HospitalInspections.org

Based on observation, interview, record review, and policy review, the provider failed to ensure:
*The results of the biological indicator tests used to monitor the effectiveness of the steam sterilization unit were received or obtained in a timely manner from the provider who was contracted to incubate and read the results.
*The high level disinfecting solution for cleaning endoscopes was tested after each reprocessing cycle for the appropriate concentration according to the manufacturer's guidelines for one of one automatic endoscopic reprocessor.
*Surgical supplies were not stored in cardboard boxes in one of one operating room (OR).
Findings include:

1. Review of the provider's sterilization load content register from 6/1/15 through 8/12/15 revealed on 7/1/15 and 8/5/15:
*A load of articles had been sterilized for the clinic.
*A biological indicator had been placed inside of the sterilizer on both of those days.
*The biological indicator had been sent to a contract provider for incubation and reading to ensure proper sterilization occurred.
*No biological indicator results had been documented.

Review of the provider's biological indicator worksheets revealed on:
*5/20/15:
-A biological indicator test had been done and sent to the contract provider.
-The results of that biological indicator were received eight days later.
*6/10/15:
- A biological indicator test had been done and sent to the contract provider.
-The results of that biological indicator were received twelve days later.

Interview on 8/18/15 at 10:15 a.m. with radiological technician (RT) A revealed:
*The provider had sterilized all the equipment for the hospital and the clinic.
*A biological indicator had been placed inside of the sterilizer to ensure the unit was working correctly.
*She was not able to test the results of the biological indicator. They were sent to a contract provider for incubation and reading.
*A courier came to the hospital every day for any deliveries to that provider.
*When a load had been completed the biological indicator was removed and sent to that contract provider by courier on the same day.
*The contract provider mailed them the test results upon completion.
*She confirmed she had not always received those results or reviewed them within a timely manner.
*She would not have waited for the results of that test before delivering those articles to the clinic or within the hospital. She had delivered those articles within a day or two after sterilizing.
*She had not contacted the contract provider when no results were received.
*She agreed the above process would have created the potential for cross-contamination (transfer from one person to another) of bacteria from one patient to another.

Review of the provider's revised January 2014 3M Attest Biological Indicator policy revealed:
*It addressed sending the biological indicator to the contracted provider for incubation and reading.
*It did not address how soon those results should have been returned, or what to do if the results were not returned from the contract provider.

2. Interview on 8/18/15 at 9:30 a.m. with licensed practical nurse (LPN) B regarding the high level disinfecting process for endoscopes revealed:
*They used Rapicide (Glutaraldehyde) for the high level disinfection of the endoscopes.
*Endoscope procedures were scheduled once a month.
*The automatic scope processor would be emptied and filled with a fresh batch of Rapicide when endoscope procedures were scheduled.
*They would test the concentration of the Rapicide prior to processing the first endoscope of the day.
*They did not test the Rapicide upon each reprocessing cycle of the endoscopes when there were multiple procedures in a day.
*She was not aware the Rapicide was to be tested each time a scope was processed.

Review of the provider's Gluteraldehyde (Rapicide)/Quality Monitoring Log on 1/26/15, 2/23/15, and 3/30/15 revealed the concentration of the Rapicide had been checked only once on each of those days.

Review of the manufacturer's Rapicide instructions revealed "Use chemical indicator strips to monitor glutaraldehyde concentration prior to each reprocessing cycle in order to detect unexpected dilution."

3. Observation and interview on 8/18/15 at 9:45 a.m. with LPN B of the OR revealed:
*There had been a large cupboard that contained multiple surgical supplies.
*Inside of those cupboards there had been five cardboard boxes.
*There had been various surgical supplies in each of those boxes.
*LPN B had not been able to identify where the boxes had been located prior to being placed in the OR.
*They had used the boxes to help organize all of the surgical supplies.
*She agreed those cardboard boxes:
-Had not been considered clean items.
-Should not have been brought into the OR. The OR was considered a clean room.

Based on interview, record review, and policy review, the provider failed to appropriately assess three of three sampled patients (5, 15, and 24) who were identified as at nutritional risk. Findings include:

1. Review of patient 5's medical record revealed:
*He had been admitted on 6/1/15 and discharged on 6/7/15.
*He had complained of abdominal pain, nausea, and vomiting.

Review of patient 5's 6/1/15 Admission Assessment noted a malnutrition risk score of zero - no risk.

Review of patient 5's Nutrition Assessments completed by the food services supervisor/dietary manager (DM) revealed:
*On 6/2/15:
-"Patient refused breakfast this morning of a clear liquid diet nursing will continue to offer him something this morning. His albuim (albumin) is good will continue to check on patient."
-Nutrition follow-up date 6/5/15.
-Nutrition follow-up reason five day high risk.
*On 6/5/15:
-"Patient had been eating fairly well the first few days but yesterday he didn't eat well at all. Nursing is offering him whatever he will accept. His albuim (albumin) is good as of now. Will continue to check on patient."
-Nutrition follow-up date 6/9/15.
-Nutrition follow-up reason five day high risk.

