HospitalInspections.org

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure all departments of the hospital reported quality monitors or provided presentations to the hospital's Quality Council.

Findings include:

Review on July 21, 2014 revealed the facility's "Plan For Improving Organizational Performance," dated approved December 2013, revealed "The Board of Directors, Medical Staff and Hospital Administration of the Evangelical Community Hospital affirm their commitment and responsibility for maintaining and improving the quality of care in the hospital. While maintaining ultimate authority, the Board of Directors has authorized the Medical Staff and Hospital Administration to accept and discharge these obligations. Statement of Goals The goal of the performance improvement program is to promote, preserve and improve the health of members of our community by continually assessing and improving the quality of care and services provided throughout the hospital. We will strive to meet or exceed the needs of our patients and their families, our employees, our medical staff and third party payors within the limits of available resources. Statement of Purpose The purpose of the performance improvement program is to provide efficient and effective mechanisms of identifying, reporting, reviewing, evaluating and monitoring all aspects of patient care. All activities in the hospital, both clinical and non-clinical, are processes that can be continuously improved. Committee Structure Performance Improvement Committee (PIC) ... The Board of Directors and Executive Committee of the Medical Staff will receive regular reports from the PIC regarding performance improvement activities of the Medical Staff and Hospital departments. ... Quality Council The role of the Quality Council is to oversee the performance improvement activities of Hospital departments and assist quality improvement teams in all phases of their quality activities. ... Hospital Departments Complete regular reports on all quality activities and submit to Quality Council. Participate in interdepartmental or interdisciplinary quality activities as requested. Model Core Values. Initiate QA/QI activities based on identified needs. ..."

Review on July 21, 2014 of the facility document "PIC" meeting minutes for 2012, 2013, and 2014 revealed no documentation of reporting of quality monitors or presentations from the departments of the hospital to the Quality Council.

Interview with EMP1 on July 23, 2014, at approximately 11:30 AM confirmed there was no documentation of quality monitors or presentations from all departments of the hospital for 2012, 2013, and 2014. EMP1 confirmed the format of the Quality Council committee changed approximately two years ago. EMP1 confirmed a calendar was used in the past that identified when each department would report their data to the Quality Council.

Based on review of facility documents, personnel files (PF) and staff interview (EMP), it was determined the facility failed to ensure nurses had the specialized qualifications required to work in the Intensive Care Unit (ICU) for seven of seven applicable PFs reviewed (PF1, PF4, PF7, PF10, PF11, PF12 and PF13).

Findings include:

Review on July 23, 2014, of the job description for the RN in ICU [Registered Nurse in Intensive Care Unit] provided by the facility revealed "Purpose of Your Position - Perform the functions of assessing, planning, implementing and evaluating patient care in accordance with established nursing standards for the ICCU [Intensive Cardiac Care Unit]. ... Qualifications 1. Satisfactory completion of an accredited school of nursing, current Pennsylvania license. 2. BLS [Basic Life Support] certification required. Advanced Cardiac Life Support [ACLS] certification and completion of basic rhythm course required before employee begins work. ..."

Review on July 24, 2014 of PF1 revealed the RN was hired on June 23, 2014, to work in the ICCU. Review of PF1's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF1, as required by their job description.

Review on July 24, 2014 of PF4 revealed the RN was hired on May 12, 2014, to work in the ICCU. Review of PF4's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF4, as required by their job description.

Review on July 24, 2014 of PF7 revealed the RN was hired on June 9, 2014, to work in the ICCU. Review of PF7's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF7, as required by their job description.

Review on July 24, 2014 of PF10 revealed the RN was hired on August 19, 2013, to work in the ICCU. Review of PF10's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF10, as required by their job description.

Review on July 24, 2014 of PF11 revealed the RN was hired on June 9, 2014, to work in the ICCU. Review of PF11's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF11, as required by their job description.

Review on July 24, 2014 of PF12 revealed the RN was hired on June 9, 2014, to work in the ICCU. Review of PF12's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF12, as required by their job description.

Review on July 24, 2014 of PF13 revealed the RN was hired on March 17, 2014, to work in the ICCU. Review of PF13's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF13, as required by their job description.

Interview with EMP25 at approximately 10:00 AM on July 24, 2014, confirmed PF1, PF4, PF7, PF10, PF11, PF12 and PF13 did not have ACLS certification prior to working in the ICCU, as required by their job descriptions.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure medical records were stored in a manner to prevent unauthorized access in the facility's sleep lab.

Findings include:

Review on July 23, 2014, of the facility's "Cardiopulmonary Services Confidentiality of Patient Records" policy, last reviewed May 2013, revealed "Purpose: To ensure the confidentiality of patient records. ... IV. All patient files are locked when staff is not present."

Observation on July 23, 2014, of the facility's sleep lab revealed an unlocked and unmonitored door which opened into the sleep lab from an unmonitored hallway. Further observation revealed an open and unoccupied office identified by EMP32 as an office used at one time by a secretary. Continued observation revealed 40 patient medical records on the desk and shelving unit, two unlocked cabinets with seven drawers containing patient medical records and one unlocked cabinet with six drawers containing patient medical records. EMP32 confirmed these patient medical records contained protected health information.

