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Based on observation, staff interview, and review of medical records, policies and procedures, e-mail documentation, incident report review, and review of the UR plan and UR documents, the governing body failed to ensure patient nutritional and safety needs were appropriately addressed (A385), maintain an infection control program that sought to minimize cross-contamination (A747), the development of a UR program (A652), and implement measures for restricting access to patients' personal health information (A431). The findings were:

1. Interview on 5/5/16 at 10 AM with the Interim CEO and Interim COO revealed the Interim CEO began this position 3/15/16 (less than 2 months ago). Both acknowledged infection control and securing patient health information were concerns that had not been identified by the facility prior to the 5/2/16 to 5/5/16 survey. They further stated they were aware of the lack of a UR program and failure of the nursing staff to provide the appropriate food consistency for patients, however, the concerns had not been effectively addressed or resolved at this time.

2. Refer to A385 for evidence regarding nursing staff failure to provide appropriate food consistency to meet patients' nutritional and safety needs.

3. Refer to A431 for evidence of the facility's failure to restrict access to personal health information.

4. Refer to A652 for evidence of the lack of a required UR program.

5. Refer to A747 for evidence of the breeches in infection control practices.

Based on staff interview, medical record review, and policy and procedure review, the facility failed to ensure the licensed independent practitioners (LIPs) met the training requirements for 2 of 2 restraints reviewed. The findings were:

Review of the behavior restraint records for patient #30 showed LIP #1 ordered the restraint on 1/29/16. The order showed the patient was being combative, delusional, making verbal threats and was confused. Further review of the documentation showed required assessments and monitoring were completed.

Review of the restraint records for patient #29 showed LIP #2 ordered the restraint on 4/25/16 due to the patient being intubated and preventing extubation. The documentation showed adequate assessment and monitoring related to the restraint.

Review of the 3/2016 approved policy and procedure titled "Restraints" showed "Physicians, LIPs, and Clinical Psychologist must have a working knowledge of the hospital policy regarding the use of restraint." The policy did not further specify how this requirement would be determined or evaluated.

Interview with the interim COO on 5/5/16 at 9:40 AM verified there was no documentation to show LIP #1 or LIP #2 had met the training requirement as specified in the hospital policy. She further stated new medical staff bylaws were being approved and she thought this area would be addressed.

Based on observation, staff interview, and the UR plan and review of policies and procedures and UR documentation, the facility failed to utilize the quality assessment and performance improvement process to identify and address issues regarding the lack of a required UR Program and breeches in infection control practices. The findings were:

1. Refer to A655, A656, A657, and A658 for evidence of the facility's failure to implement the UR plan with respect to admissions, the duration of stays, and professional services. During an interview on 5/5/16 at 10:20 AM the UR Director and CNO stated they were unable to provide documentation of UR activities. They stated the facility really just started with UR activities yesterday. They were unable to provide evidence that professional services were reviewed as part of their UR activities.

2. Refer to A749 for evidence of the facility's failure to identify and implement measures to address observed breeches in infection control practices. During an interview on 5/5/16 at 9:40 AM the infection control officer stated she did not have documentation to show the facility had been doing audits/surveillance for areas such as environmental cleaning in the OR or staff practices related to injections. She also stated she had plans for surveillance going forward that would capture that data.

Based on staff interview, medical record review, facility e-mail documentation review, and incident report review, the facility failed to ensure continuity of care between facilities for 2 of 2 patients (#6, #33) regarding dietary requirements. Failure of timely communication with the sending facility resulted in failure of the facility regarding appropriate dietary orders (A0395). This failure resulted in 1 patient (#33) receiving a diet that placed him/her at risk of aspiration. The impact of this systemic deficiency resulted in a determination the facility failed to meet the Condition of Participation for Nursing Services.

