HospitalInspections.org

Based on record review and interview, the Governing Body failed to:

A. Ensure the hospital identified and evaluated all contracted services for quality and safety (See tag A-0084)

B. Ensure the hospital developed and implemented an effective Quality Assessment and Performance Improvement program. (See tag A-0273)

C. Ensure the hospital developed and implemented an effective infection control program to prevent, control and investigate infections and communicable diseases in patients and staff. (See tag A-0749)

Based on record review and interview, the hospital failed to ensure that contracted services were evaluated for safety and effectiveness.

This failed practice had the potential to compromise patients' safety due to suboptimal services from contracted entities.

Findings:

On 06/20/17, a list of contracted services was provided. No documentation was provided that showed contracted services had been evaluated by the governing body, who is responsible for oversight.

Policy titled, "Contract Management dated 10/9/13" documented all contractors must meet defined qualifications. The policy documented the contractors are subject to monitoring and evaluation of their performance as evidence by the reviewing official's completion of a progress report.

On 06/21/17 at 9:00 am, Staff A stated contracted services were not evaluated by established quality criteria, and performance progress reports had not been completed for the contracts.

Based on record review and interview, the hospital failed to ensure patients were informed of their rights prior to staff providing care for 12 (Patients #5, 6, 8, 9, 10, 11, 13-18) of 20 records reviewed.

This failed practice had the potential to affect all current patients due to the lack of knowledge regarding care decisions.

Findings:

12 (Patients #5, 6, 8, 9, 10, 11, 13-18) of 20 records reviewed showed no documentation to support the patients were informed of their rights prior to initiation of treatment.

On 06/23/17 at 11:35 am, Staff M stated patient rights information was given in the ER and the ER clerk was responsible for scanning the information into the record. Staff M stated the form provided in the ER was not scanned in to the patients' records and there was no documentation of the patients receiving and understanding their rights.

Based on record review, observation, and interview the hospital failed to provide patients with the contact information to lodge a grievance with the State agency and their right to seek review by the Quality Improvement Organization (QIO), Kepro.

This failed practice had the potential to affect patient rights for grievances not being addressed or investigated.

Findings:

A hospital policy titled, "Patient Grievance" did not contain any contact information to lodge a grievance with the State agency or the QIO, Kepro. The policy documented patients are informed on the grievance procedures through the patient rights and responsibilities brochures and notices posted throughout the hospital.

A document titled "Patient Rights & Responsibilities" did not contain any contact information to lodge a grievance with the State agency or Kepro.

During a tour of the hospital on 06/20/17 surveyor observed the document titled "Patient Rights & Responsibilities" posted throughout the hospital. The document did not contain any contact information to lodge a grievance with the State agency or with Kepro.

On 06/20/17 at 2:53 PM, Staff A stated the document titled "Patient Rights & Responsibilities" received by each patient and that is posted throughout the hospital do not include any contact information to lodge a grievance with the State agency or with the QIO.

Based on record review and interview the hospital failed to establish a specific time frame for grievance resolution if unable to complete an investigation that exceeds the allotted 7 business days for 1 (patient #22) of 2 grievance files reviewed.

This failed practice had the potential to affect patient safety for grievances not being addressed or investigated.

Findings:

A hospital policy titled, "Patient Grievance" a response is sent to patient within 7 business days of initial reception of a grievance; if a longer time frame is necessary then a target date for resolution will be included.

Patient #22 grievance was submitted on 01/19/16. A response letter was sent to the complainant on 01/22/16 acknowledging the submitted grievance; the letter did not contain a target date for the resolution.

A resolution letter was sent to the complainant on 03/11/16 (35 days later). A document titled "RM Log..." showed the submitted occurrence report continued to be reviewed until 01/30/17 when the grievance status was closed.

On 06/23/17 at 4:00 PM, Staff B stated the grievance response letter did not include a target date.

Based on observation and interview, the hospital failed to provide a safe environment for 10 of 10 patient rooms (16 beds) in the "Hope" unit by not removing ligature fixtures and furniture from the rooms.

