HospitalInspections.org

Based on review of the medical record (MR), policies and procedures, and an interview, it was determined the facility staff failed to document all required identification information of the newborn's mother at time of delivery.

This affected Patient Identifier (PI) # 4, 1 of 2 OB (Obstetrics)/L & D (Labor and Delivery) active record reviews.

Findings include:

Policy: Records and Forms
Filing Number: (blank)
Reviewed Date: 10/30/19

Purpose: To establish guidelines for appropriate record keeping methods, provide documentation of quality care rendered, and secure statistical information.

Procedure:
...Newborn identification record with included maternal fingerprint and newborn footprints is to be completed in delivery room.

Policy: Identification of Infants
Filing Number: (blank)
Reviewed Date: 10/30/19

Procedure:
...Obtain infant footprints on the identification form along with the mother's right index fingerprint ...

1. PI # 4 was admitted to the facility on 12/2/19 with delivery of newborn on 12/2/19 at 11:06 AM.

Review of the Newborn MR included the Newborn Identification Form which revealed the infant's left and right footprints. There was no documentation of the mother's right index fingerprint.

The surveyor asked Employee Identifier (EI) # 6, OB Manager, "How does staff ensure that the newborn is placed with the correct mother if the mother's fingerprint is not obtained at time of delivery?" EI # 6 responded, "We always get the mother's fingerprint at time of delivery, however this occassion happened so sudden because of the urgent status of the delivery. But we also have strict newborn safety protocols, like our locked units, video surveillance at the nurse's station and bands on the baby's arm and leg that has to match with the mother's (parent) wristband. The bands will set off an alarm if the baby is taken close to any of our monitors that are at each exit of this unit. The baby also never leaves the mother throughout the hospital stay."

The surveyor observed EI # 6 test the security system and observed the L & D/OB department as a locked and secured unit with an audible alarm.

An interview was conducted on 12/3/19 at 1:06 PM with EI# 6, who confirmed the PI # 4's fingerprint was not obtained at time of delivery as indicated by facility policy.

Based on review of the Quality Assurance and Performance Improvement (QAPI) plan and interview, it was determined the hospital failed to assure all hospital services provided participated in QAPI. This affected the inpatient rehabilitation services and had the potential to affect all patients served.

Findings include:

Performance Improvement Plan 2018 and 2019

...Monroe County Hospital is committed to providing quality health care across the continuum of care, delivered by a collaborative multidisciplinary team of physicians, nurses and other health care professionals.

...Quality is determined through measurable outcomes, tracking the effect of process changes/improvements...

The Performance Improvement Committee meets quarterly and reviews each department's performance improvement outcomes for the previous quarter and progress toward the department's annual goals/objectives....

During the entrance conference conducted on 12/3/19 at 8:25 AM, Employee Identifier (EI) # 1, Chief Operating Officer, reported inpatient PT services were provided by contract staff.

On 12/4/19 at 8:10 AM during review of the facility PT services, the surveyor asked EI # 26, PT, what inpatient QA (quality assurance) activities were performed by the contracted PT services. EI # 26 reported no QA activities for inpatient PT services were performed. EI # 26 further stated that PT has not been a part of the QA program since it became a contract service.

On 12/5/19 at 10:45 AM, the hospital QAPI data was reviewed with EI # 4, Quality and Risk Management Director. During review of the hospital QAPI data there was no information identified related to the contracted PT services which provides all inpatient Physical Therapy needs for the hospital patients. EI # 4 was asked if the hospital had any QAPI data for PT services.

There was no QA documentation for PT services provided. EI # 4 stated this would be added to the contract.

Based on review of personnel files, facility job descriptions and interviews with the staff it was determined the facility failed to ensure the staff maintained current required ACLS (Advanced Cardiovascular Life Support) training and certification.

These deficient practices affected 2 of 8 Registered Nurse (RN) personnel files reviewed and had the potential to negatively affect all patients served by the facility.

Job Description
Job Title: Nursing Manager for Surgery, PACU (Post-Anesthesia Care Unit)

Position and Purpose:
...Performs duties in the capacity of staff nurse as needed ...

Position Qualifications:
Education/Training: ...ACLS, NRP (Neonatal Resuscitation Program), BCLS (Basic Cardiac Life Support). ...

