HospitalInspections.org

Base on observation, document review and interviews, it was determined the facility failed to check the crash cart in accordance with its policy to ensure equipment, supplies and medication are readily available for emergencies. This was observed in one (1) of three (3) crash carts inspected.

Findings:

During a tour of the surgical suite on 11/3/2021 at 12:30 PM, review of the crash cart checklist revealed the crash cart near to the operating room was not checked on the days of operations on 10/26, 10/27, 10/28 and 10/29/2021.

Review of the operating room log revealed surgical procedures were performed on 10/26, 10/27, 10/28 and 10/29/2021.

The policy titled "Crash Cart and Defibrillator Checks," which was last revised 9/18, states "Emergency Crash Carts will be checked" at least once per shift (twice each twenty-four-hour period) when the unit where they are kept is opened."

During an interview with Staff C, Chief Nursing Officer on 11/3/2021 at 12:30 PM, she confirmed this finding and she stated that the charge nurse on duty is responsible for checking the crash cart before the start of each day of surgery.

Based on observations and interview, it was determined the facility failed to ensure that expired medications in the anesthesia cart were removed and were not made available for patients' use during surgery and emergencies.

Findings:

During a tour of the facility's operating room (OR) on 11/3/2021 at 12:10 PM, the anesthesiologist medication cart was inspected, and it was observed that the cart contained three (3) expired medications. The expired medications were:

Glucagon 1mg injection expired 8/2021
Calcium Chloride vial expired 8/2021
Epinephrine 1mg injection expired 10/2021

During an interview with Staff C, Chief Nursing Officer on 11/3/2021 at 12:30 PM, she acknowledged the findings and she stated that the pharmacy staff is responsible for checking for expired medication on the anesthesia medication cart.

Based on the observation and staff interview, the facility failed to provide a functional and sanitary environment for the provision of patient care services. Each patient care area must be designed and equipped so that the types of services conducted in the facility can be performed in a manner that protects the lives and assures the physical safety of all individuals in the area.

These failures may place patients at risk for infection, falls, injury and allergic reactions.

Findings include:

During the tour of the facility on 11/02/2021 between 1:00 PM and 1:30 PM, the following findings were observed:

1. The ceiling tiles in the nonsterile corridor in the OR (Operating Room) suite was stained due to condensation from an air-condition handler.
2. Outside the OR suite, in the extended OR corridor, a ceiling tile was missing due to an active water leak caused by condensation from an air-condition handler and a bucket was placed on the floor collecting the water.
3. In the X-ray room, there was dust accumulation in and around the vent.

These observations were noted in the presence of Staff D, Director of Support Services. Upon interview at the time of observation, Staff D acknowledged findings and reported that the facility's air-conditioning system is old, and water leaks due to condensation is a problem during the summer.

The above findings were brought to the attention of Staff A, Chief Operating Officer during the onsite exit conference on 11/4/2021 at 3:00 PM.

Based on observations, document review and interview, it was determined the facility failed to employ methods for preventing and controlling infections within the operating room.

Findings include:

During an observation of a colonoscopy procedure on 11/3/2021 at 12:05 PM, the Anesthesiologist opened a vial of medication, he inserted a needle into the vial and withdrew medication and then injected the medication into the patient's intravenous port.

The Anesthesiologist did not disinfect the rubber septum of the medication vial with alcohol prior to piercing, and he did not disinfect the patient's intravenous port with alcohol before injecting the medication through it.

During an interview with Staff C, Chief Nursing Officer on 11/3/2021 at 12:10 PM she confirmed these findings.

Based on staff interview, document review and observation, it was determined the facility failed to provide a safe, functional, and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice. Specifically, the facility failed to follow infection control guidelines.

This failure may place patients at risk for contracting infections.

Findings include:

During a tour of the facility's surgical suite on 11/02/2021 at 2:30 PM, the cabinet for storing disinfected scopes (endoscopes and colonoscopes) was observed to be open during procedures in OR #B. Upon interview of Staff E, a surgical technician after the observation, he stated that the scope storage cabinet is kept open during the procedures and between the procedures to air dry the scopes after disinfection.

Review of the manufacturer reprocessing manual titled 'OLYMPUS GIF-H190, PCF-H190L/I Reprocessing manual' stated, "All equipment must be thoroughly dried prior to storage. Microorganisms proliferate in wet/moist environments. Keep the cabinet doors closed to protect the equipment from environmental contaminants and accidental contacts."

Failure to store the disinfected scopes according to manufacturer's guidelines may facilitate the growth or entry of contaminants in the scope which poses an infection hazard to patients undergoing surgical procedures.

The above finding was brought to the attention of Staff A, the Chief Operating Officer during the onsite exit conference on 11/4/2021 at 3:00 PM.

Based on Performance Improvement (PI) Meeting Minutes from 10/15/2020 to 10/15/2021 and interview, it was determined the facility failed to ensure that data was collected on all services rendered and that data was reviewed, trended, and analyzed.

Findings include:

The facility policy titled: Organizational Performance Improvement & Patient Safety Plan last revised 7/2020, states that they would "identify areas for possible improvement of existing processes and determine whether changes improved the process."

Review of the PI Meting Minutes from 10/15/2020 to 10/15/2021 showed no evidence that the facility collected data on the care patients received in the Surgical/Specialty Services. The minutes showed the number of cases for each month; however, there was no review or discussion of surgical cases to determine if there were complications, infections or any issues related to the procedure or care provided to patients.