This deficient practice had the potential to cause harm to any patient admitted to the unit with suicidal ideations.

Findings:

1. On 06/20/17 at 10:15 am, surveyors observed a room described as the Seclusion Room that contained storage racks with supplies and equipment.
2. In the 10 of 10 patient rooms (16 beds) in the "Hope" unit, the following potential risks for harm to patients and staff were observed:

A. Hospital beds were moveable with open side rails
B. O2 wall set up attached
C. Ligature fixtures
D. Long plug-in cords
E. End table with decorative looped-handle hardware
F. Screws, loose or easily removed
G.Round door knobs
H.Bathrooms with no anti-ligature fixtures
I. Metal light fixtures
J. Sinks with no anti-ligature fixtures

On 6/20/17 at 9:00 am, Staff A stated he was aware of some of the issues with the rooms.

Based on record review and interview the hospital failed to provide a policy that includes the components implemented for abuse/neglect protection from an alleged employee. Necessary components include screening, identifying, training, protecting, investigating, and reporting.

This failed practice had the potential to increase risk of abuse to all patients who seek care at the hospital.

Findings:

A hospital policy titled, "Abuse of Children, Elderly, and Incapacitated Adults and Mandatory Reporting" did not contain information related to screening, identifying, training, or protecting patients from abuse during an investigation.

On 06/23/17 at 10:55 AM, Staff A stated the policy did not contain the necessary components to protect patients from an alleged abuser.

Based on record review and interview, the hospital failed to document the use of chemical restraints for 1 (Patient #7) of 2 patient records reviewed with restraint/seclusion incidents.

This failed practice had the potential to affect any current hospital patients due to the lack of sufficient monitoring for patient safety following use of restraints.

Findings:

A policy titled "Use of Restraints or Seclusion" defined a chemical restraint as "a medication used to control behavior...is not a standard treatment...". The policy stated multiple documentation requirements, including:

1. Restraint orders, including the rationale for the restraint;

2. Type of restraint;

3. The patient's response to the restraint;

4. The discussion with the patient/family regarding the need for a restraint;

5. A Restraint Flow-sheet for each occurrence to include the date and time, type of restraint, times of assessments/reassessments.

The policy stated assessments were required every 15 minutes to include respiratory and circulatory status, vital signs, level of distress and agitation, mental status, and cognitive functioning.

Patient #7

On 04/13/17 at 6:31 pm, Staff O documented "Pt became angry w/ LPN and punched her in the lip...orders received for Olanzapine 10 mg , IM, ONCE, NOW to be given for psychotic aggression." There was no documentation the medication was treated as a chemical restraint. There was no documentation of discussion with the patient/family regarding the need for a restraint, a Restraint Flow-sheet, or assessments conducted every 15 minutes with the required information.

On 04/14/17 at 7:00 am, Staff S documented "Pt swung arm at this nurse..." At 7:10 am, Staff R documented "Medicated times one with 50 mg of Bennadryl [sic] given Im in left deltoid. 10 mg of Zyprexa given IM in right arm..." There was no documentation the medications were treated as chemical restraints. There was no documentation of discussion with the patient/family regarding the need for restraints, a Restraint Flow-sheet, or assessments conducted every 15 minutes with the required information.

On 04/17/17 at 9:50 pm, Staff P documented "He was hitting and kicking at staff. Not redirectable." At 10:20 pm, Staff Q documented "N/O Zyprexa 5 mg IM ONCE NOW." There was no documentation the medication was treated as a chemical restraint. There was no documentation of discussion with the patient/family regarding the need for restraint, a Restraint Flow-sheet, or assessments conducted every 15 minutes with the required information.

On 06/23/17 at 4:20 pm, Staff B stated the restraint was not documented per hospital policy.

Based on record review and interview it was determined the hospital failed to develop a policy and procedures ensuring restraints are not used on an as needed basis (PRN).

This failed practice has the risk of restraint misuse, violation of patient's rights, unintended patient injury, and/or decreased self-esteem for all patients admitted to the hospital requiring restraints.