Interview with EMP32 on July 23, 2014, at approximately 10:50 AM confirmed the observation of the unlocked and unmonitored door which opened into the sleep lab from an unmonitored, open and unoccupied office used at one time by a secretary, the 40 patient medical records on the desk and shelving unit, and the unlocked cabinets containing patient medical records.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure electrical control panels for the nurse call system on the facility's orthopedic patient care unit were secure.

Finding include:

Review on July 22, 2014, of the facility provided "National Electrical Code Handbook 2011" revealed "... Article 110 Requirements for Electrical Installations ... 110.26 ... F. Locked Electrical Equipment Rooms or Enclosures. Electrical equipment rooms and enclosures housing electrical apparatus that are controlled by a lock(s) shall be considered accessible to qualified persons. ..."

Tour of the facility's orthopedic patient care unit on July 22, 2014, revealed an unmarked and unlocked door leading to a supply room directly across from an elevator. This room contained wheelchairs, a blanket warmer, physical therapy equipment and patient care equipment. Further observation revealed a grey colored wall mounted panel box with two doors. One of the doors contained a handle with a locking mechanism. The doors of this panel box were in the open position. Continued observation of this panel box revealed multiple colored wires and electrical plugs. EMP26, EMP27 and EMP28 identified this panel box as the nurse call system which patients use to summon a nurse for help.

Interview with EMP26 on July 22, 2014, at approximately 11:45 AM confirmed the observation of the unmarked and unlocked door leading to a supply room directly across from an elevator. EMP26 confirmed this room contained wheelchairs, a blanket warmer, physical therapy equipment and patient care equipment. EMP26 also confirmed the grey colored wall mounted panel box with two doors, one of the doors contained a handle with a locking mechanism, that the doors of this panel box were in the open position, and that this panel box contained multiple colored wires and electrical plugs. EMP26 confirmed this room was never locked and this room was in an unmonitored hall near an elevator.

Interview with EMP27 and EMP28 on July 22, 2014, at approximately 1:00 PM revealed the nurse call system controls were referred to as the nurse call system mechanical box. EMP27 and EMP28 also confirmed the nurse call system mechanical box could be easily disrupted by pulling a connecting wire.

Interview with EMP27 on July 22, 2014, at approximately 1:30 PM revealed an electrical vendor completed work on this nurse call system, as well as in other areas of the facility approximately three months ago. Further interview revealed the facility does not have a policy, procedure or mechanism in place to ensure a vendor has locked and secured an area following completion of work.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure a system for cleaning laundry chutes was designed and implemented to prevent and minimize infection hazards, failed to ensure staff followed established policies and procedures for patients in contact isolation for one of two patients observed requiring contact isolation (MR12), failed to ensure staff handled soiled linen in a manner to prevent cross contamination on the orthopedic patient care unit, and failed to ensure single use Neo-Synephrine was used for one patient in the Emergency Department.

Findings include:

1) Review on July 22, 2014 of the facility "Infection Prevention and Control Plan," dated reviewed March 2014, revealed "Goals of the Infection Prevention and Control Program ... 2. Analyze practices that have the potential to affect the rate of hospital-acquired infections. ... Infection Control Committee Authority and Responsibility The ICC [Infection Control Committee] Chairman and/or the Infection Control Practitioner under the direction the [sic] ICC Chairman has the authority to institute surveillance, prevention or control measures or studies when there is reason to believe that patients, personnel or visitors may be in danger. This authority and responsibility includes, but not limited to: Development and implement a preventative and corrective program designed to minimize infection hazards. ... Review and approve of policies and procedures pertaining to infection surveillance and control activities in all departments/services. ..."

Observation tour on July 23, 2014, at approximately 10:00 AM of the facility's laundry chutes revealed when the chute doors were opened bags of soiled linen fell into a bin directly beneath the door. Observation revealed there were bags that were open or ripped open. There were chux pads (waterproof, disposable pads used underneath a patient who is incontinent) emerging from the open/ripped linen bags.

Interview with EMP10 on July 23, 2014 at 10:00 AM confirmed the facility had no policy in place for cleaning of the laundry chute.

Interview with EMP20 on July 23, 2014 at approximately 9:30 AM confirmed the facility had no official process for the cleaning of the laundry chutes.

2) Review on July 22, 2014, of the facility's "Infection Control Policy," last reviewed March 2014, revealed "Isolation Guidelines Purpose: Isolation practices are utilized to ensure a safe environment for patients, staff and visitors by preventing the transmission of infection. ECH [Evangelical Community Hospital] isolation policies address the prevalence of communicable diseases and multi-drug organisms (MDROs) and follow acceptable CDC [Centers for Disease Control] guidelines accordingly. Policy: The guideline defines infection prevention and control practices that will ensure the safety of patients, employees, and visitors by minimizing the risk of acquisition and transmission of hospital acquired infections. II. Specific Isolation Categories and Requirements ... B. Contact Precautions (C) are used in addition to Standard Precautions for patients known or suspected to be infected or colonized with microorganisms that can be transmitted by direct or indirect patient contact. Patients with a known history of an MDRO (MRSA, VRE, ESBL) [Methicillin-resistant Staphylococcus Aureus, Vancomycin-Resistant Enterococci, Extended Spectrum Beta-Lactamase] will be placed into Contact Precautions until cleared through infection Control. ... 4. Personal protective equipment a. Gloves must be worn to enter the room and removed before leaving the room. b. Gown must be worn to enter the room and removed before leaving the room. ..."

