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Based on medical record review and interview the facility failed to provide a copy of an "An Important Message from Medicare" (IM) to 2 of 4 inpatients (#24, #31) which could deprive patients of the information necessary to exercise their rights. Findings include:

On 11/14/12 at approximately 2 pm review of patient #31's clinical record reveal no evidence of the IM being provided to the patient since admission on 11/5/12. This finding was verified by Staff W during review.

On 11/15/12 at approximately 11 am, review of patient #24's clinical record revealed no evidence of "An Important Message from Medicare" (IM) being provided to patient #24 during a hospital admission to 5 North from 11/7/12- 11/12/12. On 11/12/12 patient #24 was discharged from the Medical unit and admitted to the Psychiatric unit. This finding was verified by Staff W during review.






29774

Based on medical record review and interview the facility failed to post state agency contact information and provide a copy of an "Important Message from Medicare" (IM) to 2 out of 2 patients (#12 & #13), which could potentially deprive patients of the information necessary to exercise their rights. Findings include:

During medical record review of patient #12 on 11/13/2012 at approximately 1155, it was revealed that the IM had not been given to, or signed by the patient. Patient #12 had been admitted on 11/9/2012 and had signed her consent for treatment, however, had not signed her IM.

This finding was confirmed during an interview with staff G on 11/15/12 at approximately 0900.

During medical record review of patient #13 on 11/13/2012 at approximately 1140, it was revealed that the IM had not been given to, or signed by the patient. Patient #13 had been admitted on 11/9/2012 and had signed his consent for treatment, however, had not signed his IM.

This finding was confirmed during an interview with staff G on 11/15/12 at approximately 0900.

Based on observation, record review and interview, the facility failed to establish a process for prompt resolution of patient grievances and inform patients admitted to the Medical Unit (5 North) of how to lodge a grievance with the State agency, as evidenced by:
- lack of a documented investigation into patient grievances
- lack of evidence of response to patient grievances
- lack of a process for incorporating patient grievances into Quality/Assurance Performance
Improvement plan
placing all patients admitted to the Medical unit at risk of being unable to exercise their rights.

Findings include:

Observations and interviews:

1. On 11/13/12 at approximately 11am the inpatient Psychiatric unit postings were observed. All required postings were found. On 11/13/12 at approximately 2 pm, review of complaints by psychiatric inpatients revealed no deficient practices in investigating, responding to complaints or following policies. A procedure for forwarding complaints to the Governing Body was noted.

2. Observations of the Emergency and non-emergency admission areas and the Medical Unit (5N) revealed no evidence that admitted patients received information, posted or printed, on how to file a complaint with the State agency. Admission packets provided to patients in each area were reviewed and confirmed by staff listed below:
-Staff X, in the Patient Access/Admitting department on 11/13/12 at 10:30 am.
-Staff Y, in the Emergency Department admissions area, on 11/13/12 at 10:45 am.
-Staff W, on the 5 North Medical Unit on 11/14/12 at approximately 1 pm.

3. On 11/14/12 from 1-2 pm, review of Medical unit patient complaints revealed that 3 out of 4 complaint investigations (for patients #40, #41, #43) did not include evidence of an investigation, including staff names and witness statements, or of a facility response based on investigative review.

4. On 11/14/12 from 1-2 pm, Staff W, responsible for investigating and responding to patient grievances on the Medical unit, stated that he could not recall the names of unnamed staff referenced in complaint investigations. Staff W also stated that he did not have evidence of facility responses to complaints and was unaware of a policy or procedure for reporting complaint data to the hospital's Quality Assurance/Performance Improvement process.

Based on observation, record review and interview, the facility's governing body failed to establish a process for prompt resolution of patient grievances and ensure review of grievances by a grievance committee.

Findings include:

Observations and interviews:

1. On 11/14/12 from 1-2 pm, review of Medical unit patient complaints revealed that 3 out of 4 complaint investigations (for patients #40, #41, #43) did not include evidence of an investigation, including staff names and witness statements, or of a facility response based on investigative review.

2. On 11/14/12 from 1-2 pm, Staff W, responsible for investigating and responding to patient grievances on the Medical unit, stated that he could not recall the names of unnamed staff referenced in complaint investigations. Staff W also stated that he did not have evidence of facility responses to complaints and was unaware of a policy or procedure for reporting complaint data to the hospital's Quality Assurance/Performance Improvement process or Board of Directors.

Based on Medical record review and interview the facility failed to ensure that the patient and/or His/Her representative were given all of the information needed in order to make an informed decision regarding care in 3 of 3 transfer records reviewed. This has the potential to impact all patients transferred from this facility. Findings include:

On 11/13/12 at approximately 1100 (11:00 AM) during tour of the ED the chart of Patient #14 was reviewed for the documentation related to transfer to another facility. It was found that the form "Physician Assessment and Certification For Transfer" was incomplete. Under "Provider Certification' the area stating " I have examined the patient and explained the following risks and benefits of being transferred/refusing transfer to the patient" is blank.

