HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that the medical staff bylaws addressed telemedicine services and the surgeon's supervision of the certified registered nurse anesthetist (CRNA).

This failed practice had the potential to effect all patients receiving telemedicine and anesthesia services provided by the hospital.

Finding:

The "Bylaws of the Medical Staff" and the "Rules & Regulations of the Medical Staff" were reviewed with no reference made to telemedicine services or the surgeon's supervision of the CRNA.

A CRNA provided anesthesia services in surgical services. The Oklahoma Nurse Practice Act states a CRNA will be "under the supervision of a medical doctor...under conditions in which timely, on-site consultation by such medical doctor...is available..."

08/28/18 at 12:00 pm, Staff G stated CRNAs were credentialed by the hospital and supervised by the surgeon; there was no anesthesiologist on staff.

Staff B and Staff D stated telemedicine services were contracted for the GeriPsychiatric Unit and for radiology.

08/28/18 at 10:06 am, Staff B stated telemedicine services and surgeon supervision of CRNAs were not included in the bylaws.

Based on record review and interview, the governing body failed to ensure that services furnished in the hospital through contracted services were reviewed for acceptable standards of practice. This failed practice had the potential to affect all current patients' safety and quality of care.

Finding:

A 16 page document titled "All Contracts by Contract Type", contained information including the department affected, the effective date of the contract and the expiration date of the contract. A "Contract Review Checklist" was also provided.

The Governing Board meeting minutes from July 2017 through August 2018 did not show evidence of a review of the contracts.

On 08/29/18 at 11:00 am, Staff B stated contracted services were not reviewed by the governing body and that he/she was unaware they needed to be presented to the governing body.

Based on record review and interview, the hospital failed to provide written responses that included the investigation process and outcomes for one (Grievance #3) of three grievances reviewed. This resulted in one complainant (Grievance #3) not receiving communication from the hospital regarding the investigation and outcome due to the complainant not being a legal representative of the patient.

This failed practice increased the likelihood for all grievances registered by complainants who were not patients or legal representatives neither to be recognized as a grievance nor receive a written response from the hospital.

Findings:

Review of hospital policy titled "Response to Customer Complaint/Grievances", no date, showed a grievance required the department mentioned in the complaint to perform an investigation and intervention. Grievances may come from patients, family members or another person on behalf of the patient. After a grievance was received staff would determine the cause of an incident and prepare a written response within 30 days of the receipt of the grievance.

Review of an untitled hospital document identified by Staff BB as the "Grievance Log" showed a grievance received on 02/21/18 by a patient's family member was determined not to be a grievance secondary to the family member not being the patient's POA (power of attorney).

On 08/31/18 at 7:50 am, Staff BB stated the patient's son, who was not the patient's POA, had initiated a grievance with the hospital due to multiple communication concerns with nursing staff and the hospitalist. Staff BB stated there was no conversation with the mother or the son about where the patient was going upon discharge. Staff BB stated that he/she and Staff B (Director of Quality/Risk) did not identify this grievance as requiring a letter due to the son not being the patient's POA.

Based on record review and interview, the hospital failed to ensure Emergency Department (ED) nursing staff performed suicide risk assessments for two (Patient #17 and 23) of two suicidal patients reviewed using a standardized risk assessment/screening tool on admission to the ED and prior to discharge home.

This failed practice had the likelihood to result in increased risk to patient safety for two suicidal patients (Patient #17 and 23) and adverse health outcomes secondary to no assessment of the patients' risk for suicide including lethality using a standardize risk assessment/screening tool.

Findings:

Review of hospital policy titled, "Scope of Service - Hospital, (undated)" showed acuity of the patient determined the reassessment frequency such as "a patient at high risk for self-harm may be observed/assessed continually".

Review of hospital policy titled "Purpose and Objective (ED), undated" showed care provided in the ED should be delivered in accordance with standards of care and hospital policy ...quality of care should be provided to all patients.

Review of document titled "Clinical Practice Guideline: Suicide Risk Assessment, dated 09/18" from the Emergency Nurses Association (ENA) showed assessment of suicide risk should include review of the family and personal medical history for suicidal risk factors. A standardized evidenced based tool (universal screening) should be used in triage to screen all patients presenting to the ED for identification of patients at risk for self-harm and "allow providers to complete a more in-depth lethality screening" (secondary screening). Prior to discharge screening questions should be reviewed with the patient ...Several predictors of suicide have been shown to be related to an increased risk of suicide in the absence of "well-validated risk assessment tools". Factors including but not limited to a patient's life events, medical history including prior psychiatric history and demographics should be considered as part of the suicide risk assessment.


Patient #17 was a 12 year old female who presented to the ED on 08/07/18 at 10:30 pm, with complaints of suicidal ideations. Triage assessment noted "history of same". At 10:51 pm, past medical/surgical history was obtained by nursing staff, psychiatric history noted psychiatric problems and suicidal ideations. There was no evidence of the following: identification of psychiatric problems, number of times patient had sought treatment for suicidal ideation, number of suicidal attempts (if any), and suicide plan. Initial nursing assessment was performed at 10:56 pm, no evidence of a psychosocial assessment to determine any thoughts of hopelessness, despair, any signs of abuse, social isolation, living situation, and social/family support systems. Patient was discharged into the care of her parents for transfer to an acute inpatient psychiatric facility for treatment of suicidal ideations at 2:10 am. There was no evidence a suicidal risk assessment was performed prior to the patient being discharged. There was no evidence the patient had been deemed safe to transfer via private vehicle with parents to an acute psychiatric inpatient facility approximately one and a half hours away.


Patient #23 was a 14 year old female who presented to the ED on 08/26/18 at 3:25 pm, with complaints of altered level of consciousness, suicidal thoughts and "voices telling me to harm myself." Triage assessment noted the patient denies any self-harm. Past medical/surgical history noted by nursing staff showed psychiatric problems (PTSD [Post Traumatic Stress Disorder], hears voices) and suicidal ideation (self-harm). There was no evidence of the following: number of times patient had sought treatment for suicidal ideation, and number of suicidal attempts (if any). Initial nursing assessment was performed at 3:55 pm, with no evidence of a psychosocial assessment to determine any thoughts of hopelessness, despair, any signs of abuse, social isolation, living situation and social/family support systems. Physician assessment performed at 3:30pm, showed the patient had a history of PTSD, anxiety, and depression from being sexually assaulted. At 7:47 pm, patient was discharged home into care of family with no evidence of a suicidal risk assessment performed prior to patient being discharge.


On 08/29/18 at 10:39 am, Staff EE (ED RN) stated they did not have a pediatric suicide risk assessment form in the EMR. Staff EE stated nursing staff screened all patients using a two question approach regarding suicidal ideation and behavior. Staff EE stated the hospital was working on a new evidence based suicide assessment tool but they had not implemented it yet.

Based on record review, interview, and observation, the hospital failed to ensure employees (Staff AA) with charges of domestic assault and battery were thoroughly screened prior to delivering direct patient care.

This failed practice had the potential to place all inpatients at increased risk for abuse.

