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Based on review of Board of Trustees (Governing Body) Meeting Minutes for November 2013 through September 2014, Joint Conference Committee Meeting Minutes for February through November 2014, Medical Staff Meeting Minutes for January through November 2014, Performance Improvement and Patient Safety Plan, and interviews, it was determined there was not an ongoing QAPI (Quality Assessment/Performance Improvement) program as follows: failed to ensure specifics of QAPI data collection were determined by the Governing Body (See A0273); failed to ensure the Governing Body prioritized QAPI activities (See A0283); failed to ensure QAPI was reported to the Governing Body for 12 of 17 departments (See A0308); and failed to ensure the QAPI plan was approved annually (See A0309). The cumulative effects of the failed practices did not ensure there was an ongoing hospital wide QAPI program to address the complexity of the services to assure patient health and safety. Findings follow.

Based on review of Board of Trustees (Governing Body) Meeting Minutes for November 2013 through September 2014, Joint Conference Committee Meeting Minutes for February 2014 through November 2014, Medical Staff Meeting Minutes for January 2014 through November 2014, and interview, it was determined the facility failed to ensure specifics of QAPI (Quality Assessment/Performance Improvement) data collection and frequency were determined by the Governing Body and failed to ensure one (Swing Bed) of three indicators traced did not specifically identify the frequency of data collection. The failed practice did not ensure the Governing Body was responsible for the QAPI program. Findings follow.

A. Review of Board of Trustees Meeting Minutes for November 2013 through September 2014, Joint Conference Committee Meeting Minutes for February 2014 through November 2014, and Medical Staff Meeting Minutes for January 2014 through November 2014 revealed the Governing Body failed to establish QAPI frequency and data collection details for the QAPI program.
B. Review of the QA Indicator traced for Swing Bed revealed data had been collected but there were no specifics as to the frequency for the data collection.
C. During an interview on 12/03/14 at 1600, the Administrator confirmed the Governing Body had not established parameters for the QA program.

Based on review of the Performance Improvement and Patient Safety Plan and interview, it was determined the facility failed to follow the Performance Improvement and Patient Safety Plan in that there was no evidence the Performance Improvement Group or Continuous Improvement Team prioritized QAPI activities. The failed practice did not ensure the facility was monitoring high risk activities and created the potential to affect any patient in the facility. Findings follow.

A. Review of the Performance Improvement and Patient Safety Plan revealed the following:
1) The goal of the QA program was to " Identify and prioritize improvement opportunities. "
2) " The Performance Improvement Group will be responsible to ... assess and prioritize the continuous improvement projects. "
3) The Continuous Improvement Team responsibility was to " Assess and prioritize the continuous projects. "
B. There was no evidence presented that QAPI activities were prioritized.
C. During an interview on 12/03/14 at 1600, the Administrator confirmed the QAPI activities were not prioritized.

Based on review of Board of Trustees (Governing Body) Meeting Minutes for November 2013 through September 2014, Joint Conference Committee Meeting Minutes for February through November 2014, Medical Staff Meeting Minutes for January through November 2014, Performance Improvement and Patient Safety Plan, and interviews, it was determined the facility failed to ensure QAPI (Quality Assurance Performance Improvement) was reported to the Governing Body for 12(Central Sterile, Dietary, Discharge Planning, Environmental Services, Emergency Services, Laboratory, Organ and Tissue Donation, Radiology, Nuclear Medicine, Respiratory, Surgical Services, and Swing Bed Services) of 17 departments. The failed practice did not ensure the Governing Body was aware of the results of all QAPI monitoring being performed in the facility, or lack thereof, and had the potential to affect any patient in the facility. Findings follow.

