HospitalInspections.org

Based on facility policy, observation, and interview, it was determined the facility failed to maintain the premises in a clean and sanitary manner.

Findings include:

The facility policy "General Cleaning and Sanitation - Environmental Services" (Section 17.02.49) included: "II. General Policy: All patient and non-patient rooms shall be thoroughly cleaned and/or disinfected, keeping in mind Standard Precautions and infection control. III. Authority and Responsibility: Infection Control Manager and/or supporting Infection Control Committee, and, Environmental Services personnel."

The policy "Infection Control Environmental Services" (Section 17.02.48) included: "IV. Infection Control Practices: Sanitation within the hospital environment depends upon cleaning thoroughness and frequency...Patient Rooms: Bathrooms shall be cleaned daily...Emergency Department and special procedure areas, such as surgery shall be thoroughly cleaned daily, utilizing approved procedures...Vents will be cleaned on a regular schedule in cooperation with plant maintenance staff...Equipment: All equipment including electrical cords and wheels, shall be wet-cleaned with approved germicide, daily before returning to storage."

The policy "Clean Up Procedure - Sleep Diagnostic Lab" (Section 28.02.04) included: "II. General Policy: This procedure applies to the cleanup of the lab after a shift...III: authority and Responsibility: Manager of Sleep Lab and Tech...Empty humidifier water each morning and rinse with tap water."

An environmental tour was conducted on August 10, 2010, at approximately 10:15 a.m. with the Assistant Director of Patient Care Services. The following observations were made:

-The patient rooms on the medical-surgical unit, #115 through #119 had bathroom ceiling vents that had a heavy coating of dust.

-The "Environmental Services Room" was observed to have a large electrical air blower sitting in the drain of the mop area. The floor was covered with pieces of paper, plastic bottle caps, and a can of compressed air lying on it's side under a ladder. There was a gallon bottle of Ultra-Clean solution with no cap on it.

-The "Dirty Utility Room" was observed to have a sink and counter top that was dirty with a dinner tray with dirty plates and utensils. A refrigerator with open bottles of juice and soda were on the counter. Inside the cabinets the surface was dirty and appeared to have rust like marks. One cabinet door was found off its hinges and on the floor. The floor was dirty and had an accumulation of dead insects. The Assistant Director of Patient Care Services stated the tray was from last evening's meal left by a staff member and the dead insects were a result from the pesticide treatment that was completed the previous day.

The two rooms used for sleep study procedures were observed to each have humidifiers partially filled with water, distilled bottles of water with minimal amounts of water left in them, and oxygen tubing still connected to the oxygen concentrators.

The Director of Patient Care Services acknowledged that according to the schedule the sleep study rooms were last used on August 6, 2010.

-The refrigerator in the medication room of the medical-surgical unit was observed to have an outdated container of yogurt, outdated can of Ensure drink, and the bottom of the refrigerator was wet and had brown rust like marks under the Ensure cans.

-The dining room area which is accessible to patients' families as well as swing bed patients had a salad bar set up with open food containers of lettuce, fruits and vegetables. It was observed that dead insects were on the floor next to the salad bar. The housekeeper was mopping this area of the floor without the food being covered.

Based on observation, record review and staff interview, it was determined the facility failed to maintain the daily logs used for recording refrigerator temperatures on the medical surgical unit (med-surg).

Findings include:

Hospital policy 24.02.04: "Drug Storage and Inspection included: I. Purpose: To establish guidelines for how medications are stored and maintained through inspections. C. Storage specifications: 1. Drugs shall be stored at appropriate temperatures. Refrigerator temperature shall be between 2.2 C (36 F) and 7.7 C (46 F). Room temperature shall be between 15 C (59 F) and 30 C (86 F). All refrigerator temperatures shall be checked and recorded regularly. All temperatures outside the recommended range shall be reported to the Pharmacist."

A tour of the facility conducted on 08/10/10, revealed 2 refrigerators in the medication room.

The medication refrigerator log for 2010, included:

January: no temperature (temp) recorded on 1/1/10, 1/2/10, 1/3/10, 1/9/10, 1/16/10, 1/17/10, 1/22/10, 1/29/10, 1/30/10 and 1/31/10.
February: no temp recorded on 2/4/10, 2/5/10, 2/6/10, 2/7/10, 2/13/10, 2/14/10, 2/19/10, 2/25/10, 2/16/10 and 2/27/10.
March: no temp recorded on 03/5/10, 3/6/10, 3/19/10 and 3/26/10.
April: no temp recorded on 4/6/10, 4/8/10, 4/17/10, 4/18/10, 4/20/10 and 4/25/10.
May: no temp recorded on 5/4/10.
June: no temp recorded on 6/30/10.
July: no temp recorded on 7/9/10, 7/10/10, 7/11/10 and 7/16/10.
August: no temp recorded through the 10th (day of tour).

