HospitalInspections.org

Based on record review and interview the facility failed to provide a copy of an "Important Message from Medicare" (IM) to 7 out of 7 patients (#1,#11,#12,#14,#15, #16,#28), which could potentially deprive patients of the information necessary to exercise their rights. Findings include:

During review of the medical records on 01/30/12 at approximately 1130, it was reveled that the IM was missing from the charts of patients #1, 11, 12, 14, 15, 16, 28.

During interview with staff E on 01/30/12 at approximately 1500 she confirmed the lack of the IM in the records. At this time staff E also confirmed with registration the lack of the documentation.

Based on Performance Improvement Committee (PIC) minutes review and interview the facility failed to maintain a hospital wide Quality Assessment Performance Improvement program as evidence by: (A 276) Failure to identify opportunities for improvement in medication errors and infection control, (A 285) Failure to prioritize performance improvement projects to promote an atmosphere of safety, positive health outcomes and quality care, (A 287) Failure to analyze the cause of adverse events, (A 288) Failure to implement activities to prevent reoccurrence of negative trends, (A 301) and failure to document reasoning for conducting projects to indicate patient benefit focused projects.

Based on document review and interview the facility failed to aggregate data, identify trends and initiate changes resulting in the potential for poor patient outcomes. Findings include:

On 2-1-2012 at approximately 0900 during document review it was revealed that 45 medication errors occurred over a 6 month period, no evidence could be produced regarding accumulating and trending data then acting on it to prevent further errors from occurring.

On 2-1-2012 at approximately 0930 during review of a hospital audit of hand hygiene it was revealed that the hospital staff were below compliance goal levels. No evidence of a performance improvement plan could be produced.

On 2-1-2012 at approximately 0830 during review of the PIC minutes it was revealed that no documented evidence of hospital data had been aggregated to initiate performance improvement projects.

On 2-1-2012 at approximately 1000 during an interview with staff B it was revealed that no "formal performance improvement projects" existed to decrease medication errors or increase compliance with hand hygiene. When staff B was asked how performance improvement opportunities were identified it was stated "A lot, of times our projects are identified through national research."

Based on document review and interview the facility failed to prioritize performance improvement projects resulting in the potential for patient harm and poor health outcomes. Findings include:

On 2/1/2012 at approximately 0830 no evidence of prioritization of projects was documented.

On 2/1/2012 at approximately 1015 during an interview with staff B it was asked how do you prioritize your projects? Staff B stated "Well most managers have a project, but we don't really have a top 3 priorities identified." During the interview staff B did pick 3 projects she felt were priorities (which had financial incentives), however, the PIC members had not identified risk areas for health safety and quality of care.

Based on document review and interview the facility failed to analyze adverse events and trend them to identify causes and prevent repeat occurrences resulting in the potential for patient harm. Findings include:

On 2/1/2012 at approximately 0900 during document review it was revealed that there were 45 medication errors in a 6 month period and no evidence of analysis and intervention was documented.

On 2/1/2012 at approximately 1030 during an interview with staff B it was stated that there were "No formal performance improvement projects" for medication errors. Staff B also stated "We counsel individually."

Based on document review and interview the facility failed to implement actions to prevent reoccurrence of adverse events resulting in the potential for patient harm. Findings include:

On 2/1/2012 at approximately 0830 during review of the PIC minutes no evidence of preventative action was documented regarding the repeated medication errors and noncompliance with hand hygiene in the hospital.

On 2/1/2012 at approximately 1030 this finding was confirmed with staff B.

Based on document review and interview the facility failed to document rationality for the performance improvement projects that were in place. Findings include:

On 2/1/2012 during review of the PIC minutes no evidence was documented regarding the reasoning for projects. When reviewing the projects that were in place there was emphasis on efficient use of resources including fiscal efficiency included in the project progress data.

On 2/1/2012 at approximately 1030 during an interview with staff B it was confirmed that project reasoning is "Not always documented, sometimes a group of physicians will discuss a common problem and then bring it to the PIC meeting and present a project to fix the issue, sometimes it is a one on one conversation, sometimes it is based on national research. It depends on the situation."

