HospitalInspections.org

A. Based on a review of Hospital policy, a review of Grievance log, and staff interview, it was determined in 2 of 3 (Pts #35, #36) medical records reviewed for grievance resolution, the Hospital failed to ensure the written notice included all required components.

Findings include:

1. The Hospital policy titled "Complaints and Grievances" (Reviewed 5/11) was reviewed on 5/16/12. It indicated "Process: 1. d. In resolution of grievances, the hospital will provide the complainant with written notice of its decision that contains the name of the hospital, the contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion..."

2. The grievance of Pt #35 was reviewed on 5/16/12. It indicated Pt #35's spouse verbalized a complaint on 4/12/12 concerning various aspects of care, staff responses, and ongoing concerns. On 4/13/12, it indicated "... Closing case. Response letter sent." On 4/16/12, Pt #35's spouse called the Hospital and indicated "just wants to make sure that the issues get addressed..." and was informed that the nurse managers had been advised of the concerns. The response letter, dated 4/13/12, indicated the nurse managers had "been made aware of the situation when Pt #35 was in those units." There was no documentation to indicate what decisions had been made, what steps had been taken, the results of the grievance process, the date of completion, or whether the investigation was still in process.

3. The grievance of Pt #36 was reviewed on 5/16/12. It indicated Pt #36 emailed a complaint on 5/15/12 concerning "delay in response to answering of call lights on more than one occasion." It further indicated "Will send response letter to patient and apologize for not meeting expectations. Will close case." The response letter, dated 5/15/12, indicated "... Department managers utilize this information for staff growth and development..." There was no documentation to indicate what decisions had been made, what steps had been taken, the results of the grievance process, the date of completion, or whether the investigation was still in process.

4. During a staff interview, conducted with the Patient Representative and the Patient Relations Manager on 5/16/12 at 2:40 PM, the above findings were confirmed.

A. Based on a review of Hospital policy, medical record review, and staff interview, it was determined in 1 of 3 (Pt #29) medical records reviewed, in which the patient was hospitalized for more than 96 hours and had an IV catheter, the Hospital failed to ensure IV catheters were changed every 96 hours, as per Hospital policy.

Findings include:

1. The Hospital policy titled "IV dressing change" (Lippencott 2012) was reviewed on 5/16/12. It indicated "... Peripheral IV catheters should be replaced no more frequently than every 72 to 96 hours..."

2. The medical record of Pt #29 was reviewed on 5/16/12. Pt #29 was admitted to the Hospital on 3/30/12 with the diagnosis CHF. Nursing documentation indicated an IV was started on 3/30/12 and it was discontinued on 4/4/12, beyond the 96 hour time frame.

3. During a staff interview, conducted with the ALC on 5/17/12 at 2:00 PM, the above findings were confirmed.

A. Based on Facility policy, medical record review and staff interview, it was determined the Hospital failed to ensure the blood product administration protocol was followed as required. This was evident in 1 (Pt. #21) of 5 medical records reviewed with patients receiving blood products.

Findings include:

1. The Hospital policy titled "Blood and Blood Product Administration" (effective 10/4/11) was reviewed on 5/16/12. It indicated "Assess baseline temperature, pulse, respirations and blood pressure prior to initiating blood products, 15 minutes after each unit begins and upon completion of each unit.."

2. The medical record of Pt #21 was reviewed on 5/16/12. Pt #21 was admitted on 4/24/12 with Chronic Kidney Disease. Pt. #21 had two units of PRBCs ordered on 04/28/12. Unit donor #40KXO7874 was initiated at 10:23 am. The pre transfusion VS was recorded at 10:23 am, the second set of VS was recorded at 10:25 am and hourly thereafter. The second unit, donor #40GJ83744 was started at 4:45 pm. There was no further documented VS for this unit of blood.

3. The above findings were verified with the ALC during a staff interview, conducted on 05/16/12 at 10:30 am.

A. Based on a review of Hospital policy and procedure, a review of radiation Dosimetry Reports, and staff interview, it was determined that the Hospital failed to ensure all radiation badges were utilized per policy.

Findings include:

1. The Hospital policy and procedure titled, "Radiation Protection Program - Hazardous Materials" (revision date 3/12) with a revision date of 3/7/23, was reviewed on 5/15/12. It indicated under, "POLICY: Radiation Monitoring Badges Occupationally exposed personnel...Those personnel who have the potential of receiving 10% of the MPD limits...in 1 year must wear radiation monitoring badges ..."

2. The LANDAUR Radiation Dosimetry Report with a report date of 3/19/12 was reviewed. It indicated participant Number 00590 turned in a collar badge that was "unused".

3. During an interview with the Director of Radiology, conducted on 5/15/12 at 11:15 AM, it was verbalized that no one knew why participant Number 00590 turned in a collar badge that was unused. It was also verbalized that the dosimeter badges are distributed to personnel that need to wear them, however, it is up to each individual supervisor to ensure the badges are collected and turned in to Landaur for reading. The above findings were confirmed.

A. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that in 10 of 11 coolers/freezers observed, the Hospital failed to ensure the temperatures were recorded in accordance with policy/procedure.

Findings include:

1. The Hospital policy and procedure titled, "STORAGE" ( reviewed 9/11) was reviewed on 5/16/12. It indicated under "Temperature Monitoring: ...Lead Worker to complete daily storage temperature logs for refrigerators and freezers - the temperature of all refrigerators and freezers should be recorded, twice a day at 6:00 AM and 6:00 PM...."

2. During a tour of the Dietary department, conducted on 5/16/12 at 10:30 AM, it was observed that 10 of 11 refrigerators/freezers temperature logs were missing 3 or more recorded temperatures for the month of May 2012. These were all verified by the administrative escort.

3. During an interview with the Director of Dietary, conducted on 5/16/12 at 11:15 AM, the above findings were confirmed.

B. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that the Dietary staff failed to ensure all equipment was cleaned in accordance with policy and procedure.

Findings include:

1. The Hospital policy and procedure titled, "Warewashing" (reviewed 9/11) was reviewed on 5/16/12. It indicated under "Policy Statement: All dishes, utensils, pots, pans, and service ware will be thoroughly cleaned and sanitized following each use."

2. During a tour of the Dietary Department, conducted on 5/16/12 at 11:15 AM, The following was observed: The cutting wheel on the electric can opener was coated with a dark brown matter that fragmented off when scraped with the end of a closed pen; The cook's line cooler had 3 metal drip pans with a white coating and debris that came off when rubbed with a finger.

3. During an interview with the Director of Dietary, conducted on 5/16/12 at 11:15 AM, the above findings were confirmed.

C. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that the Hospital failed to ensure all foods were stored properly.

Findings include:

1. The Hospital policy and procedure titled, "STORAGE" (reviewed 9/11) was reviewed on 5/16/12. It indicated under "Procedure: General:... food will be stored at least 6 inches above the floor... Labeling: All food items not stored in original packaging must be clearly labeled...Labels must have the name or description of the item, today's date, time of preparation or storage..."

2. During a tour of the Dietary Department, conducted on 5/16/12 at 11:15 AM, the following was observed: 7 Vegetable Base 16oz had no dates, 2 opened chicken base 16 oz were opened and had no dates, an opened large white plastic container that had a manufacturer label identifying the contents as "cottage cheese" was opened and had a label that identified the contents as "bacon grease", there were no dates on the label, in the Tray-line roll in freezer, a carton (box) of ice cream was stored on the floor.

3. During an interview with the Director of Dietary, conducted on 5/16/12 at 11:15 AM, the above findings were confirmed.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on May 15-17, 2012, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on May 15-17, 2012, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the HCFA/CMS Form 2567, dated 5/17/12.

A. Based on a review of Hospital policy, review of Hospital personnel files, and staff interview, it was determined in 13 of 24 employees files reviewed (E #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13), that the Hospital failed to ensure all patient care personnel were immunized for Pertussis to prevent the potential for the spread of infection, as per Hospital policy.

Findings include:

1. The Hospital Policy titled "Pertussis Infection Prevention and Control" (reviewed 6/11) was reviewed on 5/15/12. It indicated under 'POLICY: All persons with direct patient contact or working in clinical areas shall receive the pertussis vaccine unless granted an exemption."

2. During a review of 23 employee Immunization Records on 5/16/12, documentation indicated 13 of the 23 (E #1, E #2, E #3, E #4, E #5, E #6, E #7, E #8, E #9, E #10, E #11, E #12, E #13), had no documentation to indicate the employees had received, had previously received, or were granted an exemption to the Pertussis vaccination.

3. During an interview with the CMO and the ALC, conducted on 5/17/12 at 9:45 am., the CMO verbalized that the Hospital had a plan for implementing the Pertussis vaccination policy; however, the plan had not been implemented. It was further verbalized, by both, that they were aware that the policy had been in place for over a year. Both further verbalized that they were aware of the lack of overall compliance with the Pertussis vaccination policy, mainly in the area of physicians and residents.

B. Based on a review of Hospital policy, a review of CDC guidelines, medical record review, observation, and staff interview, it was determined in 2 of 7 (Pts #7, #40) medical records reviewed, in which the patient was either in or had symptoms of a potential infectious disease, the Hospital failed to ensure its Infection Control policy was followed.

Findings include:

1. The Hospital policy titled "Organization Policy: Surveillance, Prevention, and Control Of Infection" (Revised 4/12) was reviewed on 5/17/12. It indicated "Contact Isolation: Gown and gloves; Droplet Isolation: Mask, gloves, gown, and eye protection... Disease or Condition: Respiratory Infection... Expanded Precautions: Droplet... Disease or Condition: Clostridium Difficile... Expanded Precautions: Contact..." It further indicated "Isolation/ Transmission Based Precautions: 1. C. A physician's order is not necessary to initiate or discontinue isolation."

