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Based on document review and interview, the governing board failed to ensure 1 service provided by a contractor complied with all standards for the service.

Findings include:

1. Review of the governing board minutes for calendar year 2015, indicated they did not include review of reports for the contracted nursing service.

2. Interview of employee #A3, Clinical Safety Manager, 12-15-2015 at 12:30 pm, confirmed the above and no further documentation was provided prior to exit.

Based on document review and interview, the facility failed to include in its Quality Assurance Performance Improvement (QAPI) program for calendar year 2015, monitors and standards for 1 service provided by a contractor.

Findings include:

1. Review of the facility's QAPI program for calendar year 2015 indicated it did not include monitors and standards for contracted nursing.

2. Interview of employee #A3, Clinical Safety Manager, 12-15-2015 at 12:30 pm, confirmed the above and no further documentation was provided prior to exit.

Based on Life Safety Code (LSC) survey, OrthoIndy Hospital Building 01 and Building 06 were found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) Chapter 18, New Health Occupancies.

OrthoIndy Hospital is comprised of the main hospital in Indianapolis, IN (Building 01), the ambulatory surgery center in Brownsburg, IN (Building 02), physical therapy in Fishers, IN (Building 03), physical therapy in Indianapolis, IN (Building 04), physical therapy in Carmel, IN (Building 05), the ambulatory surgery center in Greenwood, IN (Building 06) and physical therapy in Greenwood, IN (Building 07).

Building 01 is a two story fully sprinklered building, except for the elevator machine rooms, of Type II (222) construction with a basement and has a fire alarm system with smoke detection in the corridors, patient rooms and spaces open to the corridors. Building 01 provides overnight care. Building 01 has a capacity of 38 and had a census of 33 at the time of this survey.

Building 02 is a two story fully sprinklered building of Type II (111) construction and has a fire alarm system with smoke detection in the corridors and spaces open to the corridors. Building 02 provides ambulatory surgical services with no overnight stays.

Building 03 is a one story fully sprinklered building of Type II (000) construction with a basement and has a fire alarm system with smoke detection in the corridor. Building 03 provides physical therapy services during regular business hours.

Building 04 is a one story fully sprinklered building of Type II (000) construction and has a fire alarm system with smoke detection at the fire alarm system panel. Building 04 provides physical therapy services during regular business hours.

Building 05 is a one story fully sprinklered building of Type II (000) construction and has a fire alarm system with smoke detection at the fire alarm system panel. Building 05 provides physical therapy services during regular business hours.

Building 06 is a two story fully sprinklered building, except for the elevator machine room, of Type II (111) construction and has a fire alarm system with smoke detection in the corridors, stairwells and spaces open to the corridors. Building 06 provides ambulatory surgical services with no overnight stays.

Building 07 is a one story fully sprinklered building of Type II (111) construction and has a fire alarm system with smoke detection in the corridor and spaces open to the corridor. Building 07 provides physical therapy services and MRI services during regular business hours.
Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure 1 of 1 fire barriers to nonconforming buildings were protected by a two hour fire wall (Building 06) (see K 011), failed to ensure exit access was arranged so 1 of 6 exits was readily accessible at all times (Building 06) (see K 038), failed to provide annunciation for 1 of 1 fire alarm systems and failed to ensure 1 of 1 fire alarm control panels, located in an area that was not continuously occupied, was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire (Building 06) (see K 051), failed to ensure a complete automatic sprinkler system was provided for 6 of 6 elevator equipment rooms (Building 01) (see K 056) and failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms (Building 06) (see K 056) and failed to ensure 2 of 2 emergency generators was equipped with a remote manual stop (Building 01 and 06) (see K 144).

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on document review, observation and interview, the facility failed to ensure 1 of 1 fire barriers to nonconforming buildings were protected by a two hour fire wall, failed to ensure exit access was arranged so 1 of 6 exits was readily accessible at all times, failed to provide annunciation for 1 of 1 fire alarm systems and failed to ensure 1 of 1 fire alarm control panels, located in an area that was not continuously occupied, was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire, failed to ensure a complete automatic sprinkler system was provided for 6 of 6 elevator equipment rooms, and failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms and failed to ensure 2 of 2 emergency generators was equipped with a remote manual stop.