Job Description
Job Title: Registered Nurse

Position Purpose: The Registered Nurse is responsible for delivery of patient care to pregnant mothers and their unborn babies in Labor and Delivery, and the immediate Postpartum setting ...

Licenses/Certifications: BCLS, ACLS, and NRP are required within the first year ...

1. Review of EI # 11, OR (Operating Room) Nursing Manager's, job description revealed required position qualifications for education/training for ACLS.

Further review of EI # 11's personnel file revealed no current ACLS certification training. The previous ACLS certification in EI # 11's personnel file expired October 2019.

An interview was conducted on 12/5/19 at 10:29 AM with EI # 8, Human Resources (HR) Director, who confirmed the above findings.

2. Review of EI # 16, OB (Obstetrics) RN's , Registered Nurse job description related to OB revealed required licenses/certifications for ACLS.

Further review of EI # 16's personnel file revealed no current ACLS certification training. The previous ACLS certification in EI # 16's personnel file expired October 2019.

An interview was conducted on 12/5/19 at 9:55 AM with EI # 8, who confirmed the above findings.

Based on review of facility policy and procedure, ED (emergency department) medical records, and staff interviews, it was determined the facility failed to ensure the ED staff followed the facility policy and procedure and documented the time(s) orders were written and/or received.

This affected 4 of 15 ED records reviewed which included PI (Patient Identifier ) # 19, PI # 12, PI # 20, PI # 16, and had the potential to negatively affect all patients who presented to the ED.

Findings include:

Policy Title: Verbal, Written and Electronic Orders-General
Revised Date: 6/17
Applies to: Pharmacy, Nursing

Policy:

Orders for patient treatment and medications...shall be written into the medical chart of the patient...

Procedure:

All verbal, written, and electronic orders for medications shall include the following criteria:

Date and time the order is prescribed verbally or via telephone
The name of the drug
Drug dosage
...The reason the drug is ordered for the patient
Specific indications for use, as appropriate...

1. PI # 19 presented to the ED on 6/10/19 at 2:10 AM with chief complaint, Acute Psychosis.

Review of the ED Notes/Orders documentation revealed Ativan 1 mg (milligram) IM (intramuscularly) and Vistaril 50 mg IM were ordered. There were no order (s) times documented.

Review of the ED Orders revealed restraints-leather 4 pt (point), Geodon 20 mg IM and Ativan 1 mg IM was documented. There was no order (s) times documented.

In an interview on 12/5/19 at 12:00 PM, Employee Identifier (EI) # 3, ER (Emergency Room) Nurse Manager, confirmed the nurse and physician who entered the medication orders and restraint order failed to follow the facility policy and document all required elements of patient treatment(s) and medication orders.

2. PI # 12 presented to the ED on 10/05/19 at 6:01 AM with chief complaint, Acute Psychosis.

Review of the ED Orders documentation revealed Mag (magnesium) Sulfate 2 gm (gram) IVPB (intravenous piggy back) and Hydralazine 10 mg IV. There were no order time(s) documented for the two IV medications.

In an interview on 12/5/19 at 12:05 PM, EI # 3 confirmed the above findings.

3. PI # 20 presented to the ED on 5/19/19 at 5:51 AM with chief complaint, Injuries to Face and Head, Assault.

Review of the ED Note/Orders documentation revealed Toradol 60 mg IM was ordered. There was no order time documented.

Further review of the ED Orders documentation revealed Morphine Sulfate 4 mg IV and Zofran 4 mg IV were ordered. There were no order time(s) documented.

In an interview on 12/5/19 at 12:08 PM, EI # 3 confirmed ED staff failed to document the time(s) the above medications were ordered in PI # 20's medical record.

4. PI # 16 presented to the ED on 9/15/19 at 8:41 PM with chief complaint, Injury to Right Ribs.

Review of the ED Note/Orders documentation revealed Morphine 4 mg IV and Zofran 4 mg IV were ordered. There were no order time(s) documented.

Further review of the ED Orders documentation revealed Zofran 8 mg ODT (orally dissolving tablet)was ordered. There was no order time documented.