A. Review of Performance Improvement and Patient Safety Plan revealed, " The Performance Improvement and Patient Safety Committee and Performance Improvement Group, in turn, further summarize Performance Improvement information received from committees and departments and submits a report to the Medical Staff, the Joint Conference Committee, and the Board of Trustees quarterly. "
B. Review of Board of Trustees (Governing Body) Meeting Minutes for 11/2013-09/2014, Joint Conference Committee Meeting Minutes for 02/2014-11/2014, and Medical Staff Meeting Minutes for 01/2014-11/2014 revealed no evidence QAPI was reported to the Governing Body for the following departments: Central Sterile, Dietary, Discharge Planning, Environmental Services, Emergency Services, Laboratory, Organ and Tissue Donation, Radiology, Nuclear Medicine, Respiratory, Surgical Services, and Swing Bed Services.
C. When asked what was done with QAPI data collected in each department, interviews with department heads revealed the following:
1) Operating Room Director on 12/02/14 at 1355 - stated she collected QA (Quality Assurance) data and kept it in a binder in the department and " no one has ever asked me for it. " She confirmed it did not get reported to anyone.
2) Regional Dietitian on 12/02/14 at 1438 - stated QA monitors included nutrition screens and reassessments, tray accuracy audits and " it does not get reported to anyone outside this department if that ' s what you ' re asking. "
3) Radiology/Nuclear Medicine Director on 12/03/14 at 0840 - stated he sent his QA to " someone in Little Rock. "
4) Administrator on 12/03/14 at 1000 - stated Environmental Services reported to their facility director and it did not get reported up any higher than that in the system
5) Case Manager on 12/03/14 at 1355 - stated their QA " goes through Little Rock, they get into our charts and look at stuff. " She also stated she sent a QA report to the Administrator. When asked what the Administrator did with the data she stated, " I don ' t know. "
6) Director of Medical Records on 12/03/14 at 1320 - stated Organ and Tissue data gets reported to Risk Management in Little Rock
7) CRNA #1 (Certified Registered Nurse Anesthetist) on 12/02/14 at 1415 - stated, " I don ' t participate in any QA. "
8) Chief Nursing Officer on 12/03/14 at 1105 - stated, " I sent QA data for Swing Bed to the Compliance Manager at Little Rock. "
9) Respiratory Therapy Manager on 12/03/14 at 1355 - stated " I sent my QA to the Corporate Compliance Manager in Little Rock. "
10) Out Patient Services Manager on 12/03/14 at 1410 - stated, " I send my QA to American Data Network and what we do ourselves we send to the Corporate Compliance Officer in Little Rock. "
11) Chief Nursing Officer on 12/03/14 at 1355 - stated " each department is supposed to turn in their QA to their respective department heads in Little Rock. "
D. During an interview with the Administrator on 12/03/14 at 0955, he stated the facility had a QA Manager but that person left in June or July 2014. Previously all QA was reported to her, but no one picked up the responsibility after she left. The Administrator confirmed the lack of QAPI being reported to the Governing Body at that time.

Based on review of Board of Trustees (Governing Body) Meeting Minutes for November 2013 through September 2014, Joint Conference Committee Meeting Minutes for February through November 2014, Medical Staff Meeting Minutes for January through November 2014, Performance Improvement and Patient Safety Plan, and interviews, it was determined the facility failed to ensure QAPI (Quality Assurance Performance Improvement) was reported to the Governing Body for 12 (Central Sterile, Dietary, Discharge Planning, Environmental Services, Emergency Services, Laboratory, Organ and Tissue Donation, Radiology/Nuclear Medicine Services, Respiratory Therapy, Surgical Services and Swing Bed Services) of 17 (Central Sterile, Dietary, Discharge Planning, Environmental Services, Emergency Services, Infection Control, Laboratory, Medical Records, Nursing, Organ and Tissue Donation, Pharmacy, Rehabilitation Services, Radiology/Nuclear Medicine Services, Respiratory Therapy, Surgical Services and Swing Bed Services) departments quarterly; failed to ensure the Governing Body determined which QA projects were to be conducted; and failed to ensure the QAPI plan was approved annually by the Governing Body. The failed practice did not ensure the Governing Body was responsible for the QAPI program in the facility, and had the potential to affect any patient in the facility. Findings follow.

