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Based on observation, interview, and document review, it was determined that the hospital failed to meet the requirements at 42 CFR 482.12 Condition of Participation for Governing Body.

Failure to meet minimum physical environment requirements resulted in an unsafe healthcare environment.

Findings:

Due to the scope and severity of deficiencies detailed under 42 CFR 482.21 Condition of Participation for Physical Plant and Environment, the Condition of Participation for Governing Body was NOT MET.

Cross-Reference: Tag A-0700

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Based on document review and interview, the hospital failed to assess its contracted services for quality and performance problems through the hospital's Quality Assurance and Performance Improvement (QAPI) program.

Failure to assess contracted services through the hospital's QAPI program can lead to an inability to identify quality and performance issues or implement appropriate corrective or improvement activities.

Findings:

1. Record review of the hospital's policy titled, "Providence Health & Services Contracts", Policy #1522869, dated 6/25/15, showed that contracts will be in compliance with regulatory guidelines and the contract owner will ensure that performance metrics are developed and tracked.

2. Review of the hospital's contract list titled, "PSPH Clinical Contract List", dated 3/15/17, showed 13 services under hospital contract. Each service enclosed an evaluation sheet that included seven value measures (personnel quality, value, expertise, met deliverables/timeframes, reliability, and able to work with stakeholders). Each measure receives a score ranging between 1 and 5, with #5 labeled as "would highly recommend" and #1 "would not re-use". The form is signed by "Person Completing Evaluation" who is generally the hospital director who has oversite of the clinical department served by the contract.

3. During an interview with Surveyor #4 on 6/13/2017 at 1:00 PM, the hospital's Quality Program Director, (Staff Member #10) acknowledged that the hospital did not integrate their clinical contracted services into the hospital-wide quality program.

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Based on interview and record review, the hospital failed to develop a process for planning nursing care in the outpatient infusion area.

Failure to develop and implement nursing care plans for patients receiving ongoing infusions or treatments limits the nurse's ability to recognize and treat complications of the patient's treatment regimen.

Findings:

1. The hospital's policy titled "Outpatient Infusion Services - Scope of Service" (Policy ID #3076112; Revised 4/18/2017) stated that patient care is planned and documented by means of electronic orders, plans of care and using the verbalized goals of the patient."

2. On 6/15/2017 at 1:45 PM, Surveyor #1 interviewed Patient #9 who was a 56-year-old patient admitted for serial albumin infusions. Patient #9 revealed that she had been a patient of the infusion center for 16 years. During the interview, Patient #9 showed Surveyor #9 her central venous line used for the infusions and reported to the surveyor that she sometimes requires oxygen during her treatments.

3. Review of Patient #9's medical record revealed that the patient was receiving albumin infusions for treatment of protein-losing enteropathy (loss of protein from the intestinal tract). Nursing documentation in the medical record confirmed that Patient #9 required oxygen therapy at times.

The surveyor was unable to locate a nursing care plan based on the patient's individual nursing care needs in the medical record. A registered nurse (Staff Member #15) assisting with the medical record review confirmed this finding

3. On 6/16/2017 at 8:45 AM, Surveyor #1 interviewed the Director over Infusion Services (Staff Member #16). The director confirmed that patients receiving treatment in the Infusion Center did not have nursing care plans.

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Based on observation, interview, record review and review of hospital policies and procedures, the hospital failed to protect patients, staff and visitors from fire risk.

Failure to maintain a safe and secure environment risks serious injury or death for patients, staff, and visitors in the event of a fire.

Findings:

The hospital failed to maintain a safe and secure patient care environment that included the following:

1. Failure to ensure the maintenance of the following items in the event of fire: means of egress, exits free of obstruction, fire alarms, policy for fire watches, sprinkler systems, appropriate locations for fire extinguishers, fire doors, gas and electric equipment, elevators, and emergency lighting.

2. Failure to remove non-compliant space heaters, and power strips.

3. Failure to inspect and test gas and vacuum piped systems.

4. Failure to conduct fire drills for staff during all shifts.

Due to the scope and severity of deficiencies cited under 42 CFR 482.41, the Condition of Participation for Physical Environment was NOT MET.

