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Based on interview and record review, the hospital medical staff failed to ensure hospital policies and procedures were revised and approved by the hospital governing board. This failure had the potential to adversely effect the quality of patient care.

Findings:

The hospital policy and procedure titled "Supply Expiration Date Surveillance" review date was 3/3/06 and the revised date was 5/27/10.

The hospital policy and procedure titled "Environmental Cleaning for Cath Lab (Cardiac Catheterization Laboratory, is an examination room in a hospital or clinic with diagnostic imaging equipment used to visualize the arteries of the heart and the chambers of the heart and treat any abnormality found)" had no review date, but the revised date was 2/23/12.

The hospital policy and procedure titled "Security Management Plan" was reviewed 7/13/06 and revised 6/14/12.

The hospital policy and procedure titled "Multi-Dose Vials" was reviewed and revised on 8/16/12.

During an interview with the hospital's Vice President of Nursing Services, on 10/21/14, at 3 PM, she stated she was aware that numerous hospital policies were outdated and was working to update them.

The hospital Governing Body Bylaws under Article III Governing Body Function, Section 2: Hospital Leadership, indicated "The periods between reviews of all policies and procedures shall be determined on a departmental basis, but in no case will it exceed two (2) years."

Based on observation, interview, and record review, the hospital failed to:

1. maintain negative room pressure (with negative room pressure, the ventilation system moves air out more quickly than air can move in. This creates negative pressure and encourages air from halls and neighboring rooms to flow into the negative pressure room, rather than allowing contaminated air out) in one of three respiratory isolation rooms that were used for patients requiring respiratory isolation, such as tuberculosis.

2. maintain negative pressure in the Procedure/Endoscopy (use of an instrument to look inside the body for medical reasons) room during Bronchoscopy (visualizing the inside of the airways) procedures.

3. maintain temperature and humidity in the Cath lab (Cardiac Catheterization Laboratory, is an examination room in a hospital or clinic with diagnostic imaging equipment used to visualize the arteries of the heart and the chambers of the heart and treat any abnormality found) and operating rooms (OR) within acceptable range.

These failures placed patients, staff and visitors at risk for contracting respiratory related infections and had the potential failure to inhibit bacterial growth and infection to patients.

Findings:

1. During a concurrent observation tour and interview on 10/15/14, at 2:30 PM, in the emergency department, accompanied by the Director of Emergency Department (DED) and the Director of Engineering (DE), the emergency department had one isolation room to house patients with infectious diseases, including air-borne infections. When asked how the negative pressure in the isolation room was monitored, the DE stated a pressure monitoring device, on the wall and outside the room, read the pressure at all times when in negative pressure mode. He stated the hospital engineer was responsible to check the pressure monthly. In addition to the one isolation room in the Emergency Department, the hospital also had one isolation room in the critical area and one in the medical-surgical unit.

On 10/16/14, the monthly monitoring log for all three isolation rooms was reviewed. The log indicated all three isolation rooms were functioning as of 9/2014.

On 10/16/14, at 2:33 PM, accompanied by the Lead Engineer (LE) and the DE, a smoke test was done to check the air pressure in the emergency department isolation room. (Negative room pressure is a ventilation system that generates negative pressure to allow air to flow into the isolation room and flow out of the isolation room through an exhaust system. A smoke test can help determine whether a room is under negative pressure. A tube containing smoke is held near the bottom of the negative pressure room door. The smoke tube is held parallel to the door, and a small amount of smoke is then generated by gently squeezing the bulb. If the room is at negative pressure, the smoke will travel under the door and into the room. If the room is not a negative pressure, the smoke will be blown outward or will stay stationary.) The smoke was blown outward towards the hallway, which indicated the room did not have negative pressure. Neither the LE nor the DE could explain why the room was not in negative pressure. The DE stated he would contact a technician to have all the isolation rooms checked.

During an observation on 10/16/14, at 3:50 PM, the isolation room in the critical area and the isolation room in the medical-surgical area were checked. Both rooms had doors open and were not occupied. The monitoring devices were turned off. The smoke test was not conducted.



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2. During an interview with the Vice President of Quality (VPQ), on 10/21/14, at 10:15 AM, she stated, "There is no log for the GI (Gastrointestinal/Procedure Endoscopy) lab checking negative pressure. There's a ping pong ball and when it's out (showing outside the room) a work order is done, and engineering fixes it."

During an interview with the DE, on 10/21/14, at 10:55 AM, when asked about negative pressure in the GI (gastrointestinal) laboratory he stated "We have to adjust it to negative pressure, and we've only adjusted it a few times in the last 12 months. I can go look through the work orders to find out." The DE returned and said "I've looked through the work orders, and it has never been in negative pressure."

During an interview with the Director of Surgical Services (DSS) and Director of Respiratory (DR), on 10/21/14, at 11:50 AM, they both stated they assumed the room was always in negative pressure. The DR stated "We do a lot of bronchoscopies in the GI lab." When asked how many, the DR stated "We average 15 a month."

During an observation with the DE, DSS, and DR, on 10/21/14, at 12 PM, in the GI lab (Procedure/Endoscopy room), the Ping Pong ball was seen while standing outside the room in the hallway. That was indicative of the room being in positive pressure.

There were no logs to review for negative pressure in the Procedure/Endoscopy laboratory.

No facility policy and procedure was provided regarding negative pressure in the Procedure/Endoscopy laboratory.

2013 Ventilation standards specific recommendations for health-care facilities are published by the American Society of Heating, Refrigerating, and Air Conditioning Engineers, Inc. (ASHRAE), and by the Federal Health Resources and Services Administration. The recommendations indicated "Bronchoscopy: should be performed in rooms with negative pressure (that have adequate ventilation, good distribution of air flow, and air exhausted directly to the outside) in accordance with federal, state, and local regulations for environmental discharges." ASHRAE also indicated "Endoscopy room: if room used for Bronchoscopy it must be negative pressure."

Centers for Disease Control (CDC) ventilation recommendation for selected areas in the Healthcare settings indicated "Bronchoscopy: room air exhausted directly outdoors."

3. During an observation and interview with the Director of Outpatient Services (DOS) of the Catheterization laboratory, on 10/7/14, at 12:05 PM, there were no thermometers (instrument used for monitoring temperature and humidity) in the four catheterization laboratory suites. When asked how staff knows the temperature and humidity in the rooms, he stated, "Staff get the numbers from engineering. If it's out of range we are notified by engineering."

During an interview and record review with the Infection Control Nurse (ICN), on 10/7/14, at 3:30 PM, the 10/2014 Catheterization laboratory logs for temperature and humidity were found to be out of range. The ICN was asked if she was notified, and stated "Yes, they usually do if it can't be resolved." She stated "Engineering gets it and documents...I will check with them to see if they document somewhere else."

During an interview with the ICN, on 10/7/14, at 4:10 PM, she stated "I talked with the Director of Engineering (DE), and he said when it's [the temperature and humidity of the cath lab] out of range they make adjustments and check the temperature the next day."

