HospitalInspections.org

Based on observation, interview and record review, the facility failed to meet the requirements of the Condition of Provision of Services.

1. The facility failed to implement an effective system to prevent and control infections and communicable diseases. The facility failed to ensure:

*sanitization of patient dishware at the proper temperature for several months;
*a dedicated hand washing sink was available in the kitchen;
*proper disinfection of reusable laryngoscope blades between patients;
*adequate tracking and analysis of infection control data; and
*effective environmental monitoring of infection control issues.

These system failures placed all patients at risk for the development of serious; possibly life-threatening, healthcare-associated infections.
Refer to CFR 485.635 (a)(3)(vi) [Tag C-0278]


2. The facility failed to ensure drugs were stored in a safe manner to prevent unauthorized access; failed to ensure outdated drugs, intravenous fluids and supplies were not available for use in 3 of 3 Emergency Room (ER) treatment rooms and at the Nursing Station. This failed practice had the potential to adversely affect all patients.

Refer to CFR 485.635 (a)(3)(iv) [Tag C-0276]


3.The facility failed to ensure a Registered Nurse (RN) assessed 5 sampled patients every 24 hours per facility policy (Patients # 2, 12, 13, 14, 15).

Refer to CFR 485.635 (d)(1)[Tag C-0294]


4.The facility failed to ensure nursing staff correctly transcribed medication orders and clarified confusing orders for 2 of 4 patients (Patients # 1, # 9) reviewed for medications.

Refer to CFR 485.635 (d)(3)[Tag C-0297]

Based on observation, interview, and record review the facility failed to ensure drugs were stored in a safe manner to prevent unauthorized access;

The facility failed to ensure outdated drugs, intravenous fluids and biological were not available for patient use.

This failed practice had the potential to adversely affect all patients on census. Citing three (3) locations in the Emergency Room, suite #s 1 , 2 and 3 and the Nursing Station.

Findings:

Observation on 8/12/2015 at 10:25 am in Emergency Room (ER) suite (# 3) revealed the room led off a hall way that was accessible to staff and visitors.
The Surveyor went into ER suite (# 3) which was opened and unattended by staff.

The Surveyor was able to open the Crash Cart without exerting much pressure or without breaking the plastic latch. Multiple medications were in the cart including:

Magnesium Sulfate, Epinephrine,Heparin, Lidocaine, Atropine, Naloxone and Benadryl. The medications were readily accessible by unauthorized persons prior to facility staff coming into the room.

Observation on 8/12/2015 in ER suite( #1) revealed multiple unattended and accessible medication was on a counter top. The drugs consisted of :

One (1) multi dose vial of folic acid, (1) opened vial of depoprovera, (2) vials of Ondesterone , a packet with Tylenol 500 mg, and a 30 mls vial of gastrograffin.

During the observation on 8/12/2015 in the ER multiple medications available for patient use were expired including the following:

Two vials of Calcium Gluconate 100 mg/ml in a 10 ml vial had an expiration date of November 2014 found in the crash cart .

Multi dose vial of Folic Acid was opened 3/10/2015 and was still available for use.

During an interview on 8/12/2015 at 2:15 pm with Staff (#13) Pharmacy Technician in charge of drugs and supplies in the facility, she stated all outdated medications and supplies should be removed from the available medications.

She stated it was required that medications be kept in locked areas.

According to Staff (#13) she was not aware until now (8/12/2015) that the locks on the crash cart was not locking as it should. She stated a different locking system would be implemented.


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ER # 1

Observation on 08-12-15 at 1:25 p.m. revealed the following:

Opened and undated multidose vials:

One (1) 50 milliliter (ml) vial of 1% Lidocaine

One (1) 20 ml vial of Xylocaine 1%

Opened and expired multidose vial :

One (1) 30 ml vial sodium chloride, labeled as opened on 07-07-15

Interview at the time of observation with Director of Nurses (DON ) # 2, she stated the vials should be dated when opened and are good for 30 days after opening.

