HospitalInspections.org

This standard is not met based on review of the hospital's Quality Assessment and Performance Improvement program minutes, and other facility documents, and interviews with staff, it was determined that the committee was unable to provide evidence of QAPI assessments related to each service provided by the hospital. Not all patient care areas within the hospital were identifying concerns, collecting and reporting to the QAPI Committee, monitoring, and evaluating their department's efficiency and quality of services to ensure desirable patient centered outcomes, namely Anesthesia, and Organ Tissue and Eye Procurement (OTEP). Neither department was actively participating in the hospital wide QAPI Program.

This was made evident by the following:

Review of the QAPI program's manual, QAPI committee meeting minutes, departmental QAPI initiatives, data collection, reporting and analysis, none of the documents included evidence that Anesthesia and OTEP departments took an active part in the QAPI program.

This was further substantiated during the survey on 4/13/15 - 4/17/15 through interviews by the survey team with the Directors of Anesthesia and OTEP, as well as during an extensive interview with the Vice President of the QAPI Program. During this interview the VP of QAPI acknowledged that one of the reasons the hospital had recently contracted anesthesia services with a new contractor is because of the former contractor's lack of initiative and involvement in QAPI.

OTEP acknowledged that their department was not monitoring, logging, and reporting data to the QAPI committee on all calls or contacts made to the tissue and eye banks for which the hospital has agreements for reporting deaths and immanent deaths so as to improve the identification of potential donors. With no recording of all calls made, the department is unable to report accurate data to the QAPI committee so that quality measures to improve their outcomes could be identified, developed, implemented, evaluated, and improved.

Based on record review and interview, it was determined that the hospital failed to develop care plans based on assessing the patient's nursing care needs for all 6 patients with Diabetes out of the total 30 sampled patients. (Patient #13, #17, #26, #27, #28 and #29).

The findings include:

Sampled patient #13 is an 69 year old male with a diagnoses of Diabetes Mellitus admitted to the hospital on 01/16/15. This patient was on Metformin, 500 mg, twice a day for his diabetic condition. A review of his care plan, on 04/16/15, revealed that nursing staff failed to develop a nursing care plan for this patient's care needs related to Diabetes.

Sampled patient #17 is an 84 year old male with Diabetes Mellitus, End Stage Renal Disease and Sepsis admitted to the hospital on 03/31/15. Review of his care plan on 01/16/15 revealed that the nursing staff failed to develop a nursing care plan for this patient's care needs related to Diabetes.

Sampled patient #26 is an 64 year old male surgical patient admitted to the hospital on 04/13/15 with a diagnoses of SBO (small bowel obstruction). This patient was also monitored for blood sugar levels. A review of patient's lab revealed that his blood sugar level was 215 mg/dl. There was no care plan developed for this patient's care needs related to Diabetes.

Sampled patient # 28 is an 53 year old male with Diabetic foot, Osteomyelitis and foot abscess admitted to the hospital on 04/14/15. A review of his care plan, on 04/16/15, revealed that nursing staff failed to develop a nursing care plan for this patient's care needs related to Diabetes.

Sampled patient #29 is an 53 year old female with a diagnoses of Diabetes Mellitus admitted to the hospital on 04/13/15. This patient was on Glyburide and Levemir for her diabetic condition. A review of his care plan, on 04/16/15, revealed that nursing staff failed to develop a nursing care plan for this patient's care needs related to Diabetes.



During an interview with the Chief Nursing Officer and VP of Quality & Performance, both acknowledge that a care plan for Diabetic complications should have been in place for all of the above sampled patients.

Based on record review conducted on 04/16/15, it was determined Operating Room Time Out Forms were not properly filled for 2 of 2 post operative patients out of 30 sampled patients. (Patient # 3 and #16).

Findings include:

Sampled patient #3 is 55 year old male admitted to the hospital on 04/13/15 for Left Total Knee Replacement. A review of his medical record on 04/16/15, revealed that the Time Out Form was incomplete and the following information was not filled in:

Operating Room Staff Initials.

Names of the Team Members Participating in the Tim Out.

Sampled Patient #16 is an 66 year old female admitted to the hospital on 04/13/15 for Right Knee Total Replacement. A review of her medical record on 04/16/15, revealed that the Time Out Form was incomplete and the following information was not filled in:

Operating Room Staff Initials.

