HospitalInspections.org

Based on interview and document review, the governing body failed to ensure that criteria for selection of medical officers were based on individual character, competence, training, experience, and judgment. This failure has the potential for decreased quality of care.
Finding includes:
On 3/11/15 while conducting record reviews of medical staff credentials, privilege and background files it was noted that 4 of 9 providers, all contractors, failed to have background checks completed. In accordance with the By Laws of The Fort Defiance Indian Hospital Board, Inc, certified July 26, 2012: pg. 3 stated "To approve the bylaws of the medical staff, ensure that only eligible candidates are appointed to the medical staff and ensure that the medical staff is accountable to the Board for the quality of care provided to patients." Page 8 of the Medical Staff Bylaws further stated "All Medical Staff members shall have experience, background, character..."
On the same day during an interview with the Human Resources staff, they acknowledged that each department was responsible for conducting background investigation on contracted employees. During a separate interview with the Chief Executive Officer, he stated that Human Resources staff is to conduct the background investigation on all employees.

Based on record review and interview, the hospital did not develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program that measured, analyzed, and tracked quality indicators and other aspects of performance including processes of care, hospital service, and operations (A273); did not monitor the effectiveness and safety of services and quality of care; and did not identify opportunities and changes that will lead to improvement (A283); did not always track medical errors and adverse patient events so that causes can be analyzed and appropriate preventive actions developed; and did not ensure that the hospital's governing body, CEO, medical staff, and/or administrative officials were responsible and accountable for ensuring compliance by the departments in hospital-wide QAPI activities (A286); did not always document the reasons for conducting quality improvement projects and the measurable progress achieved on these projects (A297); and did not ensure that adequate resources were allocated for measuring, assessing, improving, and sustaining the hospital's performance and reducing risk to patients (A315). The cumulative effects of these systemic practices resulted in the hospital's failure to comply with the statutorily mandated regulations under Quality Assessment and Performance Improvement.

Based on record review and interview, the hospital did not ensure that it's QAPI (Quality Assessment and Performance Improvement) program showed measurable improvement in indicators for which there was evidence that it will improve health outcomes; did not measure, analyze, and track quality indicators, and other aspects of performance that assessed processes of care, hospital service and operations; and did not monitor the effectiveness and safety of services and quality of care.

Findings include:

1. Review of hospital documents evidencing QAPI activities revealed that key hospital indicators were not being submitted timely so that hospital-wide compilation, tracking, and analysis of data could be conducted timely.

During an interview on 3/12/15 at 2:05 p.m., a QAPI staff member (QA1) stated that the hospital had identified 26 key indicators for the 22 hospital departments participating in quality assessment activities. QA1 added that data was to be submitted monthly (around the first week of the following month) to the QAPI department.

Review of QA summary reports documenting data gathering activities revealed that while indicator data specific to each department was being submitted, the submission however was not always made in a timely manner. In February 2014, for example, data on 10 indicators from 8 different departments including EVS (environmental services), ICU, MSU (medical surgical unit) and ICU, OB (obstetrics), Optometry, NDHC, pediatric, and pharmacy, did not submit monthly data before the due date, a non-compliance rate of 36%. Of the 10 indicators, two had no data submitted since December 2013, and eight had none since October 2013.

While the same report noted that the specific contact person or department was to be notified, review of the following month's report (March 2014) revealed that data for 12 hospital indicators (out of 26) were not submitted by 10 of the departments including data on "Fall rate" which had no data submitted by MSU and ICU since October, 2013; "C-section outcomes," no data from OB since October 2013; medication error rates and anticoagulant outcomes, no data from pharmacy since October 2013; and restraints usage (ICU), no data submitted since October 2013. The QA Summary Report in March 2014 indicated that of 26 indicators, 46% did not have indicator data submitted timely by 45% of the departments.

Further review of the QA summary reports revealed that the delay in monthly data submission was an ongoing occurrence. In May 2014, for example, the report indicated delays in data submission going back several months for several of the hospital indicators including patient surveys (no data from the Sanders Clinic since October 2013); cataract outcomes (none from the ophthalmology clinic since December 2013); pharyngitis rate (none from pediatrics since December 2013); and LWBS rate (leave without being seen by a provider) from the emergency department (no data since January 2014).

The reports further indicated that the delay in data submission had occurred notwithstanding notification of the department's contact person.

During the same interview on 3/12/15, QA1 stated that she wasn't sure about other reasons for the delay and that while submission was better, delays were still occurring.

Further review of available documents revealed notifications sent by QSD staff to the departments concerning delayed data submission from September 2014 through December 2014. In the documents, the delay some of which occurred for several months included indicator data for restraints usage (from ICU), pharyngitis rates (pediatrics), and coagulation data (pharmacy). In October 2014, a reminder note issued to the surgical department revealed the lack of submitted data from April 2014 through September 2014, a six-month period.

Notifications for February 2015 further revealed repeated reminders to the departments to send in their information for presentation and discussion during an upcoming QSD meeting or to close out the current year's QA monitors which cannot be done because of incomplete data.

In the same interview on 3/12/15, QA1 stated that the lack of timely submission is "frustrating" because incomplete data delays a lot of QAPI activities including organization, analysis, development of performance measures, if needed, and evaluation of the hospital-wide programs.

Without timely submission of data, efforts to monitor, measure, analyze, and track quality indicators and other aspects of performance that assessed processes of care and hospital service and operations could potentially be hampered and rendered ineffective.

No QA summary reports for 2015 were made available for review.

2. Review of hospital records documenting QAPI activities at the department-level revealed that while data gathering and benchmarking were being performed, there was no evidence that these were being shared with the hospital's Quality Services Department so that the information could be used for hospital-wide assessment of processes of care, services, and operations, as well as monitoring for the effectiveness and safety of services and quality of care.

Review of the Nursing Quality Dashboard for 2015, for example, revealed that data gathering, monitoring, and benchmarking for other indicators (in addition to restraints usage and falls rate as outlined in the 2014 QA monitors list), were being conducted in the ICU.

Available data from October 2014 - December 2014 indicated that while other indicators were being monitored including compliance with chart review and documentation; pressure ulcer prevalence; and temperature and narcotic log documentation, there was no evidence that the information was being shared with the Quality Services Department. Further review revealed that while restraints usage and pressure ulcer prevalence, for instance, met benchmarks in November but not in October and December 2014, there was no indication that an analysis was conducted to help assess the cause and why target goals were not achieved. During a separate interview on 3/12/15, a nursing management staff (NM1) stated that indicators (on the dashboard) were being monitored by the ICU and MSU and that data was being collected monthly. NM1 explained that while the information was being sent to the director of nursing services (CNE1), she was not receiving any feedback and was therefore unaware about how the information was being used and whether it was being reported to the QSD (Quality Services Department).

During the interview on 3/12/15, QA1 stated that data relative to restraints usage and fall rates monitored by Nursing was being reported to QSD. QA1 added however that data about other indicators being monitored was not being reported to QSD. When asked why, QA1 was unable to respond.

3. Review of the QA summary reports as well as documentation provided by several departments revealed the lack of evidence of participation in the hospital-wide QAPI program.

For example:

a. There was no documentation of participation by the surgical department including anesthesia particularly regarding activities and processes considered high-risk, high volume. Review of the QA summary report for August 2014 revealed no data submission since April 2014 by the surgical department.

b. Review of the summary report for May 2014 further revealed the lack of submission by infection control regarding hospital-acquired pneumonia since October 2013, an 8-month period.

c. On 3/12/15 at 11:10 a.m., during an interview with two dietary staff, the following dietary quality measures were presented as being monitored regularly in the dietary department: Patient tray- non delivery - data is given to dietary manager; Patient Satisfaction Survey - started October 2014 to February 2015. Data is entered in the computer and kept on file; Patient Cook Census - quantifies the meals served in each unit plus guests; Bulk Nourishment Record for the following departments - OR, ED, ACU, MSU and ICU.

One of the dietary staff stated that for QA purposes they monitor and collect data for late tray (logs), transfers, discharges, expired patients, change of diet orders. They basically monitor all activities in the kitchen. They also monitor the ACU/Guest roster signed by each patient; temperature log for all walk-ins and roll-in.

The dietary staff also showed the following forms as evidence they monitor all dietary activities: QUAT Test form; Patient Tray Form; Weekend Cleaning; Patients on Clear liquids and NPO; Supplement Distribution; Patient Snacks and Non-deliverables.

On 3/12/15 when asked how they select quality measures to include in their QA program, the dietary staff were unable to provide an answer because the QA was handled by the dietary manager who was on vacation at the time of the survey. Staff were unable to state where the information could be found.

Interview with RD1 on 3/12/15 at 11:40 a.m. revealed that she was not included in the QAPI program.

During another interview on 3/12/15 at 2:00 p.m., QA1 stated that the dietary department was "notorious" for not submitting data.

4. Review of QA summary reports made available to document hospital-wide QAPI revealed the lack of documentation of any analysis to determine the reasons for why benchmarks were not being met so that appropriate performance improvement measures could be developed. In addition, there was no documentation of any evaluation conducted to determine whether performance measures were effective in ensuring that performance improvement was attained and maintained.

Review of the QA Summary Report for May 2014 revealed that "more than half" of the hospital indicators were not being met. The report noted, for example, that the emergency department (ED) did not meet benchmarks for patients leaving the ED without being seen (LWBS) by a provider for 6 of eight months from October 2013. Further, the fall rates in the MSU and ICU exceeded goals (frequency of fall) for 6 of eight months for the same time period. While the report noted "Open to suggestions" as a "Proactive Solution/Suggestion," there was no review or analysis of why target benchmarks were not being met, suggestions or recommendations being made to address the reasons, or an evaluation of current corrective measures to determine if they needed to be revised or adjusted.

In September 2014, the Summary Report, for example, noted that falls in the ICU and MSU had been "in the red" (did not meet goals) for 6 of nine months (a rate of "67%"); LWBS (in the ED), "in the red" for 9 of 12 months (a rate of "75%);" and transfer rate, also in the ED, "in the red" for 10 of twelve months (83%). While the report noted that "MSU & ICU falls" were reported to the committee, and that LWBS and transfer rates in the emergency department were to have "presentation by the indicator owner," there was no documentation of any analysis as to why benchmarks were not met and what corrective actions were developed to ensure that processes of care and hospital services and operations meet safety and quality standards.

For 2015, no Summary Report was available for review.

