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Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by having all patient room doors at the off-site behavioral unit secured with three hinges on each door that were separated widely enough to facilitate potential ligature; having patients' bathroom doors at the off-site campus secured with 3 hinges on each that were separated widely enough to facilitate potential ligature; and having a wall mounted automatic soap dispenser in each patient bathroom at the off-site behavioral unit that provided potential ingestion and a potential ligature risk. This deficient practice presented a potential ligature risk and safety hazards for the 21 patients currently admitted to the unit. Findings:

Observations during a tour of the off-site behavioral unit on 06/07/16 at 8:30 a.m. revealed the following observations:
1) All patient room doors at the off-site behavioral unit were secured with 3 hinges on each that were separated widely enough to facilitate potential ligature.
2) All patient rooms inner bathroom doors at the off-site behavioral unit were secured with 3 hinges on each that were separated widely enough to facilitate potential ligature.
3) All patient bathrooms had a wall mounted automatic soap dispenser that provided potential ingestion of soap, and a potential ligature risk.

Interview on 06/07/16 at 10:00 a.m. with S5Administrative Assistant confirmed the above findings in each patient room.

Based on record reviews and interviews the hospital failed to develop and conduct a P.I. (Performance Improvement) Project as part of its QAPI (Quality Assurance Performance Improvement) Program, at least annually, that was proportional to the scope and complexity of the hospital's services and operations by no documented evidence that a P.I. Project was developed and conducted for 2015 and 2016.

Findings:
A review of the hospital's QAPI Program and QAPI binders as provided by S4DON for the acute care campus and S5Administrative Assistant for the psychiatric campus, as the complete QAPI information, revealed no documented evidence that a P.I. Project was developed and conducted for 2015 and 2016.

In an interview on 06/08/16 at 12:30 p.m. with S4DON for the acute care campus and S5Administrative Assistant for the psychiatric campus, S4DON indicated that he was responsible for the QAPI program for the acute care campus and S5Administrative Assistant indicated that she was responsible for the QAPI program for the psychiatric campus. S4DON and S5Administrative Assistant indicated that the hospital had not been developing and conducting P.I. Projects and further indicated that they were not aware that they had to develop and conduct a P.I. Project as part of its QAPI Program, at least annually, that was proportional to the scope and complexity of the hospital's services and operations. S4DON and S5Administrative Assistant indicated that the hospital did develop and conduct any P.I. Projects for 2015 or 2016.

Based on record reviews and interviews, the hospital's Governing Body failed to ensure the QAPI program reflected the complexity of all the hospital's services as evidenced by failing to include contracted services in the QAPI program.

Findings:
A review of the QAPI Program and binders, as provided by S4DON and S5Administrative Assistant, as the most current, revealed no documented evidence that Contract Services that provided direct patient care or services affecting the health and safety of patients were also included in the QAPI monitoring activities.

A review of the current QA (Quality Assurance) indicators being monitored in the QAPI Program revealed no documented evidence of QA indicators for the Contract Services.

In an interview on 06/08/16 at 12:30 p.m. with S4DON for the acute care campus and S5Administrative Assistant for the psychiatric campus, S4DON indicated that he was responsible for the QAPI program for the acute care campus and S5Administrative Assistant indicated that she was responsible for the QAPI program for the psychiatric campus. S4DON and S5Administrative Assistant indicated that the hospital had not developed QA indicators for the contracted services and Contract Services were not currently included in the QAPI monitoring activities.

