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Based on interview and record review, the facility failed to include 14 (Poison Control Center; Scott Radiology Group, Inc.; DesPeres Hospital; LabCorp; St Anthony's Medical Center; St Louis University Hospital; Abbott Ambulance Service; Def Interlink; LAMP; Spiritual Care; St Louis Blood Recovery system; Surgical Direct, Inc.; Iron Mountain; Senior Care Coverage Agreements for 28 physicians; Newstart Psychologist) of 32 contracted services in the facility wide Quality Assessment and Performance Improvement Program (QAPI). The facility also failed to engage in assessment, identify quality and performance problems, implement appropriate corrective or improvement activities, collect data or ensure the monitoring and sustainability of improvement activities. Without collecting or analyzing data from the contracted services, the facility cannot ascertain that the contracted services were in compliance with the Conditions of Participation as required by the Centers for Medicare & Medicaid Services (CMS) for hospitals. The facility census was 117.

Findings included:

1. Record review of the QAPI Program did not contain meeting minutes, performance Improvement projects, performance data or analysis, or evidence of patient outcomes for the above named contracted services. The contracted services represent the following patient services:
-Poison Control Center - Poison Control;
-DesPeres Hospital - Reference Laboratory;
-LabCorp - Reference Laboratory;
-St Anthony's Medical Center - Reference Laboratory;
-St Louis University Hospital - Reference Laboratory;
-Abbott Ambulance Services, Inc. - Ambulance services;
-Deaf Interlink - Patient Translators;
-LAMP - Patient Translators;
-Spiritual Care - Spiritual Care provided by four Chaplains;
-St Louis Blood Recovery System - Autotransfusion;
-Surgical Direct, Inc. - Lease of Surgical Equipment & disposables;
-Senior Care Coverage Agreements - Senior Care Coverage from 28 listed physicians; and
-Newstart Psychologist - Psychologist services.

2. Record review of the Clinical Contracts/Services dated 04/25/2011 listed all of the above services as satisfactory with quality of services even though there was no data collected, either qualified or quantified, no analysis and no reporting of performance standards by the contracted services.

3. During an interview on 04/28/11 at 1:20 PM, Staff N, Registered Nurse (RN), Director of Quality and Risk Management, stated that the above named contracted services were not part of the facility wide QAPI Program. Staff N further stated that patient outcomes for high volume or problem-prone areas had not been monitored or identified for quality improvements related to contracted services.

Based on observations, staff interviews, and review of the facility policies and procedures, the facility failed to provide suicide safe shower knobs and or trash containers to ensure a safe setting for 59 of 59 Patients on the Acute Adult and Gero (Geriatric) Psychiatric units. Of the 59 Patients on the units there were 37 Patients on Assault Precautions and 25 Patients on Suicide Precautions. All Patients on the units were allowed to have paper sacks with (2) 16" handles that could provide strangulation or ligature devices as a means of assault or suicide. The shower knobs were made of round plastic that protruded 4" out from the wall and 48" above the floor that could provide a ligature hold. All Patients rooms on these units were left open and unlocked permitting access for other Patients to showers and trash bags with handles.

The severity and cumulative effect of the systemic practices resulted in the facility being out of compliance with 42 CFR 482.13 - Condition of Participation: Patients' Rights and resulted in the facility's failure to provide a safe environment for Patients and potentially any patients admitted to the Psychiatric Units (59 capacity of 59 patients) with potential involuntary orders. Subsequently the situation constituted a condition of immediate jeopardy. The hospital administration was notified of the Immediate Jeopardy (IJ) on 04/27/11 at 9:30 AM. An immediate plan of correction was received, accepted and implemented prior to exit, therefore, the IJ was abated. The facility census at St. Alexius Hospital - Campuses was 117.

Refer to evidence A-0144 for findings.

Based on record review, interview, and policy review, facility staff failed to complete Therapeutic Support Orders for seven (#1, #2, #4, #19, #21, #32 and #34) of 26 patient records reviewed, and failed to address advanced directives on the Admission Assessment for two (#1 and #4) of nine records reviewed. This had the potential to affect all patients admitted to the facility. The facility census was 117.

Findings included:

1. Record review of the facility's policy titled "Admission Assessment and Process", last revised 11/10, showed the following direction:
-An Admission Assessment must be completed for every patient admitted to the hospital.
-Ascertain Advance Directive(s) and maintain copies when appropriate.

Record review of the facility's policy titled, "Therapeutic Support Orders," last revised 03/07, showed that facility policy required a patient's medical record to include physician documentation identifying those medical conditions leading to the orders listed below. Physicians were to complete, sign, and date the Therapeutic Support Orders on every patient within 48 hours of hospital admission. The Therapeutic Support Orders gave direction to the staff for the following:
- Section I - Cardiac or Respiratory Arrest - In the event of a cardiac or respiratory arrest, ACLS (advanced cardiac life support) or No ACLS will be initiated;
- Section II - Ongoing Care in non-arrest situations - the choices are:
- A. No limitation on care
- B. Individualized therapy with specific care options
- C. Comfort measures only - No ACLS or CPR (cardiac pulmonary resuscitation) will be initiated.

Record review of the facility's policy titled "Therapeutic Support Levels," last revised 11/08, showed the following direction:
-Each patient, upon admission, will have documented on the Therapeutic Support Level order sheet his or her preferences for Level of Resuscitation and Ongoing Care in non-arrest situations.

2. Review of Patient #1's medical record on 04/25/11 showed the patient was admitted 04/17/11. The Advance Directives section on the Admission Assessment was blank and the Therapeutic Support Orders were blank.

3. Review of Patient #2's medical record on 04/26/11 showed the patient was admitted on 04/20/11. The Therapeutic Support Orders were blank.

4. Review of Patient #4's medical record on 04/25/11 showed the patient was admitted on 04/19/11. The Advance Directives section on the Admission Assessment was blank and the Therapeutic Support Orders were blank.


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5. Review of Patient #19's medical record on 04/25/11 showed the patient was admitted on 04/19/11. The Therapeutic Support Orders were blank with no date and a physician's signature.

6. Review of Patient #21's medical record on 04/25/11 showed the patient was admitted on 04/15/11. The Therapeutic Support Orders were blank with no date or signature of physician.

During an interview on 04/25/11 at 2:33 PM with Staff E, Registered Nurse (RN), Nurse Manager, stated that he/she doesn't know what code Patient #21 would be since the Therapeutic Support Orders had not been completed.


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7. Review of Patient #32's medical record on 04/26/11 showed the patient was admitted on 04/07/11. The record showed the Therapeutic Support Orders form was not completed.

8. Review of Patient #34's medical record on 04/26/11 showed the patient was admitted on 04/14/11. The Therapeutic Support Orders form was signed and dated 04/23/11, nine days later. There were multiple resuscitation options on the form, but none were selected.

9. During an interview on 04/25/11 at 3:00 PM, Staff I, Chief Administrative Supervisor, stated nurses should complete the Advanced Directive section on the Admission Assessment.

During an interview on 04/26/11 at 9:50 AM, Staff I stated all patients should have Therapeutic Support Orders completed. Staff I confirmed staff had not completed Therapeutic Support Orders for patients #1, #2 and #4.

Based on observation and interview, the facility failed to ensure patient's privacy by displaying patient names on medical records in public view in three nursing units and failed to secure the Medication Administration Record (MAR) for one (#29) patient of eight in the Intensive Care Unit (ICU). This had the potential to affect all patients in the facility. The facility census was 117.

Findings included:

1. Observation on 04/25/11 at 3:20 PM of the fifth floor nurses' station, showed patients' first name and last initial on the spine of medical records, which were readable from the public hall.

2. Observation on 04/26/11 at 10:00 AM of the sixth floor nurses' station, showed patients' first name and last initial on the spine of the medical records, which were readable from the public hall.


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3. Observation on 04/26/11 at 11:00 AM of the third floor psychiatric unit showed medical records were labeled with patient's last names and first initials. The spine of each medical record was affixed with a large white label upon which the patient's name was printed in large black, block letters. Patient names were readable from the public hall.

During an interview on 04/26/10 at 1:30 PM, Staff Z, Nurse Manager, confirmed that patient medical files were readable from the public hall.


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4. Observation on 04/26/11 at 1:20 PM, showed two patient medical records laying on the nurses' station counter. The medical records were labeled on the spine with the patients' full first names and last initials. The names on the medical records were readable from the main hall in the ICU, where other patients and visitors could see the patient's identity.

