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Based on observation and staff interview, the CAH failed to ensure the Windham Center/ PPS Excluded Psychiatric Care unit was maintained and properly equipped for the scope of services provided to ensure the safety and well being of patients who reside on the unit. Findings include:

During a tour of the environment on 3/18/14 at 1:30 PM with the V.P. of Patient Care Services and the Director of the Windham Center the following observations were made:
1. The patient's bathroom sinks faucets and handles provide the potential attachment points for ligatures. This was noted in each of the patient rooms.
2. In the tub room, the bathtub faucet and single knob water/mixing valve provided the potential attachment points for ligature.
3. The break away shower curtain in the shower room located near room 248 was unsafe. The curtain did not break away easily, was not tamper proof and the hooks supporting the shower curtain were sharp.
All observations were confirmed by the V.P. of Patient Care Services and the Windham Center Director.
This is a repeat deficiency.

Based on observation and interview, the CAH failed to assure all drugs and biologicals were safely stored in the Radiology Department. Findings include:

On 03/18/2014 at 10:15 AM a crash cart located at the end of a short hallway near the entrance to the MRI hallway was observed to be unlocked. The Surveyor requested that the Department Manager who was accompanying the Surveyor stop to inspect it further. The Surveyor demonstrated to the Department Manager that the cart was unlocked by opening each other set of drawers. The Radiology Manager confirmed at 10:30 AM on 3/18/14 that the crash cat was unlocked. The Department Manager investigated it further through discussion with the pharmacy and determined that the pharmacy was not involved. Upon return to the crash at 10:40 AM a radiology technician was standing near the cart and was asked if s/he had knowledge as to why the crash cart was not locked. S/he stated that at the beginning of the shift s/he observed that it was locked. The technician further stated that the crash cart was wheeled down from the Radiology Department earlier that morning. Per review of the crash cart check list it was noted that a crash cart check was completed by the night shift technician between 11:00 PM March 17, 2014 and 7:00 AM March 18, 2014.

Based on patient/patient representative and staff interviews as well as record review the Condition of Participation for Provision of Services was not met as evidenced by:

The CAH failed to provide care and services in accordance with established policies and procedures, failed to assure adequate training and competency of staff when using patient equipment and failed to develop and revise a care plan to meet the needs of one patient, whose health and well being was jeopardized because of these failures.

Refer to tags C-0271, C-0295 and C-0298

Based on observation and interview the CAH failed to assure the proper storage of a portable drug box utilized for the care of newborns and mothers at the time of delivery.

Refer to Tag: C-0276

Failure to assure disinfectants and/or germicides were utilized in accordance with manufacturers' instructions; Failure to maintain safe infection control practice during transport of contaminated surgical instruments in the perioperative area.

Refer to Tag C-0278

There was a failure of Dietary Services to ensure food temperatures were consistently monitored and equipment used by dietary staff remained clean.

Refer to Tag C-0279

There was a failure of the CAH to assure policies and procedures were reviewed on an annual basis by professional personnel for Infection Control and Clinical Records.

Refer to Tag C-0280

Based on interview and record review the nursing staff failed to provide patient care in accordance with the CAH's identified procedure for the use of the EZ Stand Lift; there was a failure of Perioperative Services to develop written policy for the transport of used surgical instruments and the proper use of cleaning solution in the decontamination area. There was a failure to comply with the credentialing process to assure all background checks were accurately obtained and a failure to assure ongoing security of drug storage. Findings include:

1. Per interview on 3/19/14 with the hospital's Nursing Manager for Patient #2's unit, the hospital's policy on 3/8/14 was to follow the manufacturer's instructions for the EZ lift [a battery powered patient lift]. Instructions include; "For safe operation of the EZ Way Smart Stand?, operators should watch the training video, read through this manual, complete the competency checklist, and practice on fellow staff members before use with patients."
On 3/8/14 the EZ lift stand lift was used incorrectly to transfer Patient #2 from the bed to a chair resulting in an emergency situation and the patient suffering acute respiratory difficulty requiring a code to be called.

Per interview, on 3/19/14, RN #3 was assigned as Patient #2's primary nurse on 3/18/14. RN #3 stated s/he had received the initial training on the EZ lift in July 2013, but had not had any retraining regarding the lift since. RN #3 reported s/he had not reviewed the EZ lift video and had not completed a training checklist since the incident on 3/8/14. RN #3 also reported 3/18/14 was his/her first day assigned to Patient #2, and s/he had not used the EZ lift on Patient #2 since the patient's admission on 3/6/14.

Per interview on 3/19/14 at 9: 15 A.M. the primary nurse assigned to Patient #2 that day, RN #4, stated regarding the EZ lift: "I haven't used it with [Patient #2]. I practiced on it when they first got it [July 2013]. I certainly could use a refresher course." RN #4 reported s/he had not received any retraining on the EZ lift since the incident on 3/8/14, had not reviewed the video available, and had not completed a training checklist. RN #4 stated s/he had seen some nursing staff being trained on the EZ lift on 3/18/14, "but I was not involved in that."

Per record review and confirmed by interview with the hospital's Professional Development staff on 3/19/14, 7 staff members were trained and had completed the manufacturer's competency checklist when the EZ lift was first purchased in July 2013. None of the staff members who had received the training participated in the use of the lift the day of the incident on 3/8/14. As of 3/19/14, 4 nursing staff had received training since the incident on 3/8/14, none of whom had been assigned as the primary nurse for Patient #2 since the training.

