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Based on observation, interview and record review, the facility failed to issue a Medicare Outpatient Observation Notice (MOON) to one (19) of 48 patients, and failed to issue a MOON notice to one (16) of 48 patients in a timely fashion. These failures placed Patient 19 and Patient 16 at risk for not knowing the fees for services provided and for denying them the ability to ask questions, regarding the full financial implications of Observation status, prior to being placed on Observation status.

Findings:

A record review, on 12/5/17 at 8:0:44 a.m., indicated Patient 19 came in to the hospital for a procedure called PCI. (Percutaneous Coronary Intervention is a non-surgical procedure that uses a thin flexible tube to place a small structure, called a stent, to open up blood vessels in the heart that have been narrowed by plaque buildup.) The record showed English was not Patient 19's primary language therefore hospital sought CyraCom (certified company provider of phone & video interpretation) official interpreter for the patient for her authorization and consent for the PIC procedure. Post-PIC procedure Patient 19 was admitted under observation status. Further review of Patient 19's record showed that the form entitled, "Acknowledgement of Outpatient Observation Status" was signed by Patient 19's emergency contact. Patient 19's emergency contact was not Patient 19's DPOAHC (durable power of attorney for health care). Patient 19's record did not indicate that she lacked capacity to make health care decisions; she could exercise her own rights as a patient in the hospital, including signing the form "Acknowledgement of Outpatient Observation Status."

Patient 19 was interviewed in her room, on 12/5/17 at 9:00 a.m. Patient 19 was alert and responded appropriately to questions. Patient expressed through gestures that her English was very limited (understanding and speaking). Patient 19 requested that her daughter be present to explain any instructions regarding her health care decisions. Patient 19 did not understand the hospital's observation services. She did not know if she received a copy of the observation status acknowledgement form.

Record review, on 12/4/17 at 1:35 p.m., indicated Patient 16 was admitted to the Observation Unit from the ED (emergency department), on 12/3/17 at 11:58 a.m., with the diagnosis of syncope. (Syncope is due to a temporary reduction in blood flow and therefore a shortage of oxygen to the brain. This leads to lightheadedness or a "black out" episode, a loss of consciousness.) Patient 16 was discharged, on 12/4/17 at 12:29 p.m., therefore unavailable for interview.

Further record review showed that the MOON (Medicare Outpatient Observation Notice) was issued to the patient for acknowledgement and signature, on 12/4/17 at 11:20 a.m., the day of discharge.

MA (Manager Admitting Department), CCA (Confidential clerk for admitting) were both interviewed, on 12/5/17 at 2:10 p.m. MA stated the hospital registration clerk was responsible for issuance of form MOON/Acknowledgement of Outpatient Observation Status. MA stated forms were issued to a patient for signature after the patient's status was determined and documented by the physicians. MA said the goal of the department is for the patients to sign the form while they are in ED, and not for the patients to sign upon discharge.

Review of the hospital's document, "Medicare Outpatient Observation Notice", included the following information for patients: "...You're a hospital outpatient receiving observation services..Being an outpatient may affect what you pay in a hospital...Observation services may affect coverage and payment of your care after you leave the hospital...If you have any questions about your observation services, ask the hospital staff member giving you this notice or the doctor providing your hospital care..."

Based on staff interview and document review, the hospital failed to ensure accuracy of its privileging process when it granted clinical privileges to two physicians for medical services the hospital does not provide. By granting hospital privileges to physicians, for services not under the supervision of the hospital medical staff, carries the potential to confuse hospital services with non-hospital services and has possible adverse consequences in the quality of care.

Findings:

During a review of the hospital medical staff credential files on 12/5/17 at 10 a.m., 2 of 16 files had the following: granting of 17 distinct radiation oncology privileges, the dosing of specific body tissue and organs with ionizing radiation in order to treat diseases. By review, the hospital does not have radiation oncology listed on its license as a service the hospital provides. According to the Chief Medical Officer, interviewed at the same time, The Radiation Oncology Center is an affiliated program of the hospital township district but not part of the hospital. The Radiation Oncology Center is not overseen by the hospital's medical staff nor its radiology department, quality assessment or other manner of hospital oversight.

A review of the Medical Staff Bylaws, Rules and Regulations, dated 10/10/12, Article V stipulates: "...privileges and services must be Hospital specific, within the scope of any license, certificate, or other legal credential authorizing practice in this State and consistent with any restrictions thereon, and shall be subject to the Rules and Regulations of the clinical department and the authority of the department and the Medical Staff."

Based on observation and interview, the hospital failed to conduct an orderly transfer from its Intensive Care Unit (ICU) to another hospital for one (1) of 48 patients. For Patient 1, who had a stroke and a tracheostomy (an artificial opening in the wind pipe permitting facilitating breathing). Nursing staff failed to monitor the cardiac rhythm on telemetry as per physician's orders. The Respiratory Therapy Department did not initially participate in the discharge and had to be summoned to troubleshoot a respiratory issue. These failures resulted in lack of continuity of care during the transfer process and had the potential to cause Patient 1's medical condition to deteriorate.

Findings:

Review of the clinical record showed the hospital admitted Patient 1, on 10/31/17, after he suffered a stroke. Patient 1 was weaned from the ventilator and required oxygen to his tracheostomy Patient 1 was very obese.

