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Based on observation, review of documentation and interviews with facility staff, the facility failed to inform patients of their rights as patient rights were not posted in the outpatient registration area and facility policy did not call for the "Important Message from Medicare" to be provided to Medicare inpatients in the appropriate time frame. According to the regulation at 42 CFR 489.27(a), each Medicare beneficiary who is an inpatient (or his/her representative) must be provided the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission. Furthermore, 42 CFR 405.1205(c) requires that hospitals present a copy of the signed IM in advance of the patient's discharge, but not more than two calendar days before the patient's discharge.

The findings were:
During a review of electronic patient records on 4/16/14 at approximately 2:30 pm, the admissions director, staff #32 was asked where the "Important Message from Medicare" form could be found. Staff #32 was unable to find the form in the electronic records of 7 of 7 Medicare inpatients. Staff #32 stated the admission clerks were supposed to have the patient sign the form and send it to the social worker to discuss it with the patient after 2 days from admission.
The facility policy entitled "An Important Message from Medicare" dated 6/12 reflected in part "An Important Message from Medicare letter will be placed in the patient's medical record for discussion no earlier than two days from the date of admission by the Admitting Department Clerk ...The Social Services Director will review the letter with the patient or patient's representative every two days."
On the afternoon of 4/16/14 at approximately 4:00 pm, staff #32 presented "Important Message from Medicare" forms that were signed by 7 of 7 Medicare inpatients the afternoon of 4/16/14. All seven of the Medicare inpatients were within 2 days of admission.
During a tour of the outpatient admissions and ER/inpatient admissions areas on the afternoon of 4/16/14, there were no patient rights posted in either of these admissions areas. This finding was confirmed by the assistant administrator, staff #33. When asked what information regarding patient rights was provided to patients on admission, staff #33 stated inpatients received a copy of the patient rights, but it was not given to outpatients.

Based on observation and interviews with facility staff, the facility failed to post the patient complaint and grievance process or the contact information for the state agency to file a complaint in the outpatient registration area.
The findings were:
During a tour of the outpatient admissions area on the afternoon of 4/16/14, there was no patient complaint and grievance process or the contact information for the state agency to file a complaint posted in the outpatient admissions area. This finding was confirmed by the assistant administrator, staff #33. When asked what information regarding the complaint and grievance process was provided to patients on admission, staff #33 stated inpatients received a copy of the process, but it was not given to outpatients.

Based on review of documentation and interviews with facility staff, the facility failed to authenticate verbal orders in 3 of 3 wound care patient records reviewed. This was not in accordance with facility policy.
The findings were:
The Rules and Regulations of the Medical Staff dated 6/26/14 reflected in part "The verbal order must be signed off as soon as possible but no later than 48 hours, preferably at the next visit to the patient."
During a review of patient records in the Wound Care room on the morning of 4/16/14, the following patient records contained physician verbal orders which were not authenticated.
1. Patient #16, telephone physician order dated 3/19/14, not authenticated.
2. Patient #17, telephone physician order dated 4/4/14, not authenticated.
3. Patient #18, telephone physician order dated 4/4/14, not authenticated.
These findings were confirmed by staff #17 the morning of 4/16/14.

Based on observation, review of documentation, and interviews with facility staff, the facility failed to follow facility policies for food handling and dishwashing as undated opened food containers were found in the dry storage room and walk-in refrigerator, and dishwasher temperatures and chlorine levels were not consistently recorded.
The findings were:
The facility policy entitled "Storage and Use of Leftovers" #11006 dated 5/01 reflected in part "All leftover cold food for storage in the refrigerator is put into storage containers and completely covered with plastic or foil wrap. These are marked with the name of the item and dated." The facility policy entitled "Food Production" #831.601 dated 7/06 reflected in part "17. Food will be dated on the date received. Labeling will be done manually with a black marker." The facility form entitled "Sanitation & Safety" reflected in part "This form must be completed by the dish machine operator prior to washing dishes after each meal."
During a tour of the Dietary Department on the morning of 4/14/14, an opened undated box of rice was observed in the dry storage room, and an opened undated bag of shredded cheddar cheese was observed in the walk-in refrigerator.
The dish machine Sanitation & Safety logs were reviewed, and there were no wash or rinse temperatures recorded on the following dates: 4/5/14 lunch & dinner; 4/6/14 lunch & dinner; 4/13/14 lunch & dinner. There were no chlorine levels recorded on the following dates: 4/5/14 lunch & dinner, 4/6/14 lunch & dinner; 4/7/14 dinner; 4/8-12/14 lunch & dinner; 4/13/14 breakfast lunch & dinner.
These findings were confirmed by the dietitian, staff #21 during the tour on the morning of 4/14/14.

