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Based on record reviews and staff interview, the Hospital failed to ensure the Grievance Procedure was implemented. Findings include:

The Hospital Policy titled: Patient/Parent/Legal Guardian Grievance Procedure was approved in July 2011. The procedure noted it was the policy of the hospital to provide recourse should patients and/or parents/legal guardians feel their rights had been infringed upon or denied. The procedure indicated that the Patient Advocate had the responsibility for responding to complaints in the appropriate time frames and for maintaining confidentiality to the extent possible. Additionally, the Patient Advocate was responsible for providing a written response to the patient or parent/legal guardian regarding the results of the review within 10 business days.

Per review of the Hospital's complaint log, patients and parents had filed grievances during 2013. Examples of grievances included the following:

a. Parents raised concerns regarding the feeding of their child in January 2013.
b. A parent raised concerns regarding an event when the child turned blue in April 2013.
c Parents complained regarding the operating room schedule in June 2013.
d. Parents raised concerns regarding respiratory care of a child with a tracheostomy in December 2013.

On 1/23/14 at 9:00 A.M.. the Vice President of Performance Improvement and Safety was asked to provide copies of the written responses to above grievances for surveyor review. At 2:30 P.M., the Vice President of Performance Improvement and Safety returned and said that the Patient Advocate would always speak with the complainant; however, written responses had not been given. The Vice President of Performance Improvement said the written responses would be provided in the future.

According to the CPNP Guidelines "The Medical and Nursing administrative staff of the Franciscan Hospital for Children i.e. Medical Director and Chief Nursing Officer, will initially review and approve the guidelines under which the nurse practitioner proposes to practice."

Based on a review of the hospital's Organizational chart for nursing services and the hospital policy for credentialing of Nurse Practitioners and an interview with the Chief Nursing Officer (CNO) , the hospital failed for 2 of 2 nurse Practitioners to ensure that the CNO reviewed the credentialing files for the Advanced Practice Nurses.

Findings include:

The Review of the Organizational Chart for Nursing Services did not include that Nurse Practioners report to the CNO. The CNO revealed during interview on 1/16/14 at approximately 2:00 P.M. that she does not approve the delineation of duties for these nurses and they do not report to the CNO.

According to the Hospital's Guidelines for Nurse Practitioners it is quoted that "the Medical and Nursing administrative staff of the Franciscan Hospital for Children i.e. Medical Director and Chief Nursing Officer, will initially review and approve the guidelines under which the nurse practitioner proposes to practice."

The Credential Files for the evaluation and delineation of duties for Certified Pediatric Nurse Practitioner (CPNP), the Credential files for both CPNP #1 and CPNP#2 were reviewed.
The guidelines for CPNP# 1was signed by the Medical Director but not by the CNO, as indicated by the Hospital's Advance Practice Nurse Policy Guidelines.

The evaluation and delineation of duties for CPNP#2 were reviewed and signed by the Medical Director. The CNO had not signed the evaluation for CPNP#2 as indicated by the hospital's Guidelines for Nurse Practitioners. According to the CPNP Guidelines "The Medical and Nursing administrative staff of the Franciscan Hospital for Children i.e. Medical Director and Chief Nursing Officer, will initially review and approve the guidelines under which the nurse practitioner proposes to practice."

Interview with the Chief Nursing Officer (CNO) at approximately 2:00 P.M. on 1/ 16/14 revealed that the CNO does not evaluate the CPNP. Policy review and review of 2 credentialing files for 2 Nurse Practioners, (CPNP), indicated the hospital failed to ensure that the CNO does initially review and approve along with the Medical Director, the credentialing files for the Advanced Practice Nurses.

Based on record review and staff intervew, the facility failed to ensure Nursing Care Plan's were developed and kept current as required for 2 Patients, (# 23 and # 28).

For Patient #23 and Patient #28, the Hospital failed to ensure Nursing Care Plans (NCP) were updated according to Hospital policy titled Standards of Nursing Practice, dated 11/2011. The failure to update the NCP diminishes accurate and timely communication of patient care needs.

