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Based on record review, observation and interview the hospital failed to meet the Condition of Participation for Patients Rights as evidenced by:

Based on observation, record review and interview the facility failed to provide for patient privacy for patients evaluated in the ED (emergency department) triage (process of determining the priority of patients' treatments based upon the severity of their condition). This failed practice can result in people not involved in the patient's care being present while the patient is being examined or treated. (See A-143)

Based on observation, interview and record review, the facility failed to 1) ensure the safety of patients and staff by not maintaining the annual maintenance and inspection of medical equipment and 2) not providing a sanitary environment to protect patients from cross contamination. This failed practice has the potential to increase the risk of injury and illness to patients and staff. (See A-144)

Based on observation, record review and interview the facility failed to ensure the confidentiality and privacy of clinical records. This failed practice in a small community can result in PHI (protected health information) disclosure among community members. (See A-147)

Based on observation, record review and interview the facility failed to provide for patient privacy for triaged (the process of determining the priority of patients' treatments based upon severity of their condition) patients' in the ED (emergency department). This failed practice can result in people not involved in the patient's care being present while the patient is being examined or treated.

The findings are:

A. On 8/20/18 at 2:45 pm during observation in the ED patient #1 was observed being discharged by an Emergency Room Nurse. The discharge instructions were given while the patient was in the triage area (area of the emergency room that is used to determine severity of a patients' condition prior to treatment of the patient) and without attention to the individual's need for privacy. The triage area is in a hallway off the main entrance to the ED.

B. Record review of "Patient's Rights and Responsibilities Rev 3/24/16" states "AS A PATIENT YOU HAVE THE RIGHT TO: Be treated with courtesy and respect in a way that respects privacy, confidentiality, security and dignity"

C. On 8/21/18 at 2:30 during interview with the ED manager, the problems with the lack of space in the ED were addressed and the manager stated "We make do".

Based on observation, interview and record review, the facility failed to 1) ensure the safety of patients and staff by not maintaining the annual maintenance and inspection of medical equipment and 2) not provide a sanitary environment to protect patients from cross contamination This failed practice has the potential to increase the risk of injury and illness to patients and staff.

The findings are:


Safety:
A. On 08/20/18 at 1:45 pm, during a tour of the Emergency Department (ED) the following equipment did not contain stickers indicating annual maintenance and inspection was preformed on: 1) Glidescope, 2) Welch Allyn Vital Signs LXi, and 3) GE EKG Mac 5500 (all heart monitoring devices). This finding was confirmed by S#1.

B. On 08/20/18 at 12:45 pm during tour of the Obstetrics (OB) department, the following equipment did not contain stickers indicating annual maintenance and inspection was performed on: 1) Patient Controlled Analgesia (any method of allowing a person in pain to administer their own pain relief) and 2) Glidescope. This finding was confirmed by S#23.

C. On 08/22/18 at approximately 3:00 pm during an observation of the physical therapy room, the stickers to indicate equipment has been annually inspected and maintained was either missing or expired on the 3 of 3 treadmills.

D. On 08/21/18 at 9:45 am during tour of Endoscopy Suites, the scope-reprocessors (devices widely used in the health care setting to reprocess endoscopes) did not contain stickers indicating annual maintenance and inspection was preformed. Also 4 of 6 water filters (Filtration of the water and chemicals used in endoscopy) were not dated indicating when they were last changed.

E. On 08/20/18 at 1:00 pm during interview, S#23 confirmed the stickers were out of date or non-existent on medical eqiupment. S#23 could also not produce evidence of annual inspection and maintenance.

F. On 08/22/18 at 1:00 pm during interview, S#18 confirmed medical equipment did not have stickers and was unable to demonstrate when the medical eqiupment was last inspected.

Sanitary:

G. On 08/20/18 at 10:45 am, S #17 was observed coming into the conference room in a medical gown, cap and booties. When asked if she was coming from a surgical area, she stated that she was but was only in the pre-operation room, confirming patients awaiting surgery were also in the room.

H. On 08/20/18 at approximately 2:50 pm during tour of the physical therapy room, a sticky residue was observed and felt on the physical therapy mat treatment table.

I. On 08/20/18 at 3:00 pm during interview, S#3 confirmed that there was a sticky residue on the treatment table and acknowledged not knowing what it was and that it could lead to infection control issues. S#3 stated the treatment table was cleaned with Sani-wipe clothes (Quaternary/High Alcohol Formula [55%] for the disinfection of hard, non porous surfaces and equipment) after each use but could not articulate the manufactures recommendations for cleaning.

J. On 08/22/18 at 10:45 am during an observation of the "EDTU" (emergency department overflow room) area, bed #4 had several scratches on the mattress and bed #6 had a tear in the mattress and a sticky residue at the top, bottom and mid section of the mattress.