Findings include:

1. Observations with the Building Superintendent (BS#1) during a tour of the facility from 11:30 a.m. to 1:30 p.m. on 12/17/15 noted the set of 90 minute fire resistance rated self closing fire doors by Pod J in the two hour tenant separation fire barrier wall which separates the orthopedic surgical center (Building 06) from the outpatient physical therapy and MRI (magnetic resonance imaging) building (Building 07) failed to latch into the door frame. Each of the aforementioned doors in the door set was provided with a latching mechanism which was "dogged down" and failed to protrude into the latching plate. In addition, the set of 90 minute fire resistance rated automatic closing fire doors near the main entrance on the south side of the building in the aforementioned two hour tenant separation fire barrier could not be closed in order to ensure the clearance between the meeting edges of the door set swinging in pairs did not exceed 1/8 inch and would latch into the door frame. The door set was not provided with an astragal, rabbet or bevel.
2. In interview at the time of the observations, the Building Superintendent stated the automatic closing fire doors in the tenant separation wall on the south side of the building can only be closed with fire alarm system activation and acknowledged the two sets of fire doors in the fire barrier for a nonconforming building did not ensure the orthopedic surgical center was protected by a two hour fire wall.
3. Observation with the Building Superintendent during a tour of the facility (Building 06) from 11:30 a.m. to 1:30 p.m. on 12/17/15 noted the northwest exit discharge at the back of the surgery area led to a grass covered lawn and not to the public way.
4. In interview at the time of observation, the Building Superintendent acknowledged the aforementioned exit did not lead to a public way.
5. Observation with the Building Superintendent during a tour of the facility (Building 06)from 11:30 a.m. to 1:30 p.m. on 12/17/15 noted the facility's main fire alarm control panel (FACP) was located in the first floor Mechanical Room, which is not continuously occupied and remote from any area where continuous on site monitoring from the surgery suite could occur, such as the nurse station.

6. In interview at the time of observation, the Building Superintendent stated the FACP was monitored off site but was not provided with an onsite audible trouble alarm in the surgery suite or in an area where trouble signals are likely to be heard and acknowledged the Mechanical Room which contains the facility's main fire alarm control panel is not continuously occupied and was not provided with automatic smoke protection.

7. Based on observation with the Building Superintendent during a tour of the facility (Building 01) from 10:30 a.m. to 2:30 p.m. on 12/16/15 noted the four elevator machine rooms in the basement and two elevator machine rooms on first floor lacked sprinkler coverage.
8. In interview at the time of observation, the Building Superintendent acknowledged the elevator machine rooms lacked sprinkler coverage.
9. Observation with the Building Superintendent during a tour of the facility (Building 06)from 11:30 a.m. to 1:30 p.m. on 12/17/15 noted the elevator machine room on the second floor lacked sprinkler coverage.
10. In interview at the time of observation, the Building Superintendent acknowledged the elevator machine room lacked sprinkler coverage.
11. Observation with the Maintenance Tech during a tour of the facility (Building 01) from 10:00 a.m. to 1:00 p.m. on 12/16/15 noted no evidence of a remote manual stop device outside the room housing the emergency generator.
12. In interview at the time of observation, the Maintenance Tech stated the emergency generator was installed after 2003 and acknowledged a remote manual stop device was not found outside the room housing the emergency generator.
13. Observation with the Building Superintendent during a tour of the facility (Building 06) from 11:30 a.m. to 1:30 p.m. on 12/17/15 noted no evidence of a remote manual stop device for the emergency generator which was located outside the building on the north side. The nameplate affixed to the emergency generator stated it was manufactured in April 2010 and was rated at 505 kW.
14. In interview at the time of observation, the Building Superintendent acknowledged a remote manual stop device was not found for the emergency generator.

Based on document review and interview, the hospital failed to follow the manufacturer's recommendation for testing of 1 of 1 defibrillator.

