HospitalInspections.org

Based on observation and interview of staff on the morning of 06/16/2015, the facility failed to maintain a safe environment for patients in the Emergency Room and the Labor and Delivery Unit.

Findings were:

The hospital's "Quality Assurance and Improvement Plan", states in part "Our goal is to provide care that is: Safe-a safe environment to assure the safety of each and every patient".

· Male and Female bath rooms in the Emergency Room waiting area did not have an emergency pull cord.
· Bathroom in the Labor and Delivery Unit room # 2 did not have a pull cord that was functional.

In an interview the nurse manager on 06/2015 the lack of functional safety equipment was acknowledged. It was confirmed that the missing and not functional emergency call lights posed a risk to patients.

Based on review of documentation and interview, it was determined that the hospital failed to develop, implement and maintain an effective, ongoing, hospital wide, data driven quality assessment and performance improvement program.

Findings were:

Cross refer to:

A0286
A0308

In an interview with the Nursing Director on 6/17/15, it was admitted that the hospital's current Quality Assurance Program was not effective.

Based on review of documentation and interview, it was determined that the facility failed to report and track adverse events, analyze their causes, and implement preventative actions in the facility.

Findings were:
Facility policy entitled "Brownfield Regional Medical Center Quality Assurance and Improvement Plan" stated in part "The Quality Improvement Program includes the following activities:
· All direct patient care services and indirect services affecting patient health and safety, and tracking adverse patient events.
· Medication therapy (includes medical errors)
· Utilization Management (Hospital Payment Monitoring Program)
· Patient satisfaction surveys
· Professional staff credentialing
· Surgical case review
· Blood usage review
· Medical record review
· Risk Management Activities
· Morbidity/Mortality Review
Ø Infection Control
Ø Identify Opportunities for Improvement
Ø Focus on High Risk"

Review of Quality Improvement Committee meeting minutes for the months of May 2014 through April 2015 revealed no tracking of adverse patient events (including medication errors), no analyzation of these events and no documented implementation of preventative actions.

In an interview with the Nurse Director on 6/17/15, the above deficits in the Quality Assurance and Improvement Program were acknowledged.

Based on review of documentation and interview, it was determined that the governing body failed to ensure that every department of the hospital was involved in monthly Quality Improvement Committee meetings.

Findings were:

Facility policy entitled "Brownfield Regional Medical Center Quality Assurance and Improvement Plan" stated in part "The Quality Improvement Program includes the following activities:
· All direct patient care services and indirect services affecting patient health and safety, and tracking adverse patient events."

The same policy went on to state "The mission of Brownfield Regional Medical Center is to provide quality health care services that are accessible, affordable, and meets the needs of Brownfield and regional communities. To make our facility, programs and services available to the community and general public without restriction; to create an environment where physicians, allied health professionals and staff work together to assure that each patient of our facility receives quality, personalized, affordable care ...To achieve this goal, all employees of Brownfield Regional Medical Center will participate in ongoing quality improvement and our efforts will focus on providing quality, affordable and necessary care to our patients."

For the months of January 2015 through May 2015 the following people/departments were missing in their Quality Improvement Committee meetings:

· January 2015: Respiratory Services, Environmental Services, Infection Control, Discharge Planning, Dietary and Laboratory
· February 2015: No meeting minutes were provided to the survey team
· March 2015: Infection Control and Dietary
· April 2015: Infection Control, Radiology, Environmental Services, Discharge Planning
· May 2015: No meeting minutes were provided to the survey team.

In an interview with the Nursing Director on 6/17/15, it was acknowledged that the governing body did not ensure all departments of the hospital were represented in its Quality Improvement Committee meetings.

Based on review of documentation and interview, it was determined that the facility failed to address patient needs determined by assessment and diagnosis.
Findings were:
Facility Job Description entitled "Charge Nurse" stated under "duties related to patient care"
· "Make rounds to each patient's room several times per shift, make assignments, review patient records, update care plans, and understand each patient's case and needs."
Facility Job Description and Performance Evaluation entitled "Registered Nurse" stated under "Planning" The Nurse:
· "Develops, implements, evaluates patient's progress toward meeting care plan goals.
· Defines patient discharge needs, involves the patient and family and notes in the plan of care upon admission, during hospitalization and upon discharge.
· Defines realistic outcomes in a negotiated manner with each patient, family or significant other with achievable time frames based on nursing diagnoses.
· Carries out interventions consistent with the plan of care in a safe and appropriate manner."
Facility Job Description entitled "LVN" stated under "Responsibilities and Functions" The LVN:
· "Assists in maintaining current and updated nursing care plans for each patient."
Facility policy entitled "Contents of an Inpatient Record" stated "All inpatient records contain at least:
· Admissions form
· Attestation statement
· Discharge summary
· Discharge Instructions
· History and Physical
· Progress notes
· Diagnostic and/or therapeutic orders
· Reports of all diagnostic tests, laboratory, x-ray, EKG, EEG, ABG
· Therapy notes
· Consent to treat
· Medication Administration records
· Nurses worksheet/summary sheet
· Second nurses notes
· RN assessment
· Nursing Care Plan"
The medical records of the following patients had no care plans that identified patient problems, set goals and recognized interventions to achieve those goals:

