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Based on observation, interview and record review the facility's governing body failed to demonstrate knowledge that the contracted dialysis service was provided in a safe manner to their in patients.

The facility failed to provide evidence that the contracted dialysis services is evaluated for safety and quality by the facility's Quality Assessment and Performance Improvement process. This failed practice had the potential to adversely affect all patients who receive dialysis treatment in the hospital.

Findings:

Observation on 3/21/2013 at 10:15 am at the facility revealed there was a room with a hemodialysis machine and Reverse Osmosis (R/O) water supply equipment for dialysis

During an interview at that time with Staff (#55) Director of Quality who was present she stated the facility provided hemodialysis treatment by a contracted service.

Observation on 3/21/2013 at 9:45 am in the hemodialysis suite revealed Patient # 2 was receiving Hemodialysis treatment .

During an interview on 3/20/2013 at 11:15 with (Staff #55) the facility's Quality Director regarding the facility's role in ensuring that safe, quality services were provided to patients by the contracted dialysis agency, she stated she did not know what quality measures the dialysis service performed nor what the required quality measures were.
According to the Quality Director there was no coordination of quality performance information between the contracted dialysis agency and the Hospital.

The Quality Director stated the hemodialysis services were not included in the hospital wide QAPI initiatives.

When the Surveyor asked for the operational policies for the hemodialysis services the The Quality director stated there were no policies at the hospital that govern the hemodialysis services .

During an interview on 3/20/ 2013 at 2: 55 with the Chief Executive Officer regarding her role in ensuring the quality and safety of dialysis services in the facilty, she stated she did not play a major role in the delivery of the service beyond ensuring when a physician's order was made for hemodialysis services it was carried out.

Review of the facility's hemodialysis contract dated September 24/2012 section (A) under Hospital Obligations documented that:

"The Hospital will designate one hospital employee to act as the liaison between Company(contract company) and the Hospital. This designated employee will receive from Company all Quality Assurance reports and other documents required by this report."

Based on interview and record review the hospital failed to conduct performance improvement projects in 2012.

Findings include:

Record review of "Quality Council Meetings" in 2012 revealed no Performance improvement projects were identified. (Meetings: 3/19/12; 4/16/12; 9/13/12; 10/16/12; 11/20/12 and 12/18/12)

The Quality Assurance Director (ID# 55) acknowledged 3/22/13 at 1:20 p.m. the hospital has not conducted any Performance improvement projects in 2012. The Director stated the hospital has developed quality indicators for each service provided with the exception of Dialysis services.

Record review of a document titled "Performance Improvement Plan" dated 2013 stated "Organization: There are two types of performance improvement projects. The first is the organizational-wide performance improvement projects. These projects are initiated by Administration to support key strategic and operational objectives. The second type of project is initiated from with any component of the organization and both of these are reported to Quality Council, Medical Staff and Governing Board..."

Based on interview and record review the hospital failed to establish quality indicators for contracted Dialysis services.

Findings include:

The Quality Assurance Director (ID# 55) acknowledged 3/22/13 at 1:20 p.m. the hospital contracts Dialysis services. A Dialysis company comes to the hospital when patients require Dialysis services. The Director stated the hospital has not established any quality indicators for Dialysis services.

Record review of "Quality Council Meetings" in 2012 revealed no indicators or discussion regarding Dialysis services. (Meetings: 3/19/12; 4/16/12; 9/13/12; 10/16/12; 11/20/12 and 12/18/12)

Record review of a document titled "Performance Improvement Plan" dated 2013 stated "Monitoring and Evaluation Process: The Governing Board, management, clinical, and support services believe that indicators are central to the performance improvement process. These indicators have been identified to assess and measure the performance of key services and functions within the organization..."

Based on observation, interview and record review the facility failed to develop an individualized plan of care that addresses a patient's needs for hemodialysis treatment, wound care, nutrition, insulin dependent patients, and foley. Citing Patient #s 2 ,3, 4, 5, and 6.

Findings:

Patient # 2

Observation on 3/21/2013 at 9:30 am revealed Patient (# 2) was receiving heamodialysis treatment in the Acute Dialysis Treatment area.

