HospitalInspections.org

Based on record review and staff interview, this facility failed to ensure that each Medicare beneficiary is informed of their right to appeal discharge from the facility according to the facility's own protocol in two of two qualifying closed EMRs (Pt. #3 and 4) out of a total of 24 EMRs reviewed. Failure to notify Medicare recipients of their right to appeal discharge from this facility affects all qualifying recipients being discharged from the facility.

Findings include:

In an interview with CQO B on 4/22/2014 at 11:30 a.m. regarding this facility's protocol for informing Medicare patients of their right to appeal discharge, CQO B stated that the initial form is signed by the patient and placed on the chart. For the second notice at or around discharge, the case management staff presents the form again, explains the right to appeal to the patient again, and documents in the computer that the second notice was given.

EMR reviews for Pt. #3 and 4 were conducted on 4/22/2014 from 2:53 p.m.-3:45 p.m. accompanied by RN G who confirmed the following findings during the EMR reviews:

Pt. #3 was admitted to inpatient status on 2/26/2014 and discharged on 3/3/2014 to swing bed. The initial IM notice was signed upon admission on 2/26/2014. There is no documentation in the acute care record that a second notice was presented by case management.

Pt. #4 was admitted to inpatient status on 3/11/2014 and discharged to home on 3/14/2014. The initial IM notice was signed on 3/10/2014 when Pt. #4 was admitted as an observation patient (Pt. #4 was changed to inpatient status on 3/11/2014). There is no documentation that a second notice was presented by case management.

In an interview with case management staff, RN N and SW O, on 4/23/2014 at 11:02 a.m., both N and O confirmed that their process is to document the second notice in the EMR after talking with the patient about their appeal rights.

RN N reviewed the EMR of Pt. #3 and 4 between 11:20 a.m. and 11:30 a.m. and confirmed that there is no documentation regarding the second IM notice.

Based on observation, staff interview and review of maintenance records between 4/29 and 5/01/2014, the facility failed to construct, install and maintain the building systems to ensure life safety to patients due to (i) failure to separate four spaces from corridors, nor meet the alternative method of compliance; (ii) failure to provide proper exit signage to clearly identify the egress path to exits; (iii) due to unsealed penetrations of 1-hr fire/smoke barriers in several locations; (iv) lack of properly fire-rated vision panel in one smoke door; (v) failure to enclose three hazardous areas with a properly installed fire-rated walls and self-closing doors; (vi) lack of visible notification appliances in five locations; (vii) soiled linen receptacles not stored in a room protected as a hazardous area; (viii) failure to provide working space in front of electrical panel and equipment in two locations; (ix) failure to provide egress paths with travel interruption at stairs that go below the level of exit discharge; (x) sprinkler heads not installed in accordance with NFPA 13; and (xi) lack of proper maintenance of the sprinkler system.

The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients.

Refer to the C-231 tag, and the following tags for details:

Building 01: K17, K22, K25, K27, K29, K51, K75, and K147.
Building 03: K17, K22, K25, K38, K56, and K62.

Based on observation, staff interview and review of maintenance records, the facility failed to ensure 'life safety from fire' to patients.

Findings include

Building 01

1. Failed to protect the life safety of patients from fire due to failure to separate two spaces from corridors, nor meet the alternative method of compliance;

2. Failed to protect the life safety of patients from fire due to lack of chevron arrows in exit signs in 2 different locations in accordance with NFPA 101 7.10.1.4;

3. Failed to protect the life safety of patients from fire due to penetrations of 1-hr fire/smoke barrier in numerous locations that were not sealed in accordance with NFPA 101 19.3.7.3;

4. Failed to protect the life safety of patients from fire due to lack of properly fire-rated vision panel in one smoke door in accordance with the NFPA 101 19.3.7.5;

5. Failed to protect the life safety of patients from fire due to failure to enclose hazardous areas with a properly installed fire-rated walls and self-closing doors in accordance with NFPA 101 19.3.2.1;

6. Failed to protect the life safety of patients from fire due to lack of visible notification appliances in 5 locations to meet the minimum standards of NFPA 72;

7. Failed to protect the life safety of patients from fire due to soiled linen receptacles not stored in a room protected as a hazardous area in accordance with NFPA 101 19.7.5.5; and

8. Failed to protect the life safety of patients from fire due to failure to provide working space in front of electrical panel and equipment in two locations in accordance with NFPA 70 110-26.


