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Based on medical record review and interview the facility failed to provide a copy of an "Important Message from Medicare" (IMM) to 3 of 10 patients (#33, #45, #69), which could potentially deprive patients of the information necessary to exercise their rights. Findings include:

During medical record review of patient #45 on 02/13/2012 , it revealed that the patient was admitted on 02/07/2012 and that the IMM had not been given to, or signed by the patient within 48 hours of admission.
Review of the medical record for patient #69, it revealed that the patient was admitted on 01/30/2012 and that the IMM had not been given to, or signed by the patient within 48 hours of admission.

The findings were confirmed during an interview with staff EE on 02/14/2012 at 1500.


29774

On 2/13/12 at approximately 1315 during record review for Patient #33 revealed that the Important Message from Medicare was not signed. The patient was admitted on 2/11/12. According to Staff V the Important Message was unsigned. According to Staff V the staff responsible for obtaining those signatures is Registrations and they are "currently up on the floor" serving that purpose but had not yet obtained Patient# 33's signature.

Based on interview and record review the facility failed to ensure that the patient or his or her representative are being informed of his or her health status, and being involved in care planning and treatment. Findings include:

On 2/13/2012 at approximately 1045 during medical record review it was revealed the important Message from Medicare for 1 of 1 patients (patient #5) was unsigned as it was noted the patient was unable to sign because of incapacitation with an admitting diagnosis of delirium and was sent to his home address. Further review of the patient's chart showed the patient signed an general informed consent at the time of admission. The consent also failed to contain a date, time, and witness to the patient's signature. An interview with staff #I confirmed the patient should not have been allowed to sign the consent form in an incapacitated state.

Based on observation and interview the facility failed to ensure that the patients right to personal privacy was maintained. Findings include:

During a tour on 2-14-12 at approximately 1300 it was found at the pre-operative work station a white work board that had patient first and last name and some room numbers associated with specific patients. This board was used by staff to track patients, but was in full view of other patients and visitors.
These findings were confirmed by staff F, NN and OO.


29314

On 2/13/2012 at approximately 1000 during a tour of the Labor and Delivery unit a white board hanging on the wall across from the nurses station contained patient identifiers next to the room the patient was in. The white board was accessible to patients and visitors on the unit.


29955

On 2/13/2012 at approximately 1420 during observation it was revealed patient names were located on the white board with last name and first initials (31 of 34). According to the policy titled "use of white boards" policy #IM-110, it is stated "you may only use the first three letters of the last name and first initial (or first and last initials) in the following situations: *if health information can or must be linked to the patient's name displayed on the white board, *if the public could infer a diagnosis by virtue of the location of the patient (such as LDRP, Oncology Unit, dialysis unit, Cancer Center, etc.)."An interview of staff #O confirmed the policy was not being followed.

Based on medical record review and interview the facility failed to ensure that nursing staff developed and kept current a nursing care plan for 4 of 25 (#8,9,40,41) patients. Findings include:

On 02/13/2012 at approximately 1000 during a review of medical records on the Labor, Delivery, Recovery & Postpartum Unit (LDRP) it was discovered that patient #40 was admitted on 02/10/2012, had a caesarean section and was scheduled to be discharged 02/13/2012. No care plan was found in the patient's medical record. Staff Z confirmed that a care plan had not been completed on the patient and stated that "Care Plans can't be done in the Paragon computer system on this unit. We do them on paper." Patient #41 was admitted on 02/11/2012 , and had a vaginal delivery. A paper care plan was not found in the patient's medical record. Staff Z confirmed that a nursing care plan had not been completed on Patient #41.

These findings were verified with the Interim Director of LDRP and the Vice President of Nursing Services during the medical record review.


29314

On 2/13/2012 at approximately 1035 during review of medical record for patient's #8 and #9 it was revealed that there were no nursing care plans for either patient. This finding was confirmed with staff B.

Based on medical record review, interview and policy review the facility failed to ensure all telephone orders are authenticated by physicians for 10 of 25 charts reviewed (#5, #8, #14, #25, #26, #31, #42, #44, #45 and #46 ), resulting in the potential for medical errors and patient harm. Findings include:

On 2/13/12 at approximately 1100 during a record review for Patient # 31 revealed four telephoned physician orders dated 2/6/12, 2/7/12, 2/8/12 and 2/9/12 which were not authenticated by the ordering physician. This was confirmed by Staff U who responded, the unsigned orders appear to be from a single physician (surgeon) group. The physician order section of Patient #31's chart had multiple yellow tagged "sign here" tags on the physician order sheets prior to 2/6/12.

On 2/14/12 at approximately 1645 during a policy review of facility policy titled "Licensed Independent Practitioners Verbal / Telephone Orders" dated 8/2011 revealed that "The licensed independent practitioner shall authenticate verbal or telephone orders within 48 hours by countersignature, date and time of authentication. The authoring, supervising, covering, or legal partner physician may provide authentication of verbal and telephone orders".


