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Based on review of hospital documents for 2011 and 2012 and interviews with hospital staff, the hospital does not ensure that medication errors identified are evaluated, analyzed and action taken to improve the care and safety of patients. Errors were identified but were not analyzed to determine why they were occurring and a plan of action implemented to reduce the errors.

Findings:

1. The Pharmacy and Therapeutics Committee has not met since 06/28/11. The Quality Improvement Plan has the P & T Committee made up of the Director of Pharmacy, Director of Nursing (DON), Infection Control and a physician. This committee is to meet quarterly.

2. Pharmacy is not included in the evaluation of medication errors. Hospital staff stated that medication error reports are given to the DON. There was no evidence that these were analyzed and a plan of action implemented to reduce medication errors.

3. There was no evidence in governing body, medical staff or quality improvement meetings that the errors were analyzed to determine whether it was a personnel or system problem.

4. The errors identified by the pharmacist for March and April 2012 consisted of : 1. missed doses and incomplete orders; 2. wrong route and wrong strength (should be 7.7 mg but 75 written). There was no documentation that these were analyzed to determine why they occurred, the impact on the patients and a plan of action implemented to prevent future occurrences.

Based on record review and staff interview, it was determined the facility failed to ensure non-employee nursing personnel were oriented to hospital policies and procedures and their clinical activities were evaluated at least yearly. Findings:

On 04/16/12, the personnel record for agency nurse A was reviewed. The record did not have documentation of orientation to hospital-specific policies and procedures, documentation of verified competency to perform clinical activities, and documentation the nurse had been trained and evaluated to perform respiratory therapy treatments.

The DON stated there was no process in place to orient and evaluate agency nurses.

Based on record review and interviews with hospital staff, the hospital does not ensure the consultant pharmacist evaluates the performance and competency of pharmacy personnel who provide pharmacy services when the consultant pharmacist is not on the premises. The person designated as the Drug Room Supervisor ( C ) did not have a competency evaluation by the Consultant Pharmacist.

Based on review of policy and procedure, hospital documents, personnel files, and staff interviews the hospital failed to provide radiology services to meet the needs of the patients that are in accordance with standards of practice.

Findings:

1. On the morning of 4/25/12 staff H told surveyors radiology services were provided by employees and contract staff. There were no current policies reviewed and approved by medical staff and the radiologist indicating all radiologic services provided at the facility.

2. Quality Assurance and Performance Improvement (QAPI) documents did not incorporate radiology services into the plan. QAPI meeting minutes for 2011-2012 did not include a review of all radiology services.

4. The facility did not have documentation stipulating contract staff were oriented to the facility, licensed, trained, and competent to provide services. There was no documentation on contract personnel provided to surveyors.

5. There were no clinical performance evaluations of contracted staff.

6. There was no documentation in the policy and procedure manual indicating all of the types of radiologic procedures offered by the facility. A policy titled Nuclear Medicine stated "HMCI does not provide on-site nuclear medicine" with handwriting at the bottom of the policy indicating nuclear medicine was provided and the responsibility of the contractor." There was no policy and procedure reviewed, approved, and implemented indicating how the contracted radiology services were provided.

7. The above findings were reviewed with administration in the exit conference. No further documentation was provided.

Based on policy and procedure, interviews, and review of personnel files the facility does not ensure personnel providing radiology services are appropriately trained and competent to provide services to patients.

Findings:

1. On the morning of 4/26/2012 surveyors reviewed radiology policies. Policies provided to surveyors indicated some radiology procedures were performed by contract staff. There were no personnel files stipulating these contract staff are licensed and/or registered, competent, oriented, and trained. There was no documentation contract staff had been oriented to the facility.

2. On the morning of 4/26/2012 surveyors were told on occasion non employee contract staff provided magnetic resonance imaging (MRI). There was no information provided to surveyors on the contract staff.

3. The above findings were reviewed with administration in the exit conference. No further documentation was provided.

Based on review of policies, personnel files, and interviews, the hospital failed to provide adequate training and oversight to dietary personnel.

