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Based on document review and interview, it was determined for 2 of 2 (Pt #24, Pt #32) patients records reviewed who received LifeVests, the hospital failed to ensure an interdisciplinary Plan of Care was developed specific to the patient's needs. this has the potential to affect all patients who receive care by the hospital with an average daily census of 70 patients.

Findings include:

1. The "Lippincott Procedures-Wearable cardioverter-defibrillator (WCD) use" document (reviewed by hospital on 2/19/2021) was reviewed on 6/8/2021. The document noted "Documentation Document that the patient is wearing a WCD. Also document the patient's tolerance of the WDC, any defibrillation attempts made by the WCD, and the patient's outcome following any defibrillation attempts made by the WCD. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

2. Pt #24's record was reviewed on 6/8/2021 at approximately 2:30 PM. The record noted Pt #24 was admitted on 5/13/2021 with a diagnosis of Chronic Systolic Heart Failure. The Physician's Progress Note dated 5/23/2021 noted "LifeVest placed on 5/22/2021." The record lacked a Plan of Care and/or interventions related to the LifeVest as of 6/8/2021 at 2:30 PM. The record lacked documentation that Pt #24 was wearing the LifeVest, if any defibrillation attempts were made, was educated, the level of understanding and the level of competence to care for the Life Vest post discharge.

3. Pt #32's record was reviewed on 6/10/2021 at approximately 2:30 PM. The record noted Pt #32 was admitted on 5/27/2021 with a diagnosis of Congestive Heart Failure. The Physician's Progress Note dated 5/29/2021 noted "... had a LifeVest placed..." The record lacked a Plan of Care and/or interventions related to the LifeVest. The "After Visit Summary (discharge instructions)" lacked education related to the LifeVest. The record lacked documentation Pt #32 was wearing the LifeVest, if any defibrillation attempts were made, was educated, the level of understanding and the level of competence to care for the Life Vest post discharge.

4. During an interview on 6/9/2021 at approximately 12:30 PM, E#1 (Regional Director of Quality) stated the hospital did not have a LifeVest policy. E#1 presented the "Lippincott Procedures- Wearable cardioverter-defibrillator use." E#1 verbally agreed the Lippincott Procedure was not hospital specific and a policy should be available for nursing staff. E#1 reviewed Pt #24 and Pt #32's records and verbally agreed it was unable to be determined if the patient's were wearing the LifeVest, if any defibrillation attempts were made, was educated, the level of understanding and level of competence to care for the LifeVest post discharge. E#1 verbally agreed a Plan of Care and/or interventions were not implemented related to the LifeVest and should have been. E#1 stated the Critical Cardiac Unit nurses and the 3 East unit nurses were educated on the LifeVest November of 2020. E#1 verbally agreed patients with LifeVest could be housed on other units.

Based on document review and interview, it was determined for 2 of 2 (Pt #24, Pt #32) patient records reviewed, the Hospital failed to ensure a LifeVest policy was available for all staff who provide care to a patient with a LifeVest. This has the potential to affect all patients who receive a LifeVest with an average of 26 patients per year.

Findings include:

1. Pt #24's record was reviewed on 6/8/2021 at approximately 2:30 PM. The record noted Pt #24 was admitted on 5/13/2021 with a diagnosis of Chronic Systolic Heart Failure. A signed physician's order dated 5/12/2021 noted "Medical Order Form Zoll LifeVest". The order lacked documentation of a reason for the LifeVest, Lifevest Settings, the Prescribers contact name and number, was dated prior to the 5/13/2021 admission and the physician who signed the order had not assessed Pt #24 during the hospitalization. The Physician's Progress Note dated 5/23/2021 noted "LifeVest placed on 5/22/2021. The record lacked any other documentation of the LifeVest by the physician's, nurse's or case managers. The record lacked documentation the company was notified with the required information, lacked documentation Pt #24 was educated, the level of understanding and the level of competence to care for the LifeVest post discharge.

2. Pt #32's record was reviewed on 6/10/2021 at approximately 2:30 PM. The record noted Pt #32 was admitted on 5/27/2021 with a diagnosis of Congestive Heart Failure. The Physician's Progress Note dated 5/29/2021 noted "... had a LifeVest placed..." The record lacked any other documentation of the LifeVest by the physician's, nurse's or case managers. The record lacked documentation Pt #32 was educated, the level of understanding and the level of competence to care for the Life Vest post discharge.

3. During an interview on 6/9/2021 at approximately 12:30 PM, E#1 (Regional Director of Quality) stated the hospital did not have a LifeVest policy. E#1 presented the "Lippincott Procedures- Wearable cardioverter-defibrillator use." E#1 verbally agreed the Lippincott Procedure was not hospital specific and a policy should be available for nursing staff. E#1 reviewed Pt #24 and Pt #32's records and verbally agreed it was unable to be determined if the patient was educated, the level of understanding and level of competence to care for the LifeVest post discharge. E#1 stated the Electronic Health Record did not have a LifeVest order built into it, so the orders were hand written on the LifeVest Medical Order Form.

