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Based on observation, interview, and record review, the facility's medical staff failed to:
A) ensure that 1 of 1 CRNA (Certified Registered Nurse Anesthetist) (Personnel #30) was provided an appointment and clinical privileges to provide anesthesia care, and
B) provide re-credentialing for 2 of 3 physicians (Physician #31 and #34) who had not been re-credentialed since 7/2012.

Findings included:

A) On 2/18/15 Patient #6 was scheduled for a "laparoscopic cholecystectomy" and Personnel #30, the facility's sole CRNA provided anesthesia care. The surgical procedure started at 7:10 AM and ended at 8:10 AM. Patient #6 stayed in the PACU (post-anesthesia care unit) until approximately 9:40 AM and was subsequently transferred to room #121.

Review of Personnel #30's credential file on 2/19/15 at approximately 10:30 AM did not contain a CRNA appointment and delineation of privileges given by the medical staff.

In an interview on 2/19/15 at 1:45 PM, Personnel #27 who was responsible for medical staff credentialing was informed of the above findings and was asked to provide evidence that Personnel #30 had medical staff membership and privileges. Personnel #27 stated since she took over credentialing on 2010, she had not seen Personnel #30's current or initial membership appointments and staff privileges. Personnel #27 was asked when Personnel #30 was hired and she replied there were 2 hired dates on his file, 5/19/1998 and 1/6/2006. She did not know which one was the accurate hire date.

In an interview on 2/19/15 at approximately 1:50 PM, Personnel #1 (Director of Nursing) was informed of the above findings. She was asked to confirm if Personnel #30 was the only individual providing anesthesia care on surgical and endoscopic procedures. Personnel #1 replied "yes." She was asked to provide the total number of cases the facility had for the last 6 months. Personnel #1 replied they had "67."

B) Review of Physician #31's and Physician #34's credentialing files revealed they were not re-credentialed since 7/2012.

During an interview with Personnel #27 she confirmed Physician #31 and Physician #34 had not been re-credentialed since 7/2012. She said physicians were to be re-credentialed every 2 years.

The facility Bylaws dated 5/16/06 pages 10 and 11 required "Article VII Medical Staff 7.1.3 All appointments to the medical staff shall be for a two year period...7.2.3. The medical staff shall make recommendation to the Board concerning: 1) appointments, reappointments, and other changes in staff status; 2) granting of clinical privileges..."




27128

Based on interview and record review, the facility failed to include in their by-laws a statement of the duties and privileges of a CRNA (Certified Registered Nurse Anesthetist). The facility had 1 of 1 CRNA (Personnel #30) who provided direct anesthesia care to a tracer patient (Patient #6) on 2/18/15.

Findings included:

On 2/18/15 Patient #6 was scheduled for a "laparoscopic cholecystectomy" and Personnel #30, the facility's sole CRNA provided anesthesia care. The surgical procedure started at 7:10 AM and ended at 8:10 AM. Patient #6 stayed in the PACU (post-anesthesia care unit) until approximately 9:40 AM and was subsequently transferred to room #121.

Review of Personnel #30's credential file on 2/19/15 at approximately 10:30 AM did not contain a statement of duties and privileges from the medical staff as to whether he was active, courtesy, or any other statement of duties and privileges.

In an interview on 2/19/15 at 1:45 PM, Personnel #27 who was responsible for medical staff credentialing was informed of the above findings and was asked to provide evidence that Personnel #30 had statement of duties and privileges from the medical staff whether he was active, courtesy, or any other statement of duties and privileges. Personnel #27 stated she had no evidence.

The facility Bylaws dated 5/16/06 did not include a statement of the duties and privileges of each category of medical staff members.

Based on interview and record review, a physician (Physician #31) failed to document and complete a discharge summary within 30 days from the day of discharge, consistent with hospital medical records policy and procedure, citing 1 of 5 closed patient records on 2/19/15 (Patient #3).

