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Based on observation and staff interview, the facility failed to ensure the floors in 3 of 5 patient areas (hallway, entrance, and patient room) were kept clean and/or safe from potential fall hazards. The findings were:

Observation of the facility on 9/26/16 at 2:30 PM showed the facility main hallway and hospital entrance floor were carpeted. The following concerns were identified:
a. The carpet in the hallway throughout the facility and the hospital entrance area showed multiple darkened and whitish stains. In addition, there were prominent wrinkles in the carpet in front of the nursing station that posed a potential trip hazard.
b. Measurements of these areas on 9/28/16 at 10:30 AM showed the largest stain measured 54 inches in diameter. The 8 wrinkles in the carpet remained present, and the largest wrinkle measured 69 inches across. In addition, there were multiple blackened scuff marks over the entire floor in patient room #3.
c. Interview with the maintenance assistant on 9/28/16 at 10:05 AM revealed the carpet in the hospital hallways and conference room was about 20 years old and had been attempted to be cleaned and was "way beyond it's useful life."
d. Interview with the maintenance director on 9/28/16 at 1:05 PM confirmed the facility was unable to remove the carpet stains and wrinkles, and the carpet needed to be removed as the surface was not cleanable and the unsafe wrinkles could not be removed. He further stated one contractor had made an offer for removal of the carpet and replacement with a non-carpet cleanable floor. However, he confirmed the facility failed to have a plan with a timeframe to replace the uncleanable carpet.

Based on policy review and staff interview, the facility failed to ensure patient care policies met the annual review requirements. The annual reviews were lacking for 7 of 7 department policy and procedure manuals reviewed (emergency department, swing bed, acute nursing services, infection control, radiology, laboratory, clinical records). The findings were:

Review of department policy and procedure manuals for emergency, swing bed, acute nursing services, infection control, radiology, laboratory, clinical records showed they lacked evidence of annual review by the group of professionals. Interview with the DON by phone on 9/29/16 at 11:40 AM confirmed the group of professionals including a physician and mid-level practitioner had not completed the annual reviews. The review dates included:
a. Review of the policy book with titles, "Acute Care", "Emergency Department", "Swing Bed", and "Medications" showed the most recent date of review was 9/26/11.
b. Review of the policy book with titles, "Acute Care/Emergency Department" and "Blood Glucose Testing and Monitoring" showed the most recent date of review was 12/26/13.
c. Review of the policy book titled, "Swing Bed" showed the most recent date of review was 6/29/12.
d. Review of the policy book titled, "Infection Control and Exposure Manual" showed the most recent date of review was 12/16/11. Review of the policy book titled, "Laboratory Policies/Procedures" showed the most recent date of review was 7/20/12.
e. Review of the policy manual for radiological services and interview with the radiology director on 9/27/16 at 10:15 AM revealed she reviewed the policies annually; however, they had not been reviewed annually by a physician or mid-level practitioner.

Based on observation, policy review, and staff interview, the facility failed to ensure laryngoscope blades were disinfected prior to use in 1 of 1 storage area (emergency room crash cart). The findings were:

Observation on 9/27/16 at 9:12 AM revealed 15 multi-use laryngoscope blades stored in the emergency room crash cart that were unpackaged. Interview with nurse practitioner #1 on 9/27/16 at 9:12 AM confirmed the laryngoscope blades were not packaged and were available for use.

Review of the 7/3/14 policy titled, "Autoclave" showed the following, "ET [endotracheal] Blades: After blades have been used clean with instrument soap as you would with other instruments. Place on sink to air dry, after they are dry, wipe blade with sani wipes, place in stainless steel container, and take to autoclave area. Infection control person will place blade in an autoclave sleeve, mark that it is clean not sterile, and return to crash cart..."

