HospitalInspections.org

Based on a review of documentation and interview, the facility failed to protect and promote each patient's rights as evidenced by:


1. Failing to ensure the patients' right to be free from the inappropriate use of restraint by allowing patients to be restrained for the prevention of falls. Cross refer to A0154.


2. Failing to ensure the use of restraints were implemented in accordance with safe and appropriate techniques as determined by hospital policy in accordance with State law by inappropriately using enclosed beds and inconsistent monitoring of patients in restraints. Cross refer to A0167.


3. Failing to ensure that the use of restraint was in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under §482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law. Cross refer to A0168.


4. Failing to ensure the condition of the patient who was restrained was monitored by trained staff at intervals determined by hospital policy. Cross refer to A0175.


5. Failing to ensure that for restraint episodes, the patient medical record included alternatives or other less restrictive interventions attempted (as applicable). Cross refer to A0186.

Based on document review and staff interview the facility failed to ensure an RN (Registered Nurse) was always available during the care of the renal dialysis patients.

Findings were:

Review of "on-call" schedules for hemodialysis services revealed an LVN was scheduled for on-call one weekend a month. The LVN was responsible for dialysis care and assessment of the dialysis patient with no RN supervision during their on-call treatments of the patients.

In an interview with the clinical coordinator of dialysis services at the time of the finding he acknowledged the LVN had no RN supervision in the dialysis suite during the time they performed dialysis treatments and assessments when they were "on-call".

Based on a review of facility policy, review of clinical records and interview, the facility failed to ensure the patients' right to be free from the inappropriate use of restraint.


Five out of six clinical records reviewed for the use of medical restraints revealed inappropriate use of restraint.


Findings included:


Facility policy titled "Restraint (Use of) or Seclusion (Use of) Policy" stated in part "Prohibitions on the use of restraint or seclusion
The use of restraint or seclusion for the following reasons is prohibited:
*Coercion, discipline, convenience, or staff retaliation ...
*The routine use of restraints for the prevention of falls. The rationale that a patient should be restrained because he or she 'might' fall does not constitute an adequate basis for using a restraint. A history of falling without a current clinical basis for a restraint intervention is inadequate to demonstrate the need for restraint."


Review of the clinical record for patient #4A revealed orders each day from 5/10/17 until 5/16/17 (seven total days) that stated in part, "Clinical Justification (Reason) for Use of Restraint/Seclusion (check only that which applies) USE FOR A PATIENT WITH MEDICAL CARE NEEDS
*Patient is attempting to pull out tubes, drains, or other lines medically necessary for treatment and is unable to comply with safety instructions
*Patient is attempting to ambulate, is at risk for falling, and is non-compliant with safety instructions."


Review of the clinical record for patient #5A revealed orders on 6/10, 6/11 and 6/12/17 that stated in part, "Clinical Justification (Reason) for Use of Restraint/Seclusion (check only that which applies) USE FOR A PATIENT WITH MEDICAL CARE NEEDS
*Patient is attempting to pull out tubes, drains, or other lines medically necessary for treatment and is unable to comply with safety instructions
*Patient is attempting to ambulate, is at risk for falling, and is non-compliant with safety instructions ...
Type of intervention ordered ...
Soft wrist restraint: Left, Right
Posey vest."
Orders on 6/13 and 6/14 stated the reason for restraint was "Patient is attempting to ambulate, is at risk for falling, and is non-compliant with safety instructions ...
Type of intervention ordered ...
Soft wrist restraint: Left, Right."


Review of the clinical record for patient #6A revealed one order for restraint that was not dated or timed by the physician that stated the clinical justification for restraint included "Patient is attempting to ambulate, is at risk for falling, and is non-compliant with safety instructions ...
Type of intervention ordered:
Enclosure bed."


Review of the clinical record for patient #7A revealed an order for restraint dated 5/3/17 that stated the clinical justification for restraint included "Patient is attempting to ambulate, is at risk for falling, and is non-compliant with safety instructions ..."


Review of the clinical record for patient #8A revealed nursing restraint documentation on 5/17/17 and 5/18/17 for patient #8A that stated in part, "Reason for restraint: Attempting unsteady ambulation, non-compliant with safety instructions, removing medical device(s), unable to follow directions ... Type: Enclosure bed."


Five out of six clinical records reviewed used restraint for prevention of falls, which is an inappropriate use of restraints.


The above was confirmed in an interview with staff #36A on the morning of 8/10/17.

