HospitalInspections.org

Based on a review of facility policies and procedures, Corporate Bylaws and interview it was determined the facility failed to ensure:

a) Policies and procedures were approved by the medical staff and administrator in the Pharmacy Department.

b) Updated policies and procedures in the GI (Gastrointestinal) lab were approved by the medical staff and administrator.

c) Updated policies and procedures in the Radiology Department were approved by the medical staff and administrator.

This had the potential to negatively affect all patients served.

Findings Include:

Corporate Bylaws
Revised: 12/17/12

Article V: Officers
Section 8. Administrator

"The Administrator shall be .... In addition, the Administrator shall:

(5) Be responsible, except as otherwise provided by the Board, for employees, and for developing and maintaining personnel policies and procedures."

Article VI: Committee of the Board
Section 6: Joint Conference and Accreditation Committee:

"(b) Duties: The Joint Conference and Accreditation Committee shall:

(1) Conduct itself as a forum for the discussion of matters of administrative and medical policies and procedures requiring agreement among the Board, medical staff and administration.

...(10) Review annually the bylaws, organization and general policies of the Corporation and submit to the Board a report based on its review ... The committee shall also, ... submit recommendations to the Board for amendments to ... organization and policies at any other time during the course of the year."

1. During a tour of the Pharmacy Department on 7/7/15 at 10:30 AM the surveyor requested the current policy and procedure manual for the Pharmacy Department.

Review of the policy and procedure manual, revealed, a front sheet labeled, "Annual Review Pharmacy Policy and Procedure Manual September 2014 ... Pharmacy Director." There was no signature or date the medical staff or administrator approved the Pharmacy Department policies and procedures in the manual.

In an interview on 7/7/15 with Employee Identifier (EI) # 5, Pharmacy Director, confirmed there was no approval of the policies and procedures by the medical staff or administration for 2014.

During a tour or the GI Lab on 7/7/15 at 1:45 PM, the surveyor reviewed the GI Lab policies and procedures.

Review of the GI Lab policies and procedures revealed updates and revisions dated August 2014 and July 2015 documented by EI # 7, Director GI Lab. The signature page revealed, "The Policies and Procedures as stated in this manual are approved by the Administrator, Medical Staff, and GI Coordinator. There was no date documented as to when the policies were approved.

Further review of the signature page revealed, "Approved: ... (EI # 6), RN (Registered Nurse), GI Coordinator. The surveyor asked EI # 7 who EI # 6 was. EI # 7 stated, "She was the previous Director before me." There was no signature page indicating approval for the 2014 and 2015 updates.

In an interview with EI # 2, Chief Nursing Officer, verified the above and stated EI # 6, "has been gone for several years."


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2. During a tour of the Radiology Department on 7/8/15 at 9:30 AM the surveyor requested the current policy and procedure manual for the Radiology Department. The department director stated the policies and procedure manuals were in the conference room on 3rd floor for us to review.

Review of the policy and procedure manual on 7/9/15 at 1:00 PM, revealed a front sheet labeled, "The Radiology Department policy and procedure manuel (manual) has been reviewed as date below. Revisions are dated on the polivies (policies) revised." There was no signature or date the medical staff or administrator approved the updated Radiology Department policies and procedures in the manual.

An interview conducted 7/9/15 at 1:00 PM with EI # 11, Radiology Director, confirmed updated policies and procedures had not been approved by the medical staff and administration.

3. During a tour of the Dietary Department on 7/7/15 at 10:30 AM, the surveyor requested the current policy and procedure manual for the Dietary Department and was told the manual was in the office of the Human Resource Director, who was serving as the dietary manager.

Review of the policy and procedure manual on 7/7/15 at 1:30 PM revealed one policy had been updated in May of 2013 by the director. The remainder of the policies had not been updated since 2002.

An interview conducted 7/7/15 at 1:30 PM with EI # 12, Director of Human Resources, verified the manual had not been updated and signed by the medical staff and administration.

In an interview on 7/9/15 at 12:30 PM with EI # 2, Chief Nursing Officer, stated the facility does not have a policy for who approves facility policies or the timeframe for policies to be reviewed and approved. EI # 2 stated, "They are done as things change and presented to the medical staff at their meetings". The surveyor requested documentation from the medical staff meetings where the policies were approved. EI # 2, stated, "There were none found".

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served.

Findings include:

Refer to Life Safety Code violations.

Based on a review of facility policies and procedures, Surgery Lifepak9 (12) Crash Cart Box Check Sheet and interview, it was determined the failed to ensure staff tested and documented the Lifepak defibrillator was ready for use daily as directed per the facility policy. This had the potential to negatively affect all patients receiving surgical services at this facility.

