HospitalInspections.org

Based on interview, observation, review of crash cart checklist documentation for 3 of 3 emergency crash carts, and policy review, it was determined the hospital failed to develop a crash cart policy or routinely document that its emergency crash carts were maintained to ensure the integrity and availability of the contents of the crash carts.

Findings include:

1. A request was made for the Emergency Crash Cart policy during the first day of the survey. On 08/08/2013 a PeaceHealth Oregon Region policy titled "Crash Cart Medication Restocking," was provided. The SCOPE was identified as SHMC [Sacred Heart Medical Center]. The policy was developed for a crash cart exchange system. However, the policy lacked instruction for a registered nurse (RN) to replace used medications and supplies per the hospital's current process. I1 was asked to clarify the usage of the policy and he/she stated on 08/09/2013 at approximately 1100 that a Crash Cart policy for this facility did not exist.

2. A tour of the emergency department (ED) was conducted with I1, Director of Nursing, on 08/07/2013 at 1500. During the tour, observations of the emergency adult and pediatric crash carts were conducted. Each of the carts had a corresponding monthly checklist titled, "CGCH ED Room 1 CRASH CART" and "CGCH ED Room 2 CRASH CART." The checklists included columns for "DATE," "TIME," "Monitor Dc," "Blade Lights," "Defib Pads," "Defib Cord," "Ambu Bags," "Mondays Op Check," "Monday Cart Contents Check." and a column with a handwritten title of "Lock #" for the breakaway "padlock" number of the medication storage area within the crash cart. The hospital neglected to provide specific instructions for checking the contents of each cart and documenting the findings.

The ED crash cart checklist was reviewed. It was noted that the ED staff conducted a crash cart review twice a day. Review of the ED Room 1 CRASH CART monthly checklists for 01/2013, 02/2013, 03/2013, 04/2013, 05/2013, and 06/2013 identified that many crash cart checks were not conducted and initialed by the RNs who completed the crash cart checks. For example, no checks were documented for the following dates/shifts: 01/01/2013, PM shift; 01/24/2013, AM shift; and 01/29/2013, AM shift.

Similar findings were identified during review of ED Room 2 CRASH CART checklists for the months of 01/2013, 02/2013, 03/2013, 04/2013, 05/2013, and 06/2013.

3. The Medical Unit crash cart checklists were reviewed during a tour of the medical unit on 08/07/2013 at 1320. It was noted that the medical unit conducted a daily crash cart check. The "CRASH CART CHECKLIST" lacked instructions on how often the crash cart checks were to be conducted. Review of the Medical Unit "CRASH CART CHECKLIST" reflected that the checklist columns were labeled as "Check outdates," "Break Away Lock #," "Operational Check on Wednesday," "Defib & Battery Check," "Ambu bag & (mask) present," "Defib Pads," "Laryngoscope Blade Checks," and "Signature & EMR #." The medical unit crash cart checklist also neglected to provide instructions for daily monitoring and documenting of the contents of each cart.

A review of the checklist for 03/2013 lacked documentation that the crash cart medication outdates were checked on a daily basis. Similar findings were noted for 05/2013, 06/2013, 07/2013, and for the first week of 08/2013.

4. These findings were reviewed with I1 on 08/08/2013. He/she stated that the medical unit nursing staff were responsible for conducting the crash cart review and signing the checklists each day but the ED nursing staff conducted a review of the crash cart and signed the checklists every 12-hours. I1 acknowledged that the checklists lacked complete and thorough documentation. He/she also stated that the hospital did not have a policy that provided guidance for when and how often the staff were to monitor, document and replace supplies.

Based on observation, interview, and documentation review it was determined that the hospital failed to ensure its policies included a complete system for identifying and controlling infections of patients. The hospital failed to ensure policies were developed and implemented to address cleaning reusable instruments that were used during patient procedures; and failed to ensure surveillance activities for identifying potential sources of infection were conducted in accordance with the hospital's infection control plan.

Findings included:

A. An observation of the soiled utility room located between the hospital's medical unit and ED was conducted on 08/08/2013 at 0930. The room had a sink with an attached countertop. The countertop was adjacent to a hopper (a fixture containing water used for disposing/flushing waste).

