HospitalInspections.org

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Based on record review, interview and policy review the facility failed to comply with all federal law and regulations related to advanced directives as referenced at 42 CFR 489.102(a). Specifically, the facility failed to document it's efforts at asking, informing and educating patients about advance directives for 2 (#s 5 and 8) out of 26 sampled patients. This failed practice had the potential to disrupt patient participation in their care, as well as, deny patients the right to formulate an advanced directive. Findings:

Patient #5

Record review from 12/9-13/19 revealed Patient #5 was admitted to the hospital for labor and delivery at 39 weeks. Further review revealed the patient did not have an advance directive.

During an interview on 12/13/19 at 2:50 pm, Licensed Nurse (LN) #1 stated Patient #5's medical record contained no information on the discussion, education, and/or offering of information about advance directives.

Patient #8

Record review from 12/9-13/19 revealed Patient #8 was admitted to the facility with a diagnosis that included nondisplaced pelvic fracture. Further review revealed the patient did not have an advanced directive.

During an interview on 12/13/19 at 9:00 am, LN #1 stated that when a patient does not have an advanced directive, the Medical Doctor (MD) or Social Worker (SW) would talk to the patient and would have written a note in the Medical Record (MR). LN #1 reviewed Patient #8's MR and he/she was unable to locate a note stating that the patient received information regarding advanced directives.

Review of the facility's policy "Patient Self-Determination and Advance Directive," dated 09/2019, revealed "SSMH [Samuel Simmonds Memorial Hospital] staff are responsible to ensure each patient receives required information regarding advance directives ...If the patient does not have advance directives, a SSMH staff member will discuss advance directives with the patient using the current script and ask the patient if they would like additional information about advance directives. If the patient would like information about advance directives, a SSMH staff member will provide the patient with current SSMH advance directive brochures and forms. If the patient would like assistance in formulating advance directives, a SSMH staff member will consult social work ...Any conversation with the patient regarding advance directives and health care decisions (wishes, consents, or refusal) must be documented in the patient's health record."
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Based on interview, observation, document and policy review, the facility failed to ensure housekeeping and kitchen personnel had a system for infection control procedures in the laundry room and kitchen. Specifically, 1) 2 out of 2 housekeepers reviewed for training did not have job specific training documented upon hire, 2) housekeepers were not aware of policies regarding laundry room procedures, and 3) food was not handled and prepared according to standards to prevent foodborne illness. This failed practice placed all patients (based on a census of 4) at risk of transmission of infectious disease and/or foodborne illness. Findings:

Laundry

During an interview on 12/11/19 at 11:45 am, Housekeeper #2 stated when handling laundry from a patient infected with C-diff (Clostridium difficile- a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon and is spread mainly via hands or contaminated surfaces), he/she would wear a mask and gloves while loading laundry into the washer. Housekeeper #2 further stated he/she would not need a gown (protective garment wore over clothing) because the laundry was usually in "sugar bags" (water soluble bag used to hold contaminated laundry), so just masks and gloves were worn.

During an interview on 12/12/19 at 10:36 am, Housekeeper #1 stated when handling laundry from a patient infected with C-diff, he/she would wear a gown, mask and gloves. Housekeeper #1 stated the manager trained the housekeeping staff regarding PPE (personal protective equipment- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) upon hire. Housekeeper #1 stated if he/she had a question, he/she would ask the manager. The Housekeeper further stated the manager was currently out on leave and he/she was acting manager. Housekeeper #1 further stated he/she did not know where to look for policies or procedure questions regarding laundry and PPE.

An observation on 12/13/19 at 9:30 am revealed no PPE guidance or forms located in the laundry room.

A personnel document review on 12/12/19 at 1:30 pm revealed Housekeeper #2 started working in the facility on 10/27/16, but did not have job specific training completed until 9/17/19. Further review revealed Housekeeper #4 had a hire date of 6/5/18, but did not have job specific training completed until 9/17/19.