2. At the completion of a surgical procedure on the morning of 3/17/14, a RN was assigned to remove the contaminated instruments used during the surgical case from the OR to the decontamination room. The RN was observed wheeling an open sided cart through a corridor also utilized by the public. The cart contained multiple contaminated instruments to include sharps that were placed on the top of the open cart and on a shelf below. A disposable drape partially covered the cart and its contents. The potential safety hazard existed for both the RN, other hospital staff, patients and the public due to the inability to safely contain the contents of the contaminated instruments during transport. Per the Association of Professions in Infection Control (APIC) state ".. contaminated items should be placed in puncture-proof sealable containers and visibly marked as biohazards " APIC text of Infection Control and Epidemiology 3rd Edition. Page 55-5. Per the Association for the Advancement of Medical Instrumentation ANSI/AAMI ST 35:2003 states: page 14, " 6.2- Contaminated items should be contained during transport from point of use to the decontamination area....Bins with lids, enclosed or covered carts, closed sterilization container systems and impermeable bags are among the types of containers that may be used alone or in combination to transport contaminated items".

Per interview on 3/18/14 at 9:00 AM, the Nurse Manager for Perioperative Services confirmed the present process for transporting contaminated instruments and devices in unconstrained carts created the potential for accidental exposure to staff, patients and the public who utilize the corridor where instruments are transported. The Nurse Manager also confirmed there were no written policies for the transport of contaminated instruments to the decontamination room of Central Sterile and Reprocessing (CSR).

3. Accompanied by the Nurse Manager of Perioperative Services on 3/17/14 at 3:00 PM a tour was conducted of Central Sterile and Reprocessing (CSR) Services, where sterile and non-sterile medical and surgical supplies and equipment are decontaminated, processed, sterilized and stored for patient use. The Decontamination room is where re-usable contaminated surgical devices and instruments are brought for initial cleaning prior to being processed and sterilized. The CSR Technician assigned to the Decontamination room was asked about the enzymatic solution (used to remove the first layer of contaminates from medical instruments) and the quantity used when diluted in water. The Technician stated the product was new and s/he was instructed to use "...a 1/2 pump" of the enzymatic solution into a sink filled with water. However, the Technician was unclear about the amount of water to be used in the sink and the accuracy of the amount to be pumped from the enzymatic solution bottle. The Nurse Manager confirmed there was no written policy and procedure to assist the Technician to ensure the accuracy of water/solution ratio during the initial cleaning of the instruments.

4. Per observation, on the morning of 3/19/14, staff failed to assure all drugs were stored and/or monitored in accordance with the facility policy, titled Security: Drug Storage Areas, dated 3/19/2009. The policy stated; 'All personnel on duty shall protect drugs....and guard against the theft or diversion of drugs....Lockable storage units or lockable drug carts are provided throughout the facility for each drug storage area as required....Drugs are kept in locked storage or be inaccessible to unauthorized individuals....All storage areas are locked by combination, key or electronic code to minimize the risk of breaches in security. On the morning of 3/19/14, a portable Delivery Box containing medications including; (1) Erythromycin Opthalmic Ointment 0.5%, (1) Phytonadione (Vitamin K) 1.0 mg ampule; (2) Naloxone (used to reverse effects of narcotic overdose) 0.4 mg/ml-ampules; (2) Epinephrine 1: 10,000 Abbojects; (2) Sodium Bicarb 4.2 % AbboJects; (4) Oxytocin (a hormone used to stimulate uterine contractions) 10 units/ml vials; (1) Xylocaine 1% 20 ml vial and (1) Heparin (prevents blood clots) 10 units/ml syringe, was stored unsecured, and unmonitored for a short period of time, in the nursery of the Childbirth Center (CBC). While standing in the hall near the nurse's station, directly across from the nursery, the surveyor observed nursing staff entering patient rooms and the labor and delivery area on the unit, and without visual sight of the nursery for a period of several minutes. The small portable medication box was located in an unsecured room and easily accessible to unauthorized persons, and although the box was secured with a plastic lock, staff confirmed that there was no oversight provided to ensure the integrity of the lock remained intact.

The lack of secure storage, lack of monitoring and oversight of the medication box was confirmed by the CBC Nurse Manager during interview on the afternoon of 3/19/14. The Director of Pharmacy Services stated, during interview on the afternoon of 3/19/14, that although pharmacy staff monitor the contents of the Delivery Box on a monthly schedule, there was no other process for oversight to assure the integrity of the lock remained intact

5. Per 3/19/14 review, the "2014 Credentialing Policy and Procedures Manual," under the section titled, "Application for Reappointment," contains a reappointment process flow chart that specifies that a background check from the OIG (Office of the Inspector General) will be verified for each applicant seeking reappointment to the medical staff.
Per 3/19/14 review, the OIG background check for one of six sampled employees was submitted under an incorrect name and this was not noticed until brought to the attention of the medical services office coordinator at the time of the survey. On 3/20/14 at 8:59 AM, the medical services office coordinator confirmed that the OIG background check was not completed correctly for the staff member seeking reappointment.

This is a repeat deficiency.

Based on observation and interview the CAH failed to assure the proper storage of a portable drug box utilized for the care of newborns and mothers at the time of delivery. Findings include:

Per observation, on the morning of 3/19/14, a portable Delivery Box containing medications including; (1) Erythromycin Opthalmic Ointment 0.5%, (1) Phytonadione (Vitamin K) 1.0 mg ampule; (2) Naloxone (used to reverse effects of narcotic overdose) 0.4 mg/ml-ampules; (2) Epinephrine 1: 10,000 Abbojects; (2) Sodium Bicarb 4.2 % AbboJects; (4) Oxytocin (a hormone used to stimulate uterine contractions) 10 units/ml vials; (1) Xylocaine 1% 20 ml vial and (1) Heparin (prevents blood clots) 10 units/ml syringe, was stored unsecured, and unmonitored for a short period of time, in the nursery of the Childbirth Center (CBC). While standing in the hall near the nurse's station, directly across from the nursery, the surveyor observed nursing staff entering patient rooms as well as the labor and delivery area, and without visual sight of the nursery for a period of several minutes. The small portable medication box was was located in an unsecured room and easily accessible to unauthorized persons, and although the box was secured with a plastic lock, staff confirmed that there was no oversight provided to ensure the integrity of the lock remained intact.

