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Based on observation and review of crash cart checklist documentation for 3 of 3 emergency crash carts, and policy review, it was determined the hospital failed to document that its emergency crash carts were maintained in accordance with its policy and to assure the integrity and availability of the contents of the carts.

Findings include:

1. A hospital policy titled "EMERGENCY CRASH CART SECURITY AND ACCOUNTABILITY," effective 06/21/2012 was reviewed. The policy reflected "The nursing personnel shall visually inspect the numbered break-away lock located on the crash cart at each change of shift, documenting that the cart is properly locked with all appropriate contents present and intact. A discrepancy, broken lock or missing lock shall be reported to the Central Service and/or Pharmacy Department...Only approved locks will be used to secure the crash cart and only Pharmacy personnel will be in possession of the locks."

2. A hospital policy titled, "DEFIBRILLATOR CHECK," effective 08/16/2011 reflected "At Curry General Hospital, the defibrillator and crash cart will be inspected and tested each shift to ensure it is working properly and the code cart is sealed."

3. A tour of the hospital's Med-Surg unit and ICU was conducted on 06/26/2013. During the tour, the Nursing (Med/Surg & ICU) crash cart checklist titled "DAILY CRASH CART CHECKLIST," was reviewed with I2. The checklists were reviewed for February through June 2013. The February 2013 checklist lacked crash cart documentation for 17 of the 56 shifts. The March 2013 checklist lacked crash cart documentation for 9 of 62 shifts. The April 2013 checklist lacked crash cart documentation for 6 of 60 shifts. The May and June checklists reflected similar findings. The results were discussed with I2.

4. A tour of the Emergency Department was also conducted on 06/26/2013. The "DAILY CRASH CART CHECK LIST" for February 2013 through June 2013 were reviewed. The February 2013 checklist lacked crash cart documentation for 12 of 56 shifts. The March 2013 checklist lacked crash cart documentation for 10 of 62 shifts. The April 2013 checklist lacked crash cart documentation for 8 of 60 shifts. The May and June checklists reflected similar findings

5. A careful review of the Surgical Services crash cart was also conducted on 06/26/2013 at 1030. The following dates reflect days that the surgical suite was utilized for surgical procedures but the "Daily Crash Cart Checklist" lacked crash cart documentation. The "DAILY CRASH CART CHECKLIST" for February 2013 through June 2013 were reviewed. The February 2013 checklist lacked crash cart documentation for 2 of 20 shifts. The March 2013 checklist lacked crash cart documentation for 1 of 20 shifts. The April 2013 checklist lacked crash cart documentation for 1 of 20 shifts. May and June checklists reflected similar findings.

Based on observation and policy review, it was determined the hospital failed to ensure patient care equipment was maintained in safe operating condition in accordance with hospital policy and this regulation.

Findings included:

1. Review of a policy titled "Preventive Maintenance," revised 02/2012 reflected "Curry Health Network shall maintain a comprehensive preventive maintenance program, which includes written testing and maintenance for all equipment included in the program at established intervals of bi-annually...Documentation of the preventive maintenance program is located in the Engineering department...Equipment included in the program shall meet one (1) or more of the following criteria: The equipment is essential for life support or is used in diagnosing or monitoring any physiologic condition of the patient...The equipment has a higher than normal incident risk during routine operation due to clinical application...The equipment requires a more intensive maintenance schedule, by reason of its complexity schedule, by reason of its complexity or use factor...The equipment is supplied or maintained by an outside vendor."

2. An observation of a surgical procedure was conducted in the OR on 06/26/2013 beginning at approximately 1030. During the procedure a Stryker Neptune Ultra Smoke Evacuator (a mobile device used to suction and collect fluid from a surgical site) was used during the procedure. A preventative maintenance (PM) sticker was affixed to the device and reflected that the next PM was recommended 09/2012 (nine months prior to the observation). An Ethicon Harmonic Endo-Surgery cautery device was also observed in the OR and available for use. The cautery device had no PM sticker or any other indication that PM had been performed. This was verified with I4 on 06/26/2013 at 1240.

3. An interview was conducted with I4 on 06/27/2013 at 1600. He/she stated there was no additional documentation for PM for the suction and cautery equipment identified above.

Based on observation, interview, policy review and documentation review, it was determined that the hospital failed to ensure an acceptable provision of services. It failed to ensure policies were developed and implemented for controlling and/or identifying infections, and to ensure policies were reviewed annually by a group of professional personnel as required.