Findings:

A hospital policy titled "Use of Restraints or Seclusion" documented a restraint must never be entered on as needed basis. The same policy documents to remove restraint every two hours for at least 10 minutes and release more frequently if needed or if family member is available.

On 06/23/17 at 4:00 PM, Staff B stated the statements within the policy are unclear.

Based on record review and interview, the hospital failed to conduct face-to-face assessments following use of chemical restraints for 1 (Patient #7) of 2 patients reviewed with restraint/seclusion incidents.

This failed practice had the potential to affect all current patients due to the lack of sufficient monitoring for patient safety following the use of restraints.

Findings:

See tag A160.


37609

Based on record review and interview the hospital failed to complete a face-to-face assessment within the hospital's timeframe after a restraint or seclusion was initiated for one (Patient #21) of three patient medical records reviewed.

This failed practice had the potential to delay recognition of changes in the patient's condition to determine if restraints remained necessary.

Findings:

A hospital policy titled "Use of Restraints or Seclusion" documented face-to-face assessment will be performed within 1 hour of the initiation of restraints by the ordering physician.

Patient #21 medical record showed restraints ordered on 10/28/16 at 9:21 PM and a physician reexam/reevaluation was documented on 10/28/16 at11:50 PM (approximately 2 ½ hours later).

On 06/23/17 at 4:00 PM, Staff B stated face-to-face assessment should be completed by the physician within an hour of the restraints placed.

Based on record review and interview, the hospital failed to analyze and document the quality indicator data collected.

Findings:

Documents titled "Infection Prevention, Safety, Quality dated 2017" were provided. The minutes did not reflect an analysis of data showing a measurable improvement with evidence of how this will improve health outcomes.

On 06/22/17 at 10:40 am, Staff C stated the data was not analyzed; and stated there were no attachments to the minutes. Staff C stated she understood the minutes were incomplete and did not reflect an analysis of data.

Based on record review and interview, the hospital failed to ensure an RN supervised and evaluated nursing care for 3 (Patients #7, 8, and 16) of 20 patient records reviewed.

This failed practice had the potential to affect all current patients due to the lack of identification of supervision.

Findings:

Patient #8

A policy titled "Pain Assessment; Reassessment and Management" stated an initial comprehensive pain assessment would be performed on admission, to include the nature of the pain, duration, type, intensity, and pain relief measures that have proven effective. The policy stated a reassessment of pain would be conducted each shift, and following an intervention for pain conducted by patient care providers.

A policy titled "Patient Care Plans" stated the RN was responsible for development of patient nursing care plans based on assessment data, each shift the RN will document his/her assessment of the patient's care needs and response to interventions, and the physician will be notified of any significant changes.

On 06/19/17 at 1:56 am, Staff U documented chronic pain as an active problem for the patient on admission. There was no documentation of a pain assessment. Documentation showed the first pain assessment was conducted on 06/21/17 at 7:20 am (6 shifts without completion of a pain assessment).

On 06/21/17 at 7:20 am, Staff T documented the patient had pain present at a 9 out of 10 level at rest and a 10 out of 10 with activity. There was no documentation of interventions provided, patient response to interventions, or physician notification. There was no documentation of a pain assessment during the evening shift on 06/21/17.

On 06/22/17 at 7:20 am, Staff T documented the patient had pain present at a level of 10 out of 10 at rest and with activity. There was no documentation of interventions provided, patient response to interventions, or physician notification.

Patient #16

On 06/07/17 at 12:05 am, Staff V documented chronic pain as an active problem for the patient on admission. There was no documentation of a pain assessment.

On 06/23/17 at 4:30 pm, Staff B stated pain assessments should be conducted every shift.

Patient #7

A policy titled "Patient Monitoring, Levels of Observation" defined the staff expectations for Routine, Direct Visual Observation, and One on One (1:1) levels of monitoring. The level called "Direct Visual Observation/Line of Sight" required the assigned staff member to "keep the patient within his or her line of site [sic] at all times." The level called One on One required the assigned staff member to be "Within an arm's length of the patient at all times" and must be with the patient during toileting, bathing, and dressing. The policy stated any changes in the level of monitoring were the responsibility of the charge nurse.

