HospitalInspections.org

Based on record review and interview, the hospital failed to 1) ensure 20 of 22 (P#1 through P #20) patients admitted to the facility were advised of their patient's rights and 2) provide and explain patient's rights in a language or manner that the patient could understand for 1 (P#7) of 22 (P#1 through P#22) patients admitted to the Emergency Department (ED). This deficient practice could result in 1) patients receiving care at the hospital without being fully informed and 2) patients not knowing what to do in the event they want to file a complaint. The findings are:

A. Record review of the hospital's Patient Rights policy and procedure Policy Number: IM_REG.001 [sic] original Issue Date: February 1991, Review/Revision Date: 2015 states the following:
1) [Name of facility] will ensure that patients and or their legal representative are informed, at the time of service, of the patient rights and the mechanism for resolution of patient complaints.
2) Patient Handbook and Patients Rights flyer will inform the patient of the patients rights.
3) The Patient Handbook and Patient Rights Flyer will also contain the patient responsibilities.

B. Record review of medical charts for P#1 through P#20 revealed no signed or unsigned Patient Rights form.

C. Record review of medical charts for P#1 through P#20 revealed no evidence patients received either verbal or written rights.

D. On 04/11/18 at 2:14 pm during interview, Director of Quality (DQ) stated, "I don't think patients acknowledge they get rights."

E. On 04/11/18 at 2:20 pm during interview, Registered Nurse (RN #10) stated, "I don't know that we have that.. it (Patient Rights) is posted... They don't sign anything."

F. On 04/11/18 at 2:25 pm during interview, RN #8 stated, "It's (Patient Rights) posted for people everywhere and it's in their handbook...they do not sign anything."

G. On 04/11/18 at 2:35 pm during interview, Registration Staff (RS) stated, "We offer patients rights flyer but there is no form they sign."

H. On 04/11/18 at 2:45 pm during interview, Chief Nursing Officer (CNO) revealed that patients do not sign off on Patient Rights form. The CNO stated they have the option at registration to take a copy of the Patient Rights form.

P#7

I. Record review of medical chart for P#7 revealed patient is deaf and requires an interpreter.

J. Record review of facility complaint log, revealed P#7 filed a complaint with facility stating the facility refused to provide a sign language interpreter for his 11/18/17 stay in the Emergency Department.

K. Record review of P #7's medical chart revealed no indication an interpreter assisted in the signing of consents nor was there a patient rights form in the chart.

L. On 04/11/18 at 2:00 pm during interview, RN #10, confirmed P#7 did not have an interpreter during his 11/18/17 stay and stated, "Someone didn't know what to do."

Based on staff interview and record review, the hospital failed to ensure that patients were offered a chance to provide or create an Advance Directive (a written statement of a person's wishes regarding medical treatment). This failed practice could lead to the hospital not knowing the wishes of a patient that was unconscious and/or dying. The findings are:

A. Record review of patient medical charts revealed no forms for Advanced Directives.

B. Record review of patient medical charts in electronic records revealed on the top left side of each patients medical screen it states, "Advance Directives: Yes or No"; on the right hand side it states, "DNR (Do Not Resuscitate): Yes or No" For the charts where "Yes" was indicated, no form in the file could be located for either Advanced Directives or DNR.

C. On 04/11/18 at 2:14 pm during interview, Director of Quality stated there were no forms that patients signed regarding Advanced Directors or DNR.

D. On 04/11/18 at 2:20 pm during interview, RN #10 was shown the electronic charts of several patients where up at the top of the patients charts it states "Advance Directives: Yes or No," on the right hand side it states: "DNR (Do Not Resuscitate): Yes or No". When asked what paperwork patients fill out to indicate an answer, RN #10 stated, "I don't know that we have that...we ask that question, they don't sign anything."

E. On 04/11/18 at 2:25 pm during interview, RN #11 stated, "For DNR, we used to have a form...I don't know what happened to it."

Based on observation and interview, facility staff failed to follow accepted standards for exposure to radiation. Failure to wear personal protective equipment in the x-ray lab*could expose staff to harmful doses of ionizing radiation. The findings:

A. On 04/10/18 at 8:00 am during interview, RN #38 was asked why the operating room personnel were not wearing their protective lead vests and thyroid collars during the cystoscopy (a scope of the urinary bladder) procedure. She confirmed that all employees should have been wearing their protective shields during the cystoscopy radiologic procedure.

B. On 04/10/18 at 7:45 am, during observation of the Operating Room staff, an RN, a technician, and the physician were not wearing lead vests as required by protocol to limit exposure to the radiation emitted by the fluoroscope (a form of x-ray). Radiation badges were not observed on the personnel during the cystoscopy.

