HospitalInspections.org

At the time of the revisit on 11/06/2014, this deficiency was not corrected.
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Based on medical record review and interviews with hospital staff, the hospital did not ensure that a physician provided adequate oversite and medical supervision of the personnel providing patient care.

Findings:

Pain management procedures are performed by the Certified Registered Nurse Anesthetist (CRNA).

The medical records for pain management patients contained electronic dictated Procedure Notes that were dated, timed and electronically signed by the CRNA.

The medical records did not contain documentation the supervising physician provided oversite to the CRNA.

The above information was confirmed by Staff SS on the afternoon of 11/06/14 during chart review.

At the time of the revisit on 11/06/2014, this deficiency was not corrected.
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Based on medical record review, surveyor observations and interviews with hospital staff, the hospital does not ensure the pharmacist follows the flow of medications from entry into the hospital to disposition. During the exit conference on the afternoon of 11/06/14, Staff KK was asked if she compared the Narcotic Administration Record to the patients' medical records to verify the amount of narcotics the patients' received. She stated no.

At the time of the revisit on 11/06/2014, this deficiency was not corrected.
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Based on review of review of hospital documents, policies and procedures and meeting minutes, surveyors' observations and interviews with staff, the hospital failed to:

a. Develop and maintain an active on-going infection control/infection prevention (IC) program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases among patients and staff to include Surgical Services;

b. Analyze infection preventionist (IP) surveillance data and concerns, develop corrective actions when needed and conduct follow-up to ensure corrective actions are appropriate and sustained to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel; and

Findings:

Plan/Program:
1. The hospital has not conducted a hospital-wide IC risk assessment to identify the types of patients, risks/concerns, organisms, and diseases prevalent in the community and hospital.

2. The hospital has not developed a current infection control plan (Plan) with details of the types and frequency of monitoring for all departments to ensure infection control policies and procedures are followed and a safe and sanitary environment is maintained according to current accepted standards of practice.

3. The hospital has not conducted a tuberculin risk assessment.

4. These findings were reviewed and confirmed with Staff B and D on 11/06/14 at 1200.


Surveillance:
1. The IC program has not monitored to ensure all departments followed infection control policies and current recognized infection control practices on a regular scheduled basis to ensure compliance. Staff B confirmed she did not conduct observations of entire tasks.

2. Documents provided and meeting minutes did not demonstrate that, other than identifying patient nosocomial infections, the IC program monitored and evaluated infections of patients and staff to ensure infections and communicable diseases were not transmitted between staff and between patients and staff.

3. According to documentation provided, Central sterile processing is not monitored, including, but not limited to:
a. Appropriate cleaning and packaging of instruments occurs, including endoscopes;
b. Sterilization practices - correct temperature, correct sterilizing time and correct dry time;
c. Appropriate disinfection occurs - products used according to manufacture's guidelines;

4. No monitoring of disinfectant applications throughout the hospital departments and locations to ensure:
a. Appropriate disinfectants are selected and used; and
b. The disinfectants are applied and remain "wet" contact time according to the manufacturers guidelines.

5. Isolation monitoring was not conducted to ensure:
a. Patients are placed in appropriate isolation according to current CDC guidelines;
b. Isolation materials/supplies are readily available (Although staff knew the locations,staff had to go from area to area to show the surveyor where they would obtain the needed supplies, including the isolation signs.);
c. Staff, physicians, volunteers, and visitor follow appropriate isolation requirements; and
d. Appropriate disinfection of the room occurs.


Observations:

On 11/06/14, the surveyors observed surgical instruments on a drying rack beside the sterilizer. Staff TT told the surveyors, that since the survey on 07/23/14, all instrument packs were autoclaved for 4 minute sterilization and one minute exhaust/dry time. She stated that the instruments had to be left out so they would dry because if they unwrapped the instruments as soon as they came out of the sterilizer, they would be wet. This practice does not follow manufacture recommendations.

The surveyors observed cardboard boxes in the surgical semi-restricted area.


Meeting Minutes:
Staff B and D stated that infection control data would be taken to Quality Improvement (the hospital's quality assessment and performance improvement - QAPI).

1. The meeting minutes did not contain analysis of infections to ensure infections and communicable diseases were not transmitted between staff and between patients and staff. Although nosocomial/HAI (hospital acquired infections) were identified in the attached reports, there was no review and analysis to determine if process should be changed to improve patient care and outcomes.

2. The meeting minutes did not demonstrate central sterile services were monitored, reviewed and analyzed with corrective actions taken and follow-up to ensure compliance with accepted standards of practice.

3. The meeting minutes did not contain documentation and review of surveillance/monitoring to ensure IC policies and procedures and current standards of practice are followed. On 11/06/14 Staff B stated she had not done this yet.