Names of the Team Members Participating in the Tim Out.

Based on observation, record review and interview the facility failed to ensure that there was periodic inspection of equipment and that repairs identified on a work order would be corrected. This had the potential to affect 3 of 8 reviewed for Radiological Services out of 30 sample patients.

Findings include:

On 4/14/15 at 11:00 a.m., observation of equipment in the Radiology Department revealed that there were no Preventive Maintenance stickers on the Fluoroscopy X-ray machine, Diagnostic X-ray machine in the Continental Room, Nuclear Medicine Imaging System and the CT [computerized tomography] Scan.

During an interview on 4/14/15 at 11:20 a.m., the Biomedical Equipment Coordinator staff #4 for the Hospital revealed that preventive maintenance was every 6 months and " there should be a sticker on them " (service equipment); " that was a no-no on service equipment " .

Review of Preventive Maintenance Work Order from 11/22/14 for the Continental Room with the Diagnostic X-ray machine, the Description of Work included " 4 covers missing from bearings on table " . On 4/14/15 at 11:30 a.m., observation of the table located in this room, the 4 covers were missing from the bearings on the table. There was also a tube coil cover that separated from the base of the X-ray machine.

Review of the Service Agreement from the Imaging Company identified that the " service agreement will cover labor, both remedial and routine, all parts including X-Ray tubes and image intensifiers and all freight for parts shipments " .
On 4/14/15 at 11:30 a.m., the technician for X-ray and CT machines said " the area should be closed and covered "

On 4/14/15 at 12:00 p.m., interview with the Director of Radiology and Nuclear Medicine revealed that the service company will call her representative from the Hospital when it is time for Preventive Maintenance. Technicians will come to her and she makes a request for a service call. She said " it was filed (Preventive Maintenance Work Order) on 11/22/14 and no one followed-up; something that needs to be addressed; it fell through the cracks. "

On 4/17/15 at 9:50 a.m., during an interview with the Director of Radiology and Nuclear Medicine revealed that there was no policy; " it is a given that they need to put a sticker on all equipment when they do a service. "

This standard is not met based on observations and interviews it was determined that the FDS, (Food and Dietetic Services) staff failed to consistently ensure the safe handling of food, failed to ensure consistent hand washing when plating food, failed to maintain some areas in the food service department's environment, failed to store food, and food service supplies in a manner to protect their integrity and prevent the risk of contamination particularly in the emergency and disaster storage room. In addition, failed to ensure that items stored on shelves in the emergency and disaster storage room did not exceed the recommended safe distance from the ceiling, and did not obstruct the sprinklers in that area. The FDS failed to assess food service delivery procedures to determine the most efficient way to deliver patient meals to the units to ensure the best utilization of staff, and to ensure conservation of food quality and proper temperatures at point of delivery to the patients particularly to the medical surgical unit.

This was made evident by the following:

During the initial tour of the FDS department on 4/13/15 at approximately 10:30 a.m., and during subsequent visits throughout all days of the survey, the following deficient practices were observed.

All hand washing sinks (approximately 4) were equipped with trash receptacles that had no step on feature, requiring staff to touch the trash receptacle's lid to dispose of used paper towels once hand washing had been achieved.

One hand washing sink was located in very close proximity to a food preparation table that was being used by staff to prepare salads. The distance from the hand washing sink and the foods being prepared was such that splatter from the sink during hand washing could easily come in contact with food.

Observations were made of a large soup kettle filled with soup with a smaller long handled pot resting directly in the soup. According to staff that was not in the immediate area of the observation at the time the observation was made, the smaller pot was being used to dip soup from the large soup kettle.

Observations were made of two ovens that according to staff were no longer being used. When the ovens were opened for inspection, the first oven was very dirty with baked on debris and a box of gloves was stored inside of the oven and immediately removed. The second oven was clean but contained a few pieces of disposable plastic ware inside of the oven that was removed immediately by the AFSD.

Three large electrical panel doors along one wall were very visibly scarred without their original smooth surfaces making them difficult to clean and unsightly. Observations were made of two large industrial sized deep fryers both were observed to have a heavy build-up of baked on grease around the entire exterior perimeter and in need of cleaning.