*C. Fluoroscopy medical imaging shows continuous X-ray imaging on a monitor and the amount of ionizing radiation that a patient and the medical staff receive during a procedure depends on the procedure length and complexity. The hospital must adopt, implement, and follow radiologic policies and procedures that provide safety for affected patients and hospital personnel which are consistent with accepted professional standards for radiologic services.
Association of periOperative Registered Nurses, 2016.

Based on record review and interview, the facility failed to provide documents of completion of all annual mandatory training for Tech #32 on the machine used for the cleaning of endoscopes (visual scopes inserted to assess the throat or intestines). This failed practice could expose patients to inaccurate studies and dangerous doses of radiation. The findings:

A. Record review of Hospital annual and specialized training for Tech #32 indicated she was not current and the last competency was dated 06/12/09.

B. On 04/10/18 at 12:00 pm during interview, Tech #32 stated that "there are annual training requirements for use of the Steris (brand) cleaning equipment and the Steris representative comes to the unit often." She confirmed she was unable to provide documentation of training on the Steris machines more current than 06/12/09 or that she had documentation of having participated in a training provided by the Steris representative since the arrival of the new machines last year.

C. On 04/11/18 at 3:00 pm during interview, the Interim Director of the Operating Room stated she could not provide more up to date competency training documents on the Steris machines for Tech #32. On 4/12/18 at 3:45 pm, the Director of Education stated "annual competency should include equipment used in the department."
D. Record review of the Hospital's Annual Competency Program which was not dated requires completion of all annual mandatory training. Policy HR.019 (sic) further states competency is established through a periodic assessment and evaluation of the employee's performance.

E. Record review of training records revealed a Certificate of Completion for the Positron Emission Tomography or PET/CT scanner, a high resolution x-ray, initial training was provided for Technician #18 with an approved date range of 04/10/2015-04/30/16. The Hospital's Diagnostic Imaging, MRI (Magnetic Resonance Imaging) Technologist Competencies dated 12/20/17 does not address the scanner competencies for Technician #18 after the initial training record dated 04/30/16 expiration date. Completion of the PET/CT scanner initial training could not be provided by the manager for technician #19.

F. On 04/09/18 at 10:00 am during interview, the Director of Radiology confirmed that only 2 employees operate the PET (Positron Emission Tomography, a detailed x-ray), scanner; technician #18 and technician #19. The director confirmed that the scanner is "about 1 year old" and confimed that Siemans (manufacturer of the equipment) did the initial training for technicians #18 and 19. The Director also stated that "Siemans did annual training."

G. On 04/11/18 at 10:30 am during the interview with the Nuclear Medical Manager #5, the manager stated that technician #18 traveled out of state for initial training on the PET CT scanner and the training was done by Siemans. The manager then stated that technician #18 trained #19 and confirmed that no record of the initial training could be provided to the surveyor. When asked for the policy for training in the radiology department, the manager stated that there was "no policy" and "Siemans does not do annual training for the radiology department." The conversation with the manager was witnessed by the Manager of HR (Staff #43) and hospital representative Staff #44.

Based on observation, interview, and record review, the facility failed to ensure proper infection control procedures in the behavioral unit, the operating room and the intensive care unit. This failed practice put patients at risk of infections from cross contamination from potentially contaminated sources in these areas. The findings are:

A. On 04/10/18 at 10:00 am during observation of the Behavioral Unit, the restroom in the seclusion room was visibly dirty. The toilet had stains around the toilet seat, the sink had stains in the sink and around its perimeter. A urine bottle was on the hand rail with urine in it. The bed in the seclusion room was visibly soiled. The restroom in the opposite seclusion room was visibly dirty: The toilet had stains around the toilet seat, the sink had stains in the sink and around its perimeter and the faucet had what appeared to be limestone calcified around it.

B. On 04/10/18 at 10:30 am during interview, the Director of the Behavioral Unit stated the seclusions rooms had not been used and she did not know why the restrooms were dirty.

C. On 04/10/18 at 10:30 am during interview, the Environment Specialist/Custodian said he did not know how often the restrooms are cleaned. He could not produce cleaning logs or cleaning schedules when asked to do so. He could not recall any of the dry/wet times for the cleaning solutions. Wet times are determined by the manufacturer of a disinfectant to reach disinfection.

D. On 04/10/28 at 1:30 pm during interview, the Infection Control Director stated, "Nothing gets cleaned 3 times a day. I don't know why anyone would say that." She also stated maybe [the Environment Specialist] needs a refresher course [in cleaning protocols] every quarter. Flip cards are used for training. The previous Materials Manager used a color coded "dot" on the cleaning solution containers [to indicate wet/dry times]. The current Materials Manager is new and does not use the "dot system."

