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Based on record review and interview, staff at this facility failed to notify in-patient Medicare aged recipients of their right to appeal discharge from the facility if they so choose in 5 of 7 Medicare aged recipients out of a total 20 medical records reviewed (Patient's #6, 7, 12, 13 and 14). This deficiency potentially affects all Medicare aged recipients treated at the facility.

Findings include:

In an interview with Vice President of Quality B on 5/4/2016 at 10:45 AM regarding a policy for the Medicare Discharge Appeal form, Quality B stated the facility does not have a policy for this.

Per interview with Case Manager Q on 5/4/16 at 8:45 AM, all patients eligible for the notice should receive the Medical Discharge Appeal notice.

A medical record review was conducted on Patient #6's closed medical record on 5/3/2016 at 12:40 PM, assisted by Registered Nurse D who confirmed the following finding: Patient #6, 71 years old, was admitted to the facility on 2/26/2016 and discharged on 3/1/2016. There is no Medicare Discharge Appeal form in the record. Nurse D stated that the first notification is to be done by nursing upon admission to the facility and the second notification is done by case management.

A medical record review was conducted on Patient #7's closed medical record on 5/3/2016 at 12:40 PM, assisted by Registered Nurse D who confirmed the following finding: Patient #7, 65 years old, was admitted to the facility on 2/28/2016 and discharged on 3/2/2016. There is no Medicare Discharge Appeal form in the record.

An interview with Case Management Registered Nurse Q was conducted on 5/4/2016 at 8:51 AM regarding the discharge appeal forms for Patient #6 and #7, Nurse Q stated Q was unable to locate the forms stating, "I don't see these in the medical record."


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Patient #12's medical record review revealed Patient #12 is 75 years old, was admitted to the facility on 5/2/16 and discharged on 5/3/16. There is no Medicare Discharge Appeal form in the record. This is confirmed in interview during record review on 5/4/16 at 7:55 AM.

Patient #13's medical record review revealed Patient #13 is 79 years old, was admitted to the facility on 5/2/16 and discharged on 5/3/16. There is no Medicare Discharge Appeal form in the record. This is confirmed in interview during record review on 5/4/16 at 8:15 AM.

Patient #14's medical record review revealed Patient #14 was 67 years old, was admitted to the facility on 5/13/15 and died on 5/16/15. There is no Medicare Discharge Appeal form in the record. This is confirmed in interview during record review on 5/4/16 at 8:45 AM.

Based on observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.
Findings include:
The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:
(K-17)- Corridors wall construction & separation
(K-25)-Smoke wall penetrations not sealed
(K-27)-Smoke barrier doors not closing and latching
(K-50)-Fire drills at similar times
(K-62)-Sprinkler maintenance
(K-147)- Electrical Systems
(K-154)-Wrong information in fire watch plan
(K-155)-Wrong information in fire watch plan

Based on observation staff at this facility failed to ensure the environment is well maintained with surfaces that are smooth and cleanable for patient safety in 1 of 9 patient rooms observed (room 308). Failure to maintain wall integrity has the potential to affect all in-patients at this facility, including the 7 patients present throughout the course of the survey.

Findings include:

A tour of the Medical/Surgical unit was conducted accompanied by the Vice President of Quality B on 5/2/2016 who confirmed these findings at the time of discovery. The following observation was made:
--At 12:45 PM in unoccupied room 308 there is a gouge in the wallpaper on the corner wall by the sink which exposes the porous drywall underneath rendering this area non-cleanable.

Based on observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure live safety from fire was safe for patients and staff. The cumulative effects of the these deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.
Findings include:
The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:
(K-17)- Corridors wall construction & separation
(K-25)-Smoke wall penetrations not sealed
(K-27)-Smoke barrier doors not closing and latching
(K-50)-Fire drills at similar times
(K-62)-Sprinkler maintenance
(K-147)- Electrical Systems
(K-154)-Wrong information in fire watch plan
(K-155)-Wrong information in fire watch plan

Based on observation and interview, staff at this facility failed to remove expired biologicals from the inventory for patient use in 1 of 1 clean utility room; and failed to secure biologicals to prevent unauthorized access in 17 viewed unoccupied examination rooms out of a total 32 rooms in the clinic. This deficiency potentially affects all 7 inpatients at the time of survey, and all patients treated at the clinic.

