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Based on review of record and interview, the facility failed to conduct root cause analysis in two out two "Falls with Major Injury (FY2017)" as sentinel events.


A review of Nacogdoches Memorial Hospital Measurement and Assessment of Performance Improvement Activities, Title: Falls, Date Submitted: 05/08/17 was conducted. Two falls for Fiscal Year 2017 had been classified as "Falls with Major Injury".


Patient #6 and Patient #7 were the patients identified in Nacogdoches Memorial Hospital Fall Occurrence Reports. Review of medical records showed the following:


Patient #6 fractured her left hip and required surgery to repair it after falling in the hospital.


Patient #7 had a subdural hematoma. A subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain. This required the patient to be transferred to the Intensive Care Unit (ICU) for monitoring. The patient also had a laceration above her left eye that required sutures. These injuries were a result of her fall.


Staff #5 was interviewed on 5/24/2017. Staff #5 provided the fall reports for the two falls with major injury. The standardized form contained basic information about the patient and fall. The definition for "Fall with Major Injury" was, "Injury that requires surgery or a move to ICU for monitoring. Life threatening Injury." When asked about the outcome of the Root Cause Analysis (RCA), Staff #5 advised that an RCA had not been conducted. Staff #5 advised that these falls had not been classified as "Sentinel Events".


The Policy Title: Sentinel Events, Adverse Events, and Reportable Events, Policy #: 5.10 was reviewed.


"Adverse Event: An untoward event or occurrence, including failures in processes, which results in, or has the potential to result in, patient injury or impairment which is directly associated with care or services provided. Adverse events may result from acts of commission or omission."


"Sentinel Event: Unexpected occurrence involving death or serious injury or psychological injury of the risk thereof. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

A sentinel event:

Potentially involves a continuing threat to patient care or safety

Has significant potential for being reflective of serious underlying system problems within an organization

Potentially undermines public confidence in the organization"


"Root Cause Analysis: An interdisciplinary review process for identifying the basic or contributing causal factors that underlie a variation in performance associated with an adverse event or reportable event. It focuses primarily on systems and processes, includes an analysis of underlying cause and effect, progresses from special causes in clinical processes to common causes in organizational processes, and identifies improvements in processes or systems designed to prevent recurrence of the event."


The Policy Title: Conducting a Root Cause Analysis, Policy #: 5.11, was reviewed.


"POLICY:

In response to a sentinel event occurrence, the Director of Performance Improvement and/or Administrative Team will appoint an Event Analysis Team, who will conduct a root cause analysis. Objectives of the root cause analysis are: to identify those causative issues, systems or processes that represent core responses for occurrence of the event; to develop an action plan that will prevent recurrence of the event; and to implement the action plan, monitoring the plan's effectiveness periodically, to assure the event will not be repeated."

Based on observation, review of records, and interview, the hospital failed to identify and correct unsanitary environmental conditions that potentially created unsafe conditions for patients in 2 of 2 units toured (3rd Floor Tucker and the Emergency Department).


On 5-23-2017, a tour of the third floor, Tucker, (3T) was made with Staff #4, and Staff #8. The following conditions were observed:


Clean Linen Storage / Patient Nutrition Room:

Lower cabinet doors were soiled with scuff marks, dirt, and dried spilled liquids.

Floor was visibly soiled with dirt and debris. This was most noticeable around the door stop, baseboards, corners, and threshold.

A paper towel that appeared to have been used was found on the counter, in between a sleeve of Styrofoam cups for patient use and a container of chemically treated cleaning wipes.

A large round plastic cover was on a table beside the clean linen cart. The cover was visibly soiled with dust and debris. It was unknown as to what equipment or container this cover came from. It was propped against an open box of face masks and several boxes of gloves.

A set of staff lockers for storing their personal belongings was located in the clean linen / patient nutrition storage room.

Two rolling carts were located between the staff lockers and patient nutrition refrigerator. The carts were visibly soiled. The cart next to the refrigerator had two plastic cups used to measure patient urine. There were unused connectors on the cart that are place on patient's skin when monitoring heart rhythms. Since clean supplies were not stored in this room, staff were unable to tell if these cups and connectors had come from a patient's room or not.

The patient nutrition refrigerator was visibly soiled inside and outside. The refrigerator door handle was missing. The door seal was split and had matter collected in the seal folds. There were dried spills on the bottom shelf, in the crisper drawer, and along the bottom of the refrigerator near the floor.

There was an open carton of milk on the top shelf of the refrigerator.

The refrigerator temperature had not been checked the previous three days. Review of April's temperature log revealed temperatures had not been checked on 8 out of 30 days in the month of April.

The coffee maker was sitting on paper towels under each corner of the coffee maker. The paper towels were soiled with dried spills. The laminate counter surface had a seam that ran underneath the coffee maker. The laminate was lifting up from the counter base creating an area where liquids could collect.


Nurse's Station

Several tiles in the nursing station had missing pieces. Dirt and debris had collected in the gaps created by the missing tile.

The floor was visibly dirty. This was most noticeable around the door stop, baseboards, corners, and threshold. The walls were visibly dirty. The thermostat control was visibly dirty in the area around the temperature adjustment control.

