HospitalInspections.org

Based on review of documents and staff interview the governing body failed to ensure the medical staff has written policies and procedures for the care and appraisal of patients who present to the hospital seeking emergency care. This has the potential for the hospital to inappropriately access, treat (within the hospital's capabilities), admit or transfer patients when appropriate.

Findings include:

1. A review of the Medical Staff Bylaws and Rules and Regulations (last reviewed April, 2011) revealed the medical staff did not have a written policy and procedure describing what the process was when someone presents to the hospital seeking emergency care.

2. During interview with the Clinical Director on 3/5/12 at 3:00 p.m. he stated the hospital has a physician on site and on-call 24/7. Someone presenting to the hospital seeking emergency medical treatment would be assessed by the physician and treated/stabilized (within the hospital's capabilities) and transferred to an emergency room when appropriate. He agreed the Medical Staff Bylaws/Rules and Regulations did not contain a written policy describing the process. Soon after this interview the Clinical Director developed a written policy as to what steps would be initiated when a patient presents seeking emergency care.

3. The hospital security guard (located in a booth at the entrance to the hospital campus) was interviewed on 3/5/12 at 3:25 p.m. When asked what would he do if someone presented to the hospital seeking emergency care, he said he would call 911 and have the patient transported to an emergency room. There was no evidence to indicate that he understood the process of having the patient brought into the facility to receive assessment/stabilization by the on-site physician and possibly transferred by the physician if appropriate.

4. These findings were reviewed with the Clinical Director during the exit conference on 3/8/12 at 11:15 a.m. with no disagreement indicated.

Based on review of documents and interview with staff, it was determined the hospital failed to ensure at least one (1) patient event was adequately analyzed by the Quality Assessment/Performance Improvement (QAPI) Committee in order to identify potential opportunities for improvement (patient #28). This failure creates the potential for the hospital to miss each opportunity for improvement when the QAPI committee is not involved in the completed investigation findings of each event.

Findings include:

1. Review of the QAPI committee meeting minutes and related documentation for the April 19, 2011 meeting revealed that included in the documentation was a copy of an "Analysis of Adverse Patient Event" form, which described a serious event with a patient on 4/16/2011. On the form, the "Findings" portion stated "Investigation Continues". Further review of the meeting minutes for the following months revealed the incident and the findings of the hospital's investigation were not reported again to the QAPI committee.

2. The finding was discussed with the Director of QAPI and the hospital's interim administrator between 10:30 a.m. and 11:20 a.m. on 3/8/2012 and they concurred there was no follow-up documentation within the QAPI committee minutes.

Based on medical record review and staff interview it was determined the registered nurse (RN) failed to monitor vital signs as ordered for one (1) of one (1) patients reviewed who had tachycardia (patient #9). This failure creates the potential for the health of all patients who require frequent vital sign monitoring to be adversely impacted.

Findings include:

1. Review of the physician progress note for patient #9, documented on 3/4/12 at 1623, revealed the physician noted in part: "...complaint of chest pain since yesterday...Patient has had tachycardia (rapid heart beat). Currently vital signs with blood pressure 112/82 and pulse 130...Patient was informed that we will monitor her vital signs more closely..."

2. Review of physician orders revealed an order, written on 3/4/12 at 1553 for "TPR B/P q 4 hours while awake" (Temperature, Pulse, Respiration, Blood Pressure every 4 hours).

3. At 1400 on 3/7/12 this record was reviewed with both RN#1 and the A3 Nurse Manager. Both acknowledged they were not aware of the order to monitor vital signs every four (4) hours.

4. The vital signs record for patient #9 was reviewed. The record reflected the patient's vital signs were checked at 1500 on 3/4/12.

The next vital sign check was recorded at 0800 on 3/6/12, forty-one (41) hours after the last check. The record reflected the patient refused a vital sign check at 0800 on 3/5/12. There was no record that staff attempted to recheck vital signs until 0800 on 3/6/12. The nursing check sheets for the night of 3/5/12 through 3/6/12 revealed the patient did not sleep after 0030 on 3/6/12.

The next recorded vital sign check was 0800 on 3/7/12, twenty-four (24) hours after the last check. At the time of this record review, this was the last recorded vital sign check.

5. This record was reviewed and discussed with both the A3 Nurse Manager and RN#1 between 1400 and 1500 on 3/7/12. They both agreed the record revealed patient's vital signs had not been checked every four (4) hours, while awake, as ordered.

Based on review of documents, medical records, and staff interview, it was determined the hospital failed to ensure the medical records were completed thirty (30) days after discharge for two (2) of five (5) closed medical records reviewed (7A and 7B). This has the potential to negatively affect all discharged patients by failing to ensure medical records were closed in a timely manner.

