HospitalInspections.org

Based on observation, interview and review of the hospital admission package it was determined that the hospital failed to inform patients of the correct Quality Improvement Organization (QIO) information in the hospital and in 11 out of 11 Hospital Physician Practices surveyed.

Findings include:

Review on 3/17/17 of the hospital's admission package policy and procedure form entitled "PATIENT RIGHTS AND RESPONSIBILITIES" dated "8/16" revealed that the form had the incorrect Quality Improvement Organization (QIO) information on the Patient Rights and Responsibilities form which read as follows :

"To question any aspect of your care, and to request a review and seek resolution to any complaint. Complaints regarding the quality of your care may be directed to the appropriate department manager or directly to: "Quality Improvement Organization (QIO) [incorrect pronoun and address omitted] [incorrect phone number omitted] "

During tour of 11 of the 11 hospitals Physician Practices on 3/17/17, it was confirmed and revealed through interviews with the individual practice managers that the Patient Registration Form is signed by the patients upon initial registration and annually thereafter. The form was last updated 8/16. The Patient Registration Form states that the patient has received the "PATIENT RIGHTS AND RESPONSIBILITIES".

During tour of 11 of the 11 Hospitals Physician Practices and including the hospital on 3/17/17 revealed that the "Patient Rights and Responsibilities" are posted on the walls in the waiting rooms in all the hospitals Physician Practice's and in the Hospital itself.

It was confirmed by Staff O, (Physician Practice Transform Specialist) that the "Patient Rights and Responsibilities" are on the walls in the waiting rooms in all the Hospitals Physician Practices and in the Hospital. The incorrect information for the QIO is contained in this document. Individuals filing a complaint would have incorrect information according this posted document.

Based on observations and interviews at the Hospitals Physicians Practices, it was determined the hospital failed to lock and secure the clinic's medical records from unauthorized access at 2 of the 11 Physician Practices.

Findings include:

Observation on 3/16/17 at approximately 2:00 p.m. of the medical records at the "White Mountain Family Practice" revealed that the family practice failed to have any means to secure the medical records that are located behind the reception area in a cabinet.

Interview on 3/16/17 at approximately 2:15 p.m. with Staff J (Practice Manager) confirmed that the medical records are not locked when the office staff go home at night and the cleaning crew come in to clean. Staff J also stated that Staff J has put in "a ticket to have the lock fixed in the filing cabinet months ago, but it has not been fixed yet."


35333


Observation on 3/16/17 of the paper medical records and their storage container at the "Sleep Center" on 3/16/17 at 11:00 a.m. revealed patient medical records were not locked in the cabinet where they were stored.

During interview on 3/16/17 at 11:00 a.m. with Staff E (Manager Sleep Lab), the above findings were reviewed and Staff E confirmed the cabinets that stored patient records were not locked. Staff E revealed that it was not the practice to lock the cabinets where the patient medical records were stored in the Sleep Center and that house keeping staff and staff from a connected neighboring practice could access these patient medical records.

Based on observation and interview, it was determined that the facility failed to ensure that outdated drugs and unusable biologicals were not available for patient use in Rheumatology and Endoscopy departments.

Findings include:

Observation on 3/16/17 at 1:15 P.M. during a tour of "Rochester Rheumatology" it was revealed that two boxes of Cimzia medication had the expiration date of December 2016 and were stored in the refrigerator with other non-expired medications that were available for use.

Interview on 3/16/17 at 1:15 p.m. with Staff D (Practice Manager), reviewed the above findings and confirmed the outdated medications were stored in the refrigerator with other medications available for patient use. Staff D revealed that Rochester Rheumatology did not routinely check for outdated medications.


31937


Observation on 3/16/17 at approximately 11:00 a.m. of the Endoscopy department in room #7, revealed the sharps container that is attached to the wall inside the entrance/exit door of room #7 had 2 used syringes sitting on the top of the white dumping tray of the sharps container that had not been flipped into the container. These used syringes were accessible to anyone who had access to this unlocked room.

Interview on 3/16/17 at approximately 11:02 a.m. with Staff F (Registered Nurse), Staff F confirmed that these 2 syringes were on top of the sharps containers white tray.

Observation on 3/16/17 at approximately 11:10 a.m. of the Endoscopy department revealed an unlocked Anesthesia cart in room #2 by the room #2's entrance/exit door. In the bottom drawer of this Anesthesia cart were 2 large trays, each labeled as "Box A" and 1 smaller tray labeled as "Box B" of medications that were each secured at the cover and the base of the trays by a plastic tag.