Nursing Station:

Observation on 08-12-15 at 10:15 a.m in the medication refrigerator at the nursing station revealed an opened vial of Novolog 70/30 insulin, labeled as opened on 05-21-15. Interview at the time of observation with Licensed Vocational Nurse (LVN) # 4, she stated insulin was good for 28 days after opening and this vial should have been discarded.

Review of facility policy titled " Policy for Multi-Dose Vials,"undated, read: "...Multiple -dose vials that contain preservatives may be kept for a period of 30 days or until the expiration date, which ever comes first...when a nurse opens and punctures the rubber stopper on a multi-dose vials, that nurse should write the date and his/her initials on the vial....any vial that has been opened linger than a period of 30 days should be discarded..."

ER # 3:

Observation on 08-12-15 at 11:00 a.m. revealed the following expired intravenous(IV) fluids:

one (1) 250 milliliter (ml) bag of Dextrose 5 % Water (D5W): expired 10/2013

one ( 1) 500 ml bag of D5W: expired 12/2013

one (1) 1000 ml bag of D5W: expired 2/2013

DON # 2 stated the fluids were expired and should not be available for use in the ER.

Based on observation, interview, and record review the facility failed to implement an effective system to prevent and control infections and communicable diseases. The facility failed to ensure:

Sanitization of patient dishware at the proper temperature for several months;

A dedicated hand washing sink was available in the kitchen; food preparation and hand hygiene was performed in the same sink;

Proper disinfection of reusable laryngoscope blades between patients for 3 of 3 patients recently intubated (Patients #19, # 22, # 23)

Adequate tracking and analysis of aggregate infection control data.

Effective environmental monitoring of infection control issues.

Findings include:

Dish machine sanitization temperature:

Observation on 08-12-15 at 10:00 a.m. in the facility kitchen revealed a Hobart dishwasher. Interview at the time of observation with the Dietary Manager # 9 she stated "this is a high temperature machine only; no sanitizer is used."

She went on to say that sometimes the temperature gauge "jiggles & acts up" and also there had been " issues with the dishwasher booster a few years ago." Dietary Manager # 9 stated the proper washing temperature was 145-150 degrees Fahrenheit (F) and proper rinse temperature was 165-175 degrees F.

Record review on 08-13-15 of "Hobart Dishwasher Machine Instruction Manual, Model AM-12C" read: "...B.4...Fill and rinse...the water (rinse) should have a temperature of 180 to 195 degrees F.."

Record review on 08-13-15 of the facility monthly "Dietary Temperature Logs" for 2015 revealed consistent documentation of rinse water temperatures below sanitization requirement of 180 degrees F. The majority of days, the rinse temperature was recorded at 165 degrees F. The following is a synopsis of the rinse temperatures recorded:

January 2015: 16 of 31 days below sanitation temperature of 180 degrees F.

February 2015: 24 of 28 days below sanitation temperature of 180 degrees F.

March 2015: 25 of 31 days below sanitation temperature of 180 degrees F.

April 2015: 25 of 30 days below sanitation temperature of 180 degrees F.

May 2015: 26 of 31 days below sanitation temperature of 180 degrees F.

June 2015: 23 of 30 days below sanitation temperature of 180 degrees F.

July 2015: 16 of 31 days below sanitation temperature of 180 degrees F.

Observation on 08-13-15 at 1:00 p.m. in the kitchen with Administrator # 1 revealed two (2) failed attempts by Dietary Manager # 9 to get the dish machine to proceed from the wash to the rinse cycle. The third and fourth attempts yielded a rinse temperature of 140 degrees F.

On 08-13-15 at 1:30 p.m., the survey team requested the Administrator to provide an immediate Plan of Correction related to the dish machine sanitation issue.

On 08-13-15 at 2:00 p.m., Administrator # 1 provided the survey team with an interim Plan of Correction. The dish machine would not be utilized until fully functional and reaching proper dish sanitizing temperature. In the meantime, all meals would be served using disposable dinnerware. Vendors had been contacted requesting immediate repair service.

