HospitalInspections.org

Referenced code: Title 42 CFR 485.623 (c)(1)

Based on observation and interview, it was determined the facility failed to maintain the fire and smoke rated barrier in three (above the fire-rated doors south of the public elevators, second floor, above the fire-rated doors north of the public elevators second floor, and above the fire-rated doors in the smoke barrier on the first floor) of seven areas observed by protecting penetrations in the barrier with a system or material capable of restricting the transfer of smoke. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:

A. While touring the facility on 01/25/2017 at 1020, it was observed cables penetrating the smoke barrier above the fire-rated doors north of the public elevators were not sealed with a material capable of limiting the transfer of smoke from one side of the barrier to the other.
B. While touring the facility on 01/25/2017 at 1020, it was observed a 3 inch electrical conduit penetrating the smoke barrier above the fire-rated doors south of the public elevators was not sealed with a material capable of limiting the transfer of smoke from one side of the barrier to the other.
C. While touring the facility on 01/25/2017 at 1030, it was observed cables penetrating the smoke and fire barrier above the fire-rated doors in the smoke barrier on the first floor were not sealed with a material capable of limiting the transfer of smoke from one side of the barrier to the other.
D. During the tour, the Plant Operations Manager verified the penetrations were not sealed with a material capable of restricting the transfer of smoke from one side of the barriers to the other.
E. See K300.

Based on review of the Pharmacy Access Log, review of approved list of licensed personnel allowed in the Pharmacy after the department was closed, and interview, the facility failed to ensure 7 of 26 entries during the time period 12/17/16-01/22/17 were made by authorized personnel which was facility policy. The likelihood existed for the integrity of the Pharmacy to be comprimised. Findings follow:

A. On 01/25/17 at 1330, the Pharmacy Access Log and the list of licensed personnel approved to enter the Pharmacy after the department closed were reviewed for the time period 12/17/16-01/22/17. It was revealed 7 of 26 entries on the Pharmacy Access Log were by unauthorized personnel.
b. An interview was conducted with the Director of Pharmacy on 01/25/17 at 1340. The interview revealed only approved personnel would have access to the Pharmacy. In the same interview, the Director of Pharmacy verified 7 of 26 entries were made by unauthorized personnel.

Based on review of Policy and Procedure Manuals, review of Association of periOperative Registered Nurses (AORN) Guidelines for Perioperative Practice and interview, it was determined the facility failed to prevent and control infections in that the facility did not follow the 2016 AORN Guidelines for Perioperative Practice regarding the laundering of surgical attire. The failed practice did not assure surgical attire would be free from contaminants and had the likelihood to affect all patients admitted to the facility for surgery. Findings follow:

A. Review of Policy and Procedure Manuals on 01/24/17 at 1155 revealed "Dress Code/Restricted Area: L. Individually owned scrub attire will be laundered by the employee and may be worn into the Operating Room (OR) from outside the hospital. Home laundering of scrubs has been deemed an acceptable practice in regards to there have been no scientific evidence linking an increase in disease transmission. The following are guidelines for employees to be followed when home laundering scrub clothes:
1. Scrub clothes must be washed and dried separately from other clothing.
2. Use a detergent with chlorine bleach. Use the specified amount by the detergent manufacturer.
3. Use a hot water cycle. Cool temperatures may not disinfect clothing effectively.
4. Dry scrub clothes immediately. Do not leave them in the washing machine for a long period of time. Wet clothing, even well laundered, can support bacterial growth. Dry laundered scrubs in a dryer using a high temperature cycle.
5. Remove scrubs from the dryer immediately. Ironing may provide further bacterial reduction.
6. If the personal scrub attire becomes contaminated visibly with blood or body fluids, the Occupational Safety and Health Administration Standards for occupational exposure to blood borne pathogens should be followed. The scrub suit should be labeled with the employee name and sent to the hospital laundry services for laundering."
"Reference: AORN Guidelines for Perioperative Practice-Surgical Attire pg 102 I.F."
B. Review of AORN Guidelines for Perioperative Practice, 2016, page 107, Recommendation II revealed "All individuals who enter the semi-restricted and restricted areas should wear scrub attire that has been laundered at a health care-accredited laundry facility or disposable scrub attire provided by the facility and intended for use with in the perioperative setting."
C. During an interview with the Surgery Manager, Infection Control Nurse and Director of Nursing on 01/25/17 at 0953, the Surgery Manager and Infection Control Nurse confirmed the staff laundered their OR scrubs at home. The Surgery Manager and Infection Control Nurse confirmed they did not monitor the home laundering practices of the OR staff. The Infection Control Nurse confirmed AORN guidelines were followed in the facility. There was no evidence of the year of the AORN Guidelines for Perioperative Practice the facility referenced. The guidelines referenced were in conflict with the 2016 AORN Guidelines for Perioperative Practice.