Cross Reference: A0710

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Based on observation and interview, the hospital failed to maintain its hot water temperature at or below 120 degrees Fahrenheit.

Failure to limit hot water temperature to a maximum of 120 degrees Fahrenheit at the tap placed patients and staff at risk of injury from scalding.

Reference: Guidelines for Design and Construction of Health Care Facilities (2006), Table 2.1-4 Hot Water Use - General Hospital

Findings:

On 06/13/2017 at 3:15 PM, Surveyor #3 used a thin-stemmed thermometer to assess the temperature of hot water at the patient handwashing sink in Room #6 of the Sleep Center. The hot water temperature measured 130 degrees Fahrenheit. The Director of Education (Staff Member #1) and the Director of the Sleep Center (Staff Member #2) acknowledged the finding at the time of the observation.


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Based on observation, interview, and document review, the hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association
(NFPA), 2012 edition.

Findings:

Refer to the deficiencies written on the ACUTE CARE HOSPITAL MEDICARE LIFE SAFETY inspection reports.
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Item #1- Shower Vents

Based on observation and interview, hospital staff failed to maintain shower room vents in a manner to prevent excessive dust and debris buildup on the vanes of the vent.

Failure to maintain vents in shower rooms impedes removal of steam and can lead to mold growth.

Findings:

On 6/14/2017 at 9:10 AM, Surveyor #2 observed excessive buildup of dust and debris on the shower vents in each shower room of the inpatient psychiatric unit. The unit's manager (Staff Member #11) acknowledged the finding at the time of the observation.


Item #2- Expired Supplies

Based on observation and interview, the hospital failed to maintain patient care supplies in a manner that prevented storage and use beyond the manufacturer's designated expiration date.
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Failure to ensure patient care supplies do not exceed their expiration dates risks deteriorated and contaminated supplies being available for patient use.

Findings:

On 6/14/2017 at 9:00 AM, Surveyor #2 identified a bag of saline in the inpatient psychiatric unit medication room that had an expiration date of 4/2017. The unit's manager (Staff Member #11) acknowledged the finding at the time of the observation.


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Item #3- Equipment Maintenance


Based on observation and interview, the hospital failed to maintain a complete inventory of equipment required to meet patient needs.

Failure to ensure patient care equipment is inventoried risked equipment not receiving regular preventive maintenance placing patients at risk of receiving substandard care due to improperly maintained equipment.

Findings:

1. On 06/12/2017 at 2:30 PM, Surveyor #3 observed that a Scope Buddy (an endoscope flushing aid) in soiled utility Room #01-224 (the endoscope decontamination room) did not have a hospital inventory control number. The Director of Education (Staff Member #1) acknowledged the observation.

2. On 06/14/2017 at 8:50 AM, Surveyor #3 and the Director of Education (Staff Member #1) met with the Manager of Technical Services (Staff Member #3) to survey the hospital's Biomedical Service Program. Surveyor #3 and Staff Member #3 reviewed the inventory list of hospital equipment and concluded that the Scope Buddy was not listed. The staff member said that since s/he was not aware of the Scope Buddy, it could not have received preventive maintenance.

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ITEM #1 - CROSS-CONTAMINATION
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Based on observation and document review, the hospital failed to clean and disinfect patient care equipment in a manner that avoids cross-contamination.

Failure to safeguard against cross-contamination puts patients and staff at increased risk of exposure to infectious organisms.

Findings:
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1. Hospital Cleaning Procedure (Sealed Air Diversey Care, provided to Surveyor #3 in response to request for Operating Room & Emergency Department cleaning policies), stated, "Clean from high to low; Clean less soiled areas first then move to more soiled areas (clean to dirty);"
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2. On 06/12/2017 at 12:30 PM, the Director of Education (Staff Member #1) and Surveyor #3 observed as two RNs and two Perioperative Support Assistants (PSA) performed a between case cleaning of Operating Room #3. One of the PSAs (Staff Member #4) wiped the overhead surgical light with a disinfectant while it was positioned over the previously disinfected operating table. She did not re-wipe the operating table with disinfectant. The Interim OR Manager (Staff Member #5) and Staff Member #1 acknowledged the observation.