In an interview on 12/5/19 at 12:15 PM, EI # 3 confirmed the aforementioned findings and reported she/he had addressed ED staff policy noncompliance with a memo (memorandum) regarding the above findings.

Based on review of facility policies and procedures, facility current diet orders, observations and interviews with staff it was determined the facility dietary staff failed to:

1. Ensure the physician ordered diet was provided.

2. Maintain menus and substitutions per the facility policy.

3. Ensure quantity of servings were accurately measured according to prescribed diet.

This affected 4 of 4 1800 calorie ADA (American Diabetes Association) diet orders and had the potential to negatively affect all patients admitted to the facility.

Findings include:

Policy Title: Patient Menus
Revised Date: 11/19
Applies to: Nutrition Services

Policy: ...Patient menus are written to supply the recommended daily allowance...Nutritional needs of the patient are met in accordance with the physician's order and, in as far as the diet permits, meets the Recommended Dietary Allowance (RDA) of the Food and Nutrition Board of the National Research Council....

Procedure: The menu is planned by the Registered Dietitian and the Nutritional Services Director. When changes are necessary, they shall be made by the Nutritional Services Director and/or the Registered Dietitian. Notation of the change shall be recorded on the planned menu...

Policy Title: Patient Tray Service
Revised Date: 11/19
Applies to: Nutrition Services

Policy: The Nutritional Services Department shall provide food in the quality and quantity needed to meet the patient's need in accordance with physician's order to meet RDA to the extent medically possible....The Registered Dietitian shall be responsible for substituting foods so that the patient has adequate quality and quantity.

On 12/4/19 at 9:35 AM a tour of the Dietary Department was conducted with Employee Identifier (EI) # 22, Dietitian, and EI # 23, Dietary Manager. The surveyor asked EI # 23 if there was documentation of weekly menus and any substitutions for the last 3 months. EI # 23 verbalized there was no documentation of the menus used or any substitutions for the last 3 months.

Review of the therapeutic diet menu for 12/4/19 revealed the following menu:
3 oz (ounce) Meat Loaf
1/2 cup Noodles
1/2 cup green beans
1/2 cup peaches
1 slice coconut pie
roll or white bread
iced tea

Further review of the therapeutic diet for 12/4/19 revealed documentation "give 2 oz meat/give diet peaches/give unsweetened tea/no pie for the Diabetic diet".

On 12/4/19 at 11:15 AM, EI # 23 provided the surveyor with a list of the diets currently ordered in the facility.

Review of the list of patient diets dated 12/4/19 revealed 4 patients were on an 1800 Calorie ADA diet.

An observation was conducted on 12/4/19 at 11:30 AM to observe the facility lunch service for the patients.

EI # 29, Dietary Aide assembled the food dishes for lunch on the lunch line, cut the meatloaf, and placed serving scoop and spoons in the food dishes. The surveyor observed the serving scoop and spoons placed in the dishes for serving did not have a measure to indicate the size of the serving. The surveyor also observed the meatloaf was cut into equal parts with no allowance for smaller portions.

During the observation the following were served for a Diabetic diet:

1 piece of sliced meatloaf
2 spoonful's of noodles
2 spoonful's of green beans
2 to 3 spoonful's of mixed vegetables
cup of Dole peaches (diet peaches)
roll
unsweet tea

Following the observation, the surveyor asked EI # 23 if there was documentation on the menu of mixed vegetables served during the observation. EI # 23 verbalized there was no documentation of the mixed vegetables served during observation.

On 12/4/19 at 1:10 PM, EI # 29 was asked by the surveyor how she/he knew how much to cut for a serving size of meatloaf. EI # 29 verbalized she/he just tried to cut the meatloaf into equal sections and was not aware of how many ounces were in each section. EI # 29 also was able to verify the spoons and scoop used during the lunch services did not have any measurement on them to indicate the size of the serving.

The facility dietary staff failed to provide the physician ordered and dietitian approved 1800 ADA diet due to not measuring the quantity of food plated and by adding mixed vegetables that were not planned for the lunch menu.

An interview was conducted on 12/4/19 at 10:45 PM with EI # 22 and EI # 23 who confirmed the above findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on observations, review of the facility policies and procedures, Hospital Bylaws, and interviews it was determined the facility failed to ensure:

a) The hospital staff followed their own standards of practice for infection control and prevention.

b) The medical staff participated in quarterly infection control committee responsibilities as directed by the Hospital Bylaws.

