HospitalInspections.org

Based on review of contracted services and interview the hospital failed to have a process in place to monitor contracted services.

Findings include:
Review of contracted services on 11/6/12 & 11/7/12 revealed that a process for the communication of expectations to providers regarding performance indicators and a process to monitor how contracted services relate to hospital expectations was not in place.

Interview with Staff M, (Manager), on 11/8/12 confirmed that contracted services personnel are not monitored for compliance with hospital expectations or hospital performance indicators as other employees are.

Based on review of contracted services and interview the governing body failed to have a process in place to monitor contracted services so as to ascertain services are performed in a safe and effective manner.

Findings include:
Review of contracted services on 11/6/12 & 11/7/12 revealed that a process for the communication of expectations to providers regarding performance indicators and a process to monitor how contracted services relate to hospital expectations was not in place.

Interview with Staff M, (Manager), on 11/8/12 confirmed that contracted services personnel are not monitored for compliance with hospital expectations or hospital performance indicators as other employees are.

Based on observation and interview the hospital failed to provide privacy to a patient in MRI holding area.

Findings include:

During tour of the radiology department on 11/9/12 with Staff D (Clinical Operations Manager) and Staff E (Diagnostic Imaging Manager) it was observed that a patient located in the MRI holding area was sitting in a wheelchair wearing only a patient gown. The MRI holding area is the corridor located just inside the department access doors. When the access doors are opened the patient located in the MRI holding area corridor is clearly visible to whomever is in the public corridor.

Interview with Staff D and Staff E on 11/9/12 confirmed that patients waiting in the MRI holding area corridor do wait in a patient gown and are visible to whomever is in the public corridor when the access doors to the MRI holding area are opened.

Based on observation and interview the hospital failed to ensure a secure environment for staff and patients on the maternity floor and in the radiology department.

Findings include:

Observation during tour of the maternity center on 11/6/12 at 2:45 p.m. with Staff H, RN (Registered Nurse), revealed the maternity unit is not a locked unit. The public can access the maternity unit and go into patient rooms without staff knowledge. There is direct unmonitored access to the maternity unit from elevators and a stairway.

Interview with Staff H on 11/6/12 at 2:45 p.m. confirmed that the maternity unit is not a locked unit. There is a wanderguard system in place that will lock down the elevators while an audible alarm sounds if an infant is brought outside the maternity unit. If an infant is taken down the stairwell, an alarm will sound; however, the stairwell will not lock down. Staff H indicated that a staff person is situated at the desk at all times. Observation on 11/6/12 at 3 p.m. and observation on 11/7/12 at 11:00 a.m. and 2:30 p.m. by 3 different surveyors revealed the desk area was unattended for periods of time greater than 5 minutes.




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Tour of the radiology department on 11/9/12 revealed that several areas throughout the radiology department could be accessed at any time and that the radiology department could not be locked down to protect the safety of patients and staff.

Interview on 11/9/12 with Staff D (Clinical Operations Manager) and Staff E (Diagnostic Imaging Manager) confirmed that the radiology department could not be locked down to prevent unauthorized access. The following areas were identified by Staff E on the Hospital's schematic as areas that needed to be secured in order to secure the radiology department:

1) Ultrasound room designated for Emergency room patients
2) Corr 11036
3) South Stair 11284
4) Stor 11287
5) Control 11184
6) Recept 11271
7) Left side reception area

Based on review of Medical Staff By Laws the hospital failed to provide criteria for determining what privileges are to be granted to individual practitioners.

Findings include:

Review of Medical Staff By Laws revealed the lack of criteria for determining what privileges are to be granted to physicians and allied health professionals. The By Laws do not address indications for automatic suspension, indications for recommending termination or suspension of medical staff membership, and/or termination, suspension or reduction of clinical privileges.

Based on record review and interview it was determined that the hospital failed to have care plans to support the diagnoses that meet the patients medical and psychosocial needs.

Findings include:

During record review of five of thirty inpatient records it was found that the new software program did not have the ability at this time to add all pertinent diagnoses for the inpatients and the needed interventions and goals to meet the needs of the inpatients for a complete comprehensive care plan.

An interview on 11/6/12 with Staff J, RN (Registered Nurse) and Staff K, RN confirmed that the software program is new and that the drop down box only has certain diagnoses in it and that the software would be updated every few weeks to add new diagnoses. The Hospital no longer uses paper care plans on the medical surgical floors.

Based on record review and interview it was determined that the hospital failed to ensure that 555 patient medical records are complete and accurate.