During an interview with the DOS, on 10/7/14, at 4:35 PM, when asked what was done for the days when the temperature and humidity was out of range he stated, "I call engineering and tell them I need it adjusted. I just assumed it was corrected."

During an interview with the DE, on 10/8/14, at 9 AM, when asked about the temperature and humidity he stated, "Temperature in the OR [Operating Room] are per doctor request, if I up them they ask us to cool it down. Nothing is done when it's out of range in Cath lab or OR. I was told to keep them [doctors] comfortable by the previous Chief Executive Officer."

During a review of the Temperature and Humidity logs for the Catheterization Laboratories the following was noted:

July 2014: Temperature was out of range in Catheterization laboratory 1- 4, 19 out of 20 days. The temperature ranged from 59.8 to 65.9 degrees Fahrenheit (F - a unit of temperature measurement). The humidity was out of range in Catheterization laboratory 1- 14 out of 20 days, Catheterization laboratory 2 and 3- 17 out of 20 days, and Catheterization laboratory 4- 10 out of 20 days. The humidity ranged from 63.9 to 74 %.

August 2014: Temperature was out of range in Catheterization laboratory 1 -4, 19 out of 19 days. The temperature ranged from 57.2 to 66.1 degrees F. The humidity was out of range in Catheterization laboratory 1- 10 out of 19 days, Catheterization laboratory 2- 18 out of 19 days, Catheterization laboratory 3 - 19 of 19 days, and Catheterization laboratory 4- 5 of 19 days. The humidity ranged from 64.6 % to 70.7 %.

September 2014: Temperature was out of range in Catheterization laboratory 1 -4, 21 out of 21 days. The temperature ranged from 57 to 64.9 degrees F. The humidity was out of range in Catheterization laboratory 1 and 2- 17 out of 21 days, and Catheterization laboratory 3 and 4- 21 out of 21 days. The humidity ranged from 71.9 % to 75.5 %.

October 1-7, 2014: Temperature was out of range in Catheterization laboratory 1 - 4 7 out of 7 days. The temperature ranged from 56.9 to 63 degrees F. The humidity was out of range in Catheterization laboratory 1- 1 out of 7 days, Catheterization laboratory 2- 2 out of 7 days, Catheterization laboratory 3 and 4- 6 out of 7 days. The humidity ranged from 68.3 % to 72.6%.

During a review of the Temperature and Humidity logs for the OR the following was noted:

July 2014: Temperature was out of range in OR 1- 13 out of 20 days, OR 2- 10 out of 20 days, OR 3- 18 out of 20 days. The temperature ranged from 64.8 to 67.1 degrees F.

August 2014: Temperature was out of range in OR 1 - 11 out of 19 days, OR 2- 14 out of 19 days, OR 3- 18 out of 19 days. The temperature ranged from 65.1 to 67.1 degrees F.

September 2014: Temperature was out of range in OR 1- 20 out of 21 days, OR 2- 9 out of 21 days, OR 3- 20 out of 21 days. The temperature ranged from 55.3 to 67.6 degrees F. The humidity was out in OR 3- 1 out of 21 days at 64.9 %.

October 1-7, 2014: Temperature was out of range in OR 1- 6 out of 7 days, OR 2- 1 out of 7 days, and OR 3- 7 out of 7 days. The temperature ranged from 62.3 to 66.7 degrees F.

The hospital policy and procedure titled "Humidity and Climate control in the Cardiac Cath Lab" revised date 12/12/12, indicated: "2. Relative humidity shall be maintained between 30 % and 60 %...", "3. Temperature should be maintained between 70 degrees and 75 degrees Fahrenheit (F)...", "5. ...Deviations from the above guidelines should be corrected when rooms are in use.", and "6. Continual discrepancies will be reported...All changes will be recorded and logged by the Temperature Variance report..."

The hospital policy and procedure titled "Humidity and Climate control in the Surgery Suite" revised date 5/23/13, indicated "2. Relative humidity shall be maintained between 30 % and 60 % within the perioperative suite.", "3. Temperature should be maintained between 68 degrees and 73 degrees F within the OR...", "5. ...Deviations from the above guidelines should be corrected when rooms are in use.", and "6. Continual discrepancies will be reported..."

The 2014 Association of periOperative Registered Nurses (AORN) Standards and Recommended Practices, "Safe Environment of Care, Part II", Recommendation II reads "The surgical suite design should include areas that are defined by the activities performed in each area. Procedure room/Cath Lab temperature should be 70 - 75 degree F with the humidity 20 % - 60 %, and the Operating Room (OR) should be 68 - 75 degree F with the humidity 20 % - 60 %".

Based on observation, interview and record review, the hospital failed to provide an environment to avoid sources and transmission of infections and communicable disease as evidenced by the hospital's failure to have effective systems in place to ensure:

1. The Infection Control Risk Assessment guidelines were followed in a Hospital construction area. (A 749)

2. Staff were trained and competent to effectively clean and disinfect the patient care environment in accordance with disinfectants manufacture's guidelines. (A 749)

3. Shared equipment potentially exposed to bloodborne pathogens (bacteria and virus present in blood and body fluids was safely and effectively cleaned and disinfected between each patient use. (A 749)

4. Standards of Practice and Contract Policies and Procedures were followed and failed to establish hospital policy and procedures for acute dialysis (process which removes blood from body, removes toxins and then returns it to the persons' body) patient care. (A 749)

5. Policies and Procedures and standards of practice were followed in patient Intravenous (into the vein) Fluid Administration. (A 749)

6. Expired medications and supplies were disposed of according to hospital policy and procedure and standards of practice. (A 749)

7. The Wound Center Hyperbaric Chamber (chamber that delivers high concentration of oxygen) was disinfected according to manufactures guidelines. (A 749)

8. Isolation carts (cart that hold supplies for nurses caring for infected patients) in Patient Care Areas were properly stocked. (A 749)

9. Temperature, humidity and negative pressure (system that removes more air from room than air is allowed into room) guidelines and policies were followed in the peri-operative (around surgical area) areas. (A 749)

The cumulative effect of these system problems resulted in the hospital's inability to provide a sanitary environment and placed all patients and staff at risk of developing infectious and communicable diseases.

Based on observation, interview and record review, the hospital failed to provide an environment to avoid sources and transmission of infections and communicable diseases as evidenced by the hospital's failure to have effective systems in place to ensure:

1. The Infection Control Risk Assessment guidelines were followed in a hospital construction area.

2. Housekeeping Staff were trained and competent to effectively clean and disinfect the patient care environment in accordance with disinfectant's manufacturer's guidelines.

3. Shared equipment (equipment used for multiple patients) potentially exposed to bloodborne pathogens was safely and effectively cleaned and disinfected between each patient use.

4. Standards of Practice and Contract Policies and Procedures were followed and failed to establish hospital policy and procedures for acute dialysis (a process which removes blood from the body, removes toxins and then returns it to the persons's body).

5. Policies and Procedures and standards of practice were followed in patient Intravenous Fluid (into the vein) Administration.

6. Expired medications and supplies were disposed of according to hospital policy and procedure and standards of practice.