The lack of secure storage, lack of monitoring and oversight of the medication box was confirmed by the CBC Nurse Manager during interview on the afternoon of 3/19/14. The Director of Pharmacy Services stated, during interview on the afternoon of 3/19/14, that
although pharmacy staff monitor the contents of the Delivery Box on a monthly schedule, there was no other process for oversight to assure the integrity of the lock remained intact.

This is a repeat deficiency.

Based on observation and staff interview there was a failure of Periopertive Services to maintain standards of practice for infection prevention and control. Findings include:

1. At the completion of a surgical procedure on the morning of 3/17/14, a RN was assigned to remove the contaminated instruments used during the surgical case from the OR to the decontamination room. The RN was observed wheeling an open sided cart through a corridor also utilized by the public. The cart contained multiple contaminated instruments to include sharps that were placed on the top of the open cart and on a shelf below. A disposable drape partially covered the cart and its contents. The potential safety hazard existed for both the RN, other hospital staff, patients and the public due to the inability to safely contain the contents of the contaminated instruments during transport. Per the Association of Professions in Infection Control (APIC) state ".. contaminated items should be placed in puncture-proof sealable containers and visibly marked as biohazards " APIC text of Infection Control and Epidemiology 3rd Edition. Page 55-5. Per the Association for the Advancement of Medical Instrumentation ANSI/AAMI ST 35:2003 states: page 14, " 6.2- Contaminated items should be contained during transport from point of use to the decontamination area....Bins with lids, enclosed or covered carts, closed sterilization container systems and impermeable bags are among the types of containers that may be used alone or in combination to transport contaminated items".

Per interview on 3/18/14 at 9:00 AM, the Nurse Manager for Perioperative Services confirmed the present process for transporting contaminated instruments and devices created the potential for accidental exposure of bloodborne pathogens to staff, patients and the public who utilize the corridor where instruments are transported. The Nurse Manager also confirmed there were no written policies for the transport of contaminated instruments to the decontamination room from the operating rooms.

2. During a tour on 3/18/14 of the Perioperative service located on Level B of the CAH it was evident there was limited ability of the present environment to prevent unauthorized individuals form entering the operative and recovery areas. Although a sign to the left of the automatic glass sliding door on Level B states only authorized individuals allowed beyond the door entrance, anyone can obtain access to this unsecured area where patient care is being provided. Upon entering, an unauthorized individual could access both the PACU (Post Anesthesia Care Unit) or walk directly into the Perioperative hallways and operating rooms. A public elevator also opens directly into the corridor on Level B which leads to the Perioperative area. Directly across from the elevator are the nursing/physician dressing rooms and bathrooms and another entrance to the surgical suites. Per the Association of Professions in Infection Control ( APIC) states- " ... traffic must be controlled to maintain separation of clean from dirty areas, to segregate clean and sterile supplies from contaminating materials, and to ensure that only authorized personnel in appropriate attire enter the operating room. In the restricted zone- the actual operating room and scrub area -surgical attire and a face mask are required. APIC Text of Infection Control and Epidemiology 3rd Edition. Page 45-5.

Per interview, on the morning of 3/18/14 the Nurse Manager of Perioperative Services confirmed the present design and location of the public corridor and unsecured entrances creates a security and safety concern for both patients and the staff.

3. Accompanied by the Nurse Manager of Perioperative Services on 3/17/14 at 3:00 PM a tour was conducted of Central Sterile and Reprocessing Services (CSR), where sterile and non-sterile medical and surgical supplies and equipment are decontaminated, processed, sterilized and stored for patient use. The Decontamination room is where re-usable contaminated surgical devices and instruments are brought for initial cleaning prior to being processed and sterilized. The CSR Technician assigned to the Decontamination room was asked to explain the measuring of the enzymatic solution (used to remove the first layer of contaminates from medical instruments) and how it was diluted in water. The Technician stated the product was new and s/he was instructed to use "...a 1/2 pump" of the enzymatic solution into a sink filled with water. However, the Technician was unclear about the amount of water to be used in the sink and the accuracy of the amount to be pumped from the enzymatic solution bottle. The Nurse Manager confirmed there was no written policy and procedure to assist the Technician to ensure the accuracy of water/solution ratio. Per APIC Disinfection, Sterilization and Antisepsis: Principles, Practices, Current Issues, and New Research page 13 states: "Some of the factors that affect both disinfection and sterilization efficacy are the prior cleaning of the object....".

This is a repeat deficiency.

Based on observation, interview and record review, there was a failure of Dietary Services to ensure food temperatures were consistently monitored and equipment used by dietary staff remained clean. Findings include:

1. Per 3/18/14 review, the "Food temperature time log" states that "Prior to refrigeration all cooked potentially hazardous food will be chilled, held at 40 [degrees] within 4 hours and monitored for time and holding. Food will be discarded if the criteria is not met." On 3/18/14 at 10:09 AM, the kitchen staff provided a food temperature time log that had 2 dated entries for January 2014 and 7 entries for February 2014; the staff was not able to produce a March log. On 3/18/14 at 10:09 AM, when asked about the missing log entries, the facility cook stated, "We need to get better at keeping this." On 3/18/14 at 10:45 AM, a diet tech confirmed the above findings and stated that it is the cooks' job to record the cool down temperatures. On 3/18/14 at 4:20 PM, a second log was presented by a diet tech with 1 entry from March 2014; that entry did not include the cool down temperature. At that time, the Chief of Human Resources and Allied Services and the diet tech could not find any other logs. By telephone interview on 3/19/14 at 10:45 AM, the Director of Nutrition Services stated that it is an expectation that the cooks document chill down temperatures of potentially hazardous foods. S/he agreed that if the temperatures were not taken, the safety of the cooled foods could not be confirmed. S/he also confirmed that the current temperature log does not have a place to record whether there were no potentially hazardous food that needed monitoring and stated that the form needs to be updated
2. On 3/18/14 at 7:45 AM, during a tour of the kitchen, accompanied by a dietary tech, a fan blowing over the pot sinks and dishwashing unit was observed to have a thick coating of dust on the outer cage and blades. A second stationary fan was also observed to have a thick buildup of dust on the cage and blades. At the time of the tour, the diet tech confirmed the above observations and reported that the kitchen staff was responsible for cleaning the fans; the tech presented the Kitchen's "Cleaning List" and confirmed that cleaning the fans was not on the schedule.