Findings include:

Per review of facility policy #1482393 titled Medication Storage Policy, PHARM-018, revised 2/1/11, states under Procedure 1. "...All drugs and biologicals must be kept in a locked room or container.

A tour of the Medical/Surgical unit was conducted accompanied by the Vice President of Quality B on 5/2/2016 who confirmed these findings at the time of discovery. The following observations were made:

--At 12:30 PM in the clean utility room on a shelf with several other bottles of saline, a bottle of saline was found to have expired on March 1, 2016; outdated wound care dressing supplies. 3 packages of Aquacel that expired 1/2016, 1 package of Aquacel expired 3/2016, and one package of Duoderm that expired 2/2016.

In an interview with Registered Nurse D on 5/3/2016 at 7:27 AM regarding checking supply outdates and rotation of stock, Registered Nurse D stated it was a joint effort between the staff member who does the ordering and nursing staff on the unit.

On 5/4/2016 at 9:30 AM the minutes from the staff meetings for the Medical/Surgical unit were reviewed, The minutes identified that on 4/20/2016 staff was reminded to check supplies for outdates.



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The following rooms have unsecured biologicals and/or expired medications and in cupboards or on counter, observed during tour of the on site clinic on 5/2/16 between 2:00 PM and 2:13 PM, and between 2:50 PM and 3:20 PM:

Room #101- 1 hemocult (reagent for blood in stool)
Room #107- 1 hemocult, 4 Thin Prep (fixatives for pap smears), 9 iodine swabs (disinfectant) and 4 hibiclens swabs (disinfectant)
Room #115- 6 Thin Prep
Room #119- 1 hemocult, 5 hibiclens swabs
Room #121- 1 betadine (disinfectant)
Cast/Procedure Room - Formalin (fixative for tissue)
Room #133- 4 Sterile 3 milliliter vials of normal saline for inhalation, expired 11/15; 2 Sterile 3 milliliter vials of normal saline for inhalation, expired 11/12.
Room #134 - 2 hemocult, 4 Thin Prep, 8 Chloraprep swabs (disinfectant)
Room #137- 4 iodine swabs
Room #139- 6 iodine swabs
Room #141- 4 iodine swabs
Room #136- 5 Thin Prep, 7 Chloraprep
Room #155- 1 hemocult, 2 Thin Prep, 6 hibiclens
Room #156- 1 hemocult, 4 Thin Prep, 2 iodine swabs, 2 hibiclens swabs
Room #157- 1 hemocult, 4 Thin Prep, 2 iodine swabs, 4 hibiclens swabs
Room #165- 2 hemocult, 5 Thin Prep, 4 iodine swabs, 4 hibiclens swabs
Room #168- 2 hemocult, 5 Thin Prep, 4 hibiclens

The above findings are confirmed in interview with Staff C during the observation on 5/2/16 between 2:00 PM and 3:20 PM, who was unaware biologicals needed to be secured.

Based on observation, record review and interview, the facility failed to ensure chairs, window sills and walls are in washable condition and/or washed in 2 of 2 areas observed (Medical/Surgical Unit and Outpatient Lab Draw Room); aseptic technique is used during blood draws and medication administration in 6 of 6 staff observed ( D, E, F, O and P); personal protective equipment is worn and hand washing is performed properly in 1 of 1 kitchen staff observed (I); and failed to properly store food and food supplies in 1 of 1 kitchens. These deficiencies potentially affects all 7 inpatients and 34 Emergency Room patients treated at the facility during survey.

Findings include:

In an interview with Infection Preventionist N on 5/3/2016 at 2:30 PM regarding industry standards of practice this facility adheres to, Infection Preventionist N identified the following organizations: The Association for Professionals in Infection Control and Epidemiology, Centers for Disease Control, The Association of peri-Operative Registered Nurses, and the Association for Advancement in Medical Instrumentation.

