HospitalInspections.org

Based on review of the hospital Quality and Safety Plan, facility documentation, quality council meetings, and interview, it was determined the CAH failed to take remedial action to address deficiencies found through the quality assurance program.

Findings include:

The CAH's Quality and Safety Plan included:

"Key Aspects of the Quality and Safety Program include:
-the entire organization is dedicated to continually improve upon patient outcomes...
-Quality and safety is perceived in all aspects of SAMC's (Southeastern AZ Medical Center) operations by physicians, patients, staff and visitors...
-The measurement and surveillance of quality and patient safety will lead to improved patient care...

Mechanisms for Coordination...
Clinical processes, safety issues, and quality of care concerns are collected and analyzed by the Chief Operating Officer and the Performance Improvement Coordinator and the Medical Executive Committee. All data is reported to the Quality Council for action and follow-up...

QI Methodology...Quality Improvement efforts at Southeast Arizona Medical Center will focus on Planning, Problem solving, implementing action plans for improvement, Evaluating and Communicating results (PPIEC). Evaluation of the effects of actions taken to improve patient care, systems or processes will be incorporated into all quality improvement efforts...

Problem Solve - ...document resources needed; propose a time line for completion, and identify additional evaluation methods.
Implement - Following approval of the quality improvement project, the team will implement the corrective plan of action and determine follow-up evaluation.
Evaluate - Evaluation will consist of collecting data to compare post-implementation data to baseline and benchmarking data; whether the corrective action met anticipated expectations; and, if not, make recommendations for additional action.

Communicate - Documentation of results is forwarded to the Quality Council and Executive Staff."

The Quality Management Officer presented the Quality and Patient Safety Committee minutes. It included the "Quality Assurance Readiness" report, which included: "Medication Management: Med Error Rate for 1st QTR (Quarter), 2010: 0.08%; 2nd QTR: 0.10%. Target rate 0%. Opportunities for improvement continue to be addressed. Continue to monitor...."

The minutes also included a bar graph for January 2010 through August 2010, breaking down the medication errors into the following categories: Omissions, Wrong Med, Wrong Dose, Extra Dose, and Transcription. "Omissions" were consistently high in most months on the graph.

The Quality Management Officer presented documentation of incidents that included items including medication errors, delay in services, and hazards/unsafe conditions from January 2010 to present 9/23/10. The report had columns with the incident date, summary of incident, corrective action and resolution. Many of the following areas did not have corrective actions detailed or resolution.

Multiple medication errors indicated the category and a summary of the error. Under "Corrective Action" the majority of incidents had written "Ongoing monitoring" or "Incident Report to (initials of the Chief Nursing Officer (CNO))." The resolution column had "Incident Report to (initials of the CNO)" or was left blank. This documentation was from January 2010 to present.

Adverse Reactions:
3/10/10 - Patient's medical record noted the patient was "allergic to NSAIDS (Non-steroidal anti-inflammatory drugs) & ASA (aspirin)." The patient was given Toradol 30 milligrams and developed itching. The patient was admitted to the acute care as an ER hold to observe. No corrective action or resolution was documented.

7/19/10 - Patient eloped when the Border Patrol Agent stepped out of the room. There was no corrective action taken nor resolution documented.

Unsafe Condition:
Patient left unit and went home with family member. Heparin lock had not been removed and discharge paperwork had not been completed. The corrective action was "Patient notified; returned to hospital to complete discharge." No other corrective action or resolution was documented.

Patient Falls:
9/14/10 - Patient (Pt) being discharged from ER and was asked to wait for wheelchair assistance but got up and lost her balance. ER physician was notified. The patient had no injury and was discharged via wheelchair by ER personnel. There was no corrective action. The resolution was "Pt. discharged."
8/8/10 - Visitor reported a man had fallen in the parking lot outside of the ER and was seen sitting on the ground next to a car's passenger side door. The patient was evaluated in the ER and there were no signs of injury from the fall. The patient stated his legs were very weak and he could not walk. There was no corrective action documented and under resolution was noted the patient's chart was reviewed.
6/15/10 - Patient's bed alarm sounded and was found lying on floor and unable to stand up without assistance. The patient had a reddened right elbow and an abrasion to the right knee. The corrective action was "Incident report to (CNO initials)." No resolution was documented.
4/15/10 - Patient fall in the ER parking lot. The patient was discharged from the ER and was waiting for a taxi. He became tired of waiting for a taxi and decided to walk home when he became dizzy. The corrective action had documented "Pt discharged to care of family." No resolution was documented.

