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Based on document review and staff interview, the governing body failed to ensure all hospital contracted services were subject to quality assessment and performance improvement (QAPI) evaluation.

Findings:

1. On 11/13/14, the hospital's QAPI meeting minutes for 2013 through current were reviewed. There was no documentation that all hospital contracted services were evaluated through the QAPI process.

2. The leadership staff stated the hospital did not evaluate all contracted services through the QAPI process.

Based on document review and staff interviews, the hospital failed to ensure that there was a complete list of all contracted services.

Findings:

1. On the morning of 11/12/14, surveyors requested a list of all contracted services including the scope and services provided. Administrative staff provided the surveyors with a list that was incomplete and did not contain all contracted services.

2. On the afternoon of 11/13/14, administrative staff told surveyors that the list of contracted services was incomplete and missing "non-clinical"services.

Based on review of medical records, policies and procedures and hospital documents and interviews with hospital staff, the facility failed to ensure patient restraints were necessary to protect the patient and staff and discontinued/removed as soon as possible. This occurred in one of three medical records (Record #30 of Records #25, 30, and 31) reviewed for patients identified as having restraints applied.

Findings:

Record #30 - The record contained order for "soft" restraints from 10/18/14 through 10/21/14. Nursing staff documented bilateral soft wrist restraints were used from 10/18/14 at 2300 until 10/22/14 at 0700.

With the exception of 10/19/14, no reason was documented. The reason documented on 10/19/14 was "medically approved ventilator protocol". Nursing documentation did not support the need for the restraints. When documented, the nursing documentation listed the patient's behavior as appropriate, calm and/or cooperative.

The above findings were reviewed and verified with Staff NNN at the time of review on 11/13/14 and again during the exit conference on the afternoon of 11/13/14. No further information or documentation was provided.

Based on review of medical records, policies and procedures and hospital documents and interviews with hospital staff, the facility failed to ensure patient restraints were applied according to specific/complete orders for the restraints. This occurred in three of three medical records (Records #25, 30 and 31) reviewed for patients identified as having restraints applied.

Findings:

1. Record #25 - The record only contained one order for restraints - the order for restraints on 11/13/14 only said "soft". The order did not specify the location or reason for the restraint. Nursing documented the patient was originally placed in bilateral soft wrist restraints, but was changed to keyed bilateral wrist leather restraints at 0445 until they were discontinued at 1100. There was no order for the keyed bilateral wrist leather restraints.

2. Record #30 - The record contained order for "soft" restraints from 10/18/14 through 10/21/14.
a. The order did not specify the location of the restraints. Nursing staff documented bilateral soft wrist restraints were used from 10/18/14 at 2300 until 10/22/14 at 0700.

b. With the exception of 10/19/14, no reason was documented. The reason documented on 10/19/14 was "medically approved ventilator protocol". Nursing documentation did not support the need for the restraints. When documented, the documentation listed the patients behavior as appropriate, calm and/or cooperative.

3. Record #31 - The record documented the patient was admitted to the emergency room (ER) on 10/16/14 and placed in bilateral upper and lower soft restraints. The ER physician's order only said "soft". The order did not specify the location or reason for the restraint. While the patient was still in the ER, the ER physician restraint order was changed to keyed leather restraints with a time limit of four (4) hours. This same order was renewed after the patient had been transferred to the nursing unit. Nursing staff documented the patient originally had bilateral upper wrist and lower ankle soft restraints that were changed at 10/16/14 at 2319 to bilateral upper keyed leather wrist restraints and soft ankle restraints. The restraints were discontinued/removed at 0720 on 10/17/14.

4. The above findings were reviewed and verified with Staff NNN at the time of review on 11/13/14 and again during the exit conference on the afternoon of 11/13/14. No further information or documentation was provided.

Based on medical record review and interviews with hospital staff, the hospital does not ensure that all entries in the medical record contain the date and time when they were signed or authenticated in electronic and written form by the person responsible for the services provided. This occurred in three (Records #15, 16 and 17) of three interventional radiology medical records reviewed.

Findings:

Medical records were reviewed on the afternoon of 11/13/14.

Medical records # 15, 16 and 17 contained consents for interventional radiology procedures that did not contain the date and time when the consents were authenticated by the physician or licensed practitioner. This was confirmed by Staff GG.

Based on clinical record review and staff interview, it was determined the hospital failed to maintain complete medical records. This occured in three of three (Records #11, 12, and 13) surgical records reviewed.

Findings:
Medical records were reviewed on 11/13/14, with Staff U.