The faucet and sink used to fill the tilt skillet was observed to be in need of cleaning as well as the PVC pipe connectors underneath were coated with dust and dirt. At least 95 per cent of the baking pans, muffin cups, large and small pots used regularly to prepare, cook and bake foods had extended their usefulness, were unsightly, and was in need of replacement. All of these items were very heavily coated with black baked on substance that flaked off when scraped with the surveyor ' s pen.

Two large steamers were observed with large pans underneath collecting water from the steamer. The steamers had no floor drains underneath, or near to accommodate the water generated by the steamers other than collection in pans. During interview with the FSD, it was revealed that drains were not constructed to accommodate the steamers when the steamers were first installed.

Inspection of walk-in refrigerators revealed one refrigerator that contained two trays of jello, one green and one red. Both trays of jello had use by dates of 4/11/15 which meant the jello should have been discarded the day before on 4/12/15. Both products had leaked onto the trays where the jello was resting.

An inspection of the room that housed emergency food supplies, emergency water, and paper products was conducted during the initial tour. Multiple disposable paper products, plastic cups and lids were scattered throughout the room on the floor. Boxes of items were stored on multiple shelves exceeding the recommended height from the ceiling, obstructing the sprinkler in that area. The vent in the ceiling was very heavily coated with dust and several ceiling tiles were left askew increasing the risk of smoke escape in the case of fire. The entire room was dusty, the floor cluttered and in need of mopping. Several bunches of ripe bananas were observed and according to staff is where bananas are allowed to ripen to reduce the ripening time. The state of the room was observed by both the FSD and the assistant FSD.

Observations were made on 4/14/15 at approximately 11:30 a.m. of a food prep table in the back of the kitchen with debris that appeared to be left from earlier food preparation. A soiled knife and several slices of cold cut turkey were among the items observed on the un-cleaned prep table surface. The dietary aid identified by the FSD as the aid that was responsible for that area acknowledged that she forgot about the turkey which was discarded immediately. The aid also acknowledged that the prep table surface had not been wiped down or sanitized after making sandwiches and before setting up other food items being prepared.

During interview with the FSD during the initial tour of the kitchen, it was discovered that hot food temperatures were sometimes a concern based on test try temperatures whereby occasionally hot foods were not always hot at service point to the residents on the unit. The FSD attributed this to multi use of the two service elevators by other services including dietary.

On 4/14/15 lunch steam table test temperatures and plating services at the tray line in the kitchen was observed from start to finish including delivery to the medical unit, the largest tray service delivery unit. Several observations were made that warranted immediate correction, review and/or reconsideration to minimize the risk of cross-contamination, and improve the overall food service delivery to patients, and to ensure that when food reached the patients it would be at proper temperature, and that the integrity and quality of food was consistently maintained. These observations are as follows:

During steam table test temperature procedures the dietary staff conducting the temperatures was observed to walk away from the steam table with her gloves on to discard a probe wipe into the trash can. The dietary aid returned to the steam table and started to resume taking temperatures when interrupted by the surveyor asking that the gloves be removed, hand washing occur and re-gloving. The dietary aid acknowledged that she simply forgot.

The dietary aid that was plating the food from the steam table was observed touching the inside of the plates with a heavy duty mitten used when handling hot items. The mitten was taken off and on numerous times throughout the service and placed on the edge of the steam table. In addition, the aid was observed opening the refrigerator door handle during plating, and lifting the top of the plate warmer to remove plates with her gloved hands. Other staff had been observed opening the refrigerator and touching the same handles un-gloved. Plating services were momentarily interrupted by the surveyor just long enough for the aid to remove gloves, wash hands and re-glove. The FSD was present during the observations and acknowledged the breeches in infection control by staff.

Surveyor accompanied the dietary aid to the medical unit from the kitchen for tray delivery on the unit. The food cart was loaded onto the service elevator which arrived within seconds of being called. The food service cart was observed with one of its doors not able to be closed and stay closed. The dietary aid had to push the large cart all while trying to hold the door shut.