An Administrative Policy and Procedure, "Human Resources, Planning, Evaluation and Competency Assessment", (no date), showed "prior to offer of employment, all applicants must meet minimum qualifications", "including a background (Oklahoma State Bureau of Investigation) check".

An Administrative Policy and Procedure, "Human Resources, Background Checks", (no date), showed "a background check will apply to a new hire as a condition of employment after a written job offer is tendered to a candidate. Employment is contingent of satisfactory results." The document also showed the facility "will not permit a Subject to commence employment until a satisfactory background investigation has been obtained".

A review of 17 personnel files showed one employee, (Staff AA) licensed practical nurse (LPN) submitted an application for employment on 08/25/16, as a full-time LPN. On 12/12/17 the facility received a document, "Background Results-OK (Oklahoma)", which showed Staff AA had three charges of "Domestic Abuse-Assault and Battery" dated 12/28/15. Staff AA was hired as a full-time LPN on 2/12/18.

On 08/30/18 at 8:00 am, Staff CC stated that Human Resources would have reported the results of the background check to the Nurse Manager. He/she also stated that the employee should have gone under "Facility Review" which would have resulted in Staff AA's file being reviewed by the Human Resource Director and the Chief Nursing Officer, prior to being offered a position. Staff CC stated he/she wasn't "sure" if the Facility Review had been done, there was no documentation of the Facility Review.

On 08/30/18 at 9:00 am, Staff DD stated background checks were reviewed by the HR Director and then a meeting with the appropriate nurse manager would be conducted. He/she stated findings from that meeting would be presented to the Chief Nursing Officer and the decision whether to hire the employee would be made.

On 08/30/18 at 9:30 am, Staff C stated he/she had no knowledge of Staff AA's background check. He/she further stated the hospital board had no knowledge of Staff AA's background check. Staff C stated Staff AA "should not" be in a role of direct patient care with Assault and Battery charges. He/she further stated as the CNO, he/she "should have been notified by Human Resources" of the charges prior to Staff AA being hired as a LPN.

On 08/30/18 at 9:45 am, surveyors requested the "Facility Review" policy none was provided.

On 08/29/18 at 11:30 am, 1:30 pm, and 2:45 pm, surveyors observed Staff AA providing direct patient care on the gero-psych unit.

On 08/30/18 at 10:45 am, Staff D provided a document, "On Demand Court Records" and stated he/she located it in Staff AA's personnel file. The document showed "as of 08/30/18 at 10:32 am", the three charges of Domestic Abuse-Assault and Battery had been dismissed.

Based on record review and interview, the hospital failed to conduct timely appraisals of medical staff which caused lapses in granting privileges and allowed the physicians to continue to practice without Governing Body privileges.

This failed practice had the potential to affect all current patients' safety and quality of care by allowing physicians without privileges to continue to practice during lapses.


Finding:

A review of eight credentialing records showed three physicians (Staff P, Q, and R) continued to practice at the hospital with no privileges granted by the governing body.

1. Staff P was granted locum privileges 01/30/16 through 01/30/17 and temporary privileges 06/06/18 through 10/05/18. The hospitalist was not credentialed 01/30/17 through 06/06/18 while practicing at the hospital.

2. Staff Q was approved 10/05/16 through 10/04/17 and 03/09/18 through 08/08/18. Staff Q was not credentialed 10/05/17 through 03/09/18 while continuing to practice at the hospital.

3. Staff R was approved 02/03/16 through 02/02/18 and 06/06/18 through 06/05/20. Staff R was not credentialed 02/03/18 through 06/06/18 while continuing to practice at the hospital.


Staff B (08/29/18 at 1:00 pm) stated there were known problems with the credentialing process.

Based on record review, interviews, and observation, the hospital failed to ensure surgical staff were competent in endoscope reprocessing as evidenced by lack of knowledge of manufacturer's duodenoscopes pre-cleaning guidelines, and use of auxillary water tubes [MAJ 855] for the 180 series of endoscopes.

These failed practices had the likelihood to increase the infection risk for the approximately 748 patients receiving endoscopic care annually.

Finding:

On 08/27/18 at 11:15 am, Staff B identified Staff X as the most competent staff regarding endoscopic reprocessing.

A review of the personnel file for Staff X contained the document titled, "Competency Verification (01/30/18)" which was a checklist of Standards/Performance Skills. The skill listed as "instrument maintenance and cleaning" was the only item on the form pertaining to instrument reprocessing. The document showed no evidence of which instruments or the components were evaluated. Staff X was evaluated by Staff W.

A review of the personnel file for Staff W showed no evidence that qualified him/her as an endoscope trainer.

Based on record review and interview, the hospital failed to ensure the emergency department (ED) physician documented a medical screening examination (MSE) for two (Patient #8 and 18) of 18 ED patient medical records reviewed, during the patient's stay in the ED, or at the time of patient discharge per policy and procedure.

This failed practice had the likelihood to result in delayed or inaccurate communication between healthcare providers as the medical record provides a sequential record of patient care by promoting patient safety through timely documentation of physical assessments and interventions to decrease adverse health outcomes and ensure quality patient care.

Findings:

Review of hospital policy titled "Scope of Service - Hospital, undated" showed, all patients who presented to the emergency department (ED) would receive a medical screening examination by a physician.

Review of hospital policy titled "EMTALA Guidelines, undated" showed, all patients who presented to the hospital's ED should receive a medical screening examination (MSE) ...MSE included medical history, physical examination including examination of known chronic conditions, testing necessary to rule out an emergency medication condition (EMC) and notification/use of on-call providers for the diagnosis and stabilization as needed within the capabilities of the hospital ...there should be complete documentation of the MSE in the patient's electronic medical record (EMR).

Review of hospital document titled "Bylaws of the Medical Staff, revised 02/16" showed, medical records should be completed by the time of discharge unless information such as laboratory or diagnostic information was not available at the time of discharge.

Review of two (Patient #8 and 18) of 18 ED patient medical records showed, the physical examination portion of the medical screening examination was not documented by 08/29/18 for Patient #8 who was evaluated on 08/27/18 and Patient #18 who was evaluated on 08/25/18.

On 08/30/18 at 8:45 am, Staff EE stated, administration had identified they had "a problem with the physician" for Patient #18 and would need to start auditing their charts.

On 08/30/18 at 9:30 am, Staff B stated, the physical assessment portion of the ED physician's documentation in the EMR may not have had a hard stop requiring the physician to finish their documentation before signing out of the computer. Staff B stated, physicians had the option of saving the form "in draft" and go back to finish their documentation later.

Based on record review, interview, and observation, the hospital failed to ensure:

I. policies for equipment handling and reprocessing endoscopes were developed in accordance with manufacturers' guidelines and national standards of practice.

II. duodenoscopes were pre-cleaned and disinfected according to manufacturer's reprocessing guidelines, and auxillary water tubes [MAJ 855] were used for the 180 series of endoscopes.

III. 23 carts of surgical instruments and supplies were properly stored.

These failed practices had the likelihood to increase safety risk for the approximately 748 patients receiving endoscopic care and 3,372 patients receiving surgical care annually due to improper equipment management.


Findings:

A review of policy titled,"Infection Control Plan Fiscal Year 2019" failed to include aspects of surgical services and environmental sanitation in the surveillance plan.