3. On 6/15/2017 at 11:45 AM, Surveyor #2 observed two members of the Environmental Services Staff (Staff Member #12 and Staff Member #13) as they performed a terminal cleaning of a C-section suite in the Mother/Baby Unit. The surveyor observed that Staff Member #13 cleaned the surgical table and then proceeded to pull the uncleaned surgical lights over the table top to begin cleaning them, risking debris from the lights falling on to the clean table. The surveyor also observed that the staff member failed to extend the adjustable base of the surgical table to clean any potentially contaminated surfaces in the grooved base of the table.
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ITEM #2 - CLEANABLE SURFACES IN PATIENT CARE AREAS
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Based on observation and interview, the hospital failed to maintain patient care items to ensure surfaces are easily cleanable.
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Failure to repair or replace items that are torn or broken put patients and staff at increased risk of exposure to infectious organisms.
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Findings:
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1. On 06/12/2017 at 12:35 PM, the Director of Education (Staff Member #1) and Surveyor #3 observed four staff (Staff Member #4, Staff Member #6, Staff Member #7, and Staff Member #8) perform a between- case cleaning of Operating Room #3. After the staff members cleaned the room, the surveyor noted that the plastic lid for the Recycle hamper was cracked and broken at the sides of the hinge, exposing rough, uncleanable surfaces. The Interim OR Manager (Staff Member #5) and Staff Member #1 acknowledged the observation.
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2. On 06/14/2017 at 3:45 PM, Staff Member #1 and Surveyor #3 observed a between- case cleaning of Emergency Room #B14. After the staff member cleaned the room, the surveyor noted that the vinyl upholstery of a chair seat had an L-shaped tear that exposed the foam padding. Staff Member #1 acknowledged the torn seat created an uncleanable surface.
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ITEM #3 - EQUIPMENT STORAGE
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Based on observation and interview, the hospital failed to maintain clean patient equipment in an area separate from soiled equipment during storage.
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Failure to provide the separation between clean patient items and soiled items placed the patients at risk for possible cross contamination of patient supplies and the spread of infections.
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Finding:
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On 06/13/2017 at 3:15 PM, Surveyor #3 observed a folding bed in the Soiled Utility Closet in the Sleep Center. The Director of the Sleep Center (Staff Member #2) said the bed was clean and ready for patient use but stored in the Soiled Utility Closet because there was no other place to store it. S/he agreed that clean items for patient use should not be stored in the soiled utility closet and said they would "get rid of the bed." The Director of Education (Staff Member #1) was present at the time of the observation.
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ITEM #4 - SURGICAL ATTIRE
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Based on observation, interview and review of hospital policy and procedures, the hospital failed to ensure that staff members followed policy for surgical attire to reduce the risk of microbial contamination within the surgical environment.
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Failure to follow hospital policy for surgical attire puts patients at an increased risk of infection during surgical procedures.
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Findings:
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1. The hospital's policy and procedure, "Attire in Restricted and Semi-Restricted Areas" (Policy #86100-GEN-025; Approved 10/29/15) stated, "PROCEDURE: 1. Attire. . . D. Personnel Scrub Attire 1. All possible head and facial hair, including sideburns and neckline will be covered in the semi-restricted and restricted areas."
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2. On 6/15/2017 at 2:20 PM, Surveyor #5 observed a surgical procedure of Patient #1 in operating room #2. In observing the staff, the surveyor noted that the circulating registered nurse (RN) (Staff Member #18), surgical technician (ST) (Staff Member #19), anesthesiologist (Staff Member #20), assisting physician assistant (PA) (Staff Member #21) and the surgeon (Staff Member #22) did not have all head and facial hair contained. For most staff this included hair at the back of the neck and in one case, failure to cover sideburns.
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3. In discussion with the interim Director of Surgery (Staff Member #23), s/he acknowledged the observation and noted that this was an area of infection control the Surgery Department was working on.
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4. On 6/14/2017 at 9:30 AM, Surveyor #5 observed Patient #2 during the placement of a coronary stent (A tube-shaped device placed in the coronary arteries that supply blood to the heart) in the cardiovascular lab. The surveyor noted that several members of the procedure team did not have their hair covered under surgical bouffant style caps. This included the RNs (Staff Member #24), 2 STs (Staff Members #25 and #26) and the physician (Staff Member #27).
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5. The surveyor discussed the observation with the Assistant Manager of the cardiovascular Department (Staff Member #37). S/he confirmed that staff members are to follow the same policy regarding attire as the surgery staff and confirmed the finding.
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ITEM #5 - HAND HYGIENE
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Based on observation and policy review, the hospital staff failed to comply with facility policy for hand hygiene.
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Failure to perform hand hygiene as directed in hospital policy puts patients, staff and visitors at risk of exposure to communicable diseases.
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Findings:
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1. The hospital policy and procedure stated, "PROCEDURE: 1. Indications for Hand Washing vs. Alcohol-based Hand rubs A. Wash hands with plain soap and water or an antimicrobial soap and water when hands are visibly soiled or contaminated, when caring for a person with diarrheal illness. . . B. If hands are not visibly soiled, alcohol-based hand rubs may be used for routinely decontaminating in all clinical situations including: 1. Decontaminate hands before having direct contact with patients regardless of if gloves are worn . . .D. Perform hand hygiene before donning any type of PPE(Personal Protective Equipment)."
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2. On 6/13/2017 At 9:30 AM, Surveyor #5 witnessed a physician (Staff Member #28) enter the room of Patient #3 and proceed to perform a hands-on assessment of the patient without first performing hand hygiene.
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3. On 06/13/2017 at 1:30 PM, Surveyor #5 observed a RN (Staff Member #29) during a medication administration to Patient #4. In attempting to take clean gloves out of the dispenser box, s/he dropped a glove onto the floor. S/he picked it up and stuffed it back into the box with the clean gloves. S/he did not perform hand hygiene after picking up the glove. S/he also failed to perform hand hygiene after removing gloves. S/he walked out of the patient room without performing hand hygiene, and then reached into a cupboard and got the patient a blanket. S/he then returned to the room.