Record review of the Texas Food Establishment Rules (TFER) dated 9/2006 revealed the following: 229.165(k): "...(12) Mechanical warewashing equipment, hot water sanitization temperatures. (A)...in a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than ...(194 degrees Fahrenheit), or less than:...(ii)...(180 degrees Fahrenheit)."

Kitchen Hand Washing Sink:

Observation on 08-12-15 at 10:15 a.m. in the kitchen revealed an alcove near the food prep area with a hand washing sink, soap, and paper towels. There was a box in the sink. Interview at the time of observation with Dietary Manager # 9 she stated "this sink has not worked for a long time..months.." She went on to say the staff washed their hands in the sink located on the wall.

Further observation revealed a three compartment sink against the wall with a 4th sink immediately adjacent to these (connected). This 4th sink had a sign over it directing employees to wash their hands in this sink.

The 3rd sink on the far right of the 3 compartment sink had a sign over it "thaw meat here" with an arrow pointing down.

Further observation on 08-12-15 revealed Dietary Aide # 11 washing a large metal pot in the handwashing sink ; Head Cook # 10 filled a pot with water that she used to make gravy in this same "hand washing"sink.

Interview on 08-13-15 at 2:30 p.m. with Administrator # 1, he reported the maintenance department had repaired the handwashing sink in the alcove; both hot and cold water were available. In addition, the facility set up a meat station separate from the 3 compartment sinks.

Record review of the Texas Food Establishment Rules (TFER) dated 9/2006 revealed the following: §229.163(f)"...(i) Where to wash. Food employees shall clean their hands in a handwashing lavatory or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or warewashing ..."§229.166(g): (1) Handwashing facilities. A handwashing facility shall be located: (A) to allow convenient use by employees in food preparation, food dispensing, and warewashing areas ...A handwashing facility shall be maintained so that it is accessible at all times for employee use ....(B) A handwashing facility may not be used for purposes other than handwashing ...."

Disinfection of Laryngoscope Blades:
Observation on 08-12-15 at 12:00 p.m. in Emergency Room (ER) # 1 revealed a canvas bag with multiple ( 5 +) and various sizes of multi-use laryngoscope blades and handles. The blades were unwrapped and stored in separate slots in the bag.

Record review on 08-14-15 of the clinical records of patients who had recently received cardiopulmonary resuscitation (CPR) at the facility revealed the following:

Patient # 19: CPR and intubated or attempted on 06-14-15
Patient # 22: CPR and intubated or attempted on 06-19-15
Patient # 23: CPR and intubated or attempted on 08-07-15

Interview at time of observation with ER Registered Nurse (RN) # 12, she stated she cleaned the laryngoscope blades by "soaking them in Hibiclens and water for most of the shift after use; then I wipe them with alcohol."

Interview on 08-13-15 at 1:45 p.m. interview with Infection Control Nurse # 3 she stated she "was unsure of how the laryngoscope blades were disinfected, but I think the the staff may be soaking them in bleach."

Follow-up interview on 08-14-15 at 10:15 a.m. interview with Infection Control Nurse # 3 she stated Hibiclens was not a high level disinfectant meant for instrument disinfection. She went on to say an example high level disinfectant would be Cidex or OPA.

Interview on 08-14-15 at 11:45 a.m. with the Director of Nurses (DON) # 2 she stated the laryngoscope blades were cleaned by soaking them in Hibiclens.

Review on 08-13-15 of facility Hibiclens box label/ instructions read: " Hibiclens Skin Cleanser...active ingredient Chlorhexadine gluconate solution 4.0%..USES: antimicrobial skin cleanser...skin, wound general skin cleansing...surgical hand scrub...healthcare personnel handwash."

Review of facility policy titled :" Decontamination of Supplies and Equipment," undated, read: "Purpose: Cleaning, disinfecting and sterilizing equipment to prevent the transmission of organisms...2 Semi-Critical items are those that may come in contact with mucous membranes but do not ordinarily penetrate body surfaces. Although sterilization is preferred for these instruments, high level disinfection that destroys tuberculosis may be used...b. Items to be re-sterilized and properly disinfected will be returned to the surgery department where decontamination and sterilization will be completed according to protocol before the items are returned to the ER..."

