HospitalInspections.org

Based on document review and interview, the hospital failed to maintain a list of all contracted services, including the scope and nature of services provided for 20 of 39 contracted services.

Findings:

1. The policy/procedure Contracts (approved 3-12) indicated the following: " A current list of all contracted services will be maintained on the DH intranet ...a list will be made available annually to the Board of Directors for approval. "

2. On 5-20-13 at 1530 hours, an approved list of 19 contracted services was received from staff A15. The list of services failed to indicate a service provider for air exchange testing, anesthesia machines, biohazardous waste, elevators, endoscopes, exhaust hood certification, 2 fire services, generators, medical gas, medical physics, pest control, 5 radiology service agreement providers, snow removal, sterilizers, and trash disposal.

3. Review of facility documentation indicated the following: air exchange testing by CS1, anesthesia machine service by CS2, biohazardous waste disposal by CS3, elevators service by CS4, endoscopes repair by CS5, exhaust hood certification by CS6, fire services by CS7 and CS8, generator service by CS9, medical gas by CS10, medical physics by CS11, pest control by CS12, 5 radiology service agreements by CS13, snow removal by CS18, sterilizer service by CS19, and trash disposal by CS20.

4. On 5-22-13 at 1005 hours, staff A5 confirmed that the list of contracted services failed to include the 20 indicated service providers.

Based on document review, and interview, the facility failed to ensure that EMS (emergency medical services) reported quality data related to Glucometer issues to the quality assurance committee and failed to create a program that would ensure improvement with issues addressed by gathered data.

Findings:
1. at 1:05 PM on 5/21/13, review of the 2011 and 2012 "EMS AccuChek Annual Summary" indicated:
a. 2011 had a range of 6.78% to 19.30% of errors in the section "% Patient I.D. Errors"
b. 2012 had a range of 7.35% to 28.57% of errors in the section "% Patient I.D. Errors"

2. interview with staff member #67, the point of care testing/lab staff member, at 11:45 AM on 5/22/13 indicated:
a. the data on the annual summary (listed in #1 above) is accumulated from the "Glucometer QA/QC/Pt Record logs completed by EMS staff on a monthly basis
b. the data gathered, as stated in 1. above, was out of the accepted error range as determined by the point of care testing staff
c. a majority of the errors were mostly incomplete documentation by EMS staff and not actual patient errors
d. the quarterly reports that go to the quality assurance committee only lists the "% Patient I.D. Errors" by nursing staff--the EMS data is deleted prior to reporting
e. it is unknown what the EMS director does with EMS data or what processes were put into place to try to reduce the missed documentation/errors noted for two years by EMS staff
f. there is no known quarterly report to the quality assurance committee by the EMS director

Based on document review and interview, the governing body failed to ensure that contracted services were evaluated and reviewed through the Quality Assessment and Performance Improvement (QA) program for 20 contracted services.

Findings:

1. The policy/procedure Quality Management Plan (approved 6-12) failed to indicate that contracted services at the facility would be evaluated through the QA program.

2. Review of program documentation failed to indicate monitoring and periodic reporting for the following 20 service providers: air exchange testing, anesthesia equipment, biohazardous waste disposal, endoscope service, elevators, exhaust hood certification, fire extinguishers, fire alarm system service, generators, medical gas, medical physicist service, pest control, 5 radiology service agreement providers, snow removal and a trash disposal service.

3. During an interview on 5-22-13 at 1010 hours, staff A5 confirmed that the Quality Management Plan lacked a provision for evaluating all contracted services through the QA program.

4. During an interview on 5-22-13 at 1100 hours, staff A2 confirmed that the 2013 Board Quality minutes lacked documentation indicating that the 20 service providers were currently being reviewed through the QAPI program.

Based on policy and procedure review, observation, and staff interview, the nurse executive failed to ensure that nursing staff followed facility policies related to the expiration date of opened glucometer test strips.

Findings:
1. at 12:00 PM on 5/20/13, review of the policy and procedure "Glucose Monitoring: Accu - Chek Inform Test Strip Coding", with a revised date of 9/25/12, indicated:
a. under "Quality Control:", it reads: "...QC (quality control) material is stable for 3 months once opened...Reagent strips are stable for 30 days once opened. Upon opening a new bottle of QC material or reagent strips, document the date it was put into use, the expiration date (30 days from date opened for reagent strips,...or expiration date on the bottle, whichever is sooner), and your initials on the vial."

2. at 12:00 PM on 5/20/13, review of the policy and procedure "Glucose Monitoring: Accu - Chek Inform Blood Glucose Test", with a revised date of 9/25/12, indicated:
a. under "Quality Control:", it reads: Upon opening a new bottle of Q.C. material or reagent strips, document the date it was put into use, the expiration date (30 days from date opened for reagent strips..."