Based on document review and interview, it was determined for 2 of 30 (Pt#18, Pt #26) patient records reviewed, the Hospital failed to ensure medications were administered in correlation with sliding scale. This has the potential to affect serviced by the Hospital with a current average daily census of 70 patients.

Findings include:

1. Pt #18's record was reviewed on 6/8/2021 at approximately 12:30 PM. Pt #12 was admitted to the Hospital on 5/8/2021 with a diagnosis of hyperkalemia and acute respiratory failure. On 6/6/2021, there was a physician's order for accuchecks (blood Glucose testing) 4 times a daily and nightly. The accuchecks were scheduled to be performed at 8 AM, 12:00 PM (noon), 4 PM and 9 PM with sliding scale insulin was to be administered based on the results. Pt #18's record indicated:
6/6/2021 at 6:37 AM accucheck of 235 mg/dl- at 9:50 AM - 10 units lispro (Humalog) given subcutaneous 3 hours and 13 minutes after accucheck performed.
6/7/2021 at 6:32 AM accucheck of 264 mg/dl- at 8:24 AM - 9 units lispro (Humalog) given subcutaneous- 1 hour and 52 minutes after the accucheck performed.
6/7.2021 at 11:10 AM accucheck of 295 mg/dl- at 12:39 PM - 9 units lispro (Humalog) given subcutaneous- 1 hour 29 minutes after the accucheck performed.
6/8/2021 at 6:01 AM accucheck of 364 mg/dl- at 8:50 AM - 13 units lispro (Humalog) given subcutaneous- 2 hours and 49 minutes after the accucheck was performed.

3. Pt #26's record was reviewed on 6/10/2021 at approximately 2:00 PM. Pt #26 was admitted to the Hospital on 6/10/2021 with a diagnosis of Cellulitis Right Arm. On 6/6/2021, there was a physician's order for accuchecks 3 times daily before meals and a corresponding sliding scale for insulin administration based on the accucheck results. The record noted the following:
a) 6/7/2021 at 1:46 PM (post lunch) the accucheck was 141 mg/dl. The record noted at 11:30 AM insulin was not given;
b) 6/8/2021 at 6:07 AM the accucheck was 194 mg/dl. The record noted at 9:55 AM insulin was administered 3 hours and 48 minutes after the accucheck was performed.

2. The policy titled "Medication Administration:General Policy" (approved by the facility, 6/23/2020) was reviewed on 6/9/2021 at approximately 2:00 PM. The policy stated on page 3 under "Time-Scheduled Medications- Category Time-Critical: Medications prescribed for administration within a specific time in relation to an event or scheduled procedure (e.g. procedure, meal, dressing change). If medication is not given according scheduled time frames ...A. Document the variance in the medical record. b. Contract licensed provider..."

3. The Lippincott: https://www.nursingcenter.com/static?pageid=849327 resource was reviewed on 6/9/2021 at 2:15 PM. The document stated that, "In most hospitals, a patient's capillary blood glucose level is tested before each meal and at bedtime. Many hospitals still follow the classic 0700, 1100, 1600, and 2100 schedule. This is appropriate if meals arrive at 0730, 1130, and 1630, with a bedtime snack at 2130. Because the ideal time to check a capillary blood glucose level is 30 minutes before a meal, find out when meals are delivered in your unit. You'll need to know when a patient's capillary blood glucose level is tested because you have only 1 hour to give correction insulin based on that test result. If your facility uses electronic medical records, you should be able to get the precise time of the last blood glucose test. If you can't administer your patient's correction insulin dose on time, check his blood glucose level again to ensure that you're administering the appropriate dose."

4. During an interview on 6/8/2021 at approximately 1:00 PM, Nursing Administrator (E#16 ) stated, that the accuchecks for Pt #18 and Pt #26 were not done at the time schedule and the insulin was not administered as ordered by the physician.




32189

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on June 9-10, 2021, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on document review, and interview, it was determined the Hospital failed to ensure the preventive maintenance policy for patient care equipment was followed to ensure patient safety . This has the potential to affect all patients serviced by the Hospital with an average census of 70.

Findings include:

1. On 6/8/2021 at approximately 11:00 AM, the medical record for Pt #4 was reviewed. Pt #4 was admitted on 6/7/2021 with a the diagnosis of Suicidal Ideation. The BH (Behavioral Health) Admission Note dated 6/8/2021 indicated Pt #4 "wears a CPAP (breathing machine) at night and has it with him." The 6/7/2021 Behavioral Health Assignment Sheet indicated a sitter was assigned to Pt #4 as the CPAP was in use. Pt #4 record lack documentation the CPAP was inspected prior to use and the record lacked a physician order for use of the CPAP.

