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Based on document review and staff interview, it was determined the facility failed to ensure the Governing Body held the Medical Staff accountable for the quality of care provided to patient's by not ensuring medical records are completed in a timely fashion. This has the potential to negatively affect all patient's by leaving them with incomplete medical records.

Findings include:

1. Medical Staff By-Laws, Rules and Regulations, last reviewed 5/11, state in part: "2.16 Patient medical records are required to be completed within thirty (30) days of discharge. The Health Information Management Department (HIM) will provide each physician with a list of his/her incomplete medical records every seven (7) days. At the twenty first (21st) day for any incomplete medical records, the letter will include a warning that the record (records) will be delinquent at thirty (30) days and the physician's privileges will be suspended if any records become delinquent. 2.16(a) Suspension: A chart which is not completed within thirty (30) days of discharge will trigger suspension of the responsible physician's privileges."

2. During an interview with the director of HIM on 11/7/12 at 1000, she stated currently there are twenty one (21) delinquent medical records over one hundred twenty (120) days. The delinquency rate for July was 17.6%, August 18.5% and September 14.8% which averaged 17% for the third quarter. She also revealed during this interview that the hospital does not suspend physician's like they should. She stated she sends the physician's a letter within fifteen (15) days and continues to send them letters every fifteen (15) days (though the By-Laws, Rules and Regulations state every seven (7) days). She also calls the physician's offices and leaves messages for the physician and reminds them when she see's them walking in the halls.

Based on review of documents and staff interview it was determined the facility failed to ensure the completion of all medical records in accordance with federal regulations and the Medical Staff By-Laws, Rules and Regulations. This has the potential to negatively affect all patients by leaving them with incomplete medical records.

Findings include:

1. Medical Staff By-Laws, Rules and Regulations, last reviewed 5/11, state in part: "2.16 Patient medical records are required to be completed within thrifty (30) days of discharge. The Health Information Management Department (HIM) will provide each physician with a list of his/her incomplete medical records every seven (7) days. At the twenty first (21st) day for any incomplete medical records, the letter will include a warning that the record (records) will be delinquent at thirty (30) days and the physician's privileges will be suspended if any records become delinquent. 2.16(a) Suspension: A chart which is not completed within thirty (30) days of discharge will trigger suspension of the responsible physician's privileges."

2. During an interview with the director of HIM on 11/7/12 at 1000, she stated currently there are twenty one (21) delinquent medical records over one hundred twenty (120) days. The current delinquent rate is 17% for the third quarter (July, August & September). She also revealed during this interview that the hospital does not suspend physician's like they should. She stated she sends the physician's a letter within fifteen (15) days and continues to send them letters every fifteen (15) days (though the By-Laws, Rules and Regulations state every seven (7) days). She also calls the physician's offices and leaves messages for the physician and reminds them when she see's them walking in the halls.

Based on observation and staff interview it was determined the facility failed to ensure drugs were kept secure and locked when appropriate. This has the potential to for medications and drugs to become stolen and misused.

Findings include:

1. On 11/6/12 at 1000 a tour was made of the Obstetrics Unit. The anesthesia epidural cart was found in an unobservable egress with two (2) drawers unlocked. These drawers contained medications such as atropine, ephedrine, Phenylphrine, anectine, Robinul, spinal Marcaine, xylocaine and lidocaine with epinephrine. Some of these drugs are paralytic agents.

2. An interview was conducted with a Certified Registered Nurse Anesthetist (CRNA) on 11/7/12 at 0930 and he stated the expectation is the cart should be locked. He also revealed there have been problems with that particular cart not locking. He stated a new cart has been requested for two (2) years now.

3. On 11/6/12 at 1025 while watching a medication pass on the rehabilitation unit, it was noted the nurse left the medication cart unlocked and unattended while she went into a patient room to dispense medication. When she returned to the cart, she was questioned about locking the cart. She stated the cart is equipped with a lock and an electronic key pad to unlock. She also pointed out a strip of tape adhered to the top of the cart, next to the electronic key pad, with the password used to unlock the cart.