Based on facility policy review, clinical record review and interview, the facility failed to ensure the use of restraints were implemented in accordance with safe and appropriate techniques as determined by hospital policy in accordance with State law when:

1. The use of enclosed beds were used without a hospital policy.
2. The frequency of monitoring of patients in restraints were not consistently documented.


Findings included:


Facility Policy titled "Restraints (Use of) or Seclusion (Use of) Policy" stated in part, "Definitions:
Physical Restraint
Physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Under this definition, commonly used devices and other practices could meet the definition of a restraint, such as:
*Use of a 'net bed' or an 'enclosed bed' that prevents the patient from freely exiting the bed ...


Alternatives to the use of restraint & seclusion
*The use of restraint or seclusion is based on the assessed needs of the patient. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient [sic] a staff member or others from harm.
*The use of restraint or seclusion occurs only after alternatives to such use have been considered an/or attempted as appropriate. Such alternatives may include, but are not necessarily limited to:
...*Use of a sitter ...


Ongoing monitoring & assessment of a patient in restraint or seclusion
Minimum frequency of monitoring of a patient in restraint or seclusion:
...Patients placed in restraint for safety, non-violent, and non-destructive behavior should be monitored at least every two (2) to four (4) hours.


Application of Restraint:
Restraint shall be applied/removed in accordance with the following:
*The type of restraint used shall be consistent with the type of restraint ordered
...*Restraint devices are to be applied/removed in accordance with manufacturer's instructions and used in a manner consistent with their intended purpose ...


Documentation of the use of restraint or seclusion
Each episode of restraint or seclusion should contain at least the following documentation in the patient's medical record:
...*The intervals for monitoring
...*The identity of the physician or other licensed independent practitioner who ordered the restraint or seclusion
*Orders for restraint or seclusion ..."



1. The manual for the "Posey Bed 8060" stated in part, "Warnings and Precautions:
Importance of adhering to a care regiment: Failure to follow the doctor's order, the patient's care plan and all instructions, warning and cautions in the manual and on all labels on the Posey Bed 8060, could result in patient death or serious injury. Monitor the patient's condition according to your facility's policy, the doctor's orders, and the care plans ...


New patient selection and monitoring
Purpose: To make sure that the Posey Bed 8060 is right for the new patient and that his or her first hours in the bed are safe and secure ...
Checklist: Note: any YES (in table below) indicates that the doctor must determine if the Posey Bed 8060 is appropriate for the patient. Prior to use with a new patient, photocopy and retain this checklist to record that each item has been verified ...

1. Does the patient weigh less than 46 pounds?
2. Does the patient weigh more than 300 pounds?
3. Is the patient less than 46 inches tall?
4. Has the patient been diagnosed with any condition that may cause violent or self-destructive behaviors?
5. Has the patient been diagnosed with an excessive Pica disorder or may attempt to eat the bed canopy or padding?
6. Has the patient been diagnosed with claustrophobic tendencies?
7. Has the patient been diagnosed as at-risk and cannot re-position himself or herself when the head of the bed is raised, therefore, requiring a flat bed or gap fillers?"


Review of the clinical record for patient #6A revealed one order for restraint that was not dated or timed by the physician that stated the clinical justification for restraint included "Patient is attempting to ambulate, is at risk for falling, and is non-compliant with safety instructions ...
Type of intervention ordered:
Enclosure bed."
Nursing restraint documentation revealed patient #6A was in an enclosed bed on 4/29/17, 4/30/17, 5/1/17 and 5/2/17 without physician orders.


In an interview with staff #36A, when asked if a sitter was an alternative attempted before the enclosure bed was used, staff #36A stated, "This was a stroke patient. They should have had a sitter but I don't see where one was ordered or any documentation."


Review of the clinical record for patient #8A revealed two orders for behavioral restraints dated 5/9/17 and 5/12/17 that stated in part "Patient is physically assaultive to others or is highly agitated and assaultive, behavior preeminent."
Nursing restraint documentation on 5/17/17 and 5/18/17 for patient #8A stated in part, "Reason for restraint: Attempting unsteady ambulation, non-compliant with safety instructions, removing medical device(s), unable to follow directions ... Type: Enclosure bed."
No physician orders were found for the enclosure bed restraint. No documentation was found stating the restraint was discontinued.


The above was confirmed in an interview with staff #36A.


In an interview with staff #1A on the morning of 8/10/17, when asked for a policy on the enclosure beds, staff #1A stated, "We don't have a specific policy" and gave the manual for the Posey Bed 8060. When discussing the checklist recommended by the manufacturer, staff #1A stated, "I can tell you, we're not doing that."


