Bringing transparency to federal inspections
Tag No.: A0143
Based on a review of facility documentation, a facility tour and staff interview the facility failed to ensure each patients right to personal privacy, as a video monitor for four rooms in-patient use was situated such that anyone walking into the area of the hospital view the monitor. The area was open to all visitors and staff.
Findings were:
During a tour of the facility on the morning of 6/18/19, a camera monitor of four in-patient rooms, #6, #7, #26 and #27 was placed on the counter in the nurses' station. The monitor screen was divided into four, showing the patients bed in each of the four rooms. The nurses station could be approached from four different hallways. The monitor screen was clearly visible by anyone approaching the nurses station.
In an interview with the staff #26, she was asked, how the patient's privacy protected during treatment and other personal interventions. Staff #26 demonstrated how the monitor screen was covered with two posted noted on one corners of the monitor screen.
The above finding was confirmed by the CEO on the afternoon of 6/19/2019.
Tag No.: A0398
Based on review of documentation and interview, it was determined that Temporary/Agency nursing staff failed to receive orientation to the hospital or to the departments they served.
Findings were:
In an interview with the Assistant Director of Nursing (ADON), staff #1 stated, "we have two agency nurses that we use regularly. The agency nurses have been verbally oriented on the units." Orientation to the unit is was not documented.
The above finding was confirmed by the ADON the morning of 06/19/19.
Tag No.: A0749
Based on observation and interview, the facility failed to provide a safe and sanitary environment for its staff and patients.
Findings included:
"OSHA/Blood Borne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."
In an article published by Spectrum Health in July, 2014 it was stated "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."
The following were observed during the facility tour on the morning of 6/18/19:
*Icemaker scoop was sitting in the ice
*Patient bathrooms in the ER had wallpaper border that was torn in several areas
*One stained ceiling tile in the radiology hallway
*Chair in patient room 127 with rips making it impossible to clean
*CNA nursing station with several chips on the exterior finish of the desk making it impossible to clean
*Five discolored tiles on the sterile supply floor
*Shipping boxes were found throughout the facility
The following found expired during a tour of the facility on the morning of 6/18/19:
*Adult colorimetric CO2 detector expired 1/8/19
*500 mL bag of lactated ringers expired April 2019
*Epinephrine 1 mg/10 mL vial expired 5/1/19
*BD insyte 18 gauge [GA] intravenous [IV] catheter expired 5/2018
*BD insyte 22 GA IV catheter X 4 expired 2/2019
*22 GA IV catheter X 2 expired 3/2019
*20 GA IV catheter expired 5/31/2019
*Whitacre needle X 7 expired 3/2018 and one expired 4/2018
*10 French urethral catheter X 2 expired 4/2019
*16 French urethral catheter X 3 expired 4/2019
*22 French urethral catheter X 2 expired 3/2019
The above was confirmed during the facility tours with staff members #1 and #2.
Tag No.: A0940
Based on review of facility documents, review of medical records and staff interview, the facility failed to provide surgical services that were well organized and provided in accordance with acceptable standards of practice when:
1. The surgical services were inconsistent with needs and resources (Cross refer A0951).
2. The facility failed to ensure a properly executed informed consent form was in each patient's chart before surgery (Cross refer A0955).
Tag No.: A0951
Based on observation, review of documentation and staff interview, the facility failed to ensure surgical services were consistent with needs and resources when the facility failed to:
A. Maintain policies designed to assure the achievement and maintenance of high standards of medical practice and patient care.
B. Maintain temperature, humidity and airflow in surgical areas.
C. Ensure adequate surveillance was conducted and data collected to monitor and address post-surgical infections.
D. Perform preventive maintenance of their sterilizer according to an adopted policy, using the manufacturer's service manual as a reference.
E. Ensure the sterilization of all supplies and equipment was under the supervision of a person qualified by education, training and experience who participated in a documented continuing education program.
Findings included:
A. Facility-based policy titled "Standard Policy and/or Procedure" stated in part, "Executive Authority: The governing board authorizes the Chief Executive Officer to assure periodic review and revision of policies and procedures addressing key functions within the organization. Policies and procedures regarding nursing standards of care and practice will be periodically reviewed by the Director of Nursing. Key process plans will be approved annually by the organization's leadership, medical executive committee and governing body.