Based on observation and staff interview, it was determined the hospital failed to maintain
adequate facilities to ensure endoscopic equipment is decontaminated, disinfected and stored in a manner which is in compliance with minimum construction standards. This has the potential to adversely affect the safety of all patients by not having endoscopic equipment appropriately disinfected and stored prior to procedures.

Findings include:

1. During a tour of the hospital endoscopy instrument processing area on 11/07/12 at approximately 11:00 a.m., it was noted that the procedures used for cleaning contaminated instruments and storage of disinfected instruments does not eliminate the potential for cross contamination. The processing room was observed to have no separations or barriers between the decontamination and disinfection areas. During the observations of the processing room, it could not be determined that a negative pressure and a minimum ten (10) air exchanges per hour was met as required for a decontamination room. The cleaning of instrumentation does not allow the flow from the contaminated area to a clean area without the potential for droplet contamination due to the close proximity of the decontamination sink and the automatic processing unit used for disinfections and the lack of a physical barrier between the clean and contaminated areas.

2. During a tour of the hospital endoscopy instrument processing room and bronchoscopy procedure room on 11/07/12 at approximately 11:10 a.m., the ceiling tile in the rooms appeared to have some type of contact paper attached that was peeling loose and would not allow for proper cleaning.

3. These findings were discussed with the operating room Manager during the tour of the operating room area at approximately 11.30 a.m., on 11/07/12. It was agreed that the processing and storage of instruments was not being done to meet the minimum requirements.

Guidelines for Design and Construction of Health Care Facilities
7.7.A.5 Endoscopy suite requirements
9.9 Endoscopy Suite
9.9.B Instrument Processing Room(s)
9.9.B1. Dedicated processing room(s) for cleaning and disinfecting instrumentation must provided. In an optimal situation, cleaning room(s) should be located between two procedure rooms. However, one processing room may serve multiple procedure rooms. Size of the cleaning room(s) is dictated by the amount of equipment to be processed.

Cleaning rooms should allow for the flow of instrumentation from the contaminated area to the clean area, and finally, to storage. The clean equipment rooms, including storage, should protect the equipment from contamination.

9.9.B2.he decontamination room should be equipped with the following:
a. Utility sink(s), as appropriate to the method of decontamination used. This may require soaking sink(s), rinse sink(s), automated cleaning device(s), or a combination.
b. One freestanding handwashing station.
c. Work counter space(s).
d. Space and plumbing fixtures for automatic endoscope cleaners, sonic processor, and flash sterilizers(where required).
e. Ventilation system. Negative pressure shall be maintained and a minimum of 10 air changes per hour shall be maintained. A hood is recommended over the work counter. All air should be exhausted to the outside to avoid recirculation within the facility.
g. Floor covering monolithic and joint free.

Note: The cleaning area shall allow for the flow of instruments from the contaminated area to the clean assembly area and then to storage. A physical barrier shall be provided to prevent droplet contamination on the clean side. Clean equipment rooms, including storage, should protect the clean equipment from contamination.

A. Based on observations, document review and staff interview it was determined that infection control failed to prevent the contamination of the medication carts between patients during the administration of medications. Medication carts that become contaminated between patients can result in the cross contamination of patients resulting in health care acquired infections with negative patient outcomes.

Findings include:

Review of the policy for medication cart infection control states in part the following:

1. Position the cart just inside the door of the patients room so that it does not come into contact with equipment bed or linens.
2. Immediately after scanning the patients armband, return the scanner to the holder on the cart.
3. Decontaminate hands before touching medication cart or keyboard.
4. Administer medications to patient.
5. Decontaminate hands before touching the medication cart or keyboard.
The guidance for the administration of medications to patients in the isolation room directs the staff to enter the room and sign in to the computer located inside the patient room.