Based on record review, interview and policy review the facility failed to appropriately document telephone/verbal admission orders for three of four obstetrical patient admissions (#6, #7 and #10) resulting in the potential for patient harm. Findings include:

On 1/30/12 at approximately 1500 during record review for patient #6, revealed that she was admitted on 1/27/12 at approximately 1140. Admission orders titled "Pitocin (oxytocin) Induction/Augmentation for Labor Orders" contained a physician signature dated 1/27/12 time 1400, and under "noted by" had the RN signature with a date of 1/27/12 and a time recorded as 1200. Interview with staff H regarding how orders are implemented reveals that "these (the Induction/Augmentation) are the admission orders and if the physician doesn't want the line item implemented that it would be crossed through". An additional question for staff H regarding who took these orders and whether the protocol for taking telephone/verbal orders was followed she indicated that "no, they should have written in either T.O. or V.O. and signed it with the date and time".

On 1/30/12 at approximately 1530 during record review for patient #7 reveals that the patient was born on 1/28/12 at 0257. A document on the chart titled "South Haven Health System Newborn Standing Orders" was contained on chart for patient #7 and revealed a blank after "TORB from Dr:__ To: __" and is signed by the physician on 1/28/12 at 0830. The orders are noted by an RN on 1/28/12 at 0600. The standing orders do not contain a check next the the box "TORB". Interview with Staff H confirms that the nurse should have check the box TORB and signed it.

A review of facility policy titled "Verbal and Telephone Physician Orders/Receiving Critical Test Results" dated 10/4/11 reveals that "Verbal and telephone orders will be received and recorded by qualified personnel in accordance with laws and regulations...Telephone orders will be written then read back to the physician and verified for accuracy....The abbreviation "R", "B" will indicated that the order was read back and verified with the physician..."


31054

On 1/30/12 at approximately 1530, review of medical record for patient #10 revealed that on standing newborn admission orders there were blanks after "TORB from Dr:__ To: __" and the order was signed by the physician on 1/30/12 at 0700. "Transcribed by" and "Noted by" were unsigned. Findings were confirmed with staff H who stated, " the nurse did not sign the order. "

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all patient's medical records were completed within 30 days of discharge. Findings Include:

During interview on January 31, 2012 at approximately 1400 with the Director of Medical Records and staff N confirmed that there were 12 incomplete medical records with discharge dates greater than 30 days. The Delinquency Report provided by Staff N showed that all 12 records were missing physician signatures.


15195

During observations and tour of the Medical/SCU Unit, on 1/30/12 at approximately 1200, a box of 16 medical records was noted on the desk at the nursing station. Interview with the SCU Director #E at that time revealed that the box was left over the weekend for the Contract Hospitalist to complete and sign records. It was noted that the records had discharge dates of October and November 2011, with the physician completion date of 1/28/12. These discharges were well beyond the 30 days for completion of the medical records as required. Further interview with Staff #E revealed that the physician had been to the hospital the previous month.

Review of the Independent Contractor Agreement dated 5/1/11 for the Hospitalist, documented among services to be performed were ... " Maintain, upon request, time records and such other documentation as may be required by the Hospital ... " Review of the Hospital Medical Staff Rules and Regulations provided revealed " Completion by Medical Staff must be within 12 days after receipt of notice of incomplete medical records with the following exception; signatures will have an additional 7 days to complete. " There was no indication of a 30 day completion requirement after patient discharge.

Based on interview and record review the facility failed to ensure the Interim Nutrition Services Supervisor is informed of their role and responsibilities related to the facility's overall Quality Assurance Performance Improvement resulting in the potential to miss opportunities to optimize patient outcomes. Findings include:

On 1/31/12 at approximately 1130 during interview with the interim Nutrition Services Supervisor revealed that when asked what quality improvement projects the Nutritional Services was involved in Staff P replied "I don't know, I just started here in the end of November". Staff A reminded her of a cost recover project that the kitchen had been involved in. When asked what the results of customer satisfaction surveys were for the Nutrition Services, she was unable to recall and couldn't find the quarterly/monthly report results that are e-mailed to her. When asked whether Staff P monitors handwashing for her staff in the kitchen, she responded affirmatively, however when asked whether it was improving or was already 100% she responded "I don't record any results, I just remind them at the time to wash their hands".