Observation on July 22, 2014, at approximately 10:00 AM revealed a Stop sign posted outside of the patient room for MR12. Further observation of the Stop sign revealed "Contact Precautions Perform hand hygiene before entering room and wash hands with soap [sic] water before leaving room. Before entering room: Wear Gown Wear Gloves. Before leaving room: Remove Gloves and discard in trash can Remove Gown (turn inside-out so contaminated side is not exposed) and place in linen container or trash can if disposable."

Review of MR12 on July 22, 2014, revealed this patient was placed on Contact Precautions for a history of MRSA.

Observation of EMP29 on July 22, 2014, at approximately 10:30 AM revealed this employee entered MR12's room without wearing a gown or putting on gloves, as required by facility policy for patients on Contact Precautions.

Interview with EMP29 on July 22, 2014, at approximately 10:35 AM confirmed EMP29 entered MR12's room without wearing a gown or putting on gloves, as required by facility policy for patients on Contact Precautions.

Interview with EMP26 on July 22, 2014, at approximately 10:40 AM confirmed all employees must follow facility established isolation precautions for patients on Contact Precautions.

3) Review on July 22, 2014, of the facility's "Infection Control Policy Isolation Guidelines," last reviewed March 2014, revealed "Purpose: Isolation practices are utilized to ensure a safe environment for patients, staff and visitors by preventing the transmission of infection. Policy: The guideline defines infection prevention and control practices that will ensure the safety of patients, employees, and visitors by minimizing the risk of acquisition and transmission of hospital acquired infections. Procedure: I. General Fundamentals of Isolation Precautions ... H. Linens are handled per Standard Precautions. Refer to Linen Policy for additional information. ... II. Specific Isolation Categories and Requirements ... 6. Linen: a. Handle soiled linen to prevent contamination of HCWs [Health Care Workers] clothing and patient environment. Soiled linens should be contained at the point of use. ..."

Observation of EMP30 on July 22, 2014, revealed this employee completed patient care for MR14. Further observation revealed EMP30 placed the soiled linen on the floor. Continued observation revealed EMP30 picked up the soiled linen and carried the soiled linen against their uniform for disposal in the soiled linen container.

Interview with EMP26 and EMP30 on July 22, 2014, at the time of the observation confirmed the observation of EMP30 placing soiled linen on the floor, picking up the soiled linen, and carrying the soiled linen against their uniform for disposal in the soiled linen container.

Observation of EMP31 on July 23, 2014, revealed this employee completed patient care for MR15. Further observation revealed EMP31 placed the soiled linen on the floor. Continued observation revealed EMP31 picked up the soiled linen and carried the soiled linen against their uniform for disposal in the soiled linen container.

Interview with EMP26 and EMP31 on July 23, 2014, at the time of the observation confirmed the observation of EMP31 placing soiled linen on the floor, picking up the soiled linen, and carrying the soiled linen against their uniform for disposal in the soiled linen container.

Interview with EMP26 on July 23, 2014, at approximately 10:15 AM confirmed staff was not to place soiled linen on the floor or carry it against their uniform. EMP26 confirmed the facility's "Infection Control Policy Isolation Guidelines" applied to all staff for the handling of soiled linen for patients in isolation and patients not in isolation.

4) A request was made on July 21, 22, and 23, 2014, of EMP1, EMP18 and EMP37 for a facility policy regarding the use of nasal spray. No policy was provided.

Observation on July 21, 2014, in the emergency department (ED) revealed a container with supplies for ED staff to use when inserting a nasogastric tube (a tube inserted into the nose to the stomach). Further observation revealed an open and partially used bottle of Neo-Synephrine (nasal decongestant) 15 millimeters (ml). EMP37 confirmed the Neo-Synephrine was sprayed into the patient's nose to numb it before the nasogastric tube was inserted.

Interview with EMP37 on July 21, 2014, at approximately 2:00 PM confirmed the observation of the container with supplies for ED staff to insert a nasogastric tube and the open and partially used bottle of Neo-Synephrine. Further interview revealed the open and partially used bottle of Neo-Synephrine was meant for single use. EMP37 confirmed the bottle of Neo-Synephrine was used on multiple patients to numb the inside of the nose.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a pre-anesthesia evaluation was completed and documented within 48 hours prior to surgery for six of 11 surgical medical records reviewed (MR31, MR34, MR36, MR37, MR40 and MR41).