Findings Include:

Facility Policy: Checking Monitors and Defibrillators in OR (Operating Room) ...
Reviewed: 4-15

"The Lifepak 12 monitor and defibrillator are checked daily by the OR staff and the checklist signed..."

Review of the Surgery Lifepak9 (12) Crash Cart Box Check Sheet on 7/8/15 at 11:05 AM for May, June and July 2015 revealed there was no documentation the defibrillator was checked on 5/1/15, 5/5/15, 5/8/15, 5/12/15, 6/17/15 and 6/24/15.

During an interview on 7/8/15 at 11:05 AM with Employee Identifier (EI) # 10, Director OR, verified the OR had cases on the aforementioned dates and that there was no documentation the defibrillator was checked on the above dates.

Based on observations, review of policies and procedures, Precision Xceed Pro (blood glucose) Operator's Manual, medication refrigerator logs, Rapid Biological Indicator Process Monitor Documentation System logs and staff interview, it was determined the facility failed to:

a) Ensure the staff cleaned the blood glucose machine as directed per the Precision Xceed Pro Operator's Manual.

b) Ensure the staff disinfected the pulse oximeters in the Gastrointestinal (GI) lab after patient use and prior to returning to a clean area.

c) Ensure the staff disinfected the ventilator filters in the Respiratory Therapy Department with the approved cleansing agent per policy.

d) Ensure the staff in respiratory therapy wore gloves when cleaning contaminated equipment and disposed of the contaminated solution used to soak equipment in a dirty sink verses a clean sink.

e) Ensure the staff in the Operating Room (OR) documented medication refrigerator temperatures as directed per the facility policy.

f) Maintain an adequate number of sterilized surgical instruments available to prevent the need to flash / sterilize instruments for the scheduled procedure(s) on a routine basis.

g) Document relative humidity levels in the OR's.

h) Ensure staff performed hand hygiene prior to and between glove changes.

i) Ensure the freezer in the dietary department was in proper working condition.

This affected Patient Identifier (PI) # 23 and had the potential to negatively affect all patients served.

Findings Include:

Facility Policy: Vela Ventilator Systems
Revised: 11/1/05

"To clean the Exhalation Valve Body, Flow Sensor and Diaphragm

1. Soak in Klenzyme solution for 5 minutes..."

Facility Policy: Equipment Maintaining and Cleaning
Revised: 4/4/14

"Purpose: To provide maximum safety and to prevent and control transmission of pathogenic organisms by the consistent use of standard practices and cleaning procedures.

2. Manufacturer's recommendations are to be followed in the cleaning and disinfection of all equipment."

Precision Xceed Pro
Operator's Manual
2009 Abbott

"Cleaning the Exterior Surface

Important: It is recommended to clean after each patient for infection control."

Facility Policy: Monitoring of Refrigerator Temperatures in the OR
Reviewed: 6/07

"Policy: The refrigerator in the utility room, which contains medications for patient use, will be checked daily.

Procedure:
2. The temperature will be recorded ..."

Facility Policy: Flash Sterilization
Reviewed: 4-15

"Purpose: To sterilize items that are needed immediately for use on sterile field.

Policy: Use of flash sterilization should be kept to a minimum."

Facility Policy: Use of Gloves and Hairnets (Dietary Service Manual)
Effective date: 2/1/02

"Purpose: To prevent the spread of bacteria that may cause food borne illnesses.

Process:

c. Wash hands before and after wearing or changing gloves...
e. Change gloves when activities are changed, or when the type of food being handled is changed or when leaving the work station..."

1. During a tour of the Respiratory Department on 7/7/15 at 11:35 AM the surveyor observed a double sink which had a sign regarding hand washing and a container attached to the wall with hand washing soap. There was no splash guard between the double sink.

Further observation revealed a basin and box of Alconox (cleansing agent). The surveyor asked Employee Identifier (EI) # 8, Director of Respiratory Therapy, what the basin and Alconox was used for. EI # 8 stated that the staff uses the basin and Alconox to soak the ventilator filters in prior to sending to central sterile. EI # 8 stated the staff empties the dirty solution into the sink (hand washing). The staff failed to soak the instruments in Klenzyme (cleansing agent) as directed per the facility policy. There was no designated clean verses dirty sink for staff to use.

The surveyor asked EI # 8, if staff wore gloves when cleaning the ventilators. EI # 8 replied, "No." There were no gloves available in the cleaning area.

During interview conducted on 7/9/15 at 12:48 PM with EI # 2, Chief Nursing Officer, confirmed there was no designated sink for clean verses dirty and that staff should wear gloves when cleaning equipment.

2. During observations of care on 7/8/15 at 8:10 AM the surveyor observed EI # 9, Registered Nurse (RN), retrieve a pulse oximeter (pulse ox) from a clean counter top and proceed to Recovery Room (RR) # 1. EI # 9 obtained the patient's (unsampled) Oxygen Saturation (SaO2) with the pulse ox and then returned the pulse ox to the clean counter without cleaning.