Findings include:

Refer to A 749 and A 756.

Based on review of facility policies and procedures, observations and interviews with staff, it was determined the facility failed to ensure the staff:

a) Followed the facility policy and procedure for proper hand hygiene and glove use.

b) Ensured all supplies and PPE (personal protective equipment) considered contaminated were discarded and not used during patient care.

c) Followed principles of clean versus dirty when preparing and administering medications including IV (intravenous) medications.

d) Cleaned all re-usable equipment after patient use including the glucometer.

e) Followed the facility policy for PPE use during care of patients on Contact Isolation Precautions.

f) Followed principles of clean versus dirty when obtaining clean supplies following venipuncture.

g) Followed manufacturer's recommend submersion time for sanitization of pots and pans in the dietary department.

This affected Patient Identifier (PI) # 1, PI # 6, PI # 2, PI # 33, PI # 4, and 5 unsampled patient observations. This also had the potential to negatively affect all patients admitted to the facility and staff.

Findings include:

Policy Title: Hand Hygiene Program
Filing Number (blank)
Reviewed Date: 5/28/19

The following policy and procedure is based on the CDC (Center for Disease Control) Hand Hygiene Guideline in Health Care Settings...

Procedure:

Handwashing:

...wash hands with either non-antimicrobial or microbial soap and water...Rinse hands with water...Use towel to turn off faucet...

Alcohol Hand Rubs:

If hands are not visibly soiled, use an alcohol-based hand rub...

Before direct contact with a patient's skin...

After skin or mucous membrane contact

Moving from a contaminated-body site to a clean-body site during patient care

After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient...

Policy Title: Standard Precautions
Filing Number (blank)
Effective Date: September 2000

...Standard Precautions include...

Hands are to be washed after touching ...contaminated items, whether or not gloves have been worn...Hands must be washed immediately after removal of gloves...
Gloves shall be changed between tasks and procedures...that may contain a high concentration of microorganisms...

Patient Care Equipment

...Make sure that reusable equipment has been cleaned....appropriately, prior to use on another patient...

Policy Title: Aseptic Technique
Filing Number 3410
Applies to: Pharmacy and Nursing
Revised Date: 6/17

Purpose: To outline techniques to be used in sterile compounding in all environments and risk levels.

Policy:

Sterile products compounded outside the pharmacy are considered high risk for accidental introductions non-sterile contaminants.

Procedure:

I. Observe these steps to minimize contamination
A. Select a CLEAN, uncluttered work area.
B. Sanitize the work counter with isopropyl alcohol and let dry 15-30 seconds...

Policy Title: Medication Administration by Mouth
Filing Number: 550-262
Revised Date: 9/01

Statement of Purpose: To provide safe, accurate administration of prescribed medications.

Procedure:
...Wash hands prior to giving and after giving medications

Procedure: Steps for Manual Dishwashing
Date: Not documented

Rinse, Scrape, or Soak, Wash... Rinse... Sanitize...Air Dry
...Time for Sanitizing... Quaternary Ammonium... Follow Manufacturer's Instructions.

Diverse Three Compartment Sink Set-Up
copyright date of 2018

Cleaning Procedure...Sanitize 1 Minute... Air Dry

Policy: Guidelines for Isolation Precautions
Revised: 9/2000

...5. Contact Precautions...

B. Gloves and Handwashing...Remove gloves before leaving the patient's environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent...

C... Remove the gown before leaving the patient's environment...

E. Patient Care Equipment... If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patient.

1. On 12/3/19 at 9:20 AM an observation of medication pass was conducted on EI (Employee Identifier) # 10, RN (Registered Nurse).

EI # 10 assembled the medications, pill crusher, and laptop outside of the room of PI # 1, a patient on contact isolation.

EI # 10 entered the room with gown and gloves, positioned the patient and crushed the medications with the pill crusher.

EI # 10 then left patient room to retrieve another medication. The gown and gloves were removed at the nurses station. EI # 10 did not perform hand hygiene before entering medication room.