An interview was conducted with I8 on 08/08/2013 at approximately 0915. He/she stated that contaminated reusable instruments (such as suture packs), were pre-cleaned in the soiled utility room prior to being sterilized. Instruments used in the hospital's clinic were pre-cleaned using a similar process in the "decontam" area (soiled utility room) in the clinic.

An interview was conducted with I9 on 08/08/2013 at approximately 0930. He/she described the instrument workflow and process he/she followed to decontaminate/pre-clean instruments used in the ED. He/she stated that instruments were placed in a basin inside the sink in the soiled utility room, where they were soaked in a cleaning solution. The instruments were placed on the countertop (on a rack) between the sink and the hopper to air dry after they were cleaned. There was no physical barrier separating the countertop where the cleaned instruments were placed to dry and the adjacent hopper, in order to prevent splashing from the hopper onto the instruments.

An interview was conducted with I6 on 08/08/2013 at 1135. He/she acknowledged the hopper was used for emptying urinals and was located right next to the countertop where instruments were placed to air dry after they were cleaned.

During an interview with I9 on 08/09/2013 at 1225, he/she stated that the hopper was used for disposal of bodily waste such as stool, urine, and emesis and acknowledged that the contents of the hopper sometimes splashed from the hopper when it was used.

During a tour of the soiled utility room on 08/09/2013 at 1230, it was observed that a plexi-glass barrier had been installed between the hopper and the countertop, which was not present during previous observations.

The "Cottage Grove Community Hospital, PeaceHealth Infection Control Plan 2012," was reviewed and reflected the following internal requirements: "8. Policy Drafting and Review...Implementing and monitoring the effectiveness of policies and procedures to prevent HAIs [Healthcare Associated Infections] and occupational exposures in compliance with professional standards and state/federal regulations will be regularly performed...Peace Health Oregon Region (PHOR) infection control policies and procedures will be based on evidence-based infection control research...PHOR policies and procedures are reviewed and revised as needed...Review and revision of PHOR Infection Prevention & Control policies and procedures are the responsibility of the Infection Preventionists and ICC as needed, with input from affected hospital areas...Review and revision of non-IP policies and procedures that have an infection component are the responsibility of the respective hospital care areas (environment of care, etc.) with review and/or input of the Infection Preventionist." During an interview with I3 on 08/09/2013 at 1020, he/she stated the 2012 infection control plan was the approved plan for 2013.

Instructions for cleaning contaminated instruments were observed posted in the hospital's soiled utility room on 08/08/2013 at 0930. Review of the (undated) instructions titled "Instrument Cleaning" reflected "3. Place instruments into 'soaking tub' into which 2 pumps of Manu-Klenz per 1/2 gallon of water have been added. 4. Instruments should be allowed to soak for at least 30 minutes. They should then be scrubbed again under running water, rinsed, and placed out to air dry prior to being sent to central sterilizing."

An interview with I3 and I7 was conducted on 8/26/2013 at 1030. I7 verified that the solution used to pre-soak instruments in the soiled utility rooms located in the hospital and the clinic was V. Mueller Instrument Enzymatic-Four Enzyme, and not the Manu-Klenz reflected in the posted instructions identified above. I3 indicated it was expected that sterile processing procedures would reflect the most current AAMI (Association for the Advancement of Medical Instrumentation) guidelines. He/she further indicated that infection prevention staff (in collaboration with nursing staff) were responsible for developing policies for instrument pre-cleaning and workflow, and acknowledged there were no written policies developed for those processes. Therefore, policies were not developed, reviewed and revised in accordance with the hospital's 2012 Infection Control plan, and as required by this regulation.

Review of the 2012 ANSI/AAMI "Comprehensive guide to steam sterilization and sterility assurance in health care facilities, Amendment 3" reflected "7.2.1...Policies and procedures should be developed for all methods of decontamination of reusable items. Process audits to monitor compliance with the various policies and procedures should be performed on a scheduled basis, with appropriate follow-up addressing problems...Policies and procedures provide guidelines for maintaining control and determining methods of improving processes..." Policies were not developed for decontamination processes of reusable instruments, in accordance with AAMI guidelines as expected.

