HospitalInspections.org

Based upon review of the patient admission packet and interview, the hospital failed to ensure a process was established that identified 1) who the patient could notify to file a grievance and 2) the telephone number and address for lodging a complaint with the state agency. Findings:

Review of the admission information given to the patient on admission to the hospital revealed the patient was provided a form which identified only the patient's rights. Further review of the form revealed there failed to be information related to the grievance process, the person with whom to contact to file a grievance, or the phone number and address for lodging a complaint with the state agency.

Interview with S14 Billing/Admissions/ on 08/05/15 at 8:55 a.m. revealed when a patient was admitted to the hospital, the only information provided to the patient was the form which identified the patient rights.

Based on record review and interview, the hospital failed to ensure Medical Staff Bylaws and Medical Records policies and procedures were followed related to 1) being promptly completed, and 2) protected from fire and water damage. This was evidenced by: 1) failure of the medical staff to follow medical records policies and procedures related to having 21 patient records that were incomplete from February 2015 to July 2015, 2) failure to follow Medical Staff Bylaws related to physicians with delinquent records and suspension, and 3) failure to ensure the medical records were protected from fire and water damage.
Findings:

1) failure of the medical staff to follow medical records policies and procedures related to having 21 patient records that were incomplete from February 2015 to July 2015 and
2) failure to follow Medical Staff Bylaws related to physicians with delinquent records and suspension:

Review of the policy titled, Procedure for Completion of Incomplete Emergency Department Physician Records, presented as current by S3 Medical Records Supervisor revealed in part the following procedure: Step 1: Medical records director for the hospital will attempt to have the physician responsible for the incomplete record complete and sign his or her record on the physician's next working shift; Step 2: If the physician responsible for the incomplete record is not scheduled to return to the hospital or if the physician continues to fail to complete the record in a timely fashion, the medical records director will contact the emergency physician group with the name of the physician and details of the incomplete record; ...Step 6: If medical record is still not completed in a timely fashion, the emergency physician group will notify hospital's administration of the continued failure of the physician to complete the medical record. At that time, the hospital's board and medical staff may choose to revoke the physician's privileges.

On 08/03/15 at 2:00 p.m., interview with S3 Medical Records Supervisor revealed that the hospital had some incomplete medical records, but she was unsure of the number or time frames of the incomplete records. At that time, S3 Medical Records Supervisor removed a stack of delinquent records off a shelf in her office. S3 stated that the emergency department physicians, who were part of a group, were responsible for these incomplete records. At that time, S3 Medical Records Supervisor counted 21 incomplete records, ranging in dates from February 2015 to July 2015. S3 Medical Records Supervisor stated that she had not notified the medical director of the emergency department regarding the incomplete records.

Further interview with S3 Medical Records Supervisor on 08/04/15 at 11:20 a.m. confirmed that the policy for incomplete emergency department physician records had not been followed. She further revealed that this information had not been brought to the governing body or medical staff and none of the physicians with incomplete records had received any disciplinary action.


3) failure to ensure the medical records were protected from fire and water damage:

Review of the hospital policy titled, Policy on Record Safeguards, presented by S3 Medical Records Supervisor as current revealed in part that medical records are stored in areas well away from sources of potential fire and water hazard. The policy did not state how the records would be protected.

On 8/3/15 at 2:00 p.m., observation of the office of S3 Medical Records Supervisor revealed stacks of medical records were stored on open shelves and on top of filing cabinets. S3 Medical Records Supervisor stated that some of the records had been scanned into the computer but not all of them. There were approximately 75 records (dated July -October 2014) observed on a rolling cart in the office. S3 Medical Records Supervisor stated that these records had not been scanned and were not protected from fire or water damage. S3 Medical Records Supervisor revealed that the office had a fire door in the past but it was recently removed due to construction in the hospital. She further confirmed that all records in the office were not protected from fire and water.

