HospitalInspections.org

Based on staff interview and review of facility documents/meeting minutes, the governing body failed to ensure that the services performed under contract were provided in a safe and effective manner. Specifically, the facility failed to regularly review the performance of contracted services.

The findings were:

On 11/14/2011 at approximately 9:00 a.m., the facility was requested to provide a list of all contracted services. A review of the list provided revealed that the facility had among the facility's contracted services were contracts with: a laboratory to provide extended laboratory services, a laundry service to perform the laundering of all linens, a dialysis company to perform the dialysis of the hospital's patients needing dialysis, and a company to perform the releasing of medical records to patients and other entities requesting such services.

An interview with the Chief Operating Officer (COO) on 11/15/2011 at approximately 4:22 p.m., revealed that contracted services are evaluated using a form upon renewal of the contracted service and are placed in a computer system for retrieval. Evaluations for the four contracted services that were listed above were requested. The COO stated at that point that the contracted laboratory service and the medical record release company were "corporate contracts" and that s/he wasn't "sure if we have a review." S/he also stated that since the dialysis contract was recently started within the last year and that no form had been completed for that contract.

On 11/16/2011 at approximately 11:30 a.m., an email was provided that was sent to the members of the hospital's governing body on 7/1/2010 from the hospital's COO that outlined the process for contracted service evaluation. Attached to that email was the form that shown to the surveyor on 11/15/2011, that was to be used for the evaluation of contracted services. The form titled "Evaluation of Vendor's Contracted Services" had a portion to indicate the "time period reviewed" which stated that the review was to be "minimally annual basis."

A review of the hospital's governing body's meeting minutes revealed that contracted service evaluation was discussed during the February 2011 meeting but only included the contracts that were held with physician's to provide direction and services that were required for certain departments of the hospital. The above listed contracts were not discussed. This was confirmed with the hospital's Chief Nursing Officer (CNO) on 11/16/2011 at approximately 11:30 a.m. The CNO stated that the list and evaluation forms were presented to the governing body at the July 2010 meeting. S/he stated that the governing body had not had any other such review of the hospital's contracted services apart from those two meetings.

A subsequent interview with the hospital's CNO on 11/16/2011 at approximately 11:58 a.m., revealed that the contracted laundry service had not been formally evaluated, nor had the contracted laboratory service.

An interview with the Director of Health Information Management on 11/16/2011 at approximately 11:15 a.m., revealed that the contracted medical record releasing company began their contracted service 3/1/2010 and that s/he was not aware of the contracted service evaluation tool, but would be using the tool immediately. S/he confirmed that s/he had not apprised the governing body of the quality of the contracted service.

Based on the manner and degree of deficiencies cited, the hospital failed to be in compliance with the Condition of Participation of Medical Staff. The hospital failed to ensure that it had an organized medical staff that operated under bylaws approved by the governing body. Specifically, the hospital failed to ensure that all providers caring for patients were granted specific privileges by the governing body that delineated the procedures the practitioners were granted to perform at the hospital.

The facility failed to be in compliance with the following standard:

A 0355: Medical Staff Privileging - the facility failed to ensure that practitioners were granted specific privileges when placed on the medical staff. Specifically, the facility failed to delineate what tasks/activities/procedures the practitioners were granted privileges to do.

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Based on credential file review, review of the facility's Medical Staff Bylaws, Rules/Regulations, and staff interview the facility failed to ensure that practitioners were granted specific privileges when placed on the medical staff. Specifically, the facility failed to delineate what tasks/activities/procedures the practitioners were granted privileges to do.

The findings were:

A review of the facility's Medical Staff Bylaws, last reviewed August 3rd, 2009, revealed the following, in pertinent part:
"...Article VI Appointment to the Medical Staff
The procedures for appointment, reappointment and the granting of clinical privileges to the Medical Staff are contained in the Credentials Manual and are incorporated herein verbatim by reference..."