Based on record reviews and interviews, the hospital: 1) failed to ensure that a competency skills assessment checklist was developed for respiratory care services for staff who provided respiratory care services to patients as evidenced by no documentation of a respiratory competency skills assessment for 6 (S8RN, S14LPN, S15LPN, S16RN, S17RN, S18RN) of 6 direct patient care nurses' employee files reviewed for respiratory care competency and 2) failed to ensure that a competency skills assessment checklist was developed for Central Process and failing to provide in-services and educational opportunities for 1 (S7NA) of 1 Central Process personnel who worked in the hospital's Central Process area.
Findings:
1) failed to ensure that a competency skills assessment checklist was developed for respiratory care services for staff who provided respiratory care services to patients as evidenced by no documentation of a respiratory competency skills assessment for 6 (S8RN, S14LPN, S15LPN, S16RN, S17RN, S18RN) of 6 direct patient care nurses' employee files reviewed for respiratory care competency
A review of the employee personnel files for S8RN, S14LPN, S15LPN, S16RN, S17RN, and S18RN revealed no documented evidence of a respiratory care competency skills assessment that had been performed for the nurses who provided respiratory care to patients; in the management of oxygen tanks, nasal cannulas, hand held nebulizers, and inhalers.
In an interview on 06/07/16 at 12:30 p.m. with S4DON, he indicated that the nurses were responsible for the delivery of respiratory care services for the patients who required respiratory care services to include: management of oxygen tanks, nasal cannulas, hand held nebulizers, and inhalers. S4DON indicated that the hospital did not employ or contract with respiratory therapists. S4DON indicated that the hospital's nursing staff were not being assessed/evaluated for respiratory care skills competency upon hire or annually.

2) failed to ensure that a competency skills assessment checklist was developed for Central Process and failing to provide in-services and educational opportunities for 1 (S7NA) of 1 Central Process personnel who worked in the hospital's Central Process area.
A review of the hospital policy titled, "Sterilization" , as provided by S4DON (Infection Control Officer) revealed in part: Nursing Services and Nursing Services personnel will be responsible for the processing, sterilization and quality control of sterile supplies and equipment in the hospital's Central Process area and quality assurance tests and documentation.
In an interview on 06/06/16 at 2:15 p.m. with S4DON he indicated that Central Process was under Nursing Services. S4DON indicated that S7NA (Nursing Assistant) was under Nursing Services and that she was responsible for the Central Process area that included the decontamination, processing and sterilization of the instruments used in the Emergency Department by the emergency room staff.

A review of the employee file for S7NA revealed that her Job Description Performance Evaluation and competency assessment, dated 08/08/15, listed her job title and competency as an "Admitting Clerk". There was no documented evidence in her employee file for a Job Description or a competency skills assessment for the Central Process area. Her job application and resume indicated that she had prior work experience in a Central Process area in 1983 at another hospital. A further review of S7NA employee file revealed no documented evidence of any continuing education or in-services in Central Process since her hire date of 30 years ago.

In an interview on 06/07/16 at 12:30 p.m. with S7NA she indicated that she was responsible for the Central Process area of the hospital. S7NA indicated that she did not have a competency skills assessment checklist for Central Process. She further indicated that she did not have any further in-services or training in Central Process during her employment at the hospital.
In an interview on 06/07/16 at 12:40 p.m. with S4DON he indicated that he was responsible for the annual performance evaluation and competency for S7NA. S4DON indicated that Nursing Service did not have a competency skills assessment checklist for Central Process and that S7NA was not been evaluated on Central Process job duties and tasks, only on her job description as an admitting clerk. He indicated that she was assigned the Central Process area due to her prior experience in Central Process many years ago.

In an interview on 06/07/16 at 12:50 p.m. with S1Administrator she indicated that S7NA was assigned Central Process duties because of her prior experience at another hospital. S1Administrator indicated that S7NA was not provided with any further in-services or training in Central Process after her hire.

Based on observation, and interview the hospital failed to ensure all patient medical records were properly stored in secure locations where they were protected from fire, water damage and other threats. This deficient practice was evidenced by the storage of approximately 230 cardboard bankers boxes, 2 open 5 shelved units, and 1 open 6 shelf unit with patient records unprotected from fire and water damage. Findings:

Review of the hospital policy titled " Secure Filing of Medical Records " , Number 4036, dated 06/11/12 revealed in part: Medical Records housed within the hospital shall be kept in secure areas ...protected from damage by fire or water.