After medications were administered via PEG (Percutaneous Endoscopic Gastrostomy) tube. EI # 10 then documented the medications on the laptop., EI # 10 exited the room with the pill crusher and laptop. EI # 10 returned the pill crusher to the medication room. The pill crusher and laptop were not cleaned prior to exiting isolation room.

EI # 10 failed to observe hospital policy for isolation procedures and cleaning of equipment.

An interview was conducted on 12/5/19 at 11:45 with EI # 2, Intensive Care/Medical Surgical Manager who confirmed the above findings.

2. On 12/3/19 at 10:25 AM, an observation of care was conducted in the ED (emergency department) Exam 2 with EI # 9, ED, RN.

EI # 9 entered Exam 2 with an IV (intravenous) Zofran syringe and ETOH (isopropyl alcohol) prep (preparation) package in hand. EI # 9 sanitized hands and donned gloves. EI # 9 dropped the ETOH package on the floor. With gloved hands, EI # 9 retrieved the ETOH package from the floor, opened the alcohol package, removed the ETOH pad and cleaned the IV hub of an unsampled ED patient with the ETOH pad.

EI # 9 failed to remove gloves and perform hand hygiene after retrieving the contaminated ETOH package from the floor. EI # 9 failed to discard the contaminated ETOH package and obtain clean patient supply.

3. An observation was conducted with EI # 15, Phlebotomist, on 12/3/19 at 10:50 AM to observe a venipuncture. EI # 15 performed venipuncture to the unsampled patient's left hand, filled 4 tubes with blood, then obtained cotton ball from jar of clean cotton balls on the lab counter and obtained coban dressing from clean supply cabinet while wearing the same gloves used to obtain blood sample. EI # 15 failed to follow principles of clean versus dirty when obtaining clean supplies following a venipuncture.

An interview was conducted on 12/3/19 at 12:00 PM with EI # 30, Laboratory Director, who confirmed the above findings were against facility policy.

4. On 12/3/19 at 11:20 AM in the ICU medication room, EI # 10 reported to the surveyor the "red tape" area on the counter top was considered the clean med (medication) prep area and was to be cleaned after each use. On the med counter top, between the "red tape" area, EI # 10 mixed Piperacillin 3.75 gm (grams) with 100 ml (milliliter) Sodium Chloride for IV infusion.

EI # 10 failed to sanitize the work counter top with isopropyl alcohol before initiating the compounding procedure. EI # 10 exited the medication prep room without disinfecting the medication prep area.

EI # 10 entered room 308, donned gloves, but failed to perform hand hygiene. EI # 10 administered PI # 6's sliding scale Humulin insulin. With same gloves on, EI # 10 moved to the other side of the bed, pulled the bedsheets back, to assess the foley catheter patency. EI # 10 reported to PI # 6 that following medication administration he/she would perform incontinence care.

EI # 10 then removed/discarded his/her gloves, but failed to perform hand hygiene prior to exiting room 308. After a 1-2 minutes, EI # 10 returned with an IV extension tubing. EI # 10 donned clean gloves, but failed to perform hand hygiene. EI # 10 then administered the IV Piperacillin.

In an interview on 12/5/19 at 9:15 AM, EI # 5, Infection Control (IC) Manager confirmed EI # 10 failed to follow the facility IC policies for disinfection of the medication prep area, equipment cleaning, hand hygiene and glove use.

5. PI # 2 was admitted to the hospital on 11/29/19 with diagnoses including Lower Abdominal/ Inguinal Crease Area Pain and History Of Lumbar Disc Disease With Previous Surgery.

An observation of care was conducted on 12/3/19 at 2:00 PM to observe EI # 27, RN administer intravenous (IV) medication, Zosyn 3.375 GM in 100 ML Normal Saline as IV Piggy Back (PB).

At 2:00 PM, this surveyor observed EI # 27 prepare IV medication. At the patient's bedside, EI # 27, with gloves, identified and assessed IV site for patency, EI # 27 removed gloves and without performing hand hygiene, donned on new gloves and proceeded to connect IV fluids/ tubing to the IV site.

An interview was conducted on 12/3/19 at 2:10 PM with EI # 2 who confirmed the staff were to perform hand hygiene prior to donning clean gloves.