Based on record review and interview, the hospital failed to ensure all orders, including verbal orders, were authenticated, dated, and timed promptly for 2 (#11, #12 ) of 4 (#11, #12, #13, #14) active inpatient medical records reviewed for prompt authentication, dating, and timing of physician orders in a total sample of 20. Findings:

Review of the Medical Staff By-laws presented as current, revealed in part: "...5. All orders for treatment shall be in writing. Verbal orders for Inpatients and Outpatients may be dictated to a Registered Professional Nurse (RN-RNA) or Licensed Practical Nurse (LPN).... All telephone orders for treatment shall be given to a Registered Professional Nurse (RN) or Licensed Practical Nurse (LPN). Verbal orders shall be signed by the person to whom the order was dictated with the Physician's name per his or her name. All verbal orders must be countersigned within 24 hours by the Attending Physician issuing said orders. "Further review of the Medical Staff By-laws revealed an amendment to the Medical Staff Rules and Regulations dated 06/09/08 which stated, in part: "All medical record entries must be legible, complete, dated, timed, and authenticated by the person responsible for providing the service."

Patient #11
Patient #11 was a 74-year-old female admitted to the hospital on 07/30/5 at 3:30 p.m. and was discharged on 08/03/15. The Admitting physician was documented as S17 MD. The Attending Physician was documented as S16 MD. Diagnoses included Acute COPD (Chronic Obstructive Pulmonary Disease) Exacerbation; Acute Bronchitis. Medical history included Hypertension, GERD (Gastroesophageal Reflux Disease), COPD, CVA (Cerebral Vascular Accident-Stroke), Anorexia, and Nutritional Deficiency.

Review of the Physician Orders for Patient #11 revealed the following verbal orders were not dated and/or timed by the ordering physician: 1) 07/30/15 at 9:35 p.m. "Hold 9:00 p.m. dose all BP (blood pressure) medication." 2) 07/30/15 at 12:50 a.m.: "Norco 5/325 mg (milligrams), 1 tablet via PEG (percutaneous endoscopic gastrostomy) tube every 8 hours PRN (as needed.)" 3) 07/31/15 at 9:00 a.m.: "CE (cardiac enzymes) and EKG (electrocardiogram) every 8 hours times 2 more sets; Morphine 1 mg, IVP (intravenous push) times 1; Nitropaste ½ inch applied to chest wall times 1." 4) 07/31/15 at 11:03 a.m.: "Telemetry, BNP (B-type Natriutetic Peptide), D-Dimer now; change Lovenox to 1 mg/kg (milligram per kilogram) every 12 hours; CT scan of chest: PE (pulmonary embolism) protocol." 5) 08/01/15 at 8:40 p.m.: "Anusol suppository three times per day per rectum."

Review of the Physician Orders revealed Patient #11's admission orders dated 07/30/15 were not timed by the ordering physician. A subsequent physician's order sheet which contained Patient #11's medication orders by the physician contained no date or time documented by the ordering physician.

Review of the physician verbal order dated 07/30/15 at 4:48 p.m. on 08/04/15 which included the following: Calcium Carbonate 600 mg, two times daily; Metoprolol 100 mg, twice daily; Multivitamin, one tablet daily; change Zanaflex to 2 mg four times per day, revealed the ordering physician had not authenticated, dated, or timed the above-referenced orders. Further review revealed a physician verbal order dated 08/01/15 at 11:00 a.m. which stated "Order clarification, blood cultures times 2 sets if temperature spikes" had not been authenticated, dated, and timed.

Review of physician orders (discharge orders) for Patient #11 revealed no date or time was documented by the prescribing physician (the list of orders began after a 24-hour chart check by a nurse dated 08/03/15 at 12:20 a.m.) The subsequent page which contained a continuation of Patient #11's discharge orders did not contain a date in the Date and Time column, and did not contain a date by the nurse who signed off on the orders.


Patient #12
A review of Patient #12's medical record revealed she was a 70-year-old female admitted to the hospital on 07/29/15 at 4:37 p.m. and discharged on 08/03/15. Diagnoses included Rheumatoid Arthritis, Mononeuritis of Unspecified Site, and Constipation.