Based on record review and interview, the hospital did not identify opportunities and changes that will lead to improvement.

Finding includes:

Review of QA summary reports for 2014 revealed that the hospital had identified 26 indicators that 22 hospital departments were to monitor and collect data for its hospital-wide quality assessment and performance improvement program.

Further review of the summary report for May 2014 indicated that more than half of the hospital indicators did not not meet established goals and that quality indicators in several hospital departments were "in the red."

The summary report for July 2014, for example, revealed that several indicators monitored by the emergency department (ED) including LWBS (leave without being seen) and transfer rates did not meet goals in 6 and 7 out of the last 9 months (respectively); and that the falls rate in the ICU and MSU had not met benchmarks in 6 out of the last 9 months. While the report noted that the "owner" (responsible individual) will be invited to "discuss (the) indicator."

This notwithstanding, there was lack of documentation of any analysis conducted to understand performance improvement activities, causes, and hurdles to achieving goals; or that corrective action plans were developed and/or revised based on the analysis to address quality deficiencies in the effort to improve performance.

Further review of the summary reports revealed that because submission of indicator data was not always timely resulting in several months delay in certain cases, identification of opportunities for hospital-wide performance improvement can be hampered or delayed particularly when data was not available or incomplete when discussed during QSD meetings. Consequently, whether performance improvement had occurred or not was difficult to determine. (Cross-refer to A273)

No QA summary reports for 2015 were available for review.

Based on record review and interview, the hospital did not always track medical errors and adverse patient events so that causes can be analyzed and appropriate preventive actions developed. The hospital also did not ensure that the hospital's governing body, CEO, medical staff, and/or administrative officials were responsible and accountable for ensuring compliance by the departments in hospital-wide QAPI activities.

Finding includes:

Review of the QA summary reports for 2014 revealed that data submission for the department of surgery was not always timely preventing tracking of medical errors, analysis of cause, or the development of any preventive actions applicable hospital-wide.

The QA summary report for March 2014 revealed that the surgical department had not submitted data related to "Readmission (to the) OR," of one of 3 hospital indicator that the department was to monitor.

Further review of the summary report for July 2014 revealed that the department had "Missing data from April - July" (a 4-month) and that the contact (responsible individual) was aware.

While the August 2014 QA report noted that data for two other indicators were being submitted (diabetic amputation rates, universal protocols), "readmission to OR" continued to be delayed and, as of September 2014, had "Missing data from April - September," a 6-month period.

During a tour of the surgical department, staff interviewed revealed the lack of compliance with data submission and with the overall hospital-wide QAPI program. In a separate interview on 3/12/15, QA1 verified that submission of monthly indicator data by the surgery department was delayed.

Further record review revealed that in light of the delay, there was no indication that the hospital's governing body, CEO, or designated responsible individual was informed, and if so, intervened to ensure that the reasons for the delay were identified and addressed.

Based on record review and interview, the hospital did not always document the reasons for conducting quality improvement projects and the measurable progress achieved on these projects.

Finding includes:

Review of documents evidencing hospital-wide QAPI efforts revealed that while 26 indicators were identified to be monitored by 22 hospital departments, the reasons for selecting these projects were not always documented.

Review of QA summary reports as well as quality meeting minutes revealed that while hospital indicators were being monitored for several years, the reasons for ongoing monitoring activities were not always documented even as measurable progress were being achieved.

Review of the nursing dashboard for 2012 and 2015 revealed that fall rates, restraints usage, and compliance with charts/documentation were several indicators that had been monitored each year. In light of this, there was no documentation as to why these measures continued to be monitored and tracked over time.

Further, while information was being gathered to determine whether benchmarks were being met, there was no documentation about measurable progress being achieved and how this could be maintained over time.

During an interview on 3/12/15, when asked why the the same or similar indicators were being monitored for years by some of the departments, QA1 was unable to explain but that staff in those departments might have been used to monitoring and thought that they should continue.

Based on record review, the hospital did not ensure that that adequate resources were allocated for measuring, assessing, improving, and sustaining the hospital's performance and reducing risk to patients.

Finding includes:

Review of documents evidencing the hospital's QAPI activities revealed the lack of documentation of governing body oversight of the QAPI program.

For example:

Review of QA summary reports revealed that monthly indicator data submission was not always being met by several of the departments so that data was not available for several months hampering hospital-wide data collection efforts, monitoring, analysis, and development of corrective action plans, if needed.

While reminder notifications to delinquent departments were being made (and sometimes ignored), there was no indication that the governing body or hospital administrative staff was involved in developing corrective actions to ensure compliance. There was no analysis conducted for example, if non-compliance was a result of understaffing, workload issues, or lack of an "owner" (contact person) for the department.

Review of meeting minutes revealed that while reporting was being made by QSD to the governing body, there was no documentation that concerns raised were being discussed and addressed. Review of the meeting minutes dated 2/20/15, for instance, revealed that other than status reporting, there were no discussions about concerns or issues raised or any challenges. (Cross-refer to A273)

Based on interview and document review the facility failed to enforce the Medical Staff Bylaws. This failure has the potential to affect quality of care.
Finding includes:
On 3/11/15 while conducting record reviews of medical staff credentials, privilege and background files, it was noted that 4 of 9 providers, all contractors, failed to have background checks completed. On page 8 section C. Qualifications #9 in The Bylaws of the Medical Staff, Fort Defiance Indian Hospital Board, Inc March 29, 2013, "All Medical Staff members shall have experience, background, character..." In accordance with the Fort Defiance Indian Hospital Board, Inc. (FDIHB) policy Subject: Minimum Standards of Character & Suitability for Employment, approved by the (FDIHB) and effective 1/01/12, Section III, B. "...FDIHB has established and adopted a minimum standards of character requiring completion of a satisfactory background investigation..," and Section III, B. 1. b. "A criminal history background check... " will be completed on all employees prior to final selection or when employment commitment is made.
On the same day during an interview with the Human Resources staff they acknowledged that "each department is responsible for conducting background investigation on contracted employees. During a separate interview with the Chief Executive Officer, he stated that Human Resources staff is to conduct the background investigation on all employees.

Based on interview and document review the medical staff failed to enforce the Medical Staff Bylaws. This failure had the potential to result in decreased quality of care.
Finding includes:
On 3/11/15 while conducting record reviews of medical staff credentials, privilege and background files it was noted that 4 of 9 providers, all contractors, failed to have background checks completed. On page 8 section C. Qualifications #9 in The Bylaws of the Medical Staff, Fort Defiance Indian Hospital Board, Inc March 29, 2013, "All Medical Staff members shall have experience, background, character..." In accordance with the Fort Defiance Indian Hospital Board, Inc. (FDIHB) policy Subject: Minimum Standards of Character & Suitability for Employment, approved by the (FDIHB) and effective 1/01/12, Section III, B. "...FDIHB has established and adopted a minimum standards of character requiring completion of a satisfactory background investigation..," and Section III, B. 1. b. " A criminal history background check..." will be completed on all employees prior to final selection or when employment commitment is made.
On the same day during an interview with the Human Resources staff they acknowledged that " each department is responsible for conducting background investigation on contracted employees. During an interview with the Chief Executive Officer he stated that Human Resources staff is to conduct the background investigation on all employees. (Cross-refer to A 341).

Based on observation, record review, and interview, the hospital did not ensure that a registered nurse supervised and evaluated the nursing care of each resident (A395). Cross -refer the standards and conditions under (A747) Infection Control and (A799) Discharge Planning. The cumulative effects of these systemic practices resulted in the hospital's failure to comply with the statutorily mandated regulations under Nursing Services.

Based on observation, record review, and interview, the hospital did not ensure that a registered nurse supervised and evaluated the nursing care of each resident.

Findings include:

1. During the initial hospital tour on 3/09/15, a nurse manager (NM1) with the surveyor stated that rooms 5 - 11 in the medical-surgical unit (MSU) were being temporarily closed for occupancy because of bed bug sightings in several of the rooms two days prior, on 5/07/15. NM1 added that patients in the rooms were placed on contact isolation to control the spread of the infestation. Accordingly, the plan was to have the rooms steam-cleaned once patients in the affected rooms were either discharged or transferred to other non-infested rooms. NM1 also stated that the ICU had already been steam cleaned over the weekend (on 3/07/15) following earlier sightings of bed bugs there as well.

Following the tour on 3/09/15, preparations were made to transfer or discharge patients including Patient 7 who was prepared for surgery on 3/09/15. Accordingly, the patient was scheduled for an amputation of the left 5th metatarsal which was postponed. The patient who was discharged was then told to return later in the week once rooms have been steam-cleaned and ready for occupancy.

Review of the facility's policy on "Parasite" revealed that the purpose of the policy was to "ensure appropriate screening, notification, and isolation procedures are followed for the treatment of bed bugs, lice, or scabies..." and to "reduce the transmission to patients and staff."

The policy further required that patients will be screened by clinical staff for bed bugs and that "patients may also report that they have bed bugs, lice or scabies in their residence or on their belongings."

While staff stated that bed bugs were endemic in the community and surrounding areas served by the hospital, review of nursing admission records revealed the lack of documentation that clinical staff (registered nurses) screened patients for bed bugs at the time of admission and on an ongoing basis, or that information from patients about bed bugs in their homes or on their belongings was elicited.

In an interview on 3/11/15 at 10:00 a.m., the MSU/ICU supervisor (NM1) stated that discovery of the bed bugs started in ICU when Patient 30 told the staff that her family needed to be evacuated from their home due to bed bug infestation. According to NM1, the first action taken was to place all patients in rooms where bed bug sightings were made on contact isolation. NM1 added that on Saturday, 3/7/14, several rooms in the ICU including the nurses bathroom had bedbugs and that the ICU had to be shut down.

Review of the medical record revealed that Patient 30, an 82-year old female was admitted to the intensive care unit (ICU) of the hospital on 3/2/15 with an admitting diagnosis of status post hemicolectomy to remove an adenocarcinoma of the colon.

Review of the initial nursing assessment dated 3/02/15 revealed a skin assessment significant for the surgical incision and that no other skin conditions were identified. Further review of the assessment revealed the lack of evidence that a screening for the presence of bed bugs was conducted.

During another interview on 3/12/15, a licensed staff stated that screening for bed bugs was not routinely conducted and was not part of the nursing admission process. The staff added that she was unaware that one of the hospital's infection control policy was for all clinical staff to screen of bed bugs.