During a tour of the radiology department on the morning of 4/14/14, the following expired medical supplies were found in patient care areas available for use in patient care.
1. Found in the CT room, hydrogen peroxide, 8 oz. bottle, expired 4/13.
2. Found in the Ultrasound room, Cidex plus, 1 gallon bottle, expired 4/13; Cidex test strips, 60 strip bottle, 2 expired 4/13.
Clean pediatric patient gowns were found stored under a sink in the x-ray room.
These findings were confirmed by staff # 25 during the tour on the morning of 4/14/14.
During a tour of the Wound Care room on the morning of 4/15/14, a 16 oz. bottle of isopropyl alcohol, 70%, expired 10/10, was found available for use in patient care. Dressing supplies were found stored under a sink in the Wound Care room. This finding was confirmed during the tour on the morning of 4/15/14 by the nursing director, staff #17.
From the American Journal of Infection Control, Volume 28, Number 2, April 2000, p165: "Cabinets: Areas beneath sinks should not be considered storage areas due to proximity to sanitary sewer connections and risk of leaks or water damage. Clean or sterile patient items should be not be placed beneath sanitary sewer pipe connections or stored with soiled items; cleaning materials are the only items acceptable to be stored under sinks, from a regulatory aspect."



29937

During a tour of the Emergency Department Trauma on the afternoon of 4/15/14; arterial blood sampling kit expired 5/2013. Trach Adapter expired 6/2008. Plain gut 3 dozen expired 1/2014, Chromic Gut 3 dozen expired 2/2014. Obstetrical Department; 8 portex tracheal tubes expired 11/21 and tegraderm 4 x 4 expired 7/12 and 9/09.
The findings were confirmed during the tour by staff 17.

Based on observation and review of documentation the facility failed to have an active infection control program.1. There was no documentation, policy or procedure to assure the sterilizer located in the surgical department is monitored at least weekly with the appropriate commercial preparation of spores. 2. Surgical instruments were observed in the closed and clamped position in sterile packages available for patient use in multiple departments, creating a potential for transmission of infections.
Findings were:
CDC article, Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 p 76: Steam and low temperature sterilizers (e.g., hydrogen peroxide gas plasma, peracetic acid) should be monitored at least weekly with the appropriate commercial preparation of spores. If a sterilizer is used frequently (e.g., several loads per day), daily use of biological indicators allows earlier discovery of equipment malfunctions or procedural errors and thus minimizes the extent of patient surveillance and product recall needed in the event of a positive biological indicator. Each load should be monitored if it contains implantable objects. If feasible, implantable items should not be used until the results of spore tests are known to be negative.
Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, page 74, "Once items are cleaned, dried, and inspected, those requiring sterilization must be wrapped or placed in rigid containers and should be arranged in instrument trays/baskets according to the guidelines provided by the AAMI and other professional organizations454, 811-814, 819, 836, 962. These guidelines state that hinged instruments should be opened; closed instruments should be opened
During a tour of the surgical department on the afternoon of 4/15/14 accompanied by staff # 14 and 15 the surveyor ask staff # 15 for documentation of sterilization monitoring. Staff # 15 explained the process used. The surveyor asks for the policy documentation verifying the monitoring procedure. Staff # 14 said there were no policy and or procedure for monitoring the sterilizer. 13 surgical instruments were observed in the supply room in the closed and clamped position available for patient use. The findings were confirmed by staff # 14.
7 surgical instruments were observed in the closed and clamped position in the obstetrical room in the emergency department. 6 surgical instruments were observed in the closed and clamped position in the obstetrical room in the emergency department located in the obstetrical department. Findings were confirmed by staff # 17 during the tour.

Based on observation, review of documentation, and interviews with the emergency room staff; the facility failed to inspect the emergency crash cart trauma A&B, C&D at the change of shift per facility policy as there were 121 blanks on the crash cart forms that had not been signed by the nursing personnel from 1/1/2014 through 4/15/14 causing a potential for emergency equipment not to be in working order at the time of emergencies.
Findings were:

During a tour of the emergency room department on the morning of 4/15/14 accompanied by the staff # 17, the emergency crash cart located in trauma room contained incomplete emergency inspection forms. 1/1/14-1/31/14 had 19 signature blanks, 2/1/14-2/28/14 contained 39 signature blanks, 3/1/14-3/31/14 contained 39 signature blanks, and 4/1/14- 4/15/14 contained 20 blanks, total of 108 blank signatures, indicating the emergency crash cart had not been inspected by the nursing personnel at the change of shifts.

Review of policy Emergency Crash Cart Security and Accountability # 3016, effective 1/9, revised 6/10, the nursing personnel shall visually inspect the numbered break away lock located on the crash cart at each change of shift, documenting that the cart is properly locked with all appropriate contents present and intact.

The findings were confirmed by staff # 2 during the tour of the emergency room department.