A. Review of the Performance Improvement and Patient Safety Plan revealed the following:
1) " The Baptist Health Board of Trustees has the ultimate responsibility and accountability for the provision of quality and safe patient care/services and for the allocation of necessary resources for performance improvement. The Board delegates the implementation of this plan jointly to the hospital administrative leadership and the professional (medical) staff leadership who must set the performance improvement priorities. "
2) " The Performance Improvement and Patient Safety Committee and Performance Improvement Group, in turn, further summarize Performance Improvement information received from committees and departments and submits a report to the Medical Staff, the Joint Conference Committee, and the Board of Trustees quarterly. "
3) " The Performance Improvement and Patient Safety Program will be appraised at least annually by the Performance Improvement and Patient Safety Committee and Performance Improvement Group ...Based on the annual appraisal, the plan will be reviewed and/or revised at least annually and formal approval given by the Vice President, Chairman of Performance Improvement and Patient Safety Committee, Medical Staff, Joint Conference Committee, and the Board of Trustees. "
4) Under Quality Assessment and Improvement Committee, " Meets Bi-Monthly, maintain records of proceedings and actions, and provide a quarterly summary report to the Medical Staff, Joint Conference, and Board of Trustees. "
B. Review of Board of Trustees (Governing Body) Meeting Minutes for November 2013 through September 2014, Joint Conference Committee Meeting Minutes for February through November 2014, Medical Staff Meeting Minutes for January through November 2014 revealed QAPI was not reported to the Governing Body for 12 (Central Sterile, Dietary, Discharge Planning, Environmental Services, Emergency Services, Laboratory, Organ and Tissue Donation, Radiology/Nuclear Medicine Services, Respiratory Therapy, Surgical Services and Swing Bed Services) of 17 (Central Sterile, Dietary, Discharge Planning, Environmental Services, Emergency Services, Infection Control, Laboratory, Medical Records, Nursing, Organ and Tissue Donation, Pharmacy, Rehabilitation Services, Radiology/Nuclear Medicine Services, Respiratory Therapy, Surgical Services and Swing Bed Services) departments quarterly.
C. Review of Board of Trustees Meeting Minutes for November 2013 through September 2014 and the Performance Improvement and Patient Safety Plan revealed no evidence the Governing Body had determined which QAPI projects were to be conducted, and revealed no evidence the Governing Body had approved the annual QAPI plan.
D. During an interview on 12/03/14 at 1600, the Administrator verified 12 of 17 departments had not reported QA data to the Governing Body, the Governing Body had not determined which QAPI projects were to be conducted, and the QAPI plan was not approved by the Governing Body annually.

Based on observation, review of policy and interview, it was determined the facility failed to ensure medications were secured in two of two (Operating Room (OR) #1 and OR #2) ORs toured. By not ensuring medications were secured from non-licensed personnel, the facility could not assure the safety and efficacy of the medications. The failed practice had the likelihood to affect all patients who have operations. Findings follow:

A. During a tour of Surgical Services on 12/3/14 from 0900 to 0935, observation revealed the following medications in cabinets that were not lock or secured:
1) OR #1
a) 4-Mannitol 25% 50 milliliters(ml);
b) 2-Suprane; and
c) 3-Sevoflurane
2) OR #2
a) 7-Sevoflurane;
b) 7-Suprane; and
c) 6-boxes of 6 each Dantrolene.
B. Review of policy titled "Appropriate Medication Storage" stated "In order to ensure patient/staff safety, therapeutic efficacy, and product integrity, all medications will be safely stored, handled and secured at all times."
C. At the time of observation, on 12/02/14 the OR Director verified medications were not secured in both ORs.

