HospitalInspections.org

Based on surveyors' observations, review of hospital documents and interviews with hospital staff, the hospital failed to ensure the physical plant and environment is constructed, arranged, and maintained to ensure the safety of patients. The hospital failed to:

a. Appropriately modify rooms within the surgical areas according to nationally recognized requirements for these areas. See Tag C-0221;

b. Provide housekeeping and preventive maintenance in the surgical areas to ensure the facilities, supplies and equipment were maintained for safety and quality. Refer to Tag C-0222;

c. Provide space/rooms for collecting and handling of biohazards and trash in the surgery areas. Refer to Tag C-0223;

d. Store drugs and biologicals appropriately. Refer to Tag C-0224 and ;

e. Ensure the surgical areas and public bathrooms were clean and orderly. Refer to Tag C-0225;


See also LSC Tags

Based on surveyors' observations, review of hospital documents, and interviews with staff, the hospital failed to ensure the surgical department was constructed, arranged and maintained in a condition to ensure the adequate care and safety of the patients and staff.

Findings:

The only complete architectural plans provided to the surveyors for review were from 1968. According to these plans, the facility has inappropriately modified the surgical services area.

1. The surgical suite did not have a decontamination room to clean dirty instruments and scopes. They were being cleaned in the sterile/restricted corridor.

2. The floor throughout the surgical suite was tile and not monolithic. It cannot be adequately cleaned and disinfected. The grout between the tiles was dirty, as was the corners. There were spaces in the central/restricted corridor that had bare concrete exposed/voids in the floor covering that had not been repaired.

3. There were no designated areas/rooms for collection and holding of biohazard waste, trash or dirty linen.

5. The room identified as the recovery room did not have any emergency power outlets.

Based on facility tour/inspection and interviews with hospital staff, the hospital failed to ensure facilities and patient care equipment are maintained for safety and quality care.

Findings:

The hospital did not have a preventative maintenance program for their ultrasound equipment.
On 05/13/14, Staff S was asked for documentation of the preventative maintenance inspection for the the ultrasound equipment. The documentation provided was dated May 2012.

Based on surveyor observations and interviews with staff, the hospital failed to ensure proper storage of trash and biohazard waste was provided. There were no designated areas/rooms for collection and holding of biohazard waste and trash for pick-up in the surgical area. This finding was reviewed with administrative staff at the exit conference. No additional information was provided.

Based on surveyors' observations, review of hospital documents and interviews with hospital staff, the hospital failed to ensure drugs and biologicals were stored and maintained.

Findings:

1. The hospital has a blanket and fluid warmer located in the room that was designated as the recovery room. The manufacturer recommended temperature for IV fluids and irrigation solutions is between 77-104 degrees Fahrenheit. Irrigation solutions may be warmed at a temperature of 150 degrees Fahrenheit for no longer than 72 hours.

2. The surveyors noted the thermometer reading of the blanket/fluid warmers to be 120 degrees Fahrenheit on both days of the survey. The readings were confirmed by Staff B on 05/13/14.

3. On the morning 05/12/14 intravenous (IV) fluids and irrigation solutions were found in warmers that were not dated as to when they were put in and when they were to expire. Some of the bags and bottles were swollen, indicating they had been exposed to excessive temperatures or had been in the warmers too long. The bags and bottles were very warm to the touch.

The above findings were confirmed by Staff B and C.

Based on surveyors' observations and interviews with hospital staff, the hospital failed to maintain clean and sanitary facilities for safety of patients and personnel.

Findings:

1. The floor throughout the surgical suite was tile and not monolithic. It cannot be adequately cleaned and disinfected. The grout between the tiles was dirty, as was the corners. There were spaces in the central/restricted corridor that had bare concrete exposed/voids in the floor covering that had not been repaired.

2. There was a dark/black raised spot, approximately 3 inches by 5 inches, in the restricted corridor. Staff stated they could not remove the area from the floor. The surface was sticky against the surgical shoe coverings.

3. Public bathroom floors throughout the facility had surface areas that appeared dirty. Staff told the surveyors that they were old and stained. There was gaps between the tiles that appeared dirty.