A review of the facility's Credential Manual, revealed the following, in pertinent parts:
"...Part E: Clinical Privileges
E. Section 1. General:
(a) Medical Staff appointment or reappointment as such shall not confer any clinical privileges or right to practice at the Hospital. Each individual who has been appointed to the Medical Staff shall be entitled to exercise only those clinical privileges specifically granted by the Board.
(b) The clinical privileges recommended to the Board shall be based upon the following:
(1) the Applicant's education, training, experience, demonstrated current competence and judgment, references, utilization patterns, and health status;
(2) availability of qualified physicians or other appropriate Appointees to provide coverage as deemed necessary by the Credentials Committee in case of the Applicant's illness or unavailability...
(4) the Hospital's available resources and personnel;
(5) any previously adverse or currently pending investigations to any licensure or registration, or the voluntary relinquishment of such licensure or registration, information concerning any voluntary or involuntary termination of Medical Staff appointment or voluntary or involuntary limitation, reduction, or loss of clinical privileges at another hospital; and
(6) other relevant information, including a written report by the Chief of each of the clinical Departments in which such privileges are sought.
(c) The Applicant shall have the burden of establishing his qualifications for and current competence to exercise the clinical privileges requested.
(d) The report of the Chief of the clinical Department in which privileges are sought shall be forwarded to the Credentials Committee and processed as a part of the initial application for Medical Staff appointment..."

"... PART C: Application for Initial Appointment and Clinical Privileges
C. Section 1. Information
Applications for appointment to the Medical Staff shall be in writing, and shall be submitted on forms approved by the Board upon recommendations of the Credentials and Medical Executive Committees.

These forms shall be obtained through the Office of Medical Staff Services.

The application shall contain a request for specific clinical privileges desired by the Applicant..."

"...10. Criteria for Delineation of Privileges
(This section shall be composed of the existing criteria for Delineation of Privileges for all clinical departments and Medical Associates/Assistants.)
10.2 Anesthesia
10.3 Dental
10.4 Emergency
10.5 Family Practice
10.6 Internal Medicine
10.7 Obstetrics/Gynecology
10.8 Pathology
10.9 Pediatrics
10.10 Psychiatry
10.11 Radiation Therapy
10.12 Radiology
10.13 Surgery
10.14 Orthopedic Surgery
10.14.2 Podiatry Privilege Criteria
10.15 Surgical Specialties, Other
10.16 Endoscopic Procedures
10.17 Laser Surgery
10.18 Medical Associate II and Medical Assistant...
Delineation of Privileges - Department of Surgery
Category I: Operative Privileges
Applicants for operative privileges shall submit as part of their application proof of specialty board certification or qualification for certification and recommendation as delineated in the sub-specialty delineation of privileges. Applicant must complete the appropriate delineation of privilege for the sub-specialty for which they are requesting.

Category II: Surgical Assist Only
Applicants must meet criteria for departmental membership. Privilege is limited to performance only when primary surgeon is in attendance. E.D. call responsibility for unassigned patients is not required.
Applicant is applying for privileges in the following Surgical Specialty ______...
Required previous experience: The applicant must be able to demonstrate the required level of training as determined by the sub-specialty...

SPECIAL PROCEDURES:
CONSCIOUS SEDATION
For initial applications, must provide documentation of physician specialty training during residency. If procedure is not a normal part of physician training, physician must review the education packet and pass the test. Procedure is then considered part of physician's Core privileges...
Cardiac and Cardiothoracic Surgery...
Thoracic Surgery...