5. Observation on 04/26/11 at 1:20 PM, showed that Patient #29's MAR was sitting on top of a cart, located outside of the patient's room. The cart was located in the ICU hall where other patients and visitors could see the patient's full name, date of birth, and diagnosis.

During an interview on 04/29/11 at 11:10 AM, Staff M, Chief Nursing Officer, stated that the facility did not realize a patient's privacy was violated by using the patient's first name on the chart in public view. Staff M added that patient MARs should not be left in a hall where the public could read the patient's information.

Based on observations, staff interviews, and review of facility policies and procedures, the facility failed to ensure trash containers and shower knobs were suicide-resistant for 59 of 59 patients in the Psychiatric units. There were four Psychiatric units on two campuses. All patients were provided a paper bag with (2) handles measuring 16" in length (total of 32" of a tightly twisted, strong, paper rope) to use as garbage containers. In addition, 55 water control knobs in the showers on the psychiatric units protruded three to four inches from the shower walls and were approximately 48 inches above the floor. This provided a ligature attachment point for hanging which had been previously cited at the facility in October of 2010. These findings presented an immediate threat to the health and safety of the patients and potentially any patient admitted to the Psychiatric units. The hospital administration was notified of the Immediate Jeopardy (IJ) on 04/27/11 at 9:30 AM. An immediate plan of correction was received and accepted prior to exit, therefore, the IJ was considered abated.

The facility also failed to ensure a sitter (staff who observe a patient closely to ensure patient safety) was provided promptly for a patient with a physician's order for a sitter for one (#52) of two patients with a sitter. The facility census was 117.

Findings included:

1. Record review of the facility's policy titled, "SUICIDE PRECAUTIONS," revised 11/10, showed it was the purpose of the Psychiatric Program to specify criteria for determining suicide risk and to delineate the procedures implemented by nursing staff to ensure patient safety. The general guidelines for policy included the following:
- It is the policy of Psychiatric Services to place a patient determined to be a suicide risk on special precautions.
- All patients admitted following a suicide attempt will be considered a high risk. For these patients, suicide precautions will be initiated upon arrival to the Psychiatric Unit.
- Staff will maintain safe environment to protect the patient from self-destructive tendencies.

Record review of the facility's policy titled, "CONTRABAND," revised 11/10, showed the purpose of the policy was to define items considered as contraband and to establish controls for maintaining the safety and security of the milieu.
- Contraband (Harmful Material) is defined as: Weapons and Firearms: guns, clubs, knives, chains, ropes, cord.
- Contraband is not permitted in the therapeutic milieu of Psychiatric Services and will be secured . . .

2. Observation on 04/25/11 at 2:30 PM on the fourth floor Adult Psychiatric Unit showed paper bags with two paper rope handles in 21 of 21 patient rooms.

Review of the census report of the fourth floor Adult Psychiatric Unit dated 04/26/11 provided by nursing staff showed 18 of 21 patients on the unit were on Suicide Precautions, Assault Precautions, or both.

Review of the census report of the third floor Adult Psychiatric Unit and the Gero (Geriatric)Psychiatric Unit dated 04/27/11 provided by nursing staff showed 28 of 32 patients on the unit were on Suicide Precautions, Assault Precautions, or both.

Observation on 04/28/11 on the Forest Park Psychiatric Unit showed paper bags with two paper rope handles in six of six patient rooms.

During an interview on 04/26/11 at 2:30 PM, Staff M, RN (Registered Nurse), Chief Nursing Officer (CNO) and Campus Administrator for the Forest Park location, stated that the paper bags with handles could be found in all psychiatric patient rooms on every campus. Staff M confirmed that the handles could be used as an assault weapon for strangulation or as a means of ligature for hanging. Staff M also stated that the bags were originally purchased by the facility to store the patient's belongings (private articles of clothing) and the handles provided for ease of carrying. Staff M stated that he/she didn't know how they came to be used for trash containers.

During an interview on 04/28/11 at 12:50 AM, Staff N, RN, Director of Quality and Risk Management, and Staff CC, RN, confirmed that the paper bag handles were strong enough and long enough to be used for strangulation either for an assault or a suicide method.


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3. During an interview on 04/26/11 at 2:00 PM, Staff NN, Maintenance Director, stated that there were 55 shower heads that were not suicide resistant.

4. Observation on 04/26/11 of all psychiatric patient rooms at the Broadway campus showed there were different types of water control knobs for the showers. Water control knobs in all showers protruded horizontally from the wall of the shower approximately three to four inches which created a ligature attachment point.


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5. Observation on 4/27/2011 at 9:40 AM showed fabric (approximately one inch by four inches) was torn and dangling from the right lower leg of a cloth recliner in the Day Room, and four clean washcloths were observed laying on the sink in the Men's Room. Tied together, the torn fabric could be used as a ligature, and were accessible to all patients, including those on Suicide Precautions.

During an interview on 04/27/11 at 9:20 AM, Staff CC, Nurse Manager, stated that although patients with suicide precautions were admitted to the unit, restrooms were unlocked and patients routinely showered without supervision.


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6. Record review of the facility policy titled, "Nursing Services - Close Observation/Sitter/1:1 Monitoring" revised on 12/09, showed that 1:1 monitoring required documentation every 15 minutes by the staff member assigned to observe the patient.

Review of current Patient #52's medical record showed an order written on 04/24/11 at 3:50 PM, for a 1:1 sitter (staff who provides constant in-room monitoring of a patient). The order was written for the sitter to maintain the patient's contact isolation and to observe for safety, because the patient was a flight risk due to his/her mental illness. Further review of the patient's chart showed there was no documentation on the patient observation flow sheet (documentation every 15 minutes of patient activity) until 04/24/11 at 7:15 PM, indicating that the patient was not provided a sitter for over three hours after the order was written.

During an interview on 04/25/11 at 3:13 PM, Staff JJ, Intensive Care Unit Charge Nurse, stated that the delay in providing patient #52 with a sitter was due to a lack of staff and that he/she doesn't know if the Administrative Supervisor was contacted to assist with locating a sitter.

Record review of the facility's plan of correction dated 03/11/11, showed that if a sitter is unable to be located, the Administrative Supervisor will be contacted (page 2).

Based on record review and interview the facility failed to document in the medical record the date and time of notification to Centers for Medicare & Medicaid (CMS) of patient deaths associated with the use of restraints for two (#58 and #60) of three death records reviewed for restraints. The facility census was 117.

Findings included:

1. Review of Patient #58's discharged medical record showed the patient expired on 01/12/11. The patient had bilateral soft wrist restraint orders on 01/11/11. The medical record contained no documentation of the date and time CMS was notified of the death.

2. Review of Patient #60's discharged medical record revealed the patient expired on 08/23/10. The patient had bilateral soft wrist restraint orders on 08/23/10. The medical record contained no documentation of the date and time CMS was notified of the death.

3. During an interview on 04/29/11 at 11:35 AM, Staff N, Director of Quality and Risk, stated that the patient deaths were reported to CMS, and confirmed staff did not document in the medical record the date and time the notification was made. Staff N stated that the facility policy did not direct staff to document in the medical record, but they were aware the documentation needed to be in the medical record.

Based on policy review, observation, record review, and interview, the facility failed to:
- Properly identify patients prior to medication administration for two patients (#1 and #3) of 11 medication passes observed;
- Ensure medications were administered as ordered by the physician for two patients (#32 and #33) of 11 medication passes observed. This had the potential to affect all patients receiving medication. The facility census was 117.

Findings included:

1. Record review of the facility policy titled "Medication Administration Record (MAR)" last revised 1/2011 showed the following direction:
- General Guidelines: The nurse administering any medication will follow the five rights of medication administration: Right Patient, Right Time, Right Drug, Right Route and Right Dose. Must correctly identify patient utilizing 2 approved patient identifiers.
- Documentation: Scheduled administration times are printed on the MAR. Charting will consist of initialing the administration times. If a dose is given within plus or minus 30 minutes of the printed time, initial the time as if given at the scheduled time. If a dose is given outside the scheduled administration time, circle the printed time and write in the actual time given and initial. After the medication is administered the nurse should place their initials under the scheduled time.

2. Observation on 04/25/11 at 2:30 PM showed Staff F, Registered Nurse (RN) administered medication to Patient #1 without asking the patient his/her name and without checking the patient's armband for name and account number.

In an interview on 04/25/11 at 2:30 PM, Staff F stated he/she did not check Patient #1's armband because he/she had just came out of the room after putting a new armband on the patient.

3. Observation on 4/26/11 at 10:55 AM showed Staff H, RN, administered Patient #3's medication after checking the patient's armband with the intravenous bag of medication. Although Patient #3 was not on isolation precautions, Staff H did not bring the MAR into the patient's room.