27408

On 02/13/12 at approximately 1450 during clinical record review revealed that staff had taken a telephone order for patient #25 on 02/01/12 at 1340 for "Combined Home Medication and Inpatient Reconciliation Order Form" ; 02/02/12 at 0715 for a critical hemoglobin level; and 02/02/12 at 0800 to "type and cross match " one unit of PRBC (packed red blood cells).

On 02/13/12 at approximately 1600 during clinical record review revealed that staff had taken a telephone order for patient #26 on 02/01/12 at 2147 for "Clarification on Insulin/Humalog " and blood sugar orders ; 02/07/12 at 1506 for "Xanax 0.5 mg po every 8 hours as needed ".

The orders had not been authenticated (signed) by a physician within the 48 hour time frame according the document titled "Physician's Orders and Instructions that state at the bottom of the document "ALL VERBAL ORDERS MUST BE DATED, TIMED AND SIGNED BY THE PHYSICIAN WITHIN 48 HOURS".


31054

On 2/13/2012 at approximately 1330, record review on patient 14 revealed telephone orders from 2/6/12 at 1421 for "Admit to 5 N rehab , Albuterol Inhaler, reg diet and WB as tolerated - FWB", and on 2/7/12 at 1426 for "do not continue heparin..."were not yet authenticated by the ordering physician. Findings were reviewed with staff T who confirmed that the orders were not signed by the physician.


28273

During review of the medical records for patients # 44 and # 45 on 02/13/2012, both records revealed three (3) physician telephone orders that were not signed by the physician(s) within 48 hours.
Review of the medical record for patient #45, revealed five (5) physician telephone orders that were not signed by the physician(s) within 48 hours.

During an interview with Staff EE on 02/13/2012, he confirmed that the orders were not signed by a physician.


29314

On 2/13/2012 at approximately 1130 during medical record review for patient #8 it was revealed that there were six telephone orders that had not been authenticated within 48 hours of writing them. This finding was confirmed with staff B.



29955

On 2/13/2012 at approximately 1025 during medical record review it was revealed the physician failed to sign the order for a peripheral inserted central catheter for patient #70. An interview with staff #I confirmed the orders did not have the name of the physician, the signature of the physician, the date of the order, or the time of the order.

On 2/13/2012 at approximately 1040 during medical record review it was revealed the physician failed to authenticate a telephone order for restraints dated 2/4/2012 for patient #5. An interview with staff #I confirmed the telephone order had not been authenticated by the ordering physician.

On 2/13/2012 at approximately 1040 during medical record review it was revealed the physician failed to authenticate telephone orders dated 2/3/2012 for patient #5. An interview with staff #I confirmed the telephone order had not been authenticated by the ordering physician.


30562

On 02/13/12 at approximately 1200 during a review of clinical record #42 it was noted the following telephone orders for this patient had not been authenticated by the ordering physician. Dated 02/11/2012 @ 0745 the order for "10 mg lebatolol IVP x 1 now, 2 mg Dilaudid x 1 now." Staff P, the unit manager confirmed that these orders were without physician signature at the time of review.

Based on staff interview, record review, and policy review, it was determined the facility failed to ensure that informed consent forms for procedures and treatments were properly completed and authenticated with the signature of the attending physician for two of two records reviewed. Findings include:

On 02/13/12 at approximately 1450 during record review for patient #25 revealed that the document titled "Consent to Operation or Other Procedure" dated 02/08/12 on 1230 was not completed for the procedure "Endoscopy". The consent was signed by the " Closest relative or Legal Guardian " and witnessed by the nurse. The section of the document that attests to " providing information regarding the patient's risks, benefits and alternative methods of treatment available pertaining to the procedure " was left blank and undated.

On 02/13/12 at approximately 1500 interview with Staff T confirmed that the consent was not signed by the physician/practitioner. When asked if there was another area that the physician could document that the patient received the information was checked for verification (progress notes). Staff T indicated that the information could not be found Patient #25's record.

On 02/15/12 at approximately 0900 during review of a document titled "Informed Consent" it was determined that " ...In case where informed consent is needed, the physician or individual performing the surgery, procedure or treatment is responsible for providing the necessary information and obtaining documentation of informed consent or refusal."


29774

On 2/13/12 at approximately 1150 during record review for patient #31 revealed that the document titled "Consent to Operation or Other Procedure" completed 2/8/12 on 1503 was completed for the procedure "Peripherally inserted central catheter" and was signed by the patient and witnessed by the nurse. The section on the above mentioned document that attests to providing information regarding the patient's risks, benefits and alternative methods of treatment available pertaining to the procedure was left blank and undated. Interview with Staff U confirms that the consent was unsigned by the physician/practitioner. When asked where it was documented that the patient had been informed of her risks, benefits and alternative methods of treatment, Staff U indicated that that information could not be found on Patient #31's record.