Based on observation, review of policy and interview, it was determined the facility failed to ensure outdated medications/medication related devices were not available for patient use in four (Emergency Department(ED), In-patient Surgery, Out-patient Surgery and Obstetrics) of five (Intensive Care Unit, ED, In-patient Surgery, Out-patient Surgery and Obstetrics) areas toured. By not removing outdated medications/ medication related devices, the facility could not assure the integrity and efficacy of the medications and medication related supplies. The failed practice had the likelihood to affect all patients who receive medications/medication related devices. Findings follow:

A. During a tour of the facility on 12/02/14 from 0950 to 1105, observation revealed the following expired medications and medication related supplies:
1) Emergency Department-2 Epinephrine 1:1,000 for injection expired 12/01/14.
2) In-patient Surgery-
a) 8-Oxytocin 10units/1 ml (milliliter) expired 11/14;
b) 4-Naloxone 0.4mg (milligram)/ml expired 08/01/14;
c) 1-Anectine 200mg/10ml expired 11/24/14; and
d) 1-Anectine 200mg/10ml expired 10/20/14.
3) Out-patient Surgery-one Tubersol vial for injection opened 06/21/14 expired 07/20/14.
4) Obstetrics- 2 Glucose controls expired 11/14.
B. Review of policy titled Inspection of Medication Storage Areas stated "Each medication storage area in the hospital will be inspected once each month by pharmacy personnel using the approved inspection sheet ...Out of Dates."
C. During an interview on 12/02/14, the Nursing Operation Manager verified the availability of the expired medications and medication related devices available for patient use.

Based on observation and interview, it was determined the facility did not maintain the condition of the walls, ceilings, patient rooms and patient bathrooms free from damage to prevent injury and harm to health. The failed practice had the potential to affect all patients, staff, and visitors due to the potential harm to health and safety presented by the observed physical conditions. The facility had a census of 14 patients on 12/01/14. The findings follow:

A. On a tour of the facility on 12/02/14 at 1040 with the Director of Support Services,
the aluminum facade on the exterior wall to the left of the main entrance had a section peeled away from the exterior wall and was hanging loose. This left an exposed air space between the exterior wall and facade for moisture infiltration into the gap and the potential of mold growth on the exterior wall. A section of the facade had aluminum facade bricks that fell off and were on the ground.
B. On a tour of the facility on 12/03/14 at 0845 with the Director of Support Services the following observation were made:
1) The ceiling in the X-ray room had 4 stained ceiling tiles.
2) The sink in the Nuclear Medicine room had a white residue.
3) In the corridor wall near Patient Room 201 had a hole punched in the wall.
4) The fan coil unit in the corridor near Patient Room 201 had an accumulation of dust and a loose cover plate.
5) In Patient Room 201, the window curtain had a stain. The chair in the room had ripped upholstery.
6) In Patient Room 224, there was an accumulation of dust on the patient headwall light fixture. The rod on the towel bar in the patient bathroom was missing.
7) In Patient Room 204, there was an accumulation of dust on the patient headwall light fixture. The rod on the towel bar in the patient bathroom was missing. There was an accumulation of dust on the exhaust grille in the patient bathroom.
8) In the metal Laundry Building, there was a gap between the metal wall and the floor behind the washing machines. This opening allowed unfiltered air into the washing machine room and had the potential to allow insects and vermin into the building. The walls of the the washing machine room had exposed insulation that was discolored and had an accumulation of dust. There was exposed metal piping and air conditioning equipment that was rusted and had an accumulation of dust. A window in the building had a broken section of glass that was covered by a piece of cardboard.
C. The Director of Support Services verified the observations at the time each condition was observed on the tour.