3. During observations of care on 7/8/15 at 8:15 AM the surveyor observed EI # 9 perform a finger stick blood sugar on PI # 23. EI # 9 returned the blood glucose machine into the tray, which contained clean supplies (lancets, alcohol pads) without cleaning the machine after patient use or prior to returning to clean area.

4. During a tour of the OR on 7/8/15 at 11:30 AM the surveyor requested the OR logs for the medication refrigerator.

Review of the medication refrigerator log from May and June 2015 revealed there was no temperature documented for 5/1/15, 5/8/15, 5/24/15, 5/29/15, 6/1/15, 6/2/15, 6/3/15, 6/8/15 and 6/30/15.

During an interview on 7/8/15 at 11:30 AM with EI # 10, Director of OR, confirmed the OR was open and had performed cases on the aforementioned dates.

5. During a tour of the OR with EI # 10 on 7/8/15 at 11:50 AM the surveyor observed a sterilizer in the OR. EI # 10 stated, we use it to flash our trays with. The surveyor asked EI # 10 what types of trays were being flashed sterilized routinely and EI # 10 replied, "Cataracts."

Review of the Rapid Biological Indicator Process Monitor Documentation System logs for November 2014 thru May 2015 revealed the facility flashed sterilized cataract trays:
November 2014: x (times) 5
December 2014: x 2
January 2015: x 2
April 2015: x 5

The facility was routinely flash sterilizing cataract trays and did not follow their own policy.

During an interview on 7/8/15 12:15 AM EI # 10 confirmed the above.

6. During a tour of the OR with EI # 10 on 7/8/15 at 11:50 AM the surveyor requested the OR temperature and humidity logs. There was no humidity logs submitted.

During an interview conducted on 7/8/15 at 1:45 PM with EI # 10 verified the facility did not maintain documentation of the humidity in the OR rooms.

During an interview on 7/9/15 at 10:00 AM with EI # 4, Clinical Quality/Infection Prevention, confirmed the above findings.



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7. During a tour of the Dietary Department conducted 7/7/15 at 10:30 AM, the surveyor observed the staff plating food. During the observation several staff members failed to perform hand hygiene prior to donning gloves and between glove changes.

Further, during the tour, the surveyor observed the freezer had ice on the floor and shelves, and water dripped onto the surveyor's head when entering the freezer.

The above findings were confirmed during an interview with EI # 12, Director of Human Resources, conducted 7/7/15 at 1:30 PM.

Based on medical record review, interviews and review of Policy and Procedure, Emergency Room (ER) staff failed to maintain required documentation in the following medical records by failing to:

a) document the time of the Medical Screening Evaluation (MSE) for Medical Record (MR) Number (#) 2 and MR # 19;

b) document the risks and benefits of transfer for MR # 18;

c) notify the Health Department of an animal bite received by MR # 5;

This affected 4 of 20 ER record reviews.

Findings Include:

1. A review of MR # 2's Medical Screening Examination revealed the patient presented to the ER on 4/28/15 with a nose bleed and was examined by a physician. However, the time of the examination was not documented.

2. A review of MR # 19's Medical Screening Examination revealed the patient presented to the ER on 6/23/15 with abdominal pain and was examined by a physician. The time of the examination was not documented.

During interviews on 7/9/15 at 11:00 AM and 11:22 AM respectively, the Registered Nurse (RN)/ ER Staff, Employee Identifier (EI) #13, verified the time of the evaluation for MR # 2 and # 19 was not documented by the physician.

3. A review of MR # 18's Medical Screening Examination revealed the patient presented to the ED on 6/23/15 at 2:15 PM with Cellulitis, Osteomyelitis and Vascular Insufficiency of the foot that required a transfer to another hospital. The Risks and Benefits for transfer were documented as, "None."

During an interview on 7/9/15 at 11:12 AM, the ER Staff RN / EI #13 verified the risks and benefits were documented as none.

4. A review of MR #5 revealed the patient presented to the ER on 6/26/15 with a complaint of a dog bite. There was no documentation in the record regarding contact of the Health Department by ER staff regarding the dog bite.

During an interview on 7/9/15 at 11:17 AM, the ER Staff RN / EI #13, stated dog bites are not currently reported to the county Health Department by ER staff.

During an interview on 7/9/15 at 1:15 PM, the Clinical Quality Officer/Infection Practitioner / EI # 4, stated she/he does not report dog bites to the Health Department, but thought ER staff reported these incidents.

A review of the Policy and Procedure, "Rabies Prophylaxis: Evaluation and Treatment of Animal Bites," revised 5/09, revealed..."Make a copy of the ER record and refer it to the Infection Control Nurse, who will notify the County Health Department."
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