E. Record review of the hospital's Cleaning and Disinfecting Policy and procedure Policy Number CLN_IC.509 Original Issue Date: September 2003, Last Review/Revision Date: December 2017, BOD [Board of Directors] Approval Date: December 21, 2017 states the following: "Cleaning and disinfecting of the environment, medical equipment, devices, and supplies are an important part of the hospital wide infection control program at [facility name]. Approved cleaners and disinfectants will be utilized to provide a clean and safe environment for patients, staff, physicians, volunteers, students and visitors [sic].
1. Disinfecting procedure
a. Due to the intolerance of health care equipment to some cleaning agents manufacturer's recommendations are used to identify the type of cleaner to be utilized on a particular type of equipment to ensure adequate cleaning without damage.

F. Record review of the hospital's Infection Control Policy Statement Policy Number: CLN_IC.103, Original Issue Date: February 1989, Last Review/Revision Date: May 2017, BOD Approval Date: December 21, 2017 states the following:
1. "Infection Control policies for each department in the organization integrate environmental safety protocols as well as procedures to protect patients, employees and visitors from potential infections.
2. It is the responsibility of each department director to enforce policies in their own area and to orient new employees to department specific policies."

G. On 04/10/18 at 7:45 am during a cystoscopy (a scope and biopsy within the bladder) procedure, the following was observed:
1. The physician backed into the sterile field and touched it twice; once while moving the patient on a gurney and once while talking to the patient.
2. Plastic bags containing supplies including urostomy (urinary bladder) bags was observed sitting on the floor in an ante room of the operating suite.
3. When the patient was bought into the room, the stretcher touched the sterile field of the table containing the betadine scrub (antimicrobial scrub) solution used to prepare the skin prior to the start of the cystoscopy procedure.

I. On 04/10/18 at 11:15 am during interview, the Infection Preventionist was asked why the physician was not following standard infection protocol in the operating room during the above observation. She stated, "[Physician #1] is old school. He is lax in the OR [operating room]."

J. Record review of the Association of periOperative Registered Nurses (AORN), Guidelines for Perioperative Practice, 2016 Edition, page 76, "Sterile Technique: V.f., Only sterile items should come in contact with the sterile field. The creation and maintenance of a sterile field may influence patient outcomes. Using sterile items during an invasive procedure minimizes the risk of infection and provides the highest level of assurance that the procedural items are free of microorganisms."

K. Record review of the hospital's Infection Prevention Services and Operations policy and procedure Policy Number: CLN_IC.100 [sic] Original Issue Date: June, 1991, Review/Revision Date: May 2017, BOD [Board of Directors] Approval Date: December 21, 2017 states the following: "[Facility name] will ensure the coordination of all Infection Prevention and control activities by employing an Infection Preventionist who will be responsible for managing an organizational wide Infection Prevention Program that includes activities, which are most frequently performed, by the program, pose the greatest risk, or present the most problems for patients or staff. These services include surveillance, prevention, and control of infection."

L. On 4/11/18 at 12:00 pm during observation in the Intensive Care Unit, ICU Physician #36 and Registered Nurse (RN) #37 were in a patient's room which was designated by sign and in the medical record as contact isolation (contact isolation precautions require hospital personnel to wear a yellow disposable gown and disposable gloves). Neither the Physician nor the RN were wearing the required protective yellow gown.

M. On 4/12/18 at 11:00 am during interview, the Infection Control Manager confirmed that the patient in ICU was on isolation precautions due to Methicillin Resistant Staph Aureus [MRSA] and personnel entering the room "should be wearing yellow gowns" and gloves to prevent the spread of infection by cross contamination.




40207

40207

Based on record review and interview, the facility failed to follow accepted standards of practice which requires the completion of all annual mandatory training for techs operating the Steris brand equipment in Sterile processing. Accepted standards of practice require that competency is established through a periodic assessment and evaluation of the employee's performance. Improper operation of equipment cleaning could potentially expose patients to infection through cross contamination.
The findings are:

A. Record review of training records for the Hospital revealed that technician #32's competency for Steris equipment operation was dated 06/12/09.

B. On 04/10/18 at 12:00 pm during interview technician #32 stated that "there are annual training requirements for use of the Steris cleaning equipment and the Steris representative comes to the unit often."

C. On 04/11/18 at 3:00 pm during interview, the Interim Director of the OR [operating room] stated that the training was "not appropriate" for the Steris equipment and no additional training document could be provided for Staff #32.

D. On 04/12/18 at 3:45 pm during interview, the Director of Education stated, "annual competency should include equipment" used in the department.