Based on observation, staff interview, and review of maintenance logs and policy and procedure, the facility failed to ensure sanitary conditions in 1 of 1 kitchens and for 2 of 2 ice machines. In addition, the facility failed to have a nutrition department policy and procedure manual specific to their operation and processes. The findings were:

1. The following concerns were identified related to ice machines:
a. Observation of the ice maker/dispenser in the kitchen on 9/28/16 at 9:30 AM showed the plastic part where the ice came out was corroded with white/cream colored substance that appeared to be hard water mineral build-up. The interior of the machine where the ice was made also had large areas of what appeared to be hard water mineral build-up.
b. Observation on 9/28/16 at 9:50 AM showed the ice machine located near the nurses' station had hard water build-up on the exterior sides located around the rubber seal. The seal appeared to be in poor condition allowing seeping from the interior.
c. Interview with the maintenance assistant on 9/28/16 at 9:50 AM verified the build-up on both machines was from the hard water. Review of the maintenance logs showed the machines were cleaned and sanitized every 3 months. The last time the machines were cleaned was 6/30/16, and they were due. The maintenance assistant verified some parts may need to be replaced if they were unable to be effectively cleaned; however, there was no planned time frame to replace the worn parts.

2. Observation in the kitchen on 9/28/16 at 9:30 AM showed the vents of the hood system were soiled with dark dust and grease. There were two hand sinks in the kitchen and both had unlabeled nail brushes available for use. Three cutting boards stored on a shelf had deep scoring which made the surface no longer cleanable. Interview with the dietary manager at that time verified the cutting boards were old and in poor condition. She further revealed the hood vents were cleaned every 6 months when the contracted professionals came to service the hoods. Further, the manager was not aware it was unacceptable to share nail brushes.

According to Food Code 2013, U.S. Public Health Service, Annex 3- Public Health Reasons / Administrative Guidelines: 2-301.12 Cleaning Procedure. "...Fingernail brushes, if used properly, have been found to be effective tools in decontaminating this area of the hand. Proper use of single-use fingernail brushes, or designated individual fingernail brushes for each employee, during the handwashing procedure can achieve up to a 5-log reduction in microorganisms on the hands."

According to Food Code 2013, U.S. Public Health Service: 4-601.11 "(A) Equipment food-contact surfaces and utensils shall be clean to sight and touch...(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris."

According to Food Code 2013, U.S. Public Health Service: 4-201.11 "EQUIPMENT and UTENSILS shall be designed and constructed to be durable and to retain their characteristic qualities under normal use conditions.

3. Review of the dietary and nutrition department policy manual showed it was a purchased policy and procedure manual. There had been no revisions or facility specific procedures developed or any reviewed dates. Interview with the consultant registered dietitian on 9/29/16 at 11 AM revealed the policy manual needed to be reviewed and procedures could be tailored to fit the process used at the hospital.

Based on staff interview and review of patient services furnished under arrangements and agreements (radiology, laboratory, physical/speech therapy, pharmacy), the facility failed to maintain a list to describe the nature and scope of the services provided. The findings were:

Agreement review showed the following patient services were provided under agreement: radiology, laboratory, physical/speech therapy, and pharmacy. However, a list of these services was not maintained which described the nature and scope of the services provided. Interview with the DON on 9/29/16 at 11:40 AM confirmed the facility failed to maintain a list with the services and descriptions.

Based on observation, staff interview, and review of medical records and policy and procedure, the facility failed to ensure the medical record system was maintained under established policy and procedures (C301), and that required information was completed for 2 of 20 patients (C305). Further, the facility failed to protect medical records against loss and unauthorized use in 1 of 2 storage areas (C308). The cumulative impact of these deficiencies was a determination that the facility failed to meet the Condition of Participation for Clinical Records.

Based on review of policy and procedure, medical record review, and staff interview, the facility failed to ensure the clinical records system was maintained based on established policy and procedures. The findings were:

Review of 20 clinical in-patient records showed they were maintained by a combination of paper and electronic medical record documents. Interview with health management employee (HIM) #1 on 9/28/16 a 1:10 PM verified there were two electronic record systems with information as well as some paper documents. The original electronic medical record system was initiated in 2014 and in January 2016 the system was changed to a new electronic program. Review of the policy and procedures related to the clinical records showed the most current date of review was 12/19/13. This review was signed by the department head and board representative. Further, review of the manual showed there were no policies and procedures developed related to the use/safeguards for the electronic medical records system. Interview with HIM employee #1 on 9/28/16 at 1:10 PM verified the policies were in need of review and revision, and there were no policies and procedures related to the use of the electronic systems.