In an interview on 04/25/11 at 3:30 PM, Staff I, Chief Administrative Supervisor, confirmed Staff F and Staff H did not follow the facility policy. Staff I stated staff should check the patient's name and account number with the MAR prior to administering medications to patients.


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4. Observation on 04/26/11 at 9:00 AM showed Staff DD, Licensed Practical Nurse (LPN), administered Carbamazepine (used to control seizures) 200 mg (milligrams, a unit of measure) to Patient #32.

Review of Patient #32's MAR on 04/26/11 showed the Carbamazepine was scheduled to be given at 8:00 AM. It was initialed as if it was given at 8:00 AM rather than being documented as 9:00 AM, the time it was actually administered.

5. Observation on 04/26/11 at 9:15 AM showed Staff DD administered Metformin HCl (used to treat diabetes) 500 mg to Patient #33.

Review of Patient #33's MAR on 04/26/11 showed the Metformin HCl was scheduled to be given at 8:00 AM. It was initialed as if it was given at 8:00 AM rather than being documented as 9:15 AM, the time it was actually administered.

6. During an interview on 04/26/11 at 1:00 PM, Staff Z, Nurse Manager, stated nurses were allowed 30 minutes to give medication before and after the time it was ordered. If the medication was given beyond that timeframe, the time should be circled on the MAR, the correct time should be written, and a "Reason Code" should be cited using the codes listed on the MAR. Staff Z also stated a note should be made in the nursing notes or on the MAR page as to why the medication wasn't given at the scheduled time, and an Incident Report should be completed.

7. During an interview on 04/26/11 at 1:30 PM, Staff DD confirmed he/she didn't give Patients #32 and #33 their medications scheduled for 8:00 AM at the time listed on the MAR. Staff DD stated, "I always give them with the 9:00 AM meds because they question it (getting medications too closely together) and say they just took them (medications)." Staff DD clarified that this was a psychiatric ward with schizophrenic patients who were paranoid about taking too many medications, and stated it was a common practice to combine 8:00 AM and 9:00 AM medications when possible to ensure patients would take their medications. Staff DD stated, "I should have marked the MAR with the time I gave the medication," and said that when medications were given late, a note should be made in the nursing notes and an Occurrence Report should be completed.

Based upon record review and interview, the facility failed to accurately document the amount of nutritional supplement received daily for three patients (#7, #29, and #61) of three medical records that were reviewed for tube feeding documentation. Failure to accurately document the amount of supplement consumed put patients at risk because the dietician was unable to assess whether their calorie and protein needs were met. The facility census was 117.

Findings included:

1. Record review of the facility policy, "Nursing Service, Dietary Orders," last reviewed 11/09, showed the direction that nursing staff was responsible for the documentation of intake of snacks and supplements. Specific instructions for this expectation were not given.

2. Review of Patient #7's medical record showed a physician order dated 04/25/11 for Jevity (a nutritional supplement) 1.2 grams of protein per ml (milliliter, a unit of measure) to be given undiluted at 50 ml per hour G tube (a tube inserted directly into the patient's stomach). Review of nursing flow sheet documentation showed "50" was written for each hour of the day on 04/25/11, which indicated the amount of tube feeding administration rate, but the accurate amount of tube feeding administered within a 24 hour period was not documented.

3. Review of Patient #29's medical record showed a physician order dated 04/15/11 for Nepro (a specialty nutritional supplement for patients with kidney problems) to be given at 30 ml per hour per G tube. Review of nursing flow sheet documentation showed "30" was written for each hour of the day on 04/25/11, which indicated the amount of tube feeding administration rate, but the accurate amount of tube feeding administered within a 24 hour period was not documented.

4. Review of Patient #61's medical record showed a physician order dated 04/27/11 for Isosource (a nutritional supplement) to be given at 50 ml per hour per G tube. Review of nursing flow sheet documentation showed "50" was written for each hour of the day on 04/27-28/11, which indicated the amount of tube feeding administration rate, but the accurate amount of tube feeding administered within a 24 hour period was not documented.

5. During an interview on 04/29/11 at 9:00 AM, Staff K, Charge Nurse on the 6th floor, stated that the staff always document the rate of the tube feeding but that he/she understood the need to document the total amount the patient received during a 24 hours period.

Based on policy review, record review and interview the facility failed to:
- Ensure physicians authenticated progress notes for two patients (#1 and #4) of nine records reviewed;
- Ensure physicians and nursing staff dated, timed and signed (authenticated) orders for two patients (#15 and #33) of nine records reviewed;
- Ensure medical entries were legible for one (Patient #15) of nine records reviewed; and
- Ensure physicians authenticated dictated documents by reviewing and correcting any errors in transcription for four (Patients #15, #32, #33, and #34) of nine records reviewed. The facility census was 117.

Findings included:

1. Record review of the facility's document titled, "Rules & Regulations, 2011," last revised February, 2011, showed the following direction:
- RECORD KEEPING: All entries shall be complete legibly written in ink or typewritten, dated, timed and authenticated (i.e., signed by the author).
- PROGRESS NOTES: Physician progress notes shall be written legibly to reflect the chronological course of the patient including clinical observations, treatment and documentation of continuous care. All progress notes shall be dated, timed and authenticated (signed). Physician progress notes are intended to be written frequently enough to reflect the patient's current status, daily is recommended.

Review of the facility's policy titled, "Charting in Patient's Record," last revised 4/07, showed the following directions:
- The written signature of the person doing the charting should consist of the initial of the first name and the last name in full, and title.
- All recording on chart should be neat, legible, and meaningful. If handwriting is not legible, notes should be printed.
- All entries are to be dated and timed. Times are to be noted using military time.

2. Review of Patient #1's medical record on 04/25/11, showed physician's progress notes dated 04/19/11, 04/20/11, 04/21/11, 04/22/11, 04/23/11 and 04/24/11 had not been timed.

Review of Patient #4's medical record on 04/25/11, showed physician's progress notes dated 04/23/11, 04/24/11 and 04/25/11 had not been timed.

During an interview on 04/26/11 at 2:45 PM, Staff I, Chief Administrative Supervisor, stated physicians should time their progress notes. Staff I confirmed the physician progress notes for Patients #1 and #4 had not been timed by the physicians.


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3. Review of Patient #15's medical record on 04/25/11 showed a psychiatric evaluation was dictated on 04/24/11 and typed on 04/25/11. The physician signed the typed evaluation, but did not date and time the signature.

4. Review of Patient #33's medical record on 04/26/11 showed a Subcutaneous Insulin (an injection used to treat diabetes, administered just under the skin) Protocol was initiated and written as a telephone order on 04/25/11 at 7:15 PM. The order was not signed by the RN, (Registered Nurse), was not dated or timed, and there were no initials to indicate the RN had read back the information to the physician to ensure it was written correctly.

5. Review of Patient #15's medical record on 04/25/11 showed the following:
- A Multidisciplinary Progress Note dated 04/23/11, time was not specified. The majority of the note was illegible. The note was signed, but the writer's title (if identified) was illegible.
- Two Multidisciplinary Progress Notes were dated 04/24/11. Time was not specified on either document and the majority of the notes were illegible. Both notes were signed, but it was impossible to determine a title for either writer.
- A Multidisciplinary Progress Note dated 04/25/11, time was not specified. The majority of the note was illegible. The note was signed, but the writer's title (if identified) was illegible.

During an interview on 04/25/11 at 2:35 PM, Staff Z, Nurse Manager, attempted to decipher the documents listed above and was unable to determine more than a few words on each. Staff Z agreed the handwriting was illegible.

6. Review of Patient #15's medical record on 04/25/11 showed the following:
- A Psychiatric Evaluation was dictated and typed on 04/22/11.
- The HISTORY: section included, "(He/she) began _________, agitated." And "(He/she) was here last time in July 2010; at that time (he/she) was angry with ____________ wants Nicorette gum every hour." The document was signed by the physician without clarifying the portions that were left blank. The signature was not dated or timed.

Review of Patient #32's medical record on 04/26/11 showed the following:
- A Psychiatric Evaluation was dictated and typed 04/08/11.
- The HISTORY OF PRESENT ILLNESS: section included, "The nursing home staff reported that the patient __________ (he/she) started acting up, becoming agitated, becoming a threat to self and to others, and 911 was called." The document was signed by the physician without clarifying the portion that was left blank. The signature was not dated or timed.
- A Consultation Report was dictated 04/08/11 and typed 04/09/11.
- The REVIEW OF SYSTEMS: section included, "The patient complained of skin changes on his foot for '10 years.' __________ the left foot."
The document was signed by the physician without clarifying the portions that were left blank. The signature was not dated or timed.