Based on review of hospital documents and meeting minutes, surveyors' observations, and interviews with hospital staff, the hospital failed to develop and provide services according to standards and written policies, as evidenced by failure to:

1. Ensure that drug storage areas are maintained according to accepted professional principles and hospital policy and procedures and schedules drugs are monitored. (Refer to Tag C-0276)

2. Develop and maintain an effective ongoing infection control program, directed by a qualified staff with training, that reviewed, analyzed and provided corrective actions to prevent and reduce spread of hospital acquired infections and communicable diseases. (Refer to Tag C-0278)

3. Ensure radiology services are performed by trained and orientated staff to protect patients and staff from radiation hazards and ensure the radiology department has oversight by a Radiologist or qualified Medical Staff. (Refer to Tag C-0283)

Based on review of hospital policy and procedures, surveyor observations and interviews with hospital staff, the hospital does not ensure that current and accurate records are kept of the disposition of all scheduled drugs and ensure unusable drugs are not available for patient use.

Findings:

Review of the hospital's policy, Guidelines for Warming Cabinets", stated, "...IV Fluids and solutions should be labeled with the date that indicates when fluids were added..." the policy also states IV fluids and irrigation solutions can be warmed to a temperature not greater than 120 degrees Fahrenheit.

The hospital policy does not follow the manufacturers guidelines. The manufacturer recommended temperature for IV fluids and irrigation solutions is between 77-104 degrees Fahrenheit. Irrigation solutions may be warmed at a temperature of 150 degrees Fahrenheit for no longer than 72 hours.

The surveyors noted the thermometer reading of the blanket/fluid warmers to be 120 degrees Fahrenheit on both days of the survey. The readings were confirmed by Staff B on 05/13/14.

On the morning 05/12/14 intravenous (IV) fluids and irrigation solutions were found in warmers that were not dated as to when they were put in and when they were to expire. Some of the bags and bottles were swollen, indicating they had been exposed to excessive temperatures or had been in the warmers too long. The bags and bottles were very warm to the touch.

The above findings were confirmed by Staff B and C.

On 05/12/14 during a tour of the emergency department, unpackaged 50 milliliter bags of Normal Saline (NS) was stored on the supply carts. This was confirmed by Staff C.

During the tour of the pharmacy, Staff D was asked if she compared the Narcotic Administration Record to the patients' medical record to verify the amount of narcotics the patients' received. She stated no.

Based on review of hospital documents, policies and procedures and meeting minutes, surveyors' observations and interviews with staff, the hospital failed to:

a. Develop and maintain an active on-going infection control/infection prevention (IC) program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases among patients and staff;

b. Analyze IP surveillance data and concerns, develop corrective actions when needed and conduct follow-up to ensure corrective actions are appropriate and sustained to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel; and

c. Provide initial and on-going education/training for the infection preventionist (IP) in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program.

Findings:

Plan/Program:
1. The hospital has not conducted a hospital-wide IC risk assessment to identify the types of patients, risks/concerns, organisms, and diseases prevalent in the community and hospital.

2. The hospital has not conducted a tuberculosis risk assessment.

3. The hospital does not have a current infection control plan (Plan).

4. These findings were reviewed and confirmed with Staff B on the morning of 05/13/2014.


IP Training/Education:
1. On the morning of 04/10/2014, administrative staff told the surveyors that Staff G was the infection control preventionist (IP).

2. Review of Staff G's personnel files did not contain documentation of training in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program.

3. On the 05/12/2014, administrative staff confirmed Staff G had not received any training in establishing and maintaining a comprehensive effective infection control program.


Policies and Procedures:
1. The IC policy and procedure manual did not contain specific IC policies and procedures for each department/service (or notification of where to find specific IC policies for each department) for:
a. Central sterile services, including policies and procedures on how to process instruments and the requirements testing of the equipment, including processing of endoscopes;
b. Pharmaceutical services;
c. Nursing services;
d. Emergency services.

2. The IC policy and procedure manual did not contain policies on the different types of isolation, reflecting current standards of practice.

3. The IC manual policy and procedure did not contain specific policies for respiratory isolation protection and requirement of specialized masks, N-95 respirator. The IC policies and procedures did not specify:
a. Detail on how this was to be accomplished and by whom; and
b. Based on the current standards of practice and requirements by OSHA (Occupational Safety and Health Administration), how often fit testing would be performed.
c. No staff had been Fit tested to ensure the proper mask was identified and available.

4. The IC manual did not contain a policy and procedures on how patients and staff with potential or confirmed influenza will be medically managed, including:
a. Screening;
b. Any required tests to confirm infection;
c. Any particular requirements according to current CDC guidelines.

