HospitalInspections.org

Based on review of hospital policies/procedures, medical records, interviews, and personnel files, it was determined that the hospital failed to provide an organized nursing service 24 hours per day with registered nurses and competent nursing staff to assess, plan, deliver and supervise the care required by each patient as evidenced by:

(A395) failure to require that a registered nurse supervise and evaluate the nursing care of each patient;

(A396) failure to ensure that the nursing staff develops and keeps current, a nursing care plan for each patient; and

(A397) failure to require that nursing personnel who are assigned to provide care to patients have received the necessary orientation and have demonstrated competence to perform their patient care responsibilities.

The cumulative effect of these systemic problems resulted in the hospital's failure to meet the Condition of Nursing Services.

Based on review of hospital policies/procedures, medical records, and interviews, it was determined that the hospital failed to require that a registered nurse supervise and evaluate the nursing care of each patient as evidenced by:

1. failure to implement physicians' orders for Pt #15 and #22 who required diagnostic laboratory tests;

2. failure to supervise and evaluate the monitoring of 14 patients who required routine monitoring of vital signs and nutritional intake and were on either 1:1, 1:2, or 1:3 Safety Precautions/Observation Levels (Pts # 1, 4, 6, 7, 8, 10, 11, 13, 14, 15, 16, 21, 22, and 23); and

3. failure to complete admission assessment of patients including collection of data by interview, observation, inspection auscultation, palpation per policy for Pts # 3, 4, 6, 14, and 16.

Findings include:

1. Review of the hospital policies/procedures titled Shift Guidelines (0700-1930) and Shift Guidelines (1900-0700) revealed: "...RN Charge Nurse Responsibilities...Obtain all laboratory specimens and notify appropriate laboratory for transportation...."

Pt #15's medical record contained physician's admission orders, written as telephone orders by an RN, on 6/10/11, at 1810: "...Other Labs: Teg (Tegretol) Level...." The medical record did not contain laboratory results for a Tegretol Level; documentation that an RN obtained a blood sample for a Tegretol Level; or documentation that the physician was informed that the RN was unable to obtain a sample for a Tegretol Level.

The Director of Nursing confirmed on 6/16/11, that a physician ordered a Tegretol Level and that the record did not contain results of a Tegretol level or nursing documentation of notification of the physician of inability to obtain a Tegretol level. She also confirmed that the RN's draw the blood for blood tests and if they are unable to draw blood they contact the lab for a phlebotomist to come and draw the blood; and that the RN should notify the physician if s/he was unable to draw blood from a patient.

Pt #15 was discharged on 6/16/11 with no Tegretol level results in the medical record. S/he was readmitted on 6/17/11 and required locked seclusion due to out-of-control behavior.

Pt #22's medical record contained documentation that the patient had the following medical problems: heart disease, hypothyroidism, hypertension, and superficial cuts on arms, and left calf.

Pt #22's medical record contained physician's orders dated 6/9/11 for laboratory tests: "...CBC w/diff (Complete Blood Count with differential)...CMET (Comprehensive Metabolic Panel)...Lipid...."

The medical record contained no documented evidence of a lab report.

A Nurse Practitioner (NP) again ordered the CBC, CMET, and Lipid tests on 6/10/11. In addition, the NP ordered "...Fe+ (Iron)...B12...& UA (Urinalysis)...." The medical record did not contain laboratory results or documentation of notification of the physician or NP of the RN's inability to obtain a blood sample or urine sample for a UA from the patient. The medical record contained a lab requisition dated 6/13/11 with an unsigned note: "...difficult draw & dehydrated-missed 6/11/11...." The medical record did not contain nursing documentation of the patient being dehydrated.

The Director of Nursing confirmed on 6/16/11, that Pt #22's medical record contained physician and NP orders for lab tests; did not contain any results of lab tests; and did not contain nursing documentation that the physician or NP was notified regarding the inability to obtain the necessary specimens or the patient's dehydration. She also confirmed that the medical record did not contain documentation that the lab was notified to send a phlebotomist to obtain the blood sample.

2. Each patient's medical record contained the form titled Psychiatric Acute Care (PAC) Unit (210) Physician's Orders...Admission Orders. Review of this form revealed that it included a list of items that the physician chooses from to indicate admission orders for each patient. The list includes: "... Safety Precautions: Routine locked unit supervision...1:1 Arms length...1:2 Line of sight...1:3 q (every) 15 min. visual checks...Diet: Regular...Other...CCHO ADA (Controlled Carbohydrate American Dietetic Association)...Labs...Vital signs per routine...Other...."