Review of Patient #34's medical record on 04/26/11 showed the following:
- A Psychiatric Evaluation was dictated and typed on 04/15/11.
- The HOME MEDICATIONS: section included, "Ativan, Seroquel, Flonase, ____________, Zocor, carbidopa-levodopa which is every three hours which was ....."
- The FAMILY HISTORY: section included, "History of Parkinson in the family and so on. ___________, schizoaffective, ____________, parkinsonism, but could be because of (his/her) Parkinson ___________, also could be due to (his/her) medication. At this point, surgical and neuro __________ implant."
- The PHYSICAL EXAMINATION: section included, "GENERAL: Coherent, cooperative. (He/she) is lying on a bed, ___________." And "NEUROLOGIC: Also has ____________ because Parkinson rigidity and tremors. Gait is unsteady."
- PERSONAL/FAMILY/SOCIAL HISTORY: section included, "Born here. (He/she) has ___________. Denies drug and alcohol use."
- MENTAL STATUS EXAMINATION: section included, "(He/she) is 61 years old, coherent, guarded, __________."
The document was signed by the physician without clarifying the portions that were left blank. The signature was not dated or timed.

Review of Patient #35's medical record on 04/27/11 showed the following:
- A consultation Report was dictated on 04/24/11 and typed on 04/25/11.
- The PHYSICAL EXAMINATION: section included, "Blood pressure 148/89, pulse 80 and equal, __________, (he/she) is afebrile."
The document was signed by the physician without clarifying the portion that was left blank. The signature was not dated or timed.

Based on policy review, record review, and interview the facility failed to ensure physicians dated, timed and signed (authenticated) orders for five patients (#1, #4, #7, #15 and #32) of 18 records reviewed for authentication. The facility census was 117.

Findings included:

1. Record review of the facility's document titled, "Rules & Regulations, 2011," last revised February, 2011, showed the following direction: RECORD KEEPING: All entries shall be complete legibly written in ink or typewritten, dated, timed and authenticated (i.e., signed by the author).

Record review of the facility's policy titled, "Charting in Patient's Record," last revised 4/07, showed the following directions:
- The written signature of the person doing the charting should consist of the initial of the first name and the last name in full, and title.
- All recording on chart should be neat, legible, and meaningful. If handwriting is not legible, notes should be printed.
- All entries are to be dated and timed. Times are to be noted using military time.

2. Review of Patient #1's medical record on 04/25/11 showed:
-A physician order dated 04/18/11 to discontinue Metformin (diabetes medication); urine culture and sensitivity now if not done; chest x-ray now, if not done in emergency room; transfer patient to my service; complete blood count now and call results. The physician order was not timed.
-A physician order dated 04/19/11 for Lantus (diabetes medication) 20 units subcutaneous (an injection just under the skin) now, then 20 units (a unit of measure) before breakfast and 20 units before supper daily; Benadryl (allergy medication) 25 (milligrams, a unit of measure) three times a day as needed; hemoglobin A1C (blood test for blood sugar); basic metabolic panel and complete blood count in AM; discontinue intravenous fluids. The physician order was not timed.
-A physician order dated 04/20/11 for ultra sound of the abdomen-abdominal aorta, kidney, liver and pancreas. The physician order was not timed.
-A physician order dated 04/21/11 to discontinue Vicodin ES (pain medication) and Percocet (pain medication); Lorcet 10/650 (pain medication) one every four hours as needed; CAT scan (Computerized Axial Tomography, a type of x-ray that produces three dimensional pictures of internal organs) of abdomen and pelvis with no intravenous contrast; snack daily around 9-10 o'clock PM. The physician order was not timed.

3. Review of Patient #4's medical record on 04/25/11 showed a physician order dated 04/23/11 to decrease Accu-check (a blood sugar test) to two times a day and use sliding scale; nicotine patch (used to reduce addiction to smoking) 14 mg every day. The physician order was not timed.

4. Review of Patient #7's medical record on 04/26/11 showed a physician order dated 04/23/11 for Lovenox (blood thinner medication) 30 mg subcutaneous daily starting today. The physician order was not timed.

During an interview on 04/26/11 at 2:45 PM, Staff I, Chief Administrative Supervisor, stated all physician orders should be timed. Staff I confirmed the physician orders for Patient's #1, #4 and #7 were not timed by the physician.


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5. Review of Patient #15's medical record on 04/25/11 showed a physician order dated 04/22/11 for Zyprexa (used to treat schizophrenia) 5 mg po (by mouth) or IM (intramuscular injection) q (every) four hours prn (as needed) for agitation. The physician order was signed, but was not timed.

6. Review of Patient #32's medical record on 04/26/11 showed a physician order dated 04/14/11 to decrease Geodon (a medication used to treat schizophrenia) to 40 mg po bid (twice daily) X (times) two days, then D/C (discontinue); Zyprexa (a medication used to treat schizophrenia) 10 mg po bid. The physician order was signed but was not timed.



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7. Review of Patient #52's medical record on 04/25/11 showed the following:
- A "Therapeutic Support Order" was signed, but was not dated or timed.
- A physician order dated 04/22/11 for Tylenol (fever reducer) was signed, but was not timed.
- A physician order dated 04/23/11 for a sputum culture (test for bacteria in phlegm) and a chest x-ray was signed, but was not timed.
- A physician order dated 04/25/11 included Levaquin (antibiotic); Haldol (used to treat psychosis); Ativan (decreases anxiety). The order was signed, but was not timed.

During an interview on 04/25/11 at 3:13 PM, Staff JJ, Intensive Unit Clinical Leader, stated that all orders, including verbal and telephone orders, are to be dated and timed by the physician or nurse practitioner when they are signed.

Based on policy review, record review, and interview, the facility failed to ensure physicians signed telephone/verbal orders within 48 hours for six patients (#1, #2, #6, #7, #15 and #52) of 19 medical records reviewed. The facility census was 117.

Findings included:

1. Record review of the facility's document titled, "Rules & Regulations, 2011," last revised February, 2011, showed the following direction: VERBAL ORDERS: Verbal orders are to be cosigned by the ordering practitioner within 48 hours or by other practitioners involved in the patient's care.

Record review of the facility's policy titled "Verbal/Telephone Orders", revised 5/06, showed the following direction: Verbal orders for drugs are accepted only by personnel so designated in the medical staff rules and regulation and are authenticated by the prescribing practitioner within the stated period of time.

2. Review of Patient #1's medical record on 04/25/11 showed:
-A telephone/verbal order dated 04/21/11 at 6:15 AM to give HS (bedtime) snack and give Lantus (diabetic medication) after meals.
-A telephone order dated 04/22/11 at 6:50 AM to hold Lantus.
The telephone/verbal orders were not cosigned by the physician at the time of the record review.

3. Review of Patient #2's medical record on 04/25/11showed:
-A telephone/verbal order dated 04/22/11 at 10:00 AM to give Clonidine (blood pressure medication) 0.1 mg (milligram, a unit of measure) every four hours for systolic blood pressure greater than 150 and diastolic blood pressure greater than 90; Physical Therapy for transfers and walking; and Dulcolax (stool softener) three tablets, one time, now. The telephone/verbal order was not cosigned by the physician at the time of the record review.

4. Review of Patient #6's medical record on 04/26/11 showed a telephone order dated 04/20/11 at 11:15 AM for dressing change for penis - apply Neosporin, cover with adaptic gauze and dry dressing, daily. The telephone order was not cosigned by the physician at the time of the record review.

5. Review of Patient #7's medical record on 04/26/11 showed a telephone order dated 04/21/11 at 9:20 AM to cross match two units of packed red blood cells and transfuse today; start Jevity (nutritional supplement) at 30 ml (milliliters, a unit of measure) per hour per tube and flush every shift with 60-100 ml of water. The telephone order was not cosigned by the physician at the time of the record review.

During an interview on 4/16/11 at 2:45 PM, Staff I, Chief Administrative Supervisor, stated physicians should cosign orders within 48 hours. Staff I confirmed the telephone/verbal orders for patients #1, #2, #6 and #7 were not cosigned within 48 hours.


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6. Review of Patient #15's medical record on 04/25/11 showed a telephone order dated 04/21/11 at 10:00 PM included the patient's admission orders. The order was not signed by the physician at the time of the record review.


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7. Review of Patient #52's medical record 04/26/11 showed a verbal order from a nurse practitioner dated 04/22/11 to stop the administration of all antibiotics except Vancomycin. The order was cosigned by a physician, but was not dated or timed.