Interview of Staff A during tour states "that area is to be filled out by the sending Physician."

On 11/15/12 at approximately 1200 (12:00 noon) during record review of patient #44 and #45 it was found that the areas titled "Provider Certification" remains blank.

Interview with staff A on 11/15/12 at approximately 1300 (1:00 PM) stated that "the areas titled "Provider Certification" is blank."

Based on observation and record review, the facility failed to protect the privacy of 1 inpatient medical record placing the patient at risk of loss of privacy. Findings include:

Facility policy "Notice of Privacy Practices" states: "We at Doctor's Hospital of Michigan are required by law to maintain the privacy of individually identifiable patient health information..."

On 11/14/12 at approximately 2:30 pm patient #31's medical record was observed to be open and unattended on a countertop in a public area on 5 North. The record could have been viewed by patients or visitors but none were in the immediate vicinity of the counter. This observation was confirmed by Staff W.

Based on medical record review, policy review and interview, the facility failed to monitor and document in the medical record, patient response during the use of restraints for one (#12) of one patient in restraints resulting in the potential for patient harm. Findings include:

On 11/13/12 at approximately 1215 during record review for patient #12 revealed that the physician wrote an order for soft bilateral wrist restraints on 11/11/12 at 0030. Documentation for patient monitoring after 0030 revealed two nursing entries on a document titled "Nursing Progress Record" at 0300 "patient cont. to be restless and pulling at restraints mumbling to self. Received order for ARO 2 mg (milligrams) IM (intramuscular)." "Bladder scan done = 275. No cath done @ this time". The document titled "restraint assessment" dated 11-10-12 was left blank.

A review of facility policy titled "Restraint Policy- Non-Violent Patient" revised 9/13/12 revealed that "Staff members are trained and competent to minimize the use of restraints, and when their use is indicated, to use them safely..... 12. Monitoring of the patient shall occur at least every two hours or sooner according to patient need while the patient is restrained...The patient will be assessed every 2 hours by an RN and shall include documentation of: a. Signs of any injury related to the restraint b. nutrition/hydration c. circulation and range of motion of extremities d. hygiene/elimination- patient must be bathed every 24 hours e. physical/psychological status and comfort f. maintenance of rights, dignity and safety g. less restrictive methods considered h. observation of appropriate application i. readiness of discontinuation of restraints...".

Interview with staff G on 11/15/12 at approximately 1030 confirmed that documentation was missing regarding the monitoring of the patient after restraints were applied. Staff G responded, "that nurse has over 20 years of (nursing) experience.. she should know better and will be disciplined..."

Based on Quality Assessment Performance Improvement (QAPI) program review and interview, the facility failed to identify program priorities, frequency of data collection, action plans or documented improvement in any area. Findings include:

See tags:
A273 Failure to identify full scope of QAPI and measurable improvement.
A283 Failure to set priorities and develop/document actions plans.
A309 Failure of the governing body to determine number of improvement projects and determine priorities.

Based on interview and performance improvement documentation review, the facility failed to identify the full scope of the Quality Assessment Performance Improvement (QAPI) activities, including measurable improvement. Findings include:

File review of the QAPI program material revealed minutes and data only of a three month time period, (June, July, August 2012) although a twelve month period was requested. The QAPI plan had been updated April 2012 but failed to identify priorities and frequency of data collection. The QAPI program lacked measurable improvement in any area. Interview with the Quality Director/Chief Nursing Officer (#G) on 11/15/12 at approximately 1300, verified that only these three months were available and that priorities and frequency had not been specified. Staff #G was not able to identify any area of improvement in the past year. Staff #G had been the Quality Director for the past year and had recently been made the Chief Nursing Officer.

Based on interview and performance improvement documentation review, the facility failed to set priorities or develop action plans in the quality assessment performance improvement (QAPI) program. Findings include:

File review of the QAPI program material for the provided months of June, July, and August 2012, revealed data and minutes without priorities set or action plans documented. Interview with the Quality Director/Chief Nursing Officer (#G) on 11/15/12 at approximately 1300, verified that priorities had not been established and action plans had not been documented. Staff #G stated "We are working on the Case Management piece....but it's not documented." Staff #G verified that none of the data collection areas or discussions documented action plans.

Based on file review and interview, the governing body failed to determine priorities and the number of improvement projects to be performed. Findings include:

File review of performance improvement information provided revealed no documentation of priorities or number of improvement projects to be performed. Interview with the Director Quality/Chief Nursing Officer (#G), on 11/15/12 at approximately 1300, verified that the governing body had not specified the number of improvement projects or priorities for performance improvement.

