HospitalInspections.org

Based on staff interview, and document review, the facility failed to ensure their policy for reporting or mistreatment of vulnerable adults included definitions of abuse and neglect, and procedures for investigation and protection of vulnerable adults. Additionally, 1 of 5 vulnerable adult/ incident reports reviewed in the sample had not been reported to state officials according to the facility policy for reporting or mistreatment of vulnerable adults; and 2 of 5 vulnerable adult/incident reports reviewed in the sample had not been thoroughly investigated.

Findings include:

Review of the Reporting or Maltreatment of Vulnerable Adults policy and procedure last reviewed May 2011, revealed that the policy had not defined abuse or neglect (defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. That included staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of that requirement, was considered a form of abuse and was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.) Further review of the Reporting or Maltreatment of Vulnerable Adults policy and procedure revealed the following related to investigation of abuse/neglect, "If the alleged, suspected or known maltreatment occurred in the hospital, the reporter social worker, nurse or other health professional will contact the nurse manager, who will complete a written report (Vulnerable Adult form #100-900-140) and send a copy to the Director of Risk Management. The Reporting or Maltreatment of Vulnerable Adults policy and procedure did not include the definitions of abuse and neglect and lacked procedures that described how the hospital would protect patients' from abuse during investigation of any allegations of abuse or neglect or harassment.

The Director of Patient Safety and Juris Doctorate (JD)-A were interviewed from 8:30 a.m. to 10:00 a.m. on 11/17/11, during which they confirmed that the aforementioned policy was the facility's current vulnerable adult policy and confirmed that the policy lacked definition of abuse and neglect, and procedures for investigation and protection of vulnerable adults in the hospital.

Reporting to State Agency was not completed:
Review of incident report A revealed the following incident, "Patient approached a peer and the peer punched him multiple times in the face. Peer reports that patient kicked him." The "Outcomes:" were identified as "BLEEDING, ABRASION, CONTUSION".

Review of the patients progress notes identified the incident had been investigated, and the patient was placed on a 1:1 so he was protected from further abuse however, the incident had not been reported to the State Agency according to facility policy. Review of the Reporting or Maltreatment of Vulnerable Adults policy and procedure dated as developed June 1996 and last reviewed May 2011, revealed the following related to investigation of abuse/neglect "1. If the alleged, suspected or known maltreatment occurred in the hospital, the reporter social worker, nurse or other health professional will contact the nurse manager, who will complete a written report (Vulnerable Adult form #100-900-140) and send a copy to the Director of Risk Management. 2. The nurse manager will verbally report the alleged, suspected or known maltreatment to the Common Entry Point..." The State Agency was not notified of the alleged mistreatment.

The Director of Patient Safety and JD-A were interviewed at 8:45 a.m. on 11/17/11, during which they confirmed that patient to patient abuse that was identified in the incident report A had not been reported to the State Agency according the hospital policy and procedure.

Lack of internal investigation:
Review of incident report C revealed the following incident: "Remote telemetry [tele] entered [Patient (P)-1] into computer system as being monitored via a remote telepak, rhythms and cardiac information were charted in his chart by remote tele techs. This patient was never put on remote tele, another patient with the same first and last name was being monitored P-2. CRN [Registered nurses's (RN) Name] from [nursing unit S10] called remote tele to notify us that the MRN [medical record number] on the patient's tele strips were incorrect and that we had entered the wrong patient into the computer system. The correct MRN and patient was entered into remote telemetry's computer system at 0420 (4:20 a.m.) on 9/10/11." Both of the tele strips sent for the patient's chart included the wrong MRN number were taken out of the chart and disposed.

The electronic medical record for P-1 was reviewed and it was noted that on 9/9/11, the patient was seen in the emergency department and at 1724 (5:24 p.m.) the physician (MD) had ordered remote telemetry for monitoring the patient's heart rate and rhythm. The patient was admitted to the floor S10 at 1930 (7:30 p.m.). There was no evidence in the patient's medical record that the patient's heart rate and rhythm had been monitored by remote telemetry per physician's order until 9/10/11, at 0420 (4:20 a.m.) There were no negative outcomes noted in P-1's record related to the lack of cardiac monitoring. Internal investigation only included interviewing the RN and Telemetry Technician responsible for that patient had not been completed and interventions to minimize a reoccurrence of that type of incident had not been identified.

The Director of Patient Safety and JD-A were interviewed at 9:30 a.m. on 11/17/11, during which they confirmed that a written internal investigation of the incident had not been completed that identified the circumstances surrounding the aforementioned incident and thus interventions were not identified so as to minimize the reoccurrence of that type of incident could not be identified.