Observation on 06/07/16 at 2:30 p.m. revealed a locked room with overhead sprinklers that contained 155 cardboard bankers' boxes containing patient records from 2011 - 2014 stacked on open metal shelves. Another locked room with overhead sprinklers contained 75 cardboard bankers' boxes stacked on open metal shelves, 2 open 5 shelf units, and 1 open 6 shelf unit containing open folders of patient records from 2009 - 2011.

Interview on 06/07/16 at 3:00 p.m. with S9HIM confirmed the records in the cardboard bankers' boxes and the patient records on open shelves were not protected from fire and/or water damage if the sprinklers were activated.

Based on record review and interview the hospital failed to ensure their policy to have all medical record entries authenticated, dated and timed was enforced. This deficient practice was evidenced verbal orders not dated and timed or authenticated for 3 of 3 (#1, #2, #3) medical records reviewed for completeness.
Findings:

Review of a hospital policy titled "Medical Record Guidelines" (Policy # 3002, effective date 06/13/07), provided by S1Administrator as current, revealed the following, in part:
"...*Written orders for all medications and other treatment. The physicians must have signed and noted the date and time of each order..."

Patient #1
Review of the medical record for patient #1 revealed he was admitted to the hospital 8/4/15. Further review revealed the following orders from S2Physician:
-8/4/15 at 7:30 p.m. -a VO for an EKG and repeat cardiac enzymes at midnight. The order was authenticated with no date or time documented with the physician's signature.
-8/4/15 at 9:40 p.m.- a VO for Tylenol 650 mg po now, and a magnesium level (lab) to be added to (previous) midnight lab. The order was authenticated with the signature of (MD) with no date and time.
--8/4/15 (no time)- a VO for "EKG now", with an authentication signature of (MD) with no date and time.
- an order with no date or time written by S2Physician, which read, "Transfer to (local area hospital with name of accepting physician). No date and time documented for order and/or signature.

Patient #2
Review of the medical record for patient #2 revealed he was admitted to the hospital 3/16/16. Further review revealed the following orders from S2Physician:
-3/16/16 at 8:00 p.m.-VO for substitution of Soma with Robaxin, and Zantac 150 mg po,. q AM. The authentication signature did not include a date and time.
-3/17/17 at 11:30 a.m.- a VO to change diet to Regular, double protein only. No authentication signature of S2Physician was documented.
-3/18/16 at 3:15 a.m.- a TO for Amylase and Lipase labs now. Authentication signature of S2Physician , without date and time.
-3/18/16 at 4:15 a.m. TO : clarification of order for CT of abdomen/pelvis with/with and without contrast. Authentication signature of S2Physician with no date and time.
-3/18/16 at 10:05 a.m.- VO "may have coffee". Authentication signature of S2Physician, with no date and time.
-3/18/16 at 4:00 p.m.- VO:.Discontinue Lovenox, resume (Aspirin) home med(ication) now and q AM. No authentication signature noted.

Patient #3
Review of the medical record for Patient #3 revealed she was admitted to the hospital 4/19/16. Further review revealed the following orders from S2Physician:
-4/21/16 at 11:25 a.m.- a VO to change the patient's diet to Regular Mechanical Soft diet, with double protein. The authentication signature had no documented date and time.
-4/22/16 at 11:05 a.m.- a VO for a chest x-ray. The authentication signature of S2Physician did not have a date and time documented.
-4/22/16 at 3:25 p.m. - a VO to discharge Patient #3 to home. The authentication signature of S2Physician did not have a documented date and time.

In an interview 6/7/16 at 4:40 p.m.. S3MR with S1Administrator present, reviewed the medical records for Patients #1, #2, and #3. S3MR verified the findings above in which S2Physician's authentication signatures were not dated and timed. S3MR verified the VOs for diet changes did not have an authentication signature of the ordering physician,, S2Physician, and the transfer order for Patient #1 did not have a date and time. S3MR reported that it was an ongoing problem, trying to get S2Physician to date and sign his authentication signature and sometimes for orders. S1Administrator verified that this deficient practice had been reviewed with her recently. She reported that the hospital patient census and flow was very low, so there was no reason entries should not be dated and signed at the time of documentation.