Per review of facility policy titled Blood Cultures #2205979, revised 2/1/16, it states under Collection of Blood: #3. "Apply 2% Tincture of Iodine solution for 30 seconds; wipe it off with 70% alcohol. Repeat tincture/alcohol prep..."

Per review of facility policy titled Standard Precautions, 1.9041 #2154306, revised 5/1/11 it states under Procedures #1. "...All rooms and patient care items and bedside equipment will be cleaned between each patient use with a disinfectant..."

The facility policy titled, "Hand Hygiene/Handwashing, #2154278, dated 10/1/2015, was reviewed on 5/4/2016 at 9:15 AM. The policy states in part, "At a minimum, staff will wash their hands during the following times: ...After removing gloves." The policy also includes the procedure for soap and water handwashing and states in part, "Dry hands well with paper towels, then use the paper towel to turn off the faucet."

The facility's policy titled, "[Organization] Peripheral Intravenous Therapy Insertion and Maintenance for Adults," #1354370, dated 4/9/2015, was reviewed on 5/3/2016 at 3:26 PM. Infection Preventionist N identified that the policy does not specify to wipe ports with alcohol at each access point and stated, "It probably should." On 5/4/2015 at 10:35 AM Infection Preventionist N stated that the practice of cleaning the intravenous port between access with syringes is not required if no contamination has occurred.

Per review of facility policy titled Workstation Tray Assembly Process, #C031, revised 3/14, it states under Procedures "...No more than 20 minutes prior to serving: Takes temperatures at each workstation, taste food and record on Taste/Temperature Record..."

Per review of facility policy titled Test Tray Evaluation, #C041, revised 3/11, it states "A test tray is sent to a patient area daily and is evaluated by a Food/Nutrition associate...Records temperatures of the food on the steam table and in air curtain refrigerator. Follows the tray from the workstation to the nursing unit. Records tray delivery information. Takes point-of service temperatures...Files or places tray evaluation form in notebook in order to evaluate trends and assess the effectiveness of action plans."

Per review of manufacturer instruction for Oasis 146 Multi-Quat Sanitizer it states on the Safety Data Sheet "Wear protective gloves. Wear eye or face protection. Wear protective clothing."

APIC [Association for Professionals in Infection Control and Epidemiology] POSITION PAPER: SAFE INJECTION, INFUSION, AND MEDICATION VIAL PRACTICES IN HEALTH CARE (2016) Disinfect catheter hubs, needleless connectors, and injection ports before accessing. Use either an antiseptic containing port protector cap or vigorously apply mechanical friction with chlorhexidine/alcohol, sterile 70% isopropyl alcohol, or other approved disinfectant swab. Disinfect the rubber stopper of medication vials and the neck of glass ampuls with sterile 70% alcohol before inserting a needle or breaking the ampul.

APIC Text of Infection Control and Epidemiology, 2014, Volume III, Page 108-6, C.2. Protective laboratory coats, gowns, smocks, or uniforms designated for laboratory use must be worn while working with hazardous materials. Remove protective clothing before leaving for non-laboratory areas.
According to the APIC 3/6/2014, "Corrugated boxes should also not be present in clean storage rooms or clean supply rooms - items should be removed and placed on closed shelving or on pallets."

Medical/Surgical Unit Observations:

A tour of the Medical/Surgical unit was conducted accompanied by the Vice President of Quality B on 5/2/2016 who confirmed these findings at the time of discovery. The following observations were made:
--At 12:30 PM in the clean utility room there was a cardboard shipping container full of random supplies on the counter.
--At 12:40 PM in unoccupied room 305 there was a sticky residue on the window sill. Quality B stated, "They have to come back and clean that."

--At 12:55 PM in the medication room there was an intravenous infusion set with a total parenteral nutrition filter (filter to catch small particles for intravenous nutrition) that was in the bin with the package open rendering it no longer sterile. Quality B stated, "I'm guessing they grabbed the wrong thing."