Based on observation, review of AORN Guidelines for PeriOperative Practice and interview, it was determined the facility failed to prevent and control infections in that 4 of 4 cleaned and processed endoscopes were stored on open instrument racks attached to the wall in the clean area of the endoscope processing room. The failed practice did not assure the endoscopes remained free from contamination and was likely to affect all patients admitted to the facility for endoscopy procedures. Findings follow:

A. Observation on 01/24/17 at 1420 revealed 4 of 4 cleaned and processed endoscopes stored on open instrument racks attached to the wall in the clean area of the endoscope processing room.
B. Review of AORN Guidelines for Processing Flexible Endoscopes, page 55, Recommendation IX revealed "Flexible endoscopes and endoscope accessories should be stored in a manner that minimizes contamination and protects the device or item from damage."
Section IX.a. revealed "Cabinets used for storage of flexible endoscopes should be situated in a secure location in the clean workroom of the endoscopy processing room in a two-room design or in a separate clean area close to, but not within , the endoscopy procedure room. Locating the storage cabinet in the clean workroom or in a clean area outside the procedure room helps prevent contamination of processed endoscopes."
Section IX.a.1 revealed "Storage cabinets should have doors, and be located at least 3 feet from any sink. Ensuring storage cabinets have doors and are separated from sinks by at least 3 feet provides protection and reduces the potential for processed flexible endoscopes to be contaminated by water droplets."
Section IX.b. revealed "Flexible endoscopes should be stored in accordance with the endoscope and storage cabinet manufacturer's instructions for use."
C. Findings in A were confirmed by the Surgery Manager and the Infection Control Nurse during an interview on 01/25/17 at 0953.

Based on clinical record review, review of Medical Staff Bylaws, and interview, it was determined the facility failed to provide consent to treat for five (#1, #3-#5, and #8) of eight (#1-#8) inpatients as stated in medical staff bylaws. The failed practice did not ensure patients had given consent before treatments were administered. Findings follow.

A. Review of Medical Staff Bylaws stated "health care services will not be provided to any person within this facility until express consent has been obtained from the patient or one legally authorized to act on his behalf ...Upon admission to the Hospital as an inpatient, such patient shall be provided with the following: A statement of the patient's rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment ..."
B. Review of clinical records revealed no evidence Patients #1, #3-#5, and #8 had received a consent for treatment upon admission as an inpatient.
C. During an interview on 01/27/17 at 1210, the Director of Nursing confirmed the lack of consents.

Based on review of 2016 Governing Board Meeting Minutes, QAPI (Quality Assessment/Performance Improvement) Plan, and interview, it was determined the facility failed to ensure the QAPI plan was approved by the Governing Board. The failed practice did not ensure the Governing Board was aware of all QAPI projects and was responsible for the QAPI program and created the potential to affect all patients admitted to the facility. Findings follow.

A. Review of Governing Board Meeting Minutes for 2016 revealed the QAPI Plan had not been approved by the Board.
B. Review of the 2016 QAPI Plan stated "Ozark Health Medical Center's Performance Improvement Plan is reviewed annually and is changed or updated as indicated... The Administrator, Medical Staff, and the Governing Board will evaluate the Performance Improvement Plan at least annually."
C. In an interview on 01/25/17 at 1210, the Administrative Assistant confirmed the plan had not been approved.

Based on review of QAPI (Quality Assessment/Performance Improvement) Meeting Minutes for 2016, QAPI Plan review, and interview, it was determined the facility failed to ensure 8 (Sterile Processing, Discharge Planning, Environmental Services, Organ and Tissue, Pharmacy, Rehab Services, Radiology, and Swing Bed) of 16 (Sterile Processing, Dietary, Discharge Planning, Environmental Services, Emergency Services, Infection Control, Lab, Medical Records, Nursing, Organ & Tissue, Pharmacy, Rehab Services, Radiology, Respiratory, Surgical Services, and Swing Bed) departments reported quality data quarterly as stated in the QAPI Plan. The failed practice did not ensure departments were knowledgeable as to the status of the quality indicators, and thus were not aware of which items needed corrective action. Findings follow.

A. Review of the QAPI Plan stated, "The results of all measurement and assessment activities will be communicated to all relevant departments or services and to the Performance Improvement Committee, Medical Staff, and the Governing Board at least on a quarterly basis."
B. Review of QAPI meeting minutes for 2016 revealed the following departments failed to report quality data for the following quarters:
1) Central Processing - 2nd quarter
2) Discharge Planning - 2nd, 3rd, and 4th quarters
3) Environmental Services - 2nd and 4th quarters
4) Organ & Tissue - 2nd quarter
5) Pharmacy - 2nd and 3rd quarters
6) Rehab Services - 1st quarter
7) Radiology - 3rd quarter
8) Swing Bed - 1st, 2nd, 3rd, and 4th quarters
C. During an interview on 01/16/17 at 1210, the Utilization Review Nurse confirmed quality was not reported.

Based on policy review, clinical record review, and interview, it was determined two of two (#1 and #2) Swing-Bed patients there was no evidence they received the Important Message to Medicare upon admission and discharge and no evidence of a consent for treatment. Failure to provide these things did not ensure the patients were aware of their rights and had the potential to affect any patient admitted to Swing Bed. Findings follow.

A. Review of policy titled "Important Message From Medicare/Hospital Discharge Appeal Notice" stated "The Important Message (IM) form #CMS-R-193 will be initiated during the admission process by the Registration Clerk ...The IM form will be reissued to the beneficiary or their representative within two days of planned discharge."
B. Review of the clinical records of Swing-Bed Patients #1 and #2 revealed no evidence of a consent for treatment or an Important Message to Medicare was provided upon admission and discharge.
C. During an interview on 01/25/17 at 1030, the Director of Nursing confirmed the findings.