7. The Wound Center Hyperbaric Chamber (a patient chamber that delivers a high concentration of oxygen) was disinfected according to manufacturer's guidelines.

8. Isolation carts (a cart that holds supplies for nurses caring for infected patients) in Patient Care Areas were properly stocked.

9. Temperature, humidity and negative pressure guidelines and policies were followed in the peri-operative (around surgical areas) areas.

The cumulative effect of these system problems resulted in the hospital's inability to provide a sanitary environment and placed all patients and staff at risk of developing infectious and communicable diseases.

Findings:

1. During an observation and concurrent interview with the hospital Director of Engineering (DE) of the second floor patient care area on 10/15/13, at 11 AM, the following was observed:

The hospital had established a plastic barrier around a construction site directly next to Pod A's (the name of a nurses' station) nursing station. There were no signs posted to identify potential hazards.

The construction site was visible through the opened zippered entrance in the plastic barrier. In the construction area there were 16 eighteen-inch ceiling tiles removed, which exposed approximately forty to fifty square feet of ceiling space, plumbing pipes and wires. Two air conditioning units were observed dangling from the ceiling held by metal cables. The barricaded area was curtained off with white plastic sheeting from the ceiling to the floor. The plastic sheets had multiple gaps of approximately three to four inches and were not fully attached to the ceiling to create a tight seal. Parts of the plastic sheets were attached to the ceiling with blue painters tape. The DE stated, the work area needed to be tightly sealed and that he would repair it. The area contained no air filtration unit. The DE stated he would verify the need for an air filtration unit when construction was not in progress. He stated construction started on 8/11/14 and the ceiling tiles had been down for two months. He stated the current barrier could not be considered a durable rigid barrier.

The hospital's ICRA (Infection Control Pre-Construction Checklist and Risk Assessment) document, posted next to the construction site dated 8/11/14, indicated the in-patient nursing care area was to be considered a medium/high-risk area and therefore classified as a Type C construction site. The Type C classification indicated, "any activity that generates a moderate to high level of dust as in removing of ceiling tiles...". The hospital Infection Control Nurse (ICN) classified it as a construction level 3 and Construction Class 111 (3) was assigned to the construction. The assigned classification 3 of infectious risk triggered a group of interventions (actions that should be performed to prevent infection) which included the following:

a. Maintain negative pressure with air filtration unit.
b. Dust control: Seal holes, pipes, conduits... (tubes for protecting electrical wires).
c. Barriers: Install before construction.

The hospital policy and procedure titled "Construction: Infection Control" dated 8/27/09, indicated:

a. "Educate staff and construction workers about the importance of adhering to infection control measures during the project."
b. "Post signs to identify construction areas and potential hazards."
c. "Erect appropriate barrier containment, use durable rigid barriers for ongoing long-term projects..."
d. "Monitor the construction site daily for compliance with the infection control plan (ICRA).
e. "Ensure that barriers remain well-sealed.."

During a concurrent interview and document review of the "ICRA" and the hospital policy and procedure, with the the DE, and the ICN, on 10/15/14, at 2 PM, the DE stated that an air filtration unit was not needed when construction was not in progress and that he chose not to run it because, "I wanted to conserve energy". The ICN stated that "when ceiling tiles are down the air filtration unit should always be running until the ceiling tiles are replaced." She stated the project was started on 8/11/14 and she "hadn't seen the project in the last few weeks." The DE stated he would put an air filtration system in immediately.

The hospital "Contractor Handbook", undated, indicated:

"Hospital construction can be a risk factor for certain nosocomial (hospital acquired) infections in patients, especially those who are immune suppressed (low resistance to infection). The demolition process that disturbs dust may be associated with transmission of Aspergillus (a fungal disease) and Legionella (a fungus found in ceiling and wall spaces where dust has accumulated)."

2. During an observation and concurrent interview on 10/15/14 at 2 PM with Housekeeper (HSKP) 2 she was observed cleaning the hard surface areas in a patient room. The bedside table was wiped with a blue cloth, the table did not appear to be wet. She then moved on to clean a counter with the same cloth. When asked what product she used to clean the room she stated A-456 for everything except the floor. She stated she left the solution on surfaces for about 2 minutes and was unable to state the product and concentration that was used.

During an observation and concurrent interview with HSKP 3, on 10/16/14, at 3 PM, she stated "the cleaner only takes a minute or less, it dries quickly then it's done. I use it for the whole room except the toilet. I have a different cleaner for that. I don't know the names of the cleaners." On her housekeeping cart a metal container was observed with a pile of blue cloths and the top cloths appeared to be dry. HSKP 3 stated, "yes those are dry but the bottom ones are wet."

During an interview with the Director of Environmental Services (DES), on 10/16/14, at 12 PM, he stated "the kill time and wet time for the A-456 [the name of a cleaning solution] is ten minutes. I've educated my staff on that numerous times." The DES was unable to provide evidence of education regarding wet times and kill times for the products the hospital used to disinfect patient care areas.

The hospital policy and procedure titled "Environmental Sanitation" dated 4/1//13, was reviewed. The policy did not indicate the amount of time A-456 was to be left on hard surfaces, it indicated, "use a sanitizer in the concentration recommended by the manufacturer for surface disinfection in areas of direct patient care."

The product information for A-456 was reviewed. The review indicated the product is an EPA (Environmental Protection Agency) disinfectant approved for use to disinfect (kill germs) on hard surfaces. Under directions for use, the manufacturer stipulated, "Treated surfaces must remain wet for ten minutes."

3. During an observation and concurrent interview with the hospital Director of Patient Care Units (DPC) of the second floor patient care area, on 10/15/13, at 11 AM, the following was observed. The Equipment Tech (ET-responsible for cleaning patient care equipment), entered a dialysis patient's room and removed a telemetry box, (a box attached to a patients chest with wires and electrodes that send signals reading the patient's heart rate and heart rhythm), while the patient was receiving a dialysis treatment. The ET was not wearing personal protective equipment (PPE) (gown, gloves and mask) and did not wash her hands before leaving the room. The dialysis nurse was wearing PPE (gown, masks and gloves). The ET removed the wires from the telemetry unit and placed them on the her cart, and then walked across the hallway and placed the telemetry box on the nurse's station counter, a location where medications could be prepared. She then took a disinfectant wipe from a container and wiped the telemetry box with one wipe for less than 30 seconds. The DPC stated, "She should not have brought the telemetry box to the nurse's station to be cleaned."

During an interview with the ICN on 10/15/14, at 2 PM, she stated the disinfectant should be left on the telemetry box for two minutes. She stated, the hospital did not have a policy for the care of dialysis patients and their equipment. "The contracted dialysis company has their own policy and procedures." She stated the contractors policy would address the hospital's care of their dialysis patients and their equipment. The ICN stated the ET had no specific training for her position.

The hospital policy and procedure titled, "CLEANING AND DISINFECTING PATIENT CARE EQUIPMENT" dated 2/27/13, indicated, "Equipment Tech is responsible for cleaning the following patient care equipment... tele boxes (a small box that signals heart rhythms, placed on a patients chest) and cables. Treated surface must remain visibly wet for a full 2 minutes. Use additional wipes if needed to assure continuous 2 minute wet time."