Building 03

1. Failed to protect the life safety of patients from fire due to failure to provide corridor wall separation from other spaces, or comply with exceptions to the requirement;

2. Failed to protect the life safety of patients from fire due to failure to provide proper exit signage to clearly identify the egress path to exits;

3. Failed to protect the life safety of patients from fire due to penetrations of smoke barrier not properly sealed to maintain the required fire integrity of wall;

4. Failed to protect the life safety of patients from fire due to failure to provide egress paths at all times with travel interruption at stairs that go below the level of exit discharge;

5. Failed to protect the life safety of patients from fire due to sprinkler heads not of appropriate temperature ratings in accordance with NFPA 13 5-3.1.4.2 in two locations; and

6. Failed to protect the life safety of patients from fire due to lack of proper maintenance of the sprinkler system in accordance with NFPA 25 (1998) 2-2.1.1.

This had a potential of affecting patients, staff and the public on the Ground Floor, 1st and 2nd Floors of the hospital building.

Refer to the following K tags for details:

Bldg 01: K17, K22, K25, K27, K29, K51, K75 and K147.
Bldg 03: K17, K22, K25, K38, K56, and K62.

Based on observations, record reviews, national accepted standards of practice, and staff interview this facility failed to ensure there is a comprehensive infection control program to monitor, prevent and control potential infections in three out of ten department observations (Kitchen, Med/Surg unit, and Surgery Suite) and two of five staff performing patient care and other duties (Staff F and T). This deficiency potentially affects all patients treated at this facility including the nine patients present during the course of the survey.

Findings include:

The facility policy titled, "Infection Prevention," dated 11/2013, was reviewed on 4/23/2014 at 10:40 a.m. The policy states in part, "Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient."

In an interview with IP's U and V on 4/23/2014 at 9:20 a.m., both U and V stated that the standards of practice followed by the facility for infection control are: APIC, CDC, AORN, and AAMI.


Observations in the kitchen area:
A tour of the kitchen and affiliated areas was conducted on 4/22/2014 at 9:26 a.m. accompanied by CEO D and Chef E who confirmed the observations during the tour. The following observations were made:
In the Speed Rack refrigerator the grill cover over the blower vent had a heavy build up of dark gray dust.
In the dry storage area the compression units for two of the refrigerators had a significant amount of what appeared to be small pieces pipe insulation debris along the top of the units and on the floor between them. Pipes were exposed and uninsulated.
There was a bag of opened, undated wild rice in the dry storage area.
At the entrance to the dry storage area the soda fountain distribution rack had a build up of dust on it.
The dish machine had a build up of lime residue (from condensation/steam and hard water) along the seams of the top of the machine creating a porous surface for potential contaminants. There was also what appeared to be rodent droppings on the top of the dish machine.

An interview with Dir K and Dir M was conducted on 4/23/2014 at 8:00 a.m. Regarding the compression units for the refrigerators and exposed piping, Dir M stated that the units have been working properly as evidenced by temperature checks and if not they would be investigated. However, this does not explain why the debris was still laying on top of, and on the floor between the units.

In a follow up interview with Dir K on 4/24/2014 regarding the cleaning contract for the kitchen, it was determined that the dish machine and the grill cover in the speed rack refrigerator are the responsibility of the kitchen staff to clean.