During a tour of the hospital's ICU, on 12/4/17 at 10:10 a.m., and accompanied by the Senior Director Nursing Education (DNE) and the ICU Nurse Manager (NM) 4, Patient 1's transfer process was observed. Patient 1 was removed from the hospital's cardiac monitor. There was a 10 minute period of time that Patient 1 was not attached to a heart monitor. When questioned about Patient 1's cardiac rhythm, NM 4 asked the staff to reconnect Patient 1 to the cardiac monitor. The transport ambulance staff connected Patient 1 to their transport monitor. The transport ambulance staff said the monitor was placed on the bottom of the gurney which was out of the sight of hospital and transport staff. Concurrent record review at the mobile computer showed a physician's for continuous cardiac monitor via telemetry. The telemetry monitor allowed hospital personnel to view patient 1's cardiac rhythm and rate, oxygen saturation and respirations.

During the transfer process there was a tug on Patient 1's tracheostomy tubing and he had period of coughing. The respiratory therapist (RT) was summoned and came to attend to respiratory needs during the transfer. When questioned why wasn't RT participating in the transfer of a trached ICU patient, NM 4 shook her head and said she would speak to her staff.

Review of the hospital's policy & procedure, "Inter-facility Transfer- Inpatient Acute Care to Acute Care", last reviewed, 3/10/17, read: "POLICY: It is the policy of the Hospital that the transfer of inpatients from one acute care facility to another be safe, executed with the well-being of the patient as the foremost consideration..." "PROCEDURE:..."C. The Hospital will provide medical treatment within the capacity that minimizes the risk of the transfer...F. Appropriate Transportation Arrangement Qualified personnel using transportation equipment appropriate for the patient's medical condition shall carry out the transfer of a patient."

Based on interview and record review, the facility failed to complete and initiate comprehensive care plans for four of forty-eight patients (Patients six, eight, nine and twenty-three) when:
1. For Patient 6, there was not a care plan generated for psychosocial needs.
2. For Patient 9, there was no update to the Surgical Wound Care Plan after after an incision and drainage of the left knee and no interventions to address infection prevention.
3. For Patient 3, there was no care plan initiated to address psychosocial impact of her diagnosis of metastatic breast cancer.
4. For Patient 23, the pain care plan was not updated after a change in status.

The failure to initiate care plans for identified patient needs resulted in an inability to identify interventions and monitor the effects. Without interventions, nursing care could not systemically adjust to meet patient care needs.

Findings:

1. A review of the facility record, on 12/6/17, indicated Patient 6 was admitted to the facility, on 12/1/17, with a diagnosis of a right closed hip fracture. During a record review and concurrent interview, on 12/6/17 at 9:20 a.m., the history and physical indicated Patient 6 had a history of depression and was very tearful. A care plan was not generated for psychosocial concerns. The Charge Nurse (CN) stated Patient 6 should have a care plan written for depression.




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2. Review of the Medical Record showed the facility admitted Patient 9, on 11/5/17, with diagnoses including diabetes and septic (infected) left knee. The Plan of Care for Patient 9 showed:

a. The Surgical Wound Care Plan for the left knee was not updated after Patient 9 had an incision and drainage (I&D) of the left leg, on 11/20/17.

b. The infection care plan did not include the fact that Patient 9 was a diabetic.
(People with diabetes are more susceptible to developing infections, as high blood sugar levels can weaken the patient's immune system defenses. In addition, some diabetes-related health issues, such as nerve damage and reduced blood flow to the extremities, increase the body's vulnerability to infection. Sep 11, 2017 https://www.verywell.com/what-are-the-common-infections-with-diabetes-1087622)

3. Review of the Medical Record showed, the facility admitted Patient 3, on 11/30/17, with metastatic breast cancer.

During observation in the ICU, on 12/4/17 at 10:10 a.m., a sign was on Patient 3's door that read, "Please see Nurse before entering the room." Nurse Manager (NM) 4 stated Patient 3 was in isolation. RN 3, the primary care nurse for Patient 3, said she placed the sign because the patient had breast cancer and was young. In response to a question RN 3 indicated she did not talk with Patient 3 regarding visitors. When asked if nursing initiated a care plan for psychosocial needs related to the diagnosis, RN 3 said, "no".

Review of the ICU/CCU/5W units Structure Standards Nursing Responsibilities last revised 6/2015 included, "All responsibilities listed in the generic department of nursing performance standards including the use of the nursing process data collection and data assessment, comprehensive assessment of the patient condition with diagnosis, implementation, evaluation, teaching, patient stability of the condition, dynamic integration and care coordination when giving patient care."



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4. Review of the physician History and Physical, dated 12/5/17 at 9:13 a.m., reflected Patient 23 went to the hospital for delivery of her first baby after a pregnancy of 40 weeks and one day.

During an observation, 12/5/17 at 9:55 a.m., Patient 23 lay in bed, in active labor, with an epidural infusion in progress. (An epidural infusion provides pain relief for the lower body by injection of pain medication into the spinal column in a space just outside the spinal cord.)

