HospitalInspections.org

Based on document review and staff interview, the Hospital failed to include services provided under contract or arrangement in the Quality Assessment and Performance Improvement plan (QAPI).

Findings include:

- The QAPI program, QAPI quarterly reports from 2010-2011, and the provided Hospital contract service list reviewed on 11/16/11 at 10:45am revealed the Hospital QAPI program lacked the inclusion of all patient care contract services. For example, the following contracts not included in the Hospital QAPI program include; LTAC of Wichita (provides blood products), American Health Lab (stat laboratory testing), American Red Cross (blood products), Aramark (hospital linen), and LaCosta (janitorial maintenance service).

- Staff J interviewed on 11/16/11 at 10:50am acknowledged the Hospital failed to include all patient care contract services in the QAPI program.



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Based on document review and staff interview, the Hospital failed to include services provided under contract or arrangement in the Quality Assessment and Performance Improvement plan (QAPI).

Findings include:

- The QAPI program, QAPI quarterly reports from 2010-2011, and the provided Hospital contract service list reviewed on 11/16/11 at 10:45am revealed the Hospital QAPI program lacked the inclusion of all patient care contract services. For example, the following contracts not included in the Hospital QAPI program include; LTAC of Wichita (provides blood products), American Health Lab (stat laboratory testing), American Red Cross (blood products), Aramark (hospital linen), and LaCosta (janitorial maintenance service).

- Staff J interviewed on 11/16/11 at 10:50am acknowledged the Hospital failed to include all patient care contract services in the QAPI program.

The Hospital identified a census of 41 patients. Based on observation and staff interview the Hospital failed to maintain a clean and usable refrigerator/freezer in the Pyxis Medication Administration system. for 2 of 2 systems observed which contained refrigerator/freezers (T3 and T4 nursing units).

Findings include:

- Observations made and tour of the facility's T4 hall, on 11/14/11 at various times and on 11/15/11 from 3:02pm through 4:20pm revealed multiple unclean areas as follows:

Tour of the T4 hall medication room, on 11/14/11 at various times and on 11/15/11 from 3:02pm through 4:20pm revealed a Pyxis (Medication Administration Control System) which contained a refrigerator/freezer with the freezer area door frozen shut due to a 1.5 inch build up of ice around the entire perimeter of the freezer. The bottom shelves of the Pyxis, inside the machine, contained a bottle of Aquasonic ultrasound gel, turned over on its side with a buildup of orange colored substance underneath and around the bottle and the refrigerator 1.5 inches wide by 1 foot long. The inside of this refrigerator contained a build up of white crystallized substance which measured 1 inch wide by 6 inches long. The 2 bottom solid shelves inside the Pyxis contained a build up of brown, yellow, and white substances.

Licensed Pharmacist B interviewed on 11/16/11at 1:03pm, stated the freezers in the Pyxis machines contained no medications, that the unit nursing staff were to notify Pharmacy when the freezers needed defrosted and cleaned.

On 11/15/11 at 5:00pm a request was made for Hospital policies addressing cleaning duties and responsibilities by departments other than Housekeeping. The Hospital failed to provide this information.

- Observation of the Pyxis on the T3 hall on 11/16/11 at 8:05am revealed a refrigerator/freezer for medication storage with a 1 inch thick build up of ice around the walls of the freezer portion.

The Hospital identified a census of 41 patients. Based on observation and staff interview, the Hospital failed to ensure outdated and unusable drugs not available for patient use in the Dialysis Storage room, Rhythm Central (heart monitoring unit), and the Conference room on the T4 unit.

Findings include:

- Observation on 11/14/11 at 2:58pm and 11/15/11 at 11:10am of the dialysis supply store room contained a cabinet with a partially used multidose bottle of Heparin, 1000 Units/milliliter concentration, labeled with patient #33's name, and labeled as opened on 10/23/11. Licensed Staff C interviewed on 11/15/11 at 11:10am verified this patient was dismissed from the Hospital on 10/24/11. This medication remained available for staff use for 22 days after patient dismissal from the Hospital. Dialysis Management Licensed staff D interviewed on 11/15/11 at 10:57am verified this medication remained available for patient use and the staff should have removed it from the cart after dismissal of this patient.