Findings include:

Review of the "HIM (Health Information Management) INCOMPLETE CHART REPORT as of 11/7/12 showing charts with net age at least 21 days" shows 555 accounts are deficient. Further review of this report shows that this includes, verbal/telephone cosign orders, anesthesia reports, discharge summaries, operative reports, discharge instructions, history and physicals, physician orders, consults, and final diagnosis.


Review of the Health Information Management Department Policy and Procedure, effective 4/20/12 and revised 4/20/12, reveals "Policy: Timely completion of medical record in accordance with hospital policy, applicable statutes, regulations and accreditation standards. [Pronoun omitted] Medical Staff Rules and Regulations state that records are delinquent if they remain incomplete 21 days post-discharge. A series of notifications will be sent to physicians who have incomplete medical records on a weekly basis."

Review of the "Administrative, Medical records, Medical Staff Services" Manual on 11/8/12, reveals a procedure, "Titled: Physician Restriction/Suspension Procedure", with effective date of 4/12/2007 and a revised date of August 2012, under the section

"Definitions:

Medical Records: Restriction for Delinquent Medical Records: Physician is not permitted to admit a patient or book a patient for a future admission until their delinquent medical records are complete.

Suspension for Delinquent Medical Records: If the physician remains on the restriction list for one-month (30) days, ALL medical staff privileges are revoked until the medical record are complete."

Interview with Staff I, (Manager of Medical Records) on 11/8/12 at 2:30 p.m. confirmed that the Hospital had 555 deficient accounts; however, the facility could not "suspend all 150 physicians at once." The process was a three-step notification. First step was to email the physician 0-14 days. Second letter sent out in the 15-19 day window and an email to the physicians corresponding Chief and Chair. Third letter is sent to the physician and the corresponding Chief and Chair and a call to the physician's office that remain post 21 days. At that time the physician is on the restriction list.

Based on observation and interview the hospital failed to secure storage of medical records against unauthorized access.

Findings include:

Observation during tour of the 5 satellite locations on 11/7/12 between the hours of 8:30 a.m. and 12:00 p.m., revealed medical records were not secured from unauthorized access when department is closed.

Interview with Staff G, RN, on 11/7/12 at 11:30 a.m. confirmed that all satellite location offices owned by the hospital are cleaned after hours when the medical record staff are not present, thus allowing medical records to be accessible by personnel not authorized to view medical records.

Based on record review and interview it was determined that the Hospital failed to have care plans to support the diagnoses that meet the patients medical and psychosocial needs.

Findings include:

During record review of five of thirty inpatient records it was found that the new software program did not have the ability at this time to add all pertinent diagnoses for the inpatients and the needed interventions and goals to meet the needs of the inpatients for a complete comprehensive care plan.

An interview on 11/6/12 with Staff J, RN (Registered Nurse) and Staff K, RN confirmed that the software program is new and that the drop down box only has certain diagnoses in it and that the software would be updated every few weeks to add new diagnoses. The Hospital no longer uses paper care plans on the medical surgical floors.

Based on observation and interview the hospital failed to kept drugs and biologicals in a secure area and locked on 3 separate areas.

Findings include:
1. During tour of Surgical Suite on 11/6/12 at 4:00 p.m. it was observed that the Accuchek Medication System located in the clean sterile storage room of the surgical suite had the following medications left on the top of the cart unsecured: 6 vials of Sensorcaine 0.5% 10 ml and 1 Lidocaine 1% plain 10 ml.

Interview with Staff A, (Director Surgical Services), on 11/6/12 4:00 p.m. confirmed medications were not to be left unattended on the medication cart.

2. Observation during tour of the Fuller Unit on 11/6/12 at 1:10 p.m. revealed an intravenous solution of Magnesium Sulfate prescribed for a specific patient was in an unsecured patient refrigerator. This refrigerator is accessible to other patients and is unattended by staff.
Staff C, RN removed medication from the patient refrigerator.

Interview with Staff C on 11/6/12 at 1:10 p.m. confirmed the medication was not supposed to be in the patient refrigerator.

3. During tour of Maternity Department Operating Room 1 on 11/8/12 it was revealed that the anesthesia cart was not locked.

Interview on 11/8/12 with Staff N, RN, confirmed the anesthesia cart was unlocked.

Based on observation and interview the hospital failed to maintain an environment to meet surgical services by not having proper ceiling tiles in the semi-restricted corridor, failing to have wall finishes that are cleanable, failing to maintain dust free horizontal surfaces in operating room, and failing to maintain proper traffic patterns to create and maintain physical separation between the decontamination area and sterilization areas.