During a concurrent interview and review of Patient 23's care plans on 12/5/17 at 10:13 a.m., Clinical Nurse Specialist for Obstetrics and Gynecology (CNS) and Assistant Nurse Manager for Obstetrics (ANM) confirmed Patient 23's pain care plan began, on 11/10/17, in the facility Outpatient Clinic. CNS confirmed the pain care plan indicated Patient 23 wanted a non-medicated, vaginal birth. CNS and ANM also confirmed Patient 23 requested and received an epidural infusion for labor pain relief, on 12/5/17 at 5:58 a.m. CNS and ANM were unable to find any updated entries for the pain care plan, after 11/10/17, or any reference to initiation of the epidural infusion in any of Patient 23's care plans. CNS said care plans should address patient needs and management plans.

During an interview (with ANM present), on 12/5/17 at 2:45 p.m., Registered Nurse 1 (RN 1) said she received report from RN 2 at 7 a.m. today. RN 2 said Patient 23 began an epidural infusion around 5 a.m. for labor pain. RN 1 said she thought Patient 23 did not come in with any plan regarding delivery.

During a telephone interview (with ANM present), on 12/7/17 at 8:43 a.m., RN 2 said she cared for Patient 23 on the morning, of 12/5/17, when Patient 23 requested and received an epidural infusion. RN 2 said she remembered giving report to the nurse on the next shift, but did not remember updating the care plan. RN 2 said she normally would document any interventions or education given regarding pain control and care plans.

The facility policy titled, "Computerized Interdisciplinary Plan of Care Guidelines," dated 4/17, had the following: "The interdisciplinary plan of care assists in individualizing the patients care and establishing mutual goals. An interdisciplinary plan of care supports collaboration and communication between disciplines so care provided is observed and coordinated." Also "All changes, updates, and needed revisions are entered into the computer before shift completion and any patient condition changes are documented."

Based on observation, interview and record review, the hospital failed to have a nurse, who was trained to work in the Computerized Tomography (CT) Department, assigned in the CT department, when one (2) of 48 patients had a CT guided chest tubes insertion. This failure resulted in the procedure beginning without a "time out" (a process by which all members of the surgical/procedure team and patient, if able, verifies the identification of the patient, the procedure and site). This failure had the potential that Patient 2 would have the chest tubes inserted in the wrong site or have the wrong procedure.

Findings:

Review of the clinical record showed the hospital admitted Patient 2, on 12/1/17, for sepsis (system-wide infection and wound management.) Patient 2 was also on contact isolation for Methicillin Resistant Staphylococcus Aureus (MRSA- A very resistant microorganism that requires personal protective equipment (PPE) and attention to infection control practices. Patient 2 was admitted to the hospital's ICU and placed on telemetry (Telemetry is an automated communications process by which heart rate, rhythm, and other data are collected and transmitted to receiving equipment for monitoring.), isolation and the following Intravenous (IV) medications infusing: Dilaudid Patient Controlled Analgesia (PCA- Narcotic for pain management which requires constant evaluation of possible respiratory and central nervous system depression), Precedex (an anti-anxiety which provides sedation without respiratory depression), Magnesium (a mineral in solution which can cause irregular heart beat), Meropenem (an antibiotic), Eraxis (an antifungal).

On 12/4/17 at 11 a.m., during a tour and observation of patients in the ICU Overflow on 5 West showed bed 10 was empty and had signage on the door for "Contact Isolation". When questioned, staff said Patient 2 was being isolated for MRSA and RN 4 accompanied Patient 2 for a CT guided insertion of chest tubes. Upon arriving to the CT area with DNE, the following observations were made: RN 4, an ICU Nurse, attended to Patient 2 to monitor the telemetry readings and IV (intravenous or into the vein) medications. The Radiology Technician (RT) 1 said a CT RN usually was assigned to circulate during procedures done in the CT area. The nurse regularly assigned in the CT area, was assigned elsewhere. By observation, ICU RN 4 monitored Patient 2's vital signs, cardiac monitor, and the medications infusing via the IV. There was no "time out" prior to the first chest tube insertion.

The DNE asked RN 4 when the time out was conducted. RN 4 replied, "We did not do a time out. I did not know what they do here, their regular nurse was assigned elsewhere." RN 4 informed the team a "time out" was not performed. The physician said do the time out starting now.

The hospital's P&P, "Universal Protocol", last revised 8/31/16, had the following definition: The "Time Out" process includes active verification among all members of the surgical team for the following purposes:
- Verification of correct patient,
- Verification of and agreement on procedure to be done,
- Correct site/side or levels,
- Correct patient position and availability of correct implants (when indicated) and special equipment.

Review of the job description for RN 4 did not include circulating duties in the CT department.

Based on observation, interviews, and document reviews the hospital failed to fully administer medications when utilizing the Vial2bag system (solution connected to a drug vial which needs to be activated and mixed prior to administration) for three (31, 32, and 33) of forty-eight patients. This failure caused medication errors in which nurses did not fully administer intravenous (IV) antibiotics.

Findings:

A review, on 12/05/17, entitled document "Vial2Bag" indicated manufacturer guidelines on the use of the Vial2bag system. The document indicated that when reconstituting the medication one had to invert the vial and squeeze the IV bag to push air from the IV bag into the vial which would cause the reconstituted drug to flow into the IV bag. Once the reconstituted drug was emptied into the IV bag the medication was ready to infuse.