Based on staff interview and record review, there was a failure of the CAH to assure policies and procedures were reviewed on an annual basis by professional personnel for Infection Control and Clinical Records. Findings include:

1. Per interview on 3/20/14 at 9:30 AM the Infection Control Preventionist confirmed s/he has not had the opportunity to review on an annual basis all Infection Control policies and procedures. Per record review, the following CAH Infection Control policies had not been reviewed and/or revised to include: "Storage of Sterile Supplies" last approved 7/27/2010; "Blood Borne Pathogens" last reviewed in 2011; "Needle and Sharps" last reviewed 3/31/2010; "Resistant Organisms Isolation" last reviewed 3/22/10; " Skin and Wound Assessment and Dressing Procedure" last reviewed 7/26/2011 and "Increase Chemical Level Disinfection " last reviewed 7/29/10.

2. Per record review, the CAH's policy titled Annual Review of the Medical Records Policies and Procedures Manual, dated 6/26/2009, stated as it's purpose; 'To ensure that the Medical Records Department's Policies and Procedures Manual is up-to date
and that all staff members remain current with the evolving responsibilities of the department.'
The function stated: The Policies and Procedures Manual will be reviewed and updated, if applicable, annually by the Director of Health Information.' Per review several Medical Record department policies and procedures were identified with a most recent review date of 2009, including the Medical Records Quality Assurance Plan, whose purpose was "to assure the timeliness, accuracy and quality of the data within Springfield Hospital's medical records', which was last reviewed on 1/29/2005.

The Director of Health Information Management (HIM) confirmed, during interview on the morning of 3/20/14, the most recent review dates of 2009 and stated that the department's policies and procedures had not all been reviewed on annual basis.