Review of the hospital policy/procedures titled Shift Guidelines (0700-1930) and Shift Guidelines (1900-0700) revealed: "...RN Charge Nurse Responsibilities:...Plan care, direct and supervise others in planning Consumer care...Provide direct clinical supervision to Behavioral Health Specialists (BHS)...Behavioral Health Technicians (BHS) Responsibilities:...Perform vital signs and food intake and output as assigned. Report vital signs and intake/output to the nurse and chart on consumer's individual graphic record...Upon return to unit from meal document intake on Vital Signs sheet and consumer's individual graphic record...."

Review of the hospital policy/procedure titled Documentation revealed: "...The medical record is the chief means by which the health team members coordinate and guarantee the continuity of each client's care...Vital statistics, percentage meals eaten...information is recorded on a graphic sheet to enhance trending of the recorded behavior...Documentation of care is synonymous with care itself...all entries are made in Anasazi except for the graphic VS/ADL/Meal sheet and the observation records...."

The Activities Coordinator/ BHS Supervisor and the Director of Nursing stated during interviews conducted on 6/16/11, that staff document the patient's location and behavior every 15 minutes on the Consumer Observation form whether a patient is on 1:1, 1:2, or 1:3 Safety Precautions. Routine observations are documented every 30 minutes.

The Director of Nursing and PAC Nurse Manager confirmed during interview on 6/16/11, that the routine schedule for measuring and recording vital signs is 0600, 1100, and 1800. BHS's record vital signs on the graphic sheet at these times. In addition, the PAC Nurse Manager confirmed that the BHS's also record the patients' nutritional intake on the graphic sheet for each meal.

Review of medical records revealed:

Pt #1 was an inpatient from 6/5/2011 to 6/9/2011. S/he required routine monitoring of vital signs and nutritional intake and required 1:2 Safety Precautions for 24 hrs and then 1:3 Safety Precautions thereafter. Pt #1's medical record did not contain documentation of 1 recording of vital signs, 12 meals, and 11 entries of Safety Precautions.

Pt #4 was admitted on 6/13/11 and was a current patient on 6/16/11. S/he required routine monitoring of vital signs and nutritional intake and required 1:3 Safety Precautions. Pt #4's medical record did not contain documentation of 2 recordings of vital signs, 6 meals, and 5 entries of Safety Precautions.

Pt #6 was an inpatient from 5/28/11 to 6/1/11. S/he required routine monitoring of vital signs and nutritional intake and required 1:3 Safety Precautions. Pt #6's medical record did not contain documentation of 2 recordings of vital signs on 5/29/11 and 1 on 5/30/11. Pt #6 was transported to an Emergency Department on 5/31/11 at 1100, due to dehydration and possible complications related to a "recent" Lamictal overdose. S/he returned to the PAC Unit on 5/31/11 at 1515. Pertinent physical assessment findings prior to the transport included hypotension and tachycardia. Pt #6's medical record did not contain 5 entries of Safety Precautions on 5/31/11 from 1745 through 1845. It also did not contain documentation of 6 meals.

Pt #7 was an inpatient from 5/28/11 to 5/31/11. S/he required routine monitoring of vital signs and nutritional intake and required 1:2 Safety Precautions for his/her first inpatient day. S/he required Routine Precautions thereafter. Pt #7's medical record did not contain documentation of 1 recording of vital signs, 3 meals, and 1 entry of Safety Precautions.

Pt #8 was an inpatient from 6/5/11 to 6/10/11. S/he required routine monitoring of vital signs and nutritional intake and required 1:3 Safety Precautions for his/her first inpatient day. S/he required Routine Precautions thereafter. Pt #8's medical record contained documentation that the patient had hypertension, anemia, and hyperlipidemia. Pt #8's medical record did not contain documentation of 1 recording of vital signs, 16 meals, and 4 entries of Safety Precautions.

Pt #10 was an inpatient from 6/6/11 to 6/8/11. S/he required routine monitoring of nutritional intake. Pt #10's medical record did not contain documentation of 4 meals.

