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Based on document review, policy review and interview, the facility failed to provide a written response to patient grievances for 6 of 15 patients ( #48, #49, #51, #52, #53, #57) . Findings include:

During interview with staff K on 02/01/2011 at 1100, it was determined that the facility did not send out a written letter of resolution for resolving the above grievances. Patient #48 had a "complaint" that was submitted on 12/22/2010 as of 02/01/2011 the patient had not been sent a letter of resolution.
Patient #49 had a "complaint" that was submitted on 10/27/2010 as of 02/01/2011 the patient had not been sent a letter of resolution as of 02/01/2011. Patient #51 had a "complaint" that was submitted on 12/22/2010 as of 02/01/2011 the patient had not been sent a letter of resolution. Patient #52 had a "complaint" that was submitted on 11/18/2010 as of 02/01/2011 the patient had not been sent a letter of resolution. Patient #53 had a "grievance" that was submitted on 12/28/2010 as of 02/01/2011 the patient had not been sent a letter of resolution. Patient #57 had a "grievance" that was submitted on 10/13/2010 as of 02/01/2011 the patient had not been sent a letter of resolution.
Review of policy for Munson Health care titled Grievance Management & Review Process Policy ID # 042.010 approved 06/08/2010 reads on page 2 under Definitions: Complaint: "A concern or issue from a patient, or a patient's designated representative, about the care and/or services provided by MHC that can be promptly resolved by staff present at the time of the complaint..." Under the grievance definition it reads " If a patient care complaint cannot be resolved at the time of the complaint by the staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint becomes a grievance." The policy goes on to read on page 3 under section titled grievance management Process: #2 "The investigation and preliminary response will usually occur within 7 working days of receipt. If this is not possible, the Patient Liaison will contact the complainant, explain the delay, and provide a timeframe within which a written response may be expected, usually within 30 days" and under #4 "All grievances will be closed with a written response..."

Based on observation, interview and record review, the facility failed to develop care plans for 2 of 2 patients in isolation (#27, #29) and for 3 of 7 psychiatric unit patients (#43, #54, #55) with significant health problems. Findings include:

On 1/31/11 at approximately 1430 patient #43's clinical record was reviewed with the Director of Behavioral Health. Patient #43's History and Physical, dated 1/17/11, noted a diagnoses of Psychogenic Polydipsia and Chronic Hyponatremia. A handwritten patient information board, in the unit charting room, indicated that patient #43 was on a fluid restriction. This observation was confirmed by the Director of Behavioral Health. On 1/31/11 at 1445, staff nurse II described interventions used to limit patient #43's unsupervised access to fluids. At approximately 1500 staff HH stated that he was aware of the physician's order to restrict patient #43's fluids. The patient's Master Treatment Plan revealed no documentation related to polydipsia or fluid restrictions. Further record review revealed no care or treatment plan addressing the patient's polydipsia. This finding was verified by the Unit Director.

On 2/2/11 from 1400-1700, review of patient #54's clinical record revealed a History and Physical dated 11/7/00 that states: "the patient also has a history of self-injurious behavior...If not monitored, he reportedly will drink fluids to excess." A fluid restriction (64 ounces/day) was ordered on 11/7/10. Neither the Master Treatment Plan, or other care plan in the patient's record, addressed fluid restrictions. These finding were verified by the Director of Behavioral Health on 2/3/11 at approximately 1000.

On 2/2/11 from 1400-1700, review of patient #55's clinical record revealed a History and Physical dated 11/24/10 that states: "CMH (Community Mental Health) was in and evaluated the patient." The evaluation by CMH, dated 11/24/10, states: "sleep apnea-uses C-PAP." A C-PAP was ordered on 11/24/10 and reordered on 11/30/10. The 11/30/10 order states: "Patient may use hospital loaner. Patient unable to get his unit from home." Neither the Master Treatment Plan, or other care plan in the patient's record, addressed use of the C-PAP. These finding were verified by the Director of Behavioral Health on 2/3/11 at approximately 1000.

Facility policy 070.002, dated 9/27/10 states: Nursing care will be planned and delivered based on documented assessment of the patient's needs. Goals will be established with the patient when able, and the patient's progress towards the goal(s) will be tracked and documented." Policy 070.P032, #20, 12/24/09, states: "Plan of Care: Documented on admission and q (every) shift by an RN." Mental Health Unit Policy 099.007, dated 11/13/08, states: "The master treatment plan will be formulated by a multidisciplinary team within three (3) days"..."The planning process shall contain...specific patient problems...and treatments." "The plan will identify any restrictions or limitations of the patient's rights and include documentation describing attempts to avoid such restrictions as well as what actions will be taken as part of the plan to eliminate the need for restrictions in the future. Documentation will be in the Changes to treatment section of the Treatment Plan."