Review of the physician orders for Patient #12 on 08/05/15 revealed the following verbal orders were not authenticated, dated, and timed: 1) 07/29/15 at 4:57 p.m.: "Discontinue Hydrocortisone IV, Solumedrol 80 mg IVP every 8 hours." 2) 07/30/15 at 11:00 a.m.: "Change Zyrtec to Claritin 10 mg by mouth daily." There was no documentation by the nurse who gave the verbal order-only documentation of a notation by the receiving nurse. The orders was not authenticated, dated, and timed by the ordering physician. 3) 08/01/15 at 9:12 a.m.: Lactulose 30 ml (milliliters) by mouth times 1 now."

In an interview on 08/05/15 at 10:50 a.m., S2DON (Director of Nursing) confirmed the above referenced orders were not authenticated, dated, or timed per the Medical Staff By-laws Rules and Regulations, and the orders should have been.

Based on observation, record review, and interview, the hospital failed to ensure safe food practices were implemented as evidenced by: 1) canned foods were available for patient use that were dented 2) stored food items had no received dates, expiration dates, or open dates documented 3) expired items were available for patient use, and 4) refrigerated food was stored improperly. Findings:

Review of a dietary department policy and procedure revealed the following, in part: "D. Receiving and Storage: All orders are checked when delivered by the food director or kitchen employee in charge. All staples and canned foods are inspected for quality and quantity ....Food is dated and placed in storeroom, refrigerator or freezer as quickly as possible after delivery by dietary supervisor or employee in charge. Oldest foods should be stacked to be used first ....Stored foods are checked for breakage, leakage, spoilage. If any found, dispose of immediately and clean area to prevent contamination of other foods.
Storage: ...Incoming foods and supplies are delivered to storage area, checked for acceptability, and stored immediately or as soon as possible. Stock must be rotated so that the oldest items are always used first (FIFO-First In First Out system). Obsolete items should be removed from stock regularly."

An observation on 08/03/15 in the dietary department revealed the following: 1) Canned goods that were stored and available for patient use with no received dates and no expiration dates documented or available on the items: 6 cans of Orchard Naturals Fruit Cocktail (6 lbs, 11 oz.) with 2 cans dented; 2 cans of Sysco Peach Halves (6 lbs, 9 ounces) with no received or expiration dates documented; 7 cans of Sysco International Sliced Pineapple (6 lbs, 11 oz) with no received dates documented; 3 cans of Dole Tropical Fruit Salad (6 lbs, 3 oz) with no received dates, with 2 cans dented; 3 cans of Sysco Black-Eyed Peas (6 lbs, 15 oz) with no received dates documented, and 2 cans with an incomplete date of 4/3; Sysco Stewed Tomatoes (6 lbs, 6 oz), 1 can with a received date documented as 10/23/13 and 3 cans with no received or expiration date documented; 7 cans of Sysco Imperial Sweet Peas (6 lbs, 10 oz) with no received or expiration dates documented, and 6 cans dented; 7 cans of Sysco Imperial Sweet Peas (6 lbs, 10 oz) with no received or expiration dates documented, and 6 cans dented; 5 cans of Sysco Tomato Sauce (6 lb, 10 oz) with no received or expiration dates documented, and 4 cans dented; 4 cans of Sysco Cut Sweet potatoes (6 lbs, 14 oz) with no received dates documented, and 2 cans dented; 5 cans of Sysco Classic Beans (6 lb, 10 oz) with no received or expiration dates documented and 2 cans dented.

2) Food items that were opened and available for use in the dry goods storage area with no open dates documented: Domino's Light Brown Sugar (1 lb box); Panola Pepper Sauce; Pasta Labella (1 lb pack); Hunts Ketchup (24 oz) with approximately ½ of contents remaining; 1 container of Optimum 90% Protein Powder (16 oz) with approximately ¾ of the content remaining. This container had no manufactured date, no open date, no expiration date and the outside of the container had dried and sticky residue on parts of the surfaces.