Pt #11 was an inpatient from 6/11/11 to 6/13/11. S/he required routine monitoring of vital signs and nutritional intake. Pt #11's medical record contained documentation that the patient had a "tooth infection." Pt #11's medical record did not contain documentation of 2 recordings of vital signs, and 4 meals.

Pt #13 was an inpatient from 6/1/11 to 6/8/11. S/he required routine monitoring of vital signs and nutritional intake and required 1:2 Safety Precautions. Pt #13's medical record did not contain documentation of 3 recordings of vital signs, 20 meals, and 50 entries of Safety Precautions. Pt's medical record contained documentation that s/he was diagnosed with a urinary tract infection and placed on an antibiotic during his/her hospitalization.

Pt #14 was an inpatient from 6/2/11 to 6/6/11. S/he required routine monitoring of vital signs and nutritional intake and required 1:3 Safety Precautions. Pt #14's medical record did not contain documentation of 11 meals, and 3 entries of Safety Precautions.

Pt #15 was an inpatient from 6/10/11 to 6/16/11. S/he required routine monitoring of nutritional intake and required 1:3 Safety Precautions. Pt #15's medical record contained documentation that the patient had the following medical/health issues: "...hypothyroidism, hypercholesteremia (sic), NIDDM (Non Insulin Dependent Diabetes Mellitus), Glaucoma, left eye corneal abrasion from self-inflicted wound...." Pt #15's medical record did not contain documentation of 5 meals, and 5 entries of Safety Precautions.

Pt #16 was admitted on 6/9/11 and was a current inpatient on 6/16/11. S/he required routine monitoring of vital signs and nutritional intake and required 1:3 Safety Precautions. Pt #16's medical record did not contain documentation of 1 recording of vital signs, 6 meals, and 6 entries of Safety Precautions.

Pt #21 was an inpatient from 5/30/11 to 6/4/11. S/he required 1:3 Safety Precautions. Pt #21's medical record did not contain 5 entries of Safety Precautions.

Pt #22 was an inpatient from 6/9/11 to 6/13/11. S/he required routine monitoring of vital signs and nutritional intake. Pt #22's medical record contained documentation that the patient had the following medical problems: heart disease, hypothyroidism, hypertension, and superficial cuts on arms, and left calf. Pt #22's medical record did not contain documentation of 5 recordings of vital signs, and 10 meals.

Pt #23 was an inpatient from 6/8/11 to 6/13/11. S/he required routine monitoring of vital signs and nutritional intake and was on 1:3 Safety Precautions. Pt #23's medical record did not contain documentation of 5 recordings of vital signs, 11 meals, and 11 entries of Safety Precautions.

The Director of Nursing confirmed during interview conducted on 6/16/11 at 1500, that the documentation was incomplete.

The PAC Nurse Manager confirmed during interview conducted on 6/15/11 at 1510, that the documentation was incomplete.

BHS #16 confirmed during interview conducted on 6/16/11, that the documentation was incomplete.

3. Review of the hospital policies titled Shift Guidelines (0700-1930) and Shift Guidelines (1900-0700) revealed: "...RN Charge Nurse Responsibilities:...Monitor admission of all new Consumers to the Psychiatric Acute Care Unit, this process includes the following:...Collect assessment data by: Interview, observation, inspection, auscultation, palpation, and report to team and record data on the Nursing Admission Assessment in the consumer's record per Guidance Center policy...."

Review of the hospital policy titled Admission revealed: "...The admission process includes an assessment of biophysical, psychosocial, environmental, self-care, educational, and discharge issues pertinent to the client...."

The hospital's electronic medical records contained a "form" titled Nursing Assessment-Admission. This "form" included several sections for the RN to complete an admission assessment of the patient, including: "...Presenting problem...Mental Status...Medical History...Substance Abuse...Treatment Plan Development...Psych Nurse Tx (Treatment) Plan Area of Focus that includes medical if needed...." Included in the Medical History section is a sub-section for the RN to complete titled: "...Physical Findings (auscultation, palpation, visualization, etc.)...." This section contained a space for the RN to document physical assessment findings.

Pt #3"s medical record contained a blank Nursing Assessment-Admission "form."

Pt #4's medical record contained a blank Nursing Assessment-Admission "form."

Pt #6's medical record did not contain a Nursing-Assessment-Admission "form."