...Review Period: All policies and procedures, protocols, etc. will be reviewed/revised every two years ..."
Surgery policies and/or procedures, including infection control, were last reviewed in March of 2015.
When asked for policies and procedures related to preventive maintenance and use of the sterilizer, none were provided.
When asked for policies and procedures related to monitoring humidity and temperatures in the surgical area, none were provided.
The above was confirmed in an interview with staff #2 on the afternoon of 6/18/19.
B. The Association for the Advancement of Medical Instrumentation [AAMI] in coordination with multiple health-care related organizations created a task force to address HVAC [heating, ventilation, and air-conditioning] in the Operating Room [OR] and Sterile Processing Department [SPD] dated 9/21/15 that stated in part, "Every health care organization that provides surgical services should determine the HVAC operating parameters for ORs, the SPD, endoscope procedure rooms, and sterile storage rooms that meet their patient, personnel, and product storage needs. Pulling together a multidisciplinary team to review the current HVAC operating practice and perform a risk assessment of the affected area(s) is a good first step. The team should enter the values/parameters they will follow on a day-to-day basis into their organization's HVAC system policy, along with appropriate corrective measures to mitigate risk and restore the HVAC system to the desired parameters when conditions fall outside of those values. The team should identify medical products and devices that require tightly controlled storage conditions and move those products to a location where the humidity and temperature are maintained within the manufacturer-prescribed parameters (eg, a temperature and humidity controlled cabinet)."
ANSI/ASHRAE/ASHE [Approved American National StandardAmerican Society of Heating, Refrigerating and Air-Conditioning Engineers/American Society for Healthcare Engineering] standard 170-2017, released in 2017, stated in part, "The ventilation requirements of this standard are minimums that provide control of environmental comfort, asepsis, and odor in hospital heath care facilities ...
Table 7.1 Design Parameters - Hospital Spaces
*Operating room: Design Relative Humidity 20-60 %; Design Temperature 68-75 °F
*Labor/deliver/recovery: Design Relative Humidity 30-60%; Design Temperature 70-75
*Sterilizer equipment room: Pressure Relationship to Adjacent Area: Negative... Minimum Total ach [air changes per hour]: 10
*Decontamination room: Pressure Relationship to Adjacent Area: Negative ... Minimum Total ach: 6
*Sterile storage room: Design Relative Humidity: Max 60%; Design Temperature: Max 75 ..."
On a tour of the surgical area on the morning of 6/18/19, when asked for the humidity and temperature logs for the surgical area, staff #3 stated those were not monitored and provided a binder with blank pages for monitoring OR #1 and OR #2 humidity. When asked if any of these had been completed, staff #3 stated, "Before we have a case, I look at the temperature and humidity." When asked if these were documented, staff #3 verified they were not. When asked if there was a policy regarding the ranges of humidity and temperature, staff #3 stated, "We were in the process, but we don't have one." When asked if the decontamination area, sterilizing area, or sterile supply were monitored, staff #3 verified none of the areas in surgery were monitored for humidity, temperature or air exchange rates.
The above was verified in an interview with staff #2 on the afternoon of 6/19/19.
C. Facility-based policy titled "Surveillance for Healthcare Associated Infection" stated in part, "2.0 Definitions:
...Surveillance - the comprehensive ongoing systematic collection, analysis and interpretation of outcome- specific data for use in planning, implementing and evaluating healthcare practices closely integrated with the timely dissemination of this data to those who need it
3.1 Guiding Principles:
...3.5 The use of surveillance data does not only measure clinical outcomes such as infections, but also guides performance improvement activities and demonstrates improvements in both clinical outcomes and healthcare practices."
Facility-based policy titled "Surgical Site Infections (SSIs)" stated in part,
"1.0 Purpose: To identify the potential risks associated with surgical procedures and Surgical Site Infections (SSIs) and include this information in the risk stratification and data analysis of SSIs with the intent to improve patient outcomes.
2.1 Definitions:
SSIs - Surgical Site Infections occur as a complex interaction between the microbial contamination of the surgical site, the host response, and the local environment at the site of contamination ...
Surgical Site Infection surveillance definitions include the following:
Superficial Incisional Infection - occurs within 30 days of procedure ...
Deep Incisional Infection - [occurs within 30 ... days of surgery ...] and involves deep soft tissues of incision ...
