HospitalInspections.org

Based on a review of facility documentation and staff interview(s) EMP, it was determined the governing body failed to ensure that contracted services used by the facility are compliant with all applicable conditions of participation (COPs) and standards for contracted services.

Findings include:

On September 21, 2020, at approximately 9:00 AM a request was made to EMP2 to provide a list of all contracted services utilized by the facility with evidence the governing board was evaluating these contracted services to determine compliance with applicable COPs and standards. What was provided by EMP2, was a numerical list of vendors the facility used but no list of contracted services was provided.

On September 23, 2020, at approximately 12:30 PM a request was made again to EMP2 to provide a list of contracted services utilized by the facility with evidence the governing board was evaluating these services to ensure compliance with applicable COPs and standards but EMP2 was unable to provide evidence prior to the survey team exiting the survey.

Based on a review of facility documentation and staff interview (EMP), it was determined the governing body failed to ensure that services provided under contract were provided in a safe and effective manner

Findings include:

On September 21, 2020, at approximately 9:00 AM a request was made to EMP2 to provide a list of all contracted services utilized by the facility in addition to any quality assessment completed by the facility regarding the safety and effectiveness of the service

On September 23, 2020, at approximately 12:30 PM a request was made again to EMP2 to provide the aforementioned list of contracted services but no list was provided prior to the survey team exiting the survey.

On September 23, 2020, at approximately 1:00 PM EMP1 was asked if a list of contracted services existed in addition to any quality assessment regarding the safety and effectiveness of the service and EMP1 revealed "I would say, no."

Based on a review of facility documentation and staff interview (EMP), it was determined the facility did not maintain a list of all contracted services, including the scope and nature of the services.

Findings include:

On September 21, 2020, at approximately 9:00 AM a request was made to EMP2 to provide a list of all contracted services utilized by the facility. What was provided by EMP2, was a numerical list of vendors the facility used but no list of contracted services.

On September 23, 2020, at approximately 12:30 PM a request was made again to EMP2 to provide a list of contracted services utilized by the facility but EMP20 was unable to provide evidence prior to the survey team exiting the survey.

Based on review of facility documentation, medical records (MR), and staff (EMP) interview, it was determined the facility failed to ensure that a copy of the hospital's Patient's Bill of Rights was given to each patient or responsible party upon admission or as soon after admission as feasible for five of five medical records reviewed (MR15, MR16, MR17, MR18, and MR19).

Findings include:

Review of facility policy and procedure "Patient Bill of Rights and Responsibilities Guidelines" last reviewed January 2020, revealed "Highlands Hospital complies with the Rules and Regulations of the Pennsylvania Department of Health regarding the implementation and distribution of a patient's bill of rights and responsibilities."

Review of MR15, MR16, MR17, MR18, and MR19 revealed no documentation that the patient's or responsible party was given a copy of the Patient's Bill of Rights upon admission or soon after admission.

Interview with EMP2 on September 23, 2020, at 9:45 AM confirmed the above findings and revealed "It [Patient's Bill of Rights] doesn't have a signature line. We don't have documentation they [patients or responsible party] received it."

Based on a tour of the facility and interview with staff (EMP), it was determined the facility failed to maintain the facility in a safe and sanitary condition for pharmacy employees.

Findings include:

During a tour of the facility pharmacy area conducted on September 23, 2020, at approximately 12:00 PM. the tile floor throughout the entire pharmacy area was visibly stained and worn. In addition, multiple ceiling tiles were observed to be stained and discolored.

During the tour on September 23, 2020, at approximately 12:00 PM, EMP20 confirmed the above findings.

Based on review of facility documentation, observations, and interview (EMP), it was determined the facility failed to comply with proper environmental controls when storing sterile surgical supplies, and failed to provide proper ventilation in appropriate areas.

Findings include:

A review of The 2018 Guidelines for design and construction of Hospitals from the Facility Guidelines Institute, "Table 7.1 Design parameters-Hospital Spaces...Sterile storage room...Design Relative Humidity (k),%...Max 60...Design Temperature(l), ºF/ºC...Max 75/24."

A review of the department of surgical services/operating room "Policy...Subject: Temperature and Humidity Readings...Review date December 2, 2019" revealed, "Temperature and humidity readings will be monitored to provide a safe and comfortable environment for the physicians, staff, and patients...Objectives...2. To provide a stable environment for the storage of sterile supplies...4. Daily readings of the temperature and humidity are documented. Acceptable temperature is 68 to 73 degrees and humidity range is 35 to 60%."

During a tour of the operating room (OR) area with EMP1 on September 22, 2020, at 9:30 AM, a cart of sterile items including surgical trays was observed to be in the hallway near the PACU. Upon further tour of the OR hallway another cart of sterile supplies was observed to be near the exit door of the OR area. There was no humidity monitoring device or log documenting temperature or humidity anywhere in sight.

During an interview on September 22, 2020, at 9:50 AM, EMP1 confirmed that there were sterile supplies setting on carts in the OR hallway and there was no humidity monitor and no evidence that staff were monitoring temperature and humidity in this area.

Review of maintenance department policy "Scope of Services," last revised December 2014, revealed, "... Goal and Philosophy: ... The first priority of the Maintenance Department is to ensure that the equipment and building permit a safe and efficient environment for patients and staff. ... General Services: The Maintenance Department operates a High Pressure Steam Boiler Plan. ... The manager maintains the building and off-site locations, department procedure and equipment manuals, the records of life safety inspections, inspections and repairs to the fire alarm system, sprinkler system, elevators, boilers and pressure vessels, portable fire extinguishers and emergency generators, and blueprints for the entire facility The Director of Facilities and/or staff also oversees and coordinate any repair or construction work being performed at the Hospital by outside contractors."
Review of Guidelines for Design and Construction of hospitals, Ventilation of Health Care Facilities, revealed, "... 7. Space ventilation - hospital spaces. ... 7.1 General Requirements. The following general requirements shall apply for space ventilation: a. Spaces shall be ventilated according to Table 7-1."
Review of facility documentation for room air change summary, dated March 5, 2020, revealed actual air changes per hour were not meeting the design air changes per hour in the endoscopy room, scope wash room and negative pressure room 310. Further review of the room air change summary revealed actual room pressure for negative pressure room 310 was positive pressure.
Interview with EMP3 on September 22, 2020, at 1:15 pm confirmed the above findings.

Based on review of facility documentation, observation, and staff interview (EMP), it was determined that the facility failed to demonstrate methods for preventing and controlling the transmission of infections within the hospital.

Findings included:

On September 23, 2020, a review of the "Highlands Hospital Infection Control Manual Section 5/General ... Subject Personal Protective Equipment (PPE) ..." which was last reviewed in December, 2019, revealed: "... PURPOSE: The proper use of Personal Protective Equipment (PPE) will prevent the transmission of infections and diseases between patients, visitors and personnel and decrease the risk of Healthcare Associated Infections (HAI's). POLICY: ... Gloves will be worn when your hands are likely to be in contact with blood or body fluids, mucous membranes, skin that has open cuts or sores, or contaminated items and surfaces. Gloves will be worn for direct patient care. ".

On September 22, 2020, at about 11:14 AM, EMP10 was observed administering an intramuscular injection without gloves to MR24's left buttock in room 311.

During an interview on September 22, 2020, at approximately 11:17 AM, EMP9 stated that nursing staff "are supposed to wear gloves" when administering injections.

On September 23, 2020 at approximately 10:50 AM, EMP9 confirmed the above and added that on September 22, 2020, EMP10 reported to EMP9 "I didn't wear gloves" (when administering an injection to MR24).