I. Policies

A review of policy titled, "Endo-Cleaning, Disinfecting, and Sterilization" documented broad instructions of reprocessing of "endoscopes, bronchoscopes, colonoscopes, and gastroduodenoscopes. The policy failed to address the unique reprocessing requirements for each model or to defer completely to the manufacturers' instructions for use. The policy failed to address the specific model of equipment. The policy failed to address the use and disinfection of the manufacturer required one-way valve tubing (Olympus MAJ -855) used with the Olympus endoscope 180 series, and did not address critical steps required for duodenoscopes.

II. Endoscope

A. Improper Disinfection

A review of policy titled, "Endo-Cleaning, Disinfecting, and Sterilization" provided broad reprocessing instructions for "endoscopes [gastroscopes], bronchoscopes, colonoscopes, and gastroduodenoscopes.

A review of the Association for the Advancement of Medical Instrumentation (AAMI) article titled "FDA Releases Recommendations for Duodenoscope Reprocessing (08/15)" documented it was critical that staff responsible for reprocessing duodenoscopes have the manufacturer's instructions readily available to promote strict adherence to the reprocessing instructions in the device labeling, understand the importance of their role in reprocessing the devices, and maintain proficiency in performing these reprocessing tasks.


On 08/27/18 at 11:00am, surveyors requested the manufacturer's reprocessing manual for specialty endoscope Olympus TJF 160, and Staff X was unable to locate it. During the course of the survey, the hospital obtained a copy of the manual, and 17 pages were devoted to how to pre-clean the complex construction of endoscope's tip using a specified type of cleaning brush, and a syringe to flush the crevices and recessed areas of the endoscope's tip.


On 08/27/18 at 11:31 am, Staff W stated, the hospital did not have a manufacturer's manual for the duodenoscope currently being utilized.


On 08/29/18 at 1:22 pm, Staff X verbally described how duodenoscopes were reprocessed. Staff X stated, the hospital did not have the manufacturer's specified cleaning brush for duodenoscopes, and used a brush designed to clean a different part of the endoscope (the inner channels), and staff sometimes used a syringe to rinse the endoscope's tip.


B. Required Accessory

A review of the manual titled, "Operation Manual- Olympus GIF/CF 180" showed the use of an axillary water tube [MAJ-855] was a required accessory to the endoscope. The manual provided specific instructions for the cleaning and disinfection of the tubing.

A review of the "Olympus Important Safety Notice 01/26/09" documented the auxillary water tube was a one-way valve within the tubing that prevents backflow of fluids from the auxillary water channel of endoscope into the flushing pump tubing. The notice documented the auxillary water tube must be reprocessed following each use.


On 08/27/18 at 1:19 pm, Staff W and Staff X said the hospital used Olympus 180 series of gastroscopes and colonoscopes and didn't use the auxillary water tube.


III. Surgical Instruments

A. Uncovered Supplies in OR corridor

A review of the CDC guidelines titled, "Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)" documented sterile storage areas should be a limited access area with a controlled temperature (may be as high as 70°F) and relative humidity (30-60%).

A review of policy titled' "Humidity and Temperature Monitoring Guidelines for the Operating Room" was provided to the surveyors for surgical service air tests and balance. No policy was provided that defined the temperature and humidity conditions for sterile storage.


During the course of the survey, surveyor requested policies regarding the environmental conditions required for sterile storage and a policy titled, "Surgery-Outdated Sterile Items" was provided. The policy documented closed/open storage carts or shelves should be no lower than 8 inches from the floor, the floors should be dry and routinely cleaned so that debris/dust did not accumulate. The policy documented the floor or an obviously dusty storage environment was never acceptable storage. The policy failed to address traffic expectations, temperature, and humidity of sterile storage.


A review of policy titled, "Distribution of Sterile Supplies" documented covered or enclosed carts should be protected from different sources of contamination eg personnel contact and environment.


On 08/27/18 at 12:31 pm, Staff W stated, over the past year, sterile supplies and instruments had been stored in the surgical corridor "inner core" on the second floor instead of the designated sterile storage on the first floor. Staff W stated, storing the instruments/ supplies in the "inner core" hall was a matter of convenience.


On 08/27/18 at 2:40 pm, Staff B stated the air in the surgical corrider "inner core" was not monitored for temperature and humidity.


On 08/28/18 at 11:09 am, surveyor toured the surgical corridor identified as "inner core" and observed the following clutter in the hallway egress:

* Left wall: contained 10 five-tiered uncovered stainless carts containing primarily sterile instruments. Items on the shelves were tightly packed with no open shelf space. Five two-tiered uncovered stainless steel carts of instruments and supplies were double parked in front of the10 carts.

* Right Wall: contained eight five-tiered uncovered stainless steel carts containing primarily sterile supplies. Items on the shelves were tightly packed with no open shelf space.

* The instruments/ supplies were observed in manufacturers' sterile packing, peel pouches, and blue non-woven sterile wrapping.


On 08/28/18 at 11:09 am, within an eight minute timeframe, surveyors observed six staff ambulating back and forth in inner core hall in front of the equipment /instrument carts. Surveyors observed Staff W leaning against a five-tiered uncovered stainless cart containing sterile instruments and supplies.


On 08/30/18 at 12:16 pm, in the presence of the Infection Control Preventionist, Staff I and a surveyor moved four of the 10 five-tiered shelves away from the left and south walls in the surgical corridor inner core, and supplies fell off top shelf and shelves against the wall. Seven instruments were found under the carts in peel pouches and labeled as follows:

* One OR 62 suture passing wire
* Three OR Reusable cannula suction
* Two Disp suture passer and guide
* One Universal retrieval system


On 08/30/18 at 3:00 pm, surveyor observed the designated sterile storage area on 1st floor had 19 empty shelves and three empty small carts with three shelves each.

Based on record review, interview, and observation, the Infection Control Program failed to develop and implement an infection control plan that included surgical services and environmental sanitation, including policies, reprocessing of various endoscopes, surgical attire, proper supply storage, proper immediate use steam sterilization (IUSS), and equipment management


These failed practices had the likelihood to increase the infection control risk for the approximately 748 patients, who received endoscopic care and 3372 patients, who received surgical care annually due to inadequate surgical surveillance, improvement initiatives, and increased the risk of transferring infection through the use of unsanitary floor cleaning equipment in the housekeeping storage closets.(Refer to Tag A-0749)

Based on record review, interview, and observation, the Governing Body failed to appoint an Infection Control Preventionist (ICP) that was qualified to develop and implement the hospital infection control program.

This failed practice had the likelihood the Infection Control Preventionist would fail to identify areas of improvement opportunities, develop action plans, establish goals, and measure outcomes to reduce or mitigate infection risk.

Findings:

A review of policy titled, "Infection Control Plan Fiscal Year 2019" documented the hospital leadership "identifies" one staff member RN to the role and responsibilties of the ICP for the "enterprise", and the ICP was to attend continuing education for the advancement of professional development and expand role.

On 08/28/18 at 8:57 am, Staff B stated Staff I had been in the role of Infection Control Preventionist for one and a half years, and stated Staff I had never been formally appointed to that position.