The dietary aid observed plating the food is the same aid that delivered, and passed 95% of the trays to the patients on the medical unit. When this service was being performed by the dietary aid several staff that included nursing staff was observed on the unit about the halls, and at the nurse's station. Yet the dietary aid worked alone to enter in and out of each patient's room to serve trays. It was not until the surveyor conducted a brief on-the-spot interview with the nurse in charge of the unit was nursing staff observed to assist with the few remaining tray deliveries.

After the dietary aid delivered trays to each room the aid used the wall mounted hand sanitizer between each tray delivery. One room on the unit housed a patient on contact isolation as indicated by the signage posted on the room door. An isolation set-up was posted just outside of the room. The dietary aid donned a gown and gloves before entering the room as if she was very familiar with the procedure. Meanwhile the nurse in charge of the unit had just stated during the on-the-spot interview that nursing staff delivered trays to isolation rooms.

When the dietary had delivered the diet tray to the patient on contact isolation, she removed her gown and gloves and went to sanitize her hands using the wall mounted hand sanitizer. The dietary aid was interrupted briefly by the surveyor and advised that proper hand washing was required since the patient was on contact isolation. The dietary aid was receptive and exercised good hand washing technique prior to resuming tray delivery services to the remaining patients. This concern was reported immediately to the Director of Nursing, Infection Control coordinator and the VP of the QAPI (Quality Assessment and Performance Improvement committee for review and correction.

Tray delivery to each patient on the medical unit by the one dietary aid took approximately 45 minutes to an hour, not an efficient use of time and staff, and an increased risk of undesirable food temperatures, particularly hot foods not being hot when served.

Based on observation, record review and interview, the facility failed to ensure that equipment in the Operating Rooms were maintained in a sanitary and sterile environment.

Findings include:

On 4/15/15 at 10:00 a.m., observation of the Operating Rooms (OR) with the Interim Director of Surgical/Operative Services, the following was identified related to maintaining a sanitary and sterile environment: Rust was located on the Oxygen Tanks located in Operating Rooms C and D. On 4/15/15 at 4:10 p.m., rust was observed on the Oxygen Tanks located in Operating Room B and a Purse/personal possession was secured on the valve of one Oxygen Tank. The vinyl was torn on an arm rest located in OR-B. At the room adjacent to OR-B, the counter surrounding the sink and the drain of the sink had rust. Anesthesia supplies (plastic covered Super Circuit Suction devices) were secured onto the valve of Oxygen Tanks located in OR-B.

On 4/17/15 at 9:15 a.m., interview with the Infection Control Coordinator revealed that Housekeeping cleans between cases and at the end of the day. Facility Maintenance would be notified for anything that has rust. Employees place belongings in a locker room. Each Unit has a locker room. Omni Cell is where all supplies are stored and there is a supply area in the Anesthesiology room. Each Unit Manager or designee does environmental care rounds.

On 4/17/15 at 9:30 a.m., interview with the Interim Director of Surgical/Operative Services revealed that Housekeeping clean the sinks daily; staff in the Maintenance Department handles rust on tanks. She notified the head of Anesthesiology and spoke to each Certified Registered Nurse Anesthetist (CRNA) about possessions in the Operating Room. Supplies were removed. Purses are in the office or locker; plastic bag is just for OR. " No personal belongings from the outside should be coming into the Operating Room ".

On 4/17/15 at 10:55 a.m., the Chief Medical Officer confirmed that staff were not to bring possessions into the Operating Room and provided a document titled Article XXI Special Provisions " The employer agrees to provide lounge facilities and lockers to nurses. "

Based on observation, record review and interview, the facility failed to ensure that equipment in the Operating Rooms were maintained in a sanitary and sterile environment to avoid sources and transmission of infections and communicable diseases..

Findings include:

On 4/15/15, observation of the Operating Rooms (OR) with the Interim Director of Surgical/Operative Services, the following was identified related to maintaining a sanitary and sterile environment:

Rust was located on the Oxygen Tanks located in Operating Rooms B, C and D.

Purse/personal possession was secured on the valve of one Oxygen Tank.

Anesthesia supplies (plastic covered Super Circuit Suction devices) were secured onto the valve of Oxygen Tanks located in OR-B.

The vinyl was torn on an arm rest located in OR-B operation table.

At the room adjacent to OR-B, the counter surrounding the sink and the drain of the sink had rust.