The small food refrigerator in the medication room did not have temperatures logged for:

January: 1/1/10, 1/2/10, 1/3/10, 1/4/10, 1/7/10, 1/8/10, 1/9/10, 1/16/10, 1/17/10, 1/22/10, 1/25/10, 1/29/10, 1/30/10 and 1/31/10.
February: 2/4/10, 2/5/10, 2/6/10, 2/7/10, 2/13/10, 2/14/10, 2/19/10, 2/25/10, 2/26/10 and 2/27/10.
March: 3/5/10, 3/6/10, 3/13/10 (unreadable), 3/19/10 and 3/26/10.
April: 4/6/10, 4/9/10, 4/15/10, 4/17/10, 4/18/10, 4/20/10 and 4/25/10.
June: 6/25/10 and 6/30/10.
July: 7/10/10, 7/11/10, 7/16/10,

The Registered Nurse for the Med-Surg Unit and the DON verified on 08/10/10, the refrigerator temperature readings had not been performed daily as required. There was no recommended temperature range noted on the logs to assure patient safety of the medication and food contained in the refrigerators.

Based on review of medical records, facility policy and interview, it was determined a physician failed to complete the transfer papers on one (Patient #13) of two patients transferred to another facility.

Findings include:

The facility's policy "Transfer of Patient to Another Facility" (Section 8.02.75) included: "IV. Procedure:...4. Transfer papers will be completed:
a. Physician Authorization for Transfer form
b. Patient Transfer Acceptance or Refusal form
c. Physician Certification Medically for Transfer form
d. Transfer Summary form
e. Copy of medical records, lab and x-rays will accompany the patient."

The medical record for patient #13 revealed she was seen in the emergency department (ED) on 6/23/10, for a change in mentation, facial drooping, and slurred speech. The patient was diagnosed with a stroke and transferred from the ED to another facility on 6/24/10 at 1040 hours.

A physician order to transfer the patient to a hospital in Tucson was written 6/24/10 at 0900 hours. There was a summary of care by the physician but no transfer form in the record. There was no evidence the physician made contact with a physician at the hospital where the patient was transferred. There was no documentation of the patient acceptance to be transferred.

The Director of Patient Care Services acknowledged a transfer form should have been completed by the physician discharging the patient as required by their policy.

Based on review of facility documentation, observation and interview, it was determined the nursing staff failed to consistently check the crash cart on the medical-surgical unit every shift as required by their policy.

Findings include:

The facility's policy "Crash Cart Medications" (Section 24.02.09) included: "Crash carts should be checked by the Nursing Staff each shift. The serial number of medication and supply drawer seals will be recorded and verified during each check."

A tour of the medical-surgical unit was conducted on 8/10/10, with the Assistant Director of Patient Care Services. It was observed that the "Crash Cart /Check-Off" list was not checked and signed:

1 day shift in March 2010,
28 night shits in March 2010,
5 day shifts in April 2010,
25 night shifts in April 2010,
2 day shifts in May 2010,
15 night shifts in May 2010,
6 day shifts in June 2010,
16 night shifts in June 2010,
6 day shifts in July 2010,
13 night shifts in July 2010,
3 day shifts through August 10th,
5 night shifts through August 9th.

The Assistant Director of Patient Care Services acknowledged each shift should be verifying the serial number on the lock and that the equipment on top of the cart was intact.

Based on review of facility policy, Performance Improvement and Quality Assurance (PI & QA) meeting minutes, Medical Staff meeting minutes, and interviews, it was determined the facility failed to have an effective QA program by not identifying problems, analyzing the data collected, documenting specific corrective actions to be implemented, and then reporting this to the Medical Executive Committee.

Findings include:

The policy "Performance Improvement Policy/Plan" (Section 1.01.08) included:

"III. Authority and Responsibility: Individual departments perform the Performance Improvement and quality control function(s). Selected activities and outcomes are reported quarterly to the hospital Board of Directors, Medical Staff and to the Quality Council. Department Directors will be responsible for identifying 'Important Processes' which will be monitored throughout the organization on an ongoing basis...
A. Governing Board of Directors...The Governing Board is responsible for the quality of patient care provided. The Governing Board has the responsibility to evaluate the effectiveness of the PI activities performed throughout CQCH (Copper Queen Community Hospital) as well as the PI Program as a whole. The Board shall require specific review and evaluation of activities in order to assess, preserve and improve the overall quality and efficiency of patient care in the hospital...
C. Medical Executive Committee (MEC)...The MEC provides effective means to monitor, assess and evaluate the quality and appropriateness of patient care and the clinical performance of all individuals with delineated clinical privileges. Performance improvement opportunities are addressed and important problems in patient care is identified and resolved...
D. Quality Council / Department Managers...The Council is designed to provide support and direction for improvement efforts. Activities include but are not limited to:
1. Setting priorities for the planning and designing of important processes.
2. Overseeing ongoing measurement, periodic assessment, and periodic improvement of these important processes through the monthly and quarterly reporting process.
3. Evaluating the need to reprioritize improvement activities in response to unusual or urgent events identified through measurement and assessment...
4. Convening multi-disciplinary quality teams for specific improvement efforts, some of which may be triggered by the results of ongoing measurement, including feedback from patients/families and staff.
5. Communicating relevant activities, as necessary, throughout the organization; Reporting to the Governing Board...

IV. Department Improvement Structure
A. Structure and Criteria. Individual departments perform quality control functions and report their activities through the monthly and quarterly reports to the hospital's Medical Quality Improvement Committee and the Quality Council...

V. Procedure...Communication of Performance Improvement Results. The Quarterly Department Report is the basis for communicating the departments' contribution toward the hospital goals, performance improvement and other identified activities. The PI report is communicated monthly to department directors, managers, medical staff (MQI) (Medical Quality Improvement) and to the governing board.

VI Medical Staff Hospital Wide Quality Improvement...
B. Medication Usage Evaluation. Medication usage evaluation is performed by the medical staff as a criteria based, ongoing planned and systematic process for monitoring, assessing and evaluating the prophylactic, therapeutic, and empirical use of medications to assure that they are provided appropriately, safely and effectively. Medication usage evaluation is performed quarterly by the Pharmacy and Therapeutics Committee to assure that medication use is systematically measured. The processes measured include at least, but not limited to:
-prescribing/ordering
-preparing and dispensing
-administration, and
-monitoring of the medication's effects on patients...
E. Pharmacy and Therapeutic Function. The pharmacy and therapeutics monitoring function is performed by the Pharmacy and Therapeutics committee on a quarterly basis, reported to the MQI and includes but is not limited to the following:...The oversight responsibility governing the safe administration of drugs and biologicals throughout the institution, including analysis of medication errors. The definition and review of all significant untoward drug reactions, and analysis of the outcome of medication usage evaluation...
H. Assessment of Patients...Outcomes are reflected in the specific departments and hospital wide through the Medical Quality Improvement (MQI) Committee's reviewed and analysis of quality improvement data...."

The Medical Staff Meeting Minutes from January through July 2010 were reviewed. The minutes included the general topics of "Discussion" followed by "Action" and "Status." Some of the minutes included:

July 16, 2010:
"Laboratory, (Name of Chairman), New Business: (Name of lab manager). Nothing to report at this time." Action: "Nothing to report at this time." Status "Complete."

Pharmacy & Therapeutics (Name of Chairman). New Business: "Nothing to Report." Action: "Nothing to Report at This Time." Status "Complete."

Nursing (Name of Assistant Director of Nursing (ADON)). New Business: "Nothing to report at this time." Action: "Nothing to report at this time." Status "Complete."

June 18, 2010:
"Laboratory, (Name of Chairman), New Business: (Name of lab manager). Nothing to report at this time." Action: "Nothing to report at this time." Status "Complete."

Pharmacy & Therapeutics (Name of Chairman). New Business "1. Adverse Drug Reaction: May 2010. 2. Medication Deviation: May 2010. 3. Formulary Additions/Deletions - None."
Action: Next to each of the 3 areas were noted: "Nothing to Report at This Time." Status "Complete."

"Nursing (Name of ADON). New Business: Nothing to report at this time."
Action: "Nothing to report at this time." Status "Complete."

May 21, 2010:
"Laboratory, (Name of Chairman), New Business: (Name of lab manager). 1. Patients Calcium Value: Albumin Below 3.0"
Action: Upon motion and duly seconded the Calcium and Low Albumin will no longer be reported unless specifically asked for by the physician effective June 1, 2010. Status "Complete."

"Pharmacy & Therapeutics (Name of Chairman). Old Business 1. Printed MAR's (Medication Administration Records) on Acute. 2. Post-op Orders - Reminder."
Action: 1. "Information Only." 2. "Order such as continue post-op orders not acceptable. Drugs/orders have to be specified. Status: "Complete."
New Business "1. Adverse Drug Reaction: May 2010. 2. Medication Deviation: April 2010. 3. ? Dopamine in Non-ICU Setting. 4. Pharmacy Cost-containment Ideas..."
Action on #1 and #2: "Information Only." Status "Complete." Action on #3: "Track usage and gather info on usage and present at next meeting." Status "TBF (To be followed). Action: "Deletion from the formulary the following...."