6. PI # 33 was admitted to the hospital on 12/2/19 with diagnosis of Cellulitis of Left Arm.

An observation of care was conducted on 12/4/19 at 8:10 AM to observe EI # 28, RN administer IV medication, Rocephin I GM in 50 ML Normal Saline as IV PB.
EI # 28, wearing gloves, identified the patient, assessed the patient's IV site, removed gloves but failed to perform hand hygiene prior to donning clean gloves to connect IV medication to the patient's IV site.

7. An observation of care was conducted on 12/4/19 at 8:25 AM to observe EI # 28 perform blood sugar check on unsampled patient. EI # 28 failed to disinfect glucometer machine after use and before storage.

An interview was conducted on 12/4/19 at 8:20 AM with EI # 2 who confirmed the staff were to perform hand hygiene prior to donning clean gloves.

8. An observation was conducted with EI # 18, RN on 12/4/19 at 8:30 AM to observe administration of oral, subcutaneous (SQ), and IV medications.

EI # 18 entered room 339 and administered the oral medications to the patient, EI # 18 then proceeded to clean abdomen with alcohol and administer Lovenox injection SQ with the same gloves used to administer the oral medications. EI # 18 failed to remove used gloves and perform hand hygiene prior to moving to clean site for the administration of the Lovenox injection.

EI # 18 prepared two syringes during the observation, one syringe contained Hydromorphone 2 mg and one contained Promethazine 25 mg. Both syringes were prepared on top of laptop keyboard, which was brought into room 339 from the nurse's station and not cleaned. EI # 18 then placed the filled syringes on the computer mouse pad prior to the administration of the Hydromorphone and Promethazine IV. EI # 18 then returned laptop, keyboard, and mouse pad which were located on top of a rolling bedside table to the nurse's station and proceed to perform documentation without cleaning the laptop, keyboard, and mouse pad after use. EI # 18 failed to prepare injection medication on a clean and uncluttered work area.

An interview was conducted on 12/5/19 at 9:15 AM with EI # 2, Intensive Care Unit/Medical-Surgical Manger, who confirmed the above findings were against facility policy.

9. An observation was conducted on 12/4/19 at 8:50 AM to observe EI # 16, OB (Obstetrics) RN, perform a medication pass for PI # 4.

During the observation, EI # 16 obtained PI # 4's medications from the Medication Pyxis. EI # 16 failed to perform hand hygiene before preparing the medications. EI # 16 proceeded to PI # 4's room to administer the medications. After administering the medications, EI # 16 exited the room and returned to the nurses' station. EI # 16 failed to perform hand hygiene following medication administration.

An interview was conducted on 12/4/19 at 10:17 AM with EI # 6, OB Manager, who confirmed the above findings.

10. An observation was conducted on 12/4/19 at 1:26 PM with EI # 19, Dietary Employee, to observe cleaning and sanititation of the pots and pans used for the lunch service on 12/4/19.

EI # 19 filled and tested a 3 compartment sink as follows: first compartment with water and liquid detergent, second compartment with water, and third compartment with Diverse (Brand) J-512 Sanitizer.

EI # 19 proceeded to wash the pots and pans used during the lunch service in the first sink, submerge them in the second sink to rinse and immediately remove then submerge them and immediately remove from the third sink for the sanitizer. EI # 19 failed to allow the pots and pan to remain submerged in the sanitizer for 1 minute per the manufacturer recommendation.

After removal from the sanitizer EI # 19 placed the pots and pan on the side of the 3 compartment sink to dry and stacked 4 pans on top of each other (wet-nesting) preventing them from air drying.

11. An observation was conducted on 12/4/19 at 2:15 PM with EI # 18, RN, to observe catheter care for PI # 6. During the observation, EI # 18 removed gloves and precede to don clean gloves 5 times without performing hand hygiene.

An interview was conducted on 12/5/19 at 9:15 AM with EI # 2 who confirmed the above findings were against facility policy.



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Based on review of hospital Bylaws and Rules and Regulations, 2019 Infection Control Committee (ICC) Meeting Minutes documentation, and staff interview, it was determined the facility failed to follow their own Bylaws and ensure at least one member of the medical staff participated in Quarterly Infection Control Committee responsibilities. This had the potential to negativity affect all patients treated at the facility.