Pharmacy errors in stocking of medications:
6/1/10 - "Metolazone stocked in draw with Hydralazine in med-dispense. Error did not reach patient." No corrective action or resolution was documented.
2/17/10 - "When removing Tylenol Liquid from Med Dispense, Med drawer contained Benadryl liquid." No corrective action or resolution was documented.

The "Quality Performance Improvement Report" dated June 16, 2010, included the number of falls but only addressed one patient that fell in May 2010. The risk assessment screening tool for one patient may not have been scored high enough to be considered high risk. The other patient falls were not addressed with corrective actions. The number of medication errors were reported but the only error addressed was an intravenous (IV) medication. The clamp for the medication was not opened appropriately and subsequently the medication did not infuse. The staff would receive an inservice on administration of IV medications.

The May 10, 2010 Patient Safety Meeting included patient falls but did not address how they would be corrected/prevented. Medication errors were numbered but no specific corrective actions or resolution were documented.

The Quality Management Officer stated the Chief Nursing Officer receives medication variance reports for review. She believed the nurses received counseling when errors were made. She also stated the facility is planning to revise their quality program which should result in clearer documentation on the corrective actions being implemented.

Based on observation, review of medical records, policies and procedures, and interviews, it was determined that the hospital failed to:

1. require an ongoing program of activities for 4 (Patients #1, 12, 13, and 16) of 4 swing bed patient reviewed; and

2. have the program directed by a qualified professional.

This is a repeat deficiency from the last Medicare re-certification survey dated 5/27/2009, Event ID #YE8R11.

Findings include:

1. The hospital's policy "Swing Bed Activities" (Revised 5/08) included:

"PURPOSE All residents in the Swing Bed Unit at SOUTHEAST AZ MEDICAL CENTER will be encouraged to engage in various types of recreational activities.
POLICY Swing Bed Unit at SOUTHEAST AZ MEDICAL CENTER will provide activities for swing bed patients to include: games, equipment and supplies so that all needs for all residents will be met.
RESPONSIBILITY The Clinical Leader/Social Worker will be responsible for promoting activities. They will encourage all employees to take an active interest in the social needs of the residents...Activities will be individualized for each patient...Charting will occur on the Individual Participation Record/Activities for Daily Living, on a shift to shift basis."

Patient #1, who was a current resident in a swing bed at the time of the survey, was admitted on 9/18/10, for "skilled rehab and administration of complex meds." The admitting diagnoses were recurrent upper respiratory infection that is vancomycin resistant enterococcus (VRE) and urinary tract infection that is VRE. The patient had Clostridium-difficile (C-diff) colitis, was on contact isolation precautions, and was in a private room. Her additional diagnoses included Bi-polar disorder, psychosis, depression, and chronic renal insufficieny.

Patient #1's medical record's "Swingbed Activity Assessment" revealed the patient "spends most of time alone or watching TV." No other documentation was made on this form. Activity preferences were not recorded. A "Swing Bed Activity Flowsheet" had daily activities documented which included staff visiting patient, watching TV, and staff taking the patient in a wheelchair to smoke on the patio using isolation precautions.

On 9/21/10, the charge nurse stated she was putting some music on for the patient and the case manager had given the patient some crossword puzzles. On 9/22/10, the patient was observed in the morning and afternoon to be sitting idle in bed without music or other activity. On 9/23/10, at approximately 1:15 p.m. the patient, who was smoking on the outside patio with supervision, was interviewed regarding activities. The patient was slow to respond to questions. She stated she has no hobbies and does not do crossword puzzles. She stated she didn't recall any activities being offered to her.

Patient #12 was admitted to the swing bed unit 5/2/10, with diagnoses of bacteremia and bilateral pneumonia and discharged 5/12/10. The medical record did not include an assessment of activity preferences. The "Individual Participation Record" was in the record but was blank. There was no evidence of any activity offered to the patient.

Patient #13 was admitted to the swing bed unit 7/18/10, with diagnoses of left lower extremity deep vein thrombosis and pneumonia and discharged 7/22/10. The record contained a form "Specifically for Swing Bed Admissions" with a section "Activity Pursuit Patterns." This section was blank. The "Individual Participation Record" was also blank. There was no evidence of activities being offered to the patient.

