HospitalInspections.org

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Based on record review, interview and policy and procedure review the Hospital failed to ensure 1 of 10 records reviewed (patient #16) had the patient history and physical completed and documented no more than 30 days before or 24 hours after admission/registration. Failure to complete and document the patient ' s history and physical within 30 days prior or 24 hours after admission/registration puts all patients at risk for complications in their care, treatments and recovery.

Findings include:

- Record review on 11/30/16 revealed staff BB completed and signed patient # 16 ' s History and Physical on 9/29/16 (7 days after the patient ' s admission date of 9/22/16).

Interview on 11/30/16 at 1:20 PM, Staff A verified the History and Physical was dated 9/29/16 which was 7 days after the admission on 9/22/16. Review of the patient chart revealed Staff FF documented on 9/23/16 at 12:30 PM ...full H&P to follow soon. Review of patient chart revealed Staff BB documented on 9/23/16 at 7:00 PM ...HP to follow. Staff BB completed the History and Physical on 9/29/16.

Policy and Procedure review on 11/30/16 at 1:35 PM, policy titled " Documentation Requirements of the Medical Record " stated...A complete admission history and physical examination shall be recorded within twenty-four (24) hours of admission to the hospital or within 30 days before the patient was admitted or readmitted.

Based on policy review, staff interviews, observations, and visitor interviews, there were 6 observed deficient infection control practices (Staff F, Staff K, Staff J, Staff L at this facility from 11/28-11/30/2016. Failure of the staff to utilize appropriate personal protective equipment including gowns, gloves, masks and eye protection devices and use techniques for "isolation" precautions as recommended by the (Centers for Disease Control (CDC) placed all patients at risk for healthcare associated infections.



Findings include:

Policy titled, "Isolation Procedures", reviewed on 11/28/2106 at 12:17 PM directed staff that " ...Direct - involves direct body surface to body surface contact and physical transfer of microorganisms between a susceptible host and an infected or colonized person, such as occurs when a person then a patient, gives a bath, or performs other patient care activities that require direct personal contact. Direct contact transmission can also occur between two patients with one serving as a source of the interactions microorganisms and the other as a susceptible host. Indirect contact - involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, such as contaminated instruments or dressings or contaminated gloves hat are not changed between patients."


- Observation on 11/29/16 at 9:05AM, Staff F, walking out of Contact Isolation Room 414 and only wearing gloves not wearing a gown.

Interviewed, Staff F, and stated "patient is only neutropenic precautions and we only need to wear gloves- this sign needs to be changed."


- Observation on 11/28/2016 at 3:22 PM patient #9 and while interviewing this patient observed the urine catheter bag laying on the right side of the bed on the floor and a drain bag on the left side of his bed laying on the floor. No staff present to interview.

- Observation on 11/28/16 at 12:34 PM Prison Guard #6 sitting in a Contact Isolation Room with no gown or gloves on.

- Observation on 11/29/2016 at 9:15 AM Prison Guard #21 sitting in Room # 414 a Contact Isolation Room without wearing any Personal Protective equipment (PPE).
Interviewed on 11/28/2016 at 1:29 PM, Prison Guard #6 confirmed that he/she was told by the department he/she works for that no PPE was required by the nurse there.

Interviewed on 11/29/16, Identifier #5 on 11/29/2016 at approximately 8:15 AM, confirmed that some employees of the department were wearing PPE for a while, but not wearing any now. No formal training had been provided from the department or the Promise facility.


- Observation on 11/28/2016 at 11:23AM, staff K was wearing isolation gown half on with it sagging down her front side leaving it unexposed.

Interviewed Staff K on 11/28/2016 at 11:23AM, stated policy is to tie gown up when wearing it in a patient's room.

- Observation on 11/28/2016 at 1:15 PM, staff J standing inside a Contact Isolation room with no PPE on using the TV remote to assist the patient with her TV and holding the remote with no gloves on.

Interviewed on 11/28/16 at 1:17 PM Staff J stated "I was just in the doorway ..."


- Observation on 11/28/2016 at 1: 21PM, visitor in a patient room #402 on Contact Isolation without any PPE on.

Interviewed on 11/28/2016 at 1:21 PM, Staff L revealed that family do pretty much what they want. At that time, staff L went to room 402 and educated that visitor.