Based on observation and interview, it was determined the infection control officer failed to have a process in place to perform surveillance activities for Infection Control. The failed practices did not assure the infection control officer had conducted ongoing surveillance to identify the needed physical environment repairs that had the likelihood to hinder the disinfection of surfaces or allow for observation of disinfection techniques to assure cross contamination did not occur. The failed practices were likely to affect all persons in the facility. Findings follow:

A. A tour of the facility was conducted 12/02/14 from 0950-1125 with the Nursing Operations Manager. Observations revealed the following:
1) In the Intensive Care Unit Room 10 was used for storage. A commode was located in the corner of the room behind a curtain and when flushed, water ran onto the floor from the base of the commode;
2) In the Intensive Care Unit Room 7, a three foot long by one inch wide deep gouge was in the sheetrock underneath the window and at the wall edge was three inch by 5 inch chipped and cracked sheetrock, exposing a chalky surface underneath which has an absorbent nature and cannot be disinfected. A medication pump stand had rust on the base. Rust has a porous nature and cannot be disinfected. The laminate on the bedside table was chipped, exposing wood underneath. Wood has a porous nature and cannot be disinfected;
3) In the Intensive Care Unit Room 6, a five foot long by one inch wide deep gouge was in the sheetrock underneath the window exposing a chalky surface underneath which has an absorbent nature and cannot be disinfected;
4) In the Intensive Care Unit in the hall between Rooms 5 and 6 were two vital signs machines which had heavy layers of dust on the bases of each which did not assure they were clean;
5) In the Intensive Care Unit Room 5, dust was on the base of a workstation-on-wheels which did not assure it was clean and in the commode in the corner of the room had mosquito larva (identified by the Director of Support Services) swimming in it which did not assure it was clean;
6) In the Intensive Care Unit Room 4, the sheetrock underneath the window was chipped an scratched exposing the chalky surface underneath which has an absorbent nature and cannot be disinfected;
7) In the Intensive Care Unit Room 3, there were holes in the wall at the head of the bed as well as deep gouges in the sheetrock exposing the chalky surface underneath which has an absorbent nature and cannot be disinfected;
8) In the Intensive Care Unit Room 2, there were deep gouges in the sheetrock underneath the window, exposing the chalky surface underneath which has an absorbent nature and cannot be disinfected;
9) In the Emergency Room Trauma Room 1, a heavy layer of dust was in the basket-container underneath the keyboard on the workstation-on-wheels which did not assure it was clean and on the bottom edge of the overhead light suspended from the ceiling, was a brown sticky residue which did not assure it was clean; and
10) In the Nursery, there was rust on the steel frame of the mobile basinet. Rust has a porous nature and cannot be disinfected.
B. The findings listed above identified as A were verified by the Nursing Operations Manager at the time of the tour.
C. Observation of Environmental Services (ES) Staff #1 disinfecting Operating Room #2 after a surgical procedure on 12/03/14 from 0900-0935 revealed the following:
1) ES Staff #1 explained the basin located on a cleaning cart in the room contained "Virex", a solution used to clean the operating room;
2) ES Staff #1 placed a white cloth in the solution of Virex and wiped a blue and beige supply cart from top to bottom, then wiped a black arm board, then wiped a prep table from top to bottom and then a suture cart from top to bottom. She then rinsed the white cloth (dirty) in the solution of Virex (clean), rung it out in the clean solution and proceeded to wash the metal stand used to hold a trash bag from top to bottom, the wall behind the trash bag stand, a mayo stand from top to bottom, the wall behind the mayo stand and then placed the cloth (dirty) back into the Virex (clean), rinsed the cloth and rung it out into the solution of Virex; and
3) During cleaning the operating room, ES Staff #1 continued cleaning the entire room which included, a back table used to set up the sterile field, the wall behind the table, the wall mounted gas panel and electrical connectors, a sink in an ante room, a metal stool, a silver cabinet with glass doors, x-ray view boxes, a second mayo stand, two brown vinyl rolling stools, a Bovie electro-cautery machine stand and cords, two IV (intravenous) poles, a Bear Hugger stand and Bear Hugger device, a Glide Scope device and stand, the Anesthesia provider's chair, a patient rolling board, Operating Room (OR) bed and mattresses, a sequential compression device machine, two overhead OR lights and the bed's safety strap. All furnishings were wiped from top (cleanest) to bottom (most dirty) and then ES Staff #1 proceeded to the next piece of equipment. The same cloth (dirty) was rinsed repeatedly in the basin of Virex (clean) and never changed throughout the cleaning process. Wiping equipment from top to bottom allowed staff to work from the cleanest part of the equipment (top) to the most dirty part of the equipment (bottom/nearest the floor). By repeatedly rinsing the contaminated cloth in the solution of Virex did not assure the Virex remained uncompromised from contamination and would be effective in cleaning equipment. By not changing cleaning cloths between cleaning pieces of equipment did not assure a clean cloth was used to clean equipment.
D. The findings listed above identified as C were verified by the Director of Perioperative Services on 12/03/14 at 1035.
E. During interview with the Epidemiologist on 12/04/14 at 1015, regarding the Infection Control Program for the facility, he explained "there used to be a part-time Regional Infection Control person in the facility but that arrangement hadn't worked well so a full time Infection Control person was put into place." When describing the observations from the facility tour (i.e. gouges in sheetrock, rust, dust, etc.) he was asked if surveillance tools were utilized to evaluate the sanitary condition of the facility. He explained there were tools for surveillance but they were not being used.