Based on interviews with patient, patient representative and facility staff, as well as record review, the CAH failed to assure that all staff were adequately trained and competent in the safe use of a patient lift (EZ Lift) to transfer one patient, resulting in a failure to safely transfer the patient who then suffered an episode of acute respiratory distress requiring medical intervention. (Patient #2). Findings include:
Per patient and family interview, staff interview, and record review, on Saturday 3/8/14 at 8:45 A.M an EZ lift patient lift was used to transfer Patient #2 from the bed to a chair resulting in an emergency situation and the patient suffering acute respiratory difficulty.
Per interview on 3/19/14 at 10:23 A.M Patient #2 and the patient's daughter reported that on 3/8/14 RN #1 and three other nursing staff placed the lift's harness around the back of the patient, and hooked the harness straps to the lift. The lift was turned on, and the patient was raised off the bed. The EZ lift, with the patient standing on it, was then pivoted toward a reclining chair .Per record review, a Nurse Practitioner [NP] note, dated 3/8/14, indicated the NP had been present during the transfer process and stated, " ...there were some logistical problems utilizing the lift chair. The canvas wrap seemed to constrict [his/her] breathing a bit, and [s/he] did have an episode of acute respiratory insufficiency while in the canvas wrap. [S/he] had to be immediately eased to the floor and the wrap removed in order for [his/her] breathing pattern to return to normal. S/he did require high-flow oxygen ... " An electronic Incident Report filed at 2:25 P.M., on 3/8/14, by the Charge Nurse who was present during the incident, cited, " device failure: would not raise patient high enough. " ' Additional Information ' in the report states " ...[his/her] abdomen pushed up so [s/he] was unable to expand [his/her] lungs, [s/he] turned purple and had agonal breathing [an inadequate pattern of breathing associated with extreme physiological distress].. While attempting to pull [him/her] into chair, device securing patient under [his/her] buttocks slipped out ... "
Per interview, on 3/19/14 at 3:25 P.M., RN #2 indicated the lift was unable to raise the patient high enough to meet the seat of the recliner chair to facilitate smooth transfer of the patient to the chair. " Something was wrong with the [EZ lift] battery. Someone said the battery was dead ...it was chaotic. " RN #1 stated, during interview on 3/19/14, that during the incident on 3/8/14 Patient #2 turned blue, slumped forward, head down, " probably passed out. " The NP stated, during interview on 3/19/14, " I knew [s/he] was blue ...I didn ' t need the O2 sat [oxygen saturation level] to tell me [s/he] wasn ' t breathing. " The NP also stated that the EZ lift was not used the following day, 3/9/14, as s/he did not want the lift used until people who were comfortable using it were available.
Per interview, at 9:30 AM on 3/19/14, the unit Nurse Manager stated that s/he had been notified of the incident, on the afternoon of 3/8/14. S/he stated the decision was to not use the lift until it could be reviewed on Monday, 3/10/14. S/he further stated that following his/her review of the incident it was determined that there was not an issue with the equipment, " it was a training issue, it was failure of use of the equipment, not failure of the equipment. " The Nurse Manager also stated that, because the hospital had not yet approved a formal policy and procedure regarding use of the EZ lift at the time of the incident, the CAH ' s policy, as of 3/8/14, was to follow the manufacturer ' s instructions. Per observation on 3/18/14, a copy of the manufacturer ' s instructions was attached to the handle of the EZ lift. Instructions in the manual include " For safe operation of the EZ Way Smart Stand?, operators should watch the training video, read through this manual, complete the competency checklist, and practice on fellow staff members before use with patients. "
Per record review and confirmed during interview with the hospital's Chief of Quality and Systems Improvement on 3/19/14 , the follow up to the event report for the 3/8/14 incident indicated the " Immediate Action taken: EZ lift device, lift pad evaluated the following Monday " [3/10/14]. The report also includes ' recommendations on what needs to be done as a result of this event: Staff education and training on use of lift was reviewed and commenced to include all staff yet to be signed off: EZ lift video available on computer at nurses station and training checklist to be reviewed/completed by each staff prior to assisting current patient. " The follow up report is marked as completed 3/18/14 at 11:25 A.M.
Per interview, on 3/19/14 at 8:29 A.M., the CAH BioMed representative confirmed that his/her department is responsible for evaluating and maintaining safe functionality of the CAH' s patient cre equipment, including the EZ lift. The representative confirmed that the EZ lift had not been evaluated by the BioMed department following the incident on 3/8/14, until inquiry by the survey team on 3/19/14.
Per record review and confirmed by interview with the hospital's Professional Development staff on 3/19/14 there was no evidence that any of the staff members using the lift on 3/8/14 had ever received adequate training or assurance of competency for the lift. As of 3/19/14, only 4 nursing staff had received training since the incident on 3/8/14, none of whom had been assigned as the primary nurse for Patient #2 since the training.
Per record review and confirmed on 3/19/14 by the Nurse Manager for the unit, the lift had been used every day since the incident on 3/8/14, and instructions for using the EZ lift on Patient #2 were not revised until 3/14/14. The Nurse Manager stated the incident " was a training issue ... As we began training staff with this patient we learned they were not using the belt as you need to " . The Nurse Manager further stated between the time of the incident until 3/14/14 [6 days later] "there wasn't training going on." The Nurse Manager reported " Now we're training staff as they're working."
Per record review of Nursing Notes from 3/15/14 the nurse reports, "Patient refusing to get out of bed with lift ...because of what happened last weekend. [S/he] is very scared " & from 3/16/14 notes "Patient refused to get out of bed for supper. [S/he] feels unsafe and that staff are not trained with the lift."
Per interview with RN #3 and per record review on 3/19/14, RN #3 was assigned as Patient #2 ' s primary nurse on 3/18/14. RN #3 stated s/he had received the initial training on the EZ lift in July 2013, but had not had any retraining regarding the lift since. RN #3 reported s/he had not reviewed the EZ lift video and had not completed a training checklist since the incident on 3/8/14. RN #3 also reported 3/18/14 was his/her first day assigned to Patient #2, and s/he had not used the EZ lift on Patient #2 this admission.
On 3/19/14 at 10:23 A.M during an interview with Patient #2 and a family member, they reported that RN #3 and 2 other staff members attempted to place the EZ lift harness on Patient #2 the previous night, 3/18/14, at approximately 6:00 P.M., in order to raise the patient out of a recliner. The family member stated RN #3 asked him/her regarding the lift harness, "how does it go?" The family member stated s/he told RN #3 s/he "had it upside down."
Per interview on 3/19/14 at 9: 15 A.M. the primary nurse assigned to Patient #2 that day, RN #4, stated regarding the EZ lift: " I haven ' t used it with [Patient #2]. I practiced on it when they first got it [July 2013]. I certainly could use a refresher course." RN #4 reported h/she had not received any retraining on the EZ lift since the incident on 3/8/14, had not reviewed the video available, and had not completed a training checklist. RN #4 stated s/he had seen some nursing staff being trained on the EZ lift on 3/18/14, "but I was not involved in that " .
The unit Nurse Manager confirmed, during interview on 3/19/14, that the identified need for training to prevent a re-occurrence had not been instituted. The CAH's Professional Development staff member confirmed during interview, on 3/19/14, that training on the EZ lift as outlined by facility's policy, had not started until 3/18/14, and staff assigned to Patient #2 on 3/18 & 3/19/14 had not received any training or retraining since the incident.
Despite the fact that inappropriate use of the EZ lift, by staff, had resulted in a situation in which Patient #2 suffered a compromised airway and acute respiratory distress, and although the EZ lift had not been evaluated to assure safe functionality, and appropriate training of staff and assurance of competency with use of the EZ lift did not occur, Patient #2 was subjected to ongoing daily use of the lift by untrained staff placing the patient ' s health and well being in jeopardy.

Based on interview and record review, nursing staff failed to update the current patient care plan for 2 applicable patients. ( Patient #2, 9 ) Findings include:

1. Per record review Patient #2, whose diagnoses include immobility and pneumonia, was admitted to the hospital on 3/5/14. The patient was assessed as a high fall risk. The patient's care plan on 3/6/14 includes 'Potential for Fall' with interventions that include; "gait belt for ambulation" and the goals included "Patient will remain injury free." The care plan did not address the use of an EZ lift to assist in patient transfers, or the need for staff to receive instruction prior to its use.

Per interview on 3/19/14 with the Nurse Manager for the unit on which Patient #2 resided, the CAH's policy at that time was to follow the manufacturer's instructions for the EZ lift. Instructions include, "For safe operation of the EZ Way Smart Stand?, operators should watch the training video, read through this manual, complete the competency checklist, and practice on fellow staff members before use with patients."

On 3/7/14 an EZ lift stand lift [a battery powered patient lift] was used for the first time during this admission to transfer Patient #2 from the bed to a chair, and later from the chair back to bed. On 3/8/14 the patient lift was used again, resulting in an emergency situation and the patient suffering acute respiratory difficulty.

Per record review and confirmed during an interview on 3/19/14 with the Nurse Manager the EZ lift continued to be used on Patient #2 daily for 6 days after the incident, with no review or revision to the patient's care plan to reflect use of the lift, until 3/14/14. The Nurse Manager stated during the 6 days after the emergency situation "there wasn ' t training going on."