During an observation, on 12/04/17 at 1:15 p.m., in Patient 31's room, there was an IV bag labeled Pipercillin/Tazobactam (Antibiotic) that was attached to a Vial2Bag system. The Pipercillin/Tazobactam vial was partially full, the size of the vial approximately 15 ml and approximately 3 ml of solution was still in the vial. The IV Pipercillin/Tazobactam was not all administered to Patient 31.

During an observation, on 12/04/17 at 2:06 p.m., in Patient 32's room, there was an IV bag labeled Pipercillin/Tazobactam (Antibiotic) that was attached to a Vial2Bag system. The Pipercillin/Tazobactam vial was partially full, the size of the vial approximately 15 ml and approximately 2 ml of solution was still in the vial and not administered to Patient 32.

During an observation on 12/04/17 at 2:15 PM in Patient 33's room there was an IV bag labeled Pipercillin/Tazobactam (Antibiotic) that was attached to a Vial2Bag system. The Pipercillin/Tazobactam vial was partially full, the size of the vial approximately 15 ml and approximately 2.5 ml of solution was still in the vial and not administered to Patient 33.

During an interview, on 12/05/17 at 3:08 p.m., the Director of Pharmacy (DOP) stated that the nurses did not use the correct technique when activating the Vial2bag System. DOP acknowledged Patients 31, 32 and 33 did not get their full dose of IV antibiotics. The DOP also stated the hospital would re-train the nurses on the appropriate activation of the Vial2bag system, which would include thoroughly mixing the medication and solution, and emptying the vial.

Based on record reviews and interview, the hospital failed to ensure timely and complete medical record documentation of discharge summaries for four (37, 38, and 41 and 48) of forty-eight patients. The hospital also failed to ensure there was a discharge summary for one of 51 patients discharged on 11/16/17. This deficient practice failed to assure proper continuity of care as required upon patient discharge or transfer to other care providers and lack of communication of all final diagnoses present at the time of discharge as required in medical record documentation.

Findings:

1. A review of the medical record of Patient 37, discharged on 11/19/17, a discharge summary was incomplete.
2. A review of the medical record of Patient 38, discharged on 5/12/17, a discharge summary was incomplete.
3. A review of the medical record of Patient 41, with multiple admissions & discharges in 2017, evidenced late and missing documentation of discharge summaries, on 2/24/17 on the 26th day following discharge, on 4/3/17 on the 34th day following discharge, and on 6/20/17 on the 23rd day following discharge.
4. A review of the medical record of Patient 48, who expired on 11/16/17, the discharge summary was incomplete.

In a review of all inpatients (non-sampled) discharged, on 11/16/17; of 51 discharge records there was one missing discharge summary for an expired patient.

A review of the Hospital Medical Staff Rules & Regulations Manual (MR Document 1 ) section U, "Medical Record Responsibilities", item 11, "Discharge Summary and Discharge Diagnosis" had the following: "a. Discharge summaries are required for all patients with a stay in the hospital, including inpatients, observations and OB patients. b. The discharge summary must be completed within 72 hours of discharge, and must include: the reason for hospitalization; significant findings; procedures performed; care, treatment, and services provided; information relative to the condition of the patient at discharge; instructions to the patient and/or family, particularly in regards to physical activity limitations, medications and diet."

In addition, a review in section U "Medical Record Responsibilities", item 12 "Medical Record Completion" had the following, "a. The attending physician ....shall assure that the record is complete as required by the Bylaws, Policies and Procedures and Rules and Regulations. Incomplete records shall become delinquent fourteen (14) days after discharge from the Hospital."

A review of the "Suspension of Medical Staff Privileges Warning for Delinquent Medical Records" letters (MR Documents 6, 7, and 8) dated 2/17/17, 3/31/17, and 6/16/17, for the attending physician of Patient 41, showed a total of 27 delinquent discharge summaries.

During an interview, on 12/5/17 at 10:25 a.m., HIM 1 (Health Information Manager 1) reported that the Clinical Evaluation Committee met monthly to monitor the HIM record delinquency rate of the medical staff, which is approximately 5% of discharges. Upon request, the suspension of medical staff privileges notification letters for the attending physician of Patient 41 were provided. In addition, HIM 1 confirmed the attending physician of Patient 48 did not complete the expiration summary.

Based on record reviews and interview, the hospital failed to ensure timely and complete medical record documentation of discharge diagnoses for three (37, 38, and 41) of forty-eight patients. This deficient practice resulted in the failure to communicate patients' condition, at time of discharge or transfer to other care providers, which was necessary for continuity of care.

Findings:

In a review of 18 medical records, 6 discharge summaries were incomplete or untimely. The completions were not in accordance with the medical staff rules and regulations.

In a review of medical records, the discharge summaries and final diagnostic documentation was not timely for:
1. The medical record of Patient 37 discharged on 11/19/17.
2. The medical record of Patient 38 discharged on 5/12/17.
3. The medical record of Patient 41, with multiple inpatient stays in 2017, evidenced late documentation on summaries for discharges on 1/28/17, on 2/28/17, and on 5/27/17.