Findings include:

Monroe County Hospital Bylaws and Rules and Regulations
Section 10.5
pages 57 and 58

10.5-1 Infection Control Committee

The infection control committee shall consist of at least one member of the medical staff...

10.5-2 DUTIES

a. developing a hospital-wide infection control program and maintaining surveillance over the program;
f. acting upon recommendations related to infection control...

10.5-3 MEETINGS

The infection control committee shall meets as often as necessary....but at least quarterly....

During a review of the hospital infection control program on 12/5/19 at 9:45 AM, Employee Identifier (EI) # 5, Infection Control Manager, reported the ICC met quarterly and included representation from the medical staff who served as ICC Chairman.

Review of the 2019 ICC Meeting Minutes for Quarter 1 dated February 27, 2019, for Quarter 2, dated May 29, 2019 and for Quarter 3 dated August 29, 2019 revealed no documentation of medical staff representation during the 3 (three) 2019 ICC meetings.

On 12/5/19 at 10:35 AM, EI # 5 confirmed he/she thought the physician was present for one meeting however, there was no documentation of medical staff attendance at the 3 ICC meetings in 2019. There was no signature of the ICC Chairman on the ICC Meeting Minutes.

Based on review of the medical record, policy and procedure, facility's Patient Choice Form, and an interview, it was determined the facility failed to provide documentation the patient was offered a choice of home care providers. This affected Patient Identifier (PI) # 7, 1 of 1 discharge record reviews with a home health referral at discharge.

Findings include:

Patient Choice Form

"Your Physician has recommended additional or continued services after you leave... As a service to you, and in keeping federal requirements. we are providing you with a list of providers in the community and surrounding region who provide these services...You have the right to choose any provider to supply the care/ordered recommended by your physician."

Policy: Patient Choice Policy
Filing Number: (blank)
Effective Date: 10/11/2010
Revised Date: (blank)

Policy:

...All patients, regardless of payment sources, will be provided information on facilities/agencies available in the area and will have the ability to choose a provider for post-discharge services ...

Purpose:

The discharge of a patient from the hospital to an outside agency/facility is determined by the patient and/or designated representative in conjunction with the entire health care team. The patient/designated representative is free to choose any provider.

Procedure:

After determining that the patient will require post discharge referral, the case management staff will:
...d. Obtain the patient and/or family signature consent of post acute care provider/facility.

1. PI # 7 was admitted to the facility on 9/6/19 with diagnoses including Hypokalemia and Weakness.

Review of the medical record revealed physician orders dated 9/9/19 to "dismiss home with Home Health".

There was no documentation PI # 7 was offered a choice of home health care providers and no documentation PI # 7 signed the facility Patient Choice form.

In an interview conducted on 12/5/19 at 8:06 AM, Employee Identifier # 7, Director of Case Management, confirmed there was no documentation the patient was offered a choice of Home Health providers.

Based on medical record review, observation and interviews, it was determined the facility failed to ensure physician orders were obtained for wound care provided by Physical Therapy (PT).

This affected 1 of 1 records reviewed with PT services which included Patient Identifier (PI) # 32 and had the potential to affect all patients served by this facility.

Findings include:

1. PI # 32 was admitted to the facility on 12/4/19 with diagnosis of Diabetic Foot Infection.

Review of admission order dated 12/4/19 at 12:10 PM revealed a PT consultation of ulcer (foot).

Review of PT Initial Evaluation of Wound note dated 12/4/19 at 2:00 PM revealed the Plan of Care included: dressing/debridement daily during hospitalization.

On 12/5/19 at 8:35 AM, Employee Identifier (EI) # 26 was observed performing wound care of the foot on PI # 32.

The wound care procedure was as follows: The old dressing was removed, wound area cleaned with Normal Saline (NS), folded 4 x 4 gauze was placed between toes, covered with 4 x 4, and secured with paper tape.

Review of the physician orders revealed no orders for the above wound care that was performed by EI # 26.

On 12/5/19 at 11:45 AM, an interview was conducted with EI # 2, Intensive Care Unit/Medical Surgical Director who confirmed the above findings.