Based on staff interview, medical record review, facility e-mail documentation review, and incident report review, the facility failed to ensure patient care was adequately supervised and evaluated for 2 of 30 sample patients (#6, #33) regarding continuity of care for specialized dietary requirements. The findings were:

1. Medical record review showed patient #33 was admitted to the facility on 3/27/16 with diagnoses that included sepsis and pneumonia. Review of the information from the sending facility showed the patient had severe intellectual disability, decreased psychomotor skills, a PEG tube (percutaneous endoscopic gastrostomy, is a tube placed in the stomach to provide food and medication) and Pica (persistent eating of non-nutritive substances). This review also showed s/he received nutrition primarily through the PEG-tube due to swallowing difficulties. Review of the 3/27/16 nursing admission assessment showed documentation regarding the patient's PEG tube, severe intellectual disability, and need for staff assistance with all activities of daily living. The following concerns were identified:
a. Review of the 3/27/16 admission physician's orders included orders for a regular diet and oral medications.
b. Review of the March and April 2016 physician's orders revealed no orders for providing nutrition, medication, and/or fluids through the PEG tube until 3/29/16. Review of the 4/1/16 and 4/2/16 physician's progress notes revealed the patient had recurrent aspiration pneumonia.
c. Review of the 3/27/16 to 3/28/16 intake, output and medication administration records showed the nursing staff fed the patient a regular diet, and gave him/her oral fluids and medications.
d. Interview on 5/3/16 at 4:30 PM with CNA #1 revealed she fed the patient sausage and pancakes for breakfast on 3/28/16. She further stated the direct care staff were not aware of the patient's increased risk for aspiration until later that evening on 3/28/16.
e. Review of the nursing documentation, dated 3/27/16 to 4/2/16, showed aspiration precautions were not implemented until 3/29/16.
f. During an interview on 5/3/16 at 4:15 PM the CNO acknowledged the patient should not have received a regular diet on 3/27/16 and 3/28/16. She further stated there had been discussions about the event, but a root cause analysis had not been done; nor had measures been implemented to prevent similar incidents.
g. Interview with the director of compliance on 5/5/16 at 10:50 AM verified there was no physician's order to have a registered dietitian (RD) assess the patient, and there was no assessment or note documented by the RD on this patient during the hospital stay.
h. Review of the 4/1/16 swallowing evaluation showed recommendations included using a pump for continuous feeding for 8 hours to decrease risk of aspiration and reflux.

2. Medical record review showed patient #6 was admitted to the facility on 4/26/16 with diagnoses which included acute respiratory failure with hypercapnia (an increase in the partial pressure of carbon dioxide in the blood), and physician orders at that time included NPO (nothing by mouth). The physician diet order was changed to a regular diet on 4/26/16. Further review showed the patient's diet order was changed to a pureed diet on 4/29/16. The following concerns were identified:
a. Review of faxed information from the sending facility showed the facility received the information on 4/26/16 at 6:25 PM. The information showed the patient was on a "blended" diet. The facility failed to change the patient's diet to "pureed" until 4/29/16 (3 days).
b. Review of the care plan faxed to the facility on 4/26/16 showed under treatment, "...3. Staff to follow diet order for meals and snacks. If [the patient] does not eat, Ensure may be offered." The facility failed to incorporate the dietary requirements in the patient's plan of care in a timely manner (3 days).
c. Review of the 8/5/10 Mealtime Guidelines, written by the sending facility speech therapist and faxed to the facility on 4/26/16, showed the following, "Precautions: ...2. May cough. 3. History of aspiration pneumonias. Diet Texture: Blended (thicken if runny). Thin Liquids; thicken to nectar consistency if coughing and to pudding consistency if [s/he] refuses to drink." The facility failed to follow the speech therapy guidelines in a timely manner (3 days).
d. Review of 5/4/16 documented communication between the facility CNO and administrator of the sending facility (sent via e-mail to facility staff), confirmed there was communication the prior week concerning 2 incidents of patients receiving a diet that was not consistent with the diet the patients received at the sending facility. The following showed the sending facility process for informing the facility of patient needs, "She discussed with me their process to send the Care Plan to help support the transition in care and for providers and staff to be aware of the patient's plan of care and special needs." The facility failed to address the dietary requirements of the patient in a timely manner (3 days).
e. Interview on 5/5/16 at 9 AM with the CNO confirmed her expectation was to ensure continuity of care in a timely manner between the facility and the sending facility. She confirmed the facility failed to ensure continuity of care for dietary needs for patient #6 in a timely manner.
Review of the "NPO, CLear Liquid Diet, Enteral and Parental Nutrition and Ventilation" policy and procedure dated 9/2015 showed "Nursing is responsible to notify the Clinical Dietitian of any patients...begun on tube feeding...The Clinical Dietitian is responsible for the evaluation of the appropriateness of the feeding modality ordered and the monitoring of the administration and patients acceptance/tolerance of the feeding."