This condition level deficiency substantially limits the capacity of the hospital to furnish services of an adequate level of quality.

Findings include:

Refer to Tag C278 which reflects the hospital's failure to ensure its policies included a system for controlling and identifying infections of patients.

Refer to Tag C280 which reflects the hospital's failure to ensure patient care policies were reviewed at least annually by a group of professional personnel.

Based on observation, interview, policy review and documentation review it was determined that the hospital failed to ensure policies were developed and implemented for controlling and identifying infections of patients. The operating room (OR) ceiling was not maintained to ensure effective cleaning; and policies were not fully developed and/or implemented for terminal cleaning the OR, monitoring humidity levels in the OR, monitoring sterilizer equipment, and disinfecting/cleaning instruments and devices used for surgical and other patient care procedures, as required.

Findings included:

A. An observation of a surgical procedure was conducted in the hospital's OR on 06/26/2013 at 1045. The OR had a suspended drop ceiling composed of individual square panels (each panel was approximately 24 X 24 inches). The panels were separated and supported by a metal grid frame. During the observation, many of the panels were lifting and/or separating from the frame, creating gaps into the space between the drop ceiling and the ceiling above. Some areas had significant gaps of 1-2 inches. For example, ceiling panels were lifting with visible gaps where the OR lighting system and smoke detector attached to the ceiling near the center of the room; one panel was sagging downward from the framework into the room near the anesthesiology equipment cart; and another panel was lifting with a visible gap located directly above the surgical table during the procedure. After the procedure was completed, one of the ceiling panels located near the OR entrance area was removed by hospital staff. The ceiling above the suspended panel had been repaired using mesh and caulking materials. The mesh and caulking were loose and beginning to sag. Additionally, the inside surfaces of the OR entrance doorframe had areas of chipped paint (an uncleanable surface).

An interview was conducted with I4 on 06/26/2013 at 1230. He/she checked the OR ceiling and acknowledged that the condition of the ceiling was not acceptable because it did not allow for effective cleaning processes to occur. He/she further indicated that because of the airflow in the OR, particles from the loose ceiling repair work could blow into the OR through the gaps in the suspended ceiling.

An interview was conducted with I14 on 06/27/2013 at 1120. He/she stated the OR ceiling panels were cleaned during the terminal cleaning process. He/she stated "They [the ceiling panels] move around every time we wash them."

An interview was conducted with I12 on 06/27/2013 at 1600. He/she acknowledged the condition of the OR ceiling was an infection control problem. He/she stated the ceiling was not a cleanable surface and it could not be assured that dust and debris would not fall from the gaps in the ceiling.

A policy titled "Surgery Terminal Cleaning," dated 01/25/2012 reflected "Healthcare associated infections have been linked to external sources...patients will be provided with a safe, clean environment free from dust and organic debris..." The policy required the ceilings in the surgical area be cleaned at least monthly, terminal cleaning of the OR performed when the scheduled procedures were completed for the day, and each 24-hour period during the regular work week. The policy further required OR terminal cleaning be documented, posted outside the OR, and kept on file.

An interview was conducted with I4 on 06/27/2013 at 1100. Documentation of OR terminal cleaning activities was requested. He/she acknowledged there was no OR terminal cleaning documentation posted or kept on file as required by hospital policy.

B. An interview was conducted with I4 on 06/26/2013 at 1250. He/she stated that OR humidity levels were checked each day a surgical procedure was planned. He/she stated the hospital used AORN (Association of periOperative Registered Nurses) standards to determine acceptable humidity levels for the OR. A surgical procedure would be canceled or an adjustment would be made to the air circulation equipment if the humidity level was outside acceptable parameters.

Documentation on OR humidity log records and surgery schedules for February 1, 2013 through June 26, 2013 were reviewed. I4 was present during the review. The humidity logs were compared to the surgery schedules and reflected that OR humidity levels were not checked each day a surgical procedure was performed. For example, on 02/15/2013, there was one surgical procedure performed in the OR, however no humidity levels were documented; on 04/11/2013 there were five surgical procedures and no humidity levels were documented; on 05/13/2013, there were five surgical procedures and no humidity levels were documented; and on 06/05/2013 there were two surgical procedures performed and no humidity levels were documented.