Review of incident report D revealed the following incident: " Pt and husband arrived on the unit at 1545 (4:30 p.m.) and he was extremely anxious. RN stated MD would be in but not known when and complementary therapy would be in but not known when and got irate and said we're leaving. RN stated MD would be in shortly. They were not happy and started to walk out. RN asked them to sign the AMA [against medical advice] form stating she refused care and they kept walking and said they were not signing anything. Stated they were going back to Menominee [city] and would be seen there. RN did try to stop them but they refused." There was no medical record found in the hospitals electronic medical record computer system for that patient. There was no evidence that identified an internal investigation had been completed which included but not limited to interviewing the RN responsible for that patient.

The Director of Patient Safety was interviewed at 9:20 a.m. on 11/17/11, during which she stated that it was very unusual for a patient not to have any medical record and was unsure how that could have happened. She confirmed that a completed internal investigation related to the incident was not found in the patient's record.

Based on the Life Safety Code Substantial Complaint Validation survey completed on 11/17/11, the facility was found not in compliance with Condition of participation of Life Safety from Fire found at CFR 482.41 (b).

Refer to Life Safety Code deficiencies - K17, K21, K52, K76, and K130 for additional information.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure safety from fire therefore they were unable to meet that condition.

Based on observation and interview, the facility did not ensure that equipment in the food service department was maintained in safe and functional working order. This had the potential to affect all patients (average daily census of 358) eating food served from the foodservice department

Findings include:

Fiberglass trays were worn at the corners with exposed inner metal reinforcement and peeling fiberglass, a sanitizer machine had a malfunctioning door and wire utensil baskets were broken exposing sharp edges.

A tour of the kitchen was conducted on 11/15/11, at 10:00 a.m. and the director of food and nutritional service, the patient services manager and the production manager were present during the tour.

Twenty-five fiberglass trays were observed in a holding rack; 24 of the 25 trays had corners that were completely devoid of fiberglass revealing the inner support structure. There was frayed and peeling fiberglass around the edges of the trays. The exposed corners were frayed and with peeled fiberglass which created an uncleanable surface and created a safety hazard to patients and staff. The director verified that the trays were being used for patient tray service and were not in a desired condition.

A pot and pan washing and sanitizing machine was observed in operation. The door of the machine would not close properly during operation. The staff operating the machine had to physically hold the door shut in order for the machine to maintain a reading of 180 degrees or higher. The temperature reading without holding the door shut was 176 degrees. A temperature test strip was placed in the machine and tested. The temperature test did reveal adequate sanitation. Without the door held shut there was steam escaping around the door. There was also considerable lime scale build-up, in the form of loose crumbles, on the top of the machine over the door. The malfunctioning door had the potential to affect all customers of the food service department if the condition worsened to the point of unsatisfactory rinse temperatures. The director indicated he was not aware that the door was not closing properly.

Based on observation, interview, and document review, the facility failed to ensure a sanitary dietary environment which had the potential to affect all patients (average daily census of 358) eating food served from the foodservice department.

Findings include:

Equipment was not maintained in a sanitary manner, food was stored improperly and milk was not dated when opened.

During the kitchen tour the following items were found to be in use in an unsanitary condition:

A tour of the kitchen was conducted on 11/15/11, at 10:00 a.m. and the director of food and nutritional service, the patient services manager and the production manager were present during the tour.

Twenty-five fiberglass trays were observed in a holding rack; 24 of the 25 trays had corners that were completely devoid of fiberglass revealing the inner support structure. There was frayed and peeling fiberglass around the edges of the trays. The exposed corners were frayed and with peeled fiberglass which created an uncleanable surface and created a safety hazard to patients and staff. The director verified that the trays were being used for patient tray service. The director also verified the trays in the present were uncleanable and were not in a desired condition.

Two of 2 manual can openers had sticky soiling around the blade and blade assembly. There was also evidence of metal shaving build-up between the gear teeth. Two of 3 electric can openers had sticky soiling around the blade. The director verified that the can openers were not in an acceptable state of cleanliness. Cutting boards were observed lying haphazardly in a holding rack near the floor next to an oven. Some of the boards were stacked one on top of the next. There was cooking debris that had spilled on top of the rack and boards. Three of the 12 cutting boards were observed to be placed in close contact to each other and when examined had diffuse dark staining resembling mildew stains. The production manager verified that the boards were stained and should be stored in the rack slots to allow air circulation. A slicer was observed and verified by cook A to be ready for use. The slicer had debris on the back underside where sliced food comes out. A box of bulk blackberries and a box containing frozen pizzas were observed in the freezer. Both boxes had been opened and not properly sealed to prevent possible contamination and/or freezer burn of the foods. The freezer condenser had condensate dripping and freezing on closed boxes of ice cream bars. The director verified that items need to be properly covered after opening and that the shelving would be removed under the dripping condensate to prevent the possibility of contamination. Three of 5 gallons of milk had not been dated after opening. The production manager verified that it was the facility policy to date the milk when opened.

