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Based on document review, interview and observation, the hospital failed to follow its policy to provide documentation of routine medical equipment preventive maintenance (PM) for 2 pieces of equipment (floor scrubber, single cable column device) and failed to ensure that the ED (emergency department) eye wash station was checked weekly.

Findings include:

1. Review of policy REFERENCE CODE: EOC-ME5-P, entitled Medical Equipment: Performance Monitoring, CONTENT REVISION DATE: 4/2/2014, indicated :

Medical equipment will be serviced by IU HEALTH BALL MEMORIAL HOSPITAL
Biomedical Services, relevant information shall be entered into the medical equipment
database and Biomedical Services shall establish a preventive maintenance schedule for the
equipment.

Biomedical Services shall collaborate with appropriate managers and/or vendors to
establish communication channels to ensure Biomedical Services is provided accurate and
timely information concerning routine medical equipment maintenance

2. Review of the facility's PM documentation indicated there was none for a piece of housekeeping equipment, a floor scrubber.

3. Interview of employee #A3, Director Support Services, on 11-17-2015 at 3:35 pm, confirmed there was no documentation for the floor scrubber and no documentation was provided prior to exit.

4. On 11-16-2015 at 1:50 pm, in the presence of employee #A3, it was observed at the offsite outpatient physical therapy area, there was a piece of patient care equipment, a single cable column device. Employee #A3 was requested to provide documentation of PM for this piece of equipment.

5. Interview of employee #A3 on 11-18-2015 at 1:25 pm, indicated there was no documentation of PM for the single cable column device and no other documentation was provided prior to exit.


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6. While on tour of the ED at 1:40 PM on 11/16/15 in the company of staff member #55, the nurse manager of the unit, it was observed on the "ED Cleaning Schedule" that the eye wash station had been done once in November on 11/16/15.

7. At 1:45 PM on 11/16/15, interview with staff member #55 confirmed that the eye wash station is checked once a month, as per the cleaning schedule, as listed above.

8. At 12:40 PM on 11/18/15, interview with staff member #51, the CNO (chief nursing officer), confirmed that the ED unit did not have a policy related to the checking of eye wash stations, and that staff in ED did not realize that eye wash stations should be checked weekly.

Based on document review, observation and interview, the hospital failed to follow its policy regarding oxygen gas cylinder storage in 1 instance (emergency department), failed to ensure housekeeping maintained cleanliness in the ED (emergency department) and failed to ensure that pantry refrigerators were cleanly maintained in two areas toured, ED and med/surg nursing unit.

Findings include:

1. Review of hospital policy REFERENCE CODE: BRT-02-05-P, entitled BRT Oxygen Safety Standards, CONTENT REVISION DATE: 6/1/14, indicated for equipment standing on the floor, use a base designed for stability during storage ... .

2. On 11-16-2015 at 12:45 pm in the presence of employees #A3, Director Support Services, it was observed in the gas storage room that there was 1 small compressed oxygen gas cylinder standing upright on the floor unsecured by a base designed for stability, chain or holder.


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3. Review of the policy Turnover Cleaning (Non-C-diff), policy number EVS-1033-P, last revised 4/8/15, indicated under procedure: clean window ledges, window sills, chair, over bed table, bedside table, shelves, over bed lights, and fixtures with damp disinfectant cloth.

4. At 1:30 PM on 11/16/15, while on tour of the ED in the company of staff member #56, the nurse manager, it was observed that an accumulation of dust was present on the window ledge and blinds in room #2, on the base of the vital signs monitor at the nursing station, on top of the code cart and pediatric code cart, especially behind the defibrillators, and on the ledges above the wheels of the peds cart.

5. At 2:00 PM on 11/16/15, interview with staff member #56 confirmed that dust was present on the areas listed in 2. above.

6. At 4:10 PM on 11/17/15, interview with staff member #52, the director of support services, confirmed that housekeeping staff are to clean ED rooms daily, even if no patient was in the room that day, and that policy number EVS-1033-P is pertinent to the ED, as well as to the med/surg patient rooms. No further documentation was provided prior to exit.