2. During a staff interview, conducted with the Infection Preventionist on 5/16/12 at 12:45 PM, it was verbalized that the Hospital follows CDC guidelines. The "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007" by CDC was reviewed on 5/16/12. It indicated "Infection/ Condition: Clostridium Difficile; Type: Contact; Duration: Duration of Illness."

3. The medical record of Pt #7 was reviewed on 5/16/12. Pt #7 was admitted to the Hospital on 5/13/12 with the diagnosis Scheduled Cesarean Section. On 5/14/12 at 12:07 PM, nursing documentation indicated the physician was notified of loose stools and nausea. At 12:55 PM, there was a physician order for "C-Difficile" testing. There was no documentation to indicate Pt #7 was placed into Contact Isolation at that time pending the results of the testing.

4. The medical record of Pt #40 was reviewed on 5/17/12. It indicated Pt #40 was admitted on 5/6/12 with a diagnosis of respiratory distress. Documentation indicated that Pt #40 was on droplet precautions. During a tour of the Hospital, conducted on 5/17/12 at 1:30PM, it was observed that the sign on the door of Pt #40 indicated, "NEED TO WEAR: ...Eye Protection Wear upon entering the room. Goggles may be cleaned and be reused..." The ALC and Unit Charge Nurse were asked at this time if staff and visitors had been wearing eye protection and it was verbalized by the ALC and Unit Charge Nurse that staff and visitors had not been wearing eye protection.

C. Based on observation, hospital policy, and staff interview, it was determined the Hospital failed to ensure all outdated supplies were not available for patient use. This has the potential to effect 100% of the patients.

Findings include:

1. During a tour of the Pre-Post Op Area on 5/15/12 at 10:45AM, 14 Intravenous (IV) catheters, stored in the nurse's medication/supply area, were noted to be expired. 11 of the IV catheters were 14 gauge: 1 expired 6/09, 2 expired 8/09, 5 expired 11/09, 1 expired 5/10, 1 expired 11/10, 1 expired 5/10. 3 of the IV catheters were 24 gauge: 1 expired 10/10, 1 expired 11/10, and 1 expired 12/11.

2. The Hospital policy titled Supply/Stock Rotation (revised 6/10) was reviewed on 5/15/12. The policy indicated "Policy: All items maintained in inventory will be rotated on a first-in, first-out (fifo) basis ... Procedure: ... Dated items are checked on packages during the rotation procedure. Any supply/stock items discovered that have reached or are near expiration will be pulled and processed accordingly."

3. During a staff interview conducted with the Director of Surgery and Allied Services on 5/15/12 at 3:15 PM the above findings were confirmed.

A. Based on policy, record review and staff interview it was determined in 1 of 2 (Pt. #38) discharged records reviewed the Hospital failed to ensure all patients received initial discharge planning.

Findings include:

1. The Hospital policy titled, "Admission, Discharge, Transfer Planning" (rev.2/10) was reviewed on 5/17/12. The policy indicated under "PROCESS: 8. Implement discharge planning process: a. Planning for discharge begins at the time of admission and continues throughout the hospitalization."

2. The medical record of Pt. #38 was reviewed on 5/17/12. Pt. #38 was admitted on 3/28/12 with the diagnoses of Esophageal Adenocarcinoma with Esophageal clot removal. There was no documentation to indicate discharge planning was implemented at admission or during the hospitalization.

3. During an interview with the ALC on 5/17/12 at 2:45 PM, the above findings were confirmed.

A. Based on observation, hospital policy, and staff interview, it was determined in 2 of 2 physicians, who performed a surgical procedure on Pt. #5 , the Hospital failed to ensure the surgical dress code policy was followed.

Findings include:

1. During a tour of the Pre-op area on 5/15/12 at 11:25AM, the surgeon of Pt. #5 went into Pt. #5's Pre-op room with a surgical face mask hanging around the neck (not covering the face/nose).

2. During observation of the surgical procedure on Pt. #5 in Operating Room 20, on 5/15/12 at 12:00PM, a resident was noted wearing a necklace.

3. The Hospital policy titled Operative and Invasive Division Dress Code (revised 4/12) was reviewed on 5/15/12. The policy indicated "Policy ... General Rules ... 13. High filtration masks are worn by personnel in the restricted areas ... b. Masks may not be left hanging around the neck... Restricted Areas: (Operating Rooms ...) 19. Jewelry including necklaces ... is not allowed ... "

4. During a staff interview conducted with the Director of Surgery and Allied Services on 5/15/12 at 3:15 PM, the above findings were confirmed.