Observation on 11/15/11 at 1:55pm of a room identified as Rhythm Central (heart monitoring unit) contained a cabinet, inside the open door, which contained multiple 5 milliliter ampules of 1% Lidocaine in a clear plastic measure container, 7 expired 6/1/11, 2 expired 5/08 and 3 expired 2/1/11. Licensed Nursing staff A interviewed on 11/15/11 at 1:55pm verified the medications available for patient use.

- During tour of the Hospital, on 11/15/11 at 2:30pm, a drawer which lacked the capability of being locked, in the conference room, contained 3 Intravenous bags with the patient names torn off, but labeled with the drug name. One (1) contained Zithromycin 500 milligrams (mg), another Bumetanide 0.25 mg, and another Amiodarone (amount not distinguishable). This drawer also contained a 100 milliliter bottle of Novolin R Insulin. Licensed Nurse A stated this room remained unlocked during the day.

The Hospital identified a census of 41 patients. Based on observation, staff interview, and document review, in the room of inpatients #32, 24,and 25, 1 of 4 satellite nursing stations observed and empty patient room #464 on the T4 unit and empty patient rooms #323, #324 and the Dialysis storage room on the T3 unit, and in 1 of 3 Medication rooms observed, and chair guard and hand rails throughout the T4 unit, the Hospital failed to maintain a clean environment.

Findings include:

- The Hospital contract for Housekeeping services, reviewed on 11/16/11, documented the contracted service planned to provide labor, material, equipment and supervision to provide professional housekeeping services to maintain the cleanliness of the Hospital.

Observations made and tour of the facility's 400 unit hall, on 11/14/11 at various times and on 11/15/11 from 3:02pm through 4:20pm revealed multiple unclean areas as follows:

(1) The medication room on the 400 hall- On both sides and behind the computer portion of the Pyxis (Medication Administration Control System) multiple syringe caps, papers, dust, and empty oral medication individual dispensing packs covered the floor from the back against the wall to the front of the machine. A 1 foot by 1 foot area behind this part of the machine contained multiple yellow-orange dried splatters. The wall beside the metal preparation table 1 foot by 1 foot area contained multiple yellow-orange splatters. The outside doors of the Pyxis machine drawers contained 20 red-brown streaks which spanned from the top to the bottom of that portion of the machine.

(2) On 11/14/11 at 3:42pm the floor of the room of inpatient #32 contained dried food particles, both loose and adhered to the tile of the room.

(3) On 11/15/11 at 2:47am observation in the Dialysis equipment storage room revealed a NxStage machine with 3 streaks of dried reddish-brown liquid, 6 inches long, on the left outside wall of the machine. This machine also had white crusted substance inside the machine and on the metal pole which held the unit. Interview with Dialysis Management Licensed staff D verified this machine last used on 10/28/11 and staff should have cleaned the equipment thoroughly prior to storage. On 11/14/11 at 3:10pm Licensed Dialysis staff member E, verified the unclean machine and stated Dialysis staff usually clean the equipment when they put it in and out of storage.

(4) On 11/14/11 at 3:12pm observation in the Dialysis equipment storage room revealed flat surfaces, which included the entire length of the light fixture, tops of cabinets, window ledges and chair rail, contained a build up of dust. Environmental Services staff F, interviewed on 11/14/11 at 3:35pm identified Dialysis staff as responsible for cleaning this area. On 11/15/11 Dialysis Licensed staff D identified the Hospital housekeeping staff as responsible for cleaning this room.

(5) On 11/15/11 2:35pm a satellite nursing station on the T4 unit had a pair of wadded up gloves with paper stuck to them on the top shelf of the cabinet. The very top flat surface of the cabinet contained a build up of dust. The floor underneath this station contained a 3 inch diameter of dried brown spilled substance. A housekeeping closet in the same hall as this satellite nursing station contained an area 4 foot high up the wall and 2 inches out from the cove base which had red rusty substance.

