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Based on interview and record review the hospital failed to ensure 3 (Patients #12, #15, and #23) of 30 patient discharge notes were completed in a timely manner.

Findings included:

Patient #23 was admitted to the hospital on 09/10/14. He underwent an anterior discectomy with a spinal decompression on 09/10/14, and was discharged on 09/12/14. The discharge note was dated and signed on 10/10/14. This was 28 days after the patient was discharged.

Patient #12 was admitted to the hospital on 06/30/14 and discharged on 07/03/14. Patient #12 underwent a Diagnostic Laparoscopy on 07/02/14. Patient #12's discharge note was signed and dated on 09/15/14. This was 74 days after the patient was discharged.

Patient #15 underwent an out-patient procedure of an Arthroscopy of the right shoulder with repair of the rotator cuff on 08/01/14. Patient #15's discharge note was signed and dated 08/06/14. This was 5 days after the patient was discharged.

Personnel #2 viewed the medical records above with the surveyor on the afternoon of 11/03/14. She confirmed the documented dates on the above medical records were late.

Based on interview and record review the hospital failed to ensure a discharge summary was provided for 1 (Patient #23) of 30 patients.

Findings included:

Patient #23 was admitted to the hospital on 09/10/14 and discharged on 09/12/14. A review of Patient #23's medical record revealed there was no discharge summary.

During an interview on 10/04/14 at 11:30 AM Personnel #2 confirmed there was no discharge summary for Patient #23.

Based on observation, interview, and record review the hospital failed to ensure the hazardous pharmaceutical waste disposal of excess drugs from syringes in proper reciprocals was done in that 1 of 1 nurse (Personnel #4) wasted an excess of narcotic in the Emergency Department (ED) medication room sink, while witnessed by another nurse, Personnel #5.

Findings included:

Personnel #4 drew up "Dilaudid" for ED Patient #2 with Personnel #5 as witness to wastage.

Personnel #4 wasted the excess narcotic from the syringe into the ED medication room sink rather than in the black bin container nearby that was provided for hazardous medication wastage.

The hospital's policy and procedure "Hazardous Pharmaceutical Waste Disposal" dated 9/2013 required the hospital would "...provide an ongoing hazardous pharmaceutical waste management program..." with pharmaceutical waste to include "...Waste materials containing excess drugs, i.e., syringes..."

During an interview on 11/4/14 at 1:30 PM, Personnel #10 (pharmacist) was asked where nurses disposed of narcotic waste. She replied in the trash or sink but then was corrected by Personnel #30 who said a new process had begun this year, possibly in 03/2014, of using black bins for narcotic wastage. Personnel #10 agreed.

During an interview on 11/04/14 at 2:10 PM, Personnel #2 stated prior to the use of black bins for pharmaceutical waste disposal, nurses would waste in the sharps container, trash, or sink. She was asked if the use of black bins began in 3/2014 and she said it may have been.

Based on interviews and record reviews the hospital failed to ensure only authorized personnel had access to 1 of 1 locked pharmacy in that an access badge was left in the Intensive Care Unit (ICU) Pyxis (ADS-automatic dispensing system) for the house supervisor to have access to the pharmacy after hours.

Findings Included:

During an interview on 11/4/14 at 1:30 PM with Personnel #10 (Pharmacist) regarding who had access to the Pharmacy, she stated only pharmacy personnel. Personnel #30 interjected that there was an access badge left in the ICU Pyxis for the house supervisor to have access to the pharmacy after hours but was rarely used.

During interviews on 11/4/14 at 2:15 PM with Personnel #1 and #2 both were unaware of an access badge left in the ICU Pyxis for the house supervisor to have access to the pharmacy after hours. Personnel #2 stated there was no reason for the house supervisor to ever need access to the pharmacy as Pharmacists were on call when not in-house.

During an interview on 11/05/14 at 1130 AM Personnel #1 provided an Authorized Cardholders Report, "Selected Door: Pharmacy," dated 11/5/14 and timed 11:16 AM that revealed only Pharmacy personnel had access badges to the Pharmacy. Personnel #1 stated the ICU Pyxis access badge was deactivated yesterday by the badge company after this was brought to their attention.

Hospital policy "Medication Security" revised 10/2013 revealed "...The main pharmacy will be electronically locked at all times. Authorized personnel include Pharmacists, Pharmacy Technicians, and Pharmacist Interns working under the direct supervision of a Pharmacist. Other people are permitted access only when authorized personnel are present..."

27128

Based on observation, interview, and record review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections in that:
1) 3 of 4 physician and/or personnel (Physician #22, Personnel #23, and #24) failed to wear appropriate, effective hair restraints in the Operating Room (OR) during a sterile surgical procedure. 1 of 4 personnel (Personnel #23 wore her hat behind her ears exposing her earrings.

2) Sterilized equipment for patient use, had not been arranged so that all surfaces were exposed to the sterilizing agent for the prescribed time and temperature in that 2 of 2 retractors, 1 of 1 sponge stick, 1 of 1 scissor and 3 of 3 needle holders were sterilized with their tips in a closed position.

3) 1 of 1 personnel (Personnel #27) in the medical-surgical unit did not perform appropriate hand hygiene prior to putting on gloves and after removal of soiled gloves during the handling of blood platelets for transfusion on 11/4/14.

4) 1 of 2 registered nurses (RNs) (Personnel #5) in the emergency department (ED) did not appropriately perform hand hygiene after removal of soiled gloves.