Based on review of 2014 Discharge Planning QAPI (Quality Assessment/Performance Improvement) and interview, it was determined the facility failed to ensure there was a process in place to track and trend of readmissions to identify whether or not the readmission was preventable and if the discharge plan was responsive to the patient ' s post discharge needs. The failed practice did not allow the facility to determine if changes needed to be made to their discharge planning process and had the potential to affect any patient admitted to the facility. Findings follow.

A. Review of 2014 discharge planning quality data did not include a provision for assessing whether readmissions were due to problems in the discharge planning process.
B. During an interview on 12/03/14 at 1045, when asked if readmissions were being monitored for possible discharge planning problems, the Case Manager stated, " Not necessarily. "

Based on clinical record review and interview, it was determined the operative report for six (#14, and #16 - #20)of 10 (#11 - #20) patients did not include the time of the operation. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow:

A. Review of clinical records on 12/04/14 from 1420-1450 revealed the time of the operation was not included in the operative report for Patient #14, and #16 - #20.
B. During an interview at the time of clinical record review, the Clinical Documentation Specialist confirmed there was no time on the operative reports.

Based on review of policies and procedures, review of Audit Report Form, review of November and December calendars and interview, it was determined the facility failed to assure the activities program for Swing-Bed patients was under the direction of a qualified professional. Failure to have a qualified professional direct the activities program did not assure activities were planned which promoted optimum levels of functioning for Swing-Bed patients. This failed practice was likely to affect all patients admitted to the Swing-Bed Unit. Findings follow:
A. Review of Audit Report Form dated 07/02/14 revealed "we still do not have an Activities Coordinator or Activities Plan (or anyone to carry out activities if they are planned)" and Audit Report Form dated 10/07/14 revealed "....we do not currently have an Activities Director ...we have been in contact with (named) about getting an Activities Director...". There was no evidence the facility had actively pursued recruitment of a qualified professional for the Activities Program.
B. Review of Policy 100.0015, "Swing Bed-Activity/Assessment Program", revealed "...the hospital will provide an activities program under the direction of a qualified professional".
C. During interview with the Nursing Operations Manager on 12/01/14 at 1455, she confirmed A and B and verified the facility did not have an Activities Director for Swing Bed. When asked how activities for Swing Bed patients were conducted, she explained activities calendars were sent from Little Rock (sister/system facility) and presented calendars for November 2014 and December 2014 for review which listed activities for Swing Bed patients. She further explained the nursing staff conducted the activities outlined on the calendars.