2. Review of patient #3A's clinical record revealed no physician order for restraint on 4/10/17 and the minimum nursing restraint documentation of ongoing monitoring and assessment was not documented on 4/11/17 from 6:00 pm until 4/12/17 at 10:42 am.
When asked how long the patient was in restraints, staff #36A stated, "I don't see when the restraints were removed."
For the 49.5 hours documented the patient was in restraints, nursing documentation was incomplete.


Review of patient #4A's clinical record revealed minimum nursing restraint documentation of ongoing monitoring and assessment was not documented on 4/15/17 from 10:00 pm through 5/16/17 at 7:00 am and was not completed again until 5/16/17 at 6:34 pm.


Review of patient #5A's clinical record revealed minimum nursing restraint documentation of ongoing monitoring and assessment was incomplete from 6/23/17 through discontinuation of restraints on 6/30/17 at 10:44 am. Of the 24 times nurses documented regarding restraints between 6/23/17 and 6/30/17, 13 of those were beyond the four-hour minimum documentation limit. 10 of the nursing restraint documentation was 8-13 hours in between monitoring.


Review of patient #6A's clinical record revealed no physician order the for restraint documented on 4/29/17 through 5/2/17; the minimum nursing restraint documentation of two to four hours was not complete for the four days the patient was in restraints.


Review of patient #7A's clinical record revealed minimum nursing restraint monitoring documentation was not completed for the 30 hours the patient was in restraints (5/3/17 through 5/4/17). Documentation was only completed four times in the 30 hours the patient was in restraints.


Review of patient #8A's clinical record revealed nursing documentation indicating the patient was in an enclosed bed on 5/17/17 to 5/18/17 with no physician orders. Minimum nursing restraint documentation was not complete for those two days. Nursing documentation was completed six times on those dates, with three times being 8-10 hours apart. It was not documented when patient #8A was released from restraints.


The above was confirmed in an interview with staff #36A.

Based on review of facility documents, review of clinical records and interview, the facility failed to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner.
Four out of six records reviewed for restraint use revealed restraints applied without a physician order.


Findings included:


Facility Policy titled "Restraint (Use of) or Seclusion (Use of) Policy" stated in part, "Documentation of the use of restraint or seclusion
Each episode of restraint or seclusion should contain at least the following documentation in the patient's medical record:
...*The intervals for monitoring
...*The identity of the physician or other licensed independent practitioner who ordered the restraint or seclusion
*Orders for restraint or seclusion ..."


Review of patient #3A's clinical record revealed no physician order for restraint on 4/10/17.


Review of patient #5A's clinical record revealed nursing documentation stating the patient was restrained in left and right soft wrist restraints from 6/23/17 at 1:00 pm until 6/30/17 at 10:44 am. There was only one physician order during that time, dated 6/28/17 that was untimed.


Review of patient #6A's clinical record revealed the patient was in an enclosed bed from 4/29/17 through 5/2/17, there was one physician order with no date and time and one physician order crossed through on 5/2/17 that stated, "d/c [discontinue] restraints."


Review of patient #8A's clinical record revealed nursing documentation indicating the patient was in an enclosed bed on 5/17/17 to 5/18/17 with no physician orders.


The above was verified in an interview with staff #36A.

Based on facility document review, clinical record review and interview, the facility failed to ensure the condition of the patient who was restrained was monitored at intervals determined by hospital policy. Six out of six clinical records reviewed for restraints revealed incomplete monitoring, determined by hospital policy, by nursing staff.


Findings included:


Facility policy titled, "Restraint (Use of) and Seclusion (Use of) Policy" stated in part, "Ongoing monitoring & assessment of a patient in restraint or seclusion
Minimum frequency of monitoring of a patient in restraint or seclusion

...Patients placed in restraint for safety, non-violent, and non-destructive behavior should be monitored at least every two (2) to four (4) hours."


Review of patient #3A's clinical record revealed the minimum nursing restraint documentation of ongoing monitoring and assessment incomplete on 4/11/17 from 6:00 pm until 4/12/17 at 10:42 am. When asked how long the patient was in restraints, staff #36A stated, "I don't see when the restraints were removed." For the 49.5 hours documented the patient was in restraints, nursing documentation was incomplete.


Review of patient #4A's clinical record revealed minimum nursing restraint documentation of ongoing monitoring and assessment was incomplete on 4/15/17 from 10:00 pm through 5/16/17 at 7:00 am and was not completed again until 5/16/17 at 6:34 pm.