B. Review of the "Cottage Grove Community Hospital, PeaceHealth Infection Control Plan 2012," was reviewed and required the following internal surveillance activities: "4. Environment of Care. a. There will be Infection and Control rounds in the hospital at least once a week or more frequently if needed. Weekly rounds will be initiated with the Medical floor Nurse manager and a log will be kept."

An interview was conducted with I6 on 08/08/2013 at 1100. He/she was asked to provide the weekly infection control rounds log. He/she revealed that there had been a turnover in staff "in June," and no weekly infection control rounds had been conducted since the staff turnover occurred. He/she was unable to provide any infection control rounds log documentation.

Based on interview and review of policies and procedures it was determined that the hospital failed to have a system in place to annually review patient care policies by a professional group per this regulation.

Findings include:

1. During the CAH recertification survey, it was determined that many policies were not reviewed or revised on an annual basis per this regulation. Listed below is a sample of hospital patient care policies that have not been reviewed for more than a year:

-PeaceHealth System-Wide policy titled, "Accountability for Event Reporting," last reviewed 12/09/2010;
-Peace Health Cottage Grove policy titled, "Administration of a Significant Procedure (Medication) Without Informed Consent on an Emergency Basis," last reviewed 03/08/2012;
-Peace Health Cottage Grove policy titled, "Informed Consent for Invasive Procedure Process," last reviewed 06/27/2012;
-Peace Health Cottage Grove policy titled, "Management of OB Patient in the ED," last reviewed 05/04/2012;
-Peace Health Cottage Grove policy titled, "Mental Health Transport/Custody Hold," last reviewed 03/05/2012;
-Peace Health Oregon Region policy titled, "Patient Rights and Responsibilities, Statement of," last reviewed 03/01/2010;
-Peace Health Cottage Grove Region policy titled, "Patient Transfers," last reviewed 04/20/2012;
-Peace Health Cottage Grove Region policy titled, "Rules for Consent," last reviewed 05/13/2010; and
-PeaceHealth System-Wide policy titled, "Sentinel Event Reporting;" last reviewed 03/30/2011.

2. During an interview with I3, the Planned Care and Quality Manager, on 08/07/2013 at 1200, he/she confirmed that many of the patient care policies and procedures were not reviewed annually.

Based on documentation in 13 of 18 clinical records reviewed (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 14, 17, and 18) it was determined that the hospital failed to ensure that all clinical entries in the medical records were dated and timed, and/or authenticated in accordance with the hospital's own requirements.

Findings include:

1. The CAH Medical Staff "Rules and Regulations" reflect on page 5 "IV. MEDICAL RECORDS...PREPARATION...b. Documentation: (1) All clinical entries in the medical record shall include the time and date of entry and must be authenticated [b]y signature of the practitioner who entered the information."

2. Record # 1 contained a form titled "Cottage Grove Community Hospital Conditions of Admission and Consent Form" which had a line for the Patient/Parent/ Conservator/Guardian /Agent to sign and a line labeled "Date" that was signed and dated, but not timed per hospital Medical Staff Rules and Regulations.

Record # 2 contained a form titled "Cottage Grove Community Hospital Conditions of Admission and Consent Form" which had a line for the patient to sign and a line labeled "Date" that was signed and dated but not timed.

This same chart contained a pre-printed form titled "EMERGENCY DEPARTMENT TRIAGE FORM" which contained a line labeled "MD Signature." The form also had a section designed for "Orders" that the provider used to order standard ED patient orders. The provider checked off several orders and wrote patient specific orders also. The provider did not sign, date and time per hospital Medical Staff Rules and Regulations.

This same chart contained a form titled "Cottage Grove Community Hospital MD Discharge Worksheet," that contained a line labeled "MD signature, EMR #, Date and Time." The provider signed and dated the form but neglected to time the form per regulation.

Record #s 3 and 4 contained a form titled "Cottage Grove Community Hospital Conditions of Admission and Consent Form" which had a line for the patient to sign and a line labeled "Date" that was signed and dated but not timed.

This same chart contained a form titled "Cottage Grove Community Hospital MD Discharge Worksheet," that contained a line labeled "MD signature, EMR #, Date and Time." The provider signed and dated the form but neglected to time the form per regulation.

