HospitalInspections.org

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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that Medicare patients were notified of their right to appeal their discharge to a designated Quality Improvement Organization (QIO), as demonstrated by 2 of 5 patients reviewed (Patients #701, #702).

Failure to provide such information to Medicare patients violates their right to appeal to the QIO if they feel they are being discharged inappropriately.

Reference: 42 CFR 405.1205(b) - "Hospitals must provide each Medicare beneficiary who is an inpatient a standardized notice, the "Important Message from Medicare", within two days of their admission and again within two calendar days before discharge."

Findings:

1. Record review of the hospital's undated policy titled, "Delivery of the Important Message from Medicare", no policy number, showed that the hospital's registrar, a case manager, the administrative secretary, or another designated hospital staff member would deliver a copy of "An Important Message from Medicare" (IM) to all Medicare inpatients within two days of admission. The patient would sign the letter, and hospital personnel would date the letter. A copy of the letter would be scanned into the patient's electronic medical record.

The policy showed if the patient's stay was greater than or equal to three days, a case manager or another designated hospital staff member would deliver a second IM letter within a minimum of four hours of discharge and a maximum of 48 hours of discharge. The patient would sign the letter, and hospital personnel would date the letter. A copy of the second IM letter would be scanned into the patient's electronic medical record.

2. On 03/08/18 at 3:20 PM, Surveyor #7 reviewed the medical records of five Medicare patients. The review revealed the following:

a. Patient #701 was a 68 year-old Medicare patient who had been admitted to the hospital on 02/01/18. The patient's electronic medical record included an IM notice that had been signed by the patient on 02/02/18 at 7:54 AM.

The patient was discharged on 02/07/18. There was no evidence that the patient or a family member had been given a second IM notice within 48 hours of the patient's discharge.

b. Patient #702 was a 74 year-old Medicare patient who had been admitted to the hospital on 02/02/18 and discharged on 02/20/18. The patient's electronic medical record did not include evidence that the patient had been given an IM letter within 48 hours of admission nor within 48 hours of discharge.

3. During an interview with Surveyor #7 at the time of the record review, a hospital computer informatics specialist (Staff #701) confirmed the findings above.
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Based on observation, interview, and document review, the hospital failed to ensure that lead shielding aprons used to protect patients during radiological procedures were maintained and routinely inspected by the hospital staff.

Failure to have a system in place to ensure that shielding is routinely inspected places patients and staff at risk of unnecessary radiation exposure.

Findings included:

1. Record review of the hospital's policy titled, "Annual Apron Testing", dated 01/25/18, read "Annual testing will be comprised of a combination of inspections using tactile, visual, and X-Ray."

2. On 03/07/18 at 6:00 PM during a terminal clean of operating room (OR) #6, Surveyor #1 observed several lead aprons hanging on a rack in the OR department. Upon inspecting the integrity of the aprons, Surveyor #1 found that one of the aprons (#09826) had a one inch tear exposing the lead from within. Surveyor #1 requested the hospital's testing log to see if the torn apron had been tested. Review of the log showed that 46 of the hospital's 150 aprons (30.6%) had not been tested. The apron that the surveyor found was one of the aprons that did not get tested.

3. On 03/09/18 at 10:00 AM, Surveyor #1 interviewed the Associate Radiation Officer (ARO) (Staff #103). During the interview, the ARO stated that shielding aprons on the list that did not receive testing were either decommissioned and/or had not been located. The ARO confirmed a better system for tracking shields was needed.
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ITEM #1 PERSONAL PROTECTIVE EQUIPMENT

Based on observation and review of policy and procedures, the hospital failed to ensure unimmunized hospital staff members wore surgical masks correctly when on duty as directed by hospital policy.

Failure to wear surgical masks correctly risks transmission of the influenza virus to patients and other staff members.

Findings included:

1. Record review of the hospital's policy titled, "Influenza Immunization for Healthcare Workers," Policy #4158222 dated 10/16/17, showed that hospital staff members who were not immunized against the influenza virus would wear a surgical mask at all times when on duty. The policy showed the mask was to cover the staff member's mouth and nose.