GENERAL AND/OR VASCULAR SURGERY
Education: MD or DO Minimal formal training:
Successful completion of an ACGME or AOA accredited residency program in General Surgery. Initial applicant must provide an operative list documenting a minimum of 100 cases as primary surgeon within the past 24 months documenting core privileges.
Board Certification:
Documentation by an ABMS recognized board is required. Documentation of certification or qualification for the American Board 0" Surgery (ABS), or the American Osteopathic Board of Osteopathic Surgery (AOBS). Certification by the ABS/ABOS must be completed within five years of training.
___ General Surgery
Core privileges: include but are not limited to:
Diagnosis and treatment of illnesses or injures of the alimentary tract, abdomen and its contents, breasts, skin, soft tissues, head and neck, endocrine system and, comprehensive management of trauma patients including the musculoskeletal, hand and head injuries, care of critically ill patients with underlying surgical conditions in the ER, ICU units. Procedures to include colonoscopy, EGO, bronchoscopy, minor vascular including thrombectomy of grafts and vessels, AV grafts venous surgery, fine needle aspirations, sentinel node biopsy.
Core privileges may also include: Basic & Advanced Laparoscopic Surgery, Basic Laparoscopic Cholecystectomy and laser privileges, if documentation of training is provided.
___ Vascular Surgery -
The applicant must provide documentation of completion of an approved vascular residency program and a current operative list demonstrating a minimum of 50 cases as primary surgeon for core privileges
Core privileges: include but are not limited to:
Diagnosing and treating atherosclerosis, blockage or narrowing of the arteries, aneurysms, catheter guided procedures Laser privileges are included if appropriate documentation of training is provided
SPECIAL PROCEDURES
___Endovascular Privileges - Please request Endovascular Delineation of Privileges
___Peripheral Vascular Laser -
1) Must have vascular privileges
2) Evidence of training - with preception
___Bariatric Surgery
1) Must have general surgery/laparoscopic privileges
2) Evidence of completion of bariatric training course, to include didactic and operative laboratory work; or documentation of at least 25 open and laparoscopic bariatric surgical procedures during residency within the past 36 months or; completion of a bariatric surgery fellowship approved by the ASBS.
3) Ten cases preceptored (in attendance) by a fully trained, credentialed bariatric surgeon
4) Demonstration of 24/7 coverage of patients by credentialed bariatric surgeon
___Lap Band Bariatric Surgery
1) Must have Bariatric Surgery privileges
2) Evidence of completion of an approved lap band procedure course
3) Two (2) cases proctored
___Sleeve Gastrectomy
1) Must have Bariatric Surgery privileges
2) Evidence of completion of an approved Sleeve Gastrectomy procedure course
3) Two (2) cases proctored...
Neurosurgery...
Ophthalmology...
Oral and Maxillofacial Surgery...
Otolaryngology/Neurotology...
Pediatric Surgery...
Plastic Surgery...
Urology Surgery..."

A review of a sample of ten credential files that were reviewed on 11/15/2011 revealed that all ten credential files contained a privilege request form for "Core Privileges" which did not indicate that individual privileges were granted to practitioners.

A review of the "General Surgery Privilege Request Form" revealed that any applicant that was granted "Core Privileges in General Surgery" would include, but not be limited to: "Diagnosis and treatment of illnesses or injures of the alimentary tract, abdomen and its contents, breasts, skin, soft tissues, head and neck, endocrine system and, comprehensive management of trauma patients including the musculoskeletal, hand and head injuries, care of critically ill patients with underlying surgical conditions in the ER, ICU units. Procedures to include colonoscopy, EGO, bronchoscopy, minor vascular including thrombectomy of grafts and vessels, AV grafts venous surgery, fine needle aspirations, sentinel node biopsy."

An interview with the facility's Director of Medical Staff Resources on 11/15/2011 at approximately 1:30 p.m. during the review of the facility's Credential files revealed that the hospital granted "Core Privileges" and that specific procedures/privileges were not granted. S/he confirmed that a surgeon that specialized in breast surgery was granted core privileges in "General Surgery" which would allow the surgeon to perform all of the procedures in the core statement, including endoscopies and AV grafts. S/he stated that the hospital was currently working on "clusters" of more specific privileges for practitioners such as abdominal surgery, breast surgery, etc.

An interview with the facility's Chief Medical Officer on 11/16/2011 at approximately 1:45 p.m., revealed that the facility granted "core privileges." S/he confirmed that a breast surgeon and other subspecialists did not have more specific privileges than the general core of privileges granted to a surgical specialty.

Based on medical record review, staff interviews, and facility policy/procedure, the facility failed to ensure that nursing staff developed and kept current a nursing care plan for each patient in six of thirty sample medical records. This failure created the potential for a negative outcome.

The findings were:

Review of three open (current admissions) records (#12, #13, & #14) was conducted simultaneously with nursing unit tours on 11/14/11 at approximately 10:00 a.m. Upon review of the first open record (sample record #13), the Clinical Informatics Manager reviewing the record with the surveyor stated that the facility's previous care plan had been changed to "KOIN," an acronym later identified as knowledge/order/intervention/note, and was located under the "status board." S/he stated that the documentation for this care plan was "done through interventions." The facility's Electronic Medical Record (EMR) used a process of "interventions," which included vital signs, physical assessment, intake/output, etc, to document the nursing data. For example, in order for a nurse to document the patient's blood pressure, he or she would go in the electronic medical record under the "vital signs" intervention and then document the blood pressure and time recorded. The Clinical Informatics Manager was asked if anything related to the care plan would ever be documented anywhere but within the "interventions." S/he responded, "If there was an exception they may put a note in, but interventions are pretty comprehensive of their goals." Both other open record reviewed on the nursing units used the facility's new "KOIN" process for care plans. Additionally, later review of two more open records (#8 & #9) revealed the same KOIN process utilized for nursing care plans.