The Dialysis Contracted Provider policy and procedure titled "Infection Control", undated, indicated "Gloves are removed and hands are washed with germicidal (an agent that destroys germs) soap after each patient contact. Personal Protective Equipment, (PPE) gown, gloves and mask are worn at all times in the patient area when exposure to the patient's blood is possible. Wash hands...when leaving work area."

The Center for Disease Control (CDC) guidelines indicate, "The contamination of the dialysis patient's skin, bed clothes and environmental surfaces with pathogenic material is more common in hospital settings [referring to dialysis patients]. Items taken from a dialysis area should be cleaned and disinfected before returning to a common clean area... The routine use of infection control practices recommended for dialysis patients should be more stringent [strict] than the standard precautions routinely used in hospitals."

During an observation and concurrent interview with Registered Nurse (RN) 4 of the hospital wound care clinic, on 10/16/14, at 1:30 PM, four treatment rooms were observed. Treatment Room 1 had a drawer with sterile packaged dressings and on top of the sterile packaged dressings was a pair of unwrapped scissors. RN 4 stated, "Yes they come in a sterile package, but we re-use them for other patients after cleaning them with disinfectant wipes. We use them on the clean part of the patient dressings. RN 4 was unable to identify the time the scissors needed to remain wet with the disinfectant product to ensure they had been sterilized effectively. Yes, we will send the scissors to have them sterilized each time we use them.

4. During an observation of patient care Room 202, on 11/16/14 at 3 PM, the following was observed: The patient was hooked up to a dialysis machine (a machine that circulates a patient's blood to filter out the body's toxins). Attending the patient was RN 5 who was contracted to perform the patient's dialysis and monitor his condition. RN 5 wore a white paper gown buttoned in the front and gloves. RN 5 took off his gown and gloves and left the patient's room for the nurses station where he looked at a chart and obtained patient labels, without washing his hands prior to leaving the patient's room. RN 5 then returned to the room put on his gown and gloves and did not wash his hands before labeling the patient's intravenous fluid bags. After realizing he had obtained another patient's labels, he again took off his gown and gloves, went to the nurses station, obtained the correct labels from the correct chart without washing his hands before he left the patient's room. He returned to the room again without washing his hands before donning gloves. He had placed a clipboard and paper on top of the dialysis machine.

During an interview with the ICN, on 10/15/14, at 2 PM, she stated the hospital did not have a policy for the care of dialysis patients and their equipment. "The contracted dialysis company has their own policy and procedures." She stated the contractor's policy would address the hospital's care of their dialysis patients and their equipment."

The Dialysis Contracted Provider policy and procedure titled "Infection Control", undated, indicated "Gloves are removed and hands are washed with germicidal soap after each patient contact. Personal Protective Equipment, (PPE) gown, gloves and mask are worn at all times in the patient area when exposure to the patient's blood is possible. Wash hands...when leaving work area."

The CDC guidelines indicated, "The hemodialysis machines and its components can be a vehicle for patient to patient transmission of bloodborne viruses and pathogenic (causing disease) bacteria... The contamination of the dialysis patient's skin, bed clothes and environmental surfaces with pathogenic material is more common in hospital settings. (referring to dialysis patients). Contact transmission (the passing of infection from patient to patient) can be prevented by hand hygiene (hand washing or the use of a waterless handrub)...even with glove use, handwashing is needed because pathogens (bacteria) deposited on the outer surface of gloves can be detected on hands after glove removal. Items taken into a dialysis room , including those placed on the top of a dialysis machine should be disposed of, dedicated for single patient use or disinfected..."

5. During an observation and concurrent interview with the DPC of the second floor patient care areas, on 10/15/14, at 1:30 PM, the following was observed:

a. In Patient 21's room a bag of Normal Saline IV (intravenous solution, flowing into the vein with a needle) was infusing into the patient. The IV entrance site was not labeled with a label indicating nurse initials and the time and date the intravenous needle was inserted. The DPC stated, "All IV bags and IV sites should be labeled with date and time and nurses initials."

b. In Patient 22's room an antibiotic in a piggyback (a secondary intermittent infusion delivered through a port on the primary infusion set) was infusing into the patient. The IV entrance site was not labeled with a label indicating nurse initials and the time and date the intravenous needle was started.

c. In Patient 23's room an IV solution, that was not infusing into the patient, was hanging with the end of the line plugged into a higher port of the primary infusion tubing. The DPC stated, "the ends of the tubing should be capped off with a white cap."

d. In dialysis Patient 24's room two IV fluid bags were infusing into the patient that were not labeled with the patient's name and date and nurse's initials that hung the bags.

The hospital policy and procedure titled, "Intravascular Therapy" dated on 5/27/10, indicated in part:

IV solutions:
a. label IV fluid containers with, Patient name, Date/Time.
b. use sterile technique, keeping all ports and tubing ends from contamination...

IV sites: Label site with date, time and initials.

The "Guidelines for the Prevention of Intra-vascular-Related (veins) Infections, 2011, "published by the National Institute for Health indicated, "Secondary intermittent infusions delivered through a port on a primary infusion set pose a risk for contamination of the intravascular fluid if it is exposed to air or if it comes into contact with other surfaces."



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6. During an observation and interview with the DPC in the Clean Utility Room (room where clean supplies are stored), on 10/15/14, at 2:12 PM, there was an opened sterile "Dressing Change Tray" on top of a "Foley Cath", (a flexible tube that is often passed through the urethra [the tube through which urine moves from the bladder and out of the body] and into the bladder) tray. The DPC stated, "That (Dressing Change Tray) should have been trashed."

During an observation of the Clean Supply room of the Critical Care Unit, on 10/15/14, at 2:45 PM, there were packets of suture (a piece of material used to close a wound or connect tissues) stored in a cabinet. The following sutures had expired:

3-0 Silk straight SC-2 60 millimeter (mm) x 3 with expiration date 5/2014
3-0 Silk straight SC-2 60 mm x 2 with expiration date 8/2014
4-0 Prolene SH 36inch 26 mm x 2 with expiration date 7/2014

During an interview with the DPC, on 10/15/14, at 2:50 PM, she was shown the packets of expired suture. The DPC stated, "Someone should have checked ...these (sutures) shouldn't be in here."

The hospital policy and procedure titled "Supply Expiration Date Surveillance" revised date 7/2013, indicated "Medical supplies shall be monitored to prevent the use, or availability, of items that have exceeded their expiration date." It also indicated "POD (Nursing station supply room) Supply rooms: 3. Once items are removed from the par storeroom (room that stores a predetermined number of supplies) and placed in drawers or cabinets within a nursing unit, these supplies have become the responsibility of that entity to monitor for expire dates."

During a tour of the Wound Care Center with Licensed Vocational Nurse (LVN) 1, on 10/16/14, at 9 AM, the treatment rooms and medication cabinet were found to have expired medication.

