HospitalInspections.org

Based on staff interviews and record reviews, the Hospital failed to ensure that the Behavioral Health Service complied with the hospital-wide grievance procedure established by the governing body. The findings include:

Review of the Hospital's policy titled: "Patient Complaints and Grievances" revealed the Board of Trustees had delegated the responsibility for reviewing and resolving grievances to the Patient Care Assessment Committee. A sub-committee of the Patient Care Assessment Committee served as the Grievance Committee. The Grievance Committee membership included the Patient Care Assessment Coordinator, the Vice President of Patient Care Services, the Director of Quality and Safety, the Patient Advocate, the Risk Manager and the Privacy Officer. All grievances would be reviewed by the committee and would be entered into the complaint database.

Review of policies for the Department of Psychiatry revealed the Behavioral Health Service had "complaint" and "human rights" policies different from the Hospital's policy titled: "Patient Complaints and Grievances." All grievances on the Behavioral Health units would be investigated by the Human Rights Officer; and all reports would be forwarded to the Executive Director of the Behavioral Health Service. The Executive Director of the Behavioral Health Service would determine whether a report would be forwarded to any regulatory body.

The Patient Advocate was interviewed on 9/12/12 at 8:30 A.M. The Patient Advocate said she responds to and investigates patient grievances throughout the hospital with the exception of the three Behavioral Health Units. The Patient Advocate said the complaints she responds to are logged into the complaint database; and that data is reported to the Governing Body. The Patient Advocate said the Behavioral Health Units have their own "Human Rights Officer" who responds to complaints on those units. The Patient Advocate said the Human Rights Officer and Executive Director of Behavioral Health do not participate in the Grievance Committee. The Human Rights Officer's data is not logged into the complaint database for Governing Body review.

The Executive Director for Behavioral Health was interviewed on 9/12/12 at 11:30 A.M. and said the Human Rights Officer investigates all grievances on the Behavioral Health Units and reports to her. The Executive Director said she presents a report to the Quality and Safety Committee once a year that includes grievance data from the Behavioral Health Service.

Based on staff interviews and record reviews, the Hospital failed to ensure that all licensed nurses within the hospital-wide nursing service reported to the Vice President of Patient Care Services. The Vice President of Patient Care Services was a Registered Nurse whose responsibility included Director of Nursing Service. The findings include:

At the time of survey, the hospital was utilizing a traveling nurse in the capacity of Vice President of Patient Care Services.

1. The hospital census on the first day of survey was 167 patients. The hospital had 11 inpatient units (Unit 22 was closed for renovations.) Three of the units, totaling 61 beds, were for acute psychiatric care.

The hospital had identified the Executive Director of Behavioral Health (a Registered Nurse) as the Director of Psychiatric Nursing for the purposes of prospective payment exclusion for the three psychiatric units. Additionally, since March 2012 the Executive Director of Behavioral Health had functioned as the nurse manager of one of the three psychiatric units.

Per review of the Nursing Service's organizational chart on 9/11/12, the Executive Director of Behavioral Health did not report to Vice President of Patient Care Services.

During interview with the Vice President of Patient Care Services, on 9/12/12 at 9:00 A.M., she stated that the Executive Director of Behavioral Health did not report to her. The Vice President of Patient Care Services said she was not aware the Executive Director of Behavioral Health was a Registered Nurse.

During interview on 9/12/12 at 11:30 A.M., the Executive Director of Behavioral Health Services said she was a Registered Nurse and she reported to the Chief Operating Officer of the Hospital, not the Vice President of Patient Care Services. The Executive Director of Behavioral Health said she was also functioning as the nurse manager on one of the psychiatric units.

Review of the Executive Director of Behavioral Health Services' personnel files, on 9/14/12 at 9:00 A.M., revealed the most recent performance evaluation had been completed by the Chief Operating Officer and not the Vice President of Patient Care Services.

2. During visit to the Radiology satellite, on 9/13/12, the surveyor toured the satellite with the Director of the satellite and RN#21. RN#21 said she was employed 32 hours a week at the satellite and that there were two nurses from the hospital who were assigned to cover in her absence.

Review of RN#21's personnel file on 9/14/12 at 9:15 A.M. revealed RN#21 staffed the radiology satellite. The nurse's most recent performance evaluation was conducted by the Director of Radiology, and not the Vice President of Patient Care Services. On 9/14/12 at 9:30 A.M. the Director of Human Resources said RN#21 reported to the Director of Radiology and not the Vice President of Patient Care Services.

Based on staff interview and review of policies and procedures, the Hospital failed to ensure medication administration policies and procedures for timing of medication administration had been approved by the Hospital's medical staff.