The following are examples of observations that were made on 11/6/12 on the 5th floor in which the medication cart was contaminated between patients during the morning medication pass:

At 0950 hours Registered Nurse #1 (RN #1) took a medication cart and positioned it inside patient room 503. The nurse had to partially push the cart into the patients bathroom to allow another staff member to enter the room. After this RN #1 pushed the cart past the patient in bed B striking side of the cart and under the cart top ledge with that patients bed linens. RN #1 located the cart adjacent and to and touching the bed of the other patient in Bed A in room 503. The nurse then picked up the scanner and scanned the armband of the patient in that bed allowing the cord of the scanner to touch the patient and bed linens. The nurse returned the scanner to the cart and without any hand decontamination made an entry into cart keyboard. During the medication administration to the patient in Bed A, the patient in the other bed (Bed B ) knocked his phone onto the floor and RN #1 picked the phone up and returned it to the bedside stand..Without hand decontamination RN #1 picked up the scanner and scanned a medication for the patient in Bed A, made an entry into the keyboard then withdrew a medication and administered it intravenously to that patient. Working on the top of the cart the nurse crushed several medications and administered them to the patient A repeatedly working off of the medication cart. The cart was removed from the room and without any cleaning or decontaminated was returned to a storage area.

At 0955 Registered Nurse #2 (RN #2) took a medication cart into room 504 and placed it next to the patient in Bed A touching the bed and linens. The nurse took the scanner and reached across the bed allowing the scanner cord to touch the patient and the bed linens. The nurse without hand decontamination gave the medications to the patient and made entries into the keyboard on the cart. The nurse did decontaminate hands and moved the cart next to the bed of the other patient in room 504 touching the bed and the linens of that patient. The nurse again took the scanner and scanned the patient's armband allowing the scanner cord to touch the patient and linens. The nurse repeated given the patient their medications and made entries into the cart keyboard without hand decontamination before touching the keyboard or cart.

On 11/6/12 at 1115 hours RN #1 was questioned about the use of the medication cart. She stated they take the cart into each patients room and place it next to the bed so they can use the scanner. She asserted they are never to take the cart in an isolation room.

The following are examples of observations made on 11/6/12 on the 5th floor in which the medication cart was contaminated when taken into an isolation room:

At 1330 hours a Respiratory Therapist (RRT #1) was observed existing the elevator with a medication cart. The Therapist took the cart directly into the isolation room across from the elevator (room 501) and positioned it by the patient in Bed B. After RRT #1 completed administering the treatment he took the cart out of the room and wheeled it up the hallway and took a cleaning wipe and cleaned the keyboard, part of the scanner and around the outside top ledge of cart.

The unit manger of the 5th floor and the Infection Preventionist were both interviewed on 11/6/12 at 1145 hours. They both indicated the way the staff perform medication administration using the carts is the same on other units. They both agreed these carts are never to be taken into an isolation room.

B. Based on observations, staff interviews and document review it was determined that infection control failed to ensure that all equipment in endoscopic rooms are clean or sterilized and free from possible sources of contamination and ready for use at all times. Failure to maintain clean equipment and machines that do not have water sources which can allow the proliferation of bacteria can result in patient exposure to contaminated items or solutions that could cause health care associated infections with adverse patient outcomes.

Findings include:

During a tour of the endoscopic suite on 11/7/12 at 1100 hours the following observations were made of infection control issues:

Located in a hallway with high traffic from staff and patients was a cabinet with a pull down front closure. Located in this cabinet were clean endoscopes. When this cabinet was opened the cleaned scopes were exposed to patients and staff passing by this cabinet which could lead to the contamination of the scopes . Additionally there was a patient, awaiting a procedure, located in this hallway approximately three (3) feet from this cabinet that was repeatedly opened during the observations.