Patient #16 was admitted to the swing bed unit 8/17/10, with pneumonia and discharged 8/25/10. The medical record did not include an assessment of activity preferences, an activity participation record, or any evidence activities were offered to the patient.

On 9/21/10 the charge nurse stated there is no activity schedule but the staff tries to give the patients books or other items they may want to occupy their time. She stated they usually have very few swing bed residents but supplies are available. On 9/22/10, the nurse on duty stated there had been an activity director but she left in the beginning of the year. There has been no activity schedule or director since that time.

The Chief Nursing Officer (CNO) was interviewed on 9/22/10 regarding the activity program. She acknowledged the hospital was found out of compliance in May 2009 by not having an activity program and a qualified activity director. The plan of correction dated 6/26/09 revealed an activity director would be hired by 7/6/09, and the program would then be implemented with a monthly activities calendar posted in the unit as of 7/31/09. The CNO presented the activity reports from August 2009 through February 2010. The reports noted the number of patients seen daily by this staff member. The numbers ranged from four to seven a month. The staff member left employment in February 2010 due to an injury, and the position has remained vacant. The CNO acknowledged there is no current program but the staff should be assessing the patient's activity preferences and completing the "Individual Participation Record." This form was a daily record of what activity the patient participated in as well as the patient's response to it.

2. As noted above, the position of Activity Director remained vacant from February 2010 through the survey on 9/23/10.

Based on observation, document review and staff interview, it was determined the facility failed to ensure preventive maintenance was performed on 2 Intravenous (IV) pumps and 4 laboratory centrifuges.

Findings include:

Facility policy 1.F.33 Hospital Preventive Maintenance included: "Policy: Each instrument has a particular preventive maintenance schedule and procedure. This information is in the Bio-Med computer. Each month, a list of instruments to be checked is generated by this computer and work scheduled."

Universal Hospital Services (UHS) Exhibit A Services; Customer Responsibilities: "A. Maintenance Services: The following electrical safety, preventative maintenance and repair Services will comply with the applicable standards of the Joint Commission, and the National Fire Protection Association (NFPA99)...2. Preventive Maintenance - For the equipment indicated as covered for Preventative Maintenance in Exhibit C, UHS will provide preventative maintenance service as appropriate for Equipment. Preventative maintenance refers to a procedure ensuring proper Equipment operation and calibration. The procedure includes: inspection for mechanical defects, cleaning of interior and exterior, performance verification of operator controls and adjustments; calibration verification per manufacturer's specifications; inspection for ground integrity and current leakage; replacement of disposable parts during the Preventive maintenance as appropriate; and documentation of results. Manufacturer's specifications shall be used as source documents for preventive maintenance whenever available. Defects will be reported to Customer...."

IV pumps were listed in Exhibit C on an Annual frequency and Centrifuges were listed on a Semi- Annual frequency.

During a tour of the facility conducted on September 21, accompanied by the Director of Nursing and the Medical Surgical Registered Nurse (RN), 2 IV pumps were found in the 300 wing without current calibration stickers. The IV pump in Room 303 was last calibrated in April, 2009 and due April 2010. The IV pump in Room 304 was last calibrated in June, 2009 and due in June 2010.

The RN verified the IV pumps were used when outpatients came into the hospital to receive infusion therapy and should have been re-calibrated.

A tour of the Draw Station conducted on September 22, 2010 at 11:30 a.m., revealed 2 centrifuges without current calibration stickers. A tour of the hospital laboratory revealed 2 centrifuges without current calibration stickers.

The Laboratory Manager acknowledged the centrifuges did not have current calibration stickers. No documents were provided to show the centrifuges had preventative maintenance or were newly acquired by the facility.

Based on record review and interview, it was determined the facility failed to do an initial assessment that included activity pursuits for four (Patients #1, 12, 13, and 16) of four swing bed patient reviewed.

Findings include:

A review of medical records for patients #1, 12, 13, and 16, had initial assessments that did not include activity pursuits. No preferences were noted on the nursing assessments. Refer to Tag 385.

The CNO was interviewed 9/22/10, and acknowledged the Director of the Activities Program would normally do this part of the assessment. However, this staff member terminated her employment in February 2010.