Room 3:

One vial (glass container of medication) of Lidocaine Hydrochloride (local anesthetic for topical administration) 4% 50 milliliter (ml). It was labeled with an opened date 7/30/14.

Room 5:

One vial of Lidocaine Hydrochloride 4% 50 ml. It was opened, but without a label or date.

Medication cabinet:

Silvadene 1% cream (antibiotic) 400 grams. Labeled with an opened date 7/30/14.
Mupirocin 2% ointment (antibiotic). Labeled with an opened date 8/8/14.
Lidocaine cream (topical anesthetic). Labeled with an opened date 8/14/14.
Triple Antibiotic ointment (antibiotic). Labeled with an opened date 9/10/14.
Risamine ointment (for minor burns, cuts scrapes, irritation and itching. Protects skin from moisture). Labeled with opened date 9/10/14.

During an interview with LVN 1, on 10/16/14, at 9:15 AM, he stated "I'm not sure of when they (medications) should be tossed."

During an interview with the Director of Pharmacy (DP), on 10/16/14, at 2:35 PM, she was informed of the multiple medications (topical and ointments) found and the dates they were opened. The DP stated, "The medications are only good for 28 days after opening."

The hospital policy and procedure titled "Multi-dose Vials" revised date 8/16/12, indicated "4. Multiple-dose parenteral (administered other than through the mouth) medications ...shall be opened, dated, and stored ..., and 6. Multi dose vials shall be dated with a beyond use date of 28 days from the opened date."

7. During an observation of the Hyperbaric Chamber Oxygen Therapy room (therapy delivers concentrated oxygen to the bloodstream and assists in the healing process of wound. It also helps the body grow new blood vessels, which can improve circulation and wound healing) on 10/16/14, the Hyperbaric Chamber was uncovered and closed.

During an interview with LVN 1, on 10/16/14, at 9:30 AM, he was asked about the Hyperbaric Chamber maintenance. LVN 1 said he cleans between patients and at the end of the day when used. When asked what he wore to clean the chamber, LVN 1 stated "Nothing, just my clothes." LVN 1 stated he went to training and read the book on how to clean the chamber. When asked what he uses, LVN 1 stated, "Coverage Spray ...I get in (inside the chamber) spray and wipe. When asked if the ICN talked with him about cleaning, LVN 1 stated "No."

During an interview with the ICN, on 10/16/14, at 10:15 AM, she was asked if she has watched LVN 1 clean the Hyperbaric Chamber. The ICN stated "I've talked to him about wearing the appropriate Personal Protective Equipment (PPE), but I haven't observed him yet."

During a review of the employee file for LVN 1, the Hyperbaric Chamber Operation and Treatment Competency Assessment dated 6/24/14, indicated he was competent in "cleaning of acrylic chamber" and "cleaning around the chamber."

During a review of the product information for Coverage Spray HB Plus (ready to use disinfectant), "Directions for use" indicated, "Do not breathe spray. Treated surfaces must remain wet for 10 minutes."

The hospital policy and procedure titled "Hyperbaric Chamber and Equipment" with effective date 2/26/14, indicated under Procedure: "3. The chambers shall be cleaned daily and also between patients ..." General Care of Equipment indicated "Always keep the Chamber covered with a clean cloth sheet when not in use."

8. During an observation on 10/15/14, at 2:20 PM, outside of patient Room 235, a yellow three drawer isolation cart was observed with multiple supplies on top. The patient's medical condition required Contact precautions, (a type of precaution used for patients that have an infection that can be spread by contact with the person's skin, mucous membranes, feces, vomit, urine, wound drainage, or other body fluids, or by contact with equipment or environmental surfaces that may be contaminated by the patient/resident or by his/her secretions and excretions). The top of the cart contained: three boxes of gloves (small, medium, and large), one box of masks, and a packet of yellow isolation gowns. In drawer one was: Paper tape, Sani-cloth packages (disinfectant wipes), alcohol prep pads, Electrocardiogram (EKG) electrodes (used to test the activity of the heart), two boxes of tissues, and an arterial (pertaining to the vessel in which blood flows from the heart) blood sampling kit (a device used to obtain arterial blood samples from a patient for lab test). In drawer two was: one package of Blue sterile operating room (OR) towels, one package of chux (disposable absorbent under pads), box of masks, and two boxes of extra-large gloves. In drawer three was: two packets of yellow isolation gowns and four packets of sterile surgical gowns.

During an interview with RN 3 and the DPC, on 10/15/14, at 2:25 PM, when shown and asked what the isolation cart should contain, RN 3 stated " The things on this list." She was pointing to a sign on the wall (above the isolation cart) that illustrated the sequence for removing PPE. The sign listed: gloves, goggles/face shield, gown, and mask. The DPC stated "I don't think all of this should be in here, and nothing should be on top."

During a concurrent interview and observation of the isolation cart with the ICN, on 10/15/14, at 2:30 PM, she stated "Oh, they (paper tape, alcohol prep pads, EKG electrodes, tissues, arterial blood sampling kit, blue sterile towels, chux, and sterile surgical gowns) shouldn't be in here. We normally have the system that hangs and it's only supposed to be gowns, gloves, masks, and sani cloths." The policy was requested, and the ICN stated "We don't have a policy on what should be in the cart."

9. During an observation and interview with the Director of Outpatient Services (DOS) of the Cath lab (Cardiac Catheterization Laboratory, is an examination room in a hospital or clinic with diagnostic imaging equipment used to visualize the arteries of the heart and the chambers of the heart and treat any abnormality found), on 10/7/14, at 12:05 PM, there were no thermometers (instrument used for monitoring temperature and humidity) in the four cath lab suites. The DOS was asked how staff determines the temperature and humidity in the rooms, and he stated "Staff get the numbers from engineering. If it's out of range we are notified by engineering."

During an interview and record review with the ICN, on 10/7/14, at 3:30 PM, the 10/2014 Cath lab logs for temperature and humidity were found to be out of range. The ICN was asked if she was notified, and stated "Yes, they usually do if it can't be resolved." She then stated "Engineering gets it and documents... I will check with them to see if they document somewhere else."

During an interview with the ICN, on 10/7/14, at 4:10 PM, she stated "I talked with the DE, and he said when it's out of range they make adjustments and check the temperature the next day."

During an interview with the DOS, on 10/7/14, at 4:35 PM, he was asked what was done for the days when the temperature and humidity was out of range. The DOS stated, "I call engineering and tell them I need it adjusted. I just assumed it was corrected."

During an interview with the DE, on 10/8/14, at 9 AM, he was asked about the temperature and humidity. The DE stated, "Temperature in the OR (operating room) are per doctors request, if I up them they ask us to cool it down. Nothing is done when it's out of range in Cath lab or Operating Room. I was told to keep them (doctors) comfortable by the previous Chief Executive Officer."

During a review of the Temperature and Humidity logs for the Cath Lab the following was noted:

7/2014: Temperature was out of range in Cath labs 1- 4, 19 out of 20 days. The temperature ranged from 59.8 to 65.9 degrees Fahrenheit (F - a measure of temperature). The humidity was out of range in Cath lab 1- 14 out of 20 days, Cath labs 2 and 3- 17 out of 20 days, and Cath lab 4- 10 out 20 days. The humidity ranged from 63.9 to 74%.