Review of the PI minutes for 10/15/2020 to 10/15/2021 showed no evidence that the facility is monitoring activities of the organ procurement program.

During interview on 11/4/2021 at 10:10 AM, Staff B, the Manager of Quality, Clinical Education, and IT Application Support acknowledged the findings and she stated I don't know why it was not included.

Based on review of the Performance Improvement Committee Minutes from 10/15/2020 to 10/15/2021 and interviews, it was determined the facility failed to ensure that patient complaints were tracked, trended, and analyzed to identify patterns and institute corrective action if necessary.

Findings include:

The facility policy titled: Complaint and Resolution, last revised 7/2020 states the complaint process "Provides a forum for reduction in errors and for quality improvements through learning from patient viewpoints, concerns or needs."

Review of the patient complaint log from 1/7/2020 to 9/30/2021 showed several similarities in the nature of the complaints and evidence that most of the events occurred in the Emergency Department as indicated by the following:

-On 9/4/2020, a patient complained that she was mistreated by hospital staff, she described the staff as insensitive, that they lacked compassion and respect and that they were judgmental.
-On 11/6/2020, a complainant stated that the staff was abrupt, appeared disinterested, displayed discrimination, insensitive, lacked compassion and that they were judgmental.
-On 5/29/2021, the spouse of a patient complained that the provider appeared disinterested, insensitive, and lacked compassion.
-On 5/31/2021, a patient complained that staff in the Emergency Department (ED) did not take his complaint seriously and ignored her.
-On 6/7/2021, a patient complained that staff was rude and that he had unprofessional behavior.
-On 6/13/2021 a patient complained that the provider was abrupt and disinterested.
-On 6/14/2021, a patient complained about the care that he and his wife received during a visit to the ED. He described the provider as rude and disrespectful. He stated that he was asked to pull his pants down while he was at the front desk and his wife had an "unwarranted" GYN exam in a room that had no curtain.
-On 6/28/2021, a patient complained that the provider was insensitive, lacked compassion, lacked respect, was rude
and inappropriate.
-On 8/7/2021 the parent of a patient complained that the provider was not wearing a mask and was dismissive.
-On 8/09/2021, a patient complained that the provider lacked empathy, compassion and showed no remorse.
-On 8/16/2021, a patient complained that a staff was rude and nasty.
-On 9/11/2021, a patient complained that the provider was rude, lacked compassion, was rolling his eyes and was dismissive.
-On 9/15/2021, a patient complained that a staff was unprofessional.
-On 9/16/2021, a patient complained that the provider was disrespectful.

The Performance Improvement Minutes for the above period showed no documented evidence that the committee implemented corrective actions to address known patient care issues as stated in these complaints.

During interview on 11/4/2021 at 10:10 AM, Staff B, the Manager of Quality, Clinical Education and Applicable Support acknowledged the findings and she stated that she was not aware that this data should be included in the Performance Improvement meetings to be discussed and analyzed.

The facility's policy titled: Organizational Performance Improvement & Patient Safety Plan, last revised 7/2020, does not describe a process to collect, review and analyze patients' complaints.

Based on the review of the Performance Improvement Committee Minutes from 10/15/2020 to 10/15/2021 and interview, the facility failed to trend, analyze, and develop plans to address issues that affected patient care. Additionally, the facility minutes showed no evidence that data was collected, reviewed, and analyzed for all mortalities and CODE BLUE (resuscitation for cardiac and/or respiratory arrests) activations.

Findings include:

The facility policy titled: Organizational Performance Improvement & Patient Safety Plan last revised 7/2020, states that they would "identify areas for possible improvement of existing processes and determine whether changes improved the process."

The facility failed to use the data they collected to identify areas for improvement and implement preventive measures.

Review of the Performance Improvement Committee minutes for 10/15/2020 to 10/15/2021 showed that the facility documented the number of hospital acquired infection each month. There was no evidence of any discussion or analysis to determine causation and trends.
In nine (9) of 11 months the hospital had no documented evidence of hospital acquired infections.

The PI minutes documented the number of patient falls without injury each month but there was no documentation on the number of falls with injury each month. Additionally, there is no evidence that this data was analyzed and trended

Examples included but was not limited to following:
The December 17, 2020 meeting showed a fall rate of 7.13%
The January 21, 2021 meeting showed a fall rate of 20.88%
The February 19, 2021 meeting showed a fall rate of 11.26%
The March 19, 2021 meeting showed a fall rate of 1.48%

There is no documented evidence that this data was discussed and analyzed to determine what caused the spike in falls in January 2021.

Review of the Performance Improvement minutes for the above period showed no evidence the facility collected data on all patient mortality. The monthly minutes showed the number of COVID mortality but showed no information on other types of mortalities.

Review of the PI minutes showed no information regarding the number of Code Blue activations (coded phrase for cardiac and/or respiratory resuscitation). It did not show the number of Code Blue activations, when and where they occurred and the outcomes of the resuscitative measures.

The facility failed to use the data they collected to identify areas for improvement and implement preventive measures for these indicators.

During an interview on 11/4/2021 at 10:10 AM, Staff B, the Manager of Quality, Clinical Education, and IT Application Support acknowledged these findings.