Observation of care:
On 4/23/2014 at 7:30 a.m. an observation of CNA T performing an accucheck (checking blood sugar) on Pt. #17 was made. After preparing Pt. #17's finger for a finger stick CNA T realized T forgot to bring a lancet (poking device for the finger) and left the room with gloves on. At some point outside of the room CNA T removed the gloves and put new gloves on upon returning. After completion of the test and handling the glucometer and test strip vial with the contaminated gloves, CNA T removed the gloves, washed hands, picked up equipment and returned to the nursing station thereby re-contaminating T's hands. CNA T then used alcohol wipes to clean the monitor but not the test strip vial and left to do another patient (on contact isolation) with this equipment.

In an interview with IP's U and V on 4/23/2014 at 9:40 a.m. regarding leaving the room with gloves on, both U and V confirmed that CNA T should not have left the room without removing the gloves and washing hands.


32670


Observation on Med/Surg unit:
During tour of Medical/Surgical unit on 4/22/2014 accompanied by VP A at 9:30 AM, noted 12 reusable ice packs in kitchen freezer among food items. Per interview with RN C at the time of discovery, dirty ice packs are left in the soiled utility room and cleaned by housekeeping before being restocked in the kitchen freezer. Per interview with VP A at the time of discovery, patient care items should not be kept in the food freezer. Per CQO B on 4/23/14 at 8:30 AM the facility does not have a policy regarding the storage of ice packs.

Observations in Surgery Suite:
Per interview with Surgical Manager L on 4/23/14 at 9:00 AM this facility follows AORN standards of practice (SOP). Surgical Manger L stated the facility does not have a policy for protecting sterile fields but would reference AORN standards.

Per AORN SOP for Inpatient and Ambulatory Settings 2013 edition, under Surgical Attire, III.c.2. The surgical gown back should be considered unsterile. The back of the gown cannot be constantly monitored.

On 4/22/14 at 11:00 AM observed ST F during Pt # 24's surgery, while sterile gowned and gloved, turn away from the open sterile instrument table allowing the back of the sterile gown to brush the edge of the sterile table. CQO A acknowledged the above observation at the time of discovery.

On 4/22/14 at 10:40 AM observed ST F touch the trash bin and move it closer to the instrument table then proceed in opening sterile equipment without the benefit of hand hygiene after touching a contaminated object. CQO A acknowledged the above observation at the time of discovery.

Based on EMR review, Medical Staff Rules and Regs, and staff interview, this facility failed to ensure that telephone orders (TO) are properly authenticated with signature, date, and time within a 48-hour period of being written in one of three outpatient surgical patients (Pt. #22) and five out of 15 inpatient records (Pt.s #1, 3, 4, 10, and 14) out of a total of 24 EMRs reviewed. Failure to have properly authenticated TOs has the potential to affect all patients receiving care in this facility, including the nine patients present during the course of the survey, and the 31 patients scheduled for surgical procedures during the course of the survey.

Findings include:

The Medical Staff R/R were reviewed on 4/24/2014 at 8:30 a.m. Regarding TOs, on page 6, the R/R state in part, "Telephone orders shall be signed, timed, and dated within 48 hours of receipt by the responsible Physician/LIP [licensed independent practitioner]..."

In an interview with RN G regarding MD orders and the EMR on 4/22/2014 at 12:55 p.m., RN G stated that most MD orders are put into the EMR by nursing and co-signed by the MD. The exception to this is medication orders which remain on a paper document as part of the chart.

An EMR review was conducted on Pt. #1's closed Swing Bed record on 4/22/2014 at 1:02 p.m. accompanied by RN G who confirmed the following findings during the record review:
Pt. #1 had three TOs dated 1/16/14. They were signed by the provider on 1/24/14. On 1/17/14 there is one TO which was signed by the provider on 1/24/14. On 1/18/14 there is one TO which was signed by the provider on 1/22/14. All of these TOs were signed by the provider in excess of 48 hours.