Review of admission data for Patient (#2) revealed she was admitted to the facility on 3/16/2013 with history of vomiting and altered mental status. Her blood sugar was very high and her lab results had critical values for Createnine, BUN and blood sugar levels.

Review of the physician's history and physical revealed the patient was diagnosed with End Stage Renal Disease on Chronic Dialysis three times a week.

Further review of the patient's clinical record revealed the patient was dialyzed at the facility on 3/18/2013 with a physician's order dated 3/19/2013 for dialysis treatment on 3/20/2013.

During an interview on 3/20/2013 with the Patient's primary Nurse #70 regarding the patient's hemodialysis treatment she stated she was not sure the patient was on hemodialysis treatment.

Review of the patient's nursing care plans revealed her hemodialysis status was not addressed on her plan of care.

Patient # 3

Review of clinical data for Patient (# 3) revealed she was admitted to the facility on 3/15/2013 following hip surgery. The patient had a surgical wound on the left hip with staples.
Physician orders dated 3/19/2013 requested to change dressing on left hip daily, clean with normal saline and cover.

Observation on 3/21/2013 at 2:10 pm revealed the patient had a surgical incision approximately 8-10 inches in length with evidence of drainage.
Review of the patient's care plan revealed no mention of the patient's surgical wound.

Review of the facility's Care Plans Policy dated April 2002 documented that :
Each patient will have an individualized plan of care based upon identified nursing diagnosis and/or patient care needs and patient care standards, and will be consistent with the therapies of other disciplines.




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Patient # 4

Observation on 3/2013 at 10:35 am revealed patient (#4) was in bed with family member and a seater in the room.

Review of admission information for this patient revealed he was admitted to the above facility on 3/15/13.

Review of patient's history and physical dated 3/15/13 on 3/21/13 revealed patient had diagnoses for Urinary infection and Pneumonia.

Review of physician order dated 3/15/13 revealed patient was on intravenous antibiotics, and cardiac diet.

Review of patient #4's care plan on 3/21/13 revealed no documentation of care plan for nutrition and antibiotic therapy.

Patient #5

Observation of patient on 3/20/13 at 10:45 am revealed patient (#5) was in her room in her bed.

Review of admission information this patient revealed she was admitted to the above facility on 3/16/13.

Review of history and physical for this patient revealed patient had the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus.

Review of physician order dated 3/16/13 on 3/21/13 revealed COPD exacerbation, Oxygen supplement at 2 liters per nassle cannula to keep oxygen saturation at 95%. Patient was 1500 cal ADA diet.

Review of patient's care plan on 3/21/13 revealed no documentation addressing nutrition care needs.

Patient # 6

Observation on 3/20/2013 at 11:00 am revealed Patient (# 6) was in her room with a family member at the bed side feeding patient.

Review of admission information for Patient (#4) revealed the patient was admitted to the above facility on 3/07/2013.

Review of patient # 4's history and physical dated 3/7/13 on 3/20/13 revealed the following diagnoses: Pneumonia, Diabetes Mellitus, Chronic Heart Failure, and Gastro-oesophageal reflux disease-GERD.

Review of physician's order dated 3/7/13 on 3/20/13 revealed the patient was on 1500 calories ADA diet with Glucerna (nutrition supplement for diabetics) twice a day. There was an order for foley, Insulin injection and Glucophage, and accucheck twice a day. There was a physician order written on 3/19/13 to discontinue foley.

Review of nurse's note and flow sheet for the above period on 3/21/13 revealed no documentation for blood sugar checks for 3/13/13 and 3/14/13.

Review of healthcare plan for this patient on 3/21/13 revealed no care plan for nutrition, insulin dependence, and foley.

The Director of Nurses (DON), staff #51 reviewed the three patients' medical reocrds (#s 4, 5, and 6) above with the surveyor and confirmed no care plans found, both electronic and paper.

Review of the facility's Care Plans Policy #600 dated April 2002 documented that :
"Upon admission and completion of the admission assessment bt the RN a plan of care is formulated". Each patient will have an individualized plan of care based upon identified nursing diagnosis and/or patient care needs and patient care standards, and will be consistent with the therapies of other disciplines.