4. Concerns identified in meeting minutes showed no review and analysis to determine if corrective actions need to be developed or if current policies and procedures were followed.

5. Meeting minutes did not show employee illnesses were reviewed and analyzed to ensure transmission between staff and staff and staff and patients did not occur.

6. The meeting minutes did not reflect isolation monitoring was reviewed and analyzed to ensure:
a. Patients are placed in appropriate isolation according to current CDC guidelines;
b. Isolation materials/supplies are readily available;
c. Staff, physicians, volunteers, and visitor follow appropriate isolation requirements; and
d. Appropriate disinfection of the room occurs.

At the time of the revisit on 11/06/2014, this deficiency was not corrected.
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Based on review of education files and interviews with hospital staff, the hospital failed to assure nursing staff are adequately trained, oriented and competent to provide respiratory treatments to patients.

Findings:

Respiratory services are provided at the hospital. At the time of the recertification survey on 07/23/14, administrative staff told the surveyors that respiratory treatments are administered by the nursing staff.

At the time of the revisit on 11/06/14, the surveyor was told nursing staff still administered respiratory treatments.

Seven of seven licensed nursing personnel education and inservice files did not contain evidence of competency verification by the respiratory therapist for respiratory treatments provided.

This findings was confirmed with Staff D at the time of review on 11/06/14. She stated the respiratory therapist provided an inservice, but did not require demonstration or individual verification of skills/knowledge.

At the time of the revisit on 11/06/2014, this deficiency was not corrected.
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Based on surveyor observations, staff interviews and review of hospital documents, the hospital failed to ensure that surgical procedures are performed in a safe manner.

Findings:

Surgical patients were treated differently depending on the type of procedure performed. They were not processed as surgical patients and did not receive nursing care consistent with other surgical patients. For example, patients who had pain management surgical procedures did not receive the same documented pre-operative, intraoperative and recovery nursing assessment. This was confirmed by Staff SS during medical record review.

The surgical department (OR) was toured on the morning of 11/06/14.

Supplies in corrugated boxes were observed in the supply room in the semi-restricted area of the OR. This was confirmed by Staff SS and TT.

The sterilization logs for the OR were reviewed during the tour. The autoclave was set at a four minute sterilization time and one minute dry time. This was confirmed by Staff TT.

At the time of the revisit on 11/06/2014, this deficiency was not corrected.
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Based on review of hospital documents and interviews with surgical staff, the hospital failed to ensure a copy of the physicians' current privileges are kept/available in the surgical suite/area.

Findings:

The surgical department was toured on the morning of 11/09/14.

A binder containing the roster of practitioners with surgical privileges was provided to the surveyors by Staff SS. The binder was reviewed by the surveyors.

The binder was not current. The binder contained practitioners who no longer performed surgical procedures at the hospital. The binder did not contain current privileges for the practitioners that are currently performing surgical procedures at the hospital. This was confirmed by Staff SS during the review.

At the time of the revisit on 11/06/2014, this deficiency was not corrected.
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Based on review of hospital documents and meeting minutes, surveyors' observations, and interviews with hospital staff, the hospital failed to have an effective quality assurance program (QAPI) that analyzed data, implemented corrective action to ensure the quality and appropriateness of all patient care that was furnished, with follow-up to ensure the corrective actions were effective and maintained.

Findings:

The hospital's Quality Improvement Plan (QAPI Plan) documented the QAPI program has active continuous improvement cycles of Plan, Do, Check and Act and would involve all departments/services. Meeting minutes provided since the survey on 07/23/14, did not reflect this was being done.

Examples include, but not limited to:
1. The minutes stated that surgical staff had removed the cardboard boxes in surgery. The minutes did not reflect how the corrective action would be maintained. Surveyors observed cardboard boxes in the surgical suite on the revisit on 11/06/14.

2. Obstetric staff reported problems with medical record documentation issues and minutes stated that it was referred to IT. The minutes did not reflect a plan of action or a time for follow-up to determine if the problem was corrected.

3. QAPI meeting minutes, where infection control meeting minutes is conducted, did not demonstrate infection control was monitored to ensure:
a. An Infection Control Plan was developed with details of the types and frequency of monitoring for all departments to ensure infection control policies and procedures are followed and a safe and sanitary environment is maintained according to current accepted standards of practice.
b. A hospital-wide infection control program was instituted.
c. Nosocomial infections were reviewed and analyzed to ensure transmission did not occur between staff and patients.

4. Surgical services were not followed.
a. No review to ensure surgical site infections occurred.
b. Sterilization practice did not follow manufacture guidelines.