Findings included:

Patient #3 was discharged on 12/26/14 at 1:15 PM for Acute Cerebrovascular Accident. Review of the medical record on 2/19/15 at approximately 11:05 AM contained a discharge summary documented by Physician #31 on 2/5/15 at 1:06 PM, greater than 30 days past the required time frame.

In an interview on 2/19/15 at approximately 11:30 AM, Personnel #1 who was reviewing the medical records of Patient #3 with the surveyor confirmed the above finding.

Notification of Physicians Concerning Delinquent Dictation undated required "The Discharge Summary shall be dictated no later than 30 days from the day of discharge..."

Based on interview and record review, the medical staff did not implement and enforce rules and regulations in that complete medical histories and physical examinations were not in the patients' medical records after 24 hours of patients' admission, citing:
A) 2 of 8 in-patients on 2/19/15 (Patient #7 and #8); and

B) 4 of 5 closed patient records (Patients #1, #3, #20, and #21) on 2/19/15.

Findings included:

A) Patient #7 was admitted on 2/18/15 at 12:00 PM for "hypoxia..." Review of the medical record on 2/19/15 at approximately 12:20 PM did not contain a written or dictated physician history and physical examination.

Patient #8 was admitted on 2/15/15 at 2:00 PM for "right pneumothorax." Review of the medical record on 2/19/15 at approximately 12:30 PM included a physician history and physical examination documented on 2/17/15 at 8:36 AM, 19 hours past the required time frame.

B) Patient #1 was admitted on 12/13/14 at 12:05 PM for "Acute Chronic Renal Failure." Review of the medical record on 2/19/15 at approximately 11:00 AM contained a history and physical examination by Physician #33 documented on 1/20/15 at 1:37 PM, greater than one month past the required time frame.

Patient #3 was admitted on 12/22/14 at 11:00 AM for "Acute Cerebrovascular Accident." Review of the medical record on 2/19/15 at approximately 11:05 AM contained a history and physical examination by Physician #31 documented on 2/2/15 at 1:32 PM, greater than one month past the required time frame.

Patient #20 was admitted on 1/2/15 at 12:40 AM for "Acute Exacerbation of COPD (Chronic Obstructive Pulmonary Disease)." Review of the medical record on 2/19/15 at approximately 11:10 AM contained no history and physical examination by Physician #33.

Patient #21 was admitted on 1/12/15 at 11:51 AM for "Sepsis." Review of the medical record on 2/19/15 at approximately 11:15 AM contained a history and physical examination by Physician #31 documented on 1/28/15 at 09:53 AM, greater than 24 hours past the required time frame.

In an interview on 2/19/15 at approximately 11:30 AM and 12:30 PM, Personnel #1 and #2 who were reviewing the medical records of Patient #1, #3, #7, #8, #20, and #21 with the surveyors confirmed the above findings.

Medical Staff Rules and Regulations undated required "B. Medical Records...2. a) A complete admission history and physical examination shall be recorded or dictated...within 24 hours following admission..."




34326

Based on interview and record review the Hospital failed to ensure the dietary department was in compliance with adhering to the manual dishwashing procedures outlined in the hospital's Hand Dish Washing Procedure policy.

Findings included:

1) During a tour of the dietary department on 02/18/15 at 11:40 AM Personnel #16 said the dishwasher was not working and manual dishwashing had been utilized. She said the dietary department's Hand Dish Washing Procedure policy was followed for manual dishwashing.

During an interview on 02/18/15 at 11:50 AM Personnel #23 was asked how she manually washed the dishes. She indicated she rinsed with hot water after manually washing the dishes. Afterwards she put the dishes into the dishwasher and rinsed them. Personnel #23 said the washing cycle of the dishwasher didn't work, but the dishwasher's rinse cycle did work. When asked why she didn't follow the Hand Dish Washing Procedure policy and add bleach to the rinse water, she said she couldn't because the second sink had a disposal unit, so she rinsed the dishes under running hot water.