Review of patient #5A's clinical record revealed minimum nursing restraint documentation of ongoing monitoring and assessment was incomplete from 6/23/17 through discontinuation of restraints on 6/30/17 at 10:44 am. Of the 24 times nurses documented regarding restraints between 6/23/17 and 6/30/17, 13 of those were beyond the four-hour minimum documentation limit. 10 of the nursing restraint monitoring documentation was 8-13 hours in between monitoring.


Review of patient #6A's clinical record revealed the patient was in restraints as an enclosed bed on 4/29/17 through 5/2/17; the minimum nursing restraint documentation was not complete for the four days the patient was in restraints.


Review of patient #7A's clinical record revealed minimum nursing restraint monitoring documentation was not completed for the 30 hours the patient was in restraints (5/3/17 through 5/4/17). Documentation was only completed four times in the 30 hours the patient was in restraints.


Review of patient #8A's clinical record revealed nursing documentation indicating the patient was in an enclosed bed on 5/17/17 to 5/18/17 with no physician orders. Minimum nursing restraint documentation was not complete for those two days. Nursing documentation was completed six times on those dates, with three times being 8-10 hours apart. It was not documented when patient was released from restraints.


The above was confirmed in an interview with staff #36A.

Based on review of facility documents, clinical record review and staff interview, the facility failed to ensure there was documentation in the patient's medical record of alternatives or other less restrictive interventions attempted.


Findings included:


Facility Policy titled "Restraints (Use of) or Seclusion (Use of) Policy" stated in part, "Alternatives to the use of restraint & seclusion
*The use of restraint or seclusion is based on the assessed needs of the patient. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient [sic] a staff member or others from harm.
*The use of restraint or seclusion occurs only after alternatives to such use have been considered an/or attempted as appropriate. Such alternatives may include, but are not necessarily limited to:
...*Use of a sitter


Review of the clinical record for patient #6A revealed one order for restraint that was not dated or timed by the physician that stated the clinical justification for restraint included "Patient is attempting to ambulate, is at risk for falling, and is non-compliant with safety instructions ...
Type of intervention ordered:
Enclosure bed." There was no documentation in patient #6A's clinical record that less restrictive interventions were attempted with the patient before the enclosure bed was applied.


In an interview with staff #36A, when asked if a sitter was an alternative attempted before the enclosure bed was used, staff #36A stated, "This was a stroke patient. They should have had a sitter but I don't see where one was ordered or any documentation."


The above was confirmed in an interview with staff #36A.

Based on review of facility documents, review of surgery center documentation and interview, the facility failed to ensure proper ventilation, light, and temperature controls in appropriate areas.


Findings included:


Facility policy titled "Temperature and Humidity" stated in part, "Procedure(s) ... Task: Beginning of each day the surgery and procedural staff will check for positive air pressure, the room temperature and relative humidity.
...*If within parameters, begin cases for the day.
*If the temperature is above or below the parameters adjust the temp in the room or call Plant Operations staff ..."


Review of surgery center documentation titled "GI [gastrointestinal] lab [laboratory] temperature, humidity, and pressure record" for April, May and June of 2017 revealed goals for temperature, humidity and pressure at the top of each page. Only temperature and humidity were recorded for GI Lab 1, 2, 3 and 4. Some of the values were out of range, when discussed, staff #37A stated, "When it's one degree off, I'm not sure they did anything about that, but I'm not sure because there are no comments. We did have some problems but I can't tell you the dates."


The above was confirmed in an interview the morning of 8/9/17 with staff #37A.

The facility failed to meet the conditions of participation for Infection Control when the infection prevention and control program did not include appropriate monitoring and follow through of maintenance repair activities, Operating Room instruments storage, Reproccesing equipment cleaning, Staffs reuse of surgical masks, evaluating the hospital staff's immunization status for designated infectious diseases and failing to appropriately monitor for all post-operative infections.

Refer to A0749

Based on observation, interview, and record review the facility's Infection Control program failed to ensure a safe and sanitary environment:


A. (13) Operating Room Case Carts containing a large amount of Surgical Instruments were being stored unmonitored and unsecured in a public hallway adjacent to the facility's loading dock and Visitor elevators.


B. The (3) Steris 1E Endoscopy Reprocessers and the Steris instrument washers were not being cleaned according to the manufacturer's-recommended maintenance activities and schedule.


C. The facility's Pre-Operative areas, Operating rooms and hallways, the radiology department's patient rooms and nursing units had walls and counters with chipped laminate and holes in the walls.