During an interview with I4 on 06/26/2013 at 1315, he/she acknowledged that the OR humidity levels were not checked each day a surgical procedure was performed. He/she further stated that there was no policy developed or implemented for monitoring the humidity levels in the OR. Therefore, it could not be assured that the humidity levels were monitored and addressed in accordance with AORN standards.

C. A tour of the Radiology department was conducted on 06/27/2013 at 1420. During the tour, an interview was conducted with I11. He/she stated that the transvaginal probes used to perform ultrasound examinations of patients were disinfected in the Radiology department. I11 stated that the OR staff changed the solution (Cidex OPA) used to disinfect the probes every two weeks. He/she also stated that the OR staff did not know when an ultrasound examination was scheduled, in order to ensure the disinfectant solution was changed timely before it was re-used.

I11 provided a log titled "Record of Cidex OPA Use." He/she stated the log was used to record when the disinfectant for the probes was changed. The log for 03/28/2012 through 06/27/2013 was reviewed. The log had a "Date changed" column indicating the dates the disinfectant solution was changed. The documentation on the log reflected the disinfectant was not changed every two weeks. For example the log reflected the disinfectant was changed on 03/28/2012. The next "Date changed" was 04/19/2012, 22 days later. The log reflected the disinfectant was changed on 07/27/2012. The next "Date changed" was 09/07/2012, over a month later. The log reflected the disinfectant was changed on 12/17/2012. The next "Date changed" was 01/23/2013, over a month later.

An interview was conducted with I12 on 06/27/2013 at 1615. These findings were reviewed and he/she provided manufacturer's instructions for the CIDEX OPA disinfectant solution. Review of the manufacturer's instructions reflected "DIRECTIONS FOR USE...Immerse device completely...in CIDEX OPA Solution for a minimum of 12 minutes at...[68 degrees Fahrenheit] or higher to destroy all pathogenic
microorganisms...Storage and Disposal...Do not use beyond 14 days or sooner as indicated by CIDEX OPA Solution Test Strips."

A policy titled "Transvaginal/Endovaginal Ultrasonography - General Guidelines," effective 08/10/2010 was reviewed and reflected "...Remove the probe when finished with the examination. The probe is placed in a disinfectant for a length of time specified by the manufacturer." The policy was not fully developed and implemented. For example, it did not include how often the disinfectant solution should be changed, or any tests that may be recommended to check the solution concentration (e.g. test strips) and/or temperature in accordance with the manufacturer's instructions.

Similar findings were identified during review of the process used for disinfecting reusable laryngoscope blades (an instrument used to examine the inside of the throat for placement of an endotracheal tube).

A tour of the sterile processing department was conducted with I15 on 06/26/2013 at 1400. A container used to disinfect laryngoscope blades was observed. I15 stated that Cidex OPA was used to disinfect the blades, and should be changed every 2 weeks. Review of the "Record of Cidex OPA Use" log reflected it lacked documentation that the disinfectant solution was changed every 2 weeks.

An anesthesia department policy titled "Infection Control," dated 11/04/2009 reflected "Laryngoscope blades will be thoroughly washed, cleaned with enzymatic cleaner, rinsed with water followed by high-level disinfection with [sic] per policy and procedure...All reusable equipment is decontaminated by the above mentioned Cidex OPA high-level disinfection process." However, the policy was not fully developed to include what the process was for performing the Cidex OPA high-level disinfection.

D. A tour of the sterile processing department was conducted on 06/26/2013 at 1400 with I15. During the tour, two steam sterilizers (used to sterilize surgical instruments) were observed. I15 stated that Biological Indicators (BI) (used to measure the effectiveness of a sterilizer cycle) were used to monitor the steam sterilizers.

An interview was conducted with I9 on 06/27/2013 at 1200. He/she revealed there was no policy developed for conducting BI monitoring of the steam sterilizers. Therefore, it could not be assured that BI monitoring processes and any corrective actions that may be identified as a result of the monitoring, were consistently applied.

E. The hospital used multiple patient glucose meters (glucometers). A procedure titled "Nova StatStrip Glucometer Use," effective date 09/11/2012 reflected "...Clean the meter with a disinfectant wipe. Allow to air dry." The procedure included a process for disinfecting the meter after it was used for patients in isolation precautions. However, the policy was not developed and implemented to address cleaning/disinfection procedures after it was used for patients who were not in isolation precautions, in order to prevent carry-over of blood and infectious agents.

