HospitalInspections.org

Based on record review and interview, the hospital failed to ensure it provided for capital expenditures for at least a 3-year period as evidenced by having no documented evidence of a capital expenditure plan that covered 3 years.
Findings:

Review of the "Capital Expenditures", presented by S1ADM, revealed a hand-written notation at the top of the page of "FY (fiscal year) 2015, 2016, 2017." Further review revealed no documented evidence of a breakdown of the expenditures for each year. Further review revealed the list included "Computer Hardware & (and) Software" items with months of 1, 3, 6, 7, and 9 with no year listed. "Medical Equipment" was listed with months of 1, 2, 4, 5, 6, and 10 with no year listed.

In an interview on 12/17/15 at 10:35 a.m., S1ADM indicated they don't break down the capital expenditure budget by years for each of the 3 years. She confirmed that she had no further documentation to present that revealed items were budgeted for a 3-year period.

Based on interview and record review, the hospital's governing body failed to ensure services performed under contract were provided in a safe and effective manner as evidenced by failure to include all contracted services in the hospital's QAPI plan.

Findings:

Review of the QAPI plan presented as current by S3CC (compliance coordinator) revealed no documented evidence that the following contracted services were included in the hospital's QAPI plan: Stericycle (hazardous material disposal), Linens, Physical Therapy and Waste Disposal.

In an interview on 12/16/15 at 4:40 p.m. with S3CC, she confirmed the above referenced services were provided through contractual agreement. S3CC also confirmed the referenced contracted services were not included in the hospital's current QAPI plan.

Based on record reviews and interviews, the hospital failed to ensure each patient had the right to make informed decisions regarding his/her anesthesia care as evidenced by having the nurse inform the patients relative to their anesthesia care and obtain signatures and failing to have completed anesthesia consents for 5 (#1, #3, #4, #6, #10) of 7 (#1 - #6, #10) patient records reviewed for anesthesia consents from a total of 30 sampled records.
Findings:

Review of the Medical Staff Rules and Regulations and the hospital policy titled "Patient Consents" revealed no documented evidence that the completion of an anesthesia consent was addressed.

Patient #1

Review of the medical record for Patient #1 revealed she was admitted 12/14/15 for a surgical procedure under general anesthesia. Review of her anesthesia consent, signed by Patient #1 and witnessed by an RN at the same time on 12/10/15 at 10:45 a.m. and signed by S19Anes on 12/14/15 with no time documented, revealed no documented evidence of the type of anesthesia to be used (monitored anesthesia care, general anesthesia, epidural anesthesia, spinal anesthesia, regional (nerve block) anesthesia, and blood patch were listed), no designation of the purpose of the specific anesthesia to be used, additional risks, if any, particular to the patient because of a complicating medical condition, and reasonable therapeutic alternatives and risks associated and risks of no treatment (refers to Item 2 which was the type of anesthesia that had not been designated).


Patient #3
Review of Patient #3's medical record revealed she had a Laparoscopic Cholecystectomy on 12/15/15 under general anesthesia. Review of her anesthesia consent, signed by Patient #3 and witnessed at the same time on 12/11/15 at 8:50 a.m. and signed by S19Anes on 12/14/15 with no time documented, revealed no documented evidence of the type of anesthesia to be used (monitored anesthesia care, general anesthesia, epidural anesthesia, spinal anesthesia, regional (nerve block) anesthesia, and blood patch were listed), no designation of the purpose of the specific anesthesia to be used, the patient's diagnosis or description of the nature of the condition for which medical treatment, surgical procedure, or other therapy was indicated (name of procedure was written in the blank), additional risks, if any, particular to the patient because of a complicating medical condition, and reasonable therapeutic alternatives and risks associated and risks of no treatment (refers to Item 2 which was the type of anesthesia that had not been designated).

Patient #4
Review of the medical record for Patient #4 revealed an admission date of 11/11/15. Further review revealed the patient was admitted for Laparoscopic Gastric Sleeve surgery. Additional review revealed the patient's consent for Anesthesia or Treatment and Acknowledgement of Receipt of Medical Information had been completed on 10/21/15. The type of anesthesia to be used had not been specified on the consent. The section of the consent titled, "Material Risks associated with the transfusion of blood and blood components: a. Additional risks (if any) particular to the patient because of a complicating medical condition are..." was left blank.

Patient #6
Review of the medical record for Patient #6 revealed an admission date of 11/16/15. Further review revealed the patient was admitted for Abdominoplasty with Breast Augmentation surgery. Additional review revealed the patient's consent for Anesthesia or Treatment and Acknowledgement of Receipt of Medical Information had been completed on 11/16/15. The type of anesthesia to be used had not been specified on the consent. The section of the consent titled, "Material Risks associated with the transfusion of blood and blood components: a. Additional risks (if any) particular to the patient because of a complicating medical condition are..." was left blank.

Patient #10
Review of Patient #10's medical record revealed she had a Total Laparoscopic Hysterectomy on 12/04/15. Review of her anesthesia consent, signed by Patient #10 and witnessed at the same time on 11/23/15 at 11:00 a.m. and signed by S19Anes on 12/03/15 at 1:15 p.m., revealed no documented evidence of the type of anesthesia to be used (monitored anesthesia care, general anesthesia, epidural anesthesia, spinal anesthesia, regional (nerve block) anesthesia, and blood patch were listed), no designation of the purpose of the specific anesthesia to be used, the patient's diagnosis or description of the nature of the condition for which medical treatment, surgical procedure, or other therapy was indicated (name of procedure was written in the blank), additional risks, if any, particular to the patient because of a complicating medical condition, and reasonable therapeutic alternatives and risks associated and risks of no treatment (refers to Item 2 which was the type of anesthesia that had not been designated).

In an interview 12/16/15 at 3:15 p.m., S2DON indicated the hospital did not have a policy and procedure for obtaining Informed Consents for Anesthesia. She further indicated that the hospital policy and procedure titled Patient Consents (MR-06) was for medical and surgical procedures and did not include Anesthesia procedures. S2DON indicated the Anesthesia Department did not have a procedure related to Informed Consent.
In an interview 12/16/15 at 4:20 p.m. S19Anes reported that anesthesia consents were obtained by the nurses on the patient's preadmission visit. S19Anes reported that on the day of a patient's surgery one of the anesthesiologists or CRNAs would ask the patient if they had any questions. S19Anes reported that there wasn't enough time for the anesthesia staff to explain anesthesia and obtain consent.
In an interview 12/17/15 at 8:00 a.m., S18RN confirmed she worked in the patient pre-admission area, where patients came, prior to the day of surgery, to have pre-operative diagnostic tests performed, assessments done, and consents signed. S18RN indicated that the nurses obtained the informed consent for anesthesia from patients scheduled for surgical or other procedures. S18RN reported that on the pre-admit visit, the pre-admit nurses explained the different types of anesthesia, answered questions, and had the patient sign the Anesthesia . S18RN confirmed that no specific type of anesthesia is marked on the consent, because it may change after anesthesia staff evaluates the patient on the day of their surgery. S18RN reported that she had no anesthesia training.




30420




30984

Based on observations and interview, the hospital failed to ensure each patient received care in a safe setting as evidenced by having each patient's bed having a nurse call feature on the handrail that was inoperable for 30 of 30 licensed beds.
Findings:

Observation during the tour of PSU on 12/15/15 at 9:15 a.m., with S2DON present, revealed all of the patients' beds had a nurse call button on the handrail with a silhouette of a nurse on it.

In an interview on 12/15/15 at 9:15 a.m., S2DON confirmed all of the patients' beds had nurse call buttons on the handrails that were not functioning. She indicated that each patient room had a cord with a call button attached. She confirmed that a sedated patient could possibly press the inoperable button on the handrail in an attempt to call for assistance rather than use the button attached to the cord resulting in the staff being unaware of the patients call for assistance.