Based on record review and interview, the hospital failed to ensure radiological services were under the direction of a Radiologist as evidenced by failure of the Governing Body to appoint a member of the medical staff, specialized in radiology, as Medical Director of the hospital's Radiological Services.
Findings:
Review of the medical staff meeting minutes and Governing Body meeting minutes for 2015 and 2016 revealed no documentation of the appointment of a radiologist on the medical staff as medical director of radiological services.
In an interview 6/6/16 12:45 p.m. S1Administrator reported the hospital did not have an radiologist appointed to oversee radiological services.

Based on record review and interviews, the hospital failed ensure the Utilization Committee had two or more practitioners who were not involved in the patient's care to carry out the Utilization Review (UR) functions. Findings:

Review of the hospital's Medical Staff Bylaws and Rules and Regulations, Number 12.4 Utilization Review Committee, approved January 27, 2016, revealed in part the following: The committee shall include representation from the Medical Staff, Administration, Nursing Service, and Medical Records.

Review of the Utilization Review Committee meeting minutes dated March 9, 2016 revealed attendees as follows: S19Marketing Director, S4DON, S9HIM, S3MR, S1Administrator.

Interview on 06/08/16 at 10:00 a.m. with S1Administrator confirmed that the UR committee did not function as required and there were no physicians on the committee or involved in the meetings.

Based on record reviews, observations and interviews, the hospital's Infection Control Officer failed to identify, prevent, and control infection control issues and/or breaches by failing to implement an effective infection control risk assessment program consistent with acceptable infection control standards of practice in order to identify potential infection control issues/breaches and/or to mitigate risks associated with potential infection control risks as evidenced by:
1) failing to perform an infection control risk assessment prior to construction and renovations at the psych campus in order to identify any infection control risks during construction and renovations at the psych campus,
2) failing to have an acceptable workflow pattern in the Central Process room,
3) failing to monitor the Central Process room for the appropriate negative and positive pressures,
4) failing to have HLD (High Level Disinfectant) capability for non-disposable laryngoscope blades that were unable to be steam sterilized according to the manufacturer, and
5) failing to perform weekly BI (Biological Indicator) spore monitor testing according to CMS regulation and CDC guidelines.
Findings:
A review of the hospital policy titled, "Infection Control- Mission, Vision, Goals" , as provided by S4DON (Infection Control Officer) revealed in part: The Infection Control Program will oversee all infection control activities at the hospital and provide a safe environment for patients, staff and visitors by ensuring adequate infection control mechanisms, monitoring with active surveillance of infection control practices to identify infection control problems and to provide in-services and training as needed. The Infection Control Program will follow recognized standards of practice guidelines to include in part: CDC, CMS, OSHA, and State Licensing regulations.
1) failing to perform an infection control risk assessment prior to construction and renovations at the psych campus in order to identify any infection control risks during construction and renovations at the psych campus
A review of the hospital policy titled, "Construction and Renovation Guidelines" , as provided by S4DON revealed in part: The Infection Control Officer will be notified of plans for construction and renovation during the planning phase so a Risk Assessment and Preventive Measures Checklist can be completed to identify potential infection control issues.
In an interview on 06/08/16 at 11:45 a.m. with S1Administrator she indicated that the psych campus was currently undergoing new construction and renovations.
In an interview on 06/08/16 at 12:00 p.m. with S4DON he indicated that he was the Infection Control Officer. S4DON indicated that a Risk Assessment and Preventive Measures Checklist was not completed prior to construction and renovation to identify potential infection control issues as per hospital policy. S4DON further indicated that there was presently no Risk Assessment and Preventive Measures Checklist, in place at this time, for the construction and renovation project that was currently underway at the psych campus.