An EMR review was conducted on Pt. #3's closed inpatient record on 4/22/2014 at 2:53 p.m. accompanied by RN G who confirmed the following findings during the record review:
Pt. #3 had four TOs written by staff between 2/27/14 and 2/28/14. The provider did not sign these orders until 3/9/14. This is in excess of 48 hours.

Pt. #3 also has a TO for insulin written by nursing on 3/2/2014 for Humulin N 28 units. A stamped entry stating, "Electronically signed in the EHR" (electronic health record) is directly under that TO. A review of the Medication Profile reveals that this order was not entered onto the profile and did not have an electronic order and therefore could not have been signed by a provider. There is also no provider co-signature for the TO in the paper portion of the record.

An EMR review was conducted on Pt. #4's closed inpatient record on 4/22/2014 at 3:52 p.m. accompanied by RN G who confirmed the following findings during the record review:
Pt. #4 has one TO dated 3/10/14 which was not signed by the provider until 3/14/14, and one TO on 3/14/14 that was not signed until 3/22/14. These co-signatures are in excess of 48 hours.

An EMR review was conducted on Pt. #10's closed newborn record on 4/24/2014 at 11:45 a.m. accompanied by RN Supvr P who confirmed the following findings during the record review:
Pt. #10 has a TO dated 2/25/14 which was signed by the MD but no date or time is provided. A 48 hour time frame for the MD co-signature cannot be established without the date or time.

An EMR review was conducted on Pt. #22's closed same day surgery record on 4/24/2014 at 12:00 p.m. accompanied by Mgr L who confirmed this finding at the time of the record review:
Pt. #22 had same day surgery on 1/16/2014 and nursing wrote a TO for that same day. There is no MD co-signature for that order.

In an interview on 4/24/2014 at 12:55 p.m. with Coord H, H stated that it was explained to the medical record department on institution of the pre-operative order sheet that if the MD signed it on the bottom no further signatures were needed. The MD did sign, time and date the order form, however the time of the MDs signature is 7:30 a.m. and the time of the TO is 8:25 a.m. The MD would have had to authenticate this order separately from the initial authentication. Coord H verbalized understanding of this.




32670

Pt #14's EMR review on 4/22/2014 at 2:00 PM revealed TOs dated 4/18/2014 at 4:00 PM that are not authenticated by the MD. Per interview with CQO A on 4/22/14 at 3:30 PM, MD's enter most of their own orders in the computer system and do not always check the paper charts to authenticate. Per CQO A RNs are not currently entering MD TO's into the computer system but will be in the future in hopes to alleviate this issue.

Based on record review and staff interview, this facility failed to obtain consents for care in the facility that are separate from the consent for care in the attached but separately certified clinic in 19 out of 19 Pt.s out of a total of 24 EMR reviews (Pt.s #3, 4, 5, 6, 7, 8, 9, 10, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 24). In addition, the facility obtained consents for the Obstetric (OB) patients prior to their admission to the facility in three of three OB records (Pt.s 5, 7, and 9) out of a total of 24 EMR reviews, and consents for the care of newborns before the infant is born in two of three newborn records (Pt.s 6, and 10) out of a total of 24 EMR reviews.

Findings include:

In an interview on 4/22/2014 at 3:00 p.m. with Clerical Coord H regarding consent for treatment in this facility, Coord H stated that the consents are scanned in by registration staff for each time a patient is presenting for care. Coord H went on to say that the exception to this is the OB and baby consents which are signed by the pregnant mom when they come in for their first pre-natal visit.

EMR reviews for Pt.s #3 and 4 were conducted on 4/22/14 between 2:53 p.m. and 3:32 p.m. accompanied by RN G.
EMR reviews for Pt.s #5, 6, 7, 8, 9, and 10 were conducted on 4/24/14 between 10:46 a.m. and 11:55 a.m. accompanied by Supvr P.
EMR reviews for Pt ' s # 14, 15, 16 and 17 were conducted on 4/22/14 between 2:00 PM and 3:30 PM accompanied by RN C.
EMR reviews for Pt's # 18, 19, 20, and 21 were conducted on 4/23/14 between 12:30 PM and 1:30 PM accompanied by RN S.
EMR reviews for Pt.s # 22 and 23 were conducted on 4/24/14 between 12:00 p.m. and 12:40 p.m. accompanied by Mgr L.
EMR reviews for Pt # 24 was conducted on 4/23/14 at 8:45 AM accompanied by Surg Manager L.

