HospitalInspections.org

Based on policy review, document review, staff interview, and medical record review, the hospital failed to provide patients with the correct contact information to lodge a grievance with the State agency.
On 2/21/2017 at 1:23 PM, a policy titled, "Patient Rights/Grievance" was reviewed. The policy did not contain any contact information to lodge a grievance with the State agency.

On 2/22/2017 at 1:00 PM, a document titled, " Notice" stated " ...phone # and address for lodging a grievance with the Health Department is David Shenold, (405) 671-6576, 1000 N. E. 10th ... The correct phone number is 405-271-6576. David Shenold is no longer the Oklahoma State Department of Health intake personnel.

On 2/22/2017 at 1:03 PM, Staff B confirmed that each patient/patient representative received the document titled, "Notice" on admission.

On 2/23/2017 at 9:00 AM, medical records were reviewed. 20 of 20 medical records contained the document titled "Notice" which included the incorrect contact information for the State agency.

Based on document review, policy review and staff interview the hospital failed to maintain documentation of written notice sent to patient/patient representatives who filed a grievance/complaint.

On 2/21/2017 at 1:23 PM, the hospital's 2016 grievances were reviewed. The grievances did not contain information about the patient/patient representatives receiving written notice of the grievance resolution.

On 2/22/2017 at 12:30 PM, the policy title, "Complaint & Grievance Process" was reviewed. The policy stated, " ...final determination within a reasonable period of time and provides the individual with a written notice ..."

On 2/22/2017 at 1:01 PM, an interview was conducted with Staff B. Staff B reported all patients receive a copy of a completed grievance which includes steps taken to investigation the grievance. Staff B confirmed there is no documentation to show evidence written notice was given to the patient or patient representative.

Based on observations and interviews, the hospital failed to provide a safe care setting in regard to the patient call system equipment.

These failed practices had the potential to increase the risk of strangulation for the approximately 35 intellectually disabled inpatients per day.

Findings:

On 02/21/17 at 10:20 am, the surveyors toured the inpatient hospital. The hospital consisted of 6 separate buildings (#1, 2, 3, 4, 5, & 6). Each building housed 6 patients.

During the tour, the surveyors observed the patient rooms contained call lights. The call lights were long white cords that could pose a strangulation risk.

In Patient room 3009, the call light had been removed. Staff B explained the cord had been removed to avoid a strangulation risk. Staff B stated leadership had recently discussed modifying all call cords to minimize strangulation risk for all patients.

Based on policy review and staff interview the hospital's policy failed to implement patient protection from abuse during an investigation of an alleged employee.

On 02/22/2017 at 10:43 AM, a policy titled, "Child and Adult Abuse and Neglect Reporting and Documenting" was reviewed. The policy did not contain information to protect the patient from abuse during an investigation.

On 02/22/2017 at 12:55 PM, an interview with Staff B was conducted. Staff B reported the process is to remove staff from direct patient care and place staff on administrative leave during an investigation of alleged abuse. Staff B confirmed the process is not documented in the policy.

Based on observation and hospital policy review, the hospital failed to follow their policy to secure controlled substances in five of six medication storage areas located within the inpatient hospital. This failed practice increased the risk of unauthorized person to gain access of controlled substances.

The hospital policy titled, "Monitoring of Controlled Substances" was reviewed. The policy stated, " ...controlled substances will be maintained by a double-lock system via locked med room door and locked cabinet ...sched II-V Narcotics and all medications that require a hard prescription for refill are categorized as a controlled substance ..."

The hospital policy titled, "Administration of Medications" was reviewed. The policy stated, " ...ensure medications have been stored according to manufacturer's guidelines and are kept behind two locked doors for safety ..."

On 2/21/17 at 10:47 AM, surveyors toured the inpatient area. The inpatient area consisted of 6 separate buildings ("House" 1, 2, 3, 4, 5, and 6) which contained a medication storage room. Each of the 6 medication rooms included a "narcotic" basket located in the medication storage cabinet and a lock box located inside each refrigerator. 5 of 6 medication storage cabinets, which contained narcotics, were unlocked in the medication rooms without a licensed nurse actively present with the medications.

The surveyors observed the following control substances in unlocked cabinets/refrigerators:

~House Two: Klonopin located in an unlocked medication cabinet.

~House Three: Dexmethylphenidate located in an unlocked medication cabinet.

~House Four: Klonopin a total of 4 packages located in an unlocked medication cabinet.

~House Five: Diazepam injection located in an unlocked medication cabinet.

~House Six: Questran located in an unlocked medication cabinet and Ativan located in the refrigerator with the keys attached to the lock box.

On 2/21/17 at 10:48 AM, interview was conducted with Staff A during the tour. Staff A reported that controlled substances/narcotics are stored behind locked medication room doors and locked cabinets and/or in a locked box located in the refrigerators of each hospital building.