The PAC Nurse Manager confirmed on 6/17/11, that the medical records of Pts #3, #4, and #6 did not contain the required Nursing Admission Assessment.

Pts #14 and #16's medical records did not contain documentation of collection of admission assessment data related to physical findings obtained by auscultation, palpation, visualization as required by policy.
Pt #14's medical record contained documentation that s/he had "Chronic Health Issues," including Irritable Bowel Syndrome, Ulcerative Colitis, and a history of a bowel resection in '09. In addition, the patient had been "overusing a cough suppressant" prior to admission.

The Director of Nursing confirmed on 6/16/11, that Patients #14 and #16's medical records did not contain documentation of the required admission physical assessment.

Based on review of hospital policy/procedure, medical records, and interviews, it was determined that the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan which addressed patients' medical issues for 10 patients (Pt's #6, 8, 11, 13, 14, 15, 21, 22, 30, and 32).

Findings include:

Review of the hospital policies/procedures titled Shift Guidelines (0700-1930) and Shift Guidelines (1900-0700) revealed: "...RN Charge Nurse Responsibilities...Complete written treatment plans for assigned Consumers. Plan care, direct and supervise others in planning Consumer care. This nursing process includes amending treatment plans for each individual plan of care enhancing the continuity of care. Document Consumer's progress towards Treatment Plan objectives on the Treatment Plan each shift...."

Review of The Guidance Center policy/procedure titled Treatment Planning revealed: "...Treatment planning for consumers in the Psychiatric Acute Care (PAC) Unit is done in compliance with Medicare and JCAHO standards. In addition, the following provisions will be in effect: a. The treatment planning process shall be initiated by nursing staff upon admission to the Inpatient Program. An Initial Treatment Plan shall be relevant to presenting problems and diagnosis...b. The Individual Service Plan shall be initiated by the nursing staff upon admission and further developed by the multidisciplinary treatment team within 72 hours of admission...."

Pt #6's medical record contained documentation that the patient had low blood pressure and dehydration. S/he required transport to a medical center for intravenous fluid replacement. The patient's Treatment Plan did not address any of the documented medical issues.

Pt #8's medical record contained documentation that the patient had hypertension, anemia, and hyperlipidemia. The patient's Treatment Plan did not address any of the documented medical issues.

Pt #11's medical record contained documentation that the patient had a "tooth infection." The patient's Treatment Plan did not address the infection.

Pt #13's medical record contained documentation that the physician diagnosed the patient with a urinary tract infection and ordered an antibiotic. The patient's Treatment Plan did not address the patient's urinary tract infection.

Pt #14's medical record contained documentation that the patient has had "Chronic Health Issues," including Irritable Bowel Syndrome, Ulcerative Colitis, and a history of a bowel resection in '09. In addition, the patient had been "overusing a cough suppressant" prior to admission and the physician documented that the patient "...has detoxed successfully from overdose of unknown cough suppressant...." The patient's Treatment Plan did not address any of the documented medical issues.

Pt #15's medical record contained documentation that the patient had the following medical/health issues: "...hypothyroidism, hypercholesteremia (sic), NIDDM (Non Insulin Dependent Diabetes Mellitus), Glaucoma, left eye corneal abrasion from self-inflicted wound...." The patient's Treatment Plan did not address any of the documented medical issues.

Pt #21's medical record contained documentation that the patient has had the following medical problems: hypertension, Hepatitis B, back pain, and esophogeal erosion. The patient's Treatment Plan did not address any of the documented medical issues.

Pt #22's medical record contained documentation that the patient had the following medical problems: heart disease, hypothyroidism, hypertension, and superficial cuts on arms, and left calf. The patient's Treatment Plan did not address any of the documented medical issues.

Pt #30's medical record contained documentation that the patient had hypertension, seizures, and chronic diarrhea. The patient's Treatment Plan did not address any of the documented medical issues.

Pt #32's medical record contained documentation that the patient had hypertension, Psoriasis, and was "S/P (Status Post) overdose." The patient's Treatment Plan did not address any of the documented medical issues.

The PAC Nurse Manager and the Director of Quality Improvement/Compliance confirmed on 6/17/11, that the documented medical issues were required to be included in the patients' Treatment Plans. They also confirmed that a review of the patients' Treatment Plans revealed that the medical issues were not addressed.