Based on observation and staff interview, it was determined the facility failed to protect medical records from unauthorized access in medical record storage areas (A441). This system failure resulted in the inability of the hospital to meet the necessary requirements for the Medical Record Services Condition of Participation.

Based on observation and staff interview, the facility failed to protect medical record information from unauthorized use in 2 of 4 locations where medical records were stored. The findings were:

1. Observation on 5/3/16 at 3:52 PM at the Lander facility medical records department revealed the area contained 14 moveable cabinets, each with 7 shelves, which contained medical records. The medical records could be accessed if the door to the medical records department was unlocked. Interview with the medical records supervisor at that time revealed she was unsure if maintenance staff had a key to the lock on the door.

2. Observation on 5/4/16 at 11:50 AM revealed the Riverton facility had a rented space in another building, a short walk from the facility. There was one locked door to access the area. The area consisted of stairs going down, and two rooms with doors. The doors were not locked. Both rooms contained medical records on shelves and in boxes. Interview with the medical records supervisor at that time revealed she was not sure if maintenance staff had a key to the area, but thought so.

3. Interview with the director of plant operations on 5/4/16 at 2 PM revealed maintenance staff at the Lander facility had keys to access the medical records room. He further stated maintenance staff had keys to the off-site medical records storage area in Riverton, and were directed to take medical records there for storage without staff supervision.


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Based on observation, staff interview, and review of maintenance requests, the facility failed to ensure food sanitation requirements were met for 1 of 2 kitchens (Lander kitchen). The findings were:

1. Observation on 5/3/16 at 10 AM showed the main hand washing sink located in the kitchen and the hand washing sink near the dishroom were without hot water. The main sink water was cold when used for handwashing by the surveyor and the certified dietary manager (CDM). When checked at 10:30 AM the dishroom hand sink only had cold water available. Interview with the CDM at that time revealed the lack of hot water had been an ongoing issue for approximately 2 weeks. The manager stated the infection preventionist was aware and had made a request to maintenance to have it repaired. Review of the maintenance request showed it was dated 4/6/16 and described the problem as "Handsinks in the kitchen do not have hot water..." The information showed it was accepted and assigned on 5/3/16 at 11:39 AM.

According to Food Code 2013, U.S. Public Health Service: 5-202.12 "(A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 38 C (100 F) through a mixing valve or combination faucet."

2. Observation on 5/3/16 at 10:16 AM of the dry food storage area showed there were uncovered rodent bait traps in two locations of the storage room. These traps used food as bait. Interview with the manager at that time revealed she was unaware the bait traps were required to be covered.

According to Food Code 2013, U.S. Public Health Service: 7-206.12 "Rodent bait shall be contained in a covered, tamper-resistant bait station."

Based on review of the UR plan, staff interview, and review of UR documents, the facility failed to implement the UR plan with respect to admissions, the duration of stays, and professional services (refer to A655, A656, A657, and A658). This system failure resulted in the inability of the facility to meet the necessary requirements for the Utilization Review (UR) Condition of Participation.

Based on review of the UR plan, staff interview, and review of UR documents, the facility failed to implement the UR plan to review the medical necessity of admissions, the duration of stays, and professional services. The findings were:

1. Review of the facility's Utilization Management Plan (approved 10/12/15) showed it included procedures to review admissions, continued stays, extended stays, and medical care evaluation.