Findings include:

1. Review of Medical Staff Bylaws Rules and Regulations, last reviewed 4/11, revealed in part: "Discharge summaries not dictated and signed within 30 days of discharge shall be considered delinquent and referred to the Clinical Director".

2. Review of medical record 7A revealed the patient was discharged on 12/01/11. The discharge summary was dictated on 1/31/12, sixty-one (61) days after discharge. This is not in accordance with Medical Staff Bylaws.

3. Review of medical record 7B revealed the patient was discharged on 1/05/12. The discharge summary was dictated on 2/29/12, fifty-five (55) days after discharge. This is not in accordance with Medical Staff Bylaws.

4. The records were reviewed with the Director of Health Information Management on 3/7/12 at 1120 am and she concurred with the findings.

Based on observation and staff interview, it was determined the hospital failed to provide/maintain the required special design consideration for a safe environment and prevent potential patient injury or suicide due to the observation of a large number of looping devices on six (6) of six (6) patient care units. Therefore, this Condition is not met. Refer to deficiencies identified as A722.

Based on observation and staff interview, it was determined the hospital failed to maintain the required special design consideration for a safe environment by failing to remove all potential looping devices in the patient care units.

Findings include:

1. On 03/06/12 during the time frame of 1:30 p.m. and 2:00 p.m., a tour of the hospital building #3, fourth floor was conducted. At this time, the following design requirements of AIA guidelines for Design and Construction of Health Care Facilities in reference to behavior/psychiatric units were observed not to be met in the following patient units:

a) Regular type door hinges (not approved slant type): fifteen (15) of fifteen (15) patient bathroom doors.

b) Lever or ball-type door handles in corridors: twenty-two (22) corridor doors (All corridor doors except patient rooms).

2. On 03/06/12 during the time frame of 2:00 p.m. and 2:30 p.m., a tour of the hospital building #3, third floor was conducted. At this time, the following design requirements of AIA guidelines for Design and Construction of Health Care Facilities in reference to behavior/psychiatric units were observed not to be met in the following areas:

a) Regular type door hinges (not approved slant type): fifteen (15) of fifteen (15) patient bathroom doors.

b) Lever or ball-type door handles in corridors: twenty-two (22) corridor doors (All corridor doors except patient rooms).

3. On 03/06/12 during the time frame of 2:30 p.m. and 3:00 p.m., a tour of the hospital building #3, second floor was conducted. At this time, the following design requirements of AIA guidelines for Design and Construction of Health Care Facilities in reference to behavior/psychiatric units were observed not to be met in the following areas:

a) Regular type door hinges (not approved slant type): fifteen (15) of fifteen (15) patient bathroom doors.

b) Lever or ball-type door handles in corridors: twenty-two (22) corridor doors (All corridor doors except patient rooms).

4. On 03/07/12 at approximately 8:45 a.m., a tour of the hospital building 5, recreation area was conducted. At this time, the following design requirements of AIA guidelines for Design and Construction of Health Care Facilities in reference to behavior/psychiatric units were observed not to be met in the following areas:

a) Water service handles for hand sinks/toilet (not approved type).

5. On 03/07/12 during the time frame of 10:00 a.m. and 10:30 a.m., a tour of the hospital building #2, unit 6 was conducted. At this time, the following design requirements of AIA guidelines for Design and Construction of Health Care Facilities in reference to behavior/psychiatric units were observed not to be met in the following areas:

a) Pendant type sprinkler heads (not tamper-resistant type): fifteen (15) of fifteen (15) sprinkler head corridor area.

b) Lever or ball-type door handles in corridors: eleven (11) corridor doors (All corridor doors except patient rooms).

6. On 03/07/12 during the time frame of 13:00 a.m. and 11:00 a.m., a tour of the hospital building #2, unit 5 was conducted. At this time, the following design requirements of AIA guidelines for Design and Construction of Health Care Facilities in reference to behavior/psychiatric units were observed not to be met in the following areas:

a) Pendant type sprinkler heads (not tamper-resistant type): fifteen (15) of fifteen (15) sprinkler head corridor area.

b) Lever or ball-type door handles in corridors: ten (10) corridor doors (All corridor doors except patient rooms).

These conditions found on the patient care units are not giving the required special design consideration to prevent potential patient injury or suicide.

6. Interviews with the Building Grounds Manager and Safety Director on 03/08/12 at approximately 11:30 a.m., confirmed the aforementioned findings found on the patient care units.

A. Based upon document review and staff interview it was determined the infection control officer failed to maintain the most current (9/2011) listing of West Virginia Reportable Diseases, which is used to identify reportable diseases and the timeframe's in which to file these reports. Failing to recognize and report all required infectious/communicable diseases within the specific timeframe's can result in patient/staff and community members having exposure incidents and lead to a hospital or community outbreak.