Based on review of hospital policy/procedure, personnel files, and interview, it was determined the hospital failed to ensure that nursing personnel assigned to provide care to patients have received orientation to policies/procedures necessary to perform their patient care responsibilities and have demonstrated competence to perform their patient care responsibilities for 2 of 2 newly hired BHS's who had completed orientation (BHS #14 and #15).

Findings include:

Review of the Guidance Center policy/procedure titled Job Descriptions/Competency Checklists revealed: "...Current approved Job Descriptions and Competency Checklists will be reviewed on a regular basis:...b. At completion of the Orientation Period for newly hired or promoted/transferred employees...c. As part of the annual Performance Review process...."

The Director of Nursing confirmed on 6/16/11, that 2 BHS's hired between April, 2011 and 6/16/11 had completed orientation and are being assigned to provide patient care (BHS's #14 and #15).

BHS #14 was hired 5/2/2011. Review of BHS #14's personnel file revealed that it did not contain documentation that the BHS was oriented to policies and procedures designated as necessary to perform his/her patient care responsibilities. In addition, it did not contain documentation of BHS' #14's competence to perform patient care responsibilities.

The Director of Nursing confirmed on 6/16/11, that BHS #14's personnel file did not contain documentation of his/her orientation to specific policies and procedures designated as necessary to perform his/her patient care responsibilities and did not contain current documentation of BHS #14's competence to perform patient care.

On 6/17/11, the Director of Nursing provided a form titled "The Guidance Center Competency Ealuation (sic) Checklist: Behavioral Health Specialist." The Check List contained BHS #14's name and a list of "Skills" with a column to record a number to indicate a rating of "Level of competence," a column for "Comments/training needs," and a column titled "Supervisor."

Review of the instructions at the top of the form revealed: "...Each Psychiatric Technician is asked to complete the following checklist in order to provide a comprehensive and individualized orientation. We ask that complete (sic) this upon initiation of employment on the PAC Unit so we may provide you with necessary additional skills to meet the needs of our consumerele (sic)...." Several of the spaces in the "Level of competence" column contained "1" (Competent and Experienced). Some spaces contained "2" (Little Experience). Each space in the "Supervisor" column contained initials of the BHS Supervisor. The form was signed by BHS #14 and the "Supervisor" on 6/14/11.

The Director of Nursing and the BHS Supervisor confirmed on 6/17/11, that the form was a self-assessment form and that the Supervisor's signature and initials did not indicate whether the Supervisor had determined competence or what method the Supervisor had utilized to determine BHS #14's competence to perform patient care responsibilities.

Pt's #6, 7, 8, 10, and 11's medical records contained BHS #14's initials, indicating that BHS #14 was assigned to provide patient care for those patients.

BHS #15 was hired 4/12/2011. Review of BHS #15's personnel file revealed that BHS #15 had been employed as a BHS in PAC from 4/06 to 8/09 and as a Discharge Planner from 8/09 until 8/10. S/he was not employed by The Guidance Center from 8/10 until s/he returned 4/12/2011.

BHS #15's personnel file contained an Orientation Skills Checklist dated 10/22/06, signed by the BHS Supervisor, and signed by BHS #15 on 8/30/06. The personnel file also contained a document titled Job Description Competency Assessment Annual signed by BHS #15 on 5/1/09. The Supervisor signed the document and the date 5/1/06 was written by the Supervisor's signature.

The facility has revised a number of policies/procedures and documentation forms in the interim.

The Director of Nursing confirmed on 6/16/11, that BHS #15's personnel file did not contain current documentation of his/her orientation to specific policies and procedures designated as necessary to perform his/her patient care responsibilities and did not contain current documentation of BHS #15's competence to perform patient care.

On 6/17/11, the Director of Nursing provided a form titled The Guidance Center Competency Ealuation (sic) Checklist: Behavioral Health Specialist. The Check List contained BHS #15's name and a list of "Skills" with a column to record a number to indicate a rating of "Level of competence," a column for "Comments/training needs" and a column titled "Supervisor." The instructions at the top of the page were the same as those described above (for BHS #14). All of the spaces in the "Level of competence" column contained "1" (Competent and Experienced). Each space in the "Supervisor" column contained initials of the BHS Supervisor. The form was signed by BHS #15 and the "Supervisor" on 4/27/11.