Findings:

1. Review of the manufacturer's manual for a facility defibrillator, indicated a recommended checklist, the Zoll R Series defibrillator Series OPERATOR'S CHECKLIST, to be used to test and inspect the device, as follows:

1. Condition
Unit clean, no spills, clear of objects on top, case intact

2. Hands-free Therapy electrodes
1 set preconnected/ 1 spare

3. Paddles
Paddles clean, not pitted
Release from housing easily

4. Inspect cables for cracks, broken wires, connector
A. ECG [e;echocardiogram] electrode cable, connector
B. Defibrillator paddle cables
C. OneStep cable, connector
D. Other patient cables

5. Batteries
A. Fully charged battery in unit
B. Fully charged spare battery available

6. Disposable supplies
A. Defib gel or gel patches
B. Hands-free therapy electrodes in sealed package - 2 sets
C. ECG electrodes
D. Recorder paper
E. Alcohol wipes
F. Razors

7. Operational checks
A. Power On Sequence
Turn unit to MONITOR, 4-beep tone heard
"MONITOR" message on display
ECG size X 1
"PADDLES" or "PADS" as lead selected
B. Paddles
Paddles in holder: Set defib energy level to 30 joules, press paddles firmly into the side
wells, and simultaneously press and hold both defib discharge buttons. "30J TEST OK"
message on Recorder
C. Defibrillator
OneStep cable connected to test connector, or OneStep electrodes. Set defib energy
level to 30 joules, press SHOCK button; "30J TEST OK" message on Recorder
D. Pacer Operation (Optional)
OneStep cable not connected to Test Connector or OneStep electrodes
Turn to PACER, set pacer rate to 150 ppm, press RECORDER button
Pacer pulses occur ever (sic) 2 large divisions (10 small divisions)
Press 4:1 button, pulses occur every 8 large divisions
Set PACER OUTPUT to 0 mA [milliamps], no CHECK PADS message
Set PACER OUTPUT to 16 mA, CHECK PADS message and alarm
Reconnect OneStep cable to test connector, or OneStep electrodes. Press
Clear Pace Alarm softkey. CHECK PADS message disappears and Pace
alarm stops.
E. Recorder
Press RECORDER button; Recorder runs. Press again; Recorder stops.

8. Please check the appropriate box after each use of this checklist.
No action required
Minor problem(S) corrected
Disposable supplies replaced
Major problem(s) identified - UNIT OUT OF SERVICE

3. Review of a document entitled WEST Crash CART Check Log, Nov, 2015 (pg 2), dates 11/20-22 through 12/10/15, did not indicate the above checks were made.

4. Interview of employee #A2, Chief Nursing Officer, on 12-17-2015 at 4:30 pm, confirmed all the above and no other documentation was provided prior to exit.

Based on document review, observation and interview, the infection control officers failed to ensure that systems and policies in place were implemented regarding: hand hygiene in medication preparation areas and trash and linen handling/transport; failure to ensure proper attire in surgical areas; failed to ensure that EVS (environmental services) practices were per policy; failed to ensure the cleanliness in one OR (operating room) suite (#3) at the off site surgery center; failed to ensure cleanliness of a computer on wheels in the pre op area of the main hospital; failed to effect a change in physician hand hygiene compliance between 4th quarter 2014 and 3rd quarter 2015; failed to ensure that visitors follow proper precautions when visiting patients in contact precautions; and failed to ensure the implementation of the policy related to ordering contact precautions in the EMR (electronic medical record), so that it populates to the patient listing, for 1 of 2 contact isolation patients, pt. #7.

Findings Include:
1. Review of the policy Standard Precautions and Isolation Procedures, policy number 792458, last revised 5/2014, indicated on page two under Safe Injection Practices, that injection safety refers to the proper use and handling of supplies for administering injections and infusions (e.g.,[such as] syringes, needles, fingerstick devices, intravenous tubing, medications vials, and parenteral solutions). These practices are intended to prevent transmission of infectious diseases between one patient and another, or between a patient and healthcare personnel during preparation and administration of parenteral medications. Parenteral medications will be prepared and administered using aseptic technique.