The Chief Nursing Officer (CNO) was asked if someone else at the facility was able to explain the new care plan process more clearly. S/he presented a Nurse Manager and a Clinical Nurse Specialist from the nursing units who spoke about the process at approximately 2:15 p.m. The Nurse Manager stated, "The KOIN part come in off the general admit data," which meant that the information the patient's admitting nurse entered was where the KOIN goals came from. S/he stated there were five "parts," which were later identified as goals and included comfort, safety, treatment plan, discharge plan, and education/ knowledge. S/he continued, "The documentation all supports that: the orders, interventions, notes... In 'general admit data' are all the five things they have to activate (click on). Then they become the goals and those are the five areas they have to address on a every patient."

The Clinical Nurse Specialist, who had educated some staff on the process, stated each of the corporation's hospitals "went live" with the new care plan process on 11/1/11. S/he stated the KOIN acronym stood for "knowledge, order, intervention, and note." In regards to "note," s/he stated, "I tell people you can go in and expand a little on your nursing intervention under notes." In regards to "knowledge," s/he stated, "It is teaching patients and having them respond. I've asked nurses to put in specifically what they are teaching so you can track that in the EMR." In regards to "intervention," s/he stated, "Nursing interventions which are individualized based on the patient." Lastly in regards to "order," s/he stated it was the physician order. When asked further about the five goals, s/he stated, "KOIN is based off five goals... The goals are the same for every patient in the hospital. KOIN tells you what is automatically populated over from interventions, etc. Everything is all in one place (referring to the KOIN section of the status board). It is convenient for those looking at progress and changes day to day." When asked to further explain how KOIN was a care plan, s/he stated, "For example the pain automatically populates into KOIN from the pain intervention... The status board (which includes KOIN) is a snapshot. The EMR is the whole picture... Go through the EMR to see the changes in goals. The goals change based on the orders/interventions... Even though the goals are very broad, you are meeting them." When asked if the entire EMR was the nursing care plan or if the KOIN outlook on the status board was the nursing care plan, s/he stated, "The status board (which included KOIN) is not the care plan, it is a tool used to show the care. The care is defined through the EMR." S/he further stated, "A lot of the documentation comes from the nursing physical assessment." When asked if nurses document on the five goals defined for them by the admission nurse, s/he stated, "They don't specifically document on the five goals. They document on them through their nursing interventions and the nurses know they are met on a daily basis through their plan of care... You met goals through the physician team, physician orders, nursing interventions..." When asked how the Discharge Plan goal was documented on by nurses, s/he stated, "Everyday when you do your nursing interventions you are planning for discharge..." The Clinical Nurse Specialist was not entirely clear in the explanation of the care plan as s/he stated, "KOIN is the plan of care and goals" and moments later stated, "EMR would be the patient's plan of care." S/he also stated the status board (which includes KOIN) only populates the last information checked and there were several bugs to work out of the new system. For example it was noted on sampled medical record #12's KOIN status board, the nurse documented the patient had no difficulties with activity, however, the physical therapist documented a contrasting statement and one of the patient's primary reasons for admission was activity assistance. The Clinical Nurse Specialist finally stated, "The status board is just a tool to give report," further contradicting that the facility's new process of KOIN (part of the status board) was the nursing care plan.