29313

During an initial tour of the A7 Unit, Stroke/Telemetry Unit, on 2/1/11 at approximately 1115 it was found during medical record review that patient # 27 was ordered to be on contact isolation precautions. The patients medical record didn't have documented education and teaching of the patient in regards to contact isolation precautions.
This finding was confirmed by staff member FF.

During an initial tour of the C3 Unit, Women's Health/Pediatrics, on 2/1/11 at approximately 1525 it was found during medical record review that patient # 29 was ordered to be on contact isolation precautions. This patient was an infant, but the medical record had no documented family education and teaching in regards to contact isolation precautions.
This finding was confirmed by staff member EE.

During policy and procedure review on 2/2/11 at approximately 1100 the policy titled, "Isolation Precautions and Standard (Universal) Precautions", states, "Procedure for Isolation... 3. Patient Family Education-Instruct the patient and family when transmission base precautions will be used. Nursing has the primary responsibility for patient teaching in the inpatient areas. A sign indication the appropriate type of precaution will be placed on the patient/resident's door by the nursing staff to alert visitors to receive instructions before entering the room".

Based on interview, medical record review and policy and procedures, it was determined the facility failed to ensure that all discharged inpatient's medical records were complete, including an authenticated signature from the attending physician within 30 days following discharge.
Findings include:

During an interview, and record review with staff members AA and BB on 2/2/11 at approximately 1000, it was identified there were 117 incomplete medical records that were awaiting signatures from the physician 30 days following the patient's discharge from the hospital.
During policy and procedure review on 2/2/11 at approximately 1500 the policy titled, "Medical Record Completion", states, "Records will not be delinquent greater than 30 days after discharge."

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.

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 9, 2011 for Life Safety Code.

Based on observation and interview the facility failed to ensure that the facility, supplies, and equipment were maintained to ensure an acceptable level of safety and quality. Findings include:

During the initial tour of the Intensive Care Unit on 01/31/11 at 1230 it was determined that the following supplies were outdated and remained available for patient use on the unit:

1- " High " Blood Glucose Control Solution Bottles with the date 10/28/10 written on the side.
1- " Low " Blood Glucose Control Solution Bottles with the date 10/28/10 written on the side.
1- 26 gauge spinal needle that expired on 06/09.
1-22 gauge spinal needle that expired on 05/09.
1- vacutainer for blood draws that outdated on 01/09.
1- vacutainer for blood draws that outdated on 01/09.
11- Tracheostomy Starter Kits that outdated on 04/08.
16- Endo-tracheal Replacement Catheters that outdated on 03/08.

The " Inter-cranial Pressure " monitoring cart contained one (1) 50cc bag of normal saline that outdated on 01/01/11.

During policy review on 02/02/11 at 1600 of the policy titled " Point of Care Policy regarding dating of reagents and controls " the policy states that " ... 3 months or the manufactures expiration date ... "

The Resource Clinician for the Intensive Care Unit confirmed these findings during the initial tour on 01/31/11.



13069

Based on my observation of the facility during my walk through of the Radiology Suite, X-Ray rooms it was noted that the x-ray control button/device cord was long enough to allow the radiologist (staff) to reach into the room with the control in hand that could accidently be pushed and triggering the staff to be exposed to radiation. The head of the radiology suite was informed of the proposed danger and a request was put in place to have the device/push button control be fixed to the control table.

Staff safety is a must as well as the patients in a typical health care facility.


29774

On 1/31/11 during a tour of B-4 at approximately 1350 two B-D bactec blood culture bottles with expiration dates of of May 2010 were found and were available for patient use. Additionally in the medication refrigerator, of the same unit, three sealed packets of racepinephrine inhalation were found with a manufacturer's expiration date of June 2010. Interview of staff W reveals that these should have been discarded with the monthly check of outdated supplies. When asked for the policy for frequency of checking for outdated supplies, none could be produced. On 2/3/2011 at approximately 1230 review of policy titled "Return/Transfer of Medications to Pharmacy- MMC" states "All medication shall be returned to the Pharmacy in the following situations:... Medications become outdated or expired.."

On 1/31/2011 during facility tour of A-4, at approximately 1500 in the room labeled "soiled utility" a recently emptied large trash collection bin lined with a large plastic bag had residual garbage, a face cloth, and used gloves remaining in the bottom, a reddish liquid material was also present, and when the plastic liner was moved, a strong odor was detected. Interview with staff K regarding the frequency of cleaning of the soiled trash collection bins reveals unknown cleaning frequency or cleaning policy. Staff K confers regarding the strong odor presence and need for immediate cleaning. When asked for a general policy on cleaning trash collection bins on 2/2/2011 at approximately 1600, none could be produced.

On 1/31/11 at approximately 1520 during tour of A-4 an Intravenous Pump (IV) was found plugged in and ready for patient use in room A4523. The IV pump had residual paper tape on the front of the pump and residual stains on the face of the pump. Interview with staff Y confirms that the pump is soiled and is in need of reprocessing before patient use. Staff Y states that usually the IV pump is placed in the soiled utility room where the pump is cleaned and returned to the patient care room, ready for use. Review of policy titled "Isolation Precautions and Standard (Universal) Precautions" reveals that "Patient/Resident Care Equipment"Ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed..."