A review of the Medical Staff Rules & Regulations (MR Document 1), indicated: "(a) Discharge summaries are required for all patients with a stay in the hospital, including inpatients, observations and OB patients.
(b) The discharge summary must be completed within 72 hours of discharge, and must include ...
(c) A discharge diagnosis is to be made available to the Health Information Management Department within forty-eight (48) hours of the patient's discharge by the patient's attending physician."

Based on observations, interviews and document reviews the hospital pharmacy failed to store medications in accordance to manufacturer recommendations as evidence by:

1. The hospital staff did not store Dinoprostone (Prostin E2-medication used for the termination of pregnancy) in accordance to manufacturer recommendations of above -20 degrees Celsius (C). The Dinoprostone was stored at temperatures that were too warm. This failure potentially caused the use of compromised medications for patient use.

2. The hospital staff did not store "protect from light" medications appropriately when Lidocaine with Epinephrine (medication used for local anesthesia) and Iohexol (medication used during x-rays) were stored on shelves in direct light.

Findings:

1. A review, on 12/04/17, of the manufacture's insert for Dinoprostone (Prostin E2) indicated "Prostin E2 is a vaginal insert...STORE IN A FREEZER NOT ABOVE -20 C (-4F) BUT BRING TO ROOM TEMPERATURE JUST PRIOR TO USE..."

During an observation in the Pharmacy, on 12/04/17 at 10:21 a.m., there was a box of Dinoprostone in the freezer. There was a freezer thermometer with recorded temperatures of -11 C, nine degrees above the manufacturer's guidelines. The Dinoprostone was stored in temperatures that were too warm.

A review, on 12/04/17, of the Pharmacy Freezer Temperature Log, dated from 11/04/17 thru 12/04/17, indicated a document that had continuous monitoring of the freezer temperatures (freezer in which Dinoprostone was stored). The daily temperatures were all warmer than -20 C.

During an interview, on 12/04/17 at 10:21 a.m., the Director of Pharmacy (DOP) stated she did not know the Dinoprostone was stored inappropriately. DOP also stated she would discard and replace the Dinoprostone vaginal inserts.

2. A review of the manufacturer insert, on 12/04/17, indicated 2% Lidocaine with Epinephrine and Iohexol (lohexol also known as omnipaque is a contrast agent used during x-rays) were to be protected from light. Medications that require protection from light deteriorate under direct light. The labels of each of these medications indicated "protect from light".

During an observation, on 12/04/17 at 10:37 a.m., the Lidocaine with Epinephrine was under direct light in the pharmacy. There were approximately 10, 20 milliliter (ml) vials of the Lidocaine with Epinephrine under direct light and without a cover.

During an observation, on 12/04/17 at 10:59 p.m., the Iohexol was under direct light without a cover, in the hospital pharmacy. There were approximately 15,150 milliliter (ml) vials of Iohexol under direct light.

During an interview, on 12/04/17 at 10:37 a.m., DOP stated she did not know the Lidocaine with Epinephrine and Iohexol were stored under direct light uncovered. DOP stated she would cover these medications right away.

Based on observation, interview, and policy/document review, the facility had the following failures:

1. The kitchen's (where food was prepared) air vent slats had an accumulation of dust and a black sticky substance. This failure had the potential the dirt/debris on the air vent could fall and contaminate food and spread germs to patients.

2. Expired supplies were in a storage cart: surgical gloves and two of three packages of electrode pads used for patient procedures with heart problems. This failure had the potential to result in product degradation. Surgical gloves can dry up and crack. The tacky gel on the electrode pads can become warped and ineffective when placed on the skin to monitor the activity of the heart's rate and rhythm.

3. The special care nursery, blanket warmer's temperature monitor exceeded the maximum temperature of 130 °F (Fahrenheit) for four hours without intervention by engineering. This failure had the potential to result in burns to patients and staff from overly heated blankets.

Findings:

1. During an observational tour and concurrent interview of the modular kitchen, on 12/05/17 at 10:15 a.m., a kitchen air vent above a food preparation counter was inspected. There was moderate accumulation of dust on the vent. Further inspection showed a black sticky substance during a finger swipe. The Director of Culinary and Clinical Nutrition Services (DCCNS) stated that the dirty wall vent was a problem. DCCNS stated that it used a contracted service to clean equipment in the kitchen every Friday.

Review of the "Weekly Progress Report," dated 12/01/17, of the contracted service assignment, showed the "immediate ductwork" was cleaned. The DCCNS and Kitchen Catering Manager (KCM) verified "immediate ductwork" meant the wall vent above the food preparation area.

During an interview on 12/07/17, at 11:00 a.m., the KCM stated that the dirty wall vent above the food preparation was "probably not" cleaned for "more than a week."

Review of the hospital policy, entitled, "Sanitation and Infection Control," dated 6/17, indicated, all equipment shall be readily maintained in a clean and sanitary condition. It furthered indicated, "commercial level cleaning will be scheduled to adequately maintain the facility interior surfaces (walls, ceiling, and floors), ducts, equipment, drains, etc."