Findings include:

Review on July 24, 2014, of the facility's "Pre and Post Anesthesia Evaluation Policy," last revised July 6, 2013, revealed "Policy: Evangelical Community Hospital shall ensure that all patients receiving anesthesia or sedation and analgesia care shall be assessed, managed and monitored in a manner that optimizes patient safety. Pre and Post anesthesia evaluation policies and procedures follow state and federal law and regulations, and have been approved by the medical staff. Procedure: All patients receiving general, regional and monitored anesthesia shall have a preanesthesia evaluation completed and documented by a practitioner qualified and privileged to administer anesthesia, within 48 hours prior to surgery or a procedure requiring anesthesia services. ... Preanesthesai [sic] Evaluation The preanesthesia evaluation shall be performed within 48 hours prior to any surgery (administration of first dose of anesthesia marks the end of the 48 hours) with general, regional or monitored anesthesia, and shall include, but is not limited to: Review of the medical history, including anesthesia, drug and allergy history. Interview and examination of the patient. Notation of anesthesia risk according to established standards of practice ... Identification of potential anesthesia problems, particularly those that may suggest potential complications or contraindications to the planned procedure ... Additional preanesthesia evaluation, if applicable and as required in accordance with standard practice prior to administering anesthesia ... Development of the plan for the patient's anesthesia care, including the type of medications for induction, maintenance and postoperative care and discussion with the patient ... of the risks and benefits of the delivery of anesthesia. ..."

1) Review of MR 31 on July 24, 2014, revealed the patient had a surgical procedure performed on April 17, 2014. Further review of MR31 revealed OTH1 dated the patient's pre-anesthesia evaluation April 18, 2014.

Interview with OTH1, EMP33, EMP35 and EMP36 on July 24, 2014, at approximately 9:00 AM confirmed MR31 had a surgical procedure performed on April 17, 2014, and OTH1 dated the patient's pre-anesthesia for April 18, 2014. Further interview with OTH1 and EMP36 confirmed MR31's pre-anesthesia evaluation was dated after the completion of MR31's surgical procedure.

2) Review of MR41 on July 24, 2014, revealed the patient had a surgical procedure performed on July 21, 2014. Further review of MR41 revealed OTH2 did not date or time the patient's pre-anesthesia evaluation.

Interview with EMP33, EMP35 and EMP36 on July 24, 2014, at approximately 9:30 AM confirmed MR41 had a surgical procedure performed on July 21, 2014, and OTH2 did not date or time the patient's pre-anesthesia evaluation.

3) Review of MR34, MR36, MR37 and MR40 on July 24, 2014, revealed these patients had surgical procedures performed on May 16, 2014. Further review revealed OTH2 did not date or time these patients' pre-anesthesia evaluations.

Interview with EMP33, EMP35 and EMP36 on July 24, 2014, at approximately 9:50 AM confirmed MR34, MR36, MR37 and MR40 had surgical procedures performed on May 16, 2014, and OTH2 did not date or time these patients' pre-anesthesia evaluations.

Interview with EMP33, EMP35 and EMP36 on July 24, 2014, at approximately 10:00 AM confirmed all patients receiving anesthesia shall have a pre-anesthesia evaluation completed and documented by a practitioner within 48 hours prior to surgery.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a post anesthesia evaluation was completed and documented within 24 hours after surgery for five of 11 surgical medical records reviewed (MR34, MR36, MR37, MR40 and MR41).

Findings include:

Review on July 24, 2014, of the facility's "Pre and Post Anesthesia Evaluation Policy," last revised July 6, 2013, revealed "Policy: Evangelical Community Hospital shall ensure that all patients receiving anesthesia or sedation and analgesia care shall be assessed, managed and monitored in a manner that optimizes patient safety. Pre and Post anesthesia evaluation policies and procedures follow state and federal law and regulations, and have been approved by the medical staff. Procedure: ... Post Anesthesia Evaluation: All patients receiving general, regional or monitored anesthesia shall have a post anesthesia evaluation completed and documented by a practitioner qualified to administer anesthesia, as stated above, no later than 24 hours after surgery or a procedure requiring anesthesia services. The calculation of the 24-hour period timeframe begins at the point the patient is moved into the designated recovery area ..."

Review on July 24, 2014, of the facility's "Postoperative Anesthesia Care" policy, last revised November 3, 2013, revealed "Purpose: To outline anesthesia care and responsibilities for the postoperative patient. Policy: The anesthetist is responsible for post anesthesia care for all patients who have received anesthesia (general, regional, local anesthesia with standby). ... At least one (1) postanesthetic visit will be recorded, describing the presence or absence of anesthesia related complications: ... Each post anesthesia visit will be documented on the postanesthesia evaluation form or the progress notes. The date and time of each visit will be specific. ..."

Review of MR34, MR36, MR37, MR40 and 41 on July 24, 2014, revealed these patients had surgical procedures performed on May 16, 2014. Further review revealed OTH2 did not date or time these patients' post anesthesia evaluations.

Interview with EMP33, EMP35 and EMP36 on July 24, 2014, at approximately 9:50 AM confirmed MR34, MR36, MR37, MR40 and MR41 had surgical procedures performed on May 16, 2014, and OTH2 did not date or time these patients' post anesthesia evaluations.

Interview with EMP33, EMP35 and EMP36 on July 24, 2014, at approximately 10:00 AM confirmed all patients receiving anesthesia shall have a post anesthesia evaluation completed and documented by a practitioner within 24 hours following surgery.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure all departments of the hospital reported quality monitors or provided presentations to the hospital's Quality Council.