Based on document review, and interview the facility failed to ensure the availability of qualified nursing resources to respond to the appropriate nursing needs and care of the patient population on each nursing unit. Findings include:

On 11/14/12 at approximately 1300 (1:00 PM) during review of documents in staff files it was found that no annual competency's including infection control, emergency procedures, and unit specific procedures had been completed since 2010 in all units except Behavior health employees.

Interview of staff AN on 11/15/12 at approximately 1100 (11:00 AM) states "we are catching up on competency's now".

On 11/13/12 at approximately 1220 during record review for patient #12 revealed on a sheet titled "Doctor's Orders" the following physician orders: "neuro checks q 4 hours, fall precautions, eeg new encephalitis, pls call for any new defl (?spelling, illegible) social service consult". The orders were not timed, dated nor signed by a physician.

On 11/13/12 the lack of timed, dated and signed orders were confirmed by staff J at 1221, who said "it sure doesn't look like he signed them...".

Based on observation, policy review and interview the facility failed to monitor for and remove from availability, emergency medications that have exceeded manufacturer's expiration date, resulting in the potential for poor patient outcomes for patients requiring emergency medical interventions. Findings include:

On 11/13/12 during facility tour at approximately 1115 found two emergency carts one of which had medications: Amiodarone and Sodium Bicarbonate (injectables) each with a manufacturer's expiration date of 9/30/12.

A review of facility policy titled "Inspections of All Doctors Medical Center and Outpatient Facility Medication Storage Areas" revised 2/2012 revealed "Inspections of all Doctors Hospital of Michigan and outpatient facility medication storage areas will be conducted monthly, by representatives of the Department of Pharmacy or its designee. This includes all nursing units, medication rooms, clinics, and outpatient facilities... The "Monthly Pharmaceuticals Inspection Report will be completed every month and forwarded to the Inpatient Pharmacy administrative office..."

Interview of staff T, the director of pharmacy on 11/14/12 at approximately 1130 confirmed that the monthly checks were not completed for that area for the months of 9/2012 and 10/12, who stated, "I can't find them" referring to the monthly checks for 9/2012 and 10/2012.

Based on observation and interview the facility failed to monitor temperatures of nutrition freezers resulting in the risk for patient harm on the unit the pantry freezer resides. Findings include:

On 11/13/12 at approximately 1135 during a unit tour found in the pantry freezer popsicles, ice packets, pink wash basins filled with ice a partially used water bottle and a covered cup containing ice. A review of the document taped to the refrigerator freezer titled "Patient Floor Stock Refrigerator/Freezer Monitor for 11/2012" revealed daily temperature recordings of the refrigerator, however the area under "freezer temp" remained blank. The document also revealed that "both refrigerator ane freezer temperatures must be recorded daily...".

Interview with staff J on 11/12/12 at 1136 confirmed that freezer temperatures were not being recorded and further, there was no thermometer located in the freezer for monitoring the temperature.

Interview with staff M, registered dietician on 11/13/12 at approximately 1330, revealed that when asked why the freezer temperature is not being monitored replied "we don't have a freezer up there".

Based on interview and record review, the facility failed to provide patient #24 with a special diet as ordered when transferring the patient between the Medical and Psychiatric units on 11/12/12, placing the patient at increased risk of choking. Finding include:

On 11/13/12 at 11 am, review of a facility report regarding patient #24's choking episode on 11/12/12 was reviewed. The report revealed that patient #24 was moved from the Medical to the Psychiatric unit on 11/12/12 at approximately 4 pm. At 9:15 pm that evening, patient #24 experienced a choking episode and the Heimlich maneuverer was performed.

Record Review:

1. On 11/7/12 patient #24 was admitted to the 5 North (Medical) unit with a diagnosis or "recurrent aspiration."
2. On 11/8/12 a Mechanical Soft Diet was ordered for patient #24.
3. On 11/12/12 at 11:29 am Registered Dietitian (staff AL) documented that patient #24 continued on a Mechanical Soft Diet.
4. On 11/12/12 at approximately 4 pm patient #24 was transferred to the Psychiatric unit. There was no documentation on 11/12/12 by the discharging physician regarding the patient's dietary status or recent history or aspiration The Mechanical Soft diet order did not carry over on the Psychiatric Unit and was not addressed in discharge (transfer) orders.
5. On 11/12/12 at 9:15 pm patient #14 had a choking episode while eating a regular diet and the Heimlich Maneuver was performed. A Mechanical Soft diet was ordered.
7. The above findings were confirmed during record review on 11/12/12 with the Psychiatric Unit Manager from approximately 11-11:30 am.

