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Based on review of document and staff interview, it was determined the facility did not ensure that the medical staff provided care that was consistent with current standards of practice. Specifically, orders for blood transfusions were incomplete and inadequate. This was found in 2 of 4 medical records reviewed for patients who had received transfusion. (Medical Records #4 and #5).

Findings include:

1. A review of MR #4 on September 16, 2015 revealed, this eighty-eight year old patient presented to the facility on August 21, 2015 with a diagnosis of Anemia, Emphysema and a Leaking Heart Valve. The physician wrote an order for transfusion of 2 units of packed red blood cells (PRBC) but did not specify the timeframe that each unit should have been transfused. Each unit of blood was transfused over 2 hours and 55 minutes.

2. A review of MR #5 on September 16, 2015 revealed, this sixty-eight year old patient presented to the facility on August 13, 2015 with diagnoses of Diabetes Mellitus, Total Knee Replacement, Hypertension, Anemia, Spinal Fusion and Mitral and Aortic Stenosis. The physician gave a telephone order to transfuse 2 units of PRBC but did not specify the timeframe for which the units should have been transfused. The first unit was transfused over 3 hours and 55 minutes while the second unit was transfused over 2 hours and 45 minutes

These findings were witnessed by the Quality Coordinator on September 15, 2015.

Review of the policy titled "Blood Transfusion Guidelines," last revised 5/15, stated PRBC can be transfused over 2 - 3 hours per unit or as ordered by the physician. In addition, this policy also states the "pediatric and elderly patients may require a slower infusion time as per physician"

Based on observation, document review and interview, it was determined the facility failed to (1) develop an effective program to analyze patient data and develop actions for improvement and (2) failed to ensure quality indicators including patient care data, and other relevant data are reported to the hospital Quality Improvement Organization (QIO).

Finding Include:

(a) On 9/16/15 at 9:30 AM, a review of the facility Quality Assessment and Performance Improvement (QAPI) Committee meeting minutes for July 2014 to August 2015 was conducted. The blood transfusion audits dated from July 2014 - June 2015 had not been incorporated into the Quality Assessment and Performance Improvement (QAPI) Committee meeting minutes.
The hospital wide blood transfusion audit compliance data dated July 2014 to June 2015 ranged from 91% -98% compliance. During interview on 9/16/15, the Quality Coordinator stated that the hospital goal was 100%.
There is no evidence that the hospital developed corrective actions.

(b) A review of facility documents revealed a nurse was counseled for an incomplete documentation on a blood transfusion flow sheet. The nurse was counseled by the nurse manager for incomplete documentation and incorrect blood transfusion on 4 occasion, specifically on 7/16/15, 7/20/15, 8/10/15 and 9/10/15. There was no evidence that the counseling or corrective actions were analyzed by the QAPI committee.
There was no evidence that the blood transfusions reactions or administration errors were tracked and trended and analyzed by the QAPI committee. Furthermore, a QAPI process was not in place for staff to report blood transfusion reactions or administration errors.

The Director of Quality Systems was interviewed on 9/17/15 at 10:30 am. She reported that the Quality Coordinator was responsible for tracking the blood transfusions. The surveyor requested the Blood Transfusion Quality Improvement (QI) audit from the Quality Coordinator. The Director of Quality Systems stated that the QPIC book did not contain the blood transfusion QI.

The Quality Coordinator was interviewed on 9/18/15 at 9:33 am. This interviewee stated that she was responsible for tracking the core measurements for the hospital and ambulatory surgical care and this included immunizations and blood transfusions. She also stated that the blood transfusions are being audited by the unit nurse managers.
The Quality Coordinator stated transfusion core measurement were not reported up through Quality Improvement Committee (QPIC) and is not analyzed.

(c) Review of the QAPI minutes for the period indicated above, revealed that there was a Pain Control Report which indicated that the hospital tracked and trended "how often was your pain controlled?" The "Pain Controlled" report indicated that from January 2015 to August 2015, the hospital did not meet their established benchmark of 83.03%. The hospital had a pain management control rate of 63.0% to 70% for this period.
There is no evidence that the hospital reviewed this data to determine the decrease from 77.8% in June to 63% in July.
The report had no evidence that the data was analyzed by the QAPI team and that the hospital developed a plan for improvement.
The Patient and Guest Relation Coordinator was interviewed on 9/18/15 at 2:00 pm. This interviewee reported that the hospital did not reach their goal of 83.03% and that there were no analysis of the data.