The Director of Nursing and the BHS Supervisor confirmed on 6/17/11, that the form was a self-assessment form and that the Supervisor's signature and initials did not indicate whether the Supervisor had determined competence or what method the Supervisor had utilized to determine BHS #15's competence to perform patient care responsibilities.

Pt's #6, 7, 8, and 10's medical records contained BHS #15's initials, indicating that BHS #15 was assigned to provide patient care for those patients.

On 6/17/11, a patient in seclusion was reported to be incontinent and required manual restraint for intramuscular administration of medication. All staff are required to assist. BHS #15 was assigned to patient care responsibilities on the PAC Unit on 6/17/11. When asked to locate the Personnel Protective Equipment on the Unit, s/he was unable to do so. In addition, s/he confirmed that s/he received no specific re-orientation to policies/procedures or processes. S/he confirmed that orientation had been "mentioned."

Based on hospital policy/procedure, hospital documents, and interviews, it was determined the facility failed to ensure the patient's protected health information was kept confidential and not released to unauthorized individuals or entities.

Findings include:

Review of hospital policy #IM-101.1 titled "Health Information Confidentiality and Security" requires: "...All...information shall be...confidential...made available only...with the 'Release of Information'...."

Review of the "Authorization To Use and Disclose Protected Health Information" form revealed the form is used as a written consent for release of the patient/client's protected health information. The first blank lines are to be completed with the client's name, date of birth, and social security number. The second line includes: "I authorize The Guidance Center to exchange Protected Health Information with:_____." There are blank lines to be completed for the name of the agency/person/facility and the address of the agency/person/facility to receive the protected information. There is a box on the form for the patient/client to initial stating an understanding of what possible information is being released. The bottom of the form contains a signature line for the patient/client/or personal representative, the date, and a witness signature line. The disclosure form is completed and kept in the medical record, however, there was no release form signed by the PAC patient/client to have their personal health information disclosed to the outpatient facilities nor a signed release form by the outpatient client to have their personal health information disclosed to the PAC unit.

The DON confirmed during an interview conducted on 06/14/11 at 1630 hours, the electronic medical record contains both electronic records from the PAC patient census and the outpatient census (which includes outpatient services in Flagstaff, Williams, Show Low, and Cottonwood). The DON also stated during the interview, all clinical staff at the PAC unit and the Outpatient services have the ability to access protected health information of patients at any of The Guidance Center facilities. The DON also confirmed the hospital has the ability to "sequester" the electronic record of a patient if necessary. This is not a routine practice, but is utilized for specific situations.

The Health Information Management Supervisor and the Quality Improvement Compliance Manager confirmed during an interview conducted on 06/15/11, the patient/client electronic medical record is able to be viewed by clinical staff in the PAC inpatient unit as well as all outpatient locations, whether the patient is receiving services from the specific locations or not.

Based on direct observation, review of patient medical record and interview, it was determined that the hospital failed to require that drugs and biologicals be distributed in accordance with applicable standards of practice, consistent with Federal and State law.

Findings include:

Direct observation of RN #12's administration of medication on 6/17/11, revealed that RN #12 noted that the Depakote 500mg tablets listed on Pt #17's Medication Administration Record were not Extended Release (ER) tablets. The 500mg Depakote tablets in Pt #17's supply of medication located in the medication cart were ER tablets.

Review of Pt #17's medical record revealed medication orders on 6/7/11 at 1515: "...Depakote ER 1500 mg po (by mouth) hs (at bedtime) tonight then Depakote ER 1000mg po q (every) hs thereafter...."

Review of medication orders on 6/15/11, revealed: "...Depakote 250mg po bid X 2 days (twice a day for 2 days) then 250 mg po q AM & 500mg qhs. DC (Discontinue) prior Depakote...."

The Director of Pharmacy confirmed on 6/17/11, that the Depakote orders weren't clarified by pharmacy prior to dispensing.

Based on review of hospital policies and procedures, observation, and interviews, it was determined the hospital failed to ensure that routine preventative maintenance (PM) was performed on the hospital equipment as necessary to protect the safety and well being of the patients.

Findings include:

Review of hospital policies/procedures revealed # EC-601 titled "Medical Equipment Management" requires: "...schedule of preventative maintenance...Frequency...will be established...manufacturer's/vender's criteria...."

# EC-602 titled "Equipment Tagging and Inspection" requires: "...Maintenance Department will tag and inspect...Records are kept...Performance Log and filed in the Maintenance office."