Findings:

1. On 4/25/2012 surveyors reviewed dietary personnel records (Staff I and M) . There was no documentation, policy, procedure, or process in place stipulating how new dietary department employees would be trained on the inservice material presented before they were hired. There was no documentation the employees had been oriented and trained to the facility and specific dietary department.

2. Dietary documents did not include a departmental specific orientation and training for each dietary job description. The facility did not have evidence the dietary department employees were trained to perform the duties each were hired/assigned to do.

3. On 4/25/2012 Staff F told surveyors the Dietary Manager was Staff I. There was no documentation the Dietary Manager had oversight by the dietitian for clinical aspects of nutritional services. There was no evaluation of the Dietary Manager for clinical nutritional competency by the dietitian. The Dietary Managers evaluation was signed by the CFO. There was no documentation the dietitian oversaw the clinical aspects of the Dietary Manager's job.

4. These findings were reviewed with the administration on 4/26/12 at the exit conference.

Based on review of infection control data and meeting minutes containing infection control, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. The infection control manual contained job descriptions which documented a physician advisor appointed by medical staff would chair the infection control committee meetings. Review of meeting minutes and the "sign-in" sheet for Quality meetings did not reflect a physician attended the meetings or was involved with the infection control program.

2. Review of meeting minutes, concerning infection control for the past twelve months and infection control policies and procedures did not demonstrate an ongoing review and revision of the infection control program, plan and policies and procedures to ensure they followed the current infection control standards of practice and recognized guidelines. The majority of the infection control policies and the the plan for infection control had not been reviewed or revised since 2007.

3. Meeting minutes did not demonstrate the infection control program and practitioner reviewed the disinfectants utilized in the hospital to ensure they were effective against the organisms present at the hospital.

4. Concerns/problems identified were not carried forward and reviewed/evaluated to ensure the corrective actions were effective. Examples:
a. Meeting minutes for 07/12/2011 recorded a concern with the hospital soap would not remain on staff hands long enough to be effective. The plan of action recorded was the infection control practitioner would look at other products. The concern was not reviewed again.
b. Meeting minutes for 01/24/2012 recorded a new process for storing laryngoscope blades. The meeting minutes did not demonstrate a plan for review/evaluation to ensure the process resulted in improved aseptic practice. Meeting minutes for for 04/10/2012 did not reflect this topic was reviewed.
c. Meeting minutes for 01/24/2012 identified concerns in dietary. The food temperature problem had been analyzed, and a corrective action of education/training to staff was performed. The minutes did not demonstrate a review of plan of action would be performed to ensure the plan was effective or that a change in the plan of action needed to occur with further follow-up. Meeting minutes for 04/10/2012 did not reflect this problem/concern was reviewed.

5. Although the infection control program and meeting minutes included listings of staff illness/infections, the program did not:
a. Analyze the data to determine if transmission of illness/infection occurred between patients and staff with corrective actions and follow-up when needed.
b. Include employee, contract staff, allied health and physician's immunization status with plan of action for deficiencies. Review of personnel and credential files showed three of nine reviewed for health information did not contain complete immunization histories as recommended by the CDC (Centers for Disease Control and Prevention) and its Advisory Committee on Immunization Practices.

6. With they exception of hand washing, the infection control program did not include active surveillance/monitoring of hospital departments and practices to ensure infection control polices and infection control standards of practice were followed.
a. Although the infection control meeting minutes documented "handwashing techniques continue to improve", no evidence of active surveillance was provided. The infection control practitioner, Staff J, stated on the afternoon of 04/26/2012 that she observed hand hygiene, but did not document these observations.
b. Meeting minutes and surveillance activities provided for review did not demonstrate monitoring of the hospital disinfectants in the different departments were performed to ensure manufacturer guidelines for mixing (if applicable), application and "wet time" were followed. This finding was reviewed and verified with Staff J on the afternoon of 04/26/2012.
c. Agenda documents for 2012 recorded that departments of physical therapy, radiology, Senior Focus, surgery, environmental services and plant operations had nothing to report. The infection control plan, last recorded for 2007, and meeting minutes for 2011 and 2012 did not specify what was monitored in the different departments, how it was measured or how often.