Review of the medical record further revealed that while Resident 30 was observed in the ICU as having bed bugs on her clothing and belongings, there was no indication that staff in the MSU where the patient was transferred to following her ICU stay were informed so that appropriate steps and precautions to contain the infestation could have been instituted on the MSU.

Review of documents provided by the hospital revealed that bed bugs were observed in the ICU including the employee bathroom, the nurses station, rooms 1, 3 and 4, and under the sink in room 2 on 3/09/15. In MSU, bed bugs were also noted in rooms 7, 9, 10, 11 on 3/07/15, and again on 3/09/15 including in room 14.

Failure to conduct the required screening increased the potential for the spread of bed bugs from room-to-room, patient- to-patient, patient-to-staff, and in other places including the homes of unsuspecting patients, visitors, and hospital staff member's. Further, while the ICU had been steam-cleaned on 3/07/14, another cleaning was scheduled on 3/10/15 leading to a plan to close the MSU and ICU, as noted in documents provided for review by hospital staff on 3/12/15.

2. Review of the hospital's discharge planning policy and procedure revealed that planning is conducted on all patients to determine their needs and appropriate post-hospital destination. The policy also noted that the process begins during admission (as part of nursing admission assessment) and continuously updated until discharge.

Review of medical records revealed that while licensed nursing staff were documenting discharge planning on admission by querying for current living arrangements, ability for self-care as well as for other needs including safety, special equipment, and availability for transportation at discharge among others, there was no documentation of any evaluation, and/or follow-up or ongoing assessments of other needs that may arise during the course of the patient's stay, particularly for patients whose needs were not identified or raised by the patient at the time of admission.

For example:

a. Patient 4 is a 74-year old female who was admitted to the hospital on 3/06/15 with several diagnoses including diabetes mellitus, foot cellulitis, and amputation of 1st and 2nd toes of the right foot. Review of the medical record revealed that the patient was alert and oriented, was cooperative, and had complained of pain, assessed on 3/07/15 as an "8" (on a scale of 1 - 10 with 10 the most severe). On 3/07/15, nursing progress notes indicated that Patient 4 had limited range of motion, had unsteady gait, was a "Fall risk," and needed assistance with ADLs (activities of daily living) including dressing, elimination, locomotion/mobility, and transfers. A Morse fall scale (to assess risk for falls with >50 indicative of high risk) revealed a score of 70.

The discharge planning screening completed on 3/07/15 noted that while several data fields were completed regarding the patient's current living situations; and that the patient's husband "will provide transportation at discharge," the patient however was described as not "able to care for self under present conditions" (as noted by a "No" response).

Further review of the medical record revealed that Patient 4 was discharged on 3/09/15 after being informed that her surgery was being canceled as the "unit was being closed" (as noted above). While discharged instructions on illness, medications and wound care were given, there was no documentation that other potential discharge needs were assessed and addressed including how wound care was to be provided and by whom, how assistance with ADLs was to be rendered so that the patient was safe from falls, or that a caregiver was identified and whose understanding and ability was evaluated to ensure that he or she had the capability to assist and supervise the patient's continuing care at home.

b. Patient 7 is a 67-year-old female who was admitted to the hospital on 3/06/15 with several diagnoses including diabetes mellitus, hypertension, and cellulitis of the right foot with necrotic tissues and dry gangrene. Admission notes outlined a list of "chronic problems" including diabetes, a right patellar fracture, right leg length discrepancy, bilateral carpal tunnel syndrome, and hypothyroidism; as well as "Episodic problems" including a stage 3 chronic kidney disease, and gangrene of the left foot.

The discharge planning screening on admission (on 3/06/17) noted that Patient 7 was able to care for self under present conditions and that she did not have help at home. On 3/10/15, the medical record revealed that the patient had a 5th metatarsal mid-shaft removal with revision of the skin. On 5/11/15, a referral to physical therapy was made by the physician for gait training and fall risk assessment.

Review of the medical record revealed the lack of documentation of nursing participation in the ongoing assessment of the patient's discharge planning needs. While a physician progress note dated 3/12/15 disclosed that the patient may benefit from a facility which has a nephrologist because of her kidney problem, there was no documentation that referrals were made by nursing staff to social services, for example, to prepare the patient and ensure that she received the appropriate level of care. Further, while the patient had right foot wound dressing changes, there was no documentation that the patient's capability to perform the procedure following discharge was assessed.

Review of the job description of the registered nurse in the MSU revealed that essential duties, functions, and responsibilities included "participating in patient care planning," which involved the "assessments and evaluation of patient needs, a determination of the nursing procedures and practices to be included; and periodic evaluation of plans to ensure that intended results are being achieved." (Reference includes Patients 1 - 32)

3. Patient 4 was admitted to the hospital on 3/06/15 with several diagnoses including diabetes mellitus, foot cellulitis, and amputation of the 1st and 2nd toes of the right foot.

Initial admission notes revealed that among other problems, Patient 4 also complained of pain discomforts. A pain assessment conducted on 3/07/15 revealed pain on the right foot radiating to the right knee and that the pain was "constant," aching, sharp and throbbing. A scale used to describe the level of pain noted "8" out of 10 (with 10 being the most severe).

Review of the medical record revealed that a physician's order was made for the use of Morphine 1 mg intravenously, and Percocet (an analgesic) orally for pain. Because of "not enough relief" recorded in nurses progress notes dated 3/07/15, the Percocet was changed to Tramadol. According to the same note, the patient had stated taking "two (50-mg) tablets regularly at home for pain."

Review of the medication administration record (MAR) revealed that while Patient 4 was being given Tramadol corresponding to the pain level described, the effects of the analgesics were not always being noted in several instances following administration on 3/07/15, 3/07/15, and 3/09/15. Similarly, the effects of the Morphine being given were not always being documented after being given on 3/06/15 and 3/07/15, and 3/09/15.

During an interview on 3/12/15, a licensed staff stated that the effects of the analgesics should be noted in the electronic record within an hour after administration. Accordingly, the staff should check on the patient to determine if the pain was relieved.

Without assessing and documenting the effectiveness of pain control interventions, efforts to adjust treatment, if necessary, could be hampered.

Based on observation and interview, the hospital did not ensure that all drugs are locked when appropriate.

Findings include:

1. During a tour of the adolescent care unit on 3/10/15, the refrigerator inside the medication room behind the nursing station while closed was found to be unlocked. Inside the refrigerator, several Ativan 20mg vials in an open box were observed.

In an interview during the tour, a licensed staff identified the refrigerator as a storage for medications and that it should be locked at all times. The staff stated that she did not know why the refrigerator was unlocked.

2. On 3/9/15 at 11:45 a.m., inspection of the Eye Clinic Exam Room 1 revealed the following medications that were located in a square storage container attached to the wall with a latch that was unlocked:
(a) Fluorescein Sodium
(b) Alcaine - Proparacaine HC ophthalmic solution 0.5% - 15 ml. bottle
(c) Tropicamide ophthalmic solution - 15 ml. bottle
(d) Phenylephrine Hydrochloride 2.5% - 15 ml. bottle
(e) Tobramycin and Dexamethasone ophthalmic solution - 5 ml.

The Exam Room 2 had the following ophthalmic products stored in an unlocked storage container:
(a) Fluorescein Sodium
(b) Alcaine - Proparacaine HC ophthalmic solution 0.5%
(c) Tropicamide ophthalmic solution
(d) Phenylephrine Hydrochloride 2.5%
(e) Tobramycin and Dexamethasone ophthalmic solution
(f) Alphagan
(g) Boston eye drop
(h) NaCl ophthalmic solution

Interview with the patient care coordinator revealed that the ophthalmic products were unlocked during clinic hours for easy access. After clinic hours, all of the medications in the storage boxes were locked.

3. On 3/11/15 at 10:30 a.m. the following medications were observed unlocked in Exam Room #1 in the ENT Clinic:
(a) Dulera 100 mcg/5mg. (unopened)
(b) Acetic Acid 2% in Aqueous solution Acetate Otic solution 60 ml.

Interview with a licensed nurse confirmed that the above medications were unlocked during clinic hours and locked after clinic hours. All other medications were observed locked in the Medication room.

Based on observation, interview and record review the facility failed to ensure that outdated, mislabeled or otherwise unusable drugs were not available for patient use. This had the potential to result in decreased quality of care due to decrease efficacy of the medication.
Findings include:
1. On 3/9/15 through 3/11/15 while performing a facility tour it was noted that several medications were outdated in patient care areas to include the anesthesia carts in the operating room and the recovery room. These outdated medications were verified by the operating room nurse manager. These medications include with the quantity in () and expiration date of medication:
(3) Monoject 0.9% sodium chloride 10ml flush 10/14
(3) 5% Dextrose .45% Sodium chloride 500ml IV bag 2/15, 6/13
(2) 5% Dextrose 250ml IV bag 2/15
(4) Verapamil HCL injection 5mg/2ml (2.5mg/ml) 01/15
Epinephrine Injection 1:1000 (1mg/ml) 02/15
Ceftriaxone for injection 1 gram 01/15
Ampicillin and Sulbactam for injection 3 gram 02/15
Nitrobid 2% ointment 30 grams 02/15
Glucagon Emergency Kit for Low Blood Sugar 02/15
(2) Atropine Sulfate injection 1mg 03/01/15
(2) 50% Dextrose Injection 25 grams 03/01/15
(4) Calcium Chloride injectable 1.36mEq/ml 03/15
(1) Sodium Bicarbonate 1mEq/ml 12/14

2. Based upon review of the facility policy "Pharmacy Policy Infection Control" and revised May 29, 2012 Procedures III. A. "Multiple Dose Vials ...may be used for 28 days, unless the manufacturer suggested beyond use date is shorter. Upon opening a vial the date opened should be written on the vial ..." The following multi-use vials were expired and/or open and unlabeled:
0.9% Sodium Chloride Injection 100ml multi-pouch bag (of four) opened and unlabeled
16 ounce bottle of Alcohol 70% open, unlabeled expired 9/14
Xylocaine 1% (10mg/ml) 50ml open unlabeled
Sodium Citrate & Citric Acid Oral Solution 16 fl oz open unlabeled
1% lidocaine 10mg/ml 50ml open, labeled expired 4/2/14
Naloxone HCL 0.4mg/ml open unlabeled.