2. On 03/06/18 at 11:00 AM, Surveyor #8 observed an admitting department staff member (Staff #801) pushing a cart down the hall on the 4th floor. The staff member wore a mask that covered her mouth but did not cover her nose.

3. During an interview with Surveyor #8 at the time of the observation, the 4th floor Nurse Manager (Staff #804) stated that Staff #801 had not been immunized against the influenza virus and was wearing her mask incorrectly.

4. On 03/07/18 at 10:00 AM, Surveyor #8 observed an unimmunized registered nurse (Staff #803) speaking on her cell phone in the 5th floor hallway. The nurse wore her mask below her chin while talking.

5. During an interview with Surveyor #8 at the time of the observation, the Acute Care Unit Nurse Manager (Staff #805) stated that Staff #803 had not been immunized against the influenza virus and was wearing her mask incorrectly.


ITEM #2 CROSS CONTAMINATION

Based on observation, interview, and document review, the hospital failed to develop and implement infection control procedures that prevented cross contamination during the process of cleaning patient exam rooms in the emergency department.

Failure to prevent cross contamination during the cleaning and disinfection process places patients, visitors and staff at risk of exposure to infectious organisms.

Findings included:

1. Record review of hospital's undated procedural checklist titled, "Emergency Department Patient Room Cleaning Checklist", no policy number, showed the checklist did not include directions for staff regarding glove use, hand hygiene and measures to take to prevent cross contamination.

2. Record review of the hospital's volunteer packet titled, "Emergency Department Volunteer," dated January 2018, page 3 subtitled, "Room Cleaning," "Step 1. Always wear gloves..." Also under subtitled, "Restocking a Room," "Step 1. Wash your hands. Step 2. Put clean linens on stretcher..."

3. On 03/08/18 between 8:30 AM and 9:00 AM, Surveyor #1 observed and interviewed a housekeeper (Staff #101) while the housekeeper cleaned examination room #23 in the emergency department.

a. The housekeeper first dusted the examination light and the ceiling vent near the bed. The surveyor observed that the linens on the bed were clean.

b. During an interview at the time of the observation, the housekeeper informed Surveyor #1 that a nursing staff member routinely disinfects the medical equipment and changes the linen on the bed before a housekeeper cleans the examination room. Because of this current practice, the housekeeping staff is re-contaminating the bed and medical equipment by dusting high surfaces over lower surfaces that have been previously cleaned and disinfected.

c. The housekeeper then removed her gloves and did not perform hand hygiene prior to touching a clean curtain, thereby contaminating the curtain.

d. The housekeeper then performed hand hygiene and put on only one glove. After lifting the curtain and cleaning the bedside table, counter, and sink, the housekeeper then mopped the floor, emptied the garbage and cleaned the garbage receptacle. The housekeeper then proceeded to touch surfaces that had been previously disinfected.

4. On 03/08/18 between 9:00 AM and 9:20 AM, Surveyor #1 observed a volunteer (Staff #102) clean examination room #3 in the emergency department. During the observation, the volunteer removed the soiled linen and disinfected the bed, then preceded to touch clean bed linen with contaminated gloves.

5. During an interview with Surveyor #1, the hospital's Environmental Services Director (Staff #108) confirmed the findings above at the time of the observations.


ITEM #3 CLEANABLE SURFACES

Based on observation and interview, the hospital failed to provide a sanitary environment by ensuring furniture and other surfaces were non-porous and cleanable.

Failure to maintain a sanitary environment places patients and staff at increased risk of exposure to harmful pathogens.

Findings included:

1. On 03/07/18 between the hours of 9:00 AM and 11:30 AM, during a tour of the hospital, Surveyor #1 observed the following items that were in disrepair:

a. 5th floor nutrition room - The counter top under ice machine had a cracked surface

b. 4th floor nutrition room - The counter top under ice machine had a cracked surface.

c. 4th floor - A wooden coffee cart on 4 east had a cracked surface.

d. 4th floor rehabilitation room - One crutch had a torn arm pad.

e. 3rd floor nutrition room - The counter top under ice machine had a cracked surface. There were signs of mold inside the cabinet on the upper left corner.

f. 3rd floor between patient rooms #320 and #324 - The emergency supply cart was made of wood. The wood surface was worn down exposing the raw wood.

g. 3rd floor patient room #365 - The laminate shelf in patient restroom was taped together to keep laminate from falling off.

h. Emergency department patient room #23 - The stool in the room had a torn vinyl seat cover with an uncleanable surface.

i. Emergency department patient room #24 - The wall had peeling paint with exposed dry wall.