Based on observation, interview, and policy review, the facility failed to ensure expired medications were removed from the Post Anesthesia Care Unit (PACU). This had the potential to allow outdated medications to be administered to patients receiving care in the PACU. The facility performs approximately 200 procedures per month. The facility census was 117.

Findings included:

1. Record review of the facility's policy titled, "Expiration of Medications in the Patient Care Areas," revised 10/10, showed direction that all containers should be checked for the manufacturer's expiration date before use, but did not indicate a facility process for removing expired medications from the patient care areas.

2. Observation on 04/28/11 at 11:10 AM of the PACU refrigerator and freezer, showed the following medications were outdated:
- One Protamine Sulfate (used to reverse a medication that has made the blood too thin), Lot #600341, expired 03/11;
- Six Thrombin (a medication used to make blood clot) vials, Lot #M33T59J, expired 07/10;
- Four Sodium Hyaluronate (used during cataract procedures) vials, Lot #RC0004A, expired 01/11;
- One Sodium Hyaluronate vial, Lot #BO80119F, expired 01/11.

During an interview on 04/28/11 at 11:10 AM, Staff PP, Surgical Services Director, stated that the outdated medications should have been removed and that removing outdated medications was the responsibility of the PACU staff. Staff PP also stated that PACU staff were not assigned or scheduled to remove the outdated medications.

Based on observation and interview, the facility failed to maintain a clean, safe and sanitary environment for patient care on three (Broadway, Forest Park, and Jefferson) of three campuses. The facility is responsible for the safety, diagnosis and treatment of patients seeking hospital services. The systemic failure resulted in the facility being out of compliance with 42 CFR 482.41 - Condition of Participation: Physical Environment. The facility census was 117.

Refer to evidence A-0701and A-0724 for findings.

Based on observation and interview, the facility failed to:
-Ensure that rooms were maintained and damages repaired to 11 of 190 patient rooms on the Broadway campus, and seven rooms and two common areas of the Forest Park campus.
-Ensure that 148 out of 148 rooms indicated as being on the amended bed count form as patient use beds were maintained ready for patient use with all required systems such as nurse call, oxygen, vacuum, doors that latch and access to toilet or shower available in rooms at the Jefferson Building campus. At this campus there were no patients currently receiving services. This deficient practice affected all three campuses of the facility.

The facility also failed to protect patient's physical health and safety by failing to ensure that:
- The physical condition and cleanliness of patient care areas were safe for patients with minimal potential for injury, affecting patients on the third floor psychiatric unit at the Broadway campus (30 patients) and the psychiatric unit at the Forest Park campus (six patients). The facility census was 117.

Findings included:

1. Observations during a tour of the Forest Park campus, conducted on 04/26/11, showed the following:

-Observation at 9:06 AM showed the toilet to be badly stained in the bathroom of patient room 309.
-Observation at 9:12 AM showed the sink to be badly stained and clogged in patient room 315.
-Observation at 9:55 AM showed the toilet to be badly stained in the bathroom of patient room 274.
-Observation at 9:58 AM showed the wall covering to be bubbling away from the wall in patient room 272.
-Observation at 10:58 AM showed the wall covering to be bubbling away from the wall in patient room 205.
-Observation at 10:59 AM showed the wall covering to be bubbling away from the wall in patient room 206.
-Observation at 11:02 AM showed the linoleum floor covering to be cracked in patient room 202.
-Observation at 11:15 AM showed the wall around the water fountain in the corridor adjacent to patient room 178 to be gouged and chipped.
-Observation at 11:21 AM showed the baseboard to be peeling away adjacent to the double doors to the lounge/television room near patient room 164.

Staff HH Director of Security and Staff II engineering confirmed at that time the need for repair.


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2. During a tour of the psychiatric unit at the Forest Park facility on 04/27/11 the following observations were made:
- An area (approximately 9 inches by 6 inches) of plaster was missing near the towel dispenser in the Men's Room used by patients. A water fountain near the Nursing Station had five large (approximately one foot by one foot each) areas of plaster patches, which were crumbling. These areas prevent appropriate cleaning and disinfecting of the physical environment.

During an interview on 04/27/11 at 9:20 AM, Staff CC, Nurse Manager, stated that a water leak was discovered in the wall behind the water fountain near the Nursing Station. The water was turned off when it was determined that repair would require removal of portions of the wall and the water fountain would remain out of operation until the budget allowed funding for repairs.
- The unit was dirty, as evidenced by:
- A large dried coffee spill on the floor of the Day Room.
- Several large dust balls within an ante-room between two seclusion rooms near the Nursing Station.
- Five golf ball sized white spots on the wall above an unoccupied bed in a patient room.
- The "Dirty" Utility Room on the ward showed:
- Crumpled paper trash on the floor;
- Mop buckets covered with splotches of dried, dark material;
- A large sink with black particles dried in the base and crusty gray particles adhering to drain holes; and
- A film of dust covered the floor of the room.

During an interview on 04/27/11 at 9:20 AM, Staff CC, Nurse Manager, stated that the janitor who formerly worked on this unit was transferred to the Broadway campus as a result of facility down-sizing, and janitorial services had not been as thorough since that time. Staff CC stated that the spots on the wall were probably spots of toothpaste, but the wall should have been cleaned after the patient was discharged.


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Observation on 04/27/11 of the Jefferson Campus showed the following:
3. During an interview on 04/27/11 at 9:41 AM Staff NN stated that at the Jefferson campus the unit which would supply vacuum (suction) to the building had been removed. The system supplying oxygen to the building would need to be connected again and tested as it had been disconnected.

4. Observation starting at 10:53 AM on 04/27/11 of rooms 330, 331, 332, and 333, showed they had been renovated and previously used by physical therapy services. The rooms were open to each other with only partial walls separating the interior space of each room. Each room had a separate door into the corridor. Room 330 had a sink only and the toilet had been removed from the room. Room 331 had both the toilet and sink removed. Room 332 previously had a shower which had been removed with the toilet and sink removed also. Room 333 had a toilet and sink remaining in the room. For each of the four rooms there was only one oxygen outlet available in each room. None of the four rooms had an over bed light or reading light, vacuum outlet, nurse call system or provision for privacy curtains.

Review of the list provided by the facility of the beds which they request be licensed indicated that each of the four rooms were to accommodate two patients each.

5. Observation starting at 11:05 AM on 04/27/11 showed room 334 was previously a laundry room and had one oxygen outlet with no outlet for vacuum. There was no nurse call system in the room. The list provided by the facility showed the room was to be used for one patient.
Room 335 was previously used as an office and had one oxygen outlet with no outlet for vacuum. There was no sink, toilet, shower or nurse call system in the room. The list provided by the facility showed that the room was to be used for two patients.

6. Observation on 04/27/11 starting at 11:10 AM showed that rooms 336 and 337 were open to each other and separated only by a partial wall. Neither room had vacuum outlets. Room 336 had a hand wash sink in the bathroom and room 337 had no sink. There was no toilet or shower in either room. There were no provisions for privacy curtains. The list provided by the facility indicated that each room was to provide a maximum of four patients in each room.

7. Observation on 04/27/11 at 11:15 AM showed that rooms 343, 345, 348 and 349 were missing door latching hardware. A nurse call system for rooms 341, 343, 345, 347, 348 and 349 was present but did not function. The dining room for the area was missing 26 ceiling tiles. Each of the rooms was listed as having the potential for two patient beds.

8. Observation during tour on 04/27/11 at 11:25 AM showed room 360 was missing door hardware to keep the door latched. The bathroom had water damage to one wall near the toilet. There was a hose from the ceiling draining to the toilet. During an interview at time of tour Staff NN stated that there was a problem with the chiller's (unit on roof) drainage and that was the reason for the hose. The outside wall of the room had damage from water over the entire wall to the left of the window. Room 362 had water damage to the outside wall in a section 20 by 12 inches located below the window. Room 364 had water damage to one half of the wall surface on the left side of the room and had damaged the unit which supplied electric and oxygen to the room. Each of the rooms according to the list supplied by the facility was to have two beds.

9. Observation on 04/27/11 at 1:30 PM showed rooms 220, 221, 222, 223, 224, 225, and 226 had roller latches (does not latch positively to keep door closed) on the corridor doors. These rooms had no vacuum outlet in the room. There was a nurse call system present but was non-functional. Room 230 in this area was currently being used as a small laboratory with desks, countertops and laboratory equipment. There was no outlet for vacuum and the nurse call was non-functional. Each of the rooms was listed as having a maximum of two beds in each room.