In the Bronchoscope room was an anesthesia machine that was dusty with some areas that had a gritty feel. Additionally in this room was a travel cart which contaminated multiple Olympus endoscopic video and light source units that was covered with a layer of dust. On the side of one of these Olympus machines was a bottle that was about 3/4 full of a clear liquid. There was no information available on when the bottle was disinfected or sterilized, when it was filled or what the liquid was. The Supervisor of the endoscopic suite was questioned at the time of the tour and she said the bottle was filled with water. When questioned she said the cart had just been used for the first time the other day. She did say she was sure the bottle had been cleaned before use but did not know how long the water had been in that bottle and when the bottle had last been sterilized. This represents a situation in which bacteria could be allowed to grow when water has been poured out of its original container into another bottle and remain unused for indefinite periods of time.

The Manager of Surgical Services on 11/7/12 at 1530 hours presented information that indicated the last time the travel cart and equipment had last been used was on Friday 11/2/12. She stated the water in that container had only been there for no more than five (5) days.

Review of the manufacture manual for the Olympus water container revealed in part the following:

1. Reprocess the water container daily. The water container should be emptied, cleaned and disinfected or sterilized at least once daily. Failure to do so could pose an infection control risk and cause tissue irritation.

At 1115 hours on 11/7/12 Surgical Technician #1 (ST #1) was observed holding a endoscope up and carrying it from the reprocessing room into the hallway where patients and staff travel. The scope was not covered and the tip of the scope was hanging only about 3-4 inches from the floor. The Technician was questioned, at this time, about the scope she was carrying and she stated she had just cleaned the scope and was taking it to the storage cabinet in the hallway. When questioned if she had allowed the tip of scope to touch the floor, she stated she "didn't think that it had hit the floor." This practice allows for the possible contamination of the scope from the environment, staff or patients.

A. Based on review of medical records, documents and interviews with staff, it was determined the hospital failed to ensure there is an adequate and appropriate discharge planning process for all patients which has been specified in writing in the policies and procedures. There is a potential for patients to not have appropriate and timely discharge planning activities completed.

Findings include:

1. Review of hospital policies and procedures revealed there is only one policy relative to discharge planning activities. The policy "Discharge Planning and Referrals of Patients To Post Discharge Providers", last reviewed 7/12, includes directives for staff to allow patients to choose their own after-care providers, if needed. There are no directives in the policy for how all discharge planning activities will be accomplished for all patients from the time of admission to the time of discharge.

2. The Director of Case Management was interviewed on 11/7/2012 at 1:45 p.m. She stated the only written policy for discharge planning activities was included in the hospital's 2012 "Utilization Review (UR) Plan". Review of the UR Plan reveals it includes a section "Discharge Planning", which states "The organization requires effective and timely discharge planning for all inpatients. Organizational policies and procedures provide guidance for the collaborative process that involves physicians, key clinical disciplines, and patients (or their legal representatives)." She confirmed there are no other written policies other than what was included in the UR plan to direct staff how to carry out discharge planning activities. She stated she was not sure if the UR Plan was made available to all staff for their review and use as a reference source. Review of the hospital's policy manuals revealed the UR Plan was not included in the policy manuals.

B. Based on review of medical records, documents and interviews with staff, it was determined the hospital failed to ensure timely discharge planning activities were carried out for one (1) of twelve (12) patients (record #7) whose closed medical records for general inpatient admissions were reviewed. This has the potential for patients to not receive discharge planning activities early on in an admission, which may delay their discharge from the hospital.

Findings include:

1. Review of the hospital's Utilization Review (UR) Plan for 2012 revealed there are some directives for the Case Management Department relative to discharge planning. The UR plan states "The admission nurse for each patient initiates the discharge assessment and planning process within 24 hours of admission based on the biopsychosocial needs of the patient. The hospital will develop a discharge plan for any patient with identified post-discharge need and/or if the physician or patient/family requests that a discharge plan be developed...A Case Manager or Social Worker is assigned to coordinate discharge planning for high-priority patients. Patients in need of special post-discharge services and/or who have complex medical conditions are considered high-priority."