On 1/31/2011 at approximately 1530 during a tour of B-3 South, a recliner chair in room 3340 was found to have both armrests with upholstery tears. Interview with staff S reveals that upholstery tears when found are usually reported and replaced. Staff S agrees that this surface cannot be adequately cleaned until the armrests are reupholstered however, "a sheet is always placed between the patient and the chair's surface". When asked for a policy regarding the inspection and process for reporting tears in upholstery, on 2/2/201 at approximately 1630, none was provided.

On 1/31/2011 at approximately 1530 during a tour of B-3 South, two common shower rooms were found to have stacked uncovered clean bath towels, hand towels and face cloths stored on a bench in each common shower room. Interview with staff S reveals that this is most handy for patients needing additional towels. She was unaware of the risk of splatter and spray contamination between patients using the shower room. Staff S indicated that she would remove all linen storage in the common shower rooms and dispense towels to each patient using the common shower room. When asked for a policy regarding the storage of clean linen, on 2/2/201 at approximately 1630, none was provided.


28273

During observation of the B 4 unit on 01/31/2011 at 1415 with staff X, the pantry area was noted to be very dirty. The cupboards above and below the coffee maker and two drawers had coffee grounds spilled in them. All of the insides of the cupboards needed to be cleaned. The drawer nearest the door had a thick yellow substance that could be scraped off with the end of an ink pen. When this writer queried staff X as to whose responsibility it was to clean the area she replied that all staff are supposed to clean up any spills and if further cleaning is needed they are supposed to contact housekeeping. During observation on the B3 south unit with staff T on 01/31/2011 at 1600, an unsecured area identified as the "Soiled Holding" room was noted to contain eight spray bottles labeled as Sani-Master. Label information and Material Safety Data Sheet obtained from and reviewed with staff F both state "Keep out of reach of children" and "May be fatal if inhaled." Staff F confirmed that the product needs to be stored in a secured area.

Based on observation and interview during the walk through of the facility with the VP operation, Infection control officer, and Plant operation Manager the followings were observed;

Floor fans at various locations including but not limited to soiled room serving the ICU, patient room 3011 in B-3 North, and patient room 3024 in B-3 East.

Any type of fan use is an indication of improper or insufficient ventilation. Proper ventilation shall be provided to allow for proper air changes, patient and staff comfort, and minimize on infections.

Based on observation and interview during the walk through with the Plants Operation Manager and the Infection Control Officer the followings were noted:

1. High dusting was observed on top of C-Locker and sloped top in NICU area;
2. Lints and dirt collected on ventilation grilles, ceiling tiles, and curtain rails in both Triage assessment #1 and #2 rooms;
3. Access door, door frame, and wall leading to clean utility room serving the maternity suite;
4. exhaust grille serving the ICU clean utility room;
5. Tape used on the surface of the blanket warmer for posting a note in the ICU area;
6. Clean linen cart with exposed linen left wide open in the alcove space serving B-3 North wing;
7. The typical ice water dispensing ports exhibited with built-up in the typical pantry serving the Emergency Department and the A-2 floor.; and
8. Staff boots, coats, and other belongings are placed in the clean utility room serving the ultrasound/radiology suite on the first floor of the facility.

An immediate attention was requested to address the above items to provide a safe and healthy environment.

Based on document review and interview, the facility failed to disclose a financial interest in its home care agency. Findings include:
Document provided by staff J on 02/03/2011 at 1100 titled Michigan Home Care Agencies Listed By Counties revealed a listing given to patients who may be in need of home care. The list contained under Antrim, Benzie, Charlevoix, Crawford, Gladwin, Grand Traverse, Kalkaska, Lake, Leelanau, Manistee, Mason, Mecosta, Missaukee, Montmorency, Ogemaw, Osceola, Oscoda, Roscommon and Wexford counties the name "Munson Home Care." The document did not contain a disclosure of ownership/financial interest between Munson Heath Care and the home care agency Munson Home Care. During interview with staff J at the time of the document review this surveyor asked her how this information (ownership/financial interest) was conveyed to patients and /or their representatives She stated that they know by the name "Munson."

Based on observation during the walk through of the surgical suite on Thursday February 3, 2011 around 1:00 PM with the Plant Operation Manager it was noted that the facility failed to promote proper infection control practices. Findings include:

There are mirrors by each of the scrub sinks outside each operating room. When further investigated it was determined that the mirrors were placed for all male staff to properly cover their beard. The surgical suite supervisor was notified that the mirrors must be placed at the point where the staff start the scrub process and proceed with the proper scrubbing at the scrub sinks and not to touch any thing after scrubbing their hands. The Infection Control Officer was notified after joining our team during the survey date.