3) Expired items located in the dry goods storage room: 1 can of Duncan Hines Chocolate Buttercream Frosting (16 oz) with an expiration date of 05/29/15; 1 partially used envelope of McCormick's Slow Cookers Vegetable Beef Soup Seasoning Mix (1.2 oz.) with a "best by date" of 07/17/15; there was no open date on the seasoning mix envelope; 1 envelope of Lipton Recipe Secrets, Beefy Onion (2.2 oz) with an expiration date of 07/29/15; 1 gallon of "Nursery Purified Water" with approximately 1/3 of its contents remaining with no open date. The instructions on the Nursery Purified Water label stated 'after opening, refrigerate and use within 7 days.' "

In an interview on 08/03/15 at 3:45 p.m., S6 Dietary Manager confirmed the above referenced findings regarding food items with no received dates, opened dates, expired dates, expired food items available for patient use, and the dented cans were available for patient use. S6 Dietary Manager confirmed these practices were not consistent with regulations for safe food practices and should have been.

4) Refrigerated food item stored improperly:
An observation on 08/04/15 at 10:30 a.m. revealed a plastic zip lock bag contained several pieces of defrosted fish with juices in the bottom of the bag. The bag of fish was noted to be on an upper open-wired shelf in the refrigerator, and a box of fresh tomatoes was stored in the refrigerator on the bottom shelf directly below the bag of fish.

In an interview on 08/04/15 at 10:30 a.m., S6 Dietary Manager confirmed the bag of thawed fish was stored above the box of fresh tomatoes and should not have been stored there.

In an interview on 08/05/15 at 12:45 p.m., S5 Registered Dietician indicated she provided oversight for the dietary department at the hospital. S5 Registered Dietician confirmed she was not aware that safe food practices were not being followed regarding the above-referenced findings for safe food storage and handling practices.

Based on record review and interviews, the hospital failed to ensure the dietary staff was competent for their respective duties as evidenced by the dietary staff not having an initial and/or annual assessment(s) for competency and skills documented for 3 of 3 (S6 Dietary Manager, S7 Dietary Cook, S8 Dietary Cook) personnel files reviewed for the dietary department staff. Findings:

A review of the personnel files for S6 Dietary Manager, S7 Dietary Cook, S8 Dietary Cook, revealed no documentation of an initial and/or annual assessment(s) for competencies and skills for their respective duties in the dietary department.

In an interview on 08/05/15 at 8:30 a.m., S4 Human Resource (Director) confirmed S6 Dietary Manager, S7 Dietary Cook, S8 Dietary Cook did not have any initial and/or annual competencies documented for their respective duties, and should have had documentation of the skills and competencies.

In an interview on 08/05/15 at 12:45 p.m., S5 Registered Dietician confirmed she had not documented any assessments of skills and competencies for S6 Dietary Manager, S7 Dietary Cook, and S8 Dietary Cook upon hire and/or annually.

Based on record reviews and interviews, the hospital failed to ensure that the person designated as infection control officer developed and implemented policies and procedures governing control of infections and communicable diseases. This deficient practice was evidenced by no policies and procedures relevant to hospital construction, renovation, maintenance, demolition, and repair, including the requirement for an infection control risk assessment (ICRA) to define the scope of the project and need for barrier measures before a project gets under way.
Findings:

Review of the Infection Control Policy and Procedure Binder provided by S11 QAPI/IC (Quality Assurance/Infection Control Coordinator) revealed no evidence of any policy or procedure related to construction, renovation, maintenance, demolition, repair of the hospital, and/or an ICRA.

In an interview 8/5/15 at 11:50 a.m., S11 QAPI/IC reported the hospital did not have infection control policies and procedures related to construction, renovation, maintenance, demolition, or repair of the hospital. S11 QAPI/IC reported that an ICRA had been conducted prior to the beginning of construction, but it was not done by her and she did not have a copy. S11 QAPI/IC reported that the administrator would have that copy with the contractor's contract.

In an interview 8/5/15 at 10:10 a.m., S1 Administrator reported that no ICRA had been done prior to the start of construction on the new ER. S1 Administrator reported she was not aware of any hospital policy and procedure(s) related to construction in the hospital.