The facility storage policy reviewed last on 9/1/11, indicated, "To conserve quality of the food supply during storage." The policy statement was, "All food and supplies are stored according to approved storage methods." Within the policy it was indicated that, "All perishable foods are stored in an appropriate fashion at appropriate temperatures to ensure freshness and quality of product." The storage policy also indicated that all dairy products are to be dated and rotated to ensure freshness.

Based upon observation, interview, and document review, the hospital did not ensure policies and procedures were followed for 3 of 4 observed sterile practices where hair should have been confined.

Findings include:

Surveyor: Beskar, Karen
The hair on a staff member was not fully covered in a preparation area of the OR pharmacy where it should have been completely covered.

At 1:30 p.m. on 11/15/11, a tour of the OR pharmacy was conducted with the Director of Pharmaceutical Services. A staff member was in the "clean" room where compounding drugs were prepared under a hood. The atmosphere of the room directed the staff to gown, glove, wear foot covers, hair covers and masks. The staff member was observed with hair not fully covered. The semi-short hairs around the ears were exposed and about one-two inches of hair in the back was exposed.

The policy and procedure last reviewed 9/2010, for Surgical Attire indicated in semi-restricted and restricted areas of the surgical environment, hair must be completely confined by a head covering.

The Director of Pharmaceutical Services was interviewed at the time of the OR pharmacy tour and agreed the hair must be completely covered and verified the staff member did not have hair completely covered.

Based upon interview and document review, the hospital did not ensure a medical history and physical examination was completed prior to outpatient electroconvulsive therapy (ECT) for 3 of 3 patient records reviewed (P1, P2 and P3) in the sample who received ECT.

Findings include:

P1 underwent ECT under general anesthesia on 7/14/11, 7/28/11, 8/11/11, 8/23/11, and 9/1/11. The most recent medical history and physical (H & P) examination available in the electronic medical record was dated 4/13/11, which was more than 30 days prior to the procedures. Another H & P was completed on 9/8/11. The patient continued the series of ECT treatment on 9/12/11, 9/27/11, 10/18/11, 10/8/11 and 11/8/11. There was no other medical H & P examination documented for this series of ECT treatments.

P2 had a medical H & P examination, dated 6/22/11, documented in the electronic medical record. The patient underwent ECT under general anesthesia on 6/30/11, 7/14/11, 7/28/11, and 8/11/11. There was no other medical H & P documented in the medical record until 8/17/11. Another H & P examination was completed on 9/21/11. Although the patient continued the series of ECT treatments on 9/22/11, 10/6/11, 10/20/11, 11/3/11 and 11/17/11, there was no other H & P exams documented in the medical record.

P3 had a H & P examination completed on 7/15/11. The patient underwent ECT under general anesthesia as an outpatient on 7/21/11, 8/4/11, 8/18/11, 9/1/11, and 9/15/11. The next H & P examination was not completed until 9/20/11.

A review of the facility's behavioral health policy, Electroconvulsive Therapy (ECT) last reviewed 2/3/10, indicated each patient should receive a thorough medical examination prior to initiating ECT. The policy indicated the physical examination should be completed within 30 days of the start of an ECT series or annually for those patients receiving ongoing maintenance ECT. The facility's Medical Records Policy, last reviewed 6/11, indicated an update to a pre-operative and physical examination for patients undergoing a surgical procedure was required regardless of when it had been performed. The policy also indicated if the H & P report was older than 30 days, a new history and physical must be performed.

The Director of Inpatient Mental Health Services was interviewed at 9:10 a.m. on 11/17/11. He verified the Behavioral Health physicians completed a medical H & P examination at the beginning of the series of ECT treatments or annually.

The medical doctor (MD)-C was interviewed at 9:10 a.m. on 11/17/11, and stated patients undergoing ECT treatment always received a general anesthetic. MD-C verified patients undergoing general anesthesia for an ECT procedure did not always have an H & P examination completed within 30 days prior to the procedure.