2. Patient # 9 was admitted to the CAH on March 14, 2014 due to observed seizure activity in his/her home. S/he also had a history of multi-infarct dementia. On 3/17/ 2014 at approximately 10:30 AM the Speech Therapist conducted a bed side swallow evaluation of the patient and proceeded to write out a detailed note regarding feeding and medication pursuits relative to the patient's diagnosis of mild oral and pharyngeal dysphagia. Per review of the patient's medical record on 3/18/14 at 11:20 AM, almost 24 hours after the bed side swallow evaluation and subsequent documentation, no revision of the nursing care plan had been made to reflect the change in patient condition. At this time the Nurse Manager of the Patient Care Unit was asked to locate the care plan revision. S/he at 11:30 AM on 03/18/2014 confirmed that the care plan had not been revised to reflect the change in patient condition and further stated that it should have been updated as a patient safety issue.

Based on observation and staff interview the CAH failed to assure clinical records were stored appropriately to prevent potential damage from water, failed to assure timely completion of all medical records, and failed to assure timely review of all system policies and procedures. Findings include:

1. Per observation, during tour of the medical record storage areas with the Director of Health Information Management (HIM), at 8:30 AM on 3/20/14, medical records were stored on open shelves, in close proximity to the sprinkler systems in all three areas on A, B and C levels of the CAH. The HIM Director confirmed, during interview at the time of the tour, that the records were not protected from potential water damage. S/he further stated that there had been a previous water leak in the ceiling of the medical record storage area on level A and that although medical records had not been damaged at that time, and despite that history, no changes had been made to protect the records from potential future water exposure.
2. The Director of HIM stated, during interview on the afternoon of 3/20/14, that, although the facility policy titled Medical Record Completion, dated 4/21/2009, directed completion of medical records within 30 days after discharge, there were 186 medical records that were incomplete past the 30 day post discharge time frame as of 3/20/14. S/he provided information that indicated the number of incomplete medical records had been consistently at or above 138 since September of 2013, and further stated that the failure to complete medical records within the 30 day time frame had been an ongoing issue for the CAH.

3. Per record review, the CAH's policy titled Annual Review of the Medical Records Policies and Procedures Manual, dated 6/26/2009, stated as it's purpose; 'To ensure that the Medical Records Department's Policies and Procedures Manual is up-to date
and that all staff members remain current with the evolving responsibilities of the department.'
The function stated: The Policies and Procedures Manual will be reviewed and updated, if applicable, annually by the Director of Health Information.' Per review several Medical Record department policies and procedures were identified with a most recent review date of 2009, including the Medical Records Quality Assurance Plan, whose purpose was "to assure the timeliness, accuracy and quality of the data within Springfield Hospital's medical records', which was last reviewed on 1/29/2005. The Director of HIM confirmed, during interview on the morning of 3/20/14, the most recent review dates of 2009 and stated that the department's policies and procedures had not all been reviewed on annual basis.

Based on observation and staff interview the facility failed to assure the timely completion of all medical records. Findings include:

The Director of Health Information Management (HIM) stated, during interview on the afternoon of 3/20/14, that, although the facility policy titled Medical Record Completion, dated 4/21/2009, directed completion of medical records within 30 days after discharge, there were 186 medical records that were incomplete past the 30 day post discharge time frame as of 3/20/14. S/he provided information that indicated the number of incomplete medical records had been consistently at or above 138 since September of 2013, and further stated that the failure to complete medical records within the 30 day time frame had been an ongoing issue for the CAH.

This is a repeat deficiency.

Based on observation and interview the Condition of Participation for Surgical services was not met as evidenced by the failure of Perioperative Services to assure the safety of staff and patients during transport of contaminated surgical instruments; the failure to limit access to the operative and recovery areas to only authorized personnel; and failure to assure staff in Central Sterile Processing utilized the correct concentrations of enzymatic solutions during the processing of cleaning surgical instruments. Findings include:

1. At the completion of a surgical procedure on the morning of 3/17/14, a RN was assigned to remove the contaminated instruments used during the surgical case from the OR to the decontamination room. The RN was observed wheeling an open sided cart through a corridor also utilized by the public. The cart contained multiple contaminated instruments to include sharps that were placed on the top of the open cart and on a shelf below. A disposable drape partially covered the cart and its contents. The potential safety hazard existed for both the RN, other hospital staff, patients and the public due to the inability to safely contain the contents of the contaminated instruments during transport. Per the Association of Professions in Infection Control (APIC) state ".. contaminated items should be placed in puncture-proof sealable containers and visibly marked as biohazards " APIC text of Infection Control and Epidemiology 3rd Edition. Page 55-5. Per the Association for the Advancement of Medical Instrumentation ANSI/AAMI ST 35:2003 states: page 14, " 6.2- Contaminated items should be contained during transport from point of use to the decontamination area....Bins with lids, enclosed or covered carts, closed sterilization container systems and impermeable bags are among the types of containers that may be used alone or in combination to transport contaminated items".

Per interview on 3/18/14 at 9:00 AM, the Nurse Manager for Perioperative Services confirmed the present process for transporting contaminated instruments and devices created the potential for accidental exposure of bloodborne pathogens to staff, patients and the public who utilize the corridor where instruments are transported. The Nurse Manager also confirmed there were no written policies for the transport of contaminated instruments to the decontamination room from the operating rooms.