Review of "Association periOperative Registered Nurses (AORN) Guidelines," 2012 Edition, read : "..1.b. Items that come in contact with nonintact skin or mucous membranes are considered semicritical and should receive a minimum of high-level disinfection. Examples of semi-critical items include...laryngoscope handles and blades...examples of high level disinfectants include: gluteraldehyde-based formulas, percetic acid, stabilized hydrogen peroxide 6%, sodium hypochorite..."

Tracking and Analysis of Aggregate Infection Data

Record review of facility "Infection Control Plan," undated, read: "...B. The Infection Control Officer will prepare a summary of all areas concerning infections and report to the Medical Staff monthly..." Attached in this plan was a blank template titled "Infection Control Report" that included spaces to provide the following information ( not all inclusive) : "total # of patients; total # number admitted with infections; total # number of nosocomial infections; types of infections; types of isolation... "

Record review of Medical Executive Committee meeting minutes for 2015 failed to reveal a monthly infection control report.

Review of facility "Quality Assurance Plan: Infection Control," undated, read : " Reports of monthly Infection Control activities shall be forwarded to the Quality Assurance Committee..."

Record review on 08-13-15 of facility 2015 Quality Assurance meeting minutes failed to reveal any discussion or reports related to infection control.

Interview on 08-14-15 at 11:35 a.m. with Infection Control Nurse # 3 she stated that Infection Control was now reported to Safety Committee and not Quality Assurance. She went on to say they are in the process of revising the infection control plan and policies.

Review of the 2015 Safety Committee meeting minutes revealed a "Safety & Infection Control Surveillance Checklist" that was chiefly environmental in nature, but did include staff knowledge of hand-washing and available Personal Protective Equipment(PPE).

The Infection Control Nurse # 3 went on to say her infection control surveillance process was as follows: the nursing staff completed an "Infection Control Identification Form" for each patient. This form stayed in the patients medical record until they were discharged. The form was then forwarded to the IC Nurse and she reviewed them all. She went on to say she also reviewed all of the lab culture reports and other lab results.

Review of 2015 "Infection Control Tracking Calendar" revealed months and types of organisms. There was no information on this report that indicated if infections were healthcare acquired or community acquired infections.

When asked if the facility had patients that had been placed in isolation precautions, Infection Control Nurse # 3 said they had patients positive for C Diff (Clostridium difficile bacteria) in the past. This was not documented in any infection control report as being tracked or analyzed. Infection Control Nurse # 3 also said the facility "had not had any nosocomial infections." This also was not documented in any infection control reports.

Effective environmental monitoring of infection control issues:

Kitchen:

Interview on 08-14-15 at 11:35 a.m. with Infection Control Nurse # 3 she stated she does not monitor infection control activities in the kitchen. She was unaware of the dishwasher sanitation issues. She went on to say that she would correct this immediately.

ER:

Observation on 08-12-15 at 11 a.m. in Emergency Room (ER) #3 revealed:

One drawer that contained 25 + unwrapped plastic forceps. The uncovered instruments were stored directly on top of visible particles of dust and dirt in the drawer.

One (1) box of opened 4 x 4 gauze pads

Observation on 08-12-15 at 11 a.m. in Emergency Room (ER) #3 revealed:

One (1) plastic "bath- basin" type bin full of unwrapped scissors, tweezers, forceps, and other metal instruments.

Interview at the time of observation with RN # 12, she stated the instruments were dirty should have been discarded. She went on to say the facility previously had an autoclave but no longer had one.

Observation on 08-12-15 at 1:25 p.m. in Emergency Room (ER) # 1 revealed: eleven (11) red top blood collection tubes: expired May 2015.

Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) assessed 5 of 23 sampled patients every 24 hours per facility policy ( Patients # 2, 12, 13, 14, 15).

Findings include:

Record review of 23 sampled patient clinical records revealed the following:

Patient # 2:

85 year old male admitted on 08-06-15 with diagnoses of fever, cough, and pneumonia. Review of the daily nursing assessments failed to reveal an RN assessments performed on 08-08-15; 08-09-15; and 08-10-15.

