HospitalInspections.org

Based on facility job description review, personnel file review and interview, the facility failed to ensure nursing personnel had required valid and current licensure.

Findings were:

Staff nursing (LVN [Licensed Vocational Nurse]) job description stated in part, "Qualifications: ACLS (advanced cardiac life support), TNCC (trauma nursing core course), ENPC/PALS (emergency nursing pediatric course/pediatric advanced life support)."

Review of personnel files revealed staff #19 had no ACLS or PALS certification.

Based on a review of staffing schedules, staff #19 worked 25 shifts between Staff #19's date of hire (12/30/15) and 4/30/16.

The above was verified with the chief nursing officer on the afternoon of 5/17/16.

Based on a review of clinical records, facility documentation and interviews with staff, not every individual that presented to the hospital for evaluation or treatment had received a history and physical examination no more than 30 days prior to admission or within 24 hours after admission.

Findings were:

A review was conducted of 12 clinical records of patients cared for by staff #9 (patients #23 through
#34). The same patients had been admitted to the facility between the dates of 2-1-16 and 4-19-16. Of the 12 patients, 5 patients (patients #23, #24, #31, #32 and #33) had not received a history or physical exam.

In a review of documentation of medical staff meeting minutes, the clinical records lacking the histories and physical exams were discussed on meetings held on 2-11-16, 3-17-16 and 4-14-16. Rosters indicated that staff #9 was in attendance at these meetings.

In an interview with staff #4, staff #4 stated that e-mail reminders had been sent to staff #9 on 2-8-16,
2-18-16, 2-25-16 and 4-5-16 to remind staff #9 to complete the histories and physical exams on the clinical records for patients #23, #24, #31, #32 and #33.

In an interview with staff #9, staff #9 confirmed that the histories and physical exams for patients #23,
#24, #31, #32 and #33 had not yet been completed by the date of the survey.

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 5-17-16 in the facility cafeteria.

Based on a review of clinical records, facility documentation and interviews with staff, the facility failed to ensure that all patient records contained a Discharge Summary with outcome of hospitalization, disposition of care and provisions for follow-up care.

Findings were:

A review was conducted of 12 clinical records of patients cared for by staff #9 (patients #23 through
#34). The same patients had been discharged from the facility between the dates of 2-10-16 and 4-26-16. A discharge summary had not been completed for any of the 12 patients.

In a review of documentation of medical staff meeting minutes, the clinical records lacking the discharge summaries were discussed on meetings held on 2-11-16, 3-17-16 and 4-14-16. Rosters indicated that staff #9 was in attendance at these meetings.

In an interview with staff #4, staff #4 stated that e-mail reminders had been sent to staff #9 on 2-8-16,
2-18-16, 2-25-16 and 4-5-16 to remind staff #9 to complete the discharge summaries on the clinical records for patients #23 through #34.

In an interview with staff #9, staff #9 confirmed that the discharge summaries for patients #23 through
#34 had not yet been completed by the date of the survey.

Facility medical records department policy titled "Incomplete Records" states, in part:
"2. Timetable for completion of records is as follows:
...
C. A discharge summary will be dictated within 15 days of discharge."

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 5-17-16 in the facility cafeteria.

Based on observation, facility document review and interview, the facility failed to ensure the dietary services were managed correctly.

Findings were:

Documentation on the dishwasher stated, "Wash 160 degrees. Final Rinse 180 degrees."

The rinse and temperature chart for the dishwasher for May 2016 had the following temperatures that were out of range:
5/1/16 at supper "155/199"
5/2/16 at supper "159/181"
5/6/16 at supper "155/187"
5/7/16 at breakfast "159/181"
5/8/16 at breakfast "153/190"
5/8/16 at supper "159/191"
5/9/16 at breakfast "155/199"
5/10/16 at breakfast "157/195"
5/10/16 at supper "168/167"
5/14/16 at breakfast "139/184"
5/15/16 at supper "155/187"
5/16/16 at breakfast "192/166"
5/17/16 at breakfast "186/168"

The above was verified by the chief nursing officer during the tour on 5/17/16.

Based on observation and interview, the facility failed to provide a safe and sanitary environment for its staff and patients.

Findings were:

"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."

Tour of the facility on the afternoon of 5/17/16 revealed dust accumulation on the following:
· Fire extinguisher cabinet in the emergency room (ER) hallway
· Glove box holder in ER room two
· Welch Allyn otoscope ophthalmoscope wall unit in ER room two
· Over the bed light in guest room three
· Over the bed light in labor and delivery suite two
· X-ray film light box in the Cesarean section operation room
· Medication refrigerator in the pharmacy
· Fire extinguisher cabinet in the pharmacy

The above was verified on 5/17/16 with the chief nursing officer during the tour.

Documentation on the dishwasher stated, "Wash 160 degrees. Final Rinse 180 degrees."