Again on 11/15/11, CNO and Director of Quality were asked if someone else at the facility was able to explain the new care plan process more clearly. On 11/16/11 at approximately 8:45 a.m., an interview was conducted with a staff/charge nurse who was a member of the committee who developed the plan of care for the entire hospital corporation. When asked what the nursing care plan was, s/he stated, "The care plan is KOIN. EMR is all the information. Another component is the five goals. We address those goals with each patient. KOIN is used as an acronym to remind staff of all the care plan components." When asked how those goals were addressed, s/he stated, "We look at the goals, look at the doctor's orders, and what we'll do with that patient: labs, antibiotics, fall risk, call lights, close to nurses station, oxygen requirements, PRN medications, repositioning, involving respiratory... It is kind of asking yourself why is this patient here and what are we doing for them while they are here? Everything falls into those five goals." When asked how those goals were charted/documented on, s/he stated, "They are addressed through the interventions and other documentation. The interventions are based on orders and as nurses see fit. We document on them based on our intervention list, including pain, psychosocial assessment, intake/output, intravenous fluids, vital signs, activities of daily living." When asked if the goals could be changed, s/he stated, "No, we are saying every patient has those five goals and what we do falls into those goals. We may focus more heavily on one goal than another, but we always address each, assess, and reassess for needs." When asked if it was possible to add other goals, s/he stated, "No, we feel that any other nursing diagnosis can fall into one of those categories. They are broad and we fell that anything could be addressed under those goals." When asked where one should look in the chart for the nursing care plan, s/he stated, "Under the KOIN status board at the front of the status board, it states the five goals and that is documented on the general admission (intervention). Then you'd have to follow through the EMR to see interventions... We are trying to instill these five goals into nursing, that you should be thinking about these goals. We have laminated housewide cards on the WOWs (computers)... Get used to looking at the status board was stated in education... more multi-disciplinary. Eventually there will be a processing of 'this is what is happening to the patient.' ...There are bugs yet to be fixed... The committee (for care plans) is still meeting..." However, it was identified in chart review that the status board/ KOIN was not present and able to retrieve after the patient was discharged. Therefore, the only place to find the five goals was on the documentation done by the admission nurse the first day of the patient's hospital stay.

On 11/14/11 at approximately 4:15 p.m., the CNO was asked for the policy and procedure for nursing care plans and s/he stated there was not one. On 11/16/11 at approximately 1:15 p.m., the CNO was asked again about a policy and procedure for care plans and s/he provided one, however it was only in draft form. The draft policy stated the following, in pertinent part:
"POLICY TITLE: Plan of Care for Acute Inpatients
SCOPE: This policy applies to all Centura Health acute inpatient facilities
PURPOSE: To define a standardized process for planning and communicating the patient plan of care within and between all disciplines involved in the care of the patient.
POLICY: It is the policy of Centura Health that all patients admitted to an acute inpatient facility will have an interdisciplinary and individualized plan of care supported by documentation within the EMR.
It is the policy of Centura Health that the interdisciplinary and individualized patient plan of care is constituted of the Licensed Independent Practitioner's (LIP) orders, interventions selected specific to the patient, the notes and other documentation contained within the electronic medical records, and the healthcare professional's knowledge...
Centura Plan of Care Process...
5 Overarching Goals on Every Patient:
1. Patient Comfort 2. Patient Safety 3. Follow Treatment Plan 4. Discharge Planning 5. Patient Education/ Knowledge ->
KOIN acronym for Plan of Care:
K = Knowledge O = Orders I = Interventions N = Notes ->
KOIN Interdisciplinary Tool Status Board (for reference only)
EMR (continually being updated)
Clinical Handoff Report (speaking to nursing & patients knowledge of the plan of care)
Short Term and Long Term Goals (continually being addressed & reassessed)..."

Meeting minutes from a Nursing Leadership meeting focused on the new care plan process. It stated, in pertinent part:
"...What changes? - There will be one process for planning patient care through Centura Health, based on the proven KOIN method. - A status board will be available to be used as a tool for sharing information among disciplines in an easy and time-efficient manner. - Duplicate or extra documentation related to the Plan of Care will be eliminated. - MEDITECH Process Plans will no longer be used.
How is it beneficial? - The Plan of Care will be focused on patient centered care while meeting the regulatory requirements. - The KOIN method reduces the amount of time spent on documentation of Plan of Care. - The 'Plan of Care Tool' is a new status board which provides a quick reference for patient centered, interdisciplinary goals and plans..."

Lastly, review of one closed medical record (sample #30) at the facility's north hospital campus revealed no nursing care plan existed for the patient. The patient was admitted 10/15/11 to 10/17/11. The patient had been at the hospital prior to the facility's implementation of its new care plan process. On 11/16/11 at approximately 11:00 a.m., the Director of Nursing confirmed that no care plan was present.

In summary, although the facility's new nursing care plan process afforded goals to each patient, the goals were the same for each patient, were not able to be changed or expanded upon, and clear documentation to those goals was not evident. Instead, one would need to explore the entire medical record to find the documentation and progress towards those goals.

Based on observations, interview, and facility policy/procedure, the facility failed to ensure the hospital had a procedure for ensuring the confidentiality of patient records, specifically in the outpatient Health Learning Center. This failure created the potential for a negative outcome.