(d) The Hospital "Readmit Report" for 6/1/15 through 8/31/15 indicated that the hospital had 55 patients re-admitted to the hospital within 30 days after discharge. There is no evidence that this data was reviewed and analyzed to identify trends and develop a plan for improvement.

Upon interview on 9/18/15 at 9:35 AM, Quality Coordinator confirmed the findings and stated that this information was done at a department level and was never brought to the QAPI committee.

Review of the Hospital's Policy and Procedure "Quality Assessment and Performance Improvement 2015-2016," stated: "Data collected are systematically aggregated and analyzed to transform data into meaningful information for implementation of changes that will improve quality care, treatment and services."

The hospital did not adhere to their policy and procedure.





20003

Based on review of document and staff interview, it was determined the facility did not ensure that all departments audit and reports are included in the hospital wide Quality Assessment and Performance Improvement (QAPI) program. Specifically, there was no evidence that blood transfusions audits, pain management audits and readmission reports are reported up through the QAPI Committee.

Findings include:

See citation at:
Tag A 273.

Based on staff interview and review of document, it was determined that that the Food and Nutrition Department did not ensure that (a) physician prescribed diets in 28 of 28 diets, met the therapeutic nutritional needs of patients, (b) hospital menus were prepared based on standard of practice of menu planning, (c) menus developed for emergency preparedness is complete to meet the needs of the patients.

Findings include:

(1) A review of hospital menus and nutrient analysis was conducted on 9/15/15 at approximately 1:00 PM, in the presence of the Staff Clinical Dietitian and Corporate Clinical Dietitian.
The hospital has a one week cycle menu and a diet formulary consisting of approximately 28 different diets available to the physician for ordering of diets. Listed below are the deficits identified in the menus and the nutrient analysis of prescribed diets:

(a) The master menu had no food portions noted on the food items.

(b) There was no through nutritional analysis utilizing the menu by meal and prescribed diet.

(c) Diets listed on the physician diet formulary and patient menu are incomplete. Examples:

- Low Fat Diet- amount of fat not noted.
- High Calorie/High Protein- amount of
calorie/protein not noted.
- Low Sodium- amount of sodium not listed.
- Bariatric diet- liquid or solid not specified.
- Vegetarian Diet- no type listed.
- High and Low Fiber- amount not noted.

(d) Patient's on therapeutic diets did not have the portion size next to the food item on their menu nor did the menu document the correct diet order with the amounts restriction.

Due to the absence of nutritional data on the diet formulary, lack of portion size on the menus and a fragmented nutrient analysis; the nutritional adequacy of patient menus and validity of prescribed diets are not met.


(2) A review of the hospital's menu was performed on 9/15/15 at approximately 11:00 AM. Present during this review was the Clinical Staff Dietitian and the Corporate Clinical Dietitian.

The menu consist of a 1 week cycle menu. The hospital menus did not have portions next to the food item. Due to the absence of food portions it is unknown if these menus are nutritionally adequate as noted in the hospital policy titled, "Menus."


(3) Review of the Food Service Department "Emergency Preparedness Manual," identified the menu in the manual was not complete. Examples:

a) The menu noted, prepared powder milk,
and there was no instructions on how to
prepare this milk.
b) The menu does not specify what diets
are covered by this menu.
c) There is no diagram of where to find the
menus food items.
d) There was no menu for modified texture
diets, i.e. Mechanical soft, Pureed
and Clear Liquid.
e) There was no mention of enteral feedings
for patient on tube feedings.

These findings were acknowledged by the Food Service Operation Manager.

21204

Based on observation, staff interview and document review, the hospital did not ensure that the condition of the physical plant and overall hospital environment is maintained in a manner to ensure the safety and well-being of patients.