2. The Hospital Policy titled "Patient Supplied Equipment" (approved by the facility, 9/3/2020) was reviewed on 6/9/2021 at approximately 1:30 PM. The policy stated under process. "1. Obtain order from a licensed provide to utilize patient supplied medical equipment... 1. Clinical Engineering completes a safety inspection of patient supplied medical equipment upon request..."

3. During an interview on 6/8/2021 at approximately 12:00 AM, Director of Acute Care ( E#7 ), stated that staff did not follow hospital policy.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on June 9-10, 2021, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation, document review and interview, it was determined the hospital failed to ensure equipment was maintained to prevent cross contamination. This has the potential to affect all in-patients and out-patients who receive care that requires sterilized equipment.

Findings include:

1. During a tour on 6/9/2021 at approximately 10:30 AM with Manager of Sterile Processing Department (SPD) (E#18 ) and Director of Surgical Services, ( E#19 ) the SPD had 2 STERIS sterilizers labeled with a sticker that noted the next maintenance due date as May 2021.

2. During an interview on 6/9/2021 at approximately 10:30 AM, E#18 stated the hospital had recently changed biomed (biomedical) providers and the new provider had to obtain an agreement with STERIS before maintenance could be conducted. E#18 stated "It's scheduled for next week I think."

3. During an interview on 6/9/2021 at approximately 2:30 PM, Biomedical ( E#20 ) brought a Purchase Order dated 6/9/2021 at 1:56 PM, that noted 4 STERIS sterilizers were requested to be maintained. E#20 stated "There was some oversight on this (request for maintenance). We (biomed) thought SPD made the request and they thought we were doing it."

4. During an interview on 6/9/2021 at approximately 2:35 PM, E#19 verbally agreed the sterilizer's maintenance had not been conducted and should have been.


32822


B. Based on document review and staff interview, it was determined the Hospital failed to ensure that fluid warmers were checked and monitored per policy. This has the potential to affect all patients who receive care on the 8 E Medical Surgical Unit with a current census of 16 patients.

Findings include:

1. The policy titled "Warmer Cabinet Temperatures for Blankets and Solutions" (approved by the facility, 3/2021) was reviewed on 6/10/2021 at approximately 3:00 PM. The policy required, "Mission Partners (hospitals staff) shall monitor the warming cabinets daily. Temperatures will be logged and it will be verified that the warming cabinets are set at their correct temperatures."

2. The temperature logs for the fluid warming cabinet was reviewed on 6/9/2021 at approximately 11:00 AM. The May 2021, log indicated that staff failed failed to record the temperature on 5/5/2021, 5/19/2021, 5/20/2021, 5/21/2021, 5/26/2021 and 5/27/2021.

3. During an interview on 6/9/2021 at approximately 11:30 AM, Nursing Administrator (E #16 ) verbally agreed the temperatures were not performed on those days.

A. Based on observation, document review, and interview, it was determined for 1 of 1 Dietary Department, the Hospital failed to ensure the environment was safe and sanitary in order to prevent/control infections and communicable diseases. This has the potential to affect all patients served in the Dietary Department with a average census of 70.

Findings include:

1. On 6/8/2021 at approximately 10:30 AM-11:05 AM, an observational tour of the Dietary Department was conducted with the Vice President of Operations (E #3) and Manager of Dietary (E #4). The following infection control issues were noted:

a. The walk in freezer contained 4 pans of baked cookies which lacked a expiration date.
b. The floor of the walk in freezer contained paper and other unidentifiable debris on the floor.
c. The wall next to the grill contained a large amount of yellow sticky substances.
d. A cart identified by E #4 as a cart of dirty items was next to a cart of bread.
e. A cart identified by E #4 as a clean cart for catering contained five stickers with residue.
f. The wall above the clean food prep area contained removable dark sticky substance and four areas of tape with residue.
g. The clean tray rack contained a removable dark sticky substance on the sides.
h. The vent on the cold prep table contained a removable dark sticky substance
i. The holding refrigerator contained tape residue on the front and a removable crusty substance around the handles.
j. The clean hot plate cart contained removable dark dried crusty substance on the sides.
k. A cart identified as a dirty cart by E #4 had a five loaves of bread on top of the cart.

