HospitalInspections.org

Based on interview and review of credential files, the provider failed to include quality improvement documentation in the reappointment application for each member of the medical staff.

The 2015 hospital "Credentialing Manual" defines the hospital's reappointment procedures for medical staff. Section III, provision E, of the Manual defines the method for Processing the Reappointment Application. Specifically, item 9B
states the following, that evaluation of professional performance and clinical judgement will include review of "clinical/technical skills as indicated by the results of quality improvement activities, activity profile; other reasonable indicators."

Findings include:

A review of medical staff credential files demonstrated that four of nine credential files lacked recent quality data which would have documented the individual practitioner's skill set and clinical abilities.

a. The Chief of Medical Services was reappointed on 10/28/14 for the term of 11/25/14 through 11/24/16. The most recent quality indicators were those documented in 2012.

b. The Medical Director of Radiology was reappointed on 7/23/13 for the term of 7/23/13 through 7/22/15. The most recent quality indicators were those documented for 2012.

c. The Medical Director of Emergency Services was appointed to the Director position on 7/24/13. His previous position was one of courtesy staff. The Director was reappointed for the term of 5/28/14 through 5/27/16. The most recent quality indicators were those documented in 2012.

d. A Certified Nurse Midwife was reappointed for the term of 8/18/14 through 8/17/16. The most recent quality indicators were those documented in 2012.

On 1/13/15, at 3:15 PM, the Director of Performance Improvement confirmed to
SA survey staff that there was no quality assurance data in the credential file of the Medical Director of Emergency Services. On 1/15/15, at 9:00 AM, SA survey staff requested quality data concerning the above individuals. No data was provided.

On 1/15/15 between 9:00 and 10:00 AM, the Chief Medical Officer (CMO) discussed quality improvement (QI) activities related to medical staff. The CMO showed data and reports demonstrating the QI activities during the past year.

Based on observation and interview, the hospital preventive maintenance and infection control program did not identify and correct issues of physical plant disrepair in the surgical suite.

Findings:

Observed on 1/14/15 at 10:00 AM: The in-wall storage cabinet located in Operating Room #1 is missing the top piece of trim, exposing a gap between the cabinet and wall. In the same room an air vent is loose and partially removed from the wall. In Operating Room #2 the wall has damage to the sheetrock in several locations. These conditions create an infection control risk since proper cleaning and disinfection of the walls is not possible as required in an operating room environment. Findings were verified with the Director of Engineering, Vice President & Administrator and Assistant Operating Room Manager at time of observation.

Observed on 1/14/15 at 11:20 AM: The wall in the Janitors Closet located in the Intensive Care Unit suite had damage along the rim of the sink basin and a hole on the wall behind the door. These conditions create an infection control risk since proper cleaning is not possible. Conditions are also conducive to mold growth. Findings were verified with the Vice President & Administrator at time of observation.

Based on observation, interview, record review and document review, the facility failed to implement all infection control measures that prevent transmission of infections to patients. Specifically,the hospital infection prevention and control program failed to identify an issue with the special air handling system monitor in the Intensive Care Unit, failed to ensure that safe injection practices were followed and failed to use point of care devices in a manner consistent with hospital control policies and procedures. Facility staff failed to follow the Centers for Disease Control and Prevention (CDC) guidelines for safe injection and hand washing guidelines and facility policy "IV: Peripheral Intravenous Therapy ", effective 2/91, revised 9/14.

Findings:

1. Observed on 1/14/15 at 11:30 AM: The monitor located on the outside of the SCU 1 airborne infection isolation room does not alarm under positive pressure conditions. This is evident by observing that the monitor indicates correct negative pressure (i.e. green light) even when the door is left open or the exhaust fan inside the room is turned off. With the exhaust fan turned off and the door in a slightly opened position, a tissue placed alongside the door confirms that air is being pushed out of the room, while the monitor continues to give a green light (negative pressure) reading.

(Note: The following day facility staff diagnosed the problem with the monitor and re-calibrated the alarm to go off at the proper levels.)

Hospital policy for admittance of an airborne infectious disease patient was reviewed and does not include provisions for checking proper opreation and calibration of the monitor. Improper functioning of the monitor would result in lack of notification in the event that the air handling system fails. Findings were verified with the Director of Engineering and Vice President & Administrator at time of observation.

2. While conducting a facility tour of the surgical suite on 1/14/15 and observing patient care in the preoperative area at 0730, a surgical patient's intravenous tubing, including the medication administration port, was observed to be lying on the floor for 3 minutes while the registered nurse inserted the angiocath into the patient. The registered nurse was then made aware of the position of the tubing. The registered nurse did not perform hand hygiene prior to donning gloves for this aseptic procedure.

On 1/14/15 at 0750, a second registered nurse came to escort the surgical patient to the operating room. The intravenous tubing, including the medication administration port, were dragged along the floor until the surgical patient stepped on her intravenous tubing. The tubing was then gathered up and carried aloft into the operating room.

On 1/14/15 at 0810, while observing care in the operating room, the surgical patient was observed lying on the operating room table and her intravenous tubing, including the medication administration port, were lying on the floor behind the operating room table. The certified registered nurse anesthetist (CRNA) drew up medication to administer to the patient. The SA surveyor informed the CRNA that the patient's intravenous tubing and medication administration port were lying on the operating room floor. The CRNA put the newly drawn up medication and syringe down. He gathered up the tubing and placed it on the head of the operating room table behind the patient's head. He then cleaned the medication administration port off with an alcohol pad. The CRNA administered the medication to the patient via a different port, one more proximal to the patient. During the surgical procedure the port which had been lying on the floor multiple times was utilized by the CRNA to administer intravenous medication to the patient.

On 1/14/15 at 0815, The CRNA was observed drawing up medication from a medication vial. The CRNA failed to disinfect the rubber septum on the medication vial with alcohol prior to piercing the rubber septum with a needle to withdraw the medication. The medication was then administered to the patient.

3. During a tour of a facility extension clinic on 1/15/15, a glucometer in use at the extension clinic was cleaned after every use, however the cleaning procedure was not consistent with the manufacturer's instructions and established hospital procedure. Specifically, on 1/15/15 at 10:00 am, Nurse A stated that she cleaned the clinic glucometer with alcohol after each use. The product she used to clean the device was not consistent with the manufacturer's instructions and hospital procedure. Facility policy, "Glucometer: Accu-Chek II Inform Blood Glucose Meter" (effective date 6/07; revised 10/14) notes, "Meters must be cleaned after each use with Clorox Bleach Germicidal Wipes, allowing to air dry for one (1) minute before use." The manufacturer's instructions for cleaning is referenced in this policy. Interview of the Clinic Nurse Manager on 1/15/15 at 11:30 am confirmed that glucometers are to be cleaned with Clorox Bleach Germicidal Wipes after every use.