Findings are:

During tours of the hospital in the period from 9/15-9/18/201, the following issues were identified in the presence of the Director of Facilities who acknowledged the findings:


1) On 9/15/2015 at 11:25 AM, during a tour of the OR on the third floor of the hospital, the following were identified in the presence of the Director of Facilities.


a. The surface of the water fountain outside the OR suite by the staff elevator was found to be dirty, discolored and had a greenish black layer of dirt around the faucet opening and at the drain strainer.

b. The scrubbing sinks of the OR suite did not have the proper water temperature. When asked to measure the water temperature from various scrub sinks around the six OR rooms, the temperatures were 65 F, 65 F, 102 F, 83 F, 75 F and 90 Fahrenheit degrees.
Per CDC recommendation the hot water Temperature should be between
110 -120 F.

c. The floor of the hospital's OR at the expansion joint near ORs 5 and 6 was noted to lack floor tiles and was bumpy and not smooth. This is a tripping hazard and also potential for buildup of dirt and germs as it may be difficult for the area to be cleaned or disinfected easily.



2) During a tour of the ED on the morning of 9/16/2015, the following were identified in the presence of the Director of Facilities and the Nurse Manager of The ED:


a. It was found that the hospital has stored clean supplies in the bathroom near the
orthopedic room. The bathroom had a wood cabinet used for storage of clean supplies on
its top and inside. The stored supplies included but were not limited to: Clean urine culture
kits, boxes of clean gloves, clean cups..etc.

b. The soiled utility room did not have a hand-wash sink.

c. Flies were observed in the clean supply room of the ED.



3) During a tour of the MRI Suite on the afternoon of 9/16/2015, the following were identified in the presence of the Director of Facilities and the Administrator of the Radiology Department:

Many unsafe (ferrous containing items) that are incompatible with the MRI unit were found on the MRI suite outside the MRI room. Examples included but were not limited to:

a. The chain and tag holder of the fire extinguisher were from ferrous material and are
not suitable for use in the MRI, unless these parts are replaced with safe materials.

b. The crash cart of the unit was not ferrous free.

c. The IV Pole on the unit has metal parts that hold its wheels and these parts are not
ferrous free.

d. The linen hamper on the unit was found to have metal wheels that are not safe for MRI.


4) During a tour of the ICU on the morning of 9/17/2015, the following were identified in the presence of the Director of Facilities and the Director of Nursing:


a. The two airborne isolation rooms of the ICU did not have washable ceiling tiles
that are required for this type of room as per AIA guidelines and CDC
recommendations.

b. The curtain in the ICU were observed touching either the hand-wash sinks or
garbage containers.

c. Oxygen cylinders were observed being stored in each patient room of the ICU and the Medical - Surgical Unit. It should be noted that the Oxygen Cylinders should
not be stored in the patient rooms, instead they need to be stored in a clean supply
or storage rooms.

d. Red Containers were observed being stored in the patient bathrooms of the ICU.

This finding was brought to the attention of the Director of Nursing who stated that there is not enough space in the patient rooms and they needed the red containers in the room. In the event of a blood transfusion in any room, they will dispose the blood lines in the red containers.
Storing the red container in patient bathrooms is potential for the spread of infection.

e. The nurses' lounge was being used for storage of personal items, medical equipment
and food equipment as follow: Coats and other clothing items; bags, suitcase; medical equipment and IV poles; coffee machines, microwave; boxes of printing papers.

This is a potential for the spread of infection and a fire hazard.

5) Flies of different sizes were observed in different location of the hospital. Flies were observed in the clean supply room of the ED; Room 2162 of the Medical Surgical floor on the second floor; in the pantry area of the Ambulatory Surgical Unit and in the Wound Center.
When asked, the Manager of the Facility Operations said that they are working with the vendor to take additional measures to address this problem.
Review of the facility's Environmental Care Records, showed that there were some complaints and discussion about the spread of the flies since August 2015).



6) During a tour of the Med Surgical unit on the morning of 9/17/2015, the non-skid Tapes were observed being in disrepair and they were coming off the Parallel Bar machine (a machine used for training of people who have problem with balance and those required training for walking).