Based on record reviews and interviews, the hospital's medical staff failed to enforce its by-laws to carry out the responsibilities of the Medical Staff as evidenced by:
1) Failing to ensure discharge summaries were completed by the attending physician and not delegated to the nursing staff for 2 (#6, #23) of 7 (#1 - #6, #23) patient records reviewed for completion of discharge summaries from a total of 30 sampled patients.
2) Failing to ensure a physician using an electronic signature had on file in the Medical Records department a signed statement ensuring that he is the only one who has authority to use the electronic signature for 1 (#13) of 7 (#1 - #6, #13) patient records reviewed for approved use of an electronic signature from a total of 30 sampled patients.
Findings:

1) Failing to ensure discharge summaries were completed by the attending physician and not delegated to the nursing staff:
Review of the Medical Staff Rules and Regulations, presented as the current Rules and Regulations, revealed that the attending physician shall be responsible for the preparation of a complete medical record for each patient he/she admits. The record shall include a discharge summary.

Review of the hospital policy titled "Discharge Summary/Short Stay Report", presented as a current policy by S3CC, revealed that the physician is responsible for completing a discharge summary on all discharged patients to provide pertinent clinical summary information.


Patient #6:
Review of Patient #6's "Discharge Summary/Short Stay Report" revealed the document contained three entries completed by separate staff members. Further review revealed no documented evidence that the physician completed the discharge summary.
Patient #6's "Discharge Summary/Short Stay Report" was reviewed by S3CC, during an interview on 12/15/15 at 2:33 p.m., and she explained the reason for the 3 different entries. S3CC indicated the Physician Discharge Summary/Short Stay Report was filled in by 2 nursing staff members and signed, dated, and timed by Physician after it had been completed by the nursing staff. She explained the nurse on the floor had completed the reason for Admit and Procedures performed because that information does not change. S3CC further explained the nurses also filled out the discharge date, course of hospital stay and condition at discharge or right after discharge and the MD then signed and dated the document after it had been completed by the nursing staff.

Patient #23
Review of Patient #23's "Discharge Summary / Short Stay Report" revealed next to the "Physician Signature" was written on 09/04/15 at 10:30 a.m. "voRB (verbal order read back) S13MD/(name of nurse)". There was no documented evidence that the physician completed the discharge summary.

In an interview on 12/17/15 at 2:20 p.m., S12RN indicated she was the Coordinator for PSU. She further indicated the discharge summaries were primarily done by the PSU nurses.

In a telephone interview on 12/17/15 at 3:50 p.m., S11MedDir indicated the nurses fill out a part of the discharge summary, and the physician fills out a part of it and signs it. When informed that the regulation, as well as the Medical Staff Rules and Regulations and hospital policy, requires the discharge summary be completed by the physician, S11MedDir indicated "that's easy to fix."

2) Failing to ensure a physician using an electronic signature had on file in the Medical Records department a signed statement ensuring that he is the only one who has authority to use the electronic signature:
Review of the Medical Staff Rules and regulations revealed rubber stamps or electronic signatures may be utilized only by those physicians who have on file in the Medical Records Department a signed statement from the medical staff member whose stamp or electronic signature is involved that ensures that he/she is the only one who has the authority to use the stamp or authority to use the electronic signature.

Review of Patient #13's visit date of 09/15/15 which included her Pre-op orders revealed they were electronically co-signed by S23MD on 09/16/15 at 6:31 a.m.

Review of S23MD's signed statement of 01/21/15 in the Medical Records Department revealed he was authorized to use a signature stamp only and was not authorized to use an electronic signature.

In an interview on 12/16/15 at 9:35 a.m., S3CC confirmed S23MD's signed statement in the Medical Records Department does not address that he has authorization to use an electronic signature.

30984


Based on record reviews and interviews, the hospital's Medical Staff failed to ensure the effective implementation of its By-laws by failing to ensure a medical history and physical examination (H&P) was completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This was evidenced by having a physical examination completed with no patient history documented for 2 (#2, #18) of 11 (#1-#9, #18, #19) patient records reviewed for a completed H&P's from a sample of 30 patients.
Findings:

Review of the Medical Staff Rules and Regulations revealed a medical H&P of the patient must be completed within 30 days before admission or registration.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 12/14/15 with diagnoses of Dehydration and Left Chest pain status post Laparoscopic Gastric Sleeve. Further review revealed S24MD performed a physical exam on 12/10/15 that did not include a history. There was a documented H&P on 09/03/15, more than 30 days prior to her admission of 12/14/15 and more than 30 days prior to her procedure performed on 12/10/15. Review of the entire medical record revealed no documented evidence that a H&P was performed for Patient #2 within 30 days of admission or 24 hours after admission on 12/14/15.

In an interview on 12/15/15 at 4:30 p.m., S6RN confirmed Patient #2 did not have an H&P on her medical record. S6RN further confirmed that the patient had been admitted for longer than 24 hours at that time. Before the end of the interview, S26LPN placed a copy of the H&P from the patient's prior admission on 12/10/15. After review of this H&P, S26LPN and S6RN verified that what was placed on Patient #2 ' s current medical record was only a physical examination and did not contain all of the components of an H&P. S26LPN and S6RN confirmed there was not any part of the patient ' s history included on the physical exam dated 12/10/15. Further review of documents placed on Patient #2 ' s medical record by S26LPN revealed an H&P dated 09/03/15, more than 2 months from the patient ' s current admission.
Patient #18
Review of Patient #18's medical record revealed she was admitted on 08/07/15 with a diagnosis of Dehydration status post Lap Band surgery on 08/01/15. Further review revealed a physical exam was performed on 08/03/15 with no documented evidence of a patient history. There was no documented evidence that a complete H&P was completed within 30 days before admission or within 24 hours after admission for Patient #18.

In a telephone interview on 12/17/15 at 3:50 p.m., S11MedDir indicated they monitor H&Ps being on the chart closely and couldn't explain why a documented patient history wasn't included.

Based on record reviews and interviews, the hospital's Medical Staff failed to ensure it implemented its By-laws relative to an updated H&P prior to surgery if the H&P was performed within 30 days of the procedure as evidenced by failing to have documented evidence of an updated H&P for 3 (#1, #6, #19) of 11 (#1-#9, #18, #19) patient records reviewed for a H&P update prior to surgery from a total of 30 sampled patients.
Findings:

Review of the hospital's Medical Staff Bylaws, Rules and Regulations revealed in part:
7. A medical H&P examination of the patient must be completed within 30 days before admission or registration and prior to surgery. When the medical H&P examination are completed within 30 days before admission, an updated examination of the patient, including any changes in the patient's condition, must be completed and documented within 24 hours after admission, but prior to surgery or procedure requiring anesthesia services. The updated examination of the patient, including any changes in the patient's condition since the patient's H&P was performed that might be significant for the planned course of treatment, must be completed by a physician, MD/DO or maxillofacial surgeon for patients receiving oromaxillofacial surgery.

Patient #1
Review of the medical record for Patient #1 revealed she was admitted to the hospital and underwent a surgical procedure 12/14/15. An H&P dated 12/10/15 was noted on the record. A section at the bottom of the H&P page, noted "H&P exceeds 24 hours prior to admission, the current exam has not changed." An unchecked (blank) box was noted in front of this statement. " Follow-up/Notes " on the next line was blank. The date was filled in as 12/14/15, timed 08:00, and signed by S7MD. No other documentation as to whether or not there had been any changes or no changes in the patient ' s condition since the H&P was noted.
In an interview 12/16/15 at 3:15 p.m. S2DON verified the H&P update for Patient #1 had no documentation as to whether the patient's condition had changed or not changed from her H&P dated 12/10/15, and a blank box was unchecked next to "H&P exceeds 24 hours prior to admission, the current exam has not changed.