Based on medical record review and staff interview, the facility failed to ensure history and physical exam (H&P) information was included in 2 of 20 sample patient records (#13, #18). The findings were:

1. Review of the clinical record showed patient #13 was admitted to inpatient status on 1/12/16. Review of the electronic clinical record and the paper documentation showed there was no H&P completed. Interview with HIM employee #1 on 9/28/16 at 1:45 PM verified the document was unable to be located and it may have been lost when there was a server problem with the electronic system.

2. Medical record review showed patient #18 was admitted to the facility on 11/13/15 with diagnoses which included essential hypertension. The review showed the patient was discharged on 11/18/15. Review of the entire medical record showed no evidence that a history and physical was completed. Interview with HIM employee #1 on 9/29/16 at 10 AM confirmed the facility was unable to locate a history and physical for patient #18.

Based on observation, policy and procedure review, and staff interview, the facility failed to protect clinical records against loss and unauthorized use in 1 of 2 storage areas (the basement area). The findings were:

Review of the "Record Access" policy last dated July 1, 2008 showed "Access to the medical records will be restricted to authorized personnel...". Keys for record storage areas are "logged out through administration and are not commercially reproducible." The policy further documented that the health information management (HIM) director shall be allocated a key to the archived records storage area. The following concerns were identified:
a. Observation on 9/28/16 at 1:15 PM showed an area located in the basement with stored clinical records. The area was a room with 2 doors, one door from the hallway was locked, and was always kept locked according to HIM employee #1. The other door was accessed through an unlocked employee break room and was unlocked.
b. Interview with HIM employee #1 during the observation revealed the door was kept unlocked so the clinic staff could access the room. Inside the room the clinical records were stored on open shelves in rows with no additional security or separation. The room also served as a food storage area for employees. Observation showed refrigerator and freezer storage units which contained employee food.
c. Interview with HIM employee #1 on 9/28/16 at 1:30 PM verified the clinical records were not secured and were available to anyone who came into the room. She further revealed the policies and procedures related to the clinical records had not been reviewed or updated for several years.

Based on policy review, annual quality review information, and staff interview, the facility failed to ensure a health care policy review was included in the annual program evaluation. The findings were:

Review of the quality review information from October 2015 through July 2016 showed no evidence hospital health care policies were evaluated, reviewed, or revised.

Interview with the DON by phone on 9/29/16 at 11:40 AM confirmed that, with the exception of radiology policies, facility policies had not been reviewed annually.

Based on staff interview and review of medical records. The facility staff list, and quality assurance (QA) meeting minutes, the facility failed to ensure the QA program evaluated physician oversight of mid-level practitioner services. The facility included 7 mid-level practitioners. The findings were:

Review of 20 medical records (#1 - #20) showed each had received some care from a mid-level practitioner. Review of the list of physicians and mid-level practitioners showed the facility staff included 4 nurse practitioners, 2 advanced practice registered nurses, and 1 physician assistant. The following concerns were identified:
a. Medical record review for 20 sample patients showed no evidence a physician reviewed mid-level practitioner services provided.
b. Review of QA meeting minutes for 10/7/15, 11/10/15, 12/29/15, 1/26/16, and 7/14/16, showed no evidence services provided by mid-level practitioners were reviewed by a physician.
c. Interview with the DON on 9/29/16 at 11:40 AM confirmed the QA committee failed to ensure a physician provided oversight concerning the services provided by mid-level practitioners.

Based on staff interview and review of medical records, the facility staff list, and quality assurance (QA) meeting minutes, the facility failed to ensure the QA program evaluated the quality and appropriateness of physician services. The facility staff included 2 physicians. The findings were:

Review of 20 medical records (#1 - #20) showed each had received some care from a physician. Review of physician and mid-level staff list showed the facility had 2 physicians. The following concerns were identified:
a. Medical record review for 20 sample patients showed no evidence the records were reviewed by an outside entity.
b. Review of QA meeting minutes for 10/7/15, 11/10/15, 12/29/15, 1/26/16, and 7/14/16, showed no evidence services provided by physicians had been reviewed by an outside entity.
c. Interview with the DON on 9/29/16 at 11:40 AM confirmed the QA committee failed to ensure services provided by physicians were reviewed by an outside entity.