No Nursing topics or input recorded.

April 16, 2010:
"Laboratory, (Name of Chairman), New Business: (Name of lab manager). "1. High and Critical Potassium on Outpatients." Action: "Information only." Status "Complete."

Pharmacy & Therapeutics (Name of Chairman). New Business: "1. Adverse Drug Reaction: February & March 2010. 2. Medication Deviation: February & March 2010. 3. Medication Reconciliation - Issues in Acute and ED. 4. Post-op Surgery Orders."
Action: #1: "Information Only." #2: "Information Only." #3: "Medication Reconciliation form to be revised and submitted for approval." #4: "Information Only." Status for #1, #2, and #4 were "Complete." Status for #3 "TBF."

Nursing: "New Business: 1. Medicine Administration Deviation Reduction Program Policy 01.06.53." Action: Policy approved. Status: "Complete."

"March meeting not held."

February 19, 2010:
Pharmacy & Therapeutics. New Business: "1. "1. Adverse Drug Reaction: January 2010. 2. Medication Deviation: January 2010. 3. Formulary Additions/Deletions."
Action: #1 and #2 "Information only." #3: No Additions/Deletions to Report." Status on all 3: "Complete."

No Nursing topics or input recorded.

January 15, 2010:
Pharmacy & Therapeutics (P & T). New Business: "1. "1. Adverse Drug Reaction: November & December 2009. 2. Medication Deviation: November & December 2009. 3. Formulary Additions/Deletions...."
Action: #1 and #2 "Information only." #3: Committee approved formulary changes. Status on all 3: "Complete."

No Nursing topics or input recorded.

The meeting minutes reflected the topics of discussion but not specific information on the data collected, problems identified, analysis and corrective actions.

The PI & QA meeting minutes for July 20, 2010, had hand written notes that did not include the data collected and the resulting problems identified. The notes included:

"V. New Business A. 90 Measures to Becoming Meaningful Use.
VI. PI Teams in Progress - please forward minutes from team meetings to the PI committee chair...
VII Performance/QA Indicators - look at the tracking sheet to see if the data (or lack of) for your area is correct. Remember, we need to indicate goals. A. Patient Satisfaction:...Quarterly reports need update...update survey changed format to get more accurate details...
IX. Quality Assurance Issues/Opportunities to Improve - no report yet - new categories..."
.
The PI & QA meeting minutes for January 27, 2010, included:

All three clinics are doing chart reviews for 4 diseases in an effort to improve patient outcomes in chronic disease management...
Reformatting of PI Team - from 2009 annual evaluations, these ideas will be adopted:
1. Offer more PI education...
2. Form a smaller quality team to be more focus-driven...to meet monthly and shadows the general PI team which meets quarterly.
3. Reformat PI flowsheet...."

New Business"...1. Copper Queen Hospital Intervention Model is being developed with the help of the Flex Program staff. This is an effort to reduce hospital readmissions and improve patient outcomes. 2. We will be working on our strategic plan in August...
Quality Assurance: No report this quarter."

"QA Indicators and Performance Improvement Tracking Plan" was attached to the minutes. The department and its performance measure was listed with the percentage achieved for each quarter areas included were:
"Emergency Room Decision to Departure time (transfers)...goal under 4 hours...
Laboratory Problems with specimens received (ER) 2.9%.
Med/Surg Drs Time and date orders (Date started) 3/1/09." No data or goals noted.
"Pharmacy Narcotic discrepancies (4th quarter 2009) 3.7%. Goal 0%."

The QA Director was interviewed on 8/12/10. She stated the Department Managers conduct PI projects and track the data to determine improvement. The Department Managers present the information to her at the quarterly PI & QA meetings. Most Department PI sheets contained a statement of the problem identified and a graph of the progress. However, the PI action plan section of the form was blank. She stated information is discussed, but the data collected, problem identification, analysis and the action plan are not documented.

The quarterly PI pharmacy report recorded the number of medication errors and their breakdown but no corrective action plan was noted. There were no P & T meeting minutes. The QA Director stated the P & T notes were those recorded in the MEC meeting minutes. The nursing department was not listed on the form and there was no evidence of identified problems and data collection from nursing.

There was no demonstrated evidence that information from the QA and PI Council was shared with the MEC. The meeting minutes reflected the topics of discussion but not specific information on the data collected, problems identified, analysis and corrective actions.