Interview:

On 11/15/12 at approximately 10:30 am the patient's Attending Physician on 5 North, staff Z, was interviewed. Staff Z stated that he was not aware of a policy addressing physician responsibility for hand-off between units. Staff Z also verified that there was no physician documentation on 11/12/12 stating a reason for dropping patient #24's order for a Mechanical Soft diet when transferring between units. Staff Z stated that he did not feel that the diet change on 11/12/12 placed the patient at increased risk since the patient had been refusing the Mechanical Soft diet.


29774

Based on record review and interview the facility failed to provide evidence that their diet manual was authorized for use by the hospital Medical Staff resulting in the potential for unmet nutritional needs for the 55 patients being served by the facility. Findings include:

On 11/13/12 at approximately 1400 a review of the document titled "Manual of Nutrition Care Management Letter of Review" dated 10/8/12 was signed by the director of Food and Nutrition Services and the Clinical Nutrition Manager, however the line for VP Nursing services was left blank.

During an interview with staff M, the registered dietician on 11/13/12 at approximately 1415 it was determined the facility's therapeutic diet manual is easily accessible to all staff members in three-ring binder format located on all patient care units however, staff M confirmed that the diet manual was not approved by the Chief Nursing Officer nor the Medical Staff.

Based upon observation, interview and document review, the facility failed to provide and maintain adeqaute physical facilities for the safety and needs of the patients and community at failed to comply with applicable provisions of the 2000 Edition of the Life Safety Code. Findings include:

See tags:

A-701 Based upon observation, interview and document review, the facility failed to maintain the physical plant and hospital environment in a manner to ensure patient safety.

A-724 The hospital failed to maintian the physical facilities and equipment for safety and quality.

A-726 The facility failed to provide proper ventilation, lighting, and temperature control.

See the K-tags on the CMS-2567 dated November 19, 2012.

Based upon observation, interview and document review, the facility failed to maintain the physical plant and hospital environment in a manner to ensure patient safety. Findings include:

On 11/13/12 at approximately 4:00 PM during the facility tour of the mobile MRI dock area, the mobile MRI was in place for service that day, but the canopy to enclose the outdoor space between the hospital building and the MRI trailer was not being used. When the technician on the MRI trailer was asked why the canopy had not been used he responded that it had not been used for over a year because the canopy had many rips and holes in it due to dry rot. The outdoor temperatures during the hours the mobile MRI had been in operation on the day of the survey had been less than 40 F. Patients using the mobile MRI often are taken by wheelchair from grade level up a hydraulic lift on the side of the level of the MRI trailer. This process is currently being done with the patients exposed to the elements.

On 11/13/12 at approximately 3:30 PM, during the facility tour, there was sprayed-on fireproofing material scattered over most of the #5 stairwell steps from the basement to the first floor. The fireproofing material had fallen down from the metal pan ceiling of the stairwell. Occupants attempting to use this stairwell would have been at risk for slipping and falling.

On 11/14/12 in the afternood during the facility tour the condition of the roofs were observed and noteworthy problems in addition to minor rips in the flashing included:
a. There was a portion of the roof over the emergency department (to the South of the EC penthouse) had drain problems as evidenced by a large pond of water approximately 8 feet by 10 feet in size.
b. There was also significant vegetative growth on the roof in an area approximately 10 feet by 50 feet just south of the EC Penthouse roof area.
c. There was a six foot long portion of the roof edge flashing on the main patient tower roof (North wing, west side), which had been torn away from the roof and was bent upwards exposing the area under the roof to potential moisture.

The 5th floor Medication Room backsplash behind the handwash sink was water damaged and not sealed where it attaches to the countertop. This was observed on 11/14/12 at approximately 2:45 PM.

Based upon observation, interview and document review, the hospital failed to maintian the physical facilities and equipmentfor safety and quality. Findings include:

1. On 11/13/12 at approximately 12:45 PM during the facility tour of the kitchen, the dish machine failed to come up to temperature during the rinse cycle as evidenced by a heat tape strip on a plate being placed through the dish machine on three separate tries and failing to change the indicator black which would indicate a surface plate temperature of at least 160 F.
During the last run through we observe the water temperature gauge for the rinse cycle to increase from 160 F to approximately 170 F but no higher.
The Dietary director explained that the dish machine was not on routine preventive maintenance but was under contract for servicing by Rite-way Service whenever repairs were needed.
There was no log for routine recording of dish machine final rinse temperature. The Dietary director also explained that there was no schedule for checking that the dish machine rinse water reaches the required 180 F and that there was no schedule for validating that dishware surface temperature with test strips.

2. On 11/13/12 at approximately 12:30 PM during the facility tour of the kitchen, the wall next to the pop machine was noted to be in disrepair with the cove base chipped and broken. A review of the most recent County Health Department inspection dated 9/4/2012 identified this same issue as a non-critical violation.Also, there was a section of floor involving approximately 14 quarry tiles South of the dish machine which were heaved up over an inch high with five of them cracked causing a significant trip hazard.

