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Based on observation, interview, and document review, the facility failed to ensure a safe environment for 22 of 22 patients currently on the psychiatric unit resulting in the potential for patient harm up to and including death for all patients served on the psychiatric unit. Findings include:

On 6/13/2018 at 1032 on the psychiatric unit, the area including the restraint room was entered and revealed a small ante-area with the restraint room straight ahead and a bathroom to the right. The bathroom also contained a shower area and a shower curtain rod was observed to be present. This finding was confirmed by Staff YY at the time of discovery.

Staff YY stated on 6/13/2018 at 1032, "I thought they had removed all of those bars from the unit." As she was making that statement, Staff YY walked over to the shower curtain rod and attempted to pull it down. The rod bowed downward, but did not break or detach from the wall. Staff YY then stated, "There are some screws in there. I will get them to come down and take care of that right away. That is a ligature (a thing used for tying or binding something tightly) risk."

Facility policy regarding a safe environment in the psychiatric setting was requested and the facility provided the policy titled "Patient Observation and Special Precautions." The policy outlines observations, precautions, and procedures, but does not address the physical environment. The policy does state, "One-to-one [1:1]:..To ensure that the patient remains safe, they will be supervised while in either the shower or the bathroom by keeping the door slightly ajar. There staff member is able to discretely maintain patient observation as needed to ensure patient safety. ...In General Staff-View: ...Patient does not need to be assigned a specific staff-observer and does not need to be observed in the bathroom or shower."

Based on observation, interview, and document review the facility failed to ensure that all Intravenous (IV) tubing changes were documented in the medical record at intervals outlined in the policy in three of three (#4, 18 and 19) patient IVs that were checked for tubing change documentation, this has the potential to affect all patients receiving IV medications at this facility. Findings include:

On 6/12/2018 at 1330 during observation in the Intensive Care Unit (ICU) at Campus B patient #18 was interviewed, during the interview the IV tubing was noted to have no label with a date or time documenting when the tubing use was initiated. Staff Y was asked about the tubing, Staff Y stated "I change my tubing every morning at 0900."

On 6/12/2018 at 1400 patient #19 was interviewed, staff Y entered the room and removed all IV bags and tubing before labeling could be observed.

On 6/13/2018 at 1130 during medical record review for patient #18 and #19 with staff E the Director of the ICU and the Emergency Department (ED) documentation of the tubing changes could not be found.

On 6/14/2018 at 1030 during interview with Staff EEE the Senior Director of Patient Safety & Infection Control, she showed on the computer where the tubing changes are to be documented. She stated "The tubing changes were not documented in the medical records that were reviewed for tubing changes."




36887

On 6/12/2018 at 1117, Patient #4 was interviewed. While at the bedside, she was observed to have an intravenous (IV) infusing. There was no label present on the tubing. This was confirmed by Staff D on 6/12/2018 at 1125.

On 6/12/2018 at 1125, Staff D was queried as to if IV tubing should be labeled to which she stated it should be.

Facility policy titled "Nursing Procedures: Basic How to Details" effective 1/18/2018 was reviewed on 6/12/2018 at 1440. Policy states, "All nursing policy and procedure that is a skill set taught in the course of studies have been archived. To review a skill refer to an online professional resource education source (such as Lippincott) as a reference."

Staff EEE also provided on 6/12/2018 at 1440, a printout of the Lippincott website with a title of "IV administration set (tubing) change" revised 5/18/2018. It states, "Change primary and secondary continuous administration sets used to administer solutions other than lipids, blood, or blood products no more frequently than every 96 hours but at least every 7 days and immediately when contamination is suspected or when the integrity of the product or system is compromised. Change a secondary administration set that is detached from a primary administration set every 24 hours...Label the administration set and solution container with the date of initiation or the date when change is necessary as directed by your facility...Document the procedure."

On 6/14/2018 at 1020, the electronic medical record of Patient #4 was reviewed with Staff EEE and documentation regarding IV tubing uses or changes was not found to be present. On 6/14/2018 at 1025, Staff EEE stated, "There is a place in the record to document IV tubing changes but it wasn't in that record."

Based on observation, interview and record review the facility failed to ensure dietary staff were competent in proper sanitization of food contact surfaces, resulting in an increased risk of foodborne illness. This deficient practice has the potential to affect all 213 patients of Campus A.