7. Review of the policy Infection Control, Dietary, policy number DTY-1015-P, with a revision date of 11/7/14, indicated on page 4 under the "Storage" section, in item c.: refrigerators are cleaned thoroughly each week; spills are cleaned up and contents straightened daily.

8. Review of the Dietary Weekly Cleaning Schedule for 11/8/15 to 11/14/15 indicated the med/surg and ED refrigerators were last washed and sanitized on Friday, 11/13/15.

9. At 1:45 PM on 11/16/15, while on tour of the ED in the company of staff member #55, the ED RN (registered nurse) manager, it was observed that the pantry refrigerator was dusty and with debris on the shelf units of the door, had a drink lid under the right vegetable drawer, and dust and debris present under both vegetable drawers.

10. At 1:50 PM on 11/16/15, interview with staff member #55 confirmed that the refrigerator had dust/debris as written above.

11. At 11:00 AM on 11/17/15, while on tour of the med/surg nursing unit in the company of staff member #51, the CNO (chief nursing officer), it was observed that there was an accumulation of dust on the top of the pantry refrigerator.

12. At 11:05 AM on 11/17/15, interview with staff member #51 confirmed the dusty top of the pantry refrigerator on the med/surg unit.

Based on document review, observation and interview, the facility failed to ensure the temperature monitoring of one of one lab specimen refrigerator on the med/surg nursing unit was maintained as per policy for temperature monitoring.

Findings Include:
1. Review of the Laboratory Pathology policy, policy number BCH.GEN.011.02 for 'Temperature Monitoring" indicated the temperatures of the "instruments, refrigerators, freezers,...etc. are checked daily or when used" and these results are recorded on the appropriate log sheet.

2. Review of the Laboratory Daily Temperatures log indicated the specimen refrigerators should range between 2 and 8 degrees Celsius, or 35.6 to 46.4 degrees F (Fahrenheit).

3. At 10:45 AM on 11/17/15, while on tour of the med/surg soiled utility room in the company of staff member #51, the CNO (chief nursing officer), it was observed that the temperature log on the lab specimen refrigerator was one for medications and food, not for lab specimens, and that for 9 of 17 days in November the refrigerator was below 35.6 degrees F.

4. At 1:10 PM on 11/17/15, interview with staff member #53, the lab manager, confirmed that the wrong temperature log was being utilized on the med/surg unit and the temperatures being monitored were not appropriate per the lab temperature log that is supposed to be used.

Based on document review and interview, the medical staff failed to ensure the implementation of its rules and regulations related to updating a history and physical after admission, and prior to surgery, for 1 of 4 surgery patient records reviewed, patient #7.

Findings Include:
1. Review of medical staff rules and regulations last approved 3/14/14 indicated:
A. On page 8, under observation, ambulatory care, and ambulatory surgery patients..., it reads: H & P (history and physical) update if H & P was completed prior to date of services.
B. On page 5, under section 12. Medical Records, it reads; a complete history, physical examination record, and tentative diagnosis, in writing or dictated, shall accompany the patient to the operating room...".

2. Review of patient medical records indicated pt. #7 had a laparoscopic cholecystectomy on 10/2/15 and a H & P done on 10/1/15 that was not updated on the day of admission, on 10/2/15. The patient also had a dictated H & P on 10/2/15, but this was dictated at 11:15 AM, which was after surgery, as the patient left the surgical suite at 10:44 AM, per the intra operative nursing notes.

3. At 3:35 PM on 11/17/15, interview with staff member #56, the quality and performance improvement manager/director, confirmed that pt. #7 did not have an update on the 10/1/15 H & P, as required per medical staff rules and regulations, and the dictated H & P was done after the patient's surgery had ended, which was also not per the medical staff rules and regulations. No further documentation was provided prior to exit.

Based on document review and interview, the facility failed to include monitors, standards, and a report to the governing body, for 2 services provided by a contractor (blood bank, dietician) and 1 directly-provided service (social services) as part of its comprehensive quality assessment and performance improvement (QAPI) program for calendar year 2014 and January through October, 2015.