Findings include:

Review on July 21, 2014 revealed the facility's "Plan For Improving Organizational Performance," dated approved December 2013, revealed "The Board of Directors, Medical Staff and Hospital Administration of the Evangelical Community Hospital affirm their commitment and responsibility for maintaining and improving the quality of care in the hospital. While maintaining ultimate authority, the Board of Directors has authorized the Medical Staff and Hospital Administration to accept and discharge these obligations. Statement of Goals The goal of the performance improvement program is to promote, preserve and improve the health of members of our community by continually assessing and improving the quality of care and services provided throughout the hospital. We will strive to meet or exceed the needs of our patients and their families, our employees, our medical staff and third party payors within the limits of available resources. Statement of Purpose The purpose of the performance improvement program is to provide efficient and effective mechanisms of identifying, reporting, reviewing, evaluating and monitoring all aspects of patient care. All activities in the hospital, both clinical and non-clinical, are processes that can be continuously improved. Committee Structure Performance Improvement Committee (PIC) ... The Board of Directors and Executive Committee of the Medical Staff will receive regular reports from the PIC regarding performance improvement activities of the Medical Staff and Hospital departments. ... Quality Council The role of the Quality Council is to oversee the performance improvement activities of Hospital departments and assist quality improvement teams in all phases of their quality activities. ... Hospital Departments Complete regular reports on all quality activities and submit to Quality Council. Participate in interdepartmental or interdisciplinary quality activities as requested. Model Core Values. Initiate QA/QI activities based on identified needs. ..."

Review on July 21, 2014 of the facility document "PIC" meeting minutes for 2012, 2013, and 2014 revealed no documentation of reporting of quality monitors or presentations from the departments of the hospital to the Quality Council.

Interview with EMP1 on July 23, 2014, at approximately 11:30 AM confirmed there was no documentation of quality monitors or presentations from all departments of the hospital for 2012, 2013, and 2014. EMP1 confirmed the format of the Quality Council committee changed approximately two years ago. EMP1 confirmed a calendar was used in the past that identified when each department would report their data to the Quality Council.

Based on review of facility documents, personnel files (PF) and staff interview (EMP), it was determined the facility failed to ensure nurses had the specialized qualifications required to work in the Intensive Care Unit (ICU) for seven of seven applicable PFs reviewed (PF1, PF4, PF7, PF10, PF11, PF12 and PF13).

Findings include:

Review on July 23, 2014, of the job description for the RN in ICU [Registered Nurse in Intensive Care Unit] provided by the facility revealed "Purpose of Your Position - Perform the functions of assessing, planning, implementing and evaluating patient care in accordance with established nursing standards for the ICCU [Intensive Cardiac Care Unit]. ... Qualifications 1. Satisfactory completion of an accredited school of nursing, current Pennsylvania license. 2. BLS [Basic Life Support] certification required. Advanced Cardiac Life Support [ACLS] certification and completion of basic rhythm course required before employee begins work. ..."

Review on July 24, 2014 of PF1 revealed the RN was hired on June 23, 2014, to work in the ICCU. Review of PF1's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF1, as required by their job description.

Review on July 24, 2014 of PF4 revealed the RN was hired on May 12, 2014, to work in the ICCU. Review of PF4's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF4, as required by their job description.

Review on July 24, 2014 of PF7 revealed the RN was hired on June 9, 2014, to work in the ICCU. Review of PF7's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF7, as required by their job description.

Review on July 24, 2014 of PF10 revealed the RN was hired on August 19, 2013, to work in the ICCU. Review of PF10's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF10, as required by their job description.

Review on July 24, 2014 of PF11 revealed the RN was hired on June 9, 2014, to work in the ICCU. Review of PF11's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF11, as required by their job description.

Review on July 24, 2014 of PF12 revealed the RN was hired on June 9, 2014, to work in the ICCU. Review of PF12's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF12, as required by their job description.

Review on July 24, 2014 of PF13 revealed the RN was hired on March 17, 2014, to work in the ICCU. Review of PF13's job description revealed ACLS certification was required before the employee began work. There was no documentation of current ACLS certification for PF13, as required by their job description.

Interview with EMP25 at approximately 10:00 AM on July 24, 2014, confirmed PF1, PF4, PF7, PF10, PF11, PF12 and PF13 did not have ACLS certification prior to working in the ICCU, as required by their job descriptions.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure medical records were stored in a manner to prevent unauthorized access in the facility's sleep lab.

Findings include:

Review on July 23, 2014, of the facility's "Cardiopulmonary Services Confidentiality of Patient Records" policy, last reviewed May 2013, revealed "Purpose: To ensure the confidentiality of patient records. ... IV. All patient files are locked when staff is not present."

Observation on July 23, 2014, of the facility's sleep lab revealed an unlocked and unmonitored door which opened into the sleep lab from an unmonitored hallway. Further observation revealed an open and unoccupied office identified by EMP32 as an office used at one time by a secretary. Continued observation revealed 40 patient medical records on the desk and shelving unit, two unlocked cabinets with seven drawers containing patient medical records and one unlocked cabinet with six drawers containing patient medical records. EMP32 confirmed these patient medical records contained protected health information.