2. During an observational tour and concurrent interview in the Pulmonary Rehabilitation Clinic, on 12/05/17 at 9:10 a.m., a supply storage cart was checked. A pair of surgical gloves had an expiration date of 12/15. The Respiratory Care Practitioner (RCP) 2 stated he/she did not know where the sterile gloves were stored since it was not a supply normally used. In another drawer, two of three ECG (Electrocardiogram-a test that records the electrical activity of the heart.) medical sensor packages had expired dates of 4/2011. (The sensors are sticky patches that are placed on the skin of the chest and attached to an electrocardiogram monitor that charts the heart's electrical activity during the stress test.) The RCP 2 confirmed the expired sensors were available for use and further stated they should not be used. RCP 2 stated that the storage cart was checked, by respiratory staff during normal operation Monday through Thursdays, every time the crash cart was checked.

Review of the hospital policy, Hospital Materials Management Expired Supplies, dated 6/2017, indicated, "staff and others involved in the supply process must routinely check the expiration dates on all supplies. This includes medical supplies of all types and value." It also indicated, "Expired items must be removed from all patient care and other supply areas immediately."



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3. During a concurrent observation and interview, on 12/6/17 at 12:35 p.m., in the special care nursery clean utility room, Assistant Nurse Manager (ANM) confirmed the blanket warmer temperature monitor on the door of the warmer read 152 °F. ANM also confirmed the signage on the door indicated the blanket warmer's maximum temperature should not exceed 130 °F. ANM confirmed the interior temperature of the blanket warmer felt only slightly above body temperature to touch.

During an interview and concurrent record review with ANM, on 12/6/17 at 12:45 p.m., Senior Lead Engineer (ES 5) confirmed the temperature history, flowsheet for the special care nursery blanket warmer indicated the temperature exceeded 130 °F, since 9 a.m. on 12/6/17. ES 5 said he should have received an alert both on his computer, and on his pager, about the elevated temperature reading on the blanket warmer. ES 5 said sustained, abnormal, temperature values required physical evaluation by an engineer. ES 5 confirmed an engineer did not assess the blanket warmer's temperature.

During an observation and concurrent interview, 12/6/17 at 2:31 p.m., ANM confirmed the blanket warmer door temperature monitor read 107 °F.

During an interview and concurrent record review with ANM, on 12/7/17 at 8:43 a.m., Stationary Engineer 6 (ES 6) confirmed the temperature history, flowsheet for the blanket warmer showed the temperature reading increased from 130 °F, at 9 a.m. on 12/6/17, until decreasing at 1 p.m. ES 6 said when machine temperatures were outside the normal range for more than fifteen minutes, an engineer should physically evaluate the machine. ES 6 confirmed, the Work Order Report, indicated he adjusted/lowered the temperature of the blanket warmer on 12/6/17.

Review of, the Word Order Report, for the blanket warmer indicated, "Baby blankets must be < [less than] 106 °F." The Work Order Report also showed a work order, requested date and time, of 12/6/17 at 12:01 p.m.

Based on observation, interview, and record review, the hospital failed to implement the infection control program. This failure had the potential to result in hospital acquired infections, food borne illnesses, and compromised patients' health and safety.

The hospital failed to:

1. Maintain, sanitize, and clean the ice, water, and coffee machines which were the patients' source of hydration in three nursing units of the hospital. The accumulation of residues in the machines had the potential to contaminate the drinking water and coffee.

2. Transport clean linens in a sanitary manner in the hospital's emergency department.

3. Remove an expired, streptococcus culture, specimen tube (a container of growth medium for a patient throat swab specimen, used to determine if the patient has an infection from the bacteria streptococcus) from an Emergency Department drawer.

4. In the operating room :
a. Use protective shoe coverings prior to a bloody procedure for Patient 5 in the hospital's operating room.
b. Protect a sterile procedure tray for Foley catheter insertion (A Foley catheter is a tube inserted into the bladder to drain urine.) from contamination by a garbage can lid, and prevent cross-contamination of the occupied patient gurney by the contaminated tray.
c. Observe and follow "wet time" for disinfection of surfaces between surgical procedures.

5. In the ICU/CCU (Intensive Care Unit/Critical Care Unit):
a. Practice hand hygiene after exiting Patient 3's room.
b. Protect the communal treatment cart from contamination by an ointment used inside a contact isolation patient room.

6. In Computerized Tomography:
a. Ensure staff sanitized a medication vial before use in CT (computerized tomography).
b. Ensure staff wore PPEs (protective personal equipment) while caring for a patient diagnosed with MRSA (methicillin resistance staphylococcus aureus), in contact isolation.

Findings:

1. During a hospital tour observation with hospital staff, on 12/4/17 at 2:35 p.m., in the kitchen/patients nourishment area of 4 West nursing unit, the spout of the water and ice dispenser machine was observed with thick accumulation of grayish colored substance. The coffee machine was also observed with accumulation of dark brown colored substance and small particles around the water reservoir lid.

During an interview, 12/4/17 at 2:35 p.m., Nurse Manager (NM 6) stated the machines provided water, ice, and coffee for the patients in the unit. During a concurrent interview EVS1 ( Environmental Services Staff) staff was interviewed, EVS1 stated her responsibilities included the cleanliness of the patients' nourishment room (kitchen) equipments such as the ice, water, and coffee machines. EVS1 indicated her tasks were done for the day. When the surveyor pointed out the accumulated white colored substance in the ice machine spout, ELVIS stated it wasn't cleaned.