Patient #6
Review of Patient #6's medical record revealed an admission date of 11/16/15 for Abdominoplasty with Breast Augmentation surgery. Review of the patient's history and physical revealed it had been completed on 11/09/15 at 8:40 a.m. Further review revealed the H&P was signed on 11/16/15 by the physician, but the box denoting," H&P exceeds 24 hours prior to admission, the current exam has not changed" was left blank. Additional review revealed the section for follow-up notes was also left blank, and there was no documented update to the patient's previous H&P.

Patient #19
Review of Patient #19's "History And Physical Examination Short Stay" dated 08/06/15 by S25MD revealed the "Update" section was blank with no documented evidence whether Patient #19 had been re-evaluated, whether her condition was unchanged, or whether there were changes in her condition. The H&P update was signed by S25MD on 08/07/15 at 7:00 a.m.

In a telephone interview on 12/17/15 at 3:50 p.m., S11MedDir indicated they monitor H&Ps closely, so he couldn't explain why the above-listed H&Ps weren't updated.


30420

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by:
1) The RN delegating the initial assessment of patients in PSU to the LPN for 2 (#10, #12) of 7 (#3, #7, #8, #9, #10, #12, #14) patient records reviewed for nursing assessments from a total of 30 sampled patients.
2) Failing to ensure physician orders for Incentive Spirometry (IS) were implemented for 2 (#23, #24) of 2 patient records reviewed with physician orders for IS from a total of 30 sampled patients.
Findings:

1) The RN delegating the initial assessment of patients in PSU to the LPN:
Review of the hospital policy titled "PSU Flowsheet / Nurses Notes", approved by S2DON on 03/13/15, revealed it is the policy of the hospital that the RN is responsible for the initial assessment which is to be done when the patient is admitted to PSU. The RN is also responsible for assessing the patient daily. Staff will document using the approved flowsheet and PSU Nurses Notes to document.

Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification..."
Patient #10
Review of Patient #10's medical record revealed she had a Total Laparoscopic Hysterectomy on 12/04/15. Review of her "Physicians Orders" revealed she received 300 ml (milliliters) Lactated Ringer's bolus at 2:40 p.m. and Lasix 20 mg (milligrams) IV (intravenously) at 2:05 p.m.

Review of Patient #10's PSU Nurses Notes dated 12/04/15 at 3:10 p.m. revealed her initial assessment was performed by S26LPN with an undated and untimed statement of "Agree (with) above assessment" by S27RN. There was no documented evidence that Patient #10 was assessed by a RN to determine if she met the criteria, designated by the LSBN, for her care to be delegated to the LPN.

Patient #12
Review of Patient #12's medical record revealed she had a Septoplasty and Maxillary surgery on 12/11/15. Review of her PSU Nurses Notes dated 12/11/15 at 6:06 p.m. revealed she was initially assessed by S26LPN with a statement by the RN at 6:10 p.m. of "Agree with Assessment." There was no documented evidence that Patient #12 was assessed by a RN to determine if she met the criteria, designated by the LSBN, for her care to be delegated to the LPN.

In an interview on 12/17/15 at 2:20 p.m., S12RN indicated they allow the LPN to perform the initial assessments of patients in PSU, because the RN has to care for the patient at least every 24 hours.

2) Failing to ensure physician orders for IS were implemented:
Patient #23
Review of Patient #23's medical record revealed she was admitted on 09/01/15 with a diagnosis of Left Knee Osteoarthritis and had a Total Knee Replacement. Review of her physician orders revealed an order on 09/01/15 at 1:15 by S13MD for a CRC (Cardiac Rehab Care)/IS.

Review of Patient #23's "Progress Notes" revealed S10CRT assessed Patient #23 on 09/01/15 at 3:15 and documented "IS therapy ordered by Dr. (doctor). IS at bedside... Predicted goal for IS is 1500. report to RN." Further review revealed S10CRT performed IS on 09/02/15 at 2:30 p.m. Review of the entire medical record revealed no documented evidence that S10CRT obtained a physician's order for the frequency at which IS was to be performed by the patient and the goal to be reached.

Review of Patient #23's PSU Nurses Notes revealed the following documentation related to IS use:
09/01/15 at 7:20 p.m. - IS within reach;
09/02/15 at 7:15 a.m. - worked with patient on IS, pulled about 1750 to 2000 ten times and encouraged to use every hour while awake;
09/02/15 at 7:30 p.m. - IS at bedside, patient pulled 800 times 5 breaths, tolerated well, does not appear to understand how to perform; there was no documented evidence that the nurse re-educated the patient or referred the issue to S10CRT;
09/03/15 at 5:00 a.m. - performed IS without difficulty, pulled 1200 times 10 breaths; encouraged frequent use;
09/03/15 at 7:15 a.m. and 1:10 p.m. - "IS at bedside" with no documented evidence whether IS was performed and what level towards the goal was reached;
09/03/15 at 7:40 p.m. -IS was performed with the nurse.

Patient #24
Review of Patient #24's medical record revealed she was admitted on 07/10/15 at 10:00 a.m. with a diagnosis of Status Post Colostomy Reversal and Incisional Hernia Repair. review of her admit orders revealed an order for IS 15 times per hour while awake.

Review of Patient #24's PSU Nurses Notes revealed the following documentation relative to IS:
07/11/15 at 7:10 p.m. - patient reports she has been using her IS;
07/11/15 at 9:35 p.m. - patient tolerated 10 repetitions of IS averaging 750;
07/12/15 at 1:50 a.m. - patient using IS;
07/12/15 at 7:30 a.m. - admits to using IS;
07/13/15 at 7:00 a.m. - IS at bedside; discussed appropriate use.
There was no documented evidence that Patient #24 performed IS 15 times per hour while awake as ordered by the physician. There was no documented evidence that Patient #24 was assessed by the respiratory therapist during her admission.

In an interview on 12/17/15 at 10:45 a.m., S10CRT indicated IS is a respiratory service provided. She further indicated if there's an order for CRC, she will assess the patient, but if just IS is ordered, the service may be handled by nursing. S10CRT indicated the nurses will consult her if they think the patient needs more teaching. She indicated she instructs the patient to do their own IS every hour, and she checks them each day. She confirmed that she did not assess Patient #24 during her admission, and Patient #24 had orders for IS. She confirmed she did not obtain and write a verbal order for the specific frequency of performance of IS for Patient #23.

In an interview on 12/17/15 at 2:20 p.m., S12RN indicated she usually tells the patient to perform IS while a commercial is on the television.

30984


Based on record reviews and interview, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failing to individualize the patient's nursing care plan to include all the patients' medical diagnoses for which the patient was being treated for 2 (#4, #6) of 6 (#1, #2, #3, #4, #6, #10) patient medical records reviewed for nursing care plans out of a total sample of 30 patient medical records reviewed.
Findings:

Review of the hospital policy titled "PSU Plan of Care" revealed upon admission to PSU, the RN will review patient information, to include but not limited to, the admitting diagnosis, procedure, if applicable, physician orders, history and physical, admit history, and patient medication list. The RN will then conduct a head-to-toe assessment utilizing the nursing process to determine identifiable actual/potential nursing diagnosis. The nursing care plan is to be kept current by ongoing assessments of the patient's needs and response to interventions every shift.

Patient #4
Review of the medical record for Patient #4 revealed an admission date of 11/11/15. Further review revealed the patient was admitted for lap gastric sleeve surgery. Additional review revealed the patient had the following medical diagnoses: Hypertension, Coronary Artery Disease and Hypothyroidism.

Review of Patient #4's plan of care revealed Hypertension, Coronary Artery Disease and Hypothyroidism were not identified as problems on the patient's care plan.

Patient #6
Review of the medical record for Patient #6 revealed an admission date of 11/16/15. Further review revealed the patient was admitted for abdominoplasty with breast augmentation surgery. Additional review revealed the patient also had a medical diagnosis of Hypothyroidism.

Review of Patient #6's plan of care revealed Hypothyroidism was not identified as a problem on the patient's care plan.