(6) On 11/15/11 at 2:50pm room #464, identified by Licensed A as cleaned and ready for another patient admission, contained a 3/4 inch long by 1/8 inch wide area of red dried substance on the wall and another 1/4 inch diameter area of red dried substance. The windowsill, ledge, and chair rail along the perimeter of the room contained a build up of dust. A patient recliner in this room contained dried food particles and 2 areas of blackened raised dried substance, each measured 1/2 inch diameter. When these areas shown to Licensed staff A, staff A stated "that's gross." Upon removal of the blankets from the identified patient ready bed the mattress contained a deep crease folded over on itself and remained wet from cleaning. This mattress contained hundreds of dried white flakes between the mattress and the sheet, verified as remaining after cleaning by Licensed Nurse A. Nurse A stated the flakes could be remaining dried skin cells from the former patient.

(7) On 11/14/11 at 1:35pm the room of sampled patient #24 contained an area 1 foot long by 1 foot wide with multiple dried orange colored splatters. The floor of this room contained a buildup of dried food particles and on top of the Oxygen concentrator unit rested 2 used and dried washrags and dried used paper towels.

(8) On 11/14/11 at 12:20 the floor of patient #25's room, beside their recliner, contained a tater tot and dried lettuce, multiple 1/4 to/1/2 inch areas of dried yellow food substance, dust on the light fixtures, chair rail, windowsills, and hanging picture. A wall in this room also contained a 1 inch long dried red streak on the wall. At 12:40pm housekeeping personnel entered this room and mopped the floor after staff brought to their attention of the dried food on the floor. After Housekeeping finished and left the floor, the tater tot, dried lettuce and part of the dried yellow food remained on the floor beside the patient recliner. Licensed Nurse K verified Housekeeping left the food on the floor and failed to wipe up the dried red substance from the wall and stated Housekeeping failed to thoroughly clean frequently. On 11/15/11 at 10:22am Housekeeping Supervisor staff F verified the tater tot and dried lettuce and yellow substance remained on the floor of this room. Staff F further verified the red streak on the wall and dust on the flat surfaces and stated they needed to retrain staff. Licensed staff L interviewed on 11/15/11 at 10:40am verified patient #25's evening meal on 11/13/11 pm contained tater tots and tossed salad. The fried and loose food was on the patient's room floor since then.

(9) 50 feet of chairguard and handrail throughout the T4 unit contained a build up of dust in plain site when walking through the halls. The bottoms of 3 of 4 Mobile Nurse Computer holders contained a build up of dust and dried white substance.

- Observation of patient room #323 on 11/15/11 at 8:30am revealed a room ready for patient occupancy. The window sill and overbed light contained a visible build up of dust.

- Observation of patient room #334 on 11/15/11 at 8:35am revealed a room ready for patient occupancy. The window sill contained a visible build up of dust.

The Hospital identified a census of 41 patients. Based on observation and staff interview, the Hospital failed to maintain clean Radiology equipment and ensure cardiac tracing electrodes within manufacturers end use date.

Findings include:

- On 11/15/11 at 2:20pm the Rhythm Central room contained 48 patient electrocardiogram electrodes, which lacked identification of their expiration date. This room also contained a Betadine swab which expired on 12/08 and a statlock Intravenous sanitation and security set which expired on 2/09. Staff member H, on 11/15/11 at 2:15pm verified the Hospital staff took the electrodes out of their pouches which contained the expiration date and put in the drawer "for convenience." Staff H verified lack of knowledge of the manufacturers expiration date of the electrodes. Another drawer in this same room contained 60 of the electrodes outside of the package with no way to check for an expiration date. Staff G verified the drawer contained electrodes stored outside of their package and stated the staff should not store them like that.

On 11/15/11 at 1:40pm and again at 2:20pm a piece of portable radiology equipment sat in the hall between the T3 and T4 units. The surfaces of this equipment contained a build up of dust. Maintenance staff member I, on 11/15/11 at 1:40pm stated the Radiology staff as responsible for cleaning this equipment. The windowsill in the hallway beside this dusty piece of equipment also contained a build up of dust.