During an interview on 12/13/19 at 10:30 am, the Human Resources Director stated he/she was not able to locate job specific training documentation of Housekeeper #2 from his/her original hire date.

During an interview on 12/12/19 at 3:18 pm, when asked what procedure housekeeping staff would follow for C-diff contaminated laundry, the Infection Prevention (IP) Manager stated when handling laundry contaminated with C-diff, staff were expected to wear gloves, a mask and a gown, even if the laundry was in a sugar bag.

During an interview on 12/13/19 at 9:30 am, when asked what the appropriate PPE was when handling potentially infectious laundry, Housekeeper #3 stated the nurse would tell him/her what to wear.

During an interview on 12/13/19 at 9:35 am, IP Manager stated there was a communication book in the manager's office where the policies were kept.

A review of the facility policy "ISOLATION ROOM PROTOCOL" dated 8/2019 revealed Standard Precautions- All blood, body fluids, secretions, excretions, and contaminated items, staff to wear gloves "Yes," gown "If soiling likely" and mask "Facial protection if splash likely." Contact Precautions- C. difficile, staff were to wear gloves, gown and mask. "RED BAG LINEN" revealed "No" for both Standard and Contact Precautions. Further review of the policy revealed no mention of sugar bags, washer temperature settings or length of time of wash.

Kitchen

During an observation on 12/11/19 at 10:35 am, Dietary Staff (DS) #3 was preparing teriyaki steak on the grill. A pair of scissors had been used to trim the fat off the raw meat. DS #3 was observed to cut some additional pieces of cooked steak with the same pair of scissors. During the same observation, DS #3 was observed using the same pair of tongs on the steak while it was raw and throughout the cooking process. Additionally, DS #3 was not observed to take the temperature of the steak during the cooking process.

During an observation on 12/11/19 at 10:50 am, DS #3 was observed placing the cooking tongs on the tray where the raw steak was being prepped and trimmed. There were no observations of obtaining temperatures during the cooking process between 10:10 am and 11:10 am.

During an interview on 12/11/19 at 11:10 am when asked about cooking temperature, DS #3 stated that he/she cooked the steak to a temperature of 145 degrees. He/she stated the steak was cooked to medium rare.

During an interview on 12/11/19 at 12:50 pm, the Dietary Manager (DM) stated that staff received training on food preparation and foodborne illness monthly. The DM stated that staff were required to take a food service management certification.

Record review on 12/11/19 at 12:55 pm revealed DS #3 had completed the food service management certification.

During an observation on 12/12/19 at 10:30 am, DS #3 was observed cooking pork steaks on the grill top. DS #3 was observed to pull the thermometer out of the pocket of his/her jeans and took the steak temperature without cleaning the thermometer. DS #3 then placed the thermometer back into the jeans pocket. He/she was observed taking the meat temperature but not writing the findings.

During an observation on 12/12/19 at 10:45 am, DS #3 was observed to handle the raw pork steaks with a gloved hand, then adjust the heat control on the grill top with the same gloved hand, and return to the raw pork steak for cooking preparation.

During an observation on 12/12/19 at 11:05, DS #3 was observed to use the cooking tongs to turn the raw pork steak and then turn cooked pork steaks that were on the grill.

During an interview on 12/12/19 at 1:30 pm, the DM stated that there were temperature logs for cooking and that he/she would provide them. He/she stated the facility conducts kitchen walk troughs of food preparation for infection control purposes. He/she further stated there was a possibility of cross-contamination to patients as a result of improper food and utensil handling.

No temperature log of food cooking temperatures was provided by the time of exit on 12/13/19 at 4:30 pm.

A review of the facility policy "Food Temperatures" dated 06/2019 revealed, "All foods will be cooked to the required minimum internal cooking temperature...fish and other meat 155 degrees ...the cook is responsible for checking and recording temperatures."