In an interview on 12/17/15 at 2:20 p.m., S12RN indicated they care plan for the diagnosis or procedure for which the patient is admitted and any changes in condition that occur during their admission. She further indicated they don't include care plans for diagnoses that patients have a history of or are taking medication for, because "we'd have a book."

Based on record reviews and interviews, the hospital failed to ensure all medical records were completed within 30 days of the patient's discharge.
Findings:

Review of the Medical Staff Rules and regulations revealed that medical records must be completed within 30 days following the patient's discharge.

Review of the hospital policy titled "Physician Notification Process" revealed it is the policy of the hospital to monitor the status of incomplete medical records for each staff physician and maintain a listing of staff physicians who are deficient in timely completion of records. Medical records shall be completed within 30 days of the patient's discharge. The procedure included that incomplete charts will be pulled each evening for physicians who are scheduled for procedures. The physicians will be asked to complete all incomplete charts before leaving the facility, if scheduling permits. Each member is assigned a designated group of physicians to assist with chart completion efforts, which includes notifying physicians and their office of deficiencies and delivery of those records by courier to their offices. A weekly notification is provided to administration of physicians with incomplete records including those that are nearing 30 days. Those physicians nearing 30 days will be called by administration. Charts not completed within 30 days will be reported to the QI (Quality Improvement) Committee.

Review of the "Medical Records Delinquent Records" list, presented by S8MRC on 12/16/15, revealed that 17 medical records were delinquent, with the longest having a discharge date of 09/23/15 (77 days delinquent).

In an interview on 12/17/15 at 10:35 a.m., S1ADM indicated she had no documented evidence to present of weekly notification of physicians with records nearing 30 days of incompletion since discharge. She further indicated she had no documented evidence to present of physicians being notified that they had delinquent medical records.

Based on record reviews and interviews, the hospital failed to ensure all patient medical record entries were complete as evidenced by failing to ensure the ordering licensed practitioner dated and timed his/her authentication of orders, discharge summary, and operative report for 5 (#5,#6, #10, #11, #12) of 9 (#1 - #6, #10 - #12) patient records reviewed for dating and timing of orders, discharge summaries, and operative reports from a total sample of 30 patient records.
Findings:

Review of the Hospital's Medical Staff Bylaw Rules and Regulations revealed in part:
5. All medical records/order entries shall be properly authenticated by the physician's signature along with the date and time of the signature.

Patient #5
Review of Patient 5's medical record revealed an admission date of 11/13/15. Further review revealed an operative progress note that had been authenticated and dated by the surgeon, but his authentication had not been timed.

Patient #6
Review of Patient #6's medical record revealed an admission date of 11/16/15. Further review revealed Physician Abdominoplasty Discharge Orders, dated 11/17/15, that had been authenticated by the ordering physician. Further review revealed the physician ' s authentication of the orders had not been dated or timed.

Patient #10
Review of Patient #10's "Discharge Summary/Short Stay Report" for a discharge of 12/05/15 revealed no documented evidence the physician signed, dated, and timed the discharge summary as of the date of review on 12/15/15.

Patient #11
Review of Patient #11's "Operative Progress Note" for a procedure performed on 12/10/15 revealed no documented evidence that the physician signed, dated, and timed the note.

Patient #12
Review of patient #12's "Operative Progress Note" for a procedure performed on 12/11/15 revealed no documented evidence of the date and time the physician signed the note.

In an interview on 12/16/15 at 4:40 p.m. with S3CC, she confirmed physicians not dating and timing their authentications had been an ongoing issue.

Based on record review and interview, the hospital failed to ensure drug administration errors were documented in the patients' medical records for 2 (#20, #21) of 2 patients reviewed for medication errors.

Findings:
Review of the hospital policy titled,"Medication Error Reporting", Policy number: PHM-028; revised 3/2015, revealed in part:
Purpose: To ensure proper monitoring of medication errors in order to help safeguard patients against such occurrences.
Definitions: Drug Administration Error: In the context of this regulation, " drug administration error " is limited to those errors in administration that actually reach the patient, i.e., a medication actually is administered to a patient when it should not be, or the wrong dose is administered, or the wrong route of administration is used, etcetera, or a medication that should have been administered to the patient has not been administered.

Patient #20
Review of the hospital's occurrence reports revealed a medication error involving Patient #20. Further review revealed Patient #20 had not received Reglan and Pepcid as ordered per the MD.
.
Review of Patient #20's medical record revealed no documented evidence of an account of the medication error referenced in the occurrence report.

Patient #21
Review of the hospital's occurrence reports revealed a medication error involving Patient #25. Further review revealed Patient #25 had received 2 Percocet -7.5 milligram tablets instead of the ordered 2 Lortab- 7.5 milligram tablets.

Review of Patient #21's medical record revealed no documented evidence of an account of the medication error referenced in the occurrence report.

In an interview on 12/16/15 at 4:40 p.m. with S3CC (Compliance Coordinator), she confirmed, after review of Patient #20 and Patient #21's medical records, that there was no documentation of the medication errors referenced above in the patients' records.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements for the Condition of Participation of Infection Control as evidenced by:

1) Failure to ensure the infection control officer was qualified as evidenced by no education, training, experience, or certification for S14IP. (see findings at A-0748)

2) Failure to ensure the infection control officer implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
a) failing to ensure that surgical services were provided in accordance with acceptable professional standards of practice by failing to ensure that surgical instruments were available in a quantity that was commensurate with the hospital's expected daily procedure volume, as evidenced by the hospital's routine and frequent use of IUSS of surgical instruments for surgical procedures;
b) failing to ensure a system for identifying all potential infections was implemented, as evidenced by not all surveys sent to physicians to collect data on potential or actual infections were returned each month by all physicians;
c) Failing to ensure all personnel wore the appropriate surgical attire while in restricted OR areas as evidenced by personnel with hair exposed from under bouffant and skull cap head coverings while in the restricted areas;
d) Failing to ensure physicians followed hospital policy and standards of care in surgery by allowing physicians to perform procedures in the ORs, including epidural injections, without wearing a mask;
e)Failing to ensure surgical scrubs worn by staff in the operating suite were laundered according to acceptable standards and practice for linen used in a hospital OR, as evidenced by surgical scrubs laundered on-site no monitoring of each load.
f) Failing to ensure that staff adhered to acceptable infection control practices for the cleaning/disinfecting of patient multi-use handheld glucometers;
g) Failing to ensure a sanitary hospital environment was maintained as evidenced by having a layer of dust that resulted in a "dust bunny" after rubbing one's finger over the top of the suction canisters in Rooms "a", "b", "c", "d", "e", and "f" and having dust collected on the screens and fan blades of portable stand fans in Rooms "c" and "d"; and
h) Failing to create policies delineating the responsibilities of the medical and/or nursing staff regarding procedures for identification and handling of high risk and/or infectious bodies after death. (See findings at A-0749)


3) Failure to ensure the CEO, Medical Staff, and DON ensured the QAPI and training programs addressed problems identified by the infection control officer and was responsible for the implementation of successful corrective action plans in affected problem areas. This deficient practice was evidenced when staff, including the infection control officer, were aware that physicians did not wear masks during all procedures in ORs, but did not formulate and implement a corrective action plan for the problem. (see findings at A-0756)

Based on record review and interview the hospital failed to ensure the infection control officer was qualified as evidenced by no education, training, experience, or certification for S14IP
Findings:


Review of the personnel file for S14IP revealed no documentation of specialized training in infection control. Further review revealed no prior experience in the development or oversight of an infection control program.

In an interview 12/16/15 at 4:35 p.m., S14IP confirmed she had no prior experience in the implementation or oversight of an infection control program. S14IP further confirmed she had not received any specialized training in the development, implementation, or oversight of an infection control program.