7. Surgical practices, with the exception of possible surgical site infections, were not monitored in infection control.
a. Although 04/10/2012 meeting minutes documented no surgical site infections, the minutes did not record that two surgeons who had been sent letters on 03/15/2012, with patient and surgeries listed, requesting review of the lists and identification of any infections, had not responded.
b. Staff K and L told the surveyors on 04/25/2012 that no one monitored to ensure the disinfectant, Caviwipes, was applied:
i. To all horizontal and possible patient contact surfaces as required by policy and current recognized standards of practice,
ii. According to manufacture guidelines with the product remaining wet on the surfaces the required time.
c. Sterilization and disinfectant practices are not monitored.
i. Staff K and L told the surveyors on 04/25/2012 that central sterile practices were not reported to infection control.
ii. Review of sterilization documents showed that all sterilization loads were not documented. In case of reported infection, the patient(s) could not be tracked to the instruments/cycle used. If instrument sets were found to be unsterile, staff could not track what other instrument sets were sterilized during the same load to pull those instruments.
iii. Shortened cycles, abbreviated drying times, were utilized to sterilize between eye surgery cases. This practice was not reported and monitored through infection control to decrease the amount/need for this type of sterilization process.

Based on staff interviews and record review, the facility failed to ensure that surgical services maintained standards of safe patient care.

Findings:
According to the Association of periOperative Registered Nurses (AORN) "sterilization records should be maintained for a time specified by the health care organization's policies and in compliance with local, state, and federal regulations. Accurate and complete records are required for process verification and used in sterilizer malfunction analyses. Documentation establishes accountability. XIV.a. Every sterilization cycle and modality, including steam (eg, wrapped, unwrapped, EO, hydrogen peroxide gas plasma, liquid peracetic acid, ozone, and dry heat should be documented. Documentation should include the assigned lot number; contents of each load; and results of physical, chemical, and biological monitors". AORN also stipulates Recommendation IV "use of flash sterilization should be kept to a minimum. Flash sterilization should be used only in selected clinical situations and in a controlled manner. Further under the recommendation Iv.c.2 The sterilizer operator should use physical monitoring devices to verify cycle parameters for each load. Physical monitoring devices (eg, printouts, graphs, gauges) can indicate immediate sterilizer failure. Physical monitors record cycle parameters (ie, time, temperature) for each cycle. IV.i. Documentation of cycle information and monitoring results should be maintained in a log (electronic or manual) to provide tracking of the flashed item(s) to the individual patient. Documentation allows every load of sterilized items used on patients to be traced.

1. On 4/25/12 in afternoon surveyors reviewed sterilizer information. According to Staff K the facility has two sterilizers both are prevac. Surveyors reviewed sterilizer logs and compared to the tapes generated per load from the sterilizers. A total of 18 loads were counted on the sterilizer tapes reviewed from 1/18/12. Only 10 loads were documented in the sterilizer logs. This finding was confirmed with Staff K. Many of the documented loads did not match the times on the sterilizer tapes. Several loads on the tapes taken from sterilizers 1 and 2 were shortened "flash" cycle loads and were not documented in the sterilizer logs for tracking. This finding was confirmed with Staff G and Staff K . Staff G and K told surveyors on the afternoon of 4/25/2012 the tapes and logs had not been reviewed to ensure the sterilizers were going through a full sterilization cycle. Staff G and K also stated the tapes had not been reviewed by infection control. The infection control documentation does not reflect any surveillance of the cleaning and disinfecting processes of the operating room or central sterile.

2. On 4/25/12 surveyors reviewed operating room policies. Several policies last review and revision date was 2007. The perioperative handwashing policy does not include current recommendations from the CDC regarding the appropriate use of alcohol based sanitizers. Policies and procedures for sterilization, cleaning and disinfection of equipment does not match practice. This finding was verified with Staff K the afternoon of 4/25/2012.

3. On 4/26/12 surveyors reviewed personnel files for Staff K and G. Both files did not contain current competencies and evaluation of skills including use of sterilizers and endoscopy equipment processing.

4. The above findings were reviewed with administration at the exit conference 4/26/2012.