Based on record review, interview, and observation, the Infection Control Preventionist failed to develop and implement an infection control plan that included surgical services and environmental sanitation to ensure:

I. policies for equipment handling and reprocessing endoscopes were developed in accordance with manufacturers' guidelines and national standards of practice.

II. duodenoscopes were pre-cleaned and disinfected according to manufacturer's reprocessing guidelines, and auxillary water tubes [MAJ 855] were used for the 180 series of endoscopes.

III. three surgical staff had no exposed hair when in the restricted and semi-restricted surgical areas, and six staff removed surgical masks after use.

IV. environmental sanitation was maintained in two of two housekeeping closets, the surgical corridor, and seven cubicle curtains were laundered on a designated schedule.

V. central supply items such as nine intravenous (IV) fluids, five syringes, and 23 carts of surgical items were properly stored.

VI. immediate use steam sterilization (IUSS) was utilized only for emergent situations when an instrument had been contaminated and there was no sterile replacement available. Sterilization logs clearly documented when instruments were sterilized after a cycle of failure with sterilizers.

VII. surgical and food carts were cleaned and disinfected in separate areas to avoid cross contamination. Equipment that had not had daily pre-use quality testing performed was tagged as out of service. Filters were changed and documentation maintained for automatic endoscopic reprocessing equipment.


These failed practices had the likelihood to increase the infection control risk for the approximately 748 patients, who received endoscopic care and 3372 patients, who received surgical care annually, due to inadequate surgical surveillance, improvement initiatives and increased risk of transferring infection through the use of unsanitary floor cleaning equipment in the housekeeping storage closets.


Findings:


A review of policy titled,"Infection Control Plan Fiscal Year 2019" failed to include aspects of surgical services and environmental sanitation in the surveillance plan.

I. Policies
A review of policy titled, "Endo-Cleaning, Disinfecting, and Sterilization" documented broad instructions of reprocessing of "endoscopes, bronchoscopes, colonoscopes, and gastroduodenoscopes. The policy failed to address the unique reprocessing requirements for each model or defer completely to the manufacturers' instructions for use. The policy failed to address the specific model equipment to which the policy applied The policy failed to address the use and disinfection of the manufacturer required one-way valve (Olympus MAJ -855) used with the Olympus endoscope 180 series, and did not address the critical steps required for duodenoscopes.

II. Endoscope

A. Improper Disinfection

A review of policy titled, "Endo-Cleaning, Disinfecting, and Sterilization" provided very broad reprocessing instructions for "endoscopes [gatroscopes], bronchoscopes, colonoscopes, and gastroduodenoscopes.

A review of the AAMI article titled "FDA Releases Recommendations for Duodenoscope Reprocessing (08/15)" documented it was critical that staff responsible for reprocessing duodenoscopes have the manufacturer's instructions readily available to promote strict adherence to the reprocessing instructions in the device labeling, understand the importance of their role in reprocessing the devices, and maintain proficiency in performing these reprocessing tasks.


On 08/27/18 at 11:00am, surveyors requested the manufacturer's reprocessing manual for specialty endoscope Olympus TJF 160, and the Staff X was unable to locate it. During the course of the survey, the hospital obtained a copy of the manual, and 17 pages were devoted to how to pre-clean the complex construction of endoscope's tip using a specified type of cleaning brush, and using a syringe to flush the crevices and recessed areas of the endoscpe's tip.


On 08/27/18 at 11:31 am, Staff W stated the hospital did not have a manufacturer's manual for duodenoscope.


On 08/29/18 at 1:22 pm, Staff X verballydescribed how duodenoscopes were reprocessed. Staff X stated the hospital did not have the manufacturer's specified cleaning brush for duodenoscopes, and used a brush designed to clean a different part of the endoscope (the inner channels), and staff sometimes used a syringe to rinse the endoscope's tip.


On 08/29/18 at 1:22 pm, Staff T, Infection Control Preventionist, stated he/she did not perform any surveillance of endoscopic reprocessing.


B. Required Accessory

A review of the manual titled, "Operation Manual- Olympus GIF/CF 180" showed the use of an auxillary water tube [MAJ-855] was a required accessory to the endoscope. The manual provided specific instruction for cleaning and disinfection of the tubing.

A review of the "Olympus Important Safety Notice 01/26/09" documented the auxillary water tube was a one-way valve within the tubing that prevents backflow of fluids from the auxillary water channel of endoscope into the flushing pump tubing. The notice documented the auxillary water tube must be reprocessed following each use.


On 08/27/18 at 1:19 pm, Staff W and Staff X said used the hospital used Olympus 180 series of gastroscopes and colonoscopes and didn't use the auxillary water tube.


III. Surgical attire

A. Skull Caps

Review of "Association of PeriOperative Registered Nurses (AORN) 2018" documented a clean surgical head cover or hood used to confine all hair and completely cover the ears, scalp skin, sideburns, and nape of the neck should be worn.

Review of the current 1999 CDC HICPAC SSI Guidelines, showed, "Wear a cap or hood to fully cover hair on the head and face when entering the operating room". (Cat IB) (note Cat I recommended practices are the highest level accorded by the CDC).

Review of the policy titled, "Surgical Attire in the Operating Room" showed operating room attire should consist of standard reusable woven fabric or single-use non-woven scrubs and a surgical hat or scrubs...the surgical hat should confine hair and be changed daily.


On 08/27/18 at 11:31 am, Staff W stated male surgical staff liked wearing skull caps.


On 08/27/18 at 11:41 to 11:47 am, surveyor observed a box of skull caps available for use in the staff dressing room, and three male staff wearing them with hair exposed.


B. Masks around neck

A review of " Association of periOperative Registered Nurses (AORN) 2018" documented surgical masks should be worn at all times in the operating room and in environments where open sterile supplies or scrubbed personnel may be located. A mask should never be allowed to hang or dangle around the neck, nor should it be folded and placed in a pocket for later use; masks should be either on or off.

A review of the policy titled, "Surgical Attire in the Operating Room" showed masks should be worn at all times in the surgical suites and other areas where open sterile supplies or scrubbed staff were located, and masks should be discarded whenever removed. The policy failed to instruct staff when to remove masks.


On 08/28/18 at 2:32 - 2:45 pm, surveyor observed six surgical staff with surgical masks dangling from their necks in preop, surgical corridor, and OR lunch room.


IV. Environmental Sanitation/Hygiene

A. Sterile Corridor Floors

A review of "Association of periOperative Registered Nurses (AORN) 2016" documented all areas that were not terminally cleaned, such as sterile storage area and corridors should be cleaned according to an established schedule to reduce the number of microorganisms present.

A review of policy titled, "Housekeeping in the Surgical Suites" documented housekeeping performed terminal cleaning at the beginning of the daily surgical schedule, and at the end of the day as needed to include, but not limited to the areas of hallways and floor.


On 08/27/18 at 12:31 pm, Staff W stated over the past year, sterile supplies and instruments had been stored in the surgical corridor-inner core on second floor instead of the designated sterile storage on first floor. Staff W stated storing the instruments/ supplies in the inner core hall was a matter of convenience

On 08/28/18 at 2:00 pm, Staff Z stated the floors of the surgical corridor were mopped daily.