· Patient # 2, admitted 6/15/15 for "chest pain/rule out MI"
· Patient # 4, admitted 6/15/15 for "abdominal pain, and nausea."
· Patient # 5, admitted 12/27/14 for "bronchitis exacerbation"
· Patient # 6, admitted 1/4/15 for "obstructive chronic bronchitis"-no care plan was found in the medical record for this patient
· Patient # 7, admitted 1/17/15 for "pneumonia"
· Patient # 8, admitted 1/19/15 for "cellulitis"
· Patient # 9, admitted 2/14/15 for "asthma"-no care plan was found in the medical record for this patient.

In interviews with the Nursing Director and the Clinical IT LVN on 6/16 and 6/17/15 the missing and ineffective care plans were confirmed. The Charge Nurse on the patient care unit stated "I have been here for a year and I have never made a care plan."

Based on ¿¿¿¿¿¿¿¿¿¿¿¿¿¿¿¿¿¿¿¿¿¿observation, interview of staff, and review of medical records, it was determined that the facility failed to ensure that practitioners authenticated verbal orders within a reasonable/acceptable time.

Findings were:

The Nurse Manager was not able to produce a policy related to "Verbal Orders".

· The medical record of Patient # 8 revealed a physician's verbal order dated 01/27/2015 for " four point soft restraints". This order was not authenticated by the practitioner until 02/05/2015
· Patient # 8 had another verbal order on 01/28/2015 to continue "restraints." This order was not authenticated by the practitioner until 02/05/2015.

These two delinquent orders were confirmed by the Clinical IT LVN on 6/17/15.

Based on observation, it was determined that the facility failed to provide a sanitary environment in all areas of the hospital.

Findings were:

" OSHA/Bloodborne Pathogen Regulations Policy #138-030-060 " stated in part " The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. "

The Centers for Disease Control and Prevention (CDC) article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf>, states on page 74 that hinged instruments and instruments that are closed should be opened during the process of sterilization.

Tour of the hospital on 6/16/15 revealed the following infection control concerns:

· ER Room # 1 had cracked and abraded flooring. These cracked floors made cleaning impossible.
· There were many "sterile" hinged instruments that were found to be in the closed positions. There was no way to verify that they were in an open position during the sterilization process.
· ER Room # 2 had a bed that had paint chipping off its metal frame.
· ER Open Bay had flooring that was concrete where pipes and plumbing had been removed which created an uneven surface. This uneven surface created a trip hazard for staff and patients alike.
· Stored on a shelf adjacent to the open ER Bay were several security pads (used for padding on beds where patients were experiencing seizures.) These vinyl pads were torn in spots, rendering them impossible to clean.
· 3 stained ceiling tiles were found in the ER waiting room. These stained tiles indicate a ceiling leak.
· The folding doors leading from outside into the ER hallway needed weather stripping. This space around the doors could allow access to vectors into the facility.
· At least 10 reclining chairs were noted in patient rooms that were covered with faded and stained upholstery fabric. Several of these chairs had tears in the seating.
· The cabinetry around the hand washing sink in the nursery had peeling laminate. The floor also had gouges in the tile which prevented proper cleaning of the area.
· The floor of the nurses station had broken and missing tiles. The floor was covered with black, abraded spots which indicated improper maintenance of the area. Bugs were also noted in the fluorescent lighting fixture.
· Labor and Delivery Room # 1 had high horizontal dust. The foam rubber stirrups on the delivery bed were torn in two spots which made cleaning impossible and cross contamination likely. Caulking was peeling from the tiles and appeared dirty.
· Labor and Delivery Room # 2 had a portion of the baseboard that was missing. This exposed the sheetrock.
· The flooring in the rear of the Pharmacy was heavily stained and abraded.
· In X-ray Room # 1, several stained ceiling tiles were noted, indicating a water leak.
· In the kitchen, several packages of opened breads and meats (Salisbury steak, chicken, pork chops) were found in a freezer. These foods were improperly stored, labeled and dated.
· The kitchen had areas of high horizontal dust which indicated improper cleaning of the area.

In interviews with the Director of Maintenance, the Nurse Manager and the Dietician on 6/16/15, the above findings were confirmed.