HospitalInspections.org

Based on review of facility documents and staff interview, the facility did not inform each patient how to lodge a complaint with the State agency.

Findings:

On 04/15/2015 at 2:30 p.m., Staff V was asked who was responsible for the facility's grievances. Staff V stated she was responsible.

Review of a facility handouts given to the patients upon admission did not contain the telephone number and/or the address of how to file a grievance with the Oklahoma State Department of Health (OSDH).

On 04/15/2015 at 2:45 p.m., Staff V was asked if the OSDH contact information was provided to the patients. Staff V stated no.

Based on review of facility documents and interviews with facility staff, the facility did not provide the patients with a written notification of the grievance process. This occurred in one of one grievance (#6) reviewed for the past year at the facility.

Findings:

Review of a facility policy titled, "Consumer Grievance Procedure", and dated 04/12/2013 documented, "...The area supervisor or facility advocate will provide written notification to the consumer of the grievance outcome..."

On 04/15/2015 at 2:30 p.m., Staff V was asked who was responsible for the facility's grievances. Staff V stated she was responsible.

When asked for grievances received at the facility during the past year, Staff V stated the facility had one grievance for the past year.

Review of the grievance information provided by Staff V, did not contain documentation written notification was sent to the patient. On 04/16/15 at 2:45 p.m. Staff V was asked if the required written notification of investigation was provided to the complainant, She stated no.

Based on surveyor observation and staff interview, the hospital failed to ensure patients received care in a safe setting.

Findings:

1. A tour was conducted of the hospital in the afternoon of 04/16/2015.

2. Grab bars were installed in the patient showers. The space between the grab bars and the wall were not filled to prevent a cord being tied around it for hanging.

3. During the tour Staff Y stated he was unaware the space between the grab bars had to be filled.

Based on review of medical records, facility documents and interviews with facility staff, the facility failed to ensure patient restraints were applied according to specific/complete orders for the restraints. This occurred in one of three medical records (#1) reviewed for patients identified as having restraints applied.

Findings:

Review of a facility policy titled, " Seclusion and Restraint", and dated 05/30/2013, documented, "...If seclusion or restraint is warranted, the Licensed Independent Practitioner (LIP) shall give orders indicating the type, time limit and criteria for release..."

Record #1 did not contain orders for restraint usage. The patient was placed in a physical hold on 02/15/2015 at 4:04 a.m. and removed from the physical hold on 02/15/2015 at 4:05 a.m.

On 04/15/2015 at 3:35 p.m. Staff B was asked to locate the restraint order for Record # 1. Staff B stated there were no orders in Record #1 for restraint usage.

Based on medical record review and interviews with facility staff, the facility does not ensure that all entries in the medical record contain the date and time when they were signed or authenticated in written form by the person responsible for the services provided. This occurred in 20 of 22 medical records (#1, 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and #22) reviewed.

Findings:

The facilities medical records contained both written and electronic documentation.

Review of the written medical records contained the following facility documents: Consent to Treatment with Psychoactive Medications; System Review; Psychosocial Evaluation; Nutrition Screen; and Health and Drug History. Records #1, 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and #22 did not contain the time the above forms had been authenticated by the practitioner.

The Pain Screening form in the medical records did not contain the date and the time the data was authenticated by the practitioner, in Records #1, 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and #22.

The Discharge Summaries in the medical records did not contain the date and time the practitioner authenticated the data in records #1, 2, 3, 4, 5, 6, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and #22.

On 04/15/2015 at 3:00 p.m., Staff B stated she was not aware the discharge summaries had to be dated and timed.

Based on surveyors' observations, interviews with staff and review of hospital documents, the hospital failed to maintain an active ongoing program to prevent, control, and investigate infections and communicable diseases to minimize infections and communicable diseases in patients and staff.

Findings:

1. The staff identified as the infection control preventionist did not have ongoing training in establishing and maintaining an effective ongoing infection control program based on current principals and methods of infection control. See Tag A-0748 for details.

2. The hospital failed to ensure the infection control practitioner/nurse developed and maintained an ongoing system for identifying, reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment. See Tag A-0749 for details.

3. The hospital's leadership failed to ensure infection control activities, issues, and problems, were processed through quality assessment and performance improvement (QAPI) committee. See Tag A-0756 for details.

Based on surveyor observations, review of hospital documents, and interviews with hospital staff, the hospital failed to ensure:

a. The staff identified as the infection control preventionist (ICP) did not ongoing training in establishing and maintaining an effective ongoing infection control program based on current principals and methods of infection control.

b. The ICP developed infection control policies and procedures for patient laundry to prevent transmission of communicable diseases.

Findings:

1. On 04/15/2015 at 8:50 a.m., administrative staff identified Staff B as the person responsible for infection control.

Review of Staff B's personnel file did not contain documentation that Staff B had any training in establishing and maintaining an effective and ongoing infection control program.

On 04/16/2015 at 2:00 p.m., Staff B told surveyor the only training she had receive in infection control was the same training all staff received about blood borne pathogens. She stated she did not have any infection control training in developing and maintaining an effective hospital-wide infection control program.

2. During the tour of the hospital on 04/15/2015 between 8:50 a.m. and 11:00 a.m., the surveyors observed washers and dryers on the male and female units. Staff A told the surveyors they were for patient use. No instructions for use were posted in the laundry rooms.

The surveyors requested to review the policies and procedures for the washing and drying of patient items, including the cycles, temperatures and cleaning procedures between patient use.