A patient care observation was conducted on 5/2/2016 with Patient #2 and Registered Nurse D at 1:20 PM. Registered Nurse D washed hands at the sink in the kitchenette and shut off the faucet with clean hands prior to drying hands thereby potentially recontaminating Nurse D's hands. In an interview with Infection Preventionist N on 5/3/2016 at 2:30 PM, Infection Preventionist N shook N's head and stated that paper towel should have been used to shut off the faucet.

A patient care observation was conducted on 5/2/2016 with Patient #1 and Registered Nurse E at 2:45 PM for medication administration. After removing the protective cap from Patient #1's intravenous access, Nurse E attached a syringe of saline to flush the line, detached this syringe and without re-cleansing the port, attached a syringe with Lasix (medication to remove excess fluid). After the medication administration Nurse E detached this syringe and attached another saline flush syringe without re-cleansing the port. In an interview with Infection Preventionist N on 5/3/2016 at 2:30 PM regarding cleansing of the intravenous ports before access, N stated the expectation would be to cleanse the port prior to each access.

During an interview with Registered Nurse D on 5/3/2016 at 1:44 PM regarding intravenous port cleansing, Nurse D stated that the port of the intravenous line should be cleansed with alcohol prior to each entry. Nurse D then reached into pockets of scrub cover jacket and began pulling out numerous items-alcohol wipes, a swab cap (used to cap intravenous ports and keep them clean), a device to put a prefilled syringe into (tubex), several packages of gauze pads, a pen, and a bandage scissors. Nurse D stated that D was unaware that the Centers for Disease Control consider the inside of pockets to be an unclean area and that nothing should be carried in the pockets. In an interview with Infection Preventionist N on 5/3/2016 at 2:30 PM regarding carrying supplies in pockets, Infection Preventionist N stated that staff have been instructed not to do this.

These findings were discussed per interview on 5/3/2016 at 4:30 PM with Manager A, Quality B, and Quality C.

Procedure Room Observations:
On 5/4/201 at 6:25 AM Registered Nurse P was observed preparing Versed (sedative) for Patient #22's intravenous sedation. Nurse P removed the protective cap from the medication vial and did not cleanse the rubber septum with alcohol prior to piercing with the syringe.

At 7:17 AM Nurse P prepared Fentanyl (narcotic pain reliever) for Patient #22's procedure. Nurse P removed the protective cap from the medication vial and did not cleanse the rubber septum with alcohol prior to piercing with the syringe.

In an interview with Infection Preventionist N on 5/4/2016 at 10:35 AM regarding the expectation for cleansing medication vial septums, N stated that after removing the protective cap the expectation is the rubber septum is cleansed with alcohol prior to piercing.

An observation of Registered Nurse O performing colonoscopy scope cleaning was conducted on 5/4/2016 at 7:53 AM. After wiping down the dirty scope in soapy water, Nurse O removed gloves, applied new gloves and did not perform hand hygiene.
--At 7:58 AM, after cleaning the scope with brushes, Nurse O removed gloves, applied new gloves and did not perform hand hygiene.
--At 8:00 AM Nurse O removed gloves, washed hands at the sink with soap and water, and with clean hands shut the faucet off without using a protective towel barrier, thereby re-contaminating hands.
--At 8:05 AM after putting the scope in the automated high level disinfectant scope processor, Nurse O removed gloves, checked the concentration of the disinfectant, and applied new gloves without performing hand hygiene.

The observations in the procedure room were discussed at exit interview on 5/4/2016 at 11:00 AM with Nurse Manager A, Quality B, Quality C, and Infection Preventionist N present.


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Laboratory staff and environment observations:

On 5/2/16 at 2:13 PM Staff F performed a blood culture lab draw on Patient #11 in the Trauma room in the Emergency Department. Staff F left the lab at 2:13 PM and did not remove the lab coat worn in the lab. In the Emergency Department Staff F donned gloves, located the draw site on Patient #11's right hand, prepped the site with iodine, turned to the lab supply cart and gathered lab tubes, a butterfly needle and syringe, without changing gloves and performing hand hygiene. After two minutes, Staff F wiped off the iodine on Patient #11's hand with an alcohol wipe, inserted the needle and drew a syringe of blood. Staff F placed the blood filled syringe and needle on the mayo stand (equipment stand) and prepped the septums of the two culture vials with iodine, waited 1 minute and wiped off the iodine with an alcohol wipe, and injected the blood into the vials. At 2:35 PM Staff F located and prepared a second draw site on Patient #11's right forearm, cleaning with betadine and wiping with alcohol. Staff F changed gloves without performing hand hygiene, drew blood into a syringe, and placed the syringe and needle on the mayo stand. Staff F, prepared the vials as previously noted, injected the blood into the vials and placed them in a holder on the lab cart. Staff F removed gloves, performed hand hygiene and left the Emergency Department without cleaning the mayo stand. During both blood draws, Staff F did not prepare the draw sites twice per facility policy.

The above findings were discussed in interview with Quality C and Lab Manager U on 5/4/16 at 7:45 AM who confirmed Staff F should be prepping the draw site twice per policy, perform hand hygiene after glove removal and clean surfaces where supplies were placed.

On 5/2/26 at 3:20 PM Staff G performed a blood draw on Patient #21 in the Outpatient Lab area, Bay 3. After the patient left, Staff G did not clean the chair or counter in Bay 3. At the same time the chairs in Bay 1 and 2 were observed to have the vinyl coating removed from the right front armrest, preventing proper disinfection. This was confirmed in interview on 5/2/16 at 3:30 PM with Staff C, who agreed the chairs should be cleaned between patients and repaired.

Kitchen staff and environment observations:

The following was observed on 5/3/16 between 7:00 AM and 8:50 AM:

Staff I retrieved an omelet from the freezer wearing a glove. Staff I removed the glove after placing the omelette on a plate, and did not perform hand hygiene. Staff I proceeded to don a glove on his/her left hand, removed it and washed. Staff I was observed wiping his/her face with left arm, removing the glove from his/her left hand and held it in his/her left hand while stirring cream of wheat at the stove. Staff I placed the glove on the food prep counter, retrieved a new pair of gloves, placed them on the counter and washed his/her hands. While checking the temperature of the scrambled eggs, Staff I placed the entire thermometer into the eggs, retrieved the thermometer and wiped off the probe, did not wipe off the dial of the thermometer. Staff I had previously held the dial of the thermometer while testing the oatmeal and cream of wheat temperatures. Staff I did not record any food temperatures or taste the food prior to serving.

Per interview with Staff I on 5/3/16 at 7:23 AM, there was a higher census than usual (6 patients) and said "no test trays have since I've been here (December), but I know what they are."

At 7:28 AM, A test tray was prepared to take to the patient floor, which consisted of scrambled eggs (tested at 150 degrees), milk that had just been removed from the refrigerator and coffee. The eggs were not placed on a heated plate, but were covered. Once the six patient trays were delivered, at 8:45 AM, the milk temperature was 44 degrees, the eggs were 110 degrees and the coffee was 142 degrees. After the temperatures were taken, Staff I agreed the eggs were cold and the milk was warm.

At 8:30 AM, Staff I did not wear protective eye wear, clothing or gloves after spraying the Oasis 146 Multi-Quat inside the meal tray transport cart, and immediately began wiping the inside of the cart.

At 8:50 AM the kitchen storage, refrigerator and freezer were toured with Director J. The following was observed: Frozen peas, carrots, corn and cauliflower were in open undated bags and the dry storage had a gallon jar of Ranch dressing expired 3/4/16.

Review of the freezer temperature logs on 5/3/16 revealed there are 13 days between 11/1/15 and 4/30/16 that had temperatures above 0. Instructions on the bottom of the logs state "Call engineering whenever temperature rises above 0 F. Per interview with Supervisor K on 5/3/16 at 3:15 PM, staff should be documenting on the logs if they contacted engineering.

Review of the refrigerator temperature logs on 5/3/16 revealed there are 8 days between 11/1/15 and 4/30/16 that had temperatures above 41. Instructions on the bottom of the logs state "Call engineering whenever temperature rises above 41 F. Per interview with Supervisor K on 5/3/16 at 3:15 PM, staff should be documenting on the logs if they contacted engineering.