2. The Senior Director of Support Services (Staff # 104) confirmed these findings at the time of observations.

3. On 03/08/18 between the hours of 9:00 AM and 11:30 AM, Surveyor #1 interviewed the hospital's maintenance manager (Staff #105) regarding how the maintenance department is notified when furniture and equipment need repairs. The maintenance manager stated that department staff members were responsible for notifying the maintenance department when equipment is in disrepair.


ITEM #4 - WATER MANAGEMENT PLAN

Based on observation, interview, and document review, the hospital failed to develop and implement a water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to develop and implement a hospital-wide water management plan puts patients, staff and visitors at risk of infection from water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30 (6/2/2017): Subject line: "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"- "Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water." [Healthcare facilities must:]

"a) Conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens... could grow and spread in the facility's water system;

b) Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;

c) Specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained."

Findings included:

1. On 03/07/18 between the hours of 10:00 AM and 11:30 AM during a tour of the hospital with the Director of Support Manager (Staff #104), Surveyor #1 observed that the shower hoses in the shower rooms on the 4th floor and the sleep center were not positioned to allow for drainage of the water after use.

2. On 03/08/18 between the hours of 10:30 AM and 11:30 AM, Surveyor #1 interviewed and reviewed the water management plan with the hospital's maintenance manager (Staff #105). The water management plan showed that the risk assessment did not include devices which are known to spread and grow Legionella. The following devices were not included in the assessment:

a. Water-hammer arrestors

b. Expansion tanks

c. Electric and faucets with flow restrictors

d. Medical equipment (CPAP machines, heater-cooler units)

e. Shower hoses not hung properly to allow for drainage.

3. During the same interview, Surveyor #1 and the maintenance manager reviewed an Infection Control Risk Assessment (ICRA) and the infection prevention plan for construction that occurred at the hospital from 12/05/16 - 05/31/17. The ICRA indicated that during the project domestic water service would be intermittently shut off during the construction phase. The infection prevention plan associated with the ICRA did not identify procedures to prevent water stagnation in areas where water was turned off during the construction phase.


ITEM #5 - DISINFECTION OF PATIENT CARE EQUIPMENT

Based on observation, interview, and document review, the hospital failed to ensure that staff cleaned and disinfected hemodialysis equipment according to hospital policy.

Failure to clean and disinfect equipment places patients and staff at risk of infection.

Reference: Association for Professionals in Infection Control and Epidemiology (APIC) Guide to the Elimination of Infections in Hemodialysis (2010) - "Cleaning and disinfection of equipment and proper handling of reusable and disposable supplies is critical to the safety of patients ... All equipment, including the front of the dialysis machine, should be considered contaminated after a patient dialysis session ... Exterior (surface) cleaning and disinfection of the dialysis machine can be accomplished between each treatment using any approved EPA-registered disinfectant labeled for use in healthcare settings and in accordance with facility policy and procedure."

Findings included:

1. Record review of the hospital's hemodialysis contractor's policy titled, "Cleaning and Disinfection," Policy FMS-CS-IC-II-155-110A dated 03/20/13, showed that staff were to consider all equipment potentially contaminated with blood after use, and that staff were to clean and disinfect the dialysis machine after each dialysis treatment.

2. On 03/07/18 at 7:20 AM, Surveyor #6 inspected the Renal Equipment Storage Room, (room #B202) with the dialysis services manager (Staff #602). The surveyor made the following observations:

a. Dialysis machine #2KOSI80445 had a red smear (approximately 2 centimeters in diameter) on the front surface.

b. Reverse Osmosis (RO) machine #RO 0804028 had a dry, flaky residue (approximately 5 centimeter in diameter) on the top surface.