Findings included:

1) On 10/04/14 at 11:05 AM tracer patient (Patient #8) underwent a left elbow distal bicep repair. Personnel #23 was observed with her bouffant hat placed behind her ears. Her hair at her temples was exposed and she was wearing earrings. Personnel #24 had a full beard and wore only a mask. His beard was exposed at the sides of the mask and at the mask's edge at his neck. Personnel #24 wore a skull cap and his side burns and hair between his cap and his hair line were exposed. Physician #22 wore a cloth skull cap which exposed his side burns and his hair between his cap and his hair line. Personnel #2 confirmed the observations.

The hospital's OR Surgical Attire policy revised 6/2012 reflected on page 1-2, "...All facial and head hair, including sideburns and necklines, are to be covered...All rings, watches and bracelets should be removed. All other jewelry should be completely confined within the scrub attire (suit or hair covering) or removed..."

The AORN (Association of periOperative Registered Nurses) 2014 Edition Recommendation IV. a "...Head coverings designed to contain hair and scalp skin will minimize microbial dispersal. Skull caps may fail to contain the side hair above and in front of the ears and hair at the nape of the neck..."

2) Observations of the sterile supply room on 10/04/14 at 11:15 AM revealed 2 retractors, 1 sponge stick, 1 scissor and 3 needle holders were sterilized with their tips in a closed position. The arrangement of these instruments had not allowed the point of the greatest bio-burden, to be directly exposed to the sterilizing agent, as their tips were in the closed position. These instruments were stored in bins. Personnel #25 confirmed the observation and said their tips should have been opened. She said the surgical services followed AORN (Association of Peri-Operative Registered Nurses) guidelines.

The hospital's Use of Steam Sterilizer policy revised on 10/2014 reflected, "...All items are placed in the sterilizer in an open position..."

The AORN 2012 PeriOperative Standards and Recommended Practices For Inpatient and Ambulatory Settings, page 522 indicated, "...Cleaned surgical instruments should be organized for packaging in a manner to allow the sterilant to contact all exposed surfaces...Instruments with hinges should be opened and those with removable parts should be disassembled when placed in trays designed for sterilization...Instruments should be kept in the open and unlocked position using instrument stringers, racks, or instrument pegs designed to contain instruments..."

3) During observation on 11/4/14 at 1:00 PM on the Medical-Surgical unit, Patient #29 had 1 unit of blood platelets hung for infusion by Personnel #27 and witnessed by Personnel #28.

Upon entrance to the patient's room, Personnel #27 gloved and proceeded to the bedside. Witness RN Personnel #28 entered the room, performed hand gel hygiene, and then gloved. After the transfusion Personnel #27 took off the soiled gloves and did not perform appropriate hand hygiene.

During an interview with Personnel #2 on 11/4/14 at approximately 1:30 PM, the hospital's hand hygiene policy was reviewed and Personnel #2 was in agreement that proper hand hygiene should be performed prior to the gloving and handling of blood or blood components, and then after the removal of gloves.

4) During a tour on 11/3/14 at 1:00 PM in the ED, Personnel #5 was observed on two occasions to take off her soiled gloves after cleaning the cabinets under the sinks of treatment rooms' #2 and #3. Personnel #5 did not perform appropriate hand hygiene each time she removed her soiled gloves.

"Hand Hygiene" policy revised 04/2012 required "It is recommended that HCW (healthcare workers perform hand hygiene before and after direct patient contact, after removing gloves..."









34326

Based on record review and interview, the hospital failed to provide discharge planning evaluations to 3 of 30 patients (Patient #23, #25, and #26) who were in-patients from 9/10/14 through 10/3/14.

Findings included:

Patient #23 was admitted on 9/10/14 after a surgical procedure: "anterior discectomy with spinal decompression." Patient #23 was discharged on 9/12/14. There was no evidence in the medical record that a discharge planning evaluation was provided.

Patient #25 was admitted on 9/22/14 after a surgical procedure: "posterior lumbar interbody fusion..." Patient #25 was discharged on 9/24/14. The patient needed a "rollering walker" after discharged which the physician ordered. There was no evidence in the medical record that a discharge planning evaluation was provided.

Patient #26 was admitted on 10/1/14 after a surgical procedure: "left knee arthroplasty." Patient #26 was discharged on 10/3/14. The patient needed a "rollering walker" after discharged which the physician ordered. There was no evidence in the medical record that a discharge planning evaluation was provided.

In an interview on 11/5/14 at approximately 10:30 AM, Personnel #26 (Case Manager) was informed of the above findings. Personnel #26 confirmed that she did not provide discharge planning evaluations for the above patients.

Policy "Continuum of Care Plan" revised 1/2012 required "Pre-Discharge: Discharge planning begins at the earliest time possible...During the discharge planning process the hospital identifies any needs the patient may have for...physical care, treatment, and services after discharge..."

Based on interview and record review it was determined the hospital failed to ensure 2 (Patient #12 and #15) of 30 patients had a completed immediate post-operative (post-op) note.

Findings included:

Patient #12 was admitted to the hospital on 06/30/14 and discharged on 07/03/14. Patient #12 underwent a Diagnostic Laparoscopy on 07/02/14. Patient #12's immediate post-op note was blank.

Patient #15 underwent an out-patient procedure of an Arthroscopy of the right shoulder with repair of the rotator cuff on 08/01/14. Patient #15's immediate post-op note was not completed. The form was signed and dated 08/06/14.

During an interivew on 10/03/14 at 3:00 PM with Personnel #2 she confirmed the above findings.

The hospital's Medical Staff rules and regulations dated 11/04/2014 on page 20 reflected, "...An immediate post-operative note is required in the immediate post-operative period..."