HospitalInspections.org

Based on review of written agreements and staff interview, the facility failed to have a written agreement for the services provided by radiologists via telemedicine. The findings were:

Review of the the written agreement between a telemedicine entity and the facility for the provision of interpretations of radiological studies by radiologists revealed the agreement expired June 30, 2010. During an interview on 3/13/13 at 10:20 AM the director of operations confirmed the agreement had expired. She stated there was no other written agreement in place.

Based on observation, staff interview, and review of policies and procedures, the facility failed to ensure the operating room (OR) was disinfected properly to prevent the spread of infection during one random observation. The findings were:

Observation on 3/13/13 from 11:14 AM until 12:35 PM revealed housekeeper #1 cleaned the OR immediately following a procedure. Interview with the housekeeper at that time revealed this was a "full" cleaning, because that was the last procedure scheduled for the day. The following concerns were identified:
a. During the observation, the housekeeper placed used cloths back into the bucket containing the solution numerous times. In addition, she placed the used mop head back into the mop bucket containing solution. Review of the facility's policy "Environmental Cleaning" for the OR department (policy 1016, undated) revealed "Reusable string and microfiber mops and cleaning cloths should be changed after each use. Used cleaning mops or cloths should not be returned to the cleaning solution container.
b. At 11:46 AM the housekeeper changed the solution in the container (used with the cloths). The product used was "Lila-Phene Plus." The instructions were to mix 1 ounce of the solution with 1 gallon of water. The housekeeper placed 1 squirt of solution into the bucket, which she stated was 1 ounce. She then poured some out, and added water. When asked how much water she put in, she replied "I don't know...probably 1/2 gallon." She stated she had poured some of the solution out because she didn't want it "too strong" since she was not using a full gallon of water.
c. During the observation, the housekeeper wiped down all surfaces in the OR once with the cloth from the solution of "Lila-Phene Plus." Observation showed after 2 minutes, streaks were visible on the surfaces; the entire surface was not visibly wet. When asked if the product had a contact time, the housekeeper stated "until it dries." Review of the instructions on the label showed the surfaces were to be thoroughly wet, and allowed to remain wet for 10 minutes, and then let air dry (15 minutes wet time if Tuberculocidal activity was required).

On 3/14/13 at 8:10 AM housekeeper #1 stated nobody had told her not to put used cloths back into the solution. She further agreed that without measuring the solution and water there was no way to determine if the concentration of the solution was adequate. Furthermore, she stated she was unaware the instructions for the solution required the surfaces to remain wet for 10 minutes.

During an interview on 3/13/13 at 3:15 PM, the infection control practitioner stated staff should follow manufacturer's instructions for the solution used to clean the OR. He was not aware of the 10 minute wet contact time. Furthermore, he stated he did not monitor the cleaning of the OR.

Based on medical record review, staff interview, and review of facility policies and procedures, the facility failed to ensure written and verbal orders were signed by a physician for 4 of 20 sample patients (#3, #5, #8, #15). The findings were:

1. Review of the medical record on 3/13/13 for patient #3 showed s/he was admitted to the facility on 11/16/12. Further review showed admission physician's orders were taken by a registered nurse (RN) by phone on 11/16/13 at 3 PM. However, the facility failed to ensure the order was co-signed by the physician.

2. Review of physician orders for patient #5 showed a telephone order dated 12/21/12 to clarify the dose of Coumadin. The order was noted by an RN, but further review showed the physician failed to sign the order. On 3/13/13 at 4:20 PM the medical records supervisor confirmed the lack of a physician signature.

3. Review of physician orders for patient #8 showed orders for a Nicotine patch 21 milligrams daily and "butt paste", both ordered 9/30/12. Further review showed the physician failed to sign the orders. On 3/13/13 at 4:20 PM the medical records supervisor confirmed the lack of physician signatures.

4. Review of the medical record on 3/13/13 for patient #15 showed s/he was admitted to the facility on 1/26/13. Further review showed that a verbal physician's order taken on 1/29/13 at 8:40 AM by an RN was not co-signed by the physician. In addition, physician's orders taken by phone on 1/29/13 at 9:45 AM and 4 PM by an RN were not co-signed by the physician.

5. During an interview on 3/13/13 at 4:20 PM, the medical records supervisor stated she thought verbal orders were supposed to be signed within 24 hours. In addition, she stated the medical records of discharged patients should be complete in 15 days, which would include all signatures. Review of the policy provided by the medical records supervisor, "Incomplete Medical Record Reporting" effective 1/13/09, showed records of patients discharged were to be completed within 15 days following admission. In addition, telephone or verbal orders from the physician will be signed within 24 hours.

Based on facility form review, staff interview, and policy and procedure review, the facility failed to develop and implement written policies regarding visitation rights. The findings were:

Review of the patient rights form, which patients signed and was kept in the medical record, showed it did not include visitation. Upon request of a policy for visitation, the facility only provided a policy which addressed visitation in the labor and delivery unit. During an interview on 3/14/13 at 11 AM and 11:20 AM, the acute care clinical supervisor stated the facility did not have a policy to address visitation rights of all patients. In addition, she stated they did not have any documentation to show that patients were instructed of their visitation rights before care was provided.