3. On 11/14/12 at approximately 2:00 PM during the facility tour of the North Mechanical Room I observed that the medical air compressor, which has two pumps, was short cycling and one of the pumps was not working. The Director of Operations confirmed that the inoperable pump had siezed up. Thus, the medical air system is currently operating without any backup pump which puts patients at greater risk.

4. Baed on document review of preventive maintenance records for AHU # 1, which serves the operating room, the documented filter changes were as follows:
- 10/26/12 changed pre-filters
- 10/11/12 changed FINAL filters
- 9/27/12 changed pre-filters
- 3/5/12 changed prefilters
- 3/15/11 changed FINAL filters
- 6/17/2010 changed FINAL filters
- 7/1/2009 changed FINAL filters & pre-filters

The documentation of pre-filter change is inconsistent. There is no record of any preventive maintenance performed on this unit for the past three years.

5. The nurse call system has not been provided/maintained in several areas as observed during the facility tour on 11/13 & 14/ 2012 in the following:
- The nurse call cord was too long ( touching the floor) in the radiology toilet room off of Ultrasound Rm 120.
- The nurse call system was non-functional in four toilet rooms serving fluoroscopy 157 A&B as well as 158 A&B.
- There was no nurse call cord provided in the staff/patient toilet room for pain management.
- The nurse call cord for the EC Fast track area was non-functional.

Based upon observation, interview and document review, the facility failed to provide proper ventilation, lighting, and temperature control. Findings include:


1. On both 11/13/12 and 11/14/12 during the facility tour numerous lights were found burned out throughout the facility. These include:
- Dietary walk-in cooler light burned out
- One light out in ceiling of Dish machine area
- One light out in cardiac Imaging Room 112
- Two lights out in soiled holding/med waste room by loading dock
- One light out above sink in radiology Rm 1 (159)
- Two lights out in the Sterile Wrap Room
- Under cabinet light out at Scrub sink by OR 6

2. The ventilation system had various HVAC grills which had an accumulation of dust and dirt including dietary supply and return vents, and EC isolation room exhaust vent.

3. The supply air grill in the linen room next to room 116 was stuffed with towels. This resulted in the clean linen room not being under the required postive pressure on the day of the survey.

Based on observation, interview and document review, the facility failed to develop, implement, monitor and evaluate a program for the prevention of healthcare associated infections that encompasses the scope of services provided, resulting in the potential risk for transmission of infection among patients, visitors and staff. Findings include:

See Tags:

A-748 failure to provide adequate resources to meet the infection control program needs of the facility
A-749 failure to monitor and provide a sanitary environment

Based on interview and document review the facility failed to provide sufficient personnel for the scope of responsibilities for the Infection Prevention Program resulting in the potential risk for unrecognized lapses in infection control practices resulting in risks for transmission of infectious agents. Findings include:

Interview with staff A, the previous infection prevention manager (from February 2012 through July 2012) on 11/15/12 from approximately 1100 through 1200 revealed that he was the previous infection prevention manager, who was going to interview for this survey because the current infection prevention manager, staff AI, is off on vacation.

Staff A was asked about the 2012 Infection Control Program, plan description. Staff A indicated that they were still using the plan titled "Doctors Hospital of Michigan Infection Control Department 2010 Infection Control Plan for the Surveillance, Prevention, and Control of Infection" because they are "still doing the same surveillance". Staff A was asked for the facility 2011 and 2012 Infection Control Departmental plan in addition to the evaluation of the initiatives implemented in 2010 and 2011 plans, to which he replied, "I don't think that we have that". Staff G was asked whether there were Infection Control Plans for 2011 and 2012, to which she replied she would call the current infection preventionist "to find a current plan". On 11/15/12 at approximately 1530, a document was provided titled "Doctor's Hospital of Michigan Infection Control Department 2012 Infection Control Plan for Surveillance, Prevention, and Control of Infections". Staff G was asked whether these were just made to which staff G replied "yes". During document review of "Doctor's Hospital of Michigan Infection Control Department 2012 Infection Control Plan for Surveillance, Prevention, and Control of Infections", content refers to 2009 data.

Staff A was asked about the facility Infection Control Committee (ICC) meeting frequency and minutes to which he replied, "we didn't really have a committee meeting, I reported our surveillance data to the quality group and the surgical staff". On 11/15/12 at approximately 1000 during document review for the ICC minutes revealed a single agenda for the ICC, dated September 12, 2012. Review of minutes for the September 12, 2012 meeting revealed that there was "no previous ICC meeting minutes to review for approval". The minutes also revealed that "the committee meets every other month....It was decided that the meeting will meet quarterly...It was suggested that since we have not been having meetings and for the committee to catch up, the committee should meet monthly...". Staff AI, the current infection preventionist was interviewed on 11/15/12 at 1445, who revealed that "we (the ICC) haven't met except for in September (2012).