Personnel #23 was asked how full she filled the first sink for washing dishes and what did she add to the water. She said she didn't know how full she filled the sink with water. Personnel #23 said she squirted a good amount of dishwashing detergent into the water. She was asked why she didn't add bleach to the water like the policy indicated. Personnel #23 said she did add bleach but she forgot to tell the surveyor. She was asked where the measuring cup was for the bleach. Personnel #23 left and went into the kitchen preparation area and came back with a 1/2 cup measuring container. The surveyor asked Personnel #23 how hot the dishwashing water was at the time she washed dishes and she said it was "kind of hot."

The hospital's Hand Dish Washing Procedure policy updated on 11/14/07 indicated, "...Fill first sink with water at 110 degree-120 degrees F to within 4 inches of top. Add 1 cap of Dawn dish soap and 1/4th cup of bleach... Fill second sink with water (half full) and add 1/8th cup (2 tablespoons) of bleach... After washing equipment and utensils, place in second sink..."

Based on observation, interview, and record review, the facility failed to maintain an acceptable level of safety and quality of 2 of 2 germicidal detergent (LpH) spray bottles found in the operating room (OR) and central supply area on 2/18/15. "LpH" was used in various areas of the hospital for cleaning and disinfecting washable, hard, and non-porous surfaces.

Findings included:

During a facility tour on 2/18/15 at 2:30 PM in the surgical area, 2 spray bottles of "LpH" germicidal detergents were found in the OR and central supply areas. These containers did not have dates.

During an interview on 2/18/15 at 2:30 PM Personnel #14 who was present during the tour was informed of the above findings and was asked to provide documentation of dates for the preparation of the spray bottles. She replied that they do not document the dates on the spray bottle itself but the dates are written on a log. Review of the log showed both containers were dated on 1/19/15. Personnel #14 was asked how often they change the germicidal detergent and she replied every 2 weeks. Personnel #14 stated the individual who was in-charge of the detergents (Personnel #36) was gone for the day and would be back tomorrow.

In an interview on 2/19/15 at approximately 12:00 PM, Personnel #36 was informed of the above findings and was asked for the dates of the detergents. She replied the detergents were changed on 2/18/15 and forgot to log these dates. She confirmed the detergents were not changed every 2 weeks as required.

Policy "LpH...One Step Germicidal Detergent undated required "2. Pre-mixed LpH solution has a shelf life of 2 weeks when stored in a closed container/ spray bottle."

Based on observation, interview, and record review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases in that:
A) 1 of 3 nursing students (Personnel #26) wore her mask from the operating room (OR) to the post-anesthesia care unit (PACU) and to the in-patient area on 2/18/15, and
B) 1 of 2 registered nurses (RNs) (Personnel #1) did not wear appropriate attire in entering the restricted area.

Findings included:

A) While following a tracer patient (Patient #6) on 2/18/15 at 9:20 AM, Personnel #26 was observed wearing her used mask around her neck in the PACU. At 9:25 AM, Personnel #26 confirmed she wore the mask in the OR from the start to the end of the surgical procedure. Patient #6 recovered from anesthesia and was brought to the in-patient area. Personnel #26 with a mask hanging around her neck assisted in transporting Patient #6 to the in-patient area.

In an interview on 2/18/15 at approximately 3:15 PM, Personnel #1 was informed of the above findings and was asked for a policy and procedure. She confirmed the findings.

B) During a tour in the surgical unit with Personnel #14 on 2/18/15 at approximately 2:40 PM, Personnel #1 was observed entering the restricted area not wearing a bouffant and shoe covers.

In an interview on 2/18/15 at approximately 2:45 PM, Personnel #14 was asked if Personnel #1 wore appropriate attire when she entered the restricted area. Personnel #14 replied that she should have worn a bouffant and shoe covers.

Policy "Restricted Area in OR" undated required "Only authorized personnel in proper OR attire can be admitted into the restricted area."

The policy PPE use (personal protective equipment) undated did not provide a procedure as to when to discard masks.

The AORN (Association of periOperative Registered Nurses) 2014 Edition Recommendation VI.b.1 and VI.c. on page 56 reflected, "...Masks should not be worn hanging down from the neck...Surgical masks should be discarded after each procedure..."