Findings include:
On 6/12/18 at approximately 1:20 PM, during a tour of the kitchen at Campus A, a sanitizer bucket with wiping cloths and a quaternary ammonia sanitizer solution was observed stored on top of the prep table, directly adjacent to cutting boards and in-use utensils. When queried about the location of the sanitizer bucket, staff G1 stated that was not the usual storage location, and staff H1 then relocated the bucket to the shelf underneath the prep surface. Staff H1 was then observed to take a wiping cloth from the bucket and use it to wipe the prep table surface, cutting boards, two knives, and the table surface around the cooking equipment. The solution in the bucket was observed to be cloudy, and when tested with the facility's test strips there was no residual sanitizer. When prompted by Staff F1, staff H1 discarded the contents and a mixed a fresh sanitizer solution.

On 6/12/18 at 1:30 PM, during interview with staff H1 and G1, when asked about the procedure for testing the concentration of the sanitizer solution, Staff G1 then demonstrated the process by taking the test strip and dipping it into the solution and swishing it for several seconds. The solution temperature was measured by this surveyor to be 112 degrees Fahrenheit. When asked if there were any temperature requirements or other instructions for the testing process, Staff F1, G1 and H1 were unaware of any requirements. During the interview, upon this response, the surveyor directed Staff F1, G1 and H1 to a posting on the wall in the chemical dispensing area which contained manufacturer's instructions. Record review of the poster revealed that the poster contained instructions for testing, including that the temperature of the mixed sanitizer solution for using the test strips should be between 65 and 75 degrees Fahrenheit.

38269

Based on observation and interview the facility failed to ensure the physical environment was developed and maintained to ensure the safety of the patient resulting in the potential for harm to all patients served by the facility. Findings include:
See specific tags:

A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated June 14, 2018.
K-0211
K-0223
K-0281
K-0342
K-0353
K-0363
K-0511

Based on observation, interview and policy review, the facility failed to ensure the policy for proper surgical attire was followed and maintenance of a sanitary environment which could result in the potential for infection for the 41 patients being treated in the operating rooms and the 10 patients being treated in the Heart and Vascular Lab as well as all patients residing on the third floor of campus B. Findings include:

On 06/12/18 approximately 1030, during tour of the Heart and Vascular Lab area with Staff N two male staff were observed sitting in the monitoring room wearing scrub uniforms and skull caps. At this time Staff N was asked if the two males work at the facility and if they work in the restricted areas. Staff N stated, "yes they all work here in the lab". Staff N was further queried regarding if skull caps were regularly worn and what their policy was. Staff N stated, "yes most of the guys wear the skull caps."

O 06/12/18 at approximately 1530, during review of the policy titled "Surgical Attire" dated 11/02/2012" stated "4. Head and facial hair, including sideburns and neckline hair, will be covered with a surgical bouffant hat/hood style cover...".


38269

Based on observation interview and record review the facility failed to deliver anesthesia services consistent with recognized standards for anesthesia care, in two of three observations resulting in the potential to adversely affect all forty-one patients requiring anesthesia on the date of observation.

On 06/12/18 at approximately 1430 while touring surgical services/operating room area on campus A, Anesthesiologist Staff FF was observed through the window of the operating room door to suite 152. Staff FF was observed sitting on a stool at the head of a stretcher, where a patient was draped and undergoing a surgical procedure. Staff FF was observed to have an electronic tablet device (confirmed to be an electronic device xxxx by staff HH) in hand to which Staff FF's gaze was focused while using his ungloved hand to maneuver through screens. During the time of observation, Operating room manager staff HH stated, "they (anesthesia) do their billing on an (electronic tablet)."