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2. On 3/9/15 at 2:15 p.m., inspection of the intensive care unit refrigerator revealed the following:

Multi-dose vial of Protein Purified Derivative (PPD) had an open date of 2/1/15. Interview with a licensed nurse (LN) stated that the vial should be discarded 30 days after it was opened.

A 10 milliliter vial of multi-dose of Folic Acid (5mg./ml.) had an open date of 1/7/15. Interview with a LN revealed that once opened a multi-dose vial should be discarded after 30 days.

A 10 cc. vial of Novolin R insulin had a handwritten date smeared and unreadable by the ICU licensed nurse who stated, " If in doubt of date opened, discard. "

Levemir with a dose of 100 units/ml. showed an open date of 2/5/15. Interview with a LN revealed that medication should be discarded 30 days after open date.

Inspection of the internal temperature of the ICU medication refrigerator revealed an internal temperature reading of 54 degrees Fahrenheit and another internal thermometer read 5 degrees Centigrade.

The ICU refrigerator did not have a system of monitoring the internal temperature such as a temperature log. Interview with the ICU charge nurse revealed the temperature log was maintained by Pharmacy. The LN made a phone call to pharmacy to confirm the log. However, the pharmacist revealed that they do not maintain the temperature log for the medication refrigerator in ICU.

On 3/9/15 at 11:45 a.m., inspection of the Eye Clinic revealed that some ophthalmic products were located in a wooden storage with a latch that was unlocked. A 15 - ml. bottle of NaCl ophthalmic solution had an expiration date of 04/2014. The Patient Care Coordinator confirmed that the solution was expired and need to be discarded.

On 3/9/15 at 12:05 p.m. during inspection of the Eye Clinic, a visual field machine had a BioMed sticker indicating a last inspection date of March, 2013. This was confirmed by the Patient Care Coordinator.
Based on observation, record review, and interview, the hospital did not ensure that administrative and technical personnel were competent in their respective duties.

Findings include:

1. On 3/9/15 at 10:50 a.m., during initial inspection of the kitchen, a covered dish of cooked salmon was observed in the walk-in refrigerator #2 with a plastic cover and dated 12/18/14. The lead cook stated acknowledged that the salmon dish was a left over and needed to be disposed. Review of the facility's policy and procedure failed to address the shelf life of left over items.

2. On 3/9/15 at 11:20 a.m., the cook was observed taking the temperatures of food items in the trayline before serving to the patients. The cook was observed to clean the spike thermometer by immersing and wiping the thermometer with soap and water solution in the green bucket. Thereafter, he then immersed the thermometer a second time in a sanitizing solution of Quaternary with water in a red bucket. Without wiping or air drying the thermometer spike, the food temps were taken.

Review of the facility's policy revealed "sanitizing agents differ in the amount of contact time required and temperature requirements."

A policy "Using a thermometer SOP" revealed "wash, rinse, sanitize and air-dry before and after each use to prevent cross-contamination." Further review of policies provided showed no evidence of the cleaning and sanitizing of the thermometer in between taking temperatures of food items prior to food serving.

In an interview with the registered dietitian on 3/12/15 at 12:00 p.m. she explained that the former facility practice in cleaning the thermometer in between taking temps of food items was by the use of alcohol pads. However, the practice was discontinued due supply availability and cost.

Based on observation, interview and record review, the hospital failed to ensure the safety of patients, staff, and visitors in the event of fire (A709); and did not ensure that supplies and equipment were maintained to ensure an acceptable level of safety and quality (724). The cumulative effects of these systemic practices resulted in the hospital's failure to comply with the statutorily mandated requirements under Physical Environment and Life Safety.

Based on observation, interview and record review the hospital failed to ensure the safety of patients, staff, and visitors in the event of a fire.

Finding includes:

The hospital failed to ensure that doors protecting corridor openings met protective requirements; failed to protect vertical openings as well as hazardous areas, as required; failed to maintain means of egress; failed to provide emergency lighting; failed to test alarm systems and smoke detectors; failed to protect and maintain areas with automatic fire sprinklers, and failed to protect cooking facilities, as required.

Please refer to the attached findings following the Life Safety Code (LSC) survey dated 3/26/15.

Based on observation and interview, the hospital did not ensure that supplies and equipment were maintained to ensure an acceptable level of safety and quality.

Findings include:

1. During a tour of the MSU on 3/09/15, the following were observed.

a. The blanket warmer located in an alcove outside of the ICU and adjacent to room 5 of the MSU was observed with a biomed sticker indicating that preventive machine of the equipment was due January 2015. A facility staff in an interview stated that the equipment was currently being used to warm blankets.

b. Another equipment labeled as a Sage warmer was noted to have a biomed sticker indicating that preventive maintenance was due in September 2014. The equipment which was observed on top of the counter inside the nursing station of the pediatric unit was identified by a licensed staff as a warmer for adult cleaning wipes.

c. One Arrow multi-lumen central venous catheterization kit was observed inside the supply room next across from the nursing station in the pediatric unit. The kit which was observed with several other supply items was noted with an expiration date of November 2014.

In an interview, a central supply staff stated that the packet should have been removed from the supply room.

d. During inspection of the crash cart in the pediatric unit on 3/10/15, the cart was observed without medications calibrated for pediatric/neonatal use. While it contained emergency equipment and other items for the resuscitation of infants and children in an emergency, calculating doses from adult stock vials, for example, during an emergency could potentially increase medication errors as well as delay the administration of medications.

In an interview during the inspection, a licensed staff stated that the unit had a Broselow tape (a color-coded tape measure used to relate a child ' s height as measured by the tape to his/her weight to provide medical instructions including medication dosages). The tape however could not be found in the cart for easy reference when needed.

2. During a tour of the adolescent care unit (ACU) on 3/10/15, a clothes dryer was observed inside the laundry room of the ACU unit with a notice that read, " Do not use per maintenance 11/9. "

A licensed staff in an interview stated that the notice had been affixed to the machine since November (2014) adding that she did not know what the final decision was and whether the machine was to be repaired or replaced. The same staff stated that the unit needed two washers and two dryers to accommodate the volume of laundry processed on the unit by patients who washed their own clothes as part of the program.

3. A heavy, rectangular piece of glass panel in a metal frame which appeared to be a window fixture was observed lying on its side inside a room in the mental health clinic (1A3-10). The fixture was propped up by a chair and a metal filing cabinet.

4. During a tour of the Sanders Clinic on 3/11/15, the crash cart inside the main clinic was observed without any medications for the resuscitation of patients in the event of an emergency. In an interview during the tour, a clinical lead staff member (CS1) stated that the unit which had opened only about a month prior to the tour was still in the process of filling the cart with emergency medications with assistance from the pharmacy.

5. On 3/9/15 at 12:05 p.m. during inspection of the Eye Clinic, a visual field machine had a BioMed sticker indicating a last inspection date of March, 2013 which was confirmed by the patient care coordinator.



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6. On 3/9/15 at 10:30 a.m., during the initial tour of the kitchen, one of the handwashing sinks was noted to be slow-draining. Upon handwashing, water readily filled the sink half way and soap water splattered while hands were rinsed with flowing water.

7. On 3/9/15 at 12:10 p.m., during inspection of the outpatient rehabilitation department, a weight lifting machine on the west side of room did not have any evidence that machine inspection and maintenance had been conducted by the Bio-Med department. The interim director of the Rehab department confirmed that there was no Bio-Med sticker as proof when the weight machine was last inspected for safety and preventive maintenance.

8. On 3/10/15 at 10:45 a.m., during inspection of the radiology department, a portable x-ray machine was observed without evidence of a BioMed inspection sticker. Interview with the radiology supervisor on the same day at 11:00 a.m. revealed that there were two portable machines and that the other machine was located in the operating room, and had been "out of order" for sometime.

Further investigation revealed the only x-ray machine in the operating room was a C-arm. There was misinformation as to the location of the portable x-ray machine which was in the operating room but transported to the Sanders Clinic. On further inquiry, the portable x-ray machine turned out to be in an alcove on the multi specialty unit (MSU).




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9. On 3/9/15 while performing the unit tour of the operating room it was noted and verified with staff that 2 of the 3 Datex-Ohmeda Anesthesia machines' biomedical stickers had date due for preventive maintenance of May 2014. According to the policy Anesthesia Safety Regulations revised April 2008, section on Anesthesia Equipment Safety, it was written that "All anesthesia machines will receive preventive maintenance checks on a quarterly basis." On 3/9/15 during an interview with the lead certified registered nurse anesthetist (CRNA), and later with the biomedical lead, they both verified that the maintenance had not been completed

10. On 3/9/15 while performing a tour of the post anesthesia care unit (PACU) it was noted that 3 of 3 electronic vital signs machines had outdated biomedical stickers with a due date of April 2014.

11. On 3/11/15 while performing a tour of the emergency department it was noted that 2 of 2 EKG had outdated biomedical stickers with a due date of October 2014. On 3/11/15 during an interview with the biomedical lead he stated the "the EKG machines could not be found during the last inventory." He proceeded to have quality checks completed.

Based on record review and interview, the hospital did not ensure that the infection preventionist implemented policies governing infection control (A748); did not provide a sanitary environment to avoid sources and transmission of infection and communicable diseases; did not ensure that it had an active infection control program for the prevention, control, and investigation of infections and communicable diseases (A749); and did not ensure that the chief executive officer (CEO), the medical staff, and the director of nurses (DON) ensured that hospital-wide quality assessment and performance improvement (QAPI) and training programs addressed problems identified by the infection control officer (A756). The cumulative effects of these systemic practices resulted in the hospital's failure to comply with the statutorily mandated requirements under Infection control.

Based on record review and interview, the hospital did not ensure that the infection preventionist implemented infection control policies and procedures; and that staff were informed and implemented the policies and procedures control of the spread of infection.

Finding includes:

The hospital's infection control policy regarding "Parasite" was "to ensure (that) appropriate screening, notification, and isolation precautions are followed for the treatment of bed bugs, lice, and scabies;" and to reduce the "the risk of transmission to patients and staff."

The policy further required that patients will be screened by clinical staff for bed bugs, lice, or scabies; and that "Patients may also report that they have bed bugs, lice, or scabies in their residence or on their belongings."

Review of medical records revealed that notwithstanding the policy, there was no documentation that screening was being conducted. Initial nursing admission notes in the MSU and ICU, for example, revealed the lack of screening for bed bugs, lice, or scabies as required by the policy.