D. Multiple facility Staffs were observed wearing used surgical masks in the pre-operative patient unit and a sterile processing technician had his beard uncovered while processing surgical instruments.


E. The facility failed to enforce hospital policy relating to employee health and safety, as annual tuberculosis health questionnaire were not completed timely by hospital staff.


Findings Include:


A. An observation made on 08/09/17 during a tour of the facility revealed (13) large metal Operating Room Case Carts lined up against a wall in a public hallway 5 feet from the Patient's and Visitor's elevators, 22 feet from the Bio Medical room that had cardboard shipping boxes, dirt, trash and debris on the floor and 32 feet from the outside doors leading to the loading dock. Further observation revealed the carts were not secured or being monitored. A food service employee was observed placing drinks and food items on one of the carts. The wheels were coated with dirt and debris.


During an interview on 08/09/17 Staff #F20, Assistant Vice President confirmed the carts contained sterile operating instruments for the surgeries scheduled the next day and that the carts would be taken into the Sterile operating rooms. Staff#F20 stated, "They wipe them off...." .
.

During an interview on 08/09/17 in the Nursing Office Staff #F21, Infection Control stated, "We recognized the problem...we have talked about in the past...not in the last year...we have limited space...it's not optimal."


When asked if the Infection Control Committee had discussed the issue with the Governing Body, Staff #F18, Chief Nursing Officer stated, "We haven't specifically discussed it with the Governing Body...Staff #F22,MD, the Infection Control Chairman is aware of it...."


Review of the Infection Control subcommittee reports to the Quality Committee did not reflect a discussion for storing the Surgical Instruments in the public hallway.


On 8/10/2017 the facility moved the OR case carts to an enclosed restricted area within the Surgical Unit.


B. Observations made on the morning of 08/09/17 in the facility's


1.) Scope cleaning room revealed (3) Steris 1E Endoscopy Reprocessers with a dark yellow stains and debris noted on the machines inside door gaskets, inner tray and inner compartment on all three of the Reprocessers.

During an interview on the morning of 08/09/17 in the facility's OR scope cleaning room Staff #17, Sterile Processing Technician stated, "I clean the washers daily...the staining is from the soap...." Staff#F19, OR Director stated, "We don't use the washers daily....we just run them to have them ready..." Staff #F17 proceeded to wipe the Reprocessers with a cloth dampened with 70% isopropyl alcohol, most of the dark yellow stains were wiped off with repeated wiping, Staff #F17 stated, "...it's going to be the same tomorrow ..."

An observation on the morning of 08/10/19 in the facility's scope cleaning room revealed the Steris 1E Endoscopy Reprocessers had not developed the dark yellow stains. Staff #F19, OR Director confirmed there was no daily cleaning logs for the Reprocessers.

Review of the facility provided document Steris 1E Endoscopy manufacturer's manual reflected "...Daily Cleaning...Wipe the inner surface and seal, processing tray, and accessory rack with a soft cloth dampened with CHECK DRAIN SCREEN The drain screen is located in the bottom of the sterilant compartment. Ensure that the screen is clean. Remove any debris or lint from the screen. The screen may be removed for thorough cleaning by lifting the processing tray and unscrewing the drogue. Replace screen after cleaning with 70% isopropyl alcohol.

Staff #F16, Sterile Processing Director stated, "We run the flexible cystoscopes, bronchoscopes and Laryngoscope lights in the washers..."


2.) The Sterile Processing room revealed (2) Steris Surgical Instrument Washers currently being used. When asked about the daily maintenance of the washers, Staff #F15, Surgical Scrub Technician stated, "I only wipe the washers out..." When asked who performs the weekly maintenance, cleaning out the sprayer arms and the plastic cap on the washers, Staff #F15 stated, "We don't do the weekly maintenance, the manufacturer does it...."

Staff#F19, Operating Room (OR) Director stated, "We call the manufacturer when we need them ....they are out here all the time."

Review of the facility provided Steris maintenance documents reflected weekly visit dates. AUTOMATED WASHER DISINFECTOR TEST LOG SHEETs reflected TOSI testing, The TOSI® (Test Object Surgical Instrument) provides sterile processing professionals with a consistent, repeatable, reliable method for evaluating the cleaning effectiveness of their automated instrument washers, cart washers and ultrasonic washers ...."

The Steris maintenance logs did not include the routine maintenance of the washers.