During an observation and concurrent interview, on 12/5/17 at 9:35 a.m., in 5 West's patients' nourishment room, thick and whitish colored substances were observed inside the coffee machine's water reservoir. The bottom inside part of the hot water carafe had an accumulation of a grayish colored substance. The substance was also observed and present in both of the warming plates of the coffee machine. NM 7 confirmed the observations and said the coffee machine supplied the hot water and coffee for the patients in the unit. NM 7 added that each staff had the responsibility to maintain the cleanliness of the coffee machine especially the carafes.

A review of the hospital's preventive maintenance procedure of ice machine No. 00641, did not include specifics for cleaning and removal when there was thick and heavy accumulation of white substance in the spout dispenser.

The hospital's DEVS ( Director of Environmental Services), in an interview, 12/5/17 at 10 a.m., stated EVS did not keep records when the coffee machines were cleaned and sanitized.

2. During tour observation in ED (Emergency Department), on 12/4/17 at 10:10 a.m., RN 9 (Registered Nurse 9) and EMT (Emergency Medical Technician) were observed carrying and
supplying linen for ED patients with the linen held against their chests, touching their uniforms.

During an interview, 12/7/17 at 11:10 a.m., DMSE (Director of Medical/Surgical Education and Staff Development) and COQ (Quality and Resource Management Chief, also in charge of the hospital's infection control program) confirmed staff should carry patient linen in front, and away from their bodies to prevent potential cross contamination of bacteria from the clothing to the clean linen.


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3. During observation and concurrent interview, on 12/4/17 at 2 p.m., there was calcification on the ice machine tray and the shoot from where the ice drops, and dust on the filter. The Director of EVS (DEVS) stated the ice machine was cleaned daily by housekeeping. The DEVS stated there was dust in the filter.

During an interview, on 12/4/17 at 2:10 p.m., Stationary Engineer (ES 4) stated calcification was on the tray of the ice machine and that it takes awhile for it to build up.

4. During an observation and concurrent interview, on 12/4/17 at 10:30 a.m., a bedside cart in the Emergency Department contained a throat culture tube with an expiration date of 8/20/17. The Assistant Chief Nursing Officer (ACNO) stated the emergency room technician was responsible for checking the drawer, and should have thrown the swab out. The ACNO stated the consequences of using an expired swab for a culture could result in inaccurate results of the culture test.


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4. During observations, on 12/5/17 beginning at 9 a.m., while accompanied by the ICP/COQ (Infection Control Preventionist/Chief of Quality Management), the CNS (Medical-Surgical Clinical Nurse Specialist), and the NE 1(Operating Room Nurse Educator):

a. In operating room 3, for Patient 5, MD 2 (surgeon), ST 1 and ST 2 (scrub technicians), were at the OR gurney when MD 2 was performing a total knee replacement surgical procedure. Blood splattered from the OR gurney onto the floor. MD 2, ST 1 and ST 2 did not wear shoe covers. When the procedure was finished, the staff exited the OR and walked into other perioperative areas without performing any disinfection of shoes and without donning shoe covers. When questioned, the ICP/DQM and the NE 1 observed and confirmed the observations and said they would speak to the staff and address the observed concerns.

The facility's policy and procedure entitled "Surgical Attire", dated as revised 5/2017 referenced: AORN (Association periOperative Nurses, a professional organization which has published standards of care and recommended practices for the care of surgical patients) and OSHA (Occupational Health & Safety Administration, a government agency which is responsible for the health and safety workers). Both organizations recommend the use of shoe covers when gross contamination is anticipated. (AORN Recommendation V: "Health care personnel must follow the OSHA bloodborne pathogens standard...Health care personnel must wear surgical caps or hoods and shoe covers or boots when gross contamination can be reasonably anticipated eg, orthopedic surgery."

b. In preparation to insert a Foley catheter (tube inserted into the bladder and secured by a small air balloon to facilitate urine drainage) into Patient 5, RN 8 placed the sterile package on top of the OR garbage receptacle then onto the OR gurney where Patient 5 lay in wait for his surgical procedure. When questioned, ICP/COQ and NE 1 observed and confirmed the observations and said they would speak to the staff and address the observed concerns. They said this was not acceptable practice.

c. Operating Room Environmental Services (EVSOR) 1 and EVSOR 2 cleaned a surgical suite using a disinfectant wipe that per the manufacturer's instructions, required two minutes of dwell time (time required for disinfectant to remain in wet state in order to be effective against microorganisms.) Neither EVSOR 1 or 2 observed the two minute wet time. They wiped items in the OR suite including the lights, the gurney, the instrument table and other equipment in the room that dried before two minutes had expired and did not reapply. When questioned regarding the product being used, EVSOR 1 said it was bleach. The wipes were Sani-Clothe Disposable Germicidal Wipes and did not contain bleach. EVSOR 1 couldn't say what was the manufacturer's dwell time. The ICP/DQM and NE 1 confirmed the observation and said they would provide education to the staff. The manufacturer's recommendations for the Sani-Cloth Wipes had the instruction to observe a two minute dwell time.

Review of the hospital's policy and procedure entitled, "Environmental Sanitation in Perioperative Setting" last revised 5/2017, showed: "Purpose:...Thorough cleaning and disinfection of perioperative areas is essential to preventing the spread of potentially pathogenic microorganisms...Protocol:...Disinfectants should be applied and reapplied as needed per manufacturer's instructions for use (IFU), for the dwell time required to kill the targeted microorganisms."

