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Based on observations the Hospital failed to ensure that covering enclosing power cables in Radiology and stretcher beds were kept clean.

Findings included:

On 4/14/10 tours of the following areas of the Hospital were conducted with the Manager of the ED present: Radiology; the Medical/Surgical Unit; the Intensive Care Unit (ICU); the Oncology Unit; the ED, and the Short Stay Unit. Findings were as follows:

Observation in the General Radiology Room determined the power cables were protected by a flexible accordion-like tubing (such as used on a dryer to ventilate to the outside). Inspection of the tubing determined the there was dust in between the creases of the tubing.

Observation in the ICU determined there was light dust on top of the overhead lights located over the beds.

Observation in the ED determined that there was dust located in the bases of the stretchers. Observation determined the stretcher beds had a base that was concave creating a well-like area that was used to place equipment such as oxygen tanks and patient belongings.

Observation in the Short-Stay Unit determined the Unit used the same type of stretcher beds as the ED and although the Unit was clean and free of debris, the wells at bases were dusty.

Based on interview and documentation review the Hospital failed to ensure that: 1) the Complaint Process was followed through, and 2). staff name tags were visible to patients/visitors or that staff consistently identified themselves.

Findings included:

1). The Hospital's Policy/Procedure titled Patient Complaint indicated that letters were sent within 7 days of receipt of the complaint either to indicate the complaint investigation was either completed or was ongoing. If the investigation was completed the letter outlined the outcome of the investigation. If the investigation was not completed when the letter was sent then a follow-up letter was sent upon completion of the investigation.

Review of documents determined that the Hospital maintained a log of patient complaints to use the data to track and trend complaints as part of their Quality Improvement (QI) Program.

The QI Coordinator was interviewed on 4/14/10 at 9:00 A.M. and throughout the survey. The QI Coordinator reported being responsible for tracking the complaints and maintaining the log.

During a review of the Patient Complaint Log, dated 10/1/09 to 4/14/10, three complaints were randomly selected to determine if response letters had been sent. The selected complaints were dated 3/17/10, 3/18/10, and 3/24/10 and the Log indicated that response letters were sent on 4/12/10.

The QI Coordinator said, and review of the complaints indicated that response letters for two of three Complaints were completed on 4/12/10 however; the letters had not yet been mailed. One of three Complaints, dated 3/24/10, did not have a response letter completed or sent.

Review of the Log indicated that a complaint filed on 12/23/09 was pending and not closed.

The QI Coordinator said and review of the complaint packet indicated that the complaint was made against a Hospitalist who allegedly made inappropriate remarks to the patient. The QI Coordinator spoke with the patient and the Hospitalist who admitted to making the remarks. The Hospitalist apologized to the patient and the complaint was forwarded to the Chief of the Hospitalist for further review/action. As of 4/14/10 the Chief had not replied and there was no indication a letter had been sent to the patient.

Review of the Log indicated that a complaint, dated 1/21/10, was pending however; interview with the QI Coordinator and review of the complaint indicated that the complaint had been rescinded by the complainant who did not want a forma investigation. The Log was not updated to reflect this information.

2). Review of the Hospital's Policy/Procedure titled Appearance and Hygiene indicated that identification badges were mandatory and were to be worn in a clearly visible location on the staff member's person.

Observation during tours of the Hospital conducted on 4/14/10 indicated that staff members did not always wear hospital badges in a location that was clearly visible to patients and families. Staff members were observed with badges clipped to the lower hem of their shirts and on one occasion to the side of the shirt. One of the staff members, a registration clerk, was seated behind a desk and therefore the badge was no longer visible. Observation during the tours indicated that staff members were observed with badges clipped in the a visible location however; the badges had twisted and the side with the staff members' name was no longer visible. On one occasion a staff member was observed with a small ceramic heart pin with the staff member's first name on it. The pin was in a visible location however; the pin was small and the staff member had a printed shirt making decreasing the visibility of the pin.

Observation during a tour of the Emergency Department (ED) conducted on 4/14/10, indicated that the ED was an older ED and therefore did not have a separate supply room. Supplies were kept in several of the ED treatment rooms requiring staff to enter/exit the room in order to obtain supplies.

ED Nurse #1 was interviewed on 4/14/10 at 12:55 P.M.; ED Nurse #3 was interviewed on 4/14/10 at 3:05 P.M., and the Critical Care Technician (CCT) was interviewed on 4/14/10 at 3:15 P.M. ED Nurse #1, ED Nurse #3, and the CCT reported that although they identified themselves to a patient when providing direct care; they did not identify themselves when entering a room for supplies.

Based on interviews and documentation review the Hospital failed to follow-through on an action plan to clean stretchers.

Findings included:

Please see A-0225 for information related to the stretchers.

The Hospital's Infection Control (IC) Nurse was interviewed on 4/14/10 at 1:15 P.M. and the Hospital's Hospital-Wide Quality Data for 2009 was reviewed. The IC Nurse said and documentation indicated that in 2009 the Hospital identified there was an issue with cleanliness. The IC Nurse said and documentation indicated that a committee was formed and several meetings (CAT meetings) were held between 3/09 and 5/09 during which time a plan was formulated to to power wash the stretchers 3-4 times yearly beginning in 6/09.

Review of the Policy/Procedure titled Cleaning of Patient Equipment, effective 10/09, indicated that all stretchers were to be washed twice a year by the Environmental Services Department. In between major cleaning the stretchers were cleaned by either nursing or housekeeping. Stretchers were cleaned in between patients using Hospital approved cleaning wipes.

The IC Nurse reported not receiving evidence that power washing had been performed.

Documentation was provided by the Hospital that indicated a special cleaning unit was rented several times a year and that wheelchairs were being cleaned when the cleaning unit was rented however; the cleaning unit was not large enough to accommodate the stretchers. There was no evidence that stretchers were being power washed.