Findings include:

1. Review of the hospital's infection control manual, last reviewed 2008, revealed a list of West Virginia Reportable Infectious Diseases that was not dated as to which year it represented. The most recent listing of reportable diseases available from the Bureau of Public Health, Office of Epidemiology and Prevention Services was revised and made available 09/2011.

The list the hospital was using did not contain all of the current reportable diseases such as, Severe Acute Respiratory Syndrome (SARS), Q-Fever (coxiella burnetti), and arboviral infection. Additionally the list in use did not reflect the current reporting timeframe's such as, Giardia which is now required to be reported to the local health department within seventy-two (72) hours, and on the hospital list it was to be reported to the patient's county of residence within one (1) week of diagnosis.

2. The outdated reportable disease list in the infection control manual was discussed with the Infection Control Officer on 3/8/12 at 0915 hours and she concurred the list was not current.

B. Based on document review, observations and staff interview it was determined the infection control officer failed to develop and implement a system that ensures that all products used for environmental cleaning in patient care areas follow Center for Disease Control recommendations for hospital grade germicides that have specific instructions for mixing following manufacturer instructions. Failure to use hospital grade cleaning solutions or to properly mix these solutions can result in transmission of infections/diseases among patients or staff from environmental sources.

Findings include:

1. The following are in part Center For Disease Control (CDC) 2003 recommendations for environmental cleaning:

Use a one-step process and an Environmental Protection Agency (EPA) registered hospital disinfectant/detergent designed for general housekeeping purposes in patient-care areas when:

1. Uncertainty exists as to the nature of the soil on these surfaces e.g., blood or body fluid
contamination versus routine dust or dirt or

2. Uncertainty exists regarding the presence or absence of multi-drug resistant organisms on such surfaces.

If using a proprietary detergent/disinfectant, the manufacturers' instructions for appropriate use of the product should be followed.

2. During a tour of unit 5 on 3/6/12 at 1000 hours a container of Purcell hand sanitizing wipes (not an EPA registered hospital disinfectant) was found in the storage room and a second one was found on top of the housekeepers cart. Nursing staff at the station on this unit indicated these wipes are used to clean counters and surfaces.

3. The Housekeeping Supervisor was interviewed on 3/6/12 at 1015 hours on unit five.
She stated that housekeeping uses these wipes on counter tops, tables and to clean the kitchenettes and ice machines. The supervisor was questioned if there is a list of approved solutions and products with mixing instructions that are to be used in these patient care areas.
The supervisor said there are no lists of solutions for cleaning patient care areas and they use whatever comes up from the storeroom.

4. Another solution found on the housekeepers cart during this tour on 3/6/12 at 1000 hrs was a container labeled as "Gabriel Walls N All" which was not identified as an EPA hospital disinfectant.

5. The housekeeping supervisor was questioned on 3/6/12 at 1020 hrs concerning where the Walls N All is used. The supervisor stated they use this product in the showers. When the supervisor was informed this product is not a hospital grade disinfectant she stated they first spray the shower with a bleach solution. The supervisor was asked what concentration of bleach is be used and how they mix this solution and she stated they just pour some bleach in a spray bottle and add some water.

6. Review of the Infection Control and Housekeeping Manuals, last reviewed 2008, revealed neither manual had a list of germicides with mixing instructions ( if needed) and where these solutions are to be used.

7, The Infection Control Officer (ICO) was interviewed on 3/9/12 at 0815 hours concerning the lack of readily available lists of germicides for staff reference that specifies where and how these cleaning agents are to be used. The ICO stated she did have a list of these solutions in her manual in the laboratory but agreed they were not in the infection control or housekeeping manuals.

Based on review of documents and staff interview it was determined the hospital failed to develop a list of Home Health Agencies (HHAs) which is available for provision to patients during the discharge planning process. This failure creates the potential for a violation of the patients' right to make a choice.

Findings include:

1. The policy "Interdisciplinary Treatment and Discharge," last reviewed 3/24/11, was provided for review. This policy contained no reference to a list of Home Health Agencies that is made available to the patient.

2. At 0740 on 3/7/12 the Director of Social Work was interviewed and this policy was discussed. She stated the hospital does not have a list of HHAs.

Based on review of documents and staff interview it was determined the hospital failed to develop a list of Skilled Nursing Facilities (SNFs) which is available for provision to patients during the discharge planning process. This failure creates the potential for a violation of the patients' right to make a choice.

Findings include:

1. The policy "Interdisciplinary Treatment and Discharge," last reviewed 3/24/11, was provided for review. This policy contained no reference to a list of Skilled Nursing Facilities that is made available to the patient.

2. At 0740 on 3/7/12 the Director of Social Work was interviewed and this policy was discussed. She stated the hospital does not have a list of SNFs.