HospitalInspections.org

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Based on record review and interview, it was determined that the facility did not comply with the Condition of Participation for Governing Body. This was evident by the Governing Body's failure to ensure implementation of the facility's corrective action plan for the Immediate Jeopardy (IJ) situation on 12/04/14 regarding the failure to investigate an allegation of sexual abuse. The Governing Body failed to assume responsibility to ensure the facility's thorough and timely implementation of the Policy to investigate all allegations of abuse and to provide Quality Management Review of these investigations.

Findings:

During an Allegation Survey on 12/04/14 , an IJ situation was identified for the facility's failure to protect a patient who alleged a staff member of sexual abuse.

A return visit on 2/25/15 to review the facility's corrective actions revealed that eight additional patient complaints of staff abuse were not investigated as per the facility's Policy and Quality Management failed to review the care rendered to these patients. As a resulted, problems in this report were not identified and appropriate corrective measures were not implemented therefore placing patients at risk.

During the survey the findings identified repeat non-compliance with the Condition of Participation for Patient Rights. (See Tag A 115)

The Governing Body continued to fail to ensure that an immediate and thorough investigation was conducted regarding allegations of abuse and to ensure that Quality Management assessed, analyzed, identified areas for improvement and then implemented corrective actions to prevent a recurrence which placed all patients at risk for physical and verbal harm.

(See Tags A 145 and A 283 Repeat Deficiencies)

The Governing Body failed to assume responsibility for QAPI (Quality Assurance Performance Improvement) as evidenced by the facility's repeated failure to monitor the implementation of the "Abuse and Neglect, Mistreatment of Patient" Policy. This resulted in non-compliance with the Condition of Participation for QAPI.

(See Tag A 263)
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Based on record review and interview, it was determined that the facility failed to comply with the Condition of Participation for Patient Rights. This was evident by the facility's repeated failure to timely and effectively implement the facility's "Abuse and Neglect, Mistreatment of Patients" Policy following patients' allegations of abuse at the facility.

Findings:

The facility again failed to protect patients from potential abuse and neglect and to effectively and timely implement the facility's "Abuse and Neglect, Mistreatment of Patients" Policy to investigate allegations of abuse and neglect. This was evident when patients complained of being abused by a staff member and staff failed to implement the Policy in seven (7) of eight (8) cases reviewed (Patients #77, #78, #79, #80, #81, #82 and #83).

(See Tag A 145 Repeat Deficiency)
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Based on observations and staff interview, the facility failed to ensure that the patients' right to privacy, which includes the patients' presence and location in the facility, was maintained. This was evident on three (3) of five (5) Nursing Units toured (6 South, 8 Tower and the Emergency Room).

Findings:

During a tour of the Emergency Department on 02/26/15 at 10:30AM, the Tracking Boards were observed positioned on the walls of the ED displaying the first and last names of the patients in the ED. These Monitors were in full view of anyone walking in the ED.

During interviews on 02/26/15 during the tour, both Staff Members #3 and #4 confirmed that all of the Tracking Boards displayed the patient's first and last names. Staff Member #4 stated "We didn't think it was an issue because there is no other important information on the Board."

During a tour of 8 Tower on 02/26/15 at 1:30PM, the Telemetry Monitor Stations were observed positioned on the walls of the Main Hallway displaying the first and last names of the patients in each Pod. These Monitors were in full view of anyone walking in the hallway.

During interviews on 02/26/15, both Staff Members #1 and # 2 confirmed that all of the Monitors displayed the patient's first and last names. Staff Member #1 stated "We have considered using only last names, but that was a problem because of the number of patients we have with the same last names."

During a tour of 6 Tower on 02/27/15 at 10:25AM, the Telemetry Monitor Station was observed positioned on the wall in the Unit corridor. The Monitor displayed patients' first and last names, which were visible to patients, visitors, and / or staff walking in the corridor.

At that time this finding was confirmed with Staff #6.
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Based on record review and interview it was determined that the facility again failed to protect patients from potential abuse and neglect and to effectively and timely implement the facility's "Abuse and Neglect, Mistreatment of Patients" Policy to investigate allegations of abuse and neglect for seven (7) of eight (8) cases reviewed. This was evident when patients complained of being abused by staff and the staff failed to implement the required procedures included in the facility's Policy (Patients #77, #78, #79, #80, #81, #82 and #83).