2. During a tour on 3/18/14 of the Perioperative service located on Level B of the CAH it was evident there was limited ability of the present environment to prevent unauthorized individuals form entering the operative and recovery areas. Although a sign to the left of the automatic glass sliding door on Level B states only authorized individuals allowed beyond the door entrance, anyone can obtain access to this unsecured area where patient care is being provided. Upon entering, an unauthorized individual could access both the PACU (Post Anesthesia Care Unit) or walk directly into the Perioperative hallways and operating rooms. A public elevator also opens directly into the corridor on Level B which leads to the Perioperative area. Directly across from the elevator are the nursing/physician dressing rooms and bathrooms and another entrance to the surgical suites. Per the Association of Professions in Infection Control ( APIC) states- " ... traffic must be controlled to maintain separation of clean from dirty areas, to segregate clean and sterile supplies from contaminating materials, and to ensure that only authorized personnel in appropriate attire enter the operating room. In the restricted zone- the actual operating room and scrub area -surgical attire and a face mask are required. APIC Text of Infection Control and Epidemiology 3rd Edition. Page 45-5.

Per interview, on the morning of 3/18/14 the Nurse Manager of Perioperative Services confirmed the present design and location of the public corridor and unsecured entrances creates a security and safety concern for both patients and the staff.

3. Accompanied by the Nurse Manager of Perioperative Services on 3/17/14 at 3:00 PM a tour was conducted of Central Sterile and Reprocessing Services (CSR), where sterile and non-sterile medical and surgical supplies and equipment are decontaminated, processed, sterilized and stored for patient use. The Decontamination room is where re-usable contaminated surgical devices and instruments are brought for initial cleaning prior to being processed and sterilized. The CSR Technician assigned to the Decontamination room was asked to explain the measuring of the enzymatic solution (used to remove the first layer of contaminates from medical instruments) and the amount that was diluted in water. The Technician stated the product was new and s/he was instructed to use "...a 1/2 pump" of the enzymatic solution into a sink filled with water. However, the Technician was unclear about the amount of water to be used in the sink and the accuracy of the amount to be pumped from the enzymatic solution bottle. The Nurse Manager confirmed there was no written policy and procedure to assist the Technician to ensure the accuracy of water/solution ratio. Per APIC Disinfection, Sterilization and Antisepsis: Principles, Practices, Current Issues, and New Research page 13 states: "Some of the factors that affect both disinfection and sterilization efficacy are the prior cleaning of the object....".

Based on observation, interview and record review, the Condition of Participation: Periodic Evaluation and Quality Assurance was not met as evidenced by:

The Quality Assurance Program failed to thoroughly investigate in a timely manner the circumstances of an event resulting in respiratory compromise for a patient and the failure of the Quality Assurance Program to sufficiently implement corrective measures to prevent further opportunity of harm and/or injury for all patients.

Refer to Tag: C-0342

This is a repeat deficiency.

Based on observation, interview and record review, the CAH Quality Assurance Program failed to fully assess the events leading up to a significant patient event and failed to take appropriate remedial action to address the event in an effort to avoid the re-occurrence of like events.

Based on record review and confirmed through staff interviews the CAH Quality Assurance Program failed to implement, in a timely manner, corrective actions for a deficient practice involving the use of an EZ Stand Lift for Patient #2, who experienced acute respiratory distress as the result of inappropriate use of the lift by staff. Although an investigation of the event, by nursing management, identified the need to assure staff training and competency evaluation in the use of the lift, to assure no re-occurrence of like incidents, prior to continued use of the EZ lift, the training was not completed by all staff who continued to use the EZ lift with Patient #2.

Per interview on 3/19/14 at 10:23 A.M Patient #2 and the patient's daughter reported that on 3/8/14 RN #1 and three other nursing staff placed the lift's harness around the back of the patient, and hooked the harness straps to the lift. The lift was turned on, and the patient was raised off the bed. The EZ lift, with the patient standing on it, was then pivoted toward a reclining chair .Per record review, a Nurse Practitioner [NP] note, dated 3/8/14, indicated the NP had been present during the transfer process and stated, " ...there were some logistical problems utilizing the lift chair. The canvas wrap seemed to constrict [his/her] breathing a bit, and [s/he] did have an episode of acute respiratory insufficiency while in the canvas wrap. [S/he] had to be immediately eased to the floor and the wrap removed in order for [his/her] breathing pattern to return to normal. S/he did require high-flow oxygen ... " An electronic Incident Report filed at 2:25 P.M., on 3/8/14, by the Charge Nurse who was present during the incident, cited, " device failure: would not raise patient high enough. " ' Additional Information ' in the report states " ...[his/her] abdomen pushed up so [s/he] was unable to expand [his/her] lungs, [s/he] turned purple and had agonal breathing [an inadequate pattern of breathing associated with extreme physiological distress].. While attempting to pull [him/her] into chair, device securing patient under [his/her] buttocks slipped out ... "
Per interview, on 3/19/14 at 3:25 P.M., RN #2 indicated the lift was unable to raise the patient high enough to meet the seat of the recliner chair to facilitate smooth transfer of the patient to the chair. "Something was wrong with the [EZ lift] battery. Someone said the battery was dead ...it was chaotic." RN #1 stated, during interview on 3/19/14, that during the incident on 3/8/14 Patient #2 turned blue, slumped forward, head down, "probably passed out." The NP stated, during interview on 3/19/14, "I knew [s/he] was blue ...I didn't need the O2 sat [oxygen saturation level] to tell me [s/he] wasn't breathing." The NP also stated that the EZ lift was not used the following day, 3/9/14, as s/he did not want the lift used until people who were comfortable using it were available.
Per interview, at 9:30 AM on 3/19/14, the unit Nurse Manager stated that s/he had been notified of the incident, on the afternoon of 3/8/14. S/he stated the decision was to not use the lift until it could be reviewed on Monday, 3/10/14. S/he further stated that following his/her review of the incident it was determined that there was not an issue with the equipment, "it was a training issue, it was failure of use of the equipment, not failure of the equipment." The Nurse Manager also stated that, because the hospital had not yet approved a formal policy and procedure regarding use of the EZ lift at the time of the incident, the CAH's policy, as of 3/8/14, was to follow the manufacturer's instructions, which included: "For safe operation of the EZ Way Smart Stand?, operators should watch the training video, read through this manual, complete the competency checklist, and practice on fellow staff members before use with patients."