The findings were:

A tour of the the facility's outpatient Health Learning Center's Coumadin Clinic was conducted on 11/15/11 at approximately 10:15 a.m. The Health Learning Center also had a Diabetic Education Clinic and Podiatry Clinic. When asked where paper portions of the medical records were stored, the Health Learning Center's Business Manager stated they were stored "in front." Observations of all the Health Learning Center's program's medical records revealed they were stored in the main alcove where the secretaries/schedulers sat. The area accommodated several people and computers and the medical record storage was in a small hall to the right of the patient check-in window. The hall contained hundreds of medical records stored on file cabinets, which were without doors or any locking/enclosure methods. The entire "front area" was without doors and instead contained two areas to enter and exit, one of which was directly at the end of the medical records' file cabinets.

When the Business Manager was asked if there was a way to secure the area, s/he stated, "There is no way for it to be locked. It is not a patient area." When the Business Manager was asked if housekeeping serviced the area in the evenings, s/he stated, "Housekeeping service comes in at night and they can come back here. We have a business associate agreement, so they sign HIPPA compliance forms... Joint Commission was here this past year and didn't have a problem with it..."

After the tour of outpatient service areas, the Director of Nursing (DON) was informed, at approximately 11:15 a.m., of the concern about the confidentiality of medical records in the Health Learning Center. The DON stated that s/he agreed and s/he confirmed there was no secure storage of the records in that area. S/he stated they were already trying to form a solution.

Prior to exit from the facility on 11/16/11, the Chief Operating Officer, who was the individual responsible for all outpatient services, provided photographs of doors which had been placed within the previous 24 hours. The doors appeared to be in the initial stages of construction and were on either end of the medical records' cabinets in the Health Learning Center.

Based on staff interview, policy/procedure review, and observations, the facility failed to ensure that outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use. Specifically, the facility failed to ensure that medications in a warming cabinet were placed according to facility policy and manufacturers specifications. This failure had the potential to create negative patient outcomes.

The findings were:

A tour of the Emergency Department was conducted with the Director of Emergency Services and the Chief Medical Officer on 11/14/2011. At approximately 10:15 a.m., a warming cabinet was inspected in one of the rooms used for trauma and complex medical patients. The warming cabinet contained bags of saline solution as well as two 30 milliliter glass bottles of Mannitol for intravenous injection. The thermometer used for measuring the temperature of the warming cabinet had a reading of 116 degrees Fahrenheit, which was confirmed by the Director of Emergency Services. The Director of Emergency Services then turned the heat setting to a lower setting. S/he stated that the facility's policy/procedure required the cabinet not to exceed 104 degrees. S/he stated that the bags of fluid can remain in the cabinet for 14 days, but that s/he did not know how long the bottles of Mannitol were able to remain in the cabinet. S/he stated that the pharmacy department was responsible for the Mannitol.

An interview with the Director of the facility's Pharmacy on 11/16/2011 at approximately 8:30 a.m., revealed that the facility did not endorse storing Mannitol in the warming cabinet; rather the pharmacy had an alternate way to store Mannitol to avoid crystallization that was more appropriate. S/he also stated that the warming cabinet temperature of 116 degrees was above their recommended practice.

A review of the facility's policy/procedure titled "Warmed Solutions" last revised 6/2011, that was posted on the outside of the warming cabinet stated, in pertinent parts:
"PRACTICES:
1. The length of time fluids may safely remain in a warming cabinet is determined by manufacturer's guidelines.
This information should be checked prior to storing solutions in a warming cabinet.
2. Solutions that are routinely administered on the nursing units after warming include certain IV solutions, irrigation solutions and Continuous Ambulatory Peritoneal Dialysis (CAPD) solutions...
4. Fluids should be warmed by using a designated fluid warming cabinet with temperature controls and a calibrated thermometer. The temperature should not exceed 104 degrees Fahrenheit (40 degrees Centigrade)...
Patient care units that have warming cabinets will be responsible for checking the cabinet daily. This check will include assessing that the thermometer is functioning properly. The check information will be recorded daily on the Blanket Warmer/Warming Cabinet Checklist (IDP- B-03-k)."

Based on the onsite recertification survey, completed November 30 through December 2, 2011, the facility failed to comply with the regulations set forth for Life Safety and, therefore, deficiencies were cited under Life Safety Code tags K0025, K0027, K0076, and K0073. See survey event ID #K02U21 for full details of the cited deficiencies.