A review of the facility document titled "Job Description Nutrition Services Supervisor, Interim" on 2/1/12 at approximately 1140 revealed under subheading "Standard of Performance- Management Demonstrated effective implementation and monitoring of department activities/quality controls; participated in the program to improve organizational performance".

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based upon observation and staff interview it was determined that the facility is not properly maintaining the plumbing system or clean supply storage areas to ensure the safety of patients.

Findings include:
On 1/31/12 at approximately 10:15 AM a janitor's closet in the patient medical/surgical unit was observed with a chemical dispensing system attached to the mop sink faucet via a Y-connection with shut off valves located downstream from the built in Atmospheric Vacuum Breaker (AVB).

On 1/31/12 at approximately 10:20 AM the ice machine at the OB patient pantry was observed without an approved air gap between the machine's ice bin drain and sewer connection. On 1/31/12 at approximately 12:00 PM the ice machine at the surgery pre-operative nourishment station was observed without an approved air gap between the machine's ice bin drain and sewer connection.

On 1/31/12 at approximately 12:05 PM the scope washers installed in the scope reprocessing area were observed directly connected to the potable water supply without a backflow prevention device.

On 1/31/12 at approximately 11:40 AM a room in the Emergency Department was observed being used as a clean supply storage room. This room had previously been a toilet room, and had had plumbing fixtures removed. The walls where the fixtures were removed were observed to have drywall damage and penetrations. The room is also under negative pressure, as it is provided with an exhaust grille and no supply ventilation.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated February 1, 2012 for Life Safety Code.

Based on record review, the facility failed to monitor ventilation in the Operating Rooms.

Findings include:
On 1/31/12 at approximately 12:20 PM upon review of the temperature and humidity log for January 2012, it was discovered that the facility is not maintaining a minimum humidity level of 35% in OR 1, OR 2, and OB suite. Of 22 days recorded for the month, OR 1 had 21 days not within the limits, OR 2 had 22 days not within the limits, and the OB suite had 18 days not within the limit.

Based upon interview, document review and observation, it was determined that the facility failed to minimize the potential for the transmission of infectious agents which has the potential to affect 82 in-patients, out-patients, visitors to the facility and staff. See below, A748 and A749.

Findings include:
On 1/31/12 at approximately 10:05, interview with Staff E it was discovered that the facility is not monitoring the Airborne Infection Isolation room. When asked how the room was monitored, Staff E indicated that the maintenance staff checks the ventilation system when a suspect TB patient is in the room. When asked if there was any monitoring of the airflow or records kept while the room is in use for isolation purposes, staff E responded that no monitoring takes place while the room is in use.

Based on interview and record review the facility failed to provide training for the breadth of responsibilities for the Infection Control Officer resulting in the potential risk for infection resulting from unrecognized risks for transmission of infectious agents. Findings include.

On 2/1/12 during interview with Staff T regarding training that she has received preparing her for her role as the Infection Control Officer, Staff T replied, "Well I work in the lab so I am aware of all the cultures that are taken from patients that are here". Additionally Staff T replied that she has been "mentoring with the previous Infection Control Officer since last August", who works with her in the lab. When asked whether she has attended any special training, staff T replied that she attended a fall conference of the Michigan Society for Infection Prevention and Control, however,has not received any formal basic infection control training. Interview with Staff V requesting an orientation outline for training for the new Infection Control Officer was not received before leaving the facility.

Based on observation, interview and record review the facility failed to:
A). provide a clean and sanitary environment, nor
B). ensure the infection control officer had developed systems to monitor
- surveillance for healthcare worker communicable diseases
- ventilation and water quality
- compliance to processes for sterilization and disinfection
- air handling in airborne isolation room
- documenting environmental rounds
resulting in the potential for transmission of infectious agents among patients and visitors. Findings include:

On 1//30/12 at approximately 1115 during a tour of the facility, found the following:
In the obstetrical area
a). four full hand soap containers and two vases stored underneath the sink in the soiled utility room
b). inaccessible sink in the soiled utility room which was cluttered with soiled linen carts IV pumps, and a large trash bin
c). accumulation of dust in the clean storage room and in the corners of a patient ready room, #207
d). a metal tray with accumulated used surgical instruments located on the window sill within three feet of the procedure table for circumcisions
These findings were confirmed by Staff B and Staff H on 1/30/12. Staff H indicated that the used surgical instruments were going to be donated to a third world country in the near future.