5. The IC manual did not contain a policy and procedure for reporting State reportable infections and diseases to the proper authorities, with delineation of responsibilities, including the most current list of reportable infections and diseases.

6. The IC manual did not contain a definition of nosocomial (hospital acquired) infections.

7. The IC manual did not contain policies on disinfectant approval and list of approved disinfectants with what area used and application requirements, including:
a. mixture;
b. wet time contact with surface to be effective; and
c. what organisms each approved disinfectant kill.

8. The IC manual did not contain a hand hygiene policy and procedure that reflected all current standards of practice, including when it was appropriate to use hand sanitizer.


Surveillance:
1. The IC program has not monitored to ensure all departments followed infection control policies and current recognized infection control practices.

2. The Centers for Disease Control (CDC) and the Association for Professionals in Infection Control and Epidemiology (APIC) have identified hand hygiene as the first avenue/most important tool in the prevention of spread of organisms and diseases. Meeting minutes did not reflect hand hygiene was monitored.

On the afternoon of 05/13/2014, Staff G supplied the surveyors hand hygiene observations/surveillance. Only two to four observations were performed each month for the past five months and did not contain observations of each department and each discipline working in the hospital. When asked what she did with the monitors, Staff G said she kept them in a folder. No analysis had been performed.

3. Documents provided and meeting minutes did not demonstrate that, other than identifying patient nosocomial infections, the IC program monitored and evaluated infections of patients and staff to ensure infections and communicable diseases were not transmitted between staff and between patients and staff.

4. Central sterile processing is not monitored, including, but not limited to:
a. Maintenance and monitoring to ensure safe and effective autoclave sterilization;
b. Appropriate cleaning and packaging of instruments occurs, including endoscopes;
c. Sterilization practices - correct temperature, correct sterilizing time and correct dry time;
d. High level disinfection practices - correct product at correct temperature for correct amount of time; and
e. Appropriate disinfection occurs - products used according to manufacture's guidelines.

5. No monitoring of disinfectant applications throughout the hospital departments and locations to ensure:
a. Appropriate disinfectants are selected and used; and
b. The disinfectants are applied and remain "wet" contact time according to the manufacturers guidelines.
c. With the exception of the housekeeper, staff interviewed did not know if the hospital's disinfectants, AF 315 and PDI (red top) Sani-Wipes, and Steris Coverage Plus NPD was not effective against C-difficile and did not know the "wet" contact times in order for the disinfectants to be effective. The product, AF 315, found in all departments except surgery, is also not effective against tuberculosis or Hepatitis B.


Observations:
1. The surgical suite did not have a decontamination room to clean dirty instruments and scopes.

2. The floor throughout the surgical suite was tile and not monolithic. It cannot be adequately cleaned and disinfected. The grout between the tiles was dirty, as was the corners. There were spaces in the central/restricted corridor that had bare concrete exposed. There was a dark/black raised spot, approximately 3 inches by 5 inches, in the restricted corridor. Staff stated they could not remove the area from the floor.

3. Public bathroom floors throughout the facility had surface areas that appeared dirty. Staff told the surveyors that they were old and stained. There was gaps between the tiles that appeared dirty.

4. Although Staff K could repeat correct cleaning procedures for the surveyors on 05/12/2014, during the Life Safety survey on 05/14/2014, the surveyor observed Staff K cleaning scopes, going from dirty processes and scopes to clean processes and scopes without changing gloves.


Meeting Minutes:

Although, Staff B and C told the surveyors that the hospital held separate infection control meetings, the surveyors also reviewed meeting minutes for quality, medical staff and governing body where infection control was listed as a topic.

1. The meeting minutes did not contain review, evaluation and analysis of infections to ensure infections and communicable diseases were not transmitted between staff and between patients and staff. Although nosocomial/HAI (hospital acquired infections) were identified in the attached reports, there was not review and analysis to determine if process should be changed to improve patient care and outcomes.

2. The meeting minutes did not demonstrate central sterile services were monitored, reviewed and analyzed with corrective actions taken and follow-up to ensure compliance with accepted standards of practice.

3. The meeting minutes did not contain documentation and review of surveillance/monitoring to ensure IC policies and procedures and current standards of practice are followed. Staff B and C confirmed on the morning of 05/13/2014 that this did not occur.