Interview on 08-12-15 at 12:15 p.m. with Licensed Vocational Nurse(LVN) # 4 she stated the RNs were required to assess the patients at least every 24 hours. She was unable to locate the RN assessments for Patient # 2 on the dates listed above.

Patient # 12

86 year old female patient admitted on 04-18-15 with a diagnosis of Pyelonephritis; she was discharged in 04-22-15. Review of the daily nursing assessments failed to reveal an RN assessment performed on 04-19-15; 04-21-15; and 04-23-15.

Patient # 13

73 year old female patient admitted on 02-17-15 with fatigue, fever, and malaise; she was discharged on 02-23-15. Review of the daily nursing assessments failed to reveal an RN assessment performed on 02-20-15; 02-21-15; and 02-22-15.

Patient # 14:

85 year old female patient admitted on 03-23-15 for worsening cough and dyspnea. Review of the daily nursing assessments failed to reveal an initial RN assessment on 03-23-15 and also no RN assessments on 03-24-15; 03-27-15; and 03-29-15.

Patient # 15:

79 year old female patient admitted on 05-05-15 with congestion, shortness of breath, and lower extremity edema. Review of the daily nursing assessments failed to reveal an RN assessment on 05-09-15.

During record review on 08-14-15 at 10:45 a.m. with LVN # 14, she was unable to locate the RN assessments for Patient # 12, 13, 14, 15 on the dates listed above.

Review of facility policy titled " Charting: Documentation of patient care," undated, read: "...17. A nursing assessment will be documented every shift in every every patient. The initial assessment will be documented by the admitting RN responsible for the patient within 24 hours of admission. An RN assessment will be documented in the nurses notes for every patient at least every 24 hours..."

Based on record review and interview, the facility failed to ensure medications were transcribed correctly and confusing orders were clarified for 2 of 4 patients ( # ' s 1 and 9) reviewed for medications.

Findings include:

Patient #1

Record review of Patient #1 ' s active clinical record revealed he was admitted on 8/10/15 for Hospice respite care.

Record review of Patient #1 ' s Admission Orders revealed the following orders:

-Lisinopril 10 mg by mouth at bedtime (for hypertension)
-Trazodone 200 mg by mouth at bedtime (a medication used as a sleep aide or to treat depression or anxiety)

Record review on 8/12/15 of Patient #1 ' s MAR (Medication Administration Record) with LVN (Licensed Vocational Nurse) #4 revealed the following:

-Lisinopril 10 mg by mouth twice a day, 9 a.m. and 9 p.m.
-Trazodone 100 mg by mouth at bedtime, 9 p.m.

Further review of Patient #1 ' s MAR revealed he received the medications as follows:

Lisinopril - 8/10 once
8/11 twice
8/12 twice
8/13 once

Trazodone 100 mg - at 9 p.m. on 8/10, 11, and 12/2015

Interview on 8/13/15 at 8:30 a.m. with LVN #4, she verified the two orders were not transcribed correctly from the physician ' s order to the MAR. LVN #5 was present at this time and said the orders went through two checks and were still incorrect.

Record review of the facility ' s Policy and Procedure for Medication Administration Procedure (not dated) revealed the following:
" V. PREPARATION OF MEDICATION ADMINISTRATION RECORD ...
C. LVN or RN transcribes medication orders form physician order form to Medication Administration Record (MAR), including the following:
1. Order Date
2. Drug name and strength
3. Route
4. Frequency
5. Schedule ...
H. Medication nurse will verify correctness of MAR ' s ...before administering medications on his/her shift. "

Record review of the facility ' s Policy and Procedure for Noting Physician Orders (not dated) revealed the following:
" 4. Medication Administration Record (MAR)
a. The RN or LVN will check all physician orders for medication orders. Medications are to be transcribed to the MAR by the nurse noting the physician orders. A copy of the orders will be placed on the medication cart for the Medication nurse to check against the order written on the MAR. The copy is then sent to the pharmacy for the medication to be filled... "


Patient #9

Record review of Patient #9 ' s closed clinical record revealed he was admitted on 6/8/15 for Hospice respite care.