An interview was conducted with I13 on 06/27/2013 at 1330. I13 stated that he/she had checked the glucose meters (available for multiple patient use) at the nursing units, and found that they had dried blood on them. He/she acknowledged that the glucose meter policy was not fully developed and implemented to ensure disinfection procedures were performed between each patient as they should be. I13 stated he/she verbally trained the staff in proper cleaning procedures but he/she neglected to include the instruction in the procedure. Review of the "Stat Strip Competency Exam" used to train the nursing staff in proper testing procedures neglected to include any procedure for cleaning and disinfecting the meter.

Based on interview and review of charter documentation and policies and procedures it was determined that the hospital failed to ensure a system was in place to annually review patient care policies by a professional group per this regulation.

Findings include:

1. An interview with I3 on 06/28/2013 at 0805 reflected the facility neglected to have a professional group review the patient care policies on an annual basis.

2. a Curry Health Network Charter titled, "Charter of the Critical Access Hospital Professional Advisory Committee," reviewed 12/2011, reflected "1. Purpose In accordance with the requirements of a Critical Access Hospital (CAH), Curry Health Network (CHN) has established a CAH Professional Advisory Committee that will review...CAH's health care policies - no less than annually..."

3. During the CAH recertification survey, it was determined that many policies were not reviewed or revised on an annual basis per this regulation. Listed below is a sample of hospital patient care policies that had no review or revision for more than a year:
-Policy titled, "ASSESSMENT OF PAIN ON ADMISSION," effective 08/16/2011, no revised date listed;
-Policy titled, "BLOOD GLUCOSE SCREENING," effective 08/16/2011, no revised date listed;
-Policy titled, "CARDIOPULMONARY RESUSCITATION PROTOCOL," effective 07/19/2010, no revised date listed;
-Policy titled, "DEFIBRILLATOR CHECK," effective 08/16/2011, no revised date listed;
-Policy titled, "DIRECTIVES FOR RESUSCITATION/DNR," effective 08/16/2011, no revised date listed;
-Policy titled, "EMERGENCY CRASH CARTS," effective 07/2011, revised 07/2011;
-Policy titled, "EMERGENCY CRASH CART SECURITY AND ACCOUNTABILITY," effective 03/21/2012, no revised date listed;
-Policy titled, "EMTALA GUIDELINES FOR EMERGENCY DEPARTMENT SERVICES," effective 08/16/2011, no revised date listed;
-Policy titled, "ENDOSCOPIC EQUIPMENT - PREPARATION AND INSPECTION," revised date 12/2011;
-Policy titled, "HIGH-LEVEL DISINFECTION OF ENDOSCOPES," revised date of 12/2011;
-Policy titled, "HISTORY AND PHYSICAL - SURGICAL SERVICES," effective 11/30/2010, revised 12/2011;
-Policy titled, "INFECTION CONTROL PLAN," effective 01/24/2008, revised 02/14/2010;
-Policy titled "INITIAL PATIENT ASSESSMENT AND REASSESSMENT," effective 08/06/2011, no revised date listed;
-Policy titled, Patient Bill of Rights and Responsibility," effective date; 11/2010, no revised date listed;
-Policy titled, "PATIENT COMPLAINT AND GRIEVANCE," effective 05/05/2011, no revised date listed;
-Policy titled "PATIENT VISITATION," effective date 11/01/2011, no revised date listed;
-Policy titled, "PERFORMANCE IMPROVEMENT PLAN," effective 01/01/2012, revised 12/13/2011;
-Policy titled, "REPROCESSING FLEXIBLE ENDOSCOPES,"effective 01/22/2009, revised 04/26/2011;
-Policy titled "RISK MANAGEMENT PLAN," no effective date or revised date listed but approved on 12/06/2011;
-Policy titled, "SPECIALIZED SERVICES GENERAL POLICIES," effective 06/24/2007, revised 08/26/2011; and
-Policy titled, "TRANSFER OF PATIENT TO ANOTHER FACILITY," effective 08/16/2011, no revised date listed.

Based on interviews with administrative personnel and review of documentation, it was determined that the hospital lacked a periodic evaluation of the 2012 CAH total program.

Findings include:

1. An interview with I3 on 06/28/2013 at 0805, reflected the periodic CAH program evaluation of its total program including all services had not been completed since 05/09/2011. I3 confirmed the CAH program evaluation had not been completed since the last risk manager left the hospital.

