:

i. Minutes dated: 09/23/2019, 10/28/2019, 12/09/2019, 01/27/2020, 02/24/2020, 03/23/2020, 04/28/2020, 05/26/2020, 06/22/2020, 07/27/2020, and 08/24/2020, revealed no documented evidence that contracts were reviewed and/or evaluated.

Personnel #1 confirmed during an interview conducted 09/23/2020 (1645), that an evaluation of vendors providing contracted services had not completed, ensuring that the services were provided in a safe and effective manner.

Based on review of the hospital's policies/procedures, documents, observations on tour, and interviews, it was determined that the hospital failed to require the patient nutrition refrigerators were checked for outdates, and that the patient nutrition refrigerator temperatures were checked, and recorded daily. This deficient practice poses a potential risk to the health and safety of the patient(s), when outdated foods are not discarded to avoid consumption, or when the refrigerator temperatures are not monitored to ensure that the refrigerators are within the acceptable temperature range.

Findings include:

Policy titled "Temperature Checks of all Refrigerators and Freezers Policy" (no #; 08/2018), revealed: "...Bacteria can multiply at warm temperatures...store and display food at appropriate cold temperatures to prevent bacteria from multiplying...following must be performed when making temperature checks of all refrigerators and freezers...employees will check the temperature of refrigerator and freezer units and record temperatures on the appropriate log daily...refrigerator temperatures...between 32F to 41F...freezer temperatures...between zero (0)F or less...temperatures outside of this range must be reported to supervisor immediately...engineering or outside contractor will be called to correct the problem...perishable foods will be moved to a different refrigeration unit...."

Policy titled "Patient Refrigerator Freezer Care and Cleaning" (no #; 04/2018), revealed: "...To maintain stability of food in an infection-free environment...food refrigerators are maintained at 34-40F...food freezers are maintained at zero (0)F or lower...food refrigerator/freezer contain only food supplies for patient use...food must be dated and properly wrapped or placed in a closed container...all food with an expiration date must be discarded after that date...charge nurse or designee is responsible for checking and recording the refrigerator temperature daily...if the temperature is out of range...adjust the thermostat...document the temperature and the action taken...if desired temperature cannot be obtained within four (4) hours, notify engineering and dispose of all perishable items...."

Document review of the "Emergency Department (ED) Patient Refrigerator" logs, "4A Patient Food Refrigerator Preventive Maintenance (PM)" logs, and "4B Patient Food Refrigerator PM" logs, revealed the following refrigerator/freezer temperatures:

ED Patient Refrigerator

i. Documented on auto-generated logs maintained by Engineering; temperature range required 33F - 40F;
ii. 09/13/2020 (31.72), 09/14/2020 (31.71), 09/15/2020 (31.08), 09/16/2020 (31.19), 09/17/2020 (31.6), 09/18/2020 (31.81), 09/19/2020 (32.01), and 09/20/2020 (32.06).

4A Patient Refrigerator/Freezer

i. September 2020 (Refrigerator): Temperature recordings - eight (8) out of twenty-one (21) days, showed no documented evidence of the temperature recorded;
ii. September 2020 (Freezer): Temperature recordings - eight (8) out of twenty-one (21) days, showed no documented evidence of the temperature recorded.

4B Patient Refrigerator/Freezer

i. September 2020 (Refrigerator): Temperature recordings - nine (9) out of twenty-one (21) days, showed no documented evidence of the temperature recorded;
ii. September 2020 (Freezer): Temperature recordings - eight (8) out of twenty-one (21) days, showed no documented evidence of the temperature recorded.

Observations on tour, conducted 09/21/2020, with Personnel #1, and Personnel #2, revealed the following outdates:

i. ED Patient Refrigerator: 1% milk (x1) expired 09/19/2020; seven (7) bagged meals (turkey sandwich, fruit cup, cookies) with no expiration date;

ii. 3B Patient Refrigerator: 1% milk (x4) expired 09/13/2020; 2% milk (x3) expired 09/14/2020; 2% milk (x3) expired 09/19/2020; fat-free milk (x3) expired 09/07/2020; fat-free milk (x5) expired 09/20/2020; plastic container of strawberries with no date/name;

iii. 4B Patient Refrigerator: fat-free milk (x7) expired 09/20/2020; plastic container of frozen fruit in freezer with no date/name.

Personnel #7 confirmed during an interview conducted 09/21/2020 (1233), that the ED Patient Refrigerator temperatures are recorded by Engineering.

Personnel #19 confirmed during an interview conducted 09/21/2020 (1250), that the ED Patient Refrigerator temperatures are to be recorded by the ED nursing personnel.

Personnel #8 confirmed during an interview conducted 09/21/2020 (1255), that the ED Patient Refrigerator contained seven (7) bagged meals (turkey sandwich, fruit cup, cookies), but that neither the bags or sandwiches had an expiration date on them, and that there should be an expiration date listed on both the bag and sandwich.

Personnel #1 and Personnel #2, confirmed during an interview conducted 09/21/2020, that the identified food items found in the ED, 3B, and 4B Patient Refrigerators/Freezers were expired and/or not labeled. Additionally, Personnel #1 and Personnel #2, both revealed that the temperature logs for the 4A and 4B Patient Refrigerators/Freezers had missing dates indicating that the temperatures had not been obtained and/or recorded.