Based on record reviews, interviews, and observations the hospital failed to ensure the infection control officer implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:

1) Failing to ensure that surgical services were provided in accordance with acceptable professional standards of practice by failing to ensure that surgical instruments were available in a quantity that was commensurate with the hospital's expected daily procedure volume, as evidenced by the hospital's routine and frequent use of IUSS of surgical instruments for surgical procedures;
2) failing to ensure a system for identifying all potential infections was implemented, as evidenced by not all surveys sent to physicians to collect data on potential or actual infections were returned each month by all physicians;
3) Failing to ensure all personnel wore the appropriate surgical attire while in restricted OR areas as evidenced by personnel with hair exposed from under bouffant and skull cap head coverings while in the restricted areas;
4) Failing to ensure physicians followed hospital policy and standards of care in surgery by allowing physicians to perform procedures in the ORs, including epidural injections, without wearing a mask;
5) Failing to ensure surgical scrubs worn by staff in the operating suite were laundered according to acceptable standards and practice for linen used in a hospital OR, as evidenced by surgical scrubs laundered on-site with no monitoring of each load;
6) Failing to ensure that staff adhered to acceptable infection control practices for the cleaning/disinfecting of patient multi-use handheld glucometers;
7) Failing to ensure a sanitary hospital environment was maintained as evidenced by having a layer of dust that resulted in a "dust bunny" after rubbing one's finger over the top of the suction canisters in Rooms "a", "b", "c", "d", "e", and "f" and having dust collected on the screens and fan blades of portable stand fans in Rooms "c" and "d"; and
8) Failing to create policies delineating the responsibilities of the medical and/or nursing staff regarding procedures for identification and handling of high risk and/or infectious bodies after death. Findings:


1) failing to ensure that surgical services were provided in accordance with acceptable professional standards of practice by failing to ensure that surgical instruments were available in a quantity that was commensurate with the hospital's expected daily procedure volume, as evidenced by the hospital's routine and frequent use of IUSS of surgical instruments for surgical procedures;

A review of AORN Guidelines for Perioperative Practice, 2015 edition - Guideline for Sterilization: Recommendation VII revealed in part: Immediate Use Steam Sterilization (IUSS) should be kept to a minimum and should only be used in selected clinical situations. Immediate use is considered the shortest time possible between a sterilized item's removal from the sterilizer and its aseptic transfer to the sterile field. IUSS should only be used when there is insufficient time to process by the preferred wrapped or container method intended for terminal sterilization. IUSS should not be used as a substitute for sufficient inventory.
Review of a hospital policy titled "Immediate Use Steam Sterilization" (# STE-06, revised and approved 3/15), provided by S17RN as current, revealed, in part, the purpose of the policy and procedure was to provide for sterilizing or instruments needed in an emergency or urgent situation... IUSS was to be used only when necessary.

Review of Autoclave logs for IUSS use in December 2015 , provided by S17RN revealed, in part the following use of IUSS:
12/16/15 - 7 loads containing eye instruments processed;
12/11/15- 2 loads containing podiatry instruments processed.
In an interview 12/17/15 at 11:40 a.m. S17RN reported that the 2 loads of podiatry instruments were processed by IUSS because the instrument representative had not brought the instruments into the hospital until that morning, before the scheduled cases. She indicated IUSS was used so the scheduled surgeries would not have to be rescheduled, as there was not enough time to process the instruments in a full sterilization cycle.
12/8/15- 7 loads of eye instruments processed
12/9/15-7 loads of eye instruments processed
12/7/15- 2 loads of eye instruments processed
12/4/15- Total Laparoscopic Hysterectomy set. S17RN was unable to provided a reason for IUSS processing of this instrument set.
12/3/15- 25 loads of eye instruments processed (1 load contained 2 sets of instruments)
12/2/15- 5 loads of eye instruments processed
12/1/15- 13 loads of eye instruments processed
Further review revealed the logs were not consistently completed, with patient sticker (information), initials of staff performing the processing, and the results of the biological indicators sometimes omitted. Review of IUSS logs for 10/28/15 through 12/16/15 revealed no reason for the use of IUSS for each load.

In an interview 12/16/15 at 3:15 p.m. S17RN reported that the OR used AORN standards. S17RN indicated that the hospital routinely used IUSS, most often with ophthalmic procedures because they did not have enough sets of instruments for the usual number of scheduled surgeries in a day.

In an interview 12/17/15 at 3:50 p.m. S11MedDir reported he was not aware that the hospital was using IUSS for routine processing of surgical instruments due to insufficient inventory.


2) failing to ensure a system for identifying all potential infections was implemented, as evidenced by not all surveys sent to physicians to collect data on potential or actual infections were returned each month by all physicians.
In an interview 12/16/15 at 4:35 p.m. S14IP reported she collected data for the tracking of infections, in part, by providing a survey to all physicians who had patients under their care at the hospital by month. The physicians were to document whether or not there had been any patient with signs and symptoms of a potential infection. S14IP reported that there was a problem with getting the information returned to her from some of the physicians. She reported that if she did not receive a response from a physician, she would refax the list of patients to that physician up to 3 times. S14IP indicated that if she still did not receive a response with information requested, nothing further was done. S14IP reported she had notified administration when she had problems getting a response to the request for information, but was told just to send another fax. S14IP agreed the process for tracking infections was not complete, and left potential infections unreported.

Review of a list of physicians to whom a list of their patients receiving services at the hospital the previous month, revealed the following number a surveys not returned out of a total by month:
December 2014: 2 of 27 not returned
January 2015: 3 of 25 not returned
March 2015: 2 of 25 not returned
April 2015: 4 of 24 not returned
May 2015: 5 of 24 not returned
June 2015: 3 of 24 not returned
July 2015: 5 of 30 not returned
August 2015: 6 of 30 not returned
Sept 2015 6 of 30 not returned

In an interview 12/17/15 at 10:50 a.m. S1ADM reported that when a physician does not return the Infection Control survey for information on any potential or actual infection after surgery or a procedure, the hospital just keeps sending another fax. When asked if there was any action taken beyond that, she responded, "No."


3) failing to ensure all personnel wore the appropriate surgical attire while in restricted OR areas as evidenced by personnel with hair exposed from under bouffant and skull cap head coverings while in the restricted areas;

Review of a hospital policy and procedure titled " Surgical Attire" (revised and approved 3/15), provided by S17RN as current, revealed that all persons entering the OR would be attired by the guidelines established for (hospital name). Further review revealed the following:
"1. Proper surgical attire is worn by all persons within the restricted areas of the surgical suite. Surgical attire shall include scrub clothes, hair coverings (surgical caps), masks... 7. All possible head and facial hair, including sideburns and necklines are to be covered..."

An observation 12/16/15 at 9:05 a.m. in an OR revealed staff setting up sterile surgical instruments. S28CFA was observed to wear a skull cap, with the back lower portion of the hair on his head uncovered.

An observation in the OR restricted areas 12/16/15 from 10:00 a.m. to 10:30 a.m., with S17RN present, revealed the following, in part:
S21CRNA in the sterile corridor with a skull cap on with hair exposed at the sides and lower back of his head, S22CRNA in the sterile corridor with a skull cap on and hair exposed below the skull cap, and S29XRT walking from the sterile corridor into OR 3 with a bouffant cap on and her hair exposed across the front of her head, and strands exposed from the sides of her head . An observation of S16ORT entering the sterile corridor revealed he was wearing a skull cap with the lower portion of the back of his head exposed. S17RN confirmed the observations. S17RN, present during the observations, reported that the surgical department followed AORN recommendations and all hair should be covered in the restricted areas.


4) failing to ensure physicians followed hospital policy and standards of care in surgery by allowing physicians to perform procedures in the ORs, including epidural injections, without wearing a mask;

Review of a hospital policy and procedure titled " Surgical Attire" (revised and approved 3/15), provided by S17RN as current, revealed that all persons entering the OR would be attired by the guidelines established for (the hospital name). Further review revealed the following:
"1. Proper surgical attire is worn by all persons within the restricted areas of the surgical suite. Surgical attire shall include scrub clothes, hair coverings (surgical caps), masks. Masks are to be worn when in the presence of open sterile supplies and changed between patients and discarded. Masks are to be removed before leaving the OR suite."