Findings:

a) Review of the Memorandum titled "Allegation of Abuse Investigation" dated 02/22/15, documented on 02/20/15 at 7:40 PM that Patient #77 complained that Staff #11 "called him a "Monkey, the "N" word, and said all you "N's" are alike." He also complained that Staff #11 swung at him and missed.

There is no documented evidence that the allegations were investigated at the time of the occurrence. Staff #11 continued to work until 12:00 Midnight, four (4) hours and twenty (20) minutes after the allegation. He was not removed from patient access as required in the facility Policy until the following day 02/21/15 at 4:40PM, twenty-one (21) hours after the allegation.

Although two (2) Registered Nurses (Staff Members #19 and #20) were aware of the allegations at the time of occurrence, the investigation and escalation to Leadership were not implemented as per the Policy until 02/21/15 at 1:15PM, seventeen (17) and one-half (1/2) hours after the patient complained.

The Attending Physician was never notified, there was no documentation of "immediate findings, including a Physical / Psycho-Social Exam", and a Psychiatry Consult was not considered as required by the Policy.

At the time of the occurrence the Social Worker was not notified, did not visit the patient, perform an Assessment and provide support as required by the Policy.

An immediate and comprehensive investigation was not implemented.

An e-mail dated 02/21/15 at 10:03PM between Executive Management documented that the "allegation of abuse happened last evening but was not escalated to a Manager until this afternoon". Although this Memo notified Leadership of the delay in escalation of abuse to a Manager, corrective actions were not taken. Leadership did not ensure that the Policy was effectively implemented. They did not identify that the Attending Physician was not notified, there was no documentation of immediate findings, including a Physical / Psycho-Social Exam, a Psychiatry Consult was not considered and a Social Worker was not notified, did not visit the patient, perform an Assessment and provide support. As a result these services were not provided for the patient who was still an inpatient during the survey and corrective actions were not implemented to prevent reoccurrence.

An interview with Staff Members #12 and #13 on 02/26/15 at 11:35AM confirmed the above findings.

On 02/26/15 at 11:35AM, although the DOH Surveyor brought these findings to the attention of Executive Management, as of 03/03/15, five (5) days later, and eleven (11) days after the occurrence, the Attending Physician did not document "immediate findings, including a Physical / Psycho-Social Exam, and consider a Psychiatry Consult" although the patient was in-house.

On 03/03/15 at 1:30PM, Staff #13 provided the Surveyor with documentation that on 02/26/15 at 4:00PM, that the Social Worker met with the patient to discuss the allegation. However, there was no documented Assessment as required by facility Policy. Corrective actions were not implemented to prevent a recurrence.

On 03/03/15 at 1:30PM Staff #13 confirmed the findings.

Review of 9 South's Staffing Schedule from 02/08/15 - 03/06/15 revealed that on 02/20/15 Staff #11 worked 4:00PM and 12:00 Midnight.

A Memo authored by Staff #19 dated 02/22/15, documented on 02/20/15 before 10:00PM, that although Staff #11 notified Staff #19 that Patient #77 accused him of abuse "Reporting the alleged verbal abuse somehow slipped to the back of my mind once the patient was safely asleep."

A Memo authored by Staff #20 dated 02/22/15, documented on 02/20/15 that the Nurse's Assistant "mentioned that Patient #77 said that Staff #11 called him a Monkey and the "N" word but to my understanding the behavior issues" were being handled prior to my arrival for the tour.

An interview with Patient #77's Psychiatrist on 02/26/15 at 10:50AM revealed he was not aware of the patient's allegation of abuse and he "did not see the patient for that".

An interview with Patient #77's Attending Physician on 02/26/15 at 11:10AM revealed she was not aware of the patient's allegation of abuse.

Review of the Policy titled "Abuse and Neglect / Mistreatment of Patients" dated 01/21/15 documented that when a patient alleges abuse against an employee, the Department or Managing Supervisor must immediately inform Site Specific Leadership. The Provider must be notified and documentation is required to reflect immediate findings, including a Physical / Psycho-Social Exam. A Psychiatry Consult will be ordered if indicated. The Department Supervisor or Manager will be responsible to notify Social Work, who will then be required to visit the patient, perform an Assessment, and provide support and document findings in the Medical Record.

b) Review of the Memorandum titled "Patient Complaint Investigation" dated 01/08/15 documented that on 01/08/15 at 10:15AM Staff #21 was notified by Staff #20 that Patient #78 accused Staff Members #19 and #20 of sexually harassing him during the application of a Texas Catheter.