Findings include:

AIA, (American Institute of Architecture) Guidelines for Design and Construction of Health Care Facilities 2.1 General Hospitals 8.2 General Standards for Details and Finishes 8.2.3.4 Ceilings

(3) Semirestricted areas

(a) Ceiling finishes in semirestricted areas such as airborne infection isolation rooms, protective environment rooms, clean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms shall be smooth, scrubbable, nonabsorptive, non perforated, capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.

(b) If lay-in ceiling is provided, it shall be gasketed or clipped down to prevent the passage of particles from the cavity above the ceiling plane into the semirestricted environment. Perforated, tegular, serrated, or highly textured tiles shall not be used.

Observation during tour of the surgical suite on 11/7/12 with Staff A (Director of Surgical Services) and Staff N (Assistant Director of Surgical Services) revealed the ceiling tiles located within the semi-restricted corridor of the surgical suite were perforated ceiling tiles. These ceiling tiles were not scrubbable and thus not capable of withstanding cleaning and/or disinfecting chemicals and the tiles were not clipped or gasketed.

Interview of Staff A and Staff N on 11/7/12 confirmed the tiles were perforated and not the scrubbable, non-perforated ceiling tiles. Staff A and Staff N confirmed the ceiling tiles were not clipped and/or gasketed.

Observation on tour of the maternity department operating rooms with Staff H on 11/8/12 revealed the ceiling tiles in the semi restricted area were perforated ceiling tiles. These ceiling tiles were not scrubbable and thus not capable of withstanding cleaning and/or disinfecting chemicals and the tiles were not clipped or gasketed.

Interview on 11/8/12 with Staff H confirmed the tiles were perforated and not the scrubbable, non-perforated ceiling tiles. Staff H confirmed the ceiling tiles were not clipped and/or gasketed.


2010 Guidelines for Design and Construction of Health Care Facilities 3.7-7 Design and construction Requirements, 3.7-7.2 Architectural Details, Surfaces, and Furnishings. 3.7-7.2.3.3 Walls. Wall finishes shall be appropriate for the areas in which they are located and shall be as follows:

(1) Wall finishes shall be cleanable.

(2) Wall finishes in areas such as clean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms shall be washable, smooth, and able to withstand chemical cleaning ...


Observation during tour of surgical suite on 11/7/12 with Staff A (Director of Surgical Services) and Staff N (Assistant Director of Surgical Services) revealed 8 out of 10 operation rooms had large gouges in the sheetrock from equipment making contact with the wall surface. The sheetrock paper was torn in the 8 out of 10 operating rooms and in the corridors within the surgical suite. The smooth surface was compromised making the surface not washable or able to withstand chemical cleaning.

Interview on 11/7/12 with Staff A and Staff N during tour confirmed the smooth surface of the walls was compromised in multiple areas making the surfaces not washable or able to withstand chemical cleaning.

Observation during tour on 11/8/12 of maternity department operating rooms with Staff H (Registered Nurse) revealed operating room 1 and 2 had a wallpaper border and the sub-sterile area located between operating room 1 and 2 had torn sheetrock and holes in the walls. The border is porous and unable to withstand cleaning and the torn sheetrock in the sub-sterile area located between operating rooms 1 and 2 render the wall not scrubbable or able to withstand chemical cleaning.

Interview with Staff H on 11/8/12 confirmed both operating rooms have a wallpaper border and that the tears and holes in the sheetrock compromise the smooth surface of the walls making the surfaces not washable or able to withstand chemical cleaning.


"AORN(Association of periOperative Registered Nurses) 2009 Edition Page 439. Recommended Practices for Environmental Cleaning in the periOperative Setting. Recommendation 1 The patient should be provided a clean, safe environment.

1.b All horizontal surfaces in the OR (eg, furniture, surgical lights, booms, equipment) should be damp dusted before the first scheduled surgical procedure of the day. Plasma and monitor screens should be cleaned according to manufactures' instructions.

Dust is known to contain human skin and hair, fabric fibers, pollens, mold, fungi, insect parts, glove powder, and paper fibers among other things. Airborne particles range in size form 0.001 microns to several hundred microns. Contamination for particles can come from an external source (eg, ventilation, doors) or an internal source..."

Hospital policy (Operating Room Sanitation) with an effective date of 8/2006 states "Prior to the first scheduled procedure of the day, horizontal surfaces should be damp dusted. Damp dusting should be done with a clean cloth moistened with an appropriate agent..."


Observation during tour of the surgical suite on 11/7/12 with Staff A (Director of Surgical Services) revealed the presence of dust on horizontal surfaces in 8 of 10 operating rooms.