K. On 08/22/18 at 11:10 am during interview, S#18 and S#22, witnessed and confirmed 1) the scratches, tear and sticky reside on the mattresses in the EDTU area, and 2) confirmed this could lead to infection control issues.

Based on observation, record review and interview the facility failed to ensure the confidentiality and privacy of clinical records and interviews for patients in the ED (emergency department). This failed practice in a small community can result in PHI (protected health information) disclosure among community members.

The findings are:

A. On 8/20/18 at 1:45 pm during observation in the ED Patient #1 (P#1) was observed during the triage (process of determining priority of patients' treatments based upon severity of their condition) process. The area used for triage, initial patient examination and assessment are not separated in any way from the main ED area and is located in a hallway by an exit door. Other patients, staff, visitors and emergency personnel can witness the triage procedure, hear what is being said by the patient and to the patient by staff and view the patient documentation in the electronic record.

B. On 8/22/18 at 7:45 am during observation in an unlocked pre-operative area, lab tests were found in an unlocked cabinet. These lab tests contained patient names, dates of procedures and results of testing. Findings were confirmed by S#22.

C. Record review of "[Hospital name] Health System Notice of Health Information Privacy Practices" states "Maintain the privacy of health information that identifies you". In addition, the "Consent for Treatment" revised 3/10/17 states "I understand that information in my medical record is confidential, but may be disclosed for purposes of medical education and research, professional review activities, related to the cost, frequency, and quality of patient services provided, otherwise my medical record information will not be disclosed without my consent or the consent of my legal representative, unless required by law or a court order."

D. On 8/21/18 at 2:30 during interview with the ED manager, the problems with the lack of space in the ED that is necessary to protect patient privacy and confidentiality were addressed and the ED manager stated, "We make do".

Based on record review and interview, the hospital failed to ensure that an effective, on-going, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program was developed, implemented and maintained for the Organ, Tissue and Eye donation program and was integrated into the hospital's QAPI program. This deficient practice has the potential to result in lack of monitoring of the organ, tissue and eye donation program to ensure effectiveness and safety of services and the quality of care provided for all patients that access healthcare services at this facility.

The findings are:

A) During record review on 8/21/18 of QAPI minutes from 2017 and 2018 failed to find any mention of an Organ Procurement Organization (OPO), review of medical records post mortem (after death) to ensure that proper procedures were maintained during the organ, tissue and eye donation referral process, or other data collected for a performance improvement project.

B) During interview on 8/22/18 at 10:45 am, Staff # 15 (S#15) stated that the OPO data was not integrated into their QAPI data for 2017 but the OPO data was being integrated into their QAPI data for 2018, starting this month (August 2018). S#15 stated that reports are given monthly to the governing body with updates on each departments Quality Indicators. Governing Body makes suggestions on things to work on and also gives different perspectives to S#15. S#15 also stated meetings were held with all department directors and discusses their quality measures that were being tracked in each department, but no frequency of these meetings was given during interview.

Based on observation and interview the facility staff failed to provide an adequate number of licensed Registered Nurses (RN) to provide nursing care to all patients as needed. This failed practice has the potential to result in the lack of immediate availability of a registered nurse in the ICU (Intensive Care Unit) and Medical/Surgical Unit when required for bedside care of patients.

The findings are:

A) On 8/21/18 at 3:30 pm Staff #36 stated that "it is inconvenient to have to call in an RN from our department (interventional radiology - an area of the hospital that provides minimally invasive image-guided diagnosis and treatment of disease, which is staffed by ICU trained nurses) to monitor" and provide care for patients who require skilled nursing, "but that's what we do when there is no ICU nurse".

B) On 8/20/18 at 1:00 pm Staff #21 (RN providing care for patients on the unit) was asked who the charge nurse was on the medical/surgical unit (located on the 2nd floor), and Staff #21 responded "I don't know".

C) On 8/20/18 at 1:05 pm Staff #15 was asked what the procedure was for assigning charge nurse responsibility for the medical/surgical floor and she stated "The House Supervisor is in charge and is doing assignments". When asked if the House Supervisor is still responsible for the rest of the hospital, Staff #15 responded that the House Supervisor was responsible for staff oversight, getting necessary supplies when needed, overseeing the transfer of the ED (located on the 1st floor) patients to a higher level of care and other units of the hospital.

D) On 8/21/18 at 11:30 am, Staff #22 was asked if a patient's condition deteriorates and the patient requires an increased level of care (ICU) what the procedure was and Staff #22 replied "The House Supervisors are all ICU trained". Staff #22 also confirmed that the House Supervisor's duties may include being the charge nurse on the medical/surgical unit, assigned House Supervisor duties and care for ICU patients.

E) Record review of "General Patient Care" policy dated 4/2011 reveals: "The following factors are considered in staffing plan development: 1. Patient acuity and census 2. Staff qualifications, competencies and preferences and 3. Unit geography."