The Memorandum also documented that a Physician "evaluated and spoke with the patient. Upon assessment the patient denied any allegations of abuse and there were no physical findings of abuse".

On 02/26/15 the Surveyor requested the Physician's documentation. However, the facility never provided the information. As a result, there was no documented evidence that the Attending Physician documented "immediate findings, including a Physical / Psycho-Social Exam". There is no evidence that a Psychiatry Consult was considered. Also, there was no documented evidence that a Social Worker was notified, visited the patient, performed an Assessment, and provided support.

The Memorandum does not define the date and the time of the allegation. Therefore, making it difficult to determine timely escalation and notification of the Leadership, Management and the Physician. Also, there were no written staff statements regarding the event.

Corrective actions were not implemented to prevent a recurrence.

On 03/03/15 at 1:30PM Staff #13 confirmed the findings.

c) Review of the Memorandum titled "Allegation: Choking" dated 12/31/14 documented that on 12/20/14 PM Patient #79 accused Staff #22 of choking her.

Although the Memorandum documented that the Physician was unable to interview and examine the patient because she was sedated, the facility could not provide documented evidence that when the patient regained consciousness that the Physician documented "immediate findings, including a Physical / Psycho-Social Exam". There is no evidence that a Psychiatry Consult was considered. Also, there was no documented evidence that a Social Worker was notified, visited the patient, performed an Assessment, and provided support.

Corrective actions were not implemented to prevent a recurrence.

On 03/03/15 at 1:30PM Staff #13 confirmed the findings.

Similar findings were identified in the Medical Records for Patients #80, #81, #82 and #83.

Repeat Deficiency.
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Based on record review and interview, the facility failed to ensure that Physician Orders were in place for a patient in Four (4) Point Restraints in one (1) of four (4) Pediatric Medical Records reviewed (Patient #72).

Findings:

Patient #72 was admitted to the Emergency Department on 02/28/15 for drug ingestion. The 15-year-old patient had smoked Marijuana laced with Heroin, was combative and hypoxic requiring Narcan.

The patient was placed in Four (4) Point Violent Restraints at 11:15AM for three (3) hours, due to being a danger to himself and others. The patient was released from the Restraints at 2:15PM.

The Medical Record revealed a stat "Violent Self Destructive Level Two" Four (4) Point Restraint Physician's Order written at 11:59AM for a duration of one (1) hour.

The Order duration was for one (1) hour and the Order should have expired at 12:59PM. The Order was documented as discontinued at 1:52PM, one (1) hour and fifty-three (53) minutes later.

A new Restraint Order was ordered by the Physician at 1:52PM, for a duration of one (1) hour. The Order was discontinued on 02/28/15 at 2:17PM.

The Medical Record lacks an Order for the Restraints for the time between 12:59PM and 1:52PM.

Review of facility Policy titled "Restraints" revealed in Section 3 "Obtain an Order" that the Order may not exceed one (1) hour for children / adolescents ages nine to seventeen (9 - 17).

The Policy also states that the Physician "must be notified and consulted" if the Restraint exceeds one (1) hour.

The Record lacked evidence that the Physician was notified after the first hour of the patient in Restraints until a new Order was obtained at 1:52PM.
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Based on record review and interview it was determined that the facility did not comply with the Condition of Participation for QAPI (Quality Assessment Performance Improvement). This was evident by the facility's repeated failure to monitor the implementation of the "Abuse and Neglect, Mistreatment of Patients" Policy.

Findings:

The facility again failed to assess patient safety and the quality of care rendered for patients who complained of being abused by staff members to ensure the effective and timely implementation of the facility's "Abuse and Neglect, Mistreatment of Patients" Policy.

The facility failed to ensure that incidents of reported abuse were reviewed for compliance with the "Abuse and Neglect, Mistreatment of Patients" Policy, tracked and trended the data, identified areas for improvement, and implemented changes.