Interview on 8/19/15 at 8:30 a.m. with the DM revealed:
*Nurses completed the initial admission assessment.
*If a patient had been at nutrition risk a nutrition service consult would have been triggered.
*She visited with new patients within forty-eight hours of admission.
*She continued to monitor and watch patients during their hospital stay.
*She noted patients as a five day high risk as a reminder to herself to follow-up with the patients.
*She had not used a standardized nutrition system to score a patient's nutrition risk.
*She had not always referred patients she determined to be at nutritional risk on to the registered dietitian.



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2. Review of patient 15's care record revealed she had been admitted to skilled swing bed services on 6/5/15.

Review of patient 15's 6/8/15 Nutrition assessment revealed:
*It had been completed by the DM.
*She was on a 2 gram sodium (low salt) diet.
*Her 6/4/15 Nutritional Laboratory (lab) work indicated her albumin (a measure of protein found in the clear liquid portion of the blood) level was low at 2.2.
*"Her albumin is low will check with dietican [dietitian] and get her recommendations on it."
*Nutrition follow-up reason: 5 day high risk.

Interview on 8/19/15 at 9:00 a.m. with the DM revealed:
*She had documented she would contact the dietitian, but the patient had been discharged to the nursing home the next day so she had not contacted her in the hospital.
*The computer was to have generated notifications to the dietitian if the patient had flagged as high risk.
*The computer had not flagged as high risk, but she had documented high-risk, due to the low albumin.



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3. Review of patient 24's care record revealed she:
*Had been admitted on 4/20/15.
*Had been admitted for diarrhea.

Review of patient 24's 4/21/15 Nutrition assessment revealed:
*It had been completed by the DM.
*She was on a clear diet.
*She had diarrhea
*"Patient eating 75% of her meals and is on a clear liquid diet she came in with diarrhea and that has stopped as of last night. Her albumin (a measure of protein found in the clear liquid portion of the blood) is low. Will check with dietitian and see what she would like to do. Will continue to check on patient.
*Nutritional follow-up reason: 5 day High risk."

Interview on 8/19/15 at 10:15 a.m. with the DM regarding patient 24 revealed:
*Their electronic records would have notified both her and the RD of an abnormal laboratory result.
*The RD should have been notified when the patient's albumin was low.
*There was nothing documented that the DM had checked with the RD and there was no documentation the RD had followed up on that.
*The DM did not have a systematic way of determining when a patient was considered a "5 day High Risk."

A further interview on 8/19/15 at 10:20 a.m. with the DM and the RD revealed:
*There had been a period of time when after-the-fact they had been made aware the RD had not received all the electronic notices she should have had regarding nutritional concerns of patients.
-That might have explained why there was no nutritional follow-up to patient 24.
*The computer problem had since been resolved.

3. Review of the provider's April 2008 Patient Nutrition Screening and Assessment policy revealed:
*All patients admitted would be assessed on admission for nutritional risks by nursing services.
*A nutritional assessment-dietetic assistant intervention would be performed within seventy-two hours after admission.
*The registered dietitian was responsible for the overall nutritional care of patients.
*The registered dietitian coordinated patient's nutritional needs with the food service supervisor, nursing personnel, other involved disciplines, and physicians.
*The food service supervisor screened patients and reported the needs of patients using her training and knowledge in consultation with the dietitian.
*The food service supervisor completed the nutritional assessment-dietetic assistant intervention and followed up nutritional care as directed by the dietitian.

Based on record review, interview, and policy review, the provider failed to ensure initial activity and social services assessments had been completed for one of five (15) sampled skilled swing bed patients. Findings include:

1. Review of patient 15's care record revealed:*She had been admitted to skill swing bed services on 6/5/15.
*No social services admission assessment could be located.
*No activity admission assessment could be located.
*She had been discharged on 6/9/15.

Interview on 8/18/15 at 2:15 p.m. with the social services designee revealed she had not been working as the designee at the time of patient 15's admission.

Interview on 8/18/15 at 2:30 p.m. with the director of nursing revealed:
*No social services or activity admission assessments had been completed for patient 15.
*If the social services designee or the activity director were not present at the time of the admission, the nurse completing the nursing admission assessment was supposed to complete the social services and activity assessments. The nurse had not completed those assessments.

Review of the provider's July 2015 Activity Programming for Swing Bed Patients policy revealed "The Activity Coordinator will complete the Swing Bed Skilled Activity Assessment in the EMR [electronic medical record]."

Review of the provider's July 2012 Social Services Program policy revealed:
*"The Social Service Designee will complete a social and psychosocial assessment on all Swing Bed patients within 72 hours of admission."
*The activities coordinator was to have completed the social services assessment in the absence of the social services designee.
*The social services designee was to have completed the swing bed activities assessment in the absence of the activities coordinator.
*There was no indication who was to have completed the social services assessment if both activities and social services had been absent.