7) On the morning of 9/18/2015, during a tour of the Central Sterile, in the presence of the Manager of Facility Operation, the following findings were identified:

a. The decontamination room was lacking a hand wash sink for the staff to wash hands.

b. There was no hand-wash sink in the decontamination room of the endoscopy suite.


8) During a tour of the hospital extension clinic at Hyde Park, on September 18, 2015 at 11:00 AM, the side walk and handicap parking area was broken and in need of repair. This finding was witnessed by the administrator of the clinic when the observation was identified.

Based on observation, review of policy and procedures and staff interview, it was determined the facility did not maintain equipment to ensure that patients receive care in a safe manner.

Findings include:

During a tour of the off-site location "Hyde Park Satellite Health Center" on September 18, 2015 at 11:00 AM revealed all of the exercise equipment did not have inspection stickers to indicate the due date for inspection of the equipment.

Staff interview conducted on September 18, 2015 at 11:00 AM revealed the administrator at the location could not provide any documented evidence of the due dates for inspection of the equipment.

The facility's policy titled "Quality Assessment and Performance Improvement," last revised July 22, 2014, stated "employees, professional staff members, and volunteers' report immediately to their manager(s), risk management or other management person any defect, error, medical discrepancy, significant or risks to safety that could result in patient injury, hazardous condition, or risks in environment of care.

Based on the findings listed above the facility did not ensure that staff followed this policy.

Based on observation, review of document and staff interview, it was determined the facility failed to ensure that patients received care in a clean and sanitary environment.

Findings includes:

During a tour of the hospital's extension clinic at Hyde Park on September 18, 2015 at 11:05 AM the following observations were identified:

The hydrocollator was in need of cleaning. Portions of the heating pads in the hydrocollator had a brown color instead of a white color.

This finding was witnessed by the Physical Therapy and Wellness Manager at the time the observations were identified.

Based on document review and staff interview, it was determined the hospital failed to ensure that patients are appropriately evaluated prior to discharge.
This was evident in 1 of 5 applicable medical record. (MR#13)


Findings include:

Review of MR#13, indicated this eighty-six year old patient was brought into the hospital's emergency room by EMS (Emergency Medical Service) on 9/8/15 due to a fall at home. She complained of pain in the lower back.

The hospital triage assessment indicated that the patient has an history of falls "within last 3 months." The patient lives alone.

On 9/9/15, the Discharge Planner completed an assessment of the patient. There is no documentation that the patient's post discharge care needs were assessed..
There was no documentation whether or not the patient is able to effectively manage all activities of daily living. The discharge planner wrote that prior to the admission the patient had 2 hours of home care each week. There was no documentation of current home care service need or the patient's social support systems and their availability to assist.


Upon interview on 9/16/15 at 12:02 PM, Discharge Planner acknowledged the findings and stated that the patient has a daughter who is involved in her care. When asked where the daughter lives in proximity of the patient, she replied that the daughter lives in New Jersey.


The Hospital's "Patient Care Services Policy and Procedure," last reviewed 6/15, stated the Case Coordinator will initiate needed services as appropriate. This policy and procedure has no information requiring the need for an assessment of the patient's post discharge needs.

Based on review of the Organ, Tissue and Eye Procurement Program (OPO) Manual and staff interview, it was determined that the facility failed to ensure that this program was integrated into the Hospital Wide Quality Assessment and Performance Improvement Program (QAPI).

Findings include:

1. A review of the hospital's Organ, Tissue and Eye Procurement (OPO) Program Manual was conducted on 9/15/15 at approximately 2:30 PM. Present during the review of the contract was the Organ Donation Coordinator.
The surveyor requested the facility's tracking data and quality assessment program concerning compliance with time notification. The Organ Donation Coordinator informed the surveyor that she did not have a quality assurance program. She only had the reports sent to her by OPO and data on in-service provided to nurses.
The facility's current yearly timeliness in organ referral is 71.4%. The report notes that in prior year it was 100%.
The tissue donation report notes that the current yearly timeliness in tissue referral is at 88.7%. The year prior it was at 93.8%.

The OPO Program does not follow the facility's policy for quality assessment and performance improvement..