(See Tag A 283 Repeat Deficiency)
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Based on record review and interview, it was determined that the facility once again failed to assess patient safety and the quality of care rendered to a patient who complained of being abused by staff. This was evident by Quality Management's failure to review the alleged incidents of abuse, collect and trend the data from these reviews, and to implement actions to ensure the effective and timely implementation of the facility's "Abuse and Neglect, Mistreatment of Patients" Policy for eight (8) of eight (8) cases reviewed (Patient #77, #78, #79, #80, #81, #82, #83 and #84).

Findings:

During the DOH 02/25/15 onsite visit, a review of eight (8) of eight (8) Patient Complaints of staff abuse revealed that the Quality Management Department did not review care rendered to the patient. They failed to identify the problems documented in the Report and as a result appropriate corrective measures were not implemented to prevent a recurrence.

For example:

Review of the Memorandum titled "Allegation of Abuse Investigation" dated 02/22/15, for Patient #77 lacked documented evidence that the allegations were investigated at the time of the occurrence, that an immediate and comprehensive investigation was implemented, that the accused was immediately removed from patient care, that escalation to Leadership was timely, that the Physician documented of immediate findings and that a Psychiatry Consult was considered, and that a Social Work Assessment was provided as per Policy. Quality Management did not identify or address these issues.

Quality Management failed to review and address an e-mail dated 02/21/15 at 10:03PM between Executive Management that documented that the "allegation of abuse happened last evening but was not escalated to a Manager until this afternoon". Although this Memo notified Leadership of the delay in escalation of abuse to a Manager, corrective actions were not taken.

On 03/03/15 at 1:30PM Staff #13 confirmed the findings.

On 02/27/15 at 12:00 Noon Staff #12 agreed the Quality Management Analyses were missing.

Review of the Memorandum titled "Patient Complaint Investigation" dated 01/08/15 for Patient #78 lacked documented evidence of Physician findings and consideration of a Psychiatry Consult, and a Social Work Assessment.

The Memorandum does not define the date and the time of the allegation. Therefore making it difficult to determine timely escalation and notification to Leadership, Management and the Physician. There were no written staff statements regarding the event.

The Complaint was not reviewed by the Quality Management Department and the above quality of care issues were not identified and corrective actions were not implemented to prevent a recurrence.

On 02/27/15 at 12:00 Noon Staff #12 agreed the Quality Management Analyses were missing.

Review of the Memorandum titled "Allegation: Choking" dated 12/31/14 for Patient #79 lacked documentation of Physician findings after the patient regained consciousness and that a Psychiatric Consult was considered, and that the Social Worker assessed the patient.

The Complaint was not reviewed by the Quality Management Department and the above quality of care issues were not identified and corrective actions were not implemented to prevent a recurrence.

On 02/27/15 at 12:00 Noon Staff #12 agreed the Quality Management Analyses were missing.

During review of the findings on 03/03/15 at 1:30PM Staff #13 stated "We dropped the ball."

Similar findings were identified in the Medical Records for Patients #80, #81, #82, #83 and #84.

Refer to Tag A 145.

Repeat Deficiency.
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Based on record review, document review and interview, the facility failed to ensure documentation of the implementation of the Physician's Order for Neurological Checks in one (1) of one (1) patient with symptoms of a Stroke (Patient #71).

Findings:

The Medical Record documented that Patient #71 presented to the Emergency Department (ED) on 10/19/14 with complaints of headache and left arm numbness. The Record included documentation that the patient had a CT (Computed Tomography) of the head on 10/19/14 at 1:03PM which revealed a new acute to sub-acute infarct.

Review of the Physician's Order Sheet revealed an Order for General Neurological Status Checks every four (4) hours, entered on 10/19/14 at 6:08PM.

General Neurological Checks, as defined in the Clinical Guidelines: Ischemic Stroke and Transient Ischemic Attack (TIA) Policy, dated 01/15/15, include an Assessment of Level of Consciousness, Arousal Level, Orientation, Speech and Mood / Behavior.

Review of the Medical Record revealed no documented evidence that the General Neurological Status Checks were obtained as ordered.

On 03/09/15 at 11:36AM this finding was confirmed with Staff #17.
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Based on observations, staff interviews and review of documents, it was determined that the Food Service Director failed to take responsibility for the daily management of the Dietary Service to ensure that: a) proper safety measures for handling food were maintained, b) proper sanitation was maintained in the Kitchen, and c) Menus met the nutritional needs of the patients.

