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Based on interview and record review, the facility failed to provide written notice of the resolution for grievances for 2 (#s 8 and 9) of 11 sampled patients. Findings include:

1. During an interview on 12/4/18 at 10:58 a.m., patient #8 stated he had lodged a formal grievance with the hospital regarding patient access and scheduling. The patient stated he spoke with a patient access coordinator over the phone who apologized for the scheduling error, but gave no further information. He stated he did not receive a written notice from the facility notifying him of the grievance resolution. The patient stated he did not feel the grievance was adequately handled. He stated he was never aware the actual resolution for the grievance.

Review of patient #8's grievance, with a start date of 6/13/18, showed, "Patient c/o being given wrong information regarding his appt [sic] time." The status showed, "closed on 6/13/18." The action showed, "Referred to department manager/director." The outcome showed, "No letter sent. See comments. Same day resolution."

2. During an interview on 12/4/18 at 2:49 p.m., the representative for patient #9 stated she had a concern when she was handed an empty bag of personal belongs for patient #9. She stated she had received a phone call from the facility explaining they believed the patient's belongings had been thrown away by mistake. She stated she did not receive a letter from the facility outlining the investigation and the steps taken to resolve the issue.

Review of patient #9's grievance, with a start date of 7/21/18, showed, "Patient's mom c/o misplaced driver's license/social security card." The status showed, "Closed on 7/24/18." The comments showed, "No letter sent, hand off to Privacy Officer." The disposition showed, "resolved."

During an interview on 12/4/18 at 1:00 p.m., staff member B and K stated they tried to write a letter to each patient for every grievance resolution. Staff member B stated they did not always get a letter to the patient with the grievance resolution due to multiple phone calls, or they did not have an address for the patient. Staff member K stated they would hand off the grievance to other department managers for further investigation into the grievance, and a letter of resolution was not always created when it was handed off. Staff member K stated they currently did not have a process which helped to track the grievances which were handed off to other department heads to ensure a final letter of resolution was sent to the patient.

A review of the facility's policy and procedure titled, Patient Complaint/Grievance, showed, "10. Judgement Required and Timeliness: The resolution of the grievance will include written notice of decision and contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of the completion."

Based on observation, interview, and record review, the facility failed to ensure all medications and biologicals were kept in a secured or locked storage for use in patient care areas. This deficient practice had the potential to affect any patient being provided care at the outpatient facility. Findings include:

A. During an observation on 12/3/18 at 3:36 p.m., a red and black crash cart which was located in a hallway alcove next to the nurses' station, was locked. Staff member P lifted a rubber door stopper which was placed on top of the cart, and procured the key for the cart.

The following medications were in the unsecured crash cart:

- amiodarone 150 mg/3 ml ampule,
- amlodipine 5 mg tablet,
- Albuterol 2.5 mg/3 ml vial,
- Aspirin 81 mg tablet,
- atropine sulfate 1 mg/10 ml syringe,
- clonodine 0.1 mg tablet,
- Dextrose 50% 50 ml vial,
- diphendydramine 50 mg/ml syringe,
- Duoneb 0.5 mg/ 2.5 mg/ 3 ml vial,
- epinephrine 1 ml vial,
- Glucagon kit,
- metoprolol tartate 50 mg/ml vial,
- metoprolol tartate 50 mg tablet,
- nifedipine 10 mg tab,
- nitroglycerin 0.4 mg tablet,
- Solumedrol 125 mg/2 ml vial.

During an interview on 12/3/18 at 3:36 p.m., staff member P stated they kept the key for the crash cart under the rubber door stopper on top of the cart for quick access to the crash cart.

B. During an observation on 12/3/18 at 4:13 p.m., the following medications and biologicals were in an unlocked cabinet in procedure room #1:

- one epinephrine 1 mg/1 ml single dose ampule,
- one diphendydramine 50 mg/ml single dose ampule,
- one multi-use vial of Lidocaine 50 ml vial,
- one bottle of Benzoin Tincture,
- one open container of mentholatum,
- two bottles of Gebauer's Ethyl Chloride Spray,
- two containers of Drysol, and
- two containers of PVP Prep Solution

During an interview on 12/3/18 at 4:45 p.m., staff member P stated procedure room #1 was used for patient care, and patient were left unattended in the procedure room.

During an interview on 12/3/18 at 4:45 p.m., staff member A stated it was the expectation all medications and biologicals were kept in a secure and locked cabinet.

A review of the facility's policy and procedure titled, Procurement and Control of Medications, showed, "5. C. All medications will be stored in lockable areas and will be accessible only to personnel duly authorized, as per Policy and Procedure, to dispense and/or administer medications."

Based on observation, interview, and record review, the facility failed to ensure outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use in patient care areas. The use of expired or outdated medications could lead to potential concerns related to the medication's sterility, stability, and potency. Findings include:

A. During an observation on 12/3/18 at 3:36 p.m., a red and black crash cart had the following expired medications and biologicals:

- four boxes of atropine 0.1 mg/mg injection, 10 ml syringe, which were expired on 11/2018, and three packages of iodine swabs which expired 11/2018.