Review of a CDC document titled "CDC Clinical Reminder: Spinal Injection Procedures Performed without a Facemask Post Risk for Bacterial Meningitis" revealed in part that recommendations included face masks should always be used when injecting material or inserting a catheter into the epidural or subdural space.
An observation 12/16/15 at 9:05 a.m. in an OR revealed staff setting up sterile surgical instruments. Further observation revealed S30MD enter the OR, instruct the surveyor that he wanted her out of his OR, with no mask on. The sterile table had surgical instruments uncovered in preparation for a surgical procedure, with S20RN, S28CFA,and S31CST present in the OR and witnessing the physician in the OR without a mask while instruments were open on the sterile table.

An observation 12/16/15 at 10:31 a.m. to 10:50 a.m. , in OR #4 revealed S32MD perform a right Genicular Block on Patient #28. Further observation revealed S32MD entered the OR, performed the procedure and left without putting on a mask. At no time did the RN circulator, Certified Scrub Tech, or the Radiology Tech, present during the procedure acknowledge the physician was not wearing a mask.
In an interview 12/16/15 at 10:40 a.m. S33RN verified S32MD had not worn a mask at anytime in the OR. S33RN reported that the physicians do not always wear a mask, and it is usually during pain procedures. S33RN indicated that hospital policy stated that masks were to be worn anytime there were open surgical instruments for any and all procedures. When asked why no one acknowledged the physician did not have a mask on, and correct the deficient practice, she replied, "We can't make them (physicians)[wear a mask]."
In an interview 12/16/15 at S17RN confirmed the hospital's P&P that masks were to be worn during all procedures performed in the ORs was not enforced. She indicated that it was usually during pain procedures that the physicians performed procedures without a mask. S17RN confirmed these instances included epidural injections. S17RN indicated she was aware of the recommendations that surgical attire that included a mask be worn during the injection of the epidural or subdural spaces. When asked why the physicians were not required to use the surgical attire as per AORN and CDC standards and hospital policy, S17RN had no answer.
In an interview 12/17/15 at 9:15 a.m. S3CC reported that the problem of some physicians not compliant with the wearing of surgical masks had been identified, but had not been documented or incorporated into QA.

5) failing to ensure surgical scrubs worn by staff in the operating suite were laundered according to acceptable standards and practice for linen used in a hospital OR, as evidenced by surgical scrubs laundered on-site with no monitoring of each load.

A review of the AORN Standards and Recommended Practices for the Ambulatory Setting, 2013 Edition, - Recommended Practices for Surgical Attire, Recommendation V revealed that surgical attire should be laundered in a health care-accredited laundry facility either on-site or through a contracted service which incorporate OSHA and CDC guidelines and professional association's recommended practices that follow industry standards through the HLAC. Laundering by non- HLAC accredited facilities can not be monitored for quality, consistency or safety, and laundering may not meet the specified measures necessary to achieve a reduction in microbial levels in soiled surgical attire with measures that involve mechanical, thermal, and chemical components.
Review of a hospital policy and procedure titled "Linen Processing", (#INF-015) provided by S17RN as current, revealed, in part, it was the policy that the hospital laundry would be properly processed and commercially laundered, with the exception of some surgical attire.
Further review revealed no guidelines for the laundering of surgical scrubs, an approved detergent, or the maintenance, cleaning, and disinfection of the washer and dryer.

In an interview 12/16/15 at 3:30 p.m. S17RN reported that hospital linens were laundered by a contacted commercial laundry service, with the exception of the surgical scrubs worn by anyone going into the restricted or semi-restricted areas of the OR. S17RN reported that the surgical attire, physician's gowns used in Endoscopy, and some towels used by the Decontamination and Sterilization Department were laundered onsite by S16ORT. S17RN reported one would have to speak to S16ORT for any information for logs or monitoring required measures for the laundering of surgical scrubs.

In an interview 12/17/15 at 12: 20 p.m. S16ORT reported that he laundered OR surgical attire which included gowns worn in Endoscopy, surgical scrubs, fabric head coverings, and towels used in decontamination and sterilization. S16ORT reported he was taught by the previous employee responsible for laundered scrubs. S16ORT reported that no logs were kept for the processing of laundry onsite. S16ORT confirmed there was no process for verifying the temperature or any other parameter to be monitored for the laundering of linens used in the hospital setting.

6) failing to ensure that staff adhered to acceptable infection control practices for the cleaning/disinfecting of patient multi-use handheld glucometers;

In an interview 12/16/15 at 9:38 a.m. S15RN reported that she had just performed a capillary blood glucose on Patient #29. S15RN reported that she cleaned the glucometer with 70% alcohol spray. The RN further indicated that the process for cleaning the HemoCue machines (for capillary blood glucose and one for hematocrit reading) had recently been changed due to an inservice by the HemoCue representative in which the facility was instructed to stop using Caviwipes and start using 70% alcohol spray. The staff was requested to contact the company and inquire if there were recommended procedures for cleaning AND disinfecting the machine when used in the hospital for multiple patients.
Review of a hospital policy and procedure for the HemoCue B-Hemoglobin/Glucose Analyzer (revised and approved 3/15), provided by S17RN as current, revealed,in part, that the analyzer would be cleaned if visibly soiled to guarantee accurate readings...Cleaning of the microcurvette holder will be done daily to rid of dust, dirt, and blood... 1. Completely remove microcurvette holder from the photometer, 2) Use a Q-tip swab, soap/water or alcohol wipe to cleanse,3) Allow the holder to completely dry, 4) Place back into the machine. Further review revealed no instructions regarding disinfecting the machine.
A document, provided by S17RN 12/16/15, which was received from the HemoCue company, by the hospital, after inquiring as to the disinfection of the machine used on multiple patients was reviewed. The document cited the suggested surface disinfection agents for the analyzers included Caviwipes . The document, with a date of 11/24/14 read, " Due to the recent concerns regarding disinfection of laboratory and point-of-care instrumentation, HemoCue provides this as a guide for handling of HemoCue point-of-care analyzers- Per CDC guidelines, disinfect the analyzer between testing different patients..."

7) failing to ensure a sanitary hospital environment was maintained as evidenced by having a layer of dust that resulted in a "dust bunny" after rubbing one's finger over the top of the suction canisters in Rooms "a", "b", "c", "d", "e", and "f" and having dust collected on the screens and fan blades of portable stand fans in Rooms "c" and "d"; and

Observations on the tour of PSU on 12/15/15 at 9:15 a.m. revealed dust was collected on the tops of the suction canisters that resulted in a "dust bunny" when the surveyor rubbed her finger along the top. This was evident in Rooms "a", "b", "c", "d", "e", and "f". Continuous observations revealed the portable stand fans in Rooms "c" and "d" had dust collected on the blades and screen of the fans. These observations were confirmed during the tour by S2DON.


8) Failing to create policies delineating the responsibilities of the medical and/or nursing staff regarding procedures for identification and handling of high risk and/or infectious bodies after death.
Review of the hospital's policies revealed no documented evidence of policies delineating the responsibilities of the medical and/or nursing staff regarding procedures for identification and handling of high risk and or infectious bodies after death.
In an interview on 12/16/15 at 4:39 p.m. S3CC confirmed the hospital had no policies delineating the responsibilities of the medical and/or nursing staff regarding procedures for identification and handling of high risk and/or infectious bodies after death.