Interview with EMP32 on July 23, 2014, at approximately 10:50 AM confirmed the observation of the unlocked and unmonitored door which opened into the sleep lab from an unmonitored, open and unoccupied office used at one time by a secretary, the 40 patient medical records on the desk and shelving unit, and the unlocked cabinets containing patient medical records.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure electrical control panels for the nurse call system on the facility's orthopedic patient care unit were secure.

Finding include:

Review on July 22, 2014, of the facility provided "National Electrical Code Handbook 2011" revealed "... Article 110 Requirements for Electrical Installations ... 110.26 ... F. Locked Electrical Equipment Rooms or Enclosures. Electrical equipment rooms and enclosures housing electrical apparatus that are controlled by a lock(s) shall be considered accessible to qualified persons. ..."

Tour of the facility's orthopedic patient care unit on July 22, 2014, revealed an unmarked and unlocked door leading to a supply room directly across from an elevator. This room contained wheelchairs, a blanket warmer, physical therapy equipment and patient care equipment. Further observation revealed a grey colored wall mounted panel box with two doors. One of the doors contained a handle with a locking mechanism. The doors of this panel box were in the open position. Continued observation of this panel box revealed multiple colored wires and electrical plugs. EMP26, EMP27 and EMP28 identified this panel box as the nurse call system which patients use to summon a nurse for help.

Interview with EMP26 on July 22, 2014, at approximately 11:45 AM confirmed the observation of the unmarked and unlocked door leading to a supply room directly across from an elevator. EMP26 confirmed this room contained wheelchairs, a blanket warmer, physical therapy equipment and patient care equipment. EMP26 also confirmed the grey colored wall mounted panel box with two doors, one of the doors contained a handle with a locking mechanism, that the doors of this panel box were in the open position, and that this panel box contained multiple colored wires and electrical plugs. EMP26 confirmed this room was never locked and this room was in an unmonitored hall near an elevator.

Interview with EMP27 and EMP28 on July 22, 2014, at approximately 1:00 PM revealed the nurse call system controls were referred to as the nurse call system mechanical box. EMP27 and EMP28 also confirmed the nurse call system mechanical box could be easily disrupted by pulling a connecting wire.

Interview with EMP27 on July 22, 2014, at approximately 1:30 PM revealed an electrical vendor completed work on this nurse call system, as well as in other areas of the facility approximately three months ago. Further interview revealed the facility does not have a policy, procedure or mechanism in place to ensure a vendor has locked and secured an area following completion of work.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure a system for cleaning laundry chutes was designed and implemented to prevent and minimize infection hazards, failed to ensure staff followed established policies and procedures for patients in contact isolation for one of two patients observed requiring contact isolation (MR12), failed to ensure staff handled soiled linen in a manner to prevent cross contamination on the orthopedic patient care unit, and failed to ensure single use Neo-Synephrine was used for one patient in the Emergency Department.

Findings include:

1) Review on July 22, 2014 of the facility "Infection Prevention and Control Plan," dated reviewed March 2014, revealed "Goals of the Infection Prevention and Control Program ... 2. Analyze practices that have the potential to affect the rate of hospital-acquired infections. ... Infection Control Committee Authority and Responsibility The ICC [Infection Control Committee] Chairman and/or the Infection Control Practitioner under the direction the [sic] ICC Chairman has the authority to institute surveillance, prevention or control measures or studies when there is reason to believe that patients, personnel or visitors may be in danger. This authority and responsibility includes, but not limited to: Development and implement a preventative and corrective program designed to minimize infection hazards. ... Review and approve of policies and procedures pertaining to infection surveillance and control activities in all departments/services. ..."

Observation tour on July 23, 2014, at approximately 10:00 AM of the facility's laundry chutes revealed when the chute doors were opened bags of soiled linen fell into a bin directly beneath the door. Observation revealed there were bags that were open or ripped open. There were chux pads (waterproof, disposable pads used underneath a patient who is incontinent) emerging from the open/ripped linen bags.

Interview with EMP10 on July 23, 2014 at 10:00 AM confirmed the facility had no policy in place for cleaning of the laundry chute.

Interview with EMP20 on July 23, 2014 at approximately 9:30 AM confirmed the facility had no official process for the cleaning of the laundry chutes.

2) Review on July 22, 2014, of the facility's "Infection Control Policy," last reviewed March 2014, revealed "Isolation Guidelines Purpose: Isolation practices are utilized to ensure a safe environment for patients, staff and visitors by preventing the transmission of infection. ECH [Evangelical Community Hospital] isolation policies address the prevalence of communicable diseases and multi-drug organisms (MDROs) and follow acceptable CDC [Centers for Disease Control] guidelines accordingly. Policy: The guideline defines infection prevention and control practices that will ensure the safety of patients, employees, and visitors by minimizing the risk of acquisition and transmission of hospital acquired infections. II. Specific Isolation Categories and Requirements ... B. Contact Precautions (C) are used in addition to Standard Precautions for patients known or suspected to be infected or colonized with microorganisms that can be transmitted by direct or indirect patient contact. Patients with a known history of an MDRO (MRSA, VRE, ESBL) [Methicillin-resistant Staphylococcus Aureus, Vancomycin-Resistant Enterococci, Extended Spectrum Beta-Lactamase] will be placed into Contact Precautions until cleared through infection Control. ... 4. Personal protective equipment a. Gloves must be worn to enter the room and removed before leaving the room. b. Gown must be worn to enter the room and removed before leaving the room. ..."