4. On 6/13/2017 at 2:00 PM, Surveyor #5 observed a dietary employee (Staff Member #30) walk out of a room after speaking with Patient #5, who was in contact isolation. S/he did not perform hand hygiene after removing personal protective equipment.

5. On 6/15/2017 at 10:00 AM, Surveyor #1 observed a registered nurse (Staff Member #17) as s/he exited patient room #7 in the rehabilitation unit and noted the following:

a. Staff member #17 removed their gown and gloves as they exited the room then crossed the hallway and entered the nursing station to use a sink to wash their hands with soap and water. Room #7 had a sign on the door that stated "Contact Enteric Precautions". The sign stated that staff needed to wash their hands with soap and water upon leaving the room and that shared equipment required cleaning and disinfection. The sink Staff Member #17 used was a community sink and was not dedicated for use by staff caring for the patient in room #7.

b. On 6/16/2017 at 9:15 AM, Surveyor #2 discussed the above observation with the Manager of the Rehabilitation Unit (Staff Member #14). S/he explained that the room design put the hand sink in the middle of the patient's room, requiring staff to cross the room to use the hand sink after doffing their PPE. The staff member indicated the hospital was developing a plan to install a sink closer to the outside of the patient's room, but acknowledged there was no dedicated sink for the staff at this time.


6. On 6/15/2017 at 3:00 PM, Surveyor #5 observed a surgical procedure on Patient #1. A provider (Staff Member #20) dropped a pen on the floor and retrieved it without performing hand hygiene afterward. The same provider had allowed a heart monitor lead wire to fall on the floor. S/he did not wipe the lead or perform hand hygiene after retrieving the lead.