Based on observations, staff interview and review of the facility's policies and procedures, both the main and north campus failed to ensure that a sanitary environment was maintained in the food and dietary areas. Specifically, the facilities were not following their policies and procedures and/or the proper techniques for maintaining food sanitation.

The findings were:

1. Main Campus:

The facility's policy and procedure entitled, "Food Storage," reviewed/approved on June 1, 2011, stated the following in pertinent part: "Thermometers must be placed in all refrigerators and freezers...
All containers used for storage must be labeled and covered. This includes flour bins, rice bucket, spice containers, etc. Scoops are placed outside of bins...
Leftovers: They are kept in covered containers which have been labeled and dated...
Leftovers are kept for no longer than 48 hours. Patients are never served leftovers."

A tour of the food and dietary preparation area was conducted on 11/14/11 at approximately 10:00 a.m. with the Dietary Manager. The first area observed during the tour was an annex area prior to entering the main food preparation area. The refrigerator contained a half-full carton of milk with an expiration date of 11/7/11 and a quart container of cooked prunes that was not dated. Also, there was an unboxed towel dispenser on the floor that apparently was to be installed. In the main food preparation area there were a number of dry storage bins. The floor bin had a scoop stored in it rather than placed on the outside.

The observations regarding the discrepancies were shared with the Dietary Manager during the tour. The Manager stated that the food containers should be dated. The Manager wasn't sure why the towel dispenser was on the floor and further stated that scoops are not regularly left in the dry storage bins.


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2. North Campus
A tour of the food and dietary preparation areas was conducted on 11/15/11 at approximately 2:30 p.m. with the Dietary Director, the Executive Chef and the facility's Vice President of Operations. Direct observation of all the refrigerators and freezers in the area revealed that there were no manual readout thermometers utilized in any of the areas. When asked about the practice of monitoring temperatures in cold storage areas the Executive Chef stated, "We only use the digital readout for temperature monitoring, El Paso County does not require the use of manual thermometers." During the tour it was also noted that there was no evidence of daily freezer/refrigerator temperature checks and monitoring logs, the Executive Chef stated, "The digital readouts are monitored electronically and if there was a problem the alarm would sound."

During the tour, there were two items shown to the Executive Chef that were out of compliance with the food storage policy: 1)A large container of shredded cheese was observed to be refrigerated without being covered and dated, 2) An opened quart of expired milk was found on the cart in the refrigerator. Both items were removed by the Executive Chef.

When asked about the procedure for labeling food items for expiration dates the Executive Chef stated, "All retail items [sandwiches/salads for sale in the cafeteria] are prepared and labeled with a labeling gun identifying the appropriate expiration date." He further stated, large items prepared for use of providing single servings are manually labeled with the preparation date and will be disposed of in three or four days if not served, but we always serve all of these items." The Food Storage policy reviewed at the main Penrose St. Francis campus. It was determined that there was no statement regarding the method to be used for "date labeling" however the dietary policy reviewed at the Penrose facility states that "leftovers are kept for no longer than 48 hrs."

The Vice President of Operations was asked to provide a copy of Policies and Procedures for Food Storage in Dietary. The facility was not able to produce policies and procedures prior to the survey exit; he/she stated "we do not have any." He/she stated, "retail items in coolers have expiration dates, foods created in the back are labeled on the "[creation date]."

Specifically, the North facility was not aware of the policy and procedure entitled "Food Storage" that was reviewed and approved on June 1, 2011. This policy was presented and reviewed at the Main campus.

Based on credential file review, review of the facility's Medical Staff Bylaws, Rules/Regulations, and staff interview the facility failed to ensure that surgical privileges were delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The facility failed to ensure that the surgical service was able to maintain a roster of practitioners specifying the specific surgical privileges of each practitioner. Specifically, the facility granted general "core privileges" that only specified the type of practitioner (such as General Surgery, Orthopedic Surgery, etc.) category.

The findings were:

Cross Reference to A 0355: Medical Staff Privileging - for findings related to the facility's failure to ensure that practitioners were granted specific privileges when placed on the medical staff. Specifically, the facility failed to delineate what tasks/activities/procedures the practitioners were granted privileges to do.

An interview with the Director of Surgical Services and the Chief Medical Officer on 11/15/2011 at approximately 9:00 a.m. during a tour of the surgical services area revealed that the roster of practitioners that was maintained in the surgical department was available through the computer documentation system as well as the hospital's intranet. The listing for each physician stated the core privileges that were granted and any special privileges granted to that practitioner. There was no further delineation of what specific procedures the practitioner was granted permission to perform at the facility.