5. The following observations were made in the ICU and Cardiac/Coronary Care Unit (CCU), on 12/4/17 at 10:10 a.m., in the presence of the Senior Director of Nursing Practice & Education (DNE) and The ICU/CCU Nurse Manager (NMICU):

a. A Physician Assistant (PA) did not perform hand hygiene when leaving the bedside of a patient after patient contact and interaction. Upon leaving Patient 3's room, the PA placed both her hands at her hip onto her lab jacket while talking to nursing staff. The DNE and NMICU confirmed the observation and instructed the PA to perform hand hygiene.

Review of the hospital's, "Hand Hygiene" P&P, last revised 3/16/17, showed it was developed "...To reduce patient morbidity and mortality from hospital acquired infections...", and directed, "All personnel and physicians must wash their hands...before and after direct patient contact with patients, blood, body fluids, mucous membranes, non-intact skin and objects likely to be contaminated..."

b. Patient 4, a patient in the CCU was on contact precautions for a Clostridium Difficil (C-Diff--a very contagious infection causing colitis and diarrhea and easily transmitted by contact with an infected patient or patient's environment). RN 5 was observed wearing personal protective equipment (PPE- mask, yellow gown, and gloves) handing a treatment ointment out of the room to the certified nursing assistant (CNA) who placed the ointment in a bag and in a treatment cart that stored treatment supplies for all patients in the CCU. DNE and NMICU confirmed the observation and said they would confer with the ICP/COQ to resolve the issue. RN 5 said she was performing wound care on patient 4 and the ointment was the prescribed treatment. RN 5 asked NMICU what she should do. In a subsequent interview, 12/4/17 at 2 p.m., with the ICP/COQ and the ICP coordinator (ICPC), they agreed the observed practice was not the best practice and had the potential for spread of infection. The ICP said she would confer with pharmacy and maintenance departments to determine what can be constructed in the room to store ointments and not make it accessible to patients and visitors.

Review of the hospital's P&P, "Isolation of Hospitalized Patients", last updated 3/16/2017, showed the hospital "...practices isolation precautions in accordance with established CDC (Center for Disease Control) guidelines. 2007 Guideline for Isolation Precautions..." Under the title "2. Specifications...All patient care equipment taken into a contact isolation room must be either discarded, if disposable, or cleaned well with a hospital approved disinfectant upon removal from the room..." The P&P did not address medications and treatments brought into a room.

6. On 12/4/17 at 11 a.m., during an interview in the ICU Overflow staff said Patient 2 was being isolated for Methicillin Resistant Staphylococcus Aureus (MRSA- A microorganism that is difficult to get rid of due to it's resistance to most antibiotics). Staff also said RN 2 accompanied Patient 2 to Computerized Tomography (CT) for CT guided insertion of chest tubes. Upon arriving to CT Suite with DNE, the following observations were made:

a. RN 4 was observed caring for patient 2 who was on the CT table. Two Radiology Technicians (RT 1 and RT 2) and one Physician (MDR) also worked with patient 2. None of the staff were wearing PPE. When questioned by DNE staff left the CT Suite and applied a yellow gown and mask. None of the staff performed hand hygiene prior to donning PPE. RN 4 said Patient 2 had MRSA in his wound and it had spread to multiple areas.

The P&P, "Isolation of Hospitalized Patients" referenced above, showed the following, "Purpose: To limit the transmission of infections among patients, staff, and visitors by use of various barrier techniques based on the transmission of the infectious agent...High-risk body fluids-body fluids that are known to be able to transmit blood borne pathogens...Pleural fluid [from the lungs]..." Also gowns and gloves, "...must be worn upon every entry to isolation rooms by all healthcare workers, medical staff and visitors..."

b. MDR requested Xylocaine (injectable anesthetic) and RT 2 uncapped a vial and held it upside down for the MDR to aspirate the medication with a needle. RT 2 did not wipe the vial top with an alcohol wipe. MDR retrieved medication from the vial and administered to Patient 2. The DNE observed this action and said she would address this with staff.

Based on interview and record review the hospital failed to document a discharge plan for one (6) of 48 patients. This failure had the potential that Patient 6 would not have post discharge needs met.

Findings:

A review of the medical record indicated Patient 6 was admitted, on 12/1/17, with a diagnosis of a right hip fracture. During an interview, on 12/6/17 at 10:50 a.m., the CM 1 (Case Manager) stated Patient 6 was being discharged today, 12/6/17. CM 1 stated discharge planning started 12/3/17. There was no documentation by CM 1 of discharge planning for Patient 6. CM 1 stated there should have been documentation in Patient 6's medical record for discharge planning.

During an interview, on 12/6//17 at 11:15 a.m., the Chief of Quality Resource Management (COQ) stated the Case Manager would have a conversation with the patient and provide a list of options of places to go. The COQ stated there should be a summary of the discharge plan written by the case manager. The COQ stated if the plan changed, it would be documented.

A review of the facility's policy titled "Patient Discharge", dated 06/17, stated "Patients who are discharged from the hospital will receive instructions and individualized counseling prior to discharge". "Evidence of the instructions and the patient's or family's understanding of these instructions are noted in the patient's medical record."