On 11/15/12 at approximately 1115 a review of the facility policy and procedure manual revealed that the last infection control policy and procedure manual review was between 2009 and 2010. Interview with staff AI confirmed that "reviewing our policies is a priority for 2012".

On 11/15/12 at approximately 1445 during interview with staff AI regarding responsibility for infection control oversight of the outpatient facilities, staff AI indicated that there really is not enough time to do all that with all the new (NHSN) surveillance requirements, "I'm there (at work) until 9 or 10 o'clock some evenings..".

On 11/15/12 at approximately 1200 staff G was asked for the hand hygiene process monitor by unit for the facility for 2012. Staff G said that she "has it" however was never able to provide a copy to the surveyor before exit.

On 11/15/12 at approximately 1145, Staff A was asked whether the Infection Control Dept has any oversite of sterilization and disinfection in the facility and outpatient areas, to which Staff A replied "no".

On 11/15/12 at approximately 1150 Staff A was asked about the surveillance results that were reported the first and second quarter of 2012 and specifically any corrective action taken to reduce the rates reported for targeted health care associated infections or blood culture contamination rates, or what the impact of any corrective action that was taken to improve rates, to which he replied "we didn't capture any of that information". Staff A was asked about their first case of healthcare associated clostridium difficile reported in May 2012, and any corrective action taken for that, such as new screening protocol or development of a new policy and procedure form managing patients with clostridium difficile, to which he replied "that was our first case (of clostridium difficile), and no we didn't develop a policy on how to manage patients diagnosed with clostridium difficile".

Based on observation, interview and document review the facility failed to provide for and monitor for a sanitary environment resulting in the risk for transmission of infection among patients, visitors and staff. Findings include:

On 11/13/12 from 0930 until 1140 during facility tour found in a patient-ready room (504), dust and debris accumulation in the corners of the room and under the night stands, overhead lights that had a layer of dust, black mold accumulation on the shower head in the room's bathroom, dust accumulation in the overhead vent in the bathroom, a leak of clear fluid on the bathroom floor around the toilet and in the patient locker for bed two, remaining clean bluepads, clear bags and blankets.

This finding in room 504 was confirmed by staff J on 11/13/12 at 1040.

On 11/13/12 at approximately 1045 found in the supply room/medication room, three medication dispensing carts with tops that had accumulated brownish grime in the creases and drawers that had accumulated dust and debris underneath the medications. Additionally, found three pill crushers that had residual white powder remaining on the crushing mechanisms and dust accumulation on the bottoms.Staff J confirmed on 11/13/12 at approximately 1045 the condition of the medication carts and the pill crushers. Staff K, a floor RN was asked how often these are carts and pill crushers are cleaned, to which she replied "weekly... but it looks like they need it again". On 11/14/12 at approximately 1450 staff T, the registered pharmacist was asked whether they had a policy for cleaning frequency for the pill crusher. On 11/15/12 at approximately 1000 staff T provided a new policy that specifies cleaning frequency for pill crushers. Staff T was asked whether there was a policy prior to the one provided on 11/15/12, to which she replied "no".

On 11/13/12 at approximately 1050 found in the medication room, storage of two "One-Touch" blood glucose monitoring machines contained each in their own black case. Each blood glucose testing machine located in their own black case also contained each one pen-like lancet device and the lancet inserts and opened test strip container. The test strips, located in each of the machines' black cases had manufacturer's expiration date 12/2011 and 4/2011. A third unopened box containing another "One-Touch" kit had a manufacturers expiration date of 4/2011.

On 11/13/12 at approximately 1100, during an interview with staff L, the charge nurse, confirmed that these machines are available for use and stated "we don't use those, I didn't even know those were there".

On 11/13/12 at approximately 1105 during a tour of a patient-ready room 506 found in the patient locker, remaining clean blue pads, bags, dust accumulation in the bathroom vent, and accumulation of dust and debris in the corners of the room.

On 11/13/12 at 1106 the condition of room 506 was confirmed by staff J.

On 11/13/12 at approximately 1110 observations in room 509 revealed a nurse touching a dialysis machine without gloves standing at the bedside without personal protective equipment (PPE) donned. Additionally, the hand hygiene sink in room 509 was obstructed by an empty intravenous bag and approximately one inch gray tubing that snaked around and into the sink. Staff P, the contract hemodialysis nurse was asked whether she should have donned personal protective equipment such as gloves and gown for touching the machine and providing patient care, to which she replied, "we don't have to wear it (PPE) after the patient is put on (the hemodialysis machine)". Staff P was asked where she performs hand hygiene, to which she replied, "in the hand washing sink over there", (referring to the sink that was obstructed with an empty intravenous bag and gray tubing).