Based on observation and hospital policy, the hospital failed to ensure only authorized personnel have access to locked areas. This failed practice increased the risk for potential unauthorized person to gain access to secure areas.

A hospital policy titled, "Keys" was reviewed. The policy stated, " ...each licensed nurse shall carry a key to the medication room when on duty.

A hospital policy titled, "Monitoring of Controlled Substances" was reviewed. The policy stated, " ...controlled substances will be maintained by a double-lock system via locked med room door and locked cabinet ...sched II-V Narcotics and all medications that require a hard prescription for refill are categorized as a controlled substance ..."

A hospital policy titled, "Drug Storage Area Hospital Unit Nurse Responsibilities" was reviewed. The policy stated, " ...the nurse shall ensure that the medication room door is closed and locked when the nurse is not at the nurse's station.

On 2/21/17 at 10:47 AM, during a tour of the inpatient hospital, surveyors observed keys to access control substances attached to a lock box located in a refrigerator with the medication Ativan stored in one (House 6) of the six drug storage area without a licensed nurse present. Staff A confirmed the keys should not be located inside the refrigerator.

Based on observations and interviews, the hospital failed to ensure the patient call system equipment was maintained at an accepted level of safety.

These failed practices had the potential to increase the risk of strangulation for the approximately 35 intellectually disabled inpatients per day.

Findings:

On 02/21/17 at 10:20 am, the surveyors toured the inpatient hospital. The hospital consisted of 6 separate buildings (#1, 2, 3, 4, 5, & 6). Each building housed 6 patients.

During the tour, the surveyors observed the patient rooms contained call lights. The call lights were long white cords that could pose a strangulation risk.

In Patient room 3009, the call light had been removed. Staff B explained the cord had been removed to avoid a strangulation risk. Staff B stated leadership had recently discussed modifying all call cords to minimize strangulation risk for all patients.

Based on interviews and document review, the hospital failed to designate an Infection Control Preventionist who was qualified through education/training, certification, or experience to oversee the infection control program.

Findings:

On 02/21/17 at 10:20 am., the Administrator identified Staff D as the Infection Control Preventionist (ICP). The Administrator stated Staff D was a former staff nurse of the hospital, and had taken the ICP position approximately 6 months prior.

During an interview, Staff D stated she had no prior infection control experience and training.

On 02/21/17 at 12:36 pm, the personnel file of Staff D was reviewed. The file contained general infection control core curriculum that was given to all staff, and immunization training. The Director of Nursing stated Staff D had been scheduled for training; but due to staffing shortages, the course was canceled.

Based on observations, interviews, and document review, the infection control preventionist failed to ensure:
a. proper aseptic/sanitary practices occurred in the medication room,
b. supplies were appropriately cleaned and disinfected, or disposed of,
c. patient textiles were processed in manner to make them hygienically clean, and
d. staff wore adequate personal protective equipment when pre-rinsing grossly contaminated textiles.

These failed practices had the potential to increase the risk of infections and communicable diseases for approximately 35 intellectually disabled inpatients per day.

Findings:

On 02/21/17 at 10:20 am and 02/22/17 at 12:55 p.m., the surveyors toured the inpatient hospital. The hospital consisted of 6 separate buildings (#1, 2, 3, 4, 5, & 6). Each building housed 6 patients. Amongst other spaces, including the patients' bed rooms, each building contained a medication room, treatment room, and laundry room.

a. Medication Room Sanitation

During both tours of the hospital, the surveyors observed the medication rooms in all of the buildings, were cluttered with paper products, personal items of staff, supplies, medication, food and other items.

(A medication room should be a secured room with minimal extraneous traffic. The activities in the medication room should be those considered clean, and not a reprocessing area for contaminated items.)

In each of the buildings, the medication preparation counters were split into 2 sections, and divided by a handwashing sink. Medication supplies were kept on the smallest counter space, within the splash zone of the hand washing sink. These supplies included new medication administration cups, the medication trays, and used syringes with initials on most of the plungers.

Personal items, non-medication related items, and multiple baskets containing feeding tubes extension sets, syringes, and respiratory/nebulizing equipment cluttered the larger counter spaces.

On 02/21/17 at 10:20 am, during an interview, Staff A stated the medication room was used not only to store and prepare medication, but also to store other supplies and to clean and disinfect feeding tube and respiratory supplies and equipment. Staff A said the syringes to administer oral medication were cleaned in the medication room and reused.

Staff EE stated the basket were cleaned with hydrogen peroxide. No hydrogen peroxide was seen in the medication room, and Staff B stated hydrogen peroxide was not used to disinfect the basket.