Organ/Space Surgical Site Infection - [occurs within 30 ... days of surgery ...] and involves any part of the body excluding the skin incision ... that is opened or manipulated during the operative procedure ..."
Review of the quality improvement and infection control meeting minutes for 2019 revealed no evidence of SSI monitoring for the ten patients who had surgery in 2019.
In interviews with the surgical staff during the survey process, none were aware of SSI monitoring.
The above was confirmed with staff #2 on the afternoon of 6/19/19.
D. Facility-based policy titled "Sterilization of Instruments/Supplies" stated in part, "Central Processing will follow manufacturer's recommendations for use of steam sterilizers."
Amsco manual for the autoclave sterilizer used by the facility stated in part, "Routine Maintenance ... Daily ... 1. Clean chamber as follows:
a. Wash inside of chamber ...
b. Rinse ...
c. Remove chamber drain strainer ...
Weekly ...
a. Remove chamber drain strainer ...
b. Rinse ..."
When asked staff #10 for preventive maintenance logs for the sterilizer, staff #10 stated, "Someone comes out every quarter to do the preventive maintenance." When asked about the daily and weekly maintenance, staff #10 stated, "I don't remove the drain, maintenance does." When asked if it was completed daily, staff #10 stated they were unsure.
The above was confirmed in an interview with staff #2 on the morning of 6/18/19.
E. Facility-based policy titled "Sterilization of Instruments/Supplies" stated in part, "Policy: ...8. All personnel using other autoclaves will receive in-service classes prior to use of the sterilizers.
...Responsibilities:
...2. The OR Supervisor will ensure that all employees in the OR are trained in the use of the autoclaves as on going [sic] competency topics.
3. OR employees will be instructed on the proper packaging, cleaning and safety precautions."
When asked if orientation was provided on the use of the sterilizer, staff #10 stated the last person working there gave the orientation but nothing was documented. When asked for policies regarding sterilization, staff #10 stated there were policies related to the cleaning of instruments but none for the sterilizer.
Review of the personnel files for OR staff [staff members #10 and 11] revealed no documented education, training, experience, orientation, on-the-job training or continuing education related to sterilization.
The above was verified in an interview with staff #2 on the afternoon of 6/19/19.
Tag No.: A0955
Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure a properly executed informed consent form was in each patient's chart before surgery.
Findings included:
Facility-based policy titled "Informed Consent" stated in part, "Proper consent must be obtained before administering medical treatment or special procedures. To be valid, the consent obtained must be an informed consent. Securing the patient's signature on a form is not sufficient; the patient must, in addition, understand the circumstances to which he/she is consenting, and freely choose to enter into the agreement."
Facility-based form titled "Disclosure and consent for Medical & Surgical Procedure" stated in part, "To the patient: You have the right as a patient to be informed about your condition and the recommended medical, surgical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you, It is simply an effort to make you better informed so that you may given [sic] or withhold your consent to the procedure."
Facility-based form titled "Disclosure and consent - anesthesia" stated in part, "To the patient: You have the right, as a patient, to be informed about your condition and the recommended anesthesia/analgesia to be used so that you may make the decision whether or not to receive the anesthesia/analgesia after knowing the risks and hazards involved ..."
Review of the medical record for patient #21 revealed she received anesthesia for a Caesarean section on 5/14/19. No consent for the procedure or anesthesia was found.
The above was confirmed in an interview with staff #3 and #5 on the afternoon of 6/19/19.
Tag No.: A1568
Based on record review and staff interview the facility failed to complete a comprehensive
assessment of swing bed patients and failed to provide an ongoing program to support residents
in their choice of activities.
.
Findings were:
.
Facility document titled "Patient Activity Program" states in part, "Purpose: Encourage the patient's restoration to self-care and resumption of normal activities through programmed activities. For those patient who cannot realistically resume normal activities, to prevent further mental, physical, or emotional deterioration and to maintain a feeling of self-worth.
1. The Swing Bed Program will provide activities for the patient. Activities are essential to create an environmental that is near to the home situation. The activities will provide changes which are similar to those encountered in the community."
Interview with the Assistant Director of Nursing (ADON) on the afternoon on 6/18/19. She stated, "We do not have an Activity Director, she left in 2017." The ADON reported activity assessment of swing bed patients have not been done. Activities are not being provided for Swing Bed patients at the facility.