Personnel #2 confirmed during an interview conducted 09/22/2020 (1150), that the ED Patient Refrigerator logs were provided by the Engineering Department. Personnel #2 revealed that the ED Patient Refrigerator has an automatic reading capability that is monitored by the Engineering Department. Personnel #2 confirmed that the temperature recordings received in Engineering, are supposed to be automatically sent to the ED Charge RN's, and that the ED Charge RN's are required to check the temperature log notification daily, and to notify the ED RN Manager and/or Director if the temperature readings are out-of-range. Personnel #2 revealed that per Engineering, it was determined that the temperature log reports were not being emailed to the ED Charge RN's, and that the ED Charge RN's were not reporting to the ED RN Manager and/or Director, that they were not receiving the temperature log reports. Additionally, Personnel #2 confirmed that the temperature logs provided for the date range 09/13/2020 through 09/20/2020, showed that the ED Patient Refrigerator temperature was out of range on all eight (8) days.

Based on review of the hospital's documents, observations on tour, and interviews, it was determined that the hospital failed to require that eye wash stations were checked/tested to ensure that they were working properly. This deficient practice poses a potenial risk to the health and safety of the healthcare worker(s), when eye wash stations required to be in designated work areas, are not serviced and/or tested according to manufacturer guidelines, or policy/procedure, with the potential for the eye wash stations to not function when needed for a healthcare worker to flush/wash their eyes in an emergent/urgent situation.

Findings include:

Document titled "Corporate By-Laws of Yavapai Community Hospital Association" (04/2020), revealed: "...Objectives...the hospital shall strive to provide quality care...Board of Trustees...Duties...ensure quality care...monitor plans and procedures to ensure continued compliance with the laws, rules, and regulations of Federal, State, and local governments...Quality Improvement...monitor the hospital's quality of care primarily through its regular review of number of established quality indicators...present the results of...monitoring and evaluation...to the Board on a regular scheduled basis...."annually review the effectiveness of the Continuous Quality Improvement Program...develop policies and procedures...to improve the quality of care continuously...."

Eye wash station tag labeled "Bradley", requires: "...Test this unit each week...test-operate valve(s) each week and sign below...report any malfunctions immediately...date...signed...."

Observations on tour conducted 09/21/2020 and 09/22/2020, revealed the following:

Surgery Department

i. Eye wash station #1: Bradley tag - initials on 08/03/2020, 08/10/2020, 08/17/2020, 08/24/2020, and 09/21/2020;
ii. Eye wash station #2: Bradley tag - initials on 08/03/2020, 08/10/2020, 08/17/2020, 08/24/2020, and 09/21/2020;
iii. Eye wash station #3: Bradley tag - initials on 08/03/2020, 08/10/2020, 08/17/2020, 08/24/2020, and 09/21/2020;
iv. Eye wash station #4: Bradley tag - initials on 08/03/2020, 08/10/2020, 08/17/2020, 08/24/2020, and 09/21/2020.

Food Service Department

i. Eye wash station (dishwasher area): Tag - initials on 04/30/2020, 07/28/2020, and 09/21/2020;
ii. Eye wash station (food prep area): Tag - initials on 04/30/2020, 07/28/2020, and 09/21/2020.

Endoscopy Department

i. Eye wash station #15: Bradley tag - initials on 09/21/2020.

Laboratory Department

i. Eye wash station #22: Bradley tag - initials on 10/16/2018, 05/27/2019, 06/03/2019, 06/13/2019, 04/30/20202, and 07/28/2020.

On 09/21/2020, the Department requested a copy of the policy/procedure regarding the maintenance of eye wash stations, and it was not provided.

Personnel #50 and Personnel #51 both confirmed during a combined interview conducted 09/22/2020 (1000), that the Bradley tags attached to the identified eye wash stations located in the Surgery Department had no weekly checks performed on 08/31/2020, 09/07/2020, and 09/14/2020. Additionally, Personnel #50 revealed that it is the responsibility of the orderly in the Department to check the eye wash stations weekly.

Personnel #19 confirmed during an interview conducted 09/22/2020 (1030), that the tags attached to the identified eye wash stations located in the Food Service Department had no monthly checks performed for January, February, March, May, June, and August. Additionally, Personnel #19 revealed that the eye wash station checks, should be checked monthly.

Personnel #75 confirmed during an interview conducted 09/22/2020 (1235), that the Bradley tag attached to the identified eye was station in the Endoscopy Department had only one date, and that the eye wash station should be checked weekly.
Personnel #79 confirmed during an interview conducted 09/21/2020 (1600), that the Bradley tag attached to the identified eye was station in the Laboratory Department is required to be checked weekly, and that there were many missing weekly dates and initials on the tag. Additionally, Personnel #79 revealed that s/he did not know whose responsibility it was to check the eye wash station.

Based on review of the facility emergency plan, and staff interview, it was determined the facility failed to develop and implement a policy and procedure for sheltering in place during an emergency. Failure to adequately shelter in place during an emergency could potentially lead to harm to both patients and staff, if the facility does not have processes and supplies readily available to institute when patients and staff cannot leave the facility.

Findings include:

The facility's Emergency Plan related to a process for sheltering patients and staff during an emergency was reviewed on September 24, 2020. The Emergency Plan (EP) did not identify a process for sheltering patients and staff during an emergency.

The Director of Support Services confirmed on September 24, 2020, the facility EP plan did not identify a process for sheltering patients and staff during an emergency.