10. Observation on 04/27/11 at 3:00 PM showed rooms 251, 252, 253, 254, 255 and 256 were previously used for radiology space and still contained the equipment in the rooms. The rooms had no provision for oxygen or vacuum outlets, nurse call system or over bed lighting. There was no provision for privacy curtains in any of the rooms which all were two bed occupancy rooms. Rooms 252 and 253 shared the same open space and neither had a toilet or shower in the rooms. Room 251 had been renovated and measured 88 square feet (would need 160 square feet) with no provision for oxygen, vacuum, toilet or hand wash sink. Each of the rooms was listed on the form provided by the facility as having the potential for two patient beds.

11. Observation on 04/27/11 at 10:05 AM showed rooms 301, 303, 304, 305, 306, 307, 308, and 309 to have no provision for an outlet for vacuum. There was a nurse call system present but it did not function. Rooms 301, 303, 304, 307, and 308 were listed as having two beds per room. Rooms 305 and 306 were listed as having one patient bed.

12. Observation on 04/27/11 showed rooms 315 and 316 were missing the door hardware to the corridor doors. Each room was listed as having one patient bed.

13. Observation on 04/27/11 at 2:00 PM showed rooms 260, 262, 263, 264 and 265 all had roller latches on the corridor doors which would not keep the doors positively latched. Room 262 had water damage to the ceiling area and the outside wall. All five rooms had a nurse call system which did not function. The rooms were listed as having two patient beds per room.

14. Observation on 04/27/11 at 3:20 PM showed that rooms 441, 446, 447, and 449 had no provision for oxygen or vacuum outlets. Rooms 441, 445, and 447 had no provision for privacy curtains. Room 446 had water damage to six ceiling tiles as evidenced by stains on the tiles. Rooms 441, 445 and 447 were listed as having two beds per room. Rooms 446 and 449 were listed as having one bed per room.

Observation on 04/26/11 on the Broadway Campus showed the following:
15. Patient room doors to rooms 517 and 624 did not latch securely and required repair.

16. Patient rooms were observed to have damage to bathroom equipment and walls/ceilings from water as evidenced by stains:
-Room 402 had three stained ceiling tiles in a room with four beds. The knob to control the shower had been removed to prevent tampering by patients.
-Room 403 the soap dispenser near the hand wash sink had the cover removed and it was observed that the toilet paper holder had been damaged and three rolls of toilet paper were kept on the floor of the bathroom near the toilet.
-Room 409 had damage from water around the wall near the toilet
-Room 322 had a missing shower drain cover which left the drain open and interview with a patient who identified themself as a patient staying in the room stated she/he had placed two wash cloths into the drain and complained of sharp edges as the reason for the wash cloths covering the drain. The bathroom door was missing a pull (handle) and could not be opened. The patient stated that when needing to toilet they had to utilize a bathroom down the hall for the last several days as they could not pull open the bathroom door in their room. The vent used to ventilate the bathroom had the cover removed by maintenance and the vent was covered with enough dust/lint to prevent air flow. A piece of toilet paper held near the vent by the maintenance worker did not indicate air flowed through the vent.
-Room 318 had a hole in the ceiling of the bathroom which measured approximately six by six inches.
-Room 307 had three stained ceiling tiles in the bathroom area. The floor of the shower had discoloration over half the surface of the floor.
-Room 304 had discoloration from stains over half the surface of the shower floor and the bathroom floor was observed to have stains on portions of the floor.
-Room 305 had an area in the bathroom which had been previously repaired by placing linoleum on the floor and current damage to this patched area was present in an area approximately 12 by 12 inches. The ceiling tiles in the bathroom area were noted to have two with stains and one was damaged.
-Room 339 had been previously repaired for the wall around the toilet and the area was damaged again in an area approximately two foot by four foot. There were pieces of the drywall on the floor of the bathroom.

17. During an interview on 04/25/11 at 2:23 PM, while on the third floor psychiatric unit, Patient #15 asked this surveyor and Staff Z, Nurse Manager, to view areas of concern that he/she stated had been reported to nursing staff without a response or investigation. Patient #15 related numerous complaints about the condition of his/her room and that nursing staff wouldn't listen to the patient's concerns.
Observation of Patient #15's room showed the following:
- Curtains were missing from one of two windows in the room, which diminished patient privacy, and allowed external light to potentially interrupt sleep;
- A handle on the exterior of the bathroom door was pulled out of the wood on one side, allowing the screw to be exposed;
- A ceiling tile over Patient #15's bed was stained and displaced, and pieces of insulation had fallen out of the hole;
- The grate covering the shower drain was missing, allowing the potential for injury by a toe caught in the drain or for items to be dropped in the drain; and
- The soap dispenser on the wall over the sink fell away from the wall when soap was dispensed, potentially allowing access to a large volume of the soap solution.

Based on policy review, observation and interview, the facility failed to:
- Maintain the kitchen equipment on the Broadway Campus to provide foods of palatable temperature, which had the potential to affect all patients at the Broadway Campus;
- Ensure expired supplies were removed from patient care areas in the Surgical Department of the Broadway campus and the Emergency Department's (ED) of both the Broadway and Forest Park campuses, which had the potential to affect all patients receiving care in the Surgical Department and ED's. The facility sees approximately 2250 patients per month in the two campus ED's, and performs approximately 200 procedures per month in the surgical department.

The facility census was 117.

Findings included:

1. During interview on 04/25/11 at 11:00 AM, Staff III, the Executive Chef, stated that the following equipment was not working or in need of repair in the kitchen at the Broadway Campus:
-the meat slicer (only one in the kitchen;
-the soup tilt kettle;
-steamer (leaks);
-the hot holding cabinet near the steam table (needs a new gasket; existing gasket is torn to shreds);
-the deep fryer (clicks off in the middle of cooking);
-one stove top grill is used only as a warmer; it cannot be used to cook foods.

Observation during the noon meal on 04/25/11 at 11:00 AM, showed the hot foods on the plate were at only 120 degrees Fahrenheit at the time of tray delivery to the patients' rooms on the fifth floor. The expected temperature would be, at a minimum 135- 140 degrees Fahrenheit.






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2. Review of the facility's policy titled, "Packaging Materials, Shelf Life, and Rotation of Supplies" revised on 12/20/10, showed that supplies which are dispensed through Central Service will be checked by Central Service once a week and that if items will expire, within that week, Central Services will pull those items and return them to Central Service (page 1). The policy added that Central Service Staff will check for expired supplies in the Surgery Department (page 3).

Observation on 04/28/11 at 9:45 AM of Surgical Suite #3, showed the following outdated supplies, which were verified by Staff M, Chief Nursing Officer (CNO):
- Two pair of sterile gloves, size 7.5, Lot #010728232, expired 07/06;
- One pair of sterile gloves, size 6.5, Lot #010828352, expired 08/06;
- Two Endotracheal Tubes (a tube passed through the mouth and into the lungs to assist with breathing), size 7.0, Lot #0601000815, expired 01/11;
- Two yellow top blood collection tubes, Lot #9127988, expired 05/10;
- One gold top blood collection tube, Lot #0029686, expired 01/11;
- One gold top blood collection tube, Lot #0057641, expired 02/11;
- One red top blood collection tube, Lot #9068944, expired 03/11;
- One red top blood collection tube, Lot #9029183, expired 02/11;
- Two green top blood collection tubes, Lot #9175247, expired 11/10;
- One blue top blood collection tubes, Lot #9215142, expired 05/10.

During an interview on 04/28/11 at 9:45 AM, Staff PP, Director of Surgical Services, stated that the Operating Room staff are responsible for ensuring that expired supplies are removed from the surgical suites.

3. Observation on 04/28/11 at 10:15 AM of an orthopedic supply room in the surgery department, showed five disposable cuffs (used to create a tourniquet), Lot #60440072, expired 03/11. The outdated cuffs were verified by staff M.

4. Observation on 04/26/11 at 3:00 PM of ED Exam Room 7, showed four bottles of Pedialyte (for treatment of pediatric dehydration), Lot #77712X8, expired 12/01/10, and one Pedialyte Apple Juice, Lot #755052501, expired 10/01/10. All outdated items were verified by Staff WW, ED Director.

5. Observation on 04/26/11 at 3:17 PM in an ED exam room, showed one Cricothyrotomy Catheter (used to create an airway through the neck when a patient is unable to breathe), Lot #2067539, expired 03/11. The outdated item was verified by staff WW.

6. Observation on 04/27/11 at 9:10 AM in an ED exam room, showed four pairs of sterile gloves, Lot #05D0592, expired 04/10. The outdated gloves were verified by staff WW.