Per interview with Supervisor K on 5/3/16 at 3:30 PM, there are no test tray documentations being done.

Based on record review and interview, staff at this facility failed to ensure that a comprehensive history and physical examination is conducted for all patients requiring a history and physical at this facility in 7 out of 20 medical records reviewed (Patient # 2, 5, 7, 14, 15, 16 and 19). This deficiency potentially affects all 7 inpatients and 34 Emergency Room patients treated at the facility during survey.

Findings include:

The Medical Staff Bylaws, revised 1/6/2015, were reviewed on 5/4/2016 at 9:40 AM. The Bylaws state in part, "A complete admission history and physical examination shall be completed and documented..."

In an interview with Vice President of Quality B on 5/4/2016 at 9:40 AM regarding the content of a comprehensive history and physical, Quality B stated that a comprehensive history and physical would include the musculoskeletal system.

A medical record review conducted on 5/3/2016 at 10:05 AM for Patient #5's closed swing bed medical record revealed that the physician's history and physical examination dated 2/26/2016 does not include the musculoskeletal (muscles and bones of the body) system in the review of systems portion of the examination. This finding was confirmed by Registered Nurse D at the time of the medical record review.

A medical record review conducted on 5/3/2016 at 12:12 PM for Patient #2's open inpatient medical record revealed that the physician's history and physical examination dated 5/2/2016 does not include the musculoskeletal system in the review of systems portion of the examination. This finding was confirmed by Registered Nurse D at the time of the medical record review.

A medical record review conducted on 5/3/2016 at 1:15 PM for Patient #7's closed inpatient medical record revealed that the physician's history and physical examination dated 2/28/2016 does not include the musculoskeletal system in the review of systems portion of the examination. This finding was confirmed by Registered Nurse D at the time of the medical record review.


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Patient #14's medical record review revealed the History and Physical dictated on 5/13/15 at 7:01 PM, does not include a musculoskeletal system in the review of systems portion of the examination. This is confirmed in interview during record review on 5/4/16 at 8:45 AM with Staff M, who added it should be part of the examination.

Patient #15's medical record review revealed the History and Physical dictated on 11/29/15 at 12:29 PM, does not include a musculoskeletal system in the review of systems portion of the examination. This is confirmed in interview during record review on 5/4/16 at 9:15 AM with Staff M, who added it should be part of the examination.

Patient #16's medical record review revealed the History and Physical dictated on 12/16/15 at 3:57 PM, does not include a musculoskeletal system in the review of systems portion of the examination. This is confirmed in interview during record review on 5/4/16 at 9:30 AM with Staff M, who added it should be part of the examination.

Patient #19's medical record review revealed the Emergency Department Note with includes a physical examination, dictated on 4/16/16 at 10:47 AM, and the admission History and Physical dictated on 4/16/16 at 9:28 AM, do not include a musculoskeletal system in the review of systems portion of the examination. This is confirmed in interview during record review on 5/4/16 at 10:10 AM with Staff M, who added it should be part of the examination.

Based on record review and interview, the facility failed to ensure all verbal and telephone orders are authenticated by the physician with a date, time and within 48 hours of being written, in 3 of 20 medical records reviewed (11, 14 and 16). This deficiency potentially affects all 7 inpatients treated at the facility during survey.

Findings include:

Patient #11's medical record review revealed there is a verbal order for observation that is not dated and timed when signed by the physician. This is confirmed in interview during record review on 5/4/16 at 6:45 AM with Staff M, who added the order should be timed and dated.

Patient #14's medical record review revealed there is a telephone order to transfer the patient written on 5/16/15 at 2:30 PM. The physician did not authenticate the order until 5/20/15 at 17:00. This is confirmed in interview during record review on 5/4/16 at 6:45 AM with Staff M. Per interview with Vice President B on 5/3/16 at 12:10 PM, the staff have 48 hours to authenticate verbal and telephone orders.

Patient #16's medical record review revealed Patient #16 was admitted into hospice on 12/17/15 from there is no order for hospice admission. This is confirmed in interview during record review on 5/4/16 at 6:45 AM with Staff M, who added there should be a hospice order.