Interview with Staff A on 11/7/12 confirmed the presence of dust on horizontal surfaces in 8 of 10 operating rooms.

Observation during tour of operating rooms in the maternity department with Staff H on 11/8/12 revealed the presence of dust on horizontal surfaces in both operating rooms 1 and 2.

Interview with Staff H on 11/8/12 confirmed the presence of dust on horizontal surfaces in both operating rooms.



2009 AORN (Association of periOperative Registered Nurses) pg 647 Recommended Practices for Sterilization in the periOperative Practice Setting. Recommendation 1 Items to be sterilized should be cleaned, decontaminated, sterilized stored in a controlled environment and in accordance AORN's "Recommended practices for cleaning and caring of instruments and powered equipment" and the device manufacturer's written instructions.

1.a. Functional workflow patterns should be established to create and maintain physical separation between the decontamination and sterilization areas...

Physical separation aids in environmental and microbial control. During manual cleaning of instruments, particulates aerosolized matter, dust and microbial counts are elevated. Physical separation and vented airflow to the outside minimizes contamination of processed items...

1.a. 3 Traffic patterns should be established that define access restrictions, movement or personnel, and appropriate attire according to AORN's "Recommended practices for traffic patterns in the periOperative practice setting" to protect personnel, equipment, supplies, and instrumentation from sources of potential contamination.


Observation during tour of the central sterile supply department with Staff A (Director of Surgical Services) on 11/9/12 revealed Staff B (Sterile Processing Staff) received a loaner scope from an outside vendor. Staff B walked the scope into the clean area of central sterile processing. Staff B recognized the scope needed to go through decontamination prior to use so brought the scope to the dirty processing area. Staff B then returned to the clean side of central sterile processing area failing to change footwear.

Interview with Staff A on 11/9/12 confirmed Staff B (Sterile Processing Staff) received a loaner scope from an outside vendor. Staff B walked the scope into the clean area of central sterile processing. Staff B recognized the scope needed to go through decontamination prior to use so brought the scope to the dirty processing area. Staff B then returned to the clean side of central sterile processing area failing to change footwear.

Based on observation and interview the hospital failed to monitor operating rooms for positive pressure, failed to have current balance reports, failed to meet minimum Air Change per Hour (ACH) and failed to maintain air changes in accordance to original design for operating rooms located in the surgical suite and maternity department.

Findings include:

ANSI [Approved American National Standard]/ASHRAE/ASHE [American Society for Healthcare Engineering] Standard 170-2008 Ventilation of Health Care Facilities. Page 11. 7.4 Surgery Rooms. 7.4.1 Class B and C Operating Rooms. Operating rooms shall be maintained at a positive pressure with respect to all adjoining spaces at all times. A pressure differential shall be maintained at a value of at least =0.01 in. wc (2.5Pa).


ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Chapter 7 Health Care Facilities. Specific Design Criteria Surgery and Critical Care. 7.5 The following conditions are recommended for operating, catheterization, cystoscopic, and fracture rooms:

Air pressure should be kept positive with respect to any adjoining rooms by supplying excess air.

A differential-pressure-indication device should be installed to permit air pressure readings in the rooms. Thorough sealing of all wall, ceiling, and floor penetrations, and tight-fitting doors are essential to maintaining readable pressure.



Observation during tour of the surgical suite on 11/7/12 revealed that all ten surgical rooms failed to have differential pressure indication devices on the walls to show that the rooms are in positive pressure to the adjoining spaces.

Interview on 11/7/12 with Staff A (Director of Surgical Services) confirmed that all 10 surgical rooms failed to have differential pressure indication devices on the walls to show that the rooms are in positive pressure to the adjoining spaces.

Observation during tour of maternity department operating rooms on 11/8/12 with Staff H (RN) revealed that the 2 operating rooms failed to have differential pressure indication devices on the walls to show that the rooms are in positive pressure to the adjoining spaces.

Interview on 11/8/12 of Staff H confirmed that the 2 operating rooms failed to have differential pressure indication devices on the walls to show that the rooms are in positive pressure to the adjoining spaces.



ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Standard 170-2008 Ventilation of Health Care Facilities

A1. O&M IN HEALTH CARE FACILITIES
A1.1 Operating Rooms. Each operating room should be tested for positive pressure semi-annually or on a effective preventative maintenance schedule. When HEPA filters are present within the diffuser of operating rooms, the filter should be replaced based on pressure drop.


Review of maintenance records on 11/09/12 with Staff F (Facilities Management) revealed the facility has not had the HVAC system balanced for both operating rooms located on the maternity unit.