Based on document review and staff interview, it was determined the facility failed to conduct quarterly meetings and report their findings to the quality program and Medical Executive Committee for review and evaluation.

Findings include:

The Infection Control Committee Policy 17.01.04, effective 03/01/2009, included: "II. General Policy: The Infection Control Committee serves as a multidisciplinary subcommittee of the Medical Staff, reporting to the Medical Executive Committee...Procedure: Objectives: 1. Provides expert effective leadership in promotion of medical asepsis and oversees proper safeguards against the transmission of infection. 2. To identify, through the surveillance system, any specific problem areas in need of administrative or professional resolution and report to the Medical Staff of the Hospital. Functions: 1. Establish and implement the surveillance system for evaluating and reporting infections in patients, personnel and discharged patients...9. Provide written minutes of meetings or other committee activities to the Executive Committee of the Medical Staff...Composition: 1. The Infection Control Committee shall consist of representatives from Administration, Nursing, Laboratory, Central Service, Quality Services, Pathology, Surgery, Pharmacy, and Medical Staff Members (as required by the Bylaws of the Medical Staff) and the person directly responsible for management of the infection surveillance, prevention, and Infection Control Program, usually the Infection Control Practitioner...Meetings: The Infection Control Committee shall meet quarterly. The time and day of the meeting shall be voted on and approved by the Committee Members."

The Infection Control Plan for Copper Queen Medical Associates, effective 03/01/2009, included: "II. General Policy: All health care providers, in partnership with the medical staff, are responsible for the safety, health and well being of all patients, visitors and hospital staff. Copper Queen Medical Associates have established an Infection Control Program, which requires the participation, support and cooperation of all personnel...IV. Procedure: Commitment: A. Copper Queen Medical Associates, represented by the medical and administrative staff, along with the Board of Directors assures that an Infection Control Program is established and that this policy statement be adopted to ensure the organization has a functioning, coordinated process in place to reduce the risk of endemic, epidemic, nosocomial and nosohusial infections in patients and healthcare workers. C. The medical staff, will be responsible for its role in the Infection Control Program. In addition to reporting isolation cases, suspected infections and positive cultures, as well as providing required follow-up information, each department will be responsible for full and timely cooperation with the Infection Control Committee/Infection Control Practitioner to develop and implement remedial/corrective action...1. Program Description: Infection Control at Copper Queen Medical Associates allows for a systematic, coordinated and continuous approach: B. Patient care services include RHC's (rural health clinics)."

The Revised Bylaws for the Medical Staff of the Bisbee Hospital Association, 2008, included: "Article 14 - Committees - Standing and Special. 14.1 Designation Structure and Function; 1. There shall be such standing and special committees of the Medical Staff as may be necessary to perform the functions of the Staff required by these Bylaws or necessarily incidental thereto. All committees shall maintain a record of attendance at their meetings, maintain a record of their proceedings and submit timely reports of the activities and copies of the minutes to their meetings to the MEC (Medical Executive Committee)...3. Medical Staff committees shall be as follows:...H. Infection Control Committee...14.2. 2. Duties: The duties of the MEC shall be:...3. Meetings: The MEC shall meet at least once a month and maintain a permanent record of its proceedings and actions...4. Purpose: To be responsible and oversee the following Medical Staff functions: A. Oversee all Medical Staff Committees, including, but not limited to:...(8) Infection Control Committee...."

A review of the Infection Control Committee minutes for May 21, 2010, revealed: 1st Quarter report 2010. "The meeting was called to order by Dr____ (Medical Director of Infection Control Committee) at 0802 hours. The meeting was adjourned at 0825 hours." Information was presented from January, February and March, 2010. The previous meeting was held February 19, 2010, for the 4th Quarter of 2009. The meeting was called to order by Dr_____ (Pathologist) at 0800 hours. The meeting was adjourned at 0835 hours. Information was presented from October, November and December of 2009. An infection control meeting was held January 15, 2010, for the 1st, 2nd, and 3rd Quarters of 2009. The meeting was called to order by Dr. ______ (Pathologist) at 0800 hours. The meeting was adjourned at 0825 hours. Information presented included January of 2009 through September of 2009.

The Infection Control Coordinator, acknowledged in an interview conducted on 08/11/2010, the infection control meetings for the past year were not held quarterly. They were held late (2010) with the 1st, 2nd, and 3rd Quarters of 2009 combined.

A review of the Quality Assurance and MEC meeting minutes revealed the infection control data collection, analysis, monitoring, findings, resolutions, prevention, and corrective actions were not included in meeting minutes. No evidence was produced to verify the infection control findings were presented to the Quality Assurance or the MEC Committees.