2. Review of the medical record for patient #7 revealed the 66 year old patient was admitted on 10/9/2012 to the intensive care unit. The initial nursing assessment was completed on 10/9/2012. During the initial assessment, the nurse documented the patient had "anticipated home care needs" and was already using durable medical equipment at home. The nurse documented the Social Worker was consulted on that date for "discharge planning". The Social Worker wrote the first discharge planning assessment note on the medical record on 10/19/2012, ten (10) days after admission and after the assessment was requested. The Director of Case Management reviewed the record on 11/7/2012 at 1:45 p.m. and she agreed the patient's initial post-discharge plan was developed ten (10) days after admission to the hospital.

Based on review of medical records and staff interview, it was determined the hospital failed to provide activities for three (3) of three (3) swing bed residents (#8, 9 and 23). This has the potential for failure to provide and promote maintenance or enhancement of each resident's quality of life.

Findings Include:

1. Patient #8 was admitted to a swing bed on 10/30/12. There is no documentation in the medical record to indicate a physical activity assessment had been completed and there was no documentation to indicate any type of individual, group or bedside activities were offered.

2. Patient #9 was admitted to a swing bed on 11/3/12. There is no documentation in the medical record to indicate a physical activity assessment had been completed and there was no documentation to indicate any type of individual, group or bedside activities were offered.

3. Patient #23 was admitted to a swing bed on 10/16/12. There is no documentation in the medical record to indicate a physical activity assessment had been completed and there was no documentation to indicate any type of individual, group or bedside activities were offered.

4. During an interview with the Swing Bed Coordinator on 11/5/12 at 1100, she stated, "We currently do not have an Activities Director, our activities director unexpectedly retired in July, 2012.

A. Based on observations, document review and staff interview it was determined that infection control failed to prevent the contamination of the medication carts between patients during the administration of medications. Medication carts that become contaminated between patients can result in the cross contamination of patients resulting in health care acquired infections with negative patient outcomes.

Findings include:

Review of the policy for medication cart infection control states in part the following:

1. Position the cart just inside the door of the patients room so that it does not come into contact with equipment bed or linens.
2. Immediately after scanning the patients armband, return the scanner to the holder on the cart.
3. Decontaminate hands before touching medication cart or keyboard.
4. Administer medications to patient.
5. Decontaminate hands before touching the medication cart or keyboard.
The guidance for the administration of medications to patients in the isolation room directs the staff to enter the room and sign in to the computer located inside the patient room.

The following are examples of observations that were made on 11/6/12 on the 5th floor in which the medication cart was contaminated between patients during the morning medication pass:

At 0950 hours Registered Nurse #1 (RN #1) took a medication cart and positioned it inside patient room 503. The nurse had to partially push the cart into the patients bathroom to allow another staff member to enter the room. After this RN #1 pushed the cart past the patient in bed B striking side of the cart and under the cart top ledge with that patients bed linens. RN #1 located the cart adjacent and to and touching the bed of the other patient in Bed A in room 503. The nurse then picked up the scanner and scanned the armband of the patient in that bed allowing the cord of the scanner to touch the patient and bed linens. The nurse returned the scanner to the cart and without any hand decontamination made an entry into cart keyboard. During the medication administration to the patient in Bed A, the patient in the other bed (Bed B ) knocked his phone onto the floor and RN #1 picked the phone up and returned it to the bedside stand..Without hand decontamination RN #1 picked up the scanner and scanned a medication for the patient in Bed A, made an entry into the keyboard then withdrew a medication and administered it intravenously to that patient. Working on the top of the cart the nurse crushed several medications and administered them to the patient A repeatedly working off of the medication cart. The cart was removed from the room and without any cleaning or decontaminated was returned to a storage area.