Review of the facility provided document Steris Washer manufacturer's manual reflected " ... 6.3 Weekly Cleaning ...3. Clean wash chamber rotary spray arm assembly as follows:
a. Remove screw securing rotary spray arm assembly on top of chamber and lower rotary spray arm assembly.
b. Remove locking pin securing each spray arm on rotary spray arm hub.
c. Rinse each spray arm under running water to clean out sediment.
d. Use a fine wire (approximately wire gauge of a paper clip) to clean sediment from spray nozzles. Rinse under running water.
e. Reinstall spray arms on rotary spray arm hub.
f. Reinstall locking pin to secure both spray arms.
g. Reattach rotary spray arm assembly to top of wash chamber.
4. Remove bottom rotary spray arm assembly and clean in same way as top rotary spray arm assembly.
5. Clean rotary spray arm assembly on accessories in same way as chamber rotary spray arm assemblies.
6. Clean door gasket using a soft cloth containing a soapy solution or a mild detergent.
7. If independent monitor option is present, clean using a soft cloth containing a soapy solution or a mild detergent, clean front panel and display...."


C. Observations made on 08/09/17 of the facility's Pre-Operative areas revealed cracked laminate on the medication room counters and missing wall board by the sink in Room #366. Observation of the Operating rooms and hallways revealed chipped laminate on the Operating room #7's door. A hole in the wall in OR #7, a 12 inch hole in the wall exposing the OR sterile corridor to possible pest from within the wall and the radiology department's patient rooms and nursing units had walls and counters with chipped laminate and holes in the walls.

During an interview on the morning of 8/10/17 in the facility conference room Staff #F2, Infection control state "When we do the environmental infections control rounds if we see something that needs to be fixed we will fill out a work order."

Review of the facility provided document Environmental/ Infection Control Rounds dated 6/16/17 reflected " ...SDS (Surgery Department)...missing laminate...Back splash missing by sink in room 366 Med Room had multiple areas of missing laminate, broken cabinets ..." The backsplash had not been repaired in two months.

Review of the facility provided Work orders the Radiology and the Surgery departments from 3/1/2017 - 8/9/2017 did not reflect work orders for the needed repairs.


D. Observations made on the morning of 08/08/17 during a tour of the facility's pre-operative unit revealed (4) four medical staffs wearing surgical face masks tied around their necks. When asked about the tied face mask Staff #F9, Anesthesiologist stated, "I don't change them between patients unless they are soiled."

During an interview in the afternoon of 08/08/17 in the facility's conference room Staff #F18, Chief Nursing Officer stated,"...The masks should be discarded between each patient...."

An observation made on the morning of 08/09/17 during a tour of the facility's operating rooms revealed (2) circulating nurses wearing surgical masks in the pre-operative unit.

An observation made on the morning of 08/09/17 during a tour of the facility's sterile processing unit revealed a Sterile processing staff member with an uncovered beard. When asked if the beard should be covered Staff #F16, the Sterile Processing Director stated, "They should be covered...."

Review of the facility provided policy surgical attire (undated) reflected "All persons entering the semi-restricted and restricted areas of the surgical Suite should be in appropriate OR attire...B. Wear appropriate head cover to sufficiently cover head and facial hair...should wear a clean mask when open sterile items and equipment are present...."

Review of the facility provided document AORN (Association of periOperative Registered Nurses) guidelines (dated 2017) reflected "...A fresh surgical mask should be donned before the health care worker performs or assists with each new procedure. The mask should be replaced and discarded whenever it becomes wet or soiled or has been taken down....surgical masks should not be worn hanging around the neck. The filter portion of a surgical mask harbors bacteria collected from the nasopharyngeal airway. The contaminated mask may cross-contaminate the scrub attire...when the mask is worn hanging around the neck...."


E. The Centers for Disease Control and Prevention (CDC) article, Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, stated in part:" Every health-care setting should conduct initial and ongoing evaluations of the risk for transmission of M. tuberculosis, regardless of whether or not patients with suspected or confirmed TB disease are expected to be encountered in the setting."

Facility document entitled, "Post Offer Health Screening, Employee Health & Safety" states in part, "1) Yearly testing done on existing employees will be done using the 'Tuberculosis Health Questionnaire' and will be followed-up with a skin test when available if needed...."

Review of staff files on the afternoon of 08/09/17 in the facility conference room revealed, facility document "Annual Tuberculosis Health Questionnaire" were not completed annually as per their hospital policy.

Seven (7) of eleven (11) staff files reviewed revealed, "Annual Tuberculosis Health Questionnaire" latest completion date are as follows:
Staff #C9 - 5/18/16
Staff #C10 - 4/19/16
Staff #C11 - 5/18/16
Staff #C12 - 5/18/16
Staff #C17 - 3/19/16
Staff #C18 - 3/19/16
Staff #C21 - 3/19/16

These deficits were confirmed by the Director of Critical Care on the afternoon of 08/9/2017.