Based on observation, interview, and record review the facility failed to ensure drugs stored in the Radiology Department were kept in a secure area that was not accessible to unauthorized persons.

Findings:

Observation on 3/21/2013 at 8:35 on the Radiology Unit revealed the door to the unit led off a public corridor, the door to the unit was opened and there was no staff in attendance.

A door to the drug storage cupboard in the room was opened exposing 32 boxes of 125 milliliter syringes of Loversol 68% organically bound iodine 320 milligrams per milliliter(mg/ml) on a shelf in the cupboard. The boxes of medication were readily accessible to unauthorized persons.

During an interview with the Director of the department he stated he was not aware those drugs had to be locked up. He did admit that they were drugs and were accessible to any one entering the area.

Review of the facility's drug storage policy effective May ,2011 documented that :
"Special supplies of medications will be stocked in various areas of the hospital for convenience and rapid access" . The policy did not address storing drugs in a secure manner those areas.

3). DIETARY DEPARTMENT
Observation conducted on 3/21/13 in the dietary department at 1:13pm revealed the following areas that need repairs:
Dish washing room: 4 broken tiles, which were falling off the wall behind the dishing washing machine in the dish washing room
Wall behind the kitchen door: A hole in the wall behind the kitchen door entrance on the left hand side approximately 6 inches diameter.

Interview with staff # 56, License Dietitian (LD) on 3/21/13 during the above observation confirmed the broken tiles and hole in the wall and added "they should be repaired".



12000

Based on observation, interview and record review the hospital failed to ensure:
1) clean linen was stored covered according to hospital policy in the main linen storage building and in a linen closet on the pre-operative hallway.
2) Operating room floors, walls and door jams were free from chipped paint, cracks, and tears. (Operating room #'s 1 and 2 and the Sterile supply supply room)
3) Dietary, a hole in the wall behind kitchen door and broken tiles in the dish room.

Finding include:

LINEN:
Observation 3/20/13 at 10 a.m. revealed the following:

-Outside linen storage building: Multiple bins of clean linen in carts were not covered. Large spider webs were observed in the high ceilings above the clean linen carts.

-Linen closet on the pre-operative hallway: Linen was stacked in shelves along the wall inside the closet and was not covered.

Interview 3/20/13 at 10:20 a.m. with the Director of Nursing (ID# 51) revealed the clean linen should be covered.

Record review of a policy titled "Environment of Care / Infection Control" (no date) stated "Clean linen shall remain wrapped until needed and / or cart covers lowered and zipped when carts are not in use."

OPERATING ROOM SUITES
Observation 3/20/13 at 1 p.m. in the operating room suite area revealed the following:

-Operating Room #1: Chipped paint around the metal door frame leading into the operating room. The operating room walls had multiple cracks with paint peeling from the walls.

Operating Room #2: Chipped paint around the metal door frame leading into the operating room. The operating room walls had multiple cracks with paint peeling from the walls.
The flooring had a piece of dark brown masking tape measuring 6 inches by 3 inches covering a tear in the flooring.

Sterile supply room: Chipped paint around the metal door frame leading into the sterile supply room. The sterile supply room walls had multiple cracks with paint peeling from the walls.

The Nursing Director of Surgery (ID# 72) acknowledged 3/20/13 at 1:30 p.m. the walls and floors of the operating room suites should be smooth for cleaning and infection control control purposes.

3). DIETARY DEPARTMENT
Observation conducted on 3/21/13 in the dietary department at 1:13pm revealed the following areas that need repairs:
Dish washing room: 4 broken tiles, which were falling off the wall behind the dishing washing machine in the dish washing room
Wall behind the kitchen door: A hole in the wall behind the kitchen door entrance on the left hand side approximately 6 inches diameter.

Interview with staff # 56, License Dietitian (LD) on 3/21/13 during the above observation confirmed the broken tiles and hole in the wall and added "they should be repaired".

Based on observation, interview, and record review the facility failed to develop infection control policies based on nationally recognized guidelines that instructs staff on proper aseptic technique in wound care;

Failed to develop infection control protocols that govern activities in the hemodialysis suite; Failed to store endoscopes properly.