On 04/14/17 at 7:21 am, Staff R documented a physician order for "1 on 1 observation for violence".

On 04/15/17 at 2:15 pm, Staff R documented "...sitting in the geriatric chair, line of sight due to aggressive and undirectable behaviors." There was no documentation of an assigned staff member within arm's reach.

On 04/15/17 at 4:29 pm, Staff R documented "Remains in line of sight due to agitation and behaviors." There was no documentation of an assigned staff member within arm's reach.

On 04/15/17 at 7:20 pm, Staff R documented "Remains in line of sight, in front of the nursing station." There was no documentation of an assigned staff member within arm's reach.

There was no documentation to support an RN evaluated the patient's care to change the level of monitoring. There was no documentation an order was received to change the patient's level of monitoring from One on One monitoring to Line of Sight monitoring.

On 06/23/17 at 4:25 pm, Staff B stated the policy required nursing staff to document new orders and changes to the care plan when the level of monitoring was changed.

Based on observation and interview, the hospital failed to ensure medical records were properly stored.

This failed practice had the potential to affect all patients due to the loss of original medical records.

Findings:

During a tour of the hospital on 06/20/17 at 3:16 pm, the surveyors observed soiled/discolored cardboard boxes containing paper medical records. The records were being stored in a basement room, underneath leaking overhead pipes.

On 6/20/17 at 3:16 pm, Staff B stated records should not be stored in an area where they could become wet or soiled.

Based on observation and interview, the MRI suite was not equipped with the necessary equipment or materials to immediately respond to potential adverse events creating a hazard for patients and personnel.

Findings:

On a tour of the MRI suite on 06/20/17, surveyors observed there was no crash cart, no emergency medications or emergency response call system available. The MRI suite is a separate building from the hospital attached by an angled hallway.

On 06/20/17 at 12:00 pm, Staff B stated she was aware there were no emergency medications available in the MRI suite.

Based on record review, observation and interview, the hospital failed to maintain proper safety precautions against radiation hazards.

Findings:

On a tour of the facility on 06/20/17, surveyor observed two unidentified lead aprons hanging in the Radiology Department. Staff in the department identified the aprons as new and being ready for use.

Document titled "Radiation Safety dated 10/21/2016" states that lead aprons will be inspected to ensure proper shielding is maintained. Staff were unable to provide evidence the lead aprons were insepected to ensure proper shielding prior to putting the aprons into service.

On 06/20/17, Staff J stated the lead aprons had not been inspected and identified prior to placing into service.

Based on observation and interview, the hospital failed to provide a safe environment for 10 of 10 patient rooms (16 beds) in the "Hope" unit by not providing a seclusion room and by not removing ligature fixtures from the rooms.

This deficient practice had the potential to cause harm to any patient admitted to the unit with suicidal ideations.

Findings:

See Tag A-0144

Based on record review and interview the hospital failed to ensure the safety and well-being of the patient population.

This deficient practice had the potential to affect every patient admitted to the hospital.

Findings:

The hospital's internal/external disaster plans were provided. The plans provided by Staff H did not have an effective date or date approved by the governing body.

On 06/23/17 at 4:10 pm, Staff H stated the Emergency and Disaster plans had not been reviewed or approved by the governing body.

Based on observation and interview, the hospital failed to maintain supplies with an acceptable level of quality per the following findings:

A. Expired needles and blood collection tubes were found in a room used for patient blood specimen collection;

B. A visibly soiled supply package was found in a cart containing wound care supplies;

C. Expired DNA test kits were found in the medication room.

This failed practice had the potential to affect all patients receiving laboratory services and/or wound care due to expiration and/or contamination of supplies.

Findings:

A. During a tour of the hospital on 06/20/17 at 10:30 am, surveyors observed a room used for venipuncture and blood specimen collection. The room contained laboratory supplies including blood collection needles and tubes. The surveyor observed multiple needles with the expiration date of 12/2014. The surveyor observed multiple blue top tubes with the expiration date of 02/2017 and multiple green top tubes with the expiration date of 04/2017.