During an interview on 12/3/16 at 3:36 p.m., staff member P stated she performed a monthly critical review of the crash cart to check for expired medications. She stated she had just completed the monthly check for November on Friday 11/30/18.

B. During an observation on 12/3/18 at 4:13 p.m., in procedure room #1, the following medications and biologicals which were opened without a documented open date:

- one multi-use vial of Lidocaine 50 ml vial,
- one bottle of Benzoin Tincture,
- one open container of mentholatum,
- one bottle of Gebauer's Ethyl Chloride Spray,
- one container of Drysol, and
- two containers of PVP Prep Solution.

During an interview on 12/3/18 at 4:15 p.m., staff member P stated medications or biologicals should be dated and initialed after they were opened for use during a procedure. She stated medications should be checked for expiration monthly.

During an interview on 12/3/18 at 4:45 p.m., staff member A stated it was the expectation that medications were reviewed monthly for outdates, and any expired medications be disposed of properly. The staff member stated any multi-use medications which were opened for patient use should be dated and initialed when they were opened.

A review of the facility's policy and procedure titled, Outdated, Unusable, Recalled Medication control, showed, "Policy: 1. For the protection of its customers, [facility] will maintain an active, ongoing process to assure the retrieval and safe disposition of outdated, expired or recalled medications. Procedure: 1. Outdated and Unusable Drug Control. A. All patient care areas and ancillary medication storage areas within the hospital will be checked monthly for outdated and unusable medications by the pharmacist or designee. B. All medications will be examined for proper dating. Any out-of-date medications will be immediately removed from stock."

Based on interview, record review, and observation, the facility failed to effectively design, and implement infection control procedures which would mitigate the spread of bloodborne pathogens, and the spread of infection. This deficient practice had the potential to affect all patients and staff at the outpatient walk-in clinic. Findings include:

1. The facility failed to ensure the mitigation of the risk for the spread of bloodborne pathogens. See A749.

2. The facility failed to ensure the mitigation of the risk of the spread of infection while performing point-of-care testing in patient care areas. See A749.

3. The facility failed to ensure proper hand hygiene was performed between glove changes. See A749.

Based on observation, interview, and record review, the facility failed to ensure the mitigation of the risk for the spread of bloodborne pathogens by not properly disposing of used needles immediately after use for 2 (#s 1 and 2); failed to ensure the mitigation of the risk for the spread of infection by performing point-of-care testing in designated "clean" patient care areas, and failing to disinfect the contaminated surfaces after the procedure for 3 (#s 3, 4, and 5); and staff failed to performed proper hand hygiene between glove changes for 2 (#s 1 and 2) of 11 sampled patients. This deficient practice has the potential to affect all staff and patients at the urgent care outpatient clinic. Findings include:

1. Bloodborne Pathogens

A. During an observation on 12/3/18 at 2:36 p.m., staff member E performed a blood draw on patient #1. After staff member E removed the needle from the patient's arm, she triggered the safety cap for the needle, and placed the needle on the desk in the exam room without a barrier. When the staff member was completed placing a dressing on the patient's arm, she cleaned off the desk, and picked up the used needle and placed it in the sharps container. The staff member then placed two vials of blood in the clean caddy without a biohazard bag, and left the room. The nurse did not disinfect the desk after she provided patient care. The nurse returned to the nurses' station where she removed the vials of blood from the clean caddy and placed them in a biohazard bag. The caddy was not disinfected.

During an interview on 12/3/18 at 2:45 p.m., staff member E stated it was important to trigger the safety needle cap, and dispose of the needle in the sharps container. She stated she could not reach the sharps container at the time she performed the blood draw, so she placed the needle on the desk, and disposed of it when she was finished with the patient. She stated she did not feel it was a problem to place the vials in the clean caddy without a biohazard bag since the vials were secure. Staff member E stated she had training on bloodborne pathogens through Health Stream when she was hired.

B. During an observation on 12/3/18 at 3:40 p.m., staff member F performed a blood draw on patient #2, using a butterfly needle in the patient's left hand. When the staff member was finished with the blood draw, she slid the safety cap over the needle and placed the butterfly needle on the desk in the exam room, without a barrier. After the staff member had placed a dressing on the patient's hand, she picked up the butterfly needle off the desk and put into the sharps container. Staff member F disinfected the counter with wipes from the PDI gray top wipes. The staff member failed to dispose of the needle in the sharps container immediately after use.

During an interview on 12/3/18 at 4:00 p.m., staff member F stated it was important to activate the safety cap on the needle when she was done with a blood draw and place the needle in the sharps container. She stated she was not able to reach the sharps container after drawing the patient's blood, so she placed the needle on the desk. She stated she had training on bloodborne pathogens when she was hired.

During an interview on 12/3/18 at 4:10 p.m., staff member D stated it was the expectation of all staff to place all sharps into the sharps container immediately after use. She stated the staff were trained on bloodborne pathogens at time of hire, and annually thereafter.