The findings include:

On 9/12/12 at 9:00 A.M., survey staff interviewed the Vice President of Patient Care Services regarding the Hospital's nursing services. Survey staff requested the policy for timing of medication administration which would note medications not eligible for scheduled dosing times, medications eligible for scheduled dosing times, time-critical scheduled medications and non-time critical scheduled medications.

The policy provided for review was a general medication policy which was last reviewed by the Nursing Practice Council and Pharmacy and Therapeutics Committee in August of 2011. This policy provided nursing staff with medication administration scheduling guide windows. However, the policy did not address time-critical and non-time critical scheduled medications, medications eligible for scheduled dosing times and those not eligible for scheduled dosing times.

On 9/13/12 in the morning, the Vice President of Patient Care Services provided a policy labeled medication management. The policy noted a publication date of July 2012 and a notation on the policy that it was a draft. The Vice President said it was a corporate policy and had not been approved by the medical staff.

On 9/14/12, the Vice President provided a revised copy of the medication policy. The Vice President said the policy had been revised to include all elements for timing of medication administration and that the policy needed had not yet been approved by the medical staff.

Based on observations and interviews, the Hospital failed to consistently maintain the patient care environment to ensure an acceptable level of safety and quality.

Findings included:

Observation in the sterile core of the Operating Room (OR) (a highly-sensitive area of the operating room where sterile supplies are stored and OR attire [scrubs, and hats] is required) on 9-12-2012 at approximately 10:00 A.M., revealed a significant penetration (approximately 4 by 6 inches) in the wall. According to the Supervisor of the Sterile Processing Department, there had been a recent installation of a new sterilizer system. However, because of the sensitive environment of the sterile core, no penetrations can exist as these disruptions in the walls can provide an entrance area for potential pathogens.

Based on observations, interviews, and review of the Hospital's policies/procedures, and infection control logs, the Hospital failed to consistently ensure an acceptable level of infection prevention practice.

Findings included:

1. The hospital failed to consistently adhere to OSHA's bloodborne pathogens standard. According to the Occupational Safety and Health Administration (OSHA) regulations,1910.1030(g)(1)(A), warning labels (i.e., international biohazard symbol or the word "biohazard") shall be affixed to containers used to store, transport or ship blood or other potentially infectious materials, to reduce the risk of exposure to employees or patients.

Observation in the Endoscopy Suite on 9-12-12 at approximately 8:30 A.M., revealed a mobile bronchoscopy unit. According to the Director of Surgical Services, the mobile unit was used to perform procedures outside of the Endoscopy Suite or at a patient's bedside. After use, the soiled scope was placed in a green cinch sack for transport to the reprocessing area. However, the soiled scope lacked any warning label (i.e. biohazard symbol) to identify it as soiled equipment.

2. The Hospital failed to consistently meet CDC standards for performing diagnostic bronchoscopy procedures (to visually examine the lungs and airways via an endoscopic device).

According to the Center for Disease Control (CDC) 2005 Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Healthcare, bronchoscopy procedures are to be performed in a room that meets ventilation guidelines for an Airborne Infectious Isolation (AII) room. An AII room is designed with negative pressure (air flows from the adjacent area into the negative pressure room, ensuring that contaminated air cannot escape from the negative pressure room) to contain airborne organisms. However, bronchoscopy procedures were performed in an Ambulatory Surgical Room (Day Surgery Room # 5) under positive pressure (air flows out of the room instead of into the room), therefore the environment does not conform to AII standards as defined by the CDC.

Interview with the Charge Nurse of the Day Surgery area on 9-12-12 at approximately 9:00 A.M., revealed that a patient undergoing a diagnostic bronchoscopy procedure who potentially had an Airborne illness (i.e. Tuberculosis) would be placed in the pre-holding/post-procedure (a multi-bed area with approximately four stretchers used to hold a patient before and after their procedure). As described by the Charge Nurse, the patient would wear a mask and have the curtains drawn around them. However, this environment does not meet the CDC 2005 Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Healthcare and could potentially place staff and/or patients at risk for transmission of an Airborne illness.

3. The hospital failed to consistently maintain equipment in a manner that would reduce the risk of cross-contamination.
Observation in the Intensive Care Unit on 9-11-12 at approximately 9:45 A.M., revealed a "difficult airway carts" equipped with an endoscope (devices consisting of a tube and optical system that allows the practitioner to visualize the structures of a patient's respiratory system). The reprocessed endoscopes were coiled up and stored in a plastic bag until needed.
Guidelines and recommendations from multiple professional societies indicate that a clean endoscope be suspended vertically to promote ventilation and reduce the potential for trapped residual moisture and the risk of microbacterial growth.