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Based on interview and document review, the facility failed to ensure their written policies and procedures were developed and implemented appropriately to ensure grievances were followed up on in a timely manner for 2 of 5 patient (P41 & P42) grievances reviewed. This had the potential to affect all patients and or patient representatives who filed a grievance with the hospital.

Findings include:

The facility failed to provide written responses to the patient and or the patients' representatives once the resolution to a patient grievance had been determined.

The facility's policy, on Complaint and Grievance Resolution, last reviewed on 10/14, indicated "Once the investigation has been completed and resolution has been determined, a letter will be sent to the patient indicating what steps were taken to investigate the issue, the resolution made, the date of completion, and the name, phone number, and address of the Rice representative".

During review of grievance documents, it was noted that a grievance had been filed on behalf of P41 by her daughter on 10/20/14. The grievance alleged that P41, who had been seen in the emergency room (ER) on 10/14/14, had been treated rudely and had been misdiagnosed. The grievance indicated P41 had not received appropriate treatment from the emergency room physician (Dr-10). According to the grievance review, another daughter had also submitted a grievance 10/30/14 on behalf of P41, regarding the emergency room visit 10/14/14. The second grievance indicated P41 had experienced previous difficulties with Dr-10.

Further document review revealed the chief medical officer (CMO) had responded to the 10/30/14 grievance regarding P41 on 11/4/14 by e-mail. The e-mail documentation indicated Dr-10 had been out of town the prior week, but that the CMO had discussed the grievance with Dr-10 and that Dr-10 would be responding by letter to P41. In addition, the documentation indicated the CMO had called the daughter who'd submitted the initial grievance. According to the documentation, that daughter had reported to the CMO that she'd completed a survey that had been sent to her and had called and left a message for the CEO but had not heard back. There was no indication in the documentation, whether or when this grievance had been resolved.

P42 was seen in the emergency room on 9/15/14 and the complaint was entered into the hospital system on 10/02/14. P42 could walk fine the day before couldn't walk the day of the first ED visit. DR-10 evaluated the patients strength and did other exam, and collected UA, CBC, BMP. No significant findings. DR-10 never asked the patient to ambulate. The daughter and son - in -law had a terrible time getting the P42 into their home due to all the flights of stairs. The following morning, P42 had facial droop and arm weakness, both of which were not evident the prior day. P42's daughter indicated in the grievance that she was most upset because they were sent home without a trial of ambulation and without a diagnosis. When the daughter voiced concern that she did not know how they were going to get her father into the house, she said DR-10 said, "It's not about you, its about the patient."

The documentation indicated the grievance was resolved on 10/2/14 when the CMO met with the family. However, there was no follow up letter that went out to the family member.

When interviewed at 2:45 p.m. 2/2/15, the CMO confirmed that grievances are not always immediately resolved, and that letters are not sent to patients to identify how the facility plans to investigate and resolve the issue.

Based on interview and document review, the facility failed to develop a written plan of quality improvement for the rehabilitation and materials management departments. This had the potential to affect all current and future patients who receive inpatient and outpatient services.

Findings include:

On 2/3/15, at 2:20 p.m. the manager of inpatient, outpatient and cardiac rehabiliation (RM)-A was interviewed and stated there was no written plan for quality improvement in the rehabilitation department. Although physical therapist (PT)-A stated that chart reviews were conducted to identify improvement, no documentation was maintained to review the process described. RM-A and PT-A verified the rehabilition department, which included inpatient, outpatient and cardiac rehah, had no measureable goals that were tracked as part of quality improvement.

On 2/4/15, at 11:00 a.m. the materials manager (MM)-A was interviewed and stated there was no written quality improvement plan for materials management. The department did not have measureable goals which were tracked as part of the quality improvement program.

During an interview on 2/4/15, at 1:01 p.m. associate administrator/quality director (QD)-A confirmed the materials department does not report quality data. The QD-A indicated, "I know, it is not what it should be. Materials is not doing anything for quality. They have been under a lot of transition lately." The QD-A verified it was a problem and that the materials department did a lot of important work which required monitoring, such as outdated supplies and sterilization of equipment.

On 2/4/15, at 2:35 p.m. the QD-A verified that neither the rehabilitation department nor the materials management department had a written quality improvement plan.

Based on interview and document review, the hospital failed to provide a safe and effective means of destroying unused controlled substances for 1 of 1 post anesthesia care unit (PACU).

Findings include:

A tour of the PACU on 2/4/15, at 9:30 a.m. was completed with the director of the operating room (OR). During the tour, an automatic secure drug dispensing system was observed. All medications including controlled narcotic medications are dispensed from the system when a patient requires a medication.