On 4/17/15 at 9:15 a.m., an interview with the Infection Control Coordinator revealed that there was no active infection control surveillance of the Operating Rooms.

On 4/17/15 at 10:55 a.m., the Chief Medical Officer confirmed that staff were not to bring purse and personal possessions into the Operating Rooms.

Based on record review and interviews conducted from 04/13/15 through 04/17/15, it was determined that the hospital does not have a system in place to tract down how efficient the Organ, Tissue and Eye Procurement (OPO) requirements are met.

The findings include:

An interview with the hospital designated OPO reporting staff was conducted on 04/16/15 at 2:00 p.m. When asked if the hospital notify's the OPO of every death or imminent death in the hospital as soon as possible and what kind of system the hospital has in place to tract down if all cases are reported to OPO, the staff stated that to the best of her knowledge all patient death's are reported to OPO but the hospital does not have a system in place to tract down non reported cases.

Based on observation, record review and interview, the facility failed to ensure that 4 of 6 patients reviewed that received Respiratory Care Services out of 30 sampled patients, had medical records that contained documentation/initials from the Respiratory Therapist or Nurse/designee that Albuterol Sulfate Inhalation Solution and/or Ipratropium Bromide was administered as ordered by the Physician ( Patient #2, #5, #14 and #19).

Findings include:

Review of the Medication Administration Records (MAR) for patient #2 revealed there was no documentation/initials that " Albuterol Sulfate Inhalation Solution 2.5 milligrams (mg)/3Milliters (ML) Units Q12 [every 12 hours] @ [at] 8, 20 " was administered as ordered on 4/12/15 at 0800 and 2000. There was no documentation/initials that Albuterol Sulfate Inhalation Solution 2.5 mg/3 ML Units Q12 [every 12 hours] and Ipratropium Bromide 0.5 mg/2 ML Inhalation (0.5 mg) (Atrovent Inhalation Solution) Q12 was administered as ordered on 4/15/15 at 1000 and 2200. Review of Physician Orders on 4/8/15 for " Albuterol 2.5 mg Neb [Nebulizer] Q 12 hours scheduled 8 am and 20pm " ; and on 4/13/15 for " Duoneb every 12 hours "(Duoneb is a sterile inhalation solution containing a combination of Albuterol and Ipratropium). The History and Physical on 1/12/15 identified on the assessment " Pt [Patient] ..with COPD [Chronic Obstructive Pulmonary Disease] who appears older than stated age who now present with Acute hypercarbic respiratory failure " .

Review of the MAR for patient #5 revealed there was no documentation/initials that Albuterol Sulfate Inhalation Solution 2.5 mg/3 ML Units Q4 [every 4 hours] and Ipratropium Bromide 0.5 mg/2 ML Inhalation (0.5 mg) (Atrovent Inhalation Solution) Q4 was administered as ordered on the following date: 4/8/15 at 1800, 2200, 0200, and 0600; 4/9/15 at 2200, 0200 and 0600. Review of the MAR for patient #5 revealed there was no documentation/initials that Albuterol Sulfate Inhalation Solution 2.5 mg/3 ML Units Q6 was administered as ordered on 4/12/15 at 0800, 1400, 2000, and 0200. Review of a Physician Order form on 4/6/15 identified " Albuterol 1 UD [Unit Dose] Route neb [nebulizer] Q4 hrs [hours] " and " Atrovent 1 UD Route Neb Q4 hrs. Review of a Physician Order form on 4/11/15 identified " Albuterol 1 unit dose, Atrovent 1 unit dose neb Q6 hours " . Review of the 4/6/15 History and Physical, patient #5's assessment identified " Pt [Patient] with likely acute bronchitis with COPD [Chronic Obstructive Pulmonary Disease] exacerbation. "