While the policy also noted that patients may report presence of bed bugs, lice or scabies, nursing admission notes revealed that the information was not being elicited so that the patient would know that bed bugs, lice or scabies may be reported.

In an interview on 3/12/15, a licensed staff stated that screening for bed bugs, lice, and scabies was not being routinely conducted. The staff added that she did not know that the screening was part of the infection control policy.

Review of monthly rounding log from January 2014 through February 2015 revealed that while a a follow-up was made regarding a patient "who came in with Lice," and "having PHN (public health nurse) involved," there was no other indication that training and inservice of the policy and procedure on parasite" was provided. Further, the log did not provide any detail about what the follow-up entailed and whether training opportunities were identified and addressed.

During the initial tour on 3/09/12, a nurse management staff stated that several rooms in the MSU were being closed because of bed bug sightings in those rooms. The staff added that bed bugs were also observed in the ICU leading the temporary closure of the unit for steam cleaning on 3/07/15.

(Cross-refer to A749)

Based on observation, interview, and record review, the hospital's infection control officer (infection preventionist) did not develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases, including both healthcare community acquired infections.

Findings include:

1. During the initial hospital tour on 3/09/15 at 10:25 a.m., a nurse manager (NM1) with the surveyor stated that rooms 5 - 11 in the medical-surgical unit (MSU) were being temporarily closed for admission because of bed bugs observed in several of the rooms two days prior on 5/07/15. NM1 added that patients in the rooms were being placed on contact isolation to control the spread of the infestation. NM1 stated that the plan was to have the rooms steam-cleaned once patients in the affected rooms were either discharged or transferred to other non-infested rooms. NM1 added that the ICU had already been steam cleaned over the weekend (on 3/07/15) following earlier sightings of bed bugs there as well.

On 3/9/15 at 2:45 p.m., several of the rooms in MSU were observed to have signs posted outside the room that the patient inside was on contact isolation. Interview with a licensed nurse revealed that Rooms 5 to 11 needed pest control treatment because of bed bugs.

On 3/10/15 at 9:00 a.m., the director of nursing services (DNS) gave an update that MSU was open and that while the ICU had 3 patients, the plan was to close the unit at 3:00 p.m.

On 3/11/15 at 8:20 a.m. the DNS updated the survey team that ICU was closed and more bed bugs were found in the rooms and will be closed later that day.

On 3/11/15 at 9:30 a.m., during a tour of the MSU, Pediatrics and ICU areas revealed that MSU had 18 patient census including Pediatrics Unit while ICU remained closed.

On 3/11/15 at 9:40 a.m., interview with a licensed nurse (LN) in MSU was conducted regarding her knowledge of the bedbug timeline discovery in MSU.

The LN stated that the bedbug problem started last week (3/07/15) in Room 7 of MSU and escalated from thereon. Housekeeping staff notified her that one bed bug was also found in Room 11, a shared (2-bed) room. Thereafter, the only patient who occupied Room 11 was moved to another room while housekeeping steam cleaned the room. LN further stated that the bed bug problem kept escalating according to the night shift reports. She added that she off on Saturday and came to work on Sunday. ICU was closed on Saturday and all ICU patients were moved to MSU; and all patients were placed on isolation. On Monday 3/9/15, the night shift reported that bedbugs were found in rooms 9 and 10 and in the hallway outside room 10.

On that same morning the infection preventionist (ICP) and NM1 got together and decided to close some areas of MSU from Rooms 1 to 15.

On the same day, on 3/9/15 day shift, two patients needed to be discharged and were told to come back. The surgery of Patient 4 and 7, for example, were canceled and both were informed that they were being discharged and then readmitted once the rooms were steam cleaned.

Another patient on comfort care was discharged and instructed to return the following day. The discharge planner upon interview on 3/14/15 indicated that the patient's family was uncomfortable taking the patient home due to cultural beliefs related to dying at home.

The LN also revealed that the patients in MSU were discharged that day except the patient in Room 9 who was moved in Room 18. The night shift found a bedbug in Room 9. The LN stated that before moving the affected patient, the nurses made sure the patient was showered and hospital gown change. The patient's family was instructed to double bag the patient's personal items, wash them in hot water and dry them. Rooms 16 - 21 opened on Monday night with all pediatric patients except Room 18.

In the same interview, LN stated that she was off Tuesday (3/10/11) and came back to work on Wednesday 3/11/15. She recalled that ICP obtained an outside company exterminator to clean rooms 5 -15 last Monday (3/09/15). The exterminators started cleaning at 6:30 p.m.

On 3/11/15 at 9:30 a.m., ICU was observed closed. The MSU had 18 patients with two vacant beds: Rooms 6B and 7. The LN added that the night shift nursing staff found another bed bug in room 7 and therefore, there was no admission for that room.

On 3/11/15 at 10:00 a.m., the NM1 was interviewed. She stated that discovery of the bedbug started in ICU when Patient 30 told the staff that her family needed to be evacuated from home due to bedbug infestation. The first action taken by the hospital was to place all the patients in ICU on contact isolation. As of Saturday, 3/7/14, the rooms in ICU and the nurses bathroom had bed bugs. ICU had to be shut down. The exterminators came on Monday in MSU and Tuesday night (3/10/15) in ICU. Post fumigation, the area had to be closed for 4 hours. As of Wednesday (3//11/15), EVS decided to shut down ICU until 8:00 a.m. as housekeeping was steam cleaning again that morning. EVS was planning to open ICU by noon that Wednesday.

NM1 also stated that she did not keep track of the bed bug infestation as nursing staff reported the sightings to ICP. If the staff nurses observed a live bed bug, the nurse will collect the specimen, place it in a specimen cup, place the cup in a biohazard bag and give the specimen to the ICP nurse who then disposes the specimen in the biohazard trash disposal. She also indicated that she was not aware of any history of bedbug infestation in the facility.

Review of the hospital's infection control policy regarding "Parasite" revealed that its intent was "to ensure (that) appropriate screening, notification, and isolation precautions are followed for the treatment of bed bugs, lice, and scabies" and to "reduce the risk of transmission to patients and staff."

While one of the procedures in the policy required that patients will be screened by clinical staff for bed bugs, lice, or scabies, there was no documentation in the medical records that this was being conducted. Nursing admission notes in the MSU and ICU, for example, revealed the lack of screening as required by the policy.

Further, while the policy noted that "Patients may also report that they have bed bugs, lice, or scabies in their residence or on their belongings," there was no indication in the medical records reviewed that this information was being elicited or queried for so that the patient would know that the presence of bed bugs, lice, and scabies may be reported.

In an interview on 3/12/15, a licensed staff stated that screening for bed bugs, lice, and scabies was not routinely conducted. The staff added that she did not know that the screening was part of the infection control policy. Review of the Infection Preventionist Surveillance Time Allotment Policy revealed that medical and nursing staff, in collaboration with the nurse educator and outside resources "shall provide education for the hospital staff through the Infection Control Preventionist. " No evidence that training of staff regarding the bed bug screening policy was available.

During the survey, while the source patient was identified, there was no evidence that an investigation of the transmission of bed bugs from unit to unit and subsequently from room to room was conducted. There was no indication in Patient 30's medical record that MSU staff, for example, were informed of the incidence of bed bugs when this was identified in the ICU before or during Patient 30's transfer to the MSU.

Further, while contact isolation was in place, according to NM1 during the initial tour on 3/09/15, there was no documentation of any surveillance conducted as to how the transmission could have occurred. On 3/12/15 at 11:10 a.m., for example, a certified nurse aid was observed conducting accu-checks and entering affected rooms without the use of gowns (as required by the isolation protocol).

In several interviews, staff stated that bed bug infestation was endemic in the community served by the hospital. This notwithstanding, there was no indication that the infection control committee ensured that direct patient care staff were informed about the policy regarding the spread of the infestation, and/or that surveillance was conducted to ensure that these policies were followed. Review of the policy regarding the Authority of Infection Preventionist Committee (IPC) and Infection Preventionist revealed that the IPC "has the responsibility for monitoring the hospital-wide Infection Preventionist Program," and that the committee will recommend corrective action with the respective department. There was no documentation of any involvement or recommendations made by the committee or the medical director in the identification, prevention, surveillance, or control of the bed bug infestation.

2. Review of hospital records documenting infection control program activities revealed that surveillance was not being conducted hospital-wide.

Review of the hospital-wide policy and procedure regarding the Infection Preventionist Surveillance Plan (IPSP) revealed that the surveillance program "is an active, continuous, facility-wide ongoing program designed to identify critical infections and is used to implement control and prevention mechanisms." The IPSP also noted that surveillance "is priority-directed, targeted surveillance," and included surgical site infections, ICU patients, antibiotic resistance organisms, hospital acquired pneumonia, devise related infections, tuberculosis surveillance, and other sentinel events.

While the surveillance plan was described to be "facility-wide," there was no mention about surveillance in other hospital departments including the outpatient clinics, kitchen and dietary, housekeeping, and how staff in these departments, for example, complied with the hospital-wide infection control program.

For example:

a. There was no surveillance to ensure that contact isolation precautions were followed to control the spread of bed bug infestation (noted above). Since patients did not move from room to room, there was no evidence of any evaluation of staff compliance with contact isolation precautions, or whether interventions outlined in the hospital's policy on "Parasites" were being implemented correctly and effective.

b. There was no documentation of surveillance activities conducted regarding staff compliance with the hospital's infection control policies and procedures in other departments including the outpatient units, the Sanders Clinic and the emergency department.

c. Review of available infection control documents revealed that while surveillance was conducted regarding hospital staff compliance with hand hygiene (use of soap and water and waterless) protocols in the inpatient units for 2014, none was available for other units including the outpatients units, the Sanders Clinic, the kitchen and dietary, as well as the emergency department.

Inpatient hand hygiene data for 2014, revealed a high rate of non-compliance from between 20% - 45% for combined "Before and After Contact." In spite of this, there was no documentation of involvement by the infection preventionist committee (infection control committee) to determine the reasons for the low compliance rate. In addition there, was no documentation of recommendations made by the committee to help improve and maintain compliance.

d. During an interview on 3/12/15, an infection preventionist staff (ICP) stated that incidence data including ventilator associated pneumonia, C-section infections, blood stream infections, catheter-related urinary infections, and hand hygiene were being gathered. ICP explained that data was being collected in the laboratory and forwarded to her for compilation. When asked how the data was being used, ICP stated that while it was being presented to the committee, she did not know if there were discussions or actions taken even when some of the data did not meet benchmarks.