After further review of the consent form, it was discovered that this form is being used as a single document between this facility and the attached, but separately certified rural health clinic. The consent form is not dedicated to the inpatient facility.

The consent form also states it is valid for a year from the signing unless revoked by the patient. Each episode of inpatient treatment/outpatient procedure, to include observation patients, must have a separate consent, as Coord H indicated in the above interview.


OB/Newborn consents
On 4/22/2014 at 3:45 p.m. Coord H presented consents for care for Pt.s #5, 6, 7, 8, 9, and 10 from the OB/newborn records.

Pt. #5 was admitted to the facility on 3/14/2014 and delivered Pt. #6 on 3/14/2014. Pt. #5's consent for care was signed on 7/30/2013 and Pt. #6's consent was also signed on this date.

Pt. #7 was admitted to the facility on 2/12/2014. Pt. #7's consent for care was signed on 2/1/2014.

Pt. #9, a minor, was admitted to the facility on 2/24/2014 and delivered Pt. #10 on 2/24/2014. Pt. #9's consent for care was signed on 8/20/2013 and Pt. #10's consent was signed on 7/31/2013.

On 4/24/2014 at follow up interview with Coord H was conducted regarding clarification of the OB/Newborn consents for care. Coord H stated that the consent is attached to the account number and on the first prenatal visit (at the rural health clinic) the nurse brings the patient to the financial people and the consent for care is signed at that time.

There is not a separation of consents between the clinic and this facility.

Based on observations, record review, nationally accepted standards of practice from AORN, and staff interview the facility 1. Failed to ensure alcohol based skin preparation was dry prior to draping and the medical record reflected the dry time accurately in one of one surgical observation with MR review (Pt. #24), 2. The facility failed to ensure staff wore proper attire in one of one observations of cleaning of surgical instruments; and 3. The hospital failed to ensure proper cleaning equipment was used for scope cleaning and scopes were stored a clean area in one of one observation in scope cleaning

The cumulative effect of these deficiencies potentially affects all surgical patients treated at this facility.

Findings include:

Per review on 4/22/2014 at 12:00 PM of facility policy titled "Cleaning and Sterilization of Instruments" it states "II...... Proper attire includes: eye protection, mask, gloves and impervious gown with long sleeves."

Per review on 4/23/14 at 9:30 AM of manufacturers instructions for Chloraprep it states under directions "allow the solution to completely dry (minimum of 3 minutes on hairless skin and up to 1 hour in hair)."

Per review of 4/23/14 at 8:50 AM of facility policy titled "Prevention of Surgical Fires" it states "Do not drape patient until all flammable preps have fully dried."

AORN Recommended Practice: Cleaning and Processing Endoscopes Recommendation IX Flexible endoscopes should be stored in a manner that protects the device from damage and minimizes microbial contamination. IX.a Flexible endoscopes should be stored in a closed cabinet with venting that allows air circulation around the flexible endoscope ... " AORN perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings, 2014 Edition.

Per review on 4/22/14 at 11:30 AM of manufacturers packaging for scope brush "Kimberly Clark - Single ended cleaning brush" it states on the package "single use item".

On 4/22/14 at 11:30 AM accompanied by CQO A, observed ST F performing surgical instrument cleaning in the decontamination room wearing OR scrubs, safety glasses and gloves. Per interview with ST F at the time of the observation, the normal practice is to wear an OR scrub long sleeve jacket while cleaning instruments and then change the jacket before going back into the OR.