Observation on July 22, 2014, at approximately 10:00 AM revealed a Stop sign posted outside of the patient room for MR12. Further observation of the Stop sign revealed "Contact Precautions Perform hand hygiene before entering room and wash hands with soap [sic] water before leaving room. Before entering room: Wear Gown Wear Gloves. Before leaving room: Remove Gloves and discard in trash can Remove Gown (turn inside-out so contaminated side is not exposed) and place in linen container or trash can if disposable."

Review of MR12 on July 22, 2014, revealed this patient was placed on Contact Precautions for a history of MRSA.

Observation of EMP29 on July 22, 2014, at approximately 10:30 AM revealed this employee entered MR12's room without wearing a gown or putting on gloves, as required by facility policy for patients on Contact Precautions.

Interview with EMP29 on July 22, 2014, at approximately 10:35 AM confirmed EMP29 entered MR12's room without wearing a gown or putting on gloves, as required by facility policy for patients on Contact Precautions.

Interview with EMP26 on July 22, 2014, at approximately 10:40 AM confirmed all employees must follow facility established isolation precautions for patients on Contact Precautions.

3) Review on July 22, 2014, of the facility's "Infection Control Policy Isolation Guidelines," last reviewed March 2014, revealed "Purpose: Isolation practices are utilized to ensure a safe environment for patients, staff and visitors by preventing the transmission of infection. Policy: The guideline defines infection prevention and control practices that will ensure the safety of patients, employees, and visitors by minimizing the risk of acquisition and transmission of hospital acquired infections. Procedure: I. General Fundamentals of Isolation Precautions ... H. Linens are handled per Standard Precautions. Refer to Linen Policy for additional information. ... II. Specific Isolation Categories and Requirements ... 6. Linen: a. Handle soiled linen to prevent contamination of HCWs [Health Care Workers] clothing and patient environment. Soiled linens should be contained at the point of use. ..."

Observation of EMP30 on July 22, 2014, revealed this employee completed patient care for MR14. Further observation revealed EMP30 placed the soiled linen on the floor. Continued observation revealed EMP30 picked up the soiled linen and carried the soiled linen against their uniform for disposal in the soiled linen container.

Interview with EMP26 and EMP30 on July 22, 2014, at the time of the observation confirmed the observation of EMP30 placing soiled linen on the floor, picking up the soiled linen, and carrying the soiled linen against their uniform for disposal in the soiled linen container.

Observation of EMP31 on July 23, 2014, revealed this employee completed patient care for MR15. Further observation revealed EMP31 placed the soiled linen on the floor. Continued observation revealed EMP31 picked up the soiled linen and carried the soiled linen against their uniform for disposal in the soiled linen container.

Interview with EMP26 and EMP31 on July 23, 2014, at the time of the observation confirmed the observation of EMP31 placing soiled linen on the floor, picking up the soiled linen, and carrying the soiled linen against their uniform for disposal in the soiled linen container.

Interview with EMP26 on July 23, 2014, at approximately 10:15 AM confirmed staff was not to place soiled linen on the floor or carry it against their uniform. EMP26 confirmed the facility's "Infection Control Policy Isolation Guidelines" applied to all staff for the handling of soiled linen for patients in isolation and patients not in isolation.

4) A request was made on July 21, 22, and 23, 2014, of EMP1, EMP18 and EMP37 for a facility policy regarding the use of nasal spray. No policy was provided.

Observation on July 21, 2014, in the emergency department (ED) revealed a container with supplies for ED staff to use when inserting a nasogastric tube (a tube inserted into the nose to the stomach). Further observation revealed an open and partially used bottle of Neo-Synephrine (nasal decongestant) 15 millimeters (ml). EMP37 confirmed the Neo-Synephrine was sprayed into the patient's nose to numb it before the nasogastric tube was inserted.

Interview with EMP37 on July 21, 2014, at approximately 2:00 PM confirmed the observation of the container with supplies for ED staff to insert a nasogastric tube and the open and partially used bottle of Neo-Synephrine. Further interview revealed the open and partially used bottle of Neo-Synephrine was meant for single use. EMP37 confirmed the bottle of Neo-Synephrine was used on multiple patients to numb the inside of the nose.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a pre-anesthesia evaluation was completed and documented within 48 hours prior to surgery for six of 11 surgical medical records reviewed (MR31, MR34, MR36, MR37, MR40 and MR41).