On 4/13/15 at 12:00 p.m., patient #14 was observed to be non-responsive, on Ventilator Management.
Review of the MAR for patient #14 revealed there was no documentation/initials that Albuterol Sulfate Inhalation Solution 2.5 mg/3 ML Units Q3H [every 3 hours] was administered on the following date and times: 4/8/15 at 0940 and 1240. The times of 0940 and 1240 were circled with a note " RT unavailable Not given " . The MAR for patient #14 revealed there was no documentation/initials that Ipratropium Bromide 0.5 mg/2.5 ML Inhalation (0.5 mg) (Atrovent Inhalation Solution) Q3 was administered as ordered on 4/8/15 at 0800, 1100, 1400, and 1700. On the 4/9/15 MAR for Albuterol Sulfate Inhalation Solution 2.5 mg/3 ML Units Q3H, and Ipratropium Bromide 0.5 mg/2.5 ML Inhalation (0.5 mg) (Atrovent Inhalation Solution) Q3 did not have initials next to the following times: 0800, 1100, 1400, and 1700. Review of a 4/7/15 Physician Order identified " Duoneb q3 hours ". The History and Physical from 4/15/15 included on the assessment that patient #14 had "Respiratory failure, ventilator dependent " .

On 4/13/15 at 12:15 p.m., observation of patient #19, refused treatment as she wanted to eat lunch first while the food was warm.
Review of the MAR for patient #19 revealed there was no documentation/initials that Albuterol Sulfate Inhalation Solution 2.5 mg/3 ML Units Q4 [every 4 hours] and Ipratropium Bromide 0.5 mg/2.5 ML Inhalation (0.5 mg) (Atrovent Inhalation Solution) Q4 was administered as ordered on 4/7/15 at 1600. There was a notation on the 4/7/15 MAR next to 1600 " not given " . There was a notation on the 4/8/15 MAR for Albuterol Sulfate Inhalation Solution 2.5 mg/3 ML Units Q4 next to 1800 " not given " . The MAR on 4/9/15 did not include initials that Albuteral and Ipratropium Bromide were administered at 2200, 0200 and 0600. The MAR for 4/12/15 at 1000, 1400 and 1800 hours revealed no initials that Albuterol and Ipratropium were administered as ordered. There was a Physician Order on 4/6/15 included Duoneb 1 Unit dose Q4 hours and the 4/10/15 Physician Order identified Duoneb 1 Unit dose neb [nebulizer] Q4 hours. The History and Physical identified on 4/6/15 that patient #19 assessment included Respiratory failure acute and chronic; and a plan regarding respiratory failure and the need for mechanical ventilation.

During an interview on 4/13/15 at 11:00 a.m., with two Registered Respiratory Therapists revealed that on most days 2 staff (Respiratory Therapists) is adequate. The therapists identified the areas they respond to included but not limited to the following: all Code Blues, Rapid Responses, Conscious Sedations, Respiratory Insufficiency, C-Section Deliveries, any concerns about the baby, available for all deliveries-high risk, ICU [Intensive Care Unit], PFTs [Pulmonary Function Test], Pulmonary Week, Cardiac Catheter Lab, Transport patients vented to CT [Computed tomography] Scan, stay in the room with them, any aerosol treatment on the floor, Blood Gas, [measurement of how much oxygen and carbon dioxide are in your blood; determine the acidity (pH) of your blood], talk to patients that have smoking sensations/history of smoking, Emergency Room high acuity, Vents, Pediatric patients, CHF [Congestive Heart Failure] patients, Dialysis, Intubations from micro preemie to adults, and, calibrate and clean equipment

During an interview on 4/16/15 at 12:10 p.m., with the Medical Unit Charge Nurse regarding administration of treatment order; she revealed that " when the Respiratory Therapist is tied up or unavailable, they will call the Charge Nurse to notify us to let us know their status. Then the Unit Nurse will do it. "

During an interview on 4/16/15 at 2:40 p.m., with the Director for Respiratory Services revealed there is a back-up plan if the Respiratory Therapist is not available, to notify the nurse. The Respiratory Therapist will call each other or call the Director for Respiratory Services when they need assistance. On review of the Medication Administration Records (MARs) that included Albuterol Sulfate Inhalation Solution and Ipratropium Bromide, the Director for Respiratory Services confirmed the absence of initials on the MARs noted above.

During an interview on 4/17/15 at 10:45 a.m., with the Chief Medical Officer revealed that if the Respiratory Therapist was not able to give medical treatment, if medication is withheld; the Respiratory Therapist would document in electronic records. There may be a legitimate reason to hold medicine; often not consistent. They should initial.