8/2014: Temperature was out of range in Cath labs 1 -4, 19 out of 19 days. The temperature ranged from 57.2 to 66.1 degrees F. The humidity was out of range in Cath lab 1- 10 out of 19 days, Cath lab 2- 18 out of 19 days, Cath lab 3 - 19 of 19 days, and Cath lab 4- 5 of 19 days. The humidity ranged from 64.6% to 70.7%.

9/2014: Temperature was out of range in Cath labs 1 -4, 21 out of 21 days. The temperature ranged from 57 to 64.9 degrees F. The humidity was out of range in Cath labs 1 and 2- 17 out of 21 days, and Cath labs 3 and 4- 21 out of 21 days. The humidity ranged from 71.9% to 75.5%.

10/1-7/2014: Temperature was out of range in Cath labs 1 - 4 7 out of 7 days. The temperature ranged from 56.9 to 63 degrees F. The humidity was out of range in Cath lab 1- 1 out of 7 days, Cath lab 2- 2 out of 7 days, Cath labs 3 and 4- 6 out of 7 days. The humidity ranged from 68.3% to 72.6%.

During a review of the Temperature and Humidity logs for the OR the following was noted:

7/2014: Temperature was out of range in OR 1- 13 out of 20 days, OR 2- 10 out of 20 days, OR 3- 18 out of 20 days. The temperature ranged from 64.8 to 67.1 degrees F.

8/2014: Temperature was out of range in OR 1 - 11 out of 19 days, OR 2- 14 out of 19 days, OR 3- 18 out of 19 days. The temperature ranged from 65.1 to 67.1 degrees F.

9/2014: Temperature was out of range in OR 1- 20 out of 21 days, OR 2- 9 out of 21 days, OR 3- 20 out of 21 days. The temperature ranged from 55.3 to 67.6 degrees F. The humidity was out in OR 3- 1 out of 21 days at 64.9%.

10/1-7/2014: Temperature was out of range in OR 1- 6 out of 7 days, OR 2- 1 out of 7 days, and OR 3- 7 out of 7 days. The temperature ranged from 62.3 to 66.7 degrees F.

The hospital policy and procedure titled "Humidity and Climate control in the Cardiac Cath Lab" revised date 12/12/12, indicated: "2. Relative humidity shall be maintained between 30 % and 60 %...", "3. Temperature should be maintained between 70 degrees and 75 degrees Fahrenheit (F)...", "5. ...Deviations from the above guidelines should be corrected when rooms are in use.", and "6. Continual discrepancies will be reported...All changes will be recorded and logged by the Temperature Variance report..."

The hospital policy and procedure titled "Humidity and Climate control in the Surgery Suite" revised date 5/23/13, indicated "2. Relative humidity shall be maintained between 30% and 60% within the perioperative suite.", "3. Temperature should be maintained between 68 degrees and 73 degrees F within the OR...", "5. ...Deviations from the above guidelines should be corrected when rooms are in use.", and "6. Continual discrepancies will be reported..."

The 2014 Association of periOperative Registered Nurses (AORN) Standards and Recommended Practices, "Safe Environment of Care, Part II", Recommendation II reads "The surgical suite design should include areas that are defined by the activities performed in each area. Procedure room/Cath Lab temperature should be 70 - 75 degree F with the humidity 20% - 60%, and the Operating Room (OR) should be 68 - 75 degree F with the humidity 20% - 60%."

During an interview with the Vice President of Quality (VPQ), on 10/21/14, at 10:15 AM, she stated, "There is no log for the GI (Gastrointestinal/Procedure Endoscopy) lab checking negative pressure. There's a ping pong ball and when it's out (showing outside the room) a work order is done, and engineering fixes it."

During an interview with the DE, on 10/21/14, at 10:55 AM, he was asked about negative pressure in the GI lab. The DE stated "We have to adjust it to negative pressure, and we've only adjusted it a few times in the last 12 months. I can go look through the work orders to find out." The DE returned and said "I've looked through the work orders, and it has never been in negative pressure."

During an interview with the DOS and Director of Respiratory (DR), on 10/21/14, at 11:50 AM, they both said that they assumed the room was always in negative pressure. The DR stated "We do a lot of bronchoscopies (visualizing the inside of the airways) in the GI lab." When asked how many, the DR stated "We average 15 a month."

During an observation with the DE, DOS, and DR, on 10/21/14, at 12 PM, in the GI lab (Procedure/Endoscopy room), the ping pong ball was seen while standing outside the room in the hallway. That was indicative of the room being in positive pressure.

There were no logs to review for negative pressure in the Procedure/Endoscopy (use of an instrument to look inside the body for medical reasons) room.

No hospital policy and procedure was provided regarding negative pressure in the Procedure/Endoscopy room.

2013 Ventilation standards Specific recommendations for health-care facilities have been published by the American Society of Heating, Refrigerating, and Air Conditioning Engineers, Inc. (ASHRAE) and by the Federal Health Resources and Services Administration, indicated "Bronchoscopy: should be performed in rooms with negative pressure (that have adequate ventilation, good distribution of air flow, and air exhausted directly to the outside) in accordance with federal, state, and local regulations for environmental discharges." ASHRAE also indicated "Endoscopy room: if room used for bronchoscopy it must be negative pressure."

CDC ventilation recommendation for selected areas in the healthcare settings indicated "Bronchoscopy: room air exhausted directly outdoors."

Based on interview and record review, the hospital failed to have an effective discharge planning process as evidenced by:

1. The hospital failed to educate and train patients or their family members about essential post hospital care plans when the patients were discharged to home. This failure had the potential to cause adverse health consequences and unsafe discharge practices. (A 820)

2. The hospital case managers failed to respect patient's or their family member's choice of preferred skilled nursing facilities as post-acute care option. This failure limited patients' choice of skilled facilities. (A 823)

3. The hospital failed to analyze the data collected on 30-day readmissions to evaluate the effectiveness of its discharge planning, which had the potential to cause unmet post-acute care needs. (A 843)

The cumulative effect of these failures in the discharge planning process had caused inappropriate post-hospital discharge destinations and unsafe transition to recovery for the patients.

Based on interview and record review, the hospital failed to provide discharge instructions to two of 26 sampled patients (25 and 26).

1. For Patient 25, the hospital failed to provide discharge teaching for an indwelling catheter (a tube inserted into the bladder to drain urine) care, which had the potential for the patient to develop complications related to the catheter after discharge.

2. For Patient 26, the hospital failed to provide discharge education on a new anti-hypertensive medication (a medication that lowers blood pressure), which had the potential for the patient not understanding how to take this medication safely.