Based on observation, interview and record review, the facility failed to ensure the safety of patients and staff by not maintaining the annual maintenance and inspection of medical equipment and by not providing a sanitary environment to protect patients from cross contamination. This failed practice has the potential to increase the risk of injury and illness to patients and staff.

The findings are:

Emergency Department (ED):

A. On 08/20/18 at 2:30 pm during a tour of the Emergency Department (ED), the following equipment did not contain stickers indicating annual maintenance and inspection was preformed on: 1) Glidescope, 2) Welch Allyn Vital Signs LXi, and 3) GE EKG Mac 5500 (all heart monitoring devices).

Operation Room for Obstetrics (OB) department:

B. On 08/20/18 12:45 pm during tour of the OB department, the following equipment did not have stickers indicating annual maintenance and inspection (on each device) was preformed on: 1) Patient Controlled Analgesia (PCA) and 2) Glidescope.

C. On 08/20/18 at 1:00 pm during interview, S#23 confirmed the stickers were out of date or non-existent for the medical eqiupment and S#23 could not produce evidence of annual inspection and maintenance.

Physical Therapy department:

D.. Record review of manufacturers recommendations (undated) for cleaning of material on the treatment table indicated cleaning with a vinyl and leather cleaner or any non abrasive household detergent without damage to the surface luster and also recommends a disinfectant spray to protect against pathogens (a bacterium, virus, or other microorganism that can cause disease), including Methicillin-resistant Staphylococcus aureus (MRSA), HIV (human immunodeficiency virus), Staph (An infection caused by bacteria commonly found on the skin or in the nose) and the H1N1 Swine Flu Virus (a respiratory disease caused by influenza viruses).

E. On 08/20/18 at approximately 2:50 pm during tour of the physical therapy room, a sticky residue was observed and felt on the physical therapy mat treatment table.

F. On 08/20/18 at 3 pm during interview, S#3 confirmed that there was a sticky residue on the physical therapy treatment table and acknowledged not knowing what it was. S#3 stated the treatment table was cleaned with Sani-wipe clothes (Quaternary/High Alcohol Formula (55%) for the disinfection of hard, non porous surfaces and equipment) after each use but could not articulate the manufactures recommendations for cleaning.

H. On 08/22/18 at 3:00 pm during observation of the physical therapy room, the stickers to indicate equipment has been annually inspected and maintained was either missing or expired on the 3 of 3 treadmills.

H. On 08/22/18 at 3:10 pm during interview, Staff #18 confirmed that the treadmills for patient rehabilitation did not have preventative maintenance stickers on them and was unable to demonstrate when the treadmills were last inspected.

Endoscopy Suites:

I. On 08/21/18 at 9:30 am during tour of Endoscopy Suites, the scope-reprocessors (endoscopy tool cleaning and santizing machine) did not contain stickers indicating annual maintenance and inspection was preformed. Also, 4 of 6 water filters in the scope reprocessors were not dated indicating when they were last changed.

EDTU (emergency department overflow room):

J. On 08/22/18 at 10:45 am during an observation of the EDTU area, bed #4 had several scratches on the mattress and bed #6 had a tear in the mattress and a sticky residue at the top, bottom and mid section of the mattress.

K. On 08/22/18 at 11:10 am during interview, S#18 and S#22, witnessed and confirmed the scratches, tear and sticky reside on the mattresses in EDTU.


Operating Room (OR) #5

L. On 8/20/18 at 2:15 pm, during tour of OR #5, the following observations were made: The electronic patient monitoring machines were lacking appropriate PM (preventative maintenance) tags on them, which assures the user of the machines when the device was last checked for proper functioning and safety. PM tags were observed that stated the machine had PM performed on 03/03/2013 and PM was due on or before 03/03/2014. There were 3 of 6 machines that lacked PM tags on the anesthesia and patient care machines that the anesthesiologist or CRNA uses during surgery.

M. On 8/20/18, at 2:30 pm, during interview, S#38 stated that PM tags missing or expired has been brought to "their" attention, but the issue still exists.

N. On 8/21/18 at 9:45 am, during interview with the GE (General Electric, the company this facility contracts with to do preventative maintenance on electronic equipment) supervisor, the following statements were made:

1) The GE supervisor stated that the GE technician is at this location once a week and attends to maintenance requests in "the book", but was unable to state a specific day of the week or time of day when the technician was at this facility.

2) S# 38 and the S#17 both stated that they were unaware when the GE technician is present in the facility.

3) The facility nor the GE supervisor was able to produce a log book or record of PM performed or of the GE technicians time spent at this facility to provide evidence that the technician was present in this facility and/or of the work that was performed.