On 2/4/15, at 9:30 a.m. registered nurse (RN)-I was interviewed about the wasting of narcotic medications, when not completely utilized. RN-I, indicated she got a witness and discarded the remaining liquid from the syringe into the waste basket. When asked about the destruction of oral medications, she indicated when busy, she placed them into her pocket until she had time to take the medication to the pharmacy for destruction. When questioned whether the narcotics placed in her pocket could possibly be taken home, RN-I said, "That would never happen." The director of the OR responded by indicating, "That is not our policy." On 2/4/15, at 12:00 p.m. RN-J and RN-K confirmed they also have witnessed the destruction of medications and/or have discarded medications via the waste basket system.

Interview with the director of pharmacy on 2/4/15, at 10:45 a.m. revealed that all secure dispensing medication systems in the hospital have a wasting cabinet; however the PACU system did not. When asked the rationale for a lack of a waste cabinet in the location of the PACU, she replied that so little waste occurs in the PACU. The director of pharmacy indicated the correct/appropriate method of wasting medications would be via the sewer system for both orals and injectable liquids. In addition, verified that two witnesses were required.

Review of the number of wasted narcotic liquids from 8/1/14 thru 1/21/15, revealed 47 narcotic dosages were wasted. There was no evidence of pill form narcotics wasted.

The policy and procedure dated 5/14, and titled Medication Order Preparation, Administration, and Documentation revealed, if all or part of a controlled substance was wasted, the wastage must be witnessed by two people. Although the policy addressed the units having a waste dispenser cabinet, it did not address the units that did not have such a system available. An undated procedure titled, Rice's Pharmaceutical Waste Systems, revealed controlled substances were to be discarded utilizing the municipal sewer system.

Based on observation, interview, and record review, the hospital was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code inspection tags: K-0011, K-0038, and K-0062.

Based on observation and interview the facility failed to ensure that expired sterile supplies were monitored and removed for 4 of 14 endotracheal tubes (ET) stored on the airway cart in the emergency department (ED). In addition, the facility failed to ensure equipment was kept in a safe and sanitary manner in the rehabilitation department for 1 of 1 mini trampoline located in therapy.

Findings include:

On 2/4/15, during an ED tour from 9:30 a.m. to 11 a.m. the airway cart was observed with the following expired sterile supplies:
(1) One ET tube 6.5 mm labeled as "expired 4/2012" (21 months ago);
(2) One ET tube 6.5 mm labeled as "expired 4/2014" (9 months ago);
(3) In room 6, one irrigation bottle of normal saline 500 cc label indicated the product sterility was outdated and the product was labeled "expired 11/2013" (over 2 years ago);
(4) Two endotracheal tubes (ET) 8.5 millimeter (mm) (catheter inserted into the trachea to establish and maintain a patent airway) - label indicated the product sterility was outdated and the product was labeled "expired 12/2014" .

On, 2/4/15, at 10:30 a.m. the ED registered nurse department director (RN)-B and medical director (MD)-A verified the sterility outdates on the packages of the noted sterile supplies and confirmed they should not be available on the airway cart. RN-B stated the ED had a process for checking the sterility outdates in the supply carts and that the ED assistants were assigned to restock these carts. RN-B confirmed it was very likely the opportunity for utilizing the airway supplies (expired) in the ED rooms was high. MD-A agreed that outdated supplies cannot be kept on the airway cart.

Materials manager (MM)-1 stated the ED staff was responsible for stocked supplies and checked for outdated supplies in their department. In addition, MM-1 stated, "We don't have a policy about restocking supplies, it only addresses requesting supplies."

A policy related to monitoring for outdated "expired" sterile supplies was requested, but was not provided. The only policy provided was "request for supplies."


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On 2/3/14, at 2:30 p.m. a tour of the rehabilitation unit was conducted. A mini trampoline, located in the upper therapy room, had a torn jumping mat and foam padding was exposed on three sides. The mini trampoline also had exposed springs. The mini trampoline with its exposed and torn areas no longer had a cleanable surface. The rehabilitation manager (RM)-A verified on 2/3/14, at 2:30 p.m. that the mini trampoline should be replaced.

Based on interview, observation and document review the facility failed to ensure staff properly disinfected equipment (multi use blood glucose meters) when removed from 4 of 4 isolation rooms (Rooms- 2614, 2617, 2634 & 2636) located on the second floor nursing units. This had the potential to expose additional patients and staff on the 2nd floor to C-Diff infection. In addition, linen was uncovered in the main clean linen storage area.