Review of an ICRA titled Pre-Construction Risk Assessment (Infection Control/Safety Construction Permit) 8/5/15 at 12:05 p.m., provided by S11 QAPI/IC as the ICRA for the hospital's current construction project that included remodeling of the Emergency Services Department (ER), revealed no project start date, estimated Duration, Contractor performing work, or supervisor. No documented evidence was found that would indicate a hospital representative, and/or the hospital Infection Control Coordinator had reviewed, contributed, or evaluated the ICRA. The Project Coordinator was documented as "M.". S11 QAPI/IC reported the sections of the ICRA filled in were completed by the contractor (for the construction project). S11 QAPI indicated that no one from the hospital had contributed or documented on the ICRA. S11 QAPI indicated that the ICRA had not been completed by hospital infection control, for the need and plan for barriers measures, before the start of the construction.

Based on observation, record review, and interview the hospital failed to ensure the infection control officer developed and implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:
1) failure to maintain environmental areas in a clean and sanitary manner;
2) failure to perform surveillance that staff practices that affect infection control such as hand hygiene, correct use of Personal Protective Equipment (PPE), complete and correct cleaning and disinfecting of the environment and equipment used in or for patient care.
Findings:


1) failure to maintain environmental areas in a clean and sanitary manner.

Review of documents provided by S15 Housekeeping Supervisor in response to a request for Housekeeping/Cleaning policies and/or procedures, revealed a document titled "Discharge Patient Room". The first listed procedure read, "Look up for dirty vents and spider webs in ceiling. Clean vents with broom." Review of a document titled, " Pharmacy" revealed the first item read, "Look up for dirty vents and spider webs in ceiling. Clean vents daily with broom."

No policy or procedure was provided related to the cleaning and maintenance of linen rooms (clean or dirty) or clean supply rooms.

Observations made by surveyors 8/3/15 at 2:00 p.m. and 8/4/15 at 8:20 a.m. revealed two outside garbage dumpsters, with the covers open. Further observation revealed numerous blue gloves (PPE) that were partially inside out, as when removed after use, and in various stages of breakdown. Some gloves were bright blue and looked recently discarded, while others looked dark blue as if weathered and stuck to the ground. Other refuse was noted around the dumpsters that included a feminine hygiene applicator and flattened plastic drink bottles. Further observations included an outdoor room in a cinder block building, with a bin containing full dirty laundry cloth bags. The large bin was noted to have dark cobwebs around the top of the container. On the walls, and door (opposite the entrance door), open ceiling wood boards, and other containers were thick dark brownish-black cobwebs. The room also contained a black rolling bin with a metal chair on top of a large number of papers with cobwebs on it, a medium sized cardboard box filled with plastic sheets with most of the top edges thickly covered with cobwebs. Another rolling bin, empty, with a large amount of cobwebs on it was observed. A door on the back wall of the room was completed covered in cobwebs. The floor was observed to have large areas of dirt with dead insects near the storage bins. Flying insects (dirt daubers) flew out of the room and forced surveyors to leave to avoid being stung.


In an observation 8/4/15 at 10:10 a.m. S11 QAPI/IC (Quality Assurance and Performance Improvement/ Infection Control Coordinator) and S15 Housekeeping Supervisor confirmed the findings noted above. S15 Housekeeping Supervisor indicated the outdoor room was used to store dirty linen until it was picked up by the contracted linen service. S15 Housekeeping Supervisor reported the filled cloth bags stored in the large container were dirty linen from the hospital. The Housekeeping Supervisor indicated she did not know what the other items in the room were or who they belonged to. S11 QAPI/IC reported she was not aware of the refuse on the ground surrounding the garbage dumpsters, or the condition of the dirty linen storage room. Neither S11 QAPI or S15 Housekeeping Supervisor knew what the other items in the room were, but stated they should not be there. They both reported the contents of the other containers in the room (other than the dirty laundry bin) should have been disposed of. S15 Housekeeping Supervisor identified one of the papers under the metal chair in a large rolling bin as a patient medical record facesheet, but was unable to identify the patient without moving the chair and reaching into the bin. S11 QAPI/IC reported she was not sure to whom the responsibility fell to keep the room clean, or to ensure that trash that included used PPE was in a closed garbage dumpster and not on the ground. S15 Housekeeping Supervisor reported she did not know who was responsible for cleaning the dirty laundry room or the area of the garbage bin.