# EC-603 titled "Preventative Maintenance" requires: "...Program directors and staff will inspect...may request assistance from maintenance...Maintenance will develop a schedule...manufacturers' recommendations...Program Director's responsibility...all equipment...is inspected as scheduled...."

The Safety Officer/Trainer revealed during an interview conducted on 6/17/11 at 0800 hours,
the facility's medical equipment was inspected and tested by the nursing staff on the Psychiatric Acute Care (PAC) Unit.

The Nurse Manager revealed during an interview conducted on 6/17/11 at 1015 hours, the facility has five (3) pieces of equipment as follows: 1) blood pressure machine, 2) electro cardiogram (EKG) machine, 3) centrifuge machine. The equipment did not contain preventative maintenance stickers nor was an expiration date documented in a log.

The Nurse Manager also stated the blood pressure machine was approximately three (3) years old. According to a facility invoice, the EKG machine was purchased 05/21/10. The manufacturer, Welch Allyn, was contacted by telephone on 6/17/11, the technical support associate confirmed both pieces are recommended for yearly preventative maintenance.

During a tour of the PAC Unit, the surveyor observed the centrifuge was labeled with a preventive maintenance sticker dated 05/10/07. RN #12 confirmed on 6/17/11, that the nurses place blood specimens in the centrifuge several times a week "to be spun" before being sent to the lab.

The Nurse Manager confirmed during an interview on 06/17/11, the facility did not have a scheduled PM service for the electrical medical equipment nor was the medical equipment tagged for inventory control, according to hospital policies.

Based on review of personnel files, policies/procedures, medical record, direct observation, and interview, it was determined that the hospital failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases and failed to provide an active program for the prevention, control, and investigation of infections and communicable diseases as evidenced by:

(A748) failure to designate an infection control officer who is qualified through education, training, experience, certification and/or demonstrated competence;

(A749) failure to develop a system for identifying, reporting, investigating, and controlling diseases of patients and personnel;

(A756) failure to require that the Chief Executive Officer, medical staff, and Director of Nursing be responsible to ensure that the infection control officer implement an effective infection control program that identifies problems and implements corrective action plans.

The cumulative effect of these systemic problems resulted in the hospital's failure to meet the Condition of Infection Control.

Based on hospital policy and procedure, personnel files, and interviews, it was determined the hospital failed to designate an infection control officer who is qualified through education, training, experience, certification and/or demonstrated competence.

Findings include:

Review of the hospital job description titled Infection Control/BHS; Department: Nursing revealed: "...qualifications and experience required working knowledge, experience in infection control...Skills/Abilities: required: basic principals of epidemiology and the infectious disease process...knowledge cause disease...disease carriers...modes of transportation...host factors...colonization of infection...."

Review of the Organizational Chart revealed Employee #5 is the Inpatient Financial Specialist/Infection Control Coordinator (ICC).

Review of the personnel file of Employee #5 revealed: General Educational Development issued on 02/25/91. Certification in Business Information Management on 10/19/90. Staff Development & Education Log showed 6 hours of Infection Control Coordination Training on 4/5/07. The Job Description/Competency/Performance Assessment for Unit Assistant/Financial Specialist for time period 7/18/09 to 7/18/10 was signed and dated by the employee, the Director of Nursing and the Director of Human Resources in August 2010. No description of content of training was included. The Competence Assessment Ratings were recorded as 3 & 4's. Three (3) = "has demonstrated competence in this area," and Four (4) = "performs independently and can assist others." Overall Performance Rating: "total 218. 219-180 = Satisfactory." There were no competency ratings/check list for ICC position included in the employee's personal file.

Employee #5 confirmed during an interview on 6/17/10, s/he did not have a clinical medical background and only records/documents the data collection.

The Director of Nursing (DON) and the Nurse Manager confirmed during an interview conducted on 06/17/11, that they both work with Employee #5 as a team with the Infection Control Plan, and Employee #5 only inputs data.

Review of the Director of Nursing and the Nurse Manager (NM) personnel files revealed that they did not contain any documentation of specific infection control training, education, or competency evaluation to serve as infection control officers. The job description for DON and NM did not designate any responsibilities/certifications in infection control.

