HospitalInspections.org

Based on review of Governing Body, Medical Staff and Quality Assessment/Performance Improvement meeting minutes and incident reports for 2011 and 2012 , the hospital does not ensure that medication errors identified are analyzed and opportunities for the reduction of the errors are evaluated and a plan of action initiated. Incident reports are initiated documenting medication errors, but there is no evidence in meeting minutes that they are analyzed to determine causes and implement actions to reduce their occurrence.

Based on clinical record review and staff interview, the hospital failed to ensure a discharge summary was completed for four
(#1, 2, 3, and #8) of 19 clinical records reviewed for discharge summaries. Findings:

Patient #1 was admitted on 04/18/12 and discharged on 04/30/12. No discharge summary was found in the clinical record.

Patient #2 was admitted on 02/06/12 and discharged on 02/17/12. No discharge summary was found in the clinical record.

Patient #3 was admitted on 2/15/12 and discharged on 3/8/12. No discharge summary was found in the clinical record.

Patient #8 was admitted on 2/1/12 and discharged on 2/4/12. No discharge summary was found in the clinical record.

The Vice President of Patient Care Services stated if the record did not contain a discharge summary, one had not been done.

Based on review of policies, interviews with staff, and review of medical records the facility failed to provide radiological services in a safe manner. Staff B told surveyors radiology services were provided through employees. Four of four(D,G,H,I) radiology personnel did not have current competencies. There was no documentation the personnel had been trained in radiation safety.

Based on review of policies, and interviews with staff, the hospital failed to ensure a qualified radiologist supervises the radiology services.

Findings:

1. On the morning of 5/22/2012 staff B told surveyors radiology services were provided by employees. Staff B told surveyors the services provided included in radiology are x-ray, nuclear medicine, mammography, magnetic resonance imaging (MRI), and computed tomography (CT). There were no current policies (reviewed and approved by medical staff and the supervising radiologist) stipulating all services/procedures provided by the hospital. There were no current policies or documents reviewed and approved by the medical staff and radiologist indicating personnel competent to use the radiological equipment and administer procedures. Some of the policies provided did not match the current practice of the facility.

2. On the afternoon of 5/23/2012 Staff B told surveyors there was no Chief Radiologist. This finding was verified with Staff J on the afternoon.

Based on review of hospital documents, review of personnel and interviews with the administration, the hospital failed to have documentation showing all the personnel operating the diagnostic x-ray equipment are qualified and trained.

Findings:

1. On the afternoon of 5/22/2012 surveyors requested radiology personnel files. Employee files (D,G,H,I) did not indicate personnel providing radiology services for the hospital had current competency, evaluations, and safety training. There was no documentation the medical staff or the radiologist had developed, reviewed, and approved criteria designating personnel competent to perform radiologic procedures.

2. On 5/23/2012 these findings were presented to administration in the exit conference. No further documentation was provided.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure nutritional assessments were performed as clinically indicated. Findings:

A hospital document titled, Dietary Referral, documented twelve triggers for a nutritional assessment to be done. Three of these triggers were:
~ eating less than 50 % of usual intake for three days
~ difficulty swallowing and
~ diabetes.

Patient #1 was admitted on 04/18/12 with diagnoses which included acute/chronic renal insufficiency, pneumonia and anemia. During the course of the hospitalization, the patient was evaluated for problems with swallowing. A review of intake and output records had no documentation of meal intake percentages for the patient. There was no documentation of a nutritional assessment found in the clinical record.

Patient #2 was admitted on 02/06/12 with diagnoses which included diabetes mellitus type II, hypokalemia and a urinary tract infection. A review of intake and output records had no documentation of meal intake percentages for the patient. There was no documentation of a nutritional assessment found in the clinical record.

The Vice President of Patient Care Services was asked if meal intake percentages should be documented. She stated they should be.

She was asked if nutritional assessments should have been performed for these patients. She stated they should have been done.

Based on record review, observation and interviews with staff, the hospital does not ensure all patient care services are provided within a licensed part of the hospital that has been approved safe and in compliance with Life Safety Code Standards for Health Facilities and approved by the Oklahoma State Health Department as meeting the building requirements for hospitals.

Findings:

1. Five Oaks Medical office building is, according to hospital staff (A), a department of the hospital. This building has not been approved by the Oklahoma State Department of Health as part of the license for Grady Memorial Hospital and as meeting the requirements for Chapter 667 - Hospital Standards and National Fire Protection Association 101 Life Safety Code 2000 (NFPA 101 ).