25065

Based on record review, observation, and interview, the hospital failed to ensure the CEO, Medical Staff, and DON ensured the QAPI and training programs addressed problems identified by the infection control officer and was responsible for the implementation of successful corrective action plans in affected problem areas. This deficient practice was evidenced when staff, including the infection control officer, were aware that physicians did not wear masks during all procedures in ORs, but did not formulate and implement a corrective action plan for the problem.
Findings:


Review of the QAPI documents revealed no documentation of a problem with physicians not adhering to hospital policy and procedure and AORN standards of care.


Review of a hospital policy and procedure titled " Surgical Attire" (revised and approved 3/15), provided by S17RN as current, revealed that all persons entering the OR would be attired by the guidelines established for (the hospital name). Further review revealed the following:
"1. Proper surgical attire is worn by all persons within the restricted areas of the surgical suite. Surgical attire shall include scrub clothes, hair coverings (surgical caps), masks. Masks are to be worn when in the presence of open sterile supplies and changed between patients and discarded. Masks are to be removed before leaving the OR suite."

An observation 12/16/15 at 10:31 a.m. to 10:50 a.m. , in OR #4 revealed S32MD perform a right Genicular Block on Patient #28. Further observation revealed S32MD entered the OR, performed the procedure and left without putting on a mask. At no time did the RN circulator, Certified Scrub Tech, or the Radiology Tech, present during the procedure acknowledge the physician was not wearing a mask.
In an interview 12/16/15 at 10:40 a.m. S33RN verified S32MD had not worn a mask at anytime in the OR. S33RN reported that the physicians do not always wear a mask, and it is usually during pain procedures. S33RN indicated that hospital policy stated that masks were to be worn anytime there were open surgical instruments for any and all procedures. When asked why no one acknowledged the physician did not have a mask on, and correct the deficient practice, she replied, "We can't make them (physicians)."
In an interview 12/16/15 at S17RN confirmed the hospital's P&P that masks were to be worn during all procedures performed in the ORs was not enforced. She indicated that it was usually during pain procedures that the physicians performed procedures without a mask. S17RN confirmed these instances included epidural injections. S17RN indicated she was aware of the recommendations that surgical attire that included a mask be worn during the injection of the epidural or subdural spaces. When asked why the physicians were not required to use the surgical attire as per AORN and CDC standards and hospital policy, S17RN had no answer.
In an interview 12/17/15 at 9:15 a.m. S3CC reported that the problem of some physicians not compliant with the wearing of surgical masks had been identified, but had not documented or incorporated into QA.

Based on record reviews and interview, the hospital failed to ensure:
1) the implementation of a system for notifying patients and physicians that they can request a discharge planning evaluation.
2) the discharge planning evaluation included an assessment of the patient's insurance coverage and how it might or might not provide for necessary services post-hospitalization for 4 (#23, #24, #25, #26) of 5 (#2, #23, #24, #25, #26) patient records reviewed for discharge planning.
Findings:

1) Failing to ensure for the implementation of a system for notifying patients and physicians that they can request a discharge planning evaluation:
Review of the hospital policy titled "Discharge Planning", presented as a current policy by S3CC, revealed that during the admit process, the RN will screen the patient utilizing the Admit History and PSU Admit form to determine which patients are at risk for adverse health consequences post-discharge utilizing discharge planning criteria. Further review revealed the physician, patient and/or patient's representative may request a discharge plan. There was no documented evidence of the process for notifying the physician and patient that they could request a discharge planning evaluation in the policy.

Review of Patient R1's PSU Admit Form dated 12/16/15 at 7:00 p.m. revealed the section under "Discharge Plan" with a box to check for "Pt (patient)/caregiver aware of right to request plan" had no check in the box.

In an interview on 12/17/15 at 12:30 p.m., Patient R1, after having been informed of what a discharge planning evaluation is, indicated no one at the hospital told her that she could request a discharge planning evaluation.

In an interview on 12/17/15 at 12:40 p.m., S9LPN indicated the hospital did not have a process or system in place for notifying the physician that he/she could request a discharge plan.


2) Failing to ensure the discharge planning evaluation included an assessment of the patient's insurance coverage and how it might or might not provide for necessary services post-hospitalization:
Review of the hospital policy titled "Discharge Planning", presented as a current policy by S3CC, revealed no documented evidence that the discharge planning evaluation included an assessment of the patient's insurance coverage and how it might or might not provide for necessary services post-hospitalization.

In an interview on 12/17/15 at 12:40 p.m., S9LPN indicated they don't include a review of the patient's insurance coverage relative to how it might or might not provide for necessary services post-hospitalization.

Based on record reviews and interview, the hospital failed to ensure each patient was counseled to prepare them for post-hospital care as evidenced by failure to provide a clear indication of changes from the patient's preadmission medications to medications the patient should be taking at discharge and educating the patient or support person of the changes for 5 (#2, #23, #24, #25, #26) of 5 patient records reviewed for discharge planning from a total sample of 30 patients.
Findings:

Review of the hospital policy titled "Discharge Planning", presented as a current policy by S3CC, revealed no documented evidence that the policy addressed that there had to be a clear indication of changes between the preadmission medications and those prescribed at discharge and that the patient and/or caregiver had to be educated on the specific changes.

Review of the medical records of Patients #2, #23, #24, #25, and #26 revealed there wasn't a clear indication of changes from the patient's preadmission medications to medications the patient should be taking at discharge. Further review revealed no documented evidence that patient or caregiver was educated on the changes from the preadmission medications to those prescribed at discharge.

In an interview on 12/17/15 at 12:40 p.m., S9LPN confirmed the documentation of the medications at discharge for each of the above patients did not include a clear indication of changes from the preadmission medication and those the patient was to take at discharge, and thus the education of the patient and/or caregiver did not include this information.

Based on observation, record review, and interview the hospital failed to meet the Condition of Participation in Surgical Services as evidenced by:

1) Failing to implement and enforce policies and procedures in accordance with acceptable standards of practice (safe medical care and safe surgical patient care) as evidenced by:
a) failing to ensure that surgical services were provided in accordance with acceptable professional standards of practice by failing to ensure that surgical instruments were available in a quantity that was commensurate with the hospital's expected daily procedure volume, as evidenced by the hospital's routine and frequent use of IUSS of surgical instruments for surgical procedures;
b) failing to ensure all personnel wore the appropriate surgical attire while in restricted OR areas as evidenced by personnel with hair exposed from under bouffant and skull cap head coverings while in the restricted areas;
c) failing to ensure physicians followed hospital policy and standards of care in surgery by allowing physicians to perform procedures in the ORs, including epidural injections, without wearing a mask. (see findings in A-0951)

Based on record review, observation, and interview, the facility failed to implement and enforce policies and procedures in accordance with acceptable standards of practice (safe medical care and safe surgical patient care) as evidenced by:
1) Failing to ensure that surgical services were provided in accordance with acceptable professional standards of practice by failing to ensure that surgical instruments were available in a quantity that was commensurate with the hospital's expected daily procedure volume, as evidenced by the hospital's routine and frequent use of IUSS of surgical instruments for surgical procedures;
2) Failing to ensure all personnel wore the appropriate surgical attire while in restricted OR areas as evidenced by personnel with hair exposed from under bouffant and skull cap head coverings while in the restricted areas;
3) Failing to ensure physicians followed hospital policy and standards of care in surgery by allowing physicians to perform procedures in the ORs, including epidural injections, without wearing a mask;


1) failing to ensure that surgical services were provided in accordance with acceptable professional standards of practice by failing to ensure that surgical instruments were available in a quantity that was commensurate with the hospital's expected daily procedure volume, as evidenced by the hospital's routine and frequent use of IUSS of surgical instruments for surgical procedures;

A review of AORN Guidelines for Perioperative Practice, 2015 edition - Guideline for Sterilization: Recommendation VII revealed in part: Immediate Use Steam Sterilization (IUSS) should be kept to a minimum and should only be used in selected clinical situations. Immediate use is considered the shortest time possible between a sterilized item's removal from the sterilizer and its aseptic transfer to the sterile field. IUSS should only be used when there is insufficient time to process by the preferred wrapped or container method intended for terminal sterilization. IUSS should not be used as a substitute for sufficient inventory.
Review of a hospital policy titled "Immediate Use Steam Sterilization" (# STE-06, revised and approved 3/15), provided by S17RN as current, revealed, in part, the purpose of the policy and procedure was to provide for sterilizing or instruments needed in an emergency or urgent situation... IUSS was to be used only when necessary.