3. At the time of the observation, Surveyor #6 interviewed the dialysis manager about dialysis machine cleaning, disinfection and storage. The manager confirmed that the machines had not been cleaned and disinfected correctly. She stated that the machines stored in room B202 should be clean and ready for use.


ITEM #6 - ACCESS TO HANDWASHING SINKS

Based on observation and interview, the hospital failed to ensure unimpeded access to handwashing sinks.

Failure to maintain access to handwashing sinks discourages handwashing and places patients, staff, and visitors at increased risk of exposure to infectious organisms.

Reference: CDC 2002 Guideline for Hand Hygiene in Health-Care Settings, Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force - " ...the frequency of handwashing by personnel is affected by the accessibility of hand-hygiene facilities ...Easy access to hand-hygiene supplies, whether sink, soap, medicated detergent, or alcohol-based hand-rub solution, is essential for optimal adherence to hand-hygiene recommendations."

Facility Guidelines Institute (FGI) Guidelines for Design and Construction of Health Care Facilities (2006) - "A soiled workroom shall be provided and contain ... [a] handwashing station ..."

Findings included:

1. On 03/07/18 at 7:20 AM, Surveyor #6 inspected the Renal Equipment Storage Room, room #B202, with the Dialysis Manager (Staff #602). The surveyor observed that access to the handwashing sink was blocked by dialysis machines and equipment.

2. At the time of the observation, Surveyor #6 interviewed Staff #602 about access to the handwashing sink. Staff #602 acknowledged that the sink was blocked by the equipment.

3. On 03/07/18 at 1:10 PM, Surveyor #6 toured Rehabilitation Services with the Rehabilitation Manager (Staff #603). In the soiled utility room the surveyor observed that access to the handwashing station was blocked by therapy equipment.

4. At the time of the observation, Surveyor #6 interviewed Staff #603 about access to the handwashing station. Staff #603 acknowledged that the sink was blocked by the equipment.


ITEM #7 - ISOLATION PRECAUTIONS

Based on observation, interview, and document review, the hospital failed to ensure that staff members used isolation precautions to prevent transmission of infectious diseases.

Failure to prevent transmission of infectious agents puts patients, staff, and visitors at increased risk of exposure to communicable diseases.

Reference: CDC 2017 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings - "Healthcare personnel caring for patients on Contact Precautions wear a gown ... Safe Work Practices ... Limit surfaces touched ..."

Findings included:

1. Record review of the hospital's policy titled, "Isolation Precautions," Policy #4566426 dated 02/07/18, showed that staff entering the rooms of patients on Contact Enteric Precautions and Droplet Precautions must wear gown and gloves, and ensure that their clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients.

2. On 03/07/18 at 7:50 AM, Surveyor #6 and the 1st Floor Nurse Manager (Staff #605) observed a dialysis nurse (Staff #604) as he prepared a hemodialysis machine in Patient Room #105. The patient was being cared for using Contact Enteric Precautions and Droplet Precautions. Isolation precaution signs were posted at the door.

Staff #604 performed hand hygiene and then donned a gown, gloves, and mask before entering room #105. While preparing the dialysis machine, he reached under the gown from the neck opening and withdrew a pen. After making some notes with the pen, he reached under the gown again to return the pen.

4. On 03/07/18 at 2:23 PM, Surveyor #6 interviewed the nurse manager about the hospital's isolation precautions policy and procedure and the observation findings. Staff #605 confirmed that the nurse had not followed the infection prevention policy and procedure, and that placing a potentially contaminated pen inside of a caregiver's gown risked transmission of infectious diseases to another patient.
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Based on observation, interview, and review of policies and procedures, the hospital failed to ensure staff maintained readiness for emergencies in the operating room.

Failure to ensure staff have training and skills to utilize the malignant hyperthermia and cardiac emergency treatment carts risks delays or inability to care for a patient during life threatening emergencies.

Findings included:

1. Record review of the hospital policies titled, "Malignant Hyperthermia," Policy #2892177 dated 01/03/17, and "Code Blue [cardiac arrest] Procedure," Policy #3676285 dated 06/02/17, showed that both policies outlined the importance to be prepared and have immediate recognition of those emergencies. The "Code Blue" procedure referred staff to a current American Heart Association Handbook.