4. Concerns identified in meeting minutes showed to review and analysis to determine if corrective actions need to be developed or if current policies and procedures were followed. Example: January 2013 quality assurance meeting minutes identified an employee exposure/needle stick. No report was provided whether the employee received appropriate screening and treatment. Subsequent meeting minutes did not document if the policies and procedures for follow-up was performed according to OSHA (Occupational Safety and Health Administration) and current standards of practice.

5. The meeting minutes did not contain evidence disinfectants used in the hospital had been reviewed for appropriateness and approved for use. Staff B confirmed disinfectants had not been reviewed as part of IC.

6. The meeting minutes did not reflect employee illnesses and immunizations were part of the program. Review of health files for physicians and allied health files did not show complete immunizations as recommended by CDC and its advisory committee (ACIP). Meeting minutes did not show employee illnesses were reviewed and analyzed to ensure transmission between staff and staff and staff and patients did not occur.

7. Although the surveyor was provide with isolation cart monitoring sheets, meeting minutes did not reflect isolation monitoring was reviewed and analyzed to ensure:
a. Patients are placed in appropriate isolation according to current CDC guidelines;
b. Isolation materials/supplies are readily available (Although staff knew the locations,staff had to go from area to area to show the surveyor where they would obtain the needed supplies, including the isolation signs.);
c. Staff, physicians, volunteers, and visitor follow appropriate isolation requirements; and
d. Appropriate disinfection of the room occurs.

Based on review of the radiology department documents and interviews with hospital staff, the hospital failed to to protect patients and staff from radiation hazards.

Findings:

On 05/13/14, Staff S was asked for documentation of the preventative maintenance inspection for the the ultrasound equipment. The documentation provided was dated May 2012.

The radiology staff was asked for a current inspection. None was provided.

The hospital's MRI services are provided through a contract.

There was no documentation the contract personnel providing the MRI services were oriented to the hospital, trained, and deemed competent by the supervising radiologist and/or medical staff. This was confirmed by Staff C on the evening of 05/13/14.

Based on record review and interviews with hospital staff, the hospital failed to ensure that a list of all services provided through arrangements, contracts or agreements is maintained describing the nature and scope of the services provided.

Findings:

1. Upon arrival at the hospital, the surveyors requested the above information.

2. The original list provided by the hospital was not complete. Findings include, but not limited to:
a. The list supplied did not contain all the radiology contracts, including radiology badge readers and the physicist.
b. The list did not have the current company that provided the hospital's linen service.

3. The second list provided to replace the original list did not a complete of list all contracts/agreements, including but not limited to:
a. The organ procurement network,
b. Emergency power and water,
c. Linen service.

4. These findings were reviewed with administrative staff during the exit conference on the evening of 05/13/2014. No additional information was provided.

Based on review of medical records and personnel files and staff interview, it was determined the hospital failed to ensure nursing staff were trained and evaluated on competency to perform the essential functions of their jobs. This occurred for five of five licensed nursing personnel (Staff C, G, I, J and M) whose personnel files were reviewed.

Findings:

1. The hospital takes care of all age patients in the emergency room. Staff B and C told the surveyors on 05/12/2014 that staff were cross-trained to work different departments. The personnel files for Staff C, G, I, J, and M did not contain evidence of training, testing and/or age-specific competency verification. This findings was reviewed and confirmed with Staff B and C on the afternoon of 05/13/2014.

2. Staff C told the surveyors that hospital staff administer cardiac intravenous (IV) drips, including dopamine, Cardizem, and nitroglycerin. Patient #16 received dopamine by continuous IV drip while admitted to the hospital. The personnel files for Staff C, G, I, J, and M did not contain evidence of training and competency verification for the specialized IV drips.

3. Staff C told the surveyors that nursing staff administered respiratory treatments, including hand held nebulizer treatments when the respiratory therapists were not present in the hospital. The personnel files for Staff C, G, I, J, and M did not contain evidence of training and competency verification for administration of respiratory therapy treatments by the respiratory therapist.

4. These findings were reviewed and confirmed with Staff B and C at the time of the review on 05/13/2014.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure all entries in the medical record were signed and contained the date and time of the signatures/authenticated. This occurred in ten of twenty-one records (#7 through 13, 15, 16 and 19) reviewed for completed entries.