Based on staff interview and record review, it was determined the facility failed to ensure that all discharged patients' medical records were complete, including authentication from the physician. Findings include:

On 2/14/2012 at approximately 9:00 a.m. an interview with staff R and staff LL revealed that the facility currently had 452 incomplete medical records that were awaiting completion from 53 physicians beyond 30 days following the patient's discharge from the hospital.

Based on observation, interview and policy and procedure review the facility failed to ensure that outdated, mislabeled or any other unusable drugs or biologicals were not available for patient use. Findings include:

During observation on 2-14-12 at approximately 1300 it was found that in the pre-operative area the following medications on the Anesthesia Block Cart were unusable for patient use:
1. One 30 milliliter (ml) bottle of ropivacaine, single dose vial was opened and kept in drawer for re-use.
2. One 50 ml bottle of 1% Lidocaine had no open or expiration date.
3. Nine 1 ml ampules of Ephedrine sulfate expired on 2-1-12.

During the same observation times the following item was found in Operating Room #1 in the Anesthesia Work cart:
1. One 10 ml bottle of Neostigmine had no open or expiration date.
These findings were confirmed by staff F, NN and OO.

During policy review on 2-15-12 at approximately 0900 it was found in the policy titled, "Patient Care Unit Inspections", states, "Any medication, which is not labeled, has expired, has not been stored properly, or is otherwise not usable shall be returned promptly to the Department of Pharmaceutical Services for proper disposition".

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.

The overall physical environment was not being maintained so as to assure patient safety as evidenced by:

1. No compliant eyewash was found on February 13 at 9:18 on the 5 North inpatient unit (must leave the floor to access any other part of the hospital) in violation of MiOSHA/OSHA regulations;
2. Labeling of medical gas zone valves on the removable cover did not match what was labeled inside the valve box as found at 9:32 that could cause confusion in case of an emergency;
3. Water damaged drywall ceiling found in dry storage room on February 13 at 10:41 that indicates a lack of proper maintenance of piping or roofing above;
4. Reprocessing of inflatable pressure cuffs was found on February 13 at 11:32 and 11:35 at both invasive cardiology preparation/recovery ward nurse stations as evidenced by several cuffs hanging to dry and disinfectant in a spray bottle (trade name virex 256) was found. As such aerosolized disinfectant could contaminate nearby food products (coffee dispensing unit) and clean supplies;
5. Seven moisture stains on ceiling was found in nuclear medicine storage room on February 13 at 13:48 that indicates a lack of proper maintenance of piping or roofing above;
6. Label for medical gas zone valve was found on removable cover in nuclear medicine on February 13 at 13:50 that could cause confusion in an emergency if the cover was missing or replaced on the wrong box;
7. No eyewash was found on February 13 at 14:05 to be convenient to the invasive cardiology preparation/recovery ward work sink at the north (newer) nurse station where reusable inflatable pressure cuffs are cleaned with a disinfectant that according to MSDS sheets is hazardous to the eye and requires continuous flushing;
8. The only available hand wash sink in histology was found being used for glass washing and regent disposal on February 13 at 14:13 that could contaminate hands;
9. The only available hand wash sink in general chemistry near where HIV/hepatitis specimens are collected was found to have stacks of hand towels at the sink and in open shelving above the sink on February 13 at 14:22 that could contaminate hands;
10. Label for medical gas zone valve was found on removable cover in psychiatric unit on February 13 at 14:55 that could cause confusion in an emergency if the cover was missing or replaced on the wrong box;
11. Water damaged drywall ceiling found in female shower in psychiatric unit on February 13 at 15:01 that indicates a lack of proper maintenance of piping or roofing above;
12. Line of sight control from a staffed location was found to not be provided for crash carts located at the east ends of both corridors in the 6 Center stepdown unit on February 13 at 15:34, as such properly/fully stocked supplies and medications needed for emergent care cannot be ensured;
13. An unsecured and out of staff control crash cart was found in the radiology control room in the emergency department on February 14 at 9:55, as such properly/fully stocked supplies and medications needed for emergent care cannot be ensured;
14. Grab bars not found in patient showers adjoining inpatient which could result in a patient fall as found in room 1103 on February 14 at 11:06, room 1116 on February 14 at 11:07, room 1018 on February 14 at 11:19 (according to interview with staff person WW all non intensive care rooms in the south tower had adjoining showers that lacked grab bars);
15. Labeling for rooms served by emergency department fast track medical gas zone valves was found on February 14 at 9:16 to not reflect current room numbering scheme that could cause confusion in an emergency;
16. Defibrillator found in emergency department fast track clean supply room on February 14 at 9:22 that was not plugged into an emergency powered receptacle, as such it could not be ensured to be available at any time;
17. Perfusion storage room was found on February 14 at 13:20 being used as an office that could lead to contamination of patient care products;
18. A medical gas alarm panel was found on February 14 at 13:31 that was unlabeled as to the area/rooms being served which could lead to confusion not knowing where an alarm applied;
19. A friction catch closer was found on February 14 at 14:54 on the endoscopy storage room door that does not ensure the required discernible net air flow is provided out of the room to protect patient care products;
20. According to an interview with staff person WW on February 15 at 13:31 no pressure loss gauges are provided across final filters on any central air handling units as needed to allow staff to know that unfiltered air is not leaking around the required filters;
21. The vacuum style backflow device serving the autopsy table was measured on February 15 at 14:05 to be mounted 48 inches above floor, not at the required 84 inches above floor to prevent contamination of the facility drinking water supply;
22. The morgue clinical sink was found on February 15 at 14:06 to be dry, thereby allowing sewer vermin and explosive sewer gases to enter the enter the facility;
23. No eyewash station was found in the morgue on February 15 at 14:08 where formaldehyde is used as required by MiOSHA.