Interview with Staff F (Facilities Management) on 11/09/12 confirmed that the facility has not had the HVAC system balanced for both operating rooms located on the maternity unit.



ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Standard 170-2008 Ventilation of Health Care Facilities

7. SPACE VENTILATION

7.1 General Requirements. The following general requirements shall apply for space ventilation:

1. Spaces shall be ventilated according to Table 7-1

TABLE 7-1 Design Parameters Classes B and C operating rooms, (Pressure Relationship to Adjacent Areas) "Positive" Minimum outdoor ach [air changes per hour] (Minimum Total ach) 20...


Review of the facility's most current air balance reports dated 7/20/12 revealed 2 surgical operating rooms, room 4 and room 8, do not meet the minimum standard for Air Changes per Hour (ACH).

Interview of Staff F (Facilities Management) on 11/8/12 confirmed that 2 surgical operating rooms, room 4 and room 8, do not meet the minimum standard for Air Changes per Hour (ACH).



ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Standard 170-2008 Ventilation of Health Care Facilities

Page 11 #8. Planning, construction, and system startup.

8.1 Overview. For HVAC systems serving surgery and critical care spaces, compliance with this standard requires preparation of an acceptance testing plan.

8.5 documentation of New or Remodeled HVAC Systems. Owners shall retain an acceptance testing report for their files. In addition, the design shall include requirements for operations and maintenance staff training that is sufficient for the staff to keep all HVAC equipment in a condition that will maintain the original design intent for ventilation. Training of operating staff shall include an explanation of the design intent. The training materials shall include, at a minimum, the following:

a. O&M procedures
b. Temperature and pressure control operation in all modes
c. Acceptable tolerances for system temperature and pressures
d. Procedures for operations under emergency power or other abnormal conditions that have been considered in the facility design.

Tour of the surgical suite on 11/7/12 with Staff A (Director of Surgical Services) revealed that the air returns in several of the operating rooms were very poor. A tissue paper test was performed by holding a piece of tissue paper in front of the return. The tissue paper would be pulled flush to the return and the two returns should have equal pull. The tissue paper did not pull into the return with the same draw strength.

Interview on 11/7/12 with Staff A (Director of Surgical Services) confirmed that the air returns in several of the operating rooms were very poor. A tissue paper test was performed by holding a piece of tissue paper in front of the return. The tissue paper would be pulled flush to the return and the two returns should have equal pull. The tissue paper did not pull into the return with the same draw strength.

Review of the Hospital's most current air balance report dated 7/20/12 revealed that the report only tested air changes per hour and failed to reveal the as built designed air changes per hour. Due to this the Hospital was unable to confirm that the balance report met the as built design. Review of Hospital's as built plans with Staff F (Facility Management) on 11/9/12 confirmed that the air changes per hour for each operating room compared with the tested air changes per hour performed by the vendor, failed to meet as built design.

Interview on 11/9/12 with Staff F (Facilities Management) confirmed the air changes per hour for each operating room compared to the tested air changes per hour performed by the vendor, failed to meet as built design.


Operating rooms air supply

As built Tested
1) 2000 1615
2) 2000 1625
3) 2000 1815
4) 1200 1240
5) 2000 2014
6) 2000 1445
7) 1400 1155
8) 1400 1135
9) 2000 1482
10)2000 1235

Operating rooms returns (each OR has two returns R1 and R2) which should be balanced equally, for proper air movement.
R1 R2
1) 350 886
2) 425 205
3) 465 545
4) 355 425
5) 953 233
6) 760 420
7) 85 260
8) 344 510
9) 145 265
10)40 170

Based on observation and interview the hospital failed to identify practices and equipment upkeep that represented a break in infection control systems on one of seven units in the hospital and one of five satellite offices.

Findings include:

During tour of the King Unit on the morning of 11/7/12 a member of the housekeeping staff was observed walking out of room 742 (Contact Precaution Room) pushing their cart while wearing their personal protective equipment (gloves and apron). The housekeeper proceeded to walk down the hallway to room 741 at which time this surveyor asked them if they had just been in the precaution room to which they responded "yes".

During the same tour a nursing staff member was observed in a contact precaution room providing direct patient care (direct contact) while not wearing gloves or a protective gown. The patient in this room was later identified by record review to have C-difficile.


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During the tour of the Londonderry Rehabilitation satellite office on 11/7/12 with Staff G, RN, it was observed that the pad on the large rehabilitation table had two tears on the edge on it, showing the inside foam.

Interview on 11/7/12 with Staff L, PT (Physical Therapy Director), confirmed that Staff L was unaware of the two tears in this bed and that it could be an infection control issue when cleaning.