2. At 12:37 PM on 12/15/15, while observing medication preparation on the East nursing unit in the company of staff member #63, the infection preventionist, it was observed that the handwashing sink was within 6 to 12 inches of the counter top used for drawing up two types of insulin for patient administration. It was observed that the counter top does not have enough length to be able to be 36 inches from the handwashing sink, and there was no separation, or splash guard, for separation.

3. At 12:37 PM on 12/15/15, while observing staff RN (registered nurse) #55 preparing two types of insulin for patient administration, it was observed that the RN failed to perform hand hygiene before accessing the Omni-Cell machine to obtain the insulin, before drawing up the two syringes of insulin, after returning the insulin to the Omni-Cell and then taking the syringes to the patient room.

4. Review of the policy Bloodborne Pathogen Exposure Plan, policy number 1538175, last revised 8/2015, indicated in the section titled Methods of Implementation and Control that all employees who engage in activity where exposure to blood and body fluids is likely, must assume that these substances are infectious and use standard precautions, including proper hand hygiene techniques.

5. Review of the policy Laundry Transport and Handling, policy number 1683114, last approved on 8/2015, indicated that proper handling and separation of laundry is essential to effective infection control. Maintaining aseptic technique and avoiding cross contamination necessitates good practices.

6. Review of the policy Standard Precautions and Isolation Procedures, policy number 792458, last revised 5/2014, indicated that all patient blood and body fluids will be considered potentially infectious, and therefore Standard Precautions will be maintained. Wear gloves when there is potential contact with blood, body fluids. Under the section Linen, it reads; Handle, transport and process soiled linen in a manner that prevents skin and mucous membrane exposures and contamination of clothing and that avoids transfer of microorganisms to other patients and environments.

7. At 11:12 AM on 12/16/15, while observing in the pre/post op unit in the company of staff member #58, the surgery manager, it was observed that staff member #60, a nurse tech, was removing soiled linens from a hamper outside room #133, for transport to the soiled utility room, without wearing gloves for protection.

8. At 12:10 PM on 12/16/15, while observing in the pre op area in the company of staff member #57, the pre/post director, it was observed that the EVS staff member, failed to wear gloves when handling/transporting soiled waste from patient rooms to the soiled utility.

9. Review of the policy Dress Requirements Within The Surgical Environment, policy number 855184, last revised 5/2014, indicated reusable head coverings should be laundered in a hospital laundry service when visibly soiled or on a weekly basis.

10. Per AORN (association of periOperative registered nurses) standards of 2015, on page 114 it reads that in a study, infections "...were directly related to personnel carrying Staphylococcus aureus in their hair...", and that reusable head covering should be laundered in a health care-accredited laundry facility after each daily use and when contaminated.

11. Interview with staff member #63, the infection preventionist, at 2:00 PM on 12/15/15, confirmed:
A. Cloth/reusable head coverings are laundered twice a week, not weekly as the policy stated.
B. The facility follows AORN standards and recommendations.
C. Currently the policy and process utilized by the facility does not follow AORN standards.

12. Review of the policy Dress Requirements Within The Surgical Environment, policy number 855184, last revised 5/2014, indicated head and facial hair must be covered when in the surgical area.

13. At 3:10 PM on 12/16/15, while observing patient transport to the OR (operating room) from pre op, and while in the OR, it was observed that the anesthesiologist, staff member
#61, had hair at the back of the head/neck that was not covered by the skull cap.

14. At 9:25 AM on 12/17/15, while touring the off site surgery center in the company of staff member #58, the OR manager, it was observed that the anesthesiologist, staff member
#62, had facial hair (a beard) that was not covered by the face mask covering their nose and mouth, and had hair at the back of the head that was not covered by the skull cap.

15. At 9:30 AM on 12/17/15, interview with staff member #58 confirmed that the beard of the anesthesiologist (#62), and the hair below the skull cap, was not covered, as policy requires.