7. On 6/15/2017 at 9:00 AM, Surveyor #5 observed a provider (Staff Member #31) walk out of the room of Patient #7 who was in contact isolation, without washing their hands.
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ITEM #6 - PERSONAL PROTECTION EQUIPMENT
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Based on observation, review of policy and procedure and interview, the hospital failed to ensure that staff members wore proper personal protective equipment (PPE) when caring for patients on transmission-based precautions and failed to post isolation room signage.
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Failure to wear proper PPE and failure to post isolation room signage when caring for patients on transmission-based precautions placed patients and staff at risk for infection.
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Findings:
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1. On 6/14/2017 at 3:40 PM, Surveyor #1 observed as a physician (Staff Member #E4) entered the room of a patient (Patient #9) who was in contact enteric isolation. The physician donned a gown but did not tie the gown in back to ensure full coverage of the torso prior to entering the patient's room.
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2. On 6/14/2017 at 3:25 PM, Surveyor #1 observed an isolation cart sitting outside of room #6 in the rehabilitation unit. There was no sign on the door indicating to staff that the patient was in isolation. An interview with the manager of the rehabilitation unit (Staff Member #14) at the time of the observation revealed that the patient had MRSA (Methicillin-resistant Staphylococcus Aureus) and was currently in contact isolation. Staff placed a sign on the door at the time of the observation.
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3. On 6/15/2017 at 10:20 AM, Surveyor #5 observed a RN (Staff Member #32) from infusion services as they went into a room to check Patient #6's IV (intravenous) site. The patient was in contact enteric isolation. After putting on their PPE and touching the patient's arm, the staff member walked outside of the room to get a care item. S/he walked out of the door and took items out of the IV cart, still wearing contaminated gloves. Additionally, s/he put items that had been at the patient's bedside back into the IV cart. When leaving the patient's room, the staff member removed PPE incorrectly by removing gown first then gloves.
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4. On 6/13/2017 at 2:00 PM, Surveyor #5 observed a Dietary Staff Member (Staff member #30) as s/he exited the room of Patient #5 who was in contact isolation. The staff member was wearing an isolation gown, a mask and gloves. S/he set their clipboard on the Isolation Supply Cart while still wearing gloves. S/he walked back into the room to remove their PPE and failed to perform hand hygiene prior to leaving the room.
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5. On 6/13/2017 at 3:30 PM, Surveyor #5 observed a respiratory therapist (Staff Member #33) as s/he entered the room of Patient #8. S/he put on PPE in an incorrect order, donning gloves first, followed by gown and mask. Additionally, the staff member did not tie the gown in the back at the waist. Upon leaving the room, the staff member took off their PPE in the wrong order, doffing their gown first, then mask, then gloves. At 3:40 PM, the surveyor also noticed there was no sign on the door to alert staff and family entering the room that the patient was in isolation. The Director of Emergency Department (Staff Member #34) who accompanied Surveyor #5 agreed with the observation findings.
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6. On 6/15/2017 at 10:30 AM while touring the Orthopedic Floor, Surveyor #5 observed patient #9 with an isolation cart outside their room. There was no sign on the door to indicate the patient was in isolation. A Certified Nurse's Aide (CNA) (Staff Member #35) placed a sign on the door. Surveyor #5 asked when the patient was admitted. The CNA did not know but the Nurse Manager of the unit (Staff Member #36) stated the patient had been there for 12 hours and agreed that hospital staff should have posted the sign earlier.

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Based on document review and interview, the hospital failed to integrate its outpatient services into the hospital-wide QAPI program.

Failure to integrate the hospital's outpatient services into its hospital-wide QAPI program can lead to services, equipment, staff, and facilities inadequate to provide outpatient services offered at each location in accordance with acceptable standards of practice.

Findings:

1. Record review of the hospital's quality plan titled, "Providence Health & Services Quality & Process Improvement Plan", dated 2017, showed the goals of the plan are to provide organization-wide approach to process measurement, assessment and improvement through interdisciplinary improvement activities. Support compliance with requirements of regulatory and accreditation agencies and guidelines.

2. Review of the hospital's list of outpatient clinical services showed 10 services that delivered care at off-site locations. Three services were located at the Emilie Gamelin Pavilion, housed on campus.

3. During an interview with Surveyor #4 on 6/13/2017 at 1:00 PM, the Quality Program Director (Staff Member #10), acknowledged that the hospital did not integrate its outpatient services into the QAPI program. The staff member stated that the outpatient service quality metrics are reported to the service line's director, but that the information is not reported as part of the hospital's quality program.