2. When asked for minutes of UR committee meetings, the Regulatory Coordinator stated on 5/4/16 at 4:56 PM that the facility did not want to provide minutes because they were told by their corporate office that the meetings and minutes "were not done right."

3. During an interview on 5/5/16 at 10:20 AM the UR Director and CNO stated the facility really started with UR activities yesterday. They stated there was no documentation to show UR activities were done prior to that, and had no documentation to show the UR plan was implemented. They further stated they found one meeting from last year, and have had one recent meeting, but they found out from corporate that "it doesn't count" because they "did it wrong." On 5/5/16 at 11:10 AM the UR Director stated some outlier cases were reviewed by an outside agency, but that was not part of their UR plan. She also provided documentation to show that admissions at the Lander facility were reviewed to ensure there were physician admission orders, but that was not done at the Riverton facility.

Based on review of the UR plan and staff interview, the facility failed to implement the UR plan with respect to determinations that an admission or continued stay was not medically necessary. The findings were:

1. Review of the facility's UR plan (approved 10/12/15) showed it included procedures when physician documentation did not support an admission or continued stay.

2. During an interview on 5/5/16 at 10:20 AM the UR Director and CNO stated the facility really just started with UR activities yesterday. They stated they were unable to provide documentation to show the facility had implemented the UR plan, and did not have any examples of admissions or continued stays that had been determined to not be medically necessary.

Based on review of the UR plan and staff interview, the facility failed to implement the UR plan with respect to continued stays. The findings were:

1. Review of the UR plan (approved 10/12/15) showed it included procedures to review continued stays.

2. During an interview on 5/5/16 at 10:20 AM the UR Director and CNO stated the facility really just started with UR activities yesterday. They stated they were unable to provide documentation to show the UR plan had been implemented. The UR Director stated reviews were conducted at 3, 6, and 9 days after admission, but was unable to provide documentation of reviews or data regarding reviews.

Based on review of the UR plan and staff interview, the facility failed to implement the UR plan with respect to reviewing professional services provided. The findings were:

1. Review of the UR plan (approved 10/12/15) showed procedures to review the medical care, including professional services and the over or under-utilization of services.

2. During an interview on 5/5/16 at 10:20 AM the UR Director and CNO stated they were unable to provide documentation of UR activities. They stated the facility really just started with UR activities yesterday. They were unable to provide evidence that professional services were reviewed as part of their UR activities.

Based on review of humidity logs and policy and procedures, and staff interview, the facility failed to ensure the humidity was maintained at an acceptable level in the ORs and endoscopy room in 1 of 2 facility locations (Lander). In addition, the facility failed to ensure vents in 3 of 3 OR/procedure rooms were free of debris, lint and dust at 1 of 2 facility locations (Riverton). The findings were:

1. Review of the facility policy "Temperature and Humidity Monitoring in Perioperative Services" (revised 3/2016) revealed "...should a reading fall out of the appropriate range, maintenance will be contacted and adjust the appropriate systems to maintain the desired ranges of temperature and humidity and document their actions on the log." Review of the attached reference to the policy showed the relative humidity should be 30% to 60% in ORs and endoscopy rooms.

2. Review of the temperature and humidity logs for the Lander facility revealed the following concerns:
a. In February 2016, the humidity was less than 30% on 2 days in OR 1, 4 days in OR 2, 16 days in the endoscopy room, 15 days in OR 5, and 12 days in OR 6 (out of 29 days).
b. In March 2016, the humidity was less than 30% on 2 days in OR 1, 2 days in OR 2, 9 days in the endoscopy room, 10 days in OR 5, and 8 days in OR 6 (out of 31 days).
c. In April 2016, the humidity was less than 30% on 4 days in OR 1, 12 days in the endoscopy room, 9 days in OR 5, and 10 days in OR 6 (out of 30 days).
d. Further review of the logs showed staff indicated that maintenance was notified when the humidity was out of range; however, there lacked documentation on the logs to show what corrective action maintenance took, or that the humidity was brought into an acceptable range.