Findings:

A tour of the Kitchen was conducted on 02/25/15 at approximately 10:30AM. During the tour the following observation was noted:

a) During the tour temperature of the walk-in freezer (Freezer #8) was noted to be twenty (20) Degrees Fahrenheit outside of the acceptable range. It was noted that several of the freezers' outside thermometers were showing temperatures outside the acceptable range and there were no inside thermometers found in the freezers.

Review of the February Freezer Log for Freezer #8 had temperatures for several days recorded outside of the acceptable range. The Food Service Department parameters used for measuring freezer temperature was noted on the Daily Freezer Log as Low - 20 (twenty) and High - 15 (fifteen). On interview Staff #15 confirmed that temperatures are taken in Fahrenheit.

To maintain food safely, freezer temperatures should be held at zero (0) Degree Fahrenheit or lower. Temperature of foods stored in Freezers #4 and #8 were tested and found to be in the acceptable range.

Review of the Freezer Logs for December 2014 and January and February 2015 noted that temperatures taken daily were recorded outside the acceptable range. Temperatures were noted to range from eight (8) Degrees Fahrenheit to thirty-six (36) Degrees Fahrenheit. Temperatures were recorded out of the acceptable parameter for storing food safely for three (3) months yet no one recognized and took corrective action.

b) The entire length of one (1) of the Kitchen Exit Hallways was observed to have been used for storage of garbage and refuse. Garbage and refuse containing several high piled cardboard boxes was observed stored in the hallway. The hallway floor was found to be filthy with dirt and grime.

A large dumpster in the hallway near the Dish Room was observed overflowing with boxes and food refuse.

Three (3) large cooking oil drums stored in the Dishwashing Room were observed to be rusty and grimy with oil and food debris.

Three (3) carafes filled with water, coffee and decaffeinated coffee was observed on top of the Two (2) South Meal Truck getting ready for patients' meal service for Lunch. These three (3) carafes were observed to be dirty with food stains and not in good sanitary condition.

c) Cross Reference Tag A 630.

These findings were confirmed with Staff #15 when the observations were identified.
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Based on staff interview, review of Menus and the Nutrient Analysis of Menus, it was determined that the Food and Nutrition Department failed to ensure that the Physician Prescribed Diets met the therapeutic needs of the patients.

Findings:

A review of the Nutrient Analysis of the facility's One (1) Week Cycle Menus was conducted on 02/26/15. It was noted that the Nutrient Analysis was done for only five (5) of five (5) Diets. The five (5) Diets analyzed (Consistent Carbohydrate Diet, Consistent Carbohydrate / Dash Diet, Dash Diet, Regular Diet and Pureed Diet) did not show the food items that were analyzed.

There was no Nutrient Analysis conducted for twenty-five (25) Diets orderable available in the Electronic Medical Records for Physicians to prescribe. These Diets were not analyzed to assess compliance to the National Standard titled "Recommended Dietary Allowances (RDA) or the Dietary Reference Intake (DRI) of the Food and Nutrition Board of the National Research Council".

Due to the lack of Nutrient Analysis calculated for these Menus, there is no way to verify that the Diet Orders are provided as prescribed by the Practitioner(s) responsible for the care of the patient.

These findings were confirmed with Staff #15 when the observations were identified.
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Based on observations and staff interview, the facility failed to ensure that: a) all door, furniture and wall finishes in the facility building were maintained in good repair, b) all ventilation ducts and ceiling surfaces in the facility building were maintained in good repair and/or a clean condition, and c) that walls that enclose designated Airborne Infection Isolation Rooms were sealed to prevent air from infiltrating the environment from the outside or from other spaces.

Findings:

a). On 02/25/15 at 12:43PM, a plastic (vinyl) finish on both doors of a pair of cross-corridor doors was noted to be in disrepair (delaminating / peeling off of door surface) in the vicinity of Room 723 in the Main Building.

On 02/26/15 at 8:15AM, surfaces of tables at the Sub-Nurses' Station on the 5th Floor of the Main Building (vicinity of Room 563) were noted to be delaminating / to be in disrepair.

On 02/26/15 at 10:05AM, painted wall finishes in Room RP-286 Ultrasound 3 were noted to be in disrepair (chipped and marred).