During an interview on 12/4/18 at 4:20 p.m., staff member B stated it was the expectation of all staff to place used needles in a sharps dispenser as soon as they were completed with a venipuncture, and not to set the needles down before disposal. She stated used needles should not be placed on any surface following a venipuncture to reduce the risk for the spread of bloodborne pathogens. Staff member B stated all staff were trained on bloodborne pathogen exposures at date of hire, and annually thereafter.

2. Point-of-Care Procedures

A. During an observation on 12/3/18 at 4:10 p.m., a point-of-care urine pregnancy test for patient #3 was sitting on the designated "clean" side of the counter in the nurses' station. The counter was not disinfected after the test was removed.

B. During an observation on 12/3/18 at 4:30 p.m., the nurses' station located on the "prompt care" side of the office did not have a designated area for clean processing and dirty procedure processing. Sitting next to the hand-washing sink was a point-of-care streptococcus A antigen test for patient #4. The counter was not disinfected after the test was removed.

During an interview on 12/3/18 at 4:35 p.m., staff member H stated the nurses performed the point-of-care tests at the counter next to sink. She stated she was not sure which area was designated a clean side and which was a designated dirty side. She stated she would perform the point-of-care testing by the sink because that was where all the equipment was kept. She stated she used the sink to wash her hands.

A review of patient #4's medical visit on 12/3/18, showed the patient was treated with amoxicillin for streptococcus A.

C. During an observation on 12/3/18 at 4:30 p.m., staff member H performed a point-of-care urinalysis for patient #5. The procedure was performed next to the sink on the counter in the nurses' station. There was no clearly defined demarcation for clean versus dirty. The counter was not disinfected after the test was removed.

During an interview on 12/3/18 at 5:15 p.m., staff member D stated it was the expectation for staff to complete designated dirty procedures such as urinalysis, strep tests, and urine pregnancy tests on the side of the counter designated "dirty." She stated the point-of-care tests should not be performed on the side of the counter designated "clean." Staff member D stated the nurses' station on the "prompt care" side of the clinic did not have a designated area for performing procedures.

During an interview on 12/3/18 at 6:30 p.m., staff member A stated it was the expectation of all staff to follow infection control guidelines and not perform procedures in areas which were designated "clean."

A review of the facility's policy and procedure titled, Cleaning of Unit-Based Medical Equipment, showed, "To reduce the risk of transmission of microorganisms from patient care to the patient. Patient care equipment must be cleaned/disinfected between patients."

3. Hand Hygiene

A. During an observation on 12/3/18 at 2:36 p.m., staff member E performed a blood draw on patient #1. The staff member removed her gloves after performing the venipuncture and failed to perform hand hygiene.

During an interview on 12/3/18 at 2:45 p.m., staff member E stated she washed her hands when she entered the exam room and when she left the exam room.

B. During an observation on 12/3/18 at 3:40 p.m., staff member F performed a blood drawn on patient #2. The staff member removed her gloves after performing the venipuncture and put on a pair of clean gloves to disinfect the desk after performing the blood draw. The staff member failed to disinfect her hands between the glove changes.

During an interview on 12/3/18 at 3:45 p.m., staff member F stated she did not disinfect her hands between changing gloves. She stated she had been provided education on hand hygiene when she was hired.

A review of the facility's policy and procedure titled, Hand Hygiene, showed, " After a procedure of body fluid exposure risk - clean your hands immediately after a procedure or body fluid exposure risk. Examples... 2. Including after removing gloves."

Based on observation, interview, and record review, the facility failed to clearly advise the public that the urgent care clinic was not an emergency service department; and failed to clearly define policy and procedures which include the urgent care's integration into the hospital's services. This deficient practice had the potential to delay healthcare for patients in need of emergent services. Findings include:

During an interview on 12/3/18 at 1:00 p.m., staff member A stated the outpatient clinics serve as a "prompt care" or same-day walk in clinic for patients. Staff member A stated if a "prompt care" patient were in need of emergency services, the staff would call for an emergency transport, by calling 911.

During an observation on 12/3/18 at 2:30 p.m., there was a red sign over the building which stated "Urgent Care."

During an observation on 12/3/18 at 2:36 p.m., there were no posted signs which clearly advised the public of the services provided at the urgent care versus care which should be addressed in the emergency department.

During an interview on 12/3/18 at 2:36 p.m., staff members A and D stated there were no patient education materials or posted signs which clearly inform the public of the services provided at the "prompt care" clinic versus those provided at the emergency department.

During an interview on 12/3/18 at 4:40 p.m., staff member D stated the clinic usually called EMS several times a week to transport patients to the emergency room.

During an interview on 12/4/18 at 1:30 p.m., staff member B stated she had published an article in the facility's newsletter which outlined the services provided in the urgent care and which services should be treated at the emergency room. She stated they did not have any signage or patient brochures at the urgent care clinic which outlined the difference between the two services.

A review of the facility's policy and procedures failed to show the facility established a policy and procedure which included the urgent care's integration with hospital services.

A requested provided on 12/4/18 at 9:00 a.m., and 6:00 p.m., for a copy of the policy and procedures which define the services provided at the "prompt care" versus the services provided at the emergency department. There was no documentation provided by the end of survey.