On 08/29/18 at 1:22 pm, Staff I, Infection Control Preventionist, stated evaluation of sterile supplies was not included on the Environment Rounds Worksheet.

On 08/30/18 at 12:16 pm, in the presence of Staff I, the Infection Control Preventionist, surveyor moved four of the 10 five-tiered shelves away from the left and right walls in the surgical corridor inner core. Sani-wipes were used to lightly wipe the floors that were under the moved carts. Large amount of dirt, dust, small papers, labels, and plastic flip-lid, from medical vial, were noted on the cleaning wipes.


B. PACU Curtains

A review of the Center for Medicare and Medicaid Services titled, "Guidelines for Environmental Infection Control in Health-Care Facilities (2003)" documented high-touch housekeeping surfaces such as and the edges of privacy curtains should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact.

A review of the hospital document titled, "EVS Curtain Cleaning (no date)" provided instructions for cleaning lightly soiled cubicle curtains and heavily soiled curtains.

On 08/27/18 at 12:15 pm, surveyor observed seven cloth cubicle curtains in the Pre-op/ Phase II Recovery Area

On 08/27/18 at 12:15 pm, surveyors requested evidence of when the Pre-op /Phase II cubicle curtains had last been cleaned, none was provided. Staff T and Staff W stated they did not remember, but thought the curtains were cleaned monthly.


C. EVS Closet On 1st and 2 nd- floor

On 08/29/18 at 1:22 pm, Staff I, Infection Control Preventionist, stated housekeeping closets were not included in environmental rounds.

On 08/28/18 at 2:32 pm, surveyor observed two housekeeping closets (on 1st and 2nd floor). In both closets, surveyor observed floor drains/ sink and mopping supplies that had lint, grime, dirt, hair, small, brown indistinguishable film covered the entire sinks and floors. Staff B and Staff M stated the closet sinks and floors were very dirty and needed to be cleaned.


V. Supplies

A. Uncovered Supplies in OR corridor

A review of the CDC guidelines titled, "Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)" documented sterile storage area should be a limited access area with a controlled temperature (may be as high as 70°F) and relative humidity (30-60%).

A review of policy titled' "Humidity and Temperature Monitoring Guidelines for the Operating Room" was provided to the surveyors for surgical service air tests and balance. No policy was provided that defined the temperature and humidity conditions for sterile storage.


During the course of the survey, surveyor requested policies regarding the environmental conditions required for sterile storage and a policy titled, "Surgery-Outdated Sterile Items" was provided. The policy documented closed/open storage carts or shelves should be no lower than 8 inches from a floor that was both dry and routinely cleaned so that debris/dust did not accumulate. The policy documented the floor or an obviously dusty storage environment was never acceptable storage. The policy failed to address traffic expectations, temperature, and humidity of sterile storage.

A review of policy titled, "Distribution of Sterile Supplies" documented covered or enclosed carts protect from different sources of contamination eg personnel contact and environment.


On 08/27/18 at 12:31 pm, Staff W stated over the past year, sterile supplies and instruments had been stored in the surgical corridor-inner core on second floor instead of the designated sterile storage on first floor. Staff W stated storing the instruments/ supplies in the inner core hall was a matter of convenience.


On 08/27/18 at 2:40 pm, Staff B stated the air in the surgical corrider "inner core" was not monitored for temperature and humidity.


On 08/28/18 at 11:09 am, surveyor toured the surgical corridor identified as "inner core" and observed the following clutter in the hallway egress:

* Left wall: 10 five-tiered uncovered stainless carts contained primarily sterile instruments. The items on the shelves were tightly packed with no open shelf space. Five two-tiered uncovered stainless steel carts of instruments and supplies were double parked in front of the 10 carts.

* Right Wall: eight five-tiered uncovered stainless carts contained primarily sterile supplies. The items on the shelves were tightly packed with no open shelf space

* The instruments/ supplies were observed in manufacturers' sterile packing, peel pouches, and blue non-woven sterile wrapping.


On 08/28/18 at 11:09 am, within an eight minute timeframe, surveyors observed six staff ambulating back and forth in inner core hall in front of the equipment /instrument carts. Surveyors observed Staff W leaning against a five-tiered uncovered stainless carts that contained sterile instruments and supplies.


On 08/30/18 at 12:16 pm, in the presence of the Infection Control Preventionist, Staff I, surveyor moved four of the 10 five-tiered shelves away from the left and south walls in the surgical corridor inner core, and supplies fell off top shelf and those against wall. Seven instruments were found under the carts in peel pouches and labeled as follows:

* One OR 62 suture passing wire
* Three OR Reusable cannula suction
* Two Disp suture passer and guide
* One Universal retreval system


On 08/30/18 at 3:00 pm, surveyor observed the designated sterile storage area on 1st floor which had 19 empty shelves and three empty small carts with three shelves each.


B. Protective Wrapper removed in Advance

A review of the article titled, " CDC Guidelines -Safe Injection Practices to Prevent Transmission of Infections to Patients" documented fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) should be used for one patient only and disposed of appropriately after use. The article documented a syringe or needle/cannula should be considered contaminated once it had been used to enter or connect to a patient's intravenous infusion bag or administration set. Syringes/needles should be assembled just in time and discarded after session. (The practice of removing the protective cover of IV fluids, syringes and needles increased the risks of mistaking contaminated items for clean and tampering of IV fluids.)


* Unwrapped needle/syringes

A review of policy titled, "Anesthesia Infection Control" showed that care with needles and syringes should be taken to avoid cross contamination between cases.

On 08/27/18 at 12:01 pm, surveyor observed five unwrapped syringe/needle with no label on an unattended anesthesia cart in OR #4 (OR#4 was not being used that day).

On 08/27/18 at 12:01 pm, Staff W stated the unwrapped syringes/ needles should have been discarded.


* IV fluids

On 08/27/18 at 12:01 pm, the surveyor observed six 1000 ml IV bags hanging from an IV pole in preop, one of which was spiked with tubing.

On 08/27/18 at 12:01 pm, the surveyor observed two bags of 1000 ml of IV Normal Saline (NS) removed from their protective wrapper in the Cysto Room, which was not in use that day.

On 08/27/18 at 1:00 pm, surveyor observed 1000 ml IV NS with the protective cover removed next to a sink in the OR corridor.

On 08/31/18 at 8:30am, Staff B stated the hospital had no policy regarding removing the protective plastic cover from IV bags prior to use. He/she also stated the practice of getting the IV equipment/bag ready to grab for use was based on convenience.


C. Sink in Splash Zone

A review of the document from Association of Profession in Infection Control and Epidemiology (APIC) titled, "Infection Control Survey Tool" showed items should be stored at least 12"-18" from a sink or protective barrier (splash guard) to prevent splash contamination.

On 08/27/18 at 11:49 am, Staff W stated the medical supplies on the counter near the sink should not be there.

On 08/27/18 at 11:49 am, surveyor observed a box of gloves, a suction cannister, 1000 ml IV bag of fluids (out of protective wrap) within the splash zone of sink in the OR corridor.


