HospitalInspections.org

Based on record review and interview the facility failed to ensure documented evidence of advance directives or offering the patient more information on advance directives for 1 (#10) swing bed patient of 22 patient records reviewed. Findings:

On 9/14/2011 at 3:20 pm, the Director of Medical Records was asked to locate evidence of advance directives for Patient #10. The Director of Medical Records confirmed no documented evidence of advance directives was located. In addition, the Director confirmed there was no evidence on the computerized medical record that related to advance directives.

Review of the admissions packet for swing bed patients revealed a section on advanced directives. Included was "When you are admitted Providence Alaska Medical Center, we will ask you about your Advance Directives. If you have made one or both of these Advance directives, we will ask you for a copy since we cannot act on them until we see them if you cannot get a copy to us, please tell the health care team what they say. Once we have a copy, it will stay with your medical record for future use unless you tell us you wish to cancel it. If you have not made Advance Directives, we can provide you with more information and the typical forms..."

Based on observation and interview the facility failed to ensure antibacterial soap was available for staff working in the laundry who handled bloody and solid linens. This deficient practice created the potential for cross contamination and spread of infection. Findings:

During the tour of the laundry on 9/13/2011 at 3:30 pm, 2 staff and the supervisor confirmed they do handle bloody and soiled linens. Upon inspection of the soap used for hand hygiene, the label described the liquid soap as a rose-scented lotion soap. Surveyors asked the staff if the soap was antibacterial and they stated they weren't sure but assumed it was.

During an interview with the Infection Control Nurse on 9/13/2011 at 8:30 am surveyors asked about the product. The Infection Control Nurse stated she would look into the matter. The Infection Control Nurse placed a call to the manufacturer and was told "If the description does not say antibacterial it is not."

Based on record review and interview the facility failed to ensure consent for treatment forms were included in the clinical record for 2 (#s 18, 21) of 22 sampled patient records. Findings:

Review of clinical records on 9/12/2-11-9/14/2011 revealed there was no documented evidence of consent for treatment for swing bed Patient #s 18 and 21.

On 9/14/2011 at 3:20 pm, the Director of Medical Records was asked to locate the consent forms or show the surveyors where the information could be located on the computerized medical record. The Director of Medical Records confirmed no consents for treatment were located. In addition, the Director confirmed there was no evidence on the computerized medical record related to consent for treatment.

Based on record review and interview the facility failed to ensure a facility-wide quality improvement program was in place that consistently identified, implemented, monitored, and evaluated facility and patient care practices. This deficient practice increased the risk of suboptimal patient care and safety. Findings:

Review on 9/13-14/2011 of the facility's Quality Assurance (QA) Committee Meeting Minutes revealed the QA Committee met on 9/14/2010; 1/12/2011; 3/23/2011; and 5/11/2011. Further review revealed the following:

? There were 17 different "Topic" items listed in the meeting minutes. Only 1 of the 17 had documentation for "Actions" and there was no documentation of the "F/U Date" [follow up date] for any of the 17 topics. Documentation revealed 7 identified issues of concern were not discussed in the 3 subsequent QA meetings;

? No documentation of proper remedial actions taken that included all of the identified deficient practices;

? The facility's infection control nurse was not part of the QA Committee;

? No documentation of action plans, follow-up and evaluation of identified hospital acquired infections, State reportable infections, and community acquired MRSA (infection is caused by a strain of staph bacteria that's become resistant to the antibiotics commonly used to treat ordinary staph infection);

? Incomplete and inconsistent documentation for "Findings/Conclusions/Recommendations";

? No documentation and discussion of facility-acquired infections and medication therapy;

? No documentation of evaluation of contract services; and

? No documentation of an annual quality review that included all departments

During an interview with the Quality Assurance Director on 9/14/2011 at 10:15 am she confirmed all departments have quality calendars. Surveyors requested a copy of all the departments' quality calendars, and the QA Director provided the calendars. There were no calendars for the following departments: nursing services; hospital clinic; social services; and laundry services. She confirmed dietary; therapies and laundry were not "working on a specific project".

The QA Director stated that an annual review of every department was done. Review of the "Quality Annual Meeting" minutes revealed the hospital clinic, therapies, support services and social services were not included.

The surveyor asked if a root cause analysis (RCA) was done on any of the facility's infections. The Quality Assurance Director stated "normally we do an RCA but due to time constraints we didn't do them."

The surveyor also asked the QA Director about hand hygiene rounds. She stated that hand hygiene rounds had been done in 2010 but stated "none have been done this year."

The Quality Assurance Director gave the survey team a copy of the facility's "Quality Improvement Program" on 9/14/2011. Review of the policy (not dated) included the program "is designed to monitor and evaluate the quality of the patient/resident/client care, pursue opportunities to improve quality of care, and resolve identified problems. It is developed to include Medical Staff and all departments/care centers/facilities within PSMCC."

Based on record review and interview the facility failed to review infections and medication treatment to ensure appropriate prescription of medications and indications for use. As a result, there was no documented evidence of infections and medication use in evaluating their impact on process of care, patient outcomes, and especially, antibiotic resistance patterns. Findings:

Review of the quarterly pharmacy reports for 12/13/2010; 4/21/2011; and 7/25/2011 revealed no documentation of review of the appropriateness of antibiotic use and identified infections by a pharmacist or a physician. Review of the hospital infection surveillance report revealed identified infections from January-August 2011 for hospital acquired infections, State reportable infections, and community acquired MRSA infections.

During an interview with the Infection Control Nurse on 9/14/2011 at 8:15 am, she confirmed that a pharmacist did not look at that information. This was again confirmed during an interview with the QA Director on 9/14/2011 at 10:30 am. There was no available documented evidence infections and medication treatment use had been evaluated.