No documentation was available for review.

No data for 2015 was available for review.

3. While the hospital's Infection Preventionist Surveillance Time Allotment Policy required that the infection preventionist's time will be used "no less than thirty (30) hours per week" on surveillance, prevention, and control activities, there was no consideration of other duties and responsibilities assigned to the infection preventionist that could affect or prevent fulfillment of infection control responsibilities.

During an interview on 3/12/15, it was learned that ICP was also responsible for overseeing employee health services since September 2014 and that she spends half of her time on several tasks including ensuring employee and patient safety, providing immunizations and conducting tuberculosis testing on employees, education and training, and several others. In the same interview, ICP added that while some surveillance activities could be delegated, she however needed to provide ongoing supervision and guidance.

Because of her workload, ICP stated that while she would like to conduct surveillance activities on all departments focusing on processes and compliance with infection control practices by staff working in those departments, her time was drastically reduced. In the same interview, ICP added that she had spent a lot of time on hand hygiene surveillance, for example, and was disappointed that compliance rates remained low, particularly from direct care providers. While data had been elevated to the chain-of-command, ICP added that there had not been any effective measures undertaken to change behavior and improve performance. When documentation was requested evidencing support and assistance, including recommendations by the infection preventionist committee or by the medical director of the program, none was provided.

Based on record review and interview, the chief executive officer (CEO), the medical staff, and the director of nurses (DON) did not ensure that hospital-wide quality assessment and performance improvement (QAPI) and training programs addressed problems identified by the infection control officer.

Findings include:

1. While results of surveillance conducted for hand hygiene in the inpatient units for 2014 revealed low rates of compliance by direct care providers, there was no indication that the CEO or DON participated in efforts to increase compliance or made recommendations to correct identified deficiencies and improve performance.

In an interview on 3/12/15, ICP stated that she had spent significant time on hand hygiene surveillance involving direct patient care staff on the inpatient units and was disappointed that compliance rates were low. While ICP added that surveillance findings were elevated to the chain-of-command and discussed, there had not been any effective measures undertaken to change behavior and improve performance. Review of available records revealed the lack of documentation of any recommendations made by the infection preventionist committee, the medical director of the program, the CEO or the DON to address the problem of low compliance.

2. Review of nursing quality dashboard for 2014 revealed that incidence data including ventilator associated pneumonia, C-section infections, blood stream infections, catheter-related urinary infections, and hand hygiene were being gathered. During an interview on 3/12/15, ICP explained that data was being collected in the laboratory and forwarded to her for compilation. When asked how the data was being used, ICP stated that while it was being presented to the committee, she did not know if there was any discussion or actions undertaken even when some of the data did not meet benchmarks.

When asked if there were any minutes of any discussions made, none was made available.

3. While bed bug infestation was endemic in the community served by the hospital, there was no evidence of any CEO, DON or medical staff participation in ensuring that infection control policies were followed and implemented particularly in the screening of patients. Based on record review and interview, screening for bed bugs was not being conducted even as it was required by the hospital's infection control policy. The failure resulted in spread of the infestation affecting access to care as a result of the closure of several inpatient rooms, restrictions on admission, and the cancellation of scheduled surgical procedures.

4. There was no evidence that the job description of the infection preventionist was evaluated to ensure that she was able to fulfill the requirements and responsibilities of the position particularly regarding surveillance, prevention, and infection control. While the hospital's Infection Preventionist Surveillance Time Allotment Policy required to use "no less than thirty (30) hours per week" conducting these activities (surveillance, prevention, control), the addition of other responsibilities (employee health services) decreased the time allotted for infection control to half of her time (20 hours per week).

Review of monthly logs evidencing activities by the infection preventionist (ICP) for 2014 revealed that 17 monthly departmental rounds were conducted which included, among others, organizing policies online, reviewing cleaning schedules, answering questions from the various department and soliciting feedback, attending safety meetings, evaluating visitation policy; dissemination of information, Ebola inservice, and evaluating hygiene centers for the information desk.

In light of this, there was no indication that the workload of ICP was evaluated particularly in the lack of documented support from additional staff or from the medical director of the program (with regards to these activities). In an interview on 3/12/15, ICP added that she would like to conduct surveillance activities covering all of the hospital departments but the workload and lack of additional staffing support prevented her from doing so. ICP added that she given the additional responsibility for employee health service in September 2014. (Cross-refer to A749)

Based on record review and interview, the hospital did not provide discharge planning evaluation to its patients (A806); did not ensure that a registered nurse or a social worker developed and supervised the development of the discharge evaluation (A807); did not ensure that the results of the discharge planning was discussed with the patient or with an individual acting on behalf of the patient (A811); and did not ensure that discharge planning evaluations were included in the patient's medical record (A812). The cumulative effects of these systemic practices resulted in the hospital's failure to comply with the statutorily mandated requirements under Discharge Planning.

Based on record review and interview, the hospital did not provide discharge planning evaluation to its patients.

Findings include:

1. Review of medical records revealed that discharge planning screening was being conducted as part of the initial nursing admission. The screening process included entering "yes" or "no" responses to several data field queries (under current living arrangements) such as presence of stairs, inside running water, electricity, wood stove for cooking, wood stove for heating, availability of an outside toilet, and whether the patient had help at home.

In addition, several other data fields queried for other issues including ability for self-care; the need for shopping, cooking, home maintenance; safety issues; infection control needs, special equipment needs, and who will provide the patient transportation on discharge.

While all the data fields were completed with either yes or no responses, review of the medical records revealed the lack of documentation of any discharge planning evaluation or any ongoing evaluation to identify needs the patient may have that need to be addressed. In addtion, there was no determination made following the screening as to whether the patient need an initial evaluation (or not).

Review of the hospital's policy on inpatient discharge planning revealed that factors included in the initial assessment for discharge planning included medical condition, continuing care needs, assistance with activities of daily living, patient and family education, and assessment of patient or family wishes as appropriate.

Additionally, another factor for discharge planning included patients classified as "high risk" on admission such as frail elderly patients over 70 years and older; patients with home service needs or patients with ADL (activities of daily living) changes; patients without significant others to participate in discharge planning and other treatment questions; and patients needing help with community resources and transportation,

For example:

a. Patient 4 is a 74-year old female who was admitted to the hospital with several diagnoses including diabetes mellitus, foot cellulitis, and amputation of the 1st and 2nd toes of the right foot. Review of medical records revealed that the patient was alert and oriented, had limited range of motion, was a high risk for falls, had a surgical incision on the right foot following the amputation, and complained of pain discomfort.

Further review of the medical record revealed that while an initial discharge planning screening was completed on admission on 3/06/15 and noted that the patient was unable to care for herself (under present conditions) and needed help for chores and home maintenance, there was no indication that a discharge planning assessment was conducted to determine Patient 4's needs and ensure that arrangements could be made in a timely manner to address them. There was no documentation of attempts made to identify a capable caregiver, for example, how wound care was to be provided, and how her risk for falls was to be addressed particularly in light of the toe amputations which may affect her ability to balance and transfer.

Review of the medical record revealed that on 3/09/15, Patient 4 was discharged from the hospital. A nurse progress note that the patient's surgery was being canceled because of the "unit is being closed" (due to bed bug infestation).

b. Patient 5 is a 66-year old female who was admitted to the hospital's intensive care unit (ICU) on 3/05/15 with several diagnoses including congestive heart failure, diabetes mellitus, and pneumonia. Review of the medical record revealed that Patient 5 on admission, was alert, oriented, had exertional shortness of breath, and required oxygen inhalation.

Further record review revealed a discharge planning screening (on admission on 3/05/15) that based on information gathered from several of the data fields completed that "a consult should be completed for: Public Health Nurse."

There was no documentation in the medical record that the need for a public health nurse was evaluated, considered, or followed-through. In addition, there was no documentation of any other discharge planning activities including ongoing evaluation or any referrals if needed.

c. Patient 7 is a 67-year old who was admitted to the hospital on 3/06/15 with several diagnoses including diabetes mellitus, hypertension, right foot cellulitis, and dry gangrene. The medical record revealed that the patient was alert and oriented, had a wound on the 5th digit of the right foot that was black in color, and was independent with activities of daily living.

Further record review revealed that Patient 7 had other chronic problems including right patellar fracture, right leg length discrepancy, gangrene of the foot, and chronic kidney disease.

On 3/10/15, the medical record noted that the patient had undergone midshaft removal of the 5th metatarsal with skin revision. While the patient was not identified as a fall risk on admission, a referral was made to physical therapy on 3/11/15 for gait training and fall risk assessment.

Further record review revealed a physician progress note dated 3/12/15 describing necrotic tissues around the incision line and the plantar aspect of the foot and that because the tissues were necrotic, that more surgical intervention was needed. The same note added that due to her kidney problem, the patient might benefit from a "facility where they have a nephrologist ..."

While a discharge planning screen was completed on admission (on 3/06/15), there was no evidence of any other discharge planning assessment or evaluation in the medical record to identify discharge needs so that arrangements or referrals, if needed, could be made timely. There was no identification of a capable caregiver with verifiable competence to provide wound care asistance for, example, or attempts made to identify a nephrologist or a facility to provide further care and management for her chronic kidney disease.

During an interview on 3/12/15, the discharge planning coordinator (DPC1) stated that the hospital's discharge planning committee was interdisciplinary and included registered nurses on the inpatient units as well as the social worker. DPC1 added that the committee met three times weekly (Monday, Wednesday, Friday) and discussed patient care issues including diabetic care, rehab, and referrals (to the social workers, other professionals/agencies). DPC1 also stated that ICU rounds were conducted on new admissions and that she had oversight of the meetings.

Review of medical records however revealed the lack of documentation specific to the development and supervision of discharge planning evaluations and ongoing evaluations; care issues identified and addressed; and interventions, recommendations, and/or referrals being made. In addition, there was no documentation of attendance and whether the patient or patient's responsible party was involved or participated in any evaluation or assessment.

In the same interview, DPC1 stated that the meetings discussed all scheduled patients and that minutes and attendance were not always recorded. DPC1 added that discussions involving discharge evaluation of a specific patient was not always noted in the medical record as an individual had not been specifically designated. In the same interview, DPC1 stated that in addition to coordinating discharge planning acitivites, her other duties included utilization review where 60% of her full time hours were being used.