The following are specific findings observed in each building's medication room:

Building #1:
Plastic cup filled disassembled multiple reused syringes in the handwashing sink

Building #2:
Feeding tube extension set hanging from a paperclip suspension over hand washing sink.
On a shelf next to the mediation counter, popcorn was next to lotion and air freshener.

Building #3:
Plastic cup filled disassembled reused syringes next to handwashing sink nebulizer mask without a name
Three bottle brushes- 2 of which the bristles were brown
Palmolive dish soap
Disassembled nebulizer equipment in a basket without a name
Coffee pot

Building #4:
Plastic cup filled disassembled reused syringes next to handwashing sink - initial written on plunger handle
Palmolive dish soap
Nebulizer equipment with and without name- liquid seen in tubing
Lip balm
Lotion

Building #5:
Big Gulp drink
Water bottle
Hair brush
Basket- bulb syringe
Feeding tube extension sets in basket labeled with name.

Building #6:
Nail polish remover next to dermal wound cleaner and duoderm dressing.
(This deficient practice had the potential to expose patients to chemical contamination. Internal and external chemicals should be segregated.)
Lotion, phone chargers
Syringes with initials disassembled in cup next to hand washing sink.

b. Supplies reprocessing

On 02/21/17 at 10:20am, during an interview, Staff A and Staff B stated staff cleaned and disinfected oral syringes, feeding tube supplies, and respiratory supplies in the medication room. The details of the cleaning practices and deficient practices are as followings:

Syringes used for oral medication

The surveyors requested a policy for the cleaning/disinfecting and reusing single use syringes, and none was provided. No Governing Board authorization of reusing single use syringes for oral medication was provided to the surveyors.

The surveyors observed some plungers were unlabeled and no syringe barrels were labeled. The syringe parts were place in a small unlabeled cup to air dry. These syringes were within the splash zone of the handwashing sink.

During an interview, Staff A and Staff B stated that single use slip-tip syringes were used as single patient use items as a cost saving measure. They stated the syringes were washed in dish soap. Staff A stated the nurses were to label the syringes.

This deficient practice had the potential to expose patients to contaminated syringes.


Tube Feeding Extension Set

The hospital policy titled, "Enteral Nourishment per Gastrostomy / Jejunostomy". The policy did not document how to clean the feeding tube extension set.

Staff B provided the manufacturer's guidelines for the feeding tube extension set. The guidelines verified the sets were "single patient use only".

The surveyors observed a feeding tube extension set hanging from a paperclip suspension over hand washing sink. The extension tube contained a small amount of clear liquid.

During an interview, on 02/22/17 at 12:55 pm, Staff B stated patients' gastrostomy feedings were performed in the patients' bed rooms. The feeding bag and the feeding tube extension sets were brought to the medication room and cleaned with mild soap.

This deficient practice had the potential to expose patients to contamination associated with adequate tube feeding equipment cleaning, and residual liquid in tubing which can harbor microbial growth.

Nebulizer Equipment

Staff B provided hospital policies that designated two standards of care in regard to the cleaning/ disinfecting of nebulizer equipment. Staff B provided the surveyors with generic instructions for home care of nebulizer equipment and information from the Cystic Fibrosis Foundation. The instruction for cleaning/disinfection varied.

The first hospital policy titled, "Nebulizer Therapy 07/16" described a clean technique. The policy documented nebulizer equipment should be disassembled into the nebulizer, tubing, and the delivery piece. The tubing and deliver piece should be rinsed with warm soapy water and dried with a towel. The equipment should be placed in a sealed bag with the patient's label attached.

The second policy was titled, "Cleaning Nebulizer for patients with CF [Cystic Fibrosis] 01/23/07. The policy documented the nebulizer mask and nebulizer cups were to be cleaned after use with friction and soap and water, then rinsed and allowed to air dry. The nebulizer mask and cups were to be disinfected every 24 hours...then placed in a ziplock bag full of cold disinfectant of 70%-90% ethyl alcohol for 5 minutes or hydrogen peroxide for 30 minutes then rinsed with sterile or filtered water...then allowed to air dry. The steps of this policy were outlined by the Infection Control Preventionist and posted in the medication rooms.

Staff B stated the policy titled, "Cleaning Nebulizer for patients with CF" was based on instructions from the Cystic Fibrosis Foundation. The surveyors reviewed the foundation's instructions titled, "Nebulizer Care at Home".

Staff B provided instructions for cleaning/disinfections titled, "Devilbiss Nebulizer Cleaning". These instruction documented the equipment be disinfected daily with 3 parts water and 1part vinegar or medical bacterial-germicidal disinfectant and to follow manufacturer's guidelines.