Per record review and confirmed during interview with the hospital's Chief of Quality and Systems Improvement on 3/19/14 , the follow up to the event report for the 3/8/14 incident indicated the "Immediate Action taken: EZ lift device, lift pad evaluated the following Monday" [3/10/14]. The report also includes; 'recommendations on what needs to be done as a result of this event: Staff education and training on use of lift was reviewed and commenced to include all staff yet to be signed off: EZ lift video available on computer at nurses station and training checklist to be reviewed/completed by each staff prior to assisting current patient." The follow up report is marked as completed 3/18/14 at 11:25 A.M.
Per interview, on 3/19/14 at 8:29 A.M., the CAH BioMed representative confirmed that his/her department is responsible for evaluating and maintaining safe functionality of the CAH's patient care equipment, including the EZ lift. The representative confirmed that the EZ lift had not been evaluated by the BioMed department following the incident on 3/8/14, until inquiry by the survey team on 3/19/14.
Per record review and confirmed by interview with the hospital's Professional Development staff on 3/19/14 there was no evidence that any of the staff members using the lift on 3/8/14 had ever received adequate training or assurance of competency for the lift. As of 3/19/14, only 4 nursing staff had received training since the incident on 3/8/14, none of whom had been assigned as the primary nurse for Patient #2 since the training.
Per record review of Nursing Notes from 3/15/14 the nurse reports; "Patient refusing to get out of bed with lift ...because of what happened last weekend. [S/he] is very scared " & from 3/16/14 notes, "Patient refused to get out of bed for supper. [S/he] feels unsafe and that staff are not trained with the lift."
Per interview on 3/19/14, RN #3 was assigned as Patient #2's primary nurse on 3/18/14. RN #3 stated s/he had received the initial training on the EZ lift in July 2013, but had not had any retraining regarding the lift since. RN #3 reported s/he had not reviewed the EZ lift video and had not completed a training checklist since the incident on 3/8/14. RN #3 also reported 3/18/14 was his/her first day assigned to Patient #2, and s/he had not used the EZ lift on Patient #2 this admission.
On 3/19/14 at 10:23 A.M during an interview with Patient #2 and a family member, they reported that RN #3 and 2 other staff members attempted to place the EZ lift harness on Patient #2 the previous night, 3/18/14, at approximately 6:00 P.M., in order to raise the patient out of a recliner. The family member stated RN #3 asked him/her regarding the lift harness; "how does it go?" The family member stated s/he told RN #3 s/he "had it upside down."
Per interview on 3/19/14 at 9: 15 A.M., RN #4, the primary nurse assigned to Patient #2 that day, stated regarding the EZ lift: "I haven't used it with [Patient #2]. I practiced on it when they first got it [July 2013]. I certainly could use a refresher course " . RN #4 reported s/he had not received any retraining on the EZ lift since the incident on 3/8/14, had not reviewed the video available, and had not completed a training checklist. RN #4 stated s/he had seen some nursing staff being trained on the EZ lift on 3/18/14, "but I was not involved in that."
The unit Nurse Manager confirmed, during interview on 3/19/14, that the identified need for training to prevent a re-occurrence had not been instituted. The CAH's Professional Development staff member confirmed during interview, on 3/19/14, that training on the EZ lift as outlined by hospital policy, had not started until 3/18/14, and staff assigned to Patient #2 on 3/18/14 & 3/19/14, respectively, had not received any training since the incident.
Per record review and confirmed on 3/19/14 by the Nurse Manager for the unit, the lift had been used every day since the incident on 3/8/14, and instructions for using the EZ lift on Patient #2 were not revised until 3/14/14. The Nurse Manager stated the incident "was a training issue ... As we began training staff with this patient we learned they were not using the belt as you need to." The Nurse Manager further stated between the time of the incident until 3/14/14 [6 days later] "there wasn't training going on." The Nurse Manager reported "Now we're training staff as they're working."
Despite the fact that inappropriate use of the EZ lift was identified by nursing management as a contributing factor in the incident of 3/8/14 in which Patient #2 suffered a compromised airway and acute respiratory distress, the CAH failed to implement the action plan identified for staff training and assurance of competence to use the lift, and failed to evaluate the lift to assure it was functioning safely, and Patient #2 was subjected to ongoing daily use of the lift by untrained staff, through 3/19/14, placing the patient's health and well being in jeopardy.

Based on record review and confirmed through staff interview the CAH's Patient Visitation policies did not identify the clinical rationale for restricting or limiting visitors in the Childbirth Center (CBC), and did not address how CAH staff would be trained to assure appropriate implementation of the policies and procedures. Findings include:

Per review the CAH policy, titled Patient Visitation Rights, dated 6/14/2012, stated, as it's purpose; 'To ensure that all visitors of patients at the Springfield Hospital...enjoy equal visitation privileges consistent with patient preferences and subject to the Hospital's Justified Clinical Restrictions.' Although a separate 'Childbirth Center Visitors Policy' dated 2/5/2013, stated; 'Adults and children 12 and older may visit....', it did not clarify the clinical rationale for restricting visitation of children under the age of 12. In addition the policies did not address how CAH staff who play a role in facilitating or controlling visitor access to patients will be trained to assure appropriate, consistent implementation of the visitation policies to avoid unnecessary restrictions/limitations on patients visitors.

The Director of Professional Development, also identified as the CBC Nurse Manager, confirmed, during interview on the afternoon of 3/20/14, that the policies did not address staff training, and the CBC visitation policy did not include clinical rationale for the restriction of children under the age of 12 in that unit. (BH)