Findings:

Observation on 3/21/2013 at 2:10 pm in the room of Patient (#1) revealed Staff (# 70) Registered Nurse was preparing to do a wound dressing change for the patient.

Staff (#70) removed some items from the patient's bedside table and placed the dressing supplies on the table without cleaning the area for the clean supplies.

Staff (# 70) removed the soiled dressing from the patient's wound and placed it in the regular trash bin in the room. The patient had a surgical wound approximately eight inches in length on her left hip. There was obvious drainage on the soiled dressing that was removed.

Staff (# 70) removed the soiled gloves from her hands , put clean gloves on and did not wash her hands.

The Staff (# 70) cleaned the wound with gauze swabs moistened with normal saline solution, the soiled swabs were placed in the regular trash bin.
Staff (#70) applied clean dressings and tape with the same gloved hands,she did not remove the soiled gloves and wash her hands after cleaning the wound and prior to applying clean dressing to the wound.

Review of the facility's "Dressing Change" policy presented to the Surveyor dated September ,1999 revealed the following information :

"clean area to place clean supply, dispose of soil dressings in plastic bag.
Section 7 and 8 of the policy require staff to 'use aseptic technique to clean the wound with sterile normal saline, and don sterile gloves and apply dressing"
The policy did not instruct staff to remove soiled gloves and wash hands prior to donning clean gloves.

During an interview on 3/22/2013 at 2:45 PM with the Infection Control Director regarding the policy she stated the policy had not been revised. She statedthe policy required more opportunity for hand washing and proper disposal of soiled dressings.

The Infection Control Director acknowledges the policy did not reference any national guidelines that was used for the policy material.

Observation on 3/20/2013 at 10:15 am at the facility revealed there was a room with a hemodialysis machine and Reverse Osmosis water supply equipment for dialysis.

Observation on 3/21/2013 at 9:45 am in the hemodialysis suite revealed Patient( # 2) was receiving Hemodialysis treatment from a contracted staff.

During an interview on 3/21/2013 at 11:55 am with the Infection Control Director regarding the infection control measures implemented for the dialysis bay she stated the service was contracted and the hospital did not include the dialysis services in their infection prevention and control measures. She further stated she did not know what infection control measures was implemented the contract dialysis service.

Endoscope Cabinet
Observation 3/20/13 at 1 p.m. in the surgical suite area revealed a laminate cabinet used for storing endoscopes. Four (4) clean endoscopes were observed inside the laminate cabinet. The cabinet did not have any means of ventilation.

The Director of Surgery (ID# 72) acknowledged 3/20/13 at 1 p.m. that the scope cabinet was not ventilated. The Director further stated the hospital considered making vents in the cabinet a few years ago but then came to the conclusion that the gap between the doors served as a vent.

Record review of a book titled "Peri- Operative Standards and Recommended Practices" dated 2012 stated "Recommendation: flexible endoscopes: Improper storage conditions may cause bacterial growth....closed storage facilities help to prevent contamination of stored supplies....Flexible endoscopes should be stored in a closed cabinet with:
1) Venting that allows air circulation around the flexible endoscopes.
2) Sufficient space for storage of multiple endoscopes without touching..
Proper storage facilitates drying and decreases potential for contamination..."










12000

Based on interview and record review the hospital failed to ensure their Triage policy corresponded to actual emergency room records regarding triage classifications in 10 of 10 emergency room records reviewed. (ER record #'s 11, 12, 13, 14, 15, 16, 17, 18, 19 and 50)

Findings include:

Record review of emergency room record #'s 11, 12, 13, 14, 15, 16, 17, 18, 19 and 50 revealed that patients were prioritized according to acuity using "Emergent, Urgent or Non-Urgent."

Record review of a policy titled "Triage" dated 1/2013 stated "Patients presenting to the Emergency Department will be triaged utilizing the 5-Level Emergency Severity Index: Critical, Emergent, Urgent, Non-Urgent and Routine."

The Director of Nursing acknowledged 3/22/13 at 11:30 a.m. the hospital is transitioning over to a 5-level Emergency Severity Index and has yet to implement new triage forms to reflect the changes.