HospitalInspections.org

Based on review of documentation and interview, it was determined that the facility failed to measure, analyze and track quality indicators in their Quality Assessment and Performance Improvement program.

Findings were:

Review of Quality Assessment and Performance Improvement meeting minutes for December 2013, January 2014 and June 2014 revealed no documented tracking of medical errors or adverse events. Further, in problems that were identified, there was no documented evidence of root cause analysis, implementation of preventative actions or of feedback and learning opportunities for hospital staff.

In interviews with the Chief Nursing Officer and the Infection Control Nurse on 10/22/14, the lack of documented evidence in Quality Assessment and Performance Improvement meeting minutes of root cause analysis, implementation of preventative actions or of feedback and learning opportunities for hospital staff was confirmed.

Based on review of documentation and interview, it was determined that the facility failed to document identification of medical errors and adverse events in their Quality Assessment and Performance Improvement meeting minutes.

Findings were:

Review of Quality Assessment and Performance Improvement meeting minutes for December 2013, January 2014 and June 2014 revealed no documented tracking of medical errors or adverse events. Further, in problems that were identified, there was no documented evidence of root cause analysis, implementation of preventative actions or of feedback and learning opportunities for hospital staff.

In interviews with the Chief Nursing Officer and the Infection Control Nurse on 10/22/14, the lack of documented evidence in Quality Assessment and Performance Improvement meeting minutes of root cause analysis, implementation of preventative actions or of feedback and learning opportunities for hospital staff was confirmed.

Based on observation and interview, it was determined that the facility was not maintained to assure the safety of staff and patients.

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. "

Tour of the facility on 10/22/14 revealed the following:

· Stained ceiling tiles which indicated water leaks.
· Dirty air conditioning vents which indicated improper maintenance of the area.
· Molding that was pulling away from baseboards in the unrenovated areas of the hospital.
· A 6 inch by 6 inch gouge in the floor of a staff/patient elevator which prevented proper cleaning of the elevator floor and created a fall risk.
· OR #1 had cabinets with chipped paint. These cabinets housed sterile supplies. The chipped paint on the supply cabinets prohibited appropriate cleaning of the cabinets.
· The floors in both OR rooms had small gouges. These gouges made thorough cleaning of the floors impossible.

In interview with the Plant Operations Director and the Chief Executive Officer on 10/22/14, the above physical plant deficits were confirmed.

Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patients.

Findings were:

Facility policy entitled "Food Storage Policies" stated in part "All food items stored after opening or preparation shall be tightly covered, labeled and dated before storing."

Facility policy entitled "Physical Therapy Departmental Manual, Cleaning of Treatment Areas" stated in part, "All physical therapy staff members are responsible for maintaining a clean and safe treatment area. To promote a safe environment and to prevent the occurrence of cross contamination ...The following items are to be wiped off with hospital-issue disinfectant every day:
a) Mat tables
b) Floor mats
c) Tilt tables
d) Parallel bars
e) Mirrors
· If necessary, wipe with disinfectant after each use, also clean any other equipment for special precaution."

Tour of the dining room on 10/22/14 revealed the following:

· In the walk in refrigerator, several open gallon sized plastic jars containing condiments were found. None of these jars was labeled as to date of opening or expiration. An open, unlabeled bag of almonds was also found.
· The walk in freezer had copious amounts of ice buildup on the inside of the door. The cement floor under the door was corroded and pitted--most likely from the moisture dripping from the door and onto the floor. The ice buildup and damaged floor indicate the seal around the door of the freezer was not intact, making temperature regulation inefficient.
· Metal warming pans were stacked while wet. When these pans were separated, water dripped onto the floor. When dishes and pans are not air dried, there is potential for bacterial growth. According to FDA Food Code 2009: Annex 3 - Public Health Reasons / Administrative Guidelines - Chapter 4, Equipment, Utensils, and Linens, "4-901.11 Equipment and Utensils, Air-Drying Required: Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils."
· The oven was opened, revealing grease buildup under the gas fed burners. This indicated improper cleaning of the oven.
· The Dish Machine Temperature and Operation Log for the month of October 2014 revealed the opportunity for thrice daily temperature and chemical strip testing. The kitchen manager was asked how often chemical testing should be done in the dishwasher and she replied, "Every time the dishwasher is used." The log reflected temperatures taken twice during each dishwashing cycle but frequent missed chemical testing. According to FDA Food Code 2009: Annex 3 - Public Health Reasons / Administrative Guidelines - Chapter 4, Equipment, Utensils, and Linens, "Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: (1) The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and (2) Too much sanitizer in the final rinse water could be toxic."

Tour of the Radiology Department on 10/22/14 revealed the following:

· Stained ceiling tiles throughout-indicating roof leaks.
· Bugs in ceiling fluorescent lighting fixtures-indicating improper cleaning of the area

Tour of the Physical Therapy Department on 10/22/14 revealed the following:

· Torn pillows in patient treatment rooms. These tears put patients at risk for cross contamination.
· Torn vinyl coverings on patient treatment tables and mats, making sanitation impossible and cross contamination likely.

Tour of the Cardiology/Respiratory Care Department on 10/22/14 revealed the following:

· The storage room, which contained clean supplies, had a visibly dirty air conditioning vent spewing air and dust onto the clean supplies.
· The room where EKGs were performed had a bed the patients utilized during the test. The bed was fully made with a sheet on top. The Director of Cardiology admitted that the top sheet was changed between patients but the rest of the bedding remained intact. This practice could lead to cross contamination.

Tour of the Surgical Department on 10/22/14 revealed the following:

· OR #1 had cabinets with chipped paint. These cabinets housed sterile supplies. The chipped paint on the supply cabinets prohibited appropriate cleaning of the cabinets.
· The floors in both OR rooms had small gouges. These gouges made thorough cleaning of the floors impossible.

Tour of the common areas of the hospital on 10/22/14 revealed the following:

· Stained ceiling tiles which indicated water leaks.
· Dirty air conditioning vents which indicated improper maintenance of the area.
· Molding that was pulling away from baseboards in the unrenovated areas of the hospital.
· A 6 inch by 6 inch gouge in the floor of a staff/patient elevator which prevented proper cleaning of the elevator floor and created a fall risk.

In an interview with the Plant Operations Director on 10/22/14, the above infection control concerns were confirmed.