Findings:

1. Review of the facility's QAPI program for calendar year 2014 and January through October, 2015, indicated it did not include monitors and standards for services provided by a contracted blood bank and a contracted dietician.

2. Review of the governing board minutes for calendar year 2014 and January through October, 2015, indicated they did not include review of reports for the above-two stated contracted services.

3. Interview of employee #A8, Performance Improvement Coordinator, on 11-18-2015 at 1:15 pm, confirmed all the above and no further documentation was provided prior to exit.

4. Review of the facility's QAPI program for calendar year 2014 and January through October, 2015, indicated it did not include monitors and standards for services provided by the directly-provided service of social services.

5. Review of the governing board minutes for calendar year 2014 and January through October, 2015, indicated they did not include review of reports for the directly-provided service of social services.

6. Interview of employee #A8 on 11-18-2015 at 2:10 pm, confirmed all the above for social services and no further documentation was provided prior to exit.

Based on document review and interview the facility failed show confirmation that patients received information regarding medicaid benefits and items and services that are covered, and not covered, during their swing bed stay prior to, or at the time of, admission to swing bed status for 3 of 3 swing bed patients, #12, #13, and #14.

Findings Include:
1. Review of the patient medical records for patients #12, #13, and #14 indicated the records lacked any indication that the patients had been informed of, or received copies of, the handbook with swing bed right to choose a personal physician.

2. At 4:10 PM on 11/17/15, interview with staff member #51, the CNO (chief nursing officer), confirmed that there was no documentation for patients #12, #13, and #14 that would indicate they received information regarding their swing bed patients' rights and services. No further documentation was provided prior to exit.

Based on document review and interview, the facility failed to ensure that documentation, related to multidisciplinary care plans and conferences, included the attending physician for 3 of 3 swing bed patients, patients #12, #13, and #14.

Findings Include:
1. Review of the policy Interdisciplinary Process, policy number CMD-1004-P, last revised 11/10/14, indicated the purpose of the policy was that the interdisciplinary process would be the means by which continuity of care and collaboration of disciplines would occur within the patient treatment process, and that the interdisciplinary team consisted of all patient care services within the hospital and would meet three times weekly for collaboration of the patient's care.

2. Review of patient medical records indicated:
A. Pt. #12 was admitted to swing bed status on 11/13/15 and was discussed at the care conference on 11/16/15, but lacked any notation regarding physician involvement with the care planning of the patient, or with attendance at the meeting.
B. Pt. #13 was admitted to swing bed status on 11/5/15 and had care planned at the interdisciplinary care conference on 11/6/15, 11/9/15, 11/11/15, 11/13/15, and 11/16/15, but documentation was lacking regarding physician involvement with the care planning of the patient, or with attendance at the meetings.
C. Pt. #14 was admitted to swing bed status on 11/11/15 and was care planned on 11/13/15 and 11/16/15, and there was no notation regarding physician involvement with the care planning of the patient, or with attendance at the meetings.

3. Review of the "Interdisciplinary Meeting Roster" for the meetings held on 11/9/15, 11/11/15, 11/13/15, and 11/16/15 indicated there was no physician noted as present at any of the care conferences.

4. At 2:25 PM on 11/17/15, interview with staff member #60, the case manager/discharge planner, confirmed that physicians are not present at the interdisciplinary meetings and do not collaborate with the care plans created for each patient. No further documentation was provided prior to exit.

Based on document review and interview, the facility failed to follow its policy to provide a Consultant Dentist, who is a member of the Medical Staff, who will be available in case of dental emergencies in 1 instance.

Findings include:
1. Review of hospital policy REFERENCE CODE: SBD-1003-P, entitled Swing Bed Dental Services, REVISION DATE: 11/10/2014, indicated:

Patients are assisted in obtaining ... emergency dental care. This care is
provided by a Consultant Dentist, who is a member of the Medical Staff.

2. Interview of employee #A1, President & Chief Executive Officer, on 11-16-2015 at 11:10 am, indicated the facility, for the past 2 months and currently, could not provide emergency dental services. The employee also indicated a contract dentist had retired and another dentist in the area had passed away.