On 11/14/12 at approximately 1100, during facility policy review revealed that facility policy titled "Dialysis Infection Control Surveillance", revised 10/09 revealed that "When doing dialysis, the nurses shall wear protective gown, face shield or goggles, mask and gloves...strict handwashing technique is observed between and after all patient contacts...".

On 11/13/12 at approximately 1112 during a tour of patient-ready room 514 found a cup of coffee and a roll wrapped in a napkin located around the hand hygiene sink area. Staff J proceeded to dump the coffee and discard the roll. Staff J was asked about the policy for eating in patient care areas to which she replied "they shouldn't be eating in that room".

On 11/14/12 at approximately 1400 during review of facility policy titled "bloodborne pathogen exposure control plan" dated 9/13/12 revealed "eating, drinking, smoking, applying cosmetics or lip balm, and handing contact lenses are prohibited in work areas,,,food and drink are not placed in refrigerators, freezers, shelves, cabinets, bench tops, ovens, or microwaves where blood or there potentially infectious material are handled or may be present...".

On 11/13/12 at approximately 1135 during a tour of the pantry area found soiling and brownish/black stains on the floor. The patient-food refrigerator had soiling on the shelves and on the bottom of the unit. The molding around the refrigerator and the freezer seal, was stained black and orange with what appeared to be mold-like substance. The freezer had accumulated food stains and residual food on the bottom, in addition to a partially full bottle of water, a covered cup with ice that lacked any name, popsicles and a black knee brace that contained two ice packs, that appeared to be used. Staff J was asked on 11/13/12 at approximately 1140 regarding the condition of the refrigerator and freezer, to which she replied "those things should not be in the freezer", and she proceeded to remove them. When Staff J was asked how often these refrigerator and freezers are cleaned she replied "I'm not sure".




27065

On 11/13/12 at approximately 11:40 am, during a tour of the Psychiatric Unit Medication Room, 5 opened packages containing syringes and 2 opened packages containing needles were observed in a drawer, available for use on patients. There findings were confirmed by the Psychiatric Unit Manager. The Unit Manager stated that these supplies should have been discarded if not used at the time that the packaging was opened.


32164

On observational tour of operating room two on 11/14/12 at approximately 9:20 a.m. inspection of the supply cabinet revealed patient care supplies available for use that exceeded the manufacturer ' s expiration date as follows: (2) red rubber urinary catheters, expiration date 10/12. Staff D was present and shown expired supplies, stated "Oh, those are expired? I will take them."

On observational tour of operating room four on 11/14/12 at approximately 9:32 a.m. inspection of the anesthesia pyxis revealed one open sterile package size 8.0 endotracheal tube and two 20 ml syringes without out packaging lying in a drawer with sterile supplies available for patient use. Staff D was present and shown non-sterile items, stated "We can get rid of those."

On observational tour of the operating room center hall on 11/14/12 at approximately 9:45 a.m. inspection of the crash cart revealed patient care supplies available for use that exceeded the manufacturer's expiration date as follows: (2) Quikpace adult external pacing electrodes, expiration date 12/28/2011 (1) Duraprene sterile gloves size 8.5 expiration date 11/11, (1) Duraprene sterile gloves size 7 expiration date 2/12, (1) Duraprene sterile gloves size 6.5 expiration date 6/12, (4) 2.5 ml saline flush expiration date 4/12. Staff D was present and shown expired supplies, stated "here I'll take those and get new ones."

On observational tour of operating room seven on 11/14/12 at approximately 10:00 a.m. inspection of the anesthesia pyxis revealed patient care supplies available for use that exceeded the manufacturer's expiration date as follows: (1) 2.5 ml saline flush expiration date 4/12, (2) 3-way stopcock expiration date 9/12, (3) 25g 5 inch Whitacre Pencil Point spinal needle expiration date 3/11, (5) 27g 4.69 inch Whitacre Pencil Point spinal needle expiration date 4/11, (5) 25g 3.5 inch TW Whitacre Pencil Point spinal needle expiration date 8/11, (2) 25g 3.5 inch Quincke type point spinal needle expiration date 5/11, (3) 27g x 3.5 inch Whitacre Pencil Point spinal needle expiration date 3/11, (3) 20g 1.25 inch spinal needle introducer expiration date 3/11, (1) 25g 4.69 inch Whitacre Pencil Point spinal needle expiration date 10/10. Inspection of the anesthesia pyxis also revealed four sets of IV tubing without sterile packaging, (2) 20 ml syringes without sterile packaging and open sterile packaged endotracheal tubes sizes 7, 7.5, and 8 in a drawer with packaged sterile supplies. Inspection of the anesthesia cart revealed one open sterile packaged yankauer suction tube and two sets of suction tubing with no sterile packaging in a drawer with packaged sterile supplies. Staff D present and shown expired items, stated "Are those expired too?" Staff D asked who checks these carts, stated "CRNAs." Staff D asked does it appear they are being checked, stated "No it doesn't, this room isn't being used very much."