During an interview on 04/26/11 at 2:55 PM, staff WW stated that ED staff are responsible for checking and removing outdated supplies from the ED, and that staff are scheduled monthly to ensure expired supplies are removed.

Based on policy review, observation, record review, and interview, the facility failed to ensure the following:
- That facility staff followed the facility policy for hand hygiene;
- That facility staff followed the facility policy for contact isolation procedures;
- That all surgical equipment received a full sterilization cycle.
The systemic failure resulted in the facility being out of compliance with 42 CFR 482.42 - Condition of Participation: Infection Control. The facility census was 117.

Refer to evidence A-0749 for findings.

Based on policy review, observation, record review, and interview, the facility failed to ensure staff followed the facility's policy for hand hygiene for:
- One patient (#65) observed during a security event;
- Four patients (#18, #1, #2, and #3) of 16 patients observed during medication administration; and
- One patient (#5) observed during wound care. This had the potential to affect all patients.

The facility also failed to follow appropriate contact isolation measures to prevent the spread of infectious disease for two (#29 and #52) of two patients observed in the Intensive Care Unit (ICU). This had the potential to affect all patients, staff, and visitors.

The facility also failed to ensure that all items received a full sterilization cycle in the surgical unit due to the scheduling of patients and the number of instrument sets available for a specialized procedure. The facility census was 117.

Findings included:

1. Record review of the facility policy titled, "Hand Hygiene," last revised 4/04, gave the following direction:
-If hands are not visibly soiled, or not likely to be contaminated with bacterial spores, use an alcohol-based hand rub for decontaminating hands in all other clinical situations.
Examples:
-Before and after the use of gloves, as gloves may be or may become perforated;
-Moving from a contaminated body site to a clean body site during patient care;
-After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; and
-After contact with mucous membranes, non-intact skin, body fluids or excretions and wound dressings if hands are not visibly soiled.

2. Observation on 04/26/11 at 9:15 AM on the fourth floor adult psychiatric unit showed two security officers wearing gloves during an incident with Patient #65. The two security officers stood in the unit hall and then escorted the patient to the seclusion room where he/she was placed on the bed. The security officers continued to wear the gloves until they were dismissed from the unit. The officers removed the gloves and put them back in their pockets and failed to perform hand hygiene.

During an interview on 04/27/11 at 12:00 PM on the fourth floor adult psychiatric unit, Staff EEE, Security Guard, donned gloves. Staff EEE stated they [security guards] wore the gloves for protection of blood or other secretions if they had to 'take down' a patient with aggression. He/she was on the unit observing a patient with assault precautions. While the security guard was talking he/she wiped his/her nose several times with the same gloved hands. After a few minutes, the security guard removed the gloves and put them in his/her pocket. Staff EEE did not perform hand hygiene and did not throw the gloves in a trash container.

During an interview on 04/28/11 at 1:00 PM, Staff O, Infection Control Officer, stated that he/she hoped the security guards were not saving the gloves and reusing them for another patient.


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3. Observation on 04/25/11 at 2:30 PM showed Staff F, Registered Nurse (RN), entered Patient #1's room without using alcohol-based hand rub or washing his/her hands prior to administering the patient's medication.

4. Observation on 04/26/11 at 9:35 AM showed Staff G, LPN, entered Patient #2's room without using alcohol-based hand rub or washing his/her hands prior to administering the patient's medication.

5. Observation on 04/26/11 at 9:35 AM during medication administration for Patient #18 showed Staff DDD, LPN (licensed practical nurse), donned one glove on the left hand, drew medication from a vial into a syringe for injection, administered the medication into the arm of Patient #18, doffed the glove and put it in the trash container on the medication cart. The nurse failed to use hand hygiene after removing the glove.

6. Observation on 04/26/11 at 10:55 AM showed Staff H, RN, entered Patient #3's room without using alcohol-based hand rub or washing his/her hands prior to administering the patient's medication.

7. Observation on 04/26/11 at 10:30 AM during wound care showed Staff H, RN, wore gloves to remove Patient #5's coccyx dressing. Staff H continued to wear the same gloves to unroll gauze, apply normal saline to the gauze and pack the wound with the gauze. Staff H then removed the gloves and without using alcohol-based hand rub or washing his/her hands, applied a dry abdominal pad to the wound. Staff H gathered the trash, exited Patient #5's room, and placed the trash in the dirty utility room without using alcohol-based hand rub or washing his/her hands before exiting the patient's room.

8. In an interview on 04/25/11 at 3:00 PM, Staff I, Chief Administrative Supervisor, stated staff is to use hand gel when entering and exiting patient's rooms. On 04/26/11 at 11:00 AM, Staff I stated staff should wash their hands or use gel between dirty and clean procedures. Staff I said Staff H should have removed gloves and used hand gel or washed his/her hands after removing Patient #5's dressing and before applying a clean dressing.

9. Record review of facility policy titled, "Transmission Precautions" revised on 11/10, showed that staff should (page 2):
- Put on Protective Equipment before entering the room;
- Avoid moving items in and out of the patient's room;
- Not allow items to leave the room without being contained or disinfected. If items need to be removed they must be adequately cleaned and disinfected prior to use on another patient;
- Not take the patient's record in the patient's room.
The policy further showed that contact precautions should be followed by (page 3):
- Wearing gloves when entering a room;
- Performing hand hygiene immediately after removal of gloves;
- Wearing an isolation gown upon entering a room if patient and/or environmental contact is anticipated;
- Ensuring hand washing is completed after gown and glove removal and that hands and clothing do not contact the potentially contaminated surfaces in the room.

Record review of the facility policy titled, "Infection Control - Hand Hygiene" revised on 04/04, showed that hand hygiene should be done before and after the use of gloves and after contact with objects in the immediate vicinity of the patient (page 1).

Review of a "Contact Isolation" sign showed that staff should do the following while caring for patients in contact isolation:
- Wear gloves when entering the room, change gloves after contact with infective material, and remove gloves before leaving the room;
- Wash hands before leaving the room;
- Wear a gown if you will be in close contact with the patient or items in the room;
- Items brought into the room should be contained or disinfected before leaving the room.

10. Observation on 04/26/11 at 9:00 AM showed Staff RR, Patient Care Technician (PCT), in Patient #52's contact isolation room (diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA) - (a bacterial infection that is highly resistant to many antibiotics). While in the patient's room, staff RR failed to:
- Wear gloves at all times;
- Wash hands before he/she placed gloves on;
- Prevent exposure to potentially contaminated items in the room by removing his/her gloves and picking up a potentially contaminated observation flow sheet (a paper form which is part of the patient's permanent record), which had been lying on the counter.

During an interview on 04/26/11 at 9:05 AM, Staff SS, Director of the Intensive Care Unit (ICU), stated that staff should wear gloves at all times when in a contact isolation room and that staff should wash their hands before putting on gloves.

11. Record review of facility policy titled, "Standard Precautions" revised on 11/10, showed the patient's chart should not be allowed to come into contact with infectious material or objects that may be contaminated with infectious material. If contamination does occur, the page(s) should be placed in a clear plastic bag and photocopied before being disposed of (page 5).

Review of current patient #52's medical record on 04/28/11, showed the original observation flow sheet from 04/26/11 had been placed in the patient's chart, after the form had been written on, while lying in patient #52's contact isolation room for approximately 24 hours.

During an interview on 04/28/11 at 3:05 PM, Staff O, Infection Control Officer, stated that the facility hasn't figured out how to manage paperwork that is taken into a patient's contact isolation room, if it becomes contaminated, and is to be placed in the patient's permanent record.

12. Record review of the facility policy titled, "Infection Control - Hand Hygiene" revised on 04/04, showed that soap and water should be used whenever caring for a patient with C-diff (Clostridium Difficile, a highly contagious spore bacterium found in feces that can cause serious illnesses including botulism, tetanus, and gas gangrene), (page 1).

Observation on 04/26/11 at 9:40 AM showed Staff X, Dialysis nurse, in Patient #29's isolation room (diagnosed with C-diff) while the patient received renal dialysis (removal of waste from the body when a patient's kidneys don't work properly). Staff X was wearing a protective gown which was not tied at the waist. Staff X was also observed touching multiple surfaces in the patient's room without gloves on, then reach underneath his/her protective gown and answer a phone, potentially contaminating his/her clothing and phone. When staff X eventually put on gloves, he/she failed to wash his/her hands prior to putting them on.

During an interview on 04/26/11 at 9:07 AM, staff SS stated that protective gowns should be tied at the waist when worn by staff providing care to isolation patients, to prevent spreading disease.