On 02/27/15 at 8:44AM, four (4) tiles in a wall in the Main Building 1st Floor Operating Room (OR) Sterilization Room (Near OR #2) were noted to be cracked / damaged and need to be replaced.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken as soon as possible.

b) On 02/26/15 at 1:52PM, a heavy build-up of dust was noted on the grill of an exhaust duct in the ceiling of the ECC (Emergency & Critical Care) Building Emergency Department Adult Waiting Area (near the Main Reception Desk and Room ECC1215 Quick Look Room).

On 02/27/15 at 9:23AM, a water stain was noted on the monolithic ceiling (a hard ceiling surface usually made of drywall) in the vicinity of Bay #28 in the Adult PACU on the 1st Floor of the Main Building.

On 02/27/15 at 12:37PM, a heavy build-up of dust was noted on the grill of an exhaust duct in the ceiling of the Food Service Building Ground Floor Catering Storage Area.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken as soon as possible.

c) On 02/26/15 at 1:44PM, the doors to the ECC Building Emergency Department Airborne Infection Isolation Room ECC1195 Exam Room 2 and ECC1196 Exam Room 3 and the door to the common anteroom that serves both of the above-mentioned rooms were all noted to lack required self-closing devices. In addition, numerous unsealed penetrations (duct, plumbing, cable, and conduit) were noted in enclosure walls above suspended ceiling grid. Walls surrounding an Airborne Infection Isolation Room are required to be kept sealed.

On 02/26/15 at 2:05 PM, an unsealed conduit penetration was noted in an enclosure wall of a designated Airborne Infection Isolation Room (Room ECC1017 Treatment Room B) in the Emergency Department on the 1st Floor of the ECC Building.

On 02/27/15 at 9:23AM, an unsealed plumbing penetration was noted in an enclosure wall of a designated Airborne Infection Isolation Room (Room #27) in the Adult PACU (Post Anesthesia Care Unit) on the 1st Floor of the Main Building.
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Based on observations and staff interview, the facility failed to ensure that: a) all hand wash sinks used by staff were trimmed with wrist blades that were at least four (4) inches long, and b) accessible facilities were designed and maintained in accordance with Federal, State and Local Laws, Regulations and Guidelines.

Findings:

a) On 03/02/15 at 8:39AM, the wrist blades on a hand wash sink in the recently constructed (2014) 1st Floor "Vivo Marketplace" Retail Pharmacy (Room T106A) in the Tower Building were found to only be approximately two (2) inches long.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken as soon as possible.

b) On 02/27/15 at 10:00AM, a room identification sign for a former Operating Room that had been converted into a Storage Room 3rd Floor Main Building Women's Surgical Unit (the sign says "Supply Room") was found to lack required raised and Braille characters.

As per concurrent interviews with the facility's Director of Engineering, corrective action will be taken as soon as possible.
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Based on observation, documentation review and interview, the facility did not ensure that staff followed standard Infection Control Guidelines: a) when touching functioning hemodialysis machines and disinfecting equipment between hemodialysis patients, b) for DME (Durable Medical Equipment), and c) for single-use sterile equipment. This was evident on three (3) of seven (7) Units observed: the Emergency Department (ED), 5 South and Acute Hemodialysis.

Findings:

a) Observations on 03/04/15 at 11:30AM revealed Staff #9 touching Patient #76's functioning hemodialysis machine with an ungloved hand.

During an interview with Staff #9 at that time, the staff member agreed that she should have worn a glove to touch a functioning machine.

Observations at Station #6 on 03/04/15 at 12:00PM revealed Staff #10 disinfecting a blood pressure cuff and then placing the cuff on the "dirty" hemodialysis machine. Also, the staff member did not wipe the internal and external surfaces of the prime waste container between patient use.

During an interview with Staff #10 at that time, the staff member confirmed the findings and stated that she would clean the blood pressure cuff and the prime waste container.

b) During a tour of Unit 5 South on 02/25/15 at 10:40AM, an Electrocardiogram (EKG) machine was noted in the Clean Utility Room with an open package of leads. One lead was noted to have hair on it.

This was observed in the presence of Staff Members #5, #6 and #7.

During the tour, when asked how staff knew if the equipment was clean, Staff #6 replied that "All equipment is wiped down before being placed in the Clean Utility Room and then considered clean."