Record review of the patient ' s Nurses ' Notes revealed he was discharged on 6/10/15.

Record review of Patient #9 ' s Admission Orders revealed the following order:

- Bactrim DS one tablet by mouth for 3 days.

Record review of Patient #9 ' s MAR revealed the following:

- Bactrim DS one tablet by mouth twice a day at 9 a.m. and 9 p.m.

Further review of the patient ' s MAR revealed he received the medication four time in the three days he was at the facility, once on 6/8/15, twice on 6/9/15 and once on 6/10/15.

Further review of Patient #9 ' s closed medical record revealed no clarification order for Bactrim DS.

Record review of the facility ' s Policy and Procedure for Nursing Interpretation of the Drug Order dated 10/05 revealed the following:

" A. Any questions concerning the interpretation of the drug order should be referred to the prescribing physician or mid-level practitioner immediately. "

Based on record review and interview the facility failed to maintain clinical records that contained pertinent medical history, assessment of the health status and health care needs of 3 of 3 patients ( # ' s 1, 9, and 11) admitted for Hospice respite care.


Findings include:

Patient #1

Observation on 8/12/15 at 11:40 a.m. with DON (Director of Nursing) #2 revealed Patient #1 was in bed in his room and was alert and oriented to person, place and time.

During an interview at this time with the DON, she was asked why the patient was in the hospital. She said he was on Hospice respite care because his family went out of town. She was not sure why he was on hospice care.

Record review of Patient #1 ' s active Clinical Record revealed he was admitted on 8/10/15 at 9:46 a.m. There were no diagnoses for the admission only that he was on Hospice respite care.

Record review of the patient ' s Physician ' s Orders revealed he was on medications for breathing, blood pressure, anxiety, sleep, depression, fluid retention, pain, gastric reflux, and diabetes.

Further review of the patient ' s clinical record revealed there was no History and Physical or progress notes.

During an interview on 8/13/15 at 8:30 a.m. with LVN #4, she was asked what Patient #1 ' s diagnoses were for his medications and why he was on hospice care. She said she did not know.

During an interview on 8/13/15 at 11:00 a.m. with DON (Director of Nursing) #2, she was informed Patient #1 did not have a History and Physical (H&P) n his Clinical Record. She said he came in regularly and the H&P was probably in another admission. At 12:00 p.m. the DON had a H&P for Patient #1 dated 2/21/15. She said their Electronic Medical Record (EMR) did not regenerate H&Ps from visit to visit.

Patient #9

Record review of Patient #9 ' s closed Clinical Record revealed he was admitted on 6/8/15. No diagnoses were given.

Record review of Patient #9 ' s Physician ' s Orders revealed he was admitted for Hospice respite care.

Record review of the Patient ' s Nurses ' Notes revealed he was discharged on 6/10/15 at 2:15 p.m.

Further review of the Patient ' s Clinical Record revealed there was no History and Physical, Progress Notes, or Discharge Summary.

Record review of Patient #9 ' s closed Clinical Record revealed he was readmitted on 6/14/15 at 4:06 p.m.

Record review of Patient #9 ' s Physician ' s Orders revealed he was admitted for Hospice respite care.

Record review of the Patient ' s Nurses ' Notes revealed he had an indwelling urinary catheter, a wound, and was being given pain medication. On 6/14/15 at 9:17 p.m. the patient was pronounced dead by the Hospice nurse with the family at the bedside.

Interview on 8/13/15 at 11:50 a.m. with DON #2, she was asked if Patient #9 was brought to the facility to expire. She said he was because of some family dynamics at home.

Further review of Patient #9 ' s Clinical Record revealed he did not have a H&P, Progress Notes, or a Discharge Summary.

Patient #11

Record review of Patient #11 ' s closed Clinical Record revealed she was admitted on 7/24/15. There were no diagnoses.

Record review of Patient #11 ' s Physician ' s Orders revealed she was admitted for Hospice respite care. There were no diagnoses.