2) failing to have an acceptable workflow pattern in the Central Process room,
3) failing to monitor the Central Process room for the appropriate negative and positive pressures,
An observation on 06/06/16 at 2:45 p.m. in the presence of S4DON of the hospital's Central Process room (approximately 5 feet wide and 6 feet long), revealed a dirty and a clean area, not physically separated, with a workflow pattern that went from dirty to clean to dirty and with one door used for both entering and exiting. The door was directly across from the dirty sink area. The hospital's table top steam autoclave was located inside the room on the back wall to the right of the door. A further observation revealed a pan labeled "dirty" with an instrument in it that was located on the shelf above the autoclave and it was also next to a box containing clean autoclave supplies. Clean autoclave supplies were also noted on the shelf over the sink where instruments were decontaminated.
In an interview on 06/06/16 at 2:15 p.m. with S4DON he indicated that the Central Process room was used for both decontaminating dirty instruments from the ED and also for sterilization, since the room contained the autoclave used in the sterilization process. He indicated that the dirty and the clean areas were not physically separated and clean and dirty supplies were stored on the same shelf. S4DON was asked if the Central Process room was negative or positive pressure. He indicated that he did not know if the area was negative or positive pressure because it was not monitored.

4) failing to have HLD (High Level Disinfectant) capability for non-disposable laryngoscope blades that were unable to be steam sterilized according to the manufacturer
An observation on 06/06/16 at 2:15 p.m. in the presence of S4DON of the 2 (two) crash carts revealed that each crash cart contained approximately 8 (eight) loose non-disposable laryngoscope blades in the bottom drawer that were not identified/labeled as HLD or sterile.
In an interview on 06/06/16 at 3:00 p.m. S4DON he indicated that he did not know how the laryngoscope blades were cleaned/disinfected after each use and that the laryngoscope blades in the crash carts had not been used in a long time. He indicated that the hospital did not have a policy on the cleaning of laryngoscope blades. In another interview on 06/07/16 at 12:30 p.m. he indicated that the manufacturer instructions indicated that the laryngoscope blades could not be steam autoclaved and would have to be HLD. S4DON further indicated that the hospital did not have HLD capabilities, so the laryngoscope blades in the crash carts were probably cleaned with soap and water and them wiped with an EPA disinfectant and returned to the crash cart after use.

5) failing to perform weekly BI (Biological Indicator) spore monitor testing according to CMS regulation and CDC guidelines.
A review of the hospital policy titled, "Sterilization" , as provided by S4DON (Infection Control Officer) revealed in part: Nursing Services and Nursing Services personnel will be responsible for the processing, sterilization and quality control of sterile supplies and equipment in the hospital's Central Process area to include quality assurance tests and documentation.
A review of the CDC Guidelines 2003 and CMS regulations revealed that sterilizers must be monitored at least weekly with a BI indicator specific for spore testing.
A review of the BI spore testing log revealed that BI spore testing was being performed monthly; 01/29/16, 02/29/16, 03/29/16, 04/26/16, and 05/23/16.
In an interview on 06/07/16 at 12:45 p.m. with S7NA she indicated that she was the Central Process room person. S7NA indicated that the hospital only had one table top steam autoclave and that she was only performing and monitoring the autoclave for BI spore testing once a week.
In an interview on 06/07/16 at 12:50 p.m. with S4DON he indicated that he was the Infection Control Officer. S4DON indicated that he was monitoring the BI spore tests results in Infection Control and he was not aware that BI for spore testing had to be done weekly.
In an interview on 06/08/16 at 1:00 p.m. with S4DON he was made aware of the infection control breaches and the infection control risks identified by the surveyor during the survey. S4DON indicated that he was monitoring the Central Process room's activities in decontamination, processing and sterilization for infection control breaches; but. he was not very knowledgeable in Central Process activities and depended upon S7NA's input and knowledge. S4DON further indicated that he had not identified any of the infection control breaches or risks that were identified by the surveyor during the survey.