The rinse and temperature chart for the dishwasher for May 2016 had the following temperatures that were out of range:
5/1/16 at supper "155/199"
5/2/16 at supper "159/181"
5/6/16 at supper "155/187"
5/7/16 at breakfast "159/181"
5/8/16 at breakfast "153/190"
5/8/16 at supper "159/191"
5/9/16 at breakfast "155/199"
5/10/16 at breakfast "157/195"
5/10/16 at supper "168/167"
5/14/16 at breakfast "139/184"
5/15/16 at supper "155/187"
5/16/16 at breakfast "192/166"
5/17/16 at breakfast "186/168"

The above was verified by the chief nursing officer during the tour on 5/17/16.

Based on observation, facility document review and interview, the facility failed to ensure preventive maintenance was performed on all sterilizers used, based on the manufacturer's service manual.

Findings included:

Sterrad sterilizer booklet stated in part, "Describe required maintenance - clean the hydrogen peroxide monitor lens (Every 3 months), planned maintenance."

Olympus sterilizer booklet stated in part, "Maintenance:
Weekly Maintenance:
1. Clean CER reprocessor and basin (use lint-free cloth)
2. Inspect CER reprocessor and hook-up components for wear and tear
3. Lubricate O-rings with silicone oil
Monthly (as specified)
1. 1.0 micron water pre-filter (replace every 3 months or if below 40 PSI)
2. 0.2 micron absolute filter (replace every 6 months or if below 40 PSI)
3. Installation and disinfection of filters and filter housing (upon 0.2 micron filter replacement)
4. Active Vapor Management System (if applicable): Charcoal filter (replace every 6 months)."

Steris washer manual stated in part,
"6.2 Daily Cleaning:
6.2.1 General 1. After last cycle of the day, allow unit to cool, and then remove and clean bottom filters of wash chamber. Always clean filters while they are still wet, before foreign matter dries.
2. Remove riser valve and inspect for debris. Brush off and rinse under tap water if necessary.
6.3 Weekly Cleaning:
6.3.1 1. Clean unit exterior using a general cleaner for general stains, a stainless steel stain remover for stubborn stains, and a stainless steel polish to keep equipment looking like new. Apply as follows:
a. Using a damp cloth or sponge, apply cleaner in a back-and-forth motion, rubbing in same direction as surface grain ...
2. Clean Independent Monitor front panel and display using a soft cloth containing a soapy solution or a mild detergent. DO NOT USE ANY LEMON-BASED (Citric Acid) PRODUCT to clean the display/keyboard.
3. Wash chamber interior with a moderately alkaline detergent solution. Rinse with tap water and dry with a lint-free cloth ...
4. Clean wash chamber rotary spray assemblies as follows ...
5. Clean rotary spray arms on accessories in the same was as chamber spray arms."

Steris sterilizer manual stated in part, "A thorough preventive maintenance program is essential to safe and proper sterilizer operation. You are encouraged to contact STERIS Engineering Service concerning our Preventive Maintenance Agreement. Under terms of this agreement, preventive maintenance, adjustments, and replacement of worn parts are done on a scheduled basis to assure equipment performance at peak capability and to help avoid untimely or costly interruptions."

In an interview with staff #20, staff #20 stated that they do not have policies regarding preventive maintenance on their sterilizers. Staff #20 stated they do clean the sterilizers but do not follow the above manuals and do not record the preventive maintenance completed. Staff #20 stated they are in the process of contracting preventive maintenance for certain sterilizers.

The above was confirmed with the chief executive officer and other administrative staff on the afternoon of 5/17/16, in the facility cafeteria.

Based on facility policy review, facility document review and interview, the facility failed to ensure emergency equipment was periodically tested according to facility policy.

Findings were:

Facility policy titled, "Crash Cart Check" stated, "Policy:
1. Crash Carts will be checked monthly by Pharmacy, and daily by Nursing Services.
2. Crash Cart checks will also be performed after each "CODE BLUE" and restocked as soon as possible.
3. Defibrillator checks will be done daily.
4. Nursing personnel checking the cart shall initial the appropriate column to indicate that the cart is stocked and in working order. Crash cart will be checked monthly on the 15th by the night shift, excluding medications, for appropriate and expired equipment.
Responsibilities: The Charge Nurse will be responsible for checking or assigning licensed nursing personnel to check the cart daily."

The OB (obstetrics) crash cart check sheet for the month of March 2016 were blank on the 7th and the 17th.
The OB crash cart check sheet for the month of April 2016 were blank on the 29th and 30th.
The Med/Surg (medical-surgical) crash cart check sheet for the month of April 2016 were blank on the following days: 4th, 5th, 14th, 15th, 16th, 17th, 22nd, 23rd, 24th, 28th, and 29th.
The Med/Surg crash cart check sheet for the month of May 2016 were blank on the following days: 6th, 7th, 8th, 14th and 15th.

The above was confirmed with the chief nursing officer during the tour on 5/17/16.