Interview on 3/16/17 at approximately 11:12 a.m. with Staff F who stated that the Anesthesia cart in room #2 is always unlocked upon staff arrival in the morning and is then locked before staff leave the unit for the night.

Interview on 3/16/17 at approximately 2 p.m. with Staff K (Pharmacist) reviewed the above finding and Staff K stated that all Anesthesia carts are to be locked when not being accessed by personnel and they are not to be left unlocked. Staff K provided a list of the contents of the anesthesia carts medication trays labeled as Box A and Box B. Both box A's contain the following medications:

Cefazolin
Dexamethasone
Ephedrine
Glycopyrrolate
Ketorolac
Labetalol
Lacrilube NP Sterile Ointment
Lidocaine 2%
Metoclopramide
Metoprolol
Neostigmine
Ondansetron
Phenylephrine
Rocuronium
Sodium Chloride 0.9%
Sterile Water
Succinylcholine
Propofol 1%

Box B contains the following medications:
Albuterol
Diphenhydramine
Epinephrine
Esmolol
Etomidate
Hydralazine
Metoprolol
Naloxone
Oxytocin
Propranolol
Terbutaline
Scopolamine

Based on record review and interview, it was determined that the hospital failed to periodically check all workers in the operating room (OR) who may be regularly exposed to radiation for amount of radiation exposure.

Findings include:

Interview on 3/12/17 at 10:40 a.m. with Staff F (Director Surgical Services) revealed that the surgeons in the OR did not wear dosimetry badges when they were in the OR when the C-arm for fluoroscopic imaging was in use during surgery. Interview further revealed the rest of the OR staff did wear dosimetry badges when they were in the OR when the C-arm was in use.

Review on 3/12/17 of the Radiology Dosimetry Report (Period 10/1/16 to 12/31/16) and a list of surgeons provided by the hospital who performed procedures using the C-arm located in the OR during the above time period revealed that 1 of 19 surgeons had results for dosimetry badges for the fourth quarter of 2016.

Based on record review and interview, it was determined that the hospital failed to ensure an acceptable level of quality for dialysis equipment for 2 of 2 portable reverse osmosis (RO) machines.

Findings include:

Professional Reference: Dialystate for hemodialysis, Developed by Association for the Advancement of Medical Instrumentation, Approved August 9, 2004 by the American National Standards Institute, Inc., Document Number ANSI/AAMI RD52:2004, page 9, Section 5.2.5 Carbon Absorption, revealed: "The replacement bed should be placed in the second position, and the existing bed should be moved to the first position to replace the exhausted bed. If it is not possible to rotate the position of the beds, both beds should be replaced."

Review of the Equipment Repair Record for the Portable RO machine (serial number 1289611) from 3/1/16 to 3/1/17 revealed the contracted service for dialysis replaced the carbon bed in the first position on 9/15/16 and 2/10/17. The carbon bed in the second position was replaced on 11/15/16.

Review of the Equipment Repair Record for the Portable RO machine (serial number 1109096) from 3/1/16 to 3/1/17 revealed the contracted service for dialysis replaced the carbon tank in the first position on 9/22/16. The carbon bed in the second position was replaced on 10/14/16.

Interview on 3/17/17 at 11:10 a.m. with Staff G (Director Critical Care Unit) revealed that Staff G contacted the company responsible for performing dialysis services for the hospital when asked about changing the carbon tanks and Staff G was unable to obtain a procedure for changing carbon beds on the portable RO machine.

Based on review of records and interview, it was determined that the hospital failed to maintain relative humidity (RH) levels within acceptable standards in anesthetizing locations

Findings include:

Review on 3/17/17 of the hospital procedure titled "Environmental Monitoring in the Operating Room", Revision Date 4/15/16 revealed the following: "The humidity in the operating room suites will be maintained between 30-60 relative percent. If the humidity is above or below the acceptable level, Facilities will be notified by the OR Clinical Coordinator."

Review on 3/17/17 of the Operating Room (OR) Daily Temperature and Humidity Checks log for 3/1/17 to 3/15/17 revealed that the RH was less than 20% in at least one of the five operating rooms for 4 of the 10 days monitored. The Log indicated that the OR was using a humidity range of greater than 20% and less than 60%. The following are dates from the log when OR rooms had an RH less than 20%: On 3/6/17 OR Room 1 was 17% RH and OR Room 2 was 11% RH. On 3/9/17 OR Room 1 was 14% RH and OR Room 4 was 19% RH. On 3/10/17 OR Room 1 was 17% RH. On 3/13/17 OR Room 1 was 17% RH.