On 06/12/18 at approximately 1435 Anesthesiologist Staff EE was observed in operating room suite 153. Staff EE was sitting on a stool at the head of the stretcher where a patient was draped and undergoing a surgical procedure. Staff EE was leaned back holding and visually focused on a magazine. The tour continued to an opposite hall where suite 153 was observed from a different angle. At 1440 Staff EE was observed through the window where he continued to have the magazine in hand, staff EE flipped it over as to view another page. At 1445 the Director of Surgical Services Staff L was queried as to what Staff EE was reading, if it was acceptable practice to read while administering anesthesia and if the anesthesiologist being observed was responsible for the monitoring and subsequent care related to anesthesia. Staff L stated, "yes he is responsible and should be focused on patient care, maybe he is reading something related to the patient." Staff L called into the room to inquire what Staff EE was reading (in observation of infection control practices this surveyor did not enter the room in the middle of an orthopedic surgery). Staff L stated, "the circulator said staff EE refused to reveal what he was reading, and now the circulator is really nervous." At 1450 as observation of Staff EE in suite 153 continued, Staff EE was observed to place the magazine on the anesthesia machine, stand up and walk to the side of the patient, Staff EE stood at the side of the patient for approximately 10 seconds. Upon returning to the head of the stretcher Staff EE proceeded to take a syringe and vial from the cart (hand hygiene was not performed, and gloves were not donned) he drew up a clear liquid and pushed it through the Intravenous Line without scrubbing the hub. At 1455 Staff EE was observed to pick up the magazine, sit back down on the stool and continue flipping through the magazine.

On 06/12/18 approximately 1455 the tour returned to OR suite 152 where Staff FF was again observed sitting on a stool at the head of the patient stretcher viewing the confirmed electronic tablet. At 1456 Staff L called into suite 152 and inquired whether the electronic tablet being used by Staff FF was a personal device and if the electronic tablet was being used for billing purposes. Staff L stated, "the (electronic device) is a personal device and Staff FF was not using it for billing."

On 06/12/18 at 1500 during an interview Staff L was queried as to whether there was a policy on cleaning and bringing personal items into the sterile restricted area and if it was acceptable practice to focus on "billing" or reading materials not related to the patient, while responsible for a patient under general (any) anesthesia. Staff L confirmed that reading a magazine and or electronic tablet were not acceptable practices for the anesthesia provider responsible for a patient during any phase of anesthesia. Staff L stated, "Staff EE oversees quality for the anesthesia group and is the current Chief of Surgery, he knows better, this is not acceptable, and it will be taken care of."

On 06/13/18 at approximately 0930 all anesthesia policies, sedation policies and policies regarding personal items being brought into a restricted/sterile area were requested.

On 06/14/18 between the hours of 0900, The Manager of Accrediting and Patient Safety, Staff A stated, "there are no policies for what can and cannot be brought into the operating rooms, it should be common knowledge. There are no policies specifically for the anesthesia group."

On 06/14/18 at approximately 1000 The facility Policy titled "Sedation (minimal, moderate and deep)" version 5 effective 08/10/2016 was reviewed. Policy states "Purpose To ensure that all patients receive equally safe and effective levels of sedation care ...to ensure that if patients slip into a deeper level of sedation it will be recognized and monitored by medical personnel with an adequate level of training. This policy is written in accordance with the regulatory requirements outlined by the Centers for Medicare and Medicaid Services and based on guidelines published by the AMERICAN SOCIETY OF ANESTHESIOLOGISTS and the American college of Emergency Physicians."







36887

On 6/12/2018 at 1053 at Campus B, the third floor general medical/surgical unit was toured. Upon entering the mid-supply room at 1059 on 6/12/2018, the door was observed to have tape that had not been removed and tape residue present. This was confirmed by Staff C and D at the time of discovery.

The clean utility room on 3W was entered on 6/12/2018 at 1100. Three of five intravenous (IV) poles present were found to have clear adhesive tape pieces and tape residue on them. This was confirmed by Staff D at the time of discovery.

The medication room was entered on 6/12/2018 at 1105 and was found to have tape residue present on the countertop in three different areas as well as having tape residue present on the wall at the far end of the room. Additionally, the Pyxis machine (machine which stores and dispenses medication) had a bar code label on the top surface which was partially attached, the top left corner was curled onto itself and the adhesive area was black in color. This was confirmed by Staff D at the time of discovery.

The clean utility room on 3E was entered on 6/12/2018 at 1114 and was found to have adhesive tape and adhesive stickers partially present with adhesive residue also present on 3 of 4 walls, on multiple cupboards, and the counter top. Additionally, there was an area of exposed, unpainted drywall with drywall compound present near the door. This was confirmed by Staff D at the time of discovery.

Facility policy titled "Departmental Cleaning Responsibilities-Infection Control" effective 12/14/2016 was reviewed on 6/13/2018 at 1023. Policy states, "Purpose: ...to help maintain a sanitary environment, prevent transmission of bacteria from one patient to another through inanimate objects, and meet infection prevention and control standards."