A review of facility titled "Obstetrics Infection Control" updated 10/11 revealed that under the subheading "Cleaning;... Routine cleaning is performed by Environmental Services department according to hospital policy and procedures...Obstetric staff will have the responsibility to assist in maintaining a clean and sanitary environment.." and under the subheading of Dirty Equipment" Reusable equipment is taken to the dirty utility room and placed in a red box containing a hospital approved cleaning solution...".

On 2/1/12 at approximately 1100 during interview with the facilities Infection Control Officer revealed that when asking Staff T regarding the Infection Control Officers role in ventilation and water quality, compliance to processes for sterilization and disinfection such as a failed biological indicator or monitoring of airborne infection isolation rooms she replied " I am still learning this role since I started in August of 2011, ... I am still not sure about all my responsibilities however Staff U is continuing to mentor me". When asked how Staff T monitored the environment for cleanliness she replied that she "does daily rounds", however when mentioning the dust in the storage areas and other support areas, she indicated that "I haven't looked at those". When asked whether Staff T documented the results of environmental rounds she replied "no, I don't, I just tell them to fix it".

A review of the facility document titled "South Haven Community Hospital Infection Control Program" dated 8/25/2010, on 2/1/12 at approximately 1300 revealed that under subheading "Components of Infection Control Program...Establish and maintain a hospital Infection Control Program that involves all relevant programs, services, settings, and staff within the organization...Develop and implement effective organization-wide infection control policies and procedures, that are based on the most current guidelines or regulation proven to reduce or minimize acquisition ....Coordinate with the Occupational Medicine provider to integrate employee health activities with the Infection Control Program. Collaborate with the Director of Plant Operations regarding environmental infection control issues in the facility involving air and water as well as regulated waste....". Additionally under the above mentioned document subheading Infection Control Practitioner, the document revealed "..to report employee health activities and concerns to the Infection Control Committee...To develop and implement hospital-wide Infection Control policies and procedures and ensure regular review by the committee..." The above mentioned document also revealed under subheading Employee Health "The Occupational Medicine provider and the Infection Control Practitioner collaborate with each other to ensure that employee health issues are integrated into the infection control program..."


31054

On 02/01/2012 at approximately 11:00 during an interview with staff T it was noted that the facility failed to have a process in place for surveillance and documentation of healthcare workers illnesses resulting in potential failure to identify trends leading to the transmission of infectious illnesses among staff and patients. Staff T confirmed that no policy existed for the facility to ensure surveillance of illnesses for healthcare workers.

Based on record review and interview the facility failed to provide patients in need of post discharge care an effective discharge planning process: Findings include:

The facility failed to provide assessment and reassessment of discharge needs (See A-0820), failed to include in the discharge plan a list of skilled nursing facilities (See A-0824), failed to document in the patient's medical record that a list was presented (See A-0827), failed to allow the family their freedom to choose (See A- 0828), failed to not specify a provider to the patient (See A-0830), failed to disclose financial ownership in it's homecare agency (See A-0831).

Based on medical record review, and interview, the facility failed to conduct initial assessment and reassessment of discharge needs & plans in 4 of 5 patients (#11, #15, #63, #64), resulting in the potential of adverse health consequences upon discharge without benefit of appropriate planning. Findings include:

On 01/30/2012 at approximately 1500 during medical record review it was reveled that the discharge planning document titled South Haven Community Hospital Interdisciplinary Discharge Planning Progress Record had no discharge needs or plans documented on patients #11 (closed record) and #15. Patient #15 was being discharged after lunch to a skilled nursing facility (SNF).

During further review of closed medical records on 02/01/2012 for patients #63 and #64 who required services after discharge revealed no documentation for discharge planning on the South Haven Community Hospital Interdisciplinary Discharge Planning Progress Record.