Based on observation, interview, and record review, the hospital failed to license and post licenses for 4 of 4 (#1-4) outpatient clinics inspected during the survey. Licensing and integration into quality program are required by both the State License and the CMS provider agreement. The findings are:

A. On 04/12/18 at 1:30 pm during observation, 4 of 4 outpatient clinics toured did not have licenses on display for either the clinics, independently, or through the parent hospital. Two survey teams visited two clinics each.
1. No license was found in the Hospital's outpatient orthopedic clinic.
2. No license was found in Hospital's physical therapy clinic.
3. No license was found at the Hospital's Family Practice Clinic
4. No license was found at the Hospital's Urgent Care

B. On 04/12/18 at 1:35 pm during interview, the managers confirmed they did not have separate licenses for the outpatient clinics. They also confirmed that the clinics did not report any quality data such as adverse events or outcomes to the hospital's Quality Assurance Process Improvement (QAPI) programs.

C. Record review of the hospital's licenses indicated 27 outpatient clinics were not separately licensed and not included in the hospitals license.

D. Record review of the Hospital's QAPI program revealed no licenses for the 27 outpatient clinics.

E. Record Review of the New Mexico Administrative Code for TITLE 7 HEALTH CHAPTER 11 OUTPATIENT FACILITIES

PART 2 REQUIREMENTS FOR FACILITIES PROVIDING OUTPATIENT MEDICAL SERVICES AND INFIRMARIES

7.11.2.1 ISSUING AGENCY: New Mexico Department of Health, Public Health Division, Health Facility Licensing and Certification Bureau.

[10/31/96; 7.11.2.1 NMAC - Rn, 7 NMAC 11.2.1, 02/28/06]

7.11.2.2 SCOPE:
A. These regulations apply to the following:
(1) public, profit or nonprofit outpatient facilities, ambulatory surgical centers, diagnostic and treatment centers, or infirmaries, providing services as outlined by these regulations; or

(2) any facility providing services as outlined by these regulations which by federal regulation must be licensed by the state of New Mexico to obtain or maintain full or partial, permanent or temporary federal funding.

B. These regulations do not apply to the following: offices and treatment rooms of licensed private practitioners.

7.11.2.11 LICENSES:
A. Annual license: An annual license is issued for a one (1) year period to a facility which has met all requirements of these regulations.
B. Temporary license: The licensing authority may, at its sole discretion, issue a temporary license prior to the initial survey, or when it finds partial compliance with these regulations.
(1) A temporary license shall cover a period of time, not to exceed one hundred twenty (120) days, during which the facility must correct all specified deficiencies.
(2) In accordance with Section 24-1-5 (D) NMSA 1978, no more than two (2) consecutive temporary licenses shall be issued.
C. Amended license: A licensee must apply to the licensing authority for an amended license when there is a change of administrator/director or when there is a change of name for the facility.
(1) Application must be on a form provided by the licensing authority.
(2) Application must be accompanied by the required fee for amended license.
(3) Application must be submitted within ten (10) working days of the change.

[9/1/56, 7/1/60, 6/27/90, 10/31/96; 7.11.2.11 NMAC - Rn, 7 NMAC 11.2.11, 02/28/06]

7.11.2.12 LICENSE RENEWAL:

A. Licensee must submit a renewal application on forms provided by the licensing authority, along with the required fee at least thirty (30) days prior to expiration of the current license.
B. Upon receipt of renewal application and required fee prior to expiration of their current license, the licensing authority will issue a new license effective the day following the date of expiration of the current license if the facility is in substantial compliance with these regulations.

C. If a licensee fails to submit a renewal application with the required fee and the current license expires, the facility shall cease operations until it obtains a new license through the initial licensure procedures. Section 24-1-5 (A) NMSA 1978, as amended, provides that no health facility shall be operated without a license.

7.11.2.13 POSTING OF LICENSE: The facility's license must be posted in a conspicuous place on the licensed premises in an area visible to the public.

7.11.2.14 NONTRANSFERABLE RESTRICTION ON LICENSE:

A. A license shall not be transferred by assignment or otherwise to other persons or locations. The license shall be void and must be returned to the licensing authority when any one of the following situations occurs:
(1) ownership of the facility changes;
(2) the facility changes location;
(3) licensee of the facility changes;
(4) the facility discontinues operation.

B. A facility wishing to continue operation as a licensed facility under circumstances Paragraphs (1) - (4) of Subsection A of 7.11.2.14 NMAC above must submit an application for initial licensure in accordance with 7.11.2.10 NMAC of these regulations at least thirty 30 days prior to the anticipated change.