2. On 6/8/2021 at approximately 2:00 PM, the policy titled "Cleaning and Sanitation-Food Safety" (revised by the facility, 6/25/2019) was reviewed. The policy required that "Cleaning removes food and soils from a surface, while sanitizing reduces the number of pathogenic microorganisms on that surface to a safe level...Non Food Contact Surfaces.. for example walls floors...Keep all non food contact surfaces clean... keep non food contact surfaces free of dust, dirt food residue and other debris...Food Contact Surfaces...clean, rinse, and air dry all food contact surfaces...keep food content surfaces free of food residue , grease deposits and soil accumulation at all times...after each use or every four hours if the items are in constant use"

3. During an interview conducted on 6/8/2021 at approximately 11:00 AM, E #4 confirmed the above findings and stated, "we clean and mop the freezer floor twice a week. we don't track that. The items with residue would be difficult to fully disinfect. Most of the equipment and wall cleaning is suppose to be done on the weekend, but we don't track or log that."



B. Based on observation, document review, and interview, it was determined for 1 of 1 Laboratory Department, the Hospital failed to ensure the environment was safe and sanitary in order to prevent/control infections and communicable diseases. This has the potential to affect all patients with a average census of 70.

Findings include:

1. On 6/8/2021 at approximately 11:10 AM-11:35 AM, an observational tour of the Laboratory Department was conducted with the Vice President of Operations (E #3) and Laboratory Medical Technician (E #5). The following infection control issues were noted:

a. The specimen freezer inside bottom contained paper and a removable gray fluffy substance. No cleaning log.
b. The bio safety cabinet contained tape residue on the outside. The cleaning log for June 2021 stated that the cabinet had been cleaned on 6/8/2021.
c. The top of the chemistry freezer contained a layer of a removable fluffy substance. No cleaning logs for the freezer.
d. The wall cabinet which contained clean laboratory supplies contained al least 25 stickers with residue. No cleaning logs for the wall cabinet

2. A policy was requested. No policy was submitted by the Hospital.

3. During an interview conducted on 6/8/2021 at approximately 11:35 AM,, E #5 stated "we don't have cleaning logs for most of the lab. we don't track that."

C. Based on observation, document review, and interview, it was determined for 1 of 1 Physical Therapy/Occupational Therapy Department, the Hospital failed to ensure the environment was safe and sanitary in order to prevent/control infections and communicable diseases. This has the potential to affect all patients who receive therapy.

Findings include:

1. On 6/8/2021 at approximately 12:40 PM-1:00 PM, an observational tour of the Physical Therapy/Occupational Therapy Department, was conducted with the Director of Acute Care Services (E #7). The Mat Table had a approximately 6 inch tear which had been repaired. The tear had gaps into and exposing the foam cushion underneath the vinyl covering.

2. A policy was requested. No policy was submitted by the Hospital. .

3. During an interview conducted on 6/8/2021 at approximately 1:00 PM, E #7 stated that they had a new table ordered and will remove the old Mat Table


D. Based on observation, document review, and interview, it was determined for 1 of 1 Intensive Care Unit (ICU), the Hospital failed to ensure the environment was safe and sanitary in order to prevent/control infections and communicable diseases. This has the potential to affect all patients with a average daily census of 7.

Findings include:

1. On 6/9/2021 at approximately 9:36 AM-10:10 AM, an observational tour of the ICU, was conducted with the Director of Critical Care Services (E #14). The following infection control issues were noted:

a. 2 of 4 Glucometer (blood glucose monitoring) supply boxes contained a removable sticky residue.
b. The top of the medication cabinet contained a layer of a removable gray fluffy substance.
c. 4 of 8 intravenous infusion machines in the clean utility room contained a removable sticky substance.

2. A policy was requested. No policy was submitted by the Hospital. .

3. During an interview conducted on 6/9/2021 at approximately 10:15 AM, E #14 stated that I believe it is housekeeping's job to keep these things clean. I will have to check."


E. Based on observation, document review and interview, it was determined in 1 of 1 Contact Isolations Rooms observed, the hospital failed to insure adherence to infection control processes. This has the potential to affect all patients admitted to the hospital, with a current daily average census of 70 patients.

.Findings include:

1. A Tour of the 8th floor Medical Surgical Unit Medical was conducted on 6/9/2021 at approximately 11:00 AM, with the Nursing Administrator (E#16 ). It was noted that room #B 801- had a sign posted for Contract Precautions for C-diff. (Clostridium difficile). Two X-ray technician's were observed in the hall, outside room #B 801, cleaning the X-ray equipment which had been in the isolation room, with Oxivir TB Wipes which are not effective against C- diff.

2. The policy titled "Isolation And Transmission-Based Precautions" (approved by the facility, 6/1/2021) was reviewed on 6/10/2021 at approximately 1:45 PM. The attachment to the policy indicated "C. Diff Colitis, Patient care items should be cleaned with the hospital approved bleach product..."

3. During an interview conducted on 6/9/2021 at approximately 11:15 AM, E#16 confirmed the above findings and stated that the equipment should be cleaned with bleach after exit from the room. .