VI. Sterilization logs

On 08/29/18 at 10:01 am, Staff I stated he/she did not evaluate sterilization logs to identify risks or potential quality improvment initiatives.


*IUSS
A review of a CMS Survey and Certification Memoradum titled, "Change in Terminology and Update of Survey and Certification (S&C) Memorandum 09-55 Regarding Immediate Use Steam Sterilization (IUSS) in Surgical Settings" documented IUSS should be used in emergency situations when no other option was available.

A review of the policy titled, "Immediate Use Steam Sterilization (IUSS)" documented the use of "flash" sterilization should be kept to a minimum. The policy failed to define circumstances appropriate to perform IUSS.


A review of the IUSS logs from 07/18/18 to 08/22/18 showed six entries in the log. The log showed two IUSS entries without a patient listed; thereby increasing the difficulty of associating surgical site infections of patients with IUSS processing. The log showed 16 entries which did not meet the definition of emergent circumstances.

* 07/03/18 total of six instruments "IUSS", one of six showed "for 11:00 am case one autoclave down"

* 07/10/18 "IUSS" (no reason listed) , "multi-case", "Tedesco AM case" and had no patient indentifying label

* 07/14/18 "multiple cases"

* 07/18/18 "just came in with supplies" and "needed for next case".

* 07/20/18 no patient identifying label.

* 08/10/18 two entries showed "multi-use"

* 08/17/18 three entries showed "brought in by rep [representative] and one entry "multiple cases"

* 08/22/18 "IUSS"


On 08/29/18 at 10:37 am, Staff W stated he/she had improved on maintaining a complete IUSS log, but continued to have problems with log completion and vendor representatives bringing in instruments on the same day of surgery without furnishing enough instruments to avoid IUSS processing.


*Vpro-max- Low temp Sterilizer

A review of the policy titled, "Steris Sterilizer Cancel Cycle" failed to address the documentation requirements associated with equipment failures, or to designate a clear method of communicating when instruments involved with the failure, had been successfully sterilized.


A review of the logs titled, "Amsco V-Pro maX Sterilization Load Record" from 06/18 to 08/18 showed the following:

* On 06/05/18 three instruments were involved in a failed cycle with "aborted pressure rise low" documented on the log. The log failed to show when the three instruments were successfully sterilized. Subsequently, five other sterilizer failures occurred

* On 06/13/18 four instruments were involved in a failed cycle with "failed-pressure rise low" documented on the log. On 06/14/18, 2 cycles containing ten instruments were successful , three of which had similar names to those of the instruments in the failed cycle.


On 08/29/18 at 10:37 pm, Staff Y stated the VPro sterilizer had failed and required a repairman to service. Staff Y stated on 06/05/18, the instruments involved in the failure were sterilized by the ambulatory surgical staff in the outpatient area. Staff Y stated that in reviewing the documentation, it was difficult to ascertain when the instruments involved in the failure were sterilized.


VII. Equipment

A. Food and OR and patient care equipment washed in same room

A review of the policy titled, " Instruments and Cart, Surgery (OR) Cleaning Procedure" documented the procedure for the decontamination of surgical carts. The policy showed after trays were removed from the cart, a Super sani-Cloth [disinfectant germicidal disposible wipe] should be used to clean the cart inside and outside, and a second wipe should be used in a manner that the surface was visibly wet for a full 10 minutes. The policy documented once a month, the cart should be taken to the decontamination room to be washed.


On 08/30/18 at 2:00pm, Staff B stated the hospital had no policy regarding the cleaning of food carts or use of the decontamination room for surgical equipment on 1st floor

On 08/30/18 at 10:35 pm, surveyors observed a large tiled room (walls and floors) on the 1st Floor identified as an equipment decontamination area, adjacent to the surgical decontamination. Staff W identified the carts in the room as those from surgery and food carts.


B. Equipment

(Steris Castle Vaccuum Sterilier)
A review of policy titled, "Surgery-Quality Assurance" documented the Bowie Dick test was done daily in a high vacuum sterilizer. The policy failed to address the exceptions to performing the daily Bowie Dick testing and to instruct staff regarding documentation for the exceptions. The policy also failed to discuss how to minimize the risk of the sterilizer being used without quality testing being performed.

A review of documents titled, "Getinge Steam Sterilization Records" from 06/18 to 09/18, showed multiple days (including 07/30/18 and 07/31/18) in which Sterilizer #1's performance of the Bowie dick Test was initialed and for Sterilizer #2, the record was blank.

On 08/29/18 at 10:37 pm, Staff Y stated he/she did not document when he/she did not use Sterilizer #2 and did not post any signage on the sterilizer to communicate the equipment was not ready for use.


C. DSD

A review of the document titled, "Medivators DSD Endoscopic Reprocessing System" showed maintenance requirements to include, but not limited to; changing of four filters (disinfectant mesh, water, air, and vapor) on a scheduled basis.

On 08/27/18 at 1:19 pm, Staff X said he/she had records of the filter changes, but none were provided.

Based on record review and interview, the hospital failed to assess potential donor referrals to LifeShare of Oklahoma in a timely manner.

This failed practice had the liklihood to deny potential donors the ability to donate viable tissue and organs.

Finding:

A policy titled "Organ and Tissue Donation Attachment" documented that "within one hour of the time of death or imminent death ...contact LifeShare of Oklahoma for a preliminary assessment ..."

A report from LifeShare Oklahoma titled "2018 Tissue and Organ Data" was reviewed; the report indicated an 8.33% organ referral rate.

On 08/29/18 at 3:30 pm, surveyors requested Staff J (manager of the organ procurement process) and Staff K (back up manager of the organ procurement process) explain the report from LifeShare of Oklahoma and the low percentage of referrals made in a timely manner; neither was able to explain the report or the reason referrals were not made.

Based on record review, interview, and observation, the hopsital failed to ensure all surgical services were adequately supervised by a qualified Registered Nurse (RN).

This failed practice resulted in infection control deficiencies within the surgery department (refer to Tag A-0749) and had the likelihood to negatively impact the approximately 748 patients, who received endoscopic care and 3372 patients, who received surgical care annually.

Findings:

A review of personnel file for Staff W, Operating Room (OR) Supervisor, showed neither OR leadership training nor OR specific competencies such as standards of care, current surgical related alerts, trends, updates, and OR management.

On 08/29/18 at 8:31 am, Staff B stated Staff W had no other OR supervisory training other than that contained in his/her personnel file. Staff W stated he/she had been in the role of OR Supervisor for six years, had requested but not received, training for this role.

Based on record review and interview the hospital failed to ensure:

I. ED nursing staff performed neurological assessments and/or re-assessments for five (Patient #10, 13, 16, 18, and 19) of five patients with neurological conditions including but not limited to head trauma, loss of consciousness, and lumbar spine injuries, out of a total sample of 18 ED medical records reviewed.

II. ED nursing staff completed trauma nursing assessments for four (Patient #10, 16, 20, and 21) of four trauma patients out of total sample of 18 ED medical records reviewed.