Record # 5, 6, 7, 8, and 9 contained forms titled "Cottage Grove Community Hospital Conditions of Admission and Consent Form" which had a line for the patients to sign and a line labeled "Date" that was signed and dated but not timed.

Record #s 10 and 14 contained pre-printed forms titled "EMERGENCY DEPARTMENT TRIAGE FORM" which contained a line labeled "MD Signature." The forms also had a section designed for "Orders" that the provider used to order standard ED patient orders. The provider checked off several orders and wrote additional patient specific orders. The providers signed the forms but neglected to date and time the forms per hospital Medical Staff Rules and Regulations.

Record # 17 contained a form titled "Admission Home Med Reconciliation Orders" which had a line for the physician to sign, write EMR #, Date & Time. The physician signed and dated the order set but neglected to time the order set on Page 1-3. The nurse neglected to sign, write EMR#, date and time Page 3 of the order set.

This record also contained a form titled "General Venous Thromboembolism (VTE) that had a line labeled "Signature, EMR #, Date and Time." The provider signed and dated the form but neglected to time the order set.

This same record contained a form titled "Admission Orders" that had a line for the provider to sign, date and time. The provider signed the form and dated it but neglected to time the order set.

Record # 18 contained a form titled "General Venous Thromboembolism Prophylaxis Orders" which had a line labeled "Signature, EMR#, Date and Time." The form was signed and dated by the provider but the order was not timed.

The same chart contained a form titled "Admission Home Med Reconciliation Orders," that had a line labeled "Physician Signature, EMR#, Date & Time." The physician signed and dated the order but neglected to document the time.

Based on interview and documentation review it was determined that the hospital failed to develop written protocols for OPO (organ procurement organization) notification of patients whose death was imminent or who had died at the hospital as required by this regulation.

Findings included:

1. An interview was conducted with I3 on 08/07/2013 at 0940. He/she was asked for the hospital's written OPO policies. He/she stated that the "system policy" didn't include Cottage Grove, and he/she acknowledged that the hospital did not have written OPO policies.

2. Documents titled "Contract for Pacific Northwest Transplant Bank Organ Procurement Services," dated 07/19/2013, and "Affiliation Agreement for Tissue Recovery Between Community Blood Center Community Tissue Services and Cottage Grove Community Hospital," dated 05/24/2010 were reviewed. Although the hospital had agreements for organ, tissue and eye donation, written policies for those services had not been developed.

Based on documentation in 2 of 3 medical records of patients (#s 23 and 24) who were discharged from the hospital following the provision of swing-bed services and policy review, it was determined that the hospital failed to ensure the patients were provided with a written discharge notice before transfer or discharge in accordance with hospital policy and this regulation.

Findings included:

1. The hospital's swing bed policies were reviewed with I1 and I3 on 08/08/2013 at approximately 1400. The policy titled "Swing Bed: Standards of Care and Conditions of Participation," effective 11/19/2012 reflected "...A 'Notice of Discharge' will be issued at least twenty-four (24) hours (if possible) prior to anticipated discharge."

2. Swing-bed Patient # 23: The record reflected the patient was admitted to a swing-bed on 11/15/2012. The physician discharge summary dated 11/29/2012 reflected the patient was discharged to an assisted living facility on 11/29/2012. The record lacked documentation that the patient was provided a written discharge notice before discharge in accordance with hospital policy and this regulation. This was reviewed with I7 on 08/09/2013 at 1100.

3. Swing-bed Patient # 24: Review of the record reflected the patient was admitted to a swing-bed on 03/06/2013. Review of the physician discharge summary dated 03/19/2013 reflected the patient was discharged to an assisted living facility on 03/18/2013. The record lacked documentation that the patient was provided a written discharge notice before discharge.

Based on policy review, and review of documentation in 1 of 3 medical records of patients (# 22) who were discharged from the hospital following the provision of swing-bed services, it was determined that the hospital failed to ensure the patient was provided with a written discharge notice with all of the elements required by this regulation.

Findings included:

1. Swing-bed Patient # 22: Review of the record reflected the patient was admitted to a swing-bed on 09/21/2012. The physician discharge summary dated 09/28/2012 reflected the patient was discharged home on 09/28/2012. The record contained a document titled "Notice of Discharge From Swing Bed," dated 09/27/2012. The notice lacked documentation of all of the required elements of a discharge notice. It failed to include the name, address and telephone number of the State long term care ombudsman and the effective date of discharge. This was reviewed with I7 on 08/09/2013 at 1200.