Findings include:

Review on July 24, 2014, of the facility's "Pre and Post Anesthesia Evaluation Policy," last revised July 6, 2013, revealed "Policy: Evangelical Community Hospital shall ensure that all patients receiving anesthesia or sedation and analgesia care shall be assessed, managed and monitored in a manner that optimizes patient safety. Pre and Post anesthesia evaluation policies and procedures follow state and federal law and regulations, and have been approved by the medical staff. Procedure: All patients receiving general, regional and monitored anesthesia shall have a preanesthesia evaluation completed and documented by a practitioner qualified and privileged to administer anesthesia, within 48 hours prior to surgery or a procedure requiring anesthesia services. ... Preanesthesai [sic] Evaluation The preanesthesia evaluation shall be performed within 48 hours prior to any surgery (administration of first dose of anesthesia marks the end of the 48 hours) with general, regional or monitored anesthesia, and shall include, but is not limited to: Review of the medical history, including anesthesia, drug and allergy history. Interview and examination of the patient. Notation of anesthesia risk according to established standards of practice ... Identification of potential anesthesia problems, particularly those that may suggest potential complications or contraindications to the planned procedure ... Additional preanesthesia evaluation, if applicable and as required in accordance with standard practice prior to administering anesthesia ... Development of the plan for the patient's anesthesia care, including the type of medications for induction, maintenance and postoperative care and discussion with the patient ... of the risks and benefits of the delivery of anesthesia. ..."

1) Review of MR 31 on July 24, 2014, revealed the patient had a surgical procedure performed on April 17, 2014. Further review of MR31 revealed OTH1 dated the patient's pre-anesthesia evaluation April 18, 2014.

Interview with OTH1, EMP33, EMP35 and EMP36 on July 24, 2014, at approximately 9:00 AM confirmed MR31 had a surgical procedure performed on April 17, 2014, and OTH1 dated the patient's pre-anesthesia for April 18, 2014. Further interview with OTH1 and EMP36 confirmed MR31's pre-anesthesia evaluation was dated after the completion of MR31's surgical procedure.

2) Review of MR41 on July 24, 2014, revealed the patient had a surgical procedure performed on July 21, 2014. Further review of MR41 revealed OTH2 did not date or time the patient's pre-anesthesia evaluation.

Interview with EMP33, EMP35 and EMP36 on July 24, 2014, at approximately 9:30 AM confirmed MR41 had a surgical procedure performed on July 21, 2014, and OTH2 did not date or time the patient's pre-anesthesia evaluation.

3) Review of MR34, MR36, MR37 and MR40 on July 24, 2014, revealed these patients had surgical procedures performed on May 16, 2014. Further review revealed OTH2 did not date or time these patients' pre-anesthesia evaluations.

Interview with EMP33, EMP35 and EMP36 on July 24, 2014, at approximately 9:50 AM confirmed MR34, MR36, MR37 and MR40 had surgical procedures performed on May 16, 2014, and OTH2 did not date or time these patients' pre-anesthesia evaluations.

Interview with EMP33, EMP35 and EMP36 on July 24, 2014, at approximately 10:00 AM confirmed all patients receiving anesthesia shall have a pre-anesthesia evaluation completed and documented by a practitioner within 48 hours prior to surgery.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a post anesthesia evaluation was completed and documented within 24 hours after surgery for five of 11 surgical medical records reviewed (MR34, MR36, MR37, MR40 and MR41).

Findings include:

Review on July 24, 2014, of the facility's "Pre and Post Anesthesia Evaluation Policy," last revised July 6, 2013, revealed "Policy: Evangelical Community Hospital shall ensure that all patients receiving anesthesia or sedation and analgesia care shall be assessed, managed and monitored in a manner that optimizes patient safety. Pre and Post anesthesia evaluation policies and procedures follow state and federal law and regulations, and have been approved by the medical staff. Procedure: ... Post Anesthesia Evaluation: All patients receiving general, regional or monitored anesthesia shall have a post anesthesia evaluation completed and documented by a practitioner qualified to administer anesthesia, as stated above, no later than 24 hours after surgery or a procedure requiring anesthesia services. The calculation of the 24-hour period timeframe begins at the point the patient is moved into the designated recovery area ..."

Review on July 24, 2014, of the facility's "Postoperative Anesthesia Care" policy, last revised November 3, 2013, revealed "Purpose: To outline anesthesia care and responsibilities for the postoperative patient. Policy: The anesthetist is responsible for post anesthesia care for all patients who have received anesthesia (general, regional, local anesthesia with standby). ... At least one (1) postanesthetic visit will be recorded, describing the presence or absence of anesthesia related complications: ... Each post anesthesia visit will be documented on the postanesthesia evaluation form or the progress notes. The date and time of each visit will be specific. ..."

Review of MR34, MR36, MR37, MR40 and 41 on July 24, 2014, revealed these patients had surgical procedures performed on May 16, 2014. Further review revealed OTH2 did not date or time these patients' post anesthesia evaluations.

Interview with EMP33, EMP35 and EMP36 on July 24, 2014, at approximately 9:50 AM confirmed MR34, MR36, MR37, MR40 and MR41 had surgical procedures performed on May 16, 2014, and OTH2 did not date or time these patients' post anesthesia evaluations.

Interview with EMP33, EMP35 and EMP36 on July 24, 2014, at approximately 10:00 AM confirmed all patients receiving anesthesia shall have a post anesthesia evaluation completed and documented by a practitioner within 24 hours following surgery.