Nursing medication carts with scanners for medication dispensing were visibly dirty. One cart had a bottom drawer that did not close all the way and had tape and tape residue that went from the front of the drawer to the side of the cart. It had the appearance of being taped shut at some point in time. One cart had a piece of foam tape placed on the side of the cart by the bottom drawer. Tape and tape residue trap dirt.

The front of the nursing station was wooden. The bottom edge of the wood near the baseboards was gray with dust. Pieces of dust were hanging down off the bottom of the edge.


Hallway:

There was a water fountain in the hallway that was unserviceable. Underneath the water fountain, coming from a metal pipe, was a dried leak that was red in color. The red color was heavy in the dried spill stream but seemed to spread across the tile giving it the appearance of algae or mold growth.

The hallway floors were visibly dirty. This was most noticeable around the door stop, baseboards, corners, and threshold.

On 5-24-2017, a tour of the Emergency Department (ED) was taken with Staff #2, Staff #3, and Staff #4. The following conditions were observed:

The ED had two trauma bays. The trauma bay on the left had the following packaged supplies stored in the open at the head of the bed: Endotracheal tubes (tubes inserted into the airway when patients are unable to breath on their own), suction tubing, sterile gloves, cotton tip applicators/swabs, and other supplies. To the left of the head of the bed was a cart with sutures stored on top of it. These supplies were not protected from body fluids that may splash during a trauma. To the right of the bed was a covered supply cart. On the plastic covering was a spot of reddish-brown dried matter.

The trauma bay on the right had the same uncovered storage at the head of the bed.

Staff #3, #4, and #8 were interviewed during the tour. Staff #5 and #9 were interviewed after the tours.

During the tour of 3T, Staff #8 denied knowing that the coffee maker had been sitting on the counter on top of paper towels. Staff #4 stated she was aware that the coffee maker had been leaking for several months but a request for a new one had been denied.

Staff #8 stated that the Unit Clerk was responsible for checking refrigerator temperatures. Staff #8 stated that there had not been a Unit Clerk on duty the previous three days (May 20, 21, and 22, 2017) and that was why the temperature had not been checked. Review of the Staffing Schedule for 3T showed that a Unit Clerk was present all three days on day shift. Night shift did not have a Unit Clerk on May 20 and May 21 per the Staffing Schedule. The Staffing Schedule for 3T showed that a Unit Clerk was present on night shift for May 22. Staff #8 did not explain why the refrigerator had not been checked in April or what action had been take to correct the problem. Staff #3 did not explain why the refrigerator had not been checked in April or what action had been take to correct the problem.

When asked about the condition of the nurse's station, Staff #3 explained that 3T was scheduled to be renovated. A start date of renovations was not known.

An interview was conducted with Staff #9. Staff #9 explained that the contracted housekeeping had ended in January and the hospital now provided housekeeping service through hospital staff. Staff #9 was asked about cleaning policies and schedules. Staff #9 stated the contracted service had used their own policies for cleaning. When the contract ended, one policy had been developed for use until a full policy manual was approved. Staff #9 explained that the equipment used for cleaning when it was contracted had belonged to the contracted company. When the contract ended, the hospital did not have the equipment necessary to strip, wax and buff the floors. Staff #9 stated he did not know the last time the floors had been stripped and waxed. Staff #9 stated he did not have a schedule for deep cleaning. When asked about environmental rounds, Staff #9 stated he made weekly rounds. When it was pointed out that 3T did not get that dirty in one week, Staff #9 stated they only go to the priority areas during the weekly rounds. Monthly rounds are done by Infection Control.

Interview was conducted with Staff #5. Staff #5 stated that Infection Control had not done rounds for May yet and that they had missed April also. Staff #5 looked at the previous round notes. Staff #5 found that 3T was last rounded on in March 2017. Staff #5 stated that refrigerator logs are kept by the unit managers. Unit managers take action to correct problems. If it was a major problem, they would notify Quality and Infection Control.

During the tour of the ED, Staff #3 confirmed that, depending on the trauma, there could be body fluid contamination in the trauma bay. Staff #3 confirmed the reddish-brown dried matter on the covered supply cart was an unknown substance. Staff #3 confirmed the uncovered supplies were as close as the covered supplies, representing a potential for contamination.

A table of contents for Environmental Services was provided. When policies were requested, Staff #2 explained that the table of contents was for a policy manual that was in the process of being approved. These policies were not in place and would not go to the board for approval until June. A review was made of the only policy provided, titled "Environmental Services Cleaning Policy and Procedures". There was no policy number, approval and review date, or approval signature. Staff #2 explained that this policy was meant to be a bridge until the new policies were approved. This is due to the contracted service had used their own policies for cleaning. That contract had not been renewed in January 2017 and the hospital took over the services. The hospital did not have an Environmental Services Policies manual in place at the time of takeover of services.

The policy titled "Environmental Services Cleaning Policy and Procedures" was 7 pages. It included an introduction on page 1, Basic Cleaning Concepts on page 2 and 3, Detailed Occupied Room Cleaning on page 3, Detailed Terminal Room Cleaning on page 3, 4, 5, and 6.
The policy did not provide guidance for cleaning any other areas of the hospital.