2. Review of a Curry Health Network Charter titled, "Charter of the Critical Access Hospital Professional Advisory Committee, "reviewed 12/2011, reflected "1. Purpose In accordance with the requirements of a Critical Access Hospital (CAH), Curry Health Network (CHN) has established a CAH Professional Advisory Committee that will review (1) utilization of CAH services, (2) hospital review of a representative sample of open and closed medical records, and (3) CAH's health care policies - no less than annually...The chairperson will be the CEO. In the event that the CEO is unavailable, the Chief Nursing Officer will be the chair...The committee will meet quarterly to review the critical access hospital requirements and assure compliance with regulations."

3. Review of documentation revealed that the last CAH periodic evaluation was completed and dated 05/09/2011. The hospital lacked documentation of the completion of a more recent CAH program evaluation.

Based on policy review and review of 1 of 4 medical records of patients (Patient #18) who expired at the hospital, it was determined that the hospital failed to notify the OPO (organ procurement organization) of the patient's death as required by hospital policy and this regulation.

Findings included:

1. Review of a policy titled "Organ/Tissue/Eye Donation - Nursing Staff Responsibilities," (undated) reflected "...All deaths at curry [sic] General Hospital shall be reported to the Oregon Tissue Donation Hotline (hereinafter referred to as the Tissue Donation Hotline) for evaluation of donation referral. At the time that the Tissue Donation Hotline is notified of a death, a donor number shall be issued by the Hotline. That number shall be recorded on the Receipt of Body form as documentation that the death was reported."

2. The medical record for Patient #18 was reviewed: The record reflected the patient was admitted to the hospital on 03/06/2013 at 1130 and expired on 03/21/2013 at 0530. The record lacked documentation that the Tissue Donation Hotline (OPO) was notified in accordance with hospital policy and this regulation.

I18 reviewed the medical record for Patient #18 on 06/28/2013 at 0800, and verified there was no documentation that the OPO had been notified of the patient's death.

Based on policy review and review of medical records for 2 of 2 Swing-bed patients (Patient #s 14 and 15) who were discharged from the hospital, it was determined that the hospital failed to provide written notice to the patients before discharge in accordance with hospital policy and this regulation.

Findings included:

1. Review of the policy titled "Swing Bed Program Admission, Transfer, & Discharge Rights," (undated) reflected the following internal requirements: "Notice Before Transfer: Before a facility transfers or discharge [sic] a resident, the facility must: (i) Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the moving [sic] in writing..."

2. The Swing-bed medical record for Patient #14 was reviewed. The record reflected the patient was admitted as a "Swing-bed" patient on 02/22/2013 and discharged on 03/01/2013. The record lacked documentation that the patient received a written notice before discharge.

The Swing-bed medical record for Patient #15 was reviewed. The record reflected the patient was admitted as a "Swing-bed" patient on 05/19/2013 and discharged on 05/24/2013. The record lacked documentation that the patient received a written notice before discharge. These findings were reviewed and acknowledged by I2 on 06/25/2013 at 1450.

Based on interview, policy review and review of 2 of 2 medical records of Swing-bed patients (Patient #s 14 and 15), it was determined the hospital failed to provide an ongoing program of activities that was directed by a qualified professional in accordance with hospital policy and this regulation.

Findings included:

1. Review of a policy titled "Specialized Services General Policies," revised 08/26/2011 reflected the following internal requirements: "Activity Program: An activity program consistent with the mental, physical, spiritual, emotional, and social stimulation needs of the patient is provided. Volunteers and a certified activity planner are responsible for providing the major portion of this service."

2. During an interview on 06/28/2013 at 0830 with I8, he/she was asked if the hospital had an activities director who was certified or a qualified professional in accordance with this regulation. He/she stated "No, we do not." He/she stated the hospital had plans to coordinate with an assisted living facility in order to meet the activities director requirements. However, he/she acknowledged that those arrangements had not yet been made.

3. Swing-bed medical record for Patient #14 was reviewed. The record reflected the patient was admitted to a Swing-bed on 02/22/2013 and discharged on 03/01/2013. The record lacked documentation of an activities assessment or that any individualized activities were offered or provided.

Swing-bed medical record for Patient #15 was reviewed. The record reflected the patient was admitted to a Swing-bed on 05/19/2013 and discharged on 05/24/2013. The record lacked documentation that any individualized activities were offered or provided. These findings were reviewed and acknowledged by I8 on 06/25/2013 at 1630.