2. The hospital's swing-bed policies were reviewed with I1 and I3 on 08/08/2013 at approximately 1400. The policy titled "Swing Bed: Standards of Care and Conditions of Participation," effective 11/19/2012 reflected "...A 'Notice of Discharge' will be issued at least twenty-four (24) hours (if possible) prior to anticipated discharge." The policy failed to include a process that ensured the written discharge notice included all of the elements required by this regulation as follows:
"(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged; (iv) A statement that the resident has the right to appeal the action to the State;
(v) The name, address and telephone number of the State long term care ombudsman;
(vi) For nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and (vii) For nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act."

Based on review of documentation in 1 of 3 records of patients who received hospital swing-bed services (Record # 23), and swing-bed policy review, it was determined the hospital failed to provide an on-going program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident in accordance with hospital policy and this regulation.

Findings included:

1. Review of a policy titled "Swing Bed Activities Program," effective 11/19/2012 reflected the following: "...To provide an ongoing program of activities designed to meet the interests and the physical, mental and psychological well-being of each Swing Bed patient...Upon admission to the swing bed designation, the patient will have a recreational therapy assessment/plan of care initiated by the RN [registered nurse] which includes their interests, limitations, precautions and physical, mental, and psychosocial well-being...Goals will be individualized according to the assessment and patient preference."

2. Swing-bed record # 23 was reviewed: The record reflected the patient was admitted to a hospital swing-bed on 11/15/2012. The physician discharge summary dated 11/29/2012 reflected the patient was discharged on 11/28/2012. A document titled "Swing Bed Recreational Therapy Assessment and Plan of Care," dated 11/15/2012 reflected the patient had the following limitations: He/she needed a walker with one person for mobility, he/she was hard of hearing, and his/her glasses needed updating. The document had a section titled "Patient Interests" which was blank. The goals for the patient were reflected as "...will complete 15 minutes of recreational activity daily...will report to nursing staff when further activity is warranted." There was no documentation that the patients interests had been assessed. The record also lacked documentation that an activity care plan was initiated that included the patient's interests and limitations, or that the patient's goals were individualized according to an assessment and the patient's preference in accordance with hospital policy. The record lacked documentation that an ongoing program of activities with all of the required elements was provided in accordance with hospital policy and this regulation.

Based on interview, policy review, and review of patient rights documentation, it was determined the hospital failed to implement a written policy and procedure that ensured all patients, including emergency department (ED) patients, were informed of their visitation rights. The visitation rights must include reasons for any clinical restriction or limitation on such rights, and the right to receive visitors whom he or she designates, as required by this regulation.

Findings include:

1. Review of the system-wide policy titled, "Hospital Visitation," effective 04/29//2011 reflected "The Hospital shall inform each patient (or support, where appropriate) of his/her visitation rights, including any clinical restriction or limitation of those rights, when and in the manor the patient is informed of other patient rights...3. The Hospital shall inform each patient or support person, where appropriate, of the right subject to his/her consent, to receive the visitors whom he/she designates."

2. Review of a tri-fold brochure provided to all inpatients, titled, "Rights and Responsibilities of Patients," dated 10/28/08 neglected to reflect the patient or support person's right to receive visitors whom he/she designates and his/her right to withdraw or deny such consent at any time.

3. A tour of the ED, waiting room, ambulance entrance and nursing station was conducted with I1 on 08/07/02013 at 1500. The tour started with observation of the patient's entrance pathways into the ED. An interview with an admitting representative, I4, was conducted on 08/07/2013 at 1515. He/she stated that a copy of the Patient's Rights was not given to all ED patients. I4 confirmed that only the ED patients who were admitted to the hospital received a copy of the patient's rights that were included in the Admission Packet.

4. This information was reviewed with I1 during a tour of the ED waiting room. He/she acknowledged that there were no Patient Rights brochures posted in the ED waiting room. I1 also acknowledged that at registration, the ED patients were not given copies of the Visitation Policy including any clinical restriction or limitation on such rights, in advance of furnishing patient care whenever possible per this regulation.