HospitalInspections.org

Based on review of hospital policy and staff interview the hospital failed to include what the hospital's expectation were for the initial treatment of an emergency in its policy.

Findings include:

On 02/02/10 at 11:00 a.m. Surveyor #22198 reviewed the hospital's current policy #01-063-02, entitled "Nurse Stat" with Director of Quality and Director of Nursing Staff A, who acknowledged that the emergency policy did not define what the hospital expected their staff to do for initial treatment and stabilization of an emergency while awaiting the ambulance for transfer.

Based on tour, observation and staff interview the hospital failed to provide a safe environment for 10 of 10 current in-patients.

Findings include:

On 02/01/10 at 2:35 p.m. during tour and observation Surveyors #22198 and #20878, along with Registered Nurse B, noted for rooms #10, 11 and 12 the plumbing, faucets and hinges were a potential suicide risk.

On 02/01/10 at 11:00 a.m. Director of Quality and Director of Nursing Staff A confirmed the hospital was not able to complete the changes in each patient room to replace or cover the fixtures that were potential suicide risks as of today 02/01/10.

Director of Quality Staff A confirmed the current in-patient census was 10 as of exit 02/02/10 at 11:00 a.m.

Based on review of the Quality Assurance Program Improvement Program (QAPI) and staff interview the hospital failed to include all hospital services, even those services provided under contract in the QAPI program.

Findings include:

On 02/01/10 through 02/02/10 Surveyor #22198 reviewed QAPI material and data provided by Director of Quality and Director of Nursing Staff A, however not all departments/services were included in the list of data collection.

On 02/01/10 at 4:00 p.m. Director of Quality and Director of Nursing Staff A confirmed to Surveyor #22198, as of today she had not received data for all the hospital departments to define problem areas to initiate a QAPI program.

On 02/02/10 at 11:00 a.m. Director of Quality and Director of Nursing Staff A confirmed to Surveyor #22198, as of today she had not included all services provided under contract, arrangement or agreement in the QAPI program or data collection to ensure these services were provided in a safe and effective manner.




26711

Based on observation, policy review and staff interview the Infection Control Committee failed to develop/update infection control policies to meet the current standards of practice for infection control.

Findings include:

On 02/01/10 between 10:40 a.m. and 11:15 a.m. Infection Control policies for staff and employees were reviewed, however standards of practice were from 1991.

Interview with Director of Quality and Director of Nursing Staff A confirmed that as of today the infection Control Committee had not updated all the infection control the standards of practice and policies and procedures.

On 02/02/10 at 8:40 a.m. during open record review and observation Surveyor #20878 observed Certified Nursing Assistant (CNA) C performing vital signs of two different patients, however failed to clean the vital sign machine between patients.

This was confirmed by Licensed Practical Nurse (LPN) D who acknowledged, CNA C should be cleaning the vital sign machine between patient uses.

On 02/02/10 at 11:00 a.m. during a review of the break in infection control practice by CNA C, Director of Quality and Director of Nursing Staff A acknowledged the need to update the infection control standard of practice and policies and procedures and educate the staff.