30250


During a tour of the laboratory area on 08/10/17, it was observed in the supply closet that clean open supplies were stored on the same self as supplies in external shipping boxes with corrugated cardboard. Mice, insects, vermin, dirt with pathogenic organisms can be carried into a hospital within the cardboard boxes used as external shipping containers. Also, corrugated cardboard boxes can and do shed particles that contribute to dust in hospital environments.

The facility failed to ensure surgery-related infection risk mitigation measures were in place to monitor for Surgical Site Infections (SSI) 30 to 90 days post procedure, per recommendations.

Review of the Centers for Disease Control /National Healthcare Safety Network (CDC/NHSN) Surveillance Definition of Healthcare-Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting, last revised April 2013, stated, in part, "Surveillance of surgical patients will occur in any inpatient and/or outpatient setting where the selected NHSN (National Health Safety Network) operative procedure(s) are performed ...Surgical Site Infection - Superficial incisional SSI must meet the following criterion: Infection occurs within 30 days after any NHSN procedure ...Deep incisional SSI must meet the following criterion: Infection occurs within 30 or 90 days after the NHSN procedure ..."

A publication by the CDC entitled Surgical Site Infection Surveillance (SSI) Event, last modified April, 2015 and available at http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf, included the following: "Surveillance of SSI with feedback of appropriate data to surgeons has been shown to be an important component of strategies to reduce SSI risks ...Infection occurs within 30 or 90 days after the ...operative procedure (where day 1 = the procedure date) ..."

Facility based policy entitled, "Surveillance of Infections" stated in part,
"SURGICAL SURVEILLANCE:

1. Policy

A. Post-op surveillance is performed for 30 or 90 days post-procedure, according to the NHSN guidelines for Acute Care Hospitals, to evaluate for surgical site infections."

Review of facility based Infection Control monitoring of SSI revealed that most tracking was accomplished through lab and culture results, contact with outside hospitals, follow up with physicians, and code data surveillance in the electronic medical system.

In a telephone interview with staff member #1 on 08/10/17, she confirmed these were some of the main methods for monitoring for SSI at the facility. Staff member #1 was asked if the facility had any documentation that all operations were followed up regarding potential SSI within 30-90 days with physican input. Staff member #1 stated that previously the facility tried to implement such monitoring but physicians were not compliant with follow up. She added that same day surgery calls are completed for all procedures, this however does not meet the 30-90 day time frame recommended. Staff member #1 confirmed there was no facility based available of documentation of SSI surveillance 30-90 days post procedure.


32870


Facility policy #8061-006 entitled Preventive Maintenance Program, included the following:
"The objective of the Preventive Maintenance Program is to assure all equipment in the Equipment Management Program receives scheduled routine maintenance that will achieve high levels of reliability and safety ...Documentation for the Preventive Maintenance Program will be kept in the Biomedical Engineering Department and will be made available to the Director of Engineering at any time ...The assigned engineer or technician shall document the maintenance including any pertinent observations on the work order ..."

A tour of the 4th floor south, medical/surgical nursing unit with Staff #B1, Quality Resources Asst. Vice President, and Staff #B14, 4 South Unit Manager, on the morning of 8/9/17, revealed the following:


Patient Nourishment Area:
· Refrigerator Ref-60-06 had a maintenance inspection sticker noting last inspected 4/16.
· Above the patient ice machine, there was an approximate 4" diameter water stain on a ceiling tile. Ceiling tiles with water stains can harbor mold and may crumble, contaminating items below.


Nursing Station:
· Numerous spots of broken and chipped laminate exposed underlying permeable board, making the area impossible to clean thoroughly. The largest such area noted was approximately 12" x 3" along the edge of the desk area.


Patient Supply Area:
· Peeling wall paper in a corner of the room made thorough cleaning impossible.
· An approximate 6" x 6" water stain on a ceiling tile above patient supplies appeared to be crumbling as small pieces of the tile were hanging off of it. This had the potential to contaminate any patient supply items below.
· Approximate quantity 6 plastic bins were stored on the floor of the patient supply area.


Dirty Utility Room:
· Approximately 30" of baseboard was missing. This revealed pieces of what appeared to be broken concrete or plaster with gaps between them along the bottom of the wall. The gaps served as potential portals for pests and debris. Dirt and debris with the appearance of crumbled concrete or plaster, were visible along this area.
· A ceiling tile contained an approximate 8"x8" water stain of unknown origin and duration.