During an interview with staff E on 01/30/2012, she confirmed the lack of documentation for discharge planning for patients #11 and 15. She also confirmed that the document titled South Haven Community Hospital Interdisciplinary Discharge Planning Progress Record was where the discharge planner would complete their documentation of the assessment and reassessment of the patient needs.

During an interview with the staff N on 02/01/2012 at 1300, she confirmed the lack of documentation for discharge planning on the South Haven Community Hospital Interdisciplinary Discharge Planning Progress Record for patients #63 and #64.

Based on medical record review and interview the facility failed to provide a list of skilled nursing facilities (SNF) to 1 of 1 (#15) inpatient being discharged. resulting in the potential of adverse health consequences. Findings include:

During an interview with patient #15 and her spouse on 01/30/2012 at approximately 1100 , they stated that she was "going to be discharged after lunch to a nursing home across the street." Patient's spouse did not know the name of the facility and stated the "Doctor recommended it". When asked if they were given a list to choose from he stated "No."

During review of patient #15's medical record it revealed a lack of documentation that a list was provided for the patient to make a choice.

Based on medical record review and interview the facility failed to include a list of skilled nursing facilities(SNF) or home health agencies (HHA) in the discharge plan for 4 of 5 (#11, 15, 63, 64) records reviewed.

During review of the medical records for patients #11, 15, 63, 64 it was reveled that they lacked documentation of a list being provided to them by the hospital staff.

During interview with staff G on 01/30/2012 at 1230, she stated "I was unaware that this needed to be placed in to the patient's records.

Based on interview the facility failed to inform the patient and the family of their right to choose a post hospital care facility for 1 of 1 (#15) inpatient being discharged resulting in the denial for their right to choose. Findings include:

During an interview with patient #15 and her spouse on 01/30/2012 at approximately 1100 , they stated that she was "going to be discharged after lunch to a nursing home across the street." Patient's spouse did not know the name of the facility and stated the "Doctor recommended it". When asked if they were given a list to choose from he stated "No."

Based on interview and document review the facility failed to allow the patient and their family to make an informed decision about placement. Findings include:

During interview with patient #15 and her spouse on 01/30/20 12 approximately 1100, it revealed that the doctor recommended to the family the SNF across the street for placement. The husband of the patient was unsure of the name of the facility and stated that she was "going to be discharged after lunch."

During an interview with staff W at 1230, he stated that he recommended the nursing home across the road. He then went on to say that the patient's husband wanted her to be somewhere in town.

Review of documentation provided by the discharge planner titled Assisted Senior Living, it revealed that there is more than one skilled nursing facility in town. Per the patient's family they were not provided a copy of the list to choose from.

Based on document review the facility failed to disclose financial ownership of it's homecare agency.
Findings include:

During review of the document titled Assisted Senior Living provided by staff G, it revealed that the hospital does not disclose it's financial interest in the South Haven Community Homecare.
Per staff G, the document is given to patients to utilize when making a choice for post discharge care.

Based on record reviewed and interview, the facility failed to ensure a post anesthesia evaluation had been documented within 48 hours after surgery for 2 of 7 records reviewed(patient's # 13 and #45). Findings include:

MR #45: The patient had surgery on 01/18/12 for a right knee replacement. During the review of the clinical record on 01/30/12, it was noted a 48 hour post anesthesia evaluation had not been completed. Request for the nursing units clinical supervisor to look for the presence of the post anesthesia evaluation on the clinical record produced no document confirming such.

The findings were discussed with the hospitals leadership team during the exit conference on 02/01/12.


30988


During review of the medical record for patient #13 on 01/30/2012, it revealed a lack of post operative assessment within 48 hours on the Anesthesia Record or in the Doctor's Clinical Notes.

Based on observation, interview and record review, it was determined that the facility failed to ensure that personnel were up to date with competencies resulting in potential failure to achieve optimal patient outcome. Findings include:

On 01/30/2012 at approximately 08:45 interview with staff O indicated that staff S is the lead respiratory therapist who is relied upon to perform competency training. Review of personnel records for staff S revealed that staff S was not up to date with competencies and training for neonatal resuscitation. Staff S took the NRP exam in June, 2011 and failed the exam. Findings were confirmed with staff A who stated that staff S "had not yet retaken and passed the NRP exam."