2. The building houses physicians' offices and the laboratory that provides services for the hospital. These services are not listed as contract services.

3. Staff (B) stated on 05/23/12 in the afternoon that contrast media is administered to patients over at the physicians' building and the patients walk over to the radiology department for the procedure.

4. All the personnel in the office building are included as employees and are on the hospital's organizational chart as part of the hospital.

5. All services provided in the Five Oaks Physicians building are included in all meeting minutes as part of the hospital.

Based on review of hospital documents, infection control plan, meeting minutes, surveillance/monitoring activities, surgery logs and autoclave tapes for April and May 2012, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. Review of meeting minutes did not reflect the infection control committee had reviewed and approved the disinfectants used in the hospital to ensure they were effective against the organisms encountered in the hospital. On 05/23/2012 at 0920, Staff K told the surveyors that the hospital used Virex 256 throughout the hospital to clean/disinfect. Later, Staff K also added another disinfectant as used in the facility. The plan, monitoring activities and meeting minutes did not reflect monitoring of the disinfectants in the different areas to the hospital to ensure all departments/staff used the disinfectants according to the manufacturer's guidelines. This finding was reviewed and verified with Staff K on the morning of 05/23/2012.

2. Surgical Services - Other than a walk-through rounds, just like the ones conducted in other areas of the hospital, the infection control program did not monitor surgery and central sterile practices.

a. Staff K told the surveyors on the morning of 05/23/2012 that the surgery department used Virex 256 to clean. According to the manufacturer's guidance, the product needs to remain wet on the surface for ten (10) minutes to kill the organisms. Staff K confirmed he had not monitored staff to ensure the surgical suites were appropriately cleaned between cases and the disinfectant remained wet on all surfaces the required 10 minutes.

b. Review of infection control data showed Staff K sent written information to Staff F and the surgery staff that immediate use/flash sterilization was to be used only in emergency situations - dropped single instrument, specialty instrument needed - but was not appropriate for lack of instrument sets or for convenience. A surgery policy titled, Flash Sterilization, documented flash sterilization was to be used only when an item was contaminated during a case.

i. Review of the surgery log showed 12 cataract surgeries were conducted on 04/11/2012. Staff K stated the eye surgeons brought their own, usually 2 sets. This was confirmed with Staff F on the afternoon of 05/23/2012. Staff F told the surveyors that they used a shortened cycle dry time of one minute because they didn't have time to do full cycles between the cases. Review of the autoclave/sterilizer log and tape confirmed this use.

ii. Review of the sterilizer log and tape for April and May 2012 showed other instruments, including hysteroscopy, tonsil, and cesarean-section instrument sets, were being put through the flash/immediate use cycle, even when there was adequate time for a full cycle, including appropriate dry time. Refer to Tag - A951 for details.

c. Meeting minutes for February 20, 2012 recorded immediate use sterilization use. The document recorded Staff F "states he felt we were doing all steps correctly." On the afternoon of 05/23/2012, when interviewed, Staff F told the surveyors the surgeon did not bring the manufacturer guidelines for the eye instruments and he had not reviewed to ensure immediate use was the manufacture's recommended method of instrument sterilization. Staff F stated the hospital did not have the manufacturer guidelines for the hysteroscopy set also processed by immediate use sterilization to ensure this type of sterilization was the recommended sterilization process. Staff F told the surveyors that the hysteroscopy set was processed through a full sterilization and dry time at the end of the day.

3. Although the program and meeting minutes contain a section entitled Employee Health, the only concern addressed was needlesticks. The documentation recorded the protocol for needlesticks was followed, but it contained no analysis to determine if any policies/procedures need revision to provide a safer practice. There was no review of employee illness to ensure transmissions between staff and patients and/or staff and staff occurred.

Based on policy and procedure review, record review and staff interview, it was determined the hospital failed to:

a. have surgery department policies to ensure sterilization surveillance and

b. failed to follow and enforce the surgery department flash sterilization policy. Findings:

A hospital policy titled, Flash Sterilization, documented flash sterilization was to be used only when an item was contaminated during a case.

Tapes produced by three steam sterilizers during the months of April 2012 and May 2012 were provided by the surgery department director. The tapes were not labeled to indicate which sterilizer they came from.