Review on 3/17/17 of the OR schedules for 3/6/17 and 3/9/17 revealed that the OR performed 4 procedures in OR Room 1 and 6 procedures in OR Room 2 on 3/6/17. The OR performed 1 procedures in OR Room 1 and 4 procedures in OR Room 4 on 3/9/17.

Review of Work Orders from Facilities for 3/1/17 to 3/15/17 revealed that facilities had been notified on the above dates when humidity was below 20% RH.

Interview on 3/17/17 at 12:15 p.m. with Staff H (Senior Director, Quality Improvement) confirmed that the OR was using a RH range of 20-60% as per professional standards, not the 30-60% RH in their above mentioned procedure. Staff H also confirmed that the OR staff notify the surgeon when the humidity is out of range but do not document the notification or decision to proceed with surgery.

Based on interview and observation it was determined that the hospital failed to maintain a hospital wide surveillance program to monitor compliance with all infection control requirements in order to prevent and control a safe sanitary environment to avoid sources and transmission of infections and communicable disease.

Findings include:

During interview on 3/17/17 with Staff L (Infection Prevention Coordinator), Staff H (Senior Director of Quality Improvement) and Staff N (Registered Nurse) revealed that the hospital had no documented evidence of infection control hospital wide environmental surveillance to include all departments located in the hospital (e.g. kitchen, housekeeping, laundry department, maintenance, to include biohazard waste, supply storage) and off site locations (e.g. urgent care).

Cross reference A 726.


35333

Observation on 3/16/17 at 12:40 p.m. during a tour of "Caring Partners Obstetrics & Gynecology" revealed small tears in the front two corners of the exam table in exam room four.

Interview on 3/16/17 at 12:40 p.m. with Staff A (Practice Manager) and Staff B (Clinical Coordinator), reviewed the above findings and Staff A and Staff B confirmed there were tears in the exam table. Staff B revealed that it was practice to inspect and clean exam tables after patient use and that a repair request for the tears observed on exam room four's exam table had not been performed.


Observation on 3/16/17 at 12:50 p.m. during a tour of "Stafford Cardiology Associates" revealed small tears in the front two corners of the exam table in exam room one.

During interview on 3/16/17 at 12:50 p.m. with Staff C (Practice Manager), Staff C confirmed there were tears in the exam table. Staff C revealed that it was practice to inspect and clean exam tables after patient use and a repair request for the tears observed in exam room one's exam table had not performed.


27714

Observation on 3/16/17 at 9:30 a.m. in the recovery area of the operating room (OR) revealed a recovery chair in the hallway with two large round holes on the left side and one tear on the front foot rest.

Interview on 3/16/17 at 9:30 a.m. with Staff F (Director Surgical Services) confirmed the above finding and revealed the chair was used for patients during recovery.

Observation in the recovery area of the OR on 3/16/17 at 9:45 a.m. revealed a glucose meter with a blue substance consistent with control solution on front and back of the meter at the nursing station on the docking station. There was also a small dried red/brown substance on the back of the meter.

Interview on 3/16/17 at 9:45 a.m. with Staff I (OR, Registered Nurse) confirmed the above findings and revealed it is the policy of the hospital to clean the glucose meter after each use. Interview also revealed that the glucose meter on the docking station would be ready for use.


31937

Observation during tour of the OB (Obstetrical) surgical suite on 3/16/17 at approximately 11:40 a.m. revealed that some of the horizontal surfaces contained a heavy build up of dust.

Interview on 3/16/17 at approximately 11:41 a.m. with Staff F (RN) confirmed that there was a build up of dust on some of the horizontal surfaces.

Based on record review and interview, it was determined that the hospital failed to consistently evaluate a patient's self-care capacity in the environment from which the patient entered the hospital to help determine the likelihood of the patient returning to the same environment following discharge.

Findings include:

During interview and record review on 3/17/17 at approximately 9:45 a.m. with Staff M (Registered Nurse) revealed no documentation of the Activities of Daily Living (ADL) to determine self care capacity of the patient being cared for in the environment from which he or she entered the hospital for 2 of 5 discharged patient records.