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Based on interview and document review, the hospital failed to ensure that contracted services were evaluated for safety and effectiveness.

Findings:
On the morning of 09/26/2016, a list of contracted services was reviewed. No documentation was provided showing that contracted services had been evaluated by the governing body, who is responsible for oversight.

The hospital's Administrator confirmed that contracted services were not evaluated by established quality criteria.

On 09/27/2016, during a tour of the Sleep lab area, the surveyors observed an inventory of continuous positive airway pressure (CPAP) masks and circuits used during sleep studies. Many masks were in sterilization peel packs. The surveyor requested validation that the CPAP masks and circuits were reusable as defined by the manufacturer and disinfected in accordance to manufacturer's instruction for use. During the survey, this validation information was not provided.
~On 09/28/2016, the Chief Executive Officer provided the surveyors a letter documenting Sleep lab services will be suspended until manufacturer's guidleines for the required equipment was followed.

Based on observation, interview, medical record review and policy and procedure review, the hospital failed to provide the patient a phone number and address for lodging a grievance with the State agency.
Findings:
~On 09/27/2016 at 8:45 A.M., surveyor observed a patient ' s admission. The patient was provided documents titled, " Notice Of Privacy Practices " and " Patient Agreement On Admission " .
~On 09/27/2016 at 8:45 A.M., Staff GG reported to the surveyor the " Notice Of Privacy Practices " and " Patient Agreement On Admission " were the current forms given to the patients upon admission.
~On 09/27/2016 at 8:45 A.M., the " Notice Of Privacy Practices " and " Patient Agreement On Admission " documents were reviewed. The documents did not include State agency information.
~Review of the hospital ' s policy and procedure titled " Patient Complaint and Grievance Policy, " revised on 03/24/2016, was not consistent with the forms " Notice Of Privacy Practices " and " Patient Agreement On Admission " provided to each patients on admission. The policy documented, " ...concern has not been resolved, you may also contact: The Oklahoma State Department of Health... " " ...The mailing and street address and telephone numbers are ... "

Based on observations, interviews, and document review, the hospital failed to maintain an ongoing active infection control program designed for the prevention, control, and investigations of all infections and communicable diseases in the Sleep Lab, the Dietary Department, and the Physical Therapy Department.

Findings:

1. On 09/27/2016, during a tour of the Sleep Lab area, the surveyors observed an inventory of continuous positive airway pressure (CPAP) masks and circuits used during sleep studies. Many masks were in sterilization peel packs.
~On 09/26/2016 at 11:15 am, during an interview, Staff T stated the CPAP accessories were cleaned by hospital policy which consisted of spraying the accessories with "Control III" (an US Environmental Protection Agency (EPA) disinfectant). The disinfectant was allowed to remain on the accessories for five minutes, and then rinsed with soap and water.
~The manufacturer's label for Control III was reviewed. For non-critical instruments ( Non-critical items are those that come in contact with intact skin but not mucous membranes) the label instructed the user to mix the solution per the directions and immerse the instrument for ten minutes and then rinse in sterile water.
~The surveyor requested validation that the CPAP masks and circuits were reusable as defined by the manufacturer and disinfected in accordance to manufacturer's instruction for use. The validation information was not provided.
~The hospital's policy, titled, "Single Use Devise Criteria (no approval date)" documented, "It is the policy of Sequoyah Memorial Hospital (SMH) not to reprocess or reuse any single use items."
~On 09/28/2016, the Chief Executive Officer provided the surveyors a letter which documented the suspension of Sleep lab services until the manufacturer's guidelines for CPAP masks and circuits were followed by the contracted staff, processes and training verified by the appropriate (SMH) staff, and approved by the Infection Control / Quality Committees.

2. On 09/27/2016, the surveyors toured the Dietary Department. ~On 09/27/2016, the surveyor requested the temperature logs for the kitchen food. No food temperature logs were provided during the survey. ~During an interview, the Dietary Manager asked Staff P where the food temperature logs for 09/27/2016. Staff P stated the log's location was unknown. ~The Dietary Manager stated the kitchen had problems with the food going out of the kitchen cold. ~The hospital policy titled, "Monitoring Food Temperatures for Meal Service (no approved date", documented, "Prior to serving a meal, food temperature will be taken and documented for all hot and cold foods to ensure proper temperatures...the temperature of each food item will be recorded on the Food Temperature Log."
On 09/27/2016, during the tour of the dish washing room, the surveyor observed rusty metal ceiling grids, and a white fuzzy coating on ceiling tiles.
~During an interview, the Dietary Manager stated the ceiling deterioration was probably a result of the steam from the dishwasher.
~The hospital's "Food Inspection Report" from Oklahoma Department of Health dated 03/30/2016 documented, "Ceiling in dishwasher room has rust, paint peeling from the tile support."
~On 09/27/2016, during an interview, Chief Executive Officer stated the ceiling in the dishwasher room had been examined and confirmed the ceiling's deterioration.

3. On 09/27/2016, during a tour of the Physical Therapy Department, Staff V told the surveyor the Hydrocollator (a heating unit for hot packs) had no log for recording temperatures or dates of disinfecting the unit. Staff V stated the unit was cleaned monthly and the temperature was measured at that time.
~The surveyor requested manufacturer instructions for use and for a policy regarding the equipment and none was provided.

Based on staff interview and document review, the hospital failed to ensure surgical fire risk reduction measures were implemented within the facility's sugical suites.

Findings:
On 09/26/2016 at 4:00 pm, during the surgical unit tour, oxygen, alcohol [fuel], and cautery [heat] were observed in the surgical suites, and increased the risk of surgical fires.

During an interview, the Chief Nursing Officer stated the surgical staff did not perform a surgical fire risk assessment prior to endoscopic procedures.

The hospital policy title, "Fire Safety in Surgery" was reviewed. This policy documented "The OR (operating room) team must be aware that all of these elements (fuel, ignition, sources, and oxygen) are present in the operating room every time there is a procedure and must take every precaution to ensure that they are kept apart."