At 0955 Registered Nurse #2 (RN #2) took a medication cart into room 504 and placed it next to the patient in Bed A touching the bed and linens. The nurse took the scanner and reached across the bed allowing the scanner cord to touch the patient and the bed linens. The nurse without hand decontamination gave the medications to the patient and made entries into the keyboard on the cart. The nurse did decontaminate hands and moved the cart next to the bed of the other patient in room 504 touching the bed and the linens of that patient. The nurse again took the scanner and scanned the patient's armband allowing the scanner cord to touch the patient and linens. The nurse repeated given the patient their medications and made entries into the cart keyboard without hand decontamination before touching the keyboard or cart.

On 11/6/12 at 1115 hours RN #1 was questioned about the use of the medication cart. She stated they take the cart into each patients room and place it next to the bed so they can use the scanner. She asserted they are never to take the cart in an isolation room.

The following are examples of observations made on 11/6/12 on the 5th floor in which the medication cart was contaminated when taken into an isolation room:

At 1330 hours a Respiratory Therapist (RRT #1) was observed existing the elevator with a medication cart. The Therapist took the cart directly into the isolation room across from the elevator (room 501) and positioned it by the patient in Bed B. After RRT #1 completed administering the treatment he took the cart out of the room and wheeled it up the hallway and took a cleaning wipe and cleaned the keyboard, part of the scanner and around the outside top ledge of cart.

The unit manger of the 5th floor and the Infection Preventionist were both interviewed on 11/6/12 at 1145 hours. They both indicated the way the staff perform medication administration using the carts is the same on other units. They both agreed these carts are never to be taken into an isolation room.

B. Based on observations, staff interviews and document review it was determined that infection control failed to ensure that all equipment in endoscopic rooms are clean or sterilized and free from possible sources of contamination and ready for use at all times. Failure to maintain clean equipment and machines that do not have water sources which can allow the proliferation of bacteria can result in patient exposure to contaminated items or solutions that could cause health care associated infections with adverse patient outcomes.

Findings include:

During a tour of the endoscopic suite on 11/7/12 at 1100 hours the following observations were made of infection control issues:

Located in a hallway with high traffic from staff and patients was a cabinet with a pull down front closure. Located in this cabinet were clean endoscopes. When this cabinet was opened the cleaned scopes were exposed to patients and staff passing by this cabinet which could lead to the contamination of the scopes . Additionally there was a patient, awaiting a procedure, located in this hallway approximately three (3) feet from this cabinet that was repeatedly opened during the observations.

In the Bronchoscope room was an anesthesia machine that was dusty with some areas that had a gritty feel. Additionally in this room was a travel cart which contaminated multiple Olympus endoscopic video and light source units that was covered with a layer of dust. On the side of one of these Olympus machines was a bottle that was about 3/4 full of a clear liquid. There was no information available on when the bottle was disinfected or sterilized, when it was filled or what the liquid was. The Supervisor of the endoscopic suite was questioned at the time of the tour and she said the bottle was filled with water. When questioned she said the cart had just been used for the first time the other day. She did say she was sure the bottle had been cleaned before use but did not know how long the water had been in that bottle and when the bottle had last been sterilized. This represents a situation in which bacteria could be allowed to grow when water has been poured out of its original container into another bottle and remain unused for indefinite periods of time.

The Manager of Surgical Services on 11/7/12 at 1530 hours presented information that indicated the last time the travel cart and equipment had last been used was on Friday 11/2/12. She stated the water in that container had only been there for no more than five (5) days.

Review of the manufacture manual for the Olympus water container revealed in part the following:

1. Reprocess the water container daily. The water container should be emptied, cleaned and disinfected or sterilized at least once daily. Failure to do so could pose an infection control risk and cause tissue irritation.

At 1115 hours on 11/7/12 Surgical Technician #1 (ST #1) was observed holding a endoscope up and carrying it from the reprocessing room into the hallway where patients and staff travel. The scope was not covered and the tip of the scope was hanging only about 3-4 inches from the floor. The Technician was questioned, at this time, about the scope she was carrying and she stated she had just cleaned the scope and was taking it to the storage cabinet in the hallway. When questioned if she had allowed the tip of scope to touch the floor, she stated she "didn't thi