An observation made 8/4/15 at 8:15 a.m. revealed, in patient room "a", a thick layer of dust on the air vent in the bathroom wall. The room had a piece of tape on the door and door facing that indicated the room was cleaned and ready for patient use.

An observation made 8/5/15 at 12:00 p.m., with S11 QAPI/IC and S15 Housekeeping Supervisor revealed the following: Rooms "a", "b", and "c" contained a vent in the bathroom wall of each room. Each vent was covered with dust. S15 Housekeeping verified that all 3 rooms had tape on the door and door frame indicating the rooms were cleaned, disinfected, and ready for patient use. S15 Housekeeping Supervisor and S11 QAPI/IC confirmed that rooms "a", "b", and "c" were not ready for patient use since they contained dust. S11 QAPI/IC verified that the majority of patients currently admitted to the hospital had respiratory diagnoses and that a dusty environment could affect them negatively.

An observation made 8/5/15 at 11:50 p.m., with S11 QAPI/IC and S15 Housekeeping Supervisor present, revealed an air return vent in the pharmacy was very dusty. S15 Housekeeping Supervisor indicated the vent should have been cleaned.

2) failure to perform infection control surveillance of staff practices that affect infection control such as hand hygiene, correct use of Personal Protective Equipment (PPE), complete and correct cleaning and disinfecting of the environment and equipment used in patient care.

Review of a hospital policy titled "Infection Control Plan" revealed, in part, "Activities: Infection control activities include the following : * Monitoring and evaluation of key performance aspects of infection aspects of infection control surveillance, prevention,and management: HAI's (Hospital Acquired Infections) in special care units, Class 1 Surgical Site Infections (SSIs), Class 2 SSIs, Device-related infections, Infections in Pediatrics, Antibiotic-resistant organisms, HAI TB (Tuberculosis), Other communicable diseases, Employee trends *Continuously collecting and/or screening data to identify isolated incidents or potential infectious outbreaks."

Review of Infection Control Documentation provided revealed no raw data or reports of surveillance activities that included staff practices and adherence to infection control policies and procedures, such as hand hygiene, environmental rounds, and use of PPE, inclusive of all areas and all disciplines providing care and services in the hospital.

In an interview 8/5/15 at 12:00 p.m. S11 QAPI/IC reported she did not have any documentation of surveillance of employee practices that included hand hygiene, correct use of PPE, or of surveillance of the physical environment to ensure it was cleaned and kept in a manner to prevent infection control breeches and infestation of insects. S11 QAPI/IC reported that she did sometimes check for correct hand hygiene of the nurses, but had no plan or process as to how that would be performed. (method, number of times to check, frequency, desired thresholds). S11 QAPI/IC indicated she did not make Infection Control Physical Rounds. The IC Coordinator reported she had been unaware of the findings as indicated above.

Based on record review and interview, the hospital failed to ensure the Respiratory Therapist was qualified, consistent with State law, as evidenced by failing to assess the skills and competencies of the Respiratory Therapist upon hire and annually. Findings:

Review of the personnel file for S9Respiratory Therapist on 08/04/15 revealed no initial and/or annual assessment(s) of S9Respiratory Therapist's skills and competencies by the hospital. Further review of a document presented on 08/05/15 to the surveyor by S4Human Resource (Director) revealed a document dated 08/25/14 from another facility with S9Respiratory Therapist's skills and competencies assessment.

In an interview on 08/05/15 at 8:30 a.m., S4Human Resource confirmed S9Respiratory Therapist did not have any initial and/or annual skills and competencies assessment by the Director of Respiratory Services.

In an interview on on 08/05/15 at 11:30 a.m., S9Respiratory Therapist confirmed he had not been assessed for skills and competencies by the Director of Respiratory services upon hire and/or annually.