A review of facility policy "Infection Control" dated 06/2019 revealed, "...Procedures for preparation and serving of food must be such to minimize contamination by microorganisms ..."
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Based on record review, interview and policy review, the facility failed to ensure a follow up assessment was completed after pain medications were administered to 1 patient out of 26 sampled patients. This failed practice placed the patient at risk for inadequate pain relief. Findings:

Record review from 12/9-13/19 revealed Patient #8 was admitted to the facility with a diagnosis that included nondisplaced pelvic fracture.

Review of Patient #8's MAR (Medication Administration Record) for 9/29/19-10/3/19 revealed an as needed medication (PRN), acetaminophen (a pain medication), was administered 7 times. On 10/1/19 at 9:00 am acetaminophen was administered, "REASON" was "Pain." On 10/1/19 at 1:15 pm, acetaminophen was administered, "REASON" was "premedicate per PT [physical therapist]."

Further review of the MAR revealed no follow up or "RESULTS" of the effectiveness of the pain medication.

During an interview on 12/13/19 at 2:30 pm, Licensed Nurse (LN) #1 reviewed Patient #8's EHR (electronic health record) which revealed no follow up documentation for the PRN acetaminophen given on 10/1/19 at 9:00 am.

Further review by LN #1 of Patient #8's EHR revealed a Nurse's note written on 10/1/19 at 4:15 pm, which documented the patient was resting in bed (3 hours after the acetaminophen was given). LN #1 stated the expectation for reassessment of this medication was within 1 hour.

Review of the facility's policy "Medication Management", dated 9/19/19, revealed "PRN medication, including pain medications must be reassessed after each intervention within two hours. General guidelines are ...60 minutes for PO [by mouth] ...interventions."
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Based on observation, interview, and policy and procedure review, the facility failed to ensure confidentiality and privacy of patients' clinical information was maintained per the Health Insurance Portability and Accountability Act (HIPAA) was protected. Specifically, the patients' name, room number and diet orders were written on the patients' tray placemat and disposed of in the regular trash. This failed practice had to potential to effect all patients (based on a census of 4) to have their privacy breached. Findings:

During an observation on 12/11/19 at 11:10 am, Dietary Staff (DS) #2 was observed preparing patient trays for lunch. DS #2 handwrote the names of the patients, the room number, and the diet requirements on the paper placemat on the tray.

During an interview on 12/12/19 at 10:55 am, DS #1 revealed that when the trays return from the floor, he/she discards the trash from the tray, including the paper placement, into the regular trash can.

During on observation on 12/12/19 at 11:10 am, trays were seen with the name of the patient, room number, and dietary requirements written on the paper placemat on the tray.

During an interview on 12/12/19 at 1:15 pm, the Privacy Officer (PO) stated the facility follows HIPAA guidelines. The PO was unaware that patient names, room numbers, and dietary requirements were written on the patient's trays and thrown in the regular trash. He/she stated this was incorrect procedure. The PO stated that the staff training included instruction that all private health information was not to be thrown in the regular trash and staff should have been aware the tray placemat disposal process was not acceptable practice.

During an interview on 12/12/19 at 1:30 pm, when asked about the process for disposing of the paper placemats when trays returned to the kitchen, the Dietary Manager (DM) stated that the paper placemats were thrown in the regular trash. He/she was aware of HIPAA requirements and stated he/she would instruct the staff to stop throwing the placemats in the regular trash.

Review of the facility policy "Privacy and Security of Health Information", last reviewed 06/2019 revealed, "[the facility] will protect the privacy of patient health information ...[the facility] will follow the most recent approved version of the HIPAA Manual."
Review of the facility policy and procedure manual "HIPAA and 42 CFR Part 2" dated 03/2018 revealed, "Protected Health Information (PHI) means individually identifiable health information that is a subset of health information including demographic information collected from an individual, in any medium including oral, paper, or electronic ...that identifies the individual or could reasonably be used to identify the individual ..."and "never under any circumstances, place paper record PHI in any trash bin, recycle bin or dumpster ..."

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