3. During an interview on 5/4/16 at 4:55 PM, the director of plant operations confirmed the humidity had a been a problem in the ORs in the Lander facility. He also stated he was not able to find documentation to show what corrective action was taken when the humidity was out of range.


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4. Observation on 5/4/16 from 8:45 AM to 9 AM revealed the dust, lint and thin pieces of debris were on the vents in OR #1, OR #2 and the endoscope room. Interview with the surgical services director at the time of the observations revealed environmental services were responsible for cleaning the vents. Interview with the environmental supervisor on 5/4/16 at 1:53 PM revealed the air vents in the operating room suites were not cleaned at any time by environmental staff at the Riverton facility, and the cleaning of air vents in the operating room suites area was not on any of their check lists. He further stated that environmental staff did not pass the "red line" to perform any cleaning duties in the operating room suite at the Riverton location.

Based on observation, staff interview, and review of policies and procedures, the facility failed to enforce current guidelines for safe injection practices, hand hygiene practices, and pre-cleaning colonoscopes. The facility failed to maintain a sanitary environment in ORs and procedure rooms, and failed to determine the disinfection and sterilization requirements for dental surgery equipment and devices. The facility further failed to ensure acceptable standards of infection control practices were used for cleaning, disinfecting, and storing laryngoscope blades and handles (A749). The cumulative effect of this deficient practice resulted in a determination that the hospital failed to meet the Condition of Participation for Infection Control.

Based on observation, staff interview, and review of policies and procedures, the facility failed to follow current infection control guidelines for safe injection practices observed during anesthesia administration for 2 of 3 patients (#34, #35); 1 of 2 observations of hand hygiene practices and the pre-cleaning colonoscope process; maintaining a sanitary environment for 3 of 3 OR/procedure rooms; and cleaning, disinfecting and storing laryngoscope blades and handles during 2 random observations. The facility further failed to determine the disinfection and sterilization requirements for dental surgery equipment and devices. The dental surgery staff who were responsible for the cart performed 14 surgeries in 2016. The findings were:

Regarding safe injection practices:
1. According to the CDC recommendations for Safe Injection Practices, updated 2015, the septum of the medication vial and intravenous ports should be disinfected before piercing. Additional recommendations included vials should not be entered or re-entered with the same needle and syringe; even if the medication is for the same patient.

2. On 5/3/16 from 9:12 AM to 9:50 AM before and during the procedure for patient #34, anesthesiologist #1 was observed withdrawing and administering intravenous medications to the patient. The observation revealed the anesthesiologist did not consistently disinfect the septum on the medication vial prior to withdrawing medication into the syringe; nor did he disinfect the intravenous ports prior to administering each medication. Further observation revealed he withdrew and administered medications using the same syringe and needle five times.

3. Observation on 5/4/16 from 7:50 AM to 8:30 AM revealed anesthesiologist #2 administered intravenous medications before and during the surgical procedure for patient #35. The observation revealed the anesthesiologist did not consistently disinfect the septum on the medication vial prior to withdrawing medication into the syringe; nor did he disinfect the intravenous ports prior to administering each medication.

4. The director of perioperative services observed the above practices with the surveyor. Interview on 5/3/16 at 10:12 AM acknowledged the observed practices did not comply with the facility's infection prevention standards of practice for safe medication administration.

Regarding hand hygiene and colonoscope pre-cleaning:
1. On 5/3/16 at 9:50 AM sterile processing technician #1 was observed handling the colonoscope after it was removed from the patient, and the patient was wheeled out of the procedure room. Continuous observation revealed the following: The technician handled the colonoscope with double gloved hands, wiped it, flushed the channels, and placed it on the prep table with other items that were used during the procedure. The technician completed additional tasks, picked up the colonoscope, flushed the channels, and again placed it on the prep table. At 10 AM, (10 minutes later) she flushed the channels, wiped the colonoscope, and carried it into the sterile processing room. She removed the outer pair of the gloves before re-entering the procedure room, and proceeded to assist with the post-procedure room cleaning and disinfecting. Interview on 5/3/16 at 10:19 AM with the technician revealed she did not know the lengthy methods she used for containing and transporting the used colonoscope increased risk of cross contamination. She further stated she performed multiple tasks without performing hand hygiene because she thought removing the outer pair of two pairs of gloves eliminated the need for hand hygiene.

