HospitalInspections.org

Based on interview and record review, the facility failed to establish policies and bylaws to ensure patients admitted to the hospital by mid-level providers, were under the care of a doctor of medicine or osteopathy. Findings include:

During an interview on 6/19/24 at 7:55 a.m., staff member D stated patients admitted by mid-level providers are also under the care of a physician.

During an interview on 6/19/24 at 4:23 p.m., staff member A stated the facility had identified some gaps in their process for MD/DO oversight. Staff member A stated the facility's policies needed to be clearer in regards to patients admitted by a mid-level provider and medical record documentation of the patients being under the care of an MD/DO.

Review of the facility's document titled, Professional Staff Rules and Regulations, last revised September 2016, did not include documentation to ensure patients admitted to the hospital by a mid-level provider were under the care of an MD/DO.

Based on observation, interview, and record review, the facility failed to adhere to infection prevention standards by not performing hand hygiene in the laboratory for 1 (#18) of 34 sampled patients. This deficient practice had the potential to affect all patients who received care in the laboratory. Findings include:

During an observation on 6/18/24 at 10:20 a.m., patient #18 presented to the laboratory for a blood draw. Staff member O brought patient #18 into the blood draw area and donned a pair of blue nitrile gloves. Staff member O did not perform hand hygiene prior to donning his gloves. Staff member O proceeded with the blood draw. After an unsuccessful attempt, staff member O removed the venipuncture device and discarded it into the sharps container. Staff member O touched the sharps container twice. Staff member O proceeded to touch the counter, and the box containing tourniquets. Staff member O did not change his gloves or perform any hand hygiene prior to proceeding with the second venipuncture. Staff member O collected three vials of blood. Staff member O discarded the used venipuncture device and escorted patient #18 from the laboratory area. Staff member O doffed his gloves and discarded them in the trash. No hand hygiene was performed.

During an interview on 6/18/24 at 10:30 a.m., staff member O could not verbalize what the facility hand hygiene policy stated. Staff member O stated, "I usually just wash my hands in between patients."

Review of a facility document titled, "Hand Hygiene," with an effective date of 05/2024, showed:
"... Hand hygiene is expected of all employees before and after all patient/resident contact, after glove use..."