Findings:

1. On 10/20/14, Patient 25's clinical record was reviewed with Registered Nurse (RN) 6. Patient 25 was admitted for a urinary tract infection. She was discharged on Friday, 10/10/14, to a home health agency to care for her urinary catheter. The patient and her daughter (Family 25) received a printed, stapled, five-page information packet on "Foley Catheter Placement and Care" on 10/10/14, in the afternoon. Foley catheter is another name of an indwelling urinary catheter. The home health agency was scheduled to visit her on Monday, 10/13/14. There was no documentation found in the records that indicated licensed staff had demonstrated the catheter care to Patient 25 or her daughter prior to her discharge home.

On 10/20/14, at 4:20 PM, during a telephone interview, Family 25 stated she was given the printed catheter care instructions on Friday but had not read it yet. When asked if the nursing staff had demonstrated the catheter care to her prior to her mother's discharge, she replied, "No."

The prevention of urinary catheter complications, such as infection, as defined in Center for Disease Control (CDC) guidelines published in "Infection Control and Epidemiology" in 2009, indicated: "1) The collection bag of the catheter should always be suspended below the level of the pubic bone, including during walking or sitting. 2) Cleaning the groin and buttock areas regularly will decrease contamination of the catheter and the risk of infection. 3) anchoring the catheter to the leg with the provided strap prevents tugging injuries of the urethra."

2. On 10/20/14, Patient 26's clinical record was reviewed with RN 6. Patient 26 was admitted from home on 10/3/14 due to a heart condition. He was discharged on 10/5/14 with a new medication, Norvasc, a medication used to treat high blood pressure and heart disease. His discharge instructions included healthy diet, antibiotics, and pacemaker (small device that's placed in the chest or abdomen to help control abnormal heart rhythms), but he was not instructed on the use of his new medication, Norvasc.

The drug information on U.S. Food and Drug Administration listed the most common adverse reactions of Norvasc are headache and edema (swelling), which can occur in a dose related manner. Other adverse effects that are not dose related, but reported are; fatigue, nausea, abdominal pain, and sleepiness.

During an interview with the Vice President of Clinical Services (DNS), on 10/21/14, at 2 PM, she was informed of the above findings.

The hospital's policy titled "DISCHARGE A PATIENT FROM THE HOSPITAL,"
revised on 11/21/13, indicated: "4. It is the responsibility of the Registered Nurse to determine the completion of the discharge plan, knowledge, understanding, and the ability of the patient and/or significant other to meet continuing patient care needs upon discharge..."

Based on interview and record review, the hospital failed to grant nine of 26 sampled patients (13, 12, 14, 16, 18, 20, 9, 1, and 24) the right to be informed regarding continuing medical care at a skilled nursing facility following their acute hospital stay. This failure had taken away the eight affected patients' right to choose a preferred facility for continuing care. All eight patients were placed in the same skilled nursing facility (Facility A).

Findings:

During an interview with the Director of Case Management (DCM), on 10/9/14, at 4:30 PM, when asked to explain the hospital normal practice for a patient that required placement in a long-term care facility after the acute hospital stay, she stated when a patient was determined to need long-term care placement the patient or the responsible party would be given a "choice letter" titled, "PATIENT INFORMATION AND CHOICE LETTER SKILLED NURSING FACILITY AND REHAB." The "choice letter" included a list of rehabilitation and skilled nursing facilities for selection of post acute care. Case managers would like the patient or responsible party to select three facilities and prioritize them with numbers 1, 2, and 3. The case managers would follow the preferences and fax the patient's information to the facilities selected. If none of the facilities accepted the patient, the case manager would approach the patient and the responsible party for additional choices.

On 10/9/14, eight patients' case management worksheets were reviewed to verify such practice. The findings were as follows:

1. Patient 13 was admitted on 8/13/14 to the hospital from Facility A. On 8/18/14, a case manager (CM 1) wrote; "SPOKE WITH PT (PATIENT). STATES SHE WOULD PREFER NOT TO GO BACK TO (Name of Facility A, a skilled nursing facility) BUT UNDERSTANDS SHE NEEDS TO GET STRONGER PRIOR TO GOING HOME. CALLED [name of a staff from Facility A, (Facility A Staff)]. INFO (INFORMATION) FAXED." There was no documentation that Patient 13 was offered other options. Patient 13 was discharged to Facility A on 8/19/14. On the day of her discharge, she signed a form "PATIENT INFORMATION AND CHOICE LETTER SKILLED NURSING FACILITY AND REHAB" with the name of Facility A circled.

During an interview, on 10/9/14, at 4:30 PM, the DCM stated Patient 13 should have been offered other options such as other skilled nursing facilities to go to. The "choice letter" should have not been signed the day after her medical information was faxed to Facility A.

2. Patient 12 lived with her daughter prior to her admission to the hospital on 8/27/14. The discharge plan was "HOME WHEN MEDICALLY CLEARED." On 8/30/14, the Social Service Worker (SSW) wrote on the case management worksheet: "SPOKE WITH (NAME OF Facility A Staff) AT (NAME OF FACILITY A) PATIENT TO RETURN THERE WHEN MEDICALLY STABLE." There was no documentation between 8/27/14 and 8/30/14 indicating Patient 12 or her daughter had been consulted in regards to discharge to a skilled nursing facility. Patient 12 was discharged to Facility A on 9/3/14. The form, "PATIENT INFORMATION AND CHOICE LETTER SKILLED NURSING FACILITY AND REHAB" was signed on 9/3/14 via "verbal consent Pt (patient)."

During an interview with the DCM, on 10/9/14, at 4:30 PM, she was informed of the above findings. She stated the "choice letter" should have been signed before the SSW called Facility A Staff on 8/30/14.

During an interview with the SSW, on 10/9/14, at 4:25 PM, she was unable to provide an explanation.

3. Patient 14 was transferred from another acute hospital about 45 miles away for higher level of care on 9/8/14. The discharge plan was for her to go home and for her family to take her to and from radiation therapy three times a day. During a review of the clinical record for Patient 14, the case management worksheet, dated 9/11/14, CM 2, indicated "SPOKE WITH [name of Facility A Staff] FROM [the name of Facility A], AND SHE STATED ... " Patient 14 was discharged to Facility A on 9/12/14. The form, "PATIENT INFORMATION AND CHOICE LETTER SKILLED NURSING FACILITY AND REHAB" was signed on 9/12/14, the same day she was discharged to Facility A.

During an interview with the DCM, on 10/9/14, at 4:30 PM, she was informed of the above findings. She stated the "choice letter" should have been signed on or before 9/11/14, when CM 2 called Facility A Staff.

On 10/13/14, at 9:27 AM, during an interview with CM 2, she was unable to provide any supportive information why the "choice letter" was signed a day later.

4. Patient 16 was admitted to the hospital on 9/9/14 with lung cancer. The same day, the SSW discussed post acute care with the patient's son. The son wished for her to receive palliative care (care that reduces effects for symptoms of a medical condition without curing it), at a skilled nursing facility. At the same time, Patient 16's son picked three skilled nursing facilities, Facility B, C and D. On 9/9/14, the SSW documented she had contacted Facility C and the facility denied Patient 16. No documentation was found in the records that the SSW had attempted to contact Facility B or D for possible acceptance. The SSW contacted Facility A Staff and faxed Patient 16's information to Facility A. Patient 16 was discharged to Facility A on 9/10/14. The form, "PATIENT INFORMATION AND CHOICE LETTER SKILLED NURSING FACILITY AND REHAB" was signed on 9/10/14, the same day she was discharged to Facility A.