Findings include:

On 2/3/15, at 11:00 a.m. registered nurse (RN)-D stated they clean the glucometers with a Sani wipe and then leave to dry for at least one minute (The manufacturer recommends to allow to dry two minutes).

During observation on the second floor on 2/3/15, at 11:00 a.m. RN-D used a glucometer (equipment used to measure blood sugar level) to monitor a patient's glucose level who was located in an isolation room for MRSA (Methicillin-resistant Staphylococcus Aureus). With donned gloves and an isolation gown, RN-D pricked the patient's finger so a drop of blood was available to measure the blood sugar level via the glucometer. After completion of the task, RN-D wiped off the equipment with a Sani wipe and immediately placed it into the plastic storage case and closed the case without any further cleaning. RN-D also did not allow any time for the glucometer to dry prior to it's placement into the plastic case which snapped shut. After the glucometer had been placed in the case, RN-D removed her soiled gloves and isolation gown, used hand sanitizer and then proceeded to handle the plastic case with her bare, clean hands which she had touched with the soiled gloves (had contact with blood) and had not cleaned with Sani wipe. The plastic case had been located/placed on the counter and had not been cleaned prior to removal. RN-D left the room, carrying the glucometer case with bare hands.

During another observation on the second floor on 2/3/15, at 11:35 a.m. RN-A used a glucometer while caring for a patient in the isolation room. After use, RN-A wiped the glucometer with a Sani wipe, wiped the inside of the case, placed the glucometer into the plastic case and closed the case. RN-A did not allow the manufacturer's recommended two minutes for drying. During an interview on 2/3/15, at 11:40 a.m. RN-A stated, "I guess I do not let it dry before putting it in the case".

The chief nursing officer (CNO) and associate administrator/quality director (QD) were interviewed on 2/3/15, at 11:30 a.m.. The CNO confirmed the glucometers were taken into the isolation rooms when blood sugars were monitored. CNO indicated that facility policy did not address a procedure related to cleaning the glucometer while wearing an isolation gown nor how to remove isolation protection (before or after cleaning equipment). Furthermore, the CNO stated the counter space located inside the door of the patient's room is designated as the nurse's work area and is considered clean. The CNO could not explain how that area stays clean since it is located inside the isolation room where personal protective equipment is required. CNO and QD both agreed "we need to re-work the process and re-educate the nurses".

During an interview on 2/3/15, at 2 p.m. RN-D stated that staff use the yellow colored top Sani wipes [with bleach, used to kill bacterium] for patients with a diagnosis of Clostridium difficile (C-diff, a bacterium that causes mild to severe diarrhea and intestinal conditions like pseudomembranous colitis or inflammation of the colon and is the most frequent cause of infectious diarrhea in hospitals.) RN-D indicated the yellow top Sani wipes have to be gotten from the materials department, stating "If it is not in the room, it can't be used."

During interview on 2/3/15, at 2:15 p.m. RN-E stated that if the yellow top Sani wipes (dispatch) were not available in the room, it probably isn't being used.


30951


During a subsequent interview on 2/4/5, at 1:00 p.m. RN-H stated that glucometers were cleaned with soap and water, alcohol wipes, and sometimes with disposable wipes. When asked which wipes were used, RN-H provided the super Sani-wipes. When informed that alcohol wipes did not provide adequate disinfection for multi-use equipment and that super Sani-wipes should be used except for C-diff which needed dispatch (bleach) wipes, RN-H presented no further clarification.

On 2/4/15, at 3:30 p.m. the director of nursing (DON) and infection preventionist (IP) accompanied surveyors on an additional tour of the enteric isolation rooms (2614, 2617, 2634, 2636) where C-diff precautions were implemented by staff when patients were admitted to the unit. Patient rooms 2617 and 2634 lacked the appropriate dispatch (bleach) Sani wipes required to disinfect multiple patient use equipment; such as glucometers which were transported in and out of patient rooms. The DON stated, "we will make sure that process is hardwired".

The Isolation Procedure Policy dated 5/14, directed .....Enteric GI Contact Precautions....Clean shared patient equipment with hospital-approved bleach based disinfectant. Regular disinfectants are not effective against C. diff spores.

It was observed on 2/4/15, at 11:00 a.m. that the linen carts located in the central linen processing area were uncovered. The carts held racks of scrubs, patient gowns, towels and bed spreads. Two additional racks, with attached dust covers, contained sheets and towels and were opened with the covers folded onto the top of the racks. The materials manager (MM)-1 stated the racks of clean patient care linen and scrubs were not covered and may have been in place for more than 7 days.