Based on record review, observation and interview the hospital failed to meet the Condition of Participation for Infection Control as evidenced by:

Based on observation, interview and record review, the hospital failed to close and lock disposal containers for discarded medications and sharps (such as used needles) and follow the manufacturers recommendations for use for a disinfectant during a terminal clean (the final thorough cleaning for the day) of operating room #5. These failed practices made controlled substances available for diversion (theft) and created a potential infection and safety risk to staff performing the terminal cleaning. (See A-749)

Based on observation, interview and record review, the hospital failed to ensure that the infection control officer has a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel. This failed practice has the potential to place all patients at risk for infection(s).

The findings are:

A. On 08/20/18 at 2:15 pm during a tour of operating room #5, the following were observed:

1. Four bins containing specific discarded needles and medications were not closed or locked. A syringe was observed containing approximately 20 ml (milliliters, metric unit of liquid measurement; 0.67 fluid ounce) of a unique anesthetic used by anesthesia called Propofol. It appears as a milky liquid and is unique among the medications used in the operating room. A company disposes of special waste from the hospital. It has created a unique colored plastic bin to each category of items under the Resource Conservation and Recovery Act: black for controlled pharmaceutical waste drugs and dyes; non RCRA pharmaceuticals such as used medication vials, partially used medications; sharps including needles, blades, broken glass, etc. All are required to be closed and locked.

2. Staff performing a terminal cleaning did not change the cloth liner used to support the plastic bags for trash that was changed.

3. Staff performing the terminal cleaning did not wear appropriate personal protective equipment or PPE, i.e., gowns or shield to protect their skin during the cleaning with Virex.

B. On 08/20/18 at 2:20 pm during interview, the technicians performing the terminal clean were asked how often they changed the cloth liner that holds the plastic trash bags. They stated, "Monthly."

C. Record review of the MSDS or Material Safety Data Sheet for Virex disinfectant and deodorant in section 8 directions for use specifically requires: goggles for eye protection; gloves for hand protection; protective foot wear; protective clothing for exposed skin.

D. On 08/20/18 at 2:15 pm during interview, S# 38 confirmed that the appropriate PPE would include clothing to protect exposed skin per the manufacturer's recommendations for use. S# 38 also confirmed the sharps container was full and should be replaced. S#38 confirmed the other containers should have been closed and locked.


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E. On 8/21/18 at 10:00 am during observation in the OB (Obstetrics) operating room, the following was observed:
1. Multiple syringes out of their original sterile packaging
2. Sharps disposal (container for used needles and syringes) overflowing
3. Multiple expired items including attachments for the glidescope (instrument used for placing a breathing tube)
4. Stirrups (used to elevate legs during procedures) with tears in vinyl upholstering that allowed for the exposure of internal cloth stuffing
5. Opened packages of one-time use laryngescope (instrument used to assist with placing a breathing tube) blades

F. Record review of personnel files reveals no screening for Tuberculosis (TB) for S# 20.

G. On 8/22/18 at 2:00 pm during interview, S#22 revealed that the contract agency used to provide CRNAs (Certified Registered Nurse Anesthesist "has not screened any of the CRNAs for TB" and the" hospital policy is to do a Quantiferon blood test (aids in the detection of Mycobacterium tuberculosis) upon hire".

H. On 08/20/18 at approximately 2:50 pm during tour of the physical therapy room, a sticky residue was observed and felt on the physical therapy mat treatment table.

I. On 08/20/18 at 3:00 pm during interview, S#3 confirmed that there was a sticky residue on the treatment table and acknowledged not knowing what it was and that it could lead to infection control issues. S#3 stated the treatment table was cleaned with Sani-wipe clothes (Quaternary/High Alcohol Formula [55%] for the disinfection of hard, non porous surfaces and equipment) after each use but could not articulate the manufactures recommendations for cleaning).

J. On 08/22/18 at 11:10 am during interview, S#18 and S#22, witnessed and confirmed 1) the scratches, tear and sticky residue on the mattresses in the EDTU area and 2) confirmed this could lead to infection control issues.

Based on record review and interview, the Emergency Department (ED) nursing personnel were not adequately trained to meet the needs (all patients) anticipated by the facility for 1 (S#1) of 1 ED personnel records reviewed. This failed practice has the potential to negatively affect patient care.

The findings are:

A) Record review of skill/competency check for S#1, (date of hire 2/14/18), reveals no documentation of competency in the personnel file.

B) On 8/20/18 at 2:00 pm, S#1 stated that they left the main ED on occasion and "took observation patients to EDTU (Emergency Diagnostic and Treatment Unit - an area separate from the main patient treatment area of the ED) when tha main ED was overflowing and that S#1 "could be the only Registered Nurse (RN) in the area" to monitor the overflow ED patients in the EDTU area.

C) On 8/22/18 at 2:10 pm ED manager stated "I'm working on it" when asked about S#1's incomplete skills checklist/competency evaluation.