III. ED nursing staff performed re-assessments for 11 (Patient #8, 11, 13, 16, 17, 18, 21, 22, 23, 24, and 25) of 11 patients who presented to the ED with diagnoses including but not limited to suicidal ideation, chest pain, and acute pulmonary embolism out of a total sample of 18 ED medical records reviewed.

IV. ED nursing staff performed suicide risk assessments for two (Patient #17 and 23) out of two ED suicidal patient medical records reviewed using a standardized risk assessment/screening tool on admission to the ED and prior to discharge home. (Refer to Tag A-0144)


These failed practices had the likelihood to result in:

I. unrecognized clinical deterioration in the neurological status for five (Patient #10, 13, 16, 18, and 19) patients who presented to the ED with neurological complaints, leading to adverse patient health outcomes, and the potential to increase the risk for adverse health outcomes for all patients who presented to the ED with neurological complaints.

II. unrecognized clinical deterioration and delayed or inaccurate information communicated between health care providers for four trauma patients (Patient #10, 16, 20, and 21) secondary to nursing staff not completing trauma assessments, leading to potential adverse patient health outcomes and increasing the risk for adverse health outcomes for all trauma patients who presented to the ED.

III. unrecognized clinical deterioration and potential for adverse health outcomes for 11 ED patients (Patient #8, 11, 13, 16, 17, 18, 21, 22, 23, 24, and 25) who presented to the ED seeking emergency medical treatment and received no re-assessments of clinical status during admission or prior to discharge.

IV. increased risk of injury for two suicidal patients (Patient #17 and 23) and adverse health outcomes secondary to no assessment of patients' risk for suicide using a standardize risk assessment/screening tool.


Findings:

I. Neurological Assessments/Reassessments

Review of hospital policy titled "Scope of Service - Hospital, undated" showed patient assessment was an ongoing process that continued throughout treatment ...On admission a complete physical assessment should be completed to determine the need for additional specialized assessments (such as neurological assessments) ...Reassessment would be performed when there was a clinical change in condition, routine intervals ordered by physician or per protocols and at time of discharge.

Review of hospital policy titled "Nursing Assessment (Inpatient), undated" showed an initial ED assessment should be completed within 15 minutes of patient arrival for all "emergent" patients ...reassessments should be performed by nursing staff based on patient condition, when there was a change in clinical condition, per plan of care or as ordered by physician.

Review of hospital policy titled "Standard of Care: Trauma, undated" showed vital signs and neurological status should be monitored "frequently" ...cardiac and respiratory status should be monitored. The policy failed to define the frequency of vital signs and neurological assessments, and the assessment parameters and frequency for cardiac and respiratory status monitoring.

Review of hospital policy titled "Standard of Care: For the Emergency Department, undated" showed ED nursing staff should initiate ongoing assessment of the patient's physical problems to determine immediate needs ...ongoing assessment should be used by the ED nurse to evaluate and make revisions to the patient's plan of care, diagnoses and outcomes.

Review of document titled "Strengthening your neurologic assessment techniques: Consistent head-to-toe evaluations assure no steps are missed, dated 2014" from the Nursing 2014 Critical Care Journal showed in order to recognize subtle changes in neurological status a thorough assessment was critical ...assessment should include at a minimum, assessment of muscle strength, coordination, cranial nerves and Glasgow Coma Scale (GCS) ...earliest signs of neurological deterioration would include changes in the patient's mental status.

Review of document titled "Neurologic Emergencies, 2018" from the Emergency Nurses Associations Emergency Nursing Core Curriculum Seventh Edition showed the neurological status of patients in the ED should be monitored and re-assessment performed to determine response/outcome.


Patient #10 was a 36 year old female patient who presented to the ED at 12:40 pm, with complaints of being assaulted, punched, kicked, and chocked several times with loss of consciousness. Physical examination noted moderate distress, contusions, multiple bruises about face and neck from choking, swelling and tenderness to face and neck, and painful range of motion of neck and extremities. Bite marks noted in multiple locations. Initial nursing was performed at 1:21 pm, which showed no evidence of a focused neurological assessment performed to determine baseline neurological status. Patient was discharged to home at 2:45 pm, with no evidence of neurological assessments performed prior to discharge or at the time of discharge for a patient with identified loss of consciousness and head trauma.


Patient #13 was a 67 year old male patient who presented to the ED at 1:28 pm, with complaints of falling today striking face on floor, and history of falling backwards and hitting his head on the cement with loss of consciousness two days prior to arrival. Current medication regimen included Eliquis (an anti-coagulant, blood-thinner). Patient reported severe headache with pain 9/10. At 1:56 pm, an initial assessment was performed which showed no evidence of a focused neurological assessment. CT of the head showed bilateral subdural hematomas. Patient was transferred to a higher level of care at 4:16 pm, with no evidence of neurological assessments performed prior to transfer or at the time of discharge for patient with identified head bleed secondary to head trauma.


Patient #16 was a 17 year old female who presented to the ED at 1:27 am, after being assaulted at a party. Patient reported being hit several times in the head and face, and reported pain at 6/10. A hematoma was noted on the patient's forehead by nursing during triage. At 1:45 am, an initial assessment was performed which showed no evidence of a focused neurological assessment performed to determine baseline neurological status. Patient was discharged to home at 4:17 am, with no evidence of neurological assessments performed for patient with identified head contusion and trauma.


Patient #18 was a 27 year old male who presented to the ED at 6:21 pm, who was unresponsive and not breathing. Once patient was stabilized and labs were completed, including a urine drug screen that showed the presence of opiates, amphetamines, methamphetamines, benzodiazepines and cannabinoids (marijuana), an initial nursing assessment was completed at 6:35 pm. The initial nursing assessment showed no evidence of a focused neurological assessment performed to determine baseline neurological status. Patient was admitted and transferred to the intensive care unit (ICU) of the hospital at 8:50 pm, with no evidence of neurological assessments performed for a patient who was unresponsive and had loss of consciousness secondary to a poly-drug overdose.


Patient #19 was a 37 year old male who presented to the ED at 2:37 pm, with complaints of a low back and left shoulder injury one week prior with continuous bilateral lower extremity numbness, tingling and painful urination. At 2:40 pm, an initial neurological assessment was performed that showed bilateral lower extremity decreased sensation and movement. MRI showed osteomyelitis and discitis at L3-4 of the lumbar spine. Patient was transferred to a higher level of care at 5:35 pm, with no evidence of re-assessments of the patient's neurological status prior to transfer or at the time of discharge.


On 08/29/18 at 7:34 am, Staff FF (ED RN) stated there was no standard process in the ED for neurological assessments or re-assessments except for stroke patients.


On 08/29/18 at 10:09 am, Staff EE (ED RN) stated there was a general assessment flowsheet that included a neurological system for assessment of the patient's neurological status. He/she stated the "neuro flowsheet" would be used for ongoing assessments and the frequency would be determined based on the situation and the patient's diagnosis. Staff EE stated there was no standardized process for the frequency of neurological re-assessments in the ED.


II. Trauma Assessments

Review of hospital policy titled "Standard of Care: Trauma, undated" showed vital signs and neurological status should be monitored "frequently" ...cardiac and respiratory status should be monitored. The policy failed to define the frequency of vital signs and neurological assessments, and the assessment parameters and frequency for cardiac and respiratory status monitoring.