Three (Patients # 11, 12 and 13) of three surgical records reviewed did not contain complete intravenous fluids (IVF's) documentation.

The medical records did not contain the amount of IVF's administered during the perioperative period.

The medical records did not document when the IVF's were administered.

The above information was confirmed by Staff U during chart review.

Based on observation and staff interview, it was determined the hospital failed to ensure therapeutic facilities were provided in areas specifically designed for those purposes.

Findings:

The surgical department (OR) was toured on the afternoon of 11/12/14 with hospital staff.

A hallway adjacent to the OR had been redesigned and designated unrestricted.

Two endoscope rooms with negative air flow and a storage room for sterile supplies were located in the hallway.

Pain management procedures, which require positive air flow, were being performed in endoscope room #1.

The above information was confirmed by Staff Z during the tour.

Based on hospital document review and staff interview, it was determined the hospital failed to ensure appropriate humidity levels were maintained in the various areas of the surgery department (OR). Review of the temperature and humidity logs for the OR documented humidity levels below the accepted range of 30-60%, this was confirmed by Staff JJJ on the afternoon of 11/12/14.

Based on review of hospital documents and meeting minutes, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, were processed through quality assessment and performance improvement (QAPI) committee and:

1. Were monitored throughout the hospital, reviewed and analyzed;

2. Corrective actions were taken to prevent, identify and manage infections and communicable diseases with measures that resulted in improvement on an ongoing basis; and

3. Corrective actions were followed to ensure improvement resulted and alternative solutions/actions were not needed.

Findings:

On 11/12 and 13/14 hospital staff # BBB, CCC, and M told the surveyor that the duties for the infection control committee were handled through the Medical Quality Committee. The surveyor review meeting minutes for 2013 and 2014.


1. The meeting minutes did not show analysis of the infection control data submitted and generally contained no recommendations other than continue to "monitor". When corrective action was identified, there was no time listed for follow-up to ensure corrective actions were effective and sustained.

2. Surveillance data reviewed with Staff M on 11/12/14, did not demonstrate Staff M observed processes for surgical services. Staff M stated she had not gone to the surgical services area to inspect or observe processes to ensure infection control policies and procedures were being followed.

During the tour of surgical services on 11/12/14, the surveyors and hospital staff observed:

Operating Room #1:
Corrugated boxes
Staff in OR #1 wearing "dangling" earrings that were uncovered
Staff in OR #1 exited the OR and re-entered wearing non-sterile latex gloves.
The above information was confirmed by Staff M during the tour of the OR.

OR #4: Corrugated boxes in the substerile room. This was confirmed by Staff Z during the tour of the OR on 11/12/14.

3. Hand hygiene surveillance did not include all departments or disciplines. This was reviewed and verified with Staff M at the time of review on 11/12/14. Staff M stated she could not get all departments to always provide documentation of hand hygiene observation.

Based on medical record review and staff interview, it was determined the hospital failed to ensure there was a registered nurse circulator solely dedicated to care for patients during conscious sedation procedures. This occurred in four ( Patient #8, 9, 10 and 18) of four medical records reviewed for patients who received conscious sedation.

Findings:

Medical records were reviewed on the afternoon of 11/13/14.

According to the medical records, Patients # 8, 9, 10 and 18 all received conscious sedation. There was no evidence that another qualified registered nurse was in the room and to fulfill the circulator duties. This was confirmed by Staff U during medical record review.

According to the Association of periOperative Registered Nurses, (AORN) Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings 2013 Edition, page 417,

"... Recommendation IV: The perioperative registered nurse monitoring the patient receiving moderate sedation/analgesia should have no other responsibilities that would require leaving the patient unattended or would compromise continuous monitoring during the procedure... A designated perioperative registered nurse should continually monitor the patient during administration of moderate sedation/analgesia... An additional perioperative nurse registered nurse should be assigned to the circulating role during the administration of moderate sedation..."

Based on review of the hospital's operating room (OR) log and staff interview, the hospital failed to ensure the OR log contained all the required information.

Findings:

1. The OR and Procedure log were reviewed on the afternoon of 11/12/14.

2. The OR and Procedure logs were a computer generated register. The logs did not contain all the required information for inpatients, admitted to the hospital, that had procedures performed. This was confirmed by Staff M on the afternoon of 11/12/14 at 1500.

4. The Procedure log did not contain the name of the person administering the anesthesia and the name(s) of the circulating and scrub nurse(s).

3. The above information was presented to the hospital staff during the exit conference.