Review of Autoclave logs for IUSS use in December 2015 , provided by S17RN revealed , in part the following use of IUSS:
12/16/15 - 7 loads containing eye instruments processed;
12/11/15- 2 loads containing podiatry instruments processed.
In an interview 12/17/15 at 11:40 a.m. S17RN reported that the 2 loads of podiatry instruments were processed by IUSS because the instrument representative had not brought the instruments into the hospital until that morning, before the scheduled cases. She indicated IUSS was used so the scheduled surgeries would not have to be rescheduled, as there was not enough time to process the instruments in a full sterilization cycle.
12/8/15- 7 loads of eye instruments processed;
12/9/15-7 loads of eye instruments processed
12/7/15- 2 loads of eye instruments processed
12/4/15- Total Laparoscopic Hysterectomy set. S17RN was unable to provided a reason for IUSS processing of this instrument set.
12/3/15- 25 loads of eye instruments processed (1 load contained 2 sets of instruments)
12/2/15- 5 loads of eye instruments processed
12/1/15- 13 loads of eye instruments processed
Further review revealed the logs were not consistently completed, with patient sticker (information) , initials of staff performing the processing, and the results of the biological indicators sometimes omitted. Review of IUSS logs for 10/28/15 through 12/16/15 revealed no reason for the use of IUSS for each load.

In an interview 12/16/15 at 3:15 p.m. S17RN reported that the OR used AORN standards. S17RN indicated that the hospital routinely used IUSS, most often with ophthalmic procedures because they did not have enough sets of instruments for the usual number of scheduled surgeries in a day.

In an interview 12/17/15 at 3:50 p.m. S11MedDir reported he was not aware that the hospital was using IUSS for routine processing of surgical instruments due to insufficient inventory.


2) Failing to ensure all personnel wore the appropriate surgical attire while in restricted OR areas as evidenced by personnel with hair exposed from under bouffant and skull cap head coverings while in the restricted areas;

Review of a hospital policy and procedure titled " Surgical Attire" (revised and approved 3/15), provided by S17RN as current, revealed that all persons entering the OR would be attired by the guidelines established for (hospital name). Further review revealed the following:
"1. Proper surgical attire is worn by all persons within the restricted areas of the surgical suite. Surgical attire shall include scrub clothes, hair coverings (surgical caps), masks... 7. All possible head and facial hair, including sideburns and necklines are to be covered..."

An observation 12/16/15 at 9:05 a.m. in an OR revealed staff setting up sterile surgical instruments. S28CFA was observed to wear a skull cap, with the back lower portion of the hair on his head uncovered.

An observation in the OR restricted areas 12/16/15 from 10:00 a.m. to 10:30 a.m., with S17RN present, revealed the following, in part:
S21CRNA in the sterile corridor with a skull cap on with hair exposed at the sides and lower back of his head, S22CRNA in the sterile corridor with a skull cap on and hair exposed below the skull cap, and S29XRT walking from the sterile corridor into OR 3 with a bouffant cap on and her hair exposed across the front of her head, and strands exposed from the sides of her head . An observation of S16ORT entering the sterile corridor revealed he was wearing a skull cap with the lower portion of the back of his head exposed. S17RN confirmed the observations. S17RN, present during the observations, reported that the surgical department followed AORN recommendations and all hair should be covered in the restricted areas.


3) Failing to ensure physicians followed hospital policy and standards of care in surgery by allowing physicians to perform procedures in the ORs, including epidural injections, without wearing a mask;

Review of a hospital policy and procedure titled " Surgical Attire" (revised and approved 3/15), provided by S17RN as current, revealed that all persons entering the OR would be attired by the guidelines established for (the hospital name). Further review revealed the following:
"1. Proper surgical attire is worn by all persons within the restricted areas of the surgical suite. Surgical attire shall include scrub clothes, hair coverings (surgical caps), masks. Masks are to be worn when in the presence of open sterile supplies and changed between patients and discarded. Masks are to be removed before leaving the OR suite."

Review of a CDC document titled "CDC Clinical Reminder: Spinal Injection Procedures Performed without a Facemask Post Risk for Bacterial Meningitis" revealed in part that recommendations included face masks should always be used when injecting material or inserting a catheter into the epidural or subdural space.
An observation 12/16/15 at 9:05 a.m. in an OR revealed staff setting up sterile surgical instruments. Further observation revealed S30MD enter the OR, instruct the surveyor that he wanted her out of his OR, with no mask on. The sterile table had surgical instruments uncovered in preparation for a surgical procedure, with S20RN, S28CFA,and S31CST present in the OR and witnessing the physician in the OR without a mask while instruments were open on the sterile table.

An observation 12/16/15 at 10:31 a.m. to 10:50 a.m. , in OR #4 revealed S32MD perform a right Genicular Block on Patient #28. Further observation revealed S32MD entered the OR, performed the procedure and left without putting on a mask. At no time did the RN circulator, Certified Scrub Tech, or the Radiology Tech, present during the procedure acknowledge the physician was not wearing a mask.
In an interview 12/16/15 at 10:40 a.m. S33RN verified S32MD had not worn a mask at anytime in the OR. S33RN reported that the physicians do not always wear a mask, and it is usually during pain procedures. S33RN indicated that hospital policy stated that masks were to be worn anytime there were open surgical instruments for any and all procedures. When asked why no one acknowledged the physician did not have a mask on, and correct the deficient practice, she replied, "We can't make them (physicians)[wear a mask]."
In an interview 12/16/15 at S17RN confirmed the hospital's P&P that masks were to be worn during all procedures performed in the ORs was not enforced. She indicated that it was usually during pain procedures that the physicians performed procedures without a mask. S17RN confirmed these instances included epidural injections. S17RN indicated she was aware of the recommendations that surgical attire that included a mask be worn during the injection of the epidural or subdural spaces. When asked why the physicians were not required to use the surgical attire as per AORN and CDC standards and hospital policy, S17RN had no answer.
In an interview 12/17/15 at 9:15 a.m. S3CC reported that the problem of some physicians not compliant with the wearing of surgical masks had been identified, but had not been documented or incorporated into QA.







30984

Based on record review and interview, the hospital failed to assign an individual to be responsible for outpatient services.
Findings:

Review of the hospital organizational chart revealed no Outpatient designation on the chart.

In an interview on 12/17/15 at 10:50 a.m., S1ADM reported that no one was appointed as responsible for Outpatient Services.

Based on record review and interview, the hospital failed to ensure its respiratory care policy related to the cleaning of the I-Stat 1 Analyzer (used to perform blood gas testing) followed CDC guidelines for disinfecting equipment as evidenced by allowing staff to choose products that do not disinfect.
Findings:
Review of the CDC "Guidelines for Environmental Infection Control in Health-Care Facilities" revealed that medical equipment surfaces should be thoroughly cleaned by using EPA-registered disinfectants in accordance with manufacturer's instructions.

Review of the hospital policy titled "Care of the I-Stat 1 Analyzer and Downloader", presented as a current policy by S10CRT, revealed that the analyzer and downloader display screen and case can be cleaned using a mild non-abrasive cleaner, detergent, soap and water, Alcohol, 10% (per cent) bleach solution, or a Super Sani-Cloth.


In an interview on 12/17/15 at 10:45 a.m., S10CRT indicated the I-Stat 1 Analyzer machine is brought into the patient's room to perform the test. She confirmed some of the listed choices given to clean the equipment would not disinfect the equipment.