Center for Disease Control and Protection (CDC) article titled, "Guidelines for Preventing Health-care associated Pneumonias 2003" documented, "Small- volume medication nebulizers: in-line and hand-held ...between treatments on the same patient clean, disinfect, rinse in sterile water ...and dry small-volume in-line or hand held."

The surveyors observed some baskets were labeled with a patient's name and some were not. The surveyors observed the nebulizer tubing in multiple baskets, some tubing contained a small amount of clear liquid.

The surveyor requested validation that all nebulizer equipment used by the patients were reusable, and none were provided.

Staff B stated the second policy was developed due to two cystic fibrosis patients, who regularly have nebulizer treatments, and had been diagnosed with pseudomonas in their respiratory tract. The second policy described a disinfection technique for nebulizer equipment.

Staff B stated patients' received nebulizer treatment in the treatment room. Staff B stated all patients' nebulizer equipment were cleaned and air dried in the medication room.

These deficient practices had the potential to expose patients to contamination associated with nebulizer equipment cleaning, and residual liquid in tubing can harbor microbial growth.



c. Laundry -Hygienically Clean Textiles

The hospital policy titled, "Handling Contaminated Linen 10/16" was reviewed. The policy documented that all contaminated linens/laundry from the isolation room will be rinsed in a washer with a bleach tablet added. The hospital failed to follow CDC guidelines thereby making all patient texiles hygienically clean, including non-isolation patients.

Center for Disease Control and Protection (CDC) article titled, "Guidelines for Environmental Infection Control in Health-Care Facilities 6/03" documented extensive detailed guidelines for laundering in a healthcare facility. "Laundry in a health-care facility may include bed sheets and blankets, towels, personal clothing, patient apparel...The laundry facility in a health-care setting should be designed for efficiency in providing hygienically clean textiles, fabrics, and apparel for patients and staff..." The article specfied the laundering processes including mechanical, thermal, and chemical factors that would render textiles hygienically clean.

02/22/17 at 12:55 p.m., the surveyors toured the inpatient hospital. The hospital consisted of 6 separate buildings (#1, 2, 3, 4, 5, & 6). Each building contained a washer and dryer that serviced the textile laundering needs of the patients assigned to the building.

During interviews, Staff DD stated non-chlorinated soap was used for each routine wash cycle, and stated the washer basin was not disinfected between patient clothing. Staff B stated the hospital water temperature was 110 degrees.

This deficient practice made the assumption that all contaminated textiles could be identified and failed to acknowledge the potential infection exposure for all patients and staff from microorganisms.


d. Laundry-Adequate Personal Protective Equipment

The hospital policy titled, "Handling Contaminated Linen 10/16" was reviewed. The policy documented linen or laundry is grossly soiled, it should be rinsed in the hopper..." The policy did not define the personal protective equipment required for this activity.

The above CDC article documented, "Laundry workers should wear appropriate personal protective equipment (e.g., gloves and protective garments) while sorting soiled fabrics and textiles...

02/22/17 at 12:55 p.m., the surveyors toured the inpatient hospital. The hospital consisted of 6 separate buildings (#1, 2, 3, 4, 5, & 6). Each building contained a washer and dryer that serviced the textile laundering needs of the patients assigned to the building.

During an interview, Staff DD stated the Direct Care Specialists (DCS) were responsible for washing the patient's clothing, towels, and bed linens in house. Staff DD stated washing and drying laundry was part of Staff DD's evening duties.

Staff DD stated contaminated textiles were cleaned by hand in the hopper before being placed in the washer. The hopper was located in the laundry room. Staff DD stated gloves were worn for this pre-wash activity.

On 2/22/17 at 10:11am, the personnel files of 2 DCS were reviewed. 2 of 2 DCS files failed to have evidence of competency training for performing laundry services.

This deficient practice potentially results in infection exposure for all staff when handling all textiles not identified as contaminated.

Based on document review, policy review, and staff interview the hospital failed to adhere to their responsibilities according to the organ procurement agreement in its policy.

Findings:

On 2/22/17 at 9:15 AM, an agreement with Organ Procurement Organization (OPO), LifeShare was reviewed. The hospital's policy titled, "Organ/Tissue Donation" last reviewed by the hospital on 12/03/2015, referred to an OPO by the name of "Oklahoma Organ Sharing Network".

On 2/22/17 at 9:15 AM, a policy titled, "Organ/Tissue Donation" last reviewed by the hospital on 12/03/2015 was reviewed. The policy did not reflect the communication responsibilities stated in the agreement between the hospital and organ procurement, LifeShare.

On 2/22/17 at 12:55 AM, a staff interview was conducted regarding the procedure for communication between OPO and the hospital in an event of a death. Staff B reported the hospital contacts LifeShare within an hour of a death. Staff B confirmed in an event of a death the procedure does not correlate with the hospital's policy.