Based on hospital policy/procedure, hospital documents, and interview it, was determined the facility failed to develop a system for identifying, reporting, investigating, and controlling diseases of patients and personnel as evidenced by:

1. failure to report and investigate diseases of patients; and

2. failure to provide readily accessible personal protective equipment for all staff on the PAC Unit.

Findings include:

1. Review of hospital policy/procedure #IC-100 titled "Infection Control Plan" requires: "...Responsibilities of the Infection preventionist...gather and interpret data, and keep accurate records of all infections...investigate...evaluation and follow-up process...."

Review of the Infection Control Log revealed the headings: 1st Quarter through 4th Quarter Fiscal Year. Under the headings there is a listing of the following: 1. the patient (identified by male/female) or employee name, 2. unit or location of department, 3. date (month and day), 4. symptoms and/or diagnosis. The log does not include treatments, notifications, or follow-up process.

Review of Patient #7's medical record revealed the patient is middle aged with a history of alcohol (ETOH) abuse, depression, and with multiple stays at this facility for ETOH detoxification. The patient states s/he has a history of Clostridium Difficile (C. diff) and abdominal cramping. A stool culture was ordered and collected on 05/04/11, and was received at the laboratory on 05/05/11. Results reported on 05/06/11, at 2123 hours were negative.

Review of the infection control log revealed no input for Patient #7 regarding possible infection, diagnosis, cultures, detection, etc.

The ICC stated during an interview conducted on 0617/11 at 1430 hours, possible infections for either staff or patients are reported to her/him by telephone or e-mail. The ICC participates in morning treatment rounds, Monday through Friday and takes notes. The ICC also stated, s/he was aware of the possible infection of Patient #7, however, s/he forgot to enter the data in the log. In addition, the ICC stated that s/he did not know what C. diff was, but would ask a nurse.

The Director of Quality Improvement/Compliance confirmed during an interview conducted on 06/17/11, the ICC failed to include the possible C-diff infection in the infection control log.

The Director of Nursing stated during interview on 6/17/11, that she and the Infection Control Coordinator work as a team for infection control surveillance, prevention, monitoring, etc. However when asked to describe the specific system for surveillance or criteria utilized for reporting, she stated that any personnel can contact the Infection Control Coordinator by phone or E-mail. Neither the Director of Nursing nor the Infection Control Coordinator could describe the specific data or patient related issues that personnel are to be alert to which require notification to the Infection Control Coordinator.

2. Review of The Guidance Center policy/procedure titled Infection Control Plan revealed: "...Strategies to Minimize, Reduce and Eliminate Risks for Infection...Implementation of Standard Precautions and the proper utilization of Personal Protective Equipment (PPE)...."

Review of The Guidance Center policy/procedure titled Universal Precautions revealed: "...Barrier supplies shall be utilized to eliminate or minimize exposure to or transfer of infection. The general rule regarding blood and other body substances shall be: if it is wet, wear gloves; if it can splash, spurt or splatter, wear a gown, mask, and eye protection...."

During direct observation of patient care on the PAC Unit on 6/17/11, the surveyor observed that the PPE equipment was located in the locked medication room. RNs #12 and 13, and BHS #15 were unable to locate any other PPE equipment which would be readily available to patient care staff who are unable to unlock the medication room.

The Director of Nursing confirmed on 6/17/11, that the only PPE equipment for the PAC Unit is located in the locked medication room.

Based on review of hospital documents and interviews, it was determined that the hospital failed to require that the chief executive officer, the medical staff, and the director of nursing ensure that the infection control officer implement an effective infection control program and be responsible for identifying problems in the program and implement corrective action plans.

Findings include:

Review of the Quality Improvement Committee Agenda revealed that Infection Control Reports are quarterly agenda items.

The Director of Quality Improvement/Compliance provided the monitors which comprise the Infection Control Report. The Director of Nursing reports the Infection Control monitors to the Quality Improvement Committee. The Director of Quality Improvement was unable to provide information regarding the data included in the monitors i.e., methods of surveillance; how data is systematically gathered; criteria used to alert staff to the need for reporting information to the Infection Control Coordinator. The Director of Quality Improvement acknowledged that s/he was not aware that neither the designated Infection Control Coordinator nor the members of the Infection Control Team possess documented Skills/Abilities listed as Position Requisites of the Infection Control Coordinator.

Cross reference Tags A748 and A749.