On observational tour of operating room three on 11/14/12 at approximately 10:45 a.m. inspection of the anesthesia pyxis revealed four open sterile packaged endotracheal tubes sizes 6.5 (2), 6 and 8 in a drawer with sterile packaged supplies available for patient use. Inspection also revealed four 2.5 ml saline flushes with manufacturer's expiration date of 4/12 in a drawer available for patient use. Staff Q present, stated "Those are open because sometimes they get things ready for just in case and we can throw out those flushes."





19647

Based on observation, interview and document review the facility failed to provide for and monitor for a sanitary environment resulting in the risk for transmission of infection among patients, visitors and staff. Findings include:

1. Room 517 isolation room had a neutropenic patient on the day of the survey. This was observed at approximately 3:30 PM on 11/14/2012. The charge nurse explained that the doctor had completed rounds that morning (11/14/12) and put the patient on neutropenic precautions. The patient had been in a semi private room, so the charge nurse on the floor arranged for the patient to be moved from the semi private room to Room 517, which is a private negative pressure isolation room. This negative pressure environment puts the neutropenic at patient at risk for contaminated air being drawn from the corridor under the door into the room. The best environment for a neutropenic patient is a positive pressure protective environment room. For facilities that do not have positive pressure protective environment rooms, it is acceptable for patients in neutropenic precautions to be placed in private rooms that are neutral air pressure. It is not acceptable to place patients under neutropenic precautions in a negative pressure room.

2. There was a medical air supply line provided at the double basin sink in Decontamination Room; however, the air was not working on the day of the survey This was observed at approximately 3:00 PM on 11/14/2012. The Central Services Room technician explained that the air had been off for three months. The facility biomedical maintenance engineer investigated and reported that the shutoff valve for the medical air was closed. Also, the CSR technician was asked how frequently the brushes used to clean instruments were replaced. The CSR tech reported that brushes were not replaced on any routine frequency. When asked if there was any supply of new brushes on hand, the CSR technician reported that he did not know.




30562

On 11/14/12 at approximately 11:45 AM during a tour of the Operating Room and Pre and Post Anesthesia Care areas the following observations were noted:

1) All of the cupboards beneath the sinks throughout the department contained visible dust and debris. This included 2 sinks in the center core of the Operating Room, 1 in Pre Op, 1 in the Post Anesthesia Care Unit (PACU), and 1 in the Isolation Room attached to the PACU. In addition the cupboard beneath the sink in the Isolation room contained a stack of paper plates. Staff D stated ,"Housekeeping should be cleaning under the sinks," and then she removed the paper plates from under the sink.

2) The PACU crash cart contained 2 Multi Lumen Central Venous Catheter kits with an expiration date of 03/2010. When staff S was asked about the policy for checking supplies in the crash cart she stated,"the crash cart gets checked frequently and I don't know how those were missed."








30988

On tour of the Emergency Department (ED) 11/13/12 from 0930(9:30 AM) until 1100 (11:00 AM) in the dirty utility room under the sink 2 pink buckets full of used medical instruments- scissors, hemostats, clamps ect, cleaning products/bleach and bottom covered with dirt/grime, in this same room was found an Anesthesia Emergency Airway Kit available for patient use with 3- Intraosseus needles expired 1-10/12 and 2 11/12, an LMA airway exp 9/12, a Combitube airway exp 4/12 and Nutrake with the exp date of 2002 blacked out with marker. An open bottle of Sterile water undated and available for use was also found in the dirty utility room, a Crib in room B 5 was covered with dust, in the observation area- under the sink was dirty with a new roll of paper towels available for use, on the clean cart a bottle of Normal saline-Betadine- and Hydrogen peroxide were all open and undated. In the medication area- the freezer needed defrosting and the temp logs were not being checked daily.

These findings were confirmed with staff A during the tour.

On tour of the Outpatient Urgent care area 11/15/12 from 0800 (8:00 AM) until 0900 (9:00 AM) on the emergency crash cart was found pacer pads that were exp 12/28/11 and 2 pair peds pacer pads exp 10/28/12.

This finding was confirmed by staff AO and staff H during the tour.

On tour of the Outpatient Endoscopy area 11/15/12 form 0900 (9:00 AM) until 1030 (10:30 AM) it was found that in 2 Procedures rooms the floors were dirty/dusty with debride laying under the equipment and the O2 extension tubing approximately 20 ft long is only changed 1 time each month and lays on the dirty floor to reach the patient.

This finding was confirmed by staff AB, staff AJ, and staff H during tour.