Based on facility policy/procedure, staff interview and review of facility documents, the facility failed to ensure it complied with its operating room policy regarding sterilization of instruments. Specifically, the facility routinely flash/immediate use steam sterilized physician-owned instruments and had not implemented efforts to decrease this routine use of flash. This failure created the potential for a negative outcome.

The findings were:

The facility's Quality and Patient Safety Committee Meeting minutes from September 2011 were reviewed. They stated the following, in pertinent part: "Flash logs: [South campus] 5.9% rate for last 4 months - still clarifying rate definitions - set to set. [North campus] 9% rate - includes dental." The minutes stated the "Actions Taken" about this matter were as follows: "Have made a lot of progress... Will take dental instruments out of flash rate."

The facility's North campus flash logs and documentation were reviewed. For the months of May 2011 to October, there was a percentage of flash number and a second percentage number, which was lower and stated "no Dental" next to it. The average dental instrument flash rate for the previous six months was 3% per month.

An interview was conducted with the Operating Room Nurse Manager/Director of the facility's North Campus on 11/16/11 at approximately 11:30 a.m. Review of the flash sterilization logs revealed that dental instruments were frequently flashed. The Manager stated the instruments were placed in an Aesculap instrument pan with a lid and flashed in a Steris steam sterilizer for the recommended cycle of 4 minutes at 270 degrees. The Technicians routinely performed and documented daily biological and spore testing (3M brand) of the two steam sterilizers. In regards to dental instrument flashing, the Director stated, "I gave the surgeon the instrument supply catalog to choose the instruments [s/he] needs so that we can make five sets of dental instruments." When asked how long ago this catalog was given to the physician, s/he stated, "Six to nine months ago." The Director confirmed that the current used instruments for dental cases were all owned by the dental surgeon and brought in for the surgeries. The physician had been practicing at the hospital for years, but recently increased the number of dental surgeries performed. The Director acknowledged his/her understanding of AORN's recommended practices regarding flash sterilization. When asked about the budgeting for the additional sets s/he stated, "The purchases are not 'capital equipment,' these items and can be purchased as 'line items' for the Operating Room budget. They do not require corporate review and approval." The Director stated in a follow-up conversation, "I have called the surgeon and we will be ordering the sets soon." The anticipated date of implementation of the additional dental instrument sets was stated to be 12/31/2011.

The facility's policy and procedure titled, "Sterilization," with an effective date of 2/2011, stated the following, in pertinent part: "...IV. Flash sterilization will be kept to a minimum and used only in selected clinical situations and in a controlled manner. a. Flash sterilization will be used only when there is insufficient time to process by the preferred wrapped or container method. b. Items to be flash sterilized will be subjected to the same decontamination processes as regularly processed instruments... PROCEDURE FOR FLASH IF DEEMED NECESSARY TO PERFORM: 1. Recommended sterilization procedures: a. Before flashing instruments, contact Sterile Processing, if possible, in order to rule out alternatives to using the Main Operating Room's flash sterilizers... VI. Loaner Trays: a. Loaner trays will be requested to be delivered to SPD a minimum of the night before surgery. b. All loaner trays will be decontaminated and sterilized as all owned trays in Penrose/St. Francis SPD..."

An interview was conducted with the Director of Peri-Operative Services at the facility's South campus on 11/16/11 at approximately 12:20 p.m. When asked the difference between loaner and owned trays, s/he stated, "If they are housed in our facility, they are deemed as ours. If they are brought in, they go to SPD, are cleaned and sterilized. If immediate use because no one knew the instrument was coming, we would flash..."

The 2011 Edition PeriOperative Standards and Recommended Practices for Inpatient and Ambulatory Setting by the Association of PeriOperative Registered Nurses stated the following within "Recommended Practices for Sterilization in the Perioperative Practice Setting," pages 466 and 467, in pertinent part: "...Use of flash sterilizations should be kept to a minimum. Flash sterilization should be used only in selected clinical situations and in a controlled manner. Flash sterilization may be associated with increased risk of infection to patients because of pressure on personnel to eliminate one or more steps in the cleaning and sterilization process. Flash sterilization should be used only when there is insufficient time to process by the preferred wrapped or container method. Flash sterilization should not be used as a substituted for sufficient instrument inventory..."