Record review of the patient ' s Nurses ' Notes revealed she was discharged on 7/27/15.

Record review of Patient #11 ' s closed Clinical Record revealed she was readmitted on 8/1/15.

Record review of Patient #11 ' s Physician ' s Orders revealed she was admitted for Hospice respite care. There were no diagnoses.

Record review of the patient ' s Nurses ' Notes revealed she was discharged on 8/4/15.

For both admissions there were no H&P, Progress notes or Discharge Summaries.

Interview on 8/13/15 at 3:00 p.m. with Director of Clinical Records #8, she said the clinical records for Hospice respite care patients was a " thorn in her side " . She said she had spoken with DON #2 and she told her to contact the Hospice nurse to request the needed information. She said she called the Hospice nurse and got a History and Physical once, but then could not continue to get the needed records with each admission.

Interview on 8/13/15 at 4:20 p.m. with DON #2, she said the facility did not have a Policy and Procedure for admitting patients on Hospice respite care.

Record review of the facility ' s Rules and Regulations approved on 10/21/14 revealed the following:

" The attending physician shall be held responsible for the preparation of a complete medical record for each patient. The record shall include the following at least:

Identification Data
Chief Complaint
Present Illness
Past History
Review by Systems
Complete Physical Examination by System
Progress Notes .... "

Based on observation, interview and record review the facility failed to evaluate the temperature data collected daily for the dish washing machine to ensure safe and effective functioning;

The facility failed to monitor expiration dates of patient care supplies to ensure quality and effectiveness of the supplies. This failed practice had the potential to adversely affect all patients on census.

Findings:

During an interview on 8/12/2015 at 10:20 am with the facility's administrator it was revealed that the facility provide in house meal service for patients, staff and some members of the community.

During observation on 8/13/2015 at 1:00 pm in the dietary suite it was revealed there was a heat sanitizing dishwasher in the kitchen. During the dishwashing procedure the dish washer failed to reach the 180 degrees Fahrenheit (F) required for sanitization.

Review of temperature logs revealed information that the rinse temperature must reach 150 degrees Fahrenheit and the rinse temperature 180 degrees F or above.

Review of the dish machine temperature logs from January 1, 2015 through August 13,2015 revealed the dishwasher did not reach the sanitizing temperature as follows:

January 2015: 16 of 31 days below sanitation temperature of 180 degrees F.

February 2015: 24 of 28 days below sanitation temperature of 180 degrees F.

March 2015: 25 of 31 days below sanitation temperature of 180 degrees F.

April 2015: 25 of 30 days below sanitation temperature of 180 degrees F.

May 2015: 26 of 31 days below sanitation temperature of 180 degrees F.

June 2015: 23 of 30 days below sanitation temperature of 180 degrees F.

July 2015: 16 of 31 days below sanitation temperature of 180 degrees F.


Review of Governing Body minutes and quality data for January 1, 2015-August 12, 2015 revealed no information that the daily dishwashing temperatures were evaluated for quality.

During an interview on 8/14/2015 at 11:25 am at the facility with the Quality Director she stated the temperatures were not evaluated and staff did not report the failed temperatures.

During an interview on 8/14/2015 at 11:45 am with the facility's Administrator he stated staff would be in-serviced regarding reportable dishwashing temperature and that the Quality Assurance and Performance Improvement (QAPI) system would integrate dishwashing temperatures in the quality monitoring process.

Observation on 8/12/2015 and 8/14/2015 in Emergency Room (ER) suite one (1) and two( 2 ) revealed multiple emergency supplies with expiration dates were still available for use.

Observation on 8/14/2015 at 8:35 am revealed the one (1) trachea set marked "Quick Trach Set" located in the ER was expired since May 2015.

Observation on 8/12/2015 between the hours of 10:10 am and 11:05 am revealed Infant Electrode pads with defibrillator found on the crash cart was expired since January 2015.

Three(3) packets of Protect IV catheters with safety were expired since February 2015.

Two pairs of powdered latex surgical gloves located in the crash cart were expired since March 2015.