The Hospital policy titled Standards of Nursing Practice, dated 11/2011, indicated:

1.) the professional nurse would initiate an accurate and ongoing assessment of patient physical and psychological problems to establish a nursing diagnosis,
2.) nursing assessment included continuous information collection to establish and prioritize patient problems,
3.) patient information was continually updated as patient conditions changed,
4.) the professional nurse would formulate a comprehensive nursing care plan and implement nursing interventions utilizing appropriate scientific principles and current nursing knowledge to achieve realistic patient centered goals and
5.) nursing actions and patient's responses are evaluated for effectiveness in meeting patient goals.

A.) For Patient # 23, review of the electronic medical record (EMR), dated 1/14/14 at 1:21 A.M., indicated that a nurse medicated Patient #23 for teething pain.

Review of the EMR (Patient #23) dated 1/14/14, 1/15/14, 1/16/14 did not indicate a nurse updated Patient #23' s NCP, to include teething pain.

During interview on 1/15/14 at 10:30 A.M., with the Nurse Manager (NM) #1 said that the nurse, caring for the patient, should have updated the patient's NCP.

B.) For Patient # 28, review of the EMR, History and Physical, dated 1/15/14 indicated Patient #28 was admitted to the Hospital with apnea (stop breathing) and bradycardic (slow heart beat) episodes.

Review of the EMR (Patient #28) dated 1/16/14 did not indicate a nurse included apnea and bradycardic as patient problems in a NCP.

During interview, on 1/16/14 at 2:00 P.M., the Nurse Manager (NM) #1 said that the nurse, caring for the patient, should have included apnea and bradycardia in the patient's NCP.

Based on observation, review of documentation and interview, the Hospital failed to ensure that the equipment and the environment in the Hospital's Food Storeroom, Preparation Area, Dishmachine Area and Condiment Storage Area and equipment in the Rehabiltiation Department were maintained to ensure safety and quality.

Findings include:

On 1/15/14 at 10:30 A.M. during the tour of the Main Kitchen, the Surveyor accompanied by the Food Service Director observed the following:

a.) In the Food Storage Room:

--The surfaces of the shelves holding cans of food were in poor condition with rusted surfaces which prevented cleaning of the shelves.
--The window in the storeroom had cracked paint around the edges and a cracked window pane. Cobwebs were visible across the window.
--The walls at the entrance to the room had peeling paint on the left and missing wall tiles on the right.
--The storeroom door had a worn surface.
--The reach-in freezer outside the food storeroom had a loose handle.
--A reach-in Refrigerator outside the food storeroom had a torn gasket.
--The floor was worn and scraped throughout the food storeroom.

During an interview at this time, the Food Service Director said that the floor in the storeroom had been redone approximately two years ago.


b.) In the Preparation Area:

--The floor and the wall behind the the ovens and steamer were dusty and dirty.
--The electrical cords behind the convection oven were laden with dust.

Review of the "Kitchen Cleaning Schedule" indicated that these areas were not included on the cleaning schedule.


c) In the Dishmachine Area:

--The wall mounted fan directed at the dishmachine was laden with dust.

Review of the "Kitchen Cleaning Schedule" indicated the fan was not included on the cleaning schedule.


d) In the Condiment Cabinet Storage Area:

--The floor was paint worn throughout the area.
--The floor corners were dirty.
--A window was boarded up with rotted wood.
--The back door to the outside was not pest proof. A gap between the bottom of the door and the floor was visible. Some leaves were seen in the area and three snap traps were observed.


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e.) Observation, on 1/17/14 at 2:00 P.M., during a tour of the Rehabilitation Service Department, 3 floor exercise/therapy mats and 1 treatment table upholstery had breaks in the integrity of the material (cracks) and 4 activity chairs and 1 stool had worn varnish. Exposed Intercom wires were in a treatment room, the base of a toilet in the bathroom was cracked and in a patient treatment room, a Symmetry Posture Chart was not secured to a wall, leaving bolts exposed.

During Interview on 1/17/14 at 2:00 P.M., the Occupational and Physical Therapy Director said that the intercom was no longer used.

The document titled FHFC E(illegible) Tour (Rehabilitation Services Department Environmental Rounds form), dated 2/28/13, did not indicate breaks in the integrity of the floor mats, worn varnish activity chairs and a stool, exposed intercom wires, cracked, soiled and in an unsecured Symmetry Posture Chart.

Based on staff interviews and record review of the immediate (flash) use sterilizations logs, the Hospital failed to consistently ensure an acceptable level of infection prevention practice because the Hospital failed to follow the Associate of Perioperative Registered Nurses (AORN) standard practice guidelines for immediate use sterilization.