Based on observation interview and record review the facility failed to deliver anesthesia services consistent with recognized standards for anesthesia care, in two of three observations resulting in the potential to adversely affect all forty-one patients requiring anesthesia on the date of observation.

On 06/12/18 at approximately 1430 while touring surgical services/operating room area on campus A, Anesthesiologist Staff FF was observed through the window of the operating room door to suite 152. Staff FF was observed sitting on a stool at the head of a stretcher, where a patient was draped and undergoing a surgical procedure. Staff FF was observed to have an electronic tablet device (confirmed to be an electronic device xxxx by staff HH) in hand to which Staff FF's gaze was focused while using his ungloved hand to maneuver through screens. During the time of observation, Operating room manager staff HH stated, "they (anesthesia) do their billing on an (electronic tablet)."

On 06/12/18 at approximately 1435 Anesthesiologist Staff EE was observed in operating room suite 153. Staff EE was sitting on a stool at the head of the stretcher where a patient was draped and undergoing a surgical procedure. Staff EE was leaned back holding and visually focused on a magazine. The tour continued to an opposite hall where suite 153 was observed from a different angle. At 1440 Staff EE was observed through the window where he continued to have the magazine in hand, staff EE flipped it over as to view another page. At 1445 the Director of Surgical Services Staff L was queried as to what Staff EE was reading, if it was acceptable practice to read while administering anesthesia and if the anesthesiologist being observed was responsible for the monitoring and subsequent care related to anesthesia. Staff L stated, "yes he is responsible and should be focused on patient care, maybe he is reading something related to the patient." Staff L called into the room to inquire what Staff EE was reading (in observation of infection control practices this surveyor did not enter the room in the middle of an orthopedic surgery). Staff L stated, "the circulator said staff EE refused to reveal what he was reading, and now the circulator is really nervous." At 1450 as observation of Staff EE in suite 153 continued, Staff EE was observed to place the magazine on the anesthesia machine, stand up and walk to the side of the patient, Staff EE stood at the side of the patient for approximately 10 seconds. Upon returning to the head of the stretcher Staff EE proceeded to take a syringe and vial from the cart (hand hygiene was not performed, and gloves were not donned) he drew up a clear liquid and pushed it through the Intravenous Line without scrubbing the hub. At 1455 Staff EE was observed to pick up the magazine, sit back down on the stool and continue flipping through the magazine.

On 06/12/18 approximately 1455 the tour returned to OR suite 152 where Staff FF was again observed sitting on a stool at the head of the patient stretcher viewing the confirmed electronic tablet. At 1456 Staff L called into suite 152 and inquired whether the electronic tablet being used by Staff FF was a personal device and if the electronic tablet was being used for billing purposes. Staff L stated, "the (electronic device) is a personal device and Staff FF was not using it for billing."

On 06/12/18 at 1500 during an interview Staff L was queried as to whether there was a policy on cleaning and bringing personal items into the sterile restricted area and if it was acceptable practice to focus on "billing" or reading materials not related to the patient, while responsible for a patient under general (any) anesthesia. Staff L confirmed that reading a magazine and or electronic tablet were not acceptable practices for the anesthesia provider responsible for a patient during any phase of anesthesia. Staff L stated, "Staff EE oversees quality for the anesthesia group and is the current Chief of Surgery, he knows better, this is not acceptable, and it will be taken care of."

On 06/13/18 at approximately 0930 all anesthesia policies, sedation policies and policies regarding personal items being brought into a restricted/sterile area were requested.

On 06/14/18 between the hours of 0900, The Manager of Accrediting and Patient Safety, Staff A stated, "there are no policies for what can and cannot be brought into the operating rooms, it should be common knowledge. There are no policies specifically for the anesthesia group."

On 06/14/18 at approximately 1000 The facility Policy titled "Sedation (minimal, moderate and deep)" version 5 effective 08/10/2016 was reviewed. Policy states "Purpose To ensure that all patients receive equally safe and effective levels of sedation care ...to ensure that if patients slip into a deeper level of sedation it will be recognized and monitored by medical personnel with an adequate level of training. This policy is written in accordance with the regulatory requirements outlined by the Centers for Medicare and Medicaid Services and based on guidelines published by the AMERICAN SOCIETY OF ANESTHESIOLOGISTS and the American college of Emergency Physicians."