During an interview on 04/26/11 at 9:50 AM, staff O stated that staff must use soap and water for hand washing after providing care for a patient with C-diff because alcohol sanitizers are not effective for removing C-diff spores (bacterial cells that rapidly reproduce).

During an interview on 04/26/11 at 10:30 AM, staff O stated that staff is unable to wash their hands with soap and water when patients receive dialysis in-room because the dialysis machine uses the water from the sink, preventing staff access to water.

Review of current patient #29's medical record showed that the patient received dialysis on:
- 04/12/11 for one hour and 55 minutes;
- 04/13/11 for three hours;
- 04/14/11 for two hours and 50 minutes;
- 04/15/11 for three hours and five minutes;
- 04/16/11 for three hours and two minutes;
- 04/18/11 for three hours;
- 04/19/11 for three hours;
- 04/20/11 for three hours and three minutes;
- 04/21/11 for three hours and 5 minutes;
- 04/26/11 for three hours.
Staff caring for patient #29 during in-room dialysis would not be able to perform appropriate hand hygiene during this time.

Observation on 04/29/11 at 10:00 AM, showed the closest hand washing station to patient #29's room was approximately 20 feet away, behind a key panel locking door. This would require staff to leave patient #29's isolation room during dialysis to wash their hands, potentially contaminating other surfaces or areas in the department.

During an interview on 04/29/11 at 9:45 AM, staff O stated that the facility does not have a process in place for hand washing with soap and water during in-room dialysis, and that staff would have to use gloves and hand sanitizer instead of soap and water.

13. Record review of facility policy titled, "Standard Precautions" revised on 11/10, showed that care should be taken when collecting laboratory specimens to avoid contamination of the outside of the container and that lab specimens should be transported in a specimen bag.

During an interview on 04/26/11 at 9:55 AM, Staff GGG, Medical Technologist stated that the process for drawing blood on a patient with C-diff would be to:
- Place Personal Protective Equipment on, such as gloves and a gown;
- Prepare what items would be taken into the room, taking only what was necessary to collect the blood sample;
- Draw the patient's blood;
- Leave the patient's room, using gel sanitizer to wash hands;
- Place the potentially contaminated blood tubes in the blood draw transportation basket, with other unused blood collection tubes.

During an interview on 04/26/11 at 9:30 AM, staff O stated that he/she didn't believe that the contamination of blood collection tubes was as concerning as other forms of contamination, such as a staff member contaminating their clothes for example, because the lab tubes don't go into another patient's room.

During an interview on 04/28/11 at 3:05 PM, Staff QQ, Lab Director stated that lab staff, during routine lab draws, will draw multiple patients' labs, moving from patient room to patient room with their blood draw transportation basket.

14. Observation on 04/26/11 at 9:10 AM showed Staff TT, Respiratory Therapist, enter the room of patient #29 with a plastic bag containing ice. Staff TT placed the plastic bag on the patient's over the bed table, a potentially contaminated surface. After collecting a blood sample, staff TT placed the blood sample in the ice filled bag, took the plastic bag out of the room, and placed it on a cart located in the hall, potentially contaminating the cart. Staff TT then washed his/her hands with gel sanitizer instead of using soap and water. Staff TT picked up the plastic bag and left the department without containing the plastic bag to prevent further possible contamination. The observation was verified by staff SS.

15. Observation on 04/26/11 at 9:10 AM showed Staff UU, Physician, ask staff SS why staff caring for patient #29 were in isolation gowns. Staff SS informed the physician that the patient was positive for C-diff. Staff UU proceeded to enter the patient's room without a protective gown, place a contaminated isolation stethoscope around his/her neck, and examine the patient. While examining the patient, the physician came in contact with the patient and rested against the patient's bed, potentially contaminating the physician's clothing. The observation was verified by staff SS.

During an interview on 04/26/11 at 9:30 AM, staff O stated that if physicians are observed without appropriate protective equipment during patient care, the facility sends out a letter to the physician to inform them of appropriate use of the protective equipment.


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16. Review of a facility policy titled "Flash Sterilization" (Flash sterilization: A process designed for the steam sterilization of patient care items for immediate use) revised on 07/01/09, showed the purpose was to acquire additional sterile items for surgical procedures when time does not permit sterilization by the wrapped method. Under the procedure section #8 it was stated that flashing of supplies should be done only when the item cannot be packaged, sterilized, and stored prior to use. Sterilization practices directly affect patient safety. These practices include flash sterilization, also known as the abbreviated cycle. Some facilities may take an abbreviated approach when flash sterilizing surgical instruments. If this approach to flash sterilization does not include the proper practice of each step of the sterilization process recommended by AORN (Association of periOperating Room Nurses), patients may be at risk.

Not adhering to all steps in the complete sterilization process for flashing and other types of sterilization may result in patients acquiring a surgical site infection or other poor outcomes. For example, improperly cleaned instruments used in ophthalmic (eye) surgeries, such as cataract instruments, may result in patients acquiring Toxic Anterior Segment Syndrome (TASS).

17. Record review of a document by the manufacturer of a device, referred to by the hospital as a "grasper" (term referring to several instruments used to hold tissue during surgery), showed that under a section titled "sterilization for the US (United States) market" (name of manufacturer) does not recommend the device be sterilized by "Flash" or chemical sterilization.

18. During an interview on 04/28/11 at 3:10 PM, Staff PP, Surgical Supervisor, stated that one of the surgeons had a favorite set of "graspers" and that there are three of these sets. Due to the number of patients scheduled by this surgeon on certain days, the facility cannot do a full cycle due to time limits and does the shortened cycle of sterilization in the surgical department so that the instruments are available for the next patient.

19. During an interview on 04/28/11 at 3:00 PM, Staff OO, in Central Supply, stated that surgical instruments were not sterilized in a full length cycle in the central sterile department until the evening shift as all instruments received from the surgical area. Then the full length sterilization cycle is performed by a staff person who only works at nights and not during the day.

During an interview on 04/28/11 at 1:20 PM, Staff OO stated that the use of the shortened cycle of sterilization (flashing) has gotten better (performed less frequently) in the surgical department as additional instrumentation had been acquired from another campus of the hospital.

20. During an interview on 04/28/11 at 10:10 AM, Staff PP stated during review of the sterilization logs that it could not always be determined which loads may have been done to sterilize the "graspers" or other instruments as the contents of the loads were not always documented. The number of "indicators" (card which indicates if the sterilizer functioned properly) does show which surgical patient and surgeon the instruments were used for in surgery. On 04/14/11, the "indicator" cards showed an eye surgeon needed 10 instruments or equipment "flashed" (short sterilization cycle) and a bariatric surgeon needed 5 instruments or equipment flashed. On 4/19/11 the "indicator" cards showed an eye surgeon needed six instrument sets "flashed" and a bariatric surgeon (grasper sets utilized for these procedures) had four instrument sets "flashed". The log also showed that during one week "flashed" sterilization cycles were done on 04/20/11 (twice), 04/25/11 (five times), 04/26/11 (five times), 04/27/11 (three times) and on 04/28/11 there were two cycles run.

21. During an interview on 04/28/11 at 10:45 AM, staff PP, Surgical Supervisor, stated that the Phaco Emulsifier (an instrument used to remove a lens in the eye) is not owned by the hospital and is brought in by a medical equipment representative on the days when cataract procedures are completed. The Emulsifier is "flashed" prior to the first procedure of the day and between eye procedures, because there is not enough time to complete a full sterilization cycle. Staff PP, Surgical Supervisor, stated that due to time constraints and the number of instrument sets preferred or available for surgery, the instruments had to be available more timely than processing in a full cycle would allow.

22. Review of a document provided by Staff PP, Surgical Supervisor, on 04/28/11, indicated that for the instrument sets containing the grasper devices, were "flashed" on 04/14/11 five times, 04/18/11 one time, on 04/19/11 two times, on 04/25/11 two times and on 04/27/11 one time.


29047

Based upon interview and review of facility records, the facility failed to provide general training to the nursing staff for the service of Organ Procurement. This had the potential to affect all patients. The facility census was 117.

Findings included:

Record review of the facility training records for nursing staff showed that nursing staff did not receive Organ Procurement training at orientation or annually.

During an interview on 04/29/11 at 10:30 AM, Staff JJ, Registered Nurse (RN), Intensive Care Charge Nurse, stated he/she was responsible for overseeing the Organ Procurement process, and confirmed that the facility did not provide training to nursing staff with regard to organ procurement. Staff JJ also phoned Staff HHH, Education Nurse, who concurred that general training was not provided for nursing staff.