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 16, 2012 for Life Safety Code.

An acceptable level of quality of the patient care environment was not provided as evidenced by observation, interview, and record review as follows:

1. Wall damage found in 5 North medication room on February 13 at 9:12 that rendered the surface uncleanable;
2. Heavy dust accumulation found under automatic dispensing units in 5 North medication room on February 13 at 9:12 indicative of poor housekeeping;
3. Heavy accumulation of dust and debris found under automatic dispensing units in 3 North on February 13 at 9:47 indicative of poor housekeeping;
4. Dirty floors found in infusion ward and adjoining storage room on February 13 at 9:56 indicative of poor housekeeping;
5. Damaged wall paint found in nuclear cardio scan room on February 13 at 10:02 that rendered the surface uncleanable;
6. Damaged wall paint found in echo #2 room on February 13 at 10:04 that rendered the surface uncleanable;
7. Damaged paint found on door of echo #3 room on February 13 at 10:05 that rendered the surface uncleanable;
8. Damaged wall paint found in echo #1 room on February 13 at 10:06 that rendered the surface uncleanable;
9. Wall damaged found and clean out cover plate found missing near entry to kitchen on February 13 at 10:31 that rendered the surfaces uncleanable;
10. Damaged wall tile found at hand wash sink in dish room on February 13 at 10:36 that rendered the surface uncleanable;
11. Heavy dust and debris accumulation found under automatic dispensing units in invasive cardiology storage room on February 13 at 11:20 indicative of poor housekeeping;
12. Very heavy dust and debris accumulation found under automatic dispensing units in invasive cardiology preparation/recovery ward on February 13 at 11:30 indicative of poor housekeeping;
13. Abandoned drain under sink of invasive cardiology preparation/recovery ward at the north (newer) nurse station was found on February 13 at 11:31 partially plugged with paper that did not provide a full barrier to sewer gases or vermin from entering the facility;
14. Several examples of laminate damage was found at the invasive cardiology preparation/recovery ward south (older) nurse station on February 13 at 11:36 that rendered the surfaces uncleanable;
15. Heavy dust accumulation found on top of systems storage locker in radiology staff work area on February 13 at 11:47 indicative of poor housekeeping;
16. Wall damage was found in nuclear medicine storage room on February 13 at 13:4836 that rendered the surfaces uncleanable;
17. Heavy accumulation of dust was found under low shelves of storage room in lab on February 13 at 14:29 indicative of poor housekeeping;
18. Heavy accumulation of dust and debris found under refrigerators in the inpatient pharmacy on February 13 at 14:46 indicative of poor housekeeping;
19. Heavy dust accumulation found on exhaust grill in female shower in psychiatric unit on February 13 at 15:01 indicative of poor housekeeping;
20. Debris was found on the floor of psychiatric unit medication room on February 13 at 15:14 indicative of poor housekeeping;
21. Filthy floor stains at shoe base was found in psychiatric unit pantry on February 13 at 15:15 indicative of poor housekeeping;
22. Water damage of walls next to ice machine in psychiatric unit panty refrigerator was found on February 13 at 15:15 that rendered the surfaces uncleanable;
23. Heavy dust accumulation was found under automatic dispensing units in emergency department fast track clean supply room on February 14 at 9:19 indicative of poor housekeeping;
24. A gap was found between countertop and the loose backsplash in 11th floor pantry on February 14 at 11:11 such that a cleanable environment could not be provided;
25. Water damaged laminate countertop was found on February 14 at 11:25 at sink in 10th floor clean supply such that a cleanable environment could not be provided;
26. A gap was found between countertop and the loose backsplash and sidesplash in 10th floor clean utility on February 14 at 11:30 such that a cleanable environment could not be provided;
27. Very low shelves (that did not allow for routine floor cleaning underneath) was found on February 14 at 15:11 in sterile storage portion of CPD;
28. Very low shelves (that did not allow for routine floor cleaning underneath) was found on February 14 at 15:27 in pharmacy bulk storage;
29. A ceiling mounted recessed " can " light fixture was found on February 15 at 11:00 in patient room 716 hanging loosely;
30. Wall damage found on February 15 at 11:43 in 5 south respiratory therapy utility room rendering the wall uncleanable;
31. Several broken and cracked floor tiles found on February 15 at 11:46 in 5 south clean utility rendering the floor uncleanable;
32. Side splash was found on February 15 at 13:35 separated from workcounter in dialysis lab rendering the facility uncleanable;
33. A gap was found on February 15 at 13:35 at the underside of base cabinet toe space in dialysis lab rendering the facility uncleanable and potential harborage for vermin;
34. Back splash was found on February 15 at 13:46 separated from workcounter in 4 center inpatient unit pantry rendering the facility uncleanable.