2. On 03/07/18 at 12:30 PM, Surveyor #8 toured the peri-operative, operative, and anesthesia areas of the hospital with the Registered Nurse (RN) Managers of the surgical and pre-anesthesia care units (Staff #806 and #807). Observations made during the tour showed that the malignant hyperthermia treatment cart and the cardiac emergency treatment carts contained outdated policies and procedures (last reviewed 2011 to 2013) and the cardiac emergency treatment cart did not have a current American Heart Association (AHA) Handbook as mentioned in the policy.

3. An interview with the RN Managers (Staff #806 and #807) at the time of the observation revealed that the surgery department staff had not conducted malignant hyperthermia drills in over 5 years to practice collecting and preparing items used for treatment in order to increase the chance of the patient's recovery.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that emergency department (ED) staff members completed an emergency transfer form for all patients transferred from the ED to another hospital for specialty care or consultation, as demonstrated by 3 of 3 patients reviewed (Patient #703, #704, #705).

The purpose of the form is to provide evidence that the ED physician has explained the risks and benefits of the transfer to the patient and that the patient consents to transfer; and that all pertinent information has been provided to the receiving hospital to ensure continuity of care.

Findings included:

1. Record review of the hospital's policy titled, "Transfer of Patient to Another Facility", Policy #2597602 dated 07/27/16, showed that a "Physician's Certificate of Transfer" form would be completed when a patient was transferred from the emergency department (ED) to another hospital. This form would be signed by the ED physician, an ED nursing staff member or social worker, and the patient (if able to sign). If the patient is unable to sign, the physician would document this in the patient's medical record.

2. On 03/08/18 between 2:20 PM and 2:40 PM, review of the medical records of three ED patients who were transferred to another hospital for specialty care or consultation revealed the following:

a. Patient #703 was a 63 year-old patient who was treated in the ED on 02/17/18 for tachycardia (rapid heartbeat). The patient was subsequently transferred to another hospital for further cardiac treatment. The transfer form in the patient's record had not been signed by the patient to indicate he had consented to the transfer. There was no documentation in the record that the patient was unable to sign the form.

b. Patient #704 was an 86 year-old patient who was treated in the ED on 02/17/18 for unstable angina (chest pain). The patient was subsequently transferred to another hospital for further cardiac treatment. The transfer form in the patient's record had not been signed by the ED physician to indicate he had discussed the risks and benefits of the transfer, that the patient agreed to the transfer, and that the physician authorized the transfer.

c. Patient #705 was a 58 year-old patient who was treated in the ED on 02/16/18 for gastrointestinal bleeding. The ED physician determined that the patient required treatment in an intensive care unit. Because the hospital's intensive care unit was full, the patient was transferred to another hospital with an available intensive care unit bed. The transfer form in the patient's record had not been signed by the patient to indicate he had consented to the transfer. There was no documentation in the record that the patient was unable to sign the form. The form had also not been signed by an ED nurse or social worker to indicate all necessary steps for transferring the patient had been completed.

3. During an interview at the time of the record review, a hospital computer informatics specialist (Staff #701) confirmed the findings above.
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Based on interview and document review, the hospital failed to create policies and procedures in its' emergency preparedness plan for providing potable water and to ensure adequate alternate energy sources necessary to maintain heat and cooling during an emergency situation.

Failure to develop and implement policies and procedures to address water and energy sources needed in an emergency situation places patients, staff, and visitors at risk of injury, harm, or death.

Findings included:

1. On 03/07/18 between the hours of 8:30 AM and 12:00 PM during an interview with the hospital's Facilities Director (Staff #106), Deputy Fire Marshal #1 found that the hospital did not have policies and procedures in place to address how the hospital would provide heating and cooling for staff, patients, and visitors within the hospital in the event of a power outage.

2. On 03/08/18 between the hours of 10:00 AM and 11:30 AM, Surveyor #1 interviewed the Emergency Preparedness Manager (Staff #107) and reviewed the emergency preparedness plan. During the interview the manager was unable to provide policies and procedures to determine how the hospital would provide potable water in an event of an emergency.
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