On 10/9/14, at 4:30 PM, during an interview, the DCM stated the SSW should have contacted the other two facilities and informed the responsible party of the outcome. More choices should have been offered to the responsible party when the first choices had been exhausted.

5. Patient 18 was admitted on 7/12/14 from home. On 7/14/14, CM 1 documented: "...LATE ORDER FOR [NAME OF A REHABILITATION HOSPITAL] EVAL AND PHYSICAL THERAPY EVALUATION AND TREAT..." On 7/15/14, Patient 18 was evaluated by the rehabilitation facility and was denied. There was no further discharge plan documented regarding Patient 18's post-acute care after the denial. There was no documentation found regarding discussion of other discharge options with the patient and his wife. A nurse's note, dated 7/16/14, indicated Patient A was discharged just before 5 PM to Facility A.

On 10/9/14, at 4:30 PM, during an interview, the DCM stated there should be more documentation. No further information was provided.

On 10/15/14, at 11:40 PM, during a telephone interview, Patient 18's wife (Family 18) was asked if she and the patient were offered any choices of skilled nursing facilities, Family 18 stated "No, they told us where to go. A gal from the facility (Facility A) came in to talk to us and then next thing we knew, he was going there. We were told that is the only rehab place after [the name of an acute rehabilitation hospital]." Family 18 was asked the reason for signing the choice letter, she replied, "What letter, we didn't sign anything. We were told to go there."

6. Patient 20 was admitted on 7/11/14 from home. The case management worksheet, dated 7/15/14, indicated, "1125 (11:25 AM)...(Name of the Facility A Staff) FROM (name of Facility A) SPOKE WITH PATIENT, AND PATIENT IS AGREEABLE TO GO THERE, AND THEY ARE ABLE TO ACCEPT PATIENT..." Another entry dated 7/15/14, indicated, "1255 (12:55 PM)...CHOICE LETTER SIGNED BY PATIENT, AND VERBAL CONSENT FROM PATIENTS SON..." The form, "PATIENT INFORMATION AND CHOICE LETTER SKILLED NURSING FACILITY AND REHAB" was signed one and one-half hours after Facility A Staff had talked with Patient 20.

On 10/9/14, at 4:30 PM, during an interview, the DCM stated this was not the correct procedure. The "choice letter" should have been signed before Facility A Staff talked to the patient.

On 10/13/14, at 9:27 AM, during an interview with CM 2, she reviewed her documentation and stated Facility A Staff did talk to the patient and his responsible party before signing the "choice letter." She stated it was not the procedure to have a representative from a skilled nursing facility talk to a patient before signing the "choice letter."

7. During a review of the clinical record for Patient 9, the record indicated Patient 9 was admitted on 9/9/14 from an independent living facility for an infected wound. Patient 9 needed to be placed in a skilled nursing facility for ongoing antibiotics and wound treatment. The Case Management Worksheet, dated 9/15/14, indicated "...SNF (skilled nursing facility) ORDERS. FAXED REFERRAL TO (Facility A)." On 9/16/14, CM 3 wrote: "...NOTIFIED (name of the person in charge of the independent living facility) THAT PT IS GOING TO (Facility A) FOR SHORTTERM AND WILL RETURN TO ...AFTER SNF." During review of the discharge worksheets, there was no "choice letter" found.

On 10/9/14, at 4:25 PM, during an interview with the SSW and the DCM, both verified the above findings and were unable to provide any explanation.

8. Patient 1 was admitted to the hospital on 3/3/14 with a urinary tract infection. She needed to continue physical therapy and antibiotic treatment in a skilled nursing facility. Patient 1's daughter (Family 1) picked two skilled nursing facilities (Facility B and C) listed on the choice letter. One of the two preferred facilities denied her acceptance. CM 4 faxed Patient 1's information to Facility A without getting the second family preferred facility's response.

On 10/9/14, at 4:30 PM, the DCM was interviewed. When asked if it was the hospital's practice to fax information to another facility without a patient or responsible party's consent, she replied, "No. It is not." When the DCM was asked why Facility A was the preferred skilled nursing facility for the hospital, she replied, "They are very easy to work with. They take all patients."

9. On 10/20/14, Patient 24's case management notes were reviewed. Patient 24 was admitted on 9/29/14, after an episode of passing out. Although he had a care giver at home, Patient 24's daughter (Family 24) had informed a case manager at the hospital she wished to transfer her father to a skilled nursing facility in a geographical area close to her. On the day of Patient 24's discharge, a case manager documented; "...DAUGHTER STATES SHE IS HAVING A HARD TIME WITH PATIENT BEING IN BAKERSFIELD; INQUIRING IF HE COULD RETURN HOME FOR SEVERAL DAYS WHILE THEY FIGURE OUT WHAT TO DO..." At 1:20 PM, the SSW took over the discharge planning and documented; "SPOKE WITH PATIENT AND CAREGIVER AT BEDSIDE. PATIENT IS OPEN TO SHORT TERM SKILLED STAY... (Facility A Staff) HERE AND MEETING WITH PATIENT..." Patient 24 was transferred to Facility A on 10/2/14. There was no choice letter found in his record.

On 10/20/14, at 3:40 PM, during a telephone interview, Family 24 stated she was not given an option in selecting the skilled nursing facilities. "I did not know the facility in Bakersfield. The discharge planner said to me 'I have the discharge paper in my hand; what do you want to me to do?' I was told which facility he was going. I was coerced to it." She asked the SSW if he could stay one more day for her husband to pick him up the next day, she was told, "No."

On 10/21/14, at 4:50 PM, during an interview with the DCM, the Patient Safety Officer, and the Vice President of Clinical Services no further information was provided.

Based on interview and record review, the hospital failed to conduct an in-depth review of its 30-day readmission rates to evaluate the effectiveness of its discharge planning process. This failure had the potential for the hospital to not meet their patients' discharge needs.

Findings:

On 10/21/14, at 10:15 AM, during an interview regarding data collection on 30-day re-admissions, the Director of Case Management (DCM) stated the hospital discharge planning had been tracking 30-day re-admission rates since 2013. The tracking for this year was not accurate because the hospital joined a collaborative called "2014 Care Transitions in Kern County" and the collaborative, through a grant, was collecting data for all hospitals. The DCM was asked if the hospital had analyzed the data collected since last year to determine whether the 30-day admission rates were related to inappropriate discharge planning. She stated, "No."

The data collection for 30-day readmission for the year 2013 and 2014 were reviewed. The report included the reason for readmission, post acute care, patient mobility, continuing care by a primary care physician, living situation, and number of home medications. However, the hospital had not used the data collected to analyze the potential cause of re-admission and whether the discharge planning which had been planned for these patients were appropriate to prevent re-hospitalization.