Review of hospital policy titled "Standard of Care: For the Emergency Department, undated" showed ED nursing staff should initiate ongoing assessment of the patient's physical problems to determine immediate needs ...ongoing assessment should be used by the ED nurse to evaluate and make revisions to the patient's plan of care, diagnoses and outcomes.

Review of four (Patient #10, 16, 20 and 21) of four trauma patient records reviewed had incomplete trauma assessments completed by nursing staff for patients which included patients who presented with head trauma (two patients), head/chest trauma, and cardiac arrest as the result of trauma. There was no evidence the patient's cardiac or respiratory status was monitored during admission to the ED or at the time of discharge from the ED.

On 08/29/18 at10:09 am, Staff EE stated the trauma flowsheet should be completed on all patients who presented to the ED with signs and symptoms of trauma.


III. Physical Assessments

Review of hospital policy titled "Scope of Service - Hospital, undated" showed patient assessment was an ongoing process that continued throughout treatment ...Acuity (a measurement of the nursing care needed for the patient) of the patient determined the reassessment frequency ...Reassessment would be performed when there was a clinical change in condition, routine intervals ordered by physician or per protocols and at time of discharge.

Review of hospital policy titled "Nursing Assessment (Inpatient), undated" showed an initial ED assessment should be completed within 15 minutes of patient arrival for all patients triaged "emergent" (Level 1 or 2) ...reassessments should be performed by nursing staff based on patient condition, when there was a change in clinical condition, per plan of care or as ordered by physician.

Review of hospital policy titled "Scope of Assessment in the Emergency Department, undated" showed the intake assessment included a physical examination ...treatment of ED patients included "ongoing observations". The policy failed to define "ongoing observations" and how those observations would be documented in the patient's medical record. The policy failed to clearly identify the difference between assessment and observations, and at what frequency re-assessments should be completed for ED patients who presented with an EMC.

Review of document titled "Nursing Assessment and Resuscitation, dated 2018" from the Emergency Nurses Associations Emergency Nursing Core Curriculum Seventh Edition showed upon presentation to the ED a primary assessment was usually performed to determine the potential for any life threatening condition and intervene if necessary ...The purpose of the secondary assessment was to identify other non-life threatening conditions. Once these conditions were identified a "more focused, detailed assessment is performed." "A useful mnemonic for the secondary assessment is F (full set of vital signs/facilitate family presence), G (get resuscitation adjuncts), H (history and head-to-toe assessment) and I (inspect posterior surfaces/remove spine board) ...For critically ill patients or patients who have been injured a head-to-toe assessment should be performed. Patients with a minor injury or complaints limited to a single body system a more focused head-to-toe assessment should be performed.


Review of 11 (Patient #8, 11, 13, 16, 17, 18, 21, 22, 23, 24, and 25) out of 18 ED medical records showed no reassessments completed by nursing staff as evidenced by:


*Patient #8 was a 53 year old female who arrived at 4:15 pm, with complaints of a wound, increased swelling, bruising, and redness to the right knee. Patient had been seen in ED 4 days prior. At 4:59 pm, an initial nursing assessment was performed. At 7:35 pm, patient was admitted to the hospital, with no evidence of re-assessments prior to admission or at the time of discharge.


*Patient #11 was a 38 year old male who arrived at 3:02 pm, with complaints of shortness of breath and chest pain. At 3:02 pm, an initial nursing assessment was performed. At 5:37 pm, patient signed out AMA (Against Medical Advice), with no evidence of re-assessments prior to leaving AMA.


*Patient #13 was a 67 year old male who arrived at 1:28 pm, with complaints of falling today striking face on floor with severe headache rated 9/10, and history of falling and hitting back of his head on the cement with loss of consciousness two days prior to arrival. Current medication regimen included Eliquis. Initial nursing assessment was performed at 1:56 pm. CT showed bilateral subdural hematomas. Patient was transferred to a higher level of care at 3:59 pm, no evidence of re-assessments prior to transfer or at the time of discharge.


*Patient #16 was a 17 year old female who arrived at 1:27 am, with complaints of being assaulted and hit several times in the face and head. Initial nursing assessment was performed at 1:45 am. Patient was discharged to home at 4:17 pm, no evidence of re-assessments prior to discharge or at the time of discharge.


*Patient #17 was a 12 year old female who arrived at 10:30 pm, with suicidal ideation. Initial nursing assessment was performed at 10:56 pm, no evidence of a focused psychosocial assessment to assist in determining suicidal risk. Patient was transferred by private vehicle with parents to a psychiatric facility at 2:10 am, no evidence of re-assessments prior to transfer or at the time of discharge.


*Patient #18 was a 27 year old male who arrived at 6:21 pm, who was unresponsive and not breathing on arrival. Initial nursing assessment was performed at 6:35 pm. Patient was admitted at 8:50 pm, no evidence of re-assessments prior to admission or at the time of discharge.


*Patient #21 was a 28 year old female who arrived at 1:29 pm, with complaints of being assaulted, hit, kicked in the face and chest, and chocked multiple times. Initial nursing assessment was performed at 2:45 pm. Patient was discharged home at 4:23 pm, no evidence of re-assessments prior to discharge or at the time of discharge.


*Patient #22 was a 78 year old male who arrived at 12:33 am, with complaints of chest pain rated at 6/10 and shortness of breath. Initial nursing assessment was performed at 1:09 am. Patient was admitted at 2:44 am, no evidence of re-assessments prior to admission or at the time of discharge.


* Patient #23 was a 14 year old female who presented to the ED at 3:25 pm, with complaints of altered level of consciousness, suicidal thoughts and "voices telling me to harm myself." Initial nursing assessment was performed at 3:55 pm. At 7:47 pm, patient discharged home with no evidence of re-assessment prior to discharge or at time of discharge.


*Patient #24 was a 53 year old female who arrived at 10:28 am, with complaints of falling and injuring the right knee. Initial nursing assessment was performed at 10:31 am, bruising, tenderness, and pain 4/10 was noted. Patient was discharged home at 12:15 pm, no evidence of re-assessment at the time of patient discharge.


*Patient #25 was a 47 year old male who arrived at 11:29 pm, with complaints of shortness of breath, left side chest pain, respiratory distress, and productive cough for the past two days. At 11:35 pm, an initial nursing assessment was performed. Patient was admitted at 2:52 am, no evidence of re-assessments prior to admission or at the time of discharge.


On 08/29/18 at 7:34 am, Staff FF (ED RN) stated there was no standard process in the ED for re-assessments of patients after the initial assessment performed. Staff FF stated follow-up on patients to determine any clinical changes included vital signs and "looking in on the patient".


On 08/29/18 at 10:09 am, Staff EE (ED RN) stated the process in the ED for patient re-assessment would include monitoring patient's vital signs. Staff EE stated "we go in and check on them, we don't re-assess them". Staff EE stated "I don't know what the policy and procedure requires for re-assessment." Staff EE stated as a nurse re-assessment may be performed dependent on "situation and diagnosis". Staff EE stated there was no standard for re-assessment.