29313

Based on observation and interview the facility failed to ensure that supplies and equipment were maintained to ensure an acceptable level of safety and quality. Findings include:
During observation in the Catheter Lab Post Anesthesia Care Unit (PACU) on 2-13-12 at approximately 1300 it was found in the Anesthesia Airway Box the following items expired or not maintained:
1. Three endotracheal tubes open with stylettes and syringes attached, which makes the endotracheal tubes unusable, they are no longer sterile once package has been opened.
2. Two size 8.0, one size 7.5 and one size 7.0 endotracheal tubes with expiration dates of 05/09
3. Six nasopharyngeal airways with expiration dates of 08/10, 10/10, 10/10, 5/11, 8/11 and 9/11 respectively.
4. One CO2 detector with and expiration date of 01/09.
These findings were all confirmed by staff F, NN and OO.

Proper ventilation, light, and temperature controls as evidenced by the following observations, interviews, and record reviews:

1. Only exhaust ventilation provided in former toilet room being used for clean storage room adjoining infusion ward on February13 at 9:51 so that patient care supplies were not being protected from air borne contaminants;
2. Only 17 footcandles (fc) of artificial illumination was measured at hand wash sink in echo room #1 on February 13 at 10:06 versus the required 30 fc;
3. A recirculating floor fan was found in the emergency department CT scan room on February 14 at 9:53 that was not equipped with required filtration to ensure properly filtered ventilation is provided;
4. The maximum achievable hot water in 12th floor clean utility sink was measured on February 14 at 10:33 at only 90 degrees versus the required 105 - 120 degree range to facilitate proper hand washing;
5. Only 50 fc of artificial illumination was measured at scrub sinks between operating rooms #4 and 5 on February 14 at 13:17 versus the required 75 fc;
6. Only 64 fc of artificial illumination was measured on February 14 at 13:52 in center of operating room versus the required 150 fc;
7. Only 5 fc of artificial illumination was measured on February 14 at 15:27 in bulk pharmacy storage.

Based on observation, interview and policy review the facility failed to:
1) provide a coordinated and documented effort to reduce increasing rates of central line-associated bloodstream infections and ventilator-associated pneumonias
2) develop and evaluate an infection control plan annually
3) provide and maintain a sanitary environment
4) ensure sharps containers are available for use and not overfull
5) ensure staff are using personal protective equipment according to facility policy resulting in the potential for; ongoing acquisition of healthcare associated infections and transmission of infectious agents among patients and staff.

See specific findings in A-749


02902

The hospital did not maintain a sanitary environment so as to avoid sources and transmission of infections and communicable diseases as evidenced by:

1. Sterile packs were found on an open shelf in a passageway near the invasive radiology (angiography) procedure room on February 13 at 14:01 that as such (without proper controls) could call into question the sterility of their contents;
2. A staff refrigerator was found on February 14 at 9:18 in emergency department fast track clean supply room that the contents of which could contaminate patient care supplies;
3. A mirror was found on February 14 at 13:18 next to scrub sinks between operating rooms #4 and 5 that promotes inappropriate primping after scrubbing;
4. Open supplies found on February 14 at 13:32 in corridor outside operating room #11 that could become contaminated;
5. A staff refrigerator was found on February 14 at 14:19 in PACU clean utility that the contents of which could contaminate patient care supplies;
6. Hinged doors to isolation rooms in the south tower are not equipped with self closing hardware to ensure containment of airborne infectious agents, examples include room 1223 found February 14 at 10:22 and room 823 found February 15 at 10:38;
7. Based on February 15 interview at 13:57 with staff person WW the CDC required monthly visual check for discernible net air flow into airborne isolation rooms is not being conducted to ensure staff, patients, and visitors outside the rooms are not being contaminated.

Based on observation, interview and policy review the facility failed to:
1) provide a coordinated and documented effort to reduce increasing rates of central line-associated bloodstream infections(CLABSI) and ventilator-associated pneumonias (VAP)
2) develop and evaluate an infection control plan annually
3) provide and maintain a sanitary environment
4) ensure sharps containers are available for use and not overfull
5) ensure staff are using personal protective equipment according to facility policy resulting in the potential for; ongoing acquisition of healthcare associated infections and transmission of infectious agents among patients and staff. Findings include:

On 2/14/12 during document review for the Infection Control Committee it was revealed that in the Infection Control Committee minutes, numbers for central line associated blood-stream infections and ventilator associated pneumonias were reported by unit. Rates for CLABSI and VAP are calculated using the National Health and Safety Network database, however those rates are not used when reporting to the infection control committee, which met quarterly. Trending is also not mentioned in the minutes for which rates for three quarters of 2011 for VAP exceed national benchmarks (6.96, 6.22 2.81). Minutes fail to mention corrective action recommendations for the increasing rates. Under the "actions" column for the Infection Control Committee minutes reveals "ongoing monitoring".