16. Review of the policy Dress Requirements Within The Surgical Environment, policy number 855184, last revised 5/2014, indicated long sleeved jackets are acceptable attire for any personnel outside of the sterile field. Jacket should be snapped. T-Shirts may be worn under the scrub top but should not be visible and must be contained completely within or covered by surgical attire.

17. At 11:17 AM on 12/16/15, while observing the end of a case and between case cleaning in OR #5 in the company of staff member #58, the OR manager, it was observed that the anesthesiologist had a T-shirt under the scrub top that was visible, and two surgical nurses had long sleeved jackets that were not snapped.

18. At 3:00 PM on 12/17/15, interview with the infection practitioners, staff members #53, and #63, confirmed that per policy, T-Shirst are to be completely covered and long sleeved jackets are to be snapped in the OR suites.

19. Review of the contracted EVS company Cleaning Procedures Manual indicated:
A. The company uses a 7 step cleaning process in which step #5 is to dust mop floors and step #6 is to damp mop floors.
B. On pages 36 and 38 of the manual, it reads to prepare a five quart pail of wipers (cleaning cloths) to clean surfaces with the disinfectant solution and to prevent cross contamination, never re-dip a wiper into the clean five quart pail.

20. At 11:45 AM on 12/15/15, while observing EVS staff member #65 in the company of staff member #63, the infection preventionist, it was observed that step #5, dust mopping the floor in room #213, was not done, as staff member #65 damp mopped the floor with having dust mopped first.

21. At 12:00 PM on 12/15/15, while observing EVS staff member #64 in the company of staff member #63, the infection preventionist, it was observed that staff member #64 double dipped their cleaning cloth >3 times while terminally cleaning room #234.

22. At 12:25 PM on 12/16/15, interview with the EVS supervisor, staff member #56, confirmed that staff member #65 did not clean the floor of room 213 correctly by failing to dust mop prior to damp mopping the floor, and that staff member #64 should not be double dipping the cleaning cloths/wipers.

23. Review of the policy Environmental Cleaning of Surgical Operating Suite rooms and Equipment, policy number 1124273, last reviewed 12/2014, indicated, in Appendix A, that the contracted cleaning service was to wipe down walls, ceiling and doors with disinfectant on a monthly basis.

24. At 9:20 AM on 12/17/15, while touring the OR (suite #3) at the off site surgery center in the company of staff member #58, the OR manager, it was observed that dust was present on the two wall mounted air vents within the suite.

25. At 9:25 AM on 12/17/15, interview with staff member #58 confirmed that:
A. Walls are to be cleaned weekly.
B. The last time the walls and air vents were cleaned was Monday, 12/14/15 with evening/night contracted cleaning staff.
C. Weekly, or monthly, cleaning of the air vents may not be frequent enough to keep dust from collecting in the OR suite.

26. Review of the policy Cleaning of Noncritical Patient Care Devices, policy number 779698, last revised 5/2014, indicated that any time equipment comes in contact with a patient, it will be disinfected before being used on another patient.

27. At 2:57 PM on 12/16/15, while observing in the pre op area in the company of staff member #57, the pre/post op director, it was observed that the COW (computer on wheels) used in and out of patient rooms, had a large accumulation of dust on the base of the unit.

28. At 3:00 PM on 12/16/15, staff member #57 confirmed that:
A. A gross amount of dust was present on the base of the computer system and that each nurse is responsible for cleaning their work station.
B. The computer on wheels should be wiped down between each patient interaction.
C. The policy for the cleaning of noncritical patient care devices covers the COWs.

29. Review of the 2/19/15 infection control meeting minutes indicated the 4th quarter 2014 MD (medical doctor) compliance rate for hand hygiene was 91% in the inpatient unit, 41% in PACU (post anesthetic care unit), and 50% in the post op area. The discussion notes indicated the physician rates were posted in the physician newsletter. The 3rd quarter hand hygiene rates indicated the MD inpatient rate had decreased to 71% and the PACU rates decreased to 33%.

30. At 3:00 PM on 12/17/15, interview with the infection preventionist, staff member #63, confirmed that physicians have a lower percentage of compliance for hand hygiene. It was also confirmed that nursing staff may not have as much of an impression in changing physician habits as some pressure from the medical director, and physician chairman of the infection control committee, might have.