2. Review of "Sterilization in Health Care Facilities, AAMI Standards and Recommended Practices", 2015 edition, revealed "Contaminated reusable items should be handled as little as possible at the point of use... Devices should be transported in such a way as to prevent the solutions from dripping on the floor. Soiled items should be immediately contained and transported to a designated area, where cleaning procedures can be accomplished away from patient care."

3. Review of the policy titled "Hand Washing and Isolation Precautions, 15-08", (revised 11/2008, approved 4/2004) revealed "...Indications for handwashing and had antisepsis:...L. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient...O. Decontaminate hands after removing gloves..."

Regarding laryngoscope handles and blades:
1. Observation on 5/3/16 at 3:30 PM in the emergency room at the Lander location showed 1 laryngoscope handle in the adult crash cart was not packaged, and was available for use. Interview with the emergency room manager on 5/4/16 at 9 AM confirmed all laryngoscope handles in crash carts should be cleaned and packaged. Observation on 5/4/16 at 8:45 AM revealed 3 unpackaged laryngoscope blades were in the top drawer of the pediatric cart in the OR area. Further observation revealed the blades were sharing space with various other supplies.

2. Review of the 2015 Edition of Guidelines for Preoperative Practice, published by AORN, revealed the following recommendation: "XII.c. Cleaned and disinfected laryngoscope blades and handles should be packaged and stored in a manner that prevents contamination. Packaging assists in preventing recontamination of items that have been high-level disinfected. Packaging of laryngoscope blades to prevent recontamination is a CDC recommendation."

Regarding dental equipment, items, and supplies used for dental surgery:
1. Observation of the storage and supply room in the surgical services area of the Lander facility on 5/3/16 at 7:40 AM revealed multiple stacks of dental devices and items unpackaged and clustered in a closed plastic bin and drawers in a portable upright cart. Interview with the director of perioperative services at that time revealed the cart was used during dental surgery, but she did not know whether the devices and items in the cart required sterilization, disinfection, or packaging. Interview with the dental assistant on 5/4/16 at 4:30 PM revealed the items on the cart were used during surgery, but she did not know whether the unpackaged devices, items, and equipment in the cart required sterilization or high-level disinfection. During an interview on 5/5/16 at 9 AM the interim COO stated the facility had identified the dental cart as a possible issue. She stated facility staff were told not to touch it, and she was looking forward to working with the dental staff to address the issue.

Regarding unclean vents in surgery and procedure areas:
1. Observation on 5/4/16 from 8:45 AM to 9 AM revealed dust, lint and thin pieces of debris were on the vents in OR #1, OR #2 and the endoscope room. Interview with the director of perioperative services at the time of the observations revealed she thought environmental services were responsible for cleaning the vents.

2. Interview with the environmental supervisor on 5/4/16 at 1:53 PM revealed the air vents in the operating room suites were not cleaned at any time by environmental staff at the Riverton facility, and the cleaning of air vents in the operating room suites area was not on any of their check lists. He further stated that environmental staff did not pass the "red line" to perform any cleaning duties in the operating room suite at the Riverton location.

3. Review of the policy titled, "Environmental Sanitation, 11-14A" (revised 12/2015) showed "The following peripheral areas of the OR Suite are cleaned weekly: a. Air conditions grills are vacuumed, removing grills for proper cleaning if necessary..."

4. Review of the 2015 Edition of Guidelines for Preoperative Practice, published by AORN, revealed the following recommendation V: "A clean environment will reduce the number of micro-organisms present"... "Ventilation ducts, including air vents and grilles, should be cleaned and have their filters changed on a routine basis according to manufacturers' instructions for use."