Because of an average length of inpatient stay of 5 days, DPC1 added that discharge planning was a high volume activity. In light of the length of inpatient stay, discharge planning evaluations, if not conducted early, can result to needs that might not be thoroughly identified. Consequently, interventions or arrangements to address these needs might not be made timely before the patient is discharged.



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2. Patient 30 is an 82-year old female who was admitted to the hospital's intensive care unit (ICU) on 3/02/15 with an admitting diagnosis of status post right hemicolectomy (surgical removal of the right or left side of the colon). A history note from the surgical clinic dated 2/23/15 revealed a large colonic mass in the ascending colon confirmed during a computed tomography (CT) scan. The operative report dated 3/02/15 revealed a pre and post-operative diagnosis of right adenocarcinoma of the colon.


The nursing admission assessment dated 3/02/15 revealed an initial discharge planning screening. From the questions posed, the patient's daughter answered "No" for the presence of special equipment and infection control needs.


Review of the daily progress notes revealed the patient was alert, oriented x 3 and cooperative. The functional assessments on 3/02/15 and 3/03/15, revealed the patient needed assistance with activities of daily living such as basic hygiene, dressing, elimination/urine, and transfers.

a. Review of the inpatient surgical progress notes dated 3/04/15 revealed the patient's post operative diagnosis was status post right sided hemicolectomy with ileo-colic anastomosis. The progress notes also indicated the patient was started on tube feeding to enhance nutrition, as the albumin level went down to 2.0 and oral intake was not enough; continue full liquid diet by mouth as well; intravenous antibiotics; insulin sliding scale, oxygen 3 liters per nasal cannula for 48 hours to enhance anastomotic success; and two (2) units of packed red blood cells (PRBC) which were transfused secondary to chronic anemia. The plan for discharge was noted for Saturday (3/07/15) or Sunday (3/08/15).

On 3/03/15 a dietary consult was made for patient's tube feeding. The hospital's registered dietitian (RD1) conducted an initial assessment on 3/03/15 and placed Patient 30 on nutritional care/risk level IV which was considered high risk. The nutritional support recommendations included continuous feeding of Promote with Fiber. This formula was recommended due to its lower osmolality (380) for better tolerability as a tube feeding formula than Ensure at (680). Also it had 3.4 grams of Fiber per 8 ounces to help moderate bowel function while Ensure plus has zero fiber. A goal rate of 60 ml/hr was made so that the patient will be receiving 1440 kilocalories, 89 gms. Protein, and 1195 ml of water from the formula. The rest of the calories were to be provided by clear liquid diet. The diet order at that time was clear liquid. The documented diet problem history related to diarrhea/constipation was "some loose stool." The biochemical data revealed a glucose level of 200 on 3/03/15.

The nutritional diagnosis was increased protein needs related to healing as evidenced by status post hemicolectomy. The clinical goals include: adequate nutrition intake to meet needs: >80%; prevent malnutrition and wound healing.

The inpatient surgical progress notes dated 3/05/15 revealed the feeding tube was removed and will start on clear liquids only by mouth as prescribed in the diet order.

Review of the inpatient nursing care plan dated 3/05/15 revealed a nursing diagnosis of "impaired glucose metabolism." The goal formulated was to maintain a consistent blood glucose level. Interventions include: monitor blood glucose level as ordered; monitor labs; consult dietitian; and consult DM (diabetes mellitus) education.

Review of the inpatient nursing discharge note dated 3/07/15 revealed the patient was discharged home on 3/7/15. The document revealed that discharge education was given on the following: "illness treatment" and "nutrition intervention."

On 3/12/15 at 11:40 a.m., interview with the hospital's RD1 revealed that at the time of discharge, Patient 30's primary physician who was the surgeon and the surgical team were not present because it was a Saturday (3/07/15). She also stated that they could have coordinated the patient's next outpatient surgical clinic visit with a dietary consult and diabetic program education. Also, interview with the DPC1 on 3/12/15 at 9:30 a.m. confirmed that there was no documentation in Patient 30's medical record to show that there was a consult arranged for diabetes mellitus (DM) education program post discharge.


b. On 3/11/15 at 10:00 a.m., the multi-service unit/intensive care unit (MSU/ICU) supervisor (NM1) was interviewed. She stated that discovery of bed bugs in the facility started in intensive care unit (ICU) when Patient 30 told the staff that her family needed to be evacuated from home due to bedbug infestation. A review of the multidisciplinary progress notes showed no evidence in the patient's medical record that an initial screening for bedbugs was conducted.

The inpatient nursing transfer out of unit (from ICU to MSU) progress notes dated 3/06/15 revealed an assessment of the wound site as midline incision site that was reddish in color with no odor or drainage. The patient's skin integrity assessment dated 3/07/15 revealed the patient's skin was warm, dry, intact without breakdown. The skin assessment was limited to the post-operative incision site and dressing.

On 3/07/15, the nursing progress notes revealed the patient's daughter helping the patient pack her belongings to go home. There was no documented evidence that teachings related to infection control with bedbugs infestation was discussed with the patient and family members.

Further, there was no documented evidence of an evaluation of the discharge plan for Patient 30 related to nutritional status and infection control.

3. Patient 32 is an 89-year old female who was admitted to the emergency department (ED) on 3/10/15 with a chief complaint of nausea. The patient reported that she started to have garbled speech and numbness in the left side of the face and extremities and later developed headache. Patient denied any chest pain or shortness of breath. The patient's past medical history revealed chronic problems including acute thrombotic stroke, hypothyroidism, and recurrent transient ischemic attack (TIA). The admitting diagnosis was acute neurologic deficits.

The computed tomography (CT) scan of the head findings dated 3/10/15 revealed a small right frontal chronic infarction that was stable. There was no significant interval change compared to prior study. The physician's assessment/plan indicated an "acute neurologic deficit" was likely as the TIA was is improving. The assessment further noted that the patient had past therapeutic window in which tissue plasminogen activator (TPA - a protein involved in the breakdown of blood clots) would be useful, and the patient had refused TPA in the past. The physician ordered for the patient to be admitted for observation and monitoring. The patient's hearing loss in the right ear and vertigo were due to her previous cerebrovascular accident (CVA) or stroke.

The initial nursing assessment in MSU dated 3/11/15 revealed a discharge planning default questionnaire indicating that the patient will not be able to care for self at home; that she needed help with shopping, cooking, home maintenance and ambulating; had safety needs; had infection control needs; and needed special equipment. Transportation at the time of discharge was to be provided by the patient's son who lived with her.

Review of the progress notes dated 3/11/15 at 12:07 p.m. revealed that the patient stated she had difficulty in swallowing, however, she swallowed and tolerated morning oral medications without any event. On the same day, the physician ordered, "can have water/clears without thickener under observation. Nurses use your judgement." Prior to this physician's order, the patient had another which noted that she needed to have a diet of "pureed to consistency of nectar," and "Feedings and chin down position under observation."

Interview with the RD1 on 3/13/14 revealed that there was no nutritional consult done. Also the patient was not assessed by a speech therapist because the hospital does not have one.

Review of the social services progress notes dated 3/11/15 at 3:07 p.m. revealed a subjective/history involving a bedside visit with patient's son who was present regarding discharge planning. Patient shared that she lived with her son in her home. The patient declined short term skilled nursing home (SNF) saying that her son was available to help her and the son agreed. The patient has had numerous falling incidents, one recently where she fell backwards, hitting the back of her head. She required full assistance with activities of daily living. A discussion was also held about code status where the patient stated that she wanted to be resuscitated, saying " I still have a lot of unfinish (sic) business." The care plan noted, "desires to return to own home, refused temporary out of home care. Son (name) available to provide care/support 24/7 ...No dispositional concerns." The Decisions/Assessment/Plan included plan for long term care, wheelchair script - hand delivered to Purchased/Referred Care, and home when medically cleared.

Review of the Rehab Consultation Sheet dated 3/11/15 revealed the reason for the request was TIA (transient ischemic attack) - to evaluate ambulatory safety. The patient was assessed with good rehab potential. The assessment revealed that the patient was status post TIA and presented with overall weakness and deconditioning. The patient was also noted to have a wheelchair at home which she uses for ambulation pushing the wheelchair safely. The patient was independent with bed mobility, required assistance for transfers. Physical therapist recommended outpatient physical therapy (PT) to address impairments.

This was not evident in the nursing and social service discharge documentation.

4. Patient 10 is a 52-year old female who was admitted to the facility on 3/06/15 with admitting diagnosis of left ankle cellulitis. The patient was noted to have a large, approximately 4.5 cm in diameter, unopen wound on the left lateral ankle, which was reddish/purple in color with the appearance of an abscess. The surrounding tissue was red and edematous, and very tender to touch. The patient was also described as complaining of pain with an intensity level of 8/10 (10 the most severe) in the ankle, and stated that the Percocet and Morphine she received in the clinic did not help her.

Review of the operative report dated 3/07/15 revealed the patient was admitted on 3/6/15 for painful infected abscess on the lateral aspect of her left ankle. She was admitted to MSU for intravenous (IV) antibiotics and surgical intervention of the abscess. The operative report revealed that after the incision was made over the abscess, there was pus coming out on the left and right side of the abscess. Aerobic and anaerobic culture and sensitivity of the wound drainage was done. The patient tolerated the surgical procedure (incision and drainage of abscess) without complications.

Review of the inpatient nursing discharge form dated 3/09/15 revealed the patient was discharged home accompanied by spouse and that a discharge instruction sheet was provided to the patient. Discharge information included wound care instructions, dressing supplies including wet to dry dressing change instructions were provided by the nurse. The patient also received medications from pharmacy.

Review of the nursing progress notes dated 3/07/15 revealed that Patient 10 was a new diabetic. A plan of care dated 3/06/15 revealed a nursing diagnosis of "impaired glucose metabolism related to diabetes mellitus (DM). The interventions include: monitor blood glucose levels as ordered; monitor labs; consult dietician and consult DM Education. "

Review of the patient's laboratory results dated 3/6/15 revealed an estimated average glucose of 246 mg/dl. which was elevated. The reference range was 39-126mg/dl.

Also the hemoglobin A1C (a blood test that provides an index of average level of blood sugar over the past 2-3 months) result was 10.2% which was elevated. The reference range was 3.0 - 6.0%.