On 06/20/17 at 10:30 am, Staff B stated the expired supplies should not be used for patients and would be discarded.

B. On 06/20/17 at 11:00 am, the surveyor noted a cart labeled "Wound". The cart contained a visibly soiled package with a brown to rust colored smear in the bottom drawer.

On 06/20/17 at 11:00 am, Staff B stated the package should not have been in the cart. Staff L stated the nurses were responsible for checking the supplies in the cart monthly and after each use of a supply.

C. On 06/20/17 at 11:30 am, the surveyor noted 4 DNA test kits with the expiration date of 11/18/16 in the medication room.

On 06/20/17 at 11:30 am, Staff L stated the nurses should be checking the supplies in the room every shift.



38563

Based on observation, record review and interview the hospital failed to ensure equipment was maintained to ensure an acceptable level of safety and quality of:

A. Care Fusion refrigerated med dispense.
B. Ventilator

Findings:

A. During tour of the emergency department on 06/22/17, surveyor observed the "Care fusion refrigerated med dispenser" lacked a preventative maintenance sticker. Surveyor requested the maintenance log or documentation the care fusion dispenser had been inspected. None was provided.

On 06/23/17 at 12:40 pm, Staff A stated this machine had not been included in the preventative maintenance plan.

B. During tour of the respiratory therapy department on 06/22/17, surveyor found one of two ventilators' preventative maintenance sticker was out of date since December 2016. Surveyor requested the log or documentation that the ventilator had been inspected and deemed safe for use since the December due date. No documentation was provided.

On 06/20/17 at Staff K stated that equipment inspections had recently been conducted but this ventilator was missed.

Based on observation, record review and interview the hospital failed to maintain proper ventilation in the Operating Room, Decontamination Room and Soiled Utility Room.

Findings:

See Life Safety Code survey 06/22/17 Tag Fed-K-0320.

Based on observation and interview, the hospital did not develop a system for identifying, reporting, investigating and controlling infections of patients and personnel.

Findings:

Surveyors observed the following during a tour of the facility on 06/20/17:

A. Construction in the Emergency Department with no permit posted by Infection Control
B. Brown, rusty substance was found on packaging in Wound Cart in the ED
C. Fluids labeled "Adult Crash Cart" were found in the pediatric crash cart in the ED
D. Expired supplies were found in the adult and pediatric crash carts in the ED
E. Opened and unlabeled vials of Bupivicaine and Insulin in the ED
F. Ophthalmic instrument in the clean supply room was dusty and uncovered
G. Kangaroo pump uncovered and unable to identify if ready for use found in the 2nd floor clean equipment room
H. No bottom rack covers on shelving in the 2nd floor supply rooms
I. Cardboard box on the floor in the 2nd floor supply room
J. Open package of briefs on the supply cart in the 2nd floor supply room
K. Expired supplies (enema and baby powder) on the supply cart in the 2nd floor supply room
L. Small plastic storage cart on floor in the 2nd floor supply room
M. Open bottle of Betadine labeled 05/17 in the 2nd floor medication room
N. Expired TB vaccine in the refrigerator in the 2nd floor medication room
O. No bottom rack cover on shelving in the 3rd floor supply room
P. Expired supplies (needles and vials) in laboratory services.

On 06/22/17 at 12:00 pm, Staff D stated she agreed with the above findings.

Staff A provided a list of disinfectants and cleaning products utilized by the facility.

On 06/22/17 at 12:00 pm, Staff D stated the Governing Body had not reviewed and approved the hospital's disinfectants and cleaning products.

Based on record review and interview the hospital failed to provide an organ procurement agreement that addressed all the required information.

This failed practice had the potential to prevent the identification of individuals suitable for eye, tissue and organ donation.


Findings:

An agreement between LifeShare, an organ procurement organization, and "The Creek Nation" failed to document the developed definition of "imminent death".

A hospital policy titled, "Anatomical Donation" documented definitions of brain death and cardiac death. These definitions were excluded in the agreement.

On 06/21/17 at 4:30 PM, Staff A stated unawareness of the OPO agreement and hospital policy not correlating with one another.