According to the AORN guidelines, the use of flash sterilization should be kept to a minimum. Flash sterilization should be used only when there is insufficient time to process by the preferred wrapped or contained method. Sterilization records should include information on each load, including documentation of the reason for immediate-use sterilization is necessary to determined the validity of using immediate-use sterilization.

The Surveyor interviewed Registered Nurse (RN) #1 at 1:00 P.M. on 1/21/14. RN #1 said that one of the two autoclaves was used for immediate use sterilization and 90% of the immediate use were for dental cases.

The Surveyor interviewed RN #2 at 9:00 A.M. on 1/23/14. RN #2 said that all the sterilizers tapes for immediate use sterilization were kept. RN #2 said initials and operating room numbers were written on the tapes. RN #2 said no additional information was kept as to what were the reasons for the immediate use, or what piece of equipment was immediately sterilized, as recommended by AORN.

A randomly selected immediate-use sterilization logs/sterilizer tapes for one of two sterilizers, #2, the sterilizer used for immediate use, indicated that approximately 5-7 immediate-use sterilization cycles were performed per day from 9/12/13-10/20/13 which indicated frequent use. The documentation on the tape did not identify the reason for immediate sterilization, as recommended.

Based on record review and interview, the Hospital's anesthesia service failed to document sufficient information to determine the Patients response to care in the post-anesthesia evaluation, within 48 hours after surgery or a procedure requiring anesthesia, for 2 patients (#18 and #36) in a sample of 36 patients. Findings include:

1. For Patient #36, who had general anesthesia for a dental procedure on 1/23/14, the post-anesthesia evaluation indicated three checked boxes were marked. The marked checked boxes indicated that no apparent complications occurred, the patient returned to a baseline cardiovascular respiratory status and the pain status was addressed.

Anesthesiologist #1 was interviewed at 1:30 P.M. on 1/23/14. Anesthesiologist #1 said the only reason an anesthesiologist would see a patient, who was administered anesthesia for a dental out-patient procedure, was if the patient had an American Society of Anesthesiologists (ASA) score of III or greater (risk classification assessment tool from I-VI) and/or if a post-anesthesia care unit (PACU) nurse identified an issue. Anesthesiologist #1 said the checked boxes on the Anesthesia document tool was checked after a verbal report from a PACU nurse, not from an examination performed by someone qualified to administer anesthesia.

2. For Patient #18 , the hospital failed to adequately document that a post anesthesia evaluation was completed within 48 hours after a procedure was completed by an individual qualified to administer anesthesia.

Patient #18 was admitted to the hospital on 6/17/11 with diagnosis including respiratory distress, vent weaning, tracheostomy and cleft palate .

On 12/17/13, the patient underwent a bronchoscopy for the purpose of evaluating the patient's respiratory status. The procedure was performed under general anesthesia. The procedure began at 7:45 A.M., and ended at 8:30 A.M. At 9:45 A.M., a post anesthesia evaluation was signed by an anesthesiologist.

On 1/23/14, at 1:30 P.M., Anesthesiologist #1 said that the evaluation tool, which was a check box type, was done after a verbal report given by a PACU registered nurse. He said the anesthesiologist staff member then would sign the evaluation.



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Based on record review and staff interview, the Hospital failed to acknowledge and implement an order for Occupational Therapy for 1 Patient (# 23) in a total sample of 36 patients.

Findings include:

The Hospital policy titled Occupational Therapy, dated 11/2004, indicated that orders for Occupational Therapy were acknowledged within 24 hours of the time of the receipt of the order for Occupational therapy.

Interview on 1/15/13 at 10:30 A.M. Occupational Therapist (OT) #1 said it was Hospital policy for the Occupational Therapy staff to acknowledge an Occupational Therapy order within 72 hours of receiving the order.

For Patient # 23, review of the Electronic Medical Record (EMR) dated 9/27/13 at 12:12 P.M. indicated a physician's order for Occupational Therapy. The order was answered by an Occupational Therapist on 9/30/13 at 7:34 A.M and the Occupational Therapist initiated the Occupational Therapy assessment on 9/30/13 at 7:55 A.M.

Occupational Therapist #1 said that the time delay was because the order was written on a Friday.