When asked if the EKG machine in the Clean Utility Room was "clean", Staff #7 replied, "It doesn't look like it."

Review of the facility Policy titled "Cleaning and Disinfection: Cleaning, Low Level Disinfection and Storage of Patient Care Equipment" revealed in Section G - 3 "Equipment cleaned and disinfected on a Patient Care Unit will be used immediately or identified as clean and stored in the Clean Utility Room."

The Policy lacks clear instructions as to what "identified as clean" means.

c) During a tour of the ED on 02/26/15 at 10:30AM, an open unused single-use sterile suction catheter package was noted to be placed back in a box with other closed sterile supplies in Intake Room 5.

This was observed in the presence of Staff #4 who stated "All sterile equipment should be sealed."
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Based on record review and interview, the facility failed to: a) implement the facility Policy for Ischemic Stroke and Transient Ischemic Attack (TIA) in one (1) of one (1) patient identified in the Emergency Room (Patient #71), and b) provide a comprehensive Policy for the management and evaluation of Ischemic Stroke patients who do not receive thrombolysis.

Findings:

a) Review of the Medical Record documents that Patient #71 presented to the Emergency Department (ED) on 10/19/14 with complaints of headache and left arm numbness.

The Medical Record noted that Staff #18 assessed Patient #71 on 10/19/14 at 1:39PM and documented that as per the patient's daughter, Patient #71 "had a sudden onset of severe headache, took Tylenol and went to sleep. Woke up in AM, called daughter who noticed somewhat illogical conversation." Staff #18 assessed the patient and documented the patient with "weakness and numbness in left upper extremity, left facial droop".

The Non-Contrast Head CT results of 10/19/14 at 1:03PM, were compared to a previous CT from 09/15/14 and identified "a new acute to sub-acute infarct involves the right basal ganglia and right internal capsule". The CT findings were discussed with Staff #18 on 10/19/14 at 2:00PM, with read back.

A Neuro Consult performed on 10/19/14 at 1:55PM recommended a TEE (Transesophageal Echocardiogram) to evaluate for PFO (Patent Foramen Ovale) and a CTA (Computed Tomography Angiography) of the Head and Neck to be performed.

Review of the Admitting Attending H&P (History and Physical) Attestation Statement dated 10/19/14 at 7:58PM states, "Patient seen and examined at bedside, agree with H&P done by PA (Physician Assistant), briefly this is a 85-year-old female presents with bifrontal headache with Left arm numbness found to have Acute Stroke".

Review of the Policy titled Clinical Guidelines, Ischemic Stroke and Transient Ischemic Attack (TIA), dated 01/15/14, revealed in "Section 4.1.1: All Stroke / TIA (and Intercranial Hemorrhage) patients need a documented Initial and Discharge National Institute of Health Stroke Scale (NIHHS)".

Medical Record review on 03/09/14 revealed no documented evidence that an Initial or Follow-Up NIHHS Scale was obtained.

These findings were confirmed during interview with Staff #17 on 03/09/15 at 11:36AM.

Review of the Policy titled Clinical Guidelines, Ischemic Stroke and Transient Ischemic Attack (TIA), Section 4.8 dated 01/15/14 revealed, "Blood glucose measured by finger stick every six (6) hours for at least the first 24 (twenty-four) hours following an Ischemic Stroke".

Review of the Medical Record revealed an initial blood glucose finger stick during Triage, and a serum blood glucose result at 1:43PM, but no documentation of any further blood glucose checks for Patient #71.

On 03/09/15 at 11:36AM this finding was confirmed with Staff #17.

Interview with Staff #13 on 03/09/15 revealed, "Since the patient did not initially present with stroke-like symptoms during Triage, a Stroke Code was not activated."

b) Review of the Policy titled Stroke Team Activation for An In-House Stroke, dated July 2012, identified and referred to another Policy titled, "Policy for Standard of Care of the Stroke Patient".

This second Policy was not able to be produced during survey and as per Staff #13, this Policy "no longer exists" and has been replaced with the Clinical Guidelines in the Stroke Center Care Manual.

When facility staff were asked to provide the signs / symptoms or inclusion / exclusion criteria for initiation and implementation of their management and evaluation of Ischemic Stroke patients, Staff #13 stated, "we do not have the criteria listed in this Policy".