31. Review of the Standard Precautions and Isolation Procedures policy, number 792458, last revised 5/2014, indicated patients with known or suspected transmissible illnesses will have appropriate isolation procedures in place to inhibit the spread of that illness. In section B., Contact Precautions, it reads that precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment. This applies to patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct or indirect contact. In addition to Standard Precautions, Contact Precautions involve: b. Use of gloves and gown by healthcare workers every time the patient's environment is entered, and f., placing a contact precautions sign outside the patient's room to inform all persons of the necessary precautions.

32. Review of the policy Visiting Hours and Visitation, policy number 1673411, last approved on 8/2015, indicated in section H., Visitors to patients in isolation are subject to isolation guidelines. Visitors should check with the patient's nurse for specifics.

33. Review of the Contact Precautions document posted on the doorway of room #213, (patient #2), indicated: "To prevent the spread of infection, anyone* entering this room must wear gloves and a gown. Applies whether or not contact with patient or the patient's environment is anticipated. * Patient visitors do not need to wear gloves and a gown, but must wash hands upon entering and leaving this room.

34. At 12:20 PM on 12/15/15, interview with staff members #53, and #63, the infection practitioners, confirmed that visitors of the patient in room 213 do not need to wear gowns/gloves as the patient is "colonized" for MRSA (methicillin staph resistant staph aureus), and not an "active" infection patient. It was also stated that facility patients are able to care for themselves so that their visitors aren't doing hands on patient care.

35. At 11:45 AM on 12/15/15, while observing the patient in isolation room 213, it was observed that the family of the patient assisted in moving the patient up in bed, fluffed the pillow, straightened the covers, and reapplied the ice pack to the post surgical knee site, all while being without gown/gloves.

36. At 2:00 PM on 12/15/15, interview with staff members #53 and #63 indicated:
A. It was unknown that the family of pt. #2 (in room 213) was doing hands on patient care.
B. Confirmed that policy currently requires gloves and gown in contact isolation patient rooms, and does not allow no gown/gloves, as the posted sign indicates.
C. There is nothing posted indicating visitors of patients in contact isolation must first check with the patient's nurse before entering the room to know what appropriate attire is for the contact isolation patient, as policy indicated visitors must do.

37. Review of the Standard Precautions and Isolation Procedures policy, number 792458, last revised 5/2014, indicated that patients with known or suspected transmissible illnesses will, in addition to Standard Precautions, have Contact Precautions that involve: a. Entering an order for Contact Precautions in the electronic medical record.

38. Review of the medical records for patients #2 and #7, both contact isolation patients, indicated that nursing staff failed to enter an order for isolation for patient #7, and thus the patient was not noted on the patient listing/roster as being in contact isolation.

39. At 2:00 PM on 12/17/15, interview with staff member #51, the CNO (chief nursing officer) and #63, the infection preventionist, confirmed that nursing staff failed to order the contact isolation/precautions for pt. #7, as is required per facility policy.

Based on document review and interview, the facility, as part of the discharge planning evaluation, failed to document an assessment of the patient's insurance coverage and how that coverage might or might not provide for necessary services post-hospitalization, for 1 out of 5 medical reviewed.

Findings include:

1. Review of 5 medical records indicated Patient/Record #4 had no documentation of assessment of the patient's insurance coverage and how that coverage might or might not provide for necessary services post-hospitalization, for 1 out of 5 medical reviewed.

2. Interview of employee #A4, Manager Case Management, confirmed the above and no other documentation was provided by exit.

Based on interview, the facility failed to include in its evaluation of readmissions, whether the readmissions were potentially due to problems in discharge planning or the implementation of discharge plans, in 1 instance.

Findings include:

1. Interview of employee #A4, Manager Case Management, on 12-16-2015 at 2:00 pm, indicated the hospital did not include in its evaluation of readmissions whether the readmissions were potentially due to problems in discharge planning or the implementation of discharge plans.