The daily sterilizer logs that documented each load run in each sterilizer for April 2012 and May 2012 were reviewed. Findings included:

~ Daily spore testing for the Vacamatic sterilizer was missing on 04/03/12, 04/04/12, 04/05/12 and 04/11/12.

~ 3M Steam Pack Records were missing for instruments sterilized on 04/06/12, 04/11/12, 04/13/12 and 04/26/12.

~ On 04/04/12, a 3M Steam Pack Record documented, "C-Section Instruments". There was no documentation on the daily log that c-section instruments were sterilized on this date.

~ On 04/11/12, twelve loads of eye instruments were documented on the daily log for that date. The Vacamatic sterilizer tape for these loads documented the eye instruments were flashed every time they were sterilized.

The Director of Surgery stated there were only two sets of eye instruments and both sets were used on that date.

There was no way to distinguish between sets (i.e. set #1 and set #2) on the daily sterilizer log.

On 04/12/12, seven loads of eye instruments were flash sterilized.

On 04/13/12, the daily sterilizer log and sterilizer tape documented a hysteroscopy set was flash sterilized between cases.

On 04/18/12, four loads of eye instruments were flash sterilized.

On 04/19/12, eight loads of eye instruments were flash sterilized.

On 04/23/12, a tonsil instrument set was flash sterilized after a case.

On 04/24/12, the sub-sterile Vacamatic sterilizer tape documented a load sterilized at 7:02 a.m. There was no corresponding documentation of the contents of that load on the daily log for 04/24/12.

On 04/26/12, six loads of eye instruments were flash sterilized.

On 05/01/12, the daily sterilizer log and sterilizer tape documented a hysteroscopy set was flash sterilized between cases.

None of the daily sterilizer logs for April 2012 and May 2012 documented which loads were flash sterilized.

On 05/23/12, the Director of Surgery was asked for surgery department policies that outlined procedures for documenting records of sterilization and for sterilizer monitoring.

He stated there were no written policies and procedures for that.

He was asked if there were any surgical instruments that were flashed sterilized on a regular basis. He stated eye instruments and hysteroscopy instruments were routinely flashed between back to back cases.

He was shown the sterilizer tapes that documented hysteroscopy instruments that were flashed on 04/13/12 and on 05/01/12 when there were two hours between cases. He stated those instruments should not have been flash sterilized.

He was also shown the sterilizer tapes that documented tonsil instruments were flash sterilized on 04/23/12, when on one tonsil case was scheduled for the day.

He stated he did not know why the tonsil instruments were flashed.

Based on policy and procedure review and staff interview, it was determined the hospital failed to develop the Abuse and Neglect policy to ensure patients were protected while allegations of abuse or neglect were being investigated. Findings:

A nursing service policy titled, Abuse/Neglect, documented the hospital would suspend an employee only when abuse, neglect or exploitation of a patient was proven.

The policy further documented that an employee who had allegations made against him/her would be allowed to interact with patients as long as another staff person was present.

The Vice President of Patient Care Services stated the policy need to be changed to immediately suspend an employee from all patient contact when an allegation of abuse, neglect or exploitation was made.

Based on record review and staff interview, it was determined the hospital failed to ensure individuals who had been convicted of abusing, neglecting, or mistreating persons in a health care setting were not employed. Findings:

Thirteen personnel files for staff members currently employed were reviewed. Eight records had no evidence the State Nurse Aide Registry had been checked for findings of alleged patient abuse, neglect, mistreatment or misappropriation of patient property.

The Vice President of General Services stated inquiries with the State Nurse Aide Registry had not been done on all employees.

Based on clinical record review and staff interview, it was determined the hospital failed to provide activities according to the patients' needs for two (#1 and #2) of two records reviewed.

Patient #1 was admitted to a swing bed on 04/18/12. An activities assessment documented the patient was interested in puzzles and writing notes to friends.

A Patient Activity Participation Record documented the patient's activities included exercise and interactions with family, friends and students.

The exercise that was documented on the activities record was physical therapy services provided by the hospital as ordered by the physician.

There was no documentation the patient was offered or provided activities of her choice.

Patient #2 was admitted to a swing bed on 02/06/12. An activities assessment documented the patient was interested in comic books, mystery novels and television.

A Patient Activity Participation Record documented the patient's activities included exercise and interactions with students.

The exercise that was documented on the activities record was physical therapy services provided by the hospital as ordered by the physician.

There was no documentation the patient was offered or provided activities of her choice.

The Vice President of Patient Care Services stated therapeutic exercises were not considered diversional activities for the patients.