In an interview with Staff #B4, Director of Engineering, in a hallway of the 4 South nursing unit, on the morning of 8/9/17 during the tour, he said maintenance on the refrigerators was performed annually. He stated, "I think the sticker on the refrigerator is incorrect. I believe the maintenance was last done in July 2016 ...I don't have anything to show the technician assigned to it actually did it." The work order included the following instructions: "Refrigerator/Freezer (Annual) ...Check temperature controls with thermometer ...Do electrical safety check and apply sticker..." In addition, he stated, "The nursing station is next in line for repairs ...We've got to set our priorities."


A tour of the 5th floor south, medical/surgical nursing unit with Staff #1, Quality Resources Asst. Vice President, and Staff #B8, 5 South Unit Manager, on the morning of 8/9/17, revealed the following:


Patient Nourishment Area:
· A refrigerator which housed patient food and beverages had no maintenance sticker at all which noted when it had last been inspected and/or maintenance had been performed on it.
· Approximately 20 patient juice containers stored in the refrigerator included no expiration date and no sticker date making it impossible to ascertain when they had been placed in the refrigerator or when they should be removed.
· A plastic tub under the sink was placed under the plumbing pipes below the sink. The pipes were corroded and rusty. There was also a laminated shelf stored under the sink which included dirt and debris on it.
· In the corner of the room behind the ice machine, there was copious dirt and debris visible.


Patient Supply Area:
· An approximate 12" x 16" large water stain on a ceiling tile above patient supplies revealed either a past or current leak had occurred. This had the potential to contaminate any patient items below. In addition, there was another approximately 3"x4" water stain in a ceiling tile around what appeared to be a former light fixture that had been plugged with plastic.


Medication Room:
· There was an approximately 1" thick layer of ice on all sides of the medication refrigerator making thorough cleaning of the refrigerator impossible.


Cardiopulmonary Supply Room:
· Throughout the room, numerous gaps and holes in the walls were revealed which served as potential portals for pest and debris. The room had one unfinished and permeable cinder-block wall; the other walls were unfinished, permeable sheet-rock. The storage area housed patient respiratory supplies, including a large quantity of patient incentive spirometers available for patient use. The flooring was bare, permeable wood and had areas with copious dirt and debris on it. Permeable surfaces allow for penetration of contaminants and thus, cannot be cleaned adequately.


In an interview with Staff #B5, Director of Cardiopulmonary Services, on the morning of 8/9/17 during the tour, she stated she did not know how long the room had been in that condition. Staff #B8, 5 South Unit Manager, stated, "It's been that way as long as I've been here." When asked how long she had been in her current position, she stated, "about two years."


In an interview with Staff #B8, 5 South Unit Manager, on the morning of 8/9/17 during the tour, she stated that the pharmacy department was responsible for defrosting the medication refrigerators.


These findings were confirmed during the tour with Staff #B1, Quality Resources Asst. Vice President, and Staff #B8 and #B14, the nursing unit managers, on the morning of 8/9/17.

Based on a review of documentation and interview the facility failed to ensure that an operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon.

Findings included:

Facility based Medical Staff Bylaws, Policies, and Rules and Regulations stated in part,
"SURGERY SUITE - SURGICAL CASES/INVASIVE PROCEDURES...
5. Immediately following any complex invasive procedure, as defined by MEC, a written statement must be entered in the medical record which includes:
· The name(s) of the licensed independent practitioner(s) who performed the procedure and his or her assistant(s)
· The name of the procedure performed
· A description of the procedure
· Findings of the procedure
· Any estimated blood loss
· Any specimen(s) removed
· The postoperative diagnosis"

During a tour of the facility affiliated Ambulatory Surgical Center the following findings were noted:
* On 08/09/17 during a tour of the pre-operative area, the surveyor noted 2 of 2 pateint records (#1 and 2) had pre-printed/dictated operative forms in their records.
* Staff member #2 confirmed patients #1 and 2 were still in the pre-operative phase and their surgical procedures had not been performed.
* Staff member #2 confirmed that staff member #4 routinely used these pre-printed/dictated operative report for procedures, signing and dating the note after completing the procedure. Staff member #1 stated that staff member #4 will add a narrative note if a surgical event deviates from the pre-completed operative template. Staff member #1 verified that staff member #4 routinely does not write or dictate an operative procedure after a surgery per medical rules and regulatory requirement.

The above findings were confirmed with staff member #2 on 08/09/17.