Findings:

Records # 7, 9 through 13, 15 and 16 - the electronic Discharge Summary and History and Physical did not contain the date and time the physician signed the electronic document.

Records #7 through 11- the electronic Physician Progress Note did not contain the date and time the physician signed the electronic document.

Records #10, 11 and 13- the electronic Admit Note by the physician did not contain the date and time the physician signed the electronic document.

Record # 9- the electronic Echocardiogram Report had not been signed, dated or timed by the physician.

Record #11- the electronic surgical Consult note did not contain the date and time the physician signed the electronic document.

Record #19- the electronic Physical Therapy order did not contain the date and time the physician signed the electronic document.

The above findings were reviewed with administrative staff during the exit interview. No additional information was provided.

Based on observation, staff interviews, and a review of policies and procedures, medical records and hospital documents, the hospital failed to ensure that surgical procedures are performed in a safe manner.

Findings:

1. The surgical suite did not have a decontamination room to clean dirty instruments and scopes. They were being cleaned in the sterile/restricted corridor.

2. The floor throughout the surgical suite was tile and not monolithic. It cannot be adequately cleaned and disinfected. The grout between the tiles was dirty, as was the corners. There were spaces in the central/restricted corridor that had bare concrete exposed/voids in the floor covering that had not been repaired.

3. There was a dark/black raised spot, approximately 3 inches by 5 inches, in the restricted corridor. Staff stated they could not remove the area from the floor. The surface was sticky against the surgical shoe coverings.

4. There were not designated areas/rooms for collection and holding of biohazard waste, trash or dirty linen.

5. The room identified as the recovery room did not have any emergency power outlets.

6. Central sterile processing is not monitored, including, but not limited to:
a. Maintenance and monitoring to ensure safe and effective autoclave sterilization;
b. Appropriate cleaning and packaging of instruments occurs, including endoscopes;
c. Sterilization practices - correct temperature, correct sterilizing time and correct dry time;
d. High level disinfection practices - correct product at correct temperature for correct amount of time; and
e. Appropriate disinfection occurs - products used according to manufacture's guidelines.

When questioned about the autoclave on 05/12/2014, Staff H did not know the recommended times and temperatures for the pre-vacuum steam sterilizer. He stated they were autoclaved at 270 degrees. Staff H and K stated they just "pushed number 4." They did not know what the sterilizing and exhaust times were. When the surveyors identified that the autoclave stirp identified four (4) minutes sterilization and twenty (20) minutes of exhaust/dry time. Staff K stated, "So that's what that 's' stands for."

7. Although Staff K could repeat correct cleaning procedures for the surveyors on 05/12/2014, during the Life Safety survey on 05/14/2014, the surveyor observed Staff K cleaning scopes, going from dirty processes and scopes to clean processes and scopes without changing gloves.

8. One wall outlet had two (2) multi-outlet power strips (each with multiple equipment plugged into the strips). These power strips were directed out into the middle of the room.

9. Operative reports, pre-printed pre-operative orders, pre-printed post-operative orders, handwritten progress notes by Surgeon Y, and hand written History and Physical reports by Surgeon Y did not contain the date and time they were signed by the authors. This occurred five of five (Records #22, 23, 24, 25, and 26) surgical records review.

Based on review of hospital documents, medical records, and meeting minutes, and interviews with hospital staff, the hospital failed to ensure the quality assessment and performance improvement (QAPI) program evaluated all patient care services provided at the hospital to ensure patient health and safety.

Findings:

1. The hospital's meeting minutes, QAPI, medical staff, and governing body did not ensure all patient care services were evaluated. Hospital contract services of magnetic resonance imaging (MRI) physical therapy, consultant dietitian, and consultant pharmacist were not evaluated through the QAPI program.

2. Problems and monitors identified in QAPI reports did not always show analysis and corrective action with follow-up to ensure the corrective action was effective.

3. These findings were reviewed with administrative staff during the exit conference on the evening of 05/13/2014. No additional information was provided.

Based on document review and staff interview, it was determined the hospital failed to perform a comprehensive assessment for residents' activity needs for five (#17-#21) of five swing bed patient medical records reviewed.

Findings:

On 05/13/14, five swing bed clinical records were reviewed. None of the records had documentation of a comprehensive assessment of an activities care plan.

The above information was confirmed by Staff C on the evening of 05/13/14.