In an interview with RD1 on 3/13/15 at 11:40 a.m. she revealed that there was no nutritional consultation ordered for Patient 10. She also indicated that a laboratory result of 10.2% for A1C was a good index for nutritional referral to the dietitian and that such referral will also benefit the patient's wound healing. The dietitian also confirmed that there was no documented evidence in the discharge plan that a referral was done to the outpatient DM education program or referral the outpatient dietitian.


7. Patient 14 is a 5-month old male who was admitted to the hospital on 3/07/15 with diagnosis of respiratory syncytial virus (RSV)--a respiratory virus that infects the lungs and breathing passages) bronchiolitis (inflammation of the small airways in the lungs). The patient upon admission to the emergency department (ED) was accompanied by the mother who stated the patient was born in Chinle, one month early, and was sent to Flagstaff neonatal intensive care unit (NICU) for one week after birth. The patient presented with symptoms of increasing cough, congestion, and decreased oral intake for the past 2 days. The patient was febrile with a temperature of 101.1 degrees Fahrenheit; was fussy, irritable, coughing and slightly tachypneic (abnormally fast breathing). The patient was thought to be dehydrated on admission as indicated by his tachycardia (rapid pulse rate). He was placed on maintenance fluids.

On 3/09/15 at 2:45 p.m., during the initial tour of the facility, an interview with Patient 14's mother revealed that they will be going home that day. She stated that she brought her child in this facility because she did not like the delay in getting emergency services in Chinle hospital although it was closer to home. She was hoping that her child will not get sick again and she will not have to bring her child to that hospital especially when her child was having difficulty in breathing from the coughing.

The initial admission nursing assessment dated 3/07/15 related to discharge planning revealed information about the patient's current living arrangements that included a dwelling with the absence of inside running water and electricity; the use of wood stove for cooking and heating and requiring help at home. The additional questions indicated the patient has safety needs, however, the patient was not assessed for infection control needs.

The discharge summary dated 3/09/15 revealed the patient was positive for RSV and negative for Flu A/B. The patient's history and physical dated 3/07/15 revealed a birth history that Patient 14 is a 34-weeker and stayed one week in a Flagstaff NICU and discharged on oxygen for 2 weeks. The patient was admitted at 3 months for influenza/hydration in Chinle. The patient's immunization status for the following were all past due: Hep B; DTap; PCV-13; and Polio.

Follow-up plans included patient follow-up in 2 days and that the mother intends to schedule this with principal care physician (PCP) in Chinle. There was no documented evidence in the discharge plan related to educating the mother on maintaining fluids to prevent dehydration; increase the patient's defense against repeated infections such as bronchiolitis and pneumonia and encouraging the patient's mother to update the child's immunization status.

8. Patient 11 is a 5-month old female who was admitted to the facility on 3/08/15 with admitting diagnosis of RSV bronchiolitis. The patient's family member stated the reason for hospital stay was cough and irritated nose for about a week with no improvement. The discharge planning default questions were answered by patient's mother to indicate the patient does not have any infection control needs. The inpatient nursing care plan dated 3/08/15 revealed an admitting diagnosis of RSV bronchiolitis and a nursing diagnosis of infection related to current diagnosis. The interventions included: "appropriate precautions" and "monitor patient (pt) for signs/symptoms of infection." These interventions were not clear and specific in helping the patient's parents/caregivers to implement preventative care to avoid the recurrence of the respiratory infection. (Reference Patients 1 - 32)

Based on record review and interview, the hospital did not ensure that a registered nurse or a social worker developed and supervised the development of the discharge evaluation.

Findings include:

Review of medical records revealed that while discharge planning screening was being completed as part of the initial nursing evaluation, there was no documentation in the electronic records that the registered nurse or the social worker evaluated the discharge evaluation.

The medical record of Patient 4, for example, revealed that she is a 74-year old female who was admitted to the hospital on 3/06/15 with several diagnoses including foot cellulitis, and amputation of the 1st and 2nd toes of the right foot. Review of the record revealed that discharge planning screening during the initial nursing assessment on 3/06/15 included entering "yes" or "no" to several data field queries (under current living arrangements) such as presence of stairs, inside running water, electricity, wood stove for cooking, wood stove for heating, availability of an outside toilet, and whether the patient had help at home.

In addition, several other data fields queried for other issues including ability for self-care; the need for shopping, cooking, home maintenance; safety issues; infection control needs, special equipment needs, and who will provide the patient transportation on discharge.

While all the data fields were completed (with either yes or no responses), review of the medical record revealed the lack of documentation of further discharge planning activities including baseline functional abilities, cognitive ability, and primary caregiver support. In addition, following completion of the screening, there was no documentation being made if a discharge evaluation was to be completed based on the results of the screening.

Interview with the DCP1 on 3/12/15 at 9:30 a.m. confirmed that the initial discharge planning screening was very limited and no other documentation was present in the record until the day of the discharge.

Without documentation, determining whether the registered nurse or social worker developed and supervised the initial discharge planning screening or evaluation could not be made. (Reference Patients 1 - 32)

Based on record review and interview, the hospital did not ensure that the results of the discharge planning was discussed with the patient or with an individual acting on behalf of the patient.

Finding includes:

Review of medical records revealed the lack of documentation that the result of discharge planning screening and/or evaluations were discussed with the patient or the patient's representative. (Reference Patients 1 - 32)

Based on record review and interview, the hospital did not ensure that discharge planning evaluations were included in the patient's medical record.

Finding includes:

Review of medical records revealed the lack of documentation of discharge planning activities. Records reviewed revealed the lack of documentation specific to the development and supervision of discharge planning evaluations and ongoing evaluations; care issues identified and addressed; and interventions, recommendations, and/or referrals being made. In addition, there was no documentation of attendance and whether the patient or patient's responsible party was involved or participated in any evaluation or assessment.

During an interview on 3/12/15, the discharge planning coordinator (DPC1) stated that the discharge planning committee met three times weekly (Monday, Wednesday, Friday) and discussed patient care issues including diabetic care, rehab, and referrals (to the social workers, other professionals/agencies). DPC1 also stated that ICU rounds were conducted on new admissions and that she had oversight of the meetings.

In the same interview, however, DPC1 added that meeting minutes and attendance during the meetings were not always recorded or transcribed into the medical record of each patient whose discharge planning was being discussed. DPC1 added that this was because an individual responsible for this had not been specifically designated.

Because of an average length of inpatient stay of 5 days, DPC1 added that discharge planning was a high volume activity and that while she uses 40% of her time (on discharge planning), the remaining 60% was allocated for utilization review responsibilities. (Reference Patients 1 - 32)

Based on interview and record review, the hospital failed to ensure that anesthesia services were provided under the direction of a qualified doctor of medicine or osteopathy. Failing to provide anesthesia services under the direction of a qualified doctor can potentially lead to quality of anesthesia care concerns. The cumulative effects of these systemic practices resulted in the hospital's failure to comply with the statutorily mandated requirements under Anesthesia Services.

Finding includes:

On 3/09/15 during spontaneous interviews with the nurse manager (NM2) of the surgical service and the lead certified registered nurse anesthetist (CRNA1), they reported the director of the surgical department was also the director of anesthesia services.

On 3/11/15 the credential file of the director of surgical services (DSS) was reviewed and the file did not contain documentation or language identifying the DSS as having specialized knowledge, skills, training, experience, or certification on the administration, direction or supervision of anesthesia services.

On 3/12/15, during separate interviews with DSS and the chief medical officer (CMO), it was acknowledged that the credential file of DSS did not have documents or language specific to knowledge, skills, training, experiences or certifications on the administration, direction or supervision of anesthesia services. During further interview with both CRNA1 and DSS 3/12/15 regarding quality assessment and process improvement projects (QAPI), it was acknowledged that the reports to the quality services department (QSD) from anesthesia services had been and was lacking from part of 2014 to 3/12/15.

Based on interview and document review, the hospital failed to demonstrate that the anesthesia service was administered under appropriate supervision of each operating practitioner or by an anesthesiologist who was immediately available if needed. Failure to provide anesthesia services under the direction of a qualified doctor can lead to potential quality of anesthesia care concerns.

Finding includes:

On 3/11/15 the credential file of the director of surgical services (DSS) was reviewed and the file did not contain documentation or language identifying the DSS as having specialized knowledge, skills, training, experience or certification on the administration, direction or supervision of anesthesia services.

On 3/12/15 during separate interviews with DSS and the chief medical officer (CMO) it was acknowledged that the credential file DSD did not have documents or language specific to knowledge, skills, training, experience or certification on the administration, direction or supervision of anesthesia services. During further interview with the CMO, it was also acknowledged that there were no provisions within the current regulatory language which allowed for a non state (the Navajo Nation) to opt-out of the current physician supervision requirements that would allow the hospital to permit a nurse anesthetist to administer anesthesia without operating practitioner or anesthesiologist supervision.

Based on record review and interview, the hospital did not ensure that a registered nurse or a social worker developed and supervised the development of the discharge evaluation.

Findings include:

Review of medical records revealed that while discharge planning screening was being completed as part of the initial nursing evaluation, there was no documentation in the electronic records that the registered nurse or the social worker evaluated the discharge evaluation.

The medical record of Patient 4, for example, revealed that she is a 74-year old female who was admitted to the hospital on 3/06/15 with several diagnoses including foot cellulitis, and amputation of the 1st and 2nd toes of the right foot. Review of the record revealed that discharge planning screening during the initial nursing assessment on 3/06/15 included entering "yes" or "no" to several data field queries (under current living arrangements) such as presence of stairs, inside running water, electricity, wood stove for cooking, wood stove for heating, availability of an outside toilet, and whether the patient had help at home.

In addition, several other data fields queried for other issues including ability for self-care; the need for shopping, cooking, home maintenance; safety issues; infection control needs, special equipment needs, and who will provide the patient transportation on discharge.

While all the data fields were completed (with either yes or no responses), review of the medical record revealed the lack of documentation of further discharge planning activities including baseline functional abilities, cognitive ability, and primary caregiver support. In addition, following completion of the screening, there was no documentation being made if a discharge evaluation was to be completed based on the results of the screening.

Interview with the DCP1 on 3/12/15 at 9:30 a.m. confirmed that the initial discharge planning screening was very limited and no other documentation was present in the record until the day of the discharge.

Without documentation, determining whether the registered nurse or social worker developed and supervised the initial discharge planning screening or evaluation could not be made. (Reference Patients 1 - 32)