3. While on tour of the nursing units with staff member #51, the chief nursing officer, it was observed that:
a. in the ED (emergency department) on 5/20/13 at 2:30 PM, the glucometer test strips were not dated when opened, dated with a 30 day expiration date, nor initialed when opened
b. in the PACU (post anesthesia care unit--recovery room) unit on 5/21/13 at 10:20 AM, the glucometer test strips were not dated when opened, dated with a 30 day expiration date, nor initialed when opened
c. in the ICU (intensive care unit) at 2:30 PM on 5/20/13, the glucometer test strips were not dated when opened, dated with a 30 day expiration date, nor initialed when opened

4. interview with staff member #61, the infection control practitioner, at 9:40 AM on 5/22/13 indicated:
a. nursing is not following the current policy of dating the test strips when opening the vial with a 30 day expiration date
b. two other policies, "Glucose Monitoring: Accu-Chek Inform Quality Control Test" and "AccuChek Inform Monthly Review" also indicate the test strips are only good for 30 days after opening with the bottles to be dated by nursing staff and initialed when opened

Based on policy and procedure review, document review, observation, and interview, the infection control committee failed to ensure that an active and effective hospital-wide infection control program was approved and implemented, as per policy and procedure, for 2013; failed to approve the housekeeping chemicals used through out the facility; and failed to monitor off site contracted cleaning personnel, including the approval of their housekeeping chemicals.

Findings:
1. at 12:15 PM on 5/22/13, review of the policy and procedure "Infection Prevention & Control Program Statement", with an effective date of 2/12 (no policy number), indicated:
a. under "Policy" on page one, it reads: "...Elements of the Infection Prevention and Control Program include: Identifying risks in the healthcare organization through a risk assessment annually..."
b. under "Policy", continued on page 9, it reads: "...Infection Prevention and Control Program evaluation and revision of the program annually..."

2. review of the 2013 infection control committee meeting minutes of 2/21/13 and 5/16/13, at 9:20 AM on 5/20/13, indicated there was no action taken to approve an Infection Control Program for 2013

3. interview with staff member #61, the infection control practitioner, at 9:40 AM on 5/22/13 indicated:
a. the 2012 policy titled "infection control prevention and control program statement" indicates that an annual risk assessment will be completed and the plan/program will be updated/revised as needed
b. a 2013 risk assessment has not been completed
c. the infection control committee has not approved of a 2013 program plan for infection control and prevention

4. at 9:00 AM on 5/22/13, review of the policy "Chemicals", policy number 4003 HK (from the "Housekeeping Manual"), with a most recent approval date of 10/12/11, indicated:
a. approval of the policy was by the housekeeping supervisor (VP ancillary services and safety officer),
b. on page 2, a description of "GP Forward" indicated this was a "general purpose alkaline cleaner"
c. on page 2, a description of "Virex" indicated this was a pH neutral germicidal cleaner/disinfectant used to disinfect all surfaces..."

5. review of the infection control committee meeting minutes of 5/17/12 through 5/16/13, at 9:20 AM on 5/20/13, indicated there was no action taken by the infection control committee for approval of the chemicals used in the facility, as listed in the "Chemicals" policy

6. while on tour of the ED (emergency department) on 5/20/13 at 1:15 PM, in the company of staff members #51, the chief nursing officer, and #54, the ED nursing director, it was observed that the product GP Forward was in the housekeeping closet

7. interview with staff member #58, the ED housekeeper, at 1:20 PM on 5/20/13, indicated:
a. the GP Forward product is a cleaner, not a disinfectant and is used to clean the hospital floors
b. the Virex product is used on "touch surfaces"

8. interview with staff member #63, the environmental services director, at 10:00 AM on 5/22/13, indicated there is a contracted housekeeping agency utilized at the two off site lab facilities

9. interview with staff member # 61, the infection control practitioner, at 9:40 AM on 5/22/13 indicated:
a. the infection control committee has not approved of the chemicals used by housekeeping staff
b. this staff member disagrees with the housekeeping manager's decision to clean floors with the GP Forward product instead of the Virex disinfectant
c. housekeeping has not approached the infection control committee with the decision to discontinue disinfection of floors by using the GP Forward product
d. the current "Chemicals" policy indicates Virex will be used on all surfaces, which should include floor surfaces
e. this staff member has not been involved in the instruction of contracted off site housekeeping staff or in surveillance of their competency
f. the infection control committee has not approved of the chemicals used by the off site contracted housekeeping staff, or of their policies/procedures for appropriate cleaning processes