Per interview on 4/23/14 at 9:00 AM with Surgery Manager L, they used to provide an impervious gown for instrument cleaning but no longer do this. Surgery Manger L acknowledged the policy is to wear the impervious gown and a mask which ST F did not do.

On 4/22/14 at 11:06 AM accompanied by CQO A, observed RN Q apply Chloraprep (alcohol based skin prep) to Pt # 24's right arm in preparation for carpal tunnel surgery. Immediately after RN Q finished applying the Chloraprep MD R began applying the surgical drape to Pt # 24's right arm. There was no physical or verbal confirmation that the prep was dry or that the staff waited the minimum of three minutes to allow the solution to completely dry.

Per review on 4/23/14 at 8:45 AM of Pt # 24's MR it states under the surgery prep screen "ETOH [acronym used for alcohol] prep criteria followed? Yes". Per interview with Surgery Manager L at the time of the MR review, Surgery Manger L stated "they should not have marked it yes if they did not wait the full dry time."

Per interview on 4/23/14 at 9:00 AM, Surgical Manager L stated staff are aware of the Chloraprep dry time being 3 minutes. Per Surgical Manger L the facility does not currently verbalize when the prep is dry and it is unusual that the MD is ready to drape right away.

Per observation on 4/23/14 at 9:45 AM accompanied by Surgery Manger L, noted vented scope storage cabinet located in the dirty utility room where scope cleaning is preformed. Per interview with Surgery Manager L at the time of discovery, the scope cabinet fit best in the area they have it currently located. Surgery Manager L agreed clean items should not be stored in an area used for dirty items.

Per interview on 4/22/14 with ST F at 11:40 AM, scope brushes are used for one week and then discarded. The brushes are cleaned by running them in the Medivator (a machine used to clean scopes) with the scopes after each use.

Per interview on 4/23/14 at 9:15 AM Surgery Manager L acknowledged the the manufacturer recommendation, per packaging on the scope brush, is single use.

Per Surgery Manager L on 4/28/14 at 2:45 PM the facility does not have a policy regarding scope storage and would refer to AORN standards for scope storage.

Based on record review and staff interview, this facility does not inform Swing Bed patients about their right to perform or refuse to work while in the Swing Bed program in two of two documents reviewed (swing bed agreement, patient rights booklet). By not informing Pt's of this right the facility is prohibiting Pt's from making an informed decision. There was 0 swing bed patients out of 9 inpatients present during the course of the survey.


Findings include:

Facility documents (swing bed agreement and patient rights booklet) given to Swing Bed patients upon admission to the program were reviewed on 4/22/2014 at 12:30 p.m. These documents do not include the patient rights information related to work services indicating that patients have the right to refuse or perform work services if they choose.

In an interview on 4/23/2014 at 11:25 a.m. with RN N, SW O, and CQO B, it was stated that the right to work/not to work is not included in the patient rights information or admission agreement to the swing bed program.

Based on record review and staff interviews, this facility failed to include all of the required contents for the discharge/transfer notice in the information provided to two of two swing bed patients (Pt. #1 and 2). Failure to provide all discharge information to swing bed patients has the potential to negatively affect all swing bed patients. There was 0 swing bed patients out of 9 patients present during the course of the survey.

Findings include:

Review of the discharge information sheet given to swing bed patients was done on 4/22/2014 at 12:30 p.m. The form does not include where the patient will be transferred/discharged to, the name and contact information of the State long term care ombudsman, the contact information for the agency responsible for protecting developmentally disabled individuals, or the contact information for the agency responsible for protecting mentally ill individuals.

In an interview with SW O and RN N on 4/23/2014 at 11:25 a.m. RN N confirmed that the discharge notice does not have all of the information on it.

EMR reviews were conducted on the closed swing bed records for Pt. #1 on 4/22/2014 at 1:02 p.m. and Pt. #2 on 4/22/2014 at 2:04 p.m. accompanied by RN G who confirmed the findings at the time of the MR review. The required information is not present on the discharge form.