During an interview on 8/12/2015 at 2:15 pm with Staff (#13) Pharmacy Technician in charge of drugs and supplies in the facility, she stated all outdated medication and supplies should be removed from the available medications.


23032


Observation on 08-12-15 at 11 a.m. in Emergency Room (ER) # 3 revealed:

One (1) suction catheter kit ( located in the OB Kit): expired March 2013

One (1) patient vent circuit: expired May 2015

One (1) 25 ml bottle of opccult blood developer : expired May 2015

Three (3) bottles of packing strips: expired May 2015

Interview at the time of observation with Director of Nurses (DON) # 2, she stated the expired supplies should not be available for patient use in the ER.

Based on record review and interview the facility failed to have written protocols that defines 'imminent death and timely manner';

The facility failed to ensure staff notify the Organ Procurement Organization (OPO) when there was a death in the facility. Citing two(2) of five(5) death records that were reviewed. Patient #s 19 and 21.

Findings:

Review of the facility's policy/procedures revealed there was an Organ Procurement Organization ( OPO) agreement with the facility dated 11/7/2012.

Review of the OPO agreement revealed instructions that the facility should "notify lifegift in a timely manner of all individuals who have died, or whose death is imminent".The agreement stated the facility should consult with the OPO to be able to define 'timely notification and imminent death'.

Review of the facility's Tissue and Organ Donation Policy dated August 2008 revealed the following information:

"It is the policy of Winnie Community Hospital to promote the saving of life and and to improve the quality of life through organ and tissue donation.

All deaths will be reported to Life Gift organ donation center by calling (the listed phone #) for evaluation and determination of the eligibility of a potential organ and tissue donor.

No employee of this facility will approach any family member possible organ or tissue donation. The LifeGift requestor will do all".

The purpose of the policy was :

'To outline the hospital's guidelines for the routine notification of death to the Organ Procurement Organization(OPO) and to outline procedures to facilitate organ and tissue donations'.

There was no information in the policy that timely manner and imminent death was defined.

During interviews on 8/13/2015 9:50 am with the Chief Nursing Officer , two Registered Nurses and two Licensed Vocational Nurses (LVN) none of the staffs were able to tell what timely notification and imminent death meant to them.

The policy did not address the subject of timely notification or imminent death.

Review of five (5) patient records who died at the facility revealed the facility failed to notify the OPO of two deaths that occurred at the facility in June 2015 and August 2015.

The records revealed on 8/7/2015 Patient # 19 three years old died in the emergency room after he was found in the pool at home. On scene Cardio-Pulmonary Resuscitation (CPR) was successful but the child deteriorated and was taken to the hospital.

On 6/14/2015 Patient # 21, 35 years old was seen in the emergency room with cardiac arrest. Resuscitation was unsuccessful and the patient was pronounced dead.

There was no documentation that the OPO was notified.

During an interview on 8/14/2015 at 10:15 with the Chief Nursing Officer she stated the OPO should be notified of all patient deaths.

Based on record review and interview the facility failed to provide evidence that staff were educated on notification protocols required by the Organ Procurement Organization (OPO); and that death records were evaluated to ensure the OPO was notified of all deaths at the facility . Citing Staff #s 3,4,6, and 14.

Findings:

Review of personnel files for two Registered Nurses #s (3 and 6) and two Licensed Vocational Nurses #s (4 and 14) who provided patient care at the facility revealed no information that the staffs had training on Organ Procurement Organization (OPO) protocols and the facility's responsibility to notify the OPO of all patient deaths at the facility.

During an interview on 8/13/2015 at 9:10 am with Staff (#4) Licensed Vocational Nurse and Staff (# 3) Registered Nurse they both stated they were given instructions to call the OPO when there was a death and the OPO will ask questions. According to the Staffs they did not receive training on OPO issues and were not aware of a policy.

During an interview on 8/14/2015 at 12:15 pm with the Director of Nursing she stated Staff did not have training on OPO issues and the facility did not evaluate death records to ensure potential donors were identified.

The Director stated going forward this aspect of service would be integrated in their Quality Assurance and Performance Improvement process.