On 04/16/2015 at 1:00 p.m., Staff A stated the only policy the hospital had concerning patient laundry was policy 6-03-02, Linen Service and Laundry, with an effective date of 05/07/2004. The policy did not give specific washer and dryer use or cleaning between patients.

Based on surveyors' observations, review of hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner/nurse (ICP or ICN) developed and maintained an ongoing system for identifying, reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. On 04/15/2015, between 8:50 a.m. and 11:00 a.m., the surveyors observed the following:

~ The washers and dryers on the patients' units were not disinfected after each use. At the time of the observations, Staff A was asked when the washers and dryers were disinfected. Staff A stated housekeeping cleaned the equipment once a week. When asked, Staff A stated no staff cleaned the equipment between patient use.

~ On 04/15/2015 at 10:50 a.m., the surveyors observed staff using a product named Re-Juv-Nal. The manufacturer of the product used, Re-Juv-Nal, required the disinfectant to remain wet on the surface for ten (10) minutes to be effective. Housekeeping staff did not observe the dwell/"wet" time required for the hospital's disinfectant to be effective.

~ Nursing staff M and H provided patient care without hand hygiene use between patients.


2. The surveyors reviewed the meeting minutes for Infection Control Committee, July 2013 to January 2015, and Performance Improvement Committee, January 2014 to February 2015. The meeting minutes did not reflect/contain evidence:

~ There was no documentation that all chemicals and disinfectants used at the hospital had been reviewed and approved by the infection control officer, infection control committee, and quality assessment and performance improvement committee. On 04/16/2015 at 2:10 p.m. Staff B told surveyors that she had not reviewed and approved all chemicals and disinfectants used at the hospital.

~ Meeting minutes contained documentation the hospital had a patient with scabies during the fourth quarter of 2014 fiscal year and a patient with pediculosis during the third quarter of the 2014 fiscal year. The Centers for Disease Control (CDC) 2007 guidelines for isolation specify the patients should be placed in contact isolation for at least 24-hours after initiation of effective treatment. The meeting did not reflect the patients had been placed contact isolation. On 04/16/2015 at 2:00 p.m., Staff B told the surveyors that no patients had ever been placed in isolation that she knew.

~ Although the hospital had infection control policies for the different departments of the hospital, there was no documentation of any surveillance/monitoring to ensure the infection control policies and procedures were followed. On 04/16/2015 at 2:10 p.m., Staff B told the surveyor that she had not monitored all departments for compliance with the infection control policies.

~ Although personnel files documented education on hand hygiene, meeting minutes did not reflect issues with hand hygiene practice had been identified. On 04/16/2015 at 2:10 p.m., Staff B told the surveyors that she had no documentation of hand hygiene observations/surveillance.

~ On 04/16/2014 at 2:20 p.m., Staff B told the surveyor that patients at times had diarrhea. She stated that no stool cultures had been performed because it was felt it was a side effect of the drug withdrawal. Meeting minutes did not contain documentation that this potential problem had been reviewed and analyzed to rule out gastrointestinal organisms/illnesses as a possible reason for patient episodes of diarrhea.

~ Meeting minutes did not demonstrate infection control problems were identified and analyzed, corrective action initiated and follow-up provided to ensure the corrective actions were effective and maintained.

Based on review of hospital documents and meeting minutes, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, were processed through quality assessment and performance improvement committee and:

a. Were monitored throughout the hospital, reviewed and analyzed;

b. Corrective actions were taken to prevent, identify and manage infections and communicable diseases with measures that resulted in improvement on an ongoing basis; and

c. Corrective actions were followed to ensure improvement resulted and alternative solutions/actions were not needed.

Findings:

1. Meeting minutes, for Performance Improvement Committee were reviewed for the period of January 28, 2014 to February 24, 2015.
~ The meeting minutes only documented infection control data was presented three times during this period and only contained data related to infections and illnesses.

~ The minutes did not show analysis to determine if there was transmission of illness and infections between patients and staff or if any policies needed to be changed to reduce possible transmissions.

~ The only actions documented was to continue to monitor as the follow-up.

~ On 04/16/2015 at 2:00 p.m., Staff B stated infection control data was sent to the Performance Improvement Committee as an attachment. Staff B told the surveyors that although infections and communicable diseases occurred at the hospital during the last year, no isolation of patients had occurred. Staff B stated she reported them to the State as required.


2. The meeting minutes did not reflect/contain evidence the hospital leadership:
~ Reviewed and analyzed infection control data or lack thereof;

~ Ensured that all departments/units of the hospital were included and monitored through the infection control/prevention program;

~ Ensured infection control/prevention policies and procedures were developed, implemented and followed to ensure a safe and sanitary environment and that staff were inserviced on those policies;

~ Ensured corrective plans of action were developed to reduce and/or prevent transmission of organisms and improve patient care, ensure a safe and sanitary environment, and prevent or decrease infections and communicable diseases; and

~ Ensured follow-up/monitoring to ensure corrective actions taken were effective and sustainable.


3. Meeting minutes did not contain evidence the hospital's leadership has ensured policies and procedure were developed for all areas of the hospital concerning current accepted standards of practice in infection control. The hospital provided on-site laundry services for patients. No policies had been developed to assure the service was performed according to regulatory requirements and current standards of practice.

Based on document review and staff interview, the facility failed to incorporate an agreement with an Organ Procurement Organization (OPO).

Findings:

Review of the OPO agreement provided by the facility documented the OPO agreement expired in 2011.

On 04/16/2015 at 2:00 p.m., Staff V was asked if the facility had a current OPO agreement. Staff V stated she was unsure if the facility had a current OPO agreement. No current OPO agreement was provided.