Interview on 2/15/12 at approximately 0900 with Infection Control (IC) staff : Staff RR Staff SS and Staff TT regarding corrective action for the increased rates of CLABSI and VAP in the facility's intensive care unit from February 2011 until today reveals that all of the IC departmental staff had started in the department after October 2011 and were not involved in the 2011 CLABSI or VAP mitigation efforts. Staff Q indicated that she would look back in the IC document files to determine what evidence of actions were taken for mitigation of these healthcare associated infections. Interview with Staff B and Staff UU regarding mitigation efforts to reduce CLABSI and VAP revealed that they did take action in the Critical Care Committee for VAP mitigation in the form of monitoring hand hygiene, looking at cleaning protocols, reinforcement of the VAP Bundle from the Michigan Hospital Association's Keystone Project to reduce VAPS, in addition to more frequent reporting of rates (monthly) and evaluating a newly encountered endotracheal tube with a suctioning portal. When asked for the documentation from the Critical Care Committee's (CCC) meeting, a review of the (CCC) minutes fail to document corrective measures taken, nor reported monthly rates for CLABSI or VAP from which to measure their impact on the rates of infection.

Interview with Staff Q regarding the provision of the annual Infection Control Plans for 2010, 2011 and 2012 and the evaluation for the previous year's plan for 2010 and 2011 reveals that after review of the IC annual plans and their respective evaluations, much of the information is redundant year to year, goals are not measurable and do not lend themselves for measurement of achievement. In addition the 2012 plan mentions "to monitor the CLABSI and VAPs" however fails to mention the increased rates from the previous year's surveillance nor any corrective measures taken to mitigate CLABSI and VAP. Staff Q mentioned that the format of the annual Infection Control plan and evaluation was a "preference of the previous Infection Preventionist". The 2012 Infection Control Plan has not yet been approved by the Infection Control Committee, which is scheduled to meet on 2/17/12.

On 2/13/12 at approximately 1015 during a facility tour on 9-South found the medication room with a full needlebox. In addition to the full needlebox in the medication room found the medication refrigerator and freezer with accumulated dirt in the bottom and reddish stains on the inside door. The above were confirmed with staff U, who indicated that she thought that the medication refrigerator "was on a monthly cleaning schedule, but appeared to need cleaning again". Staff U also indicated that Housekeeping changes out the needleboxes and will come and change out the overfull needlebox today sometime. In the medication room were two patient care supplies storage drawers that were over full with both patient care equipment, sterile sealed patient care supplies and opened gauze packages along with sphygmometer tubing scissors and other miscellaneous supplies. The two storage drawers could not close completely and the sterile wrapped items caught on the drawer edge and tore the sterile packaging. The conditions of these two drawers were confirmed by staff U, who indicated that the "drawers needed to be cleaned out".

On 2/13/12 at approximately 1025 during a facility tour on 9-South found in a room that was previously used as a community shower and toilet room was converted into clean equipment storage room, which was congested with commodes, computers on wheels, an automated patient lift mechanism, chairs, IV poles and other miscellaneous patient care equipment. Accumulated dust and debris were found in the corners of the room. The hand hygiene sink and the toilet were not accessible, and the toilet was covered with a bath-blanket. Staff U indicated that the unit is short on storage space and this room serves as an over flow. When questioned how housekeeping could clean in this room staff U replied "I don't know".

On 2/13/12 at approximately 1030 during a facility tour on 9-South found in the small room with the ice machine, undersink storage of two full hand soap containers and a roll of white bags. This was confirmed by staff U.

On 2/13/12 at approximately 1140 during a facility tour on 10-South found in the units soiled utility room a sharps container that was plugged with a used hand towel. In addition in the clean storage room the room was congested with accumulated clean equipment that did not allow access to the hand hygiene sink nor the toilet facilities. Accumulated dust and debris was found in the corners of this equipment storage room. Staff V confirmed the above mentioned items and indicated that they don't really use the hand hygiene sink nor the toilet facilities in the equipment storage room.

On 2/13/12 at approximately 1150 during a facility tour on 10-South found in the medication room were two patient care supplies storage drawers that were over full with both patient care equipment, sterile sealed patient care supplies and opened gauze packages along with sphygmometer tubing, scissors and other miscellaneous supplies. The two storage drawers could not close completely and the sterile wrapped items caught on the drawer edge and tore the sterile packaging. The conditions of these two drawers were confirmed by staff V. In addition the intravenous start basket located in the medication room had accumulated dust and grime in the bottom of the basket. Staff V confirmed that the IV start basket needed cleaning out.

On 2/13/12 at approximately 1200 during a facility tour on 10-South found in the pantry, oversink storage cabinet had accumulated grime and soil with what looked like dried honey dripping down the side of the cabinet in addition to residual coffee grounds and soil stains on the face of the cabinet. Undersink cabinet had accumulated dirt and what appeared to be mold growing on the bottom of the cabinet. The food freezer in the pantry had an unmarked cup with ice and fluid and an unlabelled bag in the crisper drawer which was ordered for a patient who was no longer on the unit. The pantry on the whole was soiled and unorganized. This was confirmed by staff V.



29313

During observation on 2-13-12 in the catheter lab at approximately 1100 it was found a red biohazard sharps container was full in the preoperative area. These findings were confirmed by staff D.
During the tour of the pharmacy on 2-13-12 at approximately 1200 it was found that the pharmacy's refrigerator freezer was iced over and had not been defrosted recently. It was also observed that there were three red biohazard sharps containers full. These findings were confirmed by staff E.
During observation in the Emergency Department (ED) on 2-13-12 at approximately 1400 it was found that in two of the dirty utility rooms the patients clean urine pregnancy tests, logs and urine culture tests were being kept next to the dirty sink and was in the immediate area of possible contamination. While continuing thru the ED, in the "Fast Track" area, it was observed a full red biohazard sharps container on a cart in the clean utility room. In the main ED it was found in the clean utility room that the refrigerators freezer was frozen shut and had not been defrosted recently. In the same clean utility there was a suction canister, a food tray and three patient care buckets found under the sink. These findings were confirmed by staff M.
During observation on 2-14-12 at approximately 1300 in the preoperative surgical area that the refrigerators freezer was frozen and iced over and had not been defrosted recently. While continuing on with observations in the operating room areas, it was found that oxygen extension tubing was consistently being reused on patients. According to the manufacturer packaging this is a single use item. These findings were confirmed by Staff NN and OO. Observation of suction tubing on the floor was repeatedly seen, which has the potential for cross contamination and infection. This finding was also confirmed by staff NN and OO.

During policy and procedure review on 2-15-11 at approximately 1100 it was found in the policy titled, "Hazardous Materials and Waste Management Program", states, "Sharps and biohazardous waste sharps are disposed of in red sharps boxes and removed when 3/4 full...". Under the procedure, "Refrigerator Cleaning", states that the refrigerators are to be cleaned on a weekly basis on Fridays, including defrosting the freezers is required.


29314

On 2/13/2012 at approximately 1020 on the Labor and Delivery Unit tour, it was revealed in the nourishment room an open box of cereal undated without a patient name, a soiled refrigerator and a soiled microwave. This finding was confirmed with staff B. At 1045 on the Labor and Delivery unit there was a glucometer soiled with blood. This finding was confirmed with staff B, who then wiped the blood off with an alcohol swab.

On 2/13/2012 at approximately 1100 during a tour of 5 South it was revealed in the clean utility room supplies stored on the floor, lab tubes and packages of gauze pads stored on the edge of the sink within splashing distance. Also, stored around the sink was a jackson-pratt drain and 4 boxes of syringes. In the nourishment room it was observed that the refrigerator was soiled, soiled cups were on the counter, clean patient care items were on the edge of the sink within splashing distance, 3 - 2 liters of pop were opened and undated, 2 bottles of juice were open and undated, and a draw with miscellaneous items (silverware, condiments ect) was cluttered and soiled. These findings were confirmed with staff P.

On 2/13/2012 at approximately 1330 during a tour of 6 Central it was observed that the nourishment room was cluttered and the drawers and cupboards were soiled with crumbs and debris. In the clean supply room an IV start kit was stored on the edge of a trash can and 2 opened ambubags were opened and available for use in the storage room. This was confirmed with staff O.

On 2/13/2012 at approximately 1410 on 6 Central a transporter was observed transferring a isolation patient, who had VRE and Strep D, in his room without a gown on, then entered the hallway with her gloves still on, to ask for assistance with the transfer. The transporter then walked back into the room without applying a gown. This finding was confirmed with staff O.


29955

On 2/13/2012 at approximately 1020 during a tour of the intensive care unit it was revealed a set of IV tubing had been taken out of its sterile package and laid on the counter and was available for patient use. The unit manager confirmed the IV tubing was outside of its sterile packaging and available for patient use.

On 2/13/2012 at approximately 1025 during observation it was revealed staff #H walked into a patient room marked as contact isolation without the use of Personal Protective Equipment (PPE). An interview with the intensive care unit manager confirmed the employee did not use PPE.

On 2/13/2012 at approximately 1445 during a tour of the oncology floor supplies were being kept in the freezer area in the clean utility room. The supplies consisted of stockinette used to protect IV sites and a pair of scissors. When queried about the supplies being stored in the freezer staff #H stated it was kept in the freezer as a hiding spot from the other floors where the supply could be kept for use.

On 2/13/2012 at approximately 1620 during a tour of the medical/surgical floor it was revealed juices in the patient refrigerator were without a date and time of being opened. Staff #YY confirmed the juices did not have a date or time.

Based on policy review, record review and interview, the facility failed to document a discharge planning reassessment for 1 of 3 (#69) patients on the Behavioral Health Unit which could result in the potential of failed placement and a lack of staff's ability to properly prepare the patient for discharge. Findings include:

A review of the McLaren Flint policy titled Discharge Planning Process reads under 5. Evaluation and Reassessment "The discharge plan is evaluated on an on-going basis and revised as appropriate to ensure that case Management services are responsive to discharge needs."

During review of the medical record for patient #69 on 02/15/2012, it revealed that the discharge evaluation stated that the patient would be going home. The patient was not discharged to her home but instead went home to her daughters home due to the need for assistance. There was no reassessment documentation by a discharge planner in regards to this change. The patient's record contained only an admission evaluation and then a note from the social worker on the day of discharge.

Based on record review and interview, the facility failed to prepare 3 of 7 (#44, #46, #69) patients on the Behavioral Health Unit for discharge planning resulting in the potential of failed placement or inadequate care after discharge. Findings include:

During review of the medical record for patient #44, a review of the discharge evaluation completed at the time of the patient's admission revealed that the patient was going to be discharged to home. The patient's record contained no reassessment documentation during the 10 day stay. On the day of discharge the patient was discharged to a residential treatment center. There was no discharge planning documentation on the patient's record until the day of discharge.

Review of the medical record for patient #45, the evaluation completed at the time of the patient's admission stated that they would be going "home." The patient's record contained no reassessment documentation during the 7 day stay. On the day of discharge the patient was discharged to a residential treatment center. There was no discharge planning documentation on the patient's record until the time of discharge.

Review of the medical record for patient #45, the evaluation completed at the time of the patient's admission stated that they would be going "home." Documentation in the record dated 02/06/2012, makes reference to the fact that if the patient needs care at the time of discharge "it is possible that she can stay with her daughters if it is needed when she leaves the hospital." There is no further updates regarding discharge planning for this patient. Patient #69 was not discharged form the hospital until 02/13/2012.

During an interview with staff EE on 02/14/2012, he confirmed the findings and agreed that there is a lack of documentation in regards to what is being done for the patients for discharge planning and reevaluation to prepare the patient for discharge needs.

Based on record review and interview, the facility failed to document the transfer of patient information from the discharging facility to the receiving facility at the time of discharge for 2 of 7 (#44, #46) patients resulting in the potential for a lack in continuity of care and failure of optimal patient outcomes. Findings include:

During review of the medical records for patient's #44 and #46, who were discharged from the Behavioral Health Unit to another treatment facility, there was no documentation of the information being faxed to the next level of care.

Review of a document titled 7 Central Discharge Checklist it reads under Nursing "Discharge instructions faxed to the next level of care? (SW or Clerk to fax to next level of care-if not working-RN to fax on to next level of care) After faxing staple copy of discharge instruction sheet to this form and place in box above copy machine. All must have fax receipt attached." The check box for this task being completed by a staff member was left blank on both patient's records.

During an interview with staff EE on 02/14/2012, he stated that they "no longer use this document"; however it was available for use on all four records on the Behavioral Health Unit that this surveyor reviewed and two of the four contained incomplete documentation but had been documented on. Staff EE did confirmed that some of the documents were charted on and that some were not. He also confirmed that there was no other documentation in patient's #44 or #46 record as to records being sent to the receiving facility.

Based on record review and interview, the facility failed to reassess patient needs for 3 of 4 patients (#44, #46, #69) discharged resulting in the potential for failed placement and poor patient outcomes. Findings include:

Based on record review for patient #44, she was admitted on 02/04/2012 at which time a discharge evaluation was completed and it stated that the patient would be discharged to home. The patient was at the facility until 02/13/2012 at which time the patient was discharged to a residential treatment facility. The patient's record contained no discharge planning reassessment during the 10 day hospitalization.

Review of the medical record for patient #46, revealed that they were admitted to the hospital on 02/07/2012 and discharged on 02/13/2012. The discharge evaluation completed at the time of admission stated that the patient would be "discharged to home." At the time of discharge, the patient went to a residential treatment facility. The patient's record lacked documentation in regards to reassessment and the change in the discharge plan. The medical record contained no documentation referencing the change until the discharge summary note was put into the chart after the patient was discharged from the facility.

During a review of the medical record for patient #69, it revealed that she was admitted to the facility on 01/30/2012 and discharged on 02/13/2012. The discharge planning evaluation completed at the time of the patient's admission stated that they would be going "home." There was a note documented on 02/05/2012 referencing that the patient could possibly go to her daughters home after leaving the hospital if she required further care. There was no other discharge planning reassessments documented on the patient or the patient's needs. The patient remained at the hospital